Kirstine Shrubsole

Recommendations for post-stroke aphasia rehabilitation: an updated systematic review and evaluation of clinical practice guidelines

ABSTRACT Background: Clinical practice guidelines (CPGs) have been shown to improve patient care and outcomes. For speech pathologists working with people with post-stroke aphasia, there is currently no single high-quality guideline that summarises all of the available research knowledge into recommendations to guide decision-making. While multiple stroke and aphasia guidelines exist, some are of low methodological quality, are out of date, or do not provide recommendations that specifically guide aphasia management. As such, it may be difficult for clinicians to choose one particular guideline to follow. Aim: To identify, extract, and evaluate recommendations from high-quality CPGs to inform the management of post-stroke aphasia by speech pathologists. Methods & Procedures: An updated systematic review of stroke and speech pathology-specific clinical guidelines was conducted in January 2015. The search included multiple databases (MEDLINE, Embase, CINAHL), guideline and stroke websites, and other sources. The quality of included guidelines was assessed using the Appraisal of Guidelines and Research and Evaluation (AGREE) II tool. Guidelines that obtained a high AGREE II “Rigour of Development” score were retained and the aphasia-relevant recommendations from these guidelines were extracted for further analysis. Recommendations were evaluated according to their applicability to aphasia and the clarity of linkages between the recommendations and underlying evidence. Outcomes & Results: Five new guidelines were identified. Their AGREE II ratings ranged from 31.3 to 71.9, and one met the cut-off of 66.67 for further analysis. One hundred and eleven recommendations from four guidelines were extracted and evaluated. From these, 76 recommendations met the inclusion criteria, 25 of which were specifically targeted at aphasia management, the remainder being general rehabilitation principles that may apply to aphasia. Thirty-four recommendations were directly linked to evidence, and 42 were based on consensus. Research gaps were noted for goal-setting, counselling, patient and carer support, and discharge planning, indicating possible areas for future research. There were challenges in comparing recommendations from different CPGs, determining whether evidence was applicable to people with aphasia, and in identifying clear links between the evidence and some recommendations. Conclusions: The collated 76 (34 evidence-based, 42 consensus-based) recommendations can be used by speech pathologists to guide aphasia rehabilitation. Aphasia-specific research is required in areas such as goal-setting, counselling, patient and carer support, and discharge planning.

Priorities for Closing the Evidence-Practice Gaps in Poststroke Aphasia Rehabilitation: A Scoping Review

OBJECTIVE To identify implementation priorities for poststroke aphasia management relevant to the Australian health care context. DATA SOURCES Using systematized searches of databases (CINAHL and MEDLINE), guideline and stroke websites, and other sources, evidence was identified and extracted for 7 implementation criteria for 13 topic areas relevant to aphasia management. These 7 priority-setting criteria were identified in the implementation literature: strength of the evidence, current evidence-practice gap, clinician preference, patient preference, modifiability, measurability, and health effect. STUDY SELECTION Articles were included if they were in English, related to a specific recommendation requiring implementation, and contained information pertaining to any of the 7 prioritization criteria. DATA EXTRACTION The scoping review methodology was chosen to address the broad nature of the topic. Evidence was extracted and placed in an evidence matrix. After this, evidence was summarized and then aphasia rehabilitation topics were prioritized using an approach developed by the research team. DATA SYNTHESIS Evidence from 100 documents was extracted and summarized. Four topic areas were identified as implementation priorities for aphasia: timing, amount, and intensity of therapy; goal setting; information, education, and aphasia-friendly information; and constraint-induced language therapy. CONCLUSIONS Closing the evidence-practice gaps in the 4 priority areas identified may deliver the greatest gains in outcomes for Australian stroke survivors with aphasia. Our approach to developing implementation priorities may be useful for identifying priorities for implementation in other health care areas.

Barriers and facilitators to meeting aphasia guideline recommendations: what factors influence speech pathologists’ practice?

Abstract Purpose: To explore factors influencing Australian speech pathologists’ guideline recommended aphasia management practices. Methods: Semi-structured interviews were conducted with hospital-based speech pathologists (n = 20). Interviews focused on barriers and facilitators to implementing recommendations related to five practice areas: Aphasia-friendly Information; Collaborative Goal Setting; Timing of Therapy; Amount and Intensity of Therapy; and Conversation Partner Training. Results: Speech pathologists working only in inpatient rehabilitation settings reported performing the recommended behaviours consistently, and identified few implementation barriers. However, clinicians working in the acute setting reported performing the majority of behaviours inconsistently or rarely. Seven (of 14) Theoretical Domains Framework domains were identified as key influencing factors. Three of these – “Environmental Context and Resources,” “Beliefs about Consequences,” and “Social Influences” – were consistently reported as influencing practice across all five behaviours. Other important domains included “Knowledge”, “Beliefs about Capabilities,” “Goals,” and “Social/Professional Role and Identity”, which each influenced at least two practice behaviours. Conclusions: Speech pathologists report a number of key factors influencing their practice, which differ in how they influence behaviours (i.e., a factor may be a barrier or a facilitator) depending on the behaviour and clinical setting. Future implementation interventions need to account for the strong influence of beliefs and social influences on speech pathology practice, which may facilitate successful implementation. Implications for rehabilitation Speech pathologists’ aphasia management practices are often inconsistent with guideline recommendations. Environmental and contextual barriers were identified for all guideline-recommended practices that were investigated; however, these barriers did not necessarily impede implementation for speech pathologists working in inpatient rehabilitation settings. Strategies to improve both team functioning (social influences) and the belief systems of individual clinicians (beliefs about consequences) should be considered to improve speech pathologists’ implementation of guideline-recommended aphasia practices.

Implementing a tailored behaviour change intervention to improve speech pathologists’ aphasia practices: results of a pilot cluster randomised controlled trial

Background: There is considerable variation in aphasia management practices across the continuum of care. Australian speech pathologists working in the acute setting have reported more barriers to implementing guideline recommendations for aphasia than those working in inpatient rehabilitation settings, with acute speech pathologists performing some behaviours inconsistently or rarely. For speech pathologists to implement the best practice recommendations consistently in acute care, there is the need to change their clinical practice behaviours. However, little is known about the effectiveness of behaviour-change strategies in speech pathologists providing acute aphasia management. Hence, the aim of this study was to design and test the feasibility, acceptability, and potential effectiveness of a tailored implementation strategy to improve acute speech pathologists’ uptake of evidence in two areas of practice, Aphasiafriendly Information Provision and Collaborative Goal Setting. Methods: A pilot cluster randomised controlled trial was used. Clusters were speech pathology departments within hospitals, with four clusters allocated to receive either Intervention A (targeted at improving information provision) or Intervention B (targeted at improving goal setting). There were two clusters in each arm of the study. An implementation intervention was designed to address the known barriers for each intervention arm. Both interventions included a face-to-face workshop incorporating behaviour-change techniques. Outcomes measures were utilised to address the research questions of feasibility (e.g., treatment fidelity and retention of participants), acceptability (e.g., post-study focus groups) and potential effectiveness (e.g., medical record audits and behaviour construct surveys). The quantitative data were recorded at baseline and 3–6 month follow-up, allowing for change scores to be calculated. Results: All four clusters completed the study, with a total of 37 speech pathologists participating. The majority of participants were female (36/37 = 97.3%), entry-level clinicians (15/37 = 40.5%), with a mean age of 30 years. Medical record data from 107 patients were included in the statistical analysis (post-intervention, n = 61; information provision intervention, n = 36; and goal setting intervention, n = 25). Overall, there was a significant improvement in the target behaviour for Intervention A (Aphasia-friendly Information Provision; mean improvement 52.78%, p = 0.001), but a small non-

Closing the evidence-practice gaps in aphasia management: are we there yet? Where has a decade of implementation research taken us? A review and guide for clinicians

ABSTRACT Background: There are evidence-practice gaps in all areas of aphasia management across the continuum of care. Despite the recognition that effective implementation strategies are needed to improve the consistency of speech pathologists’ aphasia management practices, there have been few studies investigating this important issue. Therefore, little is known about the effectiveness of implementation strategies in the field of aphasiology. In light of the developing field of knowledge translation, it is important to review the aphasia implementation literature to highlight current trends, draw together findings, and determine future implementation research needs. Aims: To critically review, summarise, and discuss the implementation literature in the field of aphasiology to date, in order to guide clinical aphasiologists to work towards closing the evidence-practice gaps in aphasia management. Main contribution: A review of the literature in this developing area of expertise in the field of aphasiology, with examples of practical applications. Conclusions: Only six implementation studies have been published in aphasia (related to conversation partner training, discourse analysis, information provision, and collaborative goal-setting practices), showing there is a need for capacity building in this area. Therefore, we are not yet able to state what interventions are effective in which context, nor fully understand how behaviour change occurs for clinicians providing aphasia management. Implications for speech-language pathologists are discussed. An overarching call to action is the need for clinicians and researchers to work together to drive future implementation efforts that can succeed in closing the aphasia management evidence-practice gaps.

Factors that influence Australian speech-language pathologists’ self-reported uptake of aphasia rehabilitation recommendations from clinical practice guidelines

ABSTRACT Background: There are clinical practice guidelines for speech-language pathologists’ aphasia management practices. However, reported adherence to aphasia guideline recommendations is variable. The barriers and facilitators to meeting aphasia management recommendations are not well understood. In order to develop theory-informed strategies to improve implementation of aphasia management practices, a better understanding of these barriers and facilitators is required. Aims: This study aimed to describe barriers and facilitators to speech-language pathologists’ uptake and implementation of five prioritised recommended practices for aphasia management. Methods & Procedures: An online survey sought information from Australian speech-language pathologists working with clients with aphasia. The survey focused on five practices including goal setting, information provision, constraint-induced language therapy, timing, and intensity of intervention. The Theoretical Domains Framework was used to design the survey, with several statements generated about factors influencing practice for each domain. Outcomes & Results: Surveys were completed by 63 respondents. The theoretical domain “environmental context and resources” (e.g., “I have insufficient time to engage in…”) was the main perceived barrier for the majority of practices being investigated, whilst the theoretical domain “social/professional role and identity” (e.g., “It is part of my role with the multidisciplinary stroke team to engage in…”) was the main perceived implementation facilitator for all practices. The top three barriers and facilitators varied for each of the five recommended practices being investigated. Across clinical settings, there were commonalities and differences in the perceived barriers and facilitators to implementation. There was a significant correlation between self-reported uptake of all of the aphasia rehabilitation recommendations we investigated and participants’ total barrier scores. Total barrier scores were also significantly different between clinical settings in the area of goal setting, with acute settings having a higher number of reported barriers to goal setting than rehabilitation settings (p = 0.011). Conclusions: Implementation interventions that seek to overcome the barriers of environmental context and resources (time, competing priorities and resources) are likely to have the most effect on aphasia best practice uptake. Encouraging behaviour change in the “social professional role and identity” domain by emphasising the role of the speech-language pathologist in aphasia rehabilitation within the multidisciplinary stroke team should further improve uptake of recommended practices. At a local level, departments or individual speech pathologists need to identify their own barriers and facilitators and choose effective implementation interventions using the Behaviour Change Wheel. Both strategies should help close the evidence-practice gap in aphasia rehabilitation.

Implementation priorities for closing evidence-practice gaps in aphasia

Session 1: ICH/TIA 1100–1230 Management of unruptured intracranial arteriovenous malformations in pediatric patients with stereotactic radiosurgery D Ding, Z Xu, C-P Yen, R M Starke, J P Sheehan University of Virginia, Charlottesville, Virginia, USA Background: Unruptured intracranial arteriovenous malformations (AVM) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs. Therefore, the efficacy of stereotactic radiosurgery (SRS) for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following SRS for unruptured pediatric AVMs. Methods: We evaluated a prospective, institutional AVM SRS database, from 1989 to 2013. Patients with age <18 years at the time of SRS, unruptured nidi, and at least two years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. Results: In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure (53%). The median nidus volume, radiosurgical margin dose, and radiologic follow-up were 3.2 cm, 21.5 Gy, and 45 months, respectively. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29%, 54%, and 72%, respectively. In the multivariate Cox regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55%, 16%, and 2%, respectively. The annual post-radiosurgery hemorrhage rate was 1.3%. Conclusion: Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach. 1. Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 2014; 311:1661–1669. 2. Ding D, Xu Z, Yen CP, Starke RM, Sheehan JP. Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients. Acta Neurochir (Wien) 2014. DOI: 10.1007/s00701-0142305-4. 3. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383:614–621. Subclinical ischemic lesions in patients with intracranial haemorrhage S Singhal, J V Ly, R V Chandra, J Zhou, C Soufan, H Ma, B Clissold, V Srikanth, T G Phan Monash Health, Clayton, VIC, Australia Background and Purpose: Subclinical ischemic lesions on diffusion weighted MR imaging (MRI-DWI) have been recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH). Such lesions are postulated to be part of the amyloid angiopathy spectrum. We hypothesized that the frequency of these MRI-DWI lesions may differ between patients presenting with cSAH, lobar ICH and basal ganglia ICH. Methods: Retrospective study of patients presenting between 2011–2014 with cSAH and/or ICH and subsequent MRI. Patients with an aneurysm, arteriovenous malformation, or hemorrhagic infarct were excluded. ICH topography was classified as lobar or basal ganglia; MRI-DWI lesions were classified as subclinical if there were no associated symptoms; contrast enhanced scans were assessed for leptomeningeal contrast enhancement. Results: Of 115 eligible patients, 56 patients had MRI within 14 days of hemorrhage (mean age 69.4 ± 11.5 years; 48% male). Overall, 21% (n = 12/56) patients with cSAH and/or ICH had subclinical MRI-DWI lesions. MRI-DWI lesions occurred more frequently in patients with cSAH than basal ganglia ICH (n = 5/12 vs 2/30; p = 0.006) and in patients with lobar ICH than basal ganglia ICH (n = 5/18 vs 2/30; p = 0.04). There was no significant difference in MRI-DWI lesions between cSAH and lobar ICH. Patients with MRI-DWI lesions had more frequent adjacent leptomeningeal contrast enhancement (p < 0.001). Conclusion: Subclinical ischemic lesions occur more frequently in patients with cSAH and lobar ICH than basal ganglia ICH. More frequent leptomeningeal contrast enhancement in these patients may point to a common underlying amyloid-related small vessel vasculopathy. Impact of haematoma shape and density on 90-day outcome after intracerebral haemorrhage: The INTERACT2 study C Delcourt, S Zhang, H Arima, S Sato, R A-S Salman, X Wang, C Stapf, T Robinson, P Lavados, J Chalmers, E Heeley, C Anderson Neurology and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia The University of Sydney, Sydney, NSW, Australia Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia University of Edinburgh, NHS Lothian, Edinburg, United Kingdom Université Paris Diderot – Sorbonne Paris, AP-HP Hôpital Lariboisière, Paris, France Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom Departamento de Medicina, Clínica Alemana, Universidad del Desarrollo (P.M.L.), Santiago, Chile The George Institute for Global Health, Sydney, NSW, Australia Background: Irregularity of shape and heterogeneous density suggest multiple bleeding foci and different periods of bleeding, respectively, in acute intracerebral hemorrhage (ICH). These features predict hematoma expansion but with uncertain significance on patient outcome. The aim of this study was to assess the association of shape and density on outcome among participants of INTERACT2, an open-label randomized controlled trial. Method: Shape and density were measured in 2066 patients with baseline CT. The Barras scale was used to categorize the appearance of the ICH, on the largest axial slice, into ‘regular’ (1 to 2) vs ‘irregular’ (3 to 5); density variation into ‘homogeneous’ (1 to 2) vs ‘heterogeneous’ (3 to 5). Logistic regression models were used to assess hematoma parameters on the primary outcome defined as death or major disability (mRS 3–6) at 90 days. Secondary outcomes were death and major disability, separately. Results: Shape irregularity was associated with poor outcome (OR 1.64, 95%CI 1.33–2.03), and separately only on major disability (OR 1.5, 95% CI 1.24–1.83). Density heterogeneity was not associated with poor outcome (OR 1.09, 95%CI 0.87–1.36), or the separate components of death or disability. Abstracts

Neuroscientific Implications in Assessment and Intervention for Aphasia

Within an overarching theme of generational change in aphasiology, the aims of this paper are to (a) unify the neuroscience of the language impairment of aphasia with the psychosocial science of aphasia, (b) consider the implications of technology and (c) address the global challenge of translational research in this field. To achieve the first two aims, 10 principles of neuroplasticity will be interpreted within the World Health Organizations International Classification of Functioning, Disability and Health (ICF). Two novel treatment approaches to aphasia (UQ Aphasia LIFT and CommFit™) will be described that illustrate how the neuroplasticity principles can be interpreted more broadly within the ICF. The global challenge of translational research will bring the perspective of clinicians and consumers through to aphasia research via 3 recent sets of best practice statements for aphasia. Each demonstrates how the field of aphasiology is undertaking a knowledge synthesis within its broader remit of knowledge transfer and exchange. The Australian Aphasia Rehabilitation Pathway is described as a way of creating living clinical guidelines that are helpful to all stakeholders in aphasia research.