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Background: Evidence-based recommendations for a core outcome set (COS; minimum set of outcomes) for aphasia treatment research have been developed (the Research Outcome Measurement in Aphasia--ROMA, COS). Five recommended core outcome constructs: communication, language, quality of life, emotional well-being and patient-reported satisfaction/impact of treatment, were identified through three international consensus studies. Constructs were paired with outcome measurement instruments (OMIs) during an international consensus meeting (ROMA-1). Before the current study (ROMA-2), agreement had not been reached on OMIs for the constructs of communication or patient-reported satisfaction/impact of treatment. Aim: To establish consensus on a communication OMI for inclusion in the ROMA COS. Methods & Procedures: Research methods were based on recommendations from the Core Outcome Measures in Effectiveness Trials (COMET) Initiative. Participants with expertise in design and conduct of aphasia trials, measurement instrument development/testing and/or communication outcome measurement were recruited through an open call. Before the consensus meeting, participants agreed on a definition of communication, identified appropriate OMIs, extracted their measurement properties and established criteria for their quality assessment. During the consensus meeting they short-listed OMIs and participants without conflicts of interest voted on the two most highly ranked instruments. Consensus was defined a priori as agreement by [greater than or equal to] 70% of participants. Outcomes & Results: In total, 40 researchers from nine countries participated in ROMA-2 (including four facilitators and three-panel members who participated in pre-meeting activities only). A total of 20 OMIs were identified and evaluated. Eight short-listed communication measures were further evaluated for their measurement properties and ranked. Participants in the consensus meeting (n = 33) who did not have conflicts of interest (n = 29) voted on the top two ranked OMIs: The Scenario Test (TST) and the Communication Activities of Daily Living--3 (CADL-3). TST received 72% (n = 21) of 'yes' votes and the CADL-3 received 28% (n = 8) of 'yes' votes. Conclusions & Implications: Consensus was achieved that TST was the preferred communication OMI for inclusion in the ROMA COS. It is currently available in the original Dutch version and has been adapted into English, German and Greek. Further consideration must be given to the best way to measure communication in people with mild aphasia. Development of a patient-reported measure for satisfaction with/impact of treatment and multilingual versions of all OMIs of the COS is still required. Implementation of the ROMA COS would improve research outcome measurement and the quality, relevance, transparency, replicability and efficiency of aphasia treatment research.

This paper presents a review of the existing qualitative research literature concerning people's experience of communicating using augmentative and alternative communication (AAC). The aims of conducting this review were to find out more about the values and outcomes that are important to people about the AAC they use to support their communication. This review was conducted to provide a deeper understanding of these experiences to inform the development of a patient-reported outcome measure (PROM). A qualitative evidence synthesis of existing qualitative research literature was undertaken to explore and appraise current knowledge about the experiences of people who use AAC. From 115 qualitative research reports 19 papers were identified that responded directly to the research question and aims of the review. Data were identified that could be organized within an a priori framework consisting of the constructs of values, outcomes, and context. The review has resulted in a deeper, analytical understanding of the experiences of people who require AAC. The results indicate a set of concepts that can be used to inform the development of a PROM. A PROM can be used to assist clinicians and researchers to better understand the perspectives of people who require AAC and evaluate interventions. The results also encourage professionals to reconsider the terminology and methods used when working alongside people who require AAC and to reflect on the multidimensional factors that influence people's experience of communication. Patient-reported outcome measures (PROMs) can be useful tools to support clinician-patient communication, facilitate shared decision making and establish priorities for rehabilitation. It can be difficult to engage people who have complex communication difficulties in decisions about the important outcomes to them from using augmentative and alternative communication (AAC). This qualitative evidence synthesis provides a deeper understanding of the experiences and perspectives of people who use AAC. The results will be used to inform the development of a PROM which can be used to facilitate shared decision-making, and evaluate AAC interventions from the perspective of the people who use these technologies. [ABSTRACT FROM AUTHOR]

Background: People who have communication difficulties may benefit from using augmentative and alternative communication (AAC). Understanding and measuring outcomes from the use of AAC is an important part of evaluating the impact of devices and services. Outcome measurement needs to reflect the changing nature of the impact of using AAC on an individual's ability to participate in activities of daily life. There is a limited understanding of the concepts that should inform the evaluation of outcomes from AAC device provision, nor how people's expectations from AAC may change over time. Aims: To inform the development of a patient‐reported outcome measure for AAC by understanding more about people's expectations from AAC and how these change over time. Methods & Procedures: A longitudinal qualitative research study was designed and carried out with seven participants over a period of 2 years. Participants were recruited from a regional specialist assessment service for AAC in the south‐west of the UK. Four semi‐structured interviews were carried out: (1) before assessment for AAC, (2) after assessment, (3) directly after provision of an AAC device and (4) between 6 and 12 months after provision. An original analytic method was used in this study that built on the principles of longitudinal interpretative phenomenology analysis, applied with a dialogic theoretical lens. This approach enabled the inclusion of a range of multimodal and embodied data collected to this study and allowed the research team to draw out salient themes across the cohort group while attending to the influence of time and context on experience. Outcomes & Results: The results confirm and extend the three core concepts that were used to guide analysis: changes; contexts; future possibilities. The contextual and temporal influences on outcomes attainable from AAC for this cohort were also identified and illustrated through cross‐case comparison. Deeper, analytic, and conceptual engagement with theory, which was then applied to analysis of the data, provided methodological rigour in the study. The results enhance our understanding of people's hopes and expectations from AAC and how these change over time. Conclusions & Implications: This qualitative longitudinal research study provides new insights into the journeys of people who experience communication disability, and the shifting nature of their sense of identity as they engage with, and learn from using, AAC. The study is significant as it attends to the dynamic nature of experience and how contextual and experiential factors influence people's hopes and expectations from AAC. The paper presents an original application of longitudinal qualitative research methodology with people who use AAC which can be further applied and tested in the field of communication disability research. WHAT THIS PAPER ADDS: What is already known on this subject: We did not know the impact that time has on the concepts that have been identified to represent important outcomes from AAC. The existing concepts used to define outcomes from AAC were not adequately conceptualized to develop a patient‐reported outcome measure. This study sought to extend our knowledge about outcomes from AAC. What this paper adds to the existing knowledge: This study adds to the methodological toolkit available for qualitative inquiry in the field of communication disability research by presenting a longitudinal qualitative research methodology. It adds depth to our understanding of the concepts that underpin outcomes from AAC and highlights the dynamic nature of contexts and how this influences desired outcomes. What are the potential or actual clinical implications of this work?: This longitudinal qualitative research study provides a broader perspective on the experience of getting AAC. It will enable clinicians to better navigate the contextual and transitionary factors that influence people's experience of acquiring AAC devices. The enhanced concepts described will also support clinical conversations that consider the wider facets of communication and what AAC can add to existing communicative tool kits beyond getting a message across. [ABSTRACT FROM AUTHOR]

Background: Aphasia assessment is traditionally divided into formal and informal approaches. Informal assessment is useful in developing a rich understanding of the person with aphasia's performance, e.g., describing performance in the context of real-world activities, and exploring the impact of environmental and/or partner supports upon communication. However, defining 'informal assessment' is problematic and can result in clinical issues including idiosyncratic practices regarding why, when and how to apply informal assessment. Aims: To examine the extent to which the informal assessment literature can guide speech and language therapists (SLTs) in their clinical application of informal assessment for post-stroke aphasia. Methods & Procedures: A scoping review methodology was used. A systematic search of electronic databases (Scopus, Embase, PyscInfo, CINAHL, Ovid Medline and AMED) gave informal assessment references between 2000 and 2017 to which title/abstract and full-text screening against inclusion criteria were applied. Data were extracted from 28 resulting documents using an extraction template with fields based on the review's purpose. Main Contribution: This review examines the informal assessment guidance regarding: rationale; areas of interest for informal assessment; available methods; procedural guidance; documentation; and analytical frameworks. The rationale for using informal assessment included several aspects such as gaining a 'representative' sample of the individual's language. Ten communication areas of interest were found with 13 different assessment methods. The procedural guidance for these methods varied considerably, with the exception of conversation and semi-structured interviewing. Overall, documentation guidance was limited but numerous analytical frameworks were found. Conclusions: Several informal assessment methods are available to SLTs. However, information is mixed regarding when they might be used or how they might be applied in terms of their administration, documentation and analysis.

Background: Therapeutic alliance refers to the interactional and relational processes operating during therapeutic interventions. It has been shown to be a strong determinant of treatment efficacy in psychotherapy, and evidence is emerging from a range of healthcare and medical disciplines to suggest that the construct of therapeutic alliance may in fact be a variable component of treatment outcome, engagement and satisfaction. Although this construct appears to be highly relevant to aphasia rehabilitation, no research to date has attempted to explore this phenomenon and thus consider its potential utility as a mechanism for change. Aims: To explore speech and language therapists' perceptions and experiences of developing and maintaining therapeutic alliances in aphasia rehabilitation post-stroke. Methods & Procedures: Twenty-two, in-depth, semi-structured interviews were conducted with speech and language therapists working with people with aphasia post-stroke. Qualitative data were analysed using inductive thematic analysis. Outcomes & Results: Analysis resulted in the emergence of three overarching themes: laying the groundwork; augmenting cohesion; and contextual shapers. Recognizing personhood, developing shared expectations of therapy and establishing therapeutic ownership were central to laying the groundwork for therapeutic delivery. Augmenting cohesion was perceived to be dependent on the therapists' responsiveness and ability to resolve both conflict and resistance, as part of an ongoing active process. These processes were further moulded by contextual shapers such as the patient's family, relational continuity and organizational drivers. Conclusions & Implications: The findings suggest that therapists used multiple, complex, relational strategies to establish and manage alliances with people with aphasia, which were reliant on a fluid interplay of verbal and non-verbal skills. The data highlight the need for further training to support therapists to forge purposive alliances. Training should develop: therapeutic reflexivity; inclusivity in goal setting, relational strategies; and motivational enhancement techniques. The conceptualization of therapeutic alliance, however, is only provisional. Further research is essential to elucidate the experiences and perceptions of alliance development for people with aphasia undergoing rehabilitation.

Background: The increase in the number of reported conversation partner programmes for conversation partners of people with aphasia demonstrates increased awareness of partner needs and the positive effect of trained partners on the communicative abilities of the person with aphasia. Predominantly small-scale studies describe the effectiveness of conversation partner training (CPT) and how partners perceive this training. The view of partners on this service commission remains largely unknown. Aims: To explore the experiences of partners of people with aphasia with a CPT programme when it was newly introduced into rehabilitation settings. Methods & Procedures: Seventeen partners of people with aphasia were interviewed using a semi-structured format about their experience with Partners of Aphasic Clients Conversation Training (PACT). Transcribed interviews were analysed using qualitative content analysis. Outcomes & Results: Four categories representative of the practical nature and individual tailoring of PACT were identified: engaging with PACT; learning from PACT; reflecting on behaviour and emotions; and experiences with earlier speech and language therapy (SLT). Two themes were identified cutting across all categories: the nature of communication is difficult to grasp; and balancing roles as partner, carer and client. Conclusions & Implications: Partners appreciated the training programme once their initial lack of awareness of the interactive nature of communication had been addressed. SLTs need to be clear about the collaborative nature of conversations and what can be offered within the rehabilitation trajectory to address conversation alongside language training.

Background: Improving email writing in people with aphasia could enhance their ability to communicate, promote interaction and reduce isolation. Spelling therapies have been effective in improving single-word writing. However, there has been limited evidence on how to achieve changes to everyday writing tasks such as email writing in people with aphasia. One potential area that has been largely unexplored in the literature is the potential use of assistive writing technologies, despite some initial evidence that assistive writing software use can lead to qualitative and quantitative improvements to spontaneous writing. Aims: This within-participants case series design study aimed to investigate the effects of using assistive writing software to improve email writing in participants with dysgraphia related to aphasia. Methods & Procedures: Eight participants worked through a hierarchy of writing tasks of increasing complexity within broad topic areas that incorporate the spheres of writing need of the participants: writing for domestic needs, writing for social needs and writing for business/administrative needs. Through completing these tasks, participants had the opportunity to use the various functions of the software, such as predictive writing, word banks and text to speech. Therapy also included training and practice in basic computer and email skills to encourage increased independence. Outcome measures included email skills, keyboard skills, email writing and written picture description tasks, and a perception of disability assessment. Outcomes & Results: Four of the eight participants showed statistically significant improvements to spelling accuracy within emails when using the software. At a group level there was a significant increase in word length with the software; while four participants showed noteworthy changes to the range of word classes used. Enhanced independence in email use and improvements in participants' perceptions of their writing skills were also noted. Conclusions & Implications: This study provided some initial evidence that assistive writing technologies can support people with aphasia in email writing across a range of important performance parameters. However, more research is needed to measure the effects of these technologies on the writing of people with aphasia, and to determine the optimal compensatory mechanisms for specific people given the linguistic-strategic resources they bring to the task of email writing.

Background: Capturing evidence of the effects of therapy within everyday communication is the holy grail of aphasia treatment design and evaluation. Whilst impaired sentence production is a predominant symptom of Broca's-type aphasia, the effects of sentence production therapy on everyday conversation have not been investigated. Given the context-sensitive nature of spoken production by people with aphasia, it is difficult to extrapolate implications for everyday conversation based on results from task-based assessment (such as picture description, story retell or interview). Thus, there are strong theoretical and clinical motivations to investigate generalization from sentence production treatment to everyday conversation. Aims: To evaluate a theoretically driven treatment focused on the language production skills of participants with post-stroke Broca's aphasia and to track outcomes from psycholinguistic assessment tasks to everyday conversation. Methods & Procedures: A case series design was utilized with pragmatic selection of participants with chronic aphasia undergoing the same assessment and treatment procedures. Nine participants with Broca's aphasia and their main conversation partners took part in the study. Treatment was implemented once weekly over 8 weeks and targeted production of basic syntax--two, three and four constituent constructions--through principles of mapping and reduced syntax treatment. Use of different possible exemplars for nouns, particularly pronouns, was trained together with use of both light and heavy verbs. Participants had the opportunity to "top-up" therapy practise by completely a homework task that mirrored the therapy task. Outcomes & Results: Syntactic well-formedness was assessed in samples of constrained sentence production, narrative retell and naturally occurring conversations at baseline, 1 week post-treatment, and 1 month post-treatment. Treatment showed strong direct effects in trained and untrained sentence construction tasks, with some generalization to narrative retell tasks. There was little evidence of change in everyday conversation. Conclusions & Implications: Improvement in language production in constrained assessment tasks may not impact on everyday conversations. Implications for further research are discussed, e.g. the need for bridging interventions between constrained and unconstrained contexts of language production. Clinical implications include the potential to streamline therapy planning and delivery by making use of rich, hybrid therapies to treat individuals with similar symptom profiles but with a range of underlying deficits.

Background: Studies to date in semantic dementia have examined communication in clinical or experimental settings. There is a paucity of research describing the everyday interactional skills and difficulties seen in this condition. Aims: To examine the everyday conversation, at home, of an individual with semantic dementia. Methods & Procedures: A 71-year-old man with semantic dementia and his wife were given a video camera and asked to record natural conversation in the home situation with no researcher present. Recordings were also made in the home environment, with the individual with semantic dementia in conversation with a member of the research team. Conversation analysis was used to transcribe and analyse the data. Recurring features were noted to identify conversational patterns. Outcomes & Results: Analysis demonstrated a repeated practice by the speaker with semantic dementia of acting out a diversity of scenes (enactment). As such, the speaker regularly used direct reported speech along with paralinguistic features (such as pitch and loudness) and non-vocal communication (such as body posture, pointing and facial expression) as an adaptive strategy to communicate with others in conversation. Conclusions & Implications: This case shows that while severe difficulties may be present on neuropsychological assessment, relatively effective communicative strategies may be evident in conversation. A repeated practice of enactment in conversation allowed this individual to act out, or perform what he wanted to say, allowing him to generate a greater level of meaningful communication than his limited vocabulary alone could achieve through describing the events concerned. Such spontaneously acquired adaptive strategies require further attention in both research and clinical settings in semantic dementia and analysis of interaction in this condition, using conversation analysis, may be helpful.

Wernicke's aphasia (WA) is the classical neurological model of comprehension impairment and, as a result, the posterior temporal lobe is assumed to be critical to semantic cognition. This conclusion is potentially confused by (a) the existence of patient groups with semantic impairment following damage to other brain regions (semantic dementia and semantic aphasia) and (b) an ongoing debate about the underlying causes of comprehension impairment in WA. By directly comparing these three patient groups for the first time, we demonstrate that the comprehension impairment in Wernicke's aphasia is best accounted for by dual deficits in acoustic-phonological analysis (associated with pSTG) and semantic cognition (associated with pMTG and angular gyrus). The WA group were impaired on both nonverbal and verbal comprehension assessments consistent with a generalised semantic impairment. This semantic deficit was most similar in nature to that of the semantic aphasia group suggestive of a disruption to semantic control processes. In addition, "only" the WA group showed a strong effect of input modality on comprehension, with accuracy decreasing considerably as acoustic-phonological requirements increased. These results deviate from traditional accounts which emphasise a single impairment and, instead, implicate two deficits underlying the comprehension disorder in WA. (Contains 4 figures and 6 tables.)

When relearning words, patients with semantic dementia (SD) exhibit a characteristic rigidity, including a failure to generalise names to untrained exemplars of trained concepts. This has been attributed to an over-reliance on the medial temporal region which captures information in sparse, non-overlapping and therefore rigid representations. The current study extends previous investigations of SD relearning by re-examining the additional contribution made by the degraded cortical semantic system. The standard relearning protocol was modified by careful selection of foils to show that people with semantic dementia were sometimes able to extend their learning appropriately but that this correct generalisation was minimal (i.e. the patients under-generalised their learning). The revised assessment procedure highlighted the fact that, after relearning, the participants also incorrectly over-generalised the learned label to closely related concepts. It is unlikely that these behaviours would occur if the participants had only formed sparse hippocampal representations. These novel data build on the notion that people with semantic dementia engage both the degraded cortical semantic (neocortex) and the episodic (medial temporal) systems to learn. Because of neocortical damage to the anterior temporal lobes, relearning is disordered with a characteristic pattern of under- and over-generalisation. (Contains 1 table and 4 figures.)

Background: Naming accuracy for nouns and verbs in aphasia can vary across different elicitation contexts, for example, simple picture naming, composite picture description, narratives, and conversation. For some people with aphasia, naming may be more accurate to simple pictures as opposed to naming in spontaneous, connected speech; for others, the opposite pattern may be evident. These differences have, in some instances, been related to word class (for example, noun or verb) as well as aphasia subtype. Given that the aim of picture-naming therapies is to improve word-finding in general, these differences in naming accuracy across contexts may have important implications for the potential functional benefits of picture-naming therapies. Aims: This study aimed to explore single-word therapy for both nouns and verbs, and to answer the following questions. (1) To what extent does an increase in naming accuracy after picture-naming therapy (for both nouns and verbs) predict accurate naming of the same items in less constrained spontaneous connected speech tasks such as composite picture description and retelling of a narrative? (2) Does the word class targeted in therapy (verb or noun) dictate whether there is "carry-over" of the therapy item to connected speech tasks? (3) Does the speed at which the picture is named after therapy predict whether it will also be used appropriately in connected speech tasks? Methods & Procedures: Seven participants with aphasia of varying degrees of severity and subtype took part in ten therapy sessions over five weeks. A set of potentially useful items was collected from control participant accounts of the Cookie Theft Picture Description and the Cinderella Story from the Quantitative Production Analysis. Twenty-four of these words (twelve verbs and twelve nouns) were collated for each participant, on the basis that they had failed to name them in either simple picture naming or connected speech tasks (picture-supported narrative and unsupported retelling of a narrative). These were placed in a larger cohort of verb and noun sets for therapy. Post-therapy assessments examined naming accuracy and speed of target items in single-word picture-naming and naming accuracy in connected speech contexts. Outcomes & Results: There was a step-wise decrement in naming accuracy over the three naming contexts following targeted therapy. Simple pictures elicited the most correct names, followed by picture-supported narratives and lastly unsupported narratives. Picture-naming accuracy significantly predicted naming in the connected speech contexts for the group as a whole. The speed of picture naming after therapy did not predict the extent to which items were named in composite picture description and narrative tasks. Conclusions & Implications: The findings suggest that gains in naming accuracy obtained through picture-naming therapy may generalize to naming of the same items in more linguistically and cognitively demanding connected speech tasks. Demonstrating this generalization is methodologically challenging and the method utilized in this study may serve as one starting point for gathering a larger database in order to answer the question posed by this paper more robustly. (Contains 6 tables and 3 figures.)

Background: Studies from the amnesia literature suggest that errorless learning can produce superior results to errorful learning. However, it was found in a previous investigation by the present authors that errorless and errorful therapy produced equivalent results for patients with aphasic word-finding difficulties. A study in the academic literature of phoneme discrimination learning found that errorful learning produced equivalent results to errorless learning when feedback was given. In the authors' previous study, feedback was available to the participants in the errorful therapy. It is possible, therefore, that this feedback may have improved the results from errorless learning -- thereby reducing an underlying difference between the two techniques. Generally, feedback is thought to aid learning, however, there is little information in the speech therapy literature about this factor. Aims: The present investigation was conducted as a follow-up to authors' original study to compare errorless and errorful therapy for the amelioration of aphasic word-finding difficulties. The second aim was to replicate key findings from the original study: namely, that recognition memory, executive/problem-solving skills and monitoring ability predict immediate and long-term naming improvements but not the participants' remaining language ability. Methods & Procedures: Seven of the original 11 participants took part in a multiple baseline, crossover, case series design. Outcomes & Results: The previous results were replicated: errorless and errorful therapy produced equivalent results immediately post-therapy and at follow-up. There was no effect of omitting feedback--the participants learnt equally well without therapist's feedback about whether or not their response was correct. In addition, executive/problem-solving skills and monitoring ability again predicted immediate naming improvements not language ability. Conclusions: The findings support the view that cognitive abilities and in particular executive function are important contributors to rehabilitation.