Marian Brady

A Systematic Evaluation of the Adaptation of Depression Diagnostic Methods for Stroke Survivors Who Have Aphasia

Background and Purpose— One in 3 stroke survivors has aphasia (impaired language comprehension and expressive abilities). Conventionally, depression diagnosis uses language-based methods. We aimed to systematically review methods that have been used to diagnose depression and adaptations to these methods intended for people with aphasia. Methods— We systematically reviewed stroke studies (to January 2006) that included a depression diagnosis and individuals with aphasia. We extracted data related to depression diagnostic methods used for individuals with/without aphasia. We sought clarification from authors when required. Results— A total of 60 studies included people with aphasia. Almost half the studies (29/60; 48%) adapted their main depression diagnostic method (most typically a clinical interview and published criteria) for individuals with aphasia. Adaptive methods included: using informants (relatives or staff), clinical observation, modifying questions and visual analogue scales. Evidence of the validity or reliability of these adaptations was rarely reported. However, use of informants or clinical observation did achieve the inclusion of most people with aphasia in the diagnosis of depression. Remaining studies, that did not report adaptive methods, suggested that conventional language-based methods are suitable for individuals with only ‘mild’ aphasia. Conclusions— People with aphasia can be and have been included in depression diagnostic assessments. However, we suggest that depression and language experts collaborate to develop a more valid method of depression diagnosis for patients with aphasia that has good reliability.

Recovery From Poststroke Visual Impairment Evidence From a Clinical Trials Resource

Introduction. Limited evidence suggests that visual impairments may influence outcome after stroke. The degree of recovery from these impairments is poorly characterized. Objectives. To describe recovery and to determine whether visual impairments influence functional outcome and quality of life. Methods. We extracted demographic and outcome data from the Virtual International Stroke Trials Archive (VISTA). We examined horizontal eye movement disorders and hemianopia using the Best Gaze and Visual domains of the National Institutes of Health Stroke Scale (NIHSS) and described recovery at 30 and 90 days. Proportional odds modelling was used to examine the association between impairments at baseline, modified Rankin Scale (mRS), and European Quality of Life Score (EQ-5D) at 90 days. Results. Visual impairments were reported in 7,204/11,900 (60.5%) patients at baseline. Complete recovery occurred in 1,398/3,285 (42.6%) and 3,243/7,204 (45.0%) patients by 30 and 90 days respectively. The burden of persistent visual impairment in survivors was 1,135/4,028 (28.2%) at 30 days and 1,915/9,338 (20.5%) at 90 days. Partial gaze palsy (P < .0001; OR = 0.81; 95% CI = 0.74-0.87), forced deviation (P < .0001; OR = 0.48; 95% CI = 0.43-0.53), and complete homonymous hemianopia (P < .0001; OR = 0.67; 95% CI = 0.62-0.73) at baseline were associated with poor mRS at 90 days. Conclusions. The rate of recovery was greater in the first month after stroke, suggesting a potential time frame for interventions. The associations between visual impairments and poor mRS suggest that these impairments should be considered in multidisciplinary assessments and interventions.

Developing and evaluating the implementation of a complex intervention: using mixed methods to inform the design of a randomised controlled trial of an oral healthcare intervention after stroke

BackgroundMany interventions delivered within the stroke rehabilitation setting could be considered complex, though some are more complex than others. The degree of complexity might be based on the number of and interactions between levels, components and actions targeted within the intervention. The number of (and variation within) participant groups and the contexts in which it is delivered might also reflect the extent of complexity. Similarly, designing the evaluation of a complex intervention can be challenging. Considerations include the necessity for intervention standardisation, the multiplicity of outcome measures employed to capture the impact of a multifaceted intervention and the delivery of the intervention across different clinical settings operating within varying healthcare contexts. Our aim was to develop and evaluate the implementation of a complex, multidimensional oral health care (OHC) intervention for people in stroke rehabilitation settings which would inform the development of a randomised controlled trial.MethodsAfter reviewing the evidence for the provision of OHC following stroke, multi-disciplinary experts informed the development of our intervention. Using both quantitative and qualitative methods we evaluated the implementation of the complex OHC intervention across patients, staff and service levels of care. We also adopted a pragmatic approach to patient recruitment, the completion of assessment tools and delivery of OHC, alongside an attention to the context in which it was delivered.ResultsWe demonstrated the feasibility of implementing a complex OHC intervention across three levels of care. The complementary nature of the mixed methods approach to data gathering provided a complete picture of the implementation of the intervention and a detailed understanding of the variations within and interactions between the components of the intervention. Information on the feasibility of the outcome measures used to capture impact across a range of components was also collected, though some process orientated uncertainties including eligibility and recruitment rates remain to be further explored within a Phase II exploratory trial.ConclusionsComplex interventions can be captured and described in a manner which facilitates evaluation in the form of exploratory and subsequently definitive clinical trials. If effective, the evidence captured relating to the intervention context will facilitate translation into clinical practice.

How Well Do Standard Stroke Outcome Measures Reflect Quality of Life? A Retrospective Analysis of Clinical Trial Data

Background and Purpose— Quality of life (QoL) is important to stroke survivors yet is often recorded as a secondary measure in acute stroke randomized controlled trials. We examined whether commonly used stroke outcome measures captured aspects of QoL. Methods— We examined primary outcomes by National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI) and modified Rankin Scale (mRS), and QoL by Stroke Impact Scale (SIS) and European Quality of Life Scale (EQ-5D) from the Virtual International Stroke Trials Archive (VISTA). Using Spearman correlations and logistic regression, we described the relationships between QoL mRS, NIHSS, and BI at 3 months, stratified by respondent (patient or proxy). Using &khgr;2 analyses, we examined the mismatch between good primary outcome (mRS ⩽1, NIHSS ⩽5, or BI ≥95) but poor QoL, and poor primary outcome (mRS ≥3, NIHSS ≥20, or BI ⩽60) but good QoL. Results— Patient-assessed QoL had a stronger association with mRS (EQ-5D weighted score n=2987, P<0.0001, r=−0.7, r2=0.53; SIS recovery n=2970, P<0.0001, r=−0.71, r2=0.52). Proxy responses had a stronger association with BI (EQ-5D weighted score n=837, P<0.0001, r=0.78, r2=0.63; SIS recovery n=867, P<0.0001, r=0.68, r2=0.48). mRS explained more of the variation in QoL (EQ-5D weighted score=53%, recovery by SIS v3.0=52%) than NIHSS or BI and resulted in fewer mismatches between good primary outcome and poor QoL (P<0.0001, EQ-5D weighted score=8.5%; SIS recovery=10%; SIS-16=4.4%). Conclusions— The mRS seemed to align closely with stroke survivors’ interests, capturing more information on QoL than either NIHSS or BI. This further supports its recommendation as a primary outcome measure in acute stroke randomized controlled trials.

Exclusion and Inclusion Criteria for People with Aphasia in Studies of Depression after Stroke: A Systematic Review and Future Recommendations

Background/Aims: A third of individuals are depressed following stroke. A similar proportion have aphasia. The extent of their inclusion in depression following stroke studies affects the generalizability of findings. Methods: We systematically reviewed published studies (to December 2005) that diagnosed depression following stroke. We identified aphasia screening methods, aphasia exclusion and inclusion criteria and respective numbers of individuals with aphasia. Results: Of 129 studies (n = 19,183), aphasia screening methods were only reported by 57 (31 described a published aphasia-specific tool). No mention of aphasia was made in 13 studies. Most studies (92, 71%) reported some exclusion of people with aphasia (49 reported how many: n = 3,082, range = 2–554). Almost half of the studies (60, 47%) actually reported participants with aphasia (37 specified numbers: n = 829, range = 5–60). Aphasia exclusion or inclusion was not associated with sample source (community, acute hospital, other) or study purpose (observation, intervention, screening). Studies that reported screening for aphasia were more likely to describe aphasia exclusion and inclusion criteria and include participants with aphasia. Conclusion: Aphasia screening, exclusion and inclusion criteria reporting across studies of depression following stroke has been highly inconsistent. This impairs the interpretation of generalizability. Improved aphasia screening and reporting of exclusion and inclusion criteria are urgently recommended.

More Outcomes than Trials: A Call for Consistent Data Collection across Stroke Rehabilitation Trials

Stroke survivors experience complex combinations of impairments, activity limitations, and participation restrictions. The essential components of stroke rehabilitation remain elusive. Determining efficacy in randomized controlled trials (RCTs) is challenging; there is no commonly agreed primary outcome measure for rehabilitation trials. Clinical guidelines depend on proof of efficacy in RCTs and meta-analyses. However, diverse trial aims, differing methods, inconsistent data collection, and use of multiple assessment tools hinder comparability across trials. Consistent data collection in acute stroke trials has facilitated meta-analyses to inform trial design and clinical practice. With few exceptions, inconsistent data collection has hindered similar progress in stroke rehabilitation research. There is an urgent need for the routine collection of a core dataset of common variables in rehabilitation trials. The European Stroke Organisation Outcomes Working Group, the National Institutes of Neurological Disorders and Stroke Common Data Elements project, and the Collaborative Stroke Audit and Research project have called for consistency in data collection in stroke trials. Standardizing data collection can decrease study start up times, facilitate data sharing, and inform clinical guidelines. Although achieving consensus on which outcome measures to use in stroke rehabilitation trials is a considerable task, perhaps a feasible starting point is to achieve consistency in the collection of data on demography, stroke severity, and stroke onset to inclusion times. Longer term goals could include the development of a consensus process to establish the core dataset. This should be endorsed by researchers, funders, and journal editors in order to facilitate sustainable change.

An examination over time of language and discourse production abilities following right hemisphere brain damage

Abstract Although it is common for descriptions of communication ability in people with right hemisphere brain damage (RHBD) to include discourse deficits that affect pragmatic effectiveness, reports of these deficits are often made from subjective observations based on single cases. To date there is also very little objective information about spontaneous change over time in a representative clinical population in either discourse-specific or other aspects of language ability. In this study a group of eight individuals with post-stroke RHBD were assessed at 1 month and 6 months post-onset. The Discourse Comprehension Test was administered and seven discourse samples were elicited (three conversational, three procedural and a picture description). Detailed analyses of these samples included length, syntactic complexity, physical and illustrative gestures, verbal disruption, cohesion and topic coherence. A high level of intra-rater reliability was achieved in the analyses. Very few significant differences were evident over time in the language and discourse features measured and there were no apparent task effects. Reasons for this lack of ‘spontaneous recovery’ are discussed and some research implications drawn from this exploratory study.

People with aphasia: capacity to consent, research participation and intervention inequalities

Of 14 randomized controlled trials included in the recent Cochrane review of the evidence relating to information provision after stroke, only one included people with aphasia with the remainder either excluding this patient sub-group (10/14 trials) or failing to report any exclusion criteria. A third of people that experience a stroke will also experience aphasia, affecting their speaking, understanding, reading, and writing. The pervasive supposition that people with aphasia lack the capacity to make decisions for themselves is flawed and has the potential to lead to inequalities in care. We highlight the degree to which people with aphasia have been excluded from full participation in some areas of stroke research and the potential clinical consequences of their systematic exclusion. We emphasize the clinical and ethical need for the provision of more accessible research information and consent processes, illustrate the feasibility of adopting such an approach, and consider the broader benefits to stroke research of inclusive and accessible research approaches.

Picture description in neurologically normal adults: Concepts and topic coherence

Background: Evaluation of discourse is recognised as an important component in the diagnosis and management of adult acquired communication disorders. Picture description is a common and practical data elicitation procedure that has provided insights into the discourse of many adult groups. Such data may be analysed from several linguistic and pragmatic perspectives and, as is commonly the case with discourse measures, the usefulness of such data is limited by a paucity of relevant normative information. Aim: To determine the influences of age, education, and gender on the concepts and topic coherence of the picture description of non‐brain‐damaged adults. Methods & Procedures: A total of 225 adults described the “cookie theft” picture (Goodglass, Kaplan, & Barresi, 2001). Responses were analysed for presence and completeness of concepts (Nicholas & Brookshire, 1995) and topic coherence (Mentis & Prutting, 1991), modified (Brady, Mackenzie, & Armstrong 2003). Outcomes & Results: Both analyses, concept and topic coherence, confirmed education level as a highly important variable affecting the performance of non‐brain‐damaged adults. The number of concepts used accurately and completely, and the amount of topic subdivision, increased with amount of education (both with and without adjustment for age and gender). Clear influences of age or gender were not demonstrated, although some trends in favour of women and younger age were noted, and for one of the seven assessed concepts there was a steady reduction in the odds of being accurate and complete with every 5‐year age increase. Conclusions: Recognition of the impact of education is essential in the assessment and diagnosis of communication difficulty. The authors are grateful to all who participated in this study.

Time for a step change? Improving the efficiency, relevance, reliability, validity and transparency of aphasia rehabilitation research through core outcome measures, a common data set and improved reporting criteria

Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK Division of Linguistics, University of Athens, Athens, Greece Department of Rehabilitation Sciences, Cyprus University of Technology, Limassol, Cyprus Department of English Studies, University of Cyprus, Nicosia, Cyprus University of Valencia, Valencia, Spain Language Theory and Communication Sciences Department, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden Division of Linguistics, University of Athens, Athens, Greece on behalf of the Collaboration of Aphasia Trialists