Behind the therapy door: what is “usual care” aphasia therapy in acute stroke management?

Background: Usual care is the term used to describe everyday practice in the management of a client within a profession. The knowledge of the tasks used in therapy and key therapeutic processes used within these treatments, provides critical information about if and how the therapy works. The Very Early Rehabilitation in SpEech Randomised Controlled Trial (VERSE RCT) had three arms with therapists within the intensive Usual Care-Plus arm (UC-Plus) providing daily direct aphasia therapy at their discretion for 20 sessions. Aims: To describe usual care aphasia treatment provided in the Usual Care-Plus arm of VERSE RCT. Methods and Procedures: One in four intensive Usual Care-Plus treatment sessions were video-recorded (N = 187) within the main trial. Twenty-five of these (13%) were transcribed, coded, and analysed for therapeutic inputs to describe usual care aphasia therapy using the Template for Intervention Description and Replication (TIDieR) checklist as an overriding framework. Outcomes and Results: Therapy predominantly took place in an inpatient setting (52%) with an average session duration of 51 minutes (SD 7.8). Across the sessions, 96 different tasks were used and 57% of these focused on verbal expression at the single word level. Visual materials were most frequently used compared to the use of technology during sessions. Therapists (n = 16) did the majority of the talking during sessions and most frequently provided models as cues or problem-solving accuracy feedback. Models (55%), sentence completion (51%), and orthographic cues (44%) were the most successful at eliciting the target response. Conclusions: Considerable variability in task selection was seen in the sample which may be a hallmark of usual care. Therapists may have a preference for single word tasks and appear to produce the majority of verbal utterances during sessions, potentially creating an unequal communication environment. This study provided a comprehensive description from the Usual Care-Plus data of the VERSE RCT and may establish a baseline of therapy type for future research

Treatment integrity and differentiation in the very early rehabilitation in SpEech (VERSE) trial

Background: Key elements of treatment fidelity include treatment integrity (adherence to the treatment protocol) and treatment differentiation (the difference in treatment ingredients in the control and intervention groups). The Very Early Rehabilitation in SpEech (VERSE) trial established treatment fidelity at the macro level for key components of therapy. Aims To complete a detailed analysis of treatment integrity and differentiation at the utterance level of a therapeutic interaction. Methods This was an observational study of therapy videos collected as part of the VERSE trial. Participants were people with aphasia in the very early phase of recovery post stroke (n = 44) and speech-language pathologists (n = 25). Therapist video recorded sessions in the intensive arms of the trial (VERSE-prescribed therapy and Usual Care Plus) and 53 therapy videos (12%) were randomly selected for analysis. Therapy sessions were transcribed, and key measures reflective of therapeutic inputs and client acts were coded to determine treatment integrity and differentiation. A descriptive analysis and a Welch’s t-test for unequal variances were used to analyse the sessional data. Results Therapists in the VERSE (prescribed intervention) arm of the study, were highly adherent to the treatment protocol at the utterance level (M = 97%). Treatment differentiation between the intensive conditions in this sample was not achieved for cueing and error handling suggesting the treatment delivered between groups was similar. Conclusions Within this sample, treatment integrity to the prescribed condition was maintained. Despite significant differences on a broad level, there was not significant differentiation in the therapy provided in the two arms of the trial at the utterance level. This result supports the null finding in effectiveness between the two intensive arms of the treatment as potential key measures were not different in dosage

Treatment fidelity in aphasia randomised controlled trials

Background: Treatment fidelity is at the heart of evidence-based practice and treatment fidelity processes help to determine the ‘active ingredients’ of a treatment. Hinckley and Douglas in 2013 reviewed treatment fidelity processes in published aphasia trials and found 14% of aphasia treatment studies reported treatment fidelity. This led the authors to call for journals to make treatment fidelity reporting mandatory. Aims: To review the implementation and reporting of treatment fidelity processes in recent aphasia RCTs to update on practices since 2012. Methods and Procedures: Aphasia RCTs published between 2012 and 2017 were sourced from online databases speechBITE, MEDLINE, and CINAHL provided they were: a) an investigation of an impairment-based treatment for post-stroke aphasia; b) not a review, protocol, feasibility, or replication study c) not a surgical or pharmacological intervention and d) published in English. Articles meeting the criteria were rated using Bellg’s treatment fidelity areas with the Template for Intervention Description and Replication (TIDieR) checklist elements. Outcomes and Results: This search retrieved 110 articles and 42 met the above criteria. Nine (21%) articles explicitly reported on treatment fidelity processes. One article (2%) contained every element of the recommended treatment fidelity areas. Totally, 37 (88%) articles addressed the study design aspect of treatment fidelity by investigating therapy dosage. The least-addressed aspect of treatment fidelity was ensuring participants used the skills gained in treatment in appropriate life settings, with two (2%) articles including this. Conclusions: The current review identified 21% of articles explicitly reporting treatment fidelity processes. This paper provides updated review evidence from recent RCTs and echoes recommendations for greater incorporation of treatment fidelity in research protocols and resulting publications

An exploration of aphasia therapy dosage in the first six months of stroke recovery

Aphasia research uses the length of time within rehabilitation sessions as the main measure of dosage. Few papers detail therapeutic ingredients or outline the number of times these were delivered over the treatment period. The present observational study identified therapeutic ingredients in the Very Early Rehabiltiation in SpEech (VERSE) trial and explored the dosage provided using a model of cumulative intervention intensity (CII). Therapists video recorded one therapy session per week and 53 (12%) randomly selected therapy videos were analysed. The videos were coded for number of error productions, self-corrections and type and frequency of therapist cueing. The Western Aphasia Battery Revised-Aphasia Quotient (WABR-AQ) was used for measuring patient outcome with total verbal utterances (p \u3c 0.001) and cues used with success (p \u3c 0.001) being independent positive predictors of WABR-AQ score at six months post stroke and hypothesized as key therapeutic ingredients. The CII was calculated by counting identified therapeutic ingredients and multiplying this by the number of sessions completed. Collectively, the key ingredients occurred on average 504 times per session and over 10,000 times per participant during the treatment period. This paper reports a novel approach for identifying key treatment ingredients and detailing the dosage delivered within an early aphasia rehabilitation trial

Learned communicative non-use is a reality in very early aphasia recovery: Preliminary results from an ongoing observational study.

Recent neurorehabilitation literature in animal motor models suggests very early (before day five post-stroke) intensive (over 300 repetitions) leads to histological damage (Krakauer et al, 2012) and late rehabilitation (commenced after day 30 post-stroke) is much less effective than intervention started earlier in recovery. The intricacies of directly applying animal models of stroke recovery and rehabilitation to human language have been well documented (Varley, 2011). In humans, the first 90 days post-stroke however, are believed to be the "window of opportunity” (Meyer et al., 2010) for neuronal changes to occur as part of neuroplasticity. Research investigating human stroke recovery models, indicates that the timing of commencement of therapy combined with therapy intensity are likely to be pivotal elements in overall stroke recovery (Kerr et al, 2011). Therapy intensity to facilitate stroke recovery in humans is noted to be far less than that in animal models (Krakauer at al., 2012). Research investigating overall activity levels in stroke survivors in the acute recovery demonstrated that patients spent only 13% of their time engaged in activity and spent 60% of the time alone (Berhardt et al, 2004). Further research showed that task specific movement practice occurred in only 51% of sessions during acute and sub-acute therapy sessions (Lang et al., 2009). Similarly, aphasia research in early stroke recovery demonstrated that on average stroke survivors received between 14 minutes (Godecke et al, 2011) and 1.3 hours (Bowen et al, 2012) of therapy per week during the first month post-stroke. To better understand the interactions that occur in early stroke recovery, this study focused on observed communicative activities that may underlie the neuroplasticity principles of “use it or lose it”, and “learned non-use” (Kleim 2011)

Post-stroke lateropulsion and rehabilitation outcomes: A retrospective analysis

Purpose: A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure – FIM) and lateropulsion severity (Four-Point Pusher Score – 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation. Methods: Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005–2018) were analysed using multivariable regression models. Results: Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p \u3c 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p \u3c 0.001), longer LOS (p \u3c 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p \u3c 0.001). Conclusion: Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement. Implications for Rehabilitation: While people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation. Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery

Assessing children to identify developmental coordination disorder: A survey of occupational therapists in Australia

Background: Developmental coordination disorder (DCD), a prevalent neurodevelopmental disorder with motor and psychosocial consequences, can significantly impact children\u27s quality of life. In Australia, most children with diagnosed/suspected DCD have received occupational therapy services, more so than any other health service. As such, occupational therapists are key in identification and treatment and require a sound knowledge of diagnostic criteria and the best evidence for practice. This study explored current occupational therapy services for children with DCD. Areas for development are identified to improve the identification of, and subsequent intervention for, children with DCD. Methods: In this cross-sectional study, an online survey was completed in September and October 2020 by 175 occupational therapists working in Australia. Results: Although all therapists worked with children who met the criteria for DCD diagnosis, 70% worked with children with no specific diagnosis and 50% worked with children with outdated diagnostic labels. Australian occupational therapists used similar models/frameworks (commonly a multisensory/sensory processing approach) to guide practice with children with DCD, regardless of therapist characteristics, practice setting (clinic/community, rural/urban), how therapy is funded, or the state where the therapists completed their training/currently practiced. Although assessment practices did not differ significantly, therapists with greater years of paediatric practice and those who studied and/or practiced in Western Australia were more likely to assess to identify DCD. Half of the therapists did not assess to identify DCD; however, 60% of assessing therapists reported best practice methods in assessment for DCD, indicating emerging best practices in the Australian context. Conclusion: The findings from this study suggest that small adaptations to current occupational therapy practice may enhance the early identification of children with DCD in Australia. The existing gaps in evidence to practice must be addressed to improve current Australian practice and increase access to appropriate services and ultimately improve the quality of life for children with DCD

Awareness and knowledge of developmental coordination disorder: A survey of caregivers, teachers, allied health professionals and medical professionals in Australia

Background To allow for accurate and timely diagnosis of developmental coordination disorder (DCD) key stakeholders must be familiar with and be able to identify features of this disorder. No studies to date have investigated the awareness of DCD among key stakeholders in Australia. Methods An online survey was complete by 494 Australian participants: primary caregivers (n = 153), teachers (n = 149), allied health professionals (n = 165) and medical professionals (n = 27). Results DCD and related terms were among the least known childhood disorders. Approximately half of the sample were familiar with the term DCD but every stakeholder group were more familiar with the term dyspraxia. Allied health professionals demonstrated greater knowledge of the features of DCD, particularly motor features. Every stakeholder group showed poor recognition of the social and psychological effects of DCD. A relatively low percentage of allied health (53%) and medical (33%) professionals reported they had identified or diagnosed DCD and less than 20% of these felt that the DSM‐5 contained adequate information to make a DCD diagnosis. Most teachers (82%) believed they should play a role in identifying early warning signs of this disorder, and 80% believed there are children in the school system who were labelled as lazy or defiant when they have motor skills impairments. Primary caregivers were supportive of a diagnosis of DCD being provided; however, only 16% were confident that a physician would provide an accurate and timely diagnosis. Conclusion Key stakeholders play a unique and important role in the identification of children with DCD. Though most participants acknowledge the role that they play, all stakeholder groups demonstrated poor familiarity with the term DCD and low levels of knowledge about the features of this disorder. Improved familiarity and knowledge of the disorder is needed for access to appropriate services and improved long‐term outcomes for this condition

Unlocking the restraint—development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation

Background: Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful ‘education only’ attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention. Methods: This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5). Results: Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling. Conclusion: This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research

Hospital staff, volunteers’ and patients’ perceptions of barriers and facilitators to communication following stroke in an acute and a rehabilitation private hospital ward: A qualitative description study

Objectives To explore barriers and facilitators to patient communication in an acute and rehabilitation ward setting from the perspectives of hospital staff, volunteers and patients following stroke. Design A qualitative descriptive study as part of a larger study which aimed to develop and test a Communication Enhanced Environment model in an acute and a rehabilitation ward. Setting A metropolitan Australian private hospital. Participants Focus groups with acute and rehabilitation doctors, nurses, allied health staff and volunteers (n=51), and interviews with patients following stroke (n=7), including three with aphasia, were conducted. Results The key themes related to barriers and facilitators to communication, contained subcategories related to hospital, staff and patient factors. Hospital-related barriers to communication were private rooms, mixed wards, the physical hospital environment, hospital policies, the power imbalance between staff and patients, and task-specific communication. Staff-related barriers to communication were staff perception of time pressures, underutilisation of available resources, staff individual factors such as personality, role perception and lack of knowledge and skills regarding communication strategies. The patient-related barrier to communication involved patients’ functional and medical status. Hospital-related facilitators to communication were shared rooms/co-location of patients, visitors and volunteers. Staff-related facilitators to communication were utilisation of resources, speech pathology support, staff knowledge and utilisation of communication strategies, and individual staff factors such as personality. No patient-related facilitators to communication were reported by staff, volunteers or patients. Conclusion Barriers and facilitators to communication appeared to interconnect with potential to influence one another. This suggests communication access may vary between patients within the same setting. Practical changes may promote communication opportunities for patients in hospital early after stroke such as access to areas for patient co-location as well as areas for privacy, encouraging visitors, enhancing patient autonomy, and providing communication-trained health staff and volunteers