Pam Enderby

Aphasia after stroke: natural history and associated deficits.

Data relating to 976 patients registered as suffering an acute stroke has been analysed to determine the natural history of speech disturbance: these patients came from a community survey of 215,000 people over a 28 month period. Of the 545 patients assessed within 7 days of stroke, 24% were aphasic and 28% unassessable. At 3 weeks, when over 90% of survivors were tested, 20% of those tested had aphasia. At 6 months only 12% of survivors had significant aphasia, but 44% of patients and 57% of carers thought speech was abnormal. Of those aphasic within 7 days, 40% remained so at 6 months; 60% of those aphasic at 3 weeks remained so. There was a high correlation between early and late aphasia scores. Aphasia was associated with more severe disability (degree of limb weakness, loss of function, loss of IQ), and with a less good recovery of social activities, but did not cause any measurable increase in stress upon carers. In a Health District of 250,000 people, about 60 patients each year may be referred for speech therapy after an acute stroke.

The Frenchay Aphasia Screening Test: a short, simple test for aphasia appropriate for non-specialists.

This paper describes preliminary studies on a screening test for aphasia which takes 3-10 minutes to complete and which is suitable for use by general practitioners, junior medical staff and other non-specialists. Data are presented to show that it is a reliable, valid assessment. Using cut-off values derived from normal people, the test is sensitive, but its specificity is limited by such associated factors as hemianopia. Using cut-off values derived from patients known to have aphasia, its specificity is improved. An abnormal result needs to be interpreted in the light of all available clinical information. The test should help identify patients with linguistic disturbance.

Towards a More Inclusive Vision of Dementia Care Practice and Research

Drawing on recent literature this article explores the development of research with family carers and people with dementia and identifies a number of themes that have emerged over time. It raises fundamental questions about the nature and purpose of research and the balance of power between researchers, family carers and people with dementia. Existing notions of expertise and knowledge are called into question and the article concludes with a call for a more empowering and inclusive model of research and practice based upon a relationship-centred approach to care.

Treatment of acquired aphasia: speech therapists and volunteers compared.

This paper reports on a multicentre trial comparing the effects of speech therapists and untrained volunteers on recovery from aphasia following stroke. One hundred and fifty-five patients entered the study and 96 completed it. Patients in both treatment groups improved, and there were no differences overall in the amount of progress made. A small subgroup of patients who started treatment much later had equivalent initial scores and made almost as much progress as those who started earlier. It is suggested that the improvement in communication which occurred during treatment may be due both to the appropriate stimulation which was based on detailed and accurate speech therapy assessment, and to the regular support and encouragement provided within the therapeutic relationship.

Ten principles of good interdisciplinary team work.

BackgroundInterdisciplinary team work is increasingly prevalent, supported by policies and practices that bring care closer to the patient and challenge traditional professional boundaries. To date, there has been a great deal of emphasis on the processes of team work, and in some cases, outcomes.MethodThis study draws on two sources of knowledge to identify the attributes of a good interdisciplinary team; a published systematic review of the literature on interdisciplinary team work, and the perceptions of over 253 staff from 11 community rehabilitation and intermediate care teams in the UK. These data sources were merged using qualitative content analysis to arrive at a framework that identifies characteristics and proposes ten competencies that support effective interdisciplinary team work.ResultsTen characteristics underpinning effective interdisciplinary team work were identified: positive leadership and management attributes; communication strategies and structures; personal rewards, training and development; appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that support interdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles.ConclusionsWe propose competency statements that an effective interdisciplinary team functioning at a high level should demonstrate.

Randomised controlled trial of community based speech and language therapy in preschool children

Abstract Objective: To compare routine speech and language therapy in preschool children with delayed speech and language against 12 months of “watchful waiting.” Design: Pragmatic randomised controlled trial. Setting: 16 community clinics in Bristol. Participants: 159 preschool children with appreciable speech or language difficulties who fulfilled criteria for admission to speech and language therapy. Main outcome measures: Four quantitative measures of speech and language, assessed at 6 and 12 months; a binary variable indicating improvement, by 12 months, on the trial entry criterion. Results: Improvement in auditory comprehension was significant in favour of therapy (adjusted difference in means 4.1, 95% confidence interval 0.5 to 7.6; P=0.025). No significant differences were observed for expressive language (1.4, −2.1 to 4.8; P=0.44); phonology error rate (−4.4, −12.0 to 3.3; P=0.26); language development (0.1, −0.4 to 0.6; P=0.73); or improvement on entry criterion (odds ratio 1.3, 0.67 to 2.4; P=0.46). At the end of the trial, 70% of all children still had substantial speech and language deficits. Conclusions: This study provides little evidence for the effectiveness of speech and language therapy compared with watchful waiting over 12 months. Providers of speech and language therapy should reconsider the appropriateness, timing, nature, and intensity of such therapy in preschool children. Continued research into more specific provision to subgroups of children is also needed to identify better treatment methods. The lack of resolution of difficulties for most of the children suggests that further research is needed to identify effective ways of helping this population of children.

Speech and language handicap: Towards knowing the size of the problem

Planning speech therapy services is difficult as the size of the speech and language handicapped population is not known. A literature review has been undertaken to determine the likely incidence and prevalence of persons in the UK with speech and language disorders associated with underlying disease. The findings suggest that previous reports have underestimated the number of persons in the United Kingdom who are likely to have speech or language handicaps and that there are further information needs.

Stammering and therapy views of people who stammer.

UNLABELLED This study used a postal questionnaire to seek the views of adults who stammer concerning the effect of stammering on their lives, the speech and language therapy and other remedies they have tried, and their hopes for speech and language therapy in the future. The 332 returned questionnaires indicated that stammering had the greatest adverse effect on school life and occupation. Speech and language therapy had been helpful to many, but the nature of the benefits and specific therapies used were not cited in many responses. An emergent theme in unhelpful therapy was the dissatisfaction that arises when individual needs are not met. In the future, people want help in controlling stammering and in developing coping strategies. The desire for timely and effective therapy for children, ongoing help and for group or intensive work has implications for service organization and therapists skills. The survey highlights the need for therapists and clients to negotiate therapy aims and procedures that are clearly defined, appropriate to individual needs, achievable, and, if possible, recorded and measured. EDUCATIONAL OBJECTIVES The reader will learn about and be able to list (1) the areas most and least affected by stammering, (2) the therapy approaches respondents had found helpful, and (3) other remedies that tried to help stammering.

Barriers and facilitators to the use of high-technology augmentative and alternative communication devices: a systematic review and qualitative synthesis

BACKGROUND There has been a rapid growth in recent years of available technologies for individuals with communication difficulties. Research in the area is currently underdeveloped with practitioners having a limited body of work on which to draw to guide the process of intervention. Concerns have been raised that this newly developed technology may have limited functional usage. AIMS This review aims to investigate the potential barriers and facilitators to high-technology AAC provision and its ongoing use. The aim of the analysis is to explore factors underpinning use rather than effectiveness, thus it synthesized data from predominantly qualitative and survey studies reporting the views and perceptions of AAC users or staff providing the devices. MAIN CONTRIBUTION The review highlights the range of factors that can impact on provision and use of high-technology AAC, which practitioners should consider and address as appropriate in the intervention process. These include: ease of use of the device; reliability; availability of technical support; voice/language of the device; decision-making process; time taken to generate a message; family perceptions and support; communication partner responses; service provision; and knowledge and skills of staff. The work outlines how qualitative synthesis review methods may be applied to the consideration of published material that is not reporting outcomes data, and how this may provide valuable information to inform future studies. CONCLUSIONS Practitioners should be aware of barriers and facilitators to successful use when making recommendations, and consider how barriers where present might be overcome. Aspects of service delivery such as ongoing technical support and staff training may require further consideration. The synthesis of evidence describing views of users and providers, and the implementation of high-technology AAC systems, can provide valuable data to inform intervention studies and functional outcome measures.

Communication disorders: Planning a service to meet the needs

This paper reviews the size of the speech and language-disabled population in the United Kingdom by client groups and attempts to determine (1) those for whom speech therapy might be appropriate, (2) what pattern and level of speech therapy is appropriate and (3) how many speech therapists are required to provide this pattern and level of speech therapy. It is concluded that under present patterns of speech therapy provision, approximately 26 qualified speech therapists may be required per 100,000 population. However, it is argued that speech therapy may be trying to do too much and may be venturing into areas in which little, if anything, is known about its effectiveness. In conclusion, the paper argues that solutions to the current problems of speech therapy provision must come from the demand and the supply sides of the speech therapy service. The importance of treatment evaluation and further knowledge about patterns of spontaneous recovery are also discussed.