To communicate, individuals with severe aphasia often require facilitation by a skilled partner and the use of non-verbal modalities. Rehabilitation of functional communication, therefore, requires skills training for both the aphasic individual and their communication partner. Intervention for the individual with severe aphasia targeting use of alternative communication modalities such as drawing, gesturing and pointing to visual referents is often necessary. Family members, as key communication partners, also need training in the skills required to facilitate communication. Therapy provided to family members and individuals with chronic severe aphasia together can improve their communication (Cunningham & Ward, 2003; Hopper, Holland, & Rewega, 2002).

Early therapy, during in-patient rehabilitation, provides needed skills and strategies right at the outset, at a time when families are most receptive and highly motivated. An early intervention protocol needs to be brief: Length of stay within a program may be short, client time is often limited, and speech-language therapists are typically under considerable time pressure.

This study investigated the effectiveness of a brief structured intervention• designed to improve communication between severely aphasic individuals and their partners

• provided during early in-patient rehabilitation

• consisting of • group-based partner education (1 session)

• communication skills training for the individual with aphasia and their partner together, including supported use of pointing, gesture and drawing (3 sessions)

Anna Correll1, Ingrid Scholten2 and Willem van Steenbrugge2

1Speech Pathology Department, Repatriation General Hospital and 2Department of Speech Pathology and Audiology, Flinders University.

COMMUNICATION BETWEEN INDIVIDUALS WITH SEVERE APHASIA AND THEIR PARTNERS: A BRIEF, EARLY INTERVENTIONCOMMUNICATION BETWEEN INDIVIDUALS WITH SEVERE APHASIA AND THEIR PARTNERS: A BRIEF, EARLY INTERVENTION

INTRODUCTION

METHODStudy design

Six single-subject studies were completed, utilising a single-subject multiple-baseline across behaviours design.

ParticipantsSix individuals with severe aphasia receiving in-patient post-stroke rehabilitation, together with their key communication partners, participated.

RESULTS

InterventionComponent 1: Group-based education and training session for partners involving aphasia education and training plus practice in effective yes/no questioning techniques.

Component 2: Complementary therapy targeting reliable response to yes/no questions for the aphasic participants. Undertaken by participants A, B and C only, and subsequently omitted because it did not effect change.

Component 3: Three dyad sessions, teaching pointing to visual referents (Session 1), gesturing (Session 2), and drawing (Session 3) plus partner communication strategies (all sessions) via a sequence of structured barrier tasks.

MeasuresCommunication was measured using:• Analysis of communication during a task in which the aphasic participant tried to communicate the contents of a video which he/she had seen to his/her partner. Pencil and paper and a communication book were available.

• The Communication Effectiveness Index (CETI) (Lomas et al., 1989) completed by the partner

• A simple rating scale completed by the aphasic participant

Procedure1. Baseline measures• Western Aphasia Battery (Kertesz, 1982)

• Baseline measures with partner: Times 1, 2 and 3 (see “Measures” below)

• Baseline with stranger

2. Group-based education and training session for partners Post group measure with partner

3. Yes/no question therapy for the aphasic participants (Participants A, B and C only) Post yes/no measure with partner

4. Dyad sessions, teaching communication skills and use of non-verbal modalities Post dyad measure with partner

5. Post therapy measure with stranger Western Aphasia Battery

6. Final measure with partner, 1 month later

Overall ResultsThe intervention improved communication. After intervention:• 5 out of 6 dyads communicated more main concepts

• 5 out of 6 dyads communicated more efficiently

• 4 out of 6 individuals with severe aphasia communicated more main concepts to a stranger

• 3 out of 6 individuals with severe aphasia communicated more efficiently with a stranger

Four individuals with severe aphasia increased their use of non-verbal communication modalities. After intervention:• 2 out of 6 individuals made more use of pointing to visual referents

• 3 out of 6 individuals made more use or more effective use of gesture

• 2 out of 6 individuals made more use of drawing

All partners altered aspects of their communication. Most of these changes were maintained one month after intervention.

• 4 out of 6 partners used more visual cues to support partner comprehension

• 4 out of 6 partners provided more frequent prompts to use non-verbal communication to the individual with aphasia

• 4 out of 6 partners used fewer (inappropriate) open and forced choice questions; 2 out of 6 asked more topic-establishing questions

• 3 out of 6 partners used more repeats and verifications

• 1 partner shortened her utterance length

The yes/no communication therapy for aphasic participants was not effective and was omitted for Subjects D, E and F

Dyad CDyad C communicated more concepts more efficiently after intervention. Mrs C increased her use of gesture and pointing to convey new information after treatment, but remained limited in her ability to do this. Her daughter modified her own behaviour: She increased her use of visual cues, repeated more, and prompted Mrs C to use non-verbal communication more.

As Mrs C’s auditory comprehension was significantly impaired, visual cues such as pointing to a visual referent assisted her to understand her daughter’s message. Figure 4 demonstrates that Partner C’s use of visual cues did not change after the group-based partner training, but did increase after dyad therapy.

Figure 4: Partner C’s use of visual cues (eg gesture). This was targeted during partner training and dyad therapy.

Case IllustrationsDyad A

Dyad A communicated more concepts more efficiently after intervention. Mr A also communicated more concepts more efficiently with a stranger. He increased his use of communicative drawing, both with his wife and with the stranger. His wife also modified her behaviour: She used more visual cues such as gesturing and pointing to assist his comprehension, and asked more topic-establishing questions.

As demonstrated in Figure 1, Mr A made some use of communicative drawing prior to the dyad therapy during which drawing was addressed. He increased this after the dyad therapy. One month later, drawing retained its role as his most successful communication option.

Dyad BMr B was unable to use gesture or drawing to convey the content of the video despite treatment. His wife modified her behaviour: She increased her use of topic-establishing questions, appropriately decreased her use of open and forced choice questions, repeated more frequently and verified she had understood correctly more frequently. However, the couple’s ability to communicate concepts in this task was limited and unchanged, as was Mr B’s ability to communicate concepts to a stranger

As demonstrated in Figure 3, prior to intervention Mrs B asked open and forced choice questions, to which Mr B was unable to respond because of his expressive limitations. This was addressed during partner training, and Mrs B did not ask any open or forced choice questions during the following two measures. She did ask two open questions in the measure following dyad therapy, did not obtain meaningful responses, and ceased asking such questions again in the final measure.

Dyad DDyad D communicated more main concepts after intervention. Mr D started to use drawing after intervention, which enabled him to communicate information to his wife. He did not extend this use of drawing to his video-retelling with a stranger, and had no success communicating main concepts to her before or after intervention. Mrs D’s communication also became more effective as she increased her use of visual cues, verified more frequently, and prompted Mr D to use non-verbal communication more often.

Figure 5 demonstrates that Mr D made no use of communicative drawing until it was targeted in dyad therapy. He and his wife found it a useful mechanism for communicating, and he had extended its use in the final measure one month later.

Dyad EMr E’s spoken language improved significantly, and he therefore used this modality to communicate rather than adopting non-verbal modalities. His daughter used more visual cues, more prompts and asked fewer open and forced choice questions immediately after dyad intervention, but did not maintain these changes: With Mr E’s improved language skills such modifications were not required.

Dyad FDyad F communicated more concepts more efficiently after intervention. The individual with severe aphasia, Mrs F, also communicated more concepts more efficiently to a stranger. After intervention, she used gesture and pointing more successfully to convey new information. Her daughter also modified her communicative behaviour: She appropriately decreased her use of open and forced choice questions and used shorter utterances.

As can be seen in Figure 6, Dyad F’s ability to convey concepts improved slightly after partner training, and more after dyad therapy. One month later they were not quite as successful, but still conveyed more concepts than they had before dyad therapy.

This brief intervention provided during in-patient rehabilitation was effective in improving communication between individuals with severe aphasia and their partners.

The therapy program exposed individuals with severe aphasia and their partners to a range of non-verbal modalities in a format which not only taught the use of the modality but also demonstrated its communicative effectiveness with a regular communication partner. The results suggest that this enabled and encouraged individuals with severe aphasia to select and use the modality or modalities which they found most comfortable and effective.

The communication partners also modified their communication behaviours and so facilitated communication more effectively.

This intervention is delivered over four sessions, offered within a one to two week time frame. As such, it is sufficiently brief for realistic delivery in the acute or post-acute setting and has the potential to be clinically useful for this challenging group.

DISCUSSION

ACKNOWLEDGEMENTSHampstead Rehabilitation Centre and Repatriation General Hospital.

Communicative Dyads A, B, C, D, E and F

REFERENCESCunningham, R., & Ward, C. D. (2003). Evaluation of a training program to facilitate conversation between people with aphasia and their partners. Aphasiology, 17, 687-707.

Hopper, T., Holland, A. L., & Rewega, M. (2002). Conversational coaching: Treatment outcomes and future directions. Aphasiology, 16, 754-761.

Kertesz, A. (1982). Western Aphasia Battery. New York: Harcourt Brace Jovanovich, Inc.

Lomas, J., Pickard, L., Besta, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The Communicative Effectiveness Index: Development and psychometric evaluation of a functional communication measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113-124.

F L I N D E R SU N I V E R S I T Y

A D E L A I D EA U S T R A L I A

The situation of Mount Lofty was found

from hence and from some other cross

bearings, to be 34 59' south and 138 42

east. No land was visible so far to the

north as where the trees appeared above

the horizon, which showed the coast to

be very low, and our soundings were

fast decreasing.

From noon to six o'clock we ran thirty

miles to the northward, skirting a sandy

shore at the distance of five, and thence

to eight miles; the depth was then 5

fathoms, and we dropped the anchor upon

a bottom of sand, mixed with pieces of

dead coral.

G E N E R A L H O S P I TA L

DAW PARK

REPATRIATION

0

2

4

6

8

10

Baseline1

Baseline2

Baseline3

Postpartnertraining

Postyes/notherapy

Postdyad

therapy

Finalmeasure

Main concepts conveyed by drawing

Figure 1. Mr A’s use of drawing to convey main concepts to his wife. Drawing was targeted during dyad therapy.

Table 1. The Participants

Aphasia Apraxia Time post-stroke Partner

Dyad A Broca’s None 5 weeks Wife

Dyad B Global Ideomotor 2 weeks Wife

Dyad C Global Ideomotor 7 weeks Daughter

Dyad D Global Ideomotor 2 weeks Wife

Dyad E Broca’s None 2 weeks Daughter

Dyad F Broca’s None 7 weeks Daughter

Figure 2. Mr A’s communicative drawing with a stranger after intervention.

0%

2%

4%

6%

8%10%

12%

14%

16%

18%

20%

Baseline1

Baseline2

Baseline3

Postpartnertraining

Postyes/notherapy

Postdyad

therapy

Finalmeasure

Open & forced choice questions(% total questions)

30%

35%

40%

45%

50%

55%

60%

65%

70%

Baseline1

Baseline2

Baseline3

Postpartnertraining

Postyes/notherapy

Postdyad

therapy

Finalmeasure

Visual cues (as % turns)

0

5

10

15

20

25

30

35

40

Baseline1

Baseline2

Baseline3

Postpartnertraining

Postdyad

therapy

Finalmeasure

Drawing occasions

02

68

4

10121416182022242628

Baseline1

Baseline2

Baseline3

Postpartnertraining

Postdyad

therapy

Finalmeasure

Concepts conveyed

Figure 3. Use of (inappropriate) open and forced choice questions by Partner B. Question use was targeted during partner trainin

Figure 4. Partner C’s use of visual cues (eg gesture). This was targeted during partner training and dyad therapy.

Figure 5. Mr D’s use of communicative drawing. Drawing was targeted during dyad therapy.

Figure 6. Concepts conveyed by Dyad F. Dyad communication was targeted during partner training and dyad therapy.