Therapeutic relationships in aphasia rehabilitation: Using sociological theories to promote critical reflexivity

© 2020 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists Background: Therapeutic relationships are fundamental in aphasia rehabilitation, influencing patient experience and outcomes. While we have good understandings of the components of therapeutic relationships, there has been little exploration of how and why therapists construct and enact relationships as they do. Sociological theories may help develop nuanced understanding of the values, assumptions and structures that influence practice, and may facilitate critical reflexivity on practice. Aims: To explore the potential for theoretical approaches from outside speech–language therapy to enable a deeper understanding of the nature and enactment of therapeutic relationships in aphasia rehabilitation. Methods & Procedures: An explanatory single case study of one speech–language therapist–patient dyad in an in-patient stroke rehabilitation setting. Data included observations of five interactions, two interviews with the client and three interviews with the speech–language therapist. Analysis was guided by analytical pluralism that applied aspects of three sociological theories to guide data analysis and make visible the contextual factors that surround, shape and permeate the enactment of therapeutic relationships. Outcomes & Results: The analysis of this dyad made visible individual, interactional and broader structural features that illustrate the dynamic processes that practitioners and patients undertake to enact therapeutic relationships. Clinical practice could be viewed as a performance with each person continually negotiating how they convey different impressions to others, which shapes what work is valued and foregrounded. The patient and therapist took up or were placed in different positions within the interactions, each with associated expectations and rights, which influenced what types of relationships could, or were likely to, develop. Organizational, rehabilitation and individual practitioner structures assigned rules and boundaries that shaped how the therapist developed and enacted the therapeutic relationship. Whilst the therapist had some agency in her work and could resist the different influencing factors, such resistance was constrained because these structures had become highly internalized and routinized and was not always visible to the therapist. Conclusions & Implications: While therapists commonly value therapeutic relationships, social and structural factors consciously and unconsciously influence their ability to prioritize relational work. Sociological theories can provide new lenses on our practice that can assist therapists to be critically reflexive about practice, and to enact changes to how they work to enhance therapeutic relationships with clients. What this paper adds What is already known on the subject Therapeutic relationships are critical in aphasia rehabilitation. We have a good understanding of the different components of therapeutic relationships and how relationships are perceived by patients and practitioners. What this paper adds to existing knowledge This study is novel in its use of sociological lenses to explore contexts and complexities inherent in building and maintaining therapeutic relationships. These are often invisible to the practitioner but can have a significant impact on how relational work is enacted and what forms of relationship are possible. What are the potential or actual clinical implications of this work? This study will support clinicians to critically reflect on how they enact therapeutic relationships and may enhance awareness of the often-hidden factors which influence the ways in which they work

“Physical well-being is our top priority”: Healthcare professionals' challenges in supporting psychosocial well-being in stroke services

Background Following stroke, a sense of well-being is critical for quality of life. However, people living with stroke, and health professionals, suggest well-being is not sufficiently addressed within stroke services, contributing to persistent unmet needs. Knowing that systems and structures shape clinical practice, this study sought to understand how health professionals address well-being, and to examine how the practice context influences care practice. Methods Underpinned by Interpretive Description methodology, we interviewed 28 health professionals across multiple disciplines working in stroke services (acute and rehabilitation) throughout New Zealand. Data were analysed using Applied Tensions Analysis. Results Health professionals are managing multiple lines of work in stroke care: biomedical work of investigation, intervention and prevention; clinical work of assessment, monitoring and treatment; and moving people through service. While participants reported working to support well-being, this could be deprioritised amidst the time-oriented pressures of the other lines of work that were privileged within services, rendering it unsupported and invisible. Conclusion Stroke care is shaped by biomedical and organisational imperatives which privilege physical recovery and patient throughput. Health professionals are not provided with the knowledge, skills, time or culture of care that enable them to privilege well-being within their work. This has implications for the well-being of people with stroke, and the well-being of health professionals. In making these discourses and culture visible, and tracing how these impact on clinical practice, we hope to provide insight into why well-being work remains other to the ‘core’ work of stroke, and what needs to be considered if stroke services are to better support people’s well-being. Patient or public contributions People with stroke, family members, and people who provide support to people with stroke, and health professionals set priorities for this research. They advised on study conduct and have provided feedback on wider findings from the research

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

The thermophysiology of self-paced exercise in trained male cyclists

The four environmental parameters that contribute to environmental heat stress during prolonged outdoor exercise are ambient temperature, humidity, airflow and radiant (i.e., solar) heat. In three separate laboratory-based studies, ambient temperature, humidity and air velocity were manipulated to investigate the graded impact of these parameters on human heat exchange and the concomitant effect on thermal, cardiovascular and perceptual responses, as well as performance, during prolonged self-paced exercise. The first study (Chapter 3) investigated the effect of ambient (i.e., dry-bulb) temperature (13, 20, 28 and 36ºC) on self-paced exercise performance by minimising differences in the skin-to-air water vapour pressure gradient (i.e., evaporative potential) between conditions to isolate the effect of temperature. During exercise in the 13 and 20ºC conditions when the skin-to-air water vapour pressure gradient was matched (~2.02 kPa), exercise performance (i.e., power output) was similar (~274 W; P=1.00). However, mean power output was lower in 28ºC (~262 W) and was further declined in 36ºC (~228 W). Peak core temperature was higher in 36ºC (39.6 ± 0.4ºC) than all other conditions (P&lt;0.001) and higher in 28ºC (39.1 ± 0.4ºC) than 13ºC (38.7 ± 0.3ºC; P&lt;0.001) and 20ºC (38.8 ± 0.3ºC; P&lt;0.01). Mean heart rate was higher in 36ºC (~163 ± 14 beats·min-1) than all other conditions (P&lt;0.001), and in 20ºC (~156 ± 11 beats·min-1; P=0.009) and 28ºC (~159 ± 11 beats·min-1; P&lt;0.001) than 13ºC (~153 ± 11 beats·min-1). These findings indicate that performance is reduced at 28ºC and further impaired at 36ºC in association with a large decrease in dry heat loss and a moderate reduction in evaporative potential. The second study (Chapter 4) investigated the impact of relative humidity (RH; 33%, 50%, 70% and 88%) on heat exchange and the associated thermal, cardiovascular and perceptual responses during a prolonged self-paced cycling time trial. Cycling performance was similar in the drier environments of 33% and 50% RH (~259 W; P=1.000) but decreased at 70% RH (~246 W) and further reduced at 88% RH (~222 W). Peak core temperature was higher in 88% RH (39.49 ± 0.56ºC) than 33% (38.97 ± 0.44ºC; P&lt;0.001), 50% (39.04 ± 0.39ºC; P=0.002) and 70% RH (39.12 ± 0.47ºC; P=0.010). Heart rate was similar between all conditions (P&gt;0.056) and thermal discomfort was greater in 88% RH than all conditions. Elevations in humidity progressively narrowed the skin-to-air water vapour pressure gradient, reducing the evaporative potential. Consequently, reductions in evaporative potential exacerbated thermal and perceptual strain, especially in the 88% RH condition, despite the maintenance of a lower work rate, and by extension, a lower metabolic heat production. The third study (Chapter 5) investigated the effect of different air velocities (still air, 16, 30 and 44 km·h-1) on heat exchange and performance during prolonged self-paced exercise in 32ºC and 40% RH. Cycling time trial performance was similar between 16 (274 ± 30 W), 30 (250 ± 32 W) and 44 km·h-1 (248 ± 32 W) relative to no airflow (232 ± 42 W; all P&lt;0.001). Peak core temperature was higher in still air (39.36 ± 0.68ºC) than 16 (38.99 ± 0.49ºC), 30 (38.84 ± 0.34ºC) and 44 km·h-1 (38.83 ± 0.47ºC; all P&lt;0.002). Mean skin temperature was lower in the higher air velocity conditions (P&lt;0.001), but similar in 30 and 40 km·h-1 (P=1.00), and mean heart rate was ~2 beats·min-1 higher in still air than 44 km·h-1 (P=0.035). In the still air condition, the lower evaporative potential increased thermal strain, and led to a similar or greater circulatory strain than in conditions with airflow, despite the maintenance of a lower work rate. Moreover, the comparable exercise performance in the airflow conditions suggests additional airflow ≥16 km·h-1 provides no further benefit to self-paced exercise in the heat. The relatively small improvements in evaporative efficiency (i.e., the proportion of sweat that contributed to evaporative cooling) in conditions ≥16 km·h-1 fail to provide meaningful cooling power and do not further attenuate the development of thermal and cardiovascular strain or lead to improvements in exercise performance. The results of this thesis demonstrate reductions in work rate (i.e., power output), and therefore metabolic heat extension do not attenuate the development of thermal and physiological strain during exercise at high ambient temperatures, high humidity levels and when airflow is withheld. Furthermore, the greatest decrements to performance were observed when evaporative potential reduced, and evaporative efficiency declined leading to elevations in thermal, cardiovascular and perceptual strain. Specifically, our results show that exercise performance is affected once evaporative potential is reduced &lt;200 W·m-2 and the heat stress index is greater than 2.0. Our findings highlight the need to consider all environmental parameters when discussing heat stress because a more comprehensive understanding of all environmental parameters can help better prepare athletes and coaches with training and competition strategies in a warming world

Limited conversations about constrained futures:Exploring clinicians’ conversations about life after stroke in inpatient settings

Background and aims: After stroke, people can find it challenging to look forward to the future. Hope, a critical resource for recovery, can be threatened, and can be supported or diminished through interactions with clinicians. As such, understanding how conversations can support people embarking on life after stroke is critical. Our study explored how clinicians talk about the future with patients, and considered what factors shape how these conversations occur. Design and methods: This study drew on Interpretive Description methodology, informed by principles of ethnographic inquiry. We conducted 300 hours of observations and 76 interviews with 5 people with stroke and 37 clinicians. Data were analysed using reflexive thematic analysis. Findings: We constructed three themes that reflect how clinicians talk about the future with people in inpatient stroke services. These are: (1) Constrained temporal horizons; (2) Limited talk controlled by clinicians; and (3) Opening some doors while closing others.Conclusions: Conversations about the future after stroke were constrained and limited: constrained to short-term futures, and limited in what aspects of life after stroke were discussed. Creating conversational and relational spaces where people are supported to look to the future with a sense of possibility, hope, and potential is vital for assisting people to move forward in their life after their stroke. Given its role in supporting people to move forward in life, communication must be seen as a core clinical skill and a clinical intervention in its own right

Limited conversations about constrained futures:Exploring clinicians’ conversations about life after stroke in inpatient settings

Background and aims: After stroke, people can find it challenging to look forward to the future. Hope, a critical resource for recovery, can be threatened, and can be supported or diminished through interactions with clinicians. As such, understanding how conversations can support people embarking on life after stroke is critical. Our study explored how clinicians talk about the future with patients, and considered what factors shape how these conversations occur. Design and methods: This study drew on Interpretive Description methodology, informed by principles of ethnographic inquiry. We conducted 300 hours of observations and 76 interviews with 5 people with stroke and 37 clinicians. Data were analysed using reflexive thematic analysis. Findings: We constructed three themes that reflect how clinicians talk about the future with people in inpatient stroke services. These are: (1) Constrained temporal horizons; (2) Limited talk controlled by clinicians; and (3) Opening some doors while closing others.Conclusions: Conversations about the future after stroke were constrained and limited: constrained to short-term futures, and limited in what aspects of life after stroke were discussed. Creating conversational and relational spaces where people are supported to look to the future with a sense of possibility, hope, and potential is vital for assisting people to move forward in their life after their stroke. Given its role in supporting people to move forward in life, communication must be seen as a core clinical skill and a clinical intervention in its own right