Monday, 7 April 2014

Newcastle SLT journal club

This post is an update on the first Newcastle SLT journal club meeting, which was held last week in an as-informal-as-you-can-get pub setting. Eight students and Speech and Language Therapists attended and we received very positive feedback. We are aiming to hold the next group on/around Saturday 10th May and are expecting more members at this meeting; do sign up for the club and come along if you're interested in evidence based practice. We welcome all student and qualified health care professionals. Click here for our Facebook page.



Why are you here?


Members were asked what their reasons were for joining the club, they responded with:
  • to maintain an ability to critically appraise articles
  • belonging to a journal club will keep them motivated to stay up-to-date with the evidence: a few people acknowledged that although they regularly receive journals, specifically the International Journal of Language and Communication Disorders, despite best intentions, they did not get around to reading the articles
  • opportunity for CPD
  • boosting the CV
  • networking with other SLTs in the area - recognised as important by both students and therapists
  • offering and receiving extended support from a group of like-minded professionals/students
  • to share knowledge and experiences of practice with others

The topic of the week was Communication Partner Training



Articles discussed: 


The following critical appraisal checklist was filled in by Lauren Davies 

Author/s Savundranayagam, M.Y. & Orange, J.B.
Year: 2014
Journal: IJLCD
Volume: 49(1)
Pages:49 - 59
Question
Evidence/comments
What are the research questions?
i.e. What are the researchers trying to find out? What are the aims of the intervention?
      1)      Determine effectiveness of strategies used to resolve communication  breakdowns
      2)      Examine whether caregivers’ ratings of strategy effectiveness were consistent with evidence from video-recorded conversations and with communication strategies deemed to be effective in the literature
What is the specific target client for this intervention?
i.e. Client diagnosis; age; details of expected level of current language skills; pre-requisites for intervention)

15 caregivers of people with Alzheimer’s dementia:

14 – spouses
1 – daughter

Different stages of dementia: (rated how?)


Early
Middle
Late
Participants
6
5
4
Conversations
11
10
7
Can this intervention be applied to different types of case?

Yes, e.g. aphasia, though stages early-middle-late don’t correspond with acute – chronic: not progressive so may yield v. different results as caregivers become more in-tune with conversation capabilities of people with aphasia (PWA).
How is the intervention carried out? How well specified is the intervention?
NB this may be in an appendix.
i.e. what is the therapy approach? Who delivers it and where? How often and how much is given? Is special equipment or materials needed? What is the hierarchy of difficulty, including cues, step up/down, progression? What feedback was given to client?










Therapy approach
       -       Multi-centre investigation that used a cross-sectional design         
      -       Partners fill in PCI-DAT form (created by second author) prior to recording, this lists 22 repair strategies e.g. ‘ask for clarification’.
       -       They then fill in Likert Scale (1 = not helpful; 2= very helpful) for each.
      -         2 conversations (lunch and evening) recorded for each participant (bar two, where it was only possibly to record one conversation)
      -       Family-style meal time set up can lead to double communication compared with if people with dementia are sat alone (Altus et al, 2002).
     -       Conversations transcribed orthographically and segmented into utterances (who did this?)
     -       TSR was used; all utterances made by communication partners were coded as either 1-trouble source, 2-repair initiator and 3-4epair.

Agent of therapy/location/dosage/frequency

"Same methodology as used by Orange (1996)" – not particularly helpful 

13 dyads recorded x 2 (lunch and dinner)
2 dyads recorded x 1 (1 meal time)

agent unknown
location = nursing home

Materials/equipment needed
Recording equipment
PCI-DAT containing 22 communication strategies used to overcome conversation difficulties

Hierarchy of difficulty
None- doesn’t describe what conversations were about; this may have influence on success of repair strategies
Feedback to client
none
Other comments
How were baseline performance and outcomes measured?








  • No baseline just one or two conversations, topics unknown

    1) Calculated total occurrences of repair initiators and strategies, coded for: 1-most successful, 2-successful or ineffective.
      
    2) outcomes measured in terms of matchedness of appraisals with the literature PCI-DAT
  • Inter rater reliability 2 raters coded for 4 of 28 randomly selected transcripts:

·     0.83 trouble source
·     1 repair initiators
·      0.75 repairs (no comment on this although significant)
·      0.86 resolution type
·     0.87 strategies coded using PCI-DAT
  •        Didn’t compare with normative data – what % of repair initiator, etc, is typical in conversation?

What is the evidence that the intervention worked (or did not work)?
i.e. outcome for treated/non-treated items; for control measures etc; evidence from statistical analyses
N/A
What are the answers to the research questions?
i.e. what do the authors say about the results of their study? Were the original questions answered/aims achieved?










     1)      Early stage – communication partners use a wider variety of communication strategies than in other phases which resulted in successful resolution of communication breakdowns.
Strategy of asking to repeat used often but frequently unsuccessful in all 3 groups, possibly because they were often non-specific e.g. ‘huh’, ‘eh’. This suggests need for training on specificity for clarification.  
       2)      Early stage – most matched for ‘effective’:  over and above matched appraisals being by chance alone
'Complete task myself’ often viewed as effective; training around this as although it can increase expediency of task it can increase risk of disengagement.
Pretend to understand matched (accurately) as being moderately helpful in later stages.
Most mismatched appraisals were for effective communication strategies that were appraised as ineffective. Caregivers tended to rate repair initiators as ineffective: asking for clarification rated as unhelpful in all stages, esp later.
  •  Different stages reflect different needs; with disease progression, complexity of communication problems increases -> caregivers not knowing which strategies work best, despite having increased experience and exposure to problems.


Other comments
e.g. What level of evidence is the study? Is it good in terms of experimental design?  do authors suggest modifications/ changes?










  •       No comments on whether literature evidence matched with observed evidence of certain repair strategies being effective
  •       Would be useful to do case studies on same people over time to see if their views change; is this really an accurate representation of people’s perceptions of RIs during different stages: i.e. people in late-group may have always had those views.
  •        PCI-DAT given to caregivers prior to the first conversation; will this have primed them for what authors looking out for? And affect the results?
  •         Limited by small sample size.
  •         Primarily spouses.
  •       For the one example where a daughter was the conversation partner, rather than the spouse, the patient's stage of Alzheimer's was not given.

Would you use this intervention with your client?
Justify with reference to the information you know about your client

Possibly; mismatched appraisals provide targeted opportunities for new learning among caregivers; could use conversation analysis along with rating scales to establish any gaps in knowledge or difficulties with communication and target these in therapy.

This study has made me more aware of the importance for ongoing education of partners in progressive diseases.




The following critical appraisal checklist was filled in by Yvonne Murray (MSc)

Author/s Simmons-Mackie, Raymer, Armstrong, Holland & Cherney
Year 2010
Journal Arch Phys Med Rehab
Volume 91
Pages 1814 - 1836
Question
Evidence/comments
What are the research questions?
i.e. What are the researchers trying to find out? What are the aims of the intervention?
There are three research questions:
1.       In persons with acute aphasia, what is the influence of communication partner training on measures of the following:
a) Language impairment?
b) Communication activity/participation?
c) Psychosocial adjustment/identity?
d) Quality of life?
What intervention outcomes are maintained?
2.       In persons with chronic aphasia, what is the influence of communication partner training on measures of the following:
a) Language impairment?
b) Communication activity/participation?
c) Psychosocial adjustment/identity?
d) Quality of life?
What intervention outcomes are maintained?
3.       For communication partners of people with aphasia, what is the influence of communication partner training on measures of the following:
a) Communication activity/participation?
b) Psychosocial adjustment/identity?
c) Quality of life?
What intervention outcomes are maintained?
What is the specific target client for this intervention?
i.e. Client diagnosis; age; details of expected level of current language skills; pre-requisites for intervention)
Huge range of clients used across the 31 studies, making generalisation difficult:
-       Huge range of aetiologies, including right-hemisphere involvement and cognitive impairment
-       Cut off point for acute/chronic aphasia boundary was set at 4 months post onset by the authors of this review, no justification of this was given (why not 6 months post onset as per Basso?)
-       Communication partner details ( including age and educational level ) were rarely described and level of familiarity with the person with aphasia ranged from stranger to spouse
Can this intervention be applied to different types of case?
This type of intervention can be used with individuals with aphasia along with their families/caregivers or with communication partners only.
 The findings of this review indicate that the most cost effective approach would be to train people working in healthcare settings to enable them to communicate more effectively  with a range of people with aphasia
How is the intervention carried out? How well specified is the intervention?
NB this may be in an appendix.
i.e. what is the therapy approach? Who delivers it and where? How often and how much is given? Is special equipment or materials needed? What is the hierarchy of difficulty, including cues, step up/down, progression? What feedback was given to client?
Therapy approach
3 therapy approaches were used across the 31 studies:
-Communication skills training
-Educational approach (teaching knowledge of aphasia)
-Counselling approach (addressing depression, isolation etc.
Agent of therapy/location/dosage/frequency
Varied widely across the studies, not clear how detailed individual studies were in this regard, but it was reported that :
-       Group, individual, dyad and workshop approaches were all used
-       Dosage/frequency ranged from 4 to 35 hours of therapy in total, usually taking place in 1 to 2 hour sessions, with the longest block of intervention lasting 20 weeks.
-       Over half the studies involved training the person with aphasia and a conversation partner (remainder focused on communication partners only)
-       Location – mostly clinical settings, but some at home
Materials/equipment needed
Not specified
Hierarchy of difficulty
Varied according to study, not detailed in this review
Feedback to client
Varied according to study, not detailed in this review
Other comments
Authors commented that these details were often underspecified in the studies examined, making replication difficult
How were baseline performance and outcomes measured?
Again outcomes measures varied widely across studies, and not all targeted the same behaviour.
-       For language impairment (LI), standardised assessments (e.g. the Western Aphasia Battery) often used.
-       Very few measures of activity/participation
-       Quality of life (QoL) not assessed and little consistency for measures of psychosocial improvement.
-       Authors point out that many studies employed ‘scatter shot’ approach, measuring variety of things in the hope that something would have improved
What is the evidence that the intervention worked (or did not work)?
i.e. outcome for treated/non-treated items; for control measures etc; evidence from statistical analyses
(a)    LI – 7/31 studies indicated improvement in this area
(b)   Communication activity/participation - 21/31 studies measured this, and 19/21 reported positive outcomes
(c)    Psychosocial adjustment - 10/31 studies measured this, and 9/10 reported positive outcomes
(d)   QoL – Not measured
What are the answers to the research questions?
i.e. what do the authors say about the results of their study? Were the original questions answered/aims achieved?
Question 1: There was insufficient evidence to say whether communication partner training was effective for people with ‘acute’ aphasia in any of the four domains examined.
Question 2: Communication partner training is PROBABLY effective in improving communication activity and participation in conversation with a trained partner in those with chronic aphasia. Insufficient evidence to comment on language impairment, psychosocial adjustment or quality of life.
Question 3: Communication partner training is effective in improving communication activity and participation in conversation partners of those with aphasia. Insufficient evidence to comment on psychosocial adjustment or quality of life. (Both familiar and unfamiliar communication partners improved)
Other comments
e.g. What level of evidence is the study? Is it good in terms of experimental design?  do authors suggest modifications/ changes?
The variety and range across the 31 studies examined in this review in terms of:
-       Type of therapy approach
-       Candidates and participants
-       Outcome measures used
-       Service Delivery
Make comparison (and subsequently, clinical guideline recommendation) difficult.
Authors used ‘AAN’ classification system for selection of studies for inclusion in this review (to assess how empirical they are) but acknowledge that this may not be the best approach for the study of aphasia, which may be more suited to qualitative approaches.
Would you use this intervention with your client?
Justify with reference to the information you know about your client
This article provides support for the use of communication partner training with staff in healthcare settings as a cost effective tool in improving communication with people with aphasia.
This article does NOT provide guidelines on what is the best type of communication partner training nor who are the best candidates for it (in terms of people with aphasia and their families) and advocates use of clinical judgement in these matters.

The template used is the Critical Appraisal Checklist, created by Helen Stringer PhD, Newcastle University


Discussions


There was an interesting discussion around evidence use; people were keen for the evidence they engage with to be accessible and applicable to practice. It can be difficult to read a systematic review and take away from it how to then go forth and use it in practice. The best way in which people can do this is to be directed to the best available evidence from the review/RCT, and then read the more detailed case studies identified as comprising the best evidence; replicating these in practice. As one of the club leaders, what I can take away from this is; perhaps it will be more useful to review in-depth studies already identified as 'good evidence'. Having said that, it is still important that as clinicians we remain aware of how to critically appraise bad evidence and bigger studies should we come across them in 'the real world'.

The Newcastle University critical appraisal checklist (shown above) was well received by members. The alternative CASP checklist was also mentioned but criticised for lack of comparative 'SLT-centredness'; i.e. it did not answer questions related to how SLTs can use the study in practice. This being said, there are numerous CASP checklists tailored for particular studies, e.g. RCTs/systematic reviews, it is therefore worth being aware of them.



Moving forward


We have decided as a group that the next meeting will have the following structure:
  • Everybody will read one article and discuss this as a group


in addition
  • 50% of members will read an article and fill in the Newcastle Critical Appraisal Checklist
  • 50% of members will read another article and fill in the Newcastle Critical Appraisal Checklist
  • Both groups will feedback to each other in the meeting


It is hoped that this structure will present the group with the opportunity for natural, informal discussion; give everybody the chance to learn about an article they haven't read; and become used to analysing articles in a structured way agreed to be useful by all members.

The next meeting will be on or around Saturday 10th May (to be confirmed).


The following subjects were identified as areas of further research interest:

  
Topic for next meeting
  • AAC for adults and children - specifically perceptions and expectations around AAC
    (one student is writing her extended case report on AAC use)
  • Apraxia of speech and Dysarthria; what are the alternatives to non-speech exercises? (one student has an 'adult' placement coming up; 3 people identified this as area of interest/uncertainty)

Topics for future meetings
  • Education and SLT service provision for post-16
  • Dysfluency - specifically the social impact and social anxiety; how outcome measures are recorded
  • Neurodegenerative disorders-management and ethics
  • Traumatic Brain Injury and the less visible pragmatic communication difficulties that follow
  • Autism Spectrum Disorder
  • Child speech and language
 As you can see; we have enough to keep us going for a while!