Aphasia disrupts usual care: "I'm not mad, I'm not deaf" - the experiences of individuals with aphasia and family members in hospital.

PURPOSE: Communication difficulties are highly prevalent in the stroke population, with implications for patient experience, safety and outcomes. This study explores the experiences of people with aphasia and family members regarding healthcare communication in acute and subacute stroke settings. METHODS AND MATERIALS: A phenomenological approach was used to understand participants' experiences. Participants took part in a focus group and data were analysed using an inductive thematic approach. RESULTS: For individuals with aphasia (n = 4) and family members (n = 2), five themes were generated: "aphasia makes it hard to communicate," "hospital staff focus on the patient's medical status only," "people with aphasia do not get the help they need to improve," "staff lack the skills to communicate with people with aphasia," and "staff are crucial to improving healthcare communication." CONCLUSIONS: The stroke team has expertise in the medical management of stroke but struggle to communicate with patients with aphasia. Patients' experience of healthcare communication is often one-way and limited to following instructions, with missed opportunities to discuss core topics such as prognosis, rehabilitation, and person-specific needs. Patients and families assert that all members of the stroke healthcare team should be able to adapt communication to accommodate patients.

Person-centred care is not a reality for many patients with aphasia.Many healthcare conversations, including informal assessments and discussing prognosis, are not accessible for people with aphasia.Consequently, for people with aphasia, healthcare in hospital is characterised by confusion and exclusion.Staff are crucial to improving healthcare communication; when appropriate strategies were used, these were not only effective but very meaningful to patients.

Acceptability, feasibility and preliminary efficacy of low-moderate intensity Constraint Induced Aphasia Therapy and Multi-Modality Aphasia Therapy in chronic aphasia after stroke.

BACKGROUND: High-intensity Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) and Multi-Modality Aphasia Therapy (M-MAT) are effective interventions for chronic post-stroke aphasia but challenging to provide in clinical practice. Providing these interventions may be more feasible at lower intensities, but comparative evidence is lacking. We therefore explored feasibility, acceptability, and preliminary efficacy of the treatments at a lower intensity. METHODS: A multisite, single-blinded, randomized Phase II trial was conducted within the Phase III COMPARE trial. Groups of participants with chronic aphasia from the usual care arm of the COMPARE trial were randomized to M-MAT or CIAT-Plus, delivered at the same dose as the COMPARE trial but at lower intensity (6 hours/week × 5 weeks rather than 15 hours/week × 2 weeks). Blinded assessors measured aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient), word retrieval, connected speech, multimodal communication, functional communication, and quality of life immediately post interventions and after 12 weeks. Feasibility and acceptability were explored. RESULTS: Of 70 eligible participants, 77% consented to the trial; 78% of randomized participants completed intervention and 98% of assessment visits were conducted. Fatigue and distress ratings were low with no related withdrawals. Adverse events related to the trial (n = 4) were mild in severity. Statistically significant treatment effects were demonstrated on word retrieval and functional communication and both interventions were equally effective. CONCLUSIONS: Low-moderateintensity CIAT-Plus and M-MAT were feasible and acceptable. Both interventions show preliminary efficacy at a low-moderate intensity. These results support a powered trial investigating these interventions at a low-moderate intensity.

Towards efficient, ecological assessment of interaction: A scoping review of co-constructed communication.

BACKGROUND: The complexity of communication presents challenges for clinical assessment, outcome measurement and intervention for people with acquired brain injury. For the purposes of assessment or treatment, this complexity is usually managed by isolating specific linguistic functions or speech acts from the interactional context. Separating linguistic functions from their interactional context can lead to discourse being viewed as a static entity comprised of discrete features, rather than as a dynamic process of co-constructing meaning. The ecological validity of discourse assessments which rely on the deconstruction of linguistic functions is unclear. Previous studies have reported assessment tasks that preserve some of the dialogic features of communication, but as yet, these tasks have not been identified as a distinct genre of assessment. We suggest the term 'co-constructed communication' to describe tasks which are specifically designed to capture the dynamic, jointly produced nature of communication within a replicable assessment task. AIMS: To identify and summarize how co-constructed communication has been assessed with individuals with non-progressive acquired communication disability regarding task design, measures and psychometric robustness. METHODS: A scoping review methodology was used to identity relevant studies. Systematic database searches were conducted on studies published before July 2021. Studies in the yield were assessed against eligibility criteria, with 37 studies identified as eligible for inclusion. MAIN CONTRIBUTION: This is the first time that co-constructed communication has been defined as a genre of discourse assessment for stroke and traumatic brain injury populations. Co-constructed communication has been assessed for 144 individuals with aphasia and 111 with cognitive-communication disability. Five categories of co-constructed communication tasks were identified, ranging in complexity. Variability exists in how these assessment tasks are labelled and measured. Assessment measures require further psychometric profiling, specifically regarding test-retest reliability and validity. CONCLUSIONS: Co-constructed communication is a discourse genre which offers researchers and clinicians a replicable method to assess language and communication in an experimentally rigorous way, within an ecologically valid context, bridging the gap between experimental and ecological assessment approaches. WHAT THIS PAPER ADDS: What is already known on this subject Standardized assessments of language skills and monologue offer reliable, replicable ways to measure language. However, isolating language from an interactional context fundamentally changes the behaviour under study. This raises questions about the ecological validity of the measures we routinely use to determine diagnoses, guide treatment planning and measure the success of treatment. What this study adds to the existing knowledge This review highlights studies that conceptualize, and often quantify, interaction by combining experimental rigour and aspects of everyday dialogue. This is the first time this genre of discourse assessment has been identified. We propose the term 'co-constructed communication' to describe this genre and provide an operational definition for the term. What are the practical and clinical implications of this study? Co-constructed communication assessment tasks require refinement, particularly regarding aspects of psychometric robustness. In the future, these tasks offer pragmatic, meaningful ways to capture the effect and impact of aphasia and cognitive-communication disability within interaction.

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia.

BACKGROUND: While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity. METHODS: We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs. RESULTS: We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up. CONCLUSIONS: CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses. TRIAL REGISTRATION NUMBER: ACTRN 2615000618550.

Measuring the interactions of people with dementia and their conversation partners: a preliminary adaption of the Kagan measures of support and participation in conversation.

OBJECTIVE: While dementia can negatively affect communication, positive interactions can be facilitated by the conversation partners of people with dementia. There are few assessment tools designed to evaluate the support provided by the conversation partner and the resulting participation of the person with dementia. This study reports on an adaptation of the Measure of Support in Conversation (MSC) and Measure of Participation in Conversation (MPC) scales for use with people with dementia and their conversation partners (the MSC Dementia and MPC Dementia, respectively) and investigates the inter-and intra-rater reliability of these adapted measures. METHOD: The MSC-D and MPC-D scales were adapted from the original MSC and MPC scales to reflect current knowledge of communication and interaction involving people with dementia. Audio recordings of a total of 25 casual conversations, lasting 5-10 min, between a person with dementia and familiar aged care staff were independently rated by two raters to investigate inter-rater reliability and by one rater on two separate occasions to investigate intra-rater reliability. RESULTS: ICC analyses on the MSC-D indicated good inter-rater reliability (ICC = 0.718-0.812) and intra-rater reliability (ICC = 0.628-0.760). The MPC-D had excellent inter-rater reliability (ICC = 0.904-0.945) and intra-rater reliability (ICC = 0.925-0.957). 93.6% of all ratings were within 0.5 of each other on a nine point scale from 0 to 4. CONCLUSION: The results provide preliminary support for the use of these adapted scales. Further research is required to investigate the validity and reliability of these scales using video recordings and across a wider range of communication genres.

Aphasia disrupts usual care: the stroke team's perceptions of delivering healthcare to patients with aphasia.

PURPOSE: Communication disability, including aphasia, is prevalent in the stroke population and impacts service delivery. This study explored the experiences of the multidisciplinary stroke team in delivering healthcare to patients with aphasia. MATERIALS AND METHODS: A phenomenological approach was used to understand the experiences of delivering healthcare services in the presence of aphasia. Healthcare professionals (n = 16) were recruited across acute and subacute stroke care, with a range of discipline backgrounds and experience. Participants took part in focus groups and data were analysed using an inductive thematic approach. RESULTS: Five themes were evident: 1) aphasia is time consuming, 2) health professionals do not know how to help, 3) health professionals limit conversations with patients with aphasia, 4) health professionals want to know how to help, and 5) health professionals feel good after successful communication. CONCLUSIONS: Aphasia disrupts usual care. Health professionals want to help but are working in a non-optimal environment where communication and patient-centred care are not adequately resourced. A video abstract is available in Supplementary Material.IMPLICATIONS FOR REHABILITATIONCurrent hospital systems and ward culture make it difficult to offer patient-centred care to patients with aphasia.Health professionals want to help patients with aphasia but are working in an environment where patient-provider communication is not adequately resourced.As a result, health professionals dread, limit or avoid talking with patients with aphasia.Health professionals need support which may include ongoing education and on-the-job training, and a change in ward culture including key performance indicators focusing on patient-provider communication.

The Production of Complement Clauses in Children With Language Impairment.

PURPOSE: The purpose of this research was to provide a comprehensive description of complement-clause production in children with language impairment. Complement clauses were examined with respect to types of complement structure produced, verb use, and both semantic and syntactic accuracy. METHOD: A group of 17 children with language impairment (mean age = 6;10 [years; months]) was compared with a group of 17 younger children with typical language development (mean age = 4;6). Examples of both nonfinite complements with different subjects and sentential complements involving a range of complement-taking verbs were collected using specially designed elicitation tasks. RESULTS: The children with language impairment were able to construct both types of complement clauses, had access to a range of verbs that are utilized within these constructions, and had knowledge of the grammatical constraints imposed by these verbs. However, they were more restricted in their production of sentential complements and produced significantly fewer semantically accurate complements (both finite and nonfinite) than the children with typical language development. CONCLUSION: Children with language impairment evidenced deviant rather than merely delayed development in the area of complement-clause production. Complex sentences such as complement clauses need to be targeted in language intervention programs.

Assessment of complement clauses: a comparison between elicitation tasks and language sample data.

The aim of this study was to determine whether data from specifically designed elicitation tasks and commonly-used language sampling techniques provided the same information about children's production of complement clauses. It was predicted that elicitation tasks would yield more examples of complement clauses and children would use a wider range of verbs to form complement clauses in elicitation tasks than in language samples. A group of 20 pre-school children aged between 3;11-5;3 years were investigated. Each child completed two elicitation tasks, prompting the production of two of the major forms of complement clauses. A language sample of 100 utterances was also collected from each child. The results demonstrated that the two methods of data collection do not provide the same information about children's production of complement clauses. Significantly more examples of both types of complement clauses investigated were produced in the elicitation tasks. Similarly, children used a greater range of verbs in the elicitation tasks. Thus, language sample data under-estimate pre-school children's competency with complement clauses. Accurate and efficient methods of assessment of children's language structures are vital for speech-language pathologists to base their management decisions on. Elicitation tasks offer a viable alternative to language sampling.