Recommendations for future research

Adaptations to therapeutic technique involve increased use of summaries which, in addition to demonstrating empathy, can also support the patient to remain focused on the conversation.

Memory aids including written notes or cue cards can reinforce a message. It is suggested that therapists take a holistic approach to the patient; considering the life events experienced by the patient when exploring patient concerns.

2.5 Summary

This chapter has provided a brief background of research exploring psychological interventions after stroke, in particular for patients with communication difficulties post-stroke. Previous studies have been evaluated, with aids and adaptations for communication difficulties identified.

The importance of psychological interventions is clear given the high instance of depression after stroke and the impact this can have on outcomes, in particular for patients with communication difficulties. However, despite this, the small number of studies carried out evaluating psychological interventions after stroke has been highlighted. In spite of patients with communication difficulties after stroke representing approximately a third of stroke patients, studies including this patient group are scarce.

While a variety of interventions have been trialled, there are a number of limitations to the studies discussed. Although some studies discovered a benefit to patients’ mood, results in a number of the studies required further validation using larger sample sizes, or including additional intervention arms. In addition, many of the studies presented in this chapter recruited patients at varying times post-stroke, with some recruited many years after a stroke.

This neglects the early period post-stroke when patients are most likely to benefit from a psychological intervention (Hackett et al. 2008a). Finally, some studies were limited by their use of mood measures. While it is accepted that standardised tools of mood may not be suitable for patients with communication difficulties, alternative measures should be used. In addition, standardised mood measures need to be used to allow for direct comparisons of intervention outcomes.

2.6 Recommendations for future research

This chapter has highlighted a number of strengths and weaknesses of previous studies providing psychological interventions to patients with communication difficulties post-stroke.

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These will be taken in to account when considering a future feasibility trial including this patient group.

Future studies should place the patient at the centre of the intervention, with adjustments made to intervention delivery and communication strategies based on individual patient needs. This could include adjustments to therapist communication style such as leaving more time for patients to speak, or use of multiple methods of delivery to express a point. It could also include adaptations to the therapeutic delivery of the intervention, such as including an increased number of summaries which may aid patients with memory or concentration difficulties. Practical adaptations such as holding shorter but more regular sessions may benefit patients with fatigue or concentration problems. Outcome measures should be suitable for patient needs, such as using those specifically designed for patients with

communication difficulties. Not only do these adjustments meet NICE guidelines (NICE, 2009, Recommendation 1.1.4.5) in adjusting intervention to meet patient needs due to a disability or impairment, these are also supported by previous studies which this chapter has drawn attention to.

2.7 Conclusion

The exclusion of patients with communication difficulties from research is known to be common (Townend et al. 2007). While the reporting of inclusion or exclusion or participants with aphasia is often inconsistent, a review of studies exploring depression after stroke found that the majority of papers providing this detail reported some exclusion of patients with communication difficulties, especially in those with severe communication difficulties (Townend et al. 2007). This highlights the extent of the lack of inclusion for this group of patients in an important area of research. In excluding patients with communication difficulties from depression studies, there is no way of knowing whether findings from such research can be generalised to this patient group. As is suggested from previous research, patients with aphasia after stroke may have a range of different physical and emotional outcomes compared to those with normal communication; therefore it is crucial to involve this group of patients in order to gain a true picture of their needs and experiences.

One reason patients with communication difficulties are excluded from research studies is because of the difficulty patients may experience in completing standardised measures.

Studies often state from the outset that these patients will be excluded, leaving only patients with the ability to express themselves clearly in the study. Patients with severe communication difficulties, especially those with receptive difficulties, are often excluded due to their

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problems in understanding information. Patients with communication difficulties may therefore require alternative adaptations to assist them in communicating or in engaging in a psychological intervention.

A key conclusion to be drawn from this chapter is the dearth of studies evaluating psychological interventions for patients with communication difficulties post-stroke.

Furthermore, there is a lack of guidance from health guidelines of which psychological interventions are the most appropriate for patients with post-stroke communication difficulties, or skills required from staff delivering these interventions. This thesis therefore aims to address this need by exploring; firstly, the feasibility of providing a psychological intervention, MI, to patients with moderate to severe communication difficulties after stroke;

secondly, the level of communication ability required for patients to participate; and finally, the skills required from staff delivering this intervention.

This will begin in Chapter Three with a secondary analysis of data from a previous trial providing motivational interviewing to patients early after stroke to prevent depression. Data from this trial will be explored further in Chapter Three to examine the characteristics of patients involved in the original trial in relation to their communication ability.

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