Communication therapy for people with aphasia and their partners (APPUTE)

Background: Severe aphasia is a chronic condition and can have a big effect on how people with severe aphasia (PWSA) succeed in their communication. The communication partner’s support for the person with aphasia has been shown to be essential in achieving successful communication. However, interventions combining training both the partner and the PWSA to use hierarchical strategies in nonverbal communication are still needed.

Aims: The aim of the present paper is to describe a new intervention (APPUTE) where both the person with aphasia and the partner receive therapy equally and practise finding functional communication strategies to convey everyday messages or more complicated ones. The data collection during the APPUTE intervention is also presented.

Methods & Procedures: The data were collected during a development project including an evaluation period, two rehabilitation periods and follow-up measurement. Thirty-four PWSA and their partners participated. The linguistic functions and communication efficiency of PWSA were evaluated three times during the rehabilitation. The communication skills of the partner were also assessed, along with the success of the mutual communication.

Outcomes & Results: The communication skills and communication efficiency of the PWSA and their partners improved significantly during the rehabilitation period, and the acquired skills were retained for 6 months after the intervention. The linguistic skills of the PWSA also improved. The advanced age of the partner explained both the variance of the partner’s communication skills and the success in the mutual communication. The amount of earlier outpatient speech therapy explained the variance of the communication efficiency of PWSA as evaluated by the partners. Regarding success in mutual communication, all of the couples were able to communicate at least simple issues at the end of the rehabilitation period. The more demanding the tasks, the more difficult it became for them to succeed, especially for older PWSA with severe motor paralysis. Both the people with aphasia and their partners mainly experienced benefits from the APPUTE intervention and for the most part, the benefits were retained during follow-up.

Conclusions: The APPUTE method appears to improve the communication skills of PWSA and their partners, as well as the linguistic skills of PWSA.     

A pilot study examining the impact of aphasia camp participation on quality of life for people with aphasia

Objectives: For people with aphasia (PWA), attending an aphasia camp can result in increased confidence, social relationships, and greater participation in activities. Although much anecdotal evidence of the benefits of aphasia camps exists, systematic studies on outcomes from aphasia camp participation are lacking. The purpose of this pilot study was to examine the effect of attending the Alberta Aphasia Camp on quality of life for people with aphasia.

Methods: Nine PWA who attended the inaugural Alberta Aphasia Camp completed the Assessment for Living with Aphasia-2 before and after camp. A subset of their caregivers (n = 4) completed the Communicative Effectiveness Index, a rating scale evaluating their PWA’s communication, and were interviewed about their experiences and perceptions of camp participation.

Results: Significant changes were observed on total scores on the ALA-2, and in particular the Personal and Participation subtests. These improvements were corroborated by themes identified from interviews with caregivers.

Discussion: This study provides preliminary evidence that aphasia camp participation can result in improved outcomes for PWA across a range of domains. Aphasia camps provide a unique intervention for PWA and caregivers to experience therapeutic and recreational activities, respite and create social connections in a supported communication environment. Future studies should recruit a greater number of participants, employ control groups, and examine outcomes for caregivers.     

Reciprocal scaffolding treatment: A person with aphasia as clinical teacher

Background: Reciprocal Scaffolding Treatment (RST) is one of several potentially beneficial life participation approaches for aphasia. In RST, treatment occurs during genuine, relevant, and context dependent interactions that represent goals at the activity and participation levels of the World Health Organization International Classification of Functioning, Disability and Health (ICF; World Health Organization, 2001) and is based on an apprenticeship model of learning where novices are taught skills by a more skilled partner. RST was used to construct a communicatively challenging environment in which an expert with aphasia (AE) taught novices (graduate student clinicians) how to communicate with persons with aphasia in the context of conversation group treatment sessions. This is in contrast to many treatment techniques when the person with aphasia is the novice who is trying to relearn communication skills during treatment sessions with a speech‐language pathologist as the expert.

Aims: The goal of the study was to investigate the effect of RST on improvement in word retrieval and conversational components in an individual with anomic aphasia.

Methods & Procedures: This was a case study using pretreatment – post treatment assessment. The independent variable was application of RST and the contextual variables were the presence of novices (graduate student clinicians) and unfamiliar conversation partners (undergraduate speech‐language pathology students). The dependent variables were scores on a word fluency task (FAS) and conversational measures (CIUs and TTR). Over the course of a seven week training period, AE taught communication strategies to four novice graduate student clinicians, who used the strategies in conversation groups composed of 3 to 4 persons with aphasia.

Outcomes & Results: The individual with aphasia made positive changes in word fluency, Correct Information Units and Type‐Token Ratio.

Conclusions: These findings, while preliminary in nature, show how the authentic use of language in structured reciprocal interactions such as teaching may improve language. A reciprocal teaching environment carries with it the expectation that at least one participant have an intent to participate as an expert in order to convey information to novices. We speculate that the combination of reciprocal interaction and the intent to convey information, in this case in a unique manner, support improved language skills.     

Integrating technology and targeted treatment to improve narrative production in aphasia: A case study

Background: Studies of aphasic sentence production have identified a number of promising approaches to improving performance at the single sentence level, but these studies have typically failed to show measurable effects on multi‐sentence productions (spontaneous or narrative speech). The difficulty for aphasic speakers of producing connected speech during therapy is likely to contribute to this effect. Computer software that allows patients to record, replay, and concatenate partial utterances has shown promise in allowing narrative‐level practice during treatment of even severely non‐fluent patients.

Aims: This single‐case study continues research using SentenceShaper ^®, a computer program that supports speakers' productions while they are being formulated. The goal is to investigate the utility of a two‐step treatment that supplements improvements achieved from use of the software alone with explicit structural treatment (of multi‐clause sentences).

Methods & Procedures: We describe an aphasic speaker (CI) with severely non‐fluent, fragmented, and agrammatic speech who participated in two treatment phases. Initially, as in previous studies, CI practised producing narratives (based on wordless picture books or silent videos) while using SentenceShaper, with no explicit focus on specific syntactic elements. This phase produced marked structural improvement, so a second treatment, focused on the production of multi‐clause sentences, was designed to exploit his success using the system. Following a period of targeted treatment on such structures, CI practiced producing narratives that incorporated these structures with the help of SentenceShaper. Structural analyses based on the Quantitative Production Analysis system compared Baseline and Post‐treatment 1 performance, and then compared improvements Post‐treatment 1 with those shown after treatment 2.

Outcomes & Results: Structural measures (including mean sentence length, proportion of words in sentences and sentence well‐formedness) improved significantly from Baseline following Treatment 1, and improved significantly again following Treatment 2, such that sentence length and well‐formedness moved into the normal range.

Conclusions: Results indicate that this combined approach may be helpful in improving the connected speech of even chronic and severely non‐fluent speakers. The characteristics of this aphasic speaker that might have contributed to this outcome, and the limitations of this study, are considered.     

Social validation as a measure of improvement after aphasia treatment: Its usefulness and influencing factors

Background: Standardised language tests are the most commonly used assessment tool of aphasia by Speech-Language Pathologists (Katz et al., 2000 Katz, R. C., Hallowell, B., Code, C., Armstrong, E., Roberts, P.Pound, C. 2000. A multinational comparison of aphasia management practices. International Journal of Language and Communication Disorders, 35: 303–314. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]), yet they are limited in their ability to provide information regarding a person's ability to communicate in daily life. Social validation is a less commonly used type of assessment, but one that may provide additional information regarding language and communication abilities, based on the perceptions of persons not directly involved in the treatment. Despite its potential, there remain questions regarding its optimal use.

Aims: The goals of this study were to examine the usefulness of social validation in measuring communicative change after aphasia treatment, and to investigate the potential influence of rater characteristics on raters' perceptions.

Methods & Procedures: Narratives were elicited before and after naming treatment from 11 participants with aphasia: 7 participants were treated, 4 of whom improved and 3 of whom did not; 4 participants did not receive treatment. Three groups of 10 raters (speech-language pathologists, older and younger naïve adults) evaluated the narratives, and their ratings of the pre- and post-treatment narratives were analysed for perceived improvement.

Outcomes & Results: Results indicated that all three groups of raters observed improvement in the two treated groups of participants with aphasia, but not in the untreated group of participants with aphasia.

Conclusions: Raters' perceptions of narratives (i.e., social validation) provide a useful measure of change after aphasia treatment, which can easily be used to supplement objective language measures. Additionally, factors such as the rater's experience with aphasia or life experience do not appear to have an important influence on rater perceptions.     

Retrieval of instrumental verbs in aphasia: An explorative study

Retrieval of instrumental verbs in two conditions in two Broca and two anomic patients was studied. The instrumental verbs were divided into two classes, viz. instrumental verbs that are related in name with the instrument (e.g. to saw-a saw) and those that are not related in name (e.g. to write-a pen). The actions had to be named (a) in isolation and (b) in a sentence. Two Broca and two anomic patients were examined on both subtests. Although the raw scores on the two subtests do not reveal large differences between the four aphasic subjects, distinguishing the two classes of instrumental verbs and performing an error analysis shows that a different deficit underlies the difficulties of Broca's and anomic aphasics.     

Returning to work with aphasia: A case study

Background: For some people with aphasia, returning to work will be their eventual goal. While there are reports in the literature of incidence of return to work, and general discussion of success, there are few documented in depth studies of what this might entail for the individual with aphasia.

Aims: This paper explores returning to work with aphasia, and examines the complex relationship between the person, the aphasia and the demands of employment.

Methods & Procedures: This is a detailed case report, describing and reflecting on the experiences of GD, who returned to work following his stroke and aphasia. Therapy focused specifically on work requirements is described and the factors affecting GD's return to work explored. An interview was used to elicit GD's reflections on his experiences.

Outcome & Results: GD's language skills improved over time and with therapy, and he developed several strategies that facilitated his communication. He was able to return to work (part-time) in a modified role and this was successful initially. After an extended period (～19 months) his employment was terminated and GD explored other options. He moved on to a volunteering and charity trustee role.

Conclusions: The success (or not) of returning to work with aphasia is multi-faceted and does not rest solely with the person with aphasia. The nature of the work may have a strong bearing on success, as will the ability and willingness of the employer to engage in the process. Partnership with the person and constant review of goals and management is of overwhelming importance. We need to consider what “success” may mean in this context and the need to consider therapeutic and rehabilitation needs over a longer time frame.     

Mobile computing technology and aphasia: An integrated review of accessibility and potential uses

Background: Recently, the use of mobile computer technology in health management has received attention in research and clinical domains. The role of mobile devices such as smart phones and tablet PCs in the management of aphasia has not yet been thoroughly reviewed in the literature, and research on mobile technology and aphasia is scarce.

Aims: The aim of this paper is to review accessibility issues and the potential uses of mobile computing for people with aphasia, with a view to stimulating and guiding further research.

Main Contribution: The literature reviewed is synthesised into key design features which may enhance the accessibility of technology for people with aphasia. The importance of access to technology for non-rehabilitative purposes and the potential role of smart phones as a cost-effective, time-efficient and context-sensitive health management tool are outlined. Potential functions of speech pathology applications (apps) are also proposed, with the aim of improving the organisation and direction of research in this area.

Conclusions: Improving access to mobile computing technology by people with aphasia has the potential for enhancing both social participation and management of aphasia. It is clear from this review that more research is needed into how accessibility may be improved, as well as on the development of mobile applications that aid management of aphasia.     

The reliability of the Communication Disability Profile: A patient-reported outcome measure for aphasia

Background: The use of patient-reported outcome (PRO) measures is important for understanding the impact of aphasia from the perspective of the person with aphasia. However, communication difficulties may make it challenging for people with aphasia to self-report. The Communication Disability Profile (CDP) (Swinburn & Byng, 2006 Swinburn, K. and Byng, S. 2006. The Communication Disability Profile, London: Connect Press.  [Google Scholar]) is a newly published outcome measure that includes aphasia-friendly design features (e.g., pictures, simple wording, key words in bold, picture-rating scales) to support people with aphasia in self-reporting the impact of aphasia on their lives.

Aim: This pilot study aimed to investigate the test–retest reliability and internal consistency of the Activities, Participation, and Emotions sections of the CDP.

Methods & Procedures: A total of 16 participants with chronic aphasia of different severities and types were administered the CDP twice with a test–retest interval of approximately 2 weeks. Test–retest reliability was assessed using the Intraclass Correlation Coefficient (ICC) and “Minimal differences (MD) considered to be real”. Internal consistency was assessed using Cronbach's alpha (α) and corrected item–total correlations. Correlation coefficients, visual inspection, feedback, and observations were used to identify factors that may have affected the reliability or usability of the CDP.

Outcomes & Results: The Activities section of the CDP demonstrated high test–retest reliability with an ICC of 0.96 and a small MD value. The Participation section also demonstrated acceptable test–retest reliability (ICC?=?0.89). In addition, the Activities and Participation sections demonstrated adequate internal consistency with Cronbach's alpha of more than 0.7 and corrected item–total correlations of more than 0.3. The Emotions section of the CDP did not demonstrate an acceptable level of test–retest reliability (ICC?=?0.62) or internal consistency (α < 0.7). Additionally there were no significant relationships between the severity of aphasia or comprehension abilities and the reliability of the CDP. However, increased examiner support may be required for the use of the Emotions section and when using the CDP with people with more severe aphasia.

Conclusions: The findings of this study provided preliminary psychometric evidence to support the use of the Activities and Participation sections of the CDP as a PRO measure by people with aphasia.     

Implementing and evaluating aphasia therapy targeted at couples' conversations: A single case study

Background: In recent years conversation has become an area of interest for aphasia therapy, with several studies using conversation analysis (CA) to target and evaluate therapy. Most of these studies have focused on the main conversation partner of the person with aphasia, and in particular have targeted the partner's pedagogic behaviours in relation to the person with aphasia. Evaluations of therapy have primarily taken the form of qualitative analyses of change in conversational behaviours.

Aims: This single-case intervention study aims to advance research into interaction-focused intervention for aphasia in the following ways: by targeting intervention at the person with aphasia and the main conversation partner as a couple; by focusing on conversational behaviours where the person with aphasia can be seen to be restricted by the conversational actions of the conversation partner, in particular by recurrent questioning using closed questions and yes/no interrogatives; and by using a novel combination of qualitative and quantitative approaches to evaluate the intervention.

Methods & Procedures: CA was used to target and evaluate interaction-focused intervention for a couple where one partner has aphasia. Evidence for change was evaluated using qualitative and quantitative evidence of change in conversational behaviours; evidence from naïve raters of pre- and post-intervention conversation extracts; and interview/other feedback from the conversation partner.

Outcomes & Results: There was evidence that the intervention had changed the couple's conversational behaviours. In particular, the conversational behaviours of the non-aphasic partner were in general less restricting for the person with aphasia in that she was now using fewer questions and more instance of other types of turns, such as paraphrases. Following intervention the person with aphasia had also changed in that he was now producing turns that had more sentences, or attempts at sentences, and which developed the topic of talk across several of his turns.

Conclusions: The study provides evidence that directly targeting the conversational behaviours of the person with aphasia and/or a main conversational partner can produce positive change, and can achieve this in a way that is ecologically valid. In particular, it highlights the usefulness of targeting conversational behaviours that are proving to be maladaptive for the participants. It provides further evidence that creating change in the non-aphasic partner's conversational behaviour may facilitate change in the person with aphasia's conversational and linguistic performance.     

Qualitative research in aphasia: A review of the literature

Background: Stroke and aphasia can negatively affect a person’s ability to maintain healthy social relationships, both within the family and also with friends and the wider network. To date, this has been explored predominantly through qualitative interviews and questionnaires. Blogs written by people with aphasia constitute a novel source of data, comprised of people’s own voices on issues that are of concern to them.

Aims: To explore the impact of stroke and aphasia on a person’s relationships with family, friends and the wider network through analysing blogs written by people with aphasia.

Methods &; Procedures: Blog search engines were used to identify blogs sustained by a sole author who had aphasia following a stroke, and which reflected on their social network. The data were analysed qualitatively using framework analysis.

Outcomes &; Results: The systematic search resulted in 10 relevant blogs. Participants were aged between 26 and 69 years old, lived in the community, were at least 1 year post stroke and included six women and four men. Aphasia was a consistent thread running through the blogs affecting conversations with all parts of a person’s network and impacting on participants’ sense of self. They found it more difficult to take part in family activities and described higher degrees of dependence and changed family dynamics. Contact with friends was reduced, partly due to communication and physical difficulties. While some participants became motivated to become members of groups post stroke, contact with the wider network sometimes diminished, in part because of loss of work and community activities. An additional factor impacting on social relationships was other people’s positive or negative reaction towards the person with aphasia. Finally, the blogs reflected on the importance of support they had received, both from close family and also from the wider community.

Conclusions: This study found that social relationships played a crucial role in people’s lives following a stroke and aphasia. Nonetheless, family relationships, friendships and social exchanges within the wider social network were all substantially affected. Exploring this area through online narratives offered a rich and highly authentic source of data. The findings suggest that clinicians should incorporate social approaches in rehabilitation and consider ways to foster the maintenance of social networks. The use of social media by people with aphasia should be further explored, both as a therapeutic outlet and also as a way for people with aphasia to feel connected to a wider community.     

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.     

The problems faced by informal carers to people with aphasia after stroke: A literature review

Background: In addition to other stroke related impairments, up to 12% of those who survive stroke have ongoing problems with aphasia. Research suggests that informal carers to those with aphasia after stroke experience a greater overall burden of care than those who care for stroke survivors without aphasia. One of the keys to understanding this is a clear appreciation of the problems faced by carers of stroke survivors with aphasia.

Aims: Via review of the literature to identify the problems faced by informal carers to those having aphasia after stroke.

Methods & procedures: Studies listed in AMED, CINAHL, EMBASE, MEDLINE, and PsycINFO databases were searched for articles published up until 10^th June 2012, using specified search terms. Reference lists of papers obtained were hand-searched. The studies were rated according to the appropriateness of the study design and the quality with which the research was executed. The results of studies of higher quality were given greater weighting.

Outcomes & Results: Fourteen studies were found that complied with the study criteria. The majority of research was cross-sectional. There was a balance of qualitative and quantitative studies. There were methodological problems with all of the studies. Seven studies were rated as low quality and the remainder were rated as moderate quality. It was established that there is reasonable evidence to suggest that informal carers to people with aphasia after stroke commonly experience problems in the following areas: role changes/new responsibilities, difficulties with social and leisure activities, communication difficulties with the stroke survivor, employment and financial problems, problems in dealing with health professionals, relationship difficulties with the stroke survivor, difficulties in family relationships, lack of support or respite, managing difficult behaviours in the stroke survivor, physical health problems/fatigue, and emotional health problems.

Conclusions: This paper provides an update and improvement upon a previous review of the literature in this subject area. There is a lack of longitudinal research and therefore little is known about how the problems experienced by informal carers of stroke survivors with aphasia change over time. Carer gender and carers’ perception of the self-care deficits of the stroke survivor emerge as potentially significant covariables requiring further investigation. Clinical implications of the findings and limitations are discussed.     

Transient aphasia after right-unilateral ultrabrief electroconvulsive therapy: A case report

A brief period of aphasia is an extremely rare and likely underreported adverse effect of electroconvulsive therapy. Clinical studies that have described this phenomenon are scarce and its prevalence is unknown. We present a unique case of a 35-year old woman, who underwent an outpatient ECT session at our department, followed by a short span of aphasic symptoms, the extent of which were monitored clinically and via the czech version of the Minnesota aphasia screening test.     

High-context images: Comprehension of main,background, and inferential information by people with aphasia

Background: Professionals often recommend using high-context images as expressive and receptive communication supports, even though researchers know little about the information people with aphasia can extract from these images.

Aims: This study’s purposes were to compare the accuracy and speed with which people with and without aphasia derive main action, background, and inferential information from high-context images.

Methods & Procedures: Twenty people with and 20 people without neurological impairment selected high-context images to match spoken sentences conveying main action, background, or inferential information. Participants listened to each sentence presented twice and selected the target image from a field of four. Computation of nonparametric statistics allowed accuracy and speed comparisons between participant groups and among the three stimulus sentence conditions. Additionally, the researchers computed correlations between participants’ standardised test scores and their accuracy and speed when performing the experimental task.

Outcomes & Results: Task performance by participants without aphasia was more accurate and faster than that of participants with aphasia regardless of sentence condition. Both groups were most accurate and fastest given sentences conveying main actions. The participants with aphasia were significantly slower and less accurate when selecting high-context images to match sentences relaying background and inferential information than ones relaying main action information. This pattern differed from that of participants without aphasia who demonstrated a significant decrease in accuracy only for inferential sentences; they demonstrated significantly different response speeds among all sentence conditions. No significant correlations emerged between Western Aphasia Battery-Revised Aphasia Quotient scores or Cognitive Linguistic Quick Test Executive Functioning or Visual Spatial Domain scores and participants’ accuracy or speed of experimental task performance. However, accuracy and speed in some of the sentence stimulus conditions correlated significantly with auditory comprehension subtest scores of the Comprehensive Aphasia Test. All significant correlations indicated that accuracy increased and response speed decreased as auditory comprehension scores increased.

Conclusions: Participants with aphasia performed with less accuracy and were slower at responding than participants without aphasia. The fact that participants with aphasia took about twice as long to respond on average as participants without aphasia highlights the need for ample processing time when interacting with people with aphasia. However, despite their aphasia severity as measured by standardised testing, some participants performed well regardless of whether a stimulus sentence referenced main action, background, or inferential information. The results suggest that many people with aphasia can derive substantial information from high-context images.