Can a new intensive model of aphasia rehabilitation achieve better outcomes than usual care with chronic aphasia resulting from stroke?

INTERVENTION: The University of Queensland's Aphasia LIFT program seeks to integrate all aspects of what people with aphasia and their families want with evidence‐based components into a “package”. LIFT involves over 50 hours of intervention per participant and incorporates individual impairment‐based therapy, individual functional therapy computer therapy and group sessions for information sharing and discussion of topics related to living with aphasia & topics requested by participants. It seeks to provide participants with tools to practice language themselves through use of commercial computerised aphasia programs in treatment, as well as instruction on how to develop their own personalised therapy materials. Mobile technology such as iPads & iPhones are used frequently both to achieve communication goals such as being able to text short messages to family and friend and to maintain practice schedules. In the maintenance phase (weeks 4‐7) participants will use a tablet‐based therapy program at home, monitored and updated regularly by the speech pathologist. Data will be gathered on time spent on the therapy tasks as well as progress. The speech pathologist will also 'check‐in' with the participant via telephone to talk through any issues and check that the participant is adhering to the program. In addition, LIFT links them into community resources (peer‐led aphasia groups, stroke groups, interest groups, other professionals) so that the psychosocial benefits of the group are maintained. Family members are also part of the program. The program culminates in a challenge day in which participants present what they have achieved in front of family and friends. Group‐level data demonstrates that Aphasia LIFT yielded positive and enduring outcomes in language impairment, functional communication, and communication‐related quality of life in individuals with aphasia. The intervention arms are: Usual care: Any aphasia therapy up to 12 months post stroke, delivered by typical speech pathology service providers in outpatient hospital setting or community based rehabilitation setting in the patients’ homes or centres. LIFT: 3 week intensive program + 4 weeks maintenance, delivered by trained speech pathologists at The UQ CCRE Aphasia Clinic and other rehabilitation centres of our Partner Organisations. Participants in LIFT attend 10 x 60 minute sessions per week each of individual therapy, 5 x 60 minute sessions per week of computer‐based therapy and 2 x 60 minute sessions per week of group therapy. CONDITION: Aphasia Stroke PRIMARY OUTCOME: Assessment for Living with Aphasia: ; The ALA is a self‐rated aphasia‐friendly assessment of the impact of aphasia on a person’s everyday life. It is based on the Living with Aphasia: Framework for Outcome Measurement (A‐FROM) framework, an adaptation of the World Health Organization's International Classification of Functioning, Disability, and Health for people with aphasia. The authors reported that the ALA is psychometrically sound, with analysis of 101 participants indicating good inter‐rater reliability (Cronbach alpha 0.85). Content Information Units: ; Connected speech is considered to have greater ecological validity compared to language battery tasks. Two samples of language will be elicited using standard narrative discourse stimuli (participants tell a story about a single picture and a picture sequence) and an interactional discourse sample (barrier task used to promote a dialogue but with controlled vocabulary). The content and efficiency of language will be measured by calculating the percentage of correct information units (CIUs) and CIUs/minute. The authors report interjudge reliability to be 90% and both %CIU’s and CIUs/minute were able to differentiate 20 people with aphasia from 20 without. SECONDARY OUTCOME: Assessment of Quality of Life (AQoL‐4D): ; A 12‐item questionnaire that measures quality of life on the domains Independent Living, Mental Health, Relationships, Senses. Cronbach’s Alpha for these domains range from a satisfactory correlation of 0.54 for Senses to 0.92 for Mental Health. Boston Naming Test: ; The BNT assesses word‐finding by confrontation naming of 60 line drawings of high to low frequency objects. It is a frequently used, quick test of confrontation naming. Probe tasks of both treated & untreated items that participants fail to name at baseline will be used to specifically measure the effect of treatment on naming and its generalization to untreated named items. Internal consistency for the 60‐item version ranges from r = 0.78 to 0.96 across studies. Comprehensive Aphasia Test: ; The CAT assesses language performance across multiple modalities: comprehension of spoken language and written language, repetition, naming, reading and writing. Inter‐rater reliability is good to excellent (ICC above 0.9 in 23/26 elements of the battery) and there were significant correlations showing good concurrent validity between the CAT subtests and related tests. Family members of people with aphasia: ; Bakas Caregiver Outcomes Scale ‐ Family members and friends often report needing support. Family members’ outcomes will be measured using the Bakas Caregiver Outcomes Scale. Internal consistency (alpha = 0.90) and test‐retest reliability (ICC = 0.66; 95% CI = 0.42‐0.81) was satisfactory. Criterion‐related validity was supported by correlations with the SF‐36 (r = 0.32, p < .001) and a criterion variable measuring how caregivers' lives had changed (r = 0.67, p < .001). Family members of people with aphasia: ; Communicative Effectiveness Index (CETI) ‐ The CETI is a proxy rated measure of functional communication of the person with aphasia. Construct validity was reported to be good since the CETI showed significant change in a recovering group of people with aphasia compared to a stable group of people with aphasia. Family members of people with aphasia: ; Participant Satisfaction ‐ A semi‐structured interview with satisfaction rating scales have been designed to elicit the views of participants who are family members Participant Satisfaction: ; An aphasia‐friendly semi‐structured interview with satisfaction rating scales have been designed to elicit the views of participants with aphasia. Speech Pathology Stakeholders: ; Semi‐structured stakeholder interviews ‐ people with an interest in aphasia rehabilitation ( e.g speech pathologists, people with aphasia, speech pathology managers) will be purposively sampled and interviewed following a short video and presentation about the LIFT program. An experienced qualitative researcher will use a semi‐structured interview with participants to explore the barriers and enablers to implementing and sustaining change in use of both the LIFT components (intensive therapy, group therapy, family support, goal oriented therapy, computer‐based therapy) and the LIFT program as a whole. Treating speech pathologists: ; Australian Therapy Outcome Measure (AUSTOMs) ‐ To obtain a speech pathology perspective on outcomes of participants with aphasia across the ICF, the AusTOMs language rating scale will be used. This is a frequently used clinical outcome measure used by speech pathologists. INCLUSION CRITERIA: 1. Participants with aphasia: Confirmed stroke (medical chart) and confirmed aphasia using the Frenchay Aphasia Screening Test. Score above cut‐off on the Montreal Cognitive Assessment cognitive screen. Willing to forego other speech therapy for the duration of the study and during follow‐up Able to toilet independently or with the assistance of an accompanying caregiver. Requires at least 7 more weeks of therapy as reported by the referring speech pathologist English language, hearing and vision sufficient for therapy as judged by the referring speech pathologist and the research assistant. 2. Family members/carers of participants with aphasia: Able to speak English 3. Treating speech pathologists Qualified practising speech pathologists, employed by either UQ or the partner hospitals, who are providing either LIFT or usual care to the people with aphasia in this study. 4. Speech patholo