A Novel Approach to

AAC: Maximizing

Language Recovery for

People with Aphasia

Aimee Dietz, PhD, CCC-SLP

Associate Professor

Director of MA SLP Program

Director: Language Recovery Lab

aimee.dietz@uc.edu

Twitter: @Aimee.Dietz

13th Annual Northern Kentucky

Brain Injury Conference

Erlanger, KY

March 29, 2019

• American Speech-Language & Hearing Association-Sponsored this Talk

• NIH-NCRR 8KL2TR000078-05 & NIH-NCRR 8ULTR000077-05

• NIH-NIDCD: 1R15DC017280-01

• Collaborators

– Dr. Jennifer Vannest, Phd – Cincinnati Children’s Hospital Medical Center

– Dr. Jerzy Szaflarski, MD, PhD – University of Alabama at Birmingham

– Dr. Krista Wilkinson, PhD— Pennsylvania State University

– Dr. Weihong Yuan, PhD- Cincinnati Children’s Hospital Medical Center

• Research Assistants

– Jacqueline “Alyse” Watt, MS, CCC-SLLP– University of Cincinnati

– Thomas Maloney, MS - Cincinnati Children’s Hospital Medical Center

– Michelle Kryc, BS

– Mariah Emery

– Cassandra “Cassy” Stall

• Statistical Support

– Mekibib Altaye, PhD - Cincinnati Children’s Hospital and

Medical Center

Acknowledgements &

Disclosure Statement

Learner Outcomes Attendees will be able to:

• describe and differentiate what it means to support communication and to facilitate language recovery.

• describe how to apply principles of plasticity and intersystemic reorganization to promote language recovery in people with post-stroke aphasia.

• list the pros and cons of three common interface designs in terms of using augmentative and alternative communication for people with aphasia.

• identify at least 2 strategies to support the comprehension and expression of people with aphasia

What is Augmentative &

Alternative Communication? (ASHA, 2018)

• Augmentative and alternative communication (AAC) is an area of clinical

practice that addresses the needs of individuals with significant and complex

communication disorders characterized by impairments in speech-language

production and/or comprehension, including spoken and written modes of

communication.

• AAC uses a variety of techniques and tools, including picture communication

boards, line drawings, speech-generating devices (SGDs), tangible objects,

manual signs, gestures, and finger spelling, to help the individual express

thoughts, wants and needs, feelings, and ideas.

• AAC is augmentative when used to supplement existing speech,

and alternative when used in place of speech that is absent or not functional.

• AAC may be temporary, as when used by patients postoperatively in intensive

care, or permanent, as when used by an individual who will require the use of

some form of AAC throughout his or her lifetime.

Augmentative & Alternative

Communication (AAC): Challenges

for People with Aphasia

Example of AAC for People without Aphasia

• What are the pitfalls to this type of interface design for people with aphasia?

• What can we do to exploit the strengths of people with aphasia? – What are those strengths?

Muscle weakness, flaccidity, nor is it ataxic, spastic, hyper- or hypokinetic movement

dysarthria

Motor planning

apraxia

Cognitive Impairment

dementia

traumatic

brain injury (TBI)

Aphasia is NOT:

Aphasia Defined • An acquired language disorder

• Common causes include damage to LEFT

hemisphere:

– stroke, brain injury, tumor, degenerative diseases

Right Left Right Left

Prevalence of Aphasia Country Prevalence

China* >5,500,000

India* >5,200,000

United States1 >2,000,000

Indonesia* >1,000,000

Pakistan* >800,000

Brazil* >800,000

Nigeria* >800,000

Bangladesh* >600,000

Russia* >500,000

Mexico* >500,000

United Kingdom >350,000

Canada2 >100,000

Australia3 ~80,000

TOTAL >18,230,000

Source:

1. National Aphasia Association (2016)

2. Dickey et al.,2010

3. Australian Aphasia Association (2018)

*Extracted from population

Photo:

http://support.stroke.org/site/News2?page=NewsArticle&id=12663

Aphasia: Reality

• When you listen or read:

– unable to fully understand

all that is going on around

you

• When you speak or write

– Can only say/write a few

key words

– Jargon comes out Photo: https://www.writingforward.com/writing-

tips/read-and-write

Photo: https://abilitytools.org/blog/assistive-

technology-for-living-with-aphasia/

EXAMPLE: Fluent Aphasia

EXAMPLE: Nonfluent Aphasia

“…When I awoke and struggled to find words, I thought

for sure I had lost my tongue, but it was far worse than

that, as I was to find out… My tongue was fine but I

couldn’t come up with the right words or put them in the

right order. And then, when I tried to write or read, I had

the same trouble. And it sounded like everyone was

speaking a language I did not know. Talk about

terrifying!” –Betty LaPointe, L. L. (2005). Foundations: Adaptation, Accommodation, Aristos. In L. L. LaPointe, Aphasia and related neurogenic

language disorders (pp. 1-18). New York, NY, US: Thieme New York.

Perspective…

Photo:

https://sites.google.com/site/aphasiacdh/h

ome/what-area-of-the-brain-is-affected-by-

aphasia

AAC & Traditional Rehabilitation

• AAC is a last resort (Dietz, Weissling, Griffith, McKelvey, & Macke, 2014; Garrett & Lasker, 2007;

Simmons-Mackie, 1998; Weissling & Prentice, 2010)

• AAC often used to ONLY to

compensate for language

deficits and for basic needs

(Dietz et al., 2018; Dietz, Weissling, Griffith, McKelvey, & Macke, 2014; Garrett &

Lasker, 2007; Simmons-Mackie, 1998; Weissling & Prentice, 2010)

Photo:

https://www.pinterest.com/pin/30160050626

8640537/?lp=true

Figure used with permission from Julie Griffith, PhD

Source: Griffith, J.D. (2014) Post-stroke Language Remediation through Constraint-induced Aphasia

Therapy. University of Cincinnati, Cincinnati, Ohio.

AAC is avoided due to fear of

“learned non-use”…

Learned Non-Use is Real “Ward Talk”

– People with post-stroke aphasia have fewer interactions with nurses than post-stroke peers without aphasia

– During these interactions, nurses tended to: • use closed questions

• control the conversational floor

• restrict conversation to physical care

• use communicative repair strategies infrequently

(Hersh, Godecke, Armestrong, Ciccone, Bernhardt, 2014)

Photo: https://angelabrook.com/burnout-affects-more-than-just-

your-nurses

So….how do we help?

We have to

rethink how we

interact with

people who

have aphasia –

including the

use of AAC! Photo: https://lowestoftcommunitychurch.co.uk/sermons/rethink-prayer-the-

legacy-of-prayer/

Google Image Search:

AAC Aphasia Stroke

Google Image Search:

Stroke Wheelchair

Photo Credit: Case Western Reserve:

https://www.laboratoryequipment.com/news/2017/05/stroke-ms-

patients-walk-significantly-better-neural-stimulation

So NOW let me tell you how…

• To avoid using AAC only to compensate for language deficits

• And how to harness the principles of neural plasticity and intersystemic reorganization to use as a language recovery tool

– Even if you are NOT an SLP!

Neural Plasticity (MedicineNet)

• Neuroplasticity allows the neurons (nerve

cells) in the brain to compensate for injury

and disease and to adjust their activities in

response to new situations or to changes

in their environment…”

© ML FACTS BY COLABERRY

FUZZY SYNAPSE

• “The brain's ability to

reorganize itself by

forming new neural

connections throughout

life.

Continued…(MedicineNet)

• Neuroplasticity sometimes may

also contribute to impairment. For

example, people who are deaf may

suffer from a continual ringing in

their ears (tinnitus), the result of

the rewiring of brain cells starved

for sound. For neurons to form

beneficial connections, they must

be correctly stimulated.

• Neuroplasticity is also called brain

plasticity or brain malleability.”

Continued…(MedicineNet)

• Neuroplasticity sometimes may

also contribute to impairment. For

example, people who are deaf may

suffer from a continual ringing in

their ears (tinnitus), the result of

the rewiring of brain cells starved

for sound. For neurons to form

beneficial connections, they must

be correctly stimulated.

• Neuroplasticity is also called brain

plasticity or brain malleability.”

So, how do principles of neuroplasticity translate to the use of AAC as a language recovery tool while avoiding learned non-use?

X

Photo: http://thebrain.mcgill.ca/flash/i/i_10/i_10_cr/i_10_cr_lan/i_10_cr_lan.html

“…Undamaged

axons can also

sprout nerve

endings and

connect with

other undamaged

nerve cells,

forming new

neural pathways

to accomplish a

needed

function…”

(MedicineNet)

Hebbian Learning Neurons that

– “fire together wire together” (Hebb, 1949)

– “fire out of sync lose their link…”

(Artola & Singer 1993; Hebb, 1949; Pulvermuller & Berthier, 2008)

• Recently, CIAT researchers have modified their view on how constraints should be applied during intervention – AAC techniques are

appropriate IF they are not used as a SUBSTITUTE for language. (Difrancesco, Pulvermuller, Mohr, 2012)

Photo: http://standoutpublishing.com/g/hebb,-

donald-o..html Photo: http://www.thecni.org/wp-content/uploads/2013/09/Multiple-Sclerosis.jpeg

Photo: Colleen Kelley University of Cincinnati

TIPz: Technology

TIPz: Personalization

Grids

• People with aphasia CAN learn to sequence iconic codes

• Generalization beyond learned sequences is fair to poor

• Typically employed in a manner that promotes learned non-use

VSDs

• Presence of AAC alone does not

create learned non-use

– Learned non-use is indeed learned!

– Instruction is critical

• Personalization of AAC

– is overwhelming preferred by people

with aphasia and communication

partners

– generates improved communicative

success

– facilitates improved spoken

language

• VSDs promote quicker

generalization and learned

navigation of AAC

Hybrid Displays

PROS

• Best of both worlds

CONS

• High levels of syntactic

and semantic demands

required

• High levels of working

memory and attention

required

• The picture/scene

changes when touched

Hybrid Displays:

What do the data reveal?

• What data?

• TBD…..

• THINK: TIPz

– Technology

– Instruction

– Personalization

Copyright : Marina Gloria Gallud Carbonell

TIPz: Instruction

PURPOSE: Compare a novel AAC intervention to usual care.

TIPz: Instruction of Self-Cueing (1)

TIPz: Instruction of Self-Cueing (2)

What Happens to Language and

Communication Skills

• Aphasia severity decreased

• Spoke LESS but

– More content

– Longer sentences

• Used pictures and text to

convey thoughts

• No one used “speak

buttons”

Behavio

ral D

ata

What Happens in the Brain?

Photo: Colleen Kelley University of Cincinnati

1. The left-hemisphere

takes over language tasks!

– associated with better

recovery

2. Visual processing regions

help out!

– “backdoor” to language

© ML FACTS BY COLABERRY

FUZZY SYNAPSE

Unique Brain-Based Biomarkers

Figure 4. Blue = Pre-Treatment; Red =

Post Treatment. LI values < -0.1 indicates

right-lateralization and LI > 0.1 indicate

left-lateralization; -0.1 < LI ≤ 0.1

represent bilateral, or symmetric

language.

AAC-induced Language Recovery:

A Unique Neurobiological Mechanism? Left = Visual Word Form Area

Right = Object Recognition Object & Face Recognition • Likely alternative

bilateral,

extrasylvian

mechanisms to

help support

language

recovery

• Linking to

canonical

language regions

of interest

In Summary….

• Technology, or AAC, can

facilitate language

recovery

• Instruction is crucial

• Personalized interfaced

Photo: Colleen Kelley University of Cincinnati

PHOTO:

HTTPS://WWW.GOOGLE.COM/SEARCH?RLZ=1C5CHFA_ENUS729US729&BIW=1418&BIH=923&TBM=ISCH&SA=1&EI=ZQEVXI_

RBOAYJWTBPOOQBG&Q=WHAT+CAN+YOU+DO+IMAGE&OQ=WHAT+CAN+YOU+DO+IMAGE&GS_L=IMG.3..0J0I8I30.3244.3244

..3447...0.0..0.132.132.0J1......1....1..GWS-WIZ-IMG.L-NV9D2EUIA#IMGRC=KMERM1BQJPDIEM:

#1 Augmented Input

• Partner identifies that PWA has misunderstood

– blank expression, nodding ambiguously, looks away, answers incorrectly

• Partner then supplements the most difficult, or the most important concepts, by:

a. Writing key words on paper

b. Gesturing symbolically

c. Gesturing deictically (pointing)

d. Pantomiming

e. Referencing pictures

-communication book, communication device

(iPad?), Google ImageTM

• Recheck PWA’s comprehension: “Got it?”

(Garrett & Lasker, 2005; 2013; Wallace, Dietz, Hux, & Weissling 2012)

#2 Written Choice Method

• I have had a stroke. I would like to talk to you, but I cannot speak. We CAN converse if you ask me a question and offer me written choices to point to.

Here’s how:

• THINK OF A QUESTION YOU WOULD HAVE ASKED ME BEFORE MY STROKE.

• TRY TO FIND OUT MY OPINION, GET MY ADVICE, OR PREFERENCES.

(Garrett & Lasker, 2005;

2013)

(Garrett & Lasker, 2005; 2013)

Written Choice Strategy cont’d

• ONCE YOU’VE ASKED THE QUESTION, THINK OF POSSIBLE

ANSWERS OR CHOICES.

• WRITE THEM IN THIS NOTEBOOK. USE A DARK PEN OR

MARKER.

• USE LARGE CAPITAL LETTERS. PUT A DOT IN FRONT OF

EACH CHOICE.

• USE A SCALE FOR “HOW MUCH” QUESTIONS.

(Garrett & Lasker, 2005; 2013)

Where are you from:

• FLORIDA

• MICHIGAN

• NEBRASKA

• OTHER

Written Choice Examples

What do you want to talk about today?

• THERAPY

• MEDICINE

• ARM PAIN

• OTHER

#3 Graphic Rating Scales

The medicine helps…..

1 2 3 4 5 6 7 8 9 10

NONE SOME A LOT

The therapy is……

1 2 3 4 5 6 7 8 9 10

BAD OK GREAT

(Garrett & Lasker, 2005; 2013)

#4 Tagged Yes/No

• Ask questions using reliable response:

– Gesture

– Head nod

– Thumbs-up or -down

– Pointing

• Do you like perogies? Yes (pointing to YES) or No (pointing to NO)

YES

NO

(Garrett & Lasker, 2005; 2013)

#5 Aphasia Friendly Principles

• White Space (written)

• Pause (spoken)

• Key words*

• Topic setters*

• 14-16 point font

• Simplified syntax &

vocabulary

• Pictures

(Brennan, et al., 2005; Dietz et al., 2009; 2014; Rose et al, 2003)

Accessible Information Guidelines:

Making Information Accessible for

People with Aphasia

https://www.stroke.org

.uk/sites/default/files/

accessible_information_

guidelines.pdf1_.pdf

Making it Aphasia Friendly

HERE’S A FEW MORE!

#6 Confirm Accuracy

• EXAMPLE: "You get it?”

• Let me see if I got it right….

– Any takers?

• Use Strategies 1-5, above.

#7 Encourage Circumlocution

GROUP – What kind of a

thing is it? USE

– What do you use

it for?

ACTION

– What does it

do?

(Boyle, 2010; Sutton, 2016)

PROPERTIES

– Describe it to

me. • Color, location,

shape, size

ASSOCATION

– What does it remind you of?

#8 Encourage Writing/Pointing to First Letter

• May not be able to write the

entire word

• Form of self-cueing

• “Air writing”

– Kusho in Japanese

(Dietz et al., 2014; Garrett & Huth, 2002; Wambaugh & Wright, 2007)

#9 Encourage Drawing

• Partner or Patient

• Stimulates word

retrieval

– Highlight semantic

features

• Communicative

Sweetene

r Iced Coffee Hot

Coffee

(Farias, Davis, & Harrington, 2006)

Photo Credits: 2nd Year MA SLP Students at UC!

Photo Credits: “Pat”

#10 Encourage use of Communication

Books (Dietz et al., 2010; Garrett & Huth, 2002)

NAIL: Neurobiology of AAC-Induced Language Recovery • Aim 1: Determine the therapeutic effect of providing AAC

treatment, designed to evoke language recovery, to people with chronic, post-stroke aphasia.

• Aim 2: Evaluate underlying changes in functional and structural neuroanatomy associated with AAC treatment.

• Exploratory Aim: Identify treatment responder subgroups based on data collected in Aim 1 and Aim 2.

NIH-NIDCD R15DC017280 - 01

Selected References 1. ASHA (2018). Augmentative and alternative communication. Retrieved from https://www.asha.org/Practice-

Portal/Professional-Issues/Augmentative-and-Alternative-Communication/

2. Allendorfer, J.B., Lindsell, C.J., Siegel, M., Banks, C.L., Vannest J., Holland S.K., Szaflarski J.P. (2012) Females

and males are highly similar in language performance and cortical activation patterns during verb generation.

Cortex, 48(9), 1218-33

3. Artola, A. & Singer, W. (1993). Long-term depression of excitatory synaptic transmission and its relationship to

long-term potentiation. Trends in Neurosciences, 16, 480 - 487.

4. Dietz, A., McKelvey, M., & Beukelman, D. (2006). Visual scene display: New AAC interface for persons with aphasia,

Perspectives on Augmentative and Alternative Communication, 15(1), 13-17. doi: 10.1044/aac15.1.13

5. Dietz, A., Weissling, K., Griffith, J.,* McKelvey, M., Macke, D.* (2014). The impact of interface design during an

initial high-technology AAC experience: A collective case study of people with aphasia. Augmentative and

Alternative Communication.

6. Dietz, A., Vannest, J., Maloney, T., Altaye, M., Holland, S., & Szaflarski, J.P. (2018). Pilot study of AAC for the

treatment of post-stroke aphasia: Clinical and fMRI correlates. Aphasiology.

7. Garrett, K., & Lasker, J. (2013). Adults with severe aphasia. In D. Beukelman & P. Mirenda (Eds.), Augmentative

and alternative communication (4th ed., pp. 405-446). Baltimore, MD: Paul H. Brooks.

8. Griffith, J., Dietz, A., & Weissling, K. (2014). Supporting Narrative Retells for People with Aphasia using AAC:

Photographs or Line Drawings? Text or No Text? American Journal of Speech Language Pathology. Supplement:

Select papers from the 43rd Clinical Aphasiology Conference, S1-S12. DOI: 10.1044/2014_ASLP-13-008.

9. Hebb, D. O. (1949). The Organization of Behavior. New York: Wiley & Sons.

10. Hunt K. W. (1970). Syntactic maturity of school children and adults. Monograph of the Society for Research in

Child Development, 35, 1 - 78.

11. Hunt, K. W. (1965). Grammatical structures written at three grade levels. (Research Rep. No 3). Champaign, IL:

National Council of Teachers of English.

12. McKelvey, M., Hux, K., Dietz, A., & Beukelman, D. R. (2010). Impact of Personal Relevance and Contextualization

on Comprehension by People with Chronic Aphasia. American Journal of Speech-Language Pathology, 19, 22-33.

13. Pulvermuller, F., & Berthier, M. L. (2008). Aphasia therapy on a neuroscience basis. Aphasiology, 22(6), 563 - 599

16. Rose, M.L., Releasing the Constraints on Aphasia Therapy: The Positive Impact of Gesture and Multimodality

Treatments. American Journal of Speech-Language Pathology, 2013. 22(2): p. S227-S239.

17. Weissling, K. & Prentice, C. (2010). The timing of remediation and compensation rehabilitation programs for

individuals with acquired brain injuries: Opening the conversation. Perspectives on Augmentative and Alternative

Communication, 19(3), 87-96.