Natalie Ciccone

A comparison of aphasia therapy outcomes before and after a Very Early Rehabilitation programme following stroke

BACKGROUND Very early aphasia rehabilitation studies have shown mixed results. Differences in therapy intensity and therapy type contribute significantly to the equivocal results. AIMS To compare a standardized, prescribed very early aphasia therapy regimen with a historical usual care control group at therapy completion (4-5 weeks post-stroke) and again at follow-up (6 months). METHODS & PROCEDURES This study compared two cohorts from successive studies conducted in four Australian acute/sub-acute hospitals. The studies had near identical recruitment, blinded assessment and data-collection protocols. The Very Early Rehabilitation (VER) cohort (N = 20) had mild-severe aphasia and received up to 20 1-h sessions of impairment-based aphasia therapy, up to 5 weeks. The control cohort (n = 27) also had mild-severe aphasia and received usual care (UC) therapy for up to 4 weeks post-stroke. The primary outcome measure was the Aphasia Quotient (AQ) and a measure of communicative efficiency (DA) at therapy completion. Outcomes were measured at baseline, therapy completion and 6 months post-stroke and were compared using Generalised Estimating Equations (GEE) models. OUTCOMES & RESULTS After controlling for initial aphasia and stroke disability, the GEE models demonstrated that at the primary end-point participants receiving VER achieved 18% greater recovery on the AQ and 1.5% higher DA scores than those in the control cohort. At 6 months, the VER participants maintained a 16% advantage in recovery on the AQ and 0.6% more on DA scores over the control cohort participants. CONCLUSIONS & IMPLICATIONS A prescribed, impairment-based aphasia therapy regimen, provided daily in very early post-stroke recovery, resulted in significantly greater communication gains in people with mild-severe aphasia at completion of therapy and at 6 months, when compared with a historical control cohort. Further research is required to demonstrate large-scale and long-term efficacy.

Parental perspectives on the communication abilities of their daughters with Rett syndrome

Abstract Objective: This study describes, from the perspective of parents, how females with Rett syndrome communicate in everyday life and the barriers and facilitators to successful communication. Methods: Sixteen interviews were conducted with parents with a daughter with Rett syndrome with a pathogenic mutation in the methyl-CpG-binding protein 2 gene. Interviews were recorded and transcribed verbatim. Transcripts were analysed using directed content analysis. Results: All parents reported their daughters were able to express discomfort and pleasure, and make requests and choices using a variety of modalities including vocalisations, body movements and eye gaze. Parents also reported their daughters understood most of what they said and that the level of functional abilities, such as mobility, and environmental factors, such as characteristics of the communication partner, influenced successful communication. Conclusions: The perspectives of parents are integral to the assessment of communication abilities and have the potential to inform communication interventions for girls and women with Rett syndrome.

Amount of therapy matters in very early aphasia rehabilitation after stroke: A clinical prognostic model

BACKGROUND AND AIM The effects of very early aphasia therapy on recovery are equivocal. This article examines predictors of very early aphasia recovery through statistical modeling. METHODS This study involved a secondary analysis of merged data from two randomized, single-blind trials conducted in Australian acute and subacute hospitals. Study 1 (n = 59) compared daily therapy to usual ward care for up to 4 weeks poststroke in patients with moderate to severe aphasia. Study 2 (n = 20) compared daily group therapy to daily individual therapy for 20 1-hour sessions over 5 weeks, in patients with mild to severe aphasia. The primary outcome measure was the Western Aphasia Battery Aphasia Quotient (AQ) at therapy completion. This analysis used regression modeling to examine the effects of age, baseline AQ and baseline modified Rankin Scale (mRS), average therapy amount, therapy intensity, and number of therapy sessions on aphasia recovery. RESULTS Baseline AQ (p = 0.047), average therapy amount (p = 0.030), and baseline mRS (p = 0.043) were significant predictors in the final regression model, which explained 30% (p < 0.001) of variance in aphasia recovery. CONCLUSION The amount of very early aphasia therapy could significantly affect communication outcomes at 4 to 5 weeks poststroke. Further studies should include amount of therapy provided to enhance reliability of prognostic modeling in aphasia recovery.

“Ward talk”: Nurses’ interaction with people with and without aphasia in the very early period poststroke

Background: Nursing staff are the most frequent communication partners, after family members, for people in hospital poststroke, and they play an essential role in the multidisciplinary team. Recent research has found that patients are more cognitively and socially active when wards provide an “enriched environment” as compared to standard care. Therefore, language enrichment on acute wards is now being considered as a possible way to discourage “learned nonuse” of language in people with aphasia. Aims: This study involved an exploration of the nature of nurses’ interactions with three patients on an acute stroke ward, two with aphasia and one without, in order to understand the nature of the communicative environment in more detail. Methods & Procedures: Following all necessary ethics approval processes and consents, continuous video recordings of 7.5 hr each were run for three male patients (two aged 68 years and one aged 48 years) on the acute stroke ward within a teaching hospital in an Australian city. Two had left hemisphere strokes resulting in a Wernicke’s aphasia (WAB AQ = 47) and a global aphasia (WAB AQ = 9.2) and one had a right hemisphere stroke and no aphasia. All instances of interaction with nurses over that period were transcribed orthographically and analysed at a discourse level using a speech function analysis based on a systemic functional linguistic framework. Outcomes & Results: Overall, nurses made most of the opening moves, used closed questions, controlled the conversational floor, and did not generally interact about issues other than physical care. The patients with aphasia had restricted opportunity to use continuing and developing moves and most commonly fell into a pattern of closed question and simple response. There was little evidence of communicative repair by nurses and few supported conversation strategies employed. Patterns of moves identified through the speech function analysis revealed the disempowered position of the patients with aphasia compared to the patient without who used a wider range of speech functions that demonstrated more assertive interactions. Conclusions: This study suggests that nurses, in their role as key communication partners on the acute stroke ward, could help counter the development of learned nonuse by integrating more effective communication strategies into their daily care routines. Further conversation partner training could relieve communication breakdown and frustration and increase opportunities for satisfying conversational exchanges in this setting.

Aspects of speech-language abilities are influenced by MECP2 mutation type in girls with Rett syndrome.

This study investigates relationships between methyl‐CpG‐binding protein 2 gene (MECP2) mutation type and speech‐language abilities in girls with Rett syndrome. Cross‐sectional data on 766 girls, aged 15 years and under, with genetically confirmed Rett syndrome was obtained from the Australian Rett Syndrome Database (ARSD) (n = 244) and the International Rett Syndrome Phenotype Database (InterRett) (n = 522). Relationships between MECP2 mutation type and age of regression in speech‐language abilities, and the level of speech‐language abilities before and after this regression were investigated. The females had a median age of 4.95 years in the ARSD and 5.25 years in InterRett. The majority (89%, 685/766) acquired speech‐language abilities in the form of babble or words at some point in time. Of those who acquired babble or words, 85% (581/685) experienced a regression in these abilities. Those with a p.Arg133Cys mutation were the most likely to use one or more words, prior to (RRR = 3.45; 95% CI 1.15–10.41) and after (RRR = 5.99; 95% CI 2.00–17.92), speech‐language regression. Girls with Rett syndrome vary in their use of speech and language, and in their experience of speech‐language regression and these variations are partly explained by genotype.

Monologues and dialogues in aphasia : some initial comparisons

Background: In recent years, there has been a shift in aphasia research interest from analysis of monologues to conversational dialogues. However, where monologic research has focused primarily on aspects such as language structure and quantity, conversational research has mainly focused on pragmatic aspects of discourse such as turn taking and repair. While there is some acknowledgement of the differences between language use in monologues and dialogues in aphasia, few comparisons have been made that cover a broad range of both syntactic and semantic aspects. Aims: This study aims to compare the discourse of aphasic speakers and non-brain-damaged control speakers in monologues and dialogues by using a range of syntactic and semantic analyses. In so doing, it aims to explore whether or not it is necessary for researchers and clinicians to sample both contexts in order to gain a full picture of a persons linguistic skills. Methods & Procedures: Two individuals with aphasia of varying severity provided monologues about their stroke experience, then participated in dialogues with a “significant other” on the same topic. Two control speakers, matched as closely as possible with the speakers with aphasia, undertook the same tasks, however they discussed a serious illness they had experienced. The SALT program (Miller & Iglesias, 2008) analysed the resulting data for syntactic productivity and complexity, and semantic analyses from a Systemic Functional Linguistic framework (Halliday & Matthiessen, 2004) were used to explore ideational, interpersonal, and textual meanings. Outcomes & Results: The syntactic measures demonstrated greater consistency across contexts, with the participants with aphasia using more and longer C-units in the monologue, although demonstrating more mazes in this context. The control speakers demonstrated slightly more variation but, like the speakers with aphasia, tended to use more words per C-unit in the monologue. Semantic measures demonstrated more variable patterns although some similarities also existed. Conclusions: The variation noted in the study supports the notion that clinicians and researchers should sample a variety of contexts in order to gain an overall picture of a persons language skills. Factors such as personality, topic, and conversation partner influence all seem to play a role in discourse production, particularly from the perspective of meanings conveyed. This study raises questions as to the actual effects of these factors on language structure and function and provides direction for future research in the area.

Constraint-induced aphasia therapy (CIAT): a randomised controlled trial in very early stroke rehabilitation

Background: Communication outcomes following stroke are improved when treatments for aphasia are administered early, within the first 3 months after stroke, and provided for more than 2 hours per week. However, uncertainty remains about the optimal type of aphasia therapy. Aims: We compared constraint-induced aphasia therapy (CIAT) with individual, impairment-based intervention, both administered early and daily after acute stroke. Methods & Procedures: This prospective, single-blinded, randomised, controlled trial recruited participants with mild to severe aphasia within 10 days of an acute stroke from acute/subacute Perth metropolitan hospitals (n = 20). Participants were allocated by computer-generated block randomisation method to either the CIAT (n = 12) or individual, impairment-based intervention group (n = 8) delivered at the same intensity (45–60 min, 5 days a week) for 20 sessions over 5 weeks (15–20 hours total). The primary outcome, measured after completing the intervention, was the Aphasia Quotient (AQ) from the Western Aphasia Battery. Secondary outcomes were the AQ at 12 and 26 weeks post stroke, a Discourse Analysis (DA) score and the Stroke and Aphasia Quality of Life Scale (SAQoL), measured at therapy completion, 12 and 26 weeks post stroke. There was a 10% (n = 2) dropout at the primary end point, both participants were in the CIAT group. The estimates for each treatment group were compared using repeated measures ANOVAs. Data from the 26-week follow-up assessment are presented, however, were not included in the between-group comparisons due to the low number of data points in each group. Outcomes & Results: Within groups analyses comparing performance at baseline, therapy completion, and 12 weeks post stroke revealed a statistically significant treatment effect for the AQ (p < .001), DA (p = .002), and SAQoL (p < .001). Between groups analysis found there was no significant difference between the CIAT and individual therapy groups on any outcome measure. Conclusions: CIAT and individual therapy produced comparable amounts of change in the very early phase of recovery suggesting a standard, intensive daily dose of therapy within this period of recovery is feasible and beneficial. There were no significant differences between the two groups demonstrating that CIAT, which is provided in a group format, may be a viable option in the very early phase of aphasia recovery. The study highlights the need for further research into the impact of therapy type in very early aphasia therapy.

Community-based early intervention for language delay: a preliminary investigation

BACKGROUND A trial parent-focused early intervention (PFEI) programme for children with delayed language development is reported in which current research evidence was translated and applied within the constraints of available of clinical resources. The programme, based at a primary school, was run by a speech-language pathologist with speech-language pathology students. AIM To investigate the changes in child language development and parent and child interactions following attendance at the PFEI. METHODS & PROCEDURES Eighteen parents and their children attended six, weekly group sessions in which parents were provided with strategies to maximize language learning in everyday contexts. Pre- and post-programme assessments of vocabulary size and measures of parent-child interaction were collected. OUTCOME & RESULTS Parents and children significantly increased their communicative interactions from pre- to post-treatment. Childrens expressive vocabulary size and language skills increased significantly. Large-effect sizes were observed. CONCLUSIONS & IMPLICATIONS The positive outcomes of the intervention programme contribute to the evidence base of intervention strategies and forms of service delivery for children at risk of language delay.

A randomized controlled trial of very early rehabilitation in speech after stroke

Rationale The efficacy of rehabilitation therapy for aphasia caused by stroke is uncertain. Aims and hypothesis The Very Early Rehabilitation of Speech (VERSE) trial aims to determine if intensive prescribed aphasia therapy (VERSE) is more effective and cost saving than non-prescribed, intensive (usual care-plus) and non-intensive usual care (UC) therapy when started within 15 days of stroke onset and continued daily over four weeks. We hypothesize that aphasia therapy when started very early after stroke and delivered daily could enhance recovery of communication compared with UC. Sample size estimates A total of 246 participants (82 per arm) will provide 80% power to detect a 4.4% improvement on aphasia quotient between VERSE and UC plus at a significance level of α = 0.05. Setting Acute-care hospitals and accompanying rehabilitation services throughout Australia, 2014–2017. Design Three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment (PROBE) trial. Participants Acute stroke in previous 14 days and aphasia diagnosed by aphasia quotient (AQ) of the Western Aphasia Battery (WAB). Randomization Computer-generated blocked randomization procedure stratified by aphasia severity according to Western Aphasia Battery, to one of three arms. Intervention All participants receive UC—usual ward-based aphasia therapy. Arm 1: UC—no additional therapy; Arm 2: UC-plus usual ward-based therapy; Arm 3: VERSE therapy—a prescribed and structured aphasia therapy program. Arms 2 and 3 receive a total of 20 additional sessions (45–60 min, provided daily) of aphasia therapy. The additional intervention must be provided before day 50 post stroke. Study outcome measures The aphasia quotient of Western Aphasia Battery at 12 weeks post stroke. Secondary outcomes include discourse measures, the Stroke and Aphasia Quality of Life Scale-39 and the Aphasia Depression Rating Scale at 12 and 26 weeks. Economic evaluation Incremental cost-effectiveness ratios at 26 weeks will be reported. Discussion This trial is designed to test whether the intensive and prescribed VERSE intervention is effective in promoting maximum recovery and preventing costly health complications in a vulnerable population of survivors of stroke. It will also provide novel, prospective, aphasia specific cost-effectiveness data to guide future policy development for this population.

Development of the Aboriginal Communication Assessment After Brain Injury (ACAABI): A screening tool for identifying acquired communication disorders in Aboriginal Australians

Abstract Purpose: Acquired communication disorders (ACD), following stroke and traumatic brain injury, may not be correctly identified in Aboriginal Australians due to a lack of linguistically and culturally appropriate assessment tools. Within this paper we explore key issues that were considered in the development of the Aboriginal Communication Assessment After Brain Injury (ACAABI) – a screening tool designed to assess the presence of ACD in Aboriginal populations. Method: A literature review and consultation with key stakeholders were undertaken to explore directions needed to develop a new tool, based on existing tools and recommendations for future developments. Result: The literature searches revealed no existing screening tool for ACD in these populations, but identified tools in the areas of cognition and social-emotional wellbeing. Articles retrieved described details of the content and style of these tools, with recommendations for the development and administration of a new tool. The findings from the interview and focus group views were consistent with the approach recommended in the literature. Conclusions: There is a need for a screening tool for ACD to be developed but any tool must be informed by knowledge of Aboriginal language, culture and community input in order to be acceptable and valid.