final- turner aac therapy research proposal

AAC THERAPY FOR APHASIA

Augmentative and Alternative Communication Therapy for Individuals with Severe Aphasia

Rebecca Turner

Central Michigan University

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Abstract

Purpose: To examine the effectiveness of traditional therapy compared to Augmentative and

Alternative communication device therapy for individuals with severe aphasia.

Method: The current study is a mixed-methods strategy, concurrent triangulation design using

the Rijndam Scenario Test (RIJST) to test twenty participants’ communicative ability and a post-

treatment interview for both participants and their families. All participants have severe aphasia.

The Proloquo2go application for the iPad pro will be used as treatment on an experimental group

to test the effectiveness of AAC device therapy. A control group will receive only a few sessions

of traditional (word-finding) therapy.

Study Limitations: The study’s limitations include bias in the referral process of participants

from the local SLP in each area of recruitment, the sample size of only 20 participants, trouble

with AAC device navigation, and participants being aware that they are a part of a study.

Study Significance: The results of the study will show the benefits of using the Proloquo2go

application and AAC devices in general for those with severe aphasia, and the study will give

more reliability to the relatively new RIJST test.

Keywords: AAC devices, Aphasia, Traditional therapy, Proloquo2go, Communication, RIJST

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Augmentative and Alternative Communication Therapy for Individuals with Severe Aphasia

Many individuals with aphasia (post stroke) have trouble communicating, even with

extensive efforts for rehabilitation. These communication difficulties often stem from Broca’s or

Wernicke’s aphasia. Broca’s aphasia is characterized by a severe impairment in expressing

written or spoken speech (Shimizu, Watari & Tokuda, 2014), while Wernicke’s aphasia is

characterized by severely disrupted language comprehension (Robson, Keidel, Ralph & Sage,

2011). Difficulty with communication, whether it be expressive or receptive, can often lead to

disengagement from activities of daily life and isolation. These difficulties can also lead to issues

in family or work life as well.

As of 1998, there were only two published findings that address the success of traditional

“word finding” therapy for those with aphasia (Cress & King, 1999). Alternative ways of therapy

have since been introduced, but with no great success. With an age of technology, many

augmentative and alternative communication (AAC) computerized devices are being

implemented/tried in therapy to aid in communication of those with aphasia. While there is

evidence and research done on the benefit of using AAC devices in therapy for individuals with

aphasia, there is a need for more evidence to show the benefit of AAC use and a need for

modifications to AAC devices to make them more efficient for those with aphasia. Many of the

studies that include computerized AAC devices in therapy have had multiple participants drop

out due to devices that are confusing or difficult to navigate (Mieke, Wiegers, Wielaert,

Duivenvoorden & Ribbers, 2006). As technology improves, there is a call for new AAC devices

to be developed and used in research. These devices should aim to have better portability, be

easier to navigate, and have natural language. More research is needed to determine the

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effectiveness of AAC devices with improved technology in therapy for individuals with severe

aphasia.

Literature Review

Aphasia is an acquired disorder of language processing that often results from a stroke

and can lead to trouble with speech comprehension, expression, writing and reading (Watila &

Balarabe, 2015). There are many factors that may predict the recovery of an individual with

aphasia when the correct form of treatment is provided. According to an article within the

Journal of the Neurological Sciences, factors that may predict recovery include lesion related

factors, non-lesion related factors and treatment related factors (Watila & Balarabe, 2015).

Lesion related factors include where the lesion is located, the size of the lesion, the stroke

severity, the type of language deficit following the stroke, the stroke subtype, and metabolic

factors. Non-lesion related factors include gender, age, handedness, preexisting cognitive deficits

and education. Treatment related factors include the type of treatment used depending on all

previously stated factors in the individual (Watila & Balarabe, 2015). Treatment is generally

more beneficial when it is interactive and frequent. Interactive therapy with aphasia patients can

include many alternative forms of communication to assist in expression.

Functional communication is the goal in treatment for individuals with aphasia. Language

is used to communicate in different contexts and transfer information between individuals.

Functional communication includes using words, sentences, or body language/gestures to

communicate with others (Kempler & Mira, 2011). For individuals with aphasia, functional

communication can also relate to how they are able to function with their incomplete speech in

everyday activities of life. Untrained lexical terms, linguistic structures, communication settings

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and interaction partners are all important aspects of functional communication and all are needed

in successful treatment for individuals with aphasia (Rautakoski, 2012).

Functional communication also goes hand in hand with quality of life in those with

aphasia. Oftentimes, individuals with aphasia have a lower quality of life because of their lack of

functional communication. Quality treatment is needed to help adults with aphasia be effective

communicators, allow them participate in their activities of daily life and increase their overall

quality of life (Johansson, Carlsson & Sonnander, 2012). Treatment is the underlying factor in

improving communication for those with aphasia. Quality and effective treatment is needed to

increase communication and create an overall sense of well-being.

However, in years past, traditional (word-finding) therapy has been unsuccessful in

improving the communication abilities of those with aphasia. As of 1999, only two studies had

been published that address the success of traditional therapy (Cress & King, 2011). Since then, a

few successful studies have been released that focus on traditional methods. For some

individuals, traditional therapy is unsuccessful because of the severity of the stroke or time post-

onset of the aphasia (Hough & Johnson, 2009).

Over the past decade, the focus of therapy has started to shift to more interactive,

technological models using augmentative and alternative communication (AAC) devices and

more individual-centered therapy. AAC devices are used as voice output devices and can be

calibrated to fit the level of communication and needs of the individual (Cress & King, 2011).

Past research has suggested that AAC devices often provide communication through devices and

different techniques when an individual with aphasia’s expressive communicative skills are not

functional (Hough & Johnson, 2009). Current research suggests that AAC devices have the

potential to enhance the communicative abilities of individuals with severe aphasia, and that it is

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extremely important to integrate AAC devices in some form for therapy to be effective for those

with aphasia (Koul, Corwin & Hayes, 2004).

While research provides valid information on the effectiveness of AAC devices, it is also

known that more research needs to be done to further demonstrate the effectiveness of AAC

devices given the ever-changing technology and updated devices. Many studies provide evidence

with small sample sizes, outdated technology, or no information on generalization of the device.

Therefore, more research is needed to provide more reliable information (Aftonomos, Steele &

Wertz, 1996; Mieke, Wiegers, Wielaert, Duivenvoorden & Ribbers, 2006). Previous studies with

interactive difficult-to-navigate AAC devices have had many participants leave or have found a

lack of generalization with the device after the study. However, with frequent treatment and

individualized devices, research has shown that participants are more likely to be able to learn to

navigate their device because it is specific to them and they are receiving one-on-one

intervention (Wallace & Hux, 2014).

Past and current studies have drawn conclusions that positive AAC treatment effects are

possible, but oftentimes these effects are seen in controlled environments and have not been

generalized outside of the treatment room. In order for AAC treatment to be effective on

individuals with severe aphasia, researchers need to be open to making changes and trying new

methods with current devices. Treatment needs to be taken out of controlled environments and

mixed more with real-world contexts.

AAC devices are said to be difficult to use and carry around, and have an unnatural

vocabulary. To improve devices, training studies must provide an easier-to-use system, vast

vocabulary selection, and increased user knowledge. Treatment with AAC devices must occur in

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natural environments to ensure generalization of the tool and more effective functional

communication overall (Jacobs, Drew, Ogletree & Pierce, 2004).

Current research implies that skilled communication partners can also make a difference

between successful and unsuccessful communication, especially when it comes to

communicating with an AAC device. In treatment with AAC devices, skills and qualified

communication “receivers” are important for those learning a new device (Sandt-Loenderman,

2004).

The next steps in research examining the effectiveness of AAC devices for those with

severe aphasia must include the use of high-tech, easy to use, and natural communication devices

that will be able to aid in overall, functional communication (Sandt-Koenderman, 2004).

Purpose of Study

Traditional aphasia treatment for individuals post stroke has been unsuccessful in the

past. Computerized, alternative ways of communication have been successful in treatment, but

this form of therapy is in need of updated research to examine its effect. With updated

technology, intervention using computerized AAC devices in real-life environments should be

compared to traditional word finding intervention to determine how to best improve overall

functional communication in individuals with aphasia. The research questions that will be

analyzed once the study is completed include:

1. Does the Proloquo2go AAC application help improve overall functional

communication in individuals with severe aphasia?

2. Upon receiving AAC therapy, do individuals with aphasia and their family members

feel personally satisfied with their communicative abilities and ability to use the

device overall?

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Method

Participants

Participants will be recruited from 10 different rehabilitation centers around the Midwest in

the United States. To obtain a representative sample of candidates for AAC devices, emails and

phone calls will be made to the centers for the local SLP to refer aphasia patients. The criteria for

referral will include those that have been diagnosed with severe aphasia due to a stroke, time

post onset greater than 6 months, age 55-70, no previous AAC therapy given during therapy after

stroke, and no other existing conditions or disabilities. The first 20 referred individuals who

match all criteria will participate in the study. Using stratified random sampling, the 20 total

participants will be randomly selected to two separate groups, control and experimental. The

participants will not be aware of which group they are in. Once selected, participants will receive

a consent form agreeing to participate and explaining the purpose of the study. It will be

explained to participants that the study has no potential risks involved and all findings/results

will be secured and locked with limited access.

Materials

The Proloquo2go AAC application, which is supported by all Apple devices, will be used

for therapy with all 20 participants. Within the app, there are three vocabulary levels with five

vocabulary sets for various abilities and age levels, 23 different grid sizes for those that have

trouble with sight, easily customizable vocabulary for user interest and natural voices. Each

participant will receive an iPad Pro equipped with only the Proloquo2go app to use for therapy.

Each device will be calibrated with a natural voice depending on the gender and voice of the

participant, the vocabulary will be customized depending on each participant’s interests and

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hobbies, and words will be paired with real pictures and symbols if needed (depending on

severity) for each participant.

Standard behavior measures will include the Western Aphasia Battery (WAB), which will

be used to test each participant for aphasia severity, and the Rijndam Scenario Test (RIJST),

which will be used to test functional communication ability. Both tests will be administered

before and after treatment. The WAB evaluates language function and has high internal

consistency, test-retest reliability, and validity. The RIJST evaluates daily-life communication in

people with severe aphasia and has high internal consistency (.96), test-retest reliability (.98) and

inter/intra-judge reliability (.86-1.00).

Behavioral measures will examine overall participant and family satisfaction with the

device and their communication ability post treatment with an interview including the participant

and their family members.

Procedures

A mixed-methods strategy with a concurrent triangulation design will be used for the

study. The study will include a pre/post test for both the experimental and control groups. The

quantitative measures will include the WAB, RIJST and the rating scale, while the qualitative

measures include the overall personal satisfaction interview and the functional communicative

ability before and after the study as observed by family members and the participants (for only

the experimental group). Selection for both the experimental and control group will be

randomized.

The experimental group will first sign the consent form, then be assessed using the WAB

and RIJST. After the initial assessments, treatment will begin with the Proloquo2go app for 6

consecutive weeks for 3 hours per week. Participants will be given the outline of tasks and

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specific instructions for treatment upon arrival to the study. Treatment with the Proloquo2go app

and AAC device will be conducted in the participant’s home, local stores, and restaurants in

hopes of more generalized results. After treatment, the RIJST will be used to assess

communicative ability again and then an interview with the participant and family members will

be conducted to obtain overall satisfaction.

The control group will start with signing the consent form, be assessed using the WAB

and RIJST, then have a 6-week period of traditional “word finding” treatment. The RIJST will be

used to assess functional communication after treatment, but no interview will be conducted. The

WAB will be conducted in a traditional clinic setting. The RIJST will be conducted in the

participant’s home in order to obtain results in a natural and generalized setting. The control

group will receive minimal treatment in a traditional clinic setting. Participants will be given the

outline of tasks and specific instructions for treatment upon arrival to the study.

To minimize internal validity threats to the study, only 2 hours of use of the AAC device

will be allowed outside of treatment per week, the control group in the study will not receive

AAC treatment and instead only receive minimal traditional treatment, and the use of the WAB to

initially test severity of the participant’s aphasia does not align with the AAC or traditional

treatment.

To minimize external validity threats to the study, there will be a control group receiving

minimal traditional treatment, participants will be recruited from different rehabilitation centers

across a region and naturally, there will be a variety of differences in each participant, and there

will be a control group and an experimental group which will allow for testing each participant

individually over a period of time.

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The researcher for the study will be a specialist in AAC devices, specifically the

Proloquo2go app and a specialist in neuro-rehabilitation. Those that designed the study will not

be collecting data for the study, and instead they will just be analyzing the information post

treatment.

To analyze the data collected from the study, quantitative and qualitative analysis

measures will be used. Tables will be created with specific numbers indicating the aphasia

severity from the WAB pre-test to compare each participant. The results from the RIJST will be

analyzed through scores on different areas of communicative ability and each score in the

experimental group will be compared to the control group to analyze the effectiveness of the

AAC device. A correlational analysis will be run to examine the relationships between the scores

of the experimental and control group. The qualitative measure of compared performance in

overall functional communication and feelings of satisfaction from all participants and their

family will be analyzed through a narrative summary of the interviews. All scores will be

compared to each participant individually as well as the experimental group to the control group.

Study Limitations

This study comes with many limitations. The sampling method of recruiting participants

from various rehabilitation centers around the Midwest may not be representative of all severe

aphasia patients around the United States. Participants will be referred by each local SLP as well

which may create a bias on who is being referred for the study. If the participants with aphasia

were randomly selected from a vaster area the study may be more representative. The sample

size of the study is also a limitation. Twenty participants does not seem representative of all

people with severe aphasia. A larger sample size may help create results that have more

statistical significance.

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Limitations also include AAC device navigation, because although the AAC device seems

easy to navigate, participants that are older may find it difficult because of the touch screen

feature if they are not familiar with current technology. This could be overcome by giving a

lesson to all participants on how to use a touch screen first before beginning treatment.

A few external validity threats may be observed as well because participants are aware that

they are a part of a study. This could be helped by treating the study as normal therapy and

“trying out” the AAC device rather than treating it as a study and constantly taking data and

notes during the sessions.

Study Significance

The results and conclusions drawn in the study will give significance to the benefits of

using Proloquo2go and AAC devices in general for individuals with severe aphasia. It will also

show whether these individuals benefit more from AAC therapy than traditional aphasia therapy.

The RIJST test that will be used in the study is a relatively new test for communication

ability in those with aphasia. The test will be used as a pre/post measure along with an overall

satisfaction interview from the participant and their family. These two measures paired together

will help determine the reliability of the test to see if it is effective at determining functional

communication.

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References

Aftonomos, L. B., Steele, R. D., & Wertz, R. T. (1997). Promoting recovery in chronic aphasiawith an interactive technology. Archives of Physical Medicine and Rehabilitation, 78(8), 841-846.

Cress, C., & King, J. (1999). AAC strategies for people with primary progressive aphasiawithout dementia: Two case studies. Augmentative and Alternative Communication, 15(4), 248-259.

Hough, M., & Johnson, R. K. (2009). Use of AAC to enhance linguistic communication skills inan adult with chronic severe aphasia. Aphasiology, 23(7-8), 965-976.

Jacobs, B., Drew, R., Ogletree, B., & Pierce, K. (2004). Augmentative and AlternativeCommunication (AAC) for adults with severe aphasia: Where we stand and how we can go further. Disability and Rehabilitation, 26(21-22), 1231-1240.

Johansson, M. B., Carlsson, M., & Sonnander, K. (2011). Communication difficulties and theuse of communication strategies: From the perspective of individuals with aphasia. International Journal of Language & Communication Disorders, 47(2), 144-155.

Kempler, D., & Goral, M. (2011). A comparison of drill- and communication-based treatmentfor aphasia. Aphasiology, 25(11), 1327-1346.

Koul, R., Corwin, M., & Hayes, S. (2005). Production of graphic symbol sentences byindividuals with aphasia: Efficacy of a computer-based augmentative and alternative communication intervention. Brain and Language, 92(1), 58-77.

M.m., W., & S.a., B. (2015). Factors predicting post-stroke aphasia recovery. Journal of theNeurological Sciences, 352(1-2), 12-18.

Rautakoski, P. (2012). Self-perceptions of functional communication performance during totalcommunication intervention. Aphasiology, 26(6), 826-846.

Robson, H., Keidel, J. L., Ralph, M. A., & Sage, K. (2012). Revealing and quantifying theimpaired phonological analysis underpinning impaired comprehension in Wernicke's aphasia. Neuropsychologia, 50(2), 276-288.

Sandt‐Koenderman, M. V. (2004). High‐tech AAC and aphasia: Widening horizons?Aphasiology, 18(3), 245-263.

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W. Mieke E. Van De Sandt-Koenderman, Wiegers, J., Wielaert, S. M., Duivenvoorden, H. J., &Ribbers, G. M. (2007). A computerised communication aid in severe aphasia: An exploratory study. Disability and Rehabilitation, 29(22), 1701-1709.

Wallace, S. E., & Hux, K. (2013). Effect of two layouts on high technology AAC navigation andcontent location by people with aphasia. Disability and Rehabilitation: Assistive Technology, 9(2), 173-182.

Watari, T., Shimizu, T., & Tokuda, Y. (2014). Broca aphasia. Case Reports, 2014(Dec19).

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