Aphasia is a language disorder associated with injury to parts of the brain responsible for communication. Arguably the best way to describe aphasia is with an example. The American Speech-Language-Hearing Association (ASHA) explains that an individual may say a word they didn’t intend to (“spoon” instead of “fork”), have difficulty producing long sentences, or substitute made-up words, called neologisms, for real ones. Likewise, the inverse problems with comprehending language are just as common for individuals with aphasia as producing language. In trying to understand another person, longer sentences may not register, and figurative language may be hard to interpret. These challenges also appear as difficulties understanding and generating written words.
Defining what type of aphasia an individual has lends itself to a certain degree of ambiguity. For example, an individual with diabetes is a Type-1 or Type-2 diabetic. Both types are clearly defined and mutually exclusive. With aphasia, an individual may have expressive or receptive aphasia, or a combination of the two, but these two types are not confined to strict definitions, and the degree to which the forms effect an individual greatly vary on a case-by-case basis. An expressive form means an individual has difficulty forming words, phrases, and/or sentences, while a receptive form means an individual with difficulty understanding the spoken or written word.
Regardless of what form of aphasia an individual may have, or to what degree it may impact them, a communication modality is crucial to therapy progression. Which modality is best for an individual varies—some may require another person to communicate with them through spoken word exclusively, while others may require a written form, and for others a combination of the two.
“Unfortunately for a lot of our clients, they not only have the aphasia component, but they’ve got some underlying cognitive deficiencies as well,” says QLI speech pathologist Tana Mahrt. “Being able to piece apart what is truly language versus what is cognition can be tricky. Cognitive barriers such as initiation can impact their success in that moment.” The importance of client initiation is at the root of any therapeutic goal—teaching a person to be independent in performing specific tasks. The ability to speak or communicate for oneself is a fundamental element of independent living.
Any observer of individuals with aphasia quickly learns of the importance patience holds. It frequently takes time for a person with aphasia to produce the words and expressions desired. At QLI, the speech pathology team conducts their therapy sessions in a variety of ways to address these communicative and/or cognitive deficits. If a client is new to campus, time is spent learning what communication modality is most effective (a whiteboard and marker, for example), or what degree of image recognition exists. A client may have difficulty producing the syllables of words—in these cases a team member may say the words slowly and move the client’s mouth or facial muscles to mimic the sounds slowly, eventually piecing together the word or phrase.
“I worked with a client who began only being able to say an automatic ‘yeah,’ says Mahrt. “But upon leaving, they were able to generate their loved ones’ names.” When approaching a therapy session, Mahrt asks herself: “Is it a matter of needing support with focus for the client to understand what I’m saying? Or is it a matter of saying the right words, or a combination of both?”
Research has morphed along with the advancement of technology. QLI’s Dr. Karen Hux is leading research to observe how text-to-speech systems can support reading when a person has aphasia. Text-to-speech technology has the potential to influence cognition and reading comprehension, as well as the rate at which something is read.
The methodology behind the research has changed throughout the past couple of years. At first, individuals with aphasia read, listened to, or simultaneously read and listened to short paragraph-length stories to read from. This stage of research involved 28 participants, ranging in age from 34 to 78 years, with three different presentation modalities—a written form, an auditory form, and a combined text-to-speech form (Hux et al., 2019).
After reading and/or listening to the passage, participants answered comprehension questions. The range of time taken for the reading of the passages was far shorter for the text-to-speech modality than the written-only modality (the auditory modality had a fixed time length for each passage, so it wasn’t included in the comparison). Moreover, participants had better comprehension given the text-to-speech presentation (averaging around 72% accuracy, this compares to the listening only (58%) presentation; comprehension was roughly equal in the text-to-speech (72%) and reading only (70%) conditions).
Comprehension of the written or audible word is significant and of equal standing when considering the daily routines of the client. Speech pathologists are in close contact with the rehabilitation team, and a synthesis of observation is key for client success. Mahrt demonstrates this line of communication: “I consult with Rehabilitation Trainers in the houses, and ask, ‘What are you noticing during their routines? Are they able to sequence the process correctly when they’re getting dressed? Are they able to express to you ‘I don’t like this or that?’” For Mahrt and the entire speech pathology team, the house teams provide invaluable insight into what those routines look like in practice beyond the therapeutic session.
The importance of a coordinated team effort is paramount to achieving neuroplasticity, the development of new neural connections which facilitate recovery. “We must ensure that not only speech therapists, but physical therapists, occupational therapists, nursing, Rehabilitation Trainers, and the entire team is aware that these are the strategies we are implementing that will help this client,” says Mahrt. “And we need to make sure we implement that strategy every single time in every single interaction.”
Dr. Hux notes that although the 2019 results indicated the positive influence of text-to-speech communication, more research still remains to explore the effects this modality has on aphasia. Recently, a book club has been set up for participants. Tasked with reviewing 15-20 pages of a novel each week and text-to-speech technology provided only every other week, the researchers can figure out what works best when people with aphasia try to read a book.
The results have been encouraging. The book club participants express a strong preference for having the text-to-speech support, and their comprehension and time spent reading indicate positive effects of using the technology. In some instances, the time needed to read and understand the material went from as many as eight hours when reading by themselves to as few as two hours when reading with text-to-speech support. Dr. Hux and her colleagues hope to publish a peer-reviewed report of this study within the next year.
At QLI, we make it our mission to permeate the diagnosis and complexity of aphasia. Though a number of our clients struggle with this deficit, we are knowledgeable in implementing research-supported practices. Further, we are excited to be at the front of research efforts to understand the many facets of aphasia and its effects on day-to-day living. Through these combined efforts, we emphatically instill purpose and create hope for all clients.