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Disability and Rehabilitation, 2005, 27(6): 287 291

RESEARCH

High scores on the Western Aphasia Battery correlate with good functional communication skills (as measured with the Communicative Effectiveness Index) in aphasic stroke patients

A.M.O. BAKHEIT, S. CARRINGTON, S. GRIFFITHS, & K. SEARLE


Stroke Rehabilitation Unit, Mount Gould Hospital, Plymouth PL4 7QD, UK

Abstract Objective. To examine the correlation between an impairment-level and a functional-level assessment scale of aphasia. Design. Prospective, longitudinal study. Setting. A stroke rehabilitation unit. Subjects. Sixty-seven aphasic acute stroke patients who were undergoing a multi-disciplinary rehabilitation programme, including conventional speech and language therapy (SLT). Intervention. Patients were assessed on study entry and 4, 8, 12 and 24 weeks after the start of SLT. The language impairment was assessed with the Western Aphasia Battery (WAB) and the communicative functional limitation associated with aphasia was measured with the Communicative Effectiveness Index (CETI). Results. There was a statistically signicant correlation between the two scales for all assessment periods (Pearsons r = 0.71; P 5 0.01). Conclusion. The study suggests that in the acute and subacute stages of stroke the scores of WAB and CETI can be surmised from one another.

Keywords: Aphasia, Western Aphasia Battery, Communicative Effectiveness Index

Introduction Impairment of language function is common after stroke, occurring in approximately a third of all patients [1]. Although complete or partial recovery from aphasia has been frequently reported, almost all the studies that measured the effects of the various therapeutic interventions have used quantitative, standard impairment-level assessment scales. For example, Enderby et al. [2] assessed the treatment outcome with the Aachen Aphasia Test, while Katz and Wertz [3] used the Western Aphasia Battery. On the other hand, some authors, such as Bragoni et al. [4], devised their own impairment-based assessment scales. Because complete recovery of linguistic function after stroke is rare, speech and language therapy seeks to improve the patients ability to use the residual verbal skills together with contextual cues

and non-verbal means to achieve effective communication in social situations. Impairment-level assessment scales are unlikely to capture the changes in all of these domains. Consequently, interpretation of the evidence from these outcome measures would be improved by establishing the correlation between the impairment-based outcome measures and the scales that assess change in the subjects functional communicative skills. However, the study of the relationship between language impairment scales and those that assess the functional disability associated with aphasia has so far received little attention. A correlation between Porch Index of Communicative Ability and the Communicative Abilities in Daily Living has been previously reported [5]. However, the relationship between the Western Aphasia Battery (WAB) and functional scales has not been studied. WAB is the most widely used aphasia

Correspondence: Professor A.M.O. Bakheit, Stroke Rehabilitation Unit, Mount Gould Hospital, Plymouth PL4 7QD, UK. Tel: + 44 1752 272481; Fax: + 44 1752 272483; E-mail magid.bakheit@pcs-tr.swest.nhs.uk Accepted August 2004. ISSN 0963-8288 print/ISSN 1464-5165 online # 2005 Taylor & Francis Group Ltd DOI: 10.1080/09638280400009006

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Table I. The demographic and clinical characteristics of the study sample (n = 67). Age (years) mean (range) Gender Male Female Right hand dominant Formal education (mean (SD) years) Stroke type Ischaemic Haemorrhage Baseline FAST, mean (SD) Type of aphasia Broca Anomic Global Wernicke Conduction Transcortical (motor) Time of rst testing, mean (SD) (days) 71.9 (38 92)

impairment level test in English-speaking countries [6] and its study would be clinically important. In the present study we prospectively examined the correlation between the scores of the WAB with those of the communicative Effectiveness Index (CETI) a commonly used functional-level scale for the assessment of the communication disability associated with aphasia. Methods The data of the current study were collected as part of an on-going prospective, randomised controlled trial of the effectiveness of the intensity of conventional speech and language therapy on recovery from post-stroke aphasia. The study was approved by the local research ethics committee and consent to take part in the study was obtained from all patients, except those with severe impairment of language comprehension. The latter patients were recruited for the study only with the agreement of their next of kin. The study sample All patients who were admitted to our district general hospital during the study period with a diagnosis of rst-ever stroke were screened for impairment of language function by a speech and language therapist (SLT). A total of 68 patients completed the therapy programme and assessments. In one patient CETI scores were not available. This patient was excluded from the nal analysis. A summary of the patients demographic and clinical characteristics is given in Table I. Stroke was diagnosed according to the standard clinical criteria and conrmed with a CT head scan. The patients hand dominance was established by directly asking the patient and his/her close family members. The screening for aphasia was made with the Frenchay Aphasia Screening Test (FAST) [7]. FAST is a simple method of proven reliability and validity and is suitable for the initial assessment to identify patients with aphasia. Those who scored below the recommended cut off point (i.e., 27 if the patient is 60 years old or less or 25 if older than 60 years) were assessed further with the Western Aphasia Battery (WAB). A score of 93.8 or less on WAB was taken as conrmation of the presence of aphasia [8]. Patients who were diagnosed as having aphasia according to the WAB scores were asked to participate in the study. Patients for whom English is not the rst language were excluded because of concerns about the validity and reliability of the translated versions of WAB. Similarly, those with a diagnosis of Parkinsons disease or depressive illness were excluded,

31 36 62 10.5

(46.3%) (53.7%) (92.5%) (2.6)

62 (92.5%) 5 (7.5%) 8.3 (7.0) 21 18 15 9 3 1 32.1 (31.4%) (26.8%) (22.3%) (13.5%) (4.4%) (1.4%) (18.8)

as these disorders are known to reduce verbal uency and impair language processing [9,10] and may therefore interfere with the interpretation of the WAB scores. The therapy intervention Conventional speech and language therapy (SLT) was given to improve the patients ability to communicate with others with verbal and nonverbal means. The approach to therapy was eclectic and individualised. Therapy exercises targeted improvement in understanding and expression both of spoken and written language in order to improve communication in everyday life. These included tasks such as picture/object selection, naming objects, describing and recognising association between items, facilitating the expression of feelings and opinions and improving conversational skills. Patients were also encouraged to use gesture and other means of non-verbal communication, including a wide range of communication aides and equipment. The treatment programme for each patient was individualised to suit the patients needs and ability to tolerate the therapy session. SLT was delivered by qualied therapists of comparable experience. The treating therapist was blinded to the patients group randomisation and did not carry out any of the patients assessments. The SLT was delivered as part of a multi-disciplinary, goal-directed rehabilitation programme. Treatment was usually started in the rehabilitation unit and continued in the outpatients department or in the patients home following discharge from hospital.

The Western Aphasia Battery Outcome measures Impairment of language function was assessed with the Western Aphasia Battery [11] and functional communication was evaluated using the Communicative Effectiveness Index [12]. The Western Aphasia Battery (WAB). WAB is a validated test that can be administered in about 60 90 min. It assesses uency, language information content, comprehension, repetition and naming. Each of these subsets is scored on a numerical scale and added to form an overall score, the Aphasia Quotient (AQ). The test was administered by a qualied and experienced speech and language therapist. On the WAB verbal uency was assessed by asking the patient conversational questions and to describe a simple picture of a house and a pond with people and animals. The information content of speech was scored on the same material used to test uency. Comprehension was assessed by recording the patients yes/no responses to questions of increasing complexity, by pointing to 10 items, including objects and body parts, and by asking the patient to obey commands of increasing complexity. Repetition was tested with words, numbers and sentences of low and high probability. The raw scores for uency, comprehension, language information content, naming and repetition were added up and multiplied by two. The result was then expressed as a percentage of hypothetical score of 100 to give the Aphasia Quotient (AQ). The AQ measures the severity of the language decit and is also used as a quantitative measure of improvement (or deterioration) of language function (at the level of impairment) over time [8,11]. The Communicative Effectiveness Index (CETI ). The patients competence in functional communication was evaluated with CETI [12]. This instrument consists of 16 items chosen for their importance in every day life. The patients performance is rated by a family member or carer. Each item is scored separately on a visual analogue-type scale (0 = not at all able, 10 = as able as before stroke). The scores are added up to give the communicative effectiveness index. The maximum score on this scale is 160. CETI was developed in collaboration with aphasic patients and their carers and has been validated and shown to have an excellent test retest and interrater reliability [12]. Assessment schedule A research SLT who was not aware of the patients group randomisation or involved in the patients

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treatment carried out the initial screening and all subsequent assessments. The baseline assessment was carried out on study entry, as soon as the patient was well enough to complete the initial evaluation and tolerate therapy. Subsequent assessments of the study groups were made 4, 8, and 12 weeks later. Data analysis The data were analysed on a personal computer using the Statistical Package for Social Science for windows (SPSS version 11.0) software. The relationship between the WAB and CETI scores was examined with Pearsons correlation at baseline, and 4, 8, 12 and 24 weeks after the start of SLT. The level of statistical signicance was set at P 5 0.05 for all tests. Results As graphically illustrated in Figure 1, there was a statistically signicant positive correlation between WAB and CETI scores. The mean (SD) of all WAB and CETI scores over all test periods were 60.6 (26.0) and 99.3 (37.0), respectively, and Pearson product moment correlation coefcient was r = 0.71. The correlation was statistically signicant (P 5 0.01). Because there was a tendency for the scores of both scales to be low in the immediate aftermath of stroke and increase after therapy, data analysis was performed for the individual assessment periods in order to see if the change over time was also mirrored in the correlation between the scores. The results are summarized in Table II. These suggest that the correlation between the WAB and CETI scores is strong at low and high scores.

Figure 1. The relationship between WAB and CETI scores.

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Table II. The correlation between the WAB and CETI scores at the different periods of assessment during the study.

Assessment period Baseline 4 weeks 8 weeks 12 weeks 24 weeks

WAB, mean (SD) 44.3 61.1 66.7 67.4 69.3 (28.1) (25.2) (22.9) (25.5) (23.5)

CETI, mean (SD) 63.4 (34.1) 95.6 (29.3) 112.0 (25.1) 115.4 (28.8) 124.0 (26.4)

Pearsons r 0.70 0.67 0.53 0.66 0.68

P value 5 0.01 5 0.01 5 0.01 5 0.01 5 0.01

Discussion The ndings of this study indicate a statistically signicant correlation between the severity of poststroke language impairment and the functional limitations caused by it as measured with WAB and CETI, respectively. Furthermore, the changes in the impairment and functional limitation over time were reected by both assessment scales in a similar way. The relationship between WAB and CETI reported here suggests that the scores of one scale can be predicted from the other in the acute and subacute phases of stroke. This is despite the fundamental differences between the two assessment scales in their aims and methods of administration. To our knowledge only one other study has previously examined the relationship between WAB and CETI [13]. The study population consisted of 50 subjects with chronic aphasia who were undergoing a community-based SLT programme. The authors found a strong positive correlation between the scores of the two scales at baseline, but, in contrast to our study, there was a moderate negative correlation after completion of the therapy programme. This discrepancy may have been because, in chronic aphasics, improvement at the level of impairment lags behind the improvement in the functional communication ability as the biological recovery slows but the patients continue to acquire new communication skills. Methodological differences may also explain the discrepancy between the ndings of the two studies. In the study by Aftonomos et al. [13], the study sample was not selected randomly and the treatment and assessments were made by the same therapist. Our study sample is representative of the patient population with a hemispheric stroke that are admitted to a rehabilitation unit. The age and gender prole of the study group and the aetiological classication of their stroke are similar to those reported in major epidemiological surveys (e.g., Bonita [14]). Similarly, the incidence of the different forms of aphasia [15] (according to the classication by WAB subscores) and the frequency of the cerebral lateralisation of language function to the left hemisphere (as suggested by hand dominance) in the

study group mirrors that of the aphasic sample as a whole [16]. This suggests that our ndings are likely to be generalisable to aphasic patients in the acute and subacute stages of stroke. We chose to study patients for 6 months after recruitment. This appears to be the optimal time for follow up because most of the biological and functional recovery after stroke, including improvement in language function, is completed during this time scale.17,1 In addition, by this time most patients are discharged from hospital. Patients were reassessed 6 months after study entry on the assumption that re-integration into the community would introduce new challenges to disabled aphasic subjects. We were interested in establishing if the correlation between WAB and CETI scores is maintained over time and in different environmental settings and social contexts. This was indeed the case. However, as recovery from aphasia can continue for many years,18 it would be interesting to repeat the study in patients with longstanding aphasia. It has been suggested that high scores on CETI are not necessarily an indication of good communication ability in natural settings [19]. Nonetheless, CETI is probably preferable to other tools used for the assessment of functional limitations due to aphasia, such as the Assessment of Communicative Effectiveness in Severe Aphasia (ACESA) [20] and the Communicative Abilities in Daily Living (CADL) [5]. CETI has several advantages over these assessment scales. It assesses communicative abilities that are relevant to activities of daily living and is rated by a family member or carer who is familiar with the patients premorbid communication style. In addition, it is simple, brief and of proven validity and reliability. We speculate that CETI is more suitable than other aphasia functional assessment tools in the early period after stroke. A head-to-head comparison between these scales would be required to conrm or refute this. Acknowledgement The work leading to this publication was supported by a research grant from the Tavistock Trust for Aphasia.

The Western Aphasia Battery References


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