Reading aloud as a therapeutic intervention Protocol

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Completed May 2012

What is the evidence for reading aloud and group reading as a therapeutic intervention to improve the health and well-being of patients with neurological disorders in clinical and long-term care settings?

PROTOCOL

Reading aloud as a therapeutic intervention Protocol

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Contents 1 REVIEW TEAM .............................................................................................................. 3

2 PLAIN ENGLISH SUMMARY ....................................................................................... 4

3 BACKGROUND AND RATIONALE ............................................................................. 4

3.1 Aims and objectives .......................................................................................................... 4

3.2 Background ....................................................................................................................... 4

3.3 Importance of the proposed research ................................................................................ 6

4 METHODS FOR SYNTHESISING EVIDENCE ............................................................ 6

4.1 Search strategy .................................................................................................................. 6

4.2 Study selection .................................................................................................................. 6

4.3 Data extraction strategy .................................................................................................... 8

4.4 Quality assessment strategy .............................................................................................. 8

4.5 Methods of analysis/synthesis .......................................................................................... 8

5 PROJECT MILESTONES ................................................................................................ 8

6 JUSTIFICATION OF SUPPORT REQUIRED ............................................................... 8

7 DISSEMINATION ........................................................................................................... 9

8 REFERENCES ................................................................................................................. 9

9 APPENDICES ................................................................................................................ 10

Reading aloud as a therapeutic intervention Protocol

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1 REVIEW TEAM Julie Latchem1

Dr Janette Greenhalgh2

Dr Rumona Dickson3

1Physiotherapy Team Leader – General and Old Age Medicine, Gloucestershire Royal Hospital, Gloucestershire NHS Foundation Trust.

2Liverpool Reviews and Implementation Group (LRiG), University of Liverpool

3 Liverpool Reviews and Implementation Group (LRiG), University of Liverpool

Correspondence to:

Julie Latchem

Physiotherapy Team Leader

Gloucestershire NHS Foundation Trust

Gloucestershire Royal Hospital

Great Western Road

Gloucester

GL1 3NN

Tel: +44 (0) 8454 228527

Email: Julie.latchem@glos.nhs.uk

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2 PLAIN ENGLISH SUMMARY The Reader Organisation’s ‘Get into Reading’ model of shared reading has to date been used with a

range of different groups of people including people with dementia, depression, single mothers,

women in prisons and is currently being utilised with people with chronic pain. Whilst research into

the health benefits of this model of shared reading, is in its infancy, the research to date has been

encouraging. To date little research has been carried out considering the utilising of this model with

people with neurological conditions. Anecdotally reading groups of varying nature have been seen to

have positive effects of residents with neurological conditions in long-term settings. The aim of this

review is to establish the strength of the current evidence for use of this type of intervention (reading

aloud, group and individual or ‘lone’ reading) on improving the health and well-being of those with

neurological conditions.

3 BACKGROUND AND RATIONALE

3.1 Aims and objectives The objectives of the review are:

• To systematically review and summarise relevant evidence, identifying the breadth of research already conducted around the area of individual or ‘lone’ reading, reading aloud and group reading with people with neurological disease or insult and produce a descriptive map.

• To synthesise the evidence of the outcomes of individual or ‘lone’ reading, reading aloud and group reading interventions to map the potential benefits of the interventions for people with neurological conditions.

• To identify gaps in the literature to inform future research development in this area.

3.2 Background Get into Reading (GiR) is a reading model developed by The Reader Organisation (TRO), a national

charity which has an extensive social inclusion programme based on shared reading (Billington et al,

2010). The GiR Model is a standardised model of group reading. The principal features of the model

is the reading aloud of classic English literature in the session itself and open-ended discussion

encouraged by the facilitator. Each group session follows a standard structure - an initial period of

reflection on the previous session, the reading of a short poem to open and conclude the session and

the shared reading and discussion of a section of a novel. Each session lasts between an hour to an

hour and a half (Billington et al, 2010).

TRO’s intervention is distinguished from other reading therapies (which rely on ‘self-help’ books) in

emphasising the importance of serious, ‘classic’ literature and its role in mediating experience and

offering a model of human thinking and feeling (Davis, 2009). GiR has been nationally lauded:

finalist in 2007 NHS Health and Social Awards (Billington et al, 2010); and identified in the

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Department of Health’s recent New Horizons consultation document as a non-

pharmacological/medical intervention that can help improve quality of life (DoH, 2009).

Robust research into the patient benefits of the model is in its infancy. Observed and reported

outcomes for participants have included: being ‘taken out of the themselves’ via the stimulation of the

book or poem; feeling ‘good’, ‘better’, ‘more positive about things’ after taking part in the group;

valuing an opportunity and space to reflect on life experience, via memories or emotions evoked by

the story or poem, in a convivial and supportive environment; improved powers of concentration; a

sense of common purpose and of a shared ‘journey’; increased confidence and self-esteem; sense of

pride and achievement; valued regular social contact and decreased sense of isolation; improved

communication skills including introduction to new forms of verbal expression. (Robinson, 2008)

These preliminary findings resonate with other innovative research into reading and health, which

suggested that the act of reading together a literary text not only harnesses the power of reading as a

cognitive process: it acts as a powerful socially coalescing presence, allowing readers a sense of

subjective and shared experience at the same time. (Hodge et al, 2007) Related research suggests that

the inner neural processing of language when a mind reads a complex line of poetry or prose syntax

has the potential to galvanise existing brain pathways and to influence emotion networks and memory

function (Thierry et al, 2008; Davis, 2008). The possibility that shared reading can help make those

micro-happenings last longer and bite deeper - both at the point of delivery and in its effects over time

- is a key area requiring dedicated research.

Alongside the benefits highlighted above and the reference to neurological pathways as susceptible to

influence in private or individual reading, anecdotally reading together in groups has been observed to

be beneficial for those with neurological conditions with minor and severe disabilities and

impairments, including observations of reduced challenging behaviour (during the intervention) in

those with severe neurological insult and the engagement of mixed groups of neurological patients

(those with only mild physical impairment with those with severe disabilities and sensory and

cognitive impairments) contributing to a sense of community and connectedness in long-term care

settings. The importance of such an intervention is underlined by evidence that residents with

neurological disorders and their families living in long-term care facilities report that stimulation, a

feeling of connectedness and a sense of community is extremely important to them. (Latchem and

Kitzinger 2012)

The proposed literature review aims to provide a useful precursor into the investigation of the

potential benefit of individual reading and the GiR model of shared reading as an intervention to

improve the health and well-being of people with neurological disorders (i.e. acquired brain injury,

multiple sclerosis, huntingtons disease, stroke).

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3.3 Importance of the proposed research Neurological injury and disease progression manifests in an extensive range of symptoms and

subsequent sensory, motor and cognitive impairments. For those with neurological injury or disease

their symptoms and disabilities not only have a physical impact but a psychological and social one

too, having a potentially devastating effect on their lives. Modern medicine and therapies whilst

heavily assisting those with neurological conditions to manage their symptoms, retain or regain

independence and function for as long as possible are unable to meet all the needs of this population.

The GiR model has the potential to encourage individual self-expression, provide a platform for the

accessing and development of abstract and creative thinking, has the potential to improve divided

attention, elements of language and speech production, social skills, reduce anxiety and dis-inhibition

and provide an opportunity for social interaction, a sense of connectedness and community for those

with neurological conditions.

4 METHODS FOR SYNTHESISING EVIDENCE This research proposal is an evidence synthesis. Data will be extracted from existing papers and will

not require contact with patients, their relatives or staff.

4.1 Search strategy Seven key major electronic databases - AMED (Allied and complementary medicine), BNI (British

Nursing Index), CINAHL (Nursing and allied health), MEDLINE (General medical), PsycINFO

(Psychiatry, psychology and social sciences), Web of Knowledge (Social Sciences, Arts and

Humanities), ERIC (Education) will be searched for relevant published literature. (Please see

Appendix A) for key search terms) These databases have been selected as they cover a wide range of

health, social science, arts and education disciplines.

Systematic searching of the electronic databases, hand searching of key journals, internet searching,

‘snowballing’ technique from references of relevant research studies and consultation with experts in

the field will be conducted. A database of published literature will be assembled and held in the

EndNote X5 software package.

4.2 Study selection The citations identified by the search strategy will be assessed for inclusion in two stages by two

reviewers. Firstly all relevant titles and abstracts identified via electronic searching will be screened to

identify potentially relevant studies for inclusion in the review. Secondly, full text copies of these

potentially relevant studies will be obtained and assessed using the inclusion/exclusion criteria as

outlined in Table 1Error! Reference source not found.. The criteria specified in Table 1 will be

applied to all studies after screening.

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Table 1: Inclusion/Exclusion Criteria Inclusion Exclusion Justification

Population Adults and paediatrics

with any neurological

disease or insult,

progressive or

traumatic.

Those with

developmental or

learning difficulties

or those with a

purely mental

health diagnosis.

Clinical presentations and needs between these

groups whilst having similarities are also extremely

different. Although reading and shared reading

aloud for the excluded groups may have implication

for the focus of the review - adult and paediatric

traumatic or progressive neurology is to be included

only.

Intervention Individual reading;

reading aloud;

reading in groups.

Any form of reading

used either as a

therapeutic

intervention or as an

activity to identify

therapeutic benefit

and/or improve

health or well-being.

Narratives/life

history,

reminiscence

therapy.

Reading for

‘normal’

development of

language or

numeracy skills

development.

fMRI studies using

reading to identify

impairment.

The underpinning focus of this review is to

contribute to establishing if reading and shared

reading – specifically The Reader Organisations ‘GiR’

model - has potential implementation for those with

neurological disorders. Central to this model is

reading aloud, especially reading together in groups

and a continuation of lone reading once the group

has finished.

As the aim of this review is to look at reading as a

therapeutic intervention for those with neurological

disorders studies on ‘normal’ development in

children are not to be included nor studies utilising

reading to identify impairments are not to be

included although they may be referred to as part of

a narrative map or in introduction or background

sections of the final write up. Comparators The above compared

with each other,

placebo or no

intervention

No exclusions. Due to the aim and scope of this review comparative

exclusions would be unnecessarily limiting.

Setting Hospital wards,

rehabilitation centres,

nursing and

residential homes,

respite centres and

hospices. Outpatients

and community

settings i.e GP

surgeries.

No exclusions. Whilst there are no exclusions with regards to

location - the origins of the review is underpinned by

the clinical experience of Julie Latchem in

neurological rehabilitation and long-term settings

and her observations of the positive effects group

reading has on those with complex neurological

needs in long-term care settings. A focus on long-

term care and rehabilitation settings may occur

should vast amounts of relevant literature be

uncovered.

Outcomes Any positive or

adverse health based

outcome, any

objective health

based clinical

outcome measure.

Any subjective

outcomes whether

identified through

thematic analysis or

quantitative data

collection methods.

No exclusions. The effects of reading aloud and reading in groups

for those with neurological conditions is potentially

wide ranging. Excluding any form of health outcome

would be detrimental to the main aims of the

review.

Study design All. Nil. All research methodologies have the potential to

provide a useful insight into the effect of this

intervention. Exclusions would be detrimental to the

aims of the review.

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4.3 Data extraction strategy Study details will be extracted by an initial reviewer using a standardised data extraction form and

subsequently checked by a second reviewer. Should the same data be reported in multiple

publications, the data will be extracted and reported as a single study with all other publications listed.

4.4 Quality assessment strategy The methodological quality of each included study will be assessed using a quality appraisal tool

based on appropriate criteria relevant to the study design. The quality of individual studies will be

assessed by one reviewer and a selection will be independently checked for agreement by a second

reviewer to improve the rigour of the research. Disagreements will be resolved through consensus

and, if necessary, a third reviewer will be consulted.

4.5 Methods of analysis/synthesis The results of the data extraction and quality assessment for each study will be presented in structured

tables and as a narrative summary. The possible effects of study quality on the effectiveness data and

review findings will be discussed. All summary statistics will be extracted for each outcome and

where possible, data will be pooled using a standard meta-analysis. Themes identified through

qualitative studies will also be synthesised and presented in tables.

5 PROJECT MILESTONES

Milestone Date (estimated)

Literature searches May 2012

Article screening June 2012

Data extraction July 2012

Quality assessment July 2012

Data synthesis and presentation August 2012

Final draft of report for peer review September - October 2012

Submission of final report October - November 2012

6 JUSTIFICATION OF SUPPORT REQUIRED This project is funded by LRiG from ‘Capacity building’ funds. Costs are required for time spent on

the project by Julie Latchem to backfill her clinical hours as Physiotherapy Team Leader, General and

Old Age Medicine, Gloucestershire NHS Foundation Trust and to cover travel and accommodation

expenses to allow direction and supervision of the project from key methodologists at LRiG.

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7 DISSEMINATION The review produced as a part of this project will be submitted to LRiG. We will also prepare at least

one paper for publication in an appropriate specialist journal and will propose the work for

presentation at several conferences at which to present the findings.

8 REFERENCES Billington, J. et al (2010) An investigation into the therapeutic benefits of reading in relation to depression and well-being. Liverpool Health Inequalities research institute. Coughlan et al (2007) Step by step guide to critiquing research: Part 1 quantitative research. British Journal of Nursing 16(11) pp658-663 Davis J. (2009) Groups Reading Aloud for Wellbeing, The Lancet, 373, 2009. Davis, P. (2008) ‘Syntax and Pathways’ Interdisciplinary Science Reviews, 33:4, 265-77. Department of Health (2009) New Horizons: towards a shared vision for mental health – consultation. Hodge S, Robinson J, Davis P. (2007) Reading between the lines: community reading project, Medical Humanities 33. Latchem J. and Kitzinger J. (2012) What is important to residents with neurological conditions and their relatives in rehabilitation or long-term care centres? http://www.cardiff.ac.uk/jomec/resources/Long_Term_Care.pdf Khan, K et al (2011) Systematic reviews to support evidence based medicine. Second Edition. London. Hodder and Stoughton Ltd. Robinson, J. (2008) Reading and Talking: Walton Neuro-Rehabilitation Unit & Vauxhall Health Care Centre. HaCCRU Research Reports 114 & 115/08. Ryan et al (2007) Step by step guide to critiquing research: Part 2 qualitative research. British Journal of Nursing 16(12) pp738-744 Thierry G, Martin C, Gonzalez-Diaz V et al.(2008) Event-related potential characterisation of the Shakespearean functional shift in narrative sentence structure, NeuroImage 40: 923-931.

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9 APPENDICES Appendix a) - Key search terms

Intervention Population Location Disorders

read*aloud

Reading therap*

oral reading

lone reading

shared reading

group* read*

poem*

poetry

story-telling

literature

neuro*

stroke

CVA

CVE

multiple sclerosis

huntingtons disease

parkinsons disease

motor-neurone disease

traumatic brain injury

acquired brain injury

Dementia

Alzheimers disease

nursing home*

Residential

home*

long term care

hospital

outpatient*

community

GP surger*

doctor* surger*

aphasia

expressive aphasia receptive aphasia

dysarthria

dysphonia

prosody

phonation

divided attention

challenging

behaviour