Myth:
Assisted communication can be introduced too soon after a stroke or brain trauma.
What is assisted communication?
Assisted communication (in the following text PK) means tools and techniques that are used independently or in combination to support communication in people who have communication difficulties , for example, their speech cannot be understood or they have difficulties in expressing themselves. PK includes communication techniques without aids (eg pointing, gestures), low-tech aids (eg communication books and boards) and high-tech communication devices (eg devices and computers with speech output).
Stroke and traumatic brain injury
PK can be used in people who have suffered a stroke or traumatic brain injury. A stroke is a neurological disorder that occurs suddenly due to circulatory disorders in the brain and leads certain parts of the brain to an insufficient supply of oxygen and nutrients. As a result, various damages and/or death of brain cells occur, which leads to disruption of the functions that these parts of the brain manage. Traumatic brain injury occurs when an external mechanical force (eg a blow to the head with a blunt object) acts on the brain and leads to damage to certain functions.
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PK should be introduced after such events, but what is the expert's opinion about the time period in which access to PK should be enabled? Beukelman, Garrett and Yorkston (2007) say:
" It is wrong to wait months to decide whether these people will regain their natural speech and language sufficiently to be able to communicate. As they reevaluate their priorities in ways that will affect them for the rest of their lives, waiting will do them no good.”
Port
What is the typical time period within which PK is enabled after brain trauma or stroke? We will follow a hypothetical but typical patient named Luka . Due to an inadequate approach to the use of PK, Luka will not develop his communication skills.
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- Luka had a stroke or suffered some other brain injury.
- Luka cannot speak during hospitalization. They gave him a simple communication board on which the basic needs were marked. In addition to that board, he is also asked many questions to which he must answer with "yes" or "no".
- When transferred to a rehabilitation facility, Luka's communication board remains the same .
- Luka can speak a little again, but it includes a few names, "yes" and "no". Just before he was discharged home, the communication board was expanded to a book with pages where messages were organized by categories such as meals, places, activities and basic needs.
- Word positions in the communication book were determined during home care and then in a specialized institution. Five or six other goals are also set.
- Luka gives up his communication book because it is difficult to search (find what he wants to say in the book), and when he does find the right page, it does not always contain messages suitable for the situation. Luka primarily communicates with limited natural speech, gestures and pointing, which may or may not be effective. He often depends on his communication partner (family, therapist, etc.) to ask the right questions.
- Luka is no longer progressing on outpatient therapy and has been discharged to home care. Over the next six months (and possibly a year), he regained some speech, but not enough for his communication needs. Luka is increasingly frustrated .
- Luka's family is looking for other ways to help him communicate (like a communication device). His wife makes an appointment with his old speech therapist.
- Luka's therapist conducts an assessment and recommends the introduction of a communication device .
Of course, there are variations from country to country, differences in the sequence and duration of events, depending on factors such as the degree of speech return, the willingness of the client and his family to use PK as a temporary or permanent means of communication, and the speech therapist's knowledge of PK.
What assumptions arise from Luka's case?
- PK is at best the first aid, and at worst the last choice.
- PK will interfere with the return of speech.
- PK is not part of the therapy.
Let's consider each of these assumptions.
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PK is at best the first aid, and at worst the last choice
Many use PK as a first aid to solve the problem of communication until the return of speech. Others reach for PK only when it seems that all other methods of communication have failed. On the contrary, Fager, Doyle, and Krantounis (2007) state that PK should be used from the beginning of rehabilitation , to promote communication itself and as a solution for difficulties in speech and language skills:
"Assisted communication is a dynamic process in the recovery of an individual that is constantly developing, complementing and facilitating therapy . Assisted communication can be an important therapy tool, but also an auxiliary mechanism on the way to functional communication. It is important to consider assisted communication as part of therapy, not as an alternative or last resort."
PK is a valid way of communication that we all use in different circumstances. Just as it is part of my and your communication system, it should also be part of the communication system of an individual after brain trauma or stroke, from the very beginning, but also later in constant use.
PK will interfere with the return of speech.
It is important to emphasize that it is completely natural and justified to hope and work for the return of speech. People who have suffered trauma or stroke are used to communicating effectively through speech. They used to not have to struggle with problems such as struggling to find the right words, difficulty understanding the interlocutor, putting sentences together or shaping the articulators (e.g. lips or tongue) to pronounce words correctly.
However, PK will not prevent the return of natural speech . Moreover, research shows that the use of PK promotes improvements in communication and language skills (Schlosser & Wendt, 2008; Millar, Light, & Schlosser, 2006).
Since PK does not interfere with the return of speech abilities, it can be used together with speech for even greater progress in communication. The fact is that we all communicate in many different ways. We speak, gesture, change facial expressions and use body language. We point to things, pictures and signs in our environment, type messages and print pieces of paper.
We all use forms of PK in our everyday life, and how much you and I use it depends on the functionality of our speech and the environment. PK will be used more in situations when we should not speak (in the cinema or during a ceremony), when we cannot speak (because we are sick) or when we communicate with a person who does not understand us very well (such as a small child or a person who speaks another language).
A person who has experienced a trauma or a stroke, after which there was a loss of the ability to speak, will not use PK as much as we do, but, just like us, because of PK, they will not exclude other forms of communication, but will use it together with them . Thus, PK will be used in the appropriate situation, by speaking in another, by gesturing again when the situation dictates it, and so on. Often all these different forms of communication are used in the same conversation!
PK is not part of speech therapy.
This could be concluded by individuals who do not consider the consistent use of PK as part of speech therapy. They probably don't realize that therapy that focuses on PK is actually language therapy that uses an alternative or additional way of language production.
Speech therapists understand that this is part of their work, and the American Speech Language Hearing Association ( ASHA ; the umbrella organization of speech therapists in the USA) provides various information about the role of speech therapists in the use of PK with people who have speech difficulties.
What are the possible outcomes of this sequence of events for the individual?
In some cases, the individual's speech improves to the point where it is quite functional. However, this does not always happen, and when it does, there can sometimes be a setback in speech expression. In the period when the speech is not functional, we can observe:
- Increasing frustration with communication among individuals and their communication partners.
- Depression and/or withdrawal from social situations.
- Resistance to PK when it was finally offered.
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How can we improve these results with the help of assisted communication?
Encourage and model multimodal communication.
When we communicate with a person who has communication difficulties, we should encourage him to use multimodal communication by using it ourselves . We have to point to objects and people to replace speech, use the person's communication book or board, gesturing, facial expression and body language. In doing so, we demonstrate that these methods of communication are valuable and useful. We also provide valuable information on how to communicate using non-verbal methods.
PK is used in therapy from the very beginning and during the entire therapeutic process
Scherz (2005) states: "In terms of choosing when to make a recommendation for an assistive communication system, we need to present different options multiple times during the rehabilitation process." Introducing PK during treatment provides opportunities for successful use, increases the individual's more successful habituation to PK, and reduces impression that PK is the last selection.
How can PK be used in therapy? PK tools and strategies can be used to work on improving or compensating for areas where a person has difficulty. In a typical activity, a rating scale can be used so that a person can express how strenuous the activity is. With the help of photos or albums on the device, users can talk about their family. A communication device can be used to ask questions of the therapist. The functional use of PK makes it a daily part of an individual's life and allows individuals to get used to the idea of using its tools and strategies.
Due to the positive impact of PK on language and communication, Ansel and Weinrich (2002) advocate that "the introduction of the principle of assisted communication in the treatment of aphasia should not be left for the final stages of rehabilitation, but must be included in the entire process". Of course, PK should be used in conjunction with the remaining ability to speak and other forms of communication.
Discard the false belief that because of PK the person will not speak
People who have experienced head trauma or stroke, as well as those around them, often feel significant loss due to changes in social roles and relationships with others. People want to regain their ability to speak because of the ease and clarity of communication, but also because it is a means of returning to former social roles and relationships. It is important that we reject the belief that because of PK a person will not speak, and that an individual cannot return to their social roles if they cannot speak.
The introduction of assisted communication at the beginning of the rehabilitation process is absolutely recommended. It has been proven to help maintain functional communication and participation in therapeutic activities.
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LITERATURE:
Ansel, B. and Weinrich, M. (2002) Computerized approach to communication retraining after stroke. Current Atherosclerosis Reports , 4 (291-295).
Beukelman, D., Garrett, K., & Yorkston, K. (2007). Augmentative communication strategies for adults with acute or chronic medical conditions. Baltimore: Paul H. Brookes Publishing. (12).
Fager, S., Doyle, M. and Karantounis, R. (2007). Traumatic brain injury. In D. Beukelman, K. Garrett, & K. Yorkston (Eds.), Augmentative Communication Strategies for adults with acute or chronic medical conditions (pp. 131-162). Baltimore, MD: Paul H. Brookes.
Garrett K. and Beukelman D. (1992). Augmentative communication approaches for the person with severe aphasia. In Augmentative Communication in the Medical Setting. Editor Yorkston K. Tucson: Communications Skill Builders.
Millar, DC, Light, JC and Schlosser, RW (2006). The Impact of Augmentative and Alternative Communication Intervention on the Speech Production of Individuals With Developmental Disabilities: A Research Review. Journal of Speech, Language, and Hearing Research , 49, 248-264.
Schertz, J. (2005) Communication and Active Participation (Caregiver) Issues. Augmentative and Alternative Communication , 14(3), 20-21.
Schlosser, RW and Wendt, O. (2008). Effects of Augmentative and Alternative Communication Intervention on Speech Production in Children With Autism: A Systematic Review. American Journal of Speech-Language Pathology, 17, 212-230.
