10/24/2022

MAXIMIZING LIFE PARTICIPATION:

CONSIDERATIONS FOR AUGMENTATIVE AND
ALTERNATIVE COMMUNICATION FOR
PERSONS WITH APHASIA
Pamela Tamulevicius MSR, CCC-SLP

OBJECTIVES

• Identify the four primary areas of language that may be impaired for the
person with aphasia (PWA) and the multi-modal aspects of communication
• List three values of a person-centered approach to aphasia rehabilitation
• Identify two evidenced based augmentative and alternative
communication options for a PWA

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APHASIA

85%
1/3 of Stroke Survivors 2.5 million people are
are diagnosed with living in the US with
Aphasia aphasia

Inpatient Rehabilitation Hospital Division

Impairment of language
Spoken Language Expression
Spoken Language Comprehension
Written Expression
Reading Comprehension

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Aphasia

Non-fluent Fluent

Broca’s Global Conduction Wernicke’s

Aphasia Aphasia Aphasia Aphasia

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Diagnosis Characteristics
Dysarthria abnormalities in the strength, speed,
range, steadiness, tone, or accuracy
of movements required for
breathing, phonatory, resonatory,
articulatory, or prosodic aspects of
speech production
Acquired Apraxia neurologic speech disorder that
of Speech reflects an impaired capacity to plan
or program sensorimotor commands
necessary for directing movements
that result in phonetically and
prosodically normal speech
Cause
Neurogenic-one or more
sensorimotor problems—including
weakness or paralysis,
incoordination, involuntary
movements, or excessive, reduced, • Inspiratory muscle strength
or variable muscle tone
any process or condition that
compromises the structures and
pathways of the brain responsible
for planning and programming
motor movements for speech
Polling Question #1
10/24/2022
Treatment
• Posture adjustments to improve
upright breath support
• Expiratory muscle strength
training
training
• Phonetic placement for
articulation
• Rate modification
• Awareness
• Communication partner
strategies
• Augmentative/Alternative
communication
• Restorative- aimed at improving
or restoring impaired function
• Compensatory- aimed at
compensating for the deficit
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Manning, M., MacFarlane, A., Hickey, A., Galvin, R., & Franklin, S. (2021). “I hated being ghosted” – The relevance of social participation for living well with post‐stroke aphasia:
Qualitative interviews with working aged adults. Health Expectations, 24(4), 1504–1515. https://doi-org.ezproxy.wpunj.edu/10.1111/hex.13291
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A communication impairment is “a significant independent predictor for key

characteristics of social relationships, including the number of friends in the
social network, two types of social support, the frequency of social
participation, and social self-efficacy”
(Palmer et.al. 2021, p.1).

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MENTAL HEALTH SERVICES AND APHASIA

• Aphasia is a risk factor for depression and anxiety

• Access to services and skill of the professional in navigating communication
breakdowns due to language impairment

• Themes (K.Strong & J. Randolph, 2021)

• Barriers: Training, Stigma, Accessible Services
• Interdisciplinary Collaboration: referrals, knowledge and awareness; strategies
and tools
• Therapy Looks Different: new approach; challenges

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HEALTHCARE PERCEPTIONS

Carragher et al. 2020- small focus group of 16 acute and sub-acute

professionals
1) aphasia is time consuming
2) health professionals do not know how to help
3) health professionals limit conversations with patients with aphasia
4) health professionals want to know how to help
5) health professionals feel good after successful communication

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COMMUNICATION BILL OF RIGHTS

National Joint Committee for the Communication Needs of Persons with Severe Disabilities (NJC)

1. The right to interact socially, maintain social closeness, 11. The right to have access to functioning AAC (augmentative
and build relationships and alternative communication) and other AT (assistive
technology) services and devices at all times
2. The right to request desired objects, actions, events, and
people 12. The right to access environmental contexts, interactions,
and opportunities that promote participation as full
3. The right to refuse or reject undesired objects, actions, communication partners with other people, including
events, or choices peers
4. The right to express personal preferences and feelings 13. The right to be treated with dignity and addressed with
5. The right to make choices from meaningful alternatives respect and courtesy
6. The right to make comments and share opinions 14. The right to be addressed directly and not be spoken for
or talked about in the third person while present
7. The right to ask for and give information, including
information about changes in routine and environment 15. The right to have clear, meaningful, and culturally and
linguistically appropriate communications
8. The right to be informed about people and events in one’s
life
9. The right to access interventions and supports that
improve communication
10. The right to have communication acts acknowledged and
responded to even when the desired outcome cannot be
realized

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LIFE PARTICIPATION APPROACH TO APHASIA (LPAA)

• The explicit goal is enhancement of life participation

• Everyone affected by aphasia is entitled to service
• Success measures include documented life enhancement changes
• Both personal and environmental factors are intervention targets
• Emphasis is on availability of services as needed at all stages of aphasia

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PERSON-CENTERED FUNCTIONAL GOALS

• To maximize outcomes that lead to functional improvements that are

important to the individual
• To optimize the individual’s potential to participate in meaningful activities
• To facilitate a partnership that ensures the individual and family have a
voice in the care received and outcomes achieved
• To demonstrate to the payers the value of skilled services

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INTERNATIONAL CLASSIFICATION FOR DISABILITY AND

FUNCTIONING

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LIVING WITH APHASIA

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LIVING WITH APHASIA

Jane is a 67 year old woman with mild non-fluent aphasia

• Frustrated that she has not made significant progress
• Difficulty with word finding and discourse impacting her participation in
game night at the senior center.
• She reports feeling embarrassed and frustrated by her word finding
difficulty and pauses in communication.
• She has stopped calling her grandchildren that live across the country
because she has difficulty following the conversation and responding over
the phone.

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LIVING WITH APHASIA

Frank is a 40 year old male with severe non-fluent aphasia

• Recently celebrated 5 year anniversary with spouse and has a 2 year old
son
• Limited verbal output characterized by single syllable verbalizations.
• Frustrated in the medical setting due to communication breakdowns
resulting in Frank refusing care, crying and avoiding eye contact.

Inpatient Rehabilitation Hospital Division

Polling Question #2

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AUGMENTATIVE AND ALTERNATIVE COMMUNICATION

Augmentative- to add to someone’s speech

Alternative- to use instead of speech
An integrated group of components to enhance communication (ASHA, 2019)

No Tech/Low-Tech
High Tech

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HISTORIC CHALLENGES WITH AAC

Support only communication of basic needs without regard for other purposes of
communication

Use of AAC only with people with the most severe aphasia

Prioritization of traditional restorative treatment over compensatory/combined

approach

50% of caregivers reported receiving education about AAC approaches from SLP
during the first three months post stroke (Elman et al. 2016)

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10 BEST PRACTICES OF EFFECTIVE APHASIA THERAPISTS

Simmons-Mackie et al. (2017)

4. No one with aphasia should be discharged from services without some

means of communicating his or her needs and wishes (e.g., using AAC,
supports, trained partners) or a documented plan for how and when this will
be achieved (practice point)
6. Communication partner training should be provided to improve
communication of the person with aphasia (Level A, B)
7. Families or caregivers of people with aphasia should be included in the
rehabilitation process (Level A-C)

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DETERMINING COMMUNICATION SUPPORT

Severity of the Aphasia

• Spoken language expression

• Spoken language comprehension
• Written expression
• Reading comprehension

• Vision
• Motor Abilities
• Preferences

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ENVIRONMENT
Services, systems, policies
Attitude of others
Help with communication and conversation

• Acute Care Hospital

• Critical Illness Recovery Hospital
• Acute Inpatient Rehabilitation
• Outpatient
• Community
• Communication partners
• Supported groups

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PARTICIPATION
Activities, relationships, roles and responsibilities

• Food preferences
• Pain
• Reading
• Using the phone
• Navigating a metro system

Escher, et. al (2022)

• occupational therapy practitioners to use
group activities to enhance social
participation, leisure activities, and
engagement in instrumental activities of
daily living

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PERSONAL IDENTITY, ATTITUDES AND FEELINGS

The future
Personal view
Feelings
• Cooperative goal setting
• Education/outreach

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ASSESSMENT

• Preferences of the person with aphasia

• Age and life situation/role of the person with aphasia
• Level of communication ability
• Cognitive abilities
• Sensory functioning
• Availability of time or resources
• SLP knowledge, experience, and expertise
(Coppen & Simmons-Mackie, 2018)

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SUPPORTED CONVERSATION FOR ADULTS WITH APHASIA

• Developed by the Aphasia Institute

• Goal is to improve conversation for people with aphasia
• Treatment focuses on the communication partner and not the person with
aphasia
• Multi-modal communication approach
• Speaking, writing and drawing

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EXAMPLE TOOLS/STRATEGIES OF SUPPORTED CONVERSATION

Blank Paper
Black marker
Pencil
Pictures/ Pictographic illustrations
Flashcards (keywords)

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BLANK PAPER

Easily accessible
Able to refer back to
Able to clarify during
conversation
Use choices

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COMMUNICATION BOARDS

• What does the

individual need to
communicate?
• What do I need to
know?
• What is happening in
the environment?

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EFFECTIVENESS OF AAC SYSTEMS

Russo, et. al. (2017) reviewed that AAC devices were effective in improving
communication skills and should be considered as part of clinical
considerations when creating a plan of care.

Brock (2016) suggested grid displays (graphic symbols) and scene displays
(photographs) were effective for facilitating communication in persons with
aphasia.

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SMART PHONE OPTIONS

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COMMUNICATION AIDE- SMART PHONE APPS

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AAC DEVICES

TouchTalk
Lingraphica

The AllTalk
Lingraphica

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LIVING WITH APHASIA

Jane is a 67 year old woman with mild non-fluent aphasia

• Frustrated that she has not made significant progress
• Difficulty with word finding and discourse impacting her participation in
game night at the senior center.
• She reports feeling embarrassed and frustrated by her word finding
difficulty and pauses in communication.
• She has stopped calling her grandchildren that live across the country
because she has difficulty following the conversation and responding over
the phone.

Inpatient Rehabilitation Hospital Division

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LIVING WITH APHASIA

Frank is a 40 year old male with severe non-fluent aphasia

• Recently celebrated 5 year anniversary with spouse and has a 2 year old
son
• Limited verbal output characterized by single syllable verbalizations.
• Frustrated in the medical setting due to communication breakdowns
resulting in Frank refusing care, crying and avoiding eye contact.

Inpatient Rehabilitation Hospital Division

Polling Question #3

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NATIONAL APHASIA ASSOCIATION

www.aphasia.org

Online Support Communities

Patient and Caregiver Resources
Aphasia Bill of Rights
Caregiver Bill of Rights
Aphasia Center Locator

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ADLER APHASIA CENTER

https://adleraphasiacenter.org/

A place where people can connect with others who have been diagnosed with
aphasia.
• Support Groups
• Discussion Groups
• Topic Based Groups
• Advocacy
• Virtual Aphasia Meet-ups
Located in New Jersey

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APHASIA INSTITUTE
https://www.aphasia.ca/

• ParticiPics is a free, searchable

database of pictographic images
designed to facilitate life's
conversations. The pictographs are
specially designed for
communicating with people with
aphasia and are the product of
decades of research and experience
with people in the aphasia and
stroke communities.

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APHASIA FRIENDLY PRINT MATERIAL

https://www.med.unc.edu/ahs/sphs/card/resources/aphasia-friendly-printed-
material/

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LINGRAPHICA
www.Aphasia.com

Inpatient Rehabilitation Hospital Division

Ptamulevicius@Kessler-rehab.com

QUESTIONS?
Kessler Institute for Rehabilitation

Kessler-rehab.com

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