Augmentative and Alternative Communication (AAC) for adults with severe aphasia: where we stand and how we can go further

Augmentative and alternative communication intervention for in-patient individuals with post-stroke aphasia: study protocol of a parallel-group, pragmatic randomized controlled trial

BACKGROUND

People with post-stroke aphasia commonly receive speech-language therapy (SLT) when they are admitted to hospitals. Commonly, these patients reported communication difficulties in in-patient settings. Augmentative and alternative communication (AAC) has been reported as an effective treatment approach to improve communication effectiveness, language performance, decreasing depression, and improving quality of life for this population. However, little evidence has demonstrated the use of AAC intervention (AACT) in early recovery from people with post-stroke aphasia in in-patient rehabilitation settings for improving these patients' communication effectiveness. The pilot randomized controlled trial (RCT) will explore the effectiveness and feasibility of including AACT in regular SLT for in-patient people with post-stroke aphasia.

METHOD

This pilot RCT is a single-blind, randomized controlled trial with two parallel groups. Both groups receive a 1-h treatment session, including either both AACT and SLT or SLT only for ten consecutive days. We aim to include 22 in-patient participants with post-stroke aphasia in each group. Participants will be assessed at pre- and post-intervention and 2 weeks after intervention. The primary outcomes are the ability of communication measured by the communication of basic needs subtest in the Functional Assessment of Communication Skills for Adult (FACS) and the overall language performance measured by the Chinese Standard Aphasia Battery (ABC). The secondary outcomes include a 10-min conversation, the 10-item Hospital version of the Stroke Aphasic Depression Questionnaire (SADQH-10), the Stroke-Specific Quality of Life Scale (SS-QOL), and a patient and caregiver satisfaction questionnaire.

DISCUSSION

This pilot RCT will contribute to new scientific evidence to the field of aphasia rehabilitation in early recovery during the in-patient period. The paper describes the trial, which will explore the effect of combining AACT and SLT and SLT only, our choice of primary and secondary outcome measures, and proposed analyses. The study results will provide information for implementing AACT in the regular in-patient SLT of future RCTs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry database (ChiCTR) ChiCTR2000028870 . Registered on 5 January 2020.

Effectiveness and Utility of Visual Scene Displays as Communication Supports for Adults and Children With Complex Communication Needs: Perspectives of Clinicians and Researchers

Purpose The aims of this research study were to describe the perspectives of clinicians and researchers regarding the effectiveness of visual scene displays (VSDs) as communication supports in order to inform the translation of research to clinical practice. Method An online survey was completed by 298 clinicians and nine VSD researchers. Participants rated the effectiveness of VSDs in supporting a variety of communication functions and their strength of agreement regarding statements of VSD utility. Results Regardless of population served, clinicians and researchers rated VSDs as effective at supporting a range of communication functions. Participants also tended to agree with statements of VSD utility. Conclusions The current study highlights the perceptions of clinicians and researchers regarding the uses and benefits of VSDs for adults and children with complex communication needs and provides an initial measure of the current translation of research to clinical practice. Results indicate that VSDs can be used to support a variety of communication functions and utilities; however, further work is necessary to explore additional communication functions and delineate similarities and differences of VSD uses for differing populations. Supplemental Material https://doi.org/10.23641/asha.14551344.

Personalization of Visual Scene Displays: Preliminary Investigations of Adults with Aphasia, Typical Females across the Age-Span, and Young Adult Males and Females

Visual scene displays (VSDs) are becoming an increasingly popular method of message representation within augmentative and alternative communication (AAC) supports; however, design factors can influence the effectiveness of these images as communication supports. One issue that has come to light in recent years is the fact that selecting personalized VSDs, which depict the person with complex communication needs or an individual with whom they are familiar, are preferred over generic VSDs, which depict unfamiliar individuals. Although personalization is likely an important factor in the usability of VSDs, these images may be difficult for clinicians to obtain. As such, compromises must be identified. The purpose of this study was to explore the effects of controlling personal relevance factors (i.e., age and gender of the people depicted in generic VSDs) on the image preference patterns of adults with and without aphasia. Results from three very preliminary study summaries indicate that gender and age are both mitigating factors in image preference, as males tended to indicate preference for VSDs containing males over those containing females. In addition, females tended to indicate preference for females of a similar age depicted in VSDs.

How do stroke survivors with communication difficulties manage life after stroke in the first year? A qualitative study

BACKGROUND

Interest in how stroke survivors might be better supported to manage life after stroke has grown rapidly in recent years, with a particular emphasis on enabling 'self-management'. Post-stroke communication difficulties may pose a unique barrier to longer term adaptation and adjustment. It is important to understand how stroke survivors with communication difficulties manage life after stroke and what support may be needed to facilitate this process.

AIMS

To explore how stroke survivors with communication difficulties manage life after stroke in the first year.

METHODS & PROCEDURES

A cross-sectional qualitative study involving in-depth semi-structured interviews with stroke survivors with communication difficulties (aphasia, dysarthria or apraxia of speech) and/or their family members at single time points during the first year post-stroke. A total of 21 participants (14 stroke survivors and seven family members) took part in interviews for the study. Interview data were analysed using thematic analysis.

OUTCOME & RESULTS

A total of six themes were identified: (1) strategies to manage changes to communication; (2) testing communication outside of the home; (3) balancing support and independence; (4) hope for recovery; (5) obtaining support from healthcare professionals; and (6) adapting activities and keeping busy. Stroke survivors with communication difficulties and their family members undertook significant work (practical, relational, emotional) to manage their condition. Adaptation and adjustment was often facilitated by 'doing'; testing out which activities could be managed independently and which required additional support. Some stroke survivors and their family members demonstrated considerable resourcefulness and creativity in developing strategies to manage their communication difficulties. Despite the work undertaken, many expressed a lack of confidence in their ability and feelings of powerlessness and abandonment at the point of discharge from community services.

CONCLUSIONS & IMPLICATIONS

Stroke survivors and their family members develop personally meaningful and context-specific strategies to adjust to and manage life after stroke. Future interventions should recognize, support and build upon the active work already undertaken by stroke survivors with communication difficulties and their families. Further support before and around the point of discharge from community services may be needed to help build confidence and skills to manage in the longer term. The benefit of a supported self-management approach for stroke survivors with communication difficulties should be further investigated.

The effect of augmented input on the auditory comprehension of narratives for people with aphasia: a pilot investigation

Augmented input is the strategy of supplementing expressive language with visuographic images, print, gestures, or objects in the environment. The goal of augmented input is to facilitate comprehension of spoken language. The purpose of this study was to evaluate the relative effectiveness of two different augmented input conditions in facilitating auditory comprehension of narrative passages in adults with aphasia. One condition involved the communication partner (clinician) of the adult with aphasia actively pointing (AI-PP) out key content words using visuographic supports. The second condition involved no active pointing (AI-NPP) by the communication partner (i.e., attention was not drawn to the visuographic supports). All 12 participants with aphasia listened to two narratives; one in each condition. Auditory comprehension was measured by assessing participants' accuracy in responding to 15 multiple-choice cloze-type statements related to the narratives. Of the 12 participants, seven gave more accurate responses to comprehension items in the AI-PP condition, four gave more accurate responses in the AI-NPP condition, and one scored the same in both conditions. These differences were not statistically significant (p > 0.05). Communication-partner-referenced augmented input using combined high-context and PCS symbol visuographic supports improved response accuracy for some participants. Continued research is necessary to determine partner involvement with and frequency of augmented input that improve auditory comprehension.

Cultural adaptation and psychometric testing of The Scenario Test UK for people with aphasia

BACKGROUND

This study explores the psychometric properties of The Scenario Test UK, a culturally adapted version of the Dutch original (The Scenario Test) developed by van der Meulen et al. in 2010, which evaluates functional, daily-life communication in aphasia. The Scenario Test assesses communication in an interactive context with a supportive communication partner.

AIMS

To evaluate the reliability (internal consistency, interrater and test-retest reliability) and construct validity (convergent, discriminant and known-groups validity) of The Scenario Test UK.

METHODS & PROCEDURES

The Scenario Test UK and other language, cognition and praxis assessments were administered to persons with aphasia after stroke (3+ months post-stroke) and to non-aphasic controls. Participants were recruited primarily through community stroke groups. Measures were completed in an interview format. Standard psychometric criteria were used to evaluate reliability and construct validity.

OUTCOMES & RESULTS

A total of 74 participants with aphasia and 20 participants without aphasia took part in The Scenario Test UK. The test showed high levels of reliability. Internal consistency (Cronbach's α = 0.92), interrater reliability (ICC = 0.95) and test-retest reliability (ICC = 0.96) were excellent. Interrater agreement in scores on the individual items ranged from good to excellent (κ = 0.41-1.00) for all but two items (item 4c κ = 0.38, item 6c κ = 0.36). The test demonstrated good levels of convergent (ρ = 0.37-0.75) and discriminant validity (ρ = -0.04 to 0.23). There was strong evidence for known groups validity (U = 132.50, p < .001), with those with aphasia scoring significantly lower [median (interquartile range-IQR) = 47 (39.8-51.0)] than those without aphasia [53 (52-54)].

CONCLUSIONS & IMPLICATIONS

The data support the reliability and validity of the Scenario Test UK as an assessment of functional, daily-life communication for persons with aphasia. Further testing is needed in independent samples on the measure's psychometric properties, including its sensitivity to change. Pending this testing, The test can be used as an assessment tool to evaluate communication skills with people with aphasia, to guide goal setting for therapy and to measure outcomes in response to therapy.

Using Images With Individuals With Aphasia: Current Research and Clinical Trends

PURPOSE

Visuographic supports in the form of images are utilized during assessment and treatment for individuals with aphasia to supplement speech, language, and cognitive losses limiting communication. Clinicians rely on prior experience and intuition to make decisions regarding image-based support design and selection (e.g., augmentative and alternative communication strategies). Researchers have begun to focus on the relationship between the images and the benefits they provide for adults with aphasia.

METHOD

The aim of this review-resulting from a roundtable discussion at the 2016 Clinical Aphasiology Conference-was to disseminate summaries of current and past researches regarding image use by individuals with aphasia and to highlight areas of need within research and practice.

RESULTS

Review of the literature illuminated 4 major themes: (a) image creation, capture, and sharing; (b) image characteristics; (c) image use across linguistic domains and contexts; and (d) implications for clinical and research practices.

CONCLUSIONS

Reviewing current knowledge and practice regarding the use of visual supports for individuals with aphasia is essential to advancing therapeutic practices and providing evidence-based protocols for creating, selecting, and implementing images within augmentative and alternative communication strategies. Several gaps in knowledge were identified as future research needs (e.g., caregiver training and enhanced image feature investigation).

A Comparison of the Visual Attention Patterns of People With Aphasia and Adults Without Neurological Conditions for Camera-Engaged and Task-Engaged Visual Scenes

PURPOSE

The purpose of the study was to compare the visual attention patterns of adults with aphasia and adults without neurological conditions when viewing visual scenes with 2 types of engagement.

METHOD

Eye-tracking technology was used to measure the visual attention patterns of 10 adults with aphasia and 10 adults without neurological conditions. Participants viewed camera-engaged (i.e., human figure facing camera) and task-engaged (i.e., human figure looking at and touching an object) visual scenes.

RESULTS

Participants with aphasia responded to engagement cues by focusing on objects of interest more for task-engaged scenes than camera-engaged scenes; however, the difference in their responses to these scenes were not as pronounced as those observed in adults without neurological conditions. In addition, people with aphasia spent more time looking at background areas of interest and less time looking at person areas of interest for camera-engaged scenes than did control participants.

CONCLUSIONS

Results indicate people with aphasia visually attend to scenes differently than adults without neurological conditions. As a consequence, augmentative and alternative communication (AAC) facilitators may have different visual attention behaviors than the people with aphasia for whom they are constructing or selecting visual scenes. Further examination of the visual attention of people with aphasia may help optimize visual scene selection.

The use of Talking Mats to support people with dementia and their carers to make decisions together

Policy guidelines insist that people with dementia should be involved in decisions about key life choices and transitions. However, as dementia affects both cognitive and communication difficulties, it becomes increasingly difficult to do this, and innovative and effective ways to support people with dementia and their carers to interact with each other are needed. This project, funded by Joseph Rowntree Foundation, examined if Talking Mats, a low-tech communication framework, could support family carers and people with dementia to discuss issues around daily living with each other. The fieldwork phase took place from September 2008 to May 2009. Eighteen couples (person with dementia and their family carer) from Scotland and the North of England were involved. The couples were visited in their own homes and asked to discuss together four topics (Personal Care; Getting Around; Housework; Activities) under two different conditions: (i) using the Talking Mats framework and (ii) using their usual communication methods (UCMs). After the interviews, each participant was asked separately to complete a short questionnaire (Involvement Measure), which included five questions to evaluate how involved s/he felt in each type of discussion and a final question to measure satisfaction with the overall discussion. The findings show that both people with dementia and their carers feel more involved in discussions about how they are managing their daily living when using the Talking Mats framework, compared with their UCM. They also feel more satisfied with the outcome of those discussions. The use of Talking Mats could result in increased well-being and positive adjustment to accepting increasing levels of care for people with dementia. In addition, it could improve the relationship between the person with dementia and family carers, if all involved feel that the views of the person with dementia and the family carer have truly been acknowledged.

Use of assistive technology in cognitive rehabilitation: exploratory studies of the opinions and expectations of healthcare professionals and potential users

OBJECTIVE

To provide recommendations for the successful implementation of Assistive Technology (AT) in cognitive rehabilitation by investigating the attitudes towards AT of professionals, individuals with acquired brain injury (ABI) and their caregivers in two exploratory studies.

METHOD

A total of 147 professionals in cognitive rehabilitation filled out a web-based survey. Fifteen patients with ABI and 14 caregivers were interviewed.

RESULTS

Most professionals were willing to use AT in the future, although only 27% used AT currently in a treatment setting. Professionals with AT experience were more positive than those without about the potential of AT and their own ability to use it in their treatment programmes. Most patients and caregivers were positive about using AT in the future, still, only a minority currently used AT. Refusal to reimburse AT devices by health insurance companies appeared an important barrier for a more widespread use.

CONCLUSIONS

Although enthusiasm about AT was evident in both studies, a lack of progress in the implementation of AT was noted. This could be improved by promoting knowledge and hands-on experience of professionals who work in rehabilitation centres. More evidence on the efficacy of AT is required to improve coverage of AT devices by insurance companies.

Communication difficulties and the use of communication strategies: from the perspective of individuals with aphasia

BACKGROUND

To enhance communicative ability and thereby the possibility of increased participation of persons with aphasia, the use of communication strategies has been proposed. However, little is known about how persons with aphasia experience having conversations and how they perceive their own and their conversation partner's use of communication strategies.

AIMS

To explore how people with aphasia experience having conversations, how they handle communication difficulties, and how they perceive their own and their communication partners' use of communication strategies.

METHODS & PROCEDURES

Semi-structured interviews were conducted with four women and seven men with chronic aphasia (n = 11). Interviews were video-recorded, transcribed verbatim and analysed by qualitative content analysis.

OUTCOMES & RESULTS

Informants appreciated having conversations despite the fact that they perceived their aphasia as a serious hindrance. Different factors related to the informants, the conversation partners, the conversation itself and the physical environment were perceived to impact on conversations. The importance of the communication partners' knowledge and understanding of aphasia and their use of supporting conversation strategies were acknowledged by the informants. The informants' views on using communication aid devices or strategies varied considerably. Four themes that characterized the informants' narratives were: loss and frustration, fear and uncertainty, shared responsibility based on knowledge, and longing for the past or moving forward.

CONCLUSIONS & IMPLICATIONS

The informants longed to regain their former language ability and role as an active participant in society. To enhance participation of persons with aphasia, it is suggested that communication partner training should be an important and integral part of aphasia rehabilitation. Important elements of such training are reflecting on communication behaviours, training in real-life situations, and acknowledging each individual's special needs and preferences. To deal with the consequences of aphasia, counselling and psychological support may be needed.

Barriers and facilitators to the use of high-technology augmentative and alternative communication devices: a systematic review and qualitative synthesis

BACKGROUND

There has been a rapid growth in recent years of available technologies for individuals with communication difficulties. Research in the area is currently underdeveloped with practitioners having a limited body of work on which to draw to guide the process of intervention. Concerns have been raised that this newly developed technology may have limited functional usage.

AIMS

This review aims to investigate the potential barriers and facilitators to high-technology AAC provision and its ongoing use. The aim of the analysis is to explore factors underpinning use rather than effectiveness, thus it synthesized data from predominantly qualitative and survey studies reporting the views and perceptions of AAC users or staff providing the devices.

MAIN CONTRIBUTION

The review highlights the range of factors that can impact on provision and use of high-technology AAC, which practitioners should consider and address as appropriate in the intervention process. These include: ease of use of the device; reliability; availability of technical support; voice/language of the device; decision-making process; time taken to generate a message; family perceptions and support; communication partner responses; service provision; and knowledge and skills of staff. The work outlines how qualitative synthesis review methods may be applied to the consideration of published material that is not reporting outcomes data, and how this may provide valuable information to inform future studies.

CONCLUSIONS

Practitioners should be aware of barriers and facilitators to successful use when making recommendations, and consider how barriers where present might be overcome. Aspects of service delivery such as ongoing technical support and staff training may require further consideration. The synthesis of evidence describing views of users and providers, and the implementation of high-technology AAC systems, can provide valuable data to inform intervention studies and functional outcome measures.

Non-electronic communication aids for people with complex communication needs

Non-electronic communication aids provide one form of augmentative and alternative communication (AAC) for people with complex communication needs. The aim here was to explore non-electronic communication aids as one AAC option and research challenges. This aim was addressed by reviewing funding for the provision of AAC systems, data from an Australian pilot project providing non-electronic communication aids, an audit of aided AAC published studies (2000-2009), and discussion of the review literature. Combined, these sources indicate that although there is great demand for non-electronic communication aids, funding schemes, both in Australia and internationally, have focused on electronic communication aids. Such funding has usually failed to meet the total device costs and has not provided for adequate speech-language pathology support. Data from the pilot indicated the demand for non-electronic communication aids, and patterns suggest potential factors that govern the types selected. Despite the high demand for non-electronic aids, the research literature has tended to focus on electronic communication aids, including within intervention studies and addressing design features and long-term outcomes. Concerns about ensuring that AAC systems are chosen according to the assessed needs of individuals are discussed within the context of limitations in outcomes research and appropriate outcome measures.

A computerised communication aid in severe aphasia: An exploratory study

PURPOSE

To investigate the efficacy of TouchSpeak (TS), a handheld computerised communication aid for aphasia.

METHOD

A pre-post one-group design was used with a referred sample of 34 patients with a severe aphasia and a need for alternative and augmentative communication (AAC). The participants were trained to use TS in two self-chosen communicative situations. The ability to navigate the hierarchical vocabulary and overall communicative ability were assessed. Participants rated their communicative success with and without TS. Three years after completion of the training, participants were interviewed about their present use of TS.

RESULTS

In total, 76% used TS outside the clinic in two trained communicative situations. Overall communicative ability improved, as tested in untrained scenarios. Quality of communication with TS was rated higher than without TS. Fifty per cent obtained their own TS after the training and after 3 years 6% still used TS.

CONCLUSIONS

Aphasic communication can be supported effectively by TS. Patients with a severe aphasia are able to master a hierarchical computerised vocabulary and to use it in daily life for specific communicative situations. In addition, TS may also have a generalised effect on overall communicative ability. For most patients, the supportive role of TS is temporary.

Using a speech-generating device to enhance communicative abilities for an adult with moderate intellectual disability

For adults with disabilities who are unable to speak, the literature recommends that intervention include augmentative and alternative communication (AAC) to improve communication and interactions with others. Some adults with moderate intellectual disabilities who exhibit limited functional speech are often overlooked as candidates for AAC interventions because they have some speech abilities. The perception is that they are too old to improve their language and communication skills. This article presents a case report of a 30-year-old woman with a moderate intellectual disability and a severe expressive language disorder who uses a speech-generating device as a compensatory strategy to facilitate her communicative abilities, independence, and self-determination.