If my close relative, Bob, had a stroke causing aphasia, what would I want from his speech pathologist?

If my close relative – let’s call him Bob – had a stroke that included language loss (“aphasia“), I would want him to see a speech pathologist as soon as possible. I would want his speech pathologist to:

• be up-to-date on the latest research and clinical guidelines for aphasia rehabilitation; and
• apply the latest and best research when delivering Bob’s treatment.

So what are some of the best speech pathology rehabilitation practices for people with aphasia caused by strokes?

First, some facts:

• Up to 38% of stroke survivors have aphasia immediately after their stroke (Berthier, 2005).
• About 40% of these people experience near complete or complete recovery within a year of their stroke. But the majority have ongoing language problems (Ferro et al., 1999).
• Evidence-based speech therapy in the first three months after stroke can almost double the degree of a patient’s recovery (Brady et al., 2012). But only if the speech pathologist knows what she or he is doing and applies best practices based on clinical consensus and the research evidence.

You can read more about aphasia here.

Real world barriers – and new recommendations to help busy speech pathologists

In the best of worlds, everyone with aphasia would get intensive, personalised care by a speech pathologist for as long as they needed it. But time and hospital resources are limited (e.g. Klippi et al., 2012; Rose et al., 2013). To make things more difficult, there are several published treatment guidelines – over 76 different recommendations in all – that make it hard for speech pathologists to identify, sort and apply best practices to each patient’s care.

The good news for speech pathologists is that Drs Kirstine Shrubsole, Linda Worrall, Emma Power and Denise O’Connor have now published the results of their systematic review of aphasia rehabilitation guidelines. The review distills, consolidates and sorts existing guidelines by the level of evidence. It gives busy speech pathologists practical guidance on best practices for helping people with aphasia post-stroke, and their families.

So back to Bob. What I would want from his speech pathologist?

Based on my reading of the systematic review, here are the key things I would want for Bob and our family:

1. A proper assessment using a valid and reliable tool (e.g. Salter et al., 2006).
2. Good, “aphasia friendly“, and timely communication of Bob’s assessment results and treatment options:
   • to Bob, taking into account his age, gender, education, readiness to receive the information and of course degree of aphasia (e.g. Choi-Kwan et al., 2005; Rise et al., 2003); and
   • (with Bob’s consent), Bob’s carers and family, in formats and ways that we could all understand (e.g. Smith et al., 2008; Forster et al., 2005).
3. Treatment for Bob starting as soon as he could tolerate it.
4. At least 45 minutes of direct speech therapy for at least 5 days a week – preferably as much as Bob could tolerate (e.g. Bhogal et al., 2003; Godecke, 2009).
5. Direct treatment provided to Bob:
   • based on his assessment results and his communication impairments;
   • pursuing meaningful, measurable, challenging, realistic and documented short and long-term goals set collaboratively with Bob, his carers and the rest of his support team;
   • possibly based on models derived from cognitive neuro-psychology (e.g. Doesborgh et al., 2004);
   • perhaps including constrained-induced language therapy (e.g. Cherney et al., 2008); and
   • using all the methods available to Bob to understand others and express himself including gestures, writing, and using communication props (e.g. Rose et al., 2002).
6. Carer and family training on communication strategies to help Bob tell others what he wants, needs, thinks and feels (Kalra et al., 2004). This could include training for us in supported conversation techniques (e.g. Kagan et al., 2001).
7. If warranted, referral for counselling for Bob and/or his carers (e.g. Clark et al., 2003).
8. Coaching to hospital and other staff, carers and social workers to support Bob’s communication in the hospital.
9. Continuous updates at different stages of Bob’s recovery, with opportunities for Bob and us to ask questions and to seek clarifications (Smith et al., 2008).
10. Easy to understand information about community-based aphasia and stroke support groups and group therapy being given to Bob and his family to help him to continue to improve his communication after discharge (e.g. Brereton et al., 2007).
11. Support for Bob’s wish to return to work, including visiting Bob’s workplace to audit the communication demands of the job and then tailoring therapy to help Bob succeed.

Clinical Bottom Line

The list of recommendations set out in the systematic review is very helpful for speech pathologists looking to apply evidence and best clinical practices to help people with aphasia. Although real world resourcing and other barriers exist, the recommendations should also help to set the bar for what informed clients and their families should expect of their speech pathologists treating people with aphasia.

Principal source: Shrubsole, K., Worrall, L., Power, E., & O’Connor, D. (2017) (available online). Recommendations for post-stroke aphasia rehabilitation: an updated systematic review and evaluation of clinical practice guidelines, Aphasiology, 31;1, 1-24, last accessed on 15 November 2016 from here.

As always, any errors of interpretation of the source are mine.

Related articles:

• Aphasia
• How to write for people with acquired language problems (an example)

Image: http://tinyurl.com/zks63wg

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.

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