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Priorities for Closing the Evidence-Practice Gaps in Poststroke Aphasia Rehabilitation: A Scoping Review
Accepted Manuscript Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A scoping review Kirstine Shrubsole, Linda Worrall, Emma Power, Denise A. O’Connor PII:
S0003-9993(17)31083-3
DOI:
10.1016/j.apmr.2017.08.474
Reference:
YAPMR 57011
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 31 December 2016 Revised Date:
16 July 2017
Accepted Date: 14 August 2017
Please cite this article as: Shrubsole K, Worrall L, Power E, O’Connor DA, Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A scoping review, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2017), doi: 10.1016/j.apmr.2017.08.474. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A scoping review
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Running Head: Aphasia implementation priorities
Kirstine Shrubsole1, Linda Worrall1,, Emma Power2,, and Denise A. O’Connor3
School of Health and Rehabilitation Sciences, The University of Queensland,
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University of Sydney, 3School of Public Health and Preventive Medicine, Monash
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University.
Correspondence:
Professor Linda Worrall, Communication Disability Centre, School of Health and
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Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia. E-mail: [email protected]
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Conflicts of interest: None declared.
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Funding: This work was supported by an Australian Postgraduate Award (APA) scholarship, awarded to Kirstine Shrubsole. The preliminary findings of the study were presented by Ms Shrubsole at the 2015 Stroke conference in Melbourne, Australia, to clinicians and researchers interested in the field of stroke.
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Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A
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scoping review
3 OBJECTIVE
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To identify implementation priorities for post-stroke aphasia management relevant to the
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Australian healthcare context.
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DATA SOURCES
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Using systematized searches of databases (CINAHL, Medline), guideline and stroke
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websites, and other sources, evidence was identified and extracted for seven implementation
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criteria for 13 topic areas relevant to aphasia management. These seven priority-setting
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criteria were identified in the implementation literature; strength of the evidence; current
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evidence-practice gap; clinician preference; client preference; modifiability; measurability;
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and health impact.
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STUDY SELECTION
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Articles were included if they were in English, related to a specific recommendation
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requiring implementation, and contained information pertaining to any of the seven
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prioritisation criteria.
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DATA EXTRACTION
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The scoping review methodology was chosen to address the broad nature of the topic.
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Evidence was extracted and placed in an evidence matrix. Following this, evidence was
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summarised, then aphasia rehabilitation topics prioritised using an approach developed by the
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research team.
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DATA SYNTHESIS
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Evidence from 100 documents was extracted and summarised. Four topic areas were
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identified as implementation priorities for aphasia: Timing, Amount and Intensity of
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Therapy; Goal Setting; Information, Education and Aphasia-Friendly Information; and
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Constraint-Induced Language Therapy.
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CONCLUSIONS
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Closing the evidence-practice gaps in the four priority areas identified may deliver the
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greatest gains in outcomes for Australian stroke survivors with aphasia. Our approach to
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developing implementation priorities may be useful for identifying priorities for
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implementation in other healthcare areas.
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Key Words: aphasia, stroke, clinical practice guidelines, knowledge translation,
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implementation.
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List of Abbreviations:
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CPT = Conversation-Partner Training
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CILT = Constraint Induced Language Therapy
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CPG = Clinical Practice Guideline
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SLP = Speech-Language Pathologist
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Priorities for Closing Evidence-Practice Gaps in Aphasia Rehabilitation: A Scoping
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Review
3 The failure to translate research evidence into clinical practice results in ‘evidence-practice
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gaps’. Evidence-practice gaps have been found in many areas of healthcare and can result in
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suboptimal care (1, 2). A landmark study by McGlynn and colleagues found that patients in
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the USA received guideline-recommended care on average 55% of the time (3). Similar
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evidence-practice gaps have also been observed in Australia (4) and in aphasia rehabilitation
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(5, 6).
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There is a need to close these evidence-practice gaps by engaging in implementation
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activities. Implementation ensures that stakeholders, including healthcare professionals,
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consumers and policy makers, are aware of and actively use research evidence to inform
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health and healthcare decision-making (1). A substantial body of evidence about the effects
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of implementation strategies is now available to inform the selection and design of
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implementation activities to close evidence-practice gaps (1, 7). However, limited evidence is
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available to inform and prioritise which evidence-based practices should be targeted for
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implementation.
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In an environment of competing demands for finite health resources, implementation targets
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need to be prioritised and selected, often from a large set of evidence-based
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recommendations. Healthcare professionals such as Speech-Language Pathologists (SLPs)
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have reported the limited feasibility of implementing every single guideline recommendation
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(8). Methods for identifying implementation priorities have received little attention in the
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literature to date (9), and there is no consensus on the best approach of how to prioritise
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implementation targets at a national level.
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There are a number of criteria that could be used to prioritise implementation efforts, which
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have been suggested to be important factors in implementation. For example, the Strength of
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the Supporting Evidence is an important consideration as clinicians are more likely to
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implement Clinical Practice Guideline (CPG) recommendations that are based on strong
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supporting evidence (10, 11). Information on the Evidence-Practice Gap is important to
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identify the degree to which current practice differs from guideline recommendations, and
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whether or not implementation efforts are required (12, 13). Evidence of Client and Clinician
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Preference for implementation is also important, as patient and family expectations can
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influence change (10, 14), and local opinion leaders and existing culture can influence
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stakeholder support (10, 12, 15). Other potentially important criteria include: Measurability –
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the ability to measure change in professional behaviours and/or patient outcomes compared
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to baseline data (12, 16), Modifiability - the complexity of the behaviours being changed or
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the presence of multiple or non-modifiable barriers (10, 12, 17), and Health Impact -
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evidence of important health impact resulting from a change in the recommended practice or
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behavior, including patient outcomes, quality of care and/or economic outcomes (10, 12).
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Despite general agreement on the importance of the priority criteria, very few studies have
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applied these to identify implementation priorities in any given clinical area. Two approaches
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to identify implementation priorities are previously reported in the literature; a modified
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Delphi method and conjoint analysis, both focussing on investigating stakeholders’ priorities
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for implementation. Bayley and colleagues used a modified Delphi method to prioritise
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clinical areas ready for implementation in stroke rehabilitation (18) and traumatic brain
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injury (19) in Canada. In these studies, a panel of stakeholders was invited to consider issues
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such as the strength of the supporting evidence, the prevalence of the health problem, the
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potential impact of improved care, and the feasibility of conducting an implementation
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intervention to determine priorities for implementation efforts (18, 19). Farley and colleagues
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used Conjoint Analysis to rank stakeholder implementation priorities in postnatal depression
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(9). Health care professionals working in a UK Primary Care Trust were sent a questionnaire
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and asked to rate 16 hypothetical scenarios containing potential implementation targets with
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varying attributes (e.g. strength of supporting evidence, impact on patient care, cost etc). This
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approach produced a ranked list of implementation priorities (for example, ‘self-help’ was
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rated as the top priority for implementation and ‘screening questions for post-natal
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depression’ was ranked lowest). However this approach was limited by a low response rate
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(11%) and uncertainty in stability of stakeholder preferences over time.
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Implementation Priorities in Aphasia
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To date, there have been no systematic attempts to identify implementation priorities for
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aphasia management. However, there is evidence to support the need for implementation.
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Aphasia is often a chronic condition, associated with poor functional recovery and poor
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quality-of-life (21, 22). Despite the poor outcomes for people with aphasia and the
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increasing recognition that aphasia is an important research priority (23), there are many
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evidence-practice gaps in aphasia practice. For example, in the Australian context, a
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rehabilitation audit of stroke guideline adherence found 58% adherence to recommendations
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for aphasia management (5). In the USA, only 22% of SLPs conduct Constraint-Induced
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Language Therapy (24), an intervention of proven benefit (25).
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While evidence-practice gaps in post-stroke aphasia management exist, it is unclear which of
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these areas should be priorities for implementation. Previous work by our team has identified
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34 evidence-based aphasia and general stroke rehabilitation recommendations from high-
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quality CPGs (26). The aim of this study is to identify the priorities for implementation in
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post-stroke aphasia management, relevant to the Australian context, by conducting a scoping
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review of relevant literature.
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Methods Design: We undertook a scoping review to evaluate the literature pertaining to seven
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implementation criteria (strength of the evidence; current evidence-practice gap; clinician
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preference; client preference; modifiability; measurability; and health impact) for topics in
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aphasia rehabilitation. These criteria were selected by the research team and informed by
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supporting literature on attributes considered important to decision makers for prioritizing
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implementation efforts and the teams’ experience in past projects. A scoping review was
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selected in order to address this broad topic of implementation, whereby different study
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designs may be relevant and iterative decisions need to be made once a familiarity with the
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literature is gained (27).
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We then extracted the data, synthesised and summarised the evidence, and ranked topics to
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prioritise areas for implementation. The steps in this process are described below.
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Systematized searches:
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Systematized searches were conducted for 13 topic areas for aphasia management, and the
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seven implementation criteria. This approach involved only one reviewer due to the scope of
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the paper and resource constraints (28). The aphasia rehabilitation topic areas that were
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selected were:
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•
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Conversation Partner Training/ Supported Conversation,
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Cognitive Neuropsychological-Based Therapy,
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Constraint-Induced Language Therapy,
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•
Compensatory Strategies/AAC,
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Screening Assessment,
Goal Setting,
Timing, Amount, and Intensity of Therapy,
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Computer-Based Therapy,
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Group Therapy,
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•
Information/Education and Aphasia-Friendly Information,
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•
Counselling,
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•
Caregiver Support, and
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•
Return to Work.
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These topics were selected based on our previous paper (26), where we identified 34
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evidence-based aphasia and general stroke rehabilitation recommendations from high-quality
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Clinical Practice Guidelines (CPGs). The 34 CPG recommendations were then categorised
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into the 13 topics areas to make managing and summarizing the data more manageable. The
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working definitions and source/s from which the implementation criteria were identified are
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shown in Table 1.
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For Criterion 1 (Strength of the Evidence), the Clinical Practice Guidelines from which the
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recommendations arose were the primary sources of data (29-31). The evidence grading for
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the recommendations contained in the 13 topic areas was extracted from these clinical
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practice guidelines (see Supplementary Table 1). The recommendations pertaining to
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aphasia management in the Australian and New Zealand guidelines are identical and were
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therefore combined (Aust/NZCGSM).
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For the remaining six criteria, systematic searches of two electronic databases (CINAHL,
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Medline) were undertaken to identify relevant evidence. Search terms included population
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(aphasia OR dysphasia), key words per topic area (e.g., for ‘Screening Assessment’ search
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terms included assessment OR tool OR screener OR screening) and criteria (e.g., for ‘Current
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Evidence-Practice Gap’ search terms included current practice OR practice OR gap OR
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service OR survey). Pearling references from relevant articles and searches of speech-
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language pathology and aphasia websites (e.g., www.rcslt.org/; http://speechbite.com) were
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also undertaken. Articles were included if they were in English, related to a specific
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recommendation requiring implementation, and contained information pertaining to any of
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the seven prioritisation criteria. No search limitations were placed on the date of publication.
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The final search was run on 14 November 2014. Detailed search information can be found in
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the supplementary material.
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Screening: The first author (KS) conducted the literature searches, then screened potential
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results by abstract, retrieved the full text and excluded those that did not meet the criteria.
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Data Collection and Analysis:
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An ‘Evidence Matrix’ was developed to collate data from the search of each implementation
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criteria per aphasia topic. As this Evidence Matrix was too extensive and complex for
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decision-making, the data was then summarised to show the strength of the evidence of each
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criteria in a snapshot. This allowed for comparisons across topic areas. For Strength of the
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Evidence, where multiple recommendations per topic area existed, the evidence grading from
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the recommendation with the highest strength of evidence was used. Specifically,
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recommendations originating from the Aust/NZCGSM were classified using the NHMRC
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evidence ratings (32); as High evidence = A or B, Moderate evidence = C, or Low evidence =
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D. Recommendations from the NICE 162 was classified using the GRADE evidence ratings
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(33) as High evidence = Strong, or Low evidence = Weak.
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The evidence for the remaining six criteria (Current Evidence-Practice Gap, Clinician
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Preference, Client Preference, Measurability, Modifiability, and Health Impact) was
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evaluated using a decision-making process that was developed iteratively by the authors
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during the analysis phase, in the absence of specific published methods (see Figure 1). The
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Current Evidence-Practice Gap data was calculated by determining the difference between
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current practice in each specific topic area and 100% guideline adherence (i.e. 100% - current
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practice percentage). Where evidence was found for the implementation criteria (e.g.,
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Current Evidence-Practice Gap), this was classified as either qualitative or quantitative.
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Where data was found for current practice in both stroke and aphasia populations, the data
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from aphasia practice was used. For quantitative data, evidence was classified as Low (for
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<50% uptake of evidence, not a significant p value, or inconsistent or small effect sizes),
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Moderate (for 50-74%) or High (>75%, a significant p value or a large effect size). The
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decision to use quartiles to evaluate the uptake of recommendations was based on a similar
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study in falls prevention (34). Qualitative evidence was symbolized using QUAL, with either
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a ‘+’ to signify that the evidence was in support of implementation, or ‘–’ sign to indicate the
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evidence did not support implementation, such as negative patient reports or barriers to
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implementation. For an illustrative example of this process, please refer to Figure 2.
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(Insert Figure 1 about here).
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(Insert Figure 2 about here).
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(Insert Table 2 about here)
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When reviewing and synthesising this evidence, it became apparent there were potentially
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important differences between data reported relevant to criteria 2 – 6 in studies conducted in
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different countries (e.g. data on evidence-practice gaps for group therapy in Australia vs. in
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other countries). Given this study aimed to prioritise topics for implementation in post-stroke
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aphasia management relevant to the Australian setting, it was determined that the summary
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of the evidence relating to criteria 2 – 6 would only include studies conducted in Australia.
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Prioritisation of Topics for implementation
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The 13 topic areas were prioritised according to the summarised data for the seven criteria.
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Since stronger evidence is more likely to be implemented (11, 35) and areas with large
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evidence-practice gaps should be implementation targets (12, 13), the first two criteria were
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weighted more heavily. The remaining criteria were considered with equal weighting as
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there was no clear reason or precedent in the literature to prioritise one over the other. A
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decision-making tree was developed, where topic areas were considered to be of highest
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priority for implementation where evidence was as follows:
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a) ‘High’ evidence for Strength of the Evidence, and
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b) ‘High’ or ‘Moderate’ evidence for Current Evidence-Practice Gap, and
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c) Evidence available to support implementation in any of the other criteria (Clinician
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Preference, Client Preference, Measurability, Modifiability, and Health Impact), with
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topics ranked according to the total support across the seven criteria.
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Priority Topics were then ranked based on the total support for (c). That is, topics areas for
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which we identified evidence for more criteria in ‘c’ were ranked higher than those that had
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fewer criteria.
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Results
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The evidence matrix is presented in the supplementary online material as Table 1. The
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general stroke rehabilitation recommendations for Strength of the Evidence are presented in
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the first column for the 13 topic areas. For evidence of the Current Evidence-Practice Gap,
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Clinician Preference, Client Preference, and Health Impact, 2009 documents were identified
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for screening. Of these, 1909 documents were excluded, and findings from the remaining 100
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were included (see PRISMA flowchart, Figure 3). As Modifiability was related specifically to
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implementation barriers or enablers, and a preliminary search found limited literature in this
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area for aphasia, data for this criterion was used from search results for other criteria.
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Similarly, as information relevant to Measurability was not specifically reported in any of the
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studies retrieved, judgments were made about the complexity of the behaviours to be
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measured and whether this data appeared to be routinely collected (as determined in findings
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from the Current Evidence-Practice Gap searches).
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(Insert Figure 3 about here).
4 Summary of the Existing Evidence for Implementation
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a) Strength of the Evidence. Seven of the 13 topic areas were underpinned by high evidence
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(A or B level in the AustCGSM or Strong in the NICE162): Goal Setting;
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Timing/Amount and Intensity of Therapy; Conversation Partner Training; Constraint
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Induced Language Therapy; Information/Education and Aphasia-Friendly Information;
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Counselling; and Return to Work. A further five topic areas were underpinned by
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moderate evidence: Screening Assessment; Cognitive Neuropsychological-Based
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Therapy; Computer-Based Therapy; Group Therapy; and Caregiver Support.
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b) Current Evidence-Practice Gap. Six topic areas had gaps of moderate-to-high magnitude: Goal Setting (acute setting); Timing/Amount and Intensity of Therapy (acute and
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rehabilitation settings); Constraint Induced Language Therapy (rehabilitation setting);
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Computer-Based Therapy (rehabilitation setting); Group Therapy (acute and
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rehabilitation settings); and Information/Education and Aphasia-Friendly Information
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(acute and rehabilitation settings). The remaining seven topics had gaps of low
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magnitude: Screening Assessment; Conversation Partner Training; Cognitive
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Neuropsychological-Based Therapy; Compensatory Strategies/AAC; Counselling;
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Caregiver Support and Return to Work.
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c) Clinician Preference. There was evidence that clinicians perceived eight topic areas to be
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important (six via qualitative studies and two via quantitative studies). These were Goal
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Setting; Timing/Amount and Intensity of Therapy; Conversation Partner Training;
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Compensatory Strategies/AAC; Computer-Based Therapy; Information/Education and
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Aphasia-Friendly Information; Counselling; Caregiver Support. There was evidence that
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clinicians had either negative perceptions of, or no identified implementation need for,
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the following topics: Screening Assessment; Cognitive Neuropsychological-Based
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Therapy, Constraint Induced Language Therapy; and Group Therapy. For example, the
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majority of clinicians rated knowledge of and confidence with cognitive
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neuropsychological approaches as very good/good or very high/high (36). There was no
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Australian evidence found for clinician views on the topic Return to Work.
d) Client Preference. There was also evidence that patients perceived ten topic areas to be
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important (eight from qualitative studies, one from a quantitative study). These included
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Goal Setting; Timing/Amount and Intensity of Therapy; Conversation Partner Training;
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Cognitive Neuropsychological-Based Therapy; Compensatory Strategies/AAC; Group
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Therapy; Information/Education and Aphasia-Friendly Information; Counselling;
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Caregiver Support; and Return to Work. There was evidence that clients had negative
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perceptions of Constraint Induced Language Therapy, with only 3/11 clients expressing
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preference for CILT compared to Multi-Modal Aphasia Therapy (37). There was no
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Australian evidence found for client views on the topics Screening Assessment and
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Computer-based Therapy.
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e) Modifiability. While several topics (Timing, Amount and Intensity of Therapy, Carer
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Training/Conversation Partner Training, and Counselling) had evidence from qualitative
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studies of both barriers and facilitators to implementation, almost a third (4/13, 31%) had
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no information available.
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f) Measurability. Six topics (46%) included complex behaviours that were either difficult to
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observe or not routinely collected. These included Goal Setting; Conversation Partner
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Training; Cognitive Neuropsychological-Based Therapy; Information/Education and
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Aphasia-Friendly Information; Counselling; Caregiver Support.
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g) Health Impact. The majority of topics (9/12, 75%) had evidence of a significant health
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impact or large effect size. The remaining topics had inconsistent (Goal Setting and
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Cognitive Neuropsychological-Based Therapy) or moderate (Timing/Amount and
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Intensity of Therapy) effects. A summary of the extracted evidence for each criterion per topic area is shown in Table 2.
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(Insert Table 2 about here).
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Prioritisation process
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Four priority topic areas were identified for implementation in post-stroke aphasia
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rehabilitation. The topics “Information, Education and Aphasia-Friendly Information” and
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“Timing, Amount and Intensity of Therapy” were ranked equal first priority. “Goal Setting”
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was ranked third, and “Constraint-Induced Language Therapy” was ranked fourth for
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implementation. This decision-making process is shown in Figure 4.
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The first two prioritised areas (“Information, Education and Aphasia-Friendly Information”
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and “Timing, Amount and Intensity of Therapy”) had moderate or high evidence-practice
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gaps, and supporting evidence for all other criteria. “Goal-setting” had moderate or high
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evidence-practice gaps and had supporting evidence for 80% of the remaining criteria.
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“Constraint-Induced Language Therapy” had moderate or high evidence-practice gaps with
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supporting evidence for only two criteria (40%), but no Australian information on clinician
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preference, poor patient satisfaction, and evidence of barriers for implementation.
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(Insert Figure 4 about here).
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Discussion
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This study sought to identify priorities for implementation in post-stroke aphasia
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management relevant to the Australian setting. This is the first attempt to our knowledge of
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applying a criteria-based priority-setting process to identify clinical topic areas and their
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associated recommendations ready for implementation in aphasia rehabilitation.
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Using multiple pre-defined prioritisation criteria was a novel component of this study. While
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previous work has suggested a range of different factors to consider when deciding on which
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evidence to implement (10, 12), none of these studies used a priori criteria to evaluate the
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evidence for implementation. Some targeted attempts at priority-setting have been
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undertaken that have focused on using a consensus approach (18, 19) or Conjoint Analysis
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for treatment preferences (9, 20), but these did not extract, summarise and rank the evidence
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for a predetermined set of criteria as we have done. In this way, we have built on previous
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priority-setting attempts and provided a broad helicopter view of the available evidence for
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implementation across aphasia management recommendations in the Australian context.
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However, the benefits of this approach need to be considered alongside the considerable
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amount of work that it requires.
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Although seven criteria were used in our scoping review, it is unclear which of these are the
15
best to use, and whether all of them are necessary. It could be argued that the first two
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criteria, Strength of the Evidence and Current Evidence-Practice Gap, would provide a
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quicker and more pragmatic way to prioritise implementation targets. In this study, we found
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that these criteria had complete data sets, and the evidence for these was relatively easy to
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locate and extract from the scoping search. However, given that there is evidence that other
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criteria such as client and clinician preference can impact on the success of implementation,
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there is potential to overlook important information if using a pared-down approach.
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Locating Existing Data for the Implementation Criteria
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Searching for and synthesising the relevant data sets for aphasia-related topics was a
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challenge, as data relating to several criteria was often difficult to find. There was a lack of
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information available related to clinician and client preferences. Evidence relating to these
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criteria was often not the focus of the study, but embedded within it. One Australian study
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did directly examine speech-language pathologists’ priorities (36) but determined research
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priorities rather than priorities for implementation. Other criteria with limited quantitative
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data were modifiability and measurability. The modifiability criteria depended on reported
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barriers for each implementation topic, and these varied between clinical contexts (11).
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Measurability of guideline-recommended behaviours was not specifically reported in any of
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the studies examined. While incomplete data sets for these criteria was discouraging, it was
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not surprising, given that there has been limited research into the factors influencing
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implementation in aphasia, highlighting a need for further research.
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Determining the ‘Linkages’ and Accuracy of the ‘Gap’ Data
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The majority of information found for the current evidence-practice gap comprised audit or
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survey data, however the practice being measured did not always correspond to the guideline
15
recommendation. For example, the Australian rehabilitation stroke audit (6) found that 96%
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of the recommended intensity of swallowing and communication therapy was provided in
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clinical practice, but the audit did not measure intensity of communication therapy alone. It is
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suggested that future audit tools be more closely linked to the clinical practice guideline
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recommendations.
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One topic area, Carer Training/Conversation-Partner Training (CPT), showed some
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particularly interesting findings that may warrant further investigation. For CPT, the
22
evidence-practice gap was low (8-24% gap) in the rehabilitation setting (6, 38), indicating
23
that clinicians are using it 76-92% of the time. However, clinicians have reported low use and
24
poor or very poor confidence with CPT approaches (36). These contradictory results may
25
suggest that clinicians are not confident about implementing CPT but have implemented it
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nevertheless. Alternatively it could suggest that the audit data recorded incidences of general
2
advice given to carers about communicating with the person with aphasia, while SLPs who
3
responded to the survey may define Communication Partner Training as a specific technique
4
such as that described by Kagan and colleagues (39). These uncertainties highlight a need for
5
specific and accurate audit data on current aphasia rehabilitation practices by speech-
6
language pathologists.
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7 Implementation Priorities
9
The four implementation priorities that we identified originate from recommendations
10
referring to different aspects of SLPs’ aphasia management practices: 1.“Information,
11
Education and Aphasia-Friendly Information” refers to the process of providing written,
12
tailored, aphasia-friendly information at different stages of recovery; 2. “Timing, Amount
13
and Intensity of Therapy” refers to the timing, dosage and duration of therapy, but does not
14
specify the type of therapy that should be provided; 3. “Goal Setting” refers to a collaborative
15
process of identifying patient-related goals that are documented and updated regularly; and 4.
16
“Constraint-Induced Language Therapy” is a specific type of therapy approach (30).
17
Although we considered clinicians’ preferences for implementation in our prioritization
18
process, this was based on the limited published evidence (discussed above), and future
19
research should focus on prospectively identifying clinicians’ implementation priorities to
20
determine if they align with our findings.
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Although we used Australian evidence-practice gap data in our decision-making
22
process, the results from this study may be relevant to aphasia management in other
23
countries. The evidence informing prioritization of implementation targets was sourced
24
internationally, therefore could be applied to local evidence-practice gap data elsewhere.
25
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APHASIA IMPLEMENTATION PRIORITIES
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Study Limitations
2
Searching for evidence relevant to the seven priority-setting criteria was challenging,
3
potentially meaning that not all relevant evidence was found and summarised here.
4
Furthermore, one member of the research team conducted many aspects of the decision-
5
making process (e.g., searching for, screening and extracting data for the evidence matrix).
6
While this is acceptable within some definitions of a scoping search (28), two or more
7
researchers should ideally undertake these tasks independently to reduce the potential for bias
8
(27). The date of the last run search is also a limitation of the study, however a new targeted
9
search revealed that it is unlikely that we have missed relevant papers. Finally, the thresholds
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for categorizing the evidence into high, moderate and low was based on earlier work (34)
11
although the cut-off values were somewhat arbitrary.
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12
Conclusion and Implications
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This study identified potential implementation priorities for post-stroke aphasia management
15
in Australia. The study highlights the current evidence and gaps in evidence for
16
implementation criteria. Further research is needed in several areas, including evaluating
17
clinician and patient preferences and the feasibility of implementation. Moreover, it is
18
suggested that audit tools are developed that can accurately measure each recommendation
19
requiring implementation.
20
Priority-setting for implementation is a complex process that requires further investigation. It
21
remains to be seen whether expert opinion, systematic reviews across all seven criteria or just
22
the two most-important criteria produce similar results. It is anticipated that the priority-
23
setting framework we have presented could serve as a guide to researchers and stakeholders
24
both in stroke and aphasia rehabilitation and in other areas of healthcare. Furthermore, this
25
process could form the basis of a national strategy to improve implementation efforts in
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1
aphasia management, as closing the evidence-practice gaps in the identified priority areas
2
may deliver the greatest gains in outcomes for stroke survivors with aphasia.
3 4
6
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Hilari K, Northcott S, Roy P, Marshall J, Wiggins RD, Chataway J, et al.
Pollock A, St George B, Fenton M, Firkins L. Top ten research priorities relating to
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language therapy. Topics in stroke rehabilitation. 2014;21(4):332-8.
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Shrubsole K, Worrall L, Power E, O’Connor D. Recommendations for aphasia
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associated methodologies. Oxford, UK2009. p. 91-108.
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Rehabilitation After Stroke (NICE Clinical Guideline 162). United Kingdom2013.
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Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al.
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1
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Rose M, Ferguson A, Power E, Togher L, Worrall L. Aphasia rehabilitation in
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aphasia: A survey of current practice in Australia. International journal of speech-language
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Table 1. Definitions for Criteria for Identifying Implementation Priorities
23
Table 2. Summary of the Implementation Evidence Matrix
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Figure 1. Decision-Making Process for Classification of Evidence
25
Figure 2. Evidence Decisions for Goal-Setting Topic
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Rose ML, Attard MC, Mok Z, Lanyon LE, Foster AM. Multi-modality aphasia
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Verna A, Davidson B, Rose T. Speech-language pathology services for people with
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Kagan A, Black SE, Duchan JF, Simmons-Mackie N, Square P. Training volunteers
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Figure 3. PRISMA flow chart of included studies Figure 4. Prioritization of Implementation
2
Topics
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Table 1. Definitions for Criteria for Identifying Implementation Priorities Definition
Rationale
1. Strength of the
Evidence grading as per relevant evidence-based Clinical Practice
Recommendations underpinned by strong evidence constitute important targets
Evidence
Guideline or systematic review.
for change (there is a body of evidence that can be trusted to guide practice).
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Criteria
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Clinicians more likely to implement CPG recommendations if they are based on strong evidence. (Goossens, Bossuyt, & de Haan, 2008; Grol & Wensing,
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2004).
Evidence of the difference between recommended practice (from
Important to identify which areas have evidence-practice gaps that need
Practice Gap
research evidence) and current practice – taken from clinical audits,
addressing. Areas demonstrating higher evidence-practice gaps may constitute
surveys or other sources.
more important priorities for implementation (with greater room for
Evidence of preference or stakeholder support for performing the
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3. Clinician Preference
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2. Current Evidence-
recommended practice from the perspective of clinicians (in this
improvement). (Kitson & Straus, 2010; National Institute of Clinical Studies,
2006). Local opinion leaders and existing culture can influence change. (Flodgren et al., 2011; Grol & Wensing, 2004; National Institute of Clinical Studies, 2006).
4. Client Preference
5. Modifiability
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instance speech-language pathologists).
Evidence of preference or stakeholder support for performance of the
Patients’/family members’ expectations can influence change. Patients need to
recommended practice from the perspective of healthcare consumers,
agree with the recommended practice and be able to comply with it. (Grol &
i.e., people with aphasia or carers/family members.
Wensing, 2004).
Evidence of barriers and facilitators to implementation, such as
More complex behaviours may be more difficult to change. Behaviours may be
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complexity of behaviour or resources required to change.
more difficult to change where multiple or non-modifiable barriers exist. Important to identify barriers to change to tailor interventions. (Baker et al.,
Evidence of the measurability of performance of the recommended
Performance of recommended practices may be measured using different data
practice, in terms of feasibility of data collection and potential for
collection methods and sources (e.g. via patient medical records, clinician self-
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6. Measurability
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2010; Grol & Wensing, 2004; National Institute of Clinical Studies, 2006).
bias.
report, routinely collected data). These methods may vary in terms of feasibility
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of data collection and potential for bias. Behaviours for which performance is feasible to measure and in a manner that minimises bias are most desirable. (National Institute of Clinical Studies, 2006). Health impact should incorporate patients’ capacity to benefit from treatment.
recommended practice or behavior (including patient outcomes,
Economic advantage could be attractive to organisations and influence change.
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Evidence of important health impact resulting from a change in the
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quality of care and/or economic outcomes).
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7. Health Impact
(Grol & Wensing, 2004; National Institute of Clinical Studies, 2006).
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Table 2. Summary of the Implementation Evidence Matrix
Criteria
1. Strength of
2. Current Evidence-Practice
3. Perceived
Evidence (area
Gap
importance – Clinicians
4. Perceived
5. Modifiability
6. Measurability
7. Health Impact
Importance – Client
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of practice)
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Topic Area
C Aphasia (M)
18-23% gap (a + r) (L)
44% (L)
Nil
Q-
Q+
Q+
2. Goal Setting
B Stroke (H)
13-21% gap (r) (L)
Q+
Q+
Q-
Q+, Q-
Inconsistent (L)
100% (H)
97% (H)
Q+, Q-
Q+
Moderate (M)
Q+
Q+
Q+, Q-
Q+, Q-
Significant effect (H)
73% gap (a) (M) 3. Timing, Amount, and Intensity of
B Aphasia (H)
Therapy
50% gap (r) (M) 75-91% gap (a) (H)
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1. Screening Assessment
B Stroke (H)
8-24% gap (r) (L)
Supported Conversation
C Aphasia (M)
31% gap (a) (L)
5. Cognitive Neuropsychological-
C Aphasia (M)
25% gap (r) (L)
Q-
Q+
Nil
Q+, Q-
Inconsistent (L)
B Aphasia (H)
86% gap (r) (H)
0 (L)
27% (L)
Q-
Q+
Large effects (H)
7. Compensatory Strategies/AAC
D Aphasia (L)
39% gap (r) (L)
100% (H)
54% (M)
Q+
Q+
Significant effect (H)
8. Computer-Based Therapy
C Aphasia (M)
86% gap (r) (H)
Q+
Nil
Q+
Q+
Significant effect (H)
9. Group Therapy
C Aphasia (M)
Q-
Q+
Nil
Q+
Medium-large effects
6. Constraint-Induced Language
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Therapy
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Based Therapy
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4. Conversation Partner Training/
46-80% gap (r) (M) 100% gap (a) (H)
10. Information/Education and
A Stroke (H)
51% gap (aphasia a + r) (M)
Aphasia-Friendly Information
D Aphasia (L)
*28% gap (stroke r) (L)
11. Counselling
B Stroke (H)
34% gap (aphasia a + r) (L)
(M-H) Q+
Q+
Q+
Q+, Q-
Significant effects (H)
Q+
Q+
Q+, Q-
Q+, Q-
Significant effect (H)
Q+
Q+
Q+
Q+, Q-
Significant effects (H)
*68% gap (stroke rehab) (M) 12. Caregiver Support
C Stroke (M)
41% gap (aphasia a + r) (L)
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*38-68% gap (stroke r) (M) Q+
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Nil Q+ Q* a r
Nil
Nil
Q+
Significant effects (H)
High evidence (A or B on AustCGSM/Strong on NICE 162; ≥ 75% for Criteria 2-6; Significant clinical outcome or large effects for Criteria 7) Moderate evidence (C on AustCGSM; 50-74% for Criteria 2-6; Moderate effects for Criteria 7) Low/inconsistent evidence (D on AustCGSM/Weak on NICE 162; < 50% for Criteria 2-6; Not significant clinical outcome or inconsistent/small effects for Criteria 7) No information found Qualitative evidence to support implementation Qualitative evidence not supportive of implementation Where data present for aphasia and stroke populations, stroke data not used Acute setting Rehab setting
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M L
14-31% gap (r) (L)
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Key H
Strong (H)
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Supplementary Online Material – Evidence Matrix
Salter, Jutai [1].
Australia: Acute stroke audit 2011 82% of eligible pts had SP assessment (doesn’t specify if for speech or swallowing). No info on how many had communication screen/ax and if so, what type of screen [2]. 77% of SPs used screening assessments (across all settings) [3].
3. Perceived importance – Clinicians Australia: SLPs concerned re limited test repeatability and poor sensitivity to change in acute settings of standardized tests * Little consensus on most appropriate Ax tool in acute * 56% agree/strongly agree that informal evaluations more useful than formal ax in acute. * SPs want quick, repeatable, objective test. [4]
4. Perceived Importance – Patient Australia: No info found
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Aust 2010 / NZ 2010
2. Current Practice/Gap
Elsewhere: UK –SLP Ax not always viewed as appropriate, especially in early stages of recovery [8]
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6.5.1a) All patients should be screened for communication deficits using a screening tool that is valid and reliable.
1. Strength of Evidence Grade C
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Citation/s
70% acute SPs use their own clinical assessment based on interaction and observation. Not validated/reliable. Formal screeners used were BEST (20%), AST (15%), FAST (14%) [4]
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Guideline/s
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Criteria
Recommendation
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1. Screening Assessment
Elsewhere: US – Average time from admission to Ax was 3.9 days, 55% within 2 days [5] . UK, US, Canada, Australia - 36% use informal test in inpatient setting [6].
5. Modifiability
6. Measurability
7. Health Impact
Barriers include no widely acceptable/ appropriate screening tool currently available. Barriers may include clinician attitudes or beliefs [4].
Able to measure if assessment conducted and which assessment used. Data appears to be routinely documented, or able to be easily collected.
Need to ID presence of aphasia so that appropriate SLP services can be provided. Under identification aphasia an issue impacting on service delivery [3, 9, 10] Aphasia an independent predictor of increased LOS and increased use of rehab services [11] PWA participated in fewer activities and reported worse QOL than people without, with comparable physical abilities, well-being and social support [12]
Elsewhere: No info found.
1
Criteria Guideline/s
Citation/s
1.7b) Stroke survivors and their families/carers should be given the opportunity to participate in the process of setting goals unless they choose not to or are unable to participate. 1.7c) Health professionals should collaboratively set goals for patient care.
Aust 2010/NZ 2010.
Stroke Unit Trialists' Collaborati on [13].
Playford, et al., [30]
C
2. Current Practice/Gap
Australia: -Rehab Audit 2012 – 79% involved in setting own rehabilitation goals (excluding those with severe comm disorders). 82% of sites use formal process for goal setting [14]
Acute Audit 2011 27% of patients met with MDT to discuss assessment results, treatment plans and goals [2]. Inclusion of family members in goal setting
SPs believe living successfully with
Rehab Audit 2014 – 87% [15].
Aust 2010/ NZ 2010.
Playford, et al., (2009). [30]
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3. Perceived importance – Clinicians Australia: Joint, functional goal setting with PWA and families a significant challenge [23].
- Matched goals focused on comm’n outcomes. Mismatched goals associated with client’s desire to return to previous activities [17].
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1.7c) Goals should be prescribed, specific and challenging. They should be recorded, reviewed and updated regularly.
Aust 2010/ NZ 2010.
1. Strength of Evidence Grade B
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Recommendation
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2. Goal Setting
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Singapore - Currently no aphasia assessment tool that has been validated for use with the Singapore population. Informal language assessments most commonly reported (62.8%) [7].
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4. Perceived Importance – Patient Australia: Social communication goals strongly emphasised [25]. As people move though acute, rehab, and to home, their goals changed [18]. Participant’s level of involvement in decision-making, goal-setting and therapy activities influenced satisfaction and dissatisfaction
5. Modifiability
6. Measurability
7. Health Impact
No critical framework for goal setting [16]. Proposed SMARTER goal setting (set of principles, not validated) [28].
Able to measure if goal setting conducted, people involved and when goals revisited. Data appears to be routinely documented, or able to be easily collected. However, may be difficult to document/ observe data relating the degree to which PWA collaborated.
Goal setting enhances clients’ adherence to treatment and improves immediate client performance in some contexts, but only inconsistent evidence for any generalized effect [29]
Barriers: timeconsuming, demanding process of establishing a meaningful relationship [29-31]
2
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Disparity between SLP services and client values re goal-setting and therapy goals [18]. 37.7% of respondents reported goal attainment scaling [3].
Elsewhere: Scotland - 89% involved clients in goal setting some or most of the time and family members were encouraged to become involved [19].
[26]. Elsewhere: Scotland - Many people felt excluded from overall care management and would have liked more inclusive role. They valued being included in decision making about goals [19].
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Some discrepancy between clinician’s and PWA goals. Clinicians not always aware of clients’ goals [17].
aphasia can depend on PWA’s ability to set and work towards realistic goals [24].
Elsewhere: Scotland - Most commonly reported change to practice involved including people with aphasia more in goal setting and making goals for therapy more patient-centred. [19].
SC
and decision making limited, often due to poor access, time [16].
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Sweden– 73% of carers prepared to take part in goal setting [27].
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Langhorne, Pollock [32].
Finland – 58-85% of patients participate in therapy planning process <1 yr post stroke, vs 97% >1 yr post stroke [20].
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Aust 2010/ NZ 2010.
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1.8 The multidisciplinary stroke team should meet regularly (at least weekly) to discuss assessment of new patients, review patient management and goals, and plan for discharge.
UK - 4–20% of family members were involved in their relative’s rehab goals (general stroke, not aphasia-specific) [21] Sweden – 15-47% of pts reported participating in goal-setting during
3
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discharge planning [22].
Guideline/s
Citation/s
6.1.2b) Treatment for aphasia should be offered as early as tolerated.
Aust 2010/ NZ 2010
Godecke [33].
1. Strength of Evidence Grade B
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Recommendation
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Criteria 2. Current Practice/Gap
Australia: Inpatient = 1-5 sessions for Aust. Ave treatment session
3. Perceived importance – Clinicians Australia: Research priorities –
4. Perceived Importance – Patient Australia: High pt satisfaction
5. Modifiability
6. Measurability
7. Health Impact
Could be difficult to change amount/ timing of therapy in
Able to measure when therapy offered and
- Intensive programs incorporating group and computer therapy
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3. Timing, Amount and Intensity of Therapy
RI PT
Singapore - About twothirds of participants reported having input from client (67.9%) and family (67.9%) during goal setting at least ‘‘frequently” [7].
4
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4 hrs per week for IP rehab, 2 hrs acute, 1 hr chronic. >50% saw rehab patients daily, compared to 9% in acute [3].
M AN U
Usual care < once per week with majority of PWA not receiving any therapy in acute [10].
• intensive treatments • multi-site RCTs examining dose, timing, intensity • ideal timing for various approaches including the acute phase Acute SPs feel tension between current practice and implementatio n of more intensive inpatient therapy [23].
Only 9% of SPs provided daily therapy in acute [34]. - >75% didn’t receive therapy in acute, ave of 13 mins per week [35]. Rehab Audit 2014 recommended intensity of swallowing and communication therapy was provided 96% [15].
Rehab Audit 2012 recommended intensity of swallowing and communication therapy was provided 94% [14]. Elsewhere: Canada, US, and UK inpatient = 1-5 sessions for Aust/UK, 16-20 Canada/US [6]. UK - amount of therapy that
with intensive programs. 97% would recommend. Pts often tired after therapy, but this didn’t affect attendance [39].
RI PT
length 30m for inpatients, and 60m for chronic outpatients [6].
SC
C
TE D
Bhogal, Teasell [46]; Bakheit, Shaw [43]; Godecke [33].
EP
Aust 2010/NZ 2010
AC C
6.1.1d) As much therapy for communication difficulties should be provided as can be tolerated.
100% of clinicians would recommend intensive tx. Highlighted issues of resources. SPs felt intensive tx more difficult to provide [39]. Elsewhere: Finland Approximately half of acute SLPs had insufficient
Elsewhere: Norway 2 pts preferred less intensive vs 1 pt [40]. Hong Kong majority of participants dissatisfied with SLP services citing the need for more frequent SLP treatment sessions provided in hospital-based inpatient settings (53%) and more intensive individual or group SLP treatment provided in hospital-based SLP outpatient settings (48%) [38].
acute setting given priority given to swallowing caseload and other barriers such as role perception, poor staffing, physical environment [41, 42]. Might be hard to modify due to complex nature of resource allocation but at least one trial being conducted currently in acute setting. Recent intensity study in QLD health showed feasibility of implementing approach in outpatient setting – used group, computer and therapy assistant [39]. - Many structural barriers to implementing intensive service delivery models: inadequate space and facilities, inflexible funding models, and a lack of staffing. Clinicians reported significant
amount provided. Data appears to be routinely documented, or able to be easily collected.
shown to have high cost-benefit ratio compared to usual care [39]. - No treatment effect of intensive therapy (P > 0.05) [43]. - estimated six months group difference was not statistically significant, with 0.25 (95% CI –0.19 to 0.69) points in favour of therapy [44]. - In chronic aphasia, studies provided modest evidence for more intensive treatment. In acute aphasia, 1 study evaluated high-intensity treatment positively [45]. - At hospital discharge, participants assigned daily treatment had significantly better communication outcomes than controls (usual care) as measured by the AQ score (Kruskal-Wallis H= 6.07, df= 29,23, p = 0.014) and the FCP score (Kruskal- Wallis H = 3.96, df= 29,23, p =
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clients receive is well below that recommended by the literature [36].
time for executing therapy itself [20].
0.047) [33]. - The number of hours of therapy provided in a week was significantly correlated to greater improvement on the PICA (P<0.001) and the Token Test (P<0.027) [46].
Recommendation
Guidel ine/s
Citation/s
AC C
4. Carer Training/Conversation Partner Criteria Training
EP
TE D
M AN U
Hong Kong - frequency of inpatients' sessions, usually provided once every week (27.0%) or every month (16.2%) [38].
challenges in providing aphasia management in acute care where dysphagia is the dominant caseload [23].
SC
Finland - 11-24 sessions in 1st year post CVA [20].
RI PT
US - Intensive Aphasia Therapy used by 38.5% of SPs [37], however on ave 1.2 therapy sessions in acute [5].
UK - Relatives and PWA differed in terms of how they viewed the timing of therapy. PWA generally felt that therapy itself could be delayed in order for them to have time to ‘clear the fog’. Relatives thought that therapy could not start soon enough [8].
1. Strength of Evidence Grade
2. Current Practice/Gap
3. Perceived importance – Clinicians
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
6
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Rehab Audit 2012 Supported conversation techniques are a
Australia: Family members expressed strong desire for conversation with PWA [52].
Barriers and facilitators perceived by SPs include: having communication resources available, having skilled, knowledgeable, and supportive healthcare providers, and having the systems in place. SLPs believe that healthcare providers may be reluctant to invest the time and effort because this may create additional work when they are already under
RI PT
Rehab Audit 2014 Carer received training - 84%, Supported conversation techniques 76% [15].
Australia: Research priorities – Conversation partner training Clinicians reported low use and poor/very poor confidence with CPT approaches. Reported wanting to do more frequent, comprehensive CPT but finding time &resources limited. Acknowledged limitations of family availability [23].
Elsewhere: UK - 80% pt satisfaction with program [53].
SC
Aust 2010 /NZ 2010
B
Australia: CPT second most frequently used intervention, 69% used in acute, 92% in rehab, 93% in OP, 68% in community, 50% in aged care and private practice [3].
M AN U
Kalra, Evans [47].
A
UK - carers expressed training needs [54] Hong Kong -The additional resources or services that the family members
Able to measure if CPT provided but may be more difficult to determine what approach SLP took and whether SLP adhered to a specific program. Some data appears to be routinely documented, but other aspects may be more difficult to collect/observe.
- Training caregivers during patients' rehabilitation reduced costs and caregiver burden while improving psychosocial outcomes in caregivers and patients at one year. Patients reported less anxiety (P < 0.0001) and depression (P < 0.0001) and better quality of life (P = 0.009) in caregiver training group [47]. - Further research is needed to
TE D
Kalra, Evans [47], VisserMeily, van Heugten [48].
EP
1.3.2 Relevant members of the multidisciplinary team should provide specific and tailored training for carers/family before the stroke survivor is discharged home. This should include training, as necessary, in personal care techniques, communication strategies, physical handling techniques, ongoing prevention and other specific stroke-related problems, safe swallowing and appropriate dietary modifications, and management of behaviours and psychosocial issues.
SIGN 108, 2008
AC C
Caregivers should be offered ongoing practical information and training individualised for the needs of the person for whom they are caring
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Large number of SLPs reported training family members re communication with only five clinicians reporting very rarely or rarely doing so [23].
Elsewhere: Finland - 60% felt they had too little time for instructing significant others, especially in early phase [20].
M AN U
Elsewhere: US – (CPT) – used by 71.2% [37].
SLPs believed staff needed skills and knowledge to feel empowered to engage with patients with communication difficulties [49].
Scotland– 91% frequently or sometimes provide communication training to family [19]. Sweden - Seldom conducted. Discrepancy between what SLPs claimed to be important, and actual practice. 17% trained families in using communication strategies. Only 6% of total treatment time allocated for this treatment. Less common in acute. [22]. 76% of carers had received advice from the SLP about facilitating conversation strategies and 37% had actually been
most often indicated to be lacking was training for family members (17.4%) [38].
Sweden –Deemed important, but lack of available resources, methods, and skills. Two-thirds (66%) of SLPs were not satisfied with the extent of the family contact. [22]. Canada – SLPs rarely and only under specific conditions trained significant others to communicate better with PWA. [50]. Belgium –99.2%
workload pressures. [49]. Barriers- time, patient characteristics, acute setting issues, family. Facilitators – staff involvement, support, culture [57].
RI PT
common therapy for aphasia (72%) [14].
Sweden – (52%) of carers wanted to receive communication partner training [27].
SC
C
TE D
Kagan, Black [58]; Wertz, Weiss [59].
EP
Aust 20101 /NZ 2010
AC C
6.5.1f) For individuals with aphasia, intervention can include supported conversation techniques.
understand the relationship between specific interventions directed at the environment, healthcare communication, and health outcomes [49].
Worldwide – Systematic review perceived benefits of training in supported conversation skills were varied – some prefer earlier, some prefer later [55] . Belgium – 98.7% perceived training as important or very important by family – but 41.3% reported insufficient training [51]. US Communication strategies for
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AC C
EP
TE D
M AN U
Singapore - CPT was the second most frequently reported type of aphasia intervention, with half of the participants reportedly providing training to communication partners [7].
family and friends ranked as nd 2 top priority topic [56].
RI PT
Hong Kong -caregiver training was rarely primary focus of inpatient (9.3%) or outpatient (10.7%) sessions [38].
of SLPs perceived training as important or very important [51].
SC
trained in how to use these strategies [27].
9
Criteria
Recommendation
Guideline/s
Citation/s
6.5.1f) For individuals with aphasia, treatment targeting specific aspects of language should be considered based on models derived from cognitive neuropsychology.
Aust 2010/ NZ 2010
Doesborg h, van de SandtKoenderm an [60].
1. Strength of Evidence Grade C
2. Current Practice/Gap
Australia: Rehab Audit 2014 – 75% provided with phonological and semantic interventions [15].
M AN U
Rehab Audit 2012 – 68% provided with phonological and semantic interventions [14].
3. Perceived importance – Clinicians Australia: Majority of SLPs rated knowledge of and confidence with social, functional, and cognitive neuropsychologic al approaches as very good/good or very high/high. Research Priorities = Combining impairment and functional treatments, Using principles of neuroplasticity [23].
TE D
61.4% indicated using more than one approach to intervention. Combination of cognitive-neurological and functional approaches most frequently reported (42.9%) [3].
AC C
EP
Cognitive Neuropsychological one of the most frequently utilized approaches [23]. Elsewhere: Singapore – Cognitiveneurological approach used by majority of SPs ‘occasionally’ [7].
6. Therapy Approach – Constraint-
4. Perceived Importance – Patient Australia: Patient goals include wanting to speak better (impairment -based goals), but also want to target goals that could help them return to previous function [17].
SC
5. Therapy Approach – Cognitive Neuropsychology-Based Therapy
RI PT
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Elsewhere: Singapore – majority of SPs rated knowledge as ‘adequate’ and confidence as ‘confident’ with Cog-neuro approach [7].
Elsewhere: No info found.
5. Modifiability
6. Measurability
7. Health Impact
No barriers identified from current literature. No real gap identified as the majority of clinicians use this approach.
May be difficult to measure as clinicians often use a combination of therapy approaches [3]. However, some data appears to be routinely collected.
- After semantic treatment, patients improved on a semantic measure (mean improvement, 2.9; 95% CI, 1.2 to 4.6), whereas after phonological treatment, patients improved on phonological measures (mean improvement, 3.0; 95% CI, 1.4 to 4.7, and 3.0; 95% CI, 1.2 to 4.7). Both semantic and phonological treatments are effective – not compared to control group [60].
Criteria 10
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Induced Language Therapy
6.5.1f) For individuals with aphasia, intervention can include constraint-induced language therapy.
Aust 2010 / NZ 2010
Cherney, Patterson [45].
1. Strength of Evidence Grade B
2. Current Practice/Gap Australia: Rehab Audit 2014 – 14% provided with CILT therapy [15]. Rehab Audit 2012 – 8% provided with CILT therapy [14]. Elsewhere: US - Constraint-Induced Aphasia Therapy (CIAT), 23.1% used in past year [37].
4. Perceived Importance – Patient Australia: 6/11 expressed preference for M-MAT and three for CIAT Plus [62].
Elsewhere: US - Over 60% of SLPs felt that PWA would be very unlikely or somewhat unlikely to adhere to CILT. SLPs had concerns about duration [61].
Elsewhere: Norway 2 out of 3 patients preferred less intense therapy [40].
5. Modifiability
Potentially but more research needed into barriers. Resource/cost intensive – 90.9% felt that most facilities do not have the resources to provide CILT. Over 60% reported it would be difficult/very difficult to administer CILT [61].
6. Measurability
7. Health Impact
Able to measure when CILT used. Data appears to be routinely documented, or able to be easily collected.
5 studies involving 90 participants reported CILT resulted in positive changes on measures of language impairment and communication activity/ participation in individuals with chronic aphasia, including large ESs for 9 of 16 impairment measures and 6 of 11 activity/participation measures [45].
6. Measurability
7. Health Impact
AC C
EP
TE D
US - 22% of SLPS had conducted CILT [61].
3. Perceived importance – Clinicians Australia: All 6 SLPs preferred M- MAT as they found it more interesting, less repetitive and more interactive than CIAT Plus [62].
RI PT
Citation/s
SC
Guideline/s
M AN U
Recommendation
7. Therapy Approach - Use of Compensatory Strategies/AAC
Criteria
Recommendation
1. Strength of Evidence
Guideline/s
Citation/s
2. Current Practice/Gap
3. Perceived importance –
4. Perceived Importance –
5. Modifiability
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Elsewhere: US - Promoting Aphasics’ Communicative Effectiveness (PACE), 67.3%, Augmentative and Alternative Communication (AAC) - 62.5% [37]. US - AAC strategies have not been widely and/or consistently implemented with persons with severe chronic aphasia [64].
Elsewhere: No info found.
US - There is wide agreement that AAC technology is currently underused by people with aphasia [65].
Patient Australia: 6/11 participants expressed preference for MMAT and three for CIAT Plus [62].
Yes, evidence of some facilitators [62] but need further study of barriers.
RI PT
Rehab Audit 2012 – 55% used alternative means of communication [14].
Clinicians Australia: All 6 SLPS preferred multimodal MMAT as they found it more interesting, less repetitive and more interactive than CIAT Plus [62].
Elsewhere: Netherlands - High satisfaction initially, 2/12 still using 3 years post [66].
SC
Australia: Rehab Audit 2014 – 61% used alternative means of communication [15].
M AN U
Grade D
TE D
Rose, Douglas [63]
EP
Aust 2010/NZ 2010
AC C
6.5.1f) For individuals with aphasia, intervention can include the use of gesture.
US - PWA enjoyed and perceived benefits from using a high-flexibility AAC aid [65].
Able to measure when AAC used, but would need to ensure there is a clear definition of what constitutes AAC. Data appears to be routinely documented, or able to be easily collected.
Single-case experiment using a multiple-baseline design, statistically significant effect for iconic gesture (N = 10, T = 0, p < .005, onetailed) [63].
UK - families of PWA have considerable reservations about AAC interventions [67]. Sweden - (63%) of carers wanted to be involved in the creation of an AAC device. [68]. US - peers were worried that AAC might impede return of speech [69].
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Recommendation
Guideline/s
Citation/s
6.5.1f) For individuals with aphasia, intervention can include delivery of therapy programs via computer.
Aust 2010/ NZ 2010
Katz and Wertz [70].
1. Strength of Evidence Grade C
2. Current Practice/Gap
Australia: Rehab Audit 2014 – 14% provided with computerbased therapy [15].
Elsewhere: US - Computer Treatments, 38.5% [37].
Elsewhere: US - SLPs generally perceive computers as useful and important but not critical to successful outcomes [71].
EP
TE D
US - Survey - SLPs use computers more often for indirect or supplemental purposes than for direct therapy. When SLPs implemented computers in direct treatment, the amount accounted for less than 25% of the total session time [71].
AC C
4. Perceived Importance – Patient Australia: No info found.
Elsewhere: US - High satisfaction [72]
US - Patients reported satisfaction with software [73].
M AN U
Rehab Audit 2012 – 7% provided with computerbased therapy [14].
3. Perceived importance – Clinicians Australia: Research priorities = Web and computer based treatments [23].
Finland - Computer applications as home exercises in 31% of cases in the first year after stroke [20].
5. Modifiability
6. Measurability
7. Health Impact
Yes, some facilitators. Need more research into barriers. Could be used as a strategy to increase amount/ intensity of therapy [39].
Able to measure when computertherapy provided. Data appears to be routinely documented, or able to be easily collected.
Little evidence of any difference was found between computerfacilitated speech and language treatment versus one-on-one speech and language treatment [75].
RI PT
Criteria
SC
8. Service Delivery – ComputerBased Therapy
UK - All 6 participants interviewed perceived remotely monitored computer therapy as a positive experience [74].
Barriers could be initial costs in purchasing resources. Limited evidence about which computer programs are best. Identified barriers include lack of access and training [71].
Pilot RCT, cost effective, P=0.014 [76]. Evidence to support efficacy of computerised treatment for PWA based on a single Phase 3 study study provided Class 1 evidence, with results from a well-designed, randomised controlled clinical trial that compared treatment with notreatment [77]. Significant improvement over 26 weeks occurred on 5 language measures for computer reading treatment group, on one language measure for computer stimulation group, and on none of the language measures for the no- treatment group Katz and Wertz [70].
13
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Aust 2010 /NZ 2010
Elman and BernsteinEllis [78].
2. Current Practice/Gap Australia: Rehab Audit 2014 – 20% provided with group therapy [15]. Rehab Audit 2012 – 21% provided with group therapy [14]. Australian SLPs provided least amount of group therapy (24%) compared to SLPs working in Canada, the USA and the UK [6]
3. Perceived importance – Clinicians Australia: Group treatments rated as appropriate by fewer therapists in most phases of care [23].
Group therapy provided 53.6% in inpatient rehab, 58.6% in outpatient rehab, 36.4% in community; 20% in aged-care; 8.3% in private practice; 100% in university clinics. No group therapy in acute [3]. Group therapy targeting
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
Australia: PWA highlighted importance of being able to share their stroke story with others. Two expressed apprehension about attending a stroke and/or aphasia group. [79].
Need more research into barriers/ facilitators.
Able to measure when therapy offered and amount provided. Data appears to be routinely documented, or able to be easily collected.
Group tx showed 44% more efficient cost to benefit ratio than standard service [39].
SC
6.5.1h) Group therapy and conversation groups can be used for people with aphasia and should be available in the longer term for those with chronic and persisting aphasia.
1. Strength of Evidence Grade C
M AN U
Citation/s
Elsewhere: No info found.
TE D
Guideline/s
EP
Recommendation
RI PT
Criteria
AC C
9. Service Delivery - Group Therapy
Interactions in group setting gave participants confidence to be independent [26]. Elsewhere: Scotland - Group therapy can create tensions. Benefits of support and friendship of attending as well as from therapy. minority reported no changes to QOL. These individuals did not like having therapy in a group [80].
Evidence favouring community and outpatient groups centred on four level ii and level iii-i studies examining the efficacy of highly structured group activities for improving specific linguistic processes with five medium– large effect sizes calculated [83]. Aphasia groups that use multi-modality communication activities can improve rates of friendships and social networks. significantly higher levels of social participation, and significantly less perceived social isolation and greater
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UK - Extremely positive evaluation of intervention [81].
Elsewhere: Scotland – 44/121 used groups frequently or sometimes [19].
UK - Group therapy seen as very positive in terms of confidence and togetherness but one-to-one therapy most important early on [8].
Hong Kong- Overall satisfaction highest with support groups, family members want more intensive individual or group SLP training and regular review (47.8%) [38].
Significant improvements in communicative competence (p = 0.03 & p = 0.04) and attitudes to communication over the course of the intervention [81].
AC C
M AN U
EP
TE D
Singapore – One third of the participants (n=12) provided group therapy [7].
UK -high degree of satisfaction, peer support and social aspects particularly valued [82].
Participants receiving group communication treatment had significantly higher scores on communicative and linguistic measures (p < 0.05) than participants not receiving treatment [78].
SC
UK - OP – 7.5% of time spent on group tx [36]. Finland - 30% of acute SLTs administered group therapy [20].
social connection (p <0.014) for the 28 individuals attending a weekly aphasia group [84].
RI PT
impairments used rarely or very rarely (45.8%), [23].
10. Information, Education and Aphasia-Friendly Information
Criteria
Recommendation
1. Strength of Evidence Grade
Guideline/ s
Citation/s
2. Current Practice/Gap
3. Perceived importance – Clinicians
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
15
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Smith, Forster [85].
D
B
SIGN 108, 2008
Forster, Smith [97].
A
1.9.1c) Stroke survivors should be provided with routine, follow-up opportunities for clarification or reinforcement of the information provided.
Aust 2010/ NZ 2010
Smith, Forster [85].
B
Information should be
SIGN 108,
Hoffmann ,
D
Rehab Audit 2012 – tailored information provided to stroke survivor/family – 65% [14].
SPs think providing education and info to PWA and families is important [52].
36% received written information about both stroke and aphasia. fewer participants reporting received written aphasia information (49%) compared to written stroke information (67%) [88]. Majority reported doing so, although less education practice was targeted towards friends. 97% reported using verbal and written information in education. Only 59% frequently or very frequently provided clients with information
Australia: PWA want information about aphasia, stroke, and available services. Family education was a strong need [25].
Educating family members about aphasia, stroke, and rehabilitation was a frequently reported goal of SLPs [16]. Elsewhere: Canada Including significant others was perceived as challenging, yet a bonus to their fundamental patient-centred
Yes – appear to be some facilitators (et. Rose et al, 2013; Brown et al, 2012), but further research into barriers needed.
RI PT
Aust 2010/ NZ 2010
Hoffmann , McKenna [96].
D
Australia: Research priorities – Information needs of PWA and family [23].
PWA expressed satisfaction when information was personalised to their communication needs [26].
SC
1.9.1b) Information should be provided at different stages in the recovery process. Information should be offered in a variety of formats including easy access .
SIGN 108, 2008
van der SmagtDuijnstee, Hamers [86]; Choi-Kwon, Lee [87].
Australia: Rehab Audit 2014 – tailored information provided to stroke survivor/family 72% [15].
M AN U
SIGN 108, 2008
A
TE D
Healthcare professionals should take a patient’s age, gender, educational status and communication support needs into account when assessing their need for information. Information should be tailored to the phase of the patient’s journey.
Smith, Forster [85].
EP
Aust 2010/ NZ 2010
AC C
1.9.1a) All stroke survivors and their families/carers should be offered information tailored to meet their needs using relevant language and communication formats
Families emphasized importance of receiving verbal information, whereas others spoke about needing written information in order to have something to refer to at a later time [90].
Some evidence of barriers, from nonAustralian studies [94].
Complex to measure due to number of components recommended in target behaviours. Some data appears to be routinely documented, but other aspects may be more difficult to collect/ observe. Would need to record what information provided, by whom, to whom, when, in what format, whether it was tailored, etc.
Meta-analyses showed significant effect in favour of intervention on patient knowledge (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46, P < 0.001), carer knowledge (SMD 0.74, 95% CI 0.06 to 1.43, P = 0.03), one aspect of patient satisfaction (odds ratio (OR) 2.07, 95% CI 1.33 to 3.23, P = 0.001), and patient depression scores (mean difference (MD) -0.52, 95% CI 0.93 to -0.10, P = 0.01) [95].
Participants thought it important to receive written information about both stroke and aphasia at several stages post stroke [91].
Meta-analyses showed significant effect in favour of intervention on patient and carer knowledge, one aspect of patient satisfaction, and patient depression scores [85].
Elsewhere: Scotland - Many felt that early on they didn’t know what was wrong with them and
All significant others perceived increased knowledge and understanding of
16
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D
Elsewhere: Singapore - All participants (n=28) reported use of verbal explanation in their education practice. Written materials were frequently used (n=22; 78.6%). Nearly all (n=26; 92.9%) reported providing education about the term ‘‘aphasia’’ [7].
RI PT
Aust 2010/ NZ 2010
Only 17.5% of communication time was spent providing information. PWA received information for less time and on fewer topics [89].
Hong Kong - Family desired (in acute phase) additional information on aphasia, its causes and treatment methods (17.6%%), and in rehab/outpt phase information on aphasia and its outcome (8.7%) [38].
SC
6.5.1d) In patients with aphasia, all written information on health, aphasia, social and community supports should be available in an aphasia-friendly format.
D
they didn’t remember somebody explaining what had happened. lack of information for family members In some cases [19].
Sweden Significant others received information about aphasia: orally (34%), in writing (19%), or both (37%). Most of the participants (76%) also received information about
aphasia and related issues [92]. Family members need to have information provided in flexible and supportive manner, particularly in initial period poststroke. Systematic r/v of 17 studies on caregiver’s views [55].
M AN U
SIGN 108, 2008
about community support organisations [23].
TE D
Each patient should be assessed on his or her readiness to receive information.
McKenna [96]; WachtersKaufmann, Schuling [98]. van der SmagtDuijnstee, Hamers [86]; Choi-Kwon, Lee [87]. Brennan, Worrall [99]; Rose, Worrall [100].
EP
2008
AC C
repeated and re-offered at appropriate intervals
approach. SLPs often had unachieved ideals, such as having more frequent contacts with significant others [50]. Scotland - Many expressed concern about available support for family. Some SLPs felt they did not
Sweden - The importance information about stroke/aphasia was clearly acknowledged, especially by SOs [92]. UK- Information needs to be written down and repeated at regular intervals. Time and opportunities for clarification needed [8]. UK - Carers expressed information needs [54].
17
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AC C
EP
TE D
M AN U
Belgium – SLPs considered the following to be important or very important: providing written information (89.4%), providing information on what aphasia is (94.7%), But insufficient information provided for written (41.7%), info on aphasia (18.2%) [51].
Belgium – Family considered the following to be important or very important: providing written information (87.4%), providing information on what aphasia is (96.3%), providing information on support groups (68.75%). But insufficient information provided for written (46.2%), info on aphasia (25%) and support groups (53.2%) [51].
RI PT
have adequate time and resources to support families [80].
SC
the local aphasia association [27].
US - Survey respondents (N = 302) rated aphasia resources as ‘‘somewhat difficult to find” [93]. Worldwide –family members need to have information provided in flexible and supportive manner, particularly in initial period poststroke. Systematic r/v of 17 studies on caregiver’s views [55].
18
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Criteria
Bhogal, Teasell [101].
Aust 2010/ NZ 2010
Clark, Rubenach [104].
1.9.3 Counselling can include a problem-solving counselling approach.
Aust 2010/ NZ 2010
Evans, Matlock [105].
C
C
Australia: Rehab Audit 2014 – Formal counseling offered to patient – 32% [15]. Rehab Audit 2012 – Formal counseling offered to patient – 31% [14]. Percentage of respondents providing counseling – 66% frequently/very frequently [23].
3. Perceived importance – Clinicians Australia: Research priorities = Counselling A large number felt underprepared for significant counseling roles [23].
4. Perceived Importance – Patient Australia: Clients and families want SLP services that provide hope and positivity, state current services don’t always meet this need [52].
SLPs emphasized goals related to support, both practical and psychological [16].
Elsewhere: UK - Little consistency in approaches for addressing psychosocial issues [102].
UK – 95% of respondents offered some additional counselling or social support to their patients, often in cooperation with the voluntary sector. The type and availability of support varied, with no single aspect being offered in all districts
Elsewhere: Scotland Perceived gap for management of psychological elements of aphasia. Fostering hope and being realistic [19]. Finland 2012 -
5. Modifiability
6. Measurability
7. Health Impact
Evidence of facilitators priority for SLPs, PWA and families [23, 52].
Some data appears to be routinely documented, but other aspects may be more difficult to collect/ observe. Would need to record what type of counselling SLPs provided and what was involved.
Systematic r/v: moderate evidence that improved social support as an intervention improves outcomes and strong evidence that active educational-counseling approach has a positive impact on family functioning post stroke Bhogal, Teasell [101].
RI PT
Aust 2010/ NZ 2010
2. Current Practice/Gap
SC
1.9.3 Counselling can include an active educational counselling approach. 1.9.3 Counselling can include Information supplemented by family counselling.
1. Strength of Evidence Grade B
M AN U
Citation/s
TE D
Guideline/s
EP
Recommendation
AC C
11. Counselling
Elsewhere: UK – Trial of counselling service, In general, participants valued the service and a number of positive outcomes were described (Ireland & Wotton, 1996).
Evidence of barriers – SLPs felt underprepared [23]. Evidence of barriers problems with the setting, timing and organization of counselling and presence of client social problems. Calm, spacious and conducive setting for counselling important (Ireland & Wotton, 1996).
Improved family functioning p < .05, but no significant effects on depression, anxiety, mastery or health status [104]. Compared with control, education and counseling conditions gave significantly better outcomes 6 months after stroke on measures of caregiver stroke knowledge and the family functions problem solving, communication, and global family function (p <0.001). Counseling more effective than education alone, improved caregiver knowledge and stabilized some aspects of family function better than routine
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care, and resulted in better patient adjustment at 1 year [105].
RI PT
60% felt that they had too little time for counseling and instructing significant others, especially in the early phase [20].
Criteria Citation/s
8.6.2a) Carers should be provided with tailored information and support during all stages of the recovery process. This includes (but is not limited to) information provision and opportunities to talk with relevant health professionals about the stroke, stroke team members and their roles, test or assessment results, intervention plans, discharge planning, community services and appropriate contact
Aust 2010/ NZ 2010
Brereton, Carroll [108]; Smith, Forster [85].
1. Strength of Evidence Grade C
2. Current Practice/Gap
3. Perceived importance – Clinicians Australia: SLPs’ goals relating to coping and participation factors for family members included providing support for the family, receiving support from the family, as well as facilitation of support networks [16].
TE D
Guideline/s
Australia: Rehab Audit 2014 – Post-discharge contact provided to stroke survivor or family – 62% Formal counselling offered to family/ carer - 32%. Postdischarge needs discussed with carer82%. Stroke survivor offered information about peer support 32% [15].
EP
Recommendation
AC C
12. Caregiver Support
M AN U
SC
[103].
Rehab Audit 2012 – Post-discharge needs
Strong support networks viewed as essential to living successfully with
4. Perceived Importance – Patient Australia: PWA report the need to feel valued and understood in the rehabilitation process. The role of hope in the therapeutic relationship of significant importance [18]. Family members identified different preferences for emotional support including formal support from social
Qualitative study, both positive and negative feedback [106](Ireland & Wotton, 1996). Stroke patients benefit from counselling combined with education intervention [107].
5. Modifiability
6. Measurability
7. Health Impact
Some evidence of facilitators [16] [24]. Research into barriers needed.
Some data appears to be routinely documented, but other aspects may be more difficult to collect/ observe. Would need to record what information provided, by whom, to whom, when, in what
Systematic r/v: Evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, small reduction in depression scores may not be clinically significant [95].
Evidence of barriers from nonAustralian studies.
Some benefits were reported for all
20
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Carers’ support needs should be addressed prior to patient discharge.
SIGN 108 2008
SIGN 108 2008
D
D
Elsewhere: Hong Kong - when discharged from the admitted hospital, only 51.4%% of the family members were informed of self-help or support groups in the community [38]. Sweden - They had received information about aphasia: orally (34%), in writing (19%), or both (37%). Most of the participants (76%) also received information about local aphasia association; 76% had received advice from the SLP about facilitating
RI PT
van der SmagtDuijnstee, Hamers [86]; Brereton and Nolan [112]. Brereton and Nolan [112]; Brereton and Nolan [113].
C
Only 59% frequently or very frequently provided clients with information about community support organisations [23].
Elsewhere: Canada - If necessary, significant others were referred to social workers or psychologists or SLPs collaborated with those professionals [50].
For PWA, factors relating social support were important in facilitating a more successful life with aphasia across time [79].
SC
C
workers or counsellors and informal support from family support groups or one-toone groups [90].
M AN U
Aust 2010/ NZ 2010
Brereton, Carroll [108]; Eldred and Sykes [107]; Lee, Soeken [110];Viss er-Meily, van Heugten [48]. Bhogal, Teasell [101]; Lee, Soeken [110]; Lui, Ross [111].
aphasia. SLPs identified both family and friends as key providers of support [24].
Scotland - Many SLPs expressed concern about the level of support available for family members. Some felt
TE D
8.6.2d) Carers should be offered support services after the person’s return to the community. Such services can use a problem-solving or educational-counselling approach. Healthcare professionals should actively involve carers and find out what support they need.
Aust 2010/ NZ 2010
EP
8.6.2c) Carers should be provided with information about the availability and potential benefits of local stroke support groups and services, at or before the person’s return to the community.
discussed with carer – 76%, Stroke survivor offered information about peer support - 39%, Post-discharge contact provided to stroke survivor or family – 57% [14].
AC C
details.
Elsewhere: Germany – no measurable improvement in counselling family members of PWA, but it was appreciated [109]. Scotland - Benefits were the support and friendship of others attending the centre as well as the therapy itself. Conversely, a minority of people with aphasia in the study reported that there had been no changes in QOL. These individuals did not like having therapy
format, etc.
interventions, although trials were generally of low quality, preventing firm conclusions being drawn [108]. Few studies investigating impact of psychologically based interventions for carers of stroke survivors, and quality of evidence is varied [107]. Need for ongoing psychosocial support over the long term was apparent [55]. All significant others perceived increased knowledge and understanding of aphasia and related issues [92]. No measurable improvement in counselling family members of PWA [109].
21
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AC C
EP
Singapore - referral to community support groups made ‘‘rarely’’ or less by most participants (n=20; 71.4%). Participants indicated the lack of available support groups as a reason for the lack of referrals [7].
in a group [19].
RI PT
Sweden - The importance of emotional support as well as information about stroke/aphasia was acknowledged, especially by SOs. 63% of SOs perceived their own support from SLP services to be adequate [92].
SC
Finland - SLPs aware of need to support significant others. SLPs felt the role of significant others is important [20].
Belgium – SLPs considered the following to be important or very important: providing information on support groups (92.4%). But insufficient information provided support groups (60.0%) [51].
TE D
UK – 95% of respondents offered some additional counselling or social support, often in cooperation with the voluntary sector. The type and availability of support varied, with no single aspect being offered in all districts [103].
that they did not have adequate time and resources to support families [80].
M AN U
conversation strategies and 37% had actually been trained in how to use these strategies; 50% had had the opportunity to talk about their own situation as a SO of a PwA [27].
UK - Carers expressed needs in the area of support [54]. Belgium – Family considered the following to be important or very important: providing information on support groups (68.75%). But insufficient information provided for support groups (53.2%) (Manders (2011). Carers’ perceived need for ongoing psychosocial
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Return-to-work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively. Active management should include: • identifying the physical, cognitive, communication and psychological demands of the job (for example, multi-tasking by answering emails and telephone calls in a busy office) • identifying any impairments on work performance (for example, physical limitations, anxiety, fatigue preventing
NICE 162
Evidence linked to systematic r/v of 1 RCT Trexler, Trexler [114].
1. Strength of Evidence Grade Strong
2. Current Practice/Gap
Australia: Rehab Audit 2014 – Stroke survivors offered assistance to return to work (if they wanted to return to work) 69% [15].
3. Perceived importance – Clinicians Australia: No info found.
Elsewhere: Scotland Approximately 20% of SLPs felt that therapy intervention may vary in response to differing needs and lifestyles of people of different ages, including being of working age and wishing to return to work or a desire to drive again [19].
TE D
Citation/s
Rehab Audit 2012 Stroke survivors offered assistance to return to work 86% [14].
EP
Guideline/s
M AN U
Criteria
Recommendation
AC C
13. Return to Work
SC
RI PT
support over the long term was apparent [55].
Elsewhere: Canada - Few working-age stroke survivors with aphasia or other communication disorders have access to VR [115]
Canada – SLPs saw main role as educating and increasing
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
Australia: PWA identified the importance of work activities [25].
Research into barriers and facilitators needed in Australian context.
Data appears to be routinely documented, or able to be easily collected.
Survivors with aphasia who did return to work experienced significantly reduced hours and task modifications (Dalemans, De Witte, Lemmens, & Van den Heuvel, 2008).
Elsewhere: UK - Few younger stroke survivors recognise the value of SLT as a component of VR [117]. US - Returning to work ranked 16 out of 18 priority topics [56]. Scotland - Although many people wanted to get back to work, no-one was working and some people commented that they missed this aspect of their life [19].
Barriers to RTW: working conditions, use of electronic tools, types of speakers, productivity expectations, as well as attitude/ awareness of conversation partners as barriers to RTW. Strategies to facilitate RTW also
Average rate of successful RTW for young survivors with aphasia was 28.4% compared to 44.7% for all young stroke survivors [121]. Negative associations between return to work and aphasia (p = 0.0009) [122]
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1. 2. 3.
RI PT
Canada –Possible that SLPs and PWA do not see a role for these professionals in the work re-integration process [115]. Portugal – PWA reported consequences in Major Life Areas, most specifically in Work and Employment: work and employment was more important to PWA and professionals, than to FM [116].
SC
M AN U TE D
•
Portugal – Work and employment was more important to PWA and professionals, than to FM [116].
EP
•
awareness of aphasia. It is possible that S-LPs and PWA do not see a role for these professionals in the work re-integration process [115].
UK - Major restrictions in terms of RTW [118].
identified (Garcia et al., 2002). Issues concerning the role of the SLT in facilitating return to work [119]. Barriers to RTW - Standard therapy tools and impersonal approaches. Facilitators when health professionals related the therapy objectives to PWA’s interests and involved him in the process of setting objectives [120].
- Participation increased significantly for both groups (F = 60.65, P < .0001), but interaction between groups and time demonstrated greater improvement for the RF group relative to controls (F = 9.11, P < .007). Also, 64% of the RF group was employed at follow-up compared with 36% of control (WaldWolfkowitz z = -3.277, P < .0001). No significant differences found between groups on depression [114].
AC C
•
attendance for a full day at work, cognitive impairments preventing multitasking, and communication deficits) tailoring an intervention (for example, teaching strategies to support multi-tasking or memory difficulties, teaching the use of voice-activated software for people with difficulty typing, and delivery of work simulations) educating about the Equality Act 2010 and support available (for example, an access to work scheme) workplace visits and liaison with employers to establish reasonable accommodations, such as provision of equipment and graded return to work.
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4.
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38.
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Eldred, C. and C. Sykes, Psychosocial interventions for carers of survivors of stroke: A systematic review of interventions based on psychological principles and theoretical frameworks. British Journal of Health Psychology, 2008. 13(Pt 3): p. 563. Brereton, L., C. Carroll, and S. Barnston, Interventions for adult family carers of people who have had a stroke: A systematic review. Clinical Rehabilitation, 2007. 21(10): p. 867-884. Johannsen-Horbach, H., M. Crone, and C.W. Wallesch, Group therapy for spouses of aphasic patients. Seminars in speech and language, 1999. 20(1): p. 73. Lee, J., K. Soeken, and S.J. Picot, A meta-analysis of interventions for informal stroke caregivers. Western Journal of Nursing Research, 2007. 29(3): p. 344-56; discussion 357-364. Lui, M.H.L., F.M. Ross, and D.R. Thompson, Supporting family caregivers in stroke care: A review of the evidence for problem solving. Stroke, 2005. 36(11): p. 2514-2522. Brereton, L. and M. Nolan, ‘You do know he’s had a stroke, don’t you?’ Preparation for family care‐giving – the neglected dimension. Journal of Clinical Nursing, 2000. 9(4): p. 498-506. Brereton, L. and M. Nolan, 'Seeking': A key activity for new family carers of stroke survivors. Journal of Clinical Nursing, 2002. 11(1): p. 22-31. Trexler, L.E., et al., Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. The Journal of head trauma rehabilitation, 2010. 25(6): p. 440-446. Garcia, L.J., J. Barrette, and C. Laroche, Perceptions of the obstacles to work reintegration for persons with aphasia. Aphasiology, 2000. 14(3): p. 269-290. Matos, M.A.C., L.M.T. Jesus, and M. Cruice, Consequences of stroke and aphasia according to the ICF domains: Views of Portuguese people with aphasia, family members and professionals. Aphasiology, 2014. 28(7): p. 771-796. Kersten, P., et al., The unmet needs of young people who have had a stroke: Results of a national UK survey. Disability & Rehabilitation, 2002. 24(16): p. 860-866. Parr, S., Living with severe aphasia: Tracking social exclusion. Aphasiology, 2007. 21(1): p. 98-123. Morris, J., et al., Returning to work with aphasia: A case study. Aphasiology, 2011. 25(8): p. 890-907. Dyke, C.W., Finding General Dyke. Topics in stroke rehabilitation, 2011. 18(2): p. 144-150. Graham, J.R., S. Pereira, and R. Teasell, Aphasia and return to work in younger stroke survivors. Aphasiology, 2011. 25(8): p. 952-960. Black-Schaffer, R.M., Return to work after stroke: development of a predictive model. Archives of physical medicine and rehabilitation, 1990. 71(5): p. 285-290.
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Supplementary Table 2. Search Results Per Topic Area Search Yield (Websites) 1
Current practice/gap
Perceived importance – clinicians Perceived importance – Client Health Impact
14
1
0
65 31
1 3
Current practice/gap
11
10
Perceived importance – clinicians
29
Documents Excluded 241
Total Included 6
RI PT
Grey Literature 2
SC
Screening Assessment
Perceived importance – Client
EP
AC C
Goal Setting
Search Yield (Databases) 244
14
M AN U
Criteria
1
0 0
65 29
1 5
0
9
12
TE D
Topic Area
30
2
0
27
4
3
0
28
5
References Verna, Davidson [1], Vogel, Maruff [2], Duffy, Fossett [3], Katz, Hallowell [4], National Stroke Foundation [5], Guo, Togher [6]. Vogel, Maruff [2] Horton, Mudd [7]. Verna, Davidson [1], Armstrong [8], Lalor and Cranfield [9], Hilari [10], Dickey, Kagan [11]. Verna, Davidson [1], National Stroke Foundation [5], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Sherratt, Worrall [14], Rohde, Townley-O'Neill [15], Worrall, Brown [16], Klippi, Sellman [17], Law, Pringle [18], Johansson, Carlsson [19], Monaghan, Channell [20]. Rohde, Townley-O'Neill [15], Law, Pringle [18], Rose, Ferguson [21], Brown, Worrall [22]. Worrall, Brown [16], Law, Pringle [18], Worrall, Sherratt [23], Tomkins, Siyambalapitiya [24], Blom Johansson, Carlsson [25].
0 2
1 21
Perceived importance – clinicians Perceived importance – Client
12
2
1
12
3
Health Impact
9
6
Current practice/gap
8
Perceived importance – clinicians
21
1 12
RI PT
1 10
Perceived importance – Client
20
M AN U
12
3
12
4
0
9
6
2
6
10
3
0
19
5
7
0
19
8
TE D
1
6
EP
Conversation Partner Training
1 23
AC C
Treatment timing, amount and/or Intensity
Health Impact Current practice/gap
SC
ACCEPTED MANUSCRIPT
Levack, Taylor [26]. Verna, Davidson [1], Duffy, Fossett [3], Katz, Hallowell [4], Lalor and Cranfield [9], National Stroke Foundation [12], National Stroke Foundation [13], Klippi, Sellman [17], Ferreira [27], Godecke, Hird [28], Kong [29], Code and Heron [30], Rowe [31]. Klippi, Sellman [17], Rose, Ferguson [21], Wenke, Lawrie [32]. Horton, Mudd [7], Kong [29], Wenke, Lawrie [32], Kirmess and Maher [33]. Wenke, Lawrie [32], Cherney, Patterson [34], Bakheit, Shaw [35], Bowen, Hesketh [36], Godecke [37], Bhogal, Teasell [38]. Verna, Davidson [1], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Law, Pringle [18], Johansson, Carlsson [19], Rose, Ferguson [21], Blom Johansson, Carlsson [25], Kong [29], Rowe [31]. Klippi, Sellman [17], Johansson, Carlsson [19], Rose, Ferguson [21], O’Halloran, Lee [39], Hallé, Le Dorze [40], Manders, Marien [41]. Kong [29], Manders, Marien [41], Brown, Worrall [42], Blom Johansson, Carlsson [43], Hilton, Leenhouts [44], Denman [45], McVicker, Parr [46],
ACCEPTED MANUSCRIPT
1
Current practice/gap
192
2
3
190
5
Perceived importance – clinicians Perceived importance – Client Health Impact
6
1
0
5
2
23 17
1 1
0 0
23 17
1 1
Current practice/gap
8
1
2
7
4
Perceived importance – clinicians Perceived importance – Client
3
1
0
2
2
Health Impact Current practice/gap
6 11
2
2
M AN U
SC
RI PT
0
TE D
Compensatory strategies/AA C
2
1
0
1
2
0 2
0 2
5 10
1 5
EP
ConstraintInduced Language Therapy
1
Perceived importance – clinicians Perceived importance – Client
AC C
Cognitive Neuropsychol ogical Therapy Approach
Health Impact
8
1
0
7
1
8
4
0
6
6
Hinckley, Boyle [47]. O’Halloran, Lee [39], Kalra, Evans [48]. Verna, Davidson [1], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Rose, Ferguson [21]. [21]M. Rose et al. (2013); Guo, Togher, and Power (2013). Rohde, Townley-O'Neill [15]. Doesborgh, van de Sandt-Koenderman [49]. National Stroke Foundation [12], National Stroke Foundation [13], Rowe [31], Page and Wallace [50]. Page and Wallace [50], Rose, Attard [51] Kirmess and Maher [33], Rose, Attard [51]. Cherney, Patterson [34]. National Stroke Foundation [12], National Stroke Foundation [13], Rowe [31], True, Bartlett [52], Beukelman, Ball [53]. Rose, Attard [51]. Rose, Attard [51]; Van de SandtKoenderman, Wiegers [54]; Blom Johansson, Carlsson [43], True, Bartlett [52], Bloch [55], Lasker and
1 4
0 0
1 25
1 4
Perceived importance – clinicians Perceived importance – Client
6
2
0
6
2
6
3
0
6
3
Health Impact
6
2
0
3
Current practice/gap
68
5
Perceived importance – clinicians Perceived importance – Client
25 30
RI PT
1 25
M AN U
5
2
66
9
1
0
25
1
3
0
25
8
Health Impact
Information, Education and
Current practice/gap
AC C
EP
Group Therapy
Health Impact Current practice/gap
TE D
Computer Therapy
SC
ACCEPTED MANUSCRIPT
35
5
0
35
5
223
3
2
221
7
Beukelman [56]. Rose, Douglas [57]. Klippi et al. (2012); National Stroke Foundation (2012, 2014); Rowe [31]. Rose, Attard [51], Davis [58]. Mortley, Wade [59], Fink, Brecher [60], Cherney, Halper [61]. Palmer, Enderby [62], Brady, Kelly [63], Wertz and Katz [64], Katz and Wertz [65]. Verna, Davidson [1], Katz, Hallowell [4], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Klippi, Sellman [17], Law, Pringle [18], Rose, Ferguson [21], Code and Heron [30]. Rose, Attard [51]. Horton, Mudd [7], Law, Pringle [18], Tomkins, Siyambalapitiya [24], Kong [29], Law, Huby [66], Brumfitt and Sheeran [67], Mumby and Whitworth [68], Grohn, Worrall [69]. Wenke, Lawrie [32], Brumfitt and Sheeran [67], Elman and BernsteinEllis [70], Vickers [71], Lanyon, Rose [72]. Guo et al. (2013); National Stroke Foundation (2012, 2014); M. Rose et al.
Aphasia Friendly Information 38
4
0
36
6
Perceived importance – Client
94
7
0
89
12
Health Impact
16
3
Current practice/gap
93
1
Perceived importance – clinicians
14
Perceived importance – Client
98
Health Impact
Caregiver Support
Current practice/gap
M AN U
SC
Perceived importance – clinicians
16
3
2
91
5
0
14
4
0
0
96
2
5
6
0
6
5
164
3
2
162
7
TE D
0
EP
4
AC C
Counselling
RI PT
ACCEPTED MANUSCRIPT
(2013); Blom Johansson, Carlsson [25], Rose, Worrall [73], Knight, Worrall [74]. Rose, Ferguson [21], Hallé, Le Dorze [40], Manders, Marien [41], Brown, Worrall [42], Law, Huby [66] Sherratt, Worrall [14]. Law, Pringle [18], Worrall, Sherratt [23], Tomkins, Siyambalapitiya [24], Kong [29], Manders, Marien [41], Hilton, Leenhouts [44], Denman [45], Hinckley [75], Rose, Worrall [76], Blom Johansson, Carlsson [77], Howe, Davidson [78]. Blom Johansson, Carlsson [77], Forster, Brown [79]; Smith, Forster [80]. National Stroke Foundation [12], National Stroke Foundation [13], Rose, Ferguson [21], Brumfitt [81], Mackenzie, May [82]. Sherratt, Worrall [14], Klippi, Sellman [17], Law, Pringle [18], Rose, Ferguson [21]. Brown, Worrall [42], Ireland and Wotton [83]. Ireland and Wotton [83], Bhogal, Teasell [84], Evans, Matlock [85], Clark, Rubenach [86], Eldred and Sykes [87]. Guo, Togher [6], National Stroke Foundation [12], National Stroke
24
5
1
23
6
Perceived importance – Client
95
6
0
91
10
Health Impact
18
5
Current practice/gap
118
Perceived importance – clinicians Perceived importance – Client
10 49
M AN U
SC
Perceived importance – clinicians
0
6
2
117
3
3
0
10
3
4
0
46
7
TE D
17
EP
0
AC C
Return to Work
RI PT
ACCEPTED MANUSCRIPT
Foundation [13], Rose, Ferguson [21], Blom Johansson, Carlsson [25], Kong [29], Mackenzie, May [82]. Sherratt, Worrall [14], Klippi, Sellman [17], Brown, Worrall [22], Hallé, Le Dorze [40], Manders, Marien [41], Law, Huby [66]. Worrall, Brown [16], Law, Pringle [18], Manders, Marien [41], Blom Johansson, Carlsson [43], Hilton, Leenhouts [44], Denman [45], Grohn, Worrall [69], Blom Johansson, Carlsson [77], Howe, Davidson [78], Johannsen-Horbach, Crone [88]. Hilton, Leenhouts [44], Blom Johansson, Carlsson [77], Forster, Brown [79], Eldred and Sykes [87], Johannsen-Horbach, Crone [88], Brereton, Carroll [89]. National Stroke Foundation [12], National Stroke Foundation [13], Garcia, Barrette [90]. Law, Pringle [18], Garcia, Barrette [90], Matos, Jesus [91]. Law, Pringle [18], Worrall, Sherratt [23], Hinckley [75], Garcia, Barrette [90], Matos, Jesus [91], Parr [92], Kersten, Low [93].
ACCEPTED MANUSCRIPT
4. 5. 6. 7. 8. 9. 10. 11. 12.
2076
161
25
2014
4
Dalemans [94], Graham, Pereira [95], Black-Schaffer [96], Trexler, Trexler [97].
242
SC
Verna, A., B. Davidson, and T. Rose, Speech-language pathology services for people with aphasia: A survey of current practice in Australia. International Journal of Speech-Language Pathology, 2009. 11(3): p. 191-205. Vogel, A.P., P. Maruff, and A.T. Morgan, Evaluation of communication assessment practices during the acute stages post stroke. J Eval Clin Pract, 2010. 16(6): p. 1183-8. Duffy, J., T. Fossett, and J. Thomas, Aphasia care in acute hospital: challenges and opportunities, in Clinical Aphasiology Conference. 2010: Isle of Palms, SC. Katz, R.C., et al., A multinational comparison of aphasia management practices. Int J Lang Comm Dis, 2000. 35(2): p. 303-314. National Stroke Foundation, National Stroke Audit Acute Services Clinical Audit Report 2011: Melbourne, Australia. Guo, Y.E., L. Togher, and E. Power, Speech pathology services for people with aphasia: What is the current practice in Singapore? Disability and Rehabilitation, 2013. 36(8): p. 691-704. Horton, S., D. Mudd, and J. Lane, Is anyone speaking my language? International Journal of Language & Communication Disorders, 1998. 33(S1): p. 126-131. Armstrong, E., Communication Culture in Acute Speech Pathology Settings: Current Issues. Advances in Speech-Language Pathology, 2003. 5(2): p. 137-143 Lalor, E. and E. Cranfield, Aphasia: A description of the incidence and management in the acute hospital setting. Asia Pacific Journal of Speech, Language and Hearing, 2004. 9: p. 129-136. Hilari, K., The impact of stroke: Are people with aphasia different to those without? Disability and Rehabilitation, 2011. 33(3): p. 211218. Dickey, L., et al., Incidence and Profile of Inpatient Stroke-Induced Aphasia in Ontario, Canada. Archives of Physical Medicine and Rehabilitation, 2010. 91(2): p. 196-202. National Stroke Foundation, National Stroke Audit - Rehabilitation Services Report. 2012, National Stroke Foundation: Melbourne, Australia.
M AN U
3.
0
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2.
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EP
1.
4
AC C
Totals
0
RI PT
Health Impact
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20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
RI PT
SC
18. 19.
M AN U
16. 17.
TE D
15.
EP
14.
National Stroke Foundation, National Stroke Audit - Rehabilitation Services Report. 2014, National Stroke Foundation: Melbourne, Australia. Sherratt, S., et al., "Well it has to be language-related": Speech-language pathologists' goals for people with aphasia and their families. Int J Speech Lang Pathol, 2011. 13(4): p. 317-28. Rohde, A., et al., A comparison of client and therapist goals for people with aphasia: A qualitative exploratory study. Aphasiology, 2012. 26(10): p. 1298-1315. Worrall, L., et al., The evidence for a life-coaching approach to aphasia. Aphasiology, 2010. 24(4): p. 497-514. Klippi, A., et al., Current clinical practices in aphasia therapy in Finland: Challenges in moving towards national best practice. Folia Phoniatrica et Logopaedica, 2012. 64(4): p. 169-78. Law, J., et al., The Aphasia in Scotland Project - Final Report. 2007, Centre for Integrated Healthcare Research. Johansson, M.B., M. Carlsson, and K. Sonnander, Working with families of persons with aphasia: a survey of Swedish speech and language pathologists. Disabil Rehabil, 2011. 33(1): p. 51-62. Monaghan, J., et al., Improving patient and carer communication, multidisciplinary team working and goal-setting in stroke rehabilitation. Clinical rehabilitation, 2005. 19(2): p. 194-199. Rose, M., et al., Aphasia rehabilitation in Australia: Current practices, challenges and future directions. International Journal of Speech Language Pathology, 2013. Brown, K., et al., Exploring speech-language pathologists' perspectives about living successfully with aphasia. Int J Lang Commun Disord, 2011. 46(3): p. 300-11. Worrall, L., et al., What people with aphasia want: Their goals according to the ICF. Aphasiology, 2011. 25(3): p. 309-322. Tomkins, B., S. Siyambalapitiya, and L. Worrall, What do people with aphasia think about their health care? Factors influencing satisfaction and dissatisfaction. Aphasiology, 2013. 27(8): p. 972-991. Blom Johansson, M., et al., Communication changes and SLP services according to significant others of persons with aphasia. Aphasiology, 2012. 26(8): p. 1005-1028. Levack, W.M., et al., Is goal planning in rehabilitation effective? A systematic review. Clinical Rehabilitation, 2006. 20: p. 739-755. Ferreira, D.L., Aphasia Incidence and Intervention in the Acute Hospital Setting, in Faculty of Computing, Health and Science. 2012, Ediith Cowan University Godecke, E., et al., Very early poststroke aphasia therapy: A pilot randomized controlled efficacy trial. Int J Stroke, 2011. 7(8): p. 63544. Kong, A.P., Family members' report on speech-language pathology and community services for persons with aphasia in Hong Kong. Disabil Rehabil, 2011. 33(25-26): p. 2633-45.
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13.
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36. 37. 38. 39. 40. 41. 42. 43. 44. 45.
RI PT
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35.
M AN U
33. 34.
TE D
32.
EP
31.
Code, C. and C. Heron, Services for aphasia, other acquired adult neurogenic communication and swallowing disorders in the United Kingdom, 2000. Disabil Rehabil, 2003. 25(21): p. 1231-7. Rowe, E.T., Clinical decision-making in aphasia therapy: A survey of perceived levels of evidence for common treatment approaches", in Graduate School. 2010, South Florida. Wenke, R., et al., Feasibility and cost analysis of implementing high intensity aphasia clinics within a sub-acute setting. International Journal of Speech-Language Pathology, 2014. 16(3): p. 250-259. Kirmess, M. and L. Maher, Constraint induced language therapy in early aphasia rehabilitation. Aphasiology, 2010. 24(6): p. 725-736. Cherney, L.R., et al., Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 2008. 51: p. 1282-1299. Bakheit, A.M.O., et al., A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia. Clinical rehabilitation, 2007. 21(10): p. 885-894. Bowen, A., et al., Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial. BMJ, 2012. 345: p. e4407. Godecke, E., Efficacy of Aphasia Therapy in the Acute Setting, in Human Communication Science. 2009, Curtain University of Technology: Perth. Bhogal, S.K., R. Teasell, and M. Speechley, Intensity of aphasia therapy, impact on recovery. Stroke, 2003. 34(4): p. 987-93. O’Halloran, R., et al., Creating communicatively accessible healthcare environments: Perceptions of speech-language pathologists. International Journal of Speech-Language Pathology, 2014. 16(6): p. 603-614. Hallé, M.-C., G. Le Dorze, and A. Mingant, Speech-language therapists' process of including significant others in aphasia rehabilitation. International Journal of Language & Communication Disorders, 2014. 49(6): p. 748-760. Manders, E., A. Marien, and V. Jansse, Informing and supporting partners and children of persons with aphasia: A comparison of supply and demand. Logopedics, phoniatrics, vocology, 2011. 36(4): p. 139-144. Brown, K., et al., Living successfully with aphasia: A qualitative meta-analysis of the perspectives of individuals with aphasia, family members, and speech-language pathologists. Int J Speech Lang Pathol, 2012. 14(2): p. 141-55. Blom Johansson, M., M. Carlsson, and K. Sonnander, Communication difficulties and the use of communication strategies: From the perspective of individuals with aphasia. Int J Lang Commun Disord, 2012. 47(2): p. 144-55. Hilton, R., et al., Information, support and training needs of relatives of people with aphasia: Evidence from the literature. Aphasiology, 2014. 28(7): p. 797-822. Denman, A., Determining the needs of spouses caring for aphasic partners. Disability and Rehabilitation, 1998. 20(11): p. 411-423.
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30.
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51. 52. 53. 54. 55. 56. 57. 58. 59. 60.
RI PT
SC
50.
M AN U
49.
TE D
48.
EP
47.
McVicker, S., et al., The Communication Partner Scheme: A project to develop long-term, low-cost access to conversation for people living with aphasia. Aphasiology, 2009. 23(1): p. 52-71. Hinckley, J., et al., Towards a consumer-informed research agenda for aphasia: Preliminary work. Disability and Rehabilitation, 2013. 36(12): p. 1042-1050. Kalra, L., et al., Training carers of stroke patients: Randomised controlled trial. BMJ (Clinical research ed.), 2004. 328(7448): p. 10991099. Doesborgh, S.J., et al., Effects of semantic treatment on verbal communication and linguistic processing in aphasia after stroke: A randomized controlled trial. Stroke, 2004. 35(1): p. 141-6. Page, S.J. and S.E. Wallace, Speech language pathologists' opinions of constraint-induced language therapy. Top Stroke Rehabil, 2014. 21(4): p. 332-8. Rose, M.L., et al., Multi-modality aphasia therapy is as efficacious as a constraint-induced aphasia therapy for chronic aphasia: A phase 1 study. Aphasiology, 2013. 27(8): p. 938-971. True, G., et al., Perspectives of persons with aphasia towards SentenceShaper To Go: A qualitative study. Aphasiology, 2010. 24(9): p. 1032-1050. Beukelman, D.R., L.J. Ball, and S. Fager, An AAC personnel framework: Adults with acquired complex communication needs. Augmentative and Alternative Communication, 2008. 24(3): p. 255-267. Van de Sandt-Koenderman, W.M., et al., A computerised communication aid in severe aphasia: An exploratory study. Disabil Rehabil, 2007. 29(22): p. 1701-9. Bloch, S., Anticipatory other-completion of augmentative and alternative communication talk: A conversation analysis study. Disability and rehabilitation, 2011. 33(3): p. 261-269. Lasker, J. and D.R. Beukelman, Peers' perceptions of storytelling by an adult with aphasia. Aphasiology, 1999. 13(9-11): p. 857-869. Rose, M., J. Douglas, and T. Matyas, The comparative effectiveness of gesture and verbal treatments for a specific phonologic naming impairment. Aphasiology, 2002. 16(10-11): p. 1001-1030. Davis, L.C., Karen, Computer use in the management of aphasia: A survey of practice patterns and opinions. Contemporary Issues in Communication Science and Disorders, 2006. 33: p. 138-146. Mortley, J., J. Wade, and P. Enderby, Superhighway to promoting a client‐therapist partnership? Using the Internet to deliver word‐ retrieval computer therapy, monitored remotely with minimal speech and language therapy input. Aphasiology, 2004. 18(3): p. 193-211. Fink, R., et al., Computer-assisted treatment of word retrieval deficits in aphasia. Aphasiology, 2005. 19(10): p. 943-954.
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67. 68.
69. 70. 71. 72. 73. 74. 75.
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66.
TE D
63. 64. 65.
EP
62.
Cherney, L.R., et al., Computerized script training for aphasia: Preliminary results. American Journal of Speech-Language Pathology, 2008. 17(1): p. 19-34. Palmer, R., et al., Computer therapy compared with usual care for people with long-standing aphasia poststroke: a pilot randomized controlled trial. Stroke, 2012. 43(7): p. 1904-11. Brady, M.C., et al., Speech and language therapy for aphasia following stroke (Review). The Cochrane Library, 2012(5). Wertz, R. and R. Katz, Outcomes of computer‐provided treatment for aphasia. Aphasiology, 2004. 18(3): p. 229-244. Katz, R.C. and R.T. Wertz, The efficacy of computer-provided reading treatment for chronic aphasic adults. Journal of Speech, Language, and Hearing Research, 1997. 40: p. 493-507. Law, J., et al., Reconciling the perspective of practitioner and service user: findings from The Aphasia in Scotland study. Int J Lang Commun Disord, 2010. 45(5): p. 551-60. Brumfitt, S.M. and P. Sheeran, An evaluation of short-term group therapy for people with aphasia. Disability & Rehabilitation, 1997. 19(6): p. 221-230. Mumby, K. and A. Whitworth, Evaluating the effectiveness of intervention in long-term aphasia post-stroke: The experience from CHANT (Communication Hub for Aphasia in North Tyneside). International journal of language & communication disorders / Royal College of Speech & Language Therapists, 2012. 47(4): p. 398. Grohn, B., et al., Living successfully with aphasia during the first year post-stroke: A longitudinal qualitative study. Aphasiology, 2014. 28(12): p. 1405-1425. Elman, R.J. and E. Bernstein-Ellis, The efficacy of group communication treatment in adults with chronic aphasia. Journal of Speech, Language, and Hearing Research, 1999. 42: p. 411-419. Vickers, C.P., Social networks after the onset of aphasia: The impact of aphasia group attendance. Aphasiology, 2010. 24(6-8): p. 902913. Lanyon, L.E., M.L. Rose, and L. Worrall, The efficacy of outpatient and community-based aphasia group interventions: A systematic review. Int J Speech Lang Pathol, 2013. Rose, T., et al., Do people with aphasia receive written stroke and aphasia information? Aphasiology, 2009. 23(3): p. 364-392. Knight, K., L. Worrall, and T. Rose, The provision of health information to stroke patients within an acute hospital setting: What actually happens and how do patients feel about it? Topics in Stroke Rehabilitation, 2006. 13(1): p. 78-97. Hinckley, J.J., What people living with aphasia think about the availability of aphasia resources. American journal of speech-language pathology, 2013. 22(2): p. S310-7.
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61.
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82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93.
RI PT
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M AN U
79. 80. 81.
TE D
78.
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77.
Rose, T., et al., Do people with aphasia want written stroke and aphasia information? A verbal survey exploring preferences for when and how to provide stroke and aphasia information. Topics in Stroke Rehabilitation, 2010. 17(2): p. 79-98. Blom Johansson, M., et al., A multiple-case study of a family-oriented intervention practice in the early rehabilitation phase of persons with aphasia. Aphasiology, 2012. 27(2): p. 201-226. Howe, T., et al., 'You needed to rehab ... families as well': Family members' own goals for aphasia rehabilitation. Int J Lang Commun Disord, 2012. 47(5): p. 511-21. Forster, A., et al., Information provision for stroke patients and their caregivers (Review). The Cochrane Library, 2012(11). Smith, J., et al., Information provision for stroke patients and their caregivers. The Cochrane Library, 2008(2). Brumfitt, S., Psychosocial aspects of aphasia: Speech and language therapists' views on professional practice. Disabil Rehabil, 2006. 28(8): p. 523-34. Mackenzie, C., et al., A survey of aphasia services in the United Kingdom. International Journal of Language & Communication Disorders, 1993. 28(1): p. 43-61. Ireland, C. and G. Wotton, Time to talk: counselling for people with dysphasia. Disability and Rehabilitation, 1996. 18(11): p. 585-591. Bhogal, S.K., et al., Community reintegration after stroke. Topics in Stroke Rehabilitation, 2003. 10(2): p. 107-129. Evans, R.L., et al., Family intervention after stroke: Does counseling or education help? Stroke, 1988. 19(10): p. 1243-1249. Clark, M.S., S. Rubenach, and A. Winsor, A randomized controlled trial of an education and counselling intervention for families after stroke. Clinical Rehabilitation, 2003. 17(7): p. 703-712. Eldred, C. and C. Sykes, Psychosocial interventions for carers of survivors of stroke: A systematic review of interventions based on psychological principles and theoretical frameworks. British Journal of Health Psychology, 2008. 13(Pt 3): p. 563. Johannsen-Horbach, H., M. Crone, and C.W. Wallesch, Group therapy for spouses of aphasic patients. Seminars in speech and language, 1999. 20(1): p. 73. Brereton, L., C. Carroll, and S. Barnston, Interventions for adult family carers of people who have had a stroke: A systematic review. Clinical Rehabilitation, 2007. 21(10): p. 867-884. Garcia, L.J., J. Barrette, and C. Laroche, Perceptions of the obstacles to work reintegration for persons with aphasia. Aphasiology, 2000. 14(3): p. 269-290. Matos, M.A.C., L.M.T. Jesus, and M. Cruice, Consequences of stroke and aphasia according to the ICF domains: Views of Portuguese people with aphasia, family members and professionals. Aphasiology, 2014. 28(7): p. 771-796. Parr, S., Living with severe aphasia: Tracking social exclusion. Aphasiology, 2007. 21(1): p. 98-123. Kersten, P., et al., The unmet needs of young people who have had a stroke: Results of a national UK survey. Disability & Rehabilitation, 2002. 24(16): p. 860-866.
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Dalemans, R.J.P., A description of social participation in working-age persons with aphasia: a review of the literature. Aphasiology, 2008. 22(10): p. 1071-1091. Graham, J.R., S. Pereira, and R. Teasell, Aphasia and return to work in younger stroke survivors. Aphasiology, 2011. 25(8): p. 952-960. Black-Schaffer, R.M., Return to work after stroke: development of a predictive model. Archives of physical medicine and rehabilitation, 1990. 71(5): p. 285-290. Trexler, L.E., et al., Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. The Journal of head trauma rehabilitation, 2010. 25(6): p. 440-446.
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ACCEPTED MANUSCRIPT Supplementary Information – Systematic Searches
Bibliographic Databases
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1. Aphasia 2. Dysphasia 3. 1 or 2 4. Assessment 5. Tool 6. Screener 7. Screening 8. 4 or 5 or 6 or 7 9. Current practice 10. Practice 11. Gap 12. Service 13. 9 or 10 or 11 or 12 14. 3 and 8 and 13
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Example Search Strategy: CINAHL
Electronic database CINAHL (via EBsCoHost, 1982-present) MEDLINE (via OVID, 1950-present)
Time Period All All
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Search terms for bibliographic databases Subheading N/A
Search Terms Aphasia or Dysphasia
Topic Area
1. Assessment 2. Goal Setting
Assessment or Tool or Screener or Screening Goal setting or goal or goals
3. Timing, amount, intensity
Amount of therapy or timing of therapy or early therapy or early rehabilitation or intensity of therapy Constraint induced language therapy or constraint induced aphasia therapy or CILT or CIAT Cognitive neuropsychological therapy OR neuropsychological OR cognitive linguistic OR semantic therapy OR phonemic therapy Group therapy or group or groups Computer therapy or computer or computer treatment Conversation partner training or supported conversation or communication strategies Augmentative and alternative communication or AAC or strategy or compensatory
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Category Population
4. CILT
5. Cog neruopsych therapy 6. Group Therapy 7. Computer Therapy 8. Conversation Partner Training 9. AAC
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Criteria
10. Info/education Information OR education OR aphasia-friendly and aphasiafriendly info 11. Counselling Counselling or counseling or counsel or psychological treatment 12. Patient and Support or supporting or significant others or caregiver support family or caregivers or carers 13. Return to Return to work OR work OR employment OR work vocation OR vocational rehabilitation 2. Current Current practice or practice or gap or service practice/gap 3. Perceived Attitudes or experiences or perceptions or importance – perspectives or satisfaction AND clinicians Speech-language pathologist or speech-language pathologists 4. Perceived Attitudes or experiences or perceptions or importance – perspectives or satisfaction AND Client Patient or patients or carer or carers 7. Health Impact Health impact or cost effectiveness or cost benefit
Stroke, Speech Pathology and Aphasia Websites
Location http://www.speechpathologyaustralia.org.au http://www.aphasia.org.au http://www.rcslt.org
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Source Speech Pathology Australia Australian Aphasia Association Royal College of Speech and Language Therapists Connect – the Communication Disability Network American Speech-Language-Hearing Association ASHA’s Evidence Maps – National Center for Evidence-Based Practice in Communication Disorders The Internet Stroke Center speechBITE National Health and Medical Research Council Academy of Neurological Communication Disorders and Sciences National Stroke Foundation
http://www.ukconnect.org http://www.asha.org http://ncepmaps.org
www.strokecenter.org http://speechbite.com www.nhmrc.gov.au www.ancds.org
http://strokefoundation.com.au
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Supplementary Table 4. Search Results Per Topic Area (November 2014 to June 2017)
Goal Setting
Current practice/gap
Treatment timing, amount and/or Intensity Conversation Partner Training Cognitive Neuropsychological Therapy Approach Constraint-Induced Language Therapy Compensatory strategies/AAC Computer Therapy
Current practice/gap
Group Therapy
Current practice/gap
Current practice/gap Current practice/gap
Current practice/gap Current practice/gap Current practice/gap
Total Included 1
References Included
16 (6) 45 (2) 3 (0) 27 (5) 23 (5)
1
0
16
1
[1]
0
0
45
0
-
0
3
0
-
2
28
1
[2]
2
25
0
0
2
25
3
[2-4]
0
1
42
1
[2]
0
1
4
1
[2]
0
1
29
1
[2]
0
1
26
1
[2]
0
1
100
1
[2]
26 (7) 42 (2) 4 (0) 29 (2) 26 (6) 100
0 0 0
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Documents Excluded 109
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Perceived importance – clinicians Perceived importance – Client Health Impact
Search Yield Websites 2
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Current practice/gap
Grey Literature 0
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Screening Assessment
Search Yield Databases (Full Text retrieved) 108 (6)
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Criteria
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Topic Area
[1]
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Current practice/gap
Return to Work
Current practice/gap
0
2
0
1
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5.
2
80
20
1
[2]
6
1
[5]
119
2
[2, 3]
24
1
[2]
454
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Foster, A.M., et al., 'I do the best I can': an in-depth exploration of the aphasia management pathway in the acute hospital setting. Disability and rehabilitation, 2016. 38(18): p. 1765. Stroke Foundation, National Stroke Audit – Rehabilitation Services Report 2016. 2016: Melbourne, Australia. National Stroke Foundation, National Stroke Audit - Acute Services Report 2015. 2015: Melbourne, Australia. Beckley, F., W. Best, and S. Beeke, Delivering communication strategy training for people with aphasia: what is current clinical practice? International Journal of Language & Communication Disorders, 2017. 52(2): p. 197-213. Sekhon, J.K., J. Douglas, and M.L. Rose, Current Australian speech-language pathology practice in addressing psychological well-being in people with aphasia after stroke. International Journal of Speech-Language Pathology, 2015, Vol.17(3), p.252-262, 2015. 17(3): p. 252-262.
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2. 3. 4.
0
1
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1.
2
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Caregiver Support
5 (2) 119 (15) 24 (1) 449
0
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Current practice/gap
Totals
Current practice/gap
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Information, Education and Aphasia Friendly Information Counselling
(11) 79 (5)
S0003-9993(17)31083-3
DOI:
10.1016/j.apmr.2017.08.474
Reference:
YAPMR 57011
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 31 December 2016 Revised Date:
16 July 2017
Accepted Date: 14 August 2017
Please cite this article as: Shrubsole K, Worrall L, Power E, O’Connor DA, Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A scoping review, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2017), doi: 10.1016/j.apmr.2017.08.474. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A scoping review
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Running Head: Aphasia implementation priorities
Kirstine Shrubsole1, Linda Worrall1,, Emma Power2,, and Denise A. O’Connor3
School of Health and Rehabilitation Sciences, The University of Queensland,
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University of Sydney, 3School of Public Health and Preventive Medicine, Monash
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University.
Correspondence:
Professor Linda Worrall, Communication Disability Centre, School of Health and
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Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia. E-mail: [email protected]
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Conflicts of interest: None declared.
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Funding: This work was supported by an Australian Postgraduate Award (APA) scholarship, awarded to Kirstine Shrubsole. The preliminary findings of the study were presented by Ms Shrubsole at the 2015 Stroke conference in Melbourne, Australia, to clinicians and researchers interested in the field of stroke.
APHASIA IMPLEMENTATION PRIORITIES
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Priorities for closing the evidence-practice gaps in post-stroke aphasia rehabilitation: A
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scoping review
3 OBJECTIVE
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To identify implementation priorities for post-stroke aphasia management relevant to the
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Australian healthcare context.
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DATA SOURCES
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Using systematized searches of databases (CINAHL, Medline), guideline and stroke
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websites, and other sources, evidence was identified and extracted for seven implementation
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criteria for 13 topic areas relevant to aphasia management. These seven priority-setting
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criteria were identified in the implementation literature; strength of the evidence; current
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evidence-practice gap; clinician preference; client preference; modifiability; measurability;
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and health impact.
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STUDY SELECTION
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Articles were included if they were in English, related to a specific recommendation
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requiring implementation, and contained information pertaining to any of the seven
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prioritisation criteria.
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DATA EXTRACTION
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The scoping review methodology was chosen to address the broad nature of the topic.
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Evidence was extracted and placed in an evidence matrix. Following this, evidence was
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summarised, then aphasia rehabilitation topics prioritised using an approach developed by the
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research team.
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DATA SYNTHESIS
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Evidence from 100 documents was extracted and summarised. Four topic areas were
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identified as implementation priorities for aphasia: Timing, Amount and Intensity of
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Therapy; Goal Setting; Information, Education and Aphasia-Friendly Information; and
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Constraint-Induced Language Therapy.
3
CONCLUSIONS
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Closing the evidence-practice gaps in the four priority areas identified may deliver the
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greatest gains in outcomes for Australian stroke survivors with aphasia. Our approach to
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developing implementation priorities may be useful for identifying priorities for
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implementation in other healthcare areas.
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Key Words: aphasia, stroke, clinical practice guidelines, knowledge translation,
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implementation.
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List of Abbreviations:
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CPT = Conversation-Partner Training
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CILT = Constraint Induced Language Therapy
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CPG = Clinical Practice Guideline
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SLP = Speech-Language Pathologist
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Priorities for Closing Evidence-Practice Gaps in Aphasia Rehabilitation: A Scoping
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Review
3 The failure to translate research evidence into clinical practice results in ‘evidence-practice
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gaps’. Evidence-practice gaps have been found in many areas of healthcare and can result in
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suboptimal care (1, 2). A landmark study by McGlynn and colleagues found that patients in
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the USA received guideline-recommended care on average 55% of the time (3). Similar
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evidence-practice gaps have also been observed in Australia (4) and in aphasia rehabilitation
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(5, 6).
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There is a need to close these evidence-practice gaps by engaging in implementation
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activities. Implementation ensures that stakeholders, including healthcare professionals,
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consumers and policy makers, are aware of and actively use research evidence to inform
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health and healthcare decision-making (1). A substantial body of evidence about the effects
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of implementation strategies is now available to inform the selection and design of
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implementation activities to close evidence-practice gaps (1, 7). However, limited evidence is
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available to inform and prioritise which evidence-based practices should be targeted for
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implementation.
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In an environment of competing demands for finite health resources, implementation targets
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need to be prioritised and selected, often from a large set of evidence-based
20
recommendations. Healthcare professionals such as Speech-Language Pathologists (SLPs)
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have reported the limited feasibility of implementing every single guideline recommendation
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(8). Methods for identifying implementation priorities have received little attention in the
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literature to date (9), and there is no consensus on the best approach of how to prioritise
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implementation targets at a national level.
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There are a number of criteria that could be used to prioritise implementation efforts, which
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have been suggested to be important factors in implementation. For example, the Strength of
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the Supporting Evidence is an important consideration as clinicians are more likely to
4
implement Clinical Practice Guideline (CPG) recommendations that are based on strong
5
supporting evidence (10, 11). Information on the Evidence-Practice Gap is important to
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identify the degree to which current practice differs from guideline recommendations, and
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whether or not implementation efforts are required (12, 13). Evidence of Client and Clinician
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Preference for implementation is also important, as patient and family expectations can
9
influence change (10, 14), and local opinion leaders and existing culture can influence
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stakeholder support (10, 12, 15). Other potentially important criteria include: Measurability –
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the ability to measure change in professional behaviours and/or patient outcomes compared
12
to baseline data (12, 16), Modifiability - the complexity of the behaviours being changed or
13
the presence of multiple or non-modifiable barriers (10, 12, 17), and Health Impact -
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evidence of important health impact resulting from a change in the recommended practice or
15
behavior, including patient outcomes, quality of care and/or economic outcomes (10, 12).
16
Despite general agreement on the importance of the priority criteria, very few studies have
17
applied these to identify implementation priorities in any given clinical area. Two approaches
18
to identify implementation priorities are previously reported in the literature; a modified
19
Delphi method and conjoint analysis, both focussing on investigating stakeholders’ priorities
20
for implementation. Bayley and colleagues used a modified Delphi method to prioritise
21
clinical areas ready for implementation in stroke rehabilitation (18) and traumatic brain
22
injury (19) in Canada. In these studies, a panel of stakeholders was invited to consider issues
23
such as the strength of the supporting evidence, the prevalence of the health problem, the
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potential impact of improved care, and the feasibility of conducting an implementation
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intervention to determine priorities for implementation efforts (18, 19). Farley and colleagues
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used Conjoint Analysis to rank stakeholder implementation priorities in postnatal depression
2
(9). Health care professionals working in a UK Primary Care Trust were sent a questionnaire
3
and asked to rate 16 hypothetical scenarios containing potential implementation targets with
4
varying attributes (e.g. strength of supporting evidence, impact on patient care, cost etc). This
5
approach produced a ranked list of implementation priorities (for example, ‘self-help’ was
6
rated as the top priority for implementation and ‘screening questions for post-natal
7
depression’ was ranked lowest). However this approach was limited by a low response rate
8
(11%) and uncertainty in stability of stakeholder preferences over time.
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Implementation Priorities in Aphasia
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To date, there have been no systematic attempts to identify implementation priorities for
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aphasia management. However, there is evidence to support the need for implementation.
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Aphasia is often a chronic condition, associated with poor functional recovery and poor
14
quality-of-life (21, 22). Despite the poor outcomes for people with aphasia and the
15
increasing recognition that aphasia is an important research priority (23), there are many
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evidence-practice gaps in aphasia practice. For example, in the Australian context, a
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rehabilitation audit of stroke guideline adherence found 58% adherence to recommendations
18
for aphasia management (5). In the USA, only 22% of SLPs conduct Constraint-Induced
19
Language Therapy (24), an intervention of proven benefit (25).
20
While evidence-practice gaps in post-stroke aphasia management exist, it is unclear which of
21
these areas should be priorities for implementation. Previous work by our team has identified
22
34 evidence-based aphasia and general stroke rehabilitation recommendations from high-
23
quality CPGs (26). The aim of this study is to identify the priorities for implementation in
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post-stroke aphasia management, relevant to the Australian context, by conducting a scoping
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review of relevant literature.
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1 2
Methods Design: We undertook a scoping review to evaluate the literature pertaining to seven
4
implementation criteria (strength of the evidence; current evidence-practice gap; clinician
5
preference; client preference; modifiability; measurability; and health impact) for topics in
6
aphasia rehabilitation. These criteria were selected by the research team and informed by
7
supporting literature on attributes considered important to decision makers for prioritizing
8
implementation efforts and the teams’ experience in past projects. A scoping review was
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selected in order to address this broad topic of implementation, whereby different study
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designs may be relevant and iterative decisions need to be made once a familiarity with the
11
literature is gained (27).
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We then extracted the data, synthesised and summarised the evidence, and ranked topics to
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prioritise areas for implementation. The steps in this process are described below.
14
Systematized searches:
15
Systematized searches were conducted for 13 topic areas for aphasia management, and the
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seven implementation criteria. This approach involved only one reviewer due to the scope of
17
the paper and resource constraints (28). The aphasia rehabilitation topic areas that were
18
selected were:
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20
•
21
•
22
•
Conversation Partner Training/ Supported Conversation,
23
•
Cognitive Neuropsychological-Based Therapy,
24
•
Constraint-Induced Language Therapy,
25
•
Compensatory Strategies/AAC,
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Screening Assessment,
Goal Setting,
Timing, Amount, and Intensity of Therapy,
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APHASIA IMPLEMENTATION PRIORITIES
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•
Computer-Based Therapy,
2
•
Group Therapy,
3
•
Information/Education and Aphasia-Friendly Information,
4
•
Counselling,
5
•
Caregiver Support, and
6
•
Return to Work.
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These topics were selected based on our previous paper (26), where we identified 34
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evidence-based aphasia and general stroke rehabilitation recommendations from high-quality
9
Clinical Practice Guidelines (CPGs). The 34 CPG recommendations were then categorised
10
into the 13 topics areas to make managing and summarizing the data more manageable. The
11
working definitions and source/s from which the implementation criteria were identified are
12
shown in Table 1.
13
For Criterion 1 (Strength of the Evidence), the Clinical Practice Guidelines from which the
14
recommendations arose were the primary sources of data (29-31). The evidence grading for
15
the recommendations contained in the 13 topic areas was extracted from these clinical
16
practice guidelines (see Supplementary Table 1). The recommendations pertaining to
17
aphasia management in the Australian and New Zealand guidelines are identical and were
18
therefore combined (Aust/NZCGSM).
19
For the remaining six criteria, systematic searches of two electronic databases (CINAHL,
20
Medline) were undertaken to identify relevant evidence. Search terms included population
21
(aphasia OR dysphasia), key words per topic area (e.g., for ‘Screening Assessment’ search
22
terms included assessment OR tool OR screener OR screening) and criteria (e.g., for ‘Current
23
Evidence-Practice Gap’ search terms included current practice OR practice OR gap OR
24
service OR survey). Pearling references from relevant articles and searches of speech-
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language pathology and aphasia websites (e.g., www.rcslt.org/; http://speechbite.com) were
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also undertaken. Articles were included if they were in English, related to a specific
2
recommendation requiring implementation, and contained information pertaining to any of
3
the seven prioritisation criteria. No search limitations were placed on the date of publication.
4
The final search was run on 14 November 2014. Detailed search information can be found in
5
the supplementary material.
6
Screening: The first author (KS) conducted the literature searches, then screened potential
7
results by abstract, retrieved the full text and excluded those that did not meet the criteria.
8
Data Collection and Analysis:
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An ‘Evidence Matrix’ was developed to collate data from the search of each implementation
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criteria per aphasia topic. As this Evidence Matrix was too extensive and complex for
11
decision-making, the data was then summarised to show the strength of the evidence of each
12
criteria in a snapshot. This allowed for comparisons across topic areas. For Strength of the
13
Evidence, where multiple recommendations per topic area existed, the evidence grading from
14
the recommendation with the highest strength of evidence was used. Specifically,
15
recommendations originating from the Aust/NZCGSM were classified using the NHMRC
16
evidence ratings (32); as High evidence = A or B, Moderate evidence = C, or Low evidence =
17
D. Recommendations from the NICE 162 was classified using the GRADE evidence ratings
18
(33) as High evidence = Strong, or Low evidence = Weak.
19
The evidence for the remaining six criteria (Current Evidence-Practice Gap, Clinician
20
Preference, Client Preference, Measurability, Modifiability, and Health Impact) was
21
evaluated using a decision-making process that was developed iteratively by the authors
22
during the analysis phase, in the absence of specific published methods (see Figure 1). The
23
Current Evidence-Practice Gap data was calculated by determining the difference between
24
current practice in each specific topic area and 100% guideline adherence (i.e. 100% - current
25
practice percentage). Where evidence was found for the implementation criteria (e.g.,
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Current Evidence-Practice Gap), this was classified as either qualitative or quantitative.
2
Where data was found for current practice in both stroke and aphasia populations, the data
3
from aphasia practice was used. For quantitative data, evidence was classified as Low (for
4
<50% uptake of evidence, not a significant p value, or inconsistent or small effect sizes),
5
Moderate (for 50-74%) or High (>75%, a significant p value or a large effect size). The
6
decision to use quartiles to evaluate the uptake of recommendations was based on a similar
7
study in falls prevention (34). Qualitative evidence was symbolized using QUAL, with either
8
a ‘+’ to signify that the evidence was in support of implementation, or ‘–’ sign to indicate the
9
evidence did not support implementation, such as negative patient reports or barriers to
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implementation. For an illustrative example of this process, please refer to Figure 2.
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(Insert Figure 1 about here).
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(Insert Figure 2 about here).
13
(Insert Table 2 about here)
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When reviewing and synthesising this evidence, it became apparent there were potentially
16
important differences between data reported relevant to criteria 2 – 6 in studies conducted in
17
different countries (e.g. data on evidence-practice gaps for group therapy in Australia vs. in
18
other countries). Given this study aimed to prioritise topics for implementation in post-stroke
19
aphasia management relevant to the Australian setting, it was determined that the summary
20
of the evidence relating to criteria 2 – 6 would only include studies conducted in Australia.
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Prioritisation of Topics for implementation
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The 13 topic areas were prioritised according to the summarised data for the seven criteria.
24
Since stronger evidence is more likely to be implemented (11, 35) and areas with large
25
evidence-practice gaps should be implementation targets (12, 13), the first two criteria were
9
APHASIA IMPLEMENTATION PRIORITIES
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weighted more heavily. The remaining criteria were considered with equal weighting as
2
there was no clear reason or precedent in the literature to prioritise one over the other. A
3
decision-making tree was developed, where topic areas were considered to be of highest
4
priority for implementation where evidence was as follows:
5
a) ‘High’ evidence for Strength of the Evidence, and
6
b) ‘High’ or ‘Moderate’ evidence for Current Evidence-Practice Gap, and
7
c) Evidence available to support implementation in any of the other criteria (Clinician
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Preference, Client Preference, Measurability, Modifiability, and Health Impact), with
9
topics ranked according to the total support across the seven criteria.
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Priority Topics were then ranked based on the total support for (c). That is, topics areas for
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which we identified evidence for more criteria in ‘c’ were ranked higher than those that had
12
fewer criteria.
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Results
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The evidence matrix is presented in the supplementary online material as Table 1. The
17
general stroke rehabilitation recommendations for Strength of the Evidence are presented in
18
the first column for the 13 topic areas. For evidence of the Current Evidence-Practice Gap,
19
Clinician Preference, Client Preference, and Health Impact, 2009 documents were identified
20
for screening. Of these, 1909 documents were excluded, and findings from the remaining 100
21
were included (see PRISMA flowchart, Figure 3). As Modifiability was related specifically to
22
implementation barriers or enablers, and a preliminary search found limited literature in this
23
area for aphasia, data for this criterion was used from search results for other criteria.
24
Similarly, as information relevant to Measurability was not specifically reported in any of the
25
studies retrieved, judgments were made about the complexity of the behaviours to be
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measured and whether this data appeared to be routinely collected (as determined in findings
2
from the Current Evidence-Practice Gap searches).
3
(Insert Figure 3 about here).
4 Summary of the Existing Evidence for Implementation
6
a) Strength of the Evidence. Seven of the 13 topic areas were underpinned by high evidence
RI PT
5
(A or B level in the AustCGSM or Strong in the NICE162): Goal Setting;
8
Timing/Amount and Intensity of Therapy; Conversation Partner Training; Constraint
9
Induced Language Therapy; Information/Education and Aphasia-Friendly Information;
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7
Counselling; and Return to Work. A further five topic areas were underpinned by
11
moderate evidence: Screening Assessment; Cognitive Neuropsychological-Based
12
Therapy; Computer-Based Therapy; Group Therapy; and Caregiver Support.
13
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b) Current Evidence-Practice Gap. Six topic areas had gaps of moderate-to-high magnitude: Goal Setting (acute setting); Timing/Amount and Intensity of Therapy (acute and
15
rehabilitation settings); Constraint Induced Language Therapy (rehabilitation setting);
16
Computer-Based Therapy (rehabilitation setting); Group Therapy (acute and
17
rehabilitation settings); and Information/Education and Aphasia-Friendly Information
18
(acute and rehabilitation settings). The remaining seven topics had gaps of low
19
magnitude: Screening Assessment; Conversation Partner Training; Cognitive
20
Neuropsychological-Based Therapy; Compensatory Strategies/AAC; Counselling;
21
Caregiver Support and Return to Work.
22
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c) Clinician Preference. There was evidence that clinicians perceived eight topic areas to be
23
important (six via qualitative studies and two via quantitative studies). These were Goal
24
Setting; Timing/Amount and Intensity of Therapy; Conversation Partner Training;
25
Compensatory Strategies/AAC; Computer-Based Therapy; Information/Education and
11
APHASIA IMPLEMENTATION PRIORITIES
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Aphasia-Friendly Information; Counselling; Caregiver Support. There was evidence that
2
clinicians had either negative perceptions of, or no identified implementation need for,
3
the following topics: Screening Assessment; Cognitive Neuropsychological-Based
4
Therapy, Constraint Induced Language Therapy; and Group Therapy. For example, the
5
majority of clinicians rated knowledge of and confidence with cognitive
6
neuropsychological approaches as very good/good or very high/high (36). There was no
7
Australian evidence found for clinician views on the topic Return to Work.
d) Client Preference. There was also evidence that patients perceived ten topic areas to be
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important (eight from qualitative studies, one from a quantitative study). These included
10
Goal Setting; Timing/Amount and Intensity of Therapy; Conversation Partner Training;
11
Cognitive Neuropsychological-Based Therapy; Compensatory Strategies/AAC; Group
12
Therapy; Information/Education and Aphasia-Friendly Information; Counselling;
13
Caregiver Support; and Return to Work. There was evidence that clients had negative
14
perceptions of Constraint Induced Language Therapy, with only 3/11 clients expressing
15
preference for CILT compared to Multi-Modal Aphasia Therapy (37). There was no
16
Australian evidence found for client views on the topics Screening Assessment and
17
Computer-based Therapy.
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e) Modifiability. While several topics (Timing, Amount and Intensity of Therapy, Carer
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18
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9
19
Training/Conversation Partner Training, and Counselling) had evidence from qualitative
20
studies of both barriers and facilitators to implementation, almost a third (4/13, 31%) had
21
no information available.
22
f) Measurability. Six topics (46%) included complex behaviours that were either difficult to
23
observe or not routinely collected. These included Goal Setting; Conversation Partner
24
Training; Cognitive Neuropsychological-Based Therapy; Information/Education and
25
Aphasia-Friendly Information; Counselling; Caregiver Support.
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APHASIA IMPLEMENTATION PRIORITIES
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1
g) Health Impact. The majority of topics (9/12, 75%) had evidence of a significant health
2
impact or large effect size. The remaining topics had inconsistent (Goal Setting and
3
Cognitive Neuropsychological-Based Therapy) or moderate (Timing/Amount and
4
Intensity of Therapy) effects. A summary of the extracted evidence for each criterion per topic area is shown in Table 2.
6
(Insert Table 2 about here).
7
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5
Prioritisation process
9
Four priority topic areas were identified for implementation in post-stroke aphasia
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8
rehabilitation. The topics “Information, Education and Aphasia-Friendly Information” and
11
“Timing, Amount and Intensity of Therapy” were ranked equal first priority. “Goal Setting”
12
was ranked third, and “Constraint-Induced Language Therapy” was ranked fourth for
13
implementation. This decision-making process is shown in Figure 4.
14
The first two prioritised areas (“Information, Education and Aphasia-Friendly Information”
15
and “Timing, Amount and Intensity of Therapy”) had moderate or high evidence-practice
16
gaps, and supporting evidence for all other criteria. “Goal-setting” had moderate or high
17
evidence-practice gaps and had supporting evidence for 80% of the remaining criteria.
18
“Constraint-Induced Language Therapy” had moderate or high evidence-practice gaps with
19
supporting evidence for only two criteria (40%), but no Australian information on clinician
20
preference, poor patient satisfaction, and evidence of barriers for implementation.
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(Insert Figure 4 about here).
22 23
Discussion
24
This study sought to identify priorities for implementation in post-stroke aphasia
25
management relevant to the Australian setting. This is the first attempt to our knowledge of
13
APHASIA IMPLEMENTATION PRIORITIES
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applying a criteria-based priority-setting process to identify clinical topic areas and their
2
associated recommendations ready for implementation in aphasia rehabilitation.
3
Using multiple pre-defined prioritisation criteria was a novel component of this study. While
4
previous work has suggested a range of different factors to consider when deciding on which
5
evidence to implement (10, 12), none of these studies used a priori criteria to evaluate the
6
evidence for implementation. Some targeted attempts at priority-setting have been
7
undertaken that have focused on using a consensus approach (18, 19) or Conjoint Analysis
8
for treatment preferences (9, 20), but these did not extract, summarise and rank the evidence
9
for a predetermined set of criteria as we have done. In this way, we have built on previous
10
priority-setting attempts and provided a broad helicopter view of the available evidence for
11
implementation across aphasia management recommendations in the Australian context.
12
However, the benefits of this approach need to be considered alongside the considerable
13
amount of work that it requires.
14
Although seven criteria were used in our scoping review, it is unclear which of these are the
15
best to use, and whether all of them are necessary. It could be argued that the first two
16
criteria, Strength of the Evidence and Current Evidence-Practice Gap, would provide a
17
quicker and more pragmatic way to prioritise implementation targets. In this study, we found
18
that these criteria had complete data sets, and the evidence for these was relatively easy to
19
locate and extract from the scoping search. However, given that there is evidence that other
20
criteria such as client and clinician preference can impact on the success of implementation,
21
there is potential to overlook important information if using a pared-down approach.
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22 23
Locating Existing Data for the Implementation Criteria
24
Searching for and synthesising the relevant data sets for aphasia-related topics was a
25
challenge, as data relating to several criteria was often difficult to find. There was a lack of
14
APHASIA IMPLEMENTATION PRIORITIES
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information available related to clinician and client preferences. Evidence relating to these
2
criteria was often not the focus of the study, but embedded within it. One Australian study
3
did directly examine speech-language pathologists’ priorities (36) but determined research
4
priorities rather than priorities for implementation. Other criteria with limited quantitative
5
data were modifiability and measurability. The modifiability criteria depended on reported
6
barriers for each implementation topic, and these varied between clinical contexts (11).
7
Measurability of guideline-recommended behaviours was not specifically reported in any of
8
the studies examined. While incomplete data sets for these criteria was discouraging, it was
9
not surprising, given that there has been limited research into the factors influencing
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implementation in aphasia, highlighting a need for further research.
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11
Determining the ‘Linkages’ and Accuracy of the ‘Gap’ Data
13
The majority of information found for the current evidence-practice gap comprised audit or
14
survey data, however the practice being measured did not always correspond to the guideline
15
recommendation. For example, the Australian rehabilitation stroke audit (6) found that 96%
16
of the recommended intensity of swallowing and communication therapy was provided in
17
clinical practice, but the audit did not measure intensity of communication therapy alone. It is
18
suggested that future audit tools be more closely linked to the clinical practice guideline
19
recommendations.
20
One topic area, Carer Training/Conversation-Partner Training (CPT), showed some
21
particularly interesting findings that may warrant further investigation. For CPT, the
22
evidence-practice gap was low (8-24% gap) in the rehabilitation setting (6, 38), indicating
23
that clinicians are using it 76-92% of the time. However, clinicians have reported low use and
24
poor or very poor confidence with CPT approaches (36). These contradictory results may
25
suggest that clinicians are not confident about implementing CPT but have implemented it
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APHASIA IMPLEMENTATION PRIORITIES
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nevertheless. Alternatively it could suggest that the audit data recorded incidences of general
2
advice given to carers about communicating with the person with aphasia, while SLPs who
3
responded to the survey may define Communication Partner Training as a specific technique
4
such as that described by Kagan and colleagues (39). These uncertainties highlight a need for
5
specific and accurate audit data on current aphasia rehabilitation practices by speech-
6
language pathologists.
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7 Implementation Priorities
9
The four implementation priorities that we identified originate from recommendations
10
referring to different aspects of SLPs’ aphasia management practices: 1.“Information,
11
Education and Aphasia-Friendly Information” refers to the process of providing written,
12
tailored, aphasia-friendly information at different stages of recovery; 2. “Timing, Amount
13
and Intensity of Therapy” refers to the timing, dosage and duration of therapy, but does not
14
specify the type of therapy that should be provided; 3. “Goal Setting” refers to a collaborative
15
process of identifying patient-related goals that are documented and updated regularly; and 4.
16
“Constraint-Induced Language Therapy” is a specific type of therapy approach (30).
17
Although we considered clinicians’ preferences for implementation in our prioritization
18
process, this was based on the limited published evidence (discussed above), and future
19
research should focus on prospectively identifying clinicians’ implementation priorities to
20
determine if they align with our findings.
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21
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8
Although we used Australian evidence-practice gap data in our decision-making
22
process, the results from this study may be relevant to aphasia management in other
23
countries. The evidence informing prioritization of implementation targets was sourced
24
internationally, therefore could be applied to local evidence-practice gap data elsewhere.
25
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APHASIA IMPLEMENTATION PRIORITIES
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Study Limitations
2
Searching for evidence relevant to the seven priority-setting criteria was challenging,
3
potentially meaning that not all relevant evidence was found and summarised here.
4
Furthermore, one member of the research team conducted many aspects of the decision-
5
making process (e.g., searching for, screening and extracting data for the evidence matrix).
6
While this is acceptable within some definitions of a scoping search (28), two or more
7
researchers should ideally undertake these tasks independently to reduce the potential for bias
8
(27). The date of the last run search is also a limitation of the study, however a new targeted
9
search revealed that it is unlikely that we have missed relevant papers. Finally, the thresholds
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1
for categorizing the evidence into high, moderate and low was based on earlier work (34)
11
although the cut-off values were somewhat arbitrary.
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12
Conclusion and Implications
14
This study identified potential implementation priorities for post-stroke aphasia management
15
in Australia. The study highlights the current evidence and gaps in evidence for
16
implementation criteria. Further research is needed in several areas, including evaluating
17
clinician and patient preferences and the feasibility of implementation. Moreover, it is
18
suggested that audit tools are developed that can accurately measure each recommendation
19
requiring implementation.
20
Priority-setting for implementation is a complex process that requires further investigation. It
21
remains to be seen whether expert opinion, systematic reviews across all seven criteria or just
22
the two most-important criteria produce similar results. It is anticipated that the priority-
23
setting framework we have presented could serve as a guide to researchers and stakeholders
24
both in stroke and aphasia rehabilitation and in other areas of healthcare. Furthermore, this
25
process could form the basis of a national strategy to improve implementation efforts in
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APHASIA IMPLEMENTATION PRIORITIES
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1
aphasia management, as closing the evidence-practice gaps in the identified priority areas
2
may deliver the greatest gains in outcomes for stroke survivors with aphasia.
3 4
6
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20 21 22
Table 1. Definitions for Criteria for Identifying Implementation Priorities
23
Table 2. Summary of the Implementation Evidence Matrix
24
Figure 1. Decision-Making Process for Classification of Evidence
25
Figure 2. Evidence Decisions for Goal-Setting Topic
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Rose ML, Attard MC, Mok Z, Lanyon LE, Foster AM. Multi-modality aphasia
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Figure 3. PRISMA flow chart of included studies Figure 4. Prioritization of Implementation
2
Topics
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Table 1. Definitions for Criteria for Identifying Implementation Priorities Definition
Rationale
1. Strength of the
Evidence grading as per relevant evidence-based Clinical Practice
Recommendations underpinned by strong evidence constitute important targets
Evidence
Guideline or systematic review.
for change (there is a body of evidence that can be trusted to guide practice).
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Criteria
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Clinicians more likely to implement CPG recommendations if they are based on strong evidence. (Goossens, Bossuyt, & de Haan, 2008; Grol & Wensing,
M AN U
2004).
Evidence of the difference between recommended practice (from
Important to identify which areas have evidence-practice gaps that need
Practice Gap
research evidence) and current practice – taken from clinical audits,
addressing. Areas demonstrating higher evidence-practice gaps may constitute
surveys or other sources.
more important priorities for implementation (with greater room for
Evidence of preference or stakeholder support for performing the
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3. Clinician Preference
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2. Current Evidence-
recommended practice from the perspective of clinicians (in this
improvement). (Kitson & Straus, 2010; National Institute of Clinical Studies,
2006). Local opinion leaders and existing culture can influence change. (Flodgren et al., 2011; Grol & Wensing, 2004; National Institute of Clinical Studies, 2006).
4. Client Preference
5. Modifiability
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instance speech-language pathologists).
Evidence of preference or stakeholder support for performance of the
Patients’/family members’ expectations can influence change. Patients need to
recommended practice from the perspective of healthcare consumers,
agree with the recommended practice and be able to comply with it. (Grol &
i.e., people with aphasia or carers/family members.
Wensing, 2004).
Evidence of barriers and facilitators to implementation, such as
More complex behaviours may be more difficult to change. Behaviours may be
ACCEPTED MANUSCRIPT
complexity of behaviour or resources required to change.
more difficult to change where multiple or non-modifiable barriers exist. Important to identify barriers to change to tailor interventions. (Baker et al.,
Evidence of the measurability of performance of the recommended
Performance of recommended practices may be measured using different data
practice, in terms of feasibility of data collection and potential for
collection methods and sources (e.g. via patient medical records, clinician self-
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6. Measurability
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2010; Grol & Wensing, 2004; National Institute of Clinical Studies, 2006).
bias.
report, routinely collected data). These methods may vary in terms of feasibility
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of data collection and potential for bias. Behaviours for which performance is feasible to measure and in a manner that minimises bias are most desirable. (National Institute of Clinical Studies, 2006). Health impact should incorporate patients’ capacity to benefit from treatment.
recommended practice or behavior (including patient outcomes,
Economic advantage could be attractive to organisations and influence change.
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Evidence of important health impact resulting from a change in the
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quality of care and/or economic outcomes).
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7. Health Impact
(Grol & Wensing, 2004; National Institute of Clinical Studies, 2006).
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Table 2. Summary of the Implementation Evidence Matrix
Criteria
1. Strength of
2. Current Evidence-Practice
3. Perceived
Evidence (area
Gap
importance – Clinicians
4. Perceived
5. Modifiability
6. Measurability
7. Health Impact
Importance – Client
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of practice)
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Topic Area
C Aphasia (M)
18-23% gap (a + r) (L)
44% (L)
Nil
Q-
Q+
Q+
2. Goal Setting
B Stroke (H)
13-21% gap (r) (L)
Q+
Q+
Q-
Q+, Q-
Inconsistent (L)
100% (H)
97% (H)
Q+, Q-
Q+
Moderate (M)
Q+
Q+
Q+, Q-
Q+, Q-
Significant effect (H)
73% gap (a) (M) 3. Timing, Amount, and Intensity of
B Aphasia (H)
Therapy
50% gap (r) (M) 75-91% gap (a) (H)
M AN U
1. Screening Assessment
B Stroke (H)
8-24% gap (r) (L)
Supported Conversation
C Aphasia (M)
31% gap (a) (L)
5. Cognitive Neuropsychological-
C Aphasia (M)
25% gap (r) (L)
Q-
Q+
Nil
Q+, Q-
Inconsistent (L)
B Aphasia (H)
86% gap (r) (H)
0 (L)
27% (L)
Q-
Q+
Large effects (H)
7. Compensatory Strategies/AAC
D Aphasia (L)
39% gap (r) (L)
100% (H)
54% (M)
Q+
Q+
Significant effect (H)
8. Computer-Based Therapy
C Aphasia (M)
86% gap (r) (H)
Q+
Nil
Q+
Q+
Significant effect (H)
9. Group Therapy
C Aphasia (M)
Q-
Q+
Nil
Q+
Medium-large effects
6. Constraint-Induced Language
AC C
Therapy
EP
Based Therapy
TE D
4. Conversation Partner Training/
46-80% gap (r) (M) 100% gap (a) (H)
10. Information/Education and
A Stroke (H)
51% gap (aphasia a + r) (M)
Aphasia-Friendly Information
D Aphasia (L)
*28% gap (stroke r) (L)
11. Counselling
B Stroke (H)
34% gap (aphasia a + r) (L)
(M-H) Q+
Q+
Q+
Q+, Q-
Significant effects (H)
Q+
Q+
Q+, Q-
Q+, Q-
Significant effect (H)
Q+
Q+
Q+
Q+, Q-
Significant effects (H)
*68% gap (stroke rehab) (M) 12. Caregiver Support
C Stroke (M)
41% gap (aphasia a + r) (L)
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*38-68% gap (stroke r) (M) Q+
SC
M AN U
TE D
Nil Q+ Q* a r
Nil
Nil
Q+
Significant effects (H)
High evidence (A or B on AustCGSM/Strong on NICE 162; ≥ 75% for Criteria 2-6; Significant clinical outcome or large effects for Criteria 7) Moderate evidence (C on AustCGSM; 50-74% for Criteria 2-6; Moderate effects for Criteria 7) Low/inconsistent evidence (D on AustCGSM/Weak on NICE 162; < 50% for Criteria 2-6; Not significant clinical outcome or inconsistent/small effects for Criteria 7) No information found Qualitative evidence to support implementation Qualitative evidence not supportive of implementation Where data present for aphasia and stroke populations, stroke data not used Acute setting Rehab setting
EP
M L
14-31% gap (r) (L)
AC C
Key H
Strong (H)
RI PT
13. Return to Work
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
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Supplementary Online Material – Evidence Matrix
Salter, Jutai [1].
Australia: Acute stroke audit 2011 82% of eligible pts had SP assessment (doesn’t specify if for speech or swallowing). No info on how many had communication screen/ax and if so, what type of screen [2]. 77% of SPs used screening assessments (across all settings) [3].
3. Perceived importance – Clinicians Australia: SLPs concerned re limited test repeatability and poor sensitivity to change in acute settings of standardized tests * Little consensus on most appropriate Ax tool in acute * 56% agree/strongly agree that informal evaluations more useful than formal ax in acute. * SPs want quick, repeatable, objective test. [4]
4. Perceived Importance – Patient Australia: No info found
SC
Aust 2010 / NZ 2010
2. Current Practice/Gap
Elsewhere: UK –SLP Ax not always viewed as appropriate, especially in early stages of recovery [8]
M AN U
6.5.1a) All patients should be screened for communication deficits using a screening tool that is valid and reliable.
1. Strength of Evidence Grade C
TE D
Citation/s
70% acute SPs use their own clinical assessment based on interaction and observation. Not validated/reliable. Formal screeners used were BEST (20%), AST (15%), FAST (14%) [4]
EP
Guideline/s
RI PT
Criteria
Recommendation
AC C
1. Screening Assessment
Elsewhere: US – Average time from admission to Ax was 3.9 days, 55% within 2 days [5] . UK, US, Canada, Australia - 36% use informal test in inpatient setting [6].
5. Modifiability
6. Measurability
7. Health Impact
Barriers include no widely acceptable/ appropriate screening tool currently available. Barriers may include clinician attitudes or beliefs [4].
Able to measure if assessment conducted and which assessment used. Data appears to be routinely documented, or able to be easily collected.
Need to ID presence of aphasia so that appropriate SLP services can be provided. Under identification aphasia an issue impacting on service delivery [3, 9, 10] Aphasia an independent predictor of increased LOS and increased use of rehab services [11] PWA participated in fewer activities and reported worse QOL than people without, with comparable physical abilities, well-being and social support [12]
Elsewhere: No info found.
1
Criteria Guideline/s
Citation/s
1.7b) Stroke survivors and their families/carers should be given the opportunity to participate in the process of setting goals unless they choose not to or are unable to participate. 1.7c) Health professionals should collaboratively set goals for patient care.
Aust 2010/NZ 2010.
Stroke Unit Trialists' Collaborati on [13].
Playford, et al., [30]
C
2. Current Practice/Gap
Australia: -Rehab Audit 2012 – 79% involved in setting own rehabilitation goals (excluding those with severe comm disorders). 82% of sites use formal process for goal setting [14]
Acute Audit 2011 27% of patients met with MDT to discuss assessment results, treatment plans and goals [2]. Inclusion of family members in goal setting
SPs believe living successfully with
Rehab Audit 2014 – 87% [15].
Aust 2010/ NZ 2010.
Playford, et al., (2009). [30]
C
3. Perceived importance – Clinicians Australia: Joint, functional goal setting with PWA and families a significant challenge [23].
- Matched goals focused on comm’n outcomes. Mismatched goals associated with client’s desire to return to previous activities [17].
AC C
1.7c) Goals should be prescribed, specific and challenging. They should be recorded, reviewed and updated regularly.
Aust 2010/ NZ 2010.
1. Strength of Evidence Grade B
TE D
Recommendation
EP
2. Goal Setting
M AN U
SC
Singapore - Currently no aphasia assessment tool that has been validated for use with the Singapore population. Informal language assessments most commonly reported (62.8%) [7].
RI PT
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4. Perceived Importance – Patient Australia: Social communication goals strongly emphasised [25]. As people move though acute, rehab, and to home, their goals changed [18]. Participant’s level of involvement in decision-making, goal-setting and therapy activities influenced satisfaction and dissatisfaction
5. Modifiability
6. Measurability
7. Health Impact
No critical framework for goal setting [16]. Proposed SMARTER goal setting (set of principles, not validated) [28].
Able to measure if goal setting conducted, people involved and when goals revisited. Data appears to be routinely documented, or able to be easily collected. However, may be difficult to document/ observe data relating the degree to which PWA collaborated.
Goal setting enhances clients’ adherence to treatment and improves immediate client performance in some contexts, but only inconsistent evidence for any generalized effect [29]
Barriers: timeconsuming, demanding process of establishing a meaningful relationship [29-31]
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Disparity between SLP services and client values re goal-setting and therapy goals [18]. 37.7% of respondents reported goal attainment scaling [3].
Elsewhere: Scotland - 89% involved clients in goal setting some or most of the time and family members were encouraged to become involved [19].
[26]. Elsewhere: Scotland - Many people felt excluded from overall care management and would have liked more inclusive role. They valued being included in decision making about goals [19].
RI PT
Some discrepancy between clinician’s and PWA goals. Clinicians not always aware of clients’ goals [17].
aphasia can depend on PWA’s ability to set and work towards realistic goals [24].
Elsewhere: Scotland - Most commonly reported change to practice involved including people with aphasia more in goal setting and making goals for therapy more patient-centred. [19].
SC
and decision making limited, often due to poor access, time [16].
M AN U
C
Sweden– 73% of carers prepared to take part in goal setting [27].
TE D
Langhorne, Pollock [32].
Finland – 58-85% of patients participate in therapy planning process <1 yr post stroke, vs 97% >1 yr post stroke [20].
EP
Aust 2010/ NZ 2010.
AC C
1.8 The multidisciplinary stroke team should meet regularly (at least weekly) to discuss assessment of new patients, review patient management and goals, and plan for discharge.
UK - 4–20% of family members were involved in their relative’s rehab goals (general stroke, not aphasia-specific) [21] Sweden – 15-47% of pts reported participating in goal-setting during
3
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discharge planning [22].
Guideline/s
Citation/s
6.1.2b) Treatment for aphasia should be offered as early as tolerated.
Aust 2010/ NZ 2010
Godecke [33].
1. Strength of Evidence Grade B
SC
Recommendation
M AN U
Criteria 2. Current Practice/Gap
Australia: Inpatient = 1-5 sessions for Aust. Ave treatment session
3. Perceived importance – Clinicians Australia: Research priorities –
4. Perceived Importance – Patient Australia: High pt satisfaction
5. Modifiability
6. Measurability
7. Health Impact
Could be difficult to change amount/ timing of therapy in
Able to measure when therapy offered and
- Intensive programs incorporating group and computer therapy
AC C
EP
TE D
3. Timing, Amount and Intensity of Therapy
RI PT
Singapore - About twothirds of participants reported having input from client (67.9%) and family (67.9%) during goal setting at least ‘‘frequently” [7].
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4 hrs per week for IP rehab, 2 hrs acute, 1 hr chronic. >50% saw rehab patients daily, compared to 9% in acute [3].
M AN U
Usual care < once per week with majority of PWA not receiving any therapy in acute [10].
• intensive treatments • multi-site RCTs examining dose, timing, intensity • ideal timing for various approaches including the acute phase Acute SPs feel tension between current practice and implementatio n of more intensive inpatient therapy [23].
Only 9% of SPs provided daily therapy in acute [34]. - >75% didn’t receive therapy in acute, ave of 13 mins per week [35]. Rehab Audit 2014 recommended intensity of swallowing and communication therapy was provided 96% [15].
Rehab Audit 2012 recommended intensity of swallowing and communication therapy was provided 94% [14]. Elsewhere: Canada, US, and UK inpatient = 1-5 sessions for Aust/UK, 16-20 Canada/US [6]. UK - amount of therapy that
with intensive programs. 97% would recommend. Pts often tired after therapy, but this didn’t affect attendance [39].
RI PT
length 30m for inpatients, and 60m for chronic outpatients [6].
SC
C
TE D
Bhogal, Teasell [46]; Bakheit, Shaw [43]; Godecke [33].
EP
Aust 2010/NZ 2010
AC C
6.1.1d) As much therapy for communication difficulties should be provided as can be tolerated.
100% of clinicians would recommend intensive tx. Highlighted issues of resources. SPs felt intensive tx more difficult to provide [39]. Elsewhere: Finland Approximately half of acute SLPs had insufficient
Elsewhere: Norway 2 pts preferred less intensive vs 1 pt [40]. Hong Kong majority of participants dissatisfied with SLP services citing the need for more frequent SLP treatment sessions provided in hospital-based inpatient settings (53%) and more intensive individual or group SLP treatment provided in hospital-based SLP outpatient settings (48%) [38].
acute setting given priority given to swallowing caseload and other barriers such as role perception, poor staffing, physical environment [41, 42]. Might be hard to modify due to complex nature of resource allocation but at least one trial being conducted currently in acute setting. Recent intensity study in QLD health showed feasibility of implementing approach in outpatient setting – used group, computer and therapy assistant [39]. - Many structural barriers to implementing intensive service delivery models: inadequate space and facilities, inflexible funding models, and a lack of staffing. Clinicians reported significant
amount provided. Data appears to be routinely documented, or able to be easily collected.
shown to have high cost-benefit ratio compared to usual care [39]. - No treatment effect of intensive therapy (P > 0.05) [43]. - estimated six months group difference was not statistically significant, with 0.25 (95% CI –0.19 to 0.69) points in favour of therapy [44]. - In chronic aphasia, studies provided modest evidence for more intensive treatment. In acute aphasia, 1 study evaluated high-intensity treatment positively [45]. - At hospital discharge, participants assigned daily treatment had significantly better communication outcomes than controls (usual care) as measured by the AQ score (Kruskal-Wallis H= 6.07, df= 29,23, p = 0.014) and the FCP score (Kruskal- Wallis H = 3.96, df= 29,23, p =
5
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clients receive is well below that recommended by the literature [36].
time for executing therapy itself [20].
0.047) [33]. - The number of hours of therapy provided in a week was significantly correlated to greater improvement on the PICA (P<0.001) and the Token Test (P<0.027) [46].
Recommendation
Guidel ine/s
Citation/s
AC C
4. Carer Training/Conversation Partner Criteria Training
EP
TE D
M AN U
Hong Kong - frequency of inpatients' sessions, usually provided once every week (27.0%) or every month (16.2%) [38].
challenges in providing aphasia management in acute care where dysphagia is the dominant caseload [23].
SC
Finland - 11-24 sessions in 1st year post CVA [20].
RI PT
US - Intensive Aphasia Therapy used by 38.5% of SPs [37], however on ave 1.2 therapy sessions in acute [5].
UK - Relatives and PWA differed in terms of how they viewed the timing of therapy. PWA generally felt that therapy itself could be delayed in order for them to have time to ‘clear the fog’. Relatives thought that therapy could not start soon enough [8].
1. Strength of Evidence Grade
2. Current Practice/Gap
3. Perceived importance – Clinicians
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
6
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Rehab Audit 2012 Supported conversation techniques are a
Australia: Family members expressed strong desire for conversation with PWA [52].
Barriers and facilitators perceived by SPs include: having communication resources available, having skilled, knowledgeable, and supportive healthcare providers, and having the systems in place. SLPs believe that healthcare providers may be reluctant to invest the time and effort because this may create additional work when they are already under
RI PT
Rehab Audit 2014 Carer received training - 84%, Supported conversation techniques 76% [15].
Australia: Research priorities – Conversation partner training Clinicians reported low use and poor/very poor confidence with CPT approaches. Reported wanting to do more frequent, comprehensive CPT but finding time &resources limited. Acknowledged limitations of family availability [23].
Elsewhere: UK - 80% pt satisfaction with program [53].
SC
Aust 2010 /NZ 2010
B
Australia: CPT second most frequently used intervention, 69% used in acute, 92% in rehab, 93% in OP, 68% in community, 50% in aged care and private practice [3].
M AN U
Kalra, Evans [47].
A
UK - carers expressed training needs [54] Hong Kong -The additional resources or services that the family members
Able to measure if CPT provided but may be more difficult to determine what approach SLP took and whether SLP adhered to a specific program. Some data appears to be routinely documented, but other aspects may be more difficult to collect/observe.
- Training caregivers during patients' rehabilitation reduced costs and caregiver burden while improving psychosocial outcomes in caregivers and patients at one year. Patients reported less anxiety (P < 0.0001) and depression (P < 0.0001) and better quality of life (P = 0.009) in caregiver training group [47]. - Further research is needed to
TE D
Kalra, Evans [47], VisserMeily, van Heugten [48].
EP
1.3.2 Relevant members of the multidisciplinary team should provide specific and tailored training for carers/family before the stroke survivor is discharged home. This should include training, as necessary, in personal care techniques, communication strategies, physical handling techniques, ongoing prevention and other specific stroke-related problems, safe swallowing and appropriate dietary modifications, and management of behaviours and psychosocial issues.
SIGN 108, 2008
AC C
Caregivers should be offered ongoing practical information and training individualised for the needs of the person for whom they are caring
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Large number of SLPs reported training family members re communication with only five clinicians reporting very rarely or rarely doing so [23].
Elsewhere: Finland - 60% felt they had too little time for instructing significant others, especially in early phase [20].
M AN U
Elsewhere: US – (CPT) – used by 71.2% [37].
SLPs believed staff needed skills and knowledge to feel empowered to engage with patients with communication difficulties [49].
Scotland– 91% frequently or sometimes provide communication training to family [19]. Sweden - Seldom conducted. Discrepancy between what SLPs claimed to be important, and actual practice. 17% trained families in using communication strategies. Only 6% of total treatment time allocated for this treatment. Less common in acute. [22]. 76% of carers had received advice from the SLP about facilitating conversation strategies and 37% had actually been
most often indicated to be lacking was training for family members (17.4%) [38].
Sweden –Deemed important, but lack of available resources, methods, and skills. Two-thirds (66%) of SLPs were not satisfied with the extent of the family contact. [22]. Canada – SLPs rarely and only under specific conditions trained significant others to communicate better with PWA. [50]. Belgium –99.2%
workload pressures. [49]. Barriers- time, patient characteristics, acute setting issues, family. Facilitators – staff involvement, support, culture [57].
RI PT
common therapy for aphasia (72%) [14].
Sweden – (52%) of carers wanted to receive communication partner training [27].
SC
C
TE D
Kagan, Black [58]; Wertz, Weiss [59].
EP
Aust 20101 /NZ 2010
AC C
6.5.1f) For individuals with aphasia, intervention can include supported conversation techniques.
understand the relationship between specific interventions directed at the environment, healthcare communication, and health outcomes [49].
Worldwide – Systematic review perceived benefits of training in supported conversation skills were varied – some prefer earlier, some prefer later [55] . Belgium – 98.7% perceived training as important or very important by family – but 41.3% reported insufficient training [51]. US Communication strategies for
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AC C
EP
TE D
M AN U
Singapore - CPT was the second most frequently reported type of aphasia intervention, with half of the participants reportedly providing training to communication partners [7].
family and friends ranked as nd 2 top priority topic [56].
RI PT
Hong Kong -caregiver training was rarely primary focus of inpatient (9.3%) or outpatient (10.7%) sessions [38].
of SLPs perceived training as important or very important [51].
SC
trained in how to use these strategies [27].
9
Criteria
Recommendation
Guideline/s
Citation/s
6.5.1f) For individuals with aphasia, treatment targeting specific aspects of language should be considered based on models derived from cognitive neuropsychology.
Aust 2010/ NZ 2010
Doesborg h, van de SandtKoenderm an [60].
1. Strength of Evidence Grade C
2. Current Practice/Gap
Australia: Rehab Audit 2014 – 75% provided with phonological and semantic interventions [15].
M AN U
Rehab Audit 2012 – 68% provided with phonological and semantic interventions [14].
3. Perceived importance – Clinicians Australia: Majority of SLPs rated knowledge of and confidence with social, functional, and cognitive neuropsychologic al approaches as very good/good or very high/high. Research Priorities = Combining impairment and functional treatments, Using principles of neuroplasticity [23].
TE D
61.4% indicated using more than one approach to intervention. Combination of cognitive-neurological and functional approaches most frequently reported (42.9%) [3].
AC C
EP
Cognitive Neuropsychological one of the most frequently utilized approaches [23]. Elsewhere: Singapore – Cognitiveneurological approach used by majority of SPs ‘occasionally’ [7].
6. Therapy Approach – Constraint-
4. Perceived Importance – Patient Australia: Patient goals include wanting to speak better (impairment -based goals), but also want to target goals that could help them return to previous function [17].
SC
5. Therapy Approach – Cognitive Neuropsychology-Based Therapy
RI PT
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Elsewhere: Singapore – majority of SPs rated knowledge as ‘adequate’ and confidence as ‘confident’ with Cog-neuro approach [7].
Elsewhere: No info found.
5. Modifiability
6. Measurability
7. Health Impact
No barriers identified from current literature. No real gap identified as the majority of clinicians use this approach.
May be difficult to measure as clinicians often use a combination of therapy approaches [3]. However, some data appears to be routinely collected.
- After semantic treatment, patients improved on a semantic measure (mean improvement, 2.9; 95% CI, 1.2 to 4.6), whereas after phonological treatment, patients improved on phonological measures (mean improvement, 3.0; 95% CI, 1.4 to 4.7, and 3.0; 95% CI, 1.2 to 4.7). Both semantic and phonological treatments are effective – not compared to control group [60].
Criteria 10
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Induced Language Therapy
6.5.1f) For individuals with aphasia, intervention can include constraint-induced language therapy.
Aust 2010 / NZ 2010
Cherney, Patterson [45].
1. Strength of Evidence Grade B
2. Current Practice/Gap Australia: Rehab Audit 2014 – 14% provided with CILT therapy [15]. Rehab Audit 2012 – 8% provided with CILT therapy [14]. Elsewhere: US - Constraint-Induced Aphasia Therapy (CIAT), 23.1% used in past year [37].
4. Perceived Importance – Patient Australia: 6/11 expressed preference for M-MAT and three for CIAT Plus [62].
Elsewhere: US - Over 60% of SLPs felt that PWA would be very unlikely or somewhat unlikely to adhere to CILT. SLPs had concerns about duration [61].
Elsewhere: Norway 2 out of 3 patients preferred less intense therapy [40].
5. Modifiability
Potentially but more research needed into barriers. Resource/cost intensive – 90.9% felt that most facilities do not have the resources to provide CILT. Over 60% reported it would be difficult/very difficult to administer CILT [61].
6. Measurability
7. Health Impact
Able to measure when CILT used. Data appears to be routinely documented, or able to be easily collected.
5 studies involving 90 participants reported CILT resulted in positive changes on measures of language impairment and communication activity/ participation in individuals with chronic aphasia, including large ESs for 9 of 16 impairment measures and 6 of 11 activity/participation measures [45].
6. Measurability
7. Health Impact
AC C
EP
TE D
US - 22% of SLPS had conducted CILT [61].
3. Perceived importance – Clinicians Australia: All 6 SLPs preferred M- MAT as they found it more interesting, less repetitive and more interactive than CIAT Plus [62].
RI PT
Citation/s
SC
Guideline/s
M AN U
Recommendation
7. Therapy Approach - Use of Compensatory Strategies/AAC
Criteria
Recommendation
1. Strength of Evidence
Guideline/s
Citation/s
2. Current Practice/Gap
3. Perceived importance –
4. Perceived Importance –
5. Modifiability
11
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Elsewhere: US - Promoting Aphasics’ Communicative Effectiveness (PACE), 67.3%, Augmentative and Alternative Communication (AAC) - 62.5% [37]. US - AAC strategies have not been widely and/or consistently implemented with persons with severe chronic aphasia [64].
Elsewhere: No info found.
US - There is wide agreement that AAC technology is currently underused by people with aphasia [65].
Patient Australia: 6/11 participants expressed preference for MMAT and three for CIAT Plus [62].
Yes, evidence of some facilitators [62] but need further study of barriers.
RI PT
Rehab Audit 2012 – 55% used alternative means of communication [14].
Clinicians Australia: All 6 SLPS preferred multimodal MMAT as they found it more interesting, less repetitive and more interactive than CIAT Plus [62].
Elsewhere: Netherlands - High satisfaction initially, 2/12 still using 3 years post [66].
SC
Australia: Rehab Audit 2014 – 61% used alternative means of communication [15].
M AN U
Grade D
TE D
Rose, Douglas [63]
EP
Aust 2010/NZ 2010
AC C
6.5.1f) For individuals with aphasia, intervention can include the use of gesture.
US - PWA enjoyed and perceived benefits from using a high-flexibility AAC aid [65].
Able to measure when AAC used, but would need to ensure there is a clear definition of what constitutes AAC. Data appears to be routinely documented, or able to be easily collected.
Single-case experiment using a multiple-baseline design, statistically significant effect for iconic gesture (N = 10, T = 0, p < .005, onetailed) [63].
UK - families of PWA have considerable reservations about AAC interventions [67]. Sweden - (63%) of carers wanted to be involved in the creation of an AAC device. [68]. US - peers were worried that AAC might impede return of speech [69].
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Recommendation
Guideline/s
Citation/s
6.5.1f) For individuals with aphasia, intervention can include delivery of therapy programs via computer.
Aust 2010/ NZ 2010
Katz and Wertz [70].
1. Strength of Evidence Grade C
2. Current Practice/Gap
Australia: Rehab Audit 2014 – 14% provided with computerbased therapy [15].
Elsewhere: US - Computer Treatments, 38.5% [37].
Elsewhere: US - SLPs generally perceive computers as useful and important but not critical to successful outcomes [71].
EP
TE D
US - Survey - SLPs use computers more often for indirect or supplemental purposes than for direct therapy. When SLPs implemented computers in direct treatment, the amount accounted for less than 25% of the total session time [71].
AC C
4. Perceived Importance – Patient Australia: No info found.
Elsewhere: US - High satisfaction [72]
US - Patients reported satisfaction with software [73].
M AN U
Rehab Audit 2012 – 7% provided with computerbased therapy [14].
3. Perceived importance – Clinicians Australia: Research priorities = Web and computer based treatments [23].
Finland - Computer applications as home exercises in 31% of cases in the first year after stroke [20].
5. Modifiability
6. Measurability
7. Health Impact
Yes, some facilitators. Need more research into barriers. Could be used as a strategy to increase amount/ intensity of therapy [39].
Able to measure when computertherapy provided. Data appears to be routinely documented, or able to be easily collected.
Little evidence of any difference was found between computerfacilitated speech and language treatment versus one-on-one speech and language treatment [75].
RI PT
Criteria
SC
8. Service Delivery – ComputerBased Therapy
UK - All 6 participants interviewed perceived remotely monitored computer therapy as a positive experience [74].
Barriers could be initial costs in purchasing resources. Limited evidence about which computer programs are best. Identified barriers include lack of access and training [71].
Pilot RCT, cost effective, P=0.014 [76]. Evidence to support efficacy of computerised treatment for PWA based on a single Phase 3 study study provided Class 1 evidence, with results from a well-designed, randomised controlled clinical trial that compared treatment with notreatment [77]. Significant improvement over 26 weeks occurred on 5 language measures for computer reading treatment group, on one language measure for computer stimulation group, and on none of the language measures for the no- treatment group Katz and Wertz [70].
13
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Aust 2010 /NZ 2010
Elman and BernsteinEllis [78].
2. Current Practice/Gap Australia: Rehab Audit 2014 – 20% provided with group therapy [15]. Rehab Audit 2012 – 21% provided with group therapy [14]. Australian SLPs provided least amount of group therapy (24%) compared to SLPs working in Canada, the USA and the UK [6]
3. Perceived importance – Clinicians Australia: Group treatments rated as appropriate by fewer therapists in most phases of care [23].
Group therapy provided 53.6% in inpatient rehab, 58.6% in outpatient rehab, 36.4% in community; 20% in aged-care; 8.3% in private practice; 100% in university clinics. No group therapy in acute [3]. Group therapy targeting
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
Australia: PWA highlighted importance of being able to share their stroke story with others. Two expressed apprehension about attending a stroke and/or aphasia group. [79].
Need more research into barriers/ facilitators.
Able to measure when therapy offered and amount provided. Data appears to be routinely documented, or able to be easily collected.
Group tx showed 44% more efficient cost to benefit ratio than standard service [39].
SC
6.5.1h) Group therapy and conversation groups can be used for people with aphasia and should be available in the longer term for those with chronic and persisting aphasia.
1. Strength of Evidence Grade C
M AN U
Citation/s
Elsewhere: No info found.
TE D
Guideline/s
EP
Recommendation
RI PT
Criteria
AC C
9. Service Delivery - Group Therapy
Interactions in group setting gave participants confidence to be independent [26]. Elsewhere: Scotland - Group therapy can create tensions. Benefits of support and friendship of attending as well as from therapy. minority reported no changes to QOL. These individuals did not like having therapy in a group [80].
Evidence favouring community and outpatient groups centred on four level ii and level iii-i studies examining the efficacy of highly structured group activities for improving specific linguistic processes with five medium– large effect sizes calculated [83]. Aphasia groups that use multi-modality communication activities can improve rates of friendships and social networks. significantly higher levels of social participation, and significantly less perceived social isolation and greater
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UK - Extremely positive evaluation of intervention [81].
Elsewhere: Scotland – 44/121 used groups frequently or sometimes [19].
UK - Group therapy seen as very positive in terms of confidence and togetherness but one-to-one therapy most important early on [8].
Hong Kong- Overall satisfaction highest with support groups, family members want more intensive individual or group SLP training and regular review (47.8%) [38].
Significant improvements in communicative competence (p = 0.03 & p = 0.04) and attitudes to communication over the course of the intervention [81].
AC C
M AN U
EP
TE D
Singapore – One third of the participants (n=12) provided group therapy [7].
UK -high degree of satisfaction, peer support and social aspects particularly valued [82].
Participants receiving group communication treatment had significantly higher scores on communicative and linguistic measures (p < 0.05) than participants not receiving treatment [78].
SC
UK - OP – 7.5% of time spent on group tx [36]. Finland - 30% of acute SLTs administered group therapy [20].
social connection (p <0.014) for the 28 individuals attending a weekly aphasia group [84].
RI PT
impairments used rarely or very rarely (45.8%), [23].
10. Information, Education and Aphasia-Friendly Information
Criteria
Recommendation
1. Strength of Evidence Grade
Guideline/ s
Citation/s
2. Current Practice/Gap
3. Perceived importance – Clinicians
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
15
ACCEPTED MANUSCRIPT
Smith, Forster [85].
D
B
SIGN 108, 2008
Forster, Smith [97].
A
1.9.1c) Stroke survivors should be provided with routine, follow-up opportunities for clarification or reinforcement of the information provided.
Aust 2010/ NZ 2010
Smith, Forster [85].
B
Information should be
SIGN 108,
Hoffmann ,
D
Rehab Audit 2012 – tailored information provided to stroke survivor/family – 65% [14].
SPs think providing education and info to PWA and families is important [52].
36% received written information about both stroke and aphasia. fewer participants reporting received written aphasia information (49%) compared to written stroke information (67%) [88]. Majority reported doing so, although less education practice was targeted towards friends. 97% reported using verbal and written information in education. Only 59% frequently or very frequently provided clients with information
Australia: PWA want information about aphasia, stroke, and available services. Family education was a strong need [25].
Educating family members about aphasia, stroke, and rehabilitation was a frequently reported goal of SLPs [16]. Elsewhere: Canada Including significant others was perceived as challenging, yet a bonus to their fundamental patient-centred
Yes – appear to be some facilitators (et. Rose et al, 2013; Brown et al, 2012), but further research into barriers needed.
RI PT
Aust 2010/ NZ 2010
Hoffmann , McKenna [96].
D
Australia: Research priorities – Information needs of PWA and family [23].
PWA expressed satisfaction when information was personalised to their communication needs [26].
SC
1.9.1b) Information should be provided at different stages in the recovery process. Information should be offered in a variety of formats including easy access .
SIGN 108, 2008
van der SmagtDuijnstee, Hamers [86]; Choi-Kwon, Lee [87].
Australia: Rehab Audit 2014 – tailored information provided to stroke survivor/family 72% [15].
M AN U
SIGN 108, 2008
A
TE D
Healthcare professionals should take a patient’s age, gender, educational status and communication support needs into account when assessing their need for information. Information should be tailored to the phase of the patient’s journey.
Smith, Forster [85].
EP
Aust 2010/ NZ 2010
AC C
1.9.1a) All stroke survivors and their families/carers should be offered information tailored to meet their needs using relevant language and communication formats
Families emphasized importance of receiving verbal information, whereas others spoke about needing written information in order to have something to refer to at a later time [90].
Some evidence of barriers, from nonAustralian studies [94].
Complex to measure due to number of components recommended in target behaviours. Some data appears to be routinely documented, but other aspects may be more difficult to collect/ observe. Would need to record what information provided, by whom, to whom, when, in what format, whether it was tailored, etc.
Meta-analyses showed significant effect in favour of intervention on patient knowledge (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46, P < 0.001), carer knowledge (SMD 0.74, 95% CI 0.06 to 1.43, P = 0.03), one aspect of patient satisfaction (odds ratio (OR) 2.07, 95% CI 1.33 to 3.23, P = 0.001), and patient depression scores (mean difference (MD) -0.52, 95% CI 0.93 to -0.10, P = 0.01) [95].
Participants thought it important to receive written information about both stroke and aphasia at several stages post stroke [91].
Meta-analyses showed significant effect in favour of intervention on patient and carer knowledge, one aspect of patient satisfaction, and patient depression scores [85].
Elsewhere: Scotland - Many felt that early on they didn’t know what was wrong with them and
All significant others perceived increased knowledge and understanding of
16
ACCEPTED MANUSCRIPT
D
Elsewhere: Singapore - All participants (n=28) reported use of verbal explanation in their education practice. Written materials were frequently used (n=22; 78.6%). Nearly all (n=26; 92.9%) reported providing education about the term ‘‘aphasia’’ [7].
RI PT
Aust 2010/ NZ 2010
Only 17.5% of communication time was spent providing information. PWA received information for less time and on fewer topics [89].
Hong Kong - Family desired (in acute phase) additional information on aphasia, its causes and treatment methods (17.6%%), and in rehab/outpt phase information on aphasia and its outcome (8.7%) [38].
SC
6.5.1d) In patients with aphasia, all written information on health, aphasia, social and community supports should be available in an aphasia-friendly format.
D
they didn’t remember somebody explaining what had happened. lack of information for family members In some cases [19].
Sweden Significant others received information about aphasia: orally (34%), in writing (19%), or both (37%). Most of the participants (76%) also received information about
aphasia and related issues [92]. Family members need to have information provided in flexible and supportive manner, particularly in initial period poststroke. Systematic r/v of 17 studies on caregiver’s views [55].
M AN U
SIGN 108, 2008
about community support organisations [23].
TE D
Each patient should be assessed on his or her readiness to receive information.
McKenna [96]; WachtersKaufmann, Schuling [98]. van der SmagtDuijnstee, Hamers [86]; Choi-Kwon, Lee [87]. Brennan, Worrall [99]; Rose, Worrall [100].
EP
2008
AC C
repeated and re-offered at appropriate intervals
approach. SLPs often had unachieved ideals, such as having more frequent contacts with significant others [50]. Scotland - Many expressed concern about available support for family. Some SLPs felt they did not
Sweden - The importance information about stroke/aphasia was clearly acknowledged, especially by SOs [92]. UK- Information needs to be written down and repeated at regular intervals. Time and opportunities for clarification needed [8]. UK - Carers expressed information needs [54].
17
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AC C
EP
TE D
M AN U
Belgium – SLPs considered the following to be important or very important: providing written information (89.4%), providing information on what aphasia is (94.7%), But insufficient information provided for written (41.7%), info on aphasia (18.2%) [51].
Belgium – Family considered the following to be important or very important: providing written information (87.4%), providing information on what aphasia is (96.3%), providing information on support groups (68.75%). But insufficient information provided for written (46.2%), info on aphasia (25%) and support groups (53.2%) [51].
RI PT
have adequate time and resources to support families [80].
SC
the local aphasia association [27].
US - Survey respondents (N = 302) rated aphasia resources as ‘‘somewhat difficult to find” [93]. Worldwide –family members need to have information provided in flexible and supportive manner, particularly in initial period poststroke. Systematic r/v of 17 studies on caregiver’s views [55].
18
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Criteria
Bhogal, Teasell [101].
Aust 2010/ NZ 2010
Clark, Rubenach [104].
1.9.3 Counselling can include a problem-solving counselling approach.
Aust 2010/ NZ 2010
Evans, Matlock [105].
C
C
Australia: Rehab Audit 2014 – Formal counseling offered to patient – 32% [15]. Rehab Audit 2012 – Formal counseling offered to patient – 31% [14]. Percentage of respondents providing counseling – 66% frequently/very frequently [23].
3. Perceived importance – Clinicians Australia: Research priorities = Counselling A large number felt underprepared for significant counseling roles [23].
4. Perceived Importance – Patient Australia: Clients and families want SLP services that provide hope and positivity, state current services don’t always meet this need [52].
SLPs emphasized goals related to support, both practical and psychological [16].
Elsewhere: UK - Little consistency in approaches for addressing psychosocial issues [102].
UK – 95% of respondents offered some additional counselling or social support to their patients, often in cooperation with the voluntary sector. The type and availability of support varied, with no single aspect being offered in all districts
Elsewhere: Scotland Perceived gap for management of psychological elements of aphasia. Fostering hope and being realistic [19]. Finland 2012 -
5. Modifiability
6. Measurability
7. Health Impact
Evidence of facilitators priority for SLPs, PWA and families [23, 52].
Some data appears to be routinely documented, but other aspects may be more difficult to collect/ observe. Would need to record what type of counselling SLPs provided and what was involved.
Systematic r/v: moderate evidence that improved social support as an intervention improves outcomes and strong evidence that active educational-counseling approach has a positive impact on family functioning post stroke Bhogal, Teasell [101].
RI PT
Aust 2010/ NZ 2010
2. Current Practice/Gap
SC
1.9.3 Counselling can include an active educational counselling approach. 1.9.3 Counselling can include Information supplemented by family counselling.
1. Strength of Evidence Grade B
M AN U
Citation/s
TE D
Guideline/s
EP
Recommendation
AC C
11. Counselling
Elsewhere: UK – Trial of counselling service, In general, participants valued the service and a number of positive outcomes were described (Ireland & Wotton, 1996).
Evidence of barriers – SLPs felt underprepared [23]. Evidence of barriers problems with the setting, timing and organization of counselling and presence of client social problems. Calm, spacious and conducive setting for counselling important (Ireland & Wotton, 1996).
Improved family functioning p < .05, but no significant effects on depression, anxiety, mastery or health status [104]. Compared with control, education and counseling conditions gave significantly better outcomes 6 months after stroke on measures of caregiver stroke knowledge and the family functions problem solving, communication, and global family function (p <0.001). Counseling more effective than education alone, improved caregiver knowledge and stabilized some aspects of family function better than routine
19
ACCEPTED MANUSCRIPT
care, and resulted in better patient adjustment at 1 year [105].
RI PT
60% felt that they had too little time for counseling and instructing significant others, especially in the early phase [20].
Criteria Citation/s
8.6.2a) Carers should be provided with tailored information and support during all stages of the recovery process. This includes (but is not limited to) information provision and opportunities to talk with relevant health professionals about the stroke, stroke team members and their roles, test or assessment results, intervention plans, discharge planning, community services and appropriate contact
Aust 2010/ NZ 2010
Brereton, Carroll [108]; Smith, Forster [85].
1. Strength of Evidence Grade C
2. Current Practice/Gap
3. Perceived importance – Clinicians Australia: SLPs’ goals relating to coping and participation factors for family members included providing support for the family, receiving support from the family, as well as facilitation of support networks [16].
TE D
Guideline/s
Australia: Rehab Audit 2014 – Post-discharge contact provided to stroke survivor or family – 62% Formal counselling offered to family/ carer - 32%. Postdischarge needs discussed with carer82%. Stroke survivor offered information about peer support 32% [15].
EP
Recommendation
AC C
12. Caregiver Support
M AN U
SC
[103].
Rehab Audit 2012 – Post-discharge needs
Strong support networks viewed as essential to living successfully with
4. Perceived Importance – Patient Australia: PWA report the need to feel valued and understood in the rehabilitation process. The role of hope in the therapeutic relationship of significant importance [18]. Family members identified different preferences for emotional support including formal support from social
Qualitative study, both positive and negative feedback [106](Ireland & Wotton, 1996). Stroke patients benefit from counselling combined with education intervention [107].
5. Modifiability
6. Measurability
7. Health Impact
Some evidence of facilitators [16] [24]. Research into barriers needed.
Some data appears to be routinely documented, but other aspects may be more difficult to collect/ observe. Would need to record what information provided, by whom, to whom, when, in what
Systematic r/v: Evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, small reduction in depression scores may not be clinically significant [95].
Evidence of barriers from nonAustralian studies.
Some benefits were reported for all
20
ACCEPTED MANUSCRIPT
Carers’ support needs should be addressed prior to patient discharge.
SIGN 108 2008
SIGN 108 2008
D
D
Elsewhere: Hong Kong - when discharged from the admitted hospital, only 51.4%% of the family members were informed of self-help or support groups in the community [38]. Sweden - They had received information about aphasia: orally (34%), in writing (19%), or both (37%). Most of the participants (76%) also received information about local aphasia association; 76% had received advice from the SLP about facilitating
RI PT
van der SmagtDuijnstee, Hamers [86]; Brereton and Nolan [112]. Brereton and Nolan [112]; Brereton and Nolan [113].
C
Only 59% frequently or very frequently provided clients with information about community support organisations [23].
Elsewhere: Canada - If necessary, significant others were referred to social workers or psychologists or SLPs collaborated with those professionals [50].
For PWA, factors relating social support were important in facilitating a more successful life with aphasia across time [79].
SC
C
workers or counsellors and informal support from family support groups or one-toone groups [90].
M AN U
Aust 2010/ NZ 2010
Brereton, Carroll [108]; Eldred and Sykes [107]; Lee, Soeken [110];Viss er-Meily, van Heugten [48]. Bhogal, Teasell [101]; Lee, Soeken [110]; Lui, Ross [111].
aphasia. SLPs identified both family and friends as key providers of support [24].
Scotland - Many SLPs expressed concern about the level of support available for family members. Some felt
TE D
8.6.2d) Carers should be offered support services after the person’s return to the community. Such services can use a problem-solving or educational-counselling approach. Healthcare professionals should actively involve carers and find out what support they need.
Aust 2010/ NZ 2010
EP
8.6.2c) Carers should be provided with information about the availability and potential benefits of local stroke support groups and services, at or before the person’s return to the community.
discussed with carer – 76%, Stroke survivor offered information about peer support - 39%, Post-discharge contact provided to stroke survivor or family – 57% [14].
AC C
details.
Elsewhere: Germany – no measurable improvement in counselling family members of PWA, but it was appreciated [109]. Scotland - Benefits were the support and friendship of others attending the centre as well as the therapy itself. Conversely, a minority of people with aphasia in the study reported that there had been no changes in QOL. These individuals did not like having therapy
format, etc.
interventions, although trials were generally of low quality, preventing firm conclusions being drawn [108]. Few studies investigating impact of psychologically based interventions for carers of stroke survivors, and quality of evidence is varied [107]. Need for ongoing psychosocial support over the long term was apparent [55]. All significant others perceived increased knowledge and understanding of aphasia and related issues [92]. No measurable improvement in counselling family members of PWA [109].
21
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AC C
EP
Singapore - referral to community support groups made ‘‘rarely’’ or less by most participants (n=20; 71.4%). Participants indicated the lack of available support groups as a reason for the lack of referrals [7].
in a group [19].
RI PT
Sweden - The importance of emotional support as well as information about stroke/aphasia was acknowledged, especially by SOs. 63% of SOs perceived their own support from SLP services to be adequate [92].
SC
Finland - SLPs aware of need to support significant others. SLPs felt the role of significant others is important [20].
Belgium – SLPs considered the following to be important or very important: providing information on support groups (92.4%). But insufficient information provided support groups (60.0%) [51].
TE D
UK – 95% of respondents offered some additional counselling or social support, often in cooperation with the voluntary sector. The type and availability of support varied, with no single aspect being offered in all districts [103].
that they did not have adequate time and resources to support families [80].
M AN U
conversation strategies and 37% had actually been trained in how to use these strategies; 50% had had the opportunity to talk about their own situation as a SO of a PwA [27].
UK - Carers expressed needs in the area of support [54]. Belgium – Family considered the following to be important or very important: providing information on support groups (68.75%). But insufficient information provided for support groups (53.2%) (Manders (2011). Carers’ perceived need for ongoing psychosocial
22
ACCEPTED MANUSCRIPT
Return-to-work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively. Active management should include: • identifying the physical, cognitive, communication and psychological demands of the job (for example, multi-tasking by answering emails and telephone calls in a busy office) • identifying any impairments on work performance (for example, physical limitations, anxiety, fatigue preventing
NICE 162
Evidence linked to systematic r/v of 1 RCT Trexler, Trexler [114].
1. Strength of Evidence Grade Strong
2. Current Practice/Gap
Australia: Rehab Audit 2014 – Stroke survivors offered assistance to return to work (if they wanted to return to work) 69% [15].
3. Perceived importance – Clinicians Australia: No info found.
Elsewhere: Scotland Approximately 20% of SLPs felt that therapy intervention may vary in response to differing needs and lifestyles of people of different ages, including being of working age and wishing to return to work or a desire to drive again [19].
TE D
Citation/s
Rehab Audit 2012 Stroke survivors offered assistance to return to work 86% [14].
EP
Guideline/s
M AN U
Criteria
Recommendation
AC C
13. Return to Work
SC
RI PT
support over the long term was apparent [55].
Elsewhere: Canada - Few working-age stroke survivors with aphasia or other communication disorders have access to VR [115]
Canada – SLPs saw main role as educating and increasing
4. Perceived Importance – Patient
5. Modifiability
6. Measurability
7. Health Impact
Australia: PWA identified the importance of work activities [25].
Research into barriers and facilitators needed in Australian context.
Data appears to be routinely documented, or able to be easily collected.
Survivors with aphasia who did return to work experienced significantly reduced hours and task modifications (Dalemans, De Witte, Lemmens, & Van den Heuvel, 2008).
Elsewhere: UK - Few younger stroke survivors recognise the value of SLT as a component of VR [117]. US - Returning to work ranked 16 out of 18 priority topics [56]. Scotland - Although many people wanted to get back to work, no-one was working and some people commented that they missed this aspect of their life [19].
Barriers to RTW: working conditions, use of electronic tools, types of speakers, productivity expectations, as well as attitude/ awareness of conversation partners as barriers to RTW. Strategies to facilitate RTW also
Average rate of successful RTW for young survivors with aphasia was 28.4% compared to 44.7% for all young stroke survivors [121]. Negative associations between return to work and aphasia (p = 0.0009) [122]
23
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1. 2. 3.
RI PT
Canada –Possible that SLPs and PWA do not see a role for these professionals in the work re-integration process [115]. Portugal – PWA reported consequences in Major Life Areas, most specifically in Work and Employment: work and employment was more important to PWA and professionals, than to FM [116].
SC
M AN U TE D
•
Portugal – Work and employment was more important to PWA and professionals, than to FM [116].
EP
•
awareness of aphasia. It is possible that S-LPs and PWA do not see a role for these professionals in the work re-integration process [115].
UK - Major restrictions in terms of RTW [118].
identified (Garcia et al., 2002). Issues concerning the role of the SLT in facilitating return to work [119]. Barriers to RTW - Standard therapy tools and impersonal approaches. Facilitators when health professionals related the therapy objectives to PWA’s interests and involved him in the process of setting objectives [120].
- Participation increased significantly for both groups (F = 60.65, P < .0001), but interaction between groups and time demonstrated greater improvement for the RF group relative to controls (F = 9.11, P < .007). Also, 64% of the RF group was employed at follow-up compared with 36% of control (WaldWolfkowitz z = -3.277, P < .0001). No significant differences found between groups on depression [114].
AC C
•
attendance for a full day at work, cognitive impairments preventing multitasking, and communication deficits) tailoring an intervention (for example, teaching strategies to support multi-tasking or memory difficulties, teaching the use of voice-activated software for people with difficulty typing, and delivery of work simulations) educating about the Equality Act 2010 and support available (for example, an access to work scheme) workplace visits and liaison with employers to establish reasonable accommodations, such as provision of equipment and graded return to work.
Salter, K., et al., Identification of aphasia post stroke: A review of screening assessment tools. Brain Injury, 2006. 20(6): p. 559-68. National Stroke Foundation, National Stroke Audit Acute Services Clinical Audit Report 2011: Melbourne, Australia. Verna, A., B. Davidson, and T. Rose, Speech-language pathology services for people with aphasia: A survey of current practice in Australia. International Journal of Speech-Language Pathology, 2009. 11(3): p. 191-205.
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RI PT
SC
9.
M AN U
8.
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TE D
6. 7.
EP
5.
Vogel, A.P., P. Maruff, and A.T. Morgan, Evaluation of communication assessment practices during the acute stages post stroke. J Eval Clin Pract, 2010. 16(6): p. 1183-8. Duffy, J., T. Fossett, and J. Thomas, Aphasia care in acute hospital: challenges and opportunities, in Clinical Aphasiology Conference. 2010: Isle of Palms, SC. Katz, R.C., et al., A multinational comparison of aphasia management practices. Int J Lang Comm Dis, 2000. 35(2): p. 303-314. Guo, Y.E., L. Togher, and E. Power, Speech pathology services for people with aphasia: What is the current practice in Singapore? Disability and Rehabilitation, 2013. 36(8): p. 691-704. Horton, S., D. Mudd, and J. Lane, Is anyone speaking my language? International Journal of Language & Communication Disorders, 1998. 33(S1): p. 126-131. Armstrong, E., Communication Culture in Acute Speech Pathology Settings: Current Issues. Advances in Speech-Language Pathology, 2003. 5(2): p. 137-143
AC C
4.
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27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37.
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SC
25. 26.
M AN U
24.
TE D
23.
EP
22.
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21.
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44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54.
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43.
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42.
TE D
40. 41.
EP
39.
Kong, A.P., Family members' report on speech-language pathology and community services for persons with aphasia in Hong Kong. Disabil Rehabil, 2011. 33(25-26): p. 2633-45. Wenke, R., et al., Feasibility and cost analysis of implementing high intensity aphasia clinics within a sub-acute setting. International Journal of Speech-Language Pathology, 2014. 16(3): p. 250-259. Kirmess, M. and L. Maher, Constraint induced language therapy in early aphasia rehabilitation. Aphasiology, 2010. 24(6): p. 725-736. Foster, A.M., et al., Turning the tide: Putting acute aphasia management back on the agenda through evidence-based practice. Aphasiology, 2013: p. 1-24. Simmons‐Mackie, N.N., et al., Communicative access and decision making for people with aphasia: Implementing sustainable healthcare systems change. Aphasiology, 2007. 21(1): p. 39-66. Bakheit, A.M.O., et al., A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia. Clinical rehabilitation, 2007. 21(10): p. 885-894. Bowen, A., et al., Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: A randomised controlled trial. BMJ Open, 2012. 345. Cherney, L.R., et al., Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 2008. 51: p. 1282-1299. Bhogal, S.K., R. Teasell, and M. Speechley, Intensity of aphasia therapy, impact on recovery. Stroke, 2003. 34(4): p. 987-93. Kalra, L., et al., Training carers of stroke patients: Randomised controlled trial. BMJ (Clinical research ed.), 2004. 328(7448): p. 10991099. Visser-Meily, A., et al., Intervention studies for caregivers of stroke survivors: A critical review. Patient Education and Counseling, 2005. 56(3): p. 257-67. O’Halloran, R., et al., Creating communicatively accessible healthcare environments: Perceptions of speech-language pathologists. International Journal of Speech-Language Pathology, 2014. 16(6): p. 603-614. Hallé, M.-C., G. Le Dorze, and A. Mingant, Speech–language therapists’ process of including significant others in aphasia rehabilitation. International Journal of Language & Communication Disorders, 2014. 49(6): p. 748-760. Manders, E., A. Marien, and V. Jansse, Informing and supporting partners and children of persons with aphasia: A comparison of supply and demand. Logopedics, phoniatrics, vocology, 2011. 36(4): p. 139-144. Brown, K., et al., Living successfully with aphasia: A qualitative meta-analysis of the perspectives of individuals with aphasia, family members, and speech-language pathologists. Int J Speech Lang Pathol, 2012. 14(2): p. 141-55. McVicker, S., et al., The Communication Partner Scheme: A project to develop long-term, low-cost access to conversation for people living with aphasia. Aphasiology, 2009. 23(1): p. 52-71. Denman, A., Determining the needs of spouses caring for aphasic partners. Disability and Rehabilitation, 1998. 20(11): p. 411-423.
AC C
38.
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60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.
RI PT
SC
59.
M AN U
58.
TE D
57.
EP
56.
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90.
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Supplementary Table 2. Search Results Per Topic Area Search Yield (Websites) 1
Current practice/gap
Perceived importance – clinicians Perceived importance – Client Health Impact
14
1
0
65 31
1 3
Current practice/gap
11
10
Perceived importance – clinicians
29
Documents Excluded 241
Total Included 6
RI PT
Grey Literature 2
SC
Screening Assessment
Perceived importance – Client
EP
AC C
Goal Setting
Search Yield (Databases) 244
14
M AN U
Criteria
1
0 0
65 29
1 5
0
9
12
TE D
Topic Area
30
2
0
27
4
3
0
28
5
References Verna, Davidson [1], Vogel, Maruff [2], Duffy, Fossett [3], Katz, Hallowell [4], National Stroke Foundation [5], Guo, Togher [6]. Vogel, Maruff [2] Horton, Mudd [7]. Verna, Davidson [1], Armstrong [8], Lalor and Cranfield [9], Hilari [10], Dickey, Kagan [11]. Verna, Davidson [1], National Stroke Foundation [5], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Sherratt, Worrall [14], Rohde, Townley-O'Neill [15], Worrall, Brown [16], Klippi, Sellman [17], Law, Pringle [18], Johansson, Carlsson [19], Monaghan, Channell [20]. Rohde, Townley-O'Neill [15], Law, Pringle [18], Rose, Ferguson [21], Brown, Worrall [22]. Worrall, Brown [16], Law, Pringle [18], Worrall, Sherratt [23], Tomkins, Siyambalapitiya [24], Blom Johansson, Carlsson [25].
0 2
1 21
Perceived importance – clinicians Perceived importance – Client
12
2
1
12
3
Health Impact
9
6
Current practice/gap
8
Perceived importance – clinicians
21
1 12
RI PT
1 10
Perceived importance – Client
20
M AN U
12
3
12
4
0
9
6
2
6
10
3
0
19
5
7
0
19
8
TE D
1
6
EP
Conversation Partner Training
1 23
AC C
Treatment timing, amount and/or Intensity
Health Impact Current practice/gap
SC
ACCEPTED MANUSCRIPT
Levack, Taylor [26]. Verna, Davidson [1], Duffy, Fossett [3], Katz, Hallowell [4], Lalor and Cranfield [9], National Stroke Foundation [12], National Stroke Foundation [13], Klippi, Sellman [17], Ferreira [27], Godecke, Hird [28], Kong [29], Code and Heron [30], Rowe [31]. Klippi, Sellman [17], Rose, Ferguson [21], Wenke, Lawrie [32]. Horton, Mudd [7], Kong [29], Wenke, Lawrie [32], Kirmess and Maher [33]. Wenke, Lawrie [32], Cherney, Patterson [34], Bakheit, Shaw [35], Bowen, Hesketh [36], Godecke [37], Bhogal, Teasell [38]. Verna, Davidson [1], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Law, Pringle [18], Johansson, Carlsson [19], Rose, Ferguson [21], Blom Johansson, Carlsson [25], Kong [29], Rowe [31]. Klippi, Sellman [17], Johansson, Carlsson [19], Rose, Ferguson [21], O’Halloran, Lee [39], Hallé, Le Dorze [40], Manders, Marien [41]. Kong [29], Manders, Marien [41], Brown, Worrall [42], Blom Johansson, Carlsson [43], Hilton, Leenhouts [44], Denman [45], McVicker, Parr [46],
ACCEPTED MANUSCRIPT
1
Current practice/gap
192
2
3
190
5
Perceived importance – clinicians Perceived importance – Client Health Impact
6
1
0
5
2
23 17
1 1
0 0
23 17
1 1
Current practice/gap
8
1
2
7
4
Perceived importance – clinicians Perceived importance – Client
3
1
0
2
2
Health Impact Current practice/gap
6 11
2
2
M AN U
SC
RI PT
0
TE D
Compensatory strategies/AA C
2
1
0
1
2
0 2
0 2
5 10
1 5
EP
ConstraintInduced Language Therapy
1
Perceived importance – clinicians Perceived importance – Client
AC C
Cognitive Neuropsychol ogical Therapy Approach
Health Impact
8
1
0
7
1
8
4
0
6
6
Hinckley, Boyle [47]. O’Halloran, Lee [39], Kalra, Evans [48]. Verna, Davidson [1], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Rose, Ferguson [21]. [21]M. Rose et al. (2013); Guo, Togher, and Power (2013). Rohde, Townley-O'Neill [15]. Doesborgh, van de Sandt-Koenderman [49]. National Stroke Foundation [12], National Stroke Foundation [13], Rowe [31], Page and Wallace [50]. Page and Wallace [50], Rose, Attard [51] Kirmess and Maher [33], Rose, Attard [51]. Cherney, Patterson [34]. National Stroke Foundation [12], National Stroke Foundation [13], Rowe [31], True, Bartlett [52], Beukelman, Ball [53]. Rose, Attard [51]. Rose, Attard [51]; Van de SandtKoenderman, Wiegers [54]; Blom Johansson, Carlsson [43], True, Bartlett [52], Bloch [55], Lasker and
1 4
0 0
1 25
1 4
Perceived importance – clinicians Perceived importance – Client
6
2
0
6
2
6
3
0
6
3
Health Impact
6
2
0
3
Current practice/gap
68
5
Perceived importance – clinicians Perceived importance – Client
25 30
RI PT
1 25
M AN U
5
2
66
9
1
0
25
1
3
0
25
8
Health Impact
Information, Education and
Current practice/gap
AC C
EP
Group Therapy
Health Impact Current practice/gap
TE D
Computer Therapy
SC
ACCEPTED MANUSCRIPT
35
5
0
35
5
223
3
2
221
7
Beukelman [56]. Rose, Douglas [57]. Klippi et al. (2012); National Stroke Foundation (2012, 2014); Rowe [31]. Rose, Attard [51], Davis [58]. Mortley, Wade [59], Fink, Brecher [60], Cherney, Halper [61]. Palmer, Enderby [62], Brady, Kelly [63], Wertz and Katz [64], Katz and Wertz [65]. Verna, Davidson [1], Katz, Hallowell [4], Guo, Togher [6], National Stroke Foundation [12], National Stroke Foundation [13], Klippi, Sellman [17], Law, Pringle [18], Rose, Ferguson [21], Code and Heron [30]. Rose, Attard [51]. Horton, Mudd [7], Law, Pringle [18], Tomkins, Siyambalapitiya [24], Kong [29], Law, Huby [66], Brumfitt and Sheeran [67], Mumby and Whitworth [68], Grohn, Worrall [69]. Wenke, Lawrie [32], Brumfitt and Sheeran [67], Elman and BernsteinEllis [70], Vickers [71], Lanyon, Rose [72]. Guo et al. (2013); National Stroke Foundation (2012, 2014); M. Rose et al.
Aphasia Friendly Information 38
4
0
36
6
Perceived importance – Client
94
7
0
89
12
Health Impact
16
3
Current practice/gap
93
1
Perceived importance – clinicians
14
Perceived importance – Client
98
Health Impact
Caregiver Support
Current practice/gap
M AN U
SC
Perceived importance – clinicians
16
3
2
91
5
0
14
4
0
0
96
2
5
6
0
6
5
164
3
2
162
7
TE D
0
EP
4
AC C
Counselling
RI PT
ACCEPTED MANUSCRIPT
(2013); Blom Johansson, Carlsson [25], Rose, Worrall [73], Knight, Worrall [74]. Rose, Ferguson [21], Hallé, Le Dorze [40], Manders, Marien [41], Brown, Worrall [42], Law, Huby [66] Sherratt, Worrall [14]. Law, Pringle [18], Worrall, Sherratt [23], Tomkins, Siyambalapitiya [24], Kong [29], Manders, Marien [41], Hilton, Leenhouts [44], Denman [45], Hinckley [75], Rose, Worrall [76], Blom Johansson, Carlsson [77], Howe, Davidson [78]. Blom Johansson, Carlsson [77], Forster, Brown [79]; Smith, Forster [80]. National Stroke Foundation [12], National Stroke Foundation [13], Rose, Ferguson [21], Brumfitt [81], Mackenzie, May [82]. Sherratt, Worrall [14], Klippi, Sellman [17], Law, Pringle [18], Rose, Ferguson [21]. Brown, Worrall [42], Ireland and Wotton [83]. Ireland and Wotton [83], Bhogal, Teasell [84], Evans, Matlock [85], Clark, Rubenach [86], Eldred and Sykes [87]. Guo, Togher [6], National Stroke Foundation [12], National Stroke
24
5
1
23
6
Perceived importance – Client
95
6
0
91
10
Health Impact
18
5
Current practice/gap
118
Perceived importance – clinicians Perceived importance – Client
10 49
M AN U
SC
Perceived importance – clinicians
0
6
2
117
3
3
0
10
3
4
0
46
7
TE D
17
EP
0
AC C
Return to Work
RI PT
ACCEPTED MANUSCRIPT
Foundation [13], Rose, Ferguson [21], Blom Johansson, Carlsson [25], Kong [29], Mackenzie, May [82]. Sherratt, Worrall [14], Klippi, Sellman [17], Brown, Worrall [22], Hallé, Le Dorze [40], Manders, Marien [41], Law, Huby [66]. Worrall, Brown [16], Law, Pringle [18], Manders, Marien [41], Blom Johansson, Carlsson [43], Hilton, Leenhouts [44], Denman [45], Grohn, Worrall [69], Blom Johansson, Carlsson [77], Howe, Davidson [78], Johannsen-Horbach, Crone [88]. Hilton, Leenhouts [44], Blom Johansson, Carlsson [77], Forster, Brown [79], Eldred and Sykes [87], Johannsen-Horbach, Crone [88], Brereton, Carroll [89]. National Stroke Foundation [12], National Stroke Foundation [13], Garcia, Barrette [90]. Law, Pringle [18], Garcia, Barrette [90], Matos, Jesus [91]. Law, Pringle [18], Worrall, Sherratt [23], Hinckley [75], Garcia, Barrette [90], Matos, Jesus [91], Parr [92], Kersten, Low [93].
ACCEPTED MANUSCRIPT
4. 5. 6. 7. 8. 9. 10. 11. 12.
2076
161
25
2014
4
Dalemans [94], Graham, Pereira [95], Black-Schaffer [96], Trexler, Trexler [97].
242
SC
Verna, A., B. Davidson, and T. Rose, Speech-language pathology services for people with aphasia: A survey of current practice in Australia. International Journal of Speech-Language Pathology, 2009. 11(3): p. 191-205. Vogel, A.P., P. Maruff, and A.T. Morgan, Evaluation of communication assessment practices during the acute stages post stroke. J Eval Clin Pract, 2010. 16(6): p. 1183-8. Duffy, J., T. Fossett, and J. Thomas, Aphasia care in acute hospital: challenges and opportunities, in Clinical Aphasiology Conference. 2010: Isle of Palms, SC. Katz, R.C., et al., A multinational comparison of aphasia management practices. Int J Lang Comm Dis, 2000. 35(2): p. 303-314. National Stroke Foundation, National Stroke Audit Acute Services Clinical Audit Report 2011: Melbourne, Australia. Guo, Y.E., L. Togher, and E. Power, Speech pathology services for people with aphasia: What is the current practice in Singapore? Disability and Rehabilitation, 2013. 36(8): p. 691-704. Horton, S., D. Mudd, and J. Lane, Is anyone speaking my language? International Journal of Language & Communication Disorders, 1998. 33(S1): p. 126-131. Armstrong, E., Communication Culture in Acute Speech Pathology Settings: Current Issues. Advances in Speech-Language Pathology, 2003. 5(2): p. 137-143 Lalor, E. and E. Cranfield, Aphasia: A description of the incidence and management in the acute hospital setting. Asia Pacific Journal of Speech, Language and Hearing, 2004. 9: p. 129-136. Hilari, K., The impact of stroke: Are people with aphasia different to those without? Disability and Rehabilitation, 2011. 33(3): p. 211218. Dickey, L., et al., Incidence and Profile of Inpatient Stroke-Induced Aphasia in Ontario, Canada. Archives of Physical Medicine and Rehabilitation, 2010. 91(2): p. 196-202. National Stroke Foundation, National Stroke Audit - Rehabilitation Services Report. 2012, National Stroke Foundation: Melbourne, Australia.
M AN U
3.
0
TE D
2.
0
EP
1.
4
AC C
Totals
0
RI PT
Health Impact
ACCEPTED MANUSCRIPT
20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
RI PT
SC
18. 19.
M AN U
16. 17.
TE D
15.
EP
14.
National Stroke Foundation, National Stroke Audit - Rehabilitation Services Report. 2014, National Stroke Foundation: Melbourne, Australia. Sherratt, S., et al., "Well it has to be language-related": Speech-language pathologists' goals for people with aphasia and their families. Int J Speech Lang Pathol, 2011. 13(4): p. 317-28. Rohde, A., et al., A comparison of client and therapist goals for people with aphasia: A qualitative exploratory study. Aphasiology, 2012. 26(10): p. 1298-1315. Worrall, L., et al., The evidence for a life-coaching approach to aphasia. Aphasiology, 2010. 24(4): p. 497-514. Klippi, A., et al., Current clinical practices in aphasia therapy in Finland: Challenges in moving towards national best practice. Folia Phoniatrica et Logopaedica, 2012. 64(4): p. 169-78. Law, J., et al., The Aphasia in Scotland Project - Final Report. 2007, Centre for Integrated Healthcare Research. Johansson, M.B., M. Carlsson, and K. Sonnander, Working with families of persons with aphasia: a survey of Swedish speech and language pathologists. Disabil Rehabil, 2011. 33(1): p. 51-62. Monaghan, J., et al., Improving patient and carer communication, multidisciplinary team working and goal-setting in stroke rehabilitation. Clinical rehabilitation, 2005. 19(2): p. 194-199. Rose, M., et al., Aphasia rehabilitation in Australia: Current practices, challenges and future directions. International Journal of Speech Language Pathology, 2013. Brown, K., et al., Exploring speech-language pathologists' perspectives about living successfully with aphasia. Int J Lang Commun Disord, 2011. 46(3): p. 300-11. Worrall, L., et al., What people with aphasia want: Their goals according to the ICF. Aphasiology, 2011. 25(3): p. 309-322. Tomkins, B., S. Siyambalapitiya, and L. Worrall, What do people with aphasia think about their health care? Factors influencing satisfaction and dissatisfaction. Aphasiology, 2013. 27(8): p. 972-991. Blom Johansson, M., et al., Communication changes and SLP services according to significant others of persons with aphasia. Aphasiology, 2012. 26(8): p. 1005-1028. Levack, W.M., et al., Is goal planning in rehabilitation effective? A systematic review. Clinical Rehabilitation, 2006. 20: p. 739-755. Ferreira, D.L., Aphasia Incidence and Intervention in the Acute Hospital Setting, in Faculty of Computing, Health and Science. 2012, Ediith Cowan University Godecke, E., et al., Very early poststroke aphasia therapy: A pilot randomized controlled efficacy trial. Int J Stroke, 2011. 7(8): p. 63544. Kong, A.P., Family members' report on speech-language pathology and community services for persons with aphasia in Hong Kong. Disabil Rehabil, 2011. 33(25-26): p. 2633-45.
AC C
13.
ACCEPTED MANUSCRIPT
36. 37. 38. 39. 40. 41. 42. 43. 44. 45.
RI PT
SC
35.
M AN U
33. 34.
TE D
32.
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31.
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Dalemans, R.J.P., A description of social participation in working-age persons with aphasia: a review of the literature. Aphasiology, 2008. 22(10): p. 1071-1091. Graham, J.R., S. Pereira, and R. Teasell, Aphasia and return to work in younger stroke survivors. Aphasiology, 2011. 25(8): p. 952-960. Black-Schaffer, R.M., Return to work after stroke: development of a predictive model. Archives of physical medicine and rehabilitation, 1990. 71(5): p. 285-290. Trexler, L.E., et al., Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. The Journal of head trauma rehabilitation, 2010. 25(6): p. 440-446.
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ACCEPTED MANUSCRIPT Supplementary Information – Systematic Searches
Bibliographic Databases
SC M AN U
1. Aphasia 2. Dysphasia 3. 1 or 2 4. Assessment 5. Tool 6. Screener 7. Screening 8. 4 or 5 or 6 or 7 9. Current practice 10. Practice 11. Gap 12. Service 13. 9 or 10 or 11 or 12 14. 3 and 8 and 13
RI PT
Example Search Strategy: CINAHL
Electronic database CINAHL (via EBsCoHost, 1982-present) MEDLINE (via OVID, 1950-present)
Time Period All All
TE D
Search terms for bibliographic databases Subheading N/A
Search Terms Aphasia or Dysphasia
Topic Area
1. Assessment 2. Goal Setting
Assessment or Tool or Screener or Screening Goal setting or goal or goals
3. Timing, amount, intensity
Amount of therapy or timing of therapy or early therapy or early rehabilitation or intensity of therapy Constraint induced language therapy or constraint induced aphasia therapy or CILT or CIAT Cognitive neuropsychological therapy OR neuropsychological OR cognitive linguistic OR semantic therapy OR phonemic therapy Group therapy or group or groups Computer therapy or computer or computer treatment Conversation partner training or supported conversation or communication strategies Augmentative and alternative communication or AAC or strategy or compensatory
AC C
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Category Population
4. CILT
5. Cog neruopsych therapy 6. Group Therapy 7. Computer Therapy 8. Conversation Partner Training 9. AAC
ACCEPTED MANUSCRIPT
RI PT
M AN U
SC
Criteria
10. Info/education Information OR education OR aphasia-friendly and aphasiafriendly info 11. Counselling Counselling or counseling or counsel or psychological treatment 12. Patient and Support or supporting or significant others or caregiver support family or caregivers or carers 13. Return to Return to work OR work OR employment OR work vocation OR vocational rehabilitation 2. Current Current practice or practice or gap or service practice/gap 3. Perceived Attitudes or experiences or perceptions or importance – perspectives or satisfaction AND clinicians Speech-language pathologist or speech-language pathologists 4. Perceived Attitudes or experiences or perceptions or importance – perspectives or satisfaction AND Client Patient or patients or carer or carers 7. Health Impact Health impact or cost effectiveness or cost benefit
Stroke, Speech Pathology and Aphasia Websites
Location http://www.speechpathologyaustralia.org.au http://www.aphasia.org.au http://www.rcslt.org
AC C
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Source Speech Pathology Australia Australian Aphasia Association Royal College of Speech and Language Therapists Connect – the Communication Disability Network American Speech-Language-Hearing Association ASHA’s Evidence Maps – National Center for Evidence-Based Practice in Communication Disorders The Internet Stroke Center speechBITE National Health and Medical Research Council Academy of Neurological Communication Disorders and Sciences National Stroke Foundation
http://www.ukconnect.org http://www.asha.org http://ncepmaps.org
www.strokecenter.org http://speechbite.com www.nhmrc.gov.au www.ancds.org
http://strokefoundation.com.au
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Supplementary Table 4. Search Results Per Topic Area (November 2014 to June 2017)
Goal Setting
Current practice/gap
Treatment timing, amount and/or Intensity Conversation Partner Training Cognitive Neuropsychological Therapy Approach Constraint-Induced Language Therapy Compensatory strategies/AAC Computer Therapy
Current practice/gap
Group Therapy
Current practice/gap
Current practice/gap Current practice/gap
Current practice/gap Current practice/gap Current practice/gap
Total Included 1
References Included
16 (6) 45 (2) 3 (0) 27 (5) 23 (5)
1
0
16
1
[1]
0
0
45
0
-
0
3
0
-
2
28
1
[2]
2
25
0
0
2
25
3
[2-4]
0
1
42
1
[2]
0
1
4
1
[2]
0
1
29
1
[2]
0
1
26
1
[2]
0
1
100
1
[2]
26 (7) 42 (2) 4 (0) 29 (2) 26 (6) 100
0 0 0
RI PT
Documents Excluded 109
SC
Perceived importance – clinicians Perceived importance – Client Health Impact
Search Yield Websites 2
M AN U
Current practice/gap
Grey Literature 0
TE D
Screening Assessment
Search Yield Databases (Full Text retrieved) 108 (6)
EP
Criteria
AC C
Topic Area
[1]
ACCEPTED MANUSCRIPT
Current practice/gap
Return to Work
Current practice/gap
0
2
0
1
TE D
5.
2
80
20
1
[2]
6
1
[5]
119
2
[2, 3]
24
1
[2]
454
16
Foster, A.M., et al., 'I do the best I can': an in-depth exploration of the aphasia management pathway in the acute hospital setting. Disability and rehabilitation, 2016. 38(18): p. 1765. Stroke Foundation, National Stroke Audit – Rehabilitation Services Report 2016. 2016: Melbourne, Australia. National Stroke Foundation, National Stroke Audit - Acute Services Report 2015. 2015: Melbourne, Australia. Beckley, F., W. Best, and S. Beeke, Delivering communication strategy training for people with aphasia: what is current clinical practice? International Journal of Language & Communication Disorders, 2017. 52(2): p. 197-213. Sekhon, J.K., J. Douglas, and M.L. Rose, Current Australian speech-language pathology practice in addressing psychological well-being in people with aphasia after stroke. International Journal of Speech-Language Pathology, 2015, Vol.17(3), p.252-262, 2015. 17(3): p. 252-262.
EP
2. 3. 4.
0
1
AC C
1.
2
RI PT
Caregiver Support
5 (2) 119 (15) 24 (1) 449
0
SC
Current practice/gap
Totals
Current practice/gap
M AN U
Information, Education and Aphasia Friendly Information Counselling
(11) 79 (5)