Measures of functional, real-world communication for aphasia: a critical review

Figures & data

Table 1. Search terms used for literature search in electronic databases: PsychINFO, Cochrane Database of Systematic Reviews, Medline, Web of Science, CINAHL, PubMed and Google Scholar.

Search terms
Aphasia
AND therapy OR intervention
AND “functional communication” OR “conversational success” OR “everyday communication”

Table 2. List of instruments that aim to measure functional communication in aphasia.

Type of instrument	Name of test
Standardized test	Communicative Abilities in Daily Living 2 (CADL-2; Holland et al., 1999) Amsterdam-Nijmegen Everyday Language Test (ANELT; Blomert et al., 1994) Scenario Test (van der Meulen et al., 2010)
Non-standardized test	ACESA (ACESA; Cunningham et al., 1995) Transactional success (Ramsberger & Rende, 2002)
Observational profiles (clinician rated)	Functional Communication Profile (FCP; Sarno, 1969) Revised Edinburgh Functional Communication Profile (R-EFCP; Wirz et al., 1990) American-Speech-Language-Hearing Association Function Assessment for Communicative Skills in Adults (ASHA FACS; Frattali et al., 1995) Therapy Outcome Measure, Activity Scale (TOM (Enderby et al., 2006))
Observational profiles (client or proxy rated)	Communicative Effectiveness Index (CETI; Lomas et al., 1989) Assessment of Communicative Effectiveness in Severe Aphasia (ACESA; Cunningham et al., 1995) Functional Outcome Questionnaire for Aphasia (FOQ-A; Ketterson et al., 2008) Communicative Activity Log (CAL; Pulvermüller & Berthier, 2008) Communication Outcome after Stroke, client and carer version (COAST and carer COAST; Long et al., 2009; Long et al., 2008) Aphasia Communication Outcome Measure (ACOM; Hula et al., 2015)
Type of instrument	Name of test
Linguistic analysis of connected speech	Correct Information Unit Analysis (CIU; Nicholas & Brookshire, 1993) Information Units (IU; McNeil et al., 2001) Pragmatic Protocol (PPL; Prutting & Kirchner, 1987)
Sociological analysis of interaction	Conversation Analysis (CA; Beeke et al., 2007)

Table 3. The key components that characterise situated language use (based on Clark, 1996).

Components	Definition	Sub-components
Interactive	Joint activity between two people. Actions of one person depend on those of the other.	Feedback backchannels Co-construction of dialogue Familiarity
Multimodal	Multiple interdependent channels of communication are available and integrate into a single composite message. Different channels replace, supplement, complement and emphasize speech.	Language Prosody Gesture Facial expressions Body posture
Contextual (relies on common ground)	Common ground provides interlocutors with context that allows them to assume a degree of “givenness” of information, or directly use physical referents during communication. This relieves the communicative burden	Pre-existing: Communal common ground Personal common ground Discourse representation: Situational context Communicative context

Table 4. The different sub-types of common ground, as described by Clark (1996).

Type	Sub-type	Definition
Pre-existing	Communal common ground	Communal common ground refers to shared beliefs and knowledge based on a shared nationality or religion. Customs that are specific to a certain country or culture, will be shared and readily understood between people from that culture.
	Personal common ground	Personal common ground reflects the number of shared experiences two participants have had together, also referred to as the level of acquaintedness or personal familiarity.
Discourse representation	Situational context	The situational context includes what is physically present in the perceptual environment.
	Communicative context	The communicative context is an accumulation of what has been referred to earlier in conversation (through any modality).

Table 5. List of instruments that aim to measure functional communication in aphasia.

		Components of face-to-face communication^a
				Common ground			Psychometric properties^b
Type of instrument	Name of test	Interactive	Multimodal	Pre-existing	Situational context	Communicative context	Reported measures of reliability and validity
Standardized test	● CADL-2 (Holland et al., 1999)	-	●	-	○	-	● High IntC and IRR, moderate TRT. Good ConcV.
	● ANELT (Blomert et al., 1994)	-	-	-	●	-	● Moderate-high IRR, moderate-high TRT, moderate IntC, moderate -good ConcV for speech production.
	● Scenario Test (van der Meulen et al., 2010)	●	●	-	○	○	● High TRT and IntC, moderate-high IRR, high IntraRR. Good ConcV.
Non-standardised test	● ACESA (Cunningham et al., 1995)	○	○*	-	-	○	● Low IRR, high IntraRR and moderate-high TRT.
	● Transactional success (Ramsberger & Rende, 2002)	○	○	●	-	○	● Moderate IRR, high ConstV, low ConcV, moderate TRT.
Observational profiles (clinician rated)	● FCP (Sarno, 1969)	○*	○	-	○*	-	● Moderate IRR.
	● R-EFCP (Wirz et al., 1990)	○	●	-	-	-	● N/A
	● ASHA FACS (Frattali et al., 1995)	○	○	-	○*	-	● Moderate IntC and IRR, high IntraRR. Low-moderate ConcV.
	● TOM, Activity Scale (Enderby et al., 2006)	○	-	-	○*	-	● Moderate-high IntC, low-high IRR.
Observational profiles (client or proxy rated)	● CETI (Lomas et al., 1989)	○*	○*	○*	○*	-	● High IntC, moderate-high TRT and low-moderate IRR. Good ConcV.
	● FOQ-A (Glueckauf et al., 2003) (Ketterson et al., 2008)	○	○*	~	-	-	● High IntC and good ConcV.
	● CAL (Pulvermüller & Berthier, 2008)	○	○	○*	○*	-	● N/A
	● COAST client and carer version (Long et al., 2009; Long et al., 2008)	○	○	○*	○*	-	● Moderate-high IntC and moderate TRT. Good ConstV.
	● ACOM (Hula et al., 2015)	○	○	○*	○*	-	● Low-moderate ConcV.
Linguistic analysis of connected speech	● CIU (Nicholas & Brookshire, 1993)	-**	-	-	-	○	● High IRR, high IntraRR.
	● IU (McNeil et al., 2001)	-**	-	-	-	○	● High IRR and moderate-high ConcV.
	● PPL (Prutting & Kirchner, 1987)	○	○	-	-	○	● High IRR
Analysis of interaction	● CA (Beeke et al., 2007)	●	●	-	○	●	● N/A, but see Perkins et al. (1999) for a discussion.

^a● Component is taken into account and instrument provides insight into how this component affects communication for PWA, ○ component is taken into account, but instrument does not provide information on how this component affects communication for the PWA. * component is partly taken into account. ** depending on the type of task used to elicit the speech data. If the task is interactive, then this component is taken into account. Often a picture description or a story re-tell task is used, which are not interactive.

^bStability – measure does not vary substantially across administrations (e.g., different sessions, different materials), IntC – Internal Consistency, IRR – Inter-rater reliability, TRT – Test–retest reliability, ConcV – Concurrent Validity (correlated to other measures), ConstV – Construct validity, FaceV – Face Validity, ContV – Content validity. Some measures also reported sensitivity (to discriminate between groups or detect change), we have not reported those here for reasons of space. Psychometric properties are left blank when we have been unable to find any published data. Cut-offs based on Streiner et al. (2015) and Pritchard et al. (2018): reliability scores were labelled as follows: <0.7 = low, 0.7–0.9 = moderate, >0.9 = high. Validity scores were labelled: ≥0.3 = good. For the values themselves, see Table 6 in the Appendix.

Holland, A., Frattali, C., & Fromm, D. (1999). CADL-2: Communication activities of daily living. Austin, Texas: Pro-ed.

 Google Scholar

Blomert, L., Kean, M. L., Koster, C., & Schokker, J. (1994). Amsterdam-Nijmegen everyday language test - construction, reliability and validity. Aphasiology, 8, 381–407. doi:10.1080/02687039408248666

 Web of Science ®Google Scholar

van der Meulen, I., Sandt-Koenderman, W. M., Duivenvoorden, H. J., & Ribbers, G. M. (2010). Measuring verbal and non-verbal communication in aphasia: Reliability, validity, and sensitivity to change of the Scenario Test. International Journal Of Language & Communication Disorders / Royal College of Speech & Language Therapists, 45, 424–435. doi:10.3109/13682820903111952

 PubMed Web of Science ®Google Scholar

Cunningham, R., Farrow, V., Davies, C., & Lincoln, N. (1995). Reliability of the assessment of communicative effectiveness in severe aphasia. International Journal of Language & Communication Disorders, 30, 1–16. doi:10.3109/13682829509031319

 Google Scholar

Ramsberger, G., & Rende, B. (2002). Measuring transactional success in the conversation of people with aphasia. Aphasiology, 16, 337–353. doi:10.1080/02687040143000636

 Web of Science ®Google Scholar

Sarno, M. (1969). The functional communication profile. New York: New York University Medical Center, Institute of Rehabilitation Medicine.

 Google Scholar

Wirz, S. L., Skinner, & Dean. (1990). Revised edinburgh functional communication profile. Tucson, AZ: Communication Skill Builders.

 Google Scholar

Frattali, C., Thompson, C. M., Holland, A. L., Wohl, C. B., & Ferketic, M. M. (1995). Functional Assessment of Communication Skills for Adults (ASHA-FACS). Rockville, MD: American Speech-Language Hearing Association.

 Google Scholar

Enderby, P., John, A., & Petheram, B. (2006). Therapy outcome measures for rehabilitation professionals. Chichester: John Wiley & Sons Ltd.

 Google Scholar

Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The communicative effectiveness index: Development and psychometric evaluation of a functional communication measure for adult aphasia. The Journal of Speech and Hearing Disorders, 54, 113–124. doi:10.1044/jshd.5401.113

 PubMedGoogle Scholar

Ketterson, T. U., Glueckauf, R. L., Blonder, L. X., Gustafson, D. J., Donovan, N. J., Rodriquez, A. D., … Gonzalez-Rothi, L. J. (2008). Reliability and validity of the functional outcome questionnaire for aphasia (FOQ-A). Rehabilitation Psychology, 53, 215–223. doi:10.1037/0090-5550.53.2.215

 Web of Science ®Google Scholar

Pulvermüller, F., & Berthier, M. L. (2008). Aphasia therapy on a neuroscience basis. Aphasiology, 22, 563–599. doi:10.1080/02687030701612213

 PubMed Web of Science ®Google Scholar

Long, A., Hesketh, A., & Bowen, A. (2009). Communication outcome after stroke: A new measure of the carer’s perspective. Clinical Rehabilitation, 23, 846–856. doi:10.1177/0269215509336055

 PubMed Web of Science ®Google Scholar

Long, A., Hesketh, A., Paszek, G., Booth, M., & Bowen, A. (2008). Development of a reliable self-report outcome measure for pragmatic trials of communication therapy following stroke: The Communication Outcome after Stroke (COAST) scale. Clinical Rehabilitation, 22, 1083–1094. doi:10.1177/0269215508090091

 PubMed Web of Science ®Google Scholar

Hula, W., Doyle, P., Stone, C., Austermann Hula, S., Kellough, S., Wambaugh, J., … St Jacque, A. (2015). The Aphasia Communication Outcome Measure (ACOM): Dimensionality, item bank calibration, and initial validation. Journal of Speech, Language and Hearing Research, 58, 906–919. doi:10.1044/2015_JSLHR-L-14-0235

 PubMed Web of Science ®Google Scholar

Nicholas, L. E., & Brookshire, R. H. (1993). A system for quantifying the informativeness and efficiency of the connected speech of adults with aphasia. Journal of Speech and Hearing Research, 36, 338–350. doi:10.1044/jshr.3602.338

 PubMedGoogle Scholar

McNeil, M. R., Doyle, P. J., Fossett, T. R., Park, G. H., & Goda, A. J. (2001). Reliability and concurrent validity of the information unit scoring metric for the story retelling procedure. Aphasiology, 15, 991–1006. doi:10.1080/02687040143000348

 Web of Science ®Google Scholar

Prutting, C. A., & Kirchner, D. M. (1987). A clinical appraisal of the pragmatic aspects of language. Journal of Speech and Hearing Disorders, 52, 105–119. doi:10.1044/jshd.5202.105

 PubMedGoogle Scholar

Beeke, S., Maxim, J., & Wilkinson, R. (2007). Using conversation analysis to assess and treat people with aphasia. Seminars in Speech and Language, 28, 136–147. doi:10.1055/s-2007-970571

 PubMedGoogle Scholar

Clark, H. H. (1996). Using language. Cambridge: Cambridge University Press.

 Google Scholar

Glueckauf, R. L., Blonder, L. X., Ecklund-Johnson, E., Maher, L., Crosson, B., & Gonzalez-Rothi, L. (2003). Functional outcome questionnaire for aphasia: Overview and preliminary psychometric evaluation. NeuroRehabilitation, 18, 281–290. Retrieved from https://content.iospress.com/articles/neurorehabilitation/nre00202

 PubMed Web of Science ®Google Scholar

Perkins, L., Crisp, J., & Walshaw, D. (1999). Exploring conversation analysis as an assessment tool for aphasia: The issue of reliability. Aphasiology, 13, 259–281. doi:10.1080/026870399402091

 Web of Science ®Google Scholar

Streiner, D., Norman, G., & Cairney, J. (2015). Health measurement scales: A practical guide to their development and use. Oxford: Oxford University Press.

 Google Scholar

Pritchard, M., Hilari, K., Cocks, N., & Dipper, L. (2018). Psychometric properties of discourse measures in aphasia: Acceptability, reliability, and validity. International Journal of Language & Communication Disorder, 53, 1079–1093. doi:10.1111/1460-6984.12420

 Web of Science ®Google Scholar