Morag Bixley and colleagues discuss their analysis of current UK aphasia practice

Bixley, Morag

Blagdon, B.

Dean, M.

Langley, J.

Stanton, D.

English

De Montfort University Open Research Archive

Bulletin October 2011 | www.rcslt.org18FEATUREAPHASIAIn search of consensus on aphasia managementMorag Bixley and colleagues discuss their analysis of current UK aphasia practiceThe Aphasia Th erapy Specifi c Interest Group aims to provide a forum for education and discussion about impairment and social model-based therapy interventions for people with aphasia. Th e group’s October 2010 study day attracted 95 SLTs from around Britain. We asked delegates to complete and return consensus questionnaires, so we could collect information about the therapists, their posts and their views about current aphasia management choices. De Montfort University, Leicester, gave ethical approval for the research. Th e respondentsEight-six delegates, representing 55 diff erent adult therapy services, completed the questionnaires. Sixty-four had been working for seven years or less and the range was between one and 38 years. Sixty-six worked for 10 sessions each week; 57 worked in hospitals and 29 worked in combined posts covering acute and community caseloads. Respondents said they provided speech and language therapy to diff erent specialist services within the hospitals in which they worked: cancer, cardiac, elderly, general medical, infectious disease, intensive, neurological, stroke, renal and mental health care. Th ey identifi ed aphasia, cognitive communication impairment, dementia, dysarthria, dysphagia, dysfl uency, tracheostomy speech, and voice as the main communication and swallowing diffi  culties they addressed in the acute setting. Th ey also suggested the majority of therapy time was spent providing aphasia and dysphagia care. Despite individual diff erences, the average percentage of time devoted to language and swallowing diffi  culties was split equally. Th ere was little agreement about the name for the location where people with aphasia and dysphagia received therapy. Terms such as acute and stroke rehabilitation wards, stroke and elderly medicine units, stroke and orthopaedic units or neurological rehabilitation units appeared to be used interchangeably.Caseload prioritisationRespondents commented that the factors influencing their caseload prioritisation included client need, client and family concern, severity of the communication impairment and new clients with language difficulties. Seventy-three said they would prioritise clients with dysphagia and those who were at risk of dysphagia. Forty-one said they were guided by national and departmental guidelines. The prioritisation of swallowing therapy over language therapy could be attributable to the way in which stroke care is audited. In the Royal College of Physicians’ Sentinel Audit (2010) two of the 12 key indicators (KI) of quality of stroke care focus on swallowing care: ■  KI 2: ‘Screened for swallowing disorders within first 24 hours of admission’■  KI 9: ‘Swallow assessed by SLT within 72 hours’Although the perceived relative importance of dysphagia is pragmatic and necessary, it is significant that 52 of our respondents said they felt unhappy they did not have time to provide communication management for people with aphasia because of the priority given to dysphagia care. These comments were spontaneous and were not made in response to a direct question.ILLUSTRATION BY Don't Wake Me Up018-020_Bixley.indd   18 19/9/11   15:31:15October 2011 | www.rcslt.org  Bulletin 19FEATUREAPHASIAManagement choicesRespondents identifi ed 172 diff erent aphasia management choices in the acute setting. A grounded theme analysis identifi ed 25 themes and we further sorted these into fi ve main categories: support training and education (28%), therapy choices (24%), assessment (23%), multidisciplinary team working (16%) and speech and language therapy administration (9%). Th ese management choices are in line with current guidelines, such as those recommended by the RCSLT and RCP. It is apparent that the selection and prioritisation of appropriate choices from the diverse list of options present a challenge for therapists to overcome each time they meet a new client. Delegates identifi ed that it is diffi  cult to use the evidence base to support the use of one type of aphasia intervention over another in the acute phase. Th ey suggested this was because the majority of aphasia research is directed at evaluating the usefulness of therapy at a time when clients are medically stable.Outcome measuresWe asked delegates to describe the outcome measures they used to evaluate therapeutic input. Sixty-four indicated they used outcome measures and 50 of these used more than one type of measure (see table one for a summary). Despite the small sample of this study, the percentage of “Fifty-two of our respondents said they felt unhappy they did not have time to provide communication management” IN SEARCH OF CONSENSUS86 Aphasia Th erapy SIG delegates provided a record of current speech and language therapy practice−73 respondents prioritised clients with dysphagia−52 said they felt unhappy they did not have enough time to provide communication management for people with aphasia −Th e practices recorded could provide basis for future improvements to services 018-020_Bixley.indd   19 19/9/11   15:31:22Bulletin October 2011 | www.rcslt.org20FEATUREAPHASIATable one: Th e number of therapists using diff erent types of outcome measureTherapists Outcome measure Number ofLanguage measures Formal assessments:Comprehensive Aphasia Test1Psycholinguistic Assessments of Language Processing in Aphasia2 25Visual Analogue Self Esteem Scale3Frenchay Aphasia Screening Test4Informal assessments6Scaled measures Australian Therapy Outcome Measures5 18Therapy Outcome Measures6 9Rating scales 4Self rating scales 4Goal-setting measures East Kent Outcome System7 10Goal achievement 9Goal attainment scales8 7Multidisciplinary  measures Functional Assessment Measure9 5Barthel Index10 3Multidisciplinary team outcome measures 3Others Client satisfaction questionnaires 5Communicative Eff ectiveness Index11 1Aphasia Framework for Outcome Measurement12 11 Swinburn K, Porter G, Howard D. The Comprehensive Aphasia Test. Hove: Psychology Press, 2004.2 Kay J, Lesser R, Coltheart M. Psycholinguistic Assessments of Language Processing in Aphasia. London: Lawrence Erlbaum Associates, 1992.3 Brumfi tt S, Sheeran P. Visual Analogue Self Esteem Scale. Oxford: Winslow Press Limited, 1999. 4 Enderby P, Wood V, Wade D. FAST: Frenchay Aphasia Test. Chichester: Wiley Blackwell 2006. 5 Perry AA, Skeat J. Australian Therapy Outcome Measures for Speech Pathology. Melbourne: La Trobe University, 2004.6 Enderby P, John A. Therapy Outcome Measures: Speech-Language Pathology. London: Singular, 1997. 7 Johnson, M, Elias A. East Kent Outcome System for Speech and Language Therapy. East Kent Coastal Primary Care Trust, 2002.8 Gordon, JE. Powell C, Rockwood K. Goal attainment scaling as a measure of clinically important change in nursing-home patients. Age and Ageing, 1999, 28, 3, 275-81.9 Hall KM. The Functional Assessment Measure. Journal of Rehabilitation Outcomes 1997; 1:3, 63-65. 10 Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965: 14, 56-61.11 Lomas J, et al. The communicative eff ectiveness index: Development and psychometric evaluation of a functional communication measure for adult apahsia. Journal of Speech and Hearing Disorder, 1989; 54, 113-124. 12 Simmons-Mackie N, Kagan A. Application of the ICF in aphasia: AFROM. Seminars in Speech and Language Therapy 2007, 28:4, 244-253.impairment and living with aphasia-focused measures has made this shift in practice easier to accomplish. Successful transitionsTh e last focus of the questionnaire into acute practice was on transitions between and within services. Respondents said the information they considered useful when referring clients to other therapists was: personal social, medical and diagnostic information (57%), assessment results (46%), therapy tried and response to that therapy (42%), current communication skills (39%) and recommendations for therapy (23%). Th erapists reported they thought the transfer process worked best when transfers were written and verbal, and when they had secure and established professional links with the colleagues to whom they were referring. ConclusionsThe information we have recorded represents a record of speech and language therapy practice. This article highlights the challenges SLTs face in providing aphasia care and the choices they make. We would like our study to be used as a record of current practice, as a reference for a minimum standard or as a basis for future improvements to speech and language therapy services for people with aphasia.   ■Morag Bixley, Senior Lecturer SLT, De Montfort University; Becky Blagdon, Specialist Stroke SLT, Northamptonshire Provider Services; Mickey Dean, Senior SLT, Homerton Regional Neurological Rehabilitation Unit; Judith Langley, retired SLT; Debbie Stanton, Advanced Specialist SLT, Lewin Stroke and Rehabilitation Unit, Addenbrooke’s Hospital.References & resourcesHarbour R, Miller J. A new system for grading recommendations in evidence-based guidelines. British Medical Journal 2001; 323, 334-336. Hesketh A, Hopcutt B. Outcome measures for aphasia therapy: it’s not what you do, it’s the way that you measure it. European Journal of Disorders of Communication 1997; 32:3, 189-202.Royal College of Physicians. National Sentinel Stroke Clinical Audit Round 7. London: Royal College of Physicians, 2010.therapists measuring outcome appears to have increased since Hesketh and Hopcutt’s 1997 notable study, where half of the 115 participants indicated they used outcome measures to evaluate the eff ects of their intervention and only a quarter of these measures were designed specifi cally to measure aphasia intervention. Over the past decade, the increased use of outcome measures and aphasia-specifi c evaluation is almost certainly attributable to the increased use of audit within the healthcare system. Th e increased accessibility of formal published 018-020_Bixley.indd   20 19/9/11   15:31:28

In search of consensus on aphasia management.

Bixley, M

Dean, M

Blagdon, D

Langley, J

Stanton, D

UCL Discovery

Bulletin October 2011 | www.rcslt.org18FEATUREAPHASIAIn search of consensus on aphasia managementMorag Bixley and colleagues discuss their analysis of current UK aphasia practiceThe Aphasia Th erapy Speciﬁ c Interest Group aims to provide a forum for education and discussion about impairment and social model-based therapy interventions for people with aphasia. Th e group’s October 2010 study day attracted 95 SLTs from around Britain. We asked delegates to complete and return consensus questionnaires, so we could collect information about the therapists, their posts and their views about current aphasia management choices. De Montfort University, Leicester, gave ethical approval for the research. Th e respondentsEight-six delegates, representing 55 diﬀ erent adult therapy services, completed the questionnaires. Sixty-four had been working for seven years or less and the range was between one and 38 years. Sixty-six worked for 10 sessions each week; 57 worked in hospitals and 29 worked in combined posts covering acute and community caseloads. Respondents said they provided speech and language therapy to diﬀ erent specialist services within the hospitals in which they worked: cancer, cardiac, elderly, general medical, infectious disease, intensive, neurological, stroke, renal and mental health care. Th ey identiﬁ ed aphasia, cognitive communication impairment, dementia, dysarthria, dysphagia, dysﬂ uency, tracheostomy speech, and voice as the main communication and swallowing diﬃ  culties they addressed in the acute setting. Th ey also suggested the majority of therapy time was spent providing aphasia and dysphagia care. Despite individual diﬀ erences, the average percentage of time devoted to language and swallowing diﬃ  culties was split equally. Th ere was little agreement about the name for the location where people with aphasia and dysphagia received therapy. Terms such as acute and stroke rehabilitation wards, stroke and elderly medicine units, stroke and orthopaedic units or neurological rehabilitation units appeared to be used interchangeably.Caseload prioritisationRespondents commented that the factors influencing their caseload prioritisation included client need, client and family concern, severity of the communication impairment and new clients with language difficulties. Seventy-three said they would prioritise clients with dysphagia and those who were at risk of dysphagia. Forty-one said they were guided by national and departmental guidelines. The prioritisation of swallowing therapy over language therapy could be attributable to the way in which stroke care is audited. In the Royal College of Physicians’ Sentinel Audit (2010) two of the 12 key indicators (KI) of quality of stroke care focus on swallowing care: ■  KI 2: ‘Screened for swallowing disorders within first 24 hours of admission’■  KI 9: ‘Swallow assessed by SLT within 72 hours’Although the perceived relative importance of dysphagia is pragmatic and necessary, it is significant that 52 of our respondents said they felt unhappy they did not have time to provide communication management for people with aphasia because of the priority given to dysphagia care. These comments were spontaneous and were not made in response to a direct question.ILLUSTRATION BY Don't Wake Me Up018-020_Bixley.indd   18 19/9/11   15:31:15October 2011 | www.rcslt.org  Bulletin 19FEATUREAPHASIAManagement choicesRespondents identiﬁ ed 172 diﬀ erent aphasia management choices in the acute setting. A grounded theme analysis identiﬁ ed 25 themes and we further sorted these into ﬁ ve main categories: support training and education (28%), therapy choices (24%), assessment (23%), multidisciplinary team working (16%) and speech and language therapy administration (9%). Th ese management choices are in line with current guidelines, such as those recommended by the RCSLT and RCP. It is apparent that the selection and prioritisation of appropriate choices from the diverse list of options present a challenge for therapists to overcome each time they meet a new client. Delegates identiﬁ ed that it is diﬃ  cult to use the evidence base to support the use of one type of aphasia intervention over another in the acute phase. Th ey suggested this was because the majority of aphasia research is directed at evaluating the usefulness of therapy at a time when clients are medically stable.Outcome measuresWe asked delegates to describe the outcome measures they used to evaluate therapeutic input. Sixty-four indicated they used outcome measures and 50 of these used more than one type of measure (see table one for a summary). Despite the small sample of this study, the percentage of “Fifty-two of our respondents said they felt unhappy they did not have time to provide communication management” IN SEARCH OF CONSENSUS86 Aphasia Th erapy SIG delegates provided a record of current speech and language therapy practice−73 respondents prioritised clients with dysphagia−52 said they felt unhappy they did not have enough time to provide communication management for people with aphasia −Th e practices recorded could provide basis for future improvements to services 018-020_Bixley.indd   19 19/9/11   15:31:22Bulletin October 2011 | www.rcslt.org20FEATUREAPHASIATable one: Th e number of therapists using diﬀ erent types of outcome measureTherapists Outcome measure Number ofLanguage measures Formal assessments:Comprehensive Aphasia Test1Psycholinguistic Assessments of Language Processing in Aphasia2 25Visual Analogue Self Esteem Scale3Frenchay Aphasia Screening Test4Informal assessments6Scaled measures Australian Therapy Outcome Measures5 18Therapy Outcome Measures6 9Rating scales 4Self rating scales 4Goal-setting measures East Kent Outcome System7 10Goal achievement 9Goal attainment scales8 7Multidisciplinary  measures Functional Assessment Measure9 5Barthel Index10 3Multidisciplinary team outcome measures 3Others Client satisfaction questionnaires 5Communicative Eff ectiveness Index11 1Aphasia Framework for Outcome Measurement12 11 Swinburn K, Porter G, Howard D. The Comprehensive Aphasia Test. Hove: Psychology Press, 2004.2 Kay J, Lesser R, Coltheart M. Psycholinguistic Assessments of Language Processing in Aphasia. London: Lawrence Erlbaum Associates, 1992.3 Brumfi tt S, Sheeran P. Visual Analogue Self Esteem Scale. Oxford: Winslow Press Limited, 1999. 4 Enderby P, Wood V, Wade D. FAST: Frenchay Aphasia Test. Chichester: Wiley Blackwell 2006. 5 Perry AA, Skeat J. Australian Therapy Outcome Measures for Speech Pathology. Melbourne: La Trobe University, 2004.6 Enderby P, John A. Therapy Outcome Measures: Speech-Language Pathology. London: Singular, 1997. 7 Johnson, M, Elias A. East Kent Outcome System for Speech and Language Therapy. East Kent Coastal Primary Care Trust, 2002.8 Gordon, JE. Powell C, Rockwood K. Goal attainment scaling as a measure of clinically important change in nursing-home patients. Age and Ageing, 1999, 28, 3, 275-81.9 Hall KM. The Functional Assessment Measure. Journal of Rehabilitation Outcomes 1997; 1:3, 63-65. 10 Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965: 14, 56-61.11 Lomas J, et al. The communicative eff ectiveness index: Development and psychometric evaluation of a functional communication measure for adult apahsia. Journal of Speech and Hearing Disorder, 1989; 54, 113-124. 12 Simmons-Mackie N, Kagan A. Application of the ICF in aphasia: AFROM. Seminars in Speech and Language Therapy 2007, 28:4, 244-253.impairment and living with aphasia-focused measures has made this shift in practice easier to accomplish. Successful transitionsTh e last focus of the questionnaire into acute practice was on transitions between and within services. Respondents said the information they considered useful when referring clients to other therapists was: personal social, medical and diagnostic information (57%), assessment results (46%), therapy tried and response to that therapy (42%), current communication skills (39%) and recommendations for therapy (23%). Th erapists reported they thought the transfer process worked best when transfers were written and verbal, and when they had secure and established professional links with the colleagues to whom they were referring. ConclusionsThe information we have recorded represents a record of speech and language therapy practice. This article highlights the challenges SLTs face in providing aphasia care and the choices they make. We would like our study to be used as a record of current practice, as a reference for a minimum standard or as a basis for future improvements to speech and language therapy services for people with aphasia.   ■Morag Bixley, Senior Lecturer SLT, De Montfort University; Becky Blagdon, Specialist Stroke SLT, Northamptonshire Provider Services; Mickey Dean, Senior SLT, Homerton Regional Neurological Rehabilitation Unit; Judith Langley, retired SLT; Debbie Stanton, Advanced Specialist SLT, Lewin Stroke and Rehabilitation Unit, Addenbrooke’s Hospital.References & resourcesHarbour R, Miller J. A new system for grading recommendations in evidence-based guidelines. British Medical Journal 2001; 323, 334-336. Hesketh A, Hopcutt B. Outcome measures for aphasia therapy: it’s not what you do, it’s the way that you measure it. European Journal of Disorders of Communication 1997; 32:3, 189-202.Royal College of Physicians. National Sentinel Stroke Clinical Audit Round 7. London: Royal College of Physicians, 2010.therapists measuring outcome appears to have increased since Hesketh and Hopcutt’s 1997 notable study, where half of the 115 participants indicated they used outcome measures to evaluate the eﬀ ects of their intervention and only a quarter of these measures were designed speciﬁ cally to measure aphasia intervention. Over the past decade, the increased use of outcome measures and aphasia-speciﬁ c evaluation is almost certainly attributable to the increased use of audit within the healthcare system. Th e increased accessibility of formal published 018-020_Bixley.indd   20 19/9/11   15:31:28

In search of consensus on aphasia management

https://dora.dmu.ac.uk/bitstream/2086/11098/1/Pages%20from%20RCSLT_Oct_2011_Bulletin.pdf

In search of consensus on aphasia management.

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