Anne Hesketh

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial

Objective To assess the effectiveness of enhanced communication therapy in the first four months after stroke compared with an attention control (unstructured social contact). Design Externally randomised, pragmatic, parallel, superiority trial with blinded outcome assessment. Setting Twelve UK hospital and community stroke services. Participants 170 adults (mean age 70 years) randomised within two weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers. Interventions Enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants’ needs for up to four months, with continuity from hospital to community. Comparison was with similarly resourced social contact (without communication therapy) from employed visitors. Outcome measures Primary outcome was blinded, functional communicative ability at six months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (unblinded, six months): participants’ perceptions on the Communication Outcomes After Stroke scale (COAST); carers’ perceptions of participants from part of the Carer COAST; carers’ wellbeing on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events. Results Therapist and visitor contact both had good uptake from service users. An average 22 contacts (intervention or control) over 13 weeks were accepted by users. Impairment focused therapy was the approach most often used by the speech and language therapists. Visitors most often provided general conversation. In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure. Both groups improved on the TOM activity subscale. The estimated six months group difference was not statistically significant, with 0.25 (95% CI –0.19 to 0.69) points in favour of therapy. Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference. Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care. There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95% CI 0.16 to 1.1)). Conclusions Communication therapy had no added benefit beyond that from everyday communication in the first four months after stroke. Future research should evaluate reorganised services that support functional communication practice early in the stroke pathway. This project was funded by the NIHR Health Technology Assessment programme (project No 02/11/04) and is published in full in Health Technology Assessment 2012;16(26):1-160. Trial registration ISRCTN78617680

Phonological awareness therapy and articulatory training approaches for children with phonological disorders: a comparative outcome study.

Sixty-one children, aged 3.6-5.0, with developmental phonological disorders (PD) participated in a study comparing the effects of metaphonologically (MET) or articulation-based (ART) therapy. Maturational effects were controlled for by the inclusion of 59 normally speaking control children of the same age range. Measures of phonological (speech) output and phonological awareness were taken before and after therapy for all subjects and at 3 months post-therapy for PD children. Results showed that PD children improved significantly in both phonological output and awareness skills across the intervention period compared with control children, but that there was no significant difference on the awareness measure between ART and MET groups. ART and MET groups differed from each other on one measure of speech improvement only, with the ART group making more change than the MET group on individual probe scores. Follow-up measures for both therapy groups indicated that there was little difference between the groups on phonological awareness change or speech development 3 months after intervention, though there was a trend for MET children to continue to make more long-term change than the ART group on one output measure. Additional analysis showed that there were generally few significant implications for outcome between PD children with good initial phonological awareness skills and those who initially had poor phonological awareness skills.

Comparison of the effectiveness of the Hanen Parent Programme and traditional clinic therapy

BACKGROUND Both direct (clinician to child) and indirect (clinician to carer) approaches are currently used in the management of children with language delay, but there is as yet little evidence about their relative effects or resource implications. AIMS This research project compared the Hanen Parent Programme (HPP) in terms of its effectiveness and consequent suitability for an inner-city UK population with clinic-based, direct intervention. METHODS & PROCEDURES Thirty-seven children aged 2;06-3;06 years with a diagnosis of language impairment and their parents took part in the research project. The children were allocated on a geographical basis to receive therapy either as part of an HPP or in a clinic. Nineteen children and their families took part in one of the five Hanen groups that ran successively over 16 months; 18 children and their families received clinic-based intervention. The childrens language was assessed using the PLS-3 (UK version) and from an analysis of audio-taped parent and child interaction at three assessment points, one pretherapy and two post-therapy over 12 months. Two parent language measures were also analysed. OUTCOMES & RESULTS Significant gains in language scores were shown by 71% of the children over 12 months. There were no statistically significant differences in child language scores between the two therapy groups at any assessment point. However, the HPP was twice as intensive (in terms of therapist time) as clinic therapy based on average group size, which has resource implications. CONCLUSIONS. Results suggest that there are parent and child factors that need consideration when choosing an appropriate intervention programme for a child with language impairment. Parental expectations, existing interaction style and the level of child language may be important influencing factors.

Development of a reliable self-report outcome measure for pragmatic trials of communication therapy following stroke: the Communication Outcome after Stroke (COAST) scale

Objective: To develop and validate a clinically feasible measure of communication effectiveness for people with any type of communication problem following stroke. Design: Cross-sectional, interview-based, psychometric study, building on the development phase for construction of the Communication Outcome after Stroke (COAST) scale. Setting: A community sample from the northwest of England, UK. Subjects: One hundred and two people with communication problems (aphasia and/or dysarthria) following a stroke, within the previous 4—12 months. Interventions: Administration of the COAST scale, on two occasions, within a two-week period, and collection of demographic and other data relating to disability, degree of aphasia (where appropriate) and hospital diagnosis of aphasia/dysarthria. Main measures: Acceptability (missing values), reliability (internal consistency and test—retest reliability) and item analysis (item redundancy). Results: Ninety-seven (visit 1) and 98 (visit 2) respondents provided usable data for the psychometric analysis. The 29-item COAST scale showed good acceptability (few missing values, sample spread 28—100%), internal consistency and test—retest reliability for the scale (α = 0.95; ICC = 0.90) and its subscales (α = 0.65—0.93; ICC = 0.72—0.88), but possible item redundancy. A revised scale of 20 items was produced, demonstrating good internal consistency and test—retest reliability (α = 0.83—92; ICC = 0.72—0.88). Conclusions: The COAST is a patient-centred, practical and reliable measure that can be used to assess self-perceived communication effectiveness for people with aphasia and/or dysarthria. Further testing on construct validity and responsiveness to change is needed before the measure can be firmly recommended for use within clinical practice and research.

Communication outcome after stroke: a new measure of the carer’s perspective:

Objective: To validate a measure of the carer’s perspective of a stroke survivor’s communication in everyday life. Design: Cross-sectional, interview-based, psychometric study. Setting: A community sample from the northwest of England, UK. Subjects: Fifty-eight carers and 58 stroke survivors with communication problems (aphasia and/or dysarthria) following a stroke within the previous 4—12 months. Interventions: Administration of the 20-item Carer Communication Outcome after Stroke (Carer COAST) scale, on two occasions, within a two-week period; the 15-item Carers of Older People in Europe (COPE) Index, the patient Communication Outcome after Stroke (COAST) Scale, and collection of demographic and other data relating to the stroke survivor’s disability (Barthel Index), degree of aphasia (Frenchay Aphasia Screening Test) and hospital diagnosis of aphasia/dysarthria. Main measures: Acceptability (missing values), reliability (internal consistency and test—retest reliability) and construct validity. Results: Carer COAST showed good acceptability (no incomplete items, sample spread 24—100%), internal consistency and test—retest reliability for the scale (a = 0.94; intraclass correlation (ICC) = 0.91) and its subscales (a = 0.78—0.90; ICC = 0.75—0.87), and indicative evidence on construct validity (Carer COAST, COPE subscales and COAST). There were statistically significant correlations between the communication items of Carer COAST and the negative impact of caregiving (rs = —0.29) and the financial difficulties of caregiving (rs = —0.38). Conclusions: The Carer COAST scale has considerable potential as a reliable and valid measure of the carer’s perspective on the communication effectiveness of stroke survivors. Intercorrelations with COPE provide specific evidence of the impact of caring for a person with communication difficulties following a stroke.

Early Literacy Achievement of Children with a History of Speech Problems.

BACKGROUND There are conflicting reports in the research literature of the literacy outcome of children with speech disorder. The link between phonological awareness and literacy in typically developing and literacy delayed children is well established, but there is less research specifically into children with an isolated speech disorder (i.e. with age-appropriate language skills). There is a clinical need for clarification on their likely outcome as a group and for a means of predicting those individuals who might need support in literacy development. AIMS To assess literacy and phonological awareness skills at age 6;6-7;6 years in children with a history of speech disorder, and to identify factors in their early profile that were predictive of later achievement. METHODS & PROCEDURES Thirty-five children who had participated in an earlier therapy research study agreed to further assessment of their speech, language and literacy abilities. The children had originally been recruited between the ages of 3;6 and 5;0 years as having a moderate-to-severe speech disorder, and there were measures at that time of their non-verbal, language, phonological output and phonological awareness abilities. Follow-up assessments of phonological awareness, speech and early literacy were undertaken. OUTCOMES & RESULTS As a group, the children had made good progress in speech and showed phonological awareness and literacy development at an age-appropriate level. However, a small number of children had phonological awareness and literacy delay. Phonological awareness at 3;6-5;0 years was the best predictor of literacy achievement. CONCLUSIONS Speech and language therapists can be confident about the early literacy achievement of most children with isolated speech disorder, but should undertake assessment of phonological awareness to identify those children whose phonological awareness skills after speech intervention continue to be low.

Memory and language in middle childhood in individuals with a history of specific language impairment.

This study reports on the sensitivity of sentence repetition as a marker of specific language impairment (SLI) in different subgroups of children in middle childhood and examines the role of memory and grammatical knowledge in the performance of children with and without language difficulties on this task. Eleven year old children, 197 with a history of SLI and 75 typically developing (TD) peers were administered sentence repetition, phonological short term memory (PSTM) and grammatical morphology tasks. Children with a history of SLI were divided into four subgroups: specific language impairment, non-specific language impairment, low cognition with resolved language and resolved. Performance on the sentence repetition task was significantly impaired in all four subgroups of children with a history of SLI when compared to their age peers. Regression analyses revealed grammatical knowledge was predictive of performance for TD children and children with a history of SLI. However, memory abilities were significantly predictive of sentence repetition task performance for children with a history of SLI only. Processes involved in sentence repetition are more taxing of PSTM for individuals with a history of SLI in middle childhood in a way that does not appear to be the case for TD children.

Using errorless learning to treat letter-by-letter reading: Contrasting word versus letter-based therapy

Some pure alexic readers have been shown to activate lexical and semantic knowledge under brief presentation conditions. This ability is not seen when letter-by-letter reading accuracy is high or the reading impairment is very severe. It is also unlikely to occur under normal untimed presentation because the pure alexic will make deliberate use of their letter-by-letter strategy. This paper presents data from a moderately severe letter-by-letter reader, FD, who had visual processing problems affecting reading. He also had other mild aphasic characteristics. FD showed implicit reading abilities under brief presentation conditions, being able to make lexical decisions and semantic categorisations well above chance. FD was given two therapy programmes, the first, whole word therapy to exploit this implicit ability and the second to improve letter-by-letter accuracy and speed. FD showed some improvement in reading ability after both therapy programmes, particularly for words of personal interest to him. His letter naming accuracy and reading of visually similar words were the most resistant to change. A striking effect of therapy was the cessation of FDs letter-by-letter reading and the emergence of some of the characteristics of deep dyslexia. Even when therapy concentrated on letter accuracy, FD did not revert back to his original letter-by-letter reading strategy.The results are discussed with reference to the two theories of pure alexia. Some conclusions are drawn about the need for therapists to examine and exploit all residual reading skills when devising therapeutic programmes.

The use of relative clauses by children with language impairment

Recently, there has been increased attention to the development of complex syntax by children with language disorder. An example is the work of Schuele and Nicholls and Schuele and Tolbert who describe the acquisition of relative clauses by a group of children with SLI. The current paper presents data from 66 children with language impairment, aged 6 to 11 years. Their use of relative clauses is examined in two contexts, an elicitation and a narrative task. Data are presented on the omission of obligatory relative markers, postulated by Schuele and Tolbert as a recognizable stage in development by SLI but not typically developing children. Obligatory marker omission was rare in the current data. A more common pattern was use of the “reduced relative”, described by Schuele and Tolbert as a developmental step prior to the production of full relative clauses. Possible reasons for the discrepancies are considered.

Metaphonological Abilities of Phonologically Disordered Children

There is currently a great deal of interest in the underlying metaphonological abilities of children with phonological output impairment and their possible relationship with both the continuing speech problem and later literacy development. We present data from 61 children with phonological output problems and 59 normal speakers on a range of metaphonological, speech output, language and cognitive assessments. While supporting an overall group difference in metaphonological ability, the range of individual variation is highlighted. Some weak relationships were found between metaphonological skills and other language and cognitive performance, but not between metaphonological ability and severity of speech performance. The accepted developmental order of phonological awareness tasks was not entirely supported; rather, subgroups of children were found who were showing quite different orders of difficulty. A distinction between segmentation and rhyming skills was confirmed.