The perspectives of adults with aphasia and their team members regarding the importance of nine life areas for rehabilitation: a pilot investigation

Objectives: Client-centred rehabilitation implies that persons with aphasia and their significant others are actively involved in all decisions regarding rehabilitation, including the setting of rehabilitation priorities and goals. This study aimed to describe and compare the perspectives of adults with aphasia, their significant others and their speech-language pathologists (SLPs) regarding the importance of nine life areas for the rehabilitation of adults with aphasia.

Method: A total of 15 adults with expressive aphasia rated the importance of nine life areas using the Talking Mats? framework. A questionnaire was used to obtain the ratings of 15 of their significant others and the 15 SLPs treating them.

Results: Most life areas were rated as important to work on in rehabilitation by most participants. The adults with aphasia rated the areas as important more frequently than their significant others and SLPs. All participants rated Communication as important. Statistically significant differences were noted for three of the nine life areas.

Discussion: The life areas which the participants were questioned about seem to provide a good starting point for rehabilitation teams to find common ground for collaborative goal setting. The Talking Mats? approach allowed adults with aphasia to participate in the process. It can be a useful tool to promote client-centred rehabilitation for adults with expressive communication difficulties.     

Management of communication disorders using family member input, group treatment, and telerehabilitation

Today, speech-language pathologists (SLPs) practice stroke rehabilitation in environments where they have less time to manage the communication impairments of patients who are more medically fragile than ever before. Many SLPs have creatively adapted their practice to maximize functional outcomes for their patients. This article highlights three techniques designed to enhance functional SLP outcomes: maximizing family member input; providing group treatment; and providing treatment in remote, functional settings via telepractice technology.     

Requirements for multidisciplinary teamwork in psychiatric rehabilitation

Psychiatric rehabilitation by its very nature is multidisciplinary because of the many competencies required for its implementation. In promoting optimal levels of recovery from schizophrenia and other disabling mental disorders, teams must combine the expert contributions of professionals and paraprofessionals who can individualize a comprehensive array of evidence-based services with competency, consistency, continuity, coordination, collaboration, and fidelity. The authors describe the properties and functions of the multidisciplinary team and key attributes of effective teams. The importance of teams' involving clients, their relatives, and other supporters in setting personally relevant life goals is emphasized. The authors provide examples of the challenges posed by the need to individualize services and of the ways in which barriers to communication and coordination can be overcome. The roles of the various team members are described, including leadership roles and the unique role of the psychiatrist, in the context of newly emerging, evidence-based treatments for psychiatric rehabilitation.     

“I definitely think it’s a feasible and worthwhile option”: perspectives of speech-language pathologists providing online aphasia group therapy

Background: Speech-language pathologists (SLPs) have begun to incorporate telepractice methods into clinical service delivery and online intervention for aphasia is recognised as an appropriate alternative to face-to-face services. However, little is known about the SLP experience of telepractice with no known study exploring the provision of aphasia group therapy online. The purpose of this study was to describe the experience of SLPs who provided the online aphasia group therapy, Telerehabilitation Group Aphasia Intervention and Networking (TeleGAIN), to people with aphasia (PWA) and their perceptions regarding the outcomes of intervention and feasibility of implementation into clinical practice.

Aims: The aim of this study was to describe the experience of SLPs who provide TeleGAIN to people with aphasia including the perceived outcomes of the intervention and treatment procedures.

Methods & Procedures: Three SLPs with experience in aphasia rehabilitation delivered at least one 12 week block of TeleGAIN – an aphasia group intervention purposefully developed for delivery via telepractice. Prior to TeleGAIN, SLPs were trained in using the technology required and the goals, activities, and constructs of TeleGAIN. The goals of TeleGAIN for PWA were to 1) create opportunities for communicative success, 2) share personal life history, and 3) provide support for living successfully with aphasia through networking with others. The SLPs provided this intervention to 21 PWA across six groups. Following completion of all treatment blocks, each SLP participated in a semi-structured interview exploring their perceptions of TeleGAIN and the potential for implementation. Interviews were analysed using qualitative content analysis and key categories were identified.

Outcomes & Results: SLPs enjoyed providing the online aphasia group therapy TeleGAIN, and considered the intervention to be feasible and worthwhile. SLPs developed a range of strategies to manage the barriers to implementing the online group successfully and promoted those factors that facilitated more efficient and effective group sessions. In addition, benefits for individuals with aphasia, SLPs and SLP services were recognised despite challenges with technology and group dynamics experienced during TeleGAIN.

Conclusions: The results from this study suggested that although SLPs may take time to improve their skills and confidence in telepractice, they were successfully able to provide online group aphasia therapy to PWA. The experience of the SLPs in this study suggested that commonly cited barriers to telepractice such as rapport building and technology issues were able to be overcome. SLPs perceived that TeleGAIN offered PWA many communication and psychosocial benefits and may improve SLP service provision. Findings support investigation of the implementation of TeleGAIN into clinical services.     

A comparison of client and therapist goals for people with aphasia: A qualitative exploratory study

Background: A considerable body of literature attests to the efficacy of client and therapist collaborative goal setting to achieving optimal rehabilitation outcomes. Collaborative goal setting and shared decision making relies on good communication, thus potentially disadvantaging people with aphasia.

Aims: This study aims to identify the similarities and differences between client goals and therapist goals in rehabilitation for people with aphasia and to explore reasons why any differences occur.

Methods & Procedures: Three speech-language pathologists and four people with aphasia participated in in-depth semi-structured interviews to identify rehabilitation goals. All the interviews were transcribed and analysed using qualitative content analysis.

Outcomes & Results: Results indicated both matching and mismatching of goals between the clients and the speech-language pathologists. Matched goals tended to focus on communication outcomes. Mismatched goals were those associated with the client's desire to return to previously valued activities. Reasons for the mismatching included: impaired communication made collaboration on goal setting difficult, the service-delivery approach, the goal was perceived to be outside the speech-language pathologist's scope of practice, and the goal was not considered to be appropriate within the confines of the rehabilitative situation.

Conclusions: This study highlights the need for speech-language pathologists to understand their clients' goals and how these can be incorporated into rehabilitation. A re-examination of some professional beliefs was highlighted. Future research may lead to educational resources that enable better collaborative goal setting between therapist and client so that outcomes of rehabilitation are optimised.     

Speech-language pathologists’ practices regarding assessment,analysis, target selection,intervention, and service delivery for children with speech sound disorders

A survey of 231 Australian speech-language pathologists (SLPs) was undertaken to describe practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders (SSD). The participants typically worked in private practice, education, or community health settings and 67.6% had a waiting list for services. For each child, most of the SLPs spent 10–40 min in pre-assessment activities, 30–60 min undertaking face-to-face assessments, and 30–60 min completing paperwork after assessments. During an assessment SLPs typically conducted a parent interview, single-word speech sampling, collected a connected speech sample, and used informal tests. They also determined children’s stimulability and estimated intelligibility. With multilingual children, informal assessment procedures and English-only tests were commonly used and SLPs relied on family members or interpreters to assist. Common analysis techniques included determination of phonological processes, substitutions–omissions–distortions–additions (SODA), and phonetic inventory. Participants placed high priority on selecting target sounds that were stimulable, early developing, and in error across all word positions and 60.3% felt very confident or confident selecting an appropriate intervention approach. Eight intervention approaches were frequently used: auditory discrimination, minimal pairs, cued articulation, phonological awareness, traditional articulation therapy, auditory bombardment, Nuffield Centre Dyspraxia Programme, and core vocabulary. Children typically received individual therapy with an SLP in a clinic setting. Parents often observed and participated in sessions and SLPs typically included siblings and grandparents in intervention sessions. Parent training and home programs were more frequently used than the group therapy. Two-thirds kept up-to-date by reading journal articles monthly or every 6 months. There were many similarities with previously reported practices for children with SSD in the US, UK, and the Netherlands, with some (but not all) practices aligning with current research evidence.     

Caring for depressed and suicidal older patients: a survey of physicians and nurse practitioners

OBJECTIVE: This study sought to describe patterns of mental health care for depressed and suicidal geriatric patients by primary care physicians (MDs) and nurse practitioners (NPs). METHODS: A probability sample of 300 Illinois MDs from the AMA Physician Masterfile and a national sample of 595 NPs from the American Academy of Nurse Practitioners were surveyed. Sixty-three percent of MDs and 61 percent of NPs responded regarding their approaches to assessing, treating, and referring older adult patients who were depressed or suicidal. Respondents rated their confidence in assessing and treating depression and suicidality and identified barriers to mental health treatment in a primary care setting. RESULTS: Both similarities and differences were found among MDs and NPs in their patterns of managing depressed and suicidal older adults. NPs used more varied approaches in assessing, treating, and referring their geriatric patients with mental health problems. MDs relied more heavily on psychotropic medications for the treatment of depression and on psychiatrists when referring suicidal older patients. NPs were more likely than MDs to note lack of training and referral resources as barriers to treating depression of older patients. NPs rated their training in geriatric mental health more favorably than MDs. CONCLUSIONS: In terms of assessment of depression, preferred treatment approaches, the use of referral resources, and perceived barriers to mental health care, there appears to be a greater orientation towards a psychosocial approach among NPs. Primary care MDs and NPs often have different perspectives that in combination could enhance the mental health care of geriatric patients.     

The role of language familiarity in bilingual stuttering assessment

The aim of this study was to evaluate the ability of English-speaking speech-language pathologists (SLPs) to evaluate stuttering behaviour in two Spanish–English bilingual adults who stutter (AWS1 and AWS2). The English-speaking SLPs were asked to judge the frequency, severity, type, duration, and physical concomitants of stuttering in both languages of the two AWS. The combined results from the English-speaking SLPs were then compared to the judgements of three Spanish–English bilingual SLPs. Results indicated that English-speaking SLPs (1) judged stuttering frequency to be greater in Spanish than English for AWS1, and equal in Spanish and English for AWS2, (2) were more accurate at evaluating individual moments of stuttering for the English samples compared to the Spanish samples, (3) identified fewer and less severe stuttering behaviours than the bilingual SLPs in both languages, and (4) were accurate judges of overall stuttering severity in both languages. The results correspond to past research examining the accuracy of stuttering evaluations in unfamiliar languages. Possible explanations for the findings, clinical implications, and future research directions are discussed.     

Parental involvement in speech intervention: a national survey

A survey of 277 speech language pathologists (SLPs) investigated beliefs and practice regarding parents' involvement in service planning and delivery for children with speech impairment. Although the SLPs frequently involved parents in service delivery for speech intervention, parental involvement in service planning was less frequent. SLPs working in educational settings involved parents to a lesser extent than SLPs working in health settings and private practice. More experienced SLPs involved parents less in decision-making. A gap between the SLPs' beliefs and practice was found, with stated beliefs not always reflecting practice. 40% of respondents were unhappy with the level of parental involvement and perceived workplace, personal and parental barriers to working effectively with parents. Although the SLPs indicated that they believed in and used family-centered practices, beliefs and practice regarding parent decision-making were therapist- rather than family-centered.     

Psychiatric service utilization differences by sex and locale

Underutilization of psychiatric services by men relative to women may reflect discrepancies between the male sex role in Western societies and the patient role. We hypothesize that this will be more important in a rural than a nonrural setting for two reasons. First, the relative lack of anonymity in a rural setting makes more evident incongruities between sex role conventions and actual behaviour. Second, because of the increased cultural heterogeneity of urban areas, traditional sex roles are less clearly delineated. These considerations suggest that the ratio of males to females receiving treatment in a rural setting should be lower than in a nonrural setting. It was found that for treated incidence the ratio of males to females was significantly lower in a rural than in a non-rural setting (p less than .01); for treated prevalence a lower male to female ratio was found in the rural than the nonrural setting, although this did not achieve statistical significance.     

Results of in- vs outpatient post-stroke rehabilitation over 6 months

In a prospective longitudinal study, stroke patients with largely intact ADL-functions who were treated in a rehabilitation center were assessed at the beginning and end of rehabilitation treatment and 6 months afterwards. They were treated as outpatients, if they expressed a preference for this setting and if outpatient rehabilitation was logistically and geographically possible, otherwise as inpatients. We found medium- to large-size gains for physical and ADL function and associated quality-of-life dimensions (WHOQOL-BREF, SF-36). However, there were also losses in other aspects of quality of life, e. g. in the social domain. There were no differences with respect to type of setting. Patients' setting preferences influenced the development of perception of own health. There was only a small and insignificant influence of satisfaction with rehabilitation treatment. We propose an expansion of neurological outpatient rehabilitation services and a focus on factors outside the rehabilitation system that influence quality of life.     

The Integration of Treatment and Rehabilitation in Psychiatric Practice and Services: A Case Study of a Community Mental Health Center

After briefly reviewing the relationship of psychosocial rehabilitation to psychiatric practice, the authors recommend a renewed commitment of psychiatrists to bridge and integrate psychiatric treatment with psychosocial rehabilitation in practice and in the organization of services. They use the case example of an urban, community mental health center to illustrate a strategy for achieving greater integration of these two, relatively independent fields of professional practice. The Center's strategy for integration includes (1) center-wide planning, (2) structuring the medical staff office to support the task of integration, (3) establishing a model of practice and principles of care that supports both domains of intervention, (4) educating medical staff about psychosocial rehabilitation, (5) inter-disciplinary team building, including a definition and discussion of professional roles, (6) expanding services research on psychosocial rehabilitation, and (7) advocating in alliance with rehabilitation colleagues for expanded psychosocial rehabilitation services and their integration with treatment. By taking initiative to forward the integration of treatment and rehabilitation, psychiatrists better serve seriously ill patients and more effectively define their own work and roles.     

浅谈脑血管病融合病房的基本概念和建设框架

随着诊疗技术的发展,脑血管病的诊疗越来越多地需要其他相关学科的参与和合作,既往基于卒中单元为基础的合作模式需要更多的科室加入和更深入的合作方式。例如：缺血性卒中超急性期的再灌注治疗需要神经内科、神经外科、急诊科、神经重症监护科、神经介入科、放射科和康复科的配合;在卒中二级预防阶段,急性和亚急性期的卒中患者更强调营养支持和康复锻炼。融合性卒中单元作为卒中单元的升级模式,旨在促进神经病学、神经外科、康复部门的深入合作,以不同的合作模式,抓住分秒必争的契机,实施最佳临床实践,为患者争取更好的临床结果。探索脑血管病融合病房的初衷就是为了探索深入合作的融合病房模式,进一步加强再灌注治疗、二级预防、围手术期管理等卒中诊疗多环节的多科室协作,为构建适合不同医疗机构的卒中诊疗多科室联合模式提供参考。     

Clinician Perspectives of Inpatient Forensic Psychiatric Rehabilitation in a Low Secure Setting: A Qualitative Study

There is a dearth of research into what low secure forensic psychiatric rehabilitation means in Australia and internationally. The aim of this study was to understand clinician perspectives of forensic psychiatric rehabilitation in a low secure setting in Australia and offer insight into a model of care. A qualitative methodology was chosen with separate semi-structured interviews being conducted with staff members involved in decision-making for forensic psychiatric patients in a rehabilitation unit. Analysis of the interviews identified three domains that the questions related to: ‘defining and describing security’, ‘defining and describing low secure forensic psychiatric rehabilitation’ and ‘describing the role of staff and services in a low secure forensic psychiatric rehabilitation setting’. Where relevant, themes were abstracted from the questions that related to these domains. This study revealed that clinicians had a varied understanding of definitions for security but a similar understanding of what low secure forensic psychiatric rehabilitation means, what patients are suitable and the general goals of rehabilitation in this setting. Further research is needed on low secure rehabilitation and specific models of care. There is also a need to develop clear definitions for both security and rehabilitation in low secure forensic psychiatric settings.     

A pathway to personalization of integrated treatment: informatics and decision science in psychiatric rehabilitation

Personalization of treatment is a current strategic goal for improving health care. Integrated treatment approaches such as psychiatric rehabilitation benefit from personalization because they involve matching diverse arrays of treatment options to individually unique profiles of need. The need for personalization is evident in the heterogeneity of people with severe mental illness and in the findings of experimental psychopathology. One pathway to personalization lies in analysis of the judgments and decision making of human experts and other participants as they respond to complex circumstances in pursuit of treatment and rehabilitation goals. Such analysis is aided by computer simulation of human decision making, which in turn informs development of computerized clinical decision support systems. This inspires a research program involving concurrent development of databases, domain ontology, and problem-solving algorithms, toward the goal of personalizing psychiatric rehabilitation through human collaboration with intelligent cyber systems. The immediate hurdle is to demonstrate that clinical decisions beyond diagnosis really do affect outcome. This can be done by supporting the hypothesis that a human treatment team with access to a reasonably comprehensive clinical database that tracks patient status and treatment response over time achieves better outcome than a treatment team without such access, in a controlled experimental trial. Provided the hypothesis can be supported, the near future will see prototype systems that can construct an integrated assessment, formulation, and rehabilitation plan from clinical assessment data and contextual information. This will lead to advanced systems that collaborate with human decision makers to personalize psychiatric rehabilitation and optimize outcome.     

Work and mental illness. I. Toward an integration of the rehabilitation process

For centuries, philosophers and physicians have noted the beneficial impact of work for the restoration and maintenance of mental health. This paper reports the findings from a survey in which all the principal components (both providers and consumers in one catchment area) contributed data about the degree to which vocational rehabilitation was integrated into systems of care for the mentally ill. The major repetitive themes found at the interface of each participating sector were: rigidity, isolation, compensatory ad hoc operations, and narrow frames of reference. Vocational and other forms of rehabilitation were accomplished by persistent, energetic personnel inventing ingenious solutions to the roadblocks set up at system interfaces. Their problem-solving techniques pointed to ingredients that might help to integrate treatment and rehabilitation efforts. These key elements were flexibility, collaboration, data-based training, and a unified theoretical framework.     

Multiple sclerosis and rehabilitation: an overview of the different rehabilitation settings

To date, a lack of accurate information about how the different rehabilitation settings are actually delivered to people with multiple sclerosis (PwMS) is still present. Here, we described how PwMS use the different rehabilitation settings in Italy. An observational retrospective study was designed and data collected through an anonymous questionnaire distributed attending MS clinical centers, rehabilitation units, or among PwMS affiliated to the Italian MS Society. We considered as settings: out-patient ambulatory therapy (OUT), hospitalized therapy (HOSP, in-patient and out-patient hospitalized therapy), and home-based therapy (HOME). One thousand six hundred eighty-six subjects at all disability levels were included in the analysis. A high number (53%, n = 890) did not receive rehabilitation care in the last 3 months before the interview. Main causes were probably due to organizational aspects and poor transports and road networks especially in Center and the Islands. The rehabilitation setting profile of the 796 subjects obtaining rehabilitation care consisted in 58.3% (n = 464) receiving only OUT setting, 9.4% (n = 75) only HOSP setting, and 21.7% (n = 173) only HOME setting. We observed a percentage of overlap among different rehabilitation settings: 3.9% (n = 31) OUT-HOME, 3.6% (n = 29) OUT-HOSP, 2.6% (n = 21) HOSP-HOME, and 0.4% (n = 3) OUT-HOME-HOSP. The physiotherapy was the treatment more common among different rehabilitation settings. Only in the in-patient hospitalized therapy setting, the patient received more frequently diversified treatment. Considering the results, the admission to rehabilitation care in Italy is still far from the standards outlined by the recent guidelines that hypothesize a multidisciplinary evaluation and a more individualized rehabilitation plan.