Assessment of individuals with aphasia: an integrative literature review

Objective : to analyze which evaluations are used by occupational therapists, speech-language pathologists and physiotherapists on individuals presented with aphasia and what these evaluations address. Methods: the study conducted a national and international documental analysis of evaluations used by professionals working on the neurological rehabilitation of adults and/or elderly individuals with aphasia, published in the last ten years (January 2008/ June 2018). This analysis was performed by an integrative review of databases LILACS, SciELO and PubMed, using the descriptors: Health Assessment or Testing, or Protocols, or Psychometrics, or Questionnaires and Rehabilitation, combined with the descriptors: Aphasia, Occupational Therapy, Speech-language Pathology and Physiotherapy. Results: 26 studies were included, most of which were scored as level VI of scientific evidence; the years of 2013 and 2016 presented publication peaks. The studies used 54 evaluation tools, among which 13 were recurrent in the studies, mostly analyzing aspects of communication/language. It is assumed that these data are related to the fact that speech-language pathologists provide care for individuals with aphasia; however, these individuals may present other needs beyond communication, such as those related to human occupation, requiring multiprofessional and integral health care. Among the protocols, the Stroke Impact Scale (SIS) was considered the most complete, since it addresses communication, linguistic, human occupation and psy-cho-affective aspects. Conclusion: this study identified the use of few instruments dedicated to individuals with aphasia related to all aspects that involve life, with predominance of protocols and evaluations that only address disabilities, highlighting the importance of assessments that address subjectivity, evaluating individuals with aphasia in all dimensions of their lives.

occupational therapists, speech-language pathologists and physiotherapists, and what do they address?

METHODS
The papers were searched on the following databases: Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO) and Public Medicine Library (PubMed). For selection of studies, the bibliographic survey included papers published from January 2008 to June 2018.
The search used the Descriptors of Medical Subject Headings (MeSH) and Descriptors in Health Sciences (DECS) and Boolean operators AND and OR, yielding the following combinations of papers: Health Assessment or Testing, or Protocols, or Psychometrics, or Questionnaires and Rehabilitation. These descriptors were combined with the following: Aphasia, Occupational therapy, Speech-language pathology and Physiotherapy. The corresponding descriptors were used to retrieve papers published in Portuguese, Spanish and English languages.
The study included papers published in the last 10 years, national and international studies, studies involving the use of protocols/evaluations on individuals with aphasia, adults and/or elderly individuals in neurological rehabilitation with occupational therapy, speechlanguage pathology or physiotherapy. The exclusion criteria were: studies using semi-open questionnaires, adapted questionnaires and/or of unknown authorship, pharmacological and medical therapy studies, studies evaluating caregivers and/or relatives, papers and/ or abstracts without free access, literature reviews, systematic reviews, record analyses, letters, editorials and comments.
The levels of evidence were based on the scoring of the Agency for Healthcare Research and Quality (AHRQ) 10 , scored into seven levels, namely: level I -meta-analysis or systematic reviews; level IIrandomized controlled clinical trial; level III -clinical trial without randomization; level IV -cohort and case control studies; level V -systematic reviews of descriptive studies; level VI -descriptive studies; level VII -expert opinion.
These systems of evidence classification provide basis for a critical evaluation of research findings and consequently in decision-making about the incorporation of evidence into clinical practice. The papers were excluded initially by year of publication; then,

INTRODUCTION
Integrality, one of the principles of the Brazilian Unified Health System (SUS) 1 , calls for a broader health system and better social conditions. However, it is known that several factors lead to ineffectiveness of this principle: reductionism and fragmentation of care by health professionals 2 . The professionals require intersubjective knowledge of individuals about the consequences caused by pathologies in daily life 3 , and should also consider the priorities and singularities of individuals and the need for a multidisciplinary team acting in an interdisciplinary manner for integral care.
The sequelae after stroke cause several consequences in the daily lives of individuals. Stroke is one of the most common neurological lesions in adults; they are also the most disabling, because they cause clinical manifestations as motor deficits/hemiplegias, sensory alterations/hemiparesis and language alterations/ aphasias 4 . Aphasias are alterations in the linguistic processes of meaning, which impair the functions of spoken and/or written language 5 to varying degrees, directly affecting the practical life causing occupational deprivations; i.e. they cause difficulties to efficiently perform routine activities, such as writing a check, answering and sending messages by phone, reading a newspaper, talking or even understanding what is spoken 6 .
Aphasias cause difficulties in daily life 5 and thus it is assumed that they may impair human occupations that are significant to the individual, as well as occupational roles. The roles are sets of culturally influenced behaviors that guide and help to organize the performance of social functions, such as being a father, mother, student, etc. 7,8 . Based on the American Association of Occupational Therapy (AOTA) 9 , human occupations refer to daily life activities (performed on a daily basis); they have their goals, meanings and utilities, since they occur in a context. Occupations are fundamental for the identity and personal valuation, and can be classified as: Daily Life Activities (DLA), Instrumental Daily Life Activities (IDLA), Rest and Sleep, Education, Work, Play, Leisure and Social Participation 9 .
Considering that language plays a fundamental role in all aspects of life (social, affective, occupational, mental etc.), and the principles of humanized and integral care, there is an evident need to know the evaluation protocols used by rehabilitation therapists to guide the singular therapeutic planning. Thus, the following guiding question was designed: which are the evaluations used on individuals with aphasia by

LITERATURE REVIEW
The survey retrieved 5,990 papers, among which 82 on the database LILACS, two on SciELO and 5,889 on PubMed ( Figure 1). papers and/or abstracts without free access were excluded.
Thereafter, the titles and abstracts were read, and papers that did not contain the keywords were excluded. The papers were then selected for full reading, excluding duplicates (verified by the Mendeley Desktop software) and those not involving the study subject.

LILACS SciELO
PubMed "Health assessment" OR "Health testing" OR "Health protocols" OR "Psychometrics" OR "Questionnaires" AND "Rehabilitation" AND "Occupational therapy" 10 2 4893 "Health assessment" OR "Health testing" OR "Health protocols" OR "Psychometrics" OR "Questionnaires" AND "Rehabilitation" AND "Speechlanguage pathology" 12 8 68 "Health assessment" OR "Health testing" OR "Health protocols" OR "Psychometrics" OR "Questionnaires" AND "Rehabilitation" AND "Physiotherapy" 54 8 542 "Health assessment" OR "Health testing" OR "Health protocols" OR "Psychometrics" OR "Questionnaires" AND "Rehabilitation" AND "Aphasia" Based on the eligibility criteria ( Figure 2), 186 papers were selected for full reading. However, 8 papers were duplicated and 152 were not related to the study subject, addressing issues as rehabilitation of individuals without aphasia and medical techniques and protocols. Thus, 26 papers were included and evaluated in this study, retrieved from the database LILACS and 25 from PubMed; two are national and 24 international.
The number of publications was unstable over time; there were publication peaks in 2013 and 2016 ( Figure 3). Figure 4 presents the description of papers included in this study, presenting the year of publication in decreasing order; authorship; title; objectives; instruments/protocols; and level of evidence. There was predominance of studies in level VI, which corresponds to studies without strong evidences according to the principles of Evidence-Based Practice.  Promoting psychosocial well-being following stroke: study protocol for a randomized, controlled trial.

Source: Authors
To evaluate the effect of a psychosocial intervention, previously developed and tested for feasibility, based on dialogue, aiming to promote psychosocial wellbeing and coping after stroke among stroke survivors with and without aphasia. Assessing chronic stroke survivors with aphasia sheds light on prevalence of spatial neglect.
To determine the frequency of spatial neglect in chronic survivors of left-side stroke with aphasia.
BIT, CBS, The Life Space Questionnaire BI. Effectiveness of a structured sexual rehabilitation programme following stroke: A randomized controlled trial.
To evaluate the effectiveness of a structured sexual rehabilitation program in an Australian cohort of stroke. Developing complex interventions: lessons learned from a pilot study examining strategy training in acute stroke rehabilitation.
To examine the feasibility of a strategy training clinical trial in a small group of adults with stroke-related cognitive impairments in inpatient rehabilitation, and to explore the impact of strategy training on disability.
FIM. V 2014 GUIDETTI, S. et al. 27 Changes in the impact of stroke between 3 and 12 months poststroke, assessed with the Stroke Impact Scale.
To examine data collected using the Stroke Impact Scale (SIS) at 3 and 12 months after stroke, and to explore any clinically meaningful changes in daily life in relation to age, gender and stroke severity. Treatment for apraxia of speech in nonfluent variant primary progressive aphasia.
To examine a novel approach for the treatment of apraxia in nonfluent aphasia. To investigate the typicality treatment approach on improving naming within 2 inanimate categories (furniture and clothing) using a single-subject experimental design in participants and behaviors in 5 patients with aphasia.

Figure 4. Presentation of main information analyzed on the selected papers
To enhance the systematization and clarity, Figure 5 presents the 54 protocols addressed in the papers, as well as the number of papers using such instruments.
It should be mentioned that the ICF is not an evaluation instrument; rather, it is a classification instrument for identification of aspects related to structures, functions, activity and participation. It was included in this study because of its relevance for understanding the subjective needs of individuals, and especially because the referred study addresses individuals with aphasia 18 . Among the evaluations, the Barthel Index (BI) was the most used, being present in six studies, followed by Stroke and Aphasia Quality of Life Scale-39  , as well as psycho-affective conditions. The following criteria were used for analysis "yes", "no", or "implicit". The criterion "yes" or "no" was used when the evaluation uses or not categories or dimensions that evaluate the referred aspects. The implicit criterion was used when the evaluation does not present the category nor the dimension related to such criteria; however, the approach of these aspects is implicit in the protocol questions.   It should be mentioned that there are few studies addressing individuals with aphasia, especially due to the difficulty to apply the evaluations to deal with linguistic-cognitive alterations 37 . This condition may also explain the fact that publications were unstable over the years.
Most papers used multiple evaluations, with predominance of approach of communicative/linguistic aspects. It is inferred that this predominance occurs because researches related to aphasia are mostly performed by speech-language pathologists. Thus, it is understood that occupational therapists and physiotherapists address physical aspects in their research, such as functionality, independence and activities related to human occupation. Thus, communication is implicitly evaluated in social dimensions or aspects. It is suggested that this result reflects the fragmented view of healthcare professionals.
Among the evaluations included in this study, the SIS scale is the most complete, since it addresses communication/linguistic, human occupation and psychoaffective aspects. SIS is a multidimensional instrument that evaluates the aspects involved in stroke. It consists of 64 items that evaluate 8 domains: strength, hand function, daily life activities (DLA)/instrumental daily life activities (IDLA), mobility, communication, emotion, memory and thinking and participation. Another study 38 , which comprised an integrative review on the quality of life of individuals with aphasia, stated that SIS was the specific instrument of quality of life assessment most used among the studies.
Evaluations performed on individuals with aphasia should address aspects beyond language, requiring evaluation of the individual as a whole, i.e. by all health professionals 39 . The authors of this study, supported by the Franchian conception, emphasize that language is constructed as a meaningful (formal system/language) and communicative system, organizing all cognitive processes and constituting the individual that uses it, its interactions with the physical and social world. Thus, the adoption of biopsychosocial models that address all aspects of human health, evaluations/protocols that enable multidimensional understanding of the impact of aphasia on life is fundamental.
Health actions should allow conceptions of the individual in his or her entirety, approaching the real context, without dissociating the history, singularities, daily life, process of health practices, aiming at a reflexive, integral and humanized health action 40 . For the true application of integrality, health professionals should stop the reductionism and fragmentation of care.
Finally, this study highlights the importance of evaluations that deal with subjectivity, analyzing the individual with aphasia in all dimensions of life. This evidences the importance of putting the individuals in first place in all therapeutic processes, allowing the selfknowledge of their lives and their real health conditions and needs.
As a limitation, this study presents absence of some important evaluation instruments used in studies that are not publicly available. Also, it is noteworthy that, even offering a broad overview of the evaluation instruments/protocols used on individuals with aphasia, an integrative review may not represent the set of studies in a given area due to the indexing databases and descriptors used, and may not include studies found by other search methods.

CONCLUSION
This study observed a broad scenery, 54 protocols, used to evaluate the individual with aphasia by rehabilitation therapists in papers published in the last 10 years. A total of 13 protocols (used in two or more studies) were included in the analysis, among which the SIS was considered the most complete one, since it addresses communication/linguistic, human occupation and psycho-affective aspects.
The results of the literature review demonstrate the utilization of few instruments addressing individuals with aphasia related to all aspects of life, with predominance of protocols and evaluations directed only to disabilities, not addressing the individuality and not directing to a caring that recognizes the real concerns, insecurities and needs.