Treatment effectiveness across the continuum of care
Aphasia therapy is effective, but there is limited evidence on patient-related and therapy dose factors that contribute to best immediate outcomes, as well as maintenance of treatment effects.
Existing stroke clinical guidelines provide limited information for aphasia across the continuum of care.
Aphasia care in acute stroke is particularly lacking, with speech therapy time dominated by dysphagia intervention. A pathway for acute stroke aphasia care is needed to maximise recovery and improve patient experience.
This program will address clinical pathways for acute post-stroke management, communication enhanced hospital environments and optimum therapy regimes to produce the best outcomes in aphasia.
Development of a clinical pathway for acute post-stroke aphasia management
Prioritisation of dysphagia (swallowing) management has meant that in acute hospitals provision of aphasia management is limited and sub-optimal, compared to best-practice recommendations. Significant variation is noted in care of people with aphasia and their families in this setting.
The impact includes:
- poorer communicative outcomes
- reduced capacity to communicate healthcare needs
- increased negative events in hospital
- learned non-use in communication
- decreased patient satisfaction.
We have shown that barriers to achieving evidence-based approaches to care include:
- speech pathologists’ poor relationship with the research literature
- lack of confidence, self-efficacy and agency
- difficulties including people with aphasia as active participants in their healthcare
- an acute hospital culture of giving dysphagia priority.
Knowledge of these barriers will help in the design and implementation of evidence-based acute aphasia management which is essential to improving patient outcomes and experiences.
1. Develop an integrative multidisciplinary acute aphasia management pathway using the RIGHT consensus guidelines.
2. Demonstrate that theoretically-driven implementation of the pathway within a single acute hospital site can lead to improved patient outcomes.
Communication enhanced environments in acute and subacute aphasia care
Research finds the brain most receptive to enhanced recovery in the first days or weeks after stroke. In animals, environmental enrichment promotes neuroplasticity and better recovery after stroke; but few human studies have been conducted.
In any event, current aphasia intervention in early recovery, typically involving one-on-one and group therapy, falls well short of the recommended five hours per week over the first three months. Additionally, stroke survivors spend most of their hospital time inactive and alone.
The lack of opportunity for communicative interaction puts patients at risk of developing maladaptive communication behaviours and of poor language recovery. Animal research strongly suggests that “environmental enrichment” –altering the environment to promote social, cognitive and physical activity – promotes neuroplasticity and better recovery. Three studies have been conducted so far in human models, with promising results. We propose a first-ever multi-centre trial specifically testing the feasibility and effectiveness of an enrichment model for enhancing social activity and communication.
To evaluate the effectiveness, feasibility, and sustainability of an enhanced communication environmental implementation package in five acute and sub-acute sites in Western Australia and Victoria admitting over 150 strokes each year.
Do intense or non-intense therapy regimens produce best outcomes in aphasia?
The international best-practice recommendation is “people with aphasia should be offered intensive and individualised aphasia therapy designed to have a meaningful impact on communication and life”; but they have greater drop-out rates from intensive treatments.
The rationale for intensive regimens largely stems from motor retraining research. However, effects from cognitive retraining are superior following distributed practice, and recent aphasia intervention studies have showed superior results with a distributed dose. The factors underpinning better response to intensive or distributed dose are unknown: this is an important gap in knowledge hindering development of effective and cost-efficient aphasia interventions. Therefore, we will investigate the impact of intensity and patient profiles in response to distributed or intensive aphasia interventions.
To compare high-and low-intensity aphasia therapy in a nested Phase II Randomised controlled trial (RCT) study.