Characterizing Speech and Language Pathology Outcomes in Stroke Rehabilitation

Article Outline

• Abstract
• Methods
  • Patients in the SLP Subset
    • Patient sample 1 (low-level functional communicators)
    • Patient sample 2 (mid-level functional communicators)
  • Instrumentation
  • Data Analysis
• Results
  • Logistic Regression
  • Sample 1
  • Sample 2
• Discussion
• Conclusions
• Acknowledgments
• Appendix 1. FIM scoring levels for cognitive components: Comprehension and expression
  • Comprehension
  • Expression
• Appendix 2. SLP intervention documentation form*
• References
• Copyright

Abstract 

Hatfield B, Millet D, Coles J, Gassaway J, Conroy B, Smout RJ. Characterizing speech and language pathology outcomes in stroke rehabilitation.

Objectives

To describe a subset of speech-language pathology (SLP) patients in the Post-Stroke Rehabilitation Outcomes Project and to examine outcomes for patients with low admission FIM levels of auditory comprehension and verbal expression.

Design

Observational cohort study.

Setting

Five inpatient rehabilitation hospitals.

Participants

Patients (N=397) receiving poststroke SLP with admission FIM cognitive components at levels 1 through 5.

Interventions

Not applicable.

Main Outcome Measure

Increase in comprehension and expression FIM scores from admission to discharge.

Results

Cognitively and linguistically complex SLP activities (problem-solving and executive functioning skills) were associated with greater likelihood of success in low- to mid-level functioning communicators in the acute poststroke rehabilitation period.

Conclusions

The results challenge common clinical practice by suggesting that use of high-level cognitively and linguistically complex SLP activities early in a patient’s stay may result in more efficient practice and better outcomes regardless of the patient’s functional communication severity level on admission.

Key Words:  Auditory perceptual disorders , Clinical practice patterns , Problem solving , Rehabilitation , Speech therapy , Stroke

THE MIX OF SPEECH-LANGUAGE pathology (SLP) services in the poststroke population has been difficult to describe. Although there is a large body of literature that describes assessment, diagnoses, and activities involved in SLP services in the stroke population and the cognitive and communication sequelae that follow brain injury,¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸ there is little to no research that adequately describes the interaction of these activities with the medical, physical, and emotional changes that occur with a stroke. SLP activities have been studied in isolation using broad categories based on speech and language diagnoses (ie, aphasia, dysarthria, dysphagia, cognitive-communication impairment). The interventions studied to date have been described subjectively or in structured research paradigms using a single selected treatment approach⁹, ¹⁰, ¹¹, ¹² and measuring change via performance on a specified task.

Many commonly used practices and treatment paradigms have little empiric evidence of their efficacy or effectiveness in the acute rehabilitation period. For example, use of group speech and language treatment has been studied in postacute populations¹³, ¹⁴ but not during the acute rehabilitation period. Although some universally validated practices exist in the area of diagnostics for the more tangible and technical aspects of SLP service provision (ie, modified barium swallow evaluations of dysphagia, video stroboscopic evaluations of vocal fold function), there is a paucity of data that describe the duration and timing of diagnostic activities and procedures as they relate to functional outcomes and success in SLP therapy.

Emphasis on achieving greater functional outcomes given diminishing lengths of stay (LOSs) during inpatient rehabilitation places clinicians in the daunting position of making constant adjustments to treatment plans based on each individual patient’s needs. The complex nature of SLP services in stroke rehabilitation has limited the field’s ability to conduct comprehensive studies that incorporate the interactions of comorbidities, leaving clinicians without firm guidance in how to prioritize activities while developing a treatment plan across a stroke patient’s rehabilitation LOS. The policy of the American Speech-Language-Hearing Association is to provide evidenced-based practice, which is defined as “an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions.”^15(p1) However, there is no set protocol that describes which impairment to work on first or for what particular percentage of time, nor are there sufficient data to show that achieving a given performance level in a given area will enhance or detract from performance in other areas. It is left up to each individual clinician’s instincts to adjust time spent in multiple activities using multiple interventions to try to achieve the most progress in the shortest possible period of time.

One of the primary reasons for the limitations in the current literature is the highly variable, complex nature of SLP activities and interventions. Rehabilitation of communication and swallowing is both an art and a science, and as yet, there has been no systematic way to compare practices or thoroughly capture what goes on during an inpatient rehabilitation stay and across settings. The objective of this article was to describe or characterize some basic aspects of SLP practice and the effects of specific SLP activities in achieving better outcomes for a subset of patients without a diagnosis of aphasia. We hypothesized that use of cognitively and linguistically complex SLP activities sooner in the rehabilitation stay is associated with better outcomes for patients who function as lower-level communicators at admission. This hypothesis stems from our clinical and anecdotal observations of patient performance and interactions in both one-on-one and group settings.

This article builds on the Post-Stroke Rehabilitation Outcomes Project (PSROP), a study of 1161 stroke rehabilitation patients discharged from 6 inpatient rehabilitation facilities (IRFs) in the United States. This article is limited to a subset of PSROP patients from 5 of these facilities. The motivation, purpose, scope, and key findings from the larger PSROP are provided in this supplement’s introductory article.¹⁶ A notable feature of the PSROP was the development of a taxonomy of rehabilitation activities and interventions associated with each clinical discipline, including SLP.¹⁷ This taxonomy provided the methodologic breakthrough needed to characterize SLP activities and interventions discussed in the following sections.

Back to Article Outline

Methods 

The methodology governing the full PSROP, provided in this supplement by Gassaway et al,¹⁸ provides a detailed description of the larger study’s participating facilities, patient selection criteria, data collection instruments including their validity and reliability, data collection instruments, and a detailed description of the project’s final study group. The methodology is summarized in Maulden et al.¹⁹ The institutional review boards at Boston University and at each participating IRF approved the study.

Patients in the SLP Subset 

We examined a subset of the PSROP database that received at least 1 SLP session during rehabilitation as documented on project SLP intervention documentation forms. SLP sessions were documented for over 90% of patients in 5 U.S. sites. In the sixth PSROP site, at least 1 SLP session during rehabilitation was documented for only 14% of patients; thus, this site was not included in the SLP analyses presented here. Deleting this 1 site entirely and all those patients with no documented SLP sessions in the other sites left a patient population of 936 patients from 5 sites.

The next step was to identify the amount of SLP services that patients received. To investigate the demographics and functional outcomes of this patient population, the amount of SLP therapy received was divided into 3-hour blocks of time. For detailed analyses, we included all patients who received between 1 and eight 3-hour blocks (n=790) and excluded those patients who received less than 3 hours (n=86) or more that 24 hours (n=54) of SLP services. Because treatment approaches differ markedly between patients with and without a diagnosis of aphasia, we chose to exclude patients with a diagnosis of aphasia anywhere in the medical record and focused on the larger sample of 599 patients who did not have a diagnosis of aphasia. We recognize that some of these patients may have had some poststroke aphasia but that the diagnostic label was not documented in the medical record.

Because we hypothesized that patients without an aphasia diagnosis who present with severe communication deficits experience a greater improvement in expressive and receptive communication when exposed to cognitively complex SLP interventions (eg, problem-solving activities), we compared 2 subsamples: 1 of lower-level functionally communicating patients and 1 of mid-level functionally communicating patients, as determined by admission FIM cognitive component (comprehension, expression) scores. Appendix 1 provides a description of FIM levels for these components.

Patient sample 1 (low-level functional communicators) 

Sample 1a includes only patients with admission FIM comprehension levels 1 through 3. This provided a sample of 176 patients (without an aphasia diagnosis, with admission FIM comprehension levels 1–3, with 1 to eight 3-hour blocks of SLP) for initial analyses. To further define the low-level sample, we examined another subset of these patients with low admission FIM expression (levels 1–3). Sample 1b contains 141 patients without an aphasia diagnosis with both admission FIM comprehension and expression levels of 1 through 3.

Patient sample 2 (mid-level functional communicators) 

Sample 2a (n=221) includes only patients without an aphasia diagnosis with admission FIM comprehension levels of 4 and 5 who received 1 to eight 3-hour blocks of SLP. Sample 2b includes a subset of these patients (n=144) who also have admission FIM expression levels of 4 and 5.

Table 1 describes demographic information for the 2 patient samples combined (mid-level and low-level groups) by 3-hour blocks of SLP therapy. Patients with admission FIM comprehension levels of 6 and 7 were not considered in the analyses because specific SLP goals would not likely address comprehension with patients performing at this level.

Table 1. Characteristics of Patients Without Aphasia Diagnosis and With Admission FIM Comprehension Levels 1 Through 5 (n=397)

Abbreviation: CSI, Comprehensive Severity Index.

⁎ Analysis of variance (ANOVA).

† Chi-square test.

Instrumentation 

The SLP intervention documentation form (appendix 2) developed for the PSROP¹⁸ included a finite taxonomy of information, such as the targeted activity area, interventions used by the clinician, and duration of each activity. Interventions were recorded to capture the specific approach the clinician took in addressing SLP goals within an activity area. For example, during a problem-solving activity, a clinician may have used verbal cueing to implement analysis and synthesis strategies with the patient to facilitate generation of alternative solutions. In contrast, during a task to target auditory comprehension, a clinician may have used verbal cueing to introduce analysis and synthesis strategies for drawing appropriate inferences from the task stimuli. Definitions for the activities and interventions contained on the SLP intervention documentation form were provided to practicing clinicians and are available on request. Additional information such as whether the session was individual or group, time spent in evaluation and planning, and potentially influential professional discussion of the patient among colleagues was also obtained; however, specific subtest scores from standardized tests commonly administered in SLP practice were not obtained. One SLP intervention documentation form was completed for each SLP session a patient received during his/her inpatient rehabilitation stay.

A lead SLP therapist from each IRF participated in a train-the-trainer teleconference to learn how to use and teach others to use the SLP intervention documentation form. After the teleconference, the lead SLPs trained colleagues in their respective IRFs.

Each site incorporated auditing of intervention documentation form use into routine site practices. Typically, the lead SLP therapist observed a patient session and completed a separate intervention documentation form based on what was observed. The therapist providing the session completed a form as per protocol. The lead therapist reviewed and discussed differences in completion with the practicing therapist.

Face validity was built into the intervention documentation forms because they were developed and used by IRF therapists as described. Predictive validity was assessed by showing significant effects of SLP interventions (and other therapy interventions) on outcomes.²⁰, ²¹, ²² For example, the amount of variation explained in discharge FIM score, controlling for patient characteristics (including admission FIM score, severity of illness, and demographic factors), was 40% for moderate strokes and 45% for severe strokes. When total time per day spent on physical therapy (PT), occupational therapy (OT), and SLP was added, there was no increase in variation explained for discharge FIM, consistent with previous findings by Bode et al.²³ However, when time per day spent in specific PT, OT, and SLP activities was added, the amount of variation explained increased to 52% for moderate strokes and 68% for severe strokes, adding 12% and 23% explanation of variation, respectively, in discharge FIM scores.

Functional performance for each study patient at admission to and discharge from inpatient rehabilitation was obtained via retrospective chart review using the study site’s reporting of the FIM instrument.²⁴ We assumed that all clinicians providing FIM data within IRFs as part of standard practice were FIM credentialed; no additional documentation of FIM elements was performed for project purposes.

Data Analysis 

Descriptive statistics were used to describe study variables. Patient, process, and outcome variables were compared using chi-square tests for categoric data and analysis of variance tests for continuous data. Correlation analyses were used to detect multicollinearity between predictor variables. Identified predictor variables and severity of illness were combined in logistic regression analyses to determine their concurrent effects on outcomes.

For logistic regression, a stepwise selection procedure with a significance level of .10 allowed independent variables to enter and leave the model. The importance of each variable in affecting an outcome was determined by the Wald chi-square statistic and odds ratio with 95% confidence interval. Discrimination c statistics (area under receiver operating characteristic curves) were used to evaluate how well each model distinguished, for example, patients who were successful in reaching the specified FIM level at discharge from patients who were not successful.

To examine the relation between SLP activities and outcomes, we used changes in FIM elements of auditory comprehension and verbal expression. These items were selected for analysis because they most directly describe the communication status of a patient and are measured independently of cognitive components that are frequently decreased in poststroke patients (ie, memory, problem solving, social interaction). Although SLP addresses these cognitive and linguistic areas through treatment, the variables of auditory comprehension and verbal expression best represent the functional ability of the patient to interact with the environment. To define success, we identified 2 markers for low-level patients and a different pair of markers for mid-level patients (one for improvement in comprehension, one for improvement in expression).

The first analysis defined success for low-level patients (admission FIM levels 1–3 for comprehension alone and then combined levels 1–3 for expression) as the discharge comprehension FIM score increasing by 2 or more levels; a second analysis defined success as the discharge expression FIM score increasing to level 4 (minimal assistance) or higher.

Mid-level patients (admission FIM levels 4–5 for comprehension alone and then combined with expression) were considered successful if the discharge FIM comprehension score increased to level 6 or higher and, in a second analysis, the discharge FIM expression score increased to level 6 or higher.

For purposes of interpreting and discussing the data, we classified SLP activities into categories of cognitively and linguistically simple, mid-level cognitively and linguistically complex, and high-level cognitively and linguistically complex based on a clinical consensus of the average complexity of activities and demands on a patient within a given activity. Cognitively and linguistically simple activities were those that addressed the most basic skill areas or were primarily motor based: swallowing, speech intelligibility, voice, alternative and nonverbal expression, orientation, and attention. The activity of “face/neck mobility” was combined with “swallowing” during analysis because of a low number of recordings for this category. Mid-level cognitively and linguistically complex activities were those that involved greater demands of the patient or were more abstract: verbal and written expression, auditory and reading comprehension, memory, and pragmatics. High-level cognitively and linguistically complex activities involved activities with the most multiple components: executive functioning skills, problem solving, and reasoning. Although patients do participate in complex tasks within activities that are considered simple (eg, divided attention tasks in community settings) and simple tasks within activities that are considered complex (eg, engaging problem solving by locating and using the nursing call bell to request assistance), we believed that this delineation best described the average usage of these activities by clinicians on a day-to-day basis.

Back to Article Outline

Results 

This sample of 397 communicators with low- to mid-level functioning received a mean of 16.4 SLP therapy sessions over the course of their rehabilitation stays. These sessions were conducted over an average of 11.4 days and consumed an average of 602 minutes (table 2). Naturally, patients with 8 three-hour blocks of therapy received much more SLP therapy than patients with 1 to 3 blocks. Thus, for continued analyses, we included only time in each activity performed during the first block (3h) of SLP treatment time, regardless of the total number of SLP blocks of time a patient received over the whole rehabilitation stay (table 3). This ensured that patients were functioning at the identified communication level (as measured by admission FIM) at the time of participation in SLP activities. We did not measure incremental increases in FIM score during the rehabilitation stay, and therefore, it was important to reduce the confounding effect of function naturally improving over the course of rehabilitation. Had we examined time in activities later in the stay, the outcomes at discharge could have been confounded with the natural recovery process or performance of other activities. In using the first block, we hypothesized that patients would not have had time to improve in their functioning, as they might have if we had included all blocks (2–8) in regression analyses.

Table 2. SLP Process Variables: Patients Without Aphasia Diagnosis and With Admission FIM Comprehension Level of 1 Through 5 (n=397)

NOTE. Each patient in 1 block only, for example, patient with 20 total hours of SLP appears in block 6 only.

Table 3. SLP Process Variables: Patients Without Aphasia Diagnosis and With Admission FIM Comprehension Level of 1 Through 5 (n=397)

NOTE. Each patient in 1 block only: for example, patient with 20 total hours of SLP appears in block 6 only. Percentage of time spent in the first 3-hour block only is displayed.

⁎ SLP activities mean percentage of time. First line of each variable is for patients with admission FIM comprehension level 1–3 (n=176). Second line of each variable is for patients with admission FIM comprehension level 4–5 (n=221).

For these communicators with low- to mid-level functioning, the total and cognitive FIM scores increased by means of 27.7 and 5.4, respectively, from admission to discharge. Changes in FIM scores from admission to discharge and discharge destination as related to number of SLP therapy blocks for this patient sample are presented in table 4.

Table 4. PSROP SLP Outcome Variables: Patients Without Aphasia Diagnosis and With Admission FIM Comprehension of Levels 1 Through 5 (n=397)

⁎ ANOVA.

† Chi-square test.

Logistic Regression 

We allowed many variables (eg, demographics, admission functioning level, medical severity of illness, stroke locations; see table 1) to enter stepwise selection procedures to identify variables associated with greater or less likelihood of patients achieving our defined success outcomes. Because admission FIM motor and cognitive scores aggregate functional information across different activities, 2 patients with very different disabilities may have an identical score composed of higher and lower levels from different areas. This means that use of motor and cognitive scores may not adequately control for patients’ starting disability levels. To overcome this concern, we performed an additional set of regression models allowing individual motor and cognitive components of the FIM to enter instead of admission FIM motor and cognitive scores. In addition, we allowed number of minutes during the first therapy block for each SLP activity (eg, swallowing, orientation, problem solving) to enter the model. Another variable allowed to enter was the FIM discharge bladder level, because bladder function and level of continence can be considered a surrogate indicator for overall cognitive-communication functioning level. Patients with lower-level cognitive and communication function typically have lower awareness of the need to void and/or the ability to obtain necessary help for toileting to maintain continence. Bladder function seems to be an indicator of potential for recovery, a difference between those who succeed and those who do not. The level of continence has been established as a compelling factor in determining discharge disposition.²⁵

Sample 1 

Logistic regression analyses predicting increase in FIM comprehension and expression scores for communicators with low-level function are presented in table 5.

Table 5. Logistic Regression Analyses Predicting Increase in FIM Comprehension and Expression for Communicators With Low-Level Functioning Without a Diagnosis of Aphasia (Sample 1)

NOTE. Variables allowed to enter the model include admission FIM motor and cognitive scores; admission CSI score; increase in severity; net medical improvement; side of stroke: left, right, bilateral; hemorrhagic stroke; location in brain: lobar, subcortical, brainstem/cerebral, subcortical; diabetes diagnosis; female; race: black, white, other; hospital inpatient stay >20 days; admission FIM bladder level: 1–3, 4–5, 6–7; SLP activities in first 3-hour block: swallowing, speech/intelligibility, voice, verbal expression, alternative nonverbal expression, writing expression, auditory comprehension, reading comprehension, problem solving/reasoning, orientation, attention, memory, pragmatics, executive functioning, nonfunctional. Reference variables were brain side unknown, brain location unknown, and race unknown.

Abbreviation: NA, not applicable.

In sample 1a (176 patients without aphasia diagnosis, with admission FIM comprehension levels 1–3), 50% (88 patients) achieved success. Even after controlling for multiple patient characteristics, creating otherwise matched groups, several mid-level and complex SLP activities were associated with greater likelihood of success in these low-level patients, including more time spent in problem-solving and executive functioning activities in the first 3-hour block. Several SLP activities were associated with less likelihood of success: more time spent in orientation, verbal expression, and written expression activities. Low-level bladder functioning by the time of discharge was also associated with less likelihood of success (c=.812). Bladder function appears to covary with improvement in communication-cognitive function.

When we removed admission FIM motor and cognitive scores and allowed the motor and cognitive components of FIM to enter individually, the model remained the same, including for SLP activities associated with greater or less likelihood of success.

For the subset of 141 patients with FIM admission levels 1 through 3 for both comprehension and expression (sample 1b) and with success defined as reaching FIM expression level 4 or higher by discharge (77 [55%] patients successful), similar results were found: more time spent doing a cognitively and linguistically complex SLP activity (problem solving) during the first 3-hour block was associated with greater likelihood of success, as was high bladder functioning at discharge. Mid-level and simple SLP activities (eg, reading comprehension, memory) were associated with less likelihood of success (c=.849).

When we removed admission FIM motor and cognitive scores and allowed the motor and cognitive components of FIM to enter individually, similar SLP activities were associated with greater or less likelihood of success (c=.886).

Sample 2 

Logistic regression analyses predicting increase in FIM comprehension and expression for communicators with mid-level functioning are presented in table 6.

Table 6. Logistic Regression Analyses Predicting Increase in Comprehension and Expression for Mid-Level Functional Communicators: Patients Without Aphasia Diagnosis (Sample 2)

NOTE. Variables allowed to enter the model include admission FIM motor and cognitive scores; admission CSI score; increase in severity; net medical improvement; side of stroke: left, right, bilateral; hemorrhagic stroke; location in brain: lobar, subcortical, brainstem/cerebral, subcortical; diabetes diagnosis; female; race: black, white, other; hospital inpatient stay >20 days; admission FIM bladder level: 1–3, 4–5, 6–7; SLP activities in first 3-hour block: swallowing, speech/intelligibility, voice, verbal expression, alternative nonverbal expression, writing expression, auditory comprehension, reading comprehension, problem solving/reasoning, orientation, attention, memory, pragmatics, executive functioning, nonfunctional. Reference variables were brain side unknown, brain location unknown, and race unknown.

When we repeated regression analyses with sample 2a (221 patients without an aphasia diagnosis and with admission FIM comprehension scores of 4 and 5), again we found that more time spent performing mid-level and simple SLP activities (auditory comprehension) in the first 3-hour block of SLP time was associated with less likelihood of success (discharge FIM comprehension level ≥6) and more time spent in the complex activity of problem solving was associated with greater likelihood of success (c=.788). Removing admission FIM motor and cognitive scores and allowing the motor and cognitive components of FIM to enter individually produced similar results, including the SLP activity of problem solving associated with greater likelihood of success (c=.844).

When controlling for admission expression level in addition to comprehension (sample 2b), more time spent in problem-solving activities again was associated with greater likelihood of success, whereas more time spent in verbal expression was associated with less likelihood of success (c=.808). Similar results were found when we removed admission FIM motor and cognitive scores and allowed the motor and cognitive components of FIM to enter individually (c=.872).

Back to Article Outline

Discussion 

For most patients without an aphasia diagnosis, PSROP data indicate that use of activities involving problem solving is associated with greater likelihood of improved outcomes in verbal expression and auditory comprehension. These results indicate that perhaps problem-solving activities, which by their nature involve critical thinking, mental flexibility, integration of multiple components of information, and mental manipulation, generally lead to better auditory processing and inferencing skills, as measured via auditory comprehension FIM data, as well as to increased capacity for discourse, as measured via verbal expression FIM data. Taking a top-down therapeutic approach naturally may recruit a greater number of cognitive and linguistic skills (ie, error detection, revision/repair, self-regulation) that trickle down into expanded and strengthened components of functional language (ie, inferencing, expanded semantic and syntactic constructs). These areas are often decreased in poststroke patients without a diagnosis of aphasia⁸ and have at their roots a breakdown in the integration of information versus true comprehension and formulation deficits, as in those with aphasia. Clinicians did report working on individual activities of auditory comprehension and verbal expression in isolation with patients without a diagnosis of aphasia; however, the data suggest that addressing these target areas in an integrated manner results in more improvement than working on each deficit area in isolation.

The strengths of this study are many, because the breadth of the data collected and large number of subjects allowed for the formulation of homogenous groups for comparison. It also provided a comprehensive look at what patients actually experience at the hands of SLPs in a natural setting. The weaknesses of the study, however, are related to the strengths, in that multiple objective and subjective choices about how to carve out homogeneous groups were required. Additionally, despite the best efforts of clinical leaders at each site to promote accuracy and consistency in use of the intervention documentation forms, the reality of busy clinicians completing additional paperwork per treatment session may have resulted in quick decision making about the true nature of activities and interventions performed. The documentation form did not allow for recording the context in which an activity was performed, which also may have an impact on the functional outcome for a patient. For example, if a clinician addresses problem solving by using real-life materials such as bank checks or newspaper coupons, the patient’s performance, involvement, and benefit from the task may be different than the same goals targeted in a hypothetical, fabricated context. However, despite these limitations, significant variation in outcomes was found associated with differences in time spent per day in specific SLP activities.

The clinical implications of these results are potentially great, because they indicate that offering mid- to high-level cognitively and linguistically complex activities earlier in a patient’s episode of care is more likely to result in favorable outcomes. Generally, clinical consensus in SLP practice is to select an activity and intervention strategy at just a notch in complexity above the current functional performance of the patient, gradually increasing complexity as the patient progresses to maintain a relatively high patient success rate.²⁶ Initiating complex tasks within the first 3 hours of treatment seems counterintuitive at first. However, results of this study indicate that doing so may increase significantly the patient’s likelihood of advancing their independence in functional communication skills. Additionally, current practice techniques tend to match an activity with a category of impairment—that is, if a patient has decreased auditory comprehension, a clinician will select activities and use interventions directly targeting auditory comprehension. Results of this study indicate that more time spent in tasks of analysis and synthesis of information improves both verbal expression and auditory comprehension, although neither was specifically addressed via those tasks. Results also indicate that collaboration between SLP and OT early on in a patient’s rehabilitative stay potentially could improve other FIM areas such as continence. For example, accessing and using a call bell system to convey the need for toileting activates a patient’s simple cognitive-linguistic skills (ie, initiation of functional problem solving and of conveying a basic need) as a means to enhance both auditory comprehension and verbal or nonverbal communication. Addressing these skills provides the SLP with a starting point to tap into each patient’s cognitive and linguistic skills using meaningful and purposeful activities that naturally increase functional communication outcomes.

It appears that challenging a patient early in the rehabilitation stay and addressing multicomponent integration and mental manipulation tasks potentially has far-reaching effects. Asking patients who present with low linguistic ability to perform more complex cognitive and linguistic tasks may require more clinician cueing and assistance but appears to be associated with more efficient generalization of skills, as indicated by functional performance at discharge.

Future research implications of this study’s results include using these findings to guide controlled trials of trends that rose above the noise of this large data set. Results could be correlated with standardized test measures of speech and language performance, such as the auditory comprehension and verbal expression subtests of the Western Aphasia Battery.²⁷ Further analyses of PSROP data could ask different questions about current practice principles. Examining specific interventions used within each complex SLP activity, as well as specific activities and interventions used with patients with a diagnosis of aphasia, time spent in initial and interim evaluation, clinical practice variation across specific clinicians and treatment sites, and use of treatment groups will further our understanding of these current results.

Back to Article Outline

Conclusions 

For every practicing clinician who works with poststroke patients in inpatient rehabilitation there is a unique set of guiding principles, intervention techniques, and management styles learned from a body of literature, overt teaching and mentoring, experience, and pure instinct. For every stroke survivor who participates in an inpatient rehabilitation program there is a unique set of functional goals, comorbidities, learning style, and attitude toward recovery.

Historically, SLP treatment plans have been driven by individual clinician rationale; however, given the rather surprising evidence drawn from these data regarding the complexity of activities SLPs offer stroke rehabilitation patients early in their treatment, there is a clear need for further investigation of factors that drive clinician decision making, as well as patient variables that may impact the functional success or failure of achievement in a targeted skill area. The primary objective of this article was to test the hypothesis that use of cognitively and linguistically complex SLP activities early in a patient’s stay may result in better outcomes, regardless of the patient’s functional communication severity level on admission, but clearly further examination is both necessary and welcome. Future data analyses will provide a more detailed description of specific interventions and activities used in acute stroke rehabilitation with an eye toward determining best practices that will guide the type of activities, timing, frequency, duration, and interventions that make up the provision of SLP services with poststroke patients during inpatient rehabilitation.

Back to Article Outline

Acknowledgments 

We acknowledge the role and contributions of the collaborators at each of the clinical sites represented in the Post-Stroke Rehabilitation Outcomes Project: Brendan Conroy, MD (Stroke Recovery Program, National Rehabilitation Hospital, Washington, DC); Richard Zorowitz, MD (Department of Rehabilitation Medicine, University of Pennsylvania Medical Center, Philadelphia, PA); David Ryser, MD (Neuro Specialty Rehabilitation, LDS Hospital, Salt Lake City, UT); Jeffrey Teraoka, MD (Division of Physical Medicine and Rehabilitation, Stanford University, Palo Alto, CA); Frank Wong, MD, and LeeAnn Sims, RN (Rehabilitation Institute of Oregon, Legacy Health Systems, Portland, OR); Murray Brandstater, MD (Loma Linda University Medical Center, Loma Linda, CA); and Harry McNaughton, MD (Wellington and Kenepuru Hospitals, Wellington, NZ).

Back to Article Outline

Appendix 1. FIM scoring levels for cognitive components: Comprehension and expression 

Comprehension 

Includes understanding of either auditory or visual communication (eg, writing, sign language, gestures). Records the more usual modality (auditory, visual, or both).

NOTE: Comprehension of complex or abstract information includes but is not limited to understanding current events appearing in television programs or newspaper articles or abstract information on subjects such as religion, humor, math, or finances used in daily living. This may also include information given during group conversation. Information about daily needs refers to conversation, directions, questions, or statements related to a subject’s need for nutrition, fluids, elimination, hygiene, or sleep.

Expression 

Includes clear vocal or nonvocal expression of language. This item includes either intelligible speech or clear expression of language using writing or communication device. The item records the more prevalent modality (vocal, nonvocal, or both).

NOTE: Examples of complex or abstract ideas include but are not limited to discussing current events, religion, or relationships with others. Expression of basic needs and ideas refers to a subject’s ability to communicate about necessary daily activities such as nutrition, fluids, elimination, hygiene, and sleep.

Back to Article Outline

Appendix 2. SLP intervention documentation form* 

• 
  • View Large Image
  • Download to PowerPoint

© ISIS, 2003. Reprinted with permission.

Abbreviations: DPNS, direct pharyngeal nerve stimulation; EMG, electromyography; NDT, neurodevelopmental technique; ROM, range of motion.

*Definition of terms available on request.

Back to Article Outline

References 

1. Hillis AE . Cognitive neuropsychological approaches to rehabilitation of language disorders (introduction) . In:  Chapey R editors. Language intervention strategies in aphasia and related neurogenic communication disorders . 4th ed. Baltimore: Lippincott Williams & Wilkins; 2001;p. 513–523
   • View In Article
2. Davis GA . Aphasiology (disorders and clinical practice) . Boston: Allyn & Bacon; 2000;
   • View In Article
3. Elman RJ . Social and life participation approaches to aphasia intervention . In:  LaPointe L editors. Aphasia and related neurogenic language disorders . 3rd ed. New York: Thieme Medical Publishers; 2005;p. 39–50
   • View In Article
4. Logemann JA . Evaluation and treatment of swallowing disorders . Austin: ProEd; 1988;
   • View In Article
5. Freed DB . Motor speech disorders (diagnosis and treatment) . San Diego: Singular Publishing Group; 2000;
   • View In Article
6. Langmore SE , Schatz K , Olsen N . Fiber optic endoscopic examination of swallowing safety (a new procedure) . Dysphagia . 1988;2:216–219
   • View In Article
   • MEDLINE
7. Wertz RT , LaPointe LL , Rosenbek JC . Apraxia of speech in adults (the disorder and its management) . San Diego: Singular Publishing Group; 1991;
   • View In Article
8. Myers P . Communication disorders associated with right-hemisphere damage . In:  Chapey R editors. Language intervention strategies in aphasia and related neurogenic communication disorders . 4th ed.. Baltimore: Lippincott Williams & Wilkins; 2001;p. 809–828
   • View In Article
9. Wertz RT , Weiss DG , Aten JL , et al.   Comparison of clinic, home, and deferred language treatment for aphasia (a Veterans Administration cooperative study) . Arch Neurol . 1986;43:653–658
   • View In Article
   • MEDLINE
10. Johnston MV , Findley TW , DeLuca J , Katz RT . Research in physical medicine and rehabilitation: XII. Measurement tools with application to brain injury . Am J Phys Med Rehabil . 1991;70:40–56
    • View In Article
    • MEDLINE
    • CrossRef
11. Bryant M . Biofeedback in the treatment of a selected dysphagia patient . Dysphagia . 1991;6:140–144
    • View In Article
    • MEDLINE
    • CrossRef
12. Sohlberg MM , Mateer CA . Effectiveness of an attention training program . J Clin Exp Neuropsychol . 1987;9:117–130
    • View In Article
    • MEDLINE
    • CrossRef
13. Elman RJ , Bernstein-Ellis E . The efficacy of group communication treatment in adults with chronic aphasia . J Speech Lang Hear Res . 1999;42:411–419
    • View In Article
    • MEDLINE
14. Bollinger R , Musson N , Holland AL . A study of group communication intervention with chronically aphasic persons . Aphasiology . 1993;7:301–313
    • View In Article
15. Joint Coordinating Committee on Evidence-Based Practice, American Speech-Language-Hearing Association. . Position statement (Evidence-based practice in communication disorders) . 2005; Available at http://www.asha.org/NR/rdonlyres/4837FDFC-576B-4D84-BDD6-8BFF2A803AD3/0/v4PS_EBP.pdf. Accessed August 8, 2005.
    • View In Article
16. DeJong G , Horn SD , Conroy B , Nichols D , Healton EB . Opening the black box of poststroke rehabilitation (stroke rehabilitation patients, processes, and outcomes) . Arch Phys Med Rehabil . 2005;85(12(Suppl 2):S1–S7
    • View In Article
    • MEDLINE
17. DeJong G , Horn SD , Gassaway J , Dijkers M , Slavin M . Toward a taxonomy of rehabilitation interventions (using an inductive approach to examine the ‘black box’ of rehabilitation) . Arch Phys Med Rehabil . 2004;85:678–686
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (305 KB)
    • CrossRef
18. Gassaway J , Horn SD , DeJong G , Smout RJ , Clark C , James R . Applying the continuous practice improvement approach to stroke rehabilitation (methods used and baseline results) . Arch Phys Med Rehabil . 2005;86(12(Suppl 2):S16–S33
    • View In Article
    • MEDLINE
19. Maulden SA , Gassaway J , Horn SD , Smout RJ , Dejong G . Timing of initiation of rehabilitation after stroke . Arch Phys Med Rehabil . 2005;86(12(Suppl 2):S34–S40
    • View In Article
    • MEDLINE
20. Latham NK , Jette DU , Slavin M , et al.   Physical therapy during stroke rehabilitation for people with different walking abilities . Arch Phys Med Rehabil . 2005;86(12(Suppl 2):S41–S50
    • View In Article
    • MEDLINE
21. Richards LG , Latham NK , Jette DU , Rosenberg L , Smout RJ , DeJong G . Characterizing occupational therapy practice in stroke rehabilitation . Arch Phys Med Rehabil . 2005;86:S51–S60
    • View In Article
    • MEDLINE
22. Horn SD , DeJong G , Smout RJ , Gassaway J , James R , Conroy B . Stroke rehabilitation patients, practice, and outcomes (is earlier and more aggressive therapy better?) . Arch Phys Med Rehabil . 2005;86(12(Suppl 2):S101–S114
    • View In Article
    • MEDLINE
23. Bode R , Heinemann A , Semik P , Mallinson T . Patterns of therapy activities across length of stay and impairment levels (peering inside the “black box” of inpatient stroke rehabilitation) . Arch Phys Med Rehabil . 2004;85:1901–1908
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (426 KB)
    • CrossRef
24. Laughlin JA , Granger CV , Hamilton BB . Outcomes measurement in medical rehabilitation . Rehabil Manag . 1992;5:57–58
    • View In Article
25. Gresham GE , Duncan PW , Stason WB , et al.   Priorities for future research . Clinical practice guideline no. 16 . Rockville: US Department of Health & Human Services, Agency for Health Care Policy & Research;; 1995; AHCPR Publication No. 95-0662
    • View In Article
26. Porch B . Treatment of aphasia subsequent to the Porch Index of Communicative Ability (PICA) . In:  Chapey R editors. Language intervention strategies in adult aphasia . 3rd ed. Baltimore: Williams & Wilkins; 1994;p. 663–675
    • View In Article
27. Kertesz A . Western Aphasia Battery . New York: Grune & Stratton; 1982;
    • View In Article