TeleCPT: Delivery of a Better Conversations Approach to Communication Partner Training During a Global Pandemic and Beyond

Purpose: This case report provides an overview of telehealth delivery of our Better Conversations approach to communication partner training (CPT) for people with primary progressive aphasia (PPA) and their communication partner (CP). The purpose is to advance the knowledge of speech and language therapists/pathologists (SLTs) on this type of CPT and empower them to deliver teleCPT as part of their clinical practice. // Method: We provide a case report describing therapy delivery, outcomes, and self-reflections from our clinical practice, which represents a collaboration between a UK National Health Service CPT clinic and the Better Conversations Research Lab at University College London, UK. A man with PPA and his CP (a dyad) video-recorded everyday conversations at home using a video conferencing platform. These formed the basis of an evaluation of conversation barriers and facilitators, which led to four weekly 1-hr therapy sessions covering the mechanics of conversation, identification of barriers and facilitators, goal setting, and practice of positive conversation strategies. // Results: Dyad self-rating of goal attainment revealed that three of four conversation strategies were achieved much more than expected, a positive outcome given the progressive nature of F.F.'s condition. SLT access to the dyad at home via teleCPT facilitated the carryover of strategies from the session to everyday conversations in the home environment. TeleCPT was acceptable to this couple during a global pandemic, with benefits including no travel, ease of therapy scheduling around the CP's work and family commitments, and access to a specialist CPT clinic outside their geographical area. // Conclusions: TeleCPT is feasible and acceptable to clients, improving access to therapy in a way that should not just be the preserve of service delivery during a global pandemic. SLTs can enable clients and their families to have better conversations despite communication difficulties by offering teleCPT. We have shared practical suggestions for delivering teleCPT

Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

Purpose: International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool. // Materials and Methods: A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round. // Results: Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool. // Conclusions: Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed

The experiences of individuals with cervical spinal cord injury and their family during post-injury care in non-specialised and specialised units in UK

BACKGROUND: Individuals with acute cervical spinal cord injury require specialised interventions to ensure optimal clinical outcomes especially for respiratory, swallowing and communication impairments. This study explores the experiences of post-injury care for individuals with cervical spinal cord injury and their family members during admissions in specialised and non-specialised units in the United Kingdom. METHODS: Semi-structured interviews were undertaken with individuals with a cervical spinal cord injury and their family member, focussing on the experience of care across units. Eight people with spinal cord injury levels from C2 to C6, were interviewed in their current care settings. Six participants had family members present to support them. Interviews were audio-recorded and transcribed with data inputted into NVivo for thematic analysis. RESULTS: The study identified six themes from the participant interviews that highlighted different experiences of care in non-specialised and specialised settings. A number of these were related to challenges with the system, whilst others were about the personal journey of recovery. The themes were titled as: adjustment, transitions, "the golden opportunity", "when you can't eat", communication, and "in the hands of the nurses and doctors". CONCLUSIONS: Whilst participants reported being well cared for in non-specialised units, they felt that they did not receive specialist care and this delayed their rehabilitation. Participants were dependent on healthcare professionals for information and care and at times lost hope for recovery. Staff in non-specialised units require training and guidance to help provide support for those with dysphagia and communication difficulties, as well as reassurance to patients and families whilst they wait for transfer to specialised units

Training flexibility in fixed expressions in non-fluent aphasia: A case series report

Background: Many speakers with non-fluent aphasia (NFA) are able to produce some well-formed word combinations such as ‘I like it’ or ‘I don't know’, although they may not use variations such as ‘He likes it’ or ‘I don't know that person’. This suggests that these utterances represent fixed forms. Aims: This case series investigation explored the impact of a novel intervention aimed at enhancing the connected speech of individuals with NFA. The intervention, motivated by usage-based principles, involved filling open slots in semi-fixed sentence frames. Methods & Procedures: Five participants with NFA completed a 6-week intervention programme. The intervention trained participants to insert a range of different lexical items into the open slots of high-frequency phrases such as ‘I like it’ to enable more productive sentences (e.g., ‘they like flowers’). The outcomes and acceptability were examined: The primary outcome measure focused on changes in connected narrative, and the availability of trained constructions (e.g., ‘I like it’) was explored through a story completion test. Two baseline measures of behaviour were taken prior to intervention, and outcomes assessed immediately after intervention and at a 6-week maintenance assessment. Outcome & Results: A pre-/post-treatment comparison of connected speech measures showed evidence of enhanced connected speech for two of the five participants (P2 and P5). An analysis of story completion test scores revealed positive change for two participants (P1 and P2). Findings were mixed with regard to baseline stability of outcome measures and post-intervention stability of language changes. The intervention was acceptable to all participants. Conclusion & Implications: While this pilot study yielded promising findings with regard to the intervention's acceptability and increased connected speech for some participants, the findings were mixed across the sample of five participants. This research helps inform hypotheses and selection criteria for future studies

"I don't know": a usage-based approach to familiar collocations in non-fluent aphasia

Background: Familiar collocations (e.g., “it’s alright”) are an important part of everyday conversation. Such word combinations are often retained in speakers with Broca’s aphasia. However, only few investigations have studied the forms and functions of familiar collocations available to speakers with Broca’s aphasia. // Aims: We first apply a frequency-based perspective to word combinations produced by speakers with Broca’s aphasia and their conversation partners (CPs), and compare the frequency characteristics of word combinations in dyadic and non-dyadic speech. Second, we investigate the conversational functions of one prominent familiar collocation, “I don’t know” (IDK). // Methods & Procedures: In the first analysis, speech samples from interactions of nine dyads (each a speaker with Broca’s aphasia and their CP) were examined. Non-dyadic samples were selected from 39 speakers with Broca’s aphasia from AphasiaBank (MacWhinney et al., 2011). The Frequency in Language Analysis Tool (FLAT; Zimmerer & Wibrow, 2015) was used to estimate collocation strength (the degree of association between words in a combination) of well-formed bigrams (two-word combinations) and trigrams (three-word combinations). The second analysis presents a qualitative investigation of uses of IDK in dyadic exchanges. // Outcomes & Results: Analysis 1 revealed that residual trigrams in Broca’s aphasia were more strongly collocated in comparison to language produced by CPs. There was no difference in frequency-based profiles between dyadic and non-dyadic aphasic speech. Analysis 2 indicated that speakers with Broca’s aphasia and CPs used IDK to achieve a variety of communicative functions. However, patterns specific to each participant group were found. // Conclusions: These findings highlight that frequency-based analysis is useful in explaining residual, grammatically well-formed word combinations in Broca’s aphasia. This study provides evidence that IDK can aid turn construction in aphasia

Better conversations: a language and communication intervention for aphasia in posterior cortical atrophy

Posterior cortical atrophy (PCA) describes a neurodegenerative syndrome characterized by progressive difficulties in cortical visual and other posterior cortical functions consistent with parieto-occipital and occipito-temporal involvement. It is increasingly recognized that many patients develop difficulties with other aspects of daily living, in particular, with language and communication. We present a case emphasizing how language difficulties may emerge in PCA. Difficulties are interpreted as arising from interacting effects of linguistic deficits and impaired detection of nonverbal (particularly, visual) turns that normally facilitate, schedule, and disambiguate the exchange of verbal messages between speakers. We propose that relatively simple speech and language therapy interventions may hold promise in addressing language and communication difficulties as secondary features of PCA by targeting the behaviors of both the person with PCA and their communication partners

Conversation Therapy with People with Aphasia and Conversation Partners using Video Feedback: A Group and Case Series Investigation of Changes in Interaction

Conversation therapies employing video for feedback and to facilitate outcome measurement are increasingly used with people with post-stroke aphasia and their conversation partners; however the evidence base for change in everyday interaction remains limited. We investigated the effect of Better Conversations with Aphasia (BCA), an intervention that is freely available online at https://extend.ucl.ac.uk/. Eight people with chronic agrammatic aphasia, and their regular conversation partners participated in the tailored 8 week program involving significant video feedback. We explored changes in: (i) conversation facilitators (such as multi-modal turns by people with aphasia); and (ii) conversation barriers (such as use of test questions by conversation partners). The outcome of intervention was evaluated directly by measuring change in video-recorded everyday conversations. The study employed a pre-post design with multiple 5 minute samples of conversation before and after intervention, scored by trained raters blind to the point of data collection. Group level analysis showed no significant increase in conversation facilitators. There was, however, a significant reduction in the number of conversation barriers. The case series data revealed variability in conversation behaviors across occasions for the same dyad and between different dyads. Specifically, post-intervention there was a significant increase in facilitator behaviors for two dyads, a decrease for one and no significant change for five dyads. There was a significant decrease in barrier behaviors for five dyads and no significant change for three dyads. The reduction in barrier behaviors was considerable; on average change from over eight to fewer than three barrier behaviors in 5 minutes of conversation. The pre-post design has the limitation of no comparison group. However, change occurs in targeted conversational behaviors and in people with chronic aphasia and their partners. The findings suggest change can occur after eight therapy sessions and have implications for clinical practice. A reduction in barrier behaviors may be easier to obtain, although the controlled case series results demonstrate a significant increase in conversation facilitators is also possible. The rehabilitation tool is available online and video technology was central to delivering intervention and evaluating change

Association of BMI with overall survival in patients with mCRC who received chemotherapy versus EGFR and VEGF-targeted therapies

Although a raised body mass index (BMI) is associated with increased risk of colorectal cancer (CRC) and recurrence after adjuvant treatment, data in the metastatic setting is limited. We compared overall survival (OS) across BMI groups for metastatic CRC, and specifically examined the effect of BMI within the group of patients treated with targeted therapies (TT). Retrospective data were obtained from the South Australian Registry for mCRC from February 2006 to October 2012. The BMI at first treatment was grouped as underweight <18.5 kg/m(2) , Normal = 18.5 to <25 kg/m(2) , Overweight = 25 to <30 kg/m(2) , Obese I = 30 to <35 kg/m(2) , Obese II ≥35 kg/m(2) . Of 1174 patients, 42 were underweight, 462 overweight, 175 Obese I, and 77 Obese II. The OS was shorter for patients who were underweight and overweight compared to normal (OS 13.7 and 22.3 vs. 24.1 months, respectively, hazard ratio [HR] 2.21 and 1.23). The adjusted median OS was longer for normal versus overweight or obese I patients receiving chemotherapy + targeted therapy (35.7 vs 25.1 or 22.8 months, HR 1.59 and 1.63, respectively) with no difference in OS for chemotherapy alone. On breakdown by type of targeted therapy, overweight and obese I patients had a poorer outcome with Bevacizumab. The BMI is predictive of a poorer outcome for underweight and overweight patients in the whole population. Of those receiving chemotherapy and targeted therapy, BMI is an independent predictor for OS for overweight and obese I patients, specifically for those treated with Bevacizumab. Patients who are overweight or obese (group I) may be a target group for lifestyle and nutrition advice to improve OS with TT.Gargi S. Patel, Shahid Ullah, Carol Beeke, Paul Hakendorf, Robert Padbury, Timothy J. Price and Christos S. Karapeti

Enabling Better Conversations Between a Man With Aphasia and His Conversation Partner: Incorporating Writing Into Turn Taking

This article reports an intervention in the conversations between a man with chronic aphasia, Barry, and his wife, Louise (both names are pseudonyms). Preintervention analysis revealed the potential of writing as a resource for turn construction. Intervention consisted of enabling Barry to use writing to produce more complete turns at talk, thereby increasing the likelihood of mutual understanding, and encouraging Louise to modify her responses to Barry’s turns and thus enhance his interactional potential. Quantitative analysis revealed that Barry significantly increased his use of writing after intervention, but there was no change in other trained strategies. Louise eradicated correct production sequences (designed to elicit the correct production of a word despite her knowing the target) but did not implement trained strategies. In conclusion, individually tailored input underpinned by Conversation Analysis principles can alter the conversational behavior of a person with aphasia. It appears easier for a conversation partner to reduce unhelpful behaviors than to adopt facilitatory strategies. Data are in British English