What Every SLP Should Know About The Life Participation Approach to Aphasia

The Life Participation Approach to Aphasia. If you’re a Med SLP, I’m SURE you’ve heard this buzzword (or in this case, buzz-phrase) before. But, do you know what it actually means? * Cue music of impending doom * I’m only kidding… I’m here to break it down for you in a way that is easy to understand. I swear it’s not as scary as it sounds! In fact, you may already be incorporating some of its core principles into your daily practice! So, are you ready to shift your clinical perspective? Then keep on reading, my friends. The Life Participation Approach to Aphasia is a real game-changer for person-centered aphasia therapy.

What is the Life Participation Approach to Aphasia?

The Life Participation Approach to Aphasia (LPAA) is a clinical philosophy whose main goal is to help individuals living with aphasia to achieve or reconnect with their life. This is done by focusing on long-term life goals of their choice. LPAA empowers those with aphasia and their caregivers to take an active role in the goal setting and recovery process. For SLPs, this means embedding real-life tasks and the client’s wishes at the center of clinical decision-making.

LPAA Core Values

LPAA was a group project created by some real powerhouse aphasiologists back in 2000 (yes, it’s been around for that long - so why does it seem we are all just talking about it now?!). The researchers provided a statement of values to help guide clinicians and begin discussing ways in which to change our perspectives on aphasia therapy. (Summarized from Chapey et al., 2000).

1. "The chief goal is the enhancement of life participation"

   So, the SLP assesses how aphasia impacts the individual's ability to participate in chosen life goals.

2. "All those affected by aphasia are entitled to service"

   SLPs can (and should) provide support to caregivers as well as the person with aphasia. Another aspect here is working toward changing social systems so our clients can participate in their communities and be valued members.

3. "Success is measured by life enhancement changes"

   Quality of life and the attainment of participation are important outcomes, which means SLPs can use the client's feelings and perspective to judge if goals are achieved. We can look at other aspects outside of just an improvement on test scores as an indication that therapy is working.

4. "Both personal and environmental factors are targets of assessment and intervention"

   This means we should think outside of just the person with aphasia in order to establish a primary focus of life participation. Train caregivers and community members on how to best speak with someone with aphasia or make materials/the environment “aphasia-friendly.”

5. "Emphasis is on the availability of services as needed at all stages of life with aphasia.”

   The person with aphasia and SLP agree when life goals are met and discharge as needed; however, treatment can always be reestablished when new life goals are made. LPAA functions on the notion that there is no such thing as a plateau and individuals with aphasia can improve even years after their stroke.

Shift Your Perspective

LPAA is quite different from the typical medical or impairment-based rehab model that has been used time and time again. LPAA challenges SLPs to think beyond just the impairment and consider how the impairment impacts the client's participation in activities of interest. As clinicians, we need to understand that although we are experts in communication, our clients are the experts on themselves. Only they can tell us what it is they want to work on. LPAA expands the clinician's role past that of a therapist. We must level the playing field and become their teammate or partner. We can help to facilitate the achievement of meaningful life goals by supporting them. And most importantly, we become reliable communication partners with whom they can share their life goals and know we are there to help them re-engage in what they love to do.

One of my 'AHA!' moments was when I realized that it's not all about the standardized test score. Our clients may score precisely the same on an assessment, but their overall satisfaction and life participation can improve.

That's truly how we know that our therapy was successful. We can document improvements in language, but we can also report increases in social connections, changes to feelings and confidence, and participation in life situations.

Why Incorporate LPAA? 

It's essential for us as speech pathologists to incorporate these frameworks into our clinical practice, particularly in the later phases of rehab where people feel that maybe they’ve reached a plateau. Why?

• People with aphasia are more likely to become clinically depressed than those who sustain a stroke alone. 70% of those with aphasia after stroke become clinically depressed within the first year post-CVA. This increase is partly in change to social roles and relationships.

• Older individuals with aphasia engage in communication activities similar to healthy older adults, but they're limited in the amount and quality of these activities they can participate in due to aphasia

• Social exclusion can be remedied by increasing social support, providing thorough education regarding partner communication, expanding socialization opportunities, and paying close attention to the environment to reduce the risk of communication barriers.

• When asked about their treatment goals, people living with aphasia express that they want to work on tasks related to activities and participation

Living with Aphasia: Framework for Outcome Measurement (A-FROM)

Now, I want to introduce you to a model that will help you implement LPAA into your clinical practice. Cue A-FROM! The Living with Aphasia: Framework for Outcome Measurement (or the AFROM model) was developed by Drs. Aura Kagan and Nina Simmons-Mackie in 2008 as an adaption of the classic WHO ICF model. Specifically, it is a way to capture the unique needs of those living with aphasia.

There are four categories, all of which can (and should) be assessed and treated. These include:

• Personal identity, attitudes, and feelings

  The person with aphasia’s views of themself and how aphasia has impacted them

  • Confidence, motivation, the future

• Participation in life situations

  Activities of choice and life goals that are personally relevant

  • Leisure activities, work/school participation, hobbies/interests, community-based activities like shopping and going out to eat

• Language environments

  Anything outside of the person with aphasia that may be a barrier to communication

  • Community awareness of aphasia, social systems, help with conversation

• The severity of aphasia or other related impairments

  Degrees of impairment in the four domains of language

  • Speaking, listening, reading, and writing

The A-FROM model is a great way to ensure you are implementing LPAA and person-centered care into your therapy sessions. Listen to your patients and place their concerns within this framework to find meaningful goals and therapy tasks!

Are you ready to bring it on home? Let’s use a case example.

Meet Ms. K

Ms. K is a 75-year-old woman with mild anomic aphasia. She is 2 years post-CVA and is discouraged because she has not made as much progress as she hoped. She continues to have difficulty with discourse and has stopped participating in her weekly religious book club. Ms. K feels embarrassed because she struggles to discuss the book with the other participants, and she often demonstrates long pauses due to difficulty finding words. She has also stopped participating in family events and conversations due to trouble processing information at a fast pace. In particular, she avoids her daughter-in-law because she speaks quickly and "has a strong personality." When her daughter-in-law comes to visit she will actually feign a headache and go stay in her bedroom, which has really upset her son and caused a rift in their relationship.

Apply to the A-FROM Model

Let’s take what we learned from this background summary and insert it into the four A-FROM categories…

• Identity: improving her confidence in communication and advocating for herself 

• Environment: communication partner training to support her

• Participation: rejoining her book club and conversing in small groups

• Severity: discourse, word-finding, and external communication supports that target one of the above areas under the other three domains.

Scenario: Book Club

Through collaborative goal setting, we determined that it was possible to modify the book club environment to make it more accessible. Ms. K spoke with the book club leader (her pastor) and decided that he would ask her opinion on a pre-determined portion of the chapter each week. This made her feel more comfortable because she could practice beforehand in therapy to be prepared with what she wants to say.

We utilized Attentive Reading with Constrained Summarization (ARCS) using the book from her club in therapy sessions. This protocol uses reading and verbal summarization of text to improve recall and discourse. Whenever we finished the section, Ms. K would talk about the portion of the book read and we would engage in discussion to improve her confidence in understanding and speaking about the material. 

Scenario: Family Events

To address Ms. K's social isolation, we began with an educational session with her husband to express her concerns. We then started Communication Partner Training (CPT) using Supported Conversation for Adults with Aphasia™. Ms. K now had someone that was there to support her and know the strategies to assist her during family parties. They eventually trained other family members as well.

To address the avoidance of her daughter-in-law, we wrote a script to explain the difficulties she has in conversation. She also used script training for self-advocacy ("I had a stroke, so I have trouble understanding when you speak quickly. Please speak slowly and repeat yourself if I ask"). She then sat down with her husband, son, and daughter-in-law to discuss this and reported her daughter-in-law was very receptive, and she noticed changes right away in the way she interacted with her.

So, What Were the Outcomes?

Through the use of communication partner training, re-engaging in her book club, and self-advocating for herself, Ms. K's confidence began to increase. 

During the initial assessment, Ms. K was given the Communication Confidence Rating Scale for Aphasia (CCRSA) and rated herself as a 40/100 on her confidence speaking with other people. At discharge, she rated herself as an 80/100.

On her ability to connect with family and friends, she initially rated herself as a 20/100 on the CCRSA and this improved to 90/100 at discharge.

Words she used to describe herself at assessment were "embarrassed and discouraged" where at discharge she spoke about how she was more “social, content with where she was and felt her confidence growing.”

I chose this case for a specific reason, and that's for this last outcome here.

Ms. K’s WAB Aphasia Quotient was 82.7 at assessment. So that places her as mild aphasia according to the scoring. By discharge, she scored 85.4. This is not a huge difference by standardized measures. But by looking at the information above, would you say therapy was successful? Yes!

Ms. K had some really great results. The immediate changes she saw from techniques like simply training her husband in CPT and advocating for herself increased her overall confidence. This just made her more motivated to keep going! Although her standardized test score was not drastically different, she succeeded in therapy according to her own report and LPAA principles. 

Let’s Make a Pact

What do you think? Are you convinced yet? LPAA is important to aphasia therapy. Can we make a pact to start incorporating this approach into our clinical practice? Our patients will be better off for it! Remember:

• Focus on function and life participation

• Use personally relevant stimuli

• Make sure you set goals with your clients and their caregivers

• Train communication partners to increase successful conversations and social interactions

• View improvements in quality of life and participation as indicators that speech therapy was successful

Take a minute to leave a comment with either (1) what you’ve learned, or, (2) how you’ve incorporated LPAA into your practice. It’s time for speech pathologists to have discussions, support each other, and implement person-centered care in therapy!

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References:

Chapey, R., Duchan, J., Elman, R. J., Garcia, L. J., Kagan, A., Lyon, J. G. & Simmons Mackie, N. (2000, February 15). Life Participation Approach to Aphasia: A Statement of Values for the Future. The ASHA Leader, 5(3): 4 – 6.

Davidson, B., Worrall, L. & Hickson, L. (2003). Identifying the communication activities of older people with aphasia: Evidence from naturalistic observation, Aphasiology, 17(3), 243-264.

Hersh, D., Sherratt, S., Howe, T., Worrall, L., Davidson, B., & Ferguson, A. (2012). An analysis of the "goal" in aphasia rehabilitation. Aphasiology, 26(8), 971–984.

Kagan, A. & Simmons-Mackie, N. (2008). Beginning with the end: Outcome drive assessment and intervention with life participation in mind. Topics in Language Disorders, 27(4), 309–317.

Parr, S. (2007). Living with severe aphasia: Tracking social exclusion, Aphasiology, 21(1), 98-123.

Simmons-Mackie, N., Raymer, A., & Cherney, L. R. (2016). Communication partner training in aphasia: An updated systematic review. Archives of Physical Medicine and Rehabilitation, 97(12), 2202-2221.

Worrall, L. (2019) The seven habits of highly effective aphasia therapists: The perspective of people living with aphasia, International Journal of Speech-Language Pathology, 21:5, 438-447.

Worrall, L., Sherratt, S., Rogers, P., Howe, T., Hersh, D., Ferguson, A., & Davidson, B. (2011). What people with aphasia want: Their goals according to the ICF. Aphasiology, 25(3), 309-322.

The Aphasia Institute, aphasia.ca

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ABOUT THE AUTHOR

Katie Brown, MA, CCC-SLP, CBIS

Katie is the owner and founder of Neuro Speech Solutions. She is passionate about providing person-centered treatment to her clients in order to meet their life participation goals. Katie is dedicated to helping other SLPs provide functional therapy through affordable materials and education courses.

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