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Purpose A lack of social interaction during early stroke recovery can negatively affect neurological recovery and health-related quality of life of patients with aphasia following stroke. A Communication Enhanced Environment (CEE) model was developed to increase patient engagement in language activities early after stroke. This study aimed to examine staff (n = 20) and volunteer (n = 2) perceptions of a CEE model and factors influencing the implementation and use of the model. This study formed part of a broader study that developed and embedded a CEE model on two hospital wards. Materials and methods Six focus groups and one interview with hospital staff were conducted and analysed using a qualitative description approach. Feedback emailed by volunteers was included in the data set. Results Staff and volunteers perceived the CEE model benefitted themselves, the hospital system and patients. Staff identified a range of factors that influenced the implementation and use of the CEE model including individual staff, volunteer and patient factors, hospital features, the ease with which the CEE model could be used, and the implementation approach. Conclusions This study provides valuable insights into staff perceptions which may inform the implementation of interventions and future iterations of a CEE model.Implications for RehabilitationA CEE model may promote efficiency and increased patient engagement in stroke rehabilitation.The CEE model information session and aphasia communication partner training, and the provision of resources, may be useful strategies to increase staff confidence in using communication supporting strategies with patients with aphasia.Behaviour change and implementation science strategies may provide a framework to address barriers and promote facilitators to embed hospital-based interventions that require individual, ward, cultural and systems level change to reduce the evidence-based gap in clinical practice.

Background and Purpose: The factors associated with recovery of language domains after stroke remain uncertain. We described recovery of overall-language-ability, auditory comprehension, naming, and functional-communication across participants’ age, sex, and aphasia chronicity in a large, multilingual, international aphasia dataset. Methods: Individual participant data meta-analysis of systematically sourced aphasia datasets described overall-language ability using the Western Aphasia Battery Aphasia-Quotient; auditory comprehension by Aachen Aphasia Test (AAT) Token Test; naming by Boston Naming Test and functional-communication by AAT Spontaneous-Speech Communication subscale. Multivariable analyses regressed absolute score-changes from baseline across language domains onto covariates identified a priori in randomized controlled trials and all study types. Change-from-baseline scores were presented as estimates of means and 95% CIs. Heterogeneity was described using relative variance. Risk of bias was considered at dataset and meta-analysis level. Results: Assessments at baseline (median=43.6 weeks poststroke; interquartile range [4–165.1]) and first-follow-up (median=10 weeks from baseline; interquartile range [3–26]) were available for n=943 on overall-language ability, n=1056 on auditory comprehension, n=791 on naming and n=974 on functional-communication. Younger age ( Conclusions: Earlier intervention for poststroke aphasia was crucial to maximize language recovery across a range of language domains, although recovery continued to be observed to a lesser extent beyond 6 months poststroke.

Background To allow for accurate and timely diagnosis of developmental coordination disorder (DCD) key stakeholders must be familiar with and be able to identify features of this disorder. No studies to date have investigated the awareness of DCD among key stakeholders in Australia. Methods An online survey was complete by 494 Australian participants: primary caregivers (n = 153), teachers (n = 149), allied health professionals (n = 165) and medical professionals (n = 27). Results DCD and related terms were among the least known childhood disorders. Approximately half of the sample were familiar with the term DCD but every stakeholder group were more familiar with the term dyspraxia. Allied health professionals demonstrated greater knowledge of the features of DCD, particularly motor features. Every stakeholder group showed poor recognition of the social and psychological effects of DCD. A relatively low percentage of allied health (53%) and medical (33%) professionals reported they had identified or diagnosed DCD and less than 20% of these felt that the DSM‐5 contained adequate information to make a DCD diagnosis. Most teachers (82%) believed they should play a role in identifying early warning signs of this disorder, and 80% believed there are children in the school system who were labelled as lazy or defiant when they have motor skills impairments. Primary caregivers were supportive of a diagnosis of DCD being provided; however, only 16% were confident that a physician would provide an accurate and timely diagnosis. Conclusion Key stakeholders play a unique and important role in the identification of children with DCD. Though most participants acknowledge the role that they play, all stakeholder groups demonstrated poor familiarity with the term DCD and low levels of knowledge about the features of this disorder. Improved familiarity and knowledge of the disorder is needed for access to appropriate services and improved long‐term outcomes for this condition.

Background Aboriginal Australians are known to suffer high levels of acquired brain injury (stroke and traumatic brain injury) yet experience significant barriers in accessing rehabilitation services. The aim of the Healing Right Way trial is to evaluate a culturally secure intervention for Aboriginal people with newly acquired brain injury to improve their rehabilitation experience and quality of life. Following publication of the trial protocol, this paper outlines the statistical analysis plan prior to locking the database. Methods The trial involves a stepped wedge design with four steps over 3 years. Participants were 108 adult Aboriginal Australians admitted to one of eight hospitals (four rural, four urban) in Western Australia within 6 weeks of onset of a new stroke or traumatic brain injury who consented to follow-up for 26 weeks. All hospital sites started in a control phase, with the intervention assigned to pairs of sites (one metropolitan, one rural) every 26 weeks until all sites received the intervention. The two-component intervention involves training in culturally safe care for hospital sites and enhanced support provided to participants by Aboriginal Brain Injury Coordinators during their hospital stay and after discharge. The primary outcome is quality of life as measured by the Euro QOL–5D-3L VAS. A mixed effects linear regression model will be used to assess the between-group difference at 26 weeks post-injury. The model will control for injury type and severity, age at recruitment and time since commencement of the trial, as fixed effects. Recruitment site and participant will be included as random effects. Secondary outcomes include measurements of function, independence, anxiety and depression, carer strain, allied health occasions of service received and hospital compliance with minimum processes of care based on clinical guidelines and best practice models of care. Discussion The trial will provide the first data surrounding the effectiveness of an intervention package for Aboriginal people with brain injury and inform future planning of rehabilitation services for this population. The statistical analysis plan outlines the analyses to be undertaken. Trial registration Australia New Zealand Clinical Trials Registry ACTRN12618000139279. Registered 30 January, 2018.

Continued growth in the number of published clinical studies has necessitated changes to the way evidence-based resources such as clinical guidelines are developed and updated. The Australian and New Zealand Clinical Guidelines for Stroke Management (https://informme.org.au/guidelines/clinical-guidelines-for-stroke-management) are based on continual evidence surveillance and timely updates to recommendations as new research is published. In this article, we outline the main updates to recommendations since the guidelines moved into a living mode in 2018, and discuss key challenges and benefits of living guidelines.

To describe the development and determine the diagnostic accuracy of the Brisbane Evidence-Based Language Test in detecting aphasia. Consecutive acute stroke admissions ( = 100; mean = 66.49y) participated in a single (assessor) blinded cross-sectional study. Index assessment was the ∼45 min Brisbane Evidence-Based Language Test. The Brisbane Evidence-Based Language Test is further divided into four 15-25 min Short Tests: two Foundation Tests (severe impairment), Standard (moderate) and High Level Test (mild). Independent reference standard included the Language Screening Test, Aphasia Screening Test, Comprehensive Aphasia Test and/or Measure for Cognitive-Linguistic Abilities, treating team diagnosis and aphasia referral post-ward discharge. Brisbane Evidence-Based Language Test cut-off score of ≤157 demonstrated 80.8% (LR+ =10.9) sensitivity and 92.6% (LR- =0.21) specificity. All Short Tests reported specificities of ≥92.6%. Foundation Tests I (cut-off ≤61) and II (cut-off ≤51) reported lower sensitivity (≥57.5%) given their focus on severe conditions. The Standard (cut-off ≤90) and High Level Test (cut-off ≤78) reported sensitivities of ≥72.6%. The Brisbane Evidence-Based Language Test is a sensitive assessment of aphasia. Diagnostically, the High Level Test recorded the highest psychometric capabilities of the Short Tests, equivalent to the full Brisbane Evidence-Based Language Test. The test is available for download from brisbanetest.org.Implications for rehabilitationAphasia is a debilitating condition and accurate identification of language disorders is important in healthcare.Language assessment is complex and the accuracy of assessment procedures is dependent upon a variety of factors.The Brisbane Evidence-Based Language Test is a new evidence-based language test specifically designed to adapt to varying patient need, clinical contexts and co-occurring conditions.In this cross-sectional validation study, the Brisbane Evidence-Based Language Test was found to be a sensitive measure for identifying aphasia in stroke.

To examine the inter-rater reliability, intra-rater reliability, internal consistency and practice effects associated with a new test, the Brisbane Evidence-Based Language Test. Reliability estimates were obtained in a repeated-measures design through analysis of clinician video ratings of stroke participants completing the Brisbane Evidence-Based Language Test. Inter-rater reliability was determined by comparing 15 independent clinicians' scores of 15 randomly selected videos. Intra-rater reliability was determined by comparing two clinicians' scores of 35 videos when re-scored after a two-week interval. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect inter-rater reliability (0.995; 95% confidence interval: 0.990-0.998), intra-rater reliability (0.994; 95% confidence interval: 0.989-0.997) and internal consistency (Cronbach's α = 0.940 (95% confidence interval: 0.920-1.0)). Almost perfect correlations (0.998; 95% confidence interval: 0.995-0.999) between face-to-face and video ratings were obtained. The Brisbane Evidence-Based Language Test demonstrates almost perfect inter-rater reliability, intra-rater reliability and internal consistency. High correlation coefficients and narrow confidence intervals demonstrated minimal practice effects with scoring or influence of years of clinical experience on test scores. Almost perfect correlations between face-to-face and video scoring methods indicate these reliability estimates have direct application to everyday practice. The test is available from brisbanetest.org.Implications for RehabilitationThe Brisbane Evidence-Based Language Test is a new measure for the assessment of acquired language disorders.The Brisbane Evidence-Based Language Test demonstrated almost perfect inter-rater reliability, intra-rater reliability and internal consistency.High reliability estimates and narrow confidence intervals indicated that test ratings vary minimally when administered by clinicians of different experience levels, or different levels of familiarity with the new measure.The test is a reliable measure of language performance for use in clinical practice and research.

Aphasia research uses the length of time within rehabilitation sessions as the main measure of dosage. Few papers detail therapeutic ingredients or outline the number of times these were delivered over the treatment period. The present observational study identified therapeutic ingredients in the Very Early Rehabiltiation in SpEech (VERSE) trial and explored the dosage provided using a model of cumulative intervention intensity (CII). Therapists video recorded one therapy session per week and 53 (12%) randomly selected therapy videos were analysed. The videos were coded for number of error productions, self-corrections and type and frequency of therapist cueing. The Western Aphasia Battery Revised-Aphasia Quotient (WABR-AQ) was used for measuring patient outcome with total verbal utterances (

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

Stroke 53(3), 956-967 (2022). doi:10.1161/STROKEAHA.121.035216, Published by Lippincott Williams & Wilkins, Philadelphia, Pa.

Background Patients in hospital following stroke express a desire to continue therapy tasks outside of treatment activities. However, they commonly describe experiences of boredom and inactivity. An enriched environment aims to provide opportunities for physical, cognitive and social activity and informed the development of a Communication Enhanced Environment (CEE) model to promote patient engagement in language activities. Purpose Explore patient perceptions of a CEE model, and barriers and facilitators to engagement in the model. Methods A qualitative description study from a larger project that implemented a CEE model into acute and rehabilitation private hospital wards in Western Australia. Semi-structured interviews were conducted with seven patients, including four with aphasia, within 22 days post-stroke who had access to the CEE model. Results Patients described variable experiences accessing different elements of the CEE model which were influenced by individual patient factors, staff factors, hospital features as well as staff time pressures. Those who were able to access elements of the CEE model described positive opportunities for engagement in language activities. Conclusions While findings are encouraging, further exploration of the feasibility of a CEE model in this complex setting is indicated to inform the development of this intervention.Implications for rehabilitationPatient access to a CEE model is challenging in a hospital setting.Patients who were able to access elements of the CEE model described positive opportunities for engagement in language activities.Patients' access to the CEE model was influenced by patient factors, staff factors, hospital features as well as staff time pressures.

Objectives: Develop and implement a Communication Enhanced Environment model and explore its effect on language activities for patients early after stroke. Method and design: Before-and-after pilot study. Setting: An acute/slow stream rehabilitation and a rehabilitation ward in a private hospital in Perth, Western Australia. Participants: Fourteen patients recruited within 21 days of stroke. Seven recruited during the before-phase (control group: patients with aphasia = 3, patients without aphasia = 4) and seven recruited in the after-phase (intervention group: patients with aphasia = 4, patients without aphasia = 3). Intervention: The intervention group exposed to a Communication Enhanced Environment model had access to equipment, resources, planned social activities and trained communication partners. Both groups received usual stroke care. Data collection: Hospital site champions monitored the availability of the intervention. Behavioural mapping completed during the first minute of each 5-minute interval over 12 hours (between 7 am and 7 pm) determined patient engagement in language activities. Results: Seventy-one percent of the Communication Enhanced Environment model was available to the intervention group who engaged in higher, but not significant (95% CI), levels of language activities (600 of 816 observation time points, 73%) than the control group (551 of 835 observation time points, 66%). Unforeseen reorganisation of the acute ward occurred during the study. Conclusions: Implementation of a Communication Enhanced Environment model was feasible in this specific setting and may potentially influence patients’ engagement in language activities. The unforeseen contextual challenges that occurred during the study period demonstrate the challenging nature of the hospital environment and will be useful in future research planning.

BackgroundWhile meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity.MethodsWe conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs.ResultsWe analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI −0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI −0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI −1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up.ConclusionsCIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses.Trial registration numberACTRN 2615000618550.

A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure - FIM) and lateropulsion severity (Four-Point Pusher Score - 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation.Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005-2018) were analysed using multivariable regression models.Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement.Implications for RehabilitationWhile people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation.Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Background Treatment fidelity is inconsistently reported in aphasia research, contributing to uncertainty about the effectiveness of types of aphasia therapy following stroke. We outline the processes and outcomes of treatment fidelity monitoring in a pre-specified secondary analysis of the VERSE trial. Methods VERSE was a 3-arm, single-blinded RCT with a 12-week primary endpoint comparing Usual Care (UC) to two higher intensity treatments: Usual Care-Plus (UC-Plus) and VERSE, a prescribed intervention. Primary outcome results were previously reported. This secondary analysis focused on treatment fidelity. Video-recorded treatment sessions in the higher intensity study arms were evaluated for treatment adherence and treatment differentiation. Treatment components were evaluated using a pre-determined fidelity checklist. Primary outcome: prescribed amount of therapy time (minutes); secondary outcomes: (i) adherence to therapy protocol (%) and (ii) treatment differentiation between control and high intensity groups. Results Two hundred forty-six participants were randomised to Usual Care (n=81), Usual Care-Plus (n=82), and VERSE (n=83). One hundred thirty-five (82%) participants in higher intensity intervention arms received the minimum prescribed therapy minutes. From 10,805 (UC 7787; UC-Plus 1450; VERSE 1568) service events, 431 treatment protocol deviations were noted in 114 participants. Four hundred thirty-seven videos were evaluated. The VERSE therapists achieved over 84% adherence to key protocol elements. Higher stroke and aphasia severity, older age, and being in the UC-Plus group predicted more treatment deviations. Conclusions We found high levels of treatment adherence and differentiation between the intervention arms, providing greater confidence interpreting our results. The comprehensive systems for intervention fidelity monitoring and reporting in this trial make an important contribution to aphasia research and, we argue, should set a new standard for future aphasia studies. Trial registration ACTRN 12613000776707

Rationale The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown. Aims and hypotheses In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia. Sample size estimates A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05. Methods and design Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and stratified randomization by aphasia severity (mild, moderate, and severe), to 3 arms: CIAT-Plus, M-MAT (both 30 h therapy over two weeks); UC (self-reported usual community care). Study outcomes WAB-R-AQ immediately post-intervention. Secondary outcomes: WAB-R-AQ at 12-week follow-up; naming scores, discourse measures, Communicative Effectiveness Index, Scenario Test, and Stroke and Aphasia Quality of Life Scale-39 g immediately and at 12 weeks post-intervention; incremental cost-effectiveness ratios compared with UC at 12 weeks. Discussion This trial will determine whether CIAT-Plus and M-MAT are superior and more cost-effective than UC in chronic aphasia. Participant subgroups with the greatest response to CIAT-Plus and M-MAT will be described.

Background While high-quality meta-analyses have confirmed the effectiveness of aphasia therapy after stroke, there is limited evidence for the comparative effectiveness of different aphasia interventions. Two commonly used interventions, Constraint-induced Aphasia Therapy Plus (CIAT Plus) and Multi-modality Aphasia Therapy (M-MAT), are hypothesised to rely on diverse underlying neural mechanisms for recovery and may be differentially responsive to aphasia severity. COMPARE is a prospective randomised open-blinded end-point trial designed to determine whether, in people with chronic post-stroke aphasia living in the community, CIAT Plus and M-MAT provide greater therapeutic benefit compared to usual care, are differentially effective according to aphasia severity, and are cost-effective. This paper details the statistical analysis plan for the COMPARE trial developed prior to data analysis. Methods Participants (n = 216) are randomised to one of three arms, CIAT Plus, M-MAT or usual care, and undertake therapy with a study trained speech pathologist in groups of three participants stratified by aphasia severity. Therapy occurs for 3 h blocks per day for 10 days across 2 weeks. The primary clinical outcome is aphasia severity as measured by the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ) immediately post intervention. Secondary outcomes include WAB-R-AQ at 12-week follow-up, and functional communication, discourse efficiency, multimodal communication, and health-related quality of life immediately post intervention and at 12-week follow-up. Results Linear mixed models (LMMs) will be used to analyse differences between M-MAT and UC, and CIAT-Plus and UC on each outcome measure immediately and at 12 weeks post-intervention. The LMM for WAB-R-AQ will assess the differences in efficacy between M-MAT and CIAT-Plus. All analyses will control for baseline aphasia severity (fixed effect) and for the clustering effect of treatment groups (random effect). Discussion This trial will provide relative effectiveness data for two common interventions for people with chronic post-stroke aphasia, and highlight possible differential effects based on aphasia severity. Together with the health economic analysis data, the results will enable more informed personalised prescription for aphasia therapy after stroke. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN 12615000618550. Registered on 15 June 2016

Background: Contraversive lateropulsion is a common post-stroke impairment. Rehabilitation outcomes in stroke survivors exhibiting lateropulsion may differ from those without lateropulsion.Objectives: To systematically review evidence regarding associations between:1. Presence/severity of lateropulsion after stroke and functional outcome, rehabilitation length of stay, and discharge destination;2. Stroke-related factors and resolution of lateropulsion, functional outcome, rehabilitation length of stay, and discharge destination in affected stroke survivors.Methods: Medline, CINAHL, and Embase databases were searched. Journal articles published in English reporting on resolution of lateropulsion, length of stay, functional outcome, and/or discharge destination associated with post-stroke lateropulsion were included for review. Studies that did not include a comparison group (stroke survivors without lateropulsion, or sub-groups of participants with lateropulsion based on stroke-related factors), animal studies, and studies reporting only on ipsiversive lateropulsion and/or lateral medullary syndrome were excluded. Two authors independently assessed studies for inclusion. Included studies were evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies.Results: Screening identified 133 articles. Seven articles met inclusion criteria. People with contraversive lateropulsion after stroke can achieve similar improvements in function as those without lateropulsion, increasing likelihood of discharge home, but require longer rehabilitation durations to do so.Conclusions: The finding that longer rehabilitation durations are required for people with post-stroke lateropulsion to achieve their functional potential and increase likelihood of discharge home has implications for resourcing rehabilitation services. Given an additional three to four weeks in rehabilitation, people with post-stroke lateropulsion can achieve functional improvements function similar to those without lateropulsion.

Dose articulation is a universal issue of intervention development and testing. In stroke recovery, dose of a nonpharmaceutical intervention appears to influence outcome but is often poorly reported. The challenges of articulating dose in nonpharmacological stroke recovery research include: (1) the absence of specific internationally agreed dose reporting guidelines; (2) inadequate conceptualization of dose, which is multidimensional; and (3) unclear and inconsistent terminology that incorporates the multiple dose dimensions. To address these challenges, we need a well-conceptualized and consistent approach to dose articulation that can be applied across stroke recovery domains to stimulate critical thinking about dose during intervention development, as well as promote reporting of planned intervention dose versus actually delivered dose. We followed the Design Research Paradigm to develop a framework that guides how to articulate dose, conceptualizes the multidimensional nature and systemic linkages between dose dimensions, and provides reference terminology for the field. Our framework recognizes that dose is multidimensional and comprised of a duration of days that contain individual sessions and episodes that can be active (time on task) or inactive (time off task), and each individual episode can be made up of information about length, intensity, and difficulty. Clinical utility of this framework was demonstrated via hypothetical application to preclinical and clinical domains of stroke recovery. The suitability of the framework to address dose articulation challenges was confirmed with an international expert advisory group. This novel framework provides a pathway for better articulation of nonpharmacological dose that will enable transparent and accurate description, implementation, monitoring, and reporting, in stroke recovery research.

Background Effectiveness of early intensive aphasia rehabilitation after stroke is unknown. The Very Early Rehabilitation for SpEech trial (VERSE) aimed to determine whether intensive aphasia therapy, beginning within 14 days after stroke, improved communication recovery compared to usual care. Methods Prospective, randomized, single-blinded trial conducted at 17 acute-care hospitals across Australia/New Zealand from 2014 to 2018. Participants with aphasia following acute stroke were randomized to receive usual care (direct usual care aphasia therapy), or one of two higher intensity regimens (20 sessions of either non-prescribed (usual care-plus or prescribed (VERSE) direct aphasia therapy). The primary outcome was improvement of communication on the Western Aphasia Battery-Revised Aphasia Quotient (AQ) at 12 weeks after stroke. Our pre-planned intention to treat analysis combined high intensity groups for the primary outcome. Findings Among 13,654 acute stroke patients screened, 25% (3477) had aphasia, of whom 25% (866) were eligible and 246 randomized to usual care ( n = 81; 33%), usual care-plus ( n = 82; 33%) or VERSE ( n = 83; 34%). At 12 weeks after stroke, the primary outcome was assessed in 217 participants (88%); 14 had died, 9 had withdrawn, and 6 were too unwell for assessment. Communication recovery was 50.3% (95% CI 45.7–54.8) in the high intensity group ( n = 147) and 52.1% (95% CI 46.1–58.1) in the usual care group ( n = 70; difference −1.8, 95% CI −8.7–5.0). There was no difference between groups in non-fatal or fatal adverse events ( p = 0.72). Interpretation Early, intensive aphasia therapy did not improve communication recovery within 12 weeks post stroke compared to usual care.

IntroductionDespite higher incidence of brain injury among Aboriginal compared with non-Aboriginal Australians, suboptimal engagement exists between rehabilitation services and Aboriginal brain injury survivors. Aboriginal patients often feel culturally insecure in hospital and navigation of services post discharge is complex. Health professionals report feeling ill-equipped working with Aboriginal patients. This study will test the impact of a research-informed culturally secure intervention model for Aboriginal people with brain injury.Methods and analysisDesign:Stepped wedge cluster randomised control trial design; intervention sequentially introduced at four pairs of healthcare sites across Western Australia at 26-week intervals.Recruitment:Aboriginal participants aged ≥18 years within 4 weeks of an acute stroke or traumatic brain injury.Intervention:(1) Cultural security training for hospital staff and (2) local, trial-specific, Aboriginal Brain Injury Coordinators supporting participants.Primary outcome: Quality-of-life using EuroQOL-5D-3L (European Quality of Life scale, five dimensions, three severity levels) Visual Analogue Scale score at 26 weeks post injury. Recruitment of 312 participants is estimated to detect a difference of 15 points with 80% power at the 5% significance level. A linear mixed model will be used to assess the between-condition difference.Secondary outcome measures: Modified Rankin Scale, Functional Independence Measure, Modified Caregiver Strain Index, Hospital Anxiety and Depression Scale at 12 and 26 weeks post injury, rehabilitation occasions of service received, hospital compliance with minimum care processes by 26 weeks post injury, acceptability of Intervention Package, feasibility of Aboriginal Brain Injury Coordinator role.Evaluations: An economic evaluation will determine the potential cost-effectiveness of the intervention. Process evaluation will document fidelity to study processes and capture changing contexts including barriers to intervention implementation and acceptability/feasibility of the intervention through participant questionnaires at 12 and 26 weeks.Ethics and disseminationThe study has approvals from Aboriginal, university and health services human research ethics committees. Findings will be disseminated through stakeholder reports, participant workshops, peer-reviewed journal articles and conference papers.Trial registration numberACTRN12618000139279.

ObjectivesTo explore barriers and facilitators to patient communication in an acute and rehabilitation ward setting from the perspectives of hospital staff, volunteers and patients following stroke.DesignA qualitative descriptive study as part of a larger study which aimed to develop and test a Communication Enhanced Environment model in an acute and a rehabilitation ward.SettingA metropolitan Australian private hospital.ParticipantsFocus groups with acute and rehabilitation doctors, nurses, allied health staff and volunteers (n=51), and interviews with patients following stroke (n=7), including three with aphasia, were conducted.ResultsThe key themes related to barriers and facilitators to communication, contained subcategories related to hospital, staff and patient factors. Hospital-related barriers to communication were private rooms, mixed wards, the physical hospital environment, hospital policies, the power imbalance between staff and patients, and task-specific communication. Staff-related barriers to communication were staff perception of time pressures, underutilisation of available resources, staff individual factors such as personality, role perception and lack of knowledge and skills regarding communication strategies. The patient-related barrier to communication involved patients’ functional and medical status. Hospital-related facilitators to communication were shared rooms/co-location of patients, visitors and volunteers. Staff-related facilitators to communication were utilisation of resources, speech pathology support, staff knowledge and utilisation of communication strategies, and individual staff factors such as personality. No patient-related facilitators to communication were reported by staff, volunteers or patients.ConclusionsBarriers and facilitators to communication appeared to interconnect with potential to influence one another. This suggests communication access may vary between patients within the same setting. Practical changes may promote communication opportunities for patients in hospital early after stroke such as access to areas for patient co-location as well as areas for privacy, encouraging visitors, enhancing patient autonomy, and providing communication-trained health staff and volunteers.

Inclusion Body Myositis (IBM) is the most common acquired myopathy in older individuals with more than two thirds of patients experiencing impaired swallowing. There are currently no standardized exercise therapies to improve or sustain swallowing despite good evidence for exercise therapy in limb muscles. Reduced upper esophageal sphincter opening is a common abnormality associated with dysphagia in IBM. This pilot study recruited IBM patients with abnormal upper esophageal sphincter function and dysphagia into an exercise program. It was hypothesized that regular practice using the Expiratory Muscle Strength Trainer (EMST) device would improve hyolaryngeal movement by strengthening suprahyoid musculature and facilitate opening of the upper esophageal sphincter thereby improving swallowing and quality of life. Overall, IBM patients who used the EMST device demonstrated no improvement in swallowing function. Consistent with that result, there was also no change in measures of quality of life. However, further studies are needed to elucidate whether it has a preventative role in the development or progression of dysphagia in IBM as there is a suggestion that patients with a shorter duration of disease may have had some benefit. This research provides pilot data and recommendations that will guide future studies on exercise therapy and swallowing in this area.

Background Limited evidence exists to support very early intensive aphasia rehabilitation after stroke. VERSE is a PROBE trial designed to determine whether two types of intensive aphasia therapy, beginning within 14 days of acute stroke, provide greater therapeutic and cost-effectiveness than usual care. Objective To publish the detailed statistical analysis plan for the VERSE trial prior to unblinding. This statistical analysis plan was based on the published and registered VERSE trial protocol and was developed by the blinded steering committee and management team, led by the trial statistician. This plan was developed using outcome measures and trial data collection forms. Results The VERSE statistical analysis plan is consistent with reporting standards for clinical trials and provides for clear and open reporting. Conclusions Publication of a statistical analysis plan serves to reduce potential trial reporting bias and outlines transparent pre-specified analyses. Australian New Zealand Clinical Trials Registry (ANZCTR) Registration number: ACTRN12613000776707; Universal Trial Number (UTN) is U1111-1145-4130.

Background and purpose Accurate aphasia diagnosis is important in stroke care. A wide range of language tests are available and include informal assessments, tests developed by healthcare institutions and commercially published tests available for purchase in pre-packaged kits. The psychometrics of these tests are often reported online or within the purchased test manuals, not the peer-reviewed literature, therefore the diagnostic capabilities of these measures have not been systematically evaluated. This review aimed to identify both commercial and non-commercial language tests and tests used in stroke care and to examine the diagnostic capabilities of all identified measures in diagnosing aphasia in stroke populations. Methods Language tests were identified through a systematic search of 161 publisher databases, professional and resource websites and language tests reported to be used in stroke care. Two independent reviewers evaluated test manuals or associated resources for cohort or cross-sectional studies reporting the tests’ diagnostic capabilities (sensitivity, specificity, likelihood ratios or diagnostic odds ratios) in differentiating aphasic and non-aphasic stroke populations. Results Fifty-six tests met the study eligibility criteria. Six “non-specialist” brief screening tests reported sensitivity and specificity information, however none of these measures reported to meet the specific diagnostic needs of speech pathologists. The 50 remaining measures either did not report validity data (n = 7); did not compare patient test performance with a comparison group (n = 17); included non-stroke participants within their samples (n = 23) or did not compare stroke patient performance against a language reference standard (n = 3). Diagnostic sensitivity analysis was completed for six speech pathology measures (WAB, PICA, CADL-2, ASHA-FACS, Adult FAVRES and EFA-4), however all studies compared aphasic performance with that of non-stroke healthy controls and were consequently excluded from the review. Conclusions No speech pathology test was found which reported diagnostic data for identifying aphasia in stroke populations. A diagnostically validated post-stroke aphasia test is needed.

Purpose of review: \ud Early rehabilitation is recommended in many guidelines, with limited evidence to guide practice. Brain\ud neurobiology suggests that early training, at the right dose, will aid recovery. In this review, we highlight\ud recent trials of early mobilization, aphasia, dysphagia and upper limb treatment in which intervention is\ud commenced within 7 days of stroke and discuss future research directions.\ud Recent findings: \ud Trials in this early time window are few. Although the seminal AVERT trial suggests that a cautious\ud approach is necessary immediately (

This article examines the ways in which individuals with aphasia communicate opinions and feelings using evaluative language during conversation in an aphasia group. Evaluative language refers to semantic resources conveying emotions, judgments, and valuations and includes emotive adjectives, nouns, verbs, and adverbs as well as metaphor. Although individuals with aphasia are known to be able to use evaluative language in a monologic context, little is known about how people with aphasia use evaluative language in conversation, or about the role of co-construction in such usage. The data for this study were collected during a conversation group consisting of five participants with aphasia and a facilitator. The analysis used is based on Appraisal theory (Martin and White 2005) and examined the evaluation categories of Affect, Appreciation, Judgment, and Graduation. Regardless of severity, all aphasic speakers contributed an equal amount of evaluation to the interaction and demonstrated some usage of all types of evaluation. However, those with more severe aphasia relied heavily on their conversational partners to scaffold their opinions and used a range of resources including lexical items, such as exactly, and repetition (e.g., "yeah yeah yeah") to agree emphatically with opinions expressed. Lexical variety was notably less in the aphasic speakers than the non-brain-damaged group facilitator. The article discusses the patterns of skills observed together with the clinical implications for working with people with aphasia on emotional meanings.

Rationale The efficacy of rehabilitation therapy for aphasia caused by stroke is uncertain. Aims and hypothesis The Very Early Rehabilitation of Speech (VERSE) trial aims to determine if intensive prescribed aphasia therapy (VERSE) is more effective and cost saving than non-prescribed, intensive (usual care-plus) and non-intensive usual care (UC) therapy when started within 15 days of stroke onset and continued daily over four weeks. We hypothesize that aphasia therapy when started very early after stroke and delivered daily could enhance recovery of communication compared with UC. Sample size estimates A total of 246 participants (82 per arm) will provide 80% power to detect a 4.4% improvement on aphasia quotient between VERSE and UC plus at a significance level of α = 0.05. Setting Acute-care hospitals and accompanying rehabilitation services throughout Australia, 2014–2017. Design Three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment (PROBE) trial. Participants Acute stroke in previous 14 days and aphasia diagnosed by aphasia quotient (AQ) of the Western Aphasia Battery (WAB). Randomization Computer-generated blocked randomization procedure stratified by aphasia severity according to Western Aphasia Battery, to one of three arms. Intervention All participants receive UC—usual ward-based aphasia therapy. Arm 1: UC—no additional therapy; Arm 2: UC-plus usual ward-based therapy; Arm 3: VERSE therapy—a prescribed and structured aphasia therapy program. Arms 2 and 3 receive a total of 20 additional sessions (45–60 min, provided daily) of aphasia therapy. The additional intervention must be provided before day 50 post stroke. Study outcome measures The aphasia quotient of Western Aphasia Battery at 12 weeks post stroke. Secondary outcomes include discourse measures, the Stroke and Aphasia Quality of Life Scale-39 and the Aphasia Depression Rating Scale at 12 and 26 weeks. Economic evaluation Incremental cost-effectiveness ratios at 26 weeks will be reported. Discussion This trial is designed to test whether the intensive and prescribed VERSE intervention is effective in promoting maximum recovery and preventing costly health complications in a vulnerable population of survivors of stroke. It will also provide novel, prospective, aphasia specific cost-effectiveness data to guide future policy development for this population.

Very early aphasia rehabilitation studies have shown mixed results. Differences in therapy intensity and therapy type contribute significantly to the equivocal results.To compare a standardized, prescribed very early aphasia therapy regimen with a historical usual care control group at therapy completion (4-5 weeks post-stroke) and again at follow-up (6 months).This study compared two cohorts from successive studies conducted in four Australian acute/sub-acute hospitals. The studies had near identical recruitment, blinded assessment and data-collection protocols. The Very Early Rehabilitation (VER) cohort (N = 20) had mild-severe aphasia and received up to 20 1-h sessions of impairment-based aphasia therapy, up to 5 weeks. The control cohort (n = 27) also had mild-severe aphasia and received usual care (UC) therapy for up to 4 weeks post-stroke. The primary outcome measure was the Aphasia Quotient (AQ) and a measure of communicative efficiency (DA) at therapy completion. Outcomes were measured at baseline, therapy completion and 6 months post-stroke and were compared using Generalised Estimating Equations (GEE) models.After controlling for initial aphasia and stroke disability, the GEE models demonstrated that at the primary end-point participants receiving VER achieved 18% greater recovery on the AQ and 1.5% higher DA scores than those in the control cohort. At 6 months, the VER participants maintained a 16% advantage in recovery on the AQ and 0.6% more on DA scores over the control cohort participants.A prescribed, impairment-based aphasia therapy regimen, provided daily in very early post-stroke recovery, resulted in significantly greater communication gains in people with mild-severe aphasia at completion of therapy and at 6 months, when compared with a historical control cohort. Further research is required to demonstrate large-scale and long-term efficacy.

Background and Aim The effects of very early aphasia therapy on recovery are equivocal. This article examines predictors of very early aphasia recovery through statistical modeling. Methods This study involved a secondary analysis of merged data from two randomized, single-blind trials conducted in Australian acute and subacute hospitals. Study 1 ( n = 59) compared daily therapy to usual ward care for up to 4 weeks poststroke in patients with moderate to severe aphasia. Study 2 ( n = 20) compared daily group therapy to daily individual therapy for 20 1-hour sessions over 5 weeks, in patients with mild to severe aphasia. The primary outcome measure was the Western Aphasia Battery Aphasia Quotient (AQ) at therapy completion. This analysis used regression modeling to examine the effects of age, baseline AQ and baseline modified Rankin Scale (mRS), average therapy amount, therapy intensity, and number of therapy sessions on aphasia recovery. Results Baseline AQ ( p = 0.047), average therapy amount ( p = 0.030), and baseline mRS ( p = 0.043) were significant predictors in the final regression model, which explained 30% ( p Conclusion The amount of very early aphasia therapy could significantly affect communication outcomes at 4 to 5 weeks poststroke. Further studies should include amount of therapy provided to enhance reliability of prognostic modeling in aphasia recovery.

Background and purpose Early stroke rehabilitation has shown benefits over spontaneous recovery. Insufficient evidence exists to determine the benefits of early aphasia intervention. We hypothesized that daily aphasia therapy would show better communication outcomes than usual care (UC) in early poststroke recovery. Method This prospective, randomized, single-blinded, controlled trial was conducted in three acute-care hospitals in Perth, Australia, each with over 200 stroke admissions annually. Patients with acute stroke causing moderate to severe aphasia were recruited at a median of three-days (range: 0–10 days) to receive daily aphasia therapy or usual care therapy. Individually tailored, impairment-based intervention was provided for the acute hospital stay or intervention phase (median: 19 days; range: 5–76). Primary outcome measures were the aphasia quotient and functional communication profile at acute hospital discharge or four-weeks poststroke, whichever came first. A random-number generator and sealed envelopes were used to randomize participants. Assessments were completed by a blinded assessor. Results Fifty-nine participants were recruited, with six withdrawals (10%) and seven deaths (12%) at six-months. Ninety percent had ischemic strokes, with 56·5% experiencing a total anterior circulation stroke. The group mean (±SD) age was 69·1 (±13·9) years. Six participants (18·75%) in the daily aphasia therapy group did not complete the minimum (150 min) therapy required for this study. The daily aphasia therapy intervention phase mean therapy session time was 45 min (range: 30–80) and the total mean amount of therapy for the daily aphasia therapy participants was 331 min (range: 30–1415). Four (15%) participants in the usual care group received therapy. The collective total therapy provided to these participants was 295 min over seven sessions. Usual care participants received an average of 10·5 min of therapy per week during the intervention phase. At the primary end point, a generalized estimating equations model demonstrated that after controlling for initial aphasia severity, participants receiving daily aphasia therapy scored 15·1 more points ( P = 0·010) on the aphasia quotient and 11·3 more points ( P = 0·004) on the functional communication profile than those receiving usual care therapy. Conclusions Daily aphasia therapy in very early stroke recovery improved communication outcomes in people with moderate to severe aphasia.

Objectives To develop and validate a national set of best practice statements for use in post-stroke aphasia rehabilitation. Design Literature review and statement validation using the RAND/UCLA Appropriateness Method (RAM). Participants A national Community of Practice of over 250 speech pathologists, researchers, consumers and policymakers developed a framework consisting of eight areas of care in aphasia rehabilitation. This framework provided the structure for the development of a care pathway containing aphasia rehabilitation best practice statements. Nine speech pathologists with expertise in aphasia rehabilitation participated in two rounds of RAND/UCLA appropriateness ratings of the statements. Panellists consisted of researchers, service managers, clinicians and policymakers. Main outcome measures Statements that achieved a high level of agreement and an overall median score of 7–9 on a nine-point scale were rated as ‘appropriate’. Results 74 best practice statements were extracted from the literature and rated across eight areas of care (eg, receiving the right referrals, providing intervention). At the end of Round 1, 71 of the 74 statements were rated as appropriate, no statements were rated as inappropriate, and three statements were rated as uncertain. All 74 statements were then rated again in the face-to-face second round. 16 statements were added through splitting existing items or adding new statements. Seven statements were deleted leaving 83 statements. Agreement was reached for 82 of the final 83 statements. Conclusions This national set of 82 best practice statements across eight care areas for the rehabilitation of people with aphasia is the first to be validated by an expert panel. These statements form a crucial component of the Australian Aphasia Rehabilitation Pathway (AARP) (http://www.aphasiapathway.com.au) and provide the basis for more consistent implementation of evidence-based practice in stroke rehabilitation.