Aphasia assessment and the ICF

All domains of functioning and disability should be considered for assessment.

Reference: N/A
NHMRC level of Evidence: GPP

Rationale: Assessment of a person with aphasia and their family/carers needs to be flexible and holistic, considering whatever aspects are important or relevant to his or her situation. The ICF (WHO, 2001) can be used as a framework to ensure all key aspects of health have been considered.

As discussed by Bruce and Edmundson (2010), many tests can be used to assess people with aphasia. These range from functional measures of communication to tests of linguistic ability, and from single tests to comprehensive language batteries. The decision to use a particular assessment depends on:

• the user’s theoretical perspective
• their experience
• the aims of the assessment process
• the goals of therapy
• the characteristics of the person with aphasia
• the environment
• and the time and resources available (Kerr, 1993)

No single assessment can hope to measure such a complex and multidimensional process; rather a variety of assessments and protocols are needed to evaluate the different domains. Ideally the assessments should be selected based on hypotheses generated by the clinician regarding the key factors that prevent the person from participating in the areas of life most important to them. For some people, this may mean assessing impairments of body structures and functions, but for others it may mean identifying participation restrictions (Bruce, 2005). The International Classification of Functioning and Disability can be used as a framework to guide assessment selection to ensure that the purposes for assessing are being fulfilled. 

International classification of Functioning, Disability and Health

The International Classification of Functioning, Disability and Health (ICF; WHO, 2001) (see Figure 1) has been used as a framework for defining aphasia (Cruice, Worrall, Hickson, & Murison, 2003; Davidson, Worrall, & Hickson, 2003; Howe, Worrall, & Hickson, 2004; Threats & Worrall, 2004). The ICF is not an assessment tool, but the framework can help guide the selection of assessment methods. The framework encourages a broad view of aphasia as it describes‘‘conditions in terms of body function and structure, performance of activities, participation in relevant life situations, and the influence on functioning of environmental and personal factors’’ (Simmons-Mackie, Threats, & Kagan, 2005, p. 12).

Figure 1 - The WHO International Classification of Functioning, Disability and Health.

Aphasia assessments and the ICF

A number of known and commonly used aphasia assessments can be classified within the ICF structure. Below is a description of these aphasia assessments.  

Body Functions and Structure: Impairment-based tools

This area is currently lacking in systematic reviews that describe the best practice of assessment. Biddle et al. (2002) provided a broad review of speech pathology assessments tools which included three adult language assessments (the BDAE, WAB and the Porch Index of Communicative Ability (PICA).

Bruce and Edmundson (2010) provided a non-systematic review of established aphasia batteries in their commentary on Howard, Swinburn, and Porter’s (2010) “Putting the CAT out: What the Comprehensive Aphasia Test has to offer”.  Information from these reviews have been combined into a  table (see Table 3).

A comprehensive overview of the assessment of aphasia using a cognitive neuropsychological approach and therefore including the PALPA and the CAT is set out in Whitworth, Webster & Howard (2013).

Table 3 Comprehensive language batteries in use in clinical practice (Adapted from Bruce & Edmundson’s table, 2010, p92)

Activity and participation: functional assessment tools

Connected speech tools: 

It is worth noting that the reviews mentioned above focus heavily on language batteries and there has been little synthesis to date on tools which asses connected speech.  Prins & Bastiannse (2004) and Nickels (2005) have provided a critical discussion of  various methods of  analyzing spontaneous speech including:

1. Conversational analysisAims to analysis ‘natural’ conversation between a person with  aphasia and a main conversational partner

• Analytical procedures have been developed (e.g. Sacks, 1972, 1992; Jefferson 1973, 1974; Schegloff, 1968, 1981) which assist in analysing the structured organisation of conversations. Such analyses may be dependent upon transcription (Wilkinson, 2008), or may make use of rating scales of observations during interaction (either directly, or through recording), e.g. Kagan et al 2004, or may use a mixture of the two (Whitworth, Perkins & Lesser, 1997).
• Conversational breakdowns caused by the aphasia (e.g. word finding, comprehension problems) can be identified and potential strategies taught to improve the overall conversational interaction, (e.g. Beeke, Maxim & Wilkinson, 2007)

2. Discourse analysis

1. Confusion is present regarding the term ‘discourse’ ,  Nickels (2005) describes that some authors are referring to connected speech beyond the level of the sentence, while others refer to pragmatic aspects of connected speech. Some authors draw the distinction between ‘microlinguistic’ and ‘macrolinguistic’ features of discourse, in order to distinguish between description of particular wordings and grammatical aspects (‘microlinguistic’, e.g. Coehlo et al 2005) and description of the features of the structure of the discourse that draw it together as a whole and that distinguish it from another type of text (‘macrolinguistic’).
2. For both, a speech sample of communicative behaviour is required
3. Speech samples may be elicited in different ways such as through retelling a  fairy tale (Cinderella  story) or describing a picture (e.g. Cookie Theft picture)
4. Communication behaviours can be analysed (e.g. turn-taking behaviour, conversational repair, discourse cohesion, content and efficiency of language)

Various tools are available to assess a persons connected speech such as: the Profile of Word Errors and Retrieval in Speech (Powers: Herbert et al), and the “Cinderella Story” (Berndt et al., 2000) as well as various discourse measures and approaches such as Correct Information Units (Nicholas & Brookshire, 1993).

While picture description (both of static pictures and of picture sequences) and procedural discourse sampling are frequently used in clinical and research contexts with a view to time efficiency and replicability, it needs to be recognised that there are significant limitations in both the validity and reliability of such short discourse samples (Armstrong et al., 2011). The validity of such samples is intrinsically compromised because the task is unnatural and pragmatically marked (i.e. speakers do not usually describe pictures, particularly not to people who can also see the picture being described), and so when speakers fail to refer to particular features or include unusual information, the methods used to interpret these observations may not reflect the nature and extent of difficulties.  The reliability of analyses of such samples faces two main problems.  First, there is  inherent variability of language use, i.e. speakers’ use of language, including their word choice and grammatical constructions, varies depending on significant aspects of context including what they are talking about, who they are talking with, and the role that language is playing in that particular instance (Armstrong & Ferguson, 2010).  Second, the tools and measures used to describe language use are subject to factors such as the training required for their use, and their suitability for the nature of the sample being analysed.  In particular, there are differences in language use between monologic and dialogic discourse (Armstrong et al., 2011). When using this kind of sampling, it is important to recognise the value of repeated sampling in order to establish a baseline range of performance and the value of ascertaining inter- and intra-judge reliability before interpreting any observed changes in measures.

Social participation tools

Dalemans, de Witte, Lemmens, van den Heuvel, and Wade (2008) completed a systematic review on measures for rating social participation in people with aphasia. Six speech pathologists working with people with aphasia scored the instruments. Of 10 assessments  deemed to be appropriate for measuring aspects of participation, two were considered possibly suitable for use in people with aphasia: the Community Integration Questionnaire (CIQ) and the Nottingham Extended Activities of Daily Living (NEADL).  The CIQ was considered to be much closer to the concept of participation than the NEADL. The  remaining 8  that were  reported as less suitable for people with aphasia were:  The Aachen Life Quality Inventory (ALQI), Frenchay Activities Index, Impact on Participation and Autonomy (IPA), Participation Objective, Participation Subjective scale (POPS), Stroke Adapted Sickness Profile - 30 (SA-SIP),  Sickness Impact Profile (SIP), Adelaide Activities Profile and the Participation Scale.

Functional communication tools

Other tests aim assess communication in a more functional context.  Prins & Bastiaanse  (2004) provided a critical review of  four tools; the Functional Communication Profile (FCP: Sarno, 1969, 1972),  the Communicative abilities in Daily Living (CADL: Holland, 1980), the Pragmatic Protocol (PP: Prutting & Kirchner, 1987) and the American-Speech-Language-Hearing Association Functional Assessment for Communicative Skills in Adults (ASHA FACS:  Frattali, Thompson, Holland, Wohl, & Ferketic, 1995).  The  assessment tools as  described by Prins & Bastiaanse (2004) are summarised in the table below.  While it is recognised  various book chapters  may  provide a more recent review of functional communication tools, such a wide search is beyond the scope of this overview.   Other functional tools  not mentioned in Prins & Bastiaanse (2004) include the Communicative Effectiveness Index (CETI: Lomas et al ., 1989), the La Trobe  Communication Questionnaire (Douglas, O’Flaherty & Snow, 2000) and the Amsterdam-Nijmegan Everyday Language Test (ANELT, Blomert et al., 1994).

Table 5 Overview of some functional assessment tools (Adapted from Prins & Bastiaanse, 2004)

Just as there have been various discussions around the appropriateness of impairment-based assessments, there is also a wider range of views on functional assessment. As Worrall (1992, 2000, Worrall et al 2002) describes it is unrealistic to expect a single assessment to be appropriate  to assess  all individuals with aphasia, all cultures, all impairments and all settings. (in Nickels, 2005)

Resources:

1. Look for video resources on the CCRE Aphasia You Tube channel 

References:

1. World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization.