The City Gesture Checklist: The development of a novel gesture assessment

Background People with aphasia rely on gesture more than healthy controls to get their message across, but use a limited range of gesture types. Gesture therapy is thus a potential avenue of intervention for people with aphasia. However, currently no gesture assessment evaluates how they use gesture. Such a tool could inform therapy targets and measure outcomes. In gesture research, many different coding categories are used to describe gesture forms and functions. These coding methods are prohibitively time‐consuming to use in clinical practice. There is therefore a need for a ‘quick and dirty’ method of assessing gesture use. Aims To investigate current practice among UK‐based clinicians (speech and language therapists) in relation to gesture assessment and therapy, to synthesize gesture‐coding frameworks used in aphasia research, to develop a gesture checklist based on the synthesized coding frameworks suitable for use in clinical practice, and to investigate the interrater reliability (IRR) of the checklist among experienced and unfamiliar users. Methods & Procedures The research team synthesized seven gesture‐coding frameworks and trialled three resulting prototype checklists at a co‐design workshop with 20 clinicians. Attending clinicians were also consulted about their current clinical gesture practice using a questionnaire. A final City Gesture Checklist (CGC) was developed based upon outcomes and feedback from the workshop. The IRR of the CGC was evaluated between the research team and 11 further clinicians within a second workshop. Both groups used the CGC to count gestures in video clips of people with aphasia talking to a conversation partner. Main Contribution A total of 18 workshop attendees completed the current practice questionnaire. Of these, 10 reported assessing gesture informally and five also used formal assessment. Gesture‐coding synthesis highlighted six main categories of gesture form. Clinicians at the co‐design workshop provided feedback on prototype checklists regarding the relevance and usability of the gesture categories, layout, use of images and instructions. A final version of the CGC was created incorporating their recommendations. The IRR for the CGC was moderate between both the researchers and clinicians. Conclusions & Implications The CGC can be used to assess the types of gesture that people with aphasia produce. The IRR was moderate amongst both experienced users and new users who had received no training. Future research directions include investigating how to improve IRR, evaluating intra‐rater reliability and sensitivity to change, and exploring use of the CGC in clinical practice

Rekindling the love of books - a pilot project exploring whether e-readers help people to read again after a stroke

Background E-readers may facilitate reading in aphasia through “aphasia-friendly” features such as altering text size and formatting (Worrall et al, 2005), and text-to-speech functions. However, no previous research has examined whether e-readers help people with aphasia to read. Aims This project explored: • whether people with aphasia can learn to use e-readers following a brief period of training • whether e-reader training improves reading comprehension • whether e-readers increase participation in and enjoyment of reading activities Method and procedures In phase one, available e-readers were compared using an expert evaluation against a set of criteria, to identify the model with optimum accessibility features and fewest potential barriers. The Kindle Keyboard 3G TM (Amazon) was selected for trialling in phase two. Four people with self-reported reading difficulties post-stroke participated in phase two. All had mild or mild-moderate aphasia. Four one-hour training sessions aimed to trial accessibility features, identify helpful features, and teach independent operation of these. A repeated measures design was used. Outcome measures assessed reading comprehension (Gray Oral Reading Tests, Bryant & Wiederholt, 2001) and confidence and emotions associated with reading (Reading Confidence and Emotions Questionnaire, Cocks et al., 2013). Matched texts were used to compare reading comprehension using printed texts and the e-reader. Usability evaluations explored independence in e-reader use and acceptability of the technology. Participation in reading activities and reading enjoyment were explored using qualitative exit interviews. Outcomes and results Participants’ reading comprehension on the Kindle, as measured by the GORT-4, did not improve following training and did not exceed comprehension of printed texts. However, reading confidence improved significantly for three of the participants (RCEQ: p<.05, p<.01 and p<.005). Analysis of exit interviews and usability evaluations indicates that three out of four participants preferred reading on the Kindle to printed texts. These participants read more frequently on the Kindle than they had done before the training, and the technology enabled them to access more challenging texts (e.g. novels). They appreciated different features of the Kindle. Two participants experienced difficulties operating the technology, one of whom would have benefited from a longer training period. Conclusions This pilot study suggests that a short block of e-reader training led to improvements in reading confidence, participation and enjoyment. E-readers were not shown to enhance reading comprehension. Larger-scale investigations are warranted to further investigate whether and how e-readers facilitate reading for people with aphasia

A comparison of remote therapy, face to face therapy and an attention control intervention for people with aphasia: A quasi-randomised controlled feasibility study

Objective: To test the feasibility of a Randomised Controlled Trial comparing face to face and remotely delivered word finding therapy for people with aphasia Design: A quasi-randomised controlled feasibility study comparing remote therapy delivered from a University lab, remote therapy delivered from a clinical site, face to face therapy and an attention control condition Setting: A University lab and NHS outpatient service Participants: Twenty-one people with aphasia following left hemisphere stroke Interventions: Eight sessions of word finding therapy, delivered either face to face or remotely, were compared to an attention control condition comprising eight sessions of remotely delivered supported conversation. The remote conditions used mainstream video conferencing technology. Outcome measures: Feasibility was assessed by recruitment and attrition rates, participant observations and interviews, and treatment fidelity checking. Effects of therapy on word retrieval were assessed by tests of picture naming and naming in conversation. Results: Twenty-one participants were recruited over 17 months, with one lost at baseline. Compliance and satisfaction with the intervention was good. Treatment fidelity was high for both remote and face to face delivery (1251/1421 therapist behaviours were compliant with the protocol). Participants who received therapy improved on picture naming significantly more than controls (mean numerical gains: 20.2 (remote from University); 41 (remote from clinical site); 30.8 (face to face); 5.8 (attention control); p <.001). There were no significant differences between groups in the assessment of conversation. Conclusions: Word finding therapy can be delivered via mainstream internet video conferencing. Therapy improved picture naming, but not naming in conversation

A Randomised Trial of Social Support Group Intervention for People with Aphasia: A Novel Application of Virtual Reality

About a third of strokes cause aphasia, or language loss, with profound consequences for the person’s social participation and quality of life. These problems may be mitigated by group social support. But this intervention is not available to all individuals. This study investigated whether it is feasible to deliver group social support to people with aphasia via a multi-user, virtual reality platform. It also explored the indicative effects of intervention and the costs. Intervention aimed to promote wellbeing and communicative success. It enabled participants to form new social connections and share experiences of living with aphasia. It comprised 14 sessions delivered over 6 months and was led by community based co-ordinators and volunteers. Feasibility measures comprised: recruitment and retention rates, compliance with intervention and assessment of treatment fidelity. Effects of intervention were explored using a waitlist randomised controlled design, with outcome measures of wellbeing, communication, social connectedness and quality of life. Two intervention groups were randomised to an immediate condition and two were randomised to a delayed condition. The main analysis explored scores on the measures between two time points, between which those in the immediate condition had received intervention, but those in the delayed group had not (yet). A comprehensive approach to economic data collection ensured that all costs of treatment delivery were recorded. Feasibility findings showed that the recruitment target was met (N = 34) and 85.3% (29/34) of participants completed intervention. All groups ran the 14 sessions as planned, and participants attended a mean of 11.4 sessions (s.d. 2.8), which was 81.6% of the intended dose. Fidelity checking showed minimal drift from the manualised intervention. No significant change was observed on any of the outcome measures, although the study was not powered to detect these. Costs varied across the four groups, from £7,483 - £12,562 British Pounds Sterling ($10,972 -$18,419 US dollars), depending on travel costs, the relative contributions of volunteers and the number of hardware loans that were needed. The results suggest that a larger trial of remote group support, using virtual reality, would be merited. However the treatment content and regime, and the selection of outcome measures should be reviewed before conducting the trial

Using Voice Recognition Software to improve communicative writing and social participation in an individual with severe acquired dysgraphia: an experimental single case therapy study

Background Two previous single-case studies have reported that voice recognition software (VRS) can be a powerful tool for circumventing impaired writing in aphasia (Bruce et al, 2003; Estes & Bloom, 2011). However, these studies report mixed results regarding transfer of skills to functional tasks, such as emailing. Method A single-case therapy study was conducted with “Stephen”, a 63 -year old man with fluent aphasia and severe acquired dysgraphia and dyslexia limiting his social participation and ability to return to work. Treatment consisted of 16 one-hour sessions. Stephen was trained to use Dragon NaturallySpeakingRTM VRS to assist writing and Read+WriteGoldRTM text-to-speech software to assist reading, and to develop computer skills required to use email. Outcome measures evaluated writing efficiency and communicative effectiveness, the functional impact of the intervention, and changes in participation. Results Training produced significant gains in the efficiency and communicative effectiveness of Stephen’s writing, despite his underlying writing impairment remaining unchanged. Gains generalised to everyday functional communication, leading to increased social participation with Stephen undertaking a wider range of social activities and increasing his social network following treatment. Gains were maintained at follow-up assessment. Discussion Results indicate that a relatively short training period with assistive technologies achieved extensive generalisation to independent, functional communicative writing. Indeed, for this case, VRS training may have exceeded the degree of improvement in functional text writing that could have been achieved through impairment therapy, since gains were not limited to treated vocabulary. Some challenges were encountered in training Stephen to use VRS but, through adaptations to the training process, were largely overcome. Importantly, regaining independent writing skills resulted in profound and life-changing improvements to social participation. This may have resulted in Stephen reconnecting with important aspects of his pre-stroke identity, and improving his self-esteem. Conclusion This case adds to a small evidence base indicating that training in the use of VRS, in combination with text-to-speech software, may be an effective way to address writing impairments in chronic aphasia for individuals with relatively well-preserved spoken output. Not only can these technologies improve the efficiency and communicative effectiveness of writing, they can also lead to significant gains in functional communication and social participation. Further research is needed trialing this approach with a larger group of people with aphasia

Does mode of administration affect health-related quality-of-life outcomes after stroke?

Telephone interviews and postal surveys may be a resource-efficient way of assessing health-related quality-of-life post-stroke, if they produce data equivalent to face-to-face interviews. This study explored whether telephone interviews and postal surveys of the Stroke and Aphasia Quality of Life Scale (SAQOL-39g) yielded similar results to face-to-face interviews. Participants included people with aphasia and comprised two groups: group one (n =22) were 3-6 months post-stroke; group two (n =26) were ≥1 year post-stroke. They completed either a face-to-face and a telephone interview or a face-to-face interview and a postal survey of the SAQOL-39g. Response rates were higher for group two (87%) than for group one (72-77%). There were no significant differences between respondents and non-respondents on demographics, co-morbidities, stroke severity, or communication impairment. Concordance between face-to-face and telephone administrations (.90-.98) was excellent; and very good-excellent between face-to-face and postal administrations (.84-.96), although scores in postal administrations were lower (significant for psychosocial domain and overall SAQOL-39g in group two). These findings suggest that the SAQOL-39g yields similar results in different modes of administration. Researchers and clinicians may employ alternative modes, particularly in the longer term post-stroke, in order to reduce costs or facilitate clients with access difficulties

Speech and Language

This chapter introduces speech and language from a clinical speech and language therapy perspective. It describes key challenges that can impact upon speech and language with a focus on the needs of individuals with aphasia, an acquired language disorder. The spe-cific impact that aphasia may have upon Web accessibility is dis-cussed with reference to existing work which illuminates what we currently do and do not know about speech, language and Web ac-cessibility. The authors provide guidance for accommodating the needs of users with aphasia within the design of Web interactions and propose future directions for development and research

Delivering group support for people with aphasia in a virtual world: experiences of service providers

PURPOSE: This study explored the acceptability to service providers of delivering a novel group support intervention for people with aphasia (PWA) in a virtual world. MATERIALS AND METHODS: The service providers were six group coordinators and 10 volunteers. Fourteen of the service providers participated in a semi-structured qualitative interview and 15 took part in a consensus group discussion. Qualitative interviews were analysed using framework analysis. For consensus group discussions, nominal group rankings were analysed and semantically similar responses were identified. RESULTS: Service providers described the virtual world as a safe space in which to communicate, connect, and experiment. The key barriers were technical, particularly relating to sound and connectivity issues. Service providers suggested a range of improvements to the virtual world and intervention programme. They reported that PWA benefitted from accessing a support group in a virtual world, with opportunities to connect socially and to develop their communication skills. CONCLUSIONS: Service providers found delivery of group support intervention in a virtual world to be acceptable. The use of a bespoke virtual world to deliver group support intervention may enhance the experience and increase its accessibility, enabling more PWA to benefit from this type of intervention.Implications for rehabilitationPeople with aphasia benefit from group support intervention but may find it difficult to access face-to-face groups. Delivery of group support intervention in a virtual world is acceptable to service providers, can enhance the experience and increase accessibility of groups. Technical challenges present potential barriers when delivering group support in a virtual world, relating particularly to sound and connectivity. Potential benefits of this model of delivery, as perceived by service providers, include opportunities to connect socially and to develop communication skills plus specific and strong levels of enjoyment of the virtual context

Technology-Enhanced Reading Therapy for People With Aphasia: Findings From a Quasirandomized Waitlist Controlled Study.

Purpose This study investigated the effects of technology-enhanced reading therapy for people with reading impairments, using mainstream assistive reading technologies alongside reading strategies. Method The study used a quasirandomized waitlist controlled design. Twenty-one people with reading impairments following stroke were randomly assigned to receive 14 hr of therapy immediately or after a 6-week delay. During therapy, participants were trained to use assistive reading technology that offered a range of features to support reading comprehension. They developed skills in using the technology independently and in applying the technology to their personal reading goals. The primary outcome measure assessed reading comprehension, using Gray Oral Reading Test-Fourth Edition (GORT-4). Secondary measures were as follows: Reading Comprehension Battery for Aphasia-Second Edition, Reading Confidence and Emotions Questionnaire, Communication Activities of Daily Living-Second Edition, Visual Analog Mood Scales, and Assessment of Living With Aphasia. Matched texts were used with the GORT-4 to compare technology-assisted and unassisted reading comprehension. Mixed analyses of variance explored change between T1 and T2, when the immediate group had received therapy but the delayed group had not, thus serving as untreated controls. Pretherapy, posttherapy, and follow-up scores on the measures were also examined for all participants. Results GORT-4 results indicated that the immediately treated group improved significantly in technology-assisted reading following therapy, but not in unassisted reading. However, the data were not normally distributed, and secondary nonparametric analysis was not significant. The control group was unstable over the baseline, improving significantly in unassisted reading. The whole-group analysis showed significant gains in assisted (but not unassisted) reading after therapy that were maintained at follow-up. The Reading Confidence and Emotions Questionnaire results improved significantly following therapy, with good maintenance of change. Results on all other secondary measures were not significant. Conclusions Technology-assisted reading comprehension improved following the intervention, with treatment compensating for, rather than remediating, the reading impairment. Participants' confidence and emotions associated with reading also improved. Gains were achieved after 14 therapy sessions, using assistive technologies that are widely available and relatively affordable, meaning that this approach could be implemented in clinical practice

Treatment fidelity of technology-enhanced reading therapy (CommuniCATE) for people with aphasia

BACKGROUND: Treatment fidelity (TF), that is, the degree to which the treatment delivery has adhered to protocol, is an important aspect of establishing treatment validity and reliability. Research has shown that establishing TF is only done in a small percentage of aphasia treatment studies. AIMS: This project supports the work of the CommuniCATE study, which explored the benefits of technology-enhanced aphasia therapy on participants' reading, writing, speech and conversation skills. It examines the TF of the Reading strand of the CommuniCATE project by assessing whether the therapy adhered to the protocol. The following research questions were asked: Does treatment delivery adhere to treatment protocol? Does the degree of TF vary according to the person delivering the therapy (i.e. student therapist or qualified therapist)? Does the degree of TF vary over time (early treatment sessions compared with later treatment sessions)? Was the checklist tool reliable? METHODS & PROCEDURES: This study assessed the fidelity of 38 retrospective video recordings of therapy. It used a checklist measure of criteria to which the delivery of the sessions should adhere, and against which the sessions were rated. Participants were the people with aphasia receiving therapy, the students and qualified speech and language therapists delivering therapy, and the independent raters assessing the sessions. A sample of sessions was randomly chosen, including sessions delivered by qualified therapists and by students, and sessions from different time points in the treatment process. The fidelity was rated by the first author, and the fidelity rating calculated as a percentage. Comparisons in fidelity scores for the different variables were drawn using Mann-Whitney tests. The reliability of the checklist was assessed through inter and intra-rater reliability testing, and the results were analysed using Kappa statistics. OUTCOMES & RESULTS: High fidelity was found across all therapy conditions with a mean score of 98.2%. Fidelity scores were not affected by the administrator of therapy; sessions delivered by qualified and student therapists were rated equally highly. There was a small but significant effect of time, with later treatment sessions scoring more highly than earlier sessions. However, scores across both periods > 90%. Inter-rater reliability found a high percentage agreement of 93.3% and a Poor Kappa agreement level. Intra-rater agreement found a high percentage agreement of 97.3% and a Fair Kappa agreement level. CONCLUSIONS & IMPLICATIONS: The CommuniCATE reading therapy was implemented as per the protocol across time points, and withstood delegation to students. The high fidelity and good reliability scores have positive implications for the study's validity and reliability, and for the study's replication. WHAT THIS PAPER ADDS: What is already known on the subject TF refers to the degree to which the delivery of core components of a treatment matches the implementation guidelines, that is, the adherence to protocol. Despite the acknowledged importance of TF reporting, this is often neglected in the literature. What this paper adds to existing knowledge This paper shows that the TF assessment of the CommuniCATE study (reading strand) found a 98.2% fidelity score, and that high fidelity was not compromised across treatment conditions. This paper outlines the principles of TF and highlights the need for measures to be in place to establish TF, for example, manuals, training and supervision; and to monitor TF, for example, via the use of checklists. This paper also underlines the scarcity of TF measures and checks in aphasia research. This paper therefore serves as a model of TF practice in aphasia therapy research. What are the potential or actual clinical implications of this work? This study contributes to the findings of the CommuniCATE project (reading strand), and the high fidelity findings enhance the validity of the project and indicate that the therapy manual and training enable accurate implementation of delivery. This paper also contributes to the literature on TF evaluation in aphasia studies, which is presently lacking, and highlights the need for increased focus on the optimum strategies of TF reporting