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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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