Simon Horton

Supporting communication for people with aphasia in stroke rehabilitation: transfer of training in a multidisciplinary stroke team

Background: Participation of people with aphasia in clinical care and rehabilitation is an area of increasing research interest. Supported communication (SC) training, which aims to enhance the participation of aphasic patients, has been shown to improve conversation partner knowledge and skills. However, there is a lack of evidence for transfer of SC training to practice in post-acute rehabilitation settings. Aims: We aim to develop an understanding of causal mechanisms implicated in the transfer of SC training by examining the nature of the setting, staff perspectives, and the situated character of the action. Methods and Procedures: Twenty-eight staff from a multidisciplinary team were trained in SC. We collected detailed and varied data, including staff experiences of SC training and implementation, and video data of routine practice. Using a critical realist approach, we develop explanatory mechanisms for barriers to and enablers of transfer. Eleven team members (nursing, therapy, and assistant staff) took part in focus groups and interviews at the end of the study; 54 learning logs were collected over a 10-month period. Six aphasic patients and eight staff took part in video-recordings of therapy and care sessions. Outcomes & Results: Three main themes derived from staff experience data are linked to key components of the setting, indicating processes implicated in transfer of training, and impacting on outcomes such as perceptions of quality and staff confidence. Barriers, constraints, and problem-solving approaches in enacting SC were evidenced through patient factors, spaces and events, and time constraints. Staff flexibility and team working were key factors in problem-solving these obstacles. Staff reported responsive use of skills and resources and perceived impact of SC training, with most, but not all, staff reporting benefits, including increased confidence in interactions with aphasic patients. Activity analysis of video data illustrates how some mechanisms may be operating in practice, with evidence of rich use of interactional strategies and resources; a focus by staff on getting the work done; opportunities for patient active participation or emotional support that are realised or not; strategies for aphasia-related trouble and repair sequences. Conclusions: This model of SC training has clear benefits for staff communication practices and confidence, but transfer of training is subject to complex processes. Training should therefore address systems-level practices and be extended for staff who need more advanced skills. The values implicit in SC have the potential to create a culture of access and inclusion, encouraging and supporting active participation of all stroke patients.

Engagement and learning: an exploratory study of situated practice in multi-disciplinary stroke rehabilitation

Purpose. Active participation is considered to be a key factor in stroke rehabilitation. Patient engagement in learning is an important part of this process. This study sets out to explore how active participation and engagement are ‘produced’ in the course of day-to-day multi-disciplinary stroke rehabilitation. Method. Ethnographic observation, analytic concepts drawn from discourse analysis (DA) and the perspective and methods of conversation analysis (CA) were applied to videotaped data from three sessions of rehabilitation therapy each for two patients with communication impairments (dysarthria, aphasia). Findings. Engagement was facilitated (and hindered) through the interactional work of patients and healthcare professionals. An institutional ethos of ‘right practice’ was evidenced in the working practices of therapists and aligned with or resisted by patients; therapeutic activity type (impairment, activity or functional focus) impacted on the ways in which patient engagement was developed and sustained. Conclusions. This exploration of multi-disciplinary rehabilitation practice adds a new dimension to our understanding of the barriers and facilitators to patient engagement in the learning process and provides scope for further research. Harmonising the rehabilitation process across disciplines through more focused attention to ways in which patient participation is enhanced may help improve the consistency and quality of patient engagement.

“Border crossing” as a route to inclusion: A shared cause with people with a learning disability?

Background: A raft of legislation and social policy has been published in the United Kingdom to progress social inclusion for people with disabilities. Access and participation are central to the notion of inclusive living, which is about being part of a community that is sensitive to the ways of living and the needs of all its members. However, having a disability means that opportunities are not dealt out in equal measure and occupying a “place in society” is rarely an assured thing. The opposite of inclusion is exclusion. This implies barriers to and remoteness from mainstream activity, where fewer opportunities may be available for self‐expression and to influence the actions of others (Scott & Larcher, 2002). Aims: This paper seeks to broaden the debate on inclusion for people with aphasia by drawing on the documented experiences of people with learning disabilities, the development of practice initiatives, and visions for the future. The extent to which the narratives of people with aphasia find resonance in the life course of people with a learning disability gives rise to a simple question: “Is inclusion a shared cause?” Main Contribution: Addressing diverse client groups, such as people with aphasia and people with a learning disability, draws out the common experience, despite their separate traditions of service provision. Living with a disabling condition, whether physical, communicative, or intellectual, whether developmental or acquired in type, means that the usual determinants of social inclusion often appear elusive. Review of UK government policy and assessment of its impact on the two communities (people with aphasia and people with a learning disability) reveals the limitations of a single‐track approach. The need for collaborative action involving multiple agencies at the mutually dependent levels of self, community, and society becomes clear. Synthesis of the literature and practice development initiatives from the two clinical groups serves to strengthen the ongoing debate. The right to be included is shared by all human beings regardless of individual characteristics. It is about having the opportunities to perform roles that are personally meaningful, to develop relationships, to engage in self‐determination, and to have presence in the places that other people occupy. Conclusion: No matter the primary cause of the disability, marginalisation is frequently a feature of the lived experience. For people with aphasia, it is the impact of having a communication difficulty on quality of life that leads to disruptions to sense of self, autonomy and choice, social life and community participation (Cruice, Worrall, Hickson, & Murison, 2003). For people with learning disabilities, it is the incremental disempowerment with regard to the uptake of societal roles as maturation takes place (Barnes, 1997). The concept of “border crossing” is pertinent to the cause of both groups. It captures the many different ways in which individuals break out of the traditional roles cast for people with disabilities, and engage in self‐advocacy. For individuals who grow up with a learning disability “border crossing” is affected by the surrounding social support infrastructure offered by statutory services, which is informed by targeted government policy. For people with acquired language impairment, the terrain is less clear. After the initial medical crisis has passed, it is the individuals personal context (characterised by the roles and responses of marital partner, family members, work colleagues, etc.) rather than statutory service provision, that affects the degree to which individuals are able to resume former life courses.

Methodological issues in the design and evaluation of supported communication for aphasia training: a cluster-controlled feasibility study

Objective To assess the feasibility and acceptability of training stroke service staff to provide supported communication for people with moderate–severe aphasia in the acute phase; assess the suitability of outcome measures; collect data to inform sample size and Health Economic evaluation in a definitive trial. Design Phase II cluster-controlled, observer-blinded feasibility study. Settings In-patient stroke rehabilitation units in the UK matched for bed numbers and staffing were assigned to control and intervention conditions. Participants 70 stroke rehabilitation staff from all professional groups, excluding doctors, were recruited. 20 patients with moderate-severe aphasia were recruited. Intervention Supported communication for aphasia training, adapted to the stroke unit context versus usual care. Training was supplemented by a staff learning log, refresher sessions and provision of communication resources. Main outcome measures Feasibility of recruitment and acceptability of the intervention and of measures required to assess outcomes and Health Economic evaluation in a definitive trial. Staff outcomes: Measure of Support in Conversation; patient outcomes: Stroke and Aphasia Quality of Life Scale; Communicative Access Measure for Stroke; Therapy Outcome Measures for aphasia; EQ-5D-3L was used to assess health outcomes. Results Feasibility of staff recruitment was demonstrated. Training in the intervention was carried out with 28 staff and was found to be acceptable in qualitative reports. 20 patients consented to take part, 6 withdrew. 18 underwent all measures at baseline; 16 at discharge; and 14 at 6-month follow-up. Of 175 patients screened 71% were deemed to be ineligible, either lacking capacity or too unwell to participate. Poor completion rates impacted on assessment of patient outcomes. We were able to collect sufficient data at baseline, discharge and follow-up for economic evaluation. Conclusions The feasibility study informed components of the intervention and implementation in day-to-day practice. Modifications to the design are needed before a definitive cluster-randomised trial can be undertaken. Trial registration number ISRCTN37002304; Results.

Assessing and comparing the outcome measures for the rehabilitation of adults with communication disorders in randomised controlled trials: an International Classification of Functioning, Disability and Health approach

Purpose. To identify the assessment instruments and relevant outcome measures used in randomised clinical trials (RCTs) relating to interventions for adults with communication disorders, and then examine and compare the domains of the outcome measures using the International Classification of Functioning, Disability and Health (ICF) as a reference tool. Method. Published RCTs with primary focus on the effectiveness of rehabilitation for adults with communication disorders were systematically reviewed. Identified RCTs were examined for all the assessments used as outcome measures. Distinctions were made between the use of standardised assessment tools and non-standardised empirical measures. The key concepts examined by the outcome measures were then linked to the ICF using the established ICF linking rules. Results. The systematic review included 24 RCTs in which 11 trials used non-standardised empirical assessment as the outcome measure, and 18 trials included standardised instruments as the outcome measure. It is clear that all the identified items and meaningful concepts from the assessment used in the included studies can be linked to the ICF categories. Of the 108 linked level-two ICF categories, 53%% were linked to ‘body functions’, 36%% to ‘activity and participation’ and 9%% to ‘environmental factors’. Conclusions. A wide range of outcome measures have been used in RCTs of interventions for adults with communications disorders. The ICF provides a clarifying framework for systematically gathering and examining the information about the content of outcome measures and then can be used as a common reference to identify and compare the domains of the outcome measures. The high proportion of elements relating to body functions raises some questions about the purpose and aims of the interventions.

Is anyone speaking my language

This paper describes an on-going three-phase action research project undertaken by members of the Norwich Community Trust speech and language therapy adult services team. With the support of the Clinical Audit department the project was set up in order to: 1) investigate the characteristics, needs and aspirations of the population of dysphasic people in the community; 2) examine how dysphasic people and their families perceive the speech and language therapy service; 3) implement specific changes to the speech and language therapy service to dysphasic people and their families. These changes are based on proposals developed through a working partnership between the speech and language therapy department and dysphasic people and their families.

Learning‐in‐interaction: Resourceful work by people with aphasia and therapists in the course of language impairment therapy

Background: “Learning” in aphasia language therapy has been studied in various ways. Empirical approaches to learning potential have been proposed, and attempts have been made to apply a range of concepts from learning theory. “Error” has been an important consideration and has received much recent attention through the application of “errorless learning” approaches. Errorless learning has been conceptualised in terms of error‐elimination and error‐reduction methods, with and without feedback. Authors have addressed questions of how “easy” and “difficult” may be embodied within the learning context. Key principles from adult learning models have also been espoused as relevant to aphasia language t`herapy. Therapist–client interactions in aphasia language therapy embody a range of features that are implicated in the learning process. The author would like to acknowledge the contributions of all participants—people with aphasia and therapists alike—who generously permitted collection and analysis of their therapy data. Great thanks are due to three reviewers of very early versions of this paper, and to two further reviewers of a more recent version for their very helpful comments. Many thanks to Paul Conroy for illuminating conversations about errorless learning. Aims: This study seeks to explore how detailed examination of situated and contextualised interactions can further our understanding of learning. It addresses three main themes—“error and effort”, “feedback”, and “mutuality and partnership”—entailed in the learning process. Methods & Procedures: A qualitative study of therapy in day‐to‐day practice was carried out, applying Hortons (2006) therapy process framework to audio/video data, focusing specifically on “doing therapy tasks”. Extracts from 15 sessions involving 10 therapist–client dyads were purposively selected. Analysis examines interactional aspects of “Task Introductions”, “Summary”, and “Task/response management” as relevant to the three learning themes. Outcomes & Results: Key features of learning‐in‐interaction as a socially situated phenomenon emerge: “effort and error” is realised in therapist explanations, contingent enactment of accuracy/acceptability of responses, and mediated through the relative complexity of stimulus items; “feedback” functions flexibly, is calibrated responsively, and interfaces with and contributes to the ways in which “effort” is constructed in interaction; “mutuality and partnership” operates at levels that may be (quasi)conscious—through therapist/client control, or collaborative decision making for example—or unconscious, through clients asserting their processing needs or displaying their own standards. Conclusions: Concepts associated with “learning” have been explored in interaction. Close scrutiny of therapy process has revealed subtle but powerful resources brought to bear by people with aphasia. Acknowledging these contributions and incorporating them into language therapy will help to develop a more comprehensive epistemology of therapy, and ensure that people with aphasia are active participants. Future research into error elimination/reduction approaches may benefit from these findings. Translational research may benefit from the insights of this study, enabling clinicians to apply novel therapies in day‐to‐day practice.

Evaluation and discharge criteria in therapy with adults who stutter: A survey of speech and language therapists

Professional guidelines recommend that the psycho-social implications of living with a stutter should be assessed, and that therapy should target the emotional and cognitive aspects of living with a stutter (Taylor-Goh, ). Very little evidence exists about how speech and language therapists (SLTs) evaluate success of therapy or determine discharge criteria. The aim of the research reported here, which was part of a larger study of current SLT practice among clinicians working with adults who stutter, was to discover how SLTs (1) evaluate success in therapy and (2) determine whether to discharge a client who stutters. A postal self-administered questionnaire was distributed to SLTs (n = 342) who work in Britain with adults who stutter. A response rate of 77.5% was achieved. Content analysis was used to analyse open ended questions about evaluation and discharge criteria. Many therapists adopt practice in line with recommendations from the literature, but some SLTs do not report that they use outcome measures to evaluate their practice, or suggest that they sometimes adopt inappropriate discharge criteria. Other SLTs use novel methods to assist with evaluation.

Roles of cognitive status and intelligibility in everyday communication in people with Parkinson’s disease : A systematic review

BACKGROUND Communication is fundamental to human interaction and the development and maintenance of human relationships and is frequently affected in Parkinsons disease (PD). However, research and clinical practice have both tended to focus on impairment rather than participation aspects of communicative deficit in PD. In contrast, people with PD have reported that it is these participation aspects of communication that are of greatest concern to them rather than physical speech impairment. OBJECTIVE To systematically review the existing body of evidence regarding the association between cognitive status and/or intelligibility and everyday communication in PD. METHODS Five online databases were systematically searched in May 2015 (Medline Ovid, EMBASE, AMED, PsycINFO and CINAHL) and supplementary searches were also conducted. Two reviewers independently evaluated retrieved records for inclusion and then performed data extraction and quality assessment using standardised forms. Articles were eligible for inclusion if they were English-language original peer-reviewed research articles, book chapters or doctoral theses investigating the associations between at least one of cognitive status and level of intelligibility impairment and an everyday communication outcome in human participants with PD. RESULTS 4816 unique records were identified through database searches with 16 additional records identified through supplementary searches. 41 articles were suitable for full-text screening and 15 articles (12 studies) met the eligibility criteria. 10 studies assessed the role of cognitive status and 9 found that participants with greater cognitive impairment had greater everyday communication difficulties. 4 studies assessed the role of intelligibility and all found that participants with greater intelligibility impairment had greater everyday communication difficulties, although effects were often weak and not consistent. CONCLUSIONS Both cognitive status and intelligibility may be associated with everyday communicative outcomes in PD. The contribution of intelligibility to everyday communication appears to be of small magnitude, suggesting that other factors beyond predominantly motor-driven impairment-level changes in intelligibility may play an important role in everyday communication difficulties in PD.

Reporting interventions in communication partner training: a critical review and narrative synthesis of the literature

ABSTRACT Background: Communication partner training (CPT) is an umbrella term for a complex behavioural intervention for communications partners (CPs) of people with aphasia (PWA) and possibly PWA themselves, with many interacting components, deployed in flexible ways. Recent systematic reviews (Simmons-Mackie, Raymer, Armstrong, Holland, & Cherney, 2010; Simmons-Mackie, Raymer, & Cherney, 2016) have highlighted the effectiveness of CPT in addressing the skills of conversation partners and the communicative participation of people with aphasia but have suggested that CPT has been variably delivered, with no clear picture of what the essential elements of CPT are and how CPT is expected to achieve its results through hypothesised mechanisms of change (Coster, 2013). Aim: This paper aims broadly to consider specification of CPT and describes how CPT has been conducted overall and in relation to treatment recipients. Recommendations for CPT and areas for future research are considered. Methods & Procedures: A critical review and narrative synthesis was carried out through: (i) the systematic application of the 12-item TIDieR checklist (Hoffmann et al., 2014) to the 56 studies appraised in the Simmons-Mackie et al. (2010, 2016)) reviews, providing a quantitative overview of the completeness of CPT intervention reporting; and (ii) a qualitative synthesis of the reviewed CPT literature according to TIDieR items. Outcomes & Results: Half of the TIDieR checklist items were reported by 71% or more of the studies, and the rest of the items were reported by 0–63% of studies. TIDieR items relating to the treatment (goal, rationale or theory of essential elements, materials and procedures) and provision (provider, mode, timing, dose) were more frequently reported; however, the level of detail provided was often inadequate or incomplete. The interventions were insufficiently specified to enable replication for most of the studies considered. The most infrequently reported items were: name, location, intervention tailoring and modification, and planned and actual intervention adherence/fidelity. Conclusion: For a better understanding of an intervention, it is necessary to identify and describe potentially central elements and perhaps especially in complex interventions as CPT, where it is likely also more difficult. Whilst the reviewed CPT studies are on average reporting on slightly more than half of the TIDieR items, they are overall insufficiently detailed. Some items appear easier to report on, whereas other items have not been attended to, are too complex in nature to give a full report on, or simply have not been relevant for the individual study to include