LUNA in RCSLT Bulletin (Feb 2019). 

Getting up close and personal in language: LUNA, a novel treatment for discourse in aphasia rehabilitation

A version of this article appeared in the February 2019 edition of Bulletin, the professional Speech and Language Publication of the Royal College of Speech and Language Therapists (UK).

LUNA (Language Underpins Narrative in Aphasia) is a research project that takes an innovative, creative, and empowering approach to supporting people with aphasia to tell personal narratives. This is a new research project at an early stage, and we want as many cliniciansas possible to engage with us from all sectors: NHS, independent practice, voluntary services, and universities.

The importance of discourse

Aphasia is a chronic communication disability and individuals, many years post-onset, still want aphasia rehabilitation. Working on discourse is crucial because discourse is central to everyday communication, and improving everyday communication is the primary aim of aphasia treatment and a priority for people with chronic aphasia (Wallace et al 2017).

The evidence-base and expertise

Achieving improved discourse is a challenge with respect to two of the three pillars of evidence-based practice: scientific research and the clinical expertise of SLTs (the third pillar being patient preferences). The scientific researchin aphasia is largely derived from studies in chronic aphasia, and shows that word and sentence level treatments are effective at these targeted levels(Brady et al 2016), but have minimal to no benefit at the discourse level(Webster et al 2015). This tells us that treatments need to be delivered differently in order to achieve discourse benefits. Effective treatments for discourse are few, and there are concerns about the choice of treatment targets which are frequently derived from experimental stimuli rather than from everyday talk.  In addition to these issues, outcomes are difficult to demonstrate given the complexity of discourse assessment. Recent surveys of the evidence base reveal inconsistent practices and multiple measures, and there is a lack of agreement about which aspects of discourse production to assess, providing no guidance for SLTs for the what or how in conducting analysis (Bryant et al 2016; Pritchard et al 2017).

Turning now to clinical expertise and practice, there are several equally important concerns. In 2017, Bryant and colleagues published the results of an international survey of SLT practice relating to discourse assessment (Bryant et al 2017).  Although the results are not representative of the UK (only 7 UK SLTs participated) they are indicative, and show that SLTs use observation and clinical judgment to assess discourse, typically transcribing without recording, and relying mostly on discourse from picture descriptions in language tests. More formal practices are needed though for accurate diagnoses of strength and deficit in discourse production.  Other surveys investigating aphasia scope of practice more widely, also indicate that SLTs find working with discourse difficult (Rose et al 2014). They report a range of barriers including, a lack of clinical time (for analysis), resources, knowledge and skills, and confidence.  The surveyed SLTs identified training as a way of addressing afore-mentioned barriers, and indicated that the development of new discourse treatments was a research priority.

Proposing a new treatment in aphasia: Language Underpins Narrative in Aphasia (LUNA)

For all these reasons, we developed LUNA, a novel treatment for discourse production in aphasia that addresses word, sentence and discourse levels, using a personal narrative told by the individual both as the discourse for analysisand the stimulus for selecting treatment targets. Multi-level treatments are a very recent development in aphasia (Carragher et al., 2015; Whitworth et al., 2015) and LUNA builds on these to create a new discourse intervention that integrates existing treatments (semantic feature analysis and mapping therapy) with discourse level treatment (story grammar).  A key feature of LUNA is the use of personal narratives to generate all treatment targets and, simultaneously, to address salience, motivation, and identity re-negotiation for individuals with disrupted lives (Shadden & Hagstrom. 2007). Personal narratives are central to everyday communication, and are multi-functional (referential, evaluative, intra- and inter-personal).   LUNA takes a meta-linguistic approach to the treatment of personal narratives, in which participants are taught about their language and given strategies for increased control over their storytelling.

Pilot work successfully supported a grant application to The Stroke Association Rehabilitation and Long Term Care Project Grants Panel, which was funded in September 2017 (https://www.stroke.org.uk/research/can-we-develop-new-language-treatment-improve-everyday-talking-people-aphasia). LUNA is almost 3 years in length, and started May 2018; it has two stages, with end-users (NHS SLTs and people with aphasia) involved from the outset to address future implementation.

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Stage 1 has 4 aims: (1) a theoretical review of language and discourse models, and systematic review of the relevant treatment literature; (2) a UK-wide survey of SLTs’discourse practice; (3) the co-design (with NHS SLTs and people with aphasia as co-designers) of LUNA materials; and (4) delivery of a LUNA training programme to SLTs, to ensure clinically feasible methods are taken through into the next stage of the grant. Stage 2 involves testing the effectiveness of the LUNA therapy experimentally.  This involves two groups of 12 people with aphasia (one group receiving LUNA plus their usual SLT care, the other receiving their usual care only). After the therapy we will conduct participant interviews, and also compare outcomes on quantitative discourse measures and psychosocial state.  The research is developmental, and if we demonstrate that LUNA is feasible, acceptable, and shows promise, it will be scaled up into a larger randomized controlled trial delivered in the NHS.

Whos involved?

LUNA is led by Madeline Cruice and Lucy Dipper at City University of London, with co-investigators Professors Jane Marshall and Nicola Botting (also at City), and Professor Mary Boyle (Montclair State University, New Jersey) and Associate Professor Deborah Hersh (Edith Cowan University, Western Australia). Project staffing includes Dr. Madeleine Pritchard as post-doctoral researcher, and 4 research assistant posts that will be available in late 2019 to undertake assessment and discourse analysis (separate from treating team to ensure blinding). We have a strong co-design team of (1) NHS SLTs: Sukhpreet Aujla, Central London Community Healthcare NHS Trust; Nicole Charles, St George’s University Hospitals NHS Foundation Trust; Helen Day and Simon Grobler, Oxleas NHS Foundation Trust; and Fiona Johnson, Homerton University Hospital NHS Foundation Trust; and (2) people with aphasia:Jan Bannister, Lynn Scarth, Steve Morris, and Varinder Dhaliwal.

With thanks

Last, but by no means least, we would like to take the opportunity to thank our supporters: (1) thank you to the SLT Leads and/or Therapy Managers from 60+ NHS Trusts, who responded to the call for granting study leave support in principle for a team member to participate in Aim 4 LUNA training, we look forward to working with you in summer 2019; and (2) thank you to our many research students who have worked with us over the past 3 years on pilots towards LUNA – Emily Wakefield, Alice Thompson, Emma Rhodes, Alice Gardner, Amy McClean, Jayla Arnold, Ciara O’Gorman, Danielle O’Sullivan, Verity Carver, Jennie O’Grady (winner of the British Aphasiology Society Student Project Prize 2016), Sophie Street, Dimitri Dolor, and Rebecca Brothwood. Your collective interest and commitment has been encouraging and affirming of the need for this research and potential for people with aphasia.

How to get involved

We encourage as many clinicians as possible to engage with the project. You can do this by subscribing https://blogs.city.ac.uk/luna; following @LUNA_Aphasia on Twitter; and emailing luna@city.ac.uk. You can help shape the direction of LUNA, and help us understand and plan how LUNA can be implemented in the NHS in the future. Subscribing to the website will mean you will automatically receive the blog updates, hearing news and updates first hand.

References

  • Brady et al. (2016). Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD000425. Available freely at https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000425.pub4/full.
  • Bryant et al. (2016). Linguistic analysis of discourse in aphasia: A review of the literature. Clinical Linguistics & Phonetics, 30(7), 489-518.
  • Bryant et al. (2017). Clinical use of linguistic discourse analysis for the assessment of language in aphasia. Aphasiology,31(10), 1105-1026.
  • Carragher et al. (2015). Preliminary analysis from a novel treatment targeting the exchange of new information within storytelling for people with nonfluent aphasia and their partners. Aphasiology, 29(11), 1383-1408. Also available freely at http://eprints.uwe.ac.uk/26101/.
  • Pritchard et al. (2017). Reviewing the quality of discourse information measures in aphasia. International Journal of Language and Communication Disorders, 52(6), 689- 732. Also available freely at http://openaccess.city.ac.uk/17105/.
  • Rose et al. (2014). Aphasia rehabilitation in Australia: Current practices, challenge and future directions. International Journal of Speech Language Pathology, 16(2), 169-180.
  • Shadden & Hagstrom (2007). The role of narrative in the life participation approach to aphasia. Topics in Language Disorders, 27(4), 324-388.
  • Wallace et al. (2017). Which outcomes are most important to people with aphasia and their families? An international nominal group technique study framed within the ICF. Disability & Rehabilitation, 39(14), 1364-1379. Also available freely at http://openaccess.city.ac.uk/15003/.
  • Webster et al. (2015). Is it time to stop “fishing”? A review of generalization following aphasia intervention. Aphasiology, 29(11), 1240-1264. Also available freely at https://eprints.ncl.ac.uk/211253.
  • Whitworth et al. (2015). NARNIA: a new twist to an old tale. A pilot RCT to evaluate a multilevel approach to improving discourse in aphasia. Aphasiology, 29(11), 1345-1382.

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