Being deliverable in the NHS is a key facet of LUNA. We know this is no mean feat: discourse analysis is not currently clinically feasible. International research and our own survey data indicate a number of barriers, including SLTs reporting a lack of skills, knowledge, and confidence.

In July 2019, the LUNA team trained 58 eligible UK NHS SLTs across 2 days, in the use of 6 discourse analyses, at word, sentence, and discourse levels.

The training days were an opportunity to face these challenges around discourse analysis head on. We acknowledge that discourse analysis is usually complex, challenging and time consuming. We need analyses which are simpler, more straightforward, and relatively time efficient, so they can be used in everyday practice.

We’ll be looking at how far we got with addressing these challenges in data from the training days, crunched over the coming days and weeks. Tweets and feedback from the day suggest that SLTs enjoyed and got a lot from attending. Here’s a sneak peek:

https://wakelet.com/wake/1d86cb8b-4aff-4639-ac55-a11d7ba375e4

In June, we also reached the end of our LUNA phase 3 codesign process with SLTs, which involved…

• 11 sessions;
• 44 hours;
• 6 months;
• 25 discourse intervention research papers;
• 12 hours alone reviewing and debating different linguistic analyses for the LUNA protocol;
• Countless clinical resources;
• Big discussions around implementation and feasibility.

And, just like the sessions with people with aphasia – rather a lot of collective energy and brainpower.

We’re really looking forward to sharing the outputs from this process (watch out for our Lighting Talk at the British Aphasiology Society Clinical Symposium, and an article in the Stroke Association ‘Stroke News’ Winter edition). In the meantime, here’s some of our highlights from the process, gathered from Twitter:

https://wakelet.com/wake/6b14190a-606b-4a8e-b8e2-d9f23d779771

We’ve reached the end of our LUNA phase 3 codesign process with people with aphasia, which involved…

• 5 sessions;
• 27.5 hours;
• 6 months;
• 25 discourse intervention research papers.

We trialled all the different discourse therapies reported to date; shared countless stories; explored ways of putting together LUNA therapy as a whole in people’s own words, that make sense to them; and used a lot of collective energy and brainpower.

We’re really excited to share the outputs from this process (watch out for our poster at the British Aphasiology Society Clinical Symposium, and an article in the Stroke Association ‘Stroke News’ Winter edition).

In the meantime, we’ve collated our tweet highlights from the process:

https://wakelet.com/wake/cd900d0a-ad63-4340-b057-debaa1e0c9c4 

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.

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.

Who’s 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.

We’ve had two codesign meetings with our four speech and language therapists (SLTs) so far, and wanted to share some reflections on the process, and how valuable it is in the project. And we were hoping that other SLTs around the UK might chip in through the blog or on twitter and respond to our questions.

Real vs. ideal in SLT

In session 1, we invited our SLTs to reflect on the real and the ideal in the therapeutic process. Specifically, we asked them to comment on the following question:

From your own perspective, what does the process look like for you when deciding on, preparing, deliver, and evaluating aphasia treatment for someone with aphasia? [includes what resources and materials are used].

This led to some fascinating discussion and insights into how clinical decisions are made, which might be influenced by access to resources, expertise, trust, and setting. We had some particularly meaty discussion around how (therapy) resources are used; how personalised therapy resources could be (which is important in LUNA); and how intervention outcomes are currently being evaluated.

SLTs then considered an ideal situation (…we’re exploring some ‘blue sky’ thinking as a backdrop for LUNA…). This was especially illuminating, and with discussion covering how aphasia therapy and the rehabilitation process could be more ideal if we used standard outcome measures, could find more opportunities to incorporate therapy into everyday life, including self-directed therapy and involving family more in the client’s rehabilitation. SLTs also raised having more therapy time, more time to analyse client data, having resources to draw upon, and personalizing therapy.

LUNA would love to hear from SLTs across all settings – what does ideal aphasia therapy look like, from your perspective as a professional/ service provider?

Synthesising research for clinical practice

We then turned our attention to our scoping review-in-progress of discourse treatment research studies in aphasia and explored what makes a literature synthesis useable to clinicians.

So far, the list looks like this:

(1) the therapies/ treatments used are usefully described, or at least signposted so you can follow up and read the journal article;

(2) making sure the therapies themselves are clearly named and defined as acronyms and familiarity can lead to assumptions that others know the treatments being talked about (when this is in fact not the case!);

(3) presenting the findings in bite-sized chunks e.g. 5 minutes’ worth in recognition of busy practice and to therefore capitalize on small windows of time;

(4) highlighting if therapy manuals or resources are easily available, and whether the therapies must be carefully adhered to protocol or more flexibly delivered/ applied;

(5) grouping findings in a useful way perhaps around client profiles, or types of treatment, so it’s easy to see how and when a clinician might choose/read/ apply to a current client on caseload; and

(6) taking active steps to use it in practice such as taking one idea, trialing it, and feeding back at a team meeting or a “monthly challenge”.

LUNA would like to know: what makes a literature synthesis useful to you as a SLT?

We finished session 1 with some discussion around a model or framework that underpins LUNA, which attempts to represent the many aspects involves in telling a personal narrative/ story. There was much debate and discussion in the room around what we want a model or framework to achieve – and how we are going to share this more broadly with clinicians and researchers. There were many differing views.  It’s safe to say this will be an ongoing discussion throughout our project, so we’re keeping quiet on this at the moment!

Are you interested in the LUNA model or framework? We will be looking to road-test it at some point. If you are a SLT and particularly interested in this, do get in touch with us on the LUNA email luna@city.ac.uk to volunteer yourself!

Written by Madeline Cruice

SURVEY DEADLINE EXTENDED TO 4^TH DECEMBER 2018

It is possibly more than a little sad to get excited by a journal article, but I’ve recently seen @ClinAcSLT’s tweet of Tuesday last week (30^thOctober) and been really buoyed by them tweeting this BMJ paper: Does the engagement of clinicians and organisations in research improve healthcare performance: A three-stage review, by Boaz and colleagues https://bmjopen.bmj.com/content/5/12/e009415 (🔓 open access – freely available).

This review shows from what looks exhausting to be dealing with 10,239 records initially identified, and whittled down to 33 papers included in the review, that the majority report positive findings from engagement, with improvements being noted mostly in improved processes of care, and then improved health outcomes. This comes at a time that is crucial for me as the primary investigator on LUNA, leading phase 2 of LUNA, and desperate to boost our respondent numbers of SLTs working in aphasia rehabilitation for our LUNA SLT survey www.city.ac.uk/luna-survey.

What we’ve been doing so far

We’ve been tweeting like mad and bothering BAS, RCSLT CENs, and Hubs on email for weeks now, and we’ve got a delightful completed respondent sample of 144 completed valid responses – THANK YOU to everyone who has made the time and engaged in this research. It’s important in research to employ robust and replicable methods, even for survey engagement, hence I haven’t been emailing my NHS pals on their gmail accounts (or NHS email addresses) to get the word out and boost numbers. However, our numbers are still low compared to what we would like to gain for this research.

Initially we estimated that there are probably approximately 500 SLTs working in adults, in the field of aphasia rehabilitation, who are members of BAS, CENs, and Hubs (allowing for approx. 200 overlap between national and local network memberships). And we hoped to get 350 of those, thereby giving us a 70% response rate, which is nice and tidy and ideal in the survey world. At the moment, we are on 41% of our target, which feels a little glass-half-empty, however in no way shape or form do I want to downplay the time and effort of those 144 individuals who have completed to date – I know how much effort it takes to make that time, and know that other activities will have gone un-done, or people will have left work late one day because of it, or they’ve needed to complete it at home meaning less TV or partner and family chat that night. Now, time pressures are never going to change, so my attempt here in the next paragraph is to highlight why taking time to complete the survey is worthwhile, drawing on some findings from Boaz et al, and hope to encourage people for a final last push in engaging in this research.

7 reasons why it’s worthwhile to do the survey

By engaging in research, Boaz and colleagues posit various mechanisms at play to improve ‘healthcare performance’ (be it processes of care, or healthcare outcomes, see Table 2 in their paper):

1. Just being involved in the processes of the research can improve performance, by going online, reading the survey questions, considering the relevance to you and your practice, and how important it is to your clients.

2. Engaging in the survey might change your attitudes or behaviours around discourse analysis, might prompt conversation with colleagues about discourse analysis and treatment with clients with aphasia, and might encourage someone to follow-up this point in a future journal club.

3. Completing the survey might help you be more aware and give more understanding of the specific research findings, when we start discussing and disseminating these more in 2019.

4. Completing the survey might make you interested in finding out more about the project, might encourage you to read one of the papers flagged online on our website https://blogs.city.ac.uk/luna or ask a question directly to our team: luna@city.ac.uk.

5. Being involved might help you apply the findings more (once they’re out) in your local setting with colleagues and in services.

6. Being involved in one relatively easy way of keeping up to date with an important and emerging area of rehabilitation research – complete the survey, and then go to our website and subscribe by email for automatic blog postings delivering project updates and relevant information to your preferred inbox.

7. Finally, the obvious one albeit altruistic but fundamental in the long run, being involved makes the research more relevant for practicing speech and language therapists and for services, which is what we here at LUNA are all about.

SO…… go on, grab a wine or grab a water, take 15-20 minutes with your mobile or laptop or tablet or desktop (what options!), and complete the survey. If you’ve done it already, please pass the survey link onto 1 or 2 colleagues who you know are also interested in engaging in research. http://www.city.ac.uk/luna-survey

On the 15th October, Madeline Cruice gave an Aphasia Institute webinar, entitled ‘Helping people tell richer stories using the words they want to use: Language Underpins Narrative in Aphasia’. The Aphasia Institute is a Canadian community-based centre of excellence, pioneering programs and practices that help people with aphasia learn how to communicate in new ways, and begin to navigate their own lives again. Through direct service, research, education and training, the Aphasia Institute has built a reputation as a world leader and educator in aphasia.

We’ve collected and shared some of the tweets from the webinar. You do not have to be on Twitter yourself, or log in to Twitter to access!

Nearly five months ago, at the beginning of May, we began work on the LUNA project.

We’ve made good progress on Phase 1 of LUNA (the theoretical phase), and also started Phase Two (the SLT survey phase). We’ve built the webpage you’re reading this on, and set up our Twitter feed. We’ll be using both platforms to share our progress on the project, and also information about storytelling and aphasia. Make sure you’ve subscribed so that you receive our blog postings automatically to your email address, and don’t need to check in here for updates.

Developing a theoretical model for change: LUNA Phase 1

Phase 1 of LUNA is led by PI Lucy Dipper, and was the focus of May- July and is on-going (it’s not a small task!). The aim of this phase was to develop a model of change for LUNA assessment and intervention, based on empirical and theoretical work completed to date, and we are well on the way to achieving this.

Lucy and Madeleine P. have synthesised existing discourse intervention literature. Some of this work is listed on our links and references page, and will be feeding into the next phases of the project. We are looking forward to sharing our work from this phase – the first opportunity to hear about it is listed at the end of this post.

We also hosted international visitors: LUNA collaborators Professor Mary Boyle and Associate Professor Deborah Hersh came to London, and spent an intensive week working with us in July. We spent time at City, discussing facets of the project in-depth; celebrating the project start with our consultants with aphasia; and having our first whole-team meeting face to face (no mean feat for an international team stretching across three continents!). Free-range LUNA discussions also took place across London: in Mary and Deborah’s beautiful Islington home away from home; in local cafes over coffee and lunch; perambulating through the dappled shade of Highgate Woods; and in the yellow glow of the Royal Academy Summer Exhibition, curated by Grayson Perry. We’re a team that believe that stimulation and varied locations help the mind think through things differently. A busy week, in which we covered a huge amount of ground, and built a lot of project momentum.

SLT Survey: LUNA Phase 2

Phase 2 of LUNA is currently in progress, and is led by PI Madeline Cruice.

We’ll be working on Phase Two until approx. the end of December. So far, we have written the SLT survey, piloted it, obtained ethics approval, and the survey is now live. We are grateful to Dr. Lucy Bryant from the University of Technology, Sydney who helped us enormously when we were developing the survey, very generously sharing her recent survey of discourse practice in Australia. Our rationale for drawing heavily on her questions are they had been tested already in an international study, but very few SLTs in the UK had taken part. Our thanks to Dr. Sarah Northcott, Katie Monelly, Dr. Anna Caute, and Josephine Wallanger at City, University of London, in the early testing stages of the survey.

The LUNA survey will be live, until 15^thNovember – please don’t wait to complete it, if you haven’t yet! The majority of our participants are reporting that the survey is quick to complete, and has taken them 15-20 minutes.

Upcoming  

• We are delighted to be sharing our first output from the LUNA project in the Autumn. Lucy will be presenting work from Phase 1 of LUNA at the British Aphasiology Society Conference in November, in Sheffield
• Madeline C. will be sharing LUNA work with the Aphasia Institute in Toronto via webinar on 15^th October

If you have any queries or requests for further information, please don’t hesitate to contact us by email or via Twitter.