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

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

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

Carer experiences with rehabilitation in the home: speech pathology services for stroke survivors

Caring for a stroke survivor can be a complex role with carers at an increased risk of mental health difficulties. Early supported discharge from hospital with rehabilitation in the home (RITH) allows stroke survivors to return home at an earlier stage in the recovery process, potentially placing an extra burden on carers. Being involved in intensive therapy,in the home, in the early days post-stroke may be difficult with the role and experiences of carers in RITH being underresearched. This paper identifies the roles, experiences and preferences of ten carers of stroke survivors with dysarthia and dysphagia. Many carers were involved with RITH speech pathology rehabilitation and reported positively on services. Cultural and linguistic issues and the implications of home practice for carers are also discussed

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

Preparing student paramedics for the mental health challenges of the profession by using the wisdom of the experienced

Given the significant mental health issues affecting our paramedics, there exists an urgent need to promote positive mental health and well-being among future cohorts of student paramedics.  This study investigated the preparedness of student paramedics for the mental health challenges of the profession and explored the coping strategies used by experienced paramedics.The study was conducted in two parts. Part A comprised of two surveys which were developed and administered to 16 course coordinators and 302 students of the 16 accredited undergraduate paramedicine courses across Australia and New Zealand. The survey aimed to identify the perceived need for preparation within the curriculum.  In addition, the anticipations, confidence and fears of student paramedics, Course Coordinators and paramedics were also collected as a means to explore the preparedness through self-evaluation, reflection and discussion.Part B included twenty semi-structured interviews with experienced paramedics, from Australia and New Zealand. The interviews were conducted to gain an understanding of their experiences and the mental health coping strategies they employed, as well as capture the advice they would give to student paramedics. Results from the interviews were validated by three focus groups comprised of six paramedics each, representative of the geographic spread.Results suggest there is widespread recognition for the need to include preparation for the mental health challenges of the profession, within accredited undergraduate paramedic courses, with 100% of course coordinators and 97% of students recognising this need.The interviews with paramedics provided valuable insights into the experiences and strategies used to aid the survival of the paramedics throughout their careers.  Within the interviews, 70% of participants expressed a sincere love for the paramedic role, and 70% identified black humour as the coping strategy most used by themselves and colleagues.  In addition, extensive advice was given to students based upon the paramedics’ lived experiences.  This advice comprised of three themes; support, health and the profession.   These findings were mapped against the aims of Australia’s current Mental Health Policy to provide evidence-based and policy-informed guidelines for the integration of positive mental health strategies into undergraduate paramedicine curricula.Preparing student paramedics for the mental health challenges of the profession could be advantageous.  One way to achieve this is through the inclusion of key content within the undergraduate curriculum by utilising the relatable data collected on anticipation, confidence, fears and the advice offered by the veteran paramedics can be integrated. These lived experiences are highly credible and an opportunity for veterans to contribute positively to the future of paramedicine

The role-emerging, inter-professional clinical placement: Exploring its value for students in speech pathology and counselling psychology

This paper examines the experience of a speech pathology and a counselling psychology student in a role-emerging, interprofessional clinical placement. Qualitative descriptive analysis was used to explore student and staff perceptions of the placement which took place within a prerelease detention centre, housing up to six women and their young children, within the Department of Corrective Services. Student reflections were obtained before, during and post placement completion. Reflections from academic staff involved in the project were gathered following placement completion. The analysis of these sources of data revealed that, while challenging, this placement strengthened students’ collaborative problem-solving, advocacy skills and clinical competence

Interprofessional clinical placement involving speech pathology and counselling psychology: Two students\u27 experiences

This paper examines the interprofessional learning of a speech pathology and counselling psychology student in an interprofessional placement within an institution of the Department of Corrective Services in Perth, Western Australia. The institution is a pre-release centre that promotes rehabilitation and community reintegration in which up to six women are able to have their children, aged 0–4 years of age, live with them. The students provided a program to the mothers to facilitate development of a healthy mother–child relationship and the children’s communication development. This paper utilised qualitative descriptive analysis to explore two examples of student learning and found perceived growth in the students’ clinical skills, their understanding of the other profession and the concept of interprofessional collaboration. While students experience growth in a range of placements, the journey described in this paper is unusual in both the nature of the student collaboration and the placement itself. The research highlights the importance of joint clinical placements in the development of interprofessional collaborative relationships

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

A comparison of aphasia therapy outcomes before and after a Very Early Rehabilitation programme following stroke

Background Very early aphasia rehabilitation studies have shown mixed results. Differences in therapy intensity and therapy type contribute significantly to the equivocal results. Aims To compare a standardized, prescribed very early aphasia therapy regimen with a historical usual care control group at therapy completion (4-5 weeks post-stroke) and again at follow-up (6 months). Methods & Procedures This study compared two cohorts from successive studies conducted in four Australian acute/sub-acute hospitals. The studies had near identical recruitment, blinded assessment and data-collection protocols. The Very Early Rehabilitation (VER) cohort (N = 20) had mild-severe aphasia and received up to 20 1-h sessions of impairment-based aphasia therapy, up to 5 weeks. The control cohort (n = 27) also had mild-severe aphasia and received usual care (UC) therapy for up to 4 weeks post-stroke. The primary outcome measure was the Aphasia Quotient (AQ) and a measure of communicative efficiency (DA) at therapy completion. Outcomes were measured at baseline, therapy completion and 6 months post-stroke and were compared using Generalised Estimating Equations (GEE) models. Outcomes & Results After controlling for initial aphasia and stroke disability, the GEE models demonstrated that at the primary end-point participants receiving VER achieved 18% greater recovery on the AQ and 1.5% higher DA scores than those in the control cohort. At 6 months, the VER participants maintained a 16% advantage in recovery on the AQ and 0.6% more on DA scores over the control cohort participants. Conclusions & Implications A prescribed, impairment-based aphasia therapy regimen, provided daily in very early post-stroke recovery, resulted in significantly greater communication gains in people with mild-severe aphasia at completion of therapy and at 6 months, when compared with a historical control cohort. Further research is required to demonstrate large-scale and long-term efficacy