Ciara has a classical diagnosis of severe conduction aphasia. The following episode of care goals were formed using the A-FROM framework and SMARTER goal setting principles (Kagan et al. 2008 and Hersh et al. 2012).
Goal 1: Ciara’s functional word production and intelligibility will be improved to support her to conduct video-call conversations weekly with 2 of her friends.
Justification: Reduced opportunities for conversation is a significant loss that people with aphasia (PWA) experience (Davidson and Worrall 2017). Phone use increases social participation, facilitating relationship building and the organisation of social activities (Greig et al. 2008). This is particularly important for Ciara, as she lives alone. Furthermore, Ciara has expressed a desire to improve her speech. This goal enables Ciara to return to connecting with her friends from choir, book club, the pub etc. Video calls have been selected as they will allow Ciara to gain supportive cues from gesture and facial expression (Scharp et al. 2007).
Treatment Plan: Self-Monitoring Therapy (SMT) will be conducted, to improve Ciara’s ability to conduct video-calls, reducing frequency of conduite-d’approche and enable self-detection and correction of speech errors (Franklin et al. 2002). Conduite-d’approche is a process of repetitive effort to produce the appropriate word in attempting to correct errors (Alexander 2000 cited in Potagas et al. 2017). This approach was chosen because it will target three of Ciara’s deficits; naming, repetition and oral reading, with evidence of generalisation (Franklin et al. 2002). 65 functionally useful words will be selected in collaboration with Ciara (Palmer 2017). The 65 words will be split into sets of 20 and a 90% accuracy criteria set for moving onto a new set, over each stage of monitoring (Franklin et al. 2002).
SMT involves 2 distinct stages. 1) auditory training phase; consisting of “auditory awareness” and “auditory discrimination” which involves hearing a word and pointing to it and, the word which rhymes with it. 2) Self-monitoring phase; involving “external monitoring” where the SLT makes a mistake in a picture-naming task, to see if Ciara can identify it. Stage 2 also encompasses “indirect monitoring”, involving judgements via recordings of Ciara’s own naming, and “online judgement” involving Ciara judging her production immediately (Franklin et al. 2002). Feedback is an integral part of SMT. If Ciara answers incorrectly, she must choose where she got it wrong, via audio recording. To track progress, pre and post measurements of; naming, oral reading and repetition will be taken. All treated words and 20 untreated words (mix of high and low imageability and number of syllables) will be tested pre and post-therapy. Supported role play of video-calls will be conducted to use trained words in context and conversation guides will be provided to support generalisation of therapy and to prepare Ciara for calling her friends. Role plays will be video recorded to facilitate feedback from the SLT and to allow Ciara to self-evaluate her progress (Simmons-Mackie 1999). A Communication Confidence Rating Scale (CCRSA) will be administered to Ciara to measure confidence following each call. (Cherney et al. 2011).
Service Delivery: SMT will be conducted in Ciara’s home; 3 times weekly for 45 minutes for 8 weeks (Franklin et al. 2002). This incorporates time at the end of sessions for home practice explanations and troubleshooting. At least two hours of treatment per week results in vaster change than treatment delivered at lower intensity (Worrall et al. 2017). Following the SMT, 4 further weeks of therapy twice weekly for 2 hours will incorporate role play of video-calls and technical support to set up the video-calls.
Goal 2: Ciara will be supported to join and participate once weekly in a choir for PWA in the local community.
Justification: Singing is an activity which Ciara enjoyed prior to her stroke, and she has expressed an interest in returning. She will benefit from the shared experiences amongst PWA and increase her social circle (Brown et al. 2011). Furthermore, PWA have been shown to pronounce words better when singing familiar songs in a choral context, than during normal speech (Zumbansen et al. 2017).
Treatment Plan: As per Goal 1, SMT will be the primary treatment approach for this goal. SMT has shown improvements in oral reading, which should aid Ciara to read the words of songs for the choir (Franklin et al. 2002). Functional words useful for participation in choir will be included in the SMT. As this goal involves a choir for people with aphasia, it is intended that Ciara joins the choir within the first two weeks of therapy. This will provide an early sense of achievement and provide further motivation for therapy (Shill 1979). A self-devised “likert” scale will be used to measure Ciara’s progress and participation in the choir (Tamplin et al. 2013). Additionally, Ciara will collaborate with members of the choir to produce an aphasia awareness campaign. Public knowledge of aphasia is needed to remove barriers to participation for PWA (Manning 2019).
Service Delivery: SMT will be conducted to contribute to the achievement of this goal. Thus, service delivery for this goal largely mirrors that of goal 1. The additional four weeks of therapy will be used to organise an aphasia awareness campaign in the community in which the choir is situated, meeting after choir for one hour with the SLT acting as meeting facilitator (Nicholas 2012).
Goal 3: Communication strategies will be in place to support Ciara to return to minding her grandchildren, once weekly with supervision, if necessary.
Justification: Aphasia can impact on everyone in the family unit, and this goal will involve collaboration with Ciara’s family and her multidisciplinary team (Grawburg 2019 and Clarke and Forster 2015). It will allow Ciara to return to an element of her life pre-stroke, address the role loss which she has experienced since her stroke and enable her to contribute to her family (Manning et al. 2019, Wallace et al. 2016 and Worrall et al. 2011). There is a substantial evidence base documenting the benefits of Communication partner training (CPT) for enhancing the communication and participation of PWA (Simmons-Mackie et al. 2016).
Treatment Plan: Structured sessions will be conducted to support Ciara, in collaboration with her daughter to provide aphasia information that is accessible and tailored to the needs of her grandchildren. This will encompass what the grandchildren already know about aphasia, what they would like to know, and what Ciara thinks they need to know (Avent et al. 2005). Educating her grandchildren is something that Ciara may find meaningful as she worked as a teacher in the past. Furthermore, this will aid her grandchildren in understanding their grandmother’s aphasia and act as a stepping stone towards Ciara, minding them independently. CPT will be conducted with Ciara, her daughter and grandchildren. This will first comprise an introductory workshop to expose participants to the concept of “supported communication”, followed by 3 modules to cover the conceptual, technical and integrative aspects of CPT (Kagan 1998). The final training session will conclude with a 30 minute evaluation exercise. Pre and post measurement will be taken of all CPT participants using the Measure of Skill in Supported Conversation (MSC), and the Measure of level of Participation in Conversation (MPC) will be used to measure Ciara’s participation (Kagan et al. 2004). CPT sessions will be video recorded to facilitate feedback to participants (Beeke et al. 2018 and Simmons-Mackie et al. 1999).
Service Delivery: CPT training will encompass a day-long workshop, followed by 2 hour sessions once weekly for 3 weeks (Kagan 1998). Training will be conducted by an SLT with additional training in CPT (Kagan 1998). Sessions will be held at home in Ciara’s natural communication environment (Davidson and Worrall 2017).
Theoretical underpinnings
SMT is a localisation approach, chosen based on the symptoms of Ciara’s aphasia. The mechanisms of change associated with localisation approaches are; restoration, reconstitution and, compensation (Worrall et al. 2017). The choir for PWA and awareness raising activities are social theory approaches (Worrell et al. 2017). This theory views aphasia as a communication disability which is fuelled by disabling environmental factors. It suggests that society disables people rather than the disability itself (Shakespeare 2016). CPT falls under the pragmatic/functional theory approach (Worrall et al. 2017). CPT is built around the concept of partnerships in conversation. The success of a conversation is viewed with consideration of the skill and experience of the PWA and their conversation partners, in this case, Cs grandchildren and the availability of relevant RAMPs and resources (Kagan 1998). The understanding that PWA have the right to communicate is crucial to the underpinning of the approach (Kagan 1998). The true communicative capabilities of PWA can be unearthed through the skill of a conversation partner (Kagan 1998). Each of Ciara’s goals stem from a different theory. However, when examined together, they fit a biopsychosocial model; encompassing restoration of speech function, participation, environmental and personal factors (Worrall et al. 2017).
Onward referral
Occupational therapy (OT) assessment; potential for a home visit to identify and address risks related to the paresis of her right hand, which may impact on her ability to safely mind her grandchildren (Legg et al. 2007). On top of SLT support, psychological intervention may be indicated, to help Ciara cope with the changes that have occurred in her life (Northcott et al. 2017). Ciara reports being upset that she is the one being looked after. Psychological care for PWA can be indicated in many cases, despite perceptions from mental health professionals that PWA are not appropriate for psychological input (Northcott et al. 2017).
Further information
Ascertaining the age of Ciara’s grandchildren is necessary to tailor the therapy and resources to meet her goal. This may impact on the feasibility of their participation in CPT. Furthermore, establishing who currently minds the grandchildren is necessary so that they can be integrated into goal planning. A full medical history, details and outcomes of any previous therapy would further inform goal and therapy decisions. Additionally, it is not clear from the case information, if assessments of rhyming took place, these would be helpful to inform therapy further.