Speech and swallowing rehabilitation in the home: A comparison of two service delivery models for stroke survivors

Background and Aims Speech and swallowing difficulties are common sequelae for people who have suffered a stroke. Recently, there has been an increase in early discharge, community rehabilitation and the use of therapy assistants to support health professionals in stroke rehabilitation. However, the impact of these factors on communication and swallowing outcomes remains under researched. This research explored Rehabilitation in the Home (RITH) Speech Pathology (SP) services for stroke survivors with dysarthria and dysphagia. More specifically, this research investigated whether traditional speech pathology interventions, supplemented with a home practice program are effective, as well as compare usual treatment to that provided by a therapy assistant. Additionally, the experiences of the key stakeholders were also examined. Methods and Procedures Stroke survivors and their carers were recruited from RITH services in Perth, Western Australia into this pilot comparative group study. Stroke survivors with a recent stroke diagnosis and associated dysarthria and/or oral stage dysphagia were randomly allocated to either: a) treatment as usual with a speech pathologist (TAU) or b) intensive treatment with a speech pathologist and a supervised therapy assistant (INT). Evidence-based dysarthria and dysphagia treatment program content was controlled for both groups and all participants were encouraged to complete independent home practice daily. The stroke survivors were assessed at three time points, at baseline, immediately post therapy and at two months post stroke with a range of speech, swallowing and psycho-social outcome measures. SPEECH AND SWALLOWING REHABILITATION IN THE HOME 4 The perceptions, experiences and preferences of the stroke survivors and the carers were collected through questionnaires after therapy had ceased. The speech and swallowing outcome measures were analysed using a 2x2 mixed model ANOVA and the questionnaires were analysed using qualitative content analysis. Results Ten stroke survivors and their carers (n= 10) were recruited into TAU (n=5) or INT (n=5) intervention groups. The stroke survivors had an average time post onset of stroke of 39.6 days. Stroke survivors participated in regular and intensive levels of RITH SP and all completed some degree of home practice. Therapy was provided over a three week period and TAU participants received M= 470 mins (SD=85.22) and INT participants received M= 909 mins (SD=175.58) of professionally led therapy. Within groups analyses revealed a statistically significant treatment effect over time for scores on the Dysarthria Impact Profile, oral motor function, speech intelligibility, water swallow test and the chewed cookie test. There was no significant difference over time for speech rate. There were no statistically significant differences between the TAU and the INT groups on any of the measures. Carers and stroke survivors gave positive reports of RITH SP with both groups noting improvements in the stroke survivors’ speech and swallowing and commenting on the benefits of receiving rehabilitation in the home. Many stroke survivors valued and desired intensive speech pathology services; with the use of therapy assistants viewed positively by those in the INT group. Stroke survivors reported that they had difficulty practicing independently with most carers being involved with home-based speech pathology intervention. SPEECH AND SWALLOWING REHABILITATION IN THE HOME 5 Conclusions Stroke survivors in an early phase of recovery were able to participate in RITH SP and benefitted from a speech pathology intervention program targeting dysarthria and dysphagia. Intensive speech pathology and therapy assistant intervention was as effective as usual care by a speech pathologist with improvements made by all stroke survivors across the majority of speech and swallowing measures. Stroke survivors were able to complete home practice and provided positive reports on the program, staff and setting. Home practice may be difficult for stroke survivors in the early stages post stroke, and may require support with its completion. Further investigation into the effectiveness and acceptability of home based therapy, the use of therapy assistants and the role of the carer as well as the ease and impact of home programs is required. SPEECH AND SWALLOWING REHABILITATION IN THE HOME 6 COPYRIGHT AND ACCESS DECLARATION I certify that this thesis does not, to the best of my knowledge and belief: (i) incorporate without acknowledgement any material previously submitted for a degree or diploma in any institution of higher education; (ii) contain material previously published or written by another person except where due reference is made in the text; or (iii) contain any defamatory material I also grant permission for the library at Edith Cowan University to make duplicate copies of my thesis as required.