UK speech and language therapists' views and reported practices of discourse analysis in aphasia rehabilitation.

BACKGROUND: Discourse assessment and treatment in aphasia rehabilitation is a priority focus for a range of stakeholder groups. However, a significant majority of speech and language therapists (SLTs) infrequently conduct discourse analysis, and do not feel competent in doing so. Known barriers identified in other countries, specifically a lack of time, training, expertise and resources, affect use of discourse analysis in clinical practice. AIMS: To investigate UK SLTs' reported practices and views of discourse analysis, barriers and facilitators, and clinical feasibility in aphasia rehabilitation. METHODS & PROCEDURES: An online survey of 52 questions adapted from existing research and incorporating behaviour change literature was created for the study and piloted. UK SLTs working in aphasia rehabilitation for at least 6 months were invited to participate. Potential participants were contacted through national and local clinical excellence networks, a National Health Service (NHS) bespoke e-mail list, and national magazine advertisement, and the study was also advertised on social media (Twitter). Therapists read an online participant information sheet and submitted individual electronic consent online; then progressed to the Qualtrics survey. Descriptive, correlational and inferential statistical analyses were conducted, and content analysis was carried out on the questions requiring text. OUTCOMES & RESULTS: A total of 211 valid responses were received from primarily female SLTs, aged 20-40 years, working full-time in the NHS in England, in community, inpatient and acute/subacute multidisciplinary settings. A total of 30% SLTs collected discourse analysis often, were mostly very experienced, and working part-time in community settings. Years of experience was predictive of use. Discourse was most often collected using standardized picture descriptions and recounts during initial assessment. Samples were infrequently recorded, and typically transcribed in real-time. Most SLTs (53-95%) reported making clinical judgements or manually counted words, sentences, communication of ideas and errors, and were confident in doing so. Barriers included time constraints; lack of expertise, confidence, training, resources and equipment; and patient severity. Discourse 'super-users' were distinguished by significantly higher professional motivation for discourse and workplace opportunity than other SLTs, and 'non-users' were distinguished by significantly less knowledge and skills in discourse analysis than other SLTs. SLTs reported a desire and need for training, new/assistive tools and time to do more discourse analysis in practice. CONCLUSIONS & IMPLICATIONS: Clinicians were highly engaged and relatively active in at least some aspects of discourse analysis practice. Interventions that target individual clinicians as well as organizations and systems are needed to improve the uptake of discourse analysis in practice. What this paper adds What is already known on the subject? Discourse in aphasia rehabilitation is a priority in clinical practice and research. However, the majority of clinicians infrequently collect and analyse discourse. Research in Australia and the United States indicated that lack of time, assessment resources and relevant knowledge and skills are the main barriers to use. What this paper adds to existing knowledge Compared with existing research, UK SLTs were more likely to see discourse analysis as part of their role and experienced fewer barriers, and more SLTs did it at least sometimes in clinic. However, practices were limited by lack of training, giving rise to challenges in selecting and interpreting findings for clients. More use was predicted by more experience and commitment to discourse analysis, particularly where workplaces supported this approach. Less use was associated with less knowledge and skills in discourse analysis. Practice and decision-making were influenced by client factors and constrained to a lesser degree by logistical challenges. What are the potential or actual clinical implications of this study? Education and training in discourse analyses and in specific procedures are needed to improve individual clinicians' knowledge, skills and confidence in using discourse analysis for clients' rehabilitation. Equally, organizational and systems changes are needed to promote, support and reinforce discourse analysis in the workplace.

Psychometric properties of discourse measures in aphasia: acceptability, reliability, and validity.

BACKGROUND: Discourse in adults with aphasia is increasingly the focus of assessment and therapy research. A broad range of measures is available to describe discourse, but very limited information is available on their psychometric properties. As a result, the quality of these measures is unknown, and there is very little evidence to motivate the choice of one measure over another. AIMS: To explore the quality of a range of discourse measures, targeting sentence structure, coherence, story structure and cohesion. Quality was evaluated in terms of the psychometric properties of acceptability (data completeness and skewness), reliability (inter- and intra-rater), and validity (content, convergent, discriminant and known groups). METHODS & PROCEDURES: Participants with chronic mild-to-moderate aphasia were recruited from community groups. They produced a range of discourses which were grouped into Cinderella and everyday discourses. Discourses were then transcribed orthographically and analyzed using macro- and microlinguistic measures (Story Grammar, Topic Coherence, Local Coherence, Reference Chains and Predicate Argument Structure-PAS). Data were evaluated against standard predetermined criteria to ascertain the psychometric quality of the measures. OUTCOMES & RESULTS: A total of 17 participants took part in the study. All measures had high levels of acceptability, inter- and intra-rater reliability, and had good content validity, as they could be related to a level of the theoretical model of discourse production. For convergent validity, as expected, 8/10 measures correlated with the Western Aphasia Battery-Revised (WAB-R) spontaneous speech scores, and 7/10 measures correlated with the Kissing and Dancing Test (KDT) scores (r ≥ 0.3), giving an overall positive rating for construct validity. For discriminant validity, as predicted, all measures had low correlations with Raven's Coloured Progressive Matrices (RCPM) and WAB-R Auditory Verbal Comprehension scores (r < 0.3), giving an overall positive rating for construct validity. Finally, for known groups validity, all measures indicated a difference between speakers with mild and moderate aphasia except for the Local Coherence measures. Overall, Story Grammar, Topic Coherence, Reference Chains and PAS emerged as the strongest measures in the current study because they achieved the predetermined thresholds for quality in terms of each of the psychometric parameters profiled. CONCLUSIONS & IMPLICATIONS: The current study is the first to psychometrically profile measures of discourse in aphasia. It contributes to the field by identifying Story Grammar, Topic Coherence, Reference Chains and PAS as the most psychometrically robust discourse measures yet profiled with speakers with aphasia. Until further data are available indicating the strength of other discourse measures, caution should be applied when using them.

Cultural adaptation and psychometric testing of The Scenario Test UK for people with aphasia.

BACKGROUND: This study explores the psychometric properties of The Scenario Test UK, a culturally adapted version of the Dutch original (The Scenario Test) developed by van der Meulen et al. in 2010, which evaluates functional, daily-life communication in aphasia. The Scenario Test assesses communication in an interactive context with a supportive communication partner. AIMS: To evaluate the reliability (internal consistency, interrater and test-retest reliability) and construct validity (convergent, discriminant and known-groups validity) of The Scenario Test UK. METHODS & PROCEDURES: The Scenario Test UK and other language, cognition and praxis assessments were administered to persons with aphasia after stroke (3+ months post-stroke) and to non-aphasic controls. Participants were recruited primarily through community stroke groups. Measures were completed in an interview format. Standard psychometric criteria were used to evaluate reliability and construct validity. OUTCOMES & RESULTS: A total of 74 participants with aphasia and 20 participants without aphasia took part in The Scenario Test UK. The test showed high levels of reliability. Internal consistency (Cronbach's α = 0.92), interrater reliability (ICC = 0.95) and test-retest reliability (ICC = 0.96) were excellent. Interrater agreement in scores on the individual items ranged from good to excellent (κ = 0.41-1.00) for all but two items (item 4c κ = 0.38, item 6c κ = 0.36). The test demonstrated good levels of convergent (ρ = 0.37-0.75) and discriminant validity (ρ = -0.04 to 0.23). There was strong evidence for known groups validity (U = 132.50, p < .001), with those with aphasia scoring significantly lower [median (interquartile range-IQR) = 47 (39.8-51.0)] than those without aphasia [53 (52-54)]. CONCLUSIONS & IMPLICATIONS: The data support the reliability and validity of the Scenario Test UK as an assessment of functional, daily-life communication for persons with aphasia. Further testing is needed in independent samples on the measure's psychometric properties, including its sensitivity to change. Pending this testing, The test can be used as an assessment tool to evaluate communication skills with people with aphasia, to guide goal setting for therapy and to measure outcomes in response to therapy.

Integration of speech and gesture in aphasia.

BACKGROUND: Information from speech and gesture is often integrated to comprehend a message. This integration process requires the appropriate allocation of cognitive resources to both the gesture and speech modalities. People with aphasia are likely to find integration of gesture and speech difficult. This is due to a reduction in cognitive resources, a difficulty with resource allocation or a combination of the two. Despite it being likely that people who have aphasia will have difficulty with integration, empirical evidence describing this difficulty is limited. Such a difficulty was found in a single case study by Cocks et al. in 2009, and is replicated here with a greater number of participants. AIMS: To determine whether individuals with aphasia have difficulties understanding messages in which they have to integrate speech and gesture. METHODS & PROCEDURES: Thirty-one participants with aphasia (PWA) and 30 control participants watched videos of an actor communicating a message in three different conditions: verbal only, gesture only, and verbal and gesture message combined. The message related to an action in which the name of the action (e.g., 'eat') was provided verbally and the manner of the action (e.g., hands in a position as though eating a burger) was provided gesturally. Participants then selected a picture that 'best matched' the message conveyed from a choice of four pictures which represented a gesture match only (G match), a verbal match only (V match), an integrated verbal-gesture match (Target) and an unrelated foil (UR). To determine the gain that participants obtained from integrating gesture and speech, a measure of multimodal gain (MMG) was calculated. OUTCOMES & RESULTS: The PWA were less able to integrate gesture and speech than the control participants and had significantly lower MMG scores. When the PWA had difficulty integrating, they more frequently selected the verbal match. CONCLUSIONS & IMPLICATIONS: The findings suggest that people with aphasia can have difficulty integrating speech and gesture in order to obtain meaning. Therefore, when encouraging communication partners to use gesture alongside language when communicating with people with aphasia, education regarding the types of gestures that would facilitate understanding is recommended.

Reviewing the quality of discourse information measures in aphasia.

BACKGROUND: Discourse is fundamental to everyday communication, and is an increasing focus of clinical assessment, intervention and research. Aphasia can affect the information a speaker communicates in discourse. Little is known about the psychometrics of the tools for measuring information in discourse, which means it is unclear whether these measures are of sufficient quality to be used as clinical outcome measures or diagnostic tools. AIMS: To profile the measures used to describe information in aphasic discourse, and to assess the quality of these measures against standard psychometric criteria. METHODS & PROCEDURES: A scoping review method was employed. Studies were identified using a systematic search of Scopus, Medline and Embase databases. Standard psychometric criteria were used to evaluate the measures' psychometric properties. MAIN CONTRIBUTION: The current review summarizes and collates the information measures used to describe aphasic discourse, and evaluates their quality in terms of the psychometric properties of acceptability, reliability and validity. Seventy-six studies described 58 discourse information measures, with a mean of 2.28 measures used per study (SD = 1.29, range = 1-7). Measures were classified as 'functional' measures (n = 33), which focused on discourse macrostructure, and 'functional and structural' measures (n = 25), which focused on micro-linguistic and macro-structural approaches to discourse. There were no reports of the acceptability of data generated by the measures (distribution of scores, missing data). Test-retest reliability was reported for just 8/58 measures with 3/8 > 0.80. Intra-rater reliability was reported for 9/58 measures and in all cases percentage agreement was reported rather than reliability. Per cent agreement was also frequently reported for inter-rater reliability, with only 4/76 studies reporting reliability statistics for 12/58 measures; this was generally high (>.80 for 11/12 measures). The majority of measures related clearly to the discourse production model indicating content validity. A total of 36/58 measures were used to make 41 comparisons between participants with aphasia (PWA) and neurologically healthy participants (NHP), with 31/41 comparisons showing a difference between the groups. Four comparisons were made between discourse genres, with two measures showing a difference between genres, and two measures showing no difference. CONCLUSIONS: There is currently insufficient information available to justify the use of discourse information measures as sole diagnostic or outcome measurement tools. Yet the majority of measures are rooted in relevant theory, and there is emerging evidence regarding their psychometric properties. There is significant scope for further psychometric strengthening of discourse information measurement tools.

The language-gesture connection: Evidence from aphasia.

A significant body of evidence from cross-linguistic and developmental studies converges to suggest that co-speech iconic gesture mirrors language. This paper aims to identify whether gesture reflects impaired spoken language in a similar way. Twenty-nine people with aphasia (PWA) and 29 neurologically healthy control participants (NHPs) produced a narrative discourse, retelling the story of a cartoon video. Gesture and language were analysed in terms of semantic content and structure for two key motion events. The aphasic data showed an influence on gesture from lexical choices but no corresponding clausal influence. Both the groups produced gesture that matched the semantics of the spoken language and gesture that did not, although there was one particular gesture-language mismatch (semantically "light" verbs paired with semantically richer gesture) that typified the PWA narratives. These results indicate that gesture is both closely related to spoken language impairment and compensatory.

Language and iconic gesture use in procedural discourse by speakers with aphasia.

Background: Conveying instructions is an everyday use of language, and gestures are likely to be a key feature of this. Although co-speech iconic gestures are tightly integrated with language, and people with aphasia (PWA) produce procedural discourses impaired at a linguistic level, no previous studies have investigated how PWA use co-speech iconic gestures in these contexts. Aims: This study investigated how PWA communicated meaning using gesture and language in procedural discourses, compared with neurologically healthy people (NHP). We aimed to identify the relative relationship of gesture and speech, in the context of impaired language, both overall and in individual events. Methods & Procedures: Twenty-nine PWA and 29 NHP produced two procedural discourses. The structure and semantic content of language of the whole discourses were analysed through predicate argument structure and spatial motor terms, and gestures were analysed for frequency and semantic form. Gesture and language were analysed in two key events, to determine the relative information presented in each modality. Outcomes & Results: PWA and NHP used similar frequencies and forms of gestures, although PWA used syntactically simpler language and fewer spatial words. This meant, overall, relatively more information was present in PWA gesture. This finding was also reflected in the key events, where PWA used gestures conveying rich semantic information alongside semantically impoverished language more often than NHP. Conclusions: PWA gestures, containing semantic information omitted from the concurrent speech, may help listeners with meaning when language is impaired. This finding indicates gesture should be included in clinical assessments of meaning-making.

The benefits of a 5-day dysphagia intensive placement.

Finding practical dysphagia opportunities for students pre-qualification is challenging. Discussions with clinicians led to the development of a new placement model. The placement was just five days and had an accompanying workbook. The current study aimed to evaluate the benefits of the placement. Data were analysed from 40 students who attended an adult dysphagia placement and 13 who attended a paediatric dysphagia placement. Measures included a pre and post self-rating questionnaire, qualitative feedback from clinical educators and students and a pre and post measure of knowledge using concept maps. Student self-rating data indicated gains in experience, awareness, knowledge, clinical skills, competence, confidence and interest in dysphagia. Clinical educators and students also reported a range of benefits from this placement. Students who undertook a placement that focused on adult dysphagia significantly increased their knowledge of adult dysphagia, but this did not generalize to paediatric dysphagia. Despite reporting that they felt they had gained in knowledge of dysphagia, the students who did a paediatric dysphagia placement did not significantly increase their knowledge of dysphagia. The study raises a number of important considerations when designing placements including length, timing, intensity, how best to encourage generalization of knowledge, and how best to measure learning.

The impact of impaired semantic knowledge on spontaneous iconic gesture production.

BACKGROUND: Previous research has found that people with aphasia produce more spontaneous iconic gesture than control participants, especially during word-finding difficulties. There is some evidence that impaired semantic knowledge impacts on the diversity of gestural handshapes, as well as the frequency of gesture production. However, no previous research has explored how impaired semantic knowledge impacts on the frequency and type of iconic gestures produced during fluent speech compared with those produced during word-finding difficulties. AIMS: To explore the impact of impaired semantic knowledge on the frequency and type of iconic gestures produced during fluent speech and those produced during word-finding difficulties. METHODS & PROCEDURES: A group of 29 participants with aphasia and 29 control participants were video recorded describing a cartoon they had just watched. All iconic gestures were tagged and coded as either "manner," "path only," "shape outline" or "other". These gestures were then separated into either those occurring during fluent speech or those occurring during a word-finding difficulty. The relationships between semantic knowledge and gesture frequency and form were then investigated in the two different conditions. OUTCOMES & RESULTS: As expected, the participants with aphasia produced a higher frequency of iconic gestures than the control participants, but when the iconic gestures produced during word-finding difficulties were removed from the analysis, the frequency of iconic gesture was not significantly different between the groups. While there was not a significant relationship between the frequency of iconic gestures produced during fluent speech and semantic knowledge, there was a significant positive correlation between semantic knowledge and the proportion of word-finding difficulties that contained gesture. There was also a significant positive correlation between the speakers' semantic knowledge and the proportion of gestures that were produced during fluent speech that were classified as "manner". Finally while not significant, there was a positive trend between semantic knowledge of objects and the production of "shape outline" gestures during word-finding difficulties for objects. CONCLUSIONS: The results indicate that impaired semantic knowledge in aphasia impacts on both the iconic gestures produced during fluent speech and those produced during word-finding difficulties but in different ways. These results shed new light on the relationship between impaired language and iconic co-speech gesture production and also suggest that analysis of iconic gesture may be a useful addition to clinical assessment.

Iconic gesture in normal language and word searching conditions: a case of conduction aphasia.

Although there is a substantive body of research about the language used by individuals with aphasia, relatively little is known about their spontaneous iconic gesture. A single case study of LT, an individual with conduction aphasia indicated qualitative differences between the spontaneous iconic gestures produced alongside fluent speech and in tip of the tongue states. The current study examined the iconic gestures produced by another individual with conduction aphasia, WT, and a group of 11 control participants. Comparisons were made between iconic gestures produced alongside normal language and those produced alongside word-searching behaviour. Participants recounted the Tweety and Sylvester cartoon Canary Row. All gesture produced was analysed qualitatively and quantitatively. WT produced more iconic gestures than controls accompanying word searching behaviour, whereas he produced a similar frequency of iconic gestures to control participants alongside normal language. The iconic gestures produced in the two language contexts also differed qualitatively. Frequency of iconic gesture production was not affected by limb apraxia. This study suggests that there are differences between iconic gestures that are produced alongside normal language and those produced alongside word-searching behaviour. Theoretical and clinical implications of these findings are discussed.