Complementaria 2. Communication Partner Training in Aphasia An Updated Systematic Review

Accepted Manuscript
Communication partner training in aphasia: An updated systematic review
Nina Simmons-Mackie, Ph.D., Anastasia Raymer, Ph.D., Leora R. Cherney, Ph.D.
PII: S0003-9993(16)30074-0
DOI: 10.1016/j.apmr.2016.03.023
Reference: YAPMR 56521
To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 11 February 2016

Revised Date: 23 March 2016
Accepted Date: 29 March 2016
Please cite this article as: Simmons-Mackie N, Raymer A, Cherney LR, Communication partner
training in aphasia: An updated systematic review, ARCHIVES OF PHYSICAL MEDICINE AND
REHABILITATION (2016), doi: 10.1016/j.apmr.2016.03.023.
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Communication partner training in aphasia: An updated systematic review
Nina Simmons-Mackie, Ph.D.

Professor & Scholar in Residence
Department of Health & Human Sciences
Southeastern Louisiana University
Hammond, LA, USA
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Anastasia Raymer, Ph.D.
Professor
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Department of Communication Disorders & Special Education
Old Dominion University
Norfolk, VA, USA
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Leora R. Cherney, Ph.D.
Director, Center for Aphasia Research and Treatment
Rehabilitation Institute of Chicago
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Professor, Physical Medicine and Rehabilitation
Northwestern University, Feinberg School of Medicine
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Chicago, IL USA
Corresponding Author and Address:

Nina Simmons-Mackie
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580 Northwoods Drive, Abita Springs, LA 70420

nmackie@selu.edu
Phone: 985-875-1081
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Running Head: Communication Partner Training

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Key Words: aphasia; communication; treatment outcome; partner communication; rehabilitation

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I certify that no party having a direct interest in the results of the research
supporting this article has or will confer a benefit on me or on any
organization with which I am associated AND, if applicable, I certify that all
financial and material support for this research (e.g, NIH or NHS grants) and
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work are clearly identified in the title page of the manuscript.

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Reprints of this article will be available from the corresponding author

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1 Communication partner training in aphasia: An updated systematic review
2 Abstract
3 Objectives: This systematic review updates an earlier review1 describing the impact of
4 communication partner training on individuals with aphasia and their communication partners.
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5 Three clinical questions addressing effects of partner training on language, communication and
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6 participation, psychosocial adjustment, and quality of life for adults with aphasia and their
7 communication partners were addressed.
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8 Data Sources: Twelve electronic databases were searched using 23 search terms. References
9 from relevant articles were hand-searched.
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Study Selection: Three reviewers independently reviewed abstracts excluding those that failed
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11 to meet inclusion criteria. Thirty-two full text articles were reviewed by 2 independent reviewers.
12 Articles not meeting inclusion criteria were eliminated resulting in a corpus of 25 articles for full
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13 review.
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14 Data Extraction: For the 25 articles, one reviewer extracted descriptive data regarding
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15 participants, intervention, outcome measures and results. A second reviewer verified the
16 accuracy of the extracted data.

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17 Data Synthesis: The 3-member review team classified studies using the American Academy of
18 Neurology (AAN) levels of evidence2. Two independent reviewers evaluated each article using
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19 design specific tools to assess research quality.

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20 Conclusions: All 25 of the current review articles reported positive changes from partner
21 training. Therefore, to date, 56 studies across two systematic reviews have reported positive
22 outcomes from communication partner training in aphasia. The results of the current review are
23 consistent with the earlier review1 and necessitate no change to the earlier recommendations,
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Communication partner training, Page 2
24 suggesting that communication partner training should be conducted to improve partner skill in
25 facilitating the communication of people with chronic aphasia. Additional high quality research
26 is needed to strengthen the original 2010 recommendations and expand recommendations to
27 individuals with acute aphasia. High quality clinical trials are also needed to demonstrate
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28 implementation of CPT in complex environments such as health care.
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29 Keywords: aphasia; communication; treatment outcome; partner communication; rehabilitation
30 Abbreviations:
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31 Abbreviations used in Abstract and Text:
32 CPT: Communication Partner Training
33 AAN: American Academy of Neurology

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34 USA: United States of America
35 ICF: International Classification of Functioning, Disability and Health

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36 PWA: Persons with Aphasia

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37 RCT: Randomized Controlled Trail

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38
39
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40 Communication partner training in aphasia: An updated systematic review
41
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42 Traditionally aphasia rehabilitation has focused primarily on direct treatment of the

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43 individual with aphasia to decrease the severity of the language impairment and improve
44 functional communication. More recently environmental approaches that involve modifying the
45 communication environment have been introduced to facilitate communication in aphasia3.
46 Communication partner training (CPT) is a form of environmental intervention in which people
47 around the person with aphasia learn to utilize strategies and communication resources to aid the
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48 individual with aphasia1,3. For example, communication partners might be taught to use
49 multimodal communication (e.g., gestures) or provide access to pictures or written words to
50 support communication. Sometimes training takes place in a dyad with the communication
51 partner and the individual with aphasia both participating. In other cases, the communication
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52 partners take part in didactic educational opportunities to learn about aphasia and strategies to
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53 facilitate optimum communication. Thus, this evidence-based approach to improving
54 communication involves training people other than, or in addition to, the individual with aphasia.
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55 The intent is to improve the functional communication, participation, and well-being of the
56 person with aphasia. Communication partners include people with whom the person with aphasia
57
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might interact, such as family members, caregivers, friends, or health care providers.
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58 A systematic review of communication partner training (CPT) in aphasia was published
59 in 2010 to determine the level of research evidence supporting this approach1. In the 2010 article,
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60 31 published articles addressing CPT in aphasia were critically reviewed and clinical
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61 recommendations were suggested. In an extension of the 2010 report, Cherney and colleagues4
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62 reported on quality indicators for the reviewed articles and highlighted important design
63 considerations to improve the quality of CPT research.

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64 Based on the systematic review, the authors of the 2010 article concluded that CPT
65 focusing on communication skills appeared to be effective in improving partner skill in

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66 supporting communication for people with chronic aphasia; this approach was recommended for
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67 partners of people with aphasia. However, there was insufficient evidence regarding the
68 effectiveness of partner training during acute aphasia (i.e., < 4 months post onset) or the impact
69 of counseling or educational approaches for partners.

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70 The purpose of the current project is to update the findings of the 2010 and 2013 articles
71 by evaluating new research, summarizing the impact of CPT for adults with aphasia and their
72 communication partners, and reconsidering recommendations based on new evidence.
73 Methods
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74 The three major clinical questions addressed in the earlier review guided this review (see
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75 text box 1). These questions address the impact of CPT on individuals with acute aphasia (≤ 4
76 months post onset), individuals with chronic aphasia, and communication partners. Components
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77 of each clinical question were derived from domains of the World Health Organization’s
78 International Classification of Functioning, Disability and Health (ICF)5 as well as an aphasia-
79
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specific framework adapted from the ICF6. Thus, outcomes were classified into the following
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80 categories: language impairment (e.g., standard aphasia tests), communication
81 activity/participation (e.g., functional use of language, conversation rating scales),

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82 personal/psychosocial adjustment (e.g., self-esteem, confidence), and quality of life.

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83 Maintenance of changes following intervention was also included in the questions.

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84 <Text box 1 approximately here>
85 In addition, this systematic review followed guidelines for systematic reviews as defined
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86 by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)7,8.
87 PRISMA is an evidence based checklist of minimum items that can improve quality of reporting
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88 in systematic reviews or meta-analyses.

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89 The Literature Search
90 Studies that investigated communication partner training as an aphasia intervention were
91 identified through a systematic literature search. As in the earlier review “intervention was
92 defined broadly to include communication skills training as well as educational or counseling

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93 programs directed at communication partners of individuals with aphasia” with the intent of
94 improving communication with people with aphasia (PWA)1 (p. 1815). Communication skills
95 training focused on teaching communication partners to use strategies or resources to enhance
96 communication of the person with aphasia. Educational programs focused primarily on
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97 increasing partner knowledge of aphasia and related issues. Counseling programs were defined
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98 as those that concentrated on the psychosocial consequences of aphasia (e.g., dealing with
99 depression). Studies were excluded if they involved training partners to provide traditional
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100 language exercises.
101 The following electronic databases were searched: Academic Search Complete,
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Communication & Mass Media Complete, EBSCOhost, PubMed, CINAHL, PsychINFO, Social
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103 Sciences Citation Index (Web of Science), SocINDEX, TRIP database, EMBASE,
104 REHABDATA and the Cochrane Database of Systematic Reviews. In addition, all articles
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105 selected for review were hand searched for additional articles. Twenty-three search terms were
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106 used in searches as follows:

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107 (partner OR family OR spouse OR support team OR volunteer OR staff OR significant other
108 OR dyad) AND (conversation OR communication OR language OR interaction OR social

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109 OR pragmatics OR relationship) AND (therapy OR treatment OR intervention OR training
110 OR coaching OR inservice OR education) AND (aphasia)

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111 The search was limited to articles published in peer-reviewed journals between 2008 and July,
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112 2015. Criteria for inclusion were as follows: written in English, contained original data,
113 addressed one or more of the clinical questions, included adults 18 years of age or older, and
114 addressed aphasia of any etiology. Study design was not a criterion for inclusion/exclusion;
115 group designs, quantitative, qualitative, single participant experimental research as well as case
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116 studies were included to capture the full range of CPT treatment research. Group designs were
117 defined as randomized controlled trials, nonrandomized controlled trials, case series designs
118 reporting group results, and single group pre-post studies. Studies were classified as single
119 participant experimental designs if the design was experimental in nature, involved time-series
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120 measures across baseline, treatment, and follow-up phases, and included experimental control.
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121 Qualitative research included studies that conformed to accepted qualitative traditions, such as
122 ethnography, phenomenology, or grounded theory. Case studies did not involve experimental
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123 control, reported individual results, and/or were primarily descriptive in nature.
124 A total of 1,736 articles were identified in the initial search as schematized in Figure 1. The
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research librarian and one member of the review panel eliminated obvious duplicate citations,
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126 studies not written in English and studies in non-peer reviewed publications. This narrowed the
127 search to 101 articles. Abstracts from these were independently reviewed by the 3 members of
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128 the review team to determine whether articles should be included in the review. Any
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129 disagreements were discussed to achieve consensus on articles appropriate for inclusion. Based
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130 on abstract review, an additional 70 articles did not meet criteria for the review (figure 1).
131 <Figure 1 Approximately Here>

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132 The remaining 31 articles were randomly assigned to 2 members of the review team who
133 independently reviewed and evaluated the articles. During the full review, consensus was
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134 reached that 1 article should be added after hand-searching references, and 7 articles were
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135 rejected for failure to fulfill one or more of the inclusion criteria. A corpus of 25 studies met the
136 final inclusion criteria for full review.
137 Descriptive Review

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138 One reviewer extracted data from each article (using a form used in the 2010 review) to
139 provide a descriptive summary of the study including participant characteristics, intervention
140 characteristics, outcome measures, and types of results. A second reviewer confirmed data
141 extraction for accuracy.
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142 Evaluation of Research Quality
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143 AAN levels of evidence. An evaluation of research quality was conducted by two
144 reviewers utilizing the American Academy of Neurology (AAN) classification of evidence
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145 system2. Disagreements were evaluated by the third reviewer to reach consensus. The AAN
146 clinical guidelines were used in the earlier 2010 review, consistent with the widespread use of
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AAN levels of evidence in medicine and rehabilitation. Based on evidence criteria, each article
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148 was classified into an AAN class. Classes range from Class I (the highest level of evidence)
149 through Class IV (the lowest level of evidence) (see text box 2). In addition, in the 2010 review
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150 AAN procedures were employed to create clinical recommendations for partner training in
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151 aphasia based on four levels of recommendation (A, B, C, U), with A representing the highest
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152 level of recommendation2. Recommendation levels depend on the number of studies that meet
153 specified evidence levels. The current study adopted AAN procedures to determine potential
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154 changes in clinical recommendations for CPT.
155 <Text Box 2 approximately here>

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156 Additional quality reviews. In addition to AAN classification, reviewers employed

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157 “design specific” tools to measure the quality of research methods in further detail. Use of well-
158 defined, objective scales to measure design provides a clearer evaluation of research quality and
159 helps with comparisons across studies4. Therefore, the current procedures employed three
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160 different quality scales: 1) the PEDro scale to evaluate group studies9; 2) the Single Case
161 Experimental Design (SCED) scale10; and 3) the Rating of Qualitative Research (RQR)4.
162 The PEDro scale was designed for scoring the research quality of physical therapy clinical trials
163 (http://www.pedro.org.au ) and has been adapted for other applications (e.g.,
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164 www.otseeker.com). PEDro is a reliable method of evaluating the quality of trials such as
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165 randomized controlled trials, nonrandomized controlled trials, and case series research11,12. Each
166 study is evaluated across 11 quality criteria using nominal ratings of Yes (1 point) and No (0
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167 points) (see supplementary table 1 for criteria). A summary of ratings (excluding one item)
168 results in a maximum quality score of 10 for a study.
169
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Modeled after PEDro, the SCED scale evaluates single case research and is reportedly a
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170 valid and reliable tool10. As in PEDro, judges rate 11 items with 10 of the items included in a
171 total quality score (see supplementary table 2 for SCED criteria). For both PEDro and SCED,
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172 items receive points only if adherence to the criterion is explicitly reported in the article. It
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173 should be noted that the SCED scale has been substantially revised to create the Risk of Bias in
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174 N-of-1 Trials (RoBiNT) Scale13; however the SCED scale was retained for this review in order
175 to remain consistent with the earlier quality review.

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176 The PEDro and SCED scales do not address treatment fidelity or treatment replicability.
177 Because these are important elements of rigorous behavioral treatment research, these items were
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178 added by the authors of the 2010 and 2013 reviews to create PEDro+ and SCED+ scales1,4
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179 resulting in a 12 point scale. Thus, our ratings of CPT group and single case experimental
180 research include a PEDro or SCED rating and a PEDro+ or SCED+ rating.
181 In addition to PEDro and SCED, a third system was devised for the 2010 reviews in order
182 to rate qualitative research. The Rating of Qualitative Research (RQR) consists of 16 items with
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183 14 items included in the overall score (see supplementary table 3 for criteria). Items examine
184 rigor and bias in the study design, methods of data extraction, and analysis methods. The scale
185 was piloted and revised for the earlier review in order to meet reliability and validity
186 requirements4.
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187 Table 1 reports the point-to-point agreement for rating the current articles using the
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188 design specific scales. A third judge rated the article when disagreements occurred and final
189 ratings were agreed upon through consensus. Although a rating checklist was used in the current
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190 study to assess quality of case studies for descriptive purposes, this scale has not been evaluated
191 for reliability and validity; therefore, quantitative results of the case study ratings are not
192 reported.
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193 <Insert table 1 approximately here>
194 Results
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195 Descriptive Review

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196 Of the 25 articles identified for the current review, 11 were group designs, 1 was a single-
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197 participant experimental design, 2 were qualitative studies, and 11 were case studies. Following
198 is a summary of the characteristics of those studies.

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199 Research participants. Supplementary online tables 4 and 5 describe the communication
200 partners and the persons with aphasia (PWA) who participated in the 25 studies. Across all
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201 studies, reported participants included 720 communication partners and 308 PWA. The higher
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202 frequency of partners resulted from studies that trained large groups, such as health care workers.
203 For example, Welsh and Szabo14 reported training 262 nursing assistant students to communicate
204 with PWA.

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205 It should be noted that the total reported participant numbers are not appropriate
206 summary statistics for this review. Several authors published multiple articles that each reported
207 on different findings of what were apparently overlapping groups of participants. For example,
208 Rautakoski15,16,17,18 reported on different findings for up to 43 communication partners across
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209 several publications. Two other studies reported different outcomes for the same group of
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210 participants19,20. In addition, one study21 reported training of 105 health care providers, but
211 outcome data are reported for only 31 trained partners. In order to more accurately reflect unique
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212 study participants and those with outcome data, duplicate participants across studies and
213 participants with no outcome data were eliminated from frequency counts. This resulted in a total
214
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of approximately 589 communication partners and 185 PWA across the 25 studies.
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215 Communication Partners: The majority of communication partners (454/589) took part
216 in group designs, with 112 partners in qualitative studies, 22 in case studies, and 1 partner in a
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217 single case experimental study. Most communication partners (339/454) in the group studies
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218 were medical professionals or health care students. Caregivers, usually the spouse, children or
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219 close friends, served as communication partners in studies by Rautakoski,15,16,17,18 in the single
220 participant design study,22 and in all of the case studies. The relationship of the communication
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221 partners was not stated in Hagge23. Relationship length was not typically stated in studies.
222 Twenty-one (21) of the 25 articles reported the gender of communication partners. In
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223 those articles reporting gender, there were 176 unique female and 60 unique male
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224 communication partners. Nineteen articles reported ages of partners; ages ranged from 19 to 85
225 years old. Studies with medical professionals and students generally had younger participants
226 than studies that included family, typically spouses, as communication partners. Employment
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227 status of partners was reported in 17 of the 25 articles, and included many medical professionals
228 and students. Education of the partners was noted for only 11 studies.
229 Persons with aphasia: A majority of PWA (86/185) took part in group designs, with 77
230 others in qualitative studies, 1 PWA in a single participant design and 21 PWA in case studies.
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231 Across the 19 articles reporting ages of these participants, most were in the 50-70 year range. In
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232 those articles reporting gender of people with aphasia, there were 71 unique female and 114
233 unique male participants. Nineteen articles reported aphasia etiology; this was predominately
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234 stroke, with only 5 participants categorized as another condition. In the 17 articles reporting time
235 post onset of aphasia, all participants were in the chronic phase of recovery (>4 months), except
236
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for one case study31 with three participants who were 14-63 days post aphasia onset. Aphasia
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237 type was reported in 16 articles, most commonly noting nonfluent forms of aphasia (Broca’s,
238 global). Of the 19 articles reporting aphasia severity, the majority of participants had moderate-
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239 severe aphasia.

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240 Type of intervention. A variety of types of partner training were studied in the articles
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241 (see table 2). Both partners and PWA were trained in 16 studies, and training of partners alone
242 occurred in 9 studies. The format for training included training of groups of people (10/25),
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243 training of dyads (8/25), and mixed formats in which some combination of group, dyad, and
244 individual training was delivered (7/25). Typically, unfamiliar partners such as health care
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245 providers or students were trained in groups in order to introduce generic strategies that are
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246 applicable across people with aphasia, while familiar partners such as family members were
247 often trained in dyads (including their aphasic partner) to learn strategies specific to the
248 individual with aphasia. Communication partner training of health care providers or students
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249 was reported in 6 articles, training of volunteers in 1 article, and training of familiar partners
250 (e.g., family) in 18 articles.
251 The amount of training varied, with one article reporting only 1.25 hours of training,
252 while another reported as many as 100 hours of training. Most typically, training took place for
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253 10 to 15 hours. The type of partner training appeared to be related, at least in part, to regional
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254 preferences. For example, 7 of the 26 articles described CPT as an adaptation of the SPPARC
255 program, a commercially available conversational training program published in the UK41. The
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256 SPPARC training programs were reported largely by conversation analysis researchers in the
257 UK, where this approach is widely used. Six articles reported on applications of Supported
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Conversation for Adults with Aphasia (SCATM)42. SCATM approaches were used by researchers
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259 in Canada, USA, and Nordic countries. Three articles reported on adaptations of the CONNECT
260 communication partner scheme27, another UK approach that involves training volunteers to visit
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261 and communicate with people with aphasia in their homes. The remaining articles reported on
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262 various approaches such as total communication15,16,17,18 or Couples Therapy as described by

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263 Boles43. Two articles reported on training that appeared to bridge more traditional language-
264 oriented therapy with CPT25, 32. For example, Carragher et al.32 introduced “interactive
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265 storytelling” in which the person with aphasia worked to increase skill in telling stories, while
266 partners learned to support story telling.

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267 <Table 2 approximately here>

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268 Description of outcome measures. Across the 25 partner training studies, outcome
269 measures were highly varied. Outcomes were coded for general categories including
270 communication activity/participation, psychosocial factors, quality of life, and other (e.g.
271 knowledge of aphasia) (see table 3). In addition, for PWA, language impairment measures (e.g.,
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272 WAB40; CAT44) were used to document outcomes in 5/25 studies. Measures of communication
273 activity/participation were included for 17/25 studies for PWA and 20/25 studies for
274 communication partners. For PWA, these measures were scales of communication use, such as
275 the Communicative Effectiveness Index45, Measure of Participation in Conversation (MPC)46,
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276 questionnaires about communication strategies, or analysis of conversation. For communication
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277 partners, communication activities/participation outcomes included various measures, such as
278 coding communication strategy use in conversation, self-reports of strategy use, ratings of skill
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279 in supporting conversation46, and analysis of conversational interactions. Psychosocial outcomes
280 were reported in 5/25 articles for both PWA and communication partners. These included
281
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ratings or responses to interviews about confidence, attitudes, and relationships between
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282 communication partners and PWA. Only 1 of 25 studies reported quality of life outcomes (for
283 PWA only) and 5/25 studies documented changes in knowledge for communication partners.
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284 One study reported attributes of the training program as noted by communication partners and
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285 individuals with aphasia.

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286 Results of intervention for each clinical question. Table 3 provides a summary of
287 outcome measures and results of training for communication partners and PWA. These results
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288 are summarized according to each clinical question in the following sections (see text box 1 for
289 full text of questions).

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290 <Insert table 3 approximately here>

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291 Question 1 – Acute aphasia. The only paper that provided information pertaining to
292 acute aphasia was a case study of three dyads reported by Blom Johanssen et al.31. The authors
293 noted positive changes in communication for individuals with aphasia on a Swedish version of a
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294 conversation rating scale46 and a post-intervention self-report questionnaire of perceived
295 improvement.
296 Question 2 – Chronic aphasia. Of the 25 studies in this review, 17 reported outcomes for
297 people with chronic aphasia (the other 5 studies reported outcomes only for partners or only for
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298 acute aphasia). Five of the 17 studies of chronic aphasia reported language impairment
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299 outcomes; two of these noted significant improvements, one in a group study with the Western
300 Aphasia Battery40, and one in a descriptive case series using the Comprehensive Aphasia Test44.
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301 No other significant changes were reported on language measures.
302 In contrast, considerable positive changes were noted in PWA on measures of
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communication activity/participation. Following partner training, 9 of the 17 studies of chronic
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304 aphasia reported increases on rating scales and questionnaires about strategy use and the quality
305 of communication in PWA. Conversation samples of PWA, coded in 8 of the 17 studies of

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306 chronic aphasia, evidenced improved use of content words, sentences, communication strategies
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307 and topic initiation.

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308 Five of the 17 studies of people with chronic aphasia incorporated measures of
309 psychosocial adjustment/identity; all 5 of these studies noted psychosocial improvements

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310 following CPT. PWA reported improvements in self-confidence, self-perceptions, identity and
311 relationships, and reduced depression. Of the 17 studies reporting outcomes of chronic aphasia, 1
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312 single participant study22 reported improvement of the PWA on the Quality of Communication
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313 Life Scale47; no other studies of chronic aphasia reported results on a standard quality of life
314 measure. Five out of 17 studies of chronic aphasia examined maintenance of training effects; 3 of
315 these 5noted that communication outcomes on rating scales and conversation samples were
316 maintained up to 23 months following training completion.

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317 Question 3 – Communication partners. Of the 25 studies in this updated review, 21
318 reported outcomes pertaining to communication partners who took part in training. The majority
319 of outcomes across those studies centered on communication skills/activity/participation and
320 reported a variety of communication improvements. For example, 12/21 studies coded aspects of
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321 conversation between communication partners and PWA, and noted increased use of effective
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322 communication strategies or reduced use of negative behaviors by partners. Two of the 21
323 studies reported that naïve viewers readily recognized conversation improvements following
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324 communication partner training. Among the 12/21 studies that reported responses to
325 questionnaires or interviews, communication partners were consistently positive about learning
326
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and using communication strategies and accepting communication changes. An additional 5/21
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327 studies reported increases in knowledge about aphasia following partner training.
328 Only 5 of 21 studies reported outcomes pertaining to psychosocial adjustment/identity for

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329 communication partners. All 5 noted positive changes in self-confidence, self-perceptions or

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330 feelings, and one study reported reduced depression of communication partners. No studies
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331 noted quality of life outcomes for communication partners.
332 Four out of 21 studies that assessed communication partner outcomes reported
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333 maintenance of outcomes at follow up for partners; 2/4 reported that improvements were
334 maintained in knowledge of aphasia, and 2/4 indicated some decline in use of communication
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335 strategies and satisfaction with communication over time.

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336 Quality Review
337 As described in the methods section, two approaches were employed to consider the
338 quality of the 25 studies included in this update. First, studies were coded according to AAN
339 classification (Text box 2). Although 11 studies employed group designs, none of these studies
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340 included design components to assure control and randomization. Moreover, many of the studies
341 did not provide independent assessment of the primary outcome. Thus, based on AAN
342 classification, all 11 group studies received a Class IV designation. Likewise, all other trials in
343 this update received AAN Class IV designation due to lack of experimental control.
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344 In order to further evaluate the group studies, the PEDro scale 9,11 was used to evaluate
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345 design components considered essential to group treatment research. As seen in online
346 supplementary table 6, scores ranged from 0 to 4 on the 10 point scale, indicating low design
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347 quality for treatment efficacy studies. Trials consistently met criteria for reporting outcomes for
348 at least 85% of participants, intention to treat analysis, and statistical analysis of outcome data.
349
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Studies did not incorporate other elements essential in a well-designed treatment group trial,
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350 however. As noted previously, two additional elements, treatment fidelity and treatment
351 replicability, were rated for group designs. Only four studies reported sufficient detail to allow
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352 for replication of the treatment approach and no studies reported on treatment fidelity.
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353 Only one study, Boles22, was assessed with the SCED10 and SCED+ scale (online
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354 supplementary table 7). Although the study obtained a 9/12 score on the SCED+, the study was
355 classified as AAN Level IV because of insufficient experimental control in the design (i.e.,
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356 limited to ABA phases).
357 Two qualitative studies were assessed with the Rating of Qualitative Research (see online
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358 supplementary table 8). McMenamin et al.26 conducted a well-designed qualitative study with a
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359 score of 12/14; McVicker et al.27 scored 4/14. Qualitative research is classified as AAN Class IV
360 because it does not fulfill requirements related to experimental control or randomization,
361 characteristics considered essential for formulating generalizable treatment recommendations.

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362 It should be noted that many of these reviewed studies were designed to expand
363 understanding of characteristics of partner training, investigate feasibility of a form of
364 intervention, or explore new territory; thus, failure to meet quality criteria for clinical
365 recommendations does not negate the value of the research as demonstration studies or
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366 preliminary investigations. However, this set of 25 studies did not meet accepted quality criteria
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367 required to determine efficacy or effectiveness of an intervention. Thus, although studies
368 routinely reported positive outcomes from CPT, conclusions should be tempered relative to
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369 findings regarding research design quality.
370 Clinical Recommendations
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Based on the AAN procedures for translating levels of evidence into clinical
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372 recommendations, the results of the current review are consistent with the earlier review and
373 necessitate no change to the earlier recommendations. Communication partner training focusing
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374 on communication skills remains a recommended approach for enhancing functional

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375 communication of individuals with chronic aphasia. However, no new data have been offered to
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376 strengthen the earlier findings. Furthermore, there remains insufficient research evidence to
377 make recommendations regarding the impact of CPT in acute aphasia or on language
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378 impairment, psychosocial adjustment, or quality of life in chronic aphasia. No new evidence
379 supports CPT described as counseling approaches or educational partner training.

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380 Discussion
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381 Between the 2010 review and the current project, 56 different studies of communication
382 partner training in aphasia were reviewed. AAN classes of evidence for both review periods are
383 presented in table 4. Of these, 2 met criteria for a high quality clinical treatment trial (Class I),
384 and 3 single participant designs were sufficient to meet Class III criteria; all 5 of these were
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385 included in the 2010 review and, according to AAN criteria, allowed for positive clinical
386 recommendations. However, none of the 25 studies in this updated review met AAN criteria
387 required for positive clinical recommendations. Thus, the strength and scope of evidence
388 supporting communication partner training in aphasia remains unchanged despite several years
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389 of additional research.
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390 <Table 4 approximately here>
391 Additionally, there appears to have been little adherence to suggestions offered in the
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392 Cherney et al.4 article regarding research design criteria. In that article, the authors recommended
393 that authors use quality scales (e.g., PEDRO, SCED, AAN criteria) to guide research design and
394
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reporting in order to improve the quality of research reporting in CPT. In fact, the quality of CPT
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395 research for both the current and 2010 reviews has been highly varied. For example, PEDRO
396 scores across the 2 review periods ranged widely from ratings of 0/10 to 9/10. Reports on
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397 treatment fidelity were limited for both review periods, with no fidelity data in the most recent
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398 review and only 13% of studies reporting fidelity in the earlier review. Details about treatment
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399 procedures were also lacking in many studies. For example, some studies reported using
400 “adaptations” of a published approach, but failed to clearly specify the actual changes made to
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401 original protocols. Future research in CPT should include manualized training procedures that
402 are available to researchers and clinicians who wish to replicate methods.
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403 Although the current review does not change the 2010 recommendations, a number of
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404 observations were gleaned from the current analysis and from comparison to the earlier review.
405 For example, the reviewers found that the current review presented challenges not apparent in
406 the 2010 review. There appeared to be a trend for researchers to publish multiple papers
407 reporting results on different aspects of one study. This inflated the number of articles on CPT in
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408 the current review. Also, there were a number of studies that the reviewers found difficult to
409 categorize methodologically. For example, Blom Johannsen et al.31 reported multiple baseline
410 and follow-up measures, but did not adhere to traditional time series measurement (e.g., ABA,
411 ABAB design), precluding inclusion as a single case experimental design. These challenging
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412 designs were typically included as case studies despite adherence to multiple quality criteria.
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413 Interestingly, the inclusion of additional quality criteria resulted in a corpus of case studies that
414 were superior to those reviewed in the 2010 review.
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415 Reviewers also noted comparisons relative to the descriptive data. Although studies of
416 communication skill training predominated in the 2010 review, 11 of the original 31 studies were
417
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categorized as educational or counseling approaches. In the current review, all 25 research
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418 studies focused on training communication skills of partners. Either counseling and educational
419 approaches have fallen out of favor, or possibly they are no longer labeled as communication
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420 partner training in the aphasia literature.

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421 As in the earlier review, the current articles primarily reported outcomes for people with
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422 chronic aphasia and/or partners in the domain of communication activities and participation.
423 Researchers employed a wide array of outcome measurement tools. Despite an ongoing call in
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424 the aphasia literature for use of consistent outcome measures across similar treatments49,50, there
425 was little consistency in outcome measures for both the current and past review, making cross-
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426 study comparisons difficult. In fact, a number of studies employed their own measures, such as
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427 novel questionnaires or self-report scales. Although these measures provided interesting data,
428 validity and reliability data were unavailable. Additionally, despite the movement towards self-
429 report measures, the need for concurrent objective measures by independent assessors would
430 help avoid biased results or placebo effects in treatment trials. Thus, it is recommended that both
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431 self-report and objective clinical assessment (e.g., trained judges, formal tools administered by
432 independent assessors) be incorporated in CPT research.
433 Another trend observed in the current review was an effort to move out of the research
434 lab and into “real life” settings. For example, Jensen et al.21 reported on an ambitious
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435 implementation project involving a staged approach to training health care providers (105 staff
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436 trained) to communicate with PWA in a hospital setting. Rautakoski15,16 reported on CPT
437 involving people with aphasia and their family members in an inpatient rehabilitation setting.
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438 Sorin-Peters and colleagues20 trained nursing staff to implement individualized communication
439 plans in a nursing facility. While all of these projects were categorized as Class IV studies, they
440
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demonstrated the feasibility of implementing CPT in complex natural environments and
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441 provided demonstration studies that serve as a basis for controlled clinical trials.
442 Types of partners trained shifted somewhat from the earlier review. In the 2010 review,
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443 84% of articles focused on training of familiar partners, such as family members or caregivers,
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444 with only 6% addressing health care providers and 10% volunteers. In the current study, 72% of
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445 articles focused on training familiar partners, while 24% focused on training health care
446 providers or health care students. The increased training of health care providers likely reflects a
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447 growing interest in improving communication access and patient-provider communication in
448 health care52.

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449 Related to the shift in types of partners, it should be noted that two studies expanded the
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450 types of communication disorders included in CPT research19,20. Both demonstrated positive
451 results associated with training health care providers to communicate with people with cognitive
452 communication disorders and/or aphasia. While this evidence was insufficient for clinical
453 recommendations, it is important that researchers are beginning to address clinical realities; that
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454 is, staff in health care facilities are faced with a variety of communication challenges. Training
455 across disorders would seem to be a reasonable practice.
456 Study Limitations
457 One potential limitation of this study is the fact that the reviewers were not blind to
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458 article authorship. It is almost impossible for reviewers who are highly familiar with an area of
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459 research to remain blind to authorship; however, reviewer blinding is the preferred method. The
460 heterogeneity of the CPT approaches that were reported across the reviewed studies could also
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461 constitute a limitation. As the corpus of CPT studies grows, reviewers might consider dividing
462 reviews into categories such as generic training of health care providers versus individualized
463
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training of familiar partners. Another limitation is the lack of meta-analysis of the findings; the
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464 reviewers felt there were insufficient data to allow for meta-analysis. Finally, there is always the
465 potential that reports of CPT research were missed in this literature search; a variety of search
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466 engines and search terms were enlisted to minimize missed articles.
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467 Conclusions
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468 All 56 studies reviewed across the current and the 2010 article have reported positive
469 outcomes of communication partner training. These positive outcomes included effects seen for a
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470 range of aphasia severity levels and a variety of types of partners. However, no new
471 recommendations were afforded by the updated review. Interestingly, it appears that the original
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472 recommendations have been accepted as sufficient evidence of the efficacy of communication
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473 partner training for individuals with chronic aphasia. The recent research has attempted to extend
474 the findings of earlier efficacy studies into natural environments (e.g., health care) or explore
475 alternative delivery options, rather than simply expand the corpus of treatment efficacy studies.
476 However, additional high quality efficacy research is needed to strengthen the original 2010
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477 recommendations and expand recommendations to individuals with acute aphasia. In addition,
478 high quality clinical trials are needed to demonstrate that implementation of CPT in complex
479 environments, such as health care, is effective in improving communication. Finally, the lack of
480 consistent outcome measures across CPT studies remains a barrier to interpretation of results and
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481 potential for meta-analysis. The research community should identify tools to capture primary and
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482 secondary outcomes relevant to CPT, and these tools should be routinely applied to CPT
483 research.
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484 In summary, communication partner training focused on communication skills is
485 recommended for partners of people with chronic aphasia. There is insufficient research
486
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evidence to generate recommendations regarding communication partner training in acute
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487 aphasia. Additional high quality research is needed to increase the strength of existing
488 recommendations and to expand the scope of recommendations. Further research is needed
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489 regarding maintenance of partner training effects. In addition, implementation research is needed
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490 to identify the most effective methods of introducing CPT into complex systems (e.g., patient-
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491 provider communication in health care) to improve communication access for people with
492 aphasia.
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Figure 1. Flow chart of systematic review process including number of articles identified and/or
excluded a
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Table 1. Inter-rater reliability of independent quality ratings (prior to consensus)
Rating Scale Inter-Rater Reliability Range
PEDro+ 89% 67% - 100%
SCED+ 67% N/A
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RQR 92% 75% - 92%
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Table 2: Description of Interventions
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Group Designs
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Predominant Participant
CP PWA Total Tx Intervention
Reference Training Length Intervention Description Intervention Focus of
Txed Txed Amount Setting
Focus Training
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Cameron Yes No 1 hr lecture 1.25 hrs University Based on the CONNECT partner Communication Group CP
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et al 201524 15 min practice (Australia) training program
with trained PWA (www.ukconnect.org). Included [health care
didactic content and practical students]
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components (practice with &
feedback from a trained PWA).
Hagge Yes No 2 hr group 12 hrs NS A learner-centered approach Communication Group CP
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201423 communication (USA) including written and oral
training for 6 information about aphasia &
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weeks communication strategies,
reflection, direct instruction, hands
on practice. Homework activities
were based on Couples Therapy43.
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Jensen et al Yes No 2-day workshop for 1 or 2 days Hospital Multi-stage ‘implementation’ Communication Group CP
201521 25 participants; 1- (Denmark) project to introduce supported
day workshop for conversation methods (SCA) to [health care
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80 participants. health care staff, develop resources providers]

Outcomes and ultimately train staff in SCA
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measured for 31 methods. Different participants

individuals participated across stages with
final stage introducing the finalized
version of a ‘workshop’ to staff.
Training was based on SCA,
including roleplay, evaluation of
video examples of SCA, and
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practice with PWA.

McGilton et Yes No 1 day workshop 1 day + at Complex Patient-Centred Communication Communication Group CP
al 201119 & ‘support’ by least. 16 hrs Continuing Intervention (PCCI) including a
SLP for at least 2 of support Care workshop on communication
hrs per week for 8 (Canada) strategies, behavior management
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weeks strategies and the importance of
the environment, abilities focused
care and personhood. Continued
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SLP support for feedback and
demonstration. Additional
outcomes reported in Sorin-Peters
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et al.20
Nykanen Yes Yes 1 hour sessions 20 hours Inpatient Communication Therapy for Communication Individual.
et al 201325 daily for 10 days Rehab People with Aphasia and their (PWA)
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during each of 2 (Finland) Partners (APPUTE) was aimed at
rehab periods , 6- severe aphasia; couples work with Dyad
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months apart the SLP to identify strategies for
the PWA to communicate better
Follow-up eval at 6 and partners learn how to aid the
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months PWA’s communication. Focus on
the PWA initiating a variety of
communication tasks moving from
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simple naming to describing news
reports.
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Rautakoski Yes Yes Two sessions of 5- PWA Residential PWA: Total communication Communication Group PWA
2011a15 6 hrs/day 60 -72 hours Rehab modeled and strategies practiced in
separated by a 3 CP (Finland) group conversations with other Group CP
month interval 30 -35 hours PWAs
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PWA: 8 days in CP: lectures on aphasia & Dyad
first session + 4 communication strategies
days in second PWA+CP: practiced use of
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session communication strategies

CP: 2+4 days
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2011b16 6 hrs/day 60 -72 hours Rehab modeled and strategies practiced in
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CP: 2+4 days
201217 6 hrs/day 60 -72 hours Rehab modeled and strategies practiced in
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session communication strategies.
CP: 2+4 days
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201418 6 hrs/days 60 -72 hours Rehab modeled and strategies practiced in
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CP: 2+4 days
Sorin-Peters Yes No 1 day workshop 1 day + Complex Patient-Centred Communication Communication Group CP
et al 201020 & ‘support’ by 16 to 48 hrs Continuing Intervention (PCCI) : increase
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SLP for 2 to 6 hrs of support Care (LTC) staff’s awareness & increase [heath care
per week for 8 (Canada) knowledge/ use of conversation providers]
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weeks strategies; Learn to use
personalized communication plans
for each long term care resident.
Participated in short version of
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SCA. Additional outcomes
reported in McGilton et al19.
Welsh & Yes No 75 minutes One 75- College Workshop with basic information Education Group CP
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Szabo minute (USA) about aphasia (definition, Communication

201114 session characteristics, causes), first-hand [health care
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accounts by PWA and providers]

communication tips and strategies
based on SCA.
Single Participant Experimental Design

Boles, Yes Yes 60 min sessions 40 hrs University Aphasia Couples Therapy43: Dyad Communication Dyad
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201522 2/wk for 20 wk (USA) training with clinician to increase

conversational success, reduce
difficulties encountered in
conversation. Improving balance
within the conversation was top a
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priority (i.e. equalizing
participation) .
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Qualitative Studies
McMenamin Yes No 1-2 semesters; 7 hr 70 – 100 University 1 day of partner training; Education Group CP
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et al 2015a26 per week for 10-14 hours plus visits participation in 10-12 visits with a Communication
weeks with PWA PWA; weekly reflective blog;
in different fortnightly class tutorials with
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locations student partners.
(home,
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coffee shop,
clinic)
(Ireland)
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McVicker Yes Yes Initial Training: 6 hr initial Hospital Conversation Partner Scheme: Communication Group CP
et al 200927 3 2-hr sessions or training (Britain) Education on communication, Education
1 6-hr session disability, health & safety; training
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Ongoing support: 12 hours with live sessions and videos and
2-hour sessions ongoing persons with aphasia. Ongoing -
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every 6 weeks support completed weekly feedback sheets;
support groups for peer discussion
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Case Studies
Reference Partn PWA Tx Length Intervention Intervention Description Predominant Participant

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er Txed Total Tx Setting Intervention Focus of

Txed Amount Focus Training
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Beckley Yes Yes 8 weeks of 1.5 hr 12 hours Home Better Conversations with Communication Dyad
et al 201328 sessions, 1x per (Britain) Aphasia: Adaptation of SPPARC
week conversation training program.
Phase 1 focused on learning
concepts of turns, conversational
sequences & repair using video;
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Phase 2 focused on developing

strategy use by PWA & CP; Final
stage was role play and reflection
by dyad. Strategies targeted were
use of a keyword in turn initial
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position, use of writing or drawing
and verbal and non-verbal
behaviors to signal turn
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continuation.
Beeke et al Yes Yes 8 weeks of 1.5 hr 12 hours Home Better Conversations with Communication Dyad
201529 sessions, 1x per (Britain) Aphasia: Adaptation of SPPARC
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week conversation training program40.
Phase 1 focused on learning
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strategy use by PWA & CP; Final
stage was role play and reflection
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writing/drawing, keywords, and
gesture for the PWA; and letting
the conversation continue for
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further clues or if understood,
comment, and paraphrase for CPs.
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Decreasing test questions was also
targeted for the CP.
Yes Yes 8 weeks of 1.5 hr 12 hours Home Aphasia: Adaptation of SPPARC Communication Dyad
sessions, 1x per (Britain) conversation training program.
EP
week Phase 1 focused on learning
C

Beeke et al strategy use by PWA & CP; Final
AC
201430 stage was role play and reflection

writing/drawing, keywords, and
gesture for the PWA; and letting
the conversation continue for
further clues, passing a turn, and
paraphrase
ACCEPTED MANUSCRIPT
for CPs.
Blom Yes Yes 6 weeks of 45 min 4.5 hours Hospital & Individualized early family Counseling CP
Johansson sessions, 1x per Home oriented intervention including Communication (3 sessions)
et al 201331 week (Sweden) emotional support and information
for the CP and direct Dyad
PT
communication training for the (3 sessions)
dyad based on SCA.
RI
Carragher Yes Yes 1 x 1.5 hr session 9 hr NS Interactive Storytelling: Goal to Communication PWA
et al 201432 per week for 6 (Britain) improve storytelling; PWA trained Individual
weeks individually to retell a story from a
SC
video, then CP joined session for Dyad
discussion of story and
conversational coaching; identify
U
goals/strategies, practice story;
watch video for feedback and
AN
discussion of strategies.
Fox et al Yes Yes 2 x 60 min sessions 14 hours University Solution Focused Couples Communication Dyad
200933 per wk for 7 weeks Clinic therapy43 . Conversational goals
M
(USA) set; couple engaged in 3 minute
15 min daily home conversations on any topic with
practice requested clinician present, followed by self-
D
reflection and clinician feedback,
specifically focused on individual
TE
goals.
Saldert et al Yes No 1.5 hr, session, 9 hrs University SPPARC: Provided with info Communication Group CP
201334 once per week for clinic about communication, observed
x 6 wks (Sweden) videos to learn strategies to
EP
communicate with PWA; role play;
written exercises as home
assignments between sessions.
C
Strategy training individualized to

some extent to the specific dyad.
AC
Saldert et al Yes No 1.5 hr, session, 9 hrs University SPPARC: Provided with info Communication Group CP
201535 once per week for clinic about communication, observed
x 6 wks (Sweden) videos to learn strategies to
communicate with PWA; role play;
written exercises as home
assignments between sessions.
Strategy training individualized to
ACCEPTED MANUSCRIPT
some extent to the specific dyad.

Sorin-Peters Yes Yes 2 hr session, once 16 hrs Aphasia Goals for each dyad developed Education Group
& Patterson, per week for 8 Center from videotaped conversations and Communication Dyad
201436 weeks (Canada) responses on interview. Group
sessions included general
PT
information about communication
disorders, learning style
differences and their impact on
RI
communication, supportive
communication strategies.
Couples practiced their
SC
individualized communication
strategies with coaching and
feedback from trainers. Based on
U
Adult Learning and SCA.
Wilkinson et Yes Yes 8 weekly sessions, 8-16 hrs Home SPPARC/Interactive focused Communication Dyad
AN
al., 201037 1 to 2 hrs long (Britain) intervention. - Uses. handouts,
role play, written exercises, video
and transcripts to increase
M
awareness of relevant
conversational behaviors.
Discussion and practice of
D
strategies for changing relevant
conversational behaviors during
TE
direct work with the dyad
Wilkinson et Yes Yes 4 sessions 4 to 8 hrs Home SPPARC/Interactive focused Communication Dyad
al 201138 1 to 2 hrs long (Britain) intervention. - Uses. handouts,
role play, written exercises, video
EP
and transcripts to increase
awareness of relevant
conversational behaviors.
C
Discussion and practice of

strategies for changing relevant
AC
conversational behaviors during

direct work with the dyad. Specific
focus on changing topic initiation
behaviors.
ACCEPTED MANUSCRIPT
Txed= trained; Tx= training; hr=hour; min=minutes; PWA=person with aphasia; CP=communication partner; SLP=speech-language
pathologist; wk=week; NS= Not Stated; SCA= Supported Conversation for Adults with Aphasia42; SPPARC= Supporting Partners of
People with Aphasia in Relationships & Conversation41
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
Table 3. Summary of outcomes measures and intervention results for communication partners and persons with aphasia (PWA).
Group Designs
PT
Change
Reference Group Outcome Category Outcome Measure and Results
RI
*
Cameron et al Communication Partner Activity/participation Text responses to listing communication Yes
SC
201524 strategies & resources used with PWA: all
identified a greater # of strategies post-training
(0–5 strategies pre and 1–18 strategies post).
U
As a group total of 39 total strategies reported
pre, 69 reported post, and 28 effective
AN
strategies pre to 66 effective post. Types of
strategies changed after training.
M
Psychosocial Pre-post self-report of confidence (rating);
greater confidence in communicating after the
training; z = 4.624, P < 0.001.
D
Person with Aphasia N/A N/A N/A
Hagge 201423 Communication Partner

TE
Activity/participation One item on a survey asked if a Yes
EP
communication strategy was learned: 80%
agreed or strongly agreed
C
AC
ACCEPTED MANUSCRIPT
Communication Partner Activity/Participation Self-administered questionnaire about Yes

Jensen et al. knowledge of aphasia and communication
201521 Other (knowledge) practices: Post tx knowledge increased (p =
.0004, 95% CI of difference [5.8–17.6]) and
PT
less frustration for PWA (p = .03, 95% CI of
difference [−2.0 to −3.2E-6]). No change in
other 13 questions.
RI
Text responses showed changes in types of
strategies used by partner with PWA
SC
Psychosocial Qualitative interviews: staff perceived the Yes
training positively (more confident about (qualitat
communicating and more willing to engage ive)
U
PWA in conversation). Some challenges
AN
reported (particularly by acute care staff) such
as time constraints, picture tools too complex.
M
McGilton et al Communication Partner Other (knowledge) Nurses knowledge of aphasia: increased Yes
201119 p=.002
D
Psychosocial Nurse attitudes to pts: improved p=.007
No change in nurse relationship with pts and
TE
ease of caregiving
Person with Aphasia Activity/participation Perception of own communication skills:: Yes
improved (p=.037)
EP
Psychosocial Perception of nurse’s ability to relate
effectively: improved (p=.024);
Perception of relationships with nurses:
C
increased closeness (p=.041)

AC
No change in psychosocial well-being

No change in depression
Nykanen et al Communication Partner Activity/participation Communication Skill Evaluation: increased Yes
201325 p<.001
Older the partner the lower the communication
skill scores of PWA
Couple Communication Scale (CCS) showed
ACCEPTED MANUSCRIPT
better scores for simpler tasks than more

complex tasks
Perceived benefits/satisfaction with program
was good post tx and at follow-up although
PT
some difficulty reported outside of home
Person with Aphasia Impairment WAB scores improved from pre to post tx Yes
p<.001
RI
Activity/Participation Communication Skill Evaluation: increased
p<.001 & maintained at 6 month follow-up
CETI increased (p=.01)
SC
PWA who previously had more outpatient
therapy improved more.
Couple Communication Scale (CCS) showed
U
better scores for simpler tasks than more
complex tasks.
AN
Perceived benefits/satisfaction with program
was good post tx but decreased at followup; a
some difficulty reported outside of home.
M
Rautakoski Communication Partner Activity/participation Communication Strategies of the Yes – at
2011a15 Communication Partners (CSCP) 3
D
questionnaire: Trained CPs perceived a months
significant increase in the use of different after
TE
strategies (p=.016) and in the use of strategies training
to support verbal comprehension and
production (p=.026) at 3 months following the No – at
EP
first part of the training. A decrease in the use 6 month
of the strategies was seen at 6 months follow- follow
up. up
C
Control Partners: Improvements were noted

but the changes were not significant. No -
AC
control
Person with Aphasia N/A N/A
Rautakoski Communication Partner N/A N/A

2011b16
ACCEPTED MANUSCRIPT
Person with aphasia Activity/participation Use of Different Communication Methods Yes

questionnaire: PWA perceived significant
changes in use of different means of
communication including increased use of low-
PT
tech devices during (p=.004), and after
(p=.014) the intervention (p=.01); also
increased use of spontaneous nonverbal means
RI
of communication after the intervention.
(p=.014)
CPs perceived increases in PWA during
SC
intervention in spontaneous non-verbal means
(p=.01), low-tech device use (p=.004), and
high-tech device use (p=.032); and at follow up
U
for overall increase (p=.002), spontaneous non-
verbal means (p=.002), low-tech device use
AN
(p=.008), and high-tech device use (p=.024)
201217 Person with Aphasia Activity/Participation CETI rated by CP. Signif. change from Yes
M
pretreatment to 6 months post treatment
p<.002. (Mean CETI score increased from 42.6
D
(16.9) to 51.6 (16.9))
CETI rated by PWA. Change from
TE
pretreatment to 6 months post treatment was
not significant; (Mean CETI score increased
from 49.9 (14.4) to 52.4 (12.5))
EP
201418 Person with Aphasia Activity/Participation Communication Style Questionnaire completed Yes
by CP: Sig differences pre- to post on ratings
C
related to talkativeness (p=.018), rate of speech

(p=.012), and starting conversations (p=.046).
AC
Other responses showed slight increases but

they were not significant.
ACCEPTED MANUSCRIPT
Sorin-Peters et Communication Partner Activity/participation Informal 4 pt rating scale re perceptions of Yes

al 201020 workshop = Ratings of all components of the
workshop ranged from 3.4 to 3.9 out of 4. The
median score for all ratings was 4 out of 4
PT
Questionnaire re. usefulness of
Communication Plans: plans rated as very
useful in relating to residents (X of 4.3 out of
RI
5), for residents with language difficulty
(X=4.3), and in helping understand resident
communication characteristic (X=4.6); plan
SC
presentation was clear (X=4.6). Ratings of
need to talk to SLP for support was lower (X
2.1)
U
Other (knowledge) Knowledge of Aphasia Questionnaire: Paired t
test pre-post workshop p<.001; Pre-one month
AN
follow-up p=.002.
Welsh & Communication Partner Activity/participation On program evaluation survey, 94.5% Yes
M
Szabo, 201114 responded they were aware of at least two
strategies they could use when talking with a
D
PWA, and 94.2% indicated they would
incorporate what they learned into their work
TE
Other (knowledge) Questionnaire with True/False items indicated
overall improvement in knowledge about
aphasia; pre- to post-training improvements
EP
ranged from 14.4% to 32.8% correct. 64.4% of
students improved their performance on post-
session questionnaire.
C

AC
Single Case Experimental Design
Boles, 201522 Communication Partner Activity/participation Conversation: % reflective utterances: Yes

increased d=16.17
Ratings of conversations by naïve viewers:
later sessions viewed as more positive (i.e.
ACCEPTED MANUSCRIPT
more satisfying, more balanced) than earlier

sessions. No perceived difference in the
degree of struggle across sessions.
Person with Aphasia Impairment WAB: no significant change.
PT
Activity/participation Conversation: % utterances contributing to Yes
conversation: increased d=5.47
# utterances: increased d=5.40
RI
# Wds/utterance: increased d=26.76
Quality of life Quality of Communication Life: increased
from mean of 3.06 pre tx to 4.06 post tx.
SC
Qualitative Studies
U
McMenamin Communication Partner N/A N/A
AN
et al 201526
Person with Aphasia Activity/Participation From flexible brainstorm and card sort Yes
techniques, 5 themes captured the experience
M
Psychosocial for PWA. Overall PWA valued the enhanced
social relationships, increased self-confidence,
and positive identity changes associated with
D
the communication partner program.
TE
McVicker et al Communication Partner Psychosocial Nearly all ‘enjoyed visits’ with PWA
200927 Yes
Activity/participation Positive “learning curve” on communication
EP
strategies
Person with Aphasia Psychosocial Changed confidence: 80% Yes
Felt better about trying new things: 50%
C
Case Study
AC
Beckley et al. Communication Partner Activity/participation Conversational Analysis: Wife learned to Yes
201328 prompt husband to use strategies post
intervention
ACCEPTED MANUSCRIPT
Person with Aphasia Impairment No change on Pyramids & Palm Trees, and
subtest of the PALPA and VAST.
Activity/participation Conversation Analysis Profile of People with Yes
PT
Aphasia (CAPPA): Improvements in ratings
of linguistic skill with level of perceived
problem decreased from 71% to 49%.
RI
no change in ratings of repair; decrement in
ratings of initiation, turn taking & topic
SC
Conversation Analysis – increased insight
and acceptance of use of strategies;
increased use of strategies when prompted;
U
failed to generalize to independent use of
AN
strategies.
Beeke et al Communication Partner Activity/participation Counts of behaviors in pre & post conversation Yes
201529 samples:
M
CP 1: no significant effect on strategies chosen
to work on but significant reduction in test
questions, Poisson trend for frequencies (1-
D
tailed) test questions (z = −4.74, p < .0001).
CP 2: no significant effect on strategies chosen
TE
to work on but CP 2’s use of test questions
reduced significantly - Poisson trend for
frequencies (1-tailed), test questions (z = −
EP
6.18, p < .0001).
Conversation analysis: Qualitative positive
changes for CP 1 & 2
C
Person with Aphasia Activity/participation Counts of behaviors in pre & post conversation Yes
AC
samples:
PWA 1: significant increased use of strategies
in post-therapy samples: Poisson trend for
frequencies (1-tailed), writing (z = 2.83, p <
.01); mime (z = 1.89, p < .05); keyword (z =
2.87, p < .01.
PWA 2: no significant effect on strategies
ACCEPTED MANUSCRIPT
chosen to work on.

Conversation analysis: Qualitative positive
changes for PWA 1.
Beeke et al Communication Partner Activity/Participation Counts of behaviors in pre & post conversation Yes
201430
PT
samples. No increase in selected behavioral
strategies but eradicated an unhelpful
conversation behavior (non-acceptance of
RI
writing as a form of communication)
Person with Aphasia Activity/participation Strategy of writing/drawing increased Yes
significantly in post therapy samples: Poisson
SC
trend for frequencies (one-tailed), writing (z =
2.50, p = .0063).
Gesture remained at pre-intervention levels,
U
and key words showed a numerical, but not
AN
statistically significant, increase.
Blom Communication partner Activity/participation Swedish adaptation of MSC46 (SiK). Graphs
Johansson et show improvements for CP 2 and 3, but not for
M
al 201331 CP1. Not all changes were maintained by CP 2.
Estimation of conversational skills. Perceptions
varied with CP 1 and 2 noting improvements,
D
but not CP 3
Program evaluation questionnaire (5 point
TE
Other/Knowledge scale): CPs rated the extent to which the
intervention provided support from 3-5 and the
extent to which it improved conversation, Yes
EP
increased knowledge and understanding of
aphasia from 3-4.
Understanding of Aphasia and Communication
C
questionnaire: Perceived understanding

AC
increased; increases ranged from 3 points (CP

1) to about 15 points (CP 3)
Person with aphasia Activity/participation Swedish adaptation of MPC46 (DiK). Graphs Yes
show improvements for PWA 2 and 3, but not
for PWA 1. Not all changes were maintained
by PWA 2.
CP’s Estimation of PWA’s conversational
ACCEPTED MANUSCRIPT
skills: Perceived improvements noted by all

CPs but these were not maintained in dyad 3.
Program evaluation questionnaire./interview (5
point scale): PWAs rated extent to which the
PT
intervention helped from 4-5, and extent to
which it improved conversations from 3-5.
Carragher et al Communication Partner Activity/participation # salient ideas understood by CP from PWA Yes
RI
201432 story:
3/4 increased for simple stories
2/4 increased for complex stories
SC
Person with Aphasia Activity/participation # salient content words in storytelling: Yes
3/4 increased for simple stories
2/4 increased for complex stories
U
Fox et al Communication Partner Activity/participation Measure of skill in Supported Conversation Yes
200933 (MSC)45; increased from range 1.5 to 2.5 (on
AN
0–4 scale) to range of 3 to 3.5 after training.
Researcher rating of selected goal behaviors in
conversational samples (e.g., probe questions,
M
repair strategies, interruptions) – essentially no
change
D
Satisfaction Rating Scale of conversation,
average mean increase of 1.8, though
TE
slightly reduced at the 1 month follow-up.
Person with Aphasia Activity/participation Measure of Participation in Conversation Yes
(MPC) (Kagan et al., 2004); increased from
EP
range 1.5 to 2.0 (on 0–4 scale) to range of 2.5
to 3.0 after training.
Researcher rating of selected goal behaviors in
C
conversational samples– increased topic

initiation, no change in speech rate or use of
AC
questioning
Satisfaction Rating Scale of conversation,
average increase of 2.7 post tx (with max
increase of 6 points)/ some increases
maintained at 4 weeks post.
ACCEPTED MANUSCRIPT
Saldert et al Communication Partner Activity/Participation Measure of Interaction in Communication Yes

201334 (MIC): some improvement in 2 out of 3 CPs
with following effect sizes: CP 2 after Tx =
2.01 at follow-up 1.26; CP 3 effect size after
PT
Tx = 3.03 and at follow-up 2.02.
Carer COAST – Perceived functional
communication: Variable results of
RI
pre/post/follow up: 1/3 CP’s ratings higher
Psychosocial post-intervention and 2/3 CPs ratings higher at
12-week follow--up
SC
Geriatric Depression Scale: 2/3 CPs improved
after intervention and 3/3 improved at follow-
up
U
Person with Aphasia Impairment Token Test (comprehension) & word fluency: Yes
no obvious patterns on either test across
AN
pre/post/follow up
Activity/Participation Parts of COAST – Perceived functional
communication: 2/3 PWA rated higher after
M
Psychosocial intervention & 3/3 higher after follow up
Geriatric Depression Scale – 3/3 PWA
D
improved after intervention and follow-up
Saldert et al Communication Partner Activity/participation Conversation analysis showed reduced Yes
TE
201535 negative behaviors (teaching, inattentiveness,
dismissive language) at post-treatment.
Positive behaviors remained unchanged (i.e.
EP
use of response tokens such as “mm hm”)
C
Sorin-Peters & Communication partner Activity/Participation Family Intervention for Chronic Aphasia Yes
Patterson, (FICA) couples interview and questionnaire:
AC
201436 reported using specific strategies to facilitate

conversation and appeared more accepting of
communicating in different ways with PWA.
Mixed pattern of change across subjects and
items on FICA questionnaire.
Measure of Skill in Supported Conversation

ACCEPTED MANUSCRIPT
(MSC)46: Improved ratings for 3 of 4 partners

on acknowledging competence; improved
ratings on revealing competence on at least one
measure for all partners.
PT
Person with aphasia Activity/Participation Family Intervention for Chronic Aphasia Yes
(FICA) Couples interview and questionnaire:
All reported increased satisfaction with their
RI
communication abilities. All reported that
spouses were using more specific
communication strategies and appeared more
SC
understanding of their role in conversation.
Mixed pattern of change across subjects and
items on FICA questionnaire.
U
Measure of Participation in Conversation
AN
(MPC): Improved interaction ratings for 3 of 4
PWA..
Wilkinson et Communication Partner Activity/participation Qualitative changes in sequential patterns in Yes
M
al 201037 pre- and post conversations
Quantitative comparisons of samples from pre-
D
and post conversations - # of turns with
questions (negative behavior) decreased from
TE
78% to 22%
Ratings of pre- and post conversations by naïve
SLPs – 14 of 15 SLPs correctly identified post-
EP
treatment from pre-treatment segments
Interview indicated improved interaction, e.g.
“CP does not interrupt but lets PWA aphasia
C
continue”
Person with Aphasia Impairment CAT: No change post-intervention Yes
AC
CAPPA: Perceived improvements included

Activity/Participation speaking with more people in a wider range of
places about a wider range of topics.
Qualitative changes in sequential patterns in
pre- and post-intervention conversations
Quantitative comparisons of samples from
ACCEPTED MANUSCRIPT
Ratings of pre- and post conversation: turns

with at least one sentence increased from 41%
to 59%, and with 2 sentences from 0% to 12%
Ratings of pre and post conversations by naïve
PT
SLPs – 14 of 15 SLPs correctly identified post-
treatment from pre-treatment segments
Conversation partner interview post-
RI
intervention indicated PWA beginning to use
complete sentences
Wilkinson et Communication Partner Activity/participation Post intervention – more actively involved in Yes
SC
al., 201138 PWA’s turns through the use of continuers
such as ‘‘mm hm’’ and head nods.
Person with Aphasia Impairment CAT: significant change (p<.05) on 2 language Yes
U
subtests (naming & reading aloud)
Conversation analysis: Qualitative changes in
AN
Activity/participation management of topic initiation
Qualitative changes maintained at 23 months
post intervention
M
Psychosocial Disability Questionnaire: Perceived impact of
the disability decreased post-intervention with
D
improvements across categories of confidence,
self-esteem, and other emotional consequences
TE
Outcome Category: Activities/Participation refers to measures of participation in conversation or communication unless otherwise
noted; Psychosocial refers to measures of affective issues such as confidence, self-esteem, identity, depression. Isolated ratings of
EP
communicative comfort or connectedness are included under measures of participation in conversation. Environment used here to
refer to measures of environmental support and/or behaviors of the communication partner designed specifically to change the
communicative environment for the person with aphasia.
C
* Change: Yes = improvement demonstrated on at least one measure of outcome for the targeted domain; No = No improvement
AC
demonstrated on any measure of outcome for the targeted domain;

sig = statistically significant
CAPPA = Conversation Analysis Profile of People with Aphasia49
CETI = Communicative Effectiveness Index 45 – rating of functional communication typically by report of caregiver
WAB = Western Aphasia Battery40
ACCEPTED MANUSCRIPT
COAST = Communication Outcome After Stroke Scale48 - measure of functional communication & effectiveness using self-report
ratings
UDCM-Index: Use of Different Communication Methods – 20 item questionnaire developed by the investigator15,16 for participants to
report how much they use various communication method in everyday life
PT
CAT = Comprehensive Aphasia Test44
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
Table 4. Number of research studies classified by AAN Level of Evidence for 2 systematic review periods.
Class I Class II Class III Class IV
PT
2010 Review 2 0 3 26
RI
Current Review 0 0 0 25
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
Text Box 1. Clinical questions that guided the systematic review
1. In persons with acute aphasia, what is the influence of communication partner training on
measures of:
a. language impairment?
PT
b. communication activity/participation?
RI
c. psychosocial adjustment/identity?
d. quality of life?
SC
e. What intervention outcomes are maintained?
2. In persons with chronic aphasia, what is the influence of communication partner training
on measures of:
U
AN
a. language impairment?
b. communication activity/participation?
M
c. psychosocial adjustment / identity?

D
d. quality of life?
TE
e. What intervention outcomes are maintained?
3. For communication partners of people with aphasia, what is the influence of

EP
communication partner training on partner:
a. communication skills/ activity/participation?

C
b. psychosocial adjustment/identity?
AC
c. quality of life?
d. What intervention outcomes are maintained?

ACCEPTED MANUSCRIPT
Text Box 2. American Academy of Neurology levels of evidence2
Class I: Prospective, randomized, controlled clinical trial with masked outcome assessment, in a
representative population. The following are required: a) primary outcome(s) clearly
defined, b) exclusion/inclusion criteria clearly defined, c) adequate accounting for drop-
PT
outs and cross-overs with numbers sufficiently low to have minimal potential for bias d)
RI
relevant baseline characteristics are presented and substantially equivalent among
treatment groups or there is appropriate statistical adjustment for differences.
SC
Class II: Prospective matched group cohort study in a representative population with masked
outcome assessment that meets a-d above OR a RCT in a representative population that
lacks one criteria a-d.

U
AN
Class III: All other controlled trials (including well-defined natural history controls or patients
serving as own controls) in a representative population, where outcome is independently

M
assessed, or independently derived by objective outcome measurement.

D
Class IV: Evidence from uncontrolled studies, case series, case reports, or expert opinion.
TE
C EP
AC
ACCEPTED MANUSCRIPT
1,736
records identified through database
search
1,634
PT
Records excluded
as duplicates, not English or not
peer reviewed publication
RI
101
Titles and abstracts screened by 3
SC
independent judges
70 abstracts excluded:
o 52 not intervention study
U
o 14 not partner training
o 1 not original data
AN o 2 not aphasia
o 1 duplicate
M
1 record added through other
methods (e.g. hand search)
D
TE
32
full text articles reviewed
by 2 independent judges
EP
7 full text articles excluded:

o 2 not intervention study
o 1 not partner training
C
o 2 not one of clinical questions

o 2 no original data
AC
25
Articles included in final review

Complementaria 2. Communication Partner Training in Aphasia An Updated Systematic Review

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Complementaria 2. Communication Partner Training in Aphasia An Updated Systematic Review

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Communication partner training in aphasia: An updated systematic review

Nina Simmons-Mackie, Ph.D., Anastasia Raymer, Ph.D., Leora R. Cherney, Ph.D.

To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 11 February 2016

Communication partner training in aphasia: An updated systematic review

Nina Simmons-Mackie, Ph.D.

Corresponding Author and Address:

580 Northwoods Drive, Abita Springs, LA 70420

Running Head: Communication Partner Training

Key Words: aphasia; communication; treatment outcome; partner communication; rehabilitation

work are clearly identified in the title page of the manuscript.

Reprints of this article will be available from the corresponding author

1 Communication partner training in aphasia: An updated systematic review

7 communication partners were addressed.

9 from relevant articles were hand-searched.

16 accuracy of the extracted data.

19 design specific tools to assess research quality.

26 is needed to strengthen the original 2010 recommendations and expand recommendations to

32 CPT: Communication Partner Training

33 AAN: American Academy of Neurology

35 ICF: International Classification of Functioning, Disability and Health

36 PWA: Persons with Aphasia

37 RCT: Randomized Controlled Trail

40 Communication partner training in aphasia: An updated systematic review

42 Traditionally aphasia rehabilitation has focused primarily on direct treatment of the

45 communication environment have been introduced to facilitate communication in aphasia3.

46 Communication partner training (CPT) is a form of environmental intervention in which people

49 multimodal communication (e.g., gestures) or provide access to pictures or written words to

63 considerations to improve the quality of CPT research.

65 focusing on communication skills appeared to be effective in improving partner skill in

69 of counseling or educational approaches for partners.

72 communication partners, and reconsidering recommendations based on new evidence.

78 International Classification of Functioning, Disability and Health (ICF)5 as well as an aphasia-

81 activity/participation (e.g., functional use of language, conversation rating scales),

82 personal/psychosocial adjustment (e.g., self-esteem, confidence), and quality of life.

83 Maintenance of changes following intervention was also included in the questions.

84 <Text box 1 approximately here>

86 by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)7,8.

88 in systematic reviews or meta-analyses.

89 The Literature Search

90 Studies that investigated communication partner training as an aphasia intervention were

92 defined broadly to include communication skills training as well as educational or counseling

95 training focused on teaching communication partners to use strategies or resources to enhance

96 communication of the person with aphasia. Educational programs focused primarily on

106 used in searches as follows:

108 OR dyad) AND (conversation OR communication OR language OR interaction OR social

109 OR pragmatics OR relationship) AND (therapy OR treatment OR intervention OR training

110 OR coaching OR inservice OR education) AND (aphasia)

131 <Figure 1 Approximately Here>

136 final inclusion criteria for full review.

137 Descriptive Review

141 extraction for accuracy.

154 changes in clinical recommendations for CPT.

155 <Text Box 2 approximately here>

156 Additional quality reviews. In addition to AAN classification, reviewers employed

168 results in a maximum quality score of 10 for a study.

175 to remain consistent with the earlier quality review.

195 Descriptive Review

198 is a summary of the characteristics of those studies.

204 with PWA.

208 Rautakoski15,16,17,18 reported on different findings for up to 43 communication partners across

239 severe aphasia.