Lessons for the AAC field: a tribute to Dr. David Beukelman.

On February 5, 2022, the field of augmentative and alternative communication (AAC) lost a giant when Dr. David "Dave" Beukelman passed away. As the readership of this journal is aware, Dave was one of the principal founders of the AAC field and devoted his career to providing a voice to those without one. Before AAC became a field, people who could not talk were invisible or seldom noticed, unless they were in the way. For more than 40 years, he was a catalyst for change in AAC clinical practice, research, dissemination, teaching, and public policy development. This tribute aims to honor Dave's lifelong mission of serving others by sharing some of his most timeless and valued lessons. Each lesson begins with one of Dave's most enduring quotes that is then followed by a brief synopsis of the lesson Dave hoped to convey.

Intermittent Theta Burst Stimulation (iTBS) for Treatment of Chronic Post-Stroke Aphasia: Results of a Pilot Randomized, Double-Blind, Sham-Controlled Trial.

BACKGROUND Research indicates intermittent theta burst stimulation (iTBS) is a potential treatment of post-stroke aphasia. MATERIAL AND METHODS In this double-blind, sham-controlled trial (NCT01512264) participants were randomized to receive 3 weeks of sham (G0), 1 week of iTBS/2 weeks of sham (G1), 2 weeks of iTBS/1 week of sham (G2), or 3 weeks of iTBS (G3). FMRI localized residual language function in the left hemisphere; iTBS was applied to the maximum fMRI activation in the residual language cortex in the left frontal lobe. FMRI and aphasia testing were conducted pre-treatment, at ≤1 week after completing treatment, and at 3 months follow-up. RESULTS 27/36 participants completed the trial. We compared G0 to each of the individual treatment group and to all iTBS treatment groups combined (G1₋3). In individual groups, participants gained (of moderate or large effect sizes; some significant at P<0.05) on the Boston Naming Test (BNT), the Semantic Fluency Test (SFT), and the Aphasia Quotient of the Western Aphasia Battery-Revised (WAB-R AQ). In G1₋3, BNT, and SFT improved immediately after treatment, while the WAB-R AQ improved at 3 months. Compared to G0, the other groups showed greater fMRI activation in both hemispheres and non-significant increases in language lateralization to the left hemisphere. Changes in IFG connectivity were noted with iTBS, showing differences between time-points, with some of them correlating with the behavioral measures. CONCLUSIONS The results of this pilot trial support the hypothesis that iTBS applied to the ipsilesional hemisphere can improve aphasia and result in cortical plasticity.

The canonical semantic network supports residual language function in chronic post-stroke aphasia.

Current theories of language recovery after stroke are limited by a reliance on small studies. Here, we aimed to test predictions of current theory and resolve inconsistencies regarding right hemispheric contributions to long-term recovery. We first defined the canonical semantic network in 43 healthy controls. Then, in a group of 43 patients with chronic post-stroke aphasia, we tested whether activity in this network predicted performance on measures of semantic comprehension, naming, and fluency while controlling for lesion volume effects. Canonical network activation accounted for 22%-33% of the variance in language test scores. Whole-brain analyses corroborated these findings, and revealed a core set of regions showing positive relationships to all language measures. We next evaluated the relationship between activation magnitudes in left and right hemispheric portions of the network, and characterized how right hemispheric activation related to the extent of left hemispheric damage. Activation magnitudes in each hemispheric network were strongly correlated, but four right frontal regions showed heightened activity in patients with large lesions. Activity in two of these regions (inferior frontal gyrus pars opercularis and supplementary motor area) was associated with better language abilities in patients with larger lesions, but poorer language abilities in patients with smaller lesions. Our results indicate that bilateral language networks support language processing after stroke, and that right hemispheric activations related to extensive left hemispheric damage occur outside of the canonical semantic network and differentially relate to behavior depending on the extent of left hemispheric damage. Hum Brain Mapp 38:1636-1658, 2017. © 2016 Wiley Periodicals, Inc.

Neuroimaging Correlates of Post-Stroke Aphasia Rehabilitation in a Pilot Randomized Trial of Constraint-Induced Aphasia Therapy.

BACKGROUND Recovery from post-stroke aphasia is a long and complex process with an uncertain outcome. Various interventions have been proposed to augment the recovery, including constraint-induced aphasia therapy (CIAT). CIAT has been applied to patients suffering from post-stroke aphasia in several unblinded studies to show mild-to-moderate linguistic gains. The aim of the present study was to evaluate the neuroimaging correlates of CIAT in patients with chronic aphasia related to left middle cerebral artery stroke. MATERIAL AND METHODS Out of 24 patients recruited in a pilot randomized blinded trial of CIAT, 19 patients received fMRI of language. Eleven of them received CIAT (trained) and eight served as a control group (untrained). Each patient participated in three fMRI sessions (before training, after training, and 3 months later) that included semantic decision and verb generation fMRI tasks, and a battery of language tests. Matching healthy control participants were also included (N=38; matching based on age, handedness, and sex). RESULTS Language testing showed significantly improved performance on Boston Naming Test (BNT; p<0.001) in both stroke groups over time and fMRI showed differences in the distribution of the areas involved in language production between groups that were not present at baseline. Further, regression analysis with BNT indicated changes in brain regions correlated with behavioral performance (temporal gyrus, postcentral gyrus, precentral gyrus, thalamus, left middle and superior frontal gyri). CONCLUSIONS Overall, our results suggest the possibility of language-related cortical plasticity following stroke-induced aphasia with no specific effect from CIAT training.

Constraint-Induced Aphasia Therapy for Treatment of Chronic Post-Stroke Aphasia: A Randomized, Blinded, Controlled Pilot Trial.

BACKGROUND: To provide a preliminary estimate of efficacy of constraint-induced aphasia therapy (CIAT) when compared to no-intervention in patients with chronic (>1 year) post-stroke aphasia in order to plan an appropriately powered randomized controlled trial (RCT). MATERIAL AND METHODS: We conducted a pilot single-blinded RCT. 24 patients were randomized: 14 to CIAT and 10 to no-intervention. CIAT groups received up to 4 hours/day of intervention for 10 consecutive business days (40 hours or therapy). Outcomes were assessed within 1 week of intervention and at 1 and 12 weeks after intervention and included several linguistic measures and a measure of overall subjective communication abilities (mini-Communicative Abilities Log (mini-CAL)). Clinicians treating patients (CIAT group) did not communicate with other team members to maintain blinding and the testing team members were blinded to treatment group assignment. RESULTS: Overall, the results of this pilot RCT support the results of previous observational studies that CIAT may lead to improvements in linguistic abilities. At 12 weeks, the treatment group reported better subjective communication abilities (mini-CAL) than the no-intervention group (p=0.019). Other measures trended towards better performance in the CIAT group. CONCLUSIONS: In this pilot RCT intensive language therapy led to an improvement in subjective language abilities. The effects demonstrated allow the design of a definitive trial of CIAT in patients with a variety of post-stroke aphasia types. In addition, our experiences have identified important considerations for designing subsequent trial(s) of CIAT or other interventions for post-stroke aphasia.

Using Visual Scene Displays as Communication Support Options for People with Chronic, Severe Aphasia: A Summary of AAC Research and Future Research Directions.

Research about the effectiveness of communicative supports and advances in photographic technology has prompted changes in the way speech-language pathologists design and implement interventions for people with aphasia. The purpose of this paper is to describe the use of photographic images as a basis for developing communication supports for people with chronic aphasia secondary to sudden-onset events due to cerebrovascular accidents (strokes). Topics include the evolution of AAC-based supports as they relate to people with aphasia, the development and key features of visual scene displays (VSDs), and future directions concerning the incorporation of photographs into communication supports for people with chronic and severe aphasia.

The impact of interface design during an initial high-technology AAC experience: a collective case study of people with aphasia.

The purpose of this collective case study was to describe the communication behaviors of five people with chronic aphasia when they retold personal narratives to an unfamiliar communication partner using four variants of a visual scene display (VSD) interface. The results revealed that spoken language comprised roughly 70% of expressive modality units; variable patterns of use for other modalities emerged. Although inconsistent across participants, several people with aphasia experienced no trouble sources during the retells using VSDs with personally relevant photographs and text boxes. Overall, participants perceived the personally relevant photographs and the text as helpful during the retells. These patterns may serve as a springboard for future experimental investigations regarding how interface design influences the communicative and linguistic performance of people with aphasia.

The Feasibility and Benefits of a Virtual Yoga Practice for Stroke Survivors With Aphasia.

PURPOSE: The purpose of this study was to (a) examine the feasibility of a virtual, adapted, aphasia-friendly yoga program for people with aphasia; (b) evaluate evidence of improvement in patient-reported outcomes and word retrieval; (c) explore the immediate impact of a yoga session on participant subjective emotional state; and (d) assess participant motivation and perceived benefits of participating in a yoga program. METHOD: This feasibility study employed a mixed-method design to document the feasibility of a virtual, 8-week adapted yoga program. A pre-/posttreatment design was used to assess patient-reported outcome measures for resilience, stress, sleep, and pain, as well as word-finding abilities. Semistructured interviews with participants were thematically analyzed to provide insight into participants' motivation and perceptions regarding their experience. RESULTS: Comparisons of pre- and postprogram group means suggest that participation in an 8-week adapted yoga program may positively impact perceptions of resilience (large effect), stress (medium effect), sleep disturbance (medium effect), and pain (small effect) for people with aphasia. Findings from within-session reports and brief, semistructured interviews with participants indicated positive outcomes and subjective experiences and suggest that people with aphasia are motivated to participate in yoga for a variety of reasons. CONCLUSIONS: This study is an important first step in confirming the feasibility of an adapted, aphasia-friendly yoga program offered via a remote platform for people with aphasia. The findings support recent work suggesting that yoga may be a potent adjunct to traditional rehabilitation efforts to improve resilience and psychosocial aspects in persons with aphasia. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22688125.

Functional Magnetic Resonance Imaging Activation During Unscripted Discourse in People With Poststroke Aphasia.

PURPOSE: The purpose of this project was to determine the feasibility of employing a functional magnetic resonance imaging (fMRI) task that captured activation associated with overt, unscripted (or free) discourse of people with aphasia (PWA), using a continuous scan paradigm. METHOD: Seven participants (six females, ages 48-70 years) with chronic poststroke aphasia underwent two fMRI scanning sessions that included a discourse fMRI paradigm that consisted of five 1-min picture description tasks, using personally relevant photographs, interspersed with two 30-s control periods where participants looked at a fixation cross. Audio during the continuous fMRI scan was collected and marked with speaking times and coded for correct information units. Activation maps from the fMRI data were generated for the contrast between speaking and control conditions. In order to show the effects of the multi-echo data analysis, we compared it to a single-echo analysis by using only the middle echo (echo time of 30 ms). RESULTS: Through the implementation of the free discourse fMRI task, we were able to elicit activation that included bilateral regions in the planum polare, central opercular cortex, precentral gyrus, superior temporal gyrus, middle temporal gyrus, superior temporal gyrus, Crus I of the cerebellum, as well as bilateral occipital regions. CONCLUSIONS: We describe a new tool for assessing discourse recovery in PWA. By demonstrating the feasibility of a natural language paradigm in patients with chronic, poststroke aphasia, we open a new area for future research.

AAC assessment and clinical-decision making: the impact of experience.

People with complex communication needs often require a comprehensive augmentative and alternative communication (AAC) assessment to maximize participation in daily interactions. Assessment of AAC is a complex process and limited practice guidelines exist. The purpose of this qualitative study was to explore how 25 speech-language pathologists with varying levels of experience approach the AAC assessment process. Participants were classified as either (a) General Practice Speech-Language Pathologists (GPSLPs), (b) AAC Clinical Specialists (AAC-CS), or (c) AAC Research/Policy Specialists (AAC-RS). In-depth, semi-structured interviews were conducted to explore the participants' approach to AAC assessment. The results revealed that GPSLPs approach AAC assessment differently than the AAC-CS and AAC-RS; however, the Specialists reported a similar approach that may help guide the development of practice guidelines for AAC assessment.

Personnel roles in the AAC assessment process.

Completing an augmentative and alternative communication (AAC) assessment is a complex process that involves many stakeholders and professionals. To help clarify professional roles and provide assessment guidelines, an AAC Assessment Personnel Framework was developed. This framework was adapted from the work of Beukelman, Ball, and Fager in 2008, which focused on general AAC needs (not just assessment) and concentrated specifically on adults. In contrast, the present model examines the assessment process for all individuals who require AAC. The following AAC assessment personnel are discussed: AAC finders, general practice SLPs, AAC clinical specialists, facilitators and communication partners, collaborating professionals, AAC research and policy specialists, manufacturers and vendors, funding agencies and personnel, and AAC/assistive technology agencies and personnel. Current barriers for successful assessment outcomes are discussed, and suggestions for addressing personnel-related barriers are explored.

Applying Implementation Science to Support Active Collaboration in Noninvasive Brain-Computer Interface Development and Translation for Augmentative and Alternative Communication.

PURPOSE: The purpose of this article is to consider how, alongside engineering advancements, noninvasive brain-computer interface (BCI) for augmentative and alternative communication (AAC; BCI-AAC) developments can leverage implementation science to increase the clinical impact of this technology. We offer the Consolidated Framework for Implementation Research (CFIR) as a structure to help guide future BCI-AAC research. Specifically, we discuss CFIR primary domains that include intervention characteristics, the outer and inner settings, the individuals involved in the intervention, and the process of implementation, alongside pertinent subdomains including adaptability, cost, patient needs and recourses, implementation climate, other personal attributes, and the process of engaging. The authors support their view with current citations from both the AAC and BCI-AAC fields. CONCLUSIONS: The article aimed to provide thoughtful considerations for how future research may leverage the CFIR to support meaningful BCI-AAC translation for those with severe physical impairments. We believe that, although significant barriers to BCI-AAC development still exist, incorporating implementation research may be timely for the field of BCI-AAC and help account for diversity in end users, navigate implementation obstacles, and support a smooth and efficient translation of BCI-AAC technology. Moreover, the sooner clinicians, individuals who use AAC, their support networks, and engineers collectively improve BCI-AAC outcomes and the efficiency of translation, the sooner BCI-AAC may become an everyday tool in the AAC arsenal.

Finding "Zen" in Aphasia: The Benefits of Yoga as Described by Key Stakeholders.

PURPOSE: Recently, the literature has witnessed a surging interest regarding the use of mind-body approaches with people who have aphasia, generating a plethora of possible outcome measures. During this same time, a core outcome set for aphasia has been recommended. The purpose of this clinical focus article is to give our survivor, co-survivor, and clinician stakeholder coauthors a platform to share their personal narrative regarding their yoga journey, with the goal of identifying primary outcome domains central to capturing the impact of yoga on the recovery process for people with poststroke aphasia. Ultimately, we hope this clinical focus article helps clinicians understand how yoga might benefit their patients and draws attention to potential outcome measures, while also highlighting the important fact that traditional aphasia assessments do not capture the improvements stakeholders pinpoint as crucial to the essence of mind-body interventions. METHOD: This clinical focus article summarizes the case reports of Terri's and Chase's poststroke yoga journeys using the power of personal narrative and an adapted photovoice method. Additional stakeholders share in this storytelling process, using a variety of narrative tools. As this story is unveiled, several patient-identified outcome domains are highlighted as essential to document the impact of yoga on survivors. RESULTS: Terri's and Chase's yoga journeys revealed the multifaceted impact of yoga on five domains: (a) feelings of wholeness and "zen," (b) increased attentional capacity for language tasks, (c) increased verbal fluency, (d) decreased pain, and (e) relationship mutuality. CONCLUSION: Team Yoga realized that the practice of yoga-whether as a stand-alone practice or integrated into therapy sessions-fosters feelings of wholeness or "zen," which likely correlates with decreased pain with a simultaneous increase in resilience and flexibility of coping strategies to manage the host of chronic poststroke challenges. Supplemental Material https://doi.org/10.23641/asha.17003464.

Reading and writing with aphasia in the 21st century: technological applications of supported reading comprehension and written expression.

PURPOSE: People with aphasia struggle to keep up with today's text-based communication, because of their reduced ability to comprehend and compose written messages. Therefore, the communication gap between people with aphasia and the communities around them continues to grow. The purpose of this article is to highlight the literature regarding supported reading comprehension and written expression techniques for people with aphasia and to discuss the role of these interventions in the context of Web-based communication and information sharing. METHODS: This article presents an overview of compensatory strategies that support reading comprehension such as aphasia-friendly text principles, pairing text with highly contextualized pictures, the notion of reading ramps, and written expression supports including word prediction, speech-to-text, and voice banking. Additionally, ideas for integrating these strategies into Web-based communication and information-sharing applications are reviewed. CONCLUSION: Speech-language pathologists must consider available Web-based communication strategies during the aphasia rehabilitation process. In particular, interventions designed to support the reading comprehension and written expression of people with aphasia should be adapted to meet the increasing trend to utilize Web-based technology to maintain or redefine social roles following a stroke.

A scoping review of PhotoVoice for people with post-stroke aphasia.

BACKGROUND: PhotoVoice is a qualitative research methodology designed to engage and empower marginalized members of a community and/or to understand community needs. PhotoVoice seems aphasia-friendly because it relies on personal photographs to convey opinions regarding prespecified topics. However, PhotoVoice is based on a procedure referred to as the SHOWeD method. Participants are asked to reflect upon their photos by discussing (1) what they See, (2) what is Happening, (3) the relation to Our life, (3) Why the issue or condition exists, and then to (4) explain what can be Done to address the issue(s) at hand. Due to the linguistic demand required to convey complex thoughts and ideas inherent in this methodology, adaptations are likely required to successfully implement with people who have aphasia. AIMS: A scoping review was conducted to summarize the current literature regarding the use of PhotoVoice with people who have aphasia, to address two questions:(1) Are people with post-stroke aphasia included in PhotoVoice studies?(2) What, if any, modifications are required to address post-stroke aphasia and motor impairments? MAIN CONTRIBUTION: This scoping review revealed that researchers often exclude people with aphasia from post-stroke PhotoVoice research. Three studies outlined adaptations that allowed successful implementation with people who have post-stroke aphasia. CONCLUSIONS: Further inquiry regarding how best to adapt PhotoVoice for people with aphasia will facilitate their ability to be included in community-based research. This is an important step in ensuring that all post-stroke stakeholders are involved in projects related to social justice and policy for stroke survivors.

Assessing abstract thought and its relation to language with a new nonverbal paradigm: Evidence from aphasia.

In recent years, language has been shown to play a number of important cognitive roles over and above the communication of thoughts. One hypothesis gaining support is that language facilitates thought about abstract categories, such as democracy or prediction. To test this proposal, a novel set of semantic memory task trials, designed for assessing abstract thought non-linguistically, were normed for levels of abstractness. The trials were rated as more or less abstract to the degree that answering them required the participant to abstract away from both perceptual features and common setting associations corresponding to the target image. The normed materials were then used with a population of people with aphasia to assess the relationship of abstract thought to language. While the language-impaired group with aphasia showed lower overall accuracy and longer response times than controls in general, of special note is that their response times were significantly longer as a function of a trial's degree of abstractness. Further, the aphasia group's response times in reporting their degree of confidence (a separate, metacognitive measure) were negatively correlated with their language production abilities, with lower language scores predicting longer metacognitive response times. These results provide some support for the hypothesis that language is an important aid to abstract thought and to metacognition about abstract thought.

Revisiting the Role of Augmentative and Alternative Communication in Aphasia Rehabilitation.

Purpose The purpose of this article is to revisit the role of augmentative and alternative communication (AAC) in poststroke aphasia rehabilitation. The authors' intent is to provide a viewpoint that expands the use of AAC in poststroke aphasia rehabilitation. Specifically, we seek to clarify the role of AAC in restorative and participation approaches to aphasia rehabilitation while also considering the role of AAC in a comprehensive treatment plan. The authors support their viewpoint with citations from both the historic and contemporary literature on aphasia rehabilitation. Conclusions A thought-provoking viewpoint on the role of AAC in poststroke aphasia rehabilitation is proposed. More specifically, the versatility of AAC strategies is reviewed, with an emphasis on how AAC can be used to empower people with aphasia to fully participate and engage in life activities with increased independence. Moreover, we argue that AAC can be viewed as a dual-purpose tool that can simultaneously serve to drive intersystemic reorganization resulting in some improved language performance-and perhaps restoration of language function-while offering a communication alternative during inevitable anomic events.

Intensive Auditory Comprehension Treatment for Severe Aphasia: A Feasibility Study.

Background: Severe auditory comprehension impairments secondary to aphasia can adversely influence rehabilitative outcomes and quality of life. Studies examining intensive rehabilitative treatments for severe single-word auditory comprehension impairments are needed. Objectives: Our purpose was to examine the feasibility and influence of a high-intensity word-picture verification treatment on high-frequency, word response accuracy. Research questions: (a) Can people with severe aphasia tolerate an intensive comprehension treatment? (b) Does an intensive intervention increase auditory comprehension response accuracy of spoken high-frequency words? Method: This single-case ABA design study included 2 participants with chronic, severe auditory comprehension deficits secondary to stroke. A high-frequency, word-picture verification treatment was administered 2 hr/day, 5 days/week for 4 weeks and required participants to match the spoken word of the examiner to a picture representing an object. Results: Preliminary results suggest that some people with severe chronic aphasia can tolerate an intensive auditory comprehension treatment and demonstrate improvements in high-frequency, word-level response accuracy with large effect sizes suggesting generalization to untrained stimuli. Conclusions: An intensive auditory comprehension treatment protocol can contribute to improvements in response accuracy for some people with severe aphasia. Larger sample size studies are needed to further examine the influence of intensity on improvements in auditory comprehension.

The feasibility of improving discourse in people with aphasia through AAC: Clinical and functional MRI correlates.

AIMS: The purpose of this study is twofold: (1) to examine the feasibility of providing high-tech augmentative and alternative communication (AAC) treatment to people with chronic aphasia, with the goal of evoking changes in spoken language; and (2) to identify evidence of AAC-induced changes in brain activation. METHOD & PROCEDURES: We employed a pre- post-treatment design with a control (usual care) group to observe the impact of an AAC treatment on aphasia severity and spoken discourse. Further, we used functional magnetic resonance imaging (fMRI) to examine associated neural reorganization. OUTCOMES & RESULTS: Compared to the usual care group, the AAC intervention trended toward larger treatment effects and resulted in a higher number of responders on behavioral outcomes. Both groups demonstrated a trend toward greater leftward lateralization of language functions via fMRI. Secondary analyses of responders to treatment revealed increased activation in visual processing regions, primarily for the AAC group. CONCLUSIONS: This study provides preliminary guidance regarding how to implement AAC treatment in a manner that simultaneously facilitates language recovery across a variety of aphasia types and severity levels while compensating for residual deficits in people with chronic aphasia. Further, this work motivates continued efforts to unveil the role of AAC-based interventions in the aphasia recovery process and provides insight regarding the neurobiological mechanisms supporting AAC-induced language changes.

AAC for adults with acquired neurological conditions: a review.

The purpose of this review is to describe the state of the science of augmentative and alternative communication (AAC) for adults with acquired neurogenic communication disorders. Recent advances in AAC for six groups of people with degenerative and chronic acquired neurological conditions are detailed. Specifically, the topics of recent AAC technological advances, acceptance, use, limitations, and future needs of individuals with amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI), brainstem impairment, severe, chronic aphasia and apraxia of speech, primary progressive aphasia (PPA), and dementia are discussed.