Kylie Wall

Measuring the quality of dysphagia management practices following stroke: a systematic review

Adherence to recommended clinical practices improves stroke outcomes. As a result, stroke clinicians are increasingly expected to evaluate the quality of the care they provide so that areas for improvement can be targeted. Finding the best method to evaluate the quality of dysphagia management can be challenging. Aim To systematically review process indicators used to assess the quality of care provided to patients with dysphagia following acute stroke and examine the level of evidence underpinning these indicators. Methods Databases were systematically searched to identify publications (January 2006–April 2009) that describe process indicators relating to the clinical management of acute stroke-related dysphagia. Relevant process indicators were extracted from the reviewed publications for detailed post hoc analysis including supporting evidence and alignment to the current Australian and English stroke guidelines. Results Title and abstract review found 150 potential studies. Full-text review resulted in 25 publications that met the studys inclusion criteria. Thirteen process indicators were identified in the literature that related to the initial assessment, clinical management, rehabilitation and discharge planning for patients with acute stroke-related dysphagia. These processes were supported by levels of evidence ranging from high ‘level 1’ (8%) down to ‘expert opinion’ evidence (46%). Two process indicators did not align to recommendations in the clinical guidelines. This systematic review underpins informed selection of process indicators for evaluating the quality of dysphagia management following stroke. The selection of quality indicators is complicated by equivocal supporting evidence; however, indicators should reflect expected local practices, align with national stroke guidelines and be feasible for clinical auditing.

Assessing Cognition after Stroke. Who Misses Out? A Systematic Review

Background Cognitive impairments post-stroke are common. Assessment of cognition typically involves pen-and-paper tasks, which are often reliant on linguistic and motor function, creating barriers for many stroke survivors. The characteristics of stroke survivors excluded from cognitive assessments have never been investigated. Aims (1) To determine if the stroke samples included in studies evaluating clinimetric properties of cognitive assessments represent the stroke population, (2) to identify the different modes of cognitive assessments, and (3) to ascertain whether the different modes of cognitive assessments influence the stroke samples used in the studies. Summary of review We systematically reviewed studies that evaluated at least one clinimetric property of a cognitive assessment in adult stroke survivors from January 2000 to October 2013. Eligibility criteria, reasons for drop-outs and missing data were extracted. A theming process was employed to synthesize the data. From the initial yield of 3731 articles, 109 were included. Six broad categories describing reasons for exclusion were identified. Cognitive impairments were the most common (68%), then communication issues (62%), endurance problems (42%), sensory loss (39%), psychiatric illness (38%) and motor limitations (27%). The most prevalent assessment mode was pen-and-paper (73%), then virtual reality (11%), computer (6%), observational functional performance (5%), informant (3%) and telephone (3%). Regardless of mode, issues with cognition and communication were the most frequently used exclusion criteria. Conclusions Our findings indicate that cognitive assessments are not tested in representative stroke samples. Research is needed to identify valid and reliable cognitive assessments that are feasible in a wider range of stroke survivors.

Determining the Association between Language and Cognitive Tests in Poststroke Aphasia

Background Individuals with aphasia are often excluded from studies exploring poststroke cognition because so many of the standard cognitive assessments rely on language ability. Our primary objective was to examine the association between performance on cognitive tests and performance on comprehension and naming tests in poststroke aphasia. Second, we aimed to determine the association between language performance and a real-life measure of cognition (Kettle Test). Third, we explored the feasibility of administering cognitive tests in aphasia. Methods Thirty-six participants with poststroke aphasia and 32 controls were assessed on a battery of pen-and-paper cognitive tests recommended in stroke. Auditory comprehension was measured using the Comprehensive Aphasia Test and naming was measured using the Boston Naming Test. Twenty-two community dwelling participants with aphasia and controls were also asked to complete the Kettle Test. Multiple linear regressions were used to explore the relationship between language performance and performance on the cognitive tests. Feasibility was determined by quantifying missing data. Results The cognitive tests with the highest variance accounted for by auditory comprehension and naming were animal fluency (R2 = 0.67, R2 = 0.78) and the Hopkins Verbal Learning Test (recognition discrimination index) (R2 = 0.65, R2 = 0.78). All cognitive tests were significantly associated with auditory comprehension and naming, except for the Star Cancellation Test and the Kettle Test. Thirty-three percent of participants with aphasia were unable to complete all the cognitive tests. Conclusion Language and non-linguistic cognitive processes are often interrelated. Most pen-and-paper cognitive tests were significantly associated with both auditory comprehension and naming, even in tests that do not require a verbal response. Language performance was not significantly associated with a real-life cognitive performance measure. Task instructions, stimuli, and responses for completion need to be tailored for individuals with aphasia to minimize the influence of language deficits when testing non-linguistic cognitive performance.

Using technology to overcome the language barrier: the Cognitive Assessment for Aphasia App

Abstract Purpose: We developed and explored the feasibility and user acceptance of the Cognitive Assessment for Aphasia App: a non-immersive virtual reality cognitive assessment for stroke survivors, designed to be inclusive of individuals with aphasia. Methods: Participants were assessed on a battery of pen-and-paper cognitive tests and the Cognitive Assessment for Aphasia App. Feasibility was explored by quantifying missing data for test completion, determining user acceptance for the app by measuring participants’ preferred testing method, enjoyment and perceived task difficulty and time-taken to complete the test. Results: Sixty-four stroke participants (35 with aphasia, 29 without aphasia) and 32 controls were recruited. Only one participant with aphasia was unable to complete all the Cognitive Assessment for Aphasia App tasks, whereas 13 participants were unable to complete all pen-and-paper tasks. Only 14% of participants preferred the pen-and-paper tests, and preference did not significantly differ between groups. Ninety-five per cent of participants were neutral or enjoyed the app and 4% perceived it to be very difficult. Higher age was negatively associated with user acceptance measures. Conclusion: The study shows preliminary evidence for the Cognitive Assessment for Aphasia App to be a feasible cognitive assessment for stroke survivors with and without aphasia. The app is currently being validated in stroke. Implications for rehabilitation The Cognitive Assessment for Aphasia App is a feasible tool for assessing post-stroke cognition in acute, inpatient rehabilitation and community settings. In research trials examining cognition, individuals with aphasia are often excluded. The Cognitive Assessment for Aphasia App permits the inclusion of these individuals, enhancing generalizability. The Cognitive Assessment for Aphasia App provides an alternative method to assess cognition that is quicker and preferred over standard neuropsychological tests.

Post-stroke cognition is not tested in representative samples: A systematic review

Synopsis: Stroke patients with acute occlusions of the large proximal cerebral arteries and high thrombus load do not show an optimal response to i. v. thrombolysis alone. During the recent years mechanical neurointerventional revascularization techniques with clot retrievers and aspiration catheters have been developed in adjunct to systemic therapy. Today interventional thrombectomy is mainly based on a combination with stentretrievers and aspiration. Compared to prior approaches this technique is relatively easy to perform and to standardize and allows for recanalization rates of up to 90 %. Clinical success rates of more than 50 % of patients with mRS 0–2 could be achieved in experienced centers. Drawbacks of catheter based revascularization techniques are logistic demands and the descrepancy between high recanalization rates and lower rates of good clinical outcomes. The problem of futile recanalization was one of the influence factors for the failure of several randomized trials (RCTs) i. v.-lysis vs. thrombectomy. Improper patient selection, inefficient interventional techniques and late time windows were among the reasons why superiority of endovascular treatment could not be demonstrated with high levels of scientific evidence. Neurointerventional hypes and accelerated demands for RCTs at an early stage of development without proof of sufficient efficacy of a new technique led to negative or equivocal results. Hopefully better trials are on the way. To become successful the relationship between neurologists and neurointerventionists should be less competitive to work together with the aim to improve outcome of stroke patients and to keep neurointervenition in the neuro field instead of vascular medicine. Invited Speaker

Using a non-immersive virtual reality approach to assess cognition in post-stroke aphasia: validating the Cognitive Assessment for Aphasia App (C3A)

Background: As part of the symposiumonCognition andAphasia, this paper examines a new approach to assessing cognition in aphasia. Traditional pen-and-paper tests of cognition are often dependent on language skills for completion and this creates a barrier for individuals with aphasia, as results may be confounded if individuals experience difficulty responding to questions and/or understanding complex instructions. To address this issue,wedeveloped the Cognitive Assessment for Aphasia App (C3A) – a non-immersive virtual reality cognitive assessment designed to be inclusive of individuals with post-stroke aphasia (Wall et al., 2017). This assessment incorporates computerised audio and visual feedback, practice opportunities, and intuitive functional tasks to minimise dependency on language skills for completion. Developing the C3A required the input fromamultidisciplinary clinical and research team and stroke survivors.We targeted cognitive domains that are commonly affected in stroke and influence functional outcomes. The C3A included a simple reaction time task to assess psychomotor skills and attention, a sequence copy task to assess visualmemory, and a kitchen task to assess executive functioning. Aims: To (1) determine if the C3A can differentiate between controls and participants poststroke, with and without aphasia, (2) investigate construct validity by comparing performance on the C3A with neuropsychological test performance, (3) determine ecological validity by comparing the C3A results with a functional cognitive outcome measure. Methods and Procedures: Sixty-four participants with stroke (35with aphasia, 29without aphasia) and 32 controls were recruited. An Android Samsung Galaxy NotePro (12.2 in) tablet was used to run the C3A. The C3A evaluates cognitive performance using a number of measures including latency and errors and is divided into four distinct tasks: (1) simple reaction time task to assess psychomotor speed, (2) visual search task to assess neglect and attention, (3) sequence copy tasks to assess visual memory, and (4) kitchen task to assess executive functioning. Performance on the C3A was compared between groups and was examined in relation to performance on pen-and-paper tests validated in stroke (including Trail Making Test, Brixton Spatial Anticipation Test, Rey-Osterrieth Complex Figure) and the Functional Independence Measure – cognition (FIM-cog).

Measuring the impact of allied health research

Background Excellence in Research for Australia (ERA) rankings are given to academic journals in which Australian academics publish. This provides a metric on which Australian institutions and disciplines are ranked for international competitiveness. This paper explores the issues surrounding the ERA rankings of allied health journals in Australia. Methods We conducted a broad search to establish a representative list of general allied health and discipline-specific journals for common allied health disciplines. We identified the ERA rankings and impact factors for each journal and tested the congruence between these metrics within the disciplines. Results Few allied health journals have high ERA rankings (A*/A), and there is variability in the impact factors assigned to journals within the same ERA rank. There is a small group of allied health researchers worldwide, and this group is even smaller when divided by discipline. Current publication metrics may not adequately assess the impact of research, which is largely aimed at clinicians to improve clinical practice. Moreover, many journals are produced by underfunded professional associations, and readership is often constrained by small numbers of clinicians in specific allied health disciplines who are association members. Conclusion Allied health must have a stronger united voice in the next round of ERA rankings. The clinical impact of allied health journals also needs to be better understood and promoted as a research metric.