Web Posted on: December 2, 1998

The Power of Communication: AAC Applications for the Stroke Survivor

Linda Solomon, Ph.D. CCC-SLP
Karen Kroh, M.Ed., A.T.P.

The use of speech to communicate is unique to humans. When speech is impaired or absent, the impact on the person and his family is profound. Stroke is the leading cause of adult disability and communication impairment in adults. An estimated 500,000 to 600,000 individuals suffer strokes every year. Of these, 30% are under the age of 65. There are three million stroke survivors alive in the United States today. Over one million people nationwide suffer from aphasia or dysarthria, the primary communication impairments caused by stroke.

Aphasia is an acquired disorder caused by brain damage, which affects a person's ability to communicate. The primary symptom of aphasia is an impairment in the ability to express oneself when speaking. The understanding of speech, reading, and writing are also often impaired. Dysarthria is an impairment in speaking caused by weakness, incoordination, or other disability, which effects the mechanical aspects of producing speech.

The goal of Augmentative and Alternative Communication is to enable an individual with communication deficits to actively participate in a variety of communicative settings and situations. The American Speech-Language-Hearing Association defines AAC as follows: Augmentative and alternative communication is an area of clinical practice that attempts to compensate (either temporarily or permanently) for the impairment and disability patterns of individuals with severe expressive communication disorders (i.e. the severely speech-language and writing impaired)(ASHA, 1989, p. 107).

For many years, AAC has been seen as strictly the use of technological devices. However, successful AAC systems should combine high tech, light tech and communicative strategies.

Communicative Purposes

There are four primary communicative functions, as described by Light (1988) that are common to all people. The most obvious communicative function is to express an individuals wants and needs. We also communicate to share information with others, develop a social closeness with others and inclusion in society by adherence to social etiquette.

Assessment of Speech/Language/Cognitive abilities Formal and Informal assessment of the individual's abilities are prerequisites to the AAC evaluation. Results of a comprehensive aphasia examination provide information concerning understanding by listening and reading, and expression by talking and writing. In addition, pragmatic skills, attempt to communicate and appropriateness of these attempts are considered. Cognitive abilities include orientation, memory, problem solving, abstract thinking and organization. In order to benefit from AAC approaches, a functional level of cognitive abilities is requisite.

Visual/Perceptual Skills

A range of visual skills is assessed including but not limited to acuity, scanning, tracking and figure ground to determine necessary features in an AAC device. It is vital that the patient be evaluated have glasses/contacts to correct visual acuity if required. Stroke survivors usually recognize common visual symbols and logos. Some individuals may use drawing as a form of communication. Recognition of visual symbols enhances a user's ability to access an AAC device.

Motor Skills

Most stroke survivors have sufficient motor skills following a stroke to use direct selection to access the device. Apraxia and hemiplegia may be side effects of strokes, which require alternative access methods.

Communications Style

Garrett and Beukelman introduce a classification system for individuals with aphasia as an aid in planning AAC interventions. The categories of people with aphasia are based on the severity of communication impairments that affect the individual abilities to meet current needs and to participate in communication exchanges. For example, the controlled-situation communicator can indicate needs by spontaneously pointing to objects and items. The primary communication techniques facilitators may use are the written-choice communication and supported conversation techniques. The comprehensive communicator retains a variety of communication skills, which may be too fragmented or inconsistent for effective communication to occur without support. These individuals use multiple techniques including writing, gesture, drawing, and a communication book.

Conduct Strategy and Device Trails

To ensure that the recommended devices and communication strategies match the skills and needs of the person with the communication impairment, trial application in a simulated or real communication situation is useful. It is important for AAC teams to determine whether a client can participate successfully in communication situations and to verify that their responses are accurate. It is also important to teach communication partners to facilitate AAC strategies.

Case Presentations:

CH, a 45-year-old policeman had a brainstem stroke, which resulted in quadriplegia and severe dysarthria. Speech production was limited to minimally differentiated one-syllable words. AAC evaluation revealed that CH was an active communicator who uses multimodal communication. Solutions for client included Dynavox, computer access, environmental control and development of manual alphabet to augment intelligibility of speech.

WP, a 75 year old retires salesman had a left CVA resulting in severe aphasia. Auditory comprehension continued to improve to mild level of impairment. Speech was fluent marked with severe dyspraxia and severe anomia. WP, an active and creative communicator, successfully used a word communication book which included detailed biographical information, likes, dislikes, and favorite places. He effectively communicates using speech, writing, gesture and the communication book, which he carries in his shirt pocket. MB, an 82-year-old female had a severe stroke resulting in global aphasia with a profound expressive/receptive aphasia. MB developed effective use of a picture communication book and gesture to communicate basic wants and needs. Her communication partners were trained in facilitating techniques and strategies.

References

National Aphasia Association, Aphasia Fact Sheet, New York, N.Y.

Kagan, Aura, Winckel, J.&Shumway, E. Pictographic Communication Resources: Enhancing Communicative Access. Aphasia Center, North York, 1996.

Beukelman, David, and Mirenda, P., Augmentative and Alternative Communication: Management of Severe Communication Disorders in Children and Adults, 1998.

Lloyd, Lyle (Editor) et, al, Augmentative and Alternative Communication: A Handbook of Principles and Practices, 1997.

American Speech-Language-Hearing Association. (1989). Competencies for speech language pathologists providing services in augmentative communication. ASHA, 31, 107-110.

Light J. (1988). Interaction involving individuals using augmentative and alternative communication systems: State of the art and future directions. Augmentative and Alternative Communication, 4, 66-82.