S c h o l a r l y a r t i c l e A u g m e n t a t iv e a n d A l t e r n a t iv e C o m m u n i c a t i o n : R e l e v a n c e f o r P h y s i o t h e r a p i s t s A B S T R A C T : Communication is one o f the critical components in determining quality o f life o f individuals and fam ilies. A ll members o f the transdisciplinary rehabilitation team therefore need to develop the knowledge and skills to communicate effectively with clients with little or no speech. This involves creating opportunities f o r comm unicative interaction and facilitation o f functional communication. The fie ld o f augmentative and alternative communication (AAC) provides strategies and techniques which facilitate the interaction process, and is applicable to a wide range o f medical conditions which may impact on the functionality and intelligibility o f speech. These strategies are classified either as aided or unaided. The role o f the physiotherapist in A A C assessm ent and intervention is explored in the context o f transdisciplinary teamwork. The importance o f exposing students to AAC as p a rt o f the undergraduate and postgraduate training programs f o r physiotherapists is discussed. K E Y WORDS: QUALITY OF U FE, AUGMENTATIVE A N D ALTERNATIVE COMMUNICATION, PHYSIOTHERAPY, TRANSDISCIPLINARY TEAMWORK, TRAINING ROSE J, B.Sc Physiotherapy (RAND) BA HONS AAC (UP)1; ALANT E, D. Phil (UP)1 1 Centre for A ugm en tative an d A lternative C o m m unication, University o f Pretoria. INTRODUCI'ION Issu es p erta in in g to q u ality o f life, self- efficacy, se lf-c are an d se lf-resp o n sib ility are receiv in g a g rea t d eal o f atten tio n fro m p h y sio th erap y rese arch e rs an d clin­ icians alike. Ensuring that clients have c o n tro l o f th e ir lives, an d sp ecifically o f th e ir re h a b ilita tio n /tre a tm e n t p r o ­ g ram m es, is b ec o m in g a co re v alu e o f p ro fessio n al p ractice (Eales, S tew art and N o ak es, 2000; E ales and S tew art, 2001). M o re than ever, the aim is to em p o w er p atien ts to m a n ag e th e ir ow n h ealth n eeds th ro u g h active involvem ent, not o nly o f the fam ily, bu t also o f the clien t th ro u g h o u t the process. H ow ever, for p h y s io th e r a p is ts , ‘c o lla b o r a tio n in a so cially b ased , c lien t-c en te re d m o d el o f C O R R E S P O N D E N C E TO: J R ose C A A C U n iv ersity o f P reto ria, P re to ria 0 002 26 S an d h u rst V illage, S an d h u rst 2196 Tel: (012) 7 8 3 -0 1 6 3 (W ) (0 1 2 ) 420-2001 (H ) h ealth care is a rad ical c h a n g e fro m the tre a tm e n t o f p a tie n ts in la rg e a c u te h o sp itals d o m in a te d by a m ed ical m odel o f h e a lth c a re ’ (R ich ard so n , 1999:468). T h e p r o c e s s o f c o m m u n ic a tio n b etw een clin ician an d clien t (and fam ily) is p iv o tal in en h an cin g m u tu al u n d er­ sta n d in g and co o p e ratio n in the re h a b il­ itation process. A lthough physiotherapists have b eg u n to ex p lo re w ay s o f e m p o w ­ erin g th e ir clien ts, the field o f fu n ctio n al c o m m u n ic atio n has receiv ed little a tte n ­ tion. W ithout en su rin g that the clien t can b e clearly u n d ersto o d it is im p o ssib le fo r p h y sio th erap ists to p ay m o re than lip serv ice to th e ir id eals o f clien t-c en te re d intervention. T his issue b eco m es p articu ­ larly p ertin en t w hen d ea lin g w ith clients w ho have ‘little o r no fu n ctio n al s p e e c h ’ ( L N F S ) 1. To facilitate c o m m u n ic atio n w ithin th e p h y s io th e ra p y co n te x t, th e ra p ists n eed to co n s id e r tw o im p o rta n t issues: - F irs tly , o p p o r tu n itie s n e e d to b e cre ate d to fac ilita te c lien t/th e ra p ist co m m u n icativ e in teraction. G enerally th e ra p ists rec o g n ize the im p o rtan ce o f listen in g to an d d isc u ssin g relev an t issues w ith clients, in o rd er to enhance the clien t-th e ra p ist rela tio n sh ip and th ereb y the efficacy o f intervention. H o w ev er, w h e n th e in d iv id u a l is u n ab le to speak, th e rap ists tend to d o m in a te th e co n v e rsa tio n a l in te r­ a ctio n an d w ill o ften even “sp eak fo r” th e client. - Secondly, th e clien t needs to c o m ­ m u n icate effectively, w h ich b eco m es very d ifficu lt w hen the n atu ral ability to sp e ak has b ee n lost. T rad itio n ally the d o m a in o f “sp e ec h ” has been d esig n ated to th e sp eech therapist. H ow ever, as c o m m u n ic atio n is such an in teg ral p art o f d aily living, o th e r in te ractio n p artn e rs b ec o m e v itally im p o rta n t in fac ilita tin g this process. T h e ch a lle n g e to p h y sio th erap is ts is to acq u ire the relev an t k n o w led g e and s k ills to f a c ilita te c o m m u n ic a tiv e in te r a c tio n w ith c lie n ts w h o a re u n ab le to use sp eech as th eir p rim ary m ean s o f c o m m u n ic atio n . T h e field o f a u g m e n ta tiv e a n d a lte rn a tiv e c o m m u n ic atio n (A A C ) pro v id es the I L N F S refers to a p e r so n w ho h a s less th a n 15 in te llig ib le words 18 SA J o u r n a l o f P h y s i o t h e r a p y 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) b ro ad fram ew o rk w ith in w hich fu n c­ tional co m m u n icatio n strateg ies can b e learn ed an d im p lem en ted . DEFINING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) A A C refers to ‘the tran sd iscip lin ary field th a t uses a v ariety sy m b o ls, strategies an d tech n iq u es to a s sist p eo p le w h o are u n ab le to m eet th e ir c o m m u n ic atio n n ee d s th ro u g h n atu ra l sp eech a n d /o r w ritin g ’ (L lo y d e t al, 1997:1). A A C sy stem s can b e u se d to su p p le m e n t ex istin g co m m u n icatio n efforts thereby en a b lin g users to: - ex p ress b asic needs an d d esires - tran sfe r in fo rm atio n - estab lish social clo sen ess, and - d em o n strate social etiq u ette U n less co m m u n ic atio n em b ra ce s all fo u r th ese p u rp o ses o f co m m u n icatio n (L ight, 1988) q u ality o f in teractio n w ill b e co m p ro m ised . F u n ctio n a l c o m m u n i­ ca tio n skills red u c e learn ed h elp lessn ess an d en h a n ce in d ep en d en ce. A A C services have b ee n offered by m em b ers o f tran sd iscip lin ary team s at h o m e, at school, in the w o rk p lace, in m edical settings, and in ex ten d e d care facilities since the early eig h ties in the U SA (L lo y d e t al, 1997). In South A frica the c h a lle n g e is fo r all th o se involved w ith clients w ith co m m u n icatio n deficits to b u ild th e k n o w led g e and skills n ec es­ sary to fac ilita te fu n ctio n al c o m m u n i­ cation so as to im p ro v e q u ality o f life. USERS OF AUGMENTATIVE AND ALTERNATIVE COMMUNICATION C o n d itio n s , w h ich c o m m o n ly a ffe c t sp eech , in clu d e cereb ral palsy, autism , m ental disability, trau m atic b rain injury, spinal ch o rd injury, stroke, am y o tro p h ic lateral sc lero sis and G u illan B arre. In ad d itio n p atien ts in IC U are often u n ab le to c o m m u n ic ate as a co n s eq u e n ce o f surgery, tra u m a an d life th re a te n in g m edical co n d itio n s. F ig u res p u b lish ed b y B e u k elm an and A nsel (1 9 9 5 ) in d icate th a t in th e U n ited S ta te s 0 .8 % -1 .2 % o f th e p o p u la tio n experience severe com m unication im pair­ m ents th a t w o u ld b en efit fro m A A C in terv en tio n . A study d o n e b y E n d erb y an d P h ilip p (cited in B e u k e lm a n & M iren d a 1998) co n c lu d e d th a t 1.4% o f th e to ta l p o p u la tio n in th e U n ite d K in g d o m have a severe c o m m u n ic atio n d iso rd er th at m akes it d ifficu lt fo r them to be u n d ersto o d by an y o n e o u tsid e th eir im m ed ia te fam ily. In South A frica th ere have b een no co m p re h en siv e surveys id e n tify in g severe co m m u n ic atio n d iso r­ d ers am o n g st the total p o p u latio n b u t a survey by A lan t an d E m m e tt (1995) in d icated th a t 39% o f learn ers in schools fo r ch ild ren w ith severe d isab ilities have little o r no fu n ctio n al speech. T h is is significantly h ig h er than the 6% rep o rted in F irst W orld co u n tries. T h e high in c i­ d en ce in South A frica is c o u ld b e due to in a d e q u a te r e h a b ilita tio n fac ilitie s an d services, ex a ce rb a te d b y the lack o f tran sd iscip lin ary team w ork. AAC: ASSESSMENT AND INTERVENTION T h e ch o ice o f A A C in terv en tio n strate­ gies an d tech n iq u es is d ep e n d en t o n an in -d ep th assessm en t, w h ich id en tifies th e specific c lie n t’s stren g th s an d needs. T h e A A C a sse ssm e n t, w h ich sh o u ld alw ays be carried o u t b y a tran sd isci­ p lin ary team , fo cu se s on w h at th e clien t can d o so as to affec t a co m m u n icatio n sy stem as q u ic k ly as p o ssib le. T ra n s­ d isc ip lin ary team w o rk , w hich p ro m o tes ro le release, is cen tral to the effectiv e fu n ctio n in g o f the p h y sio th erap is t w ith ­ in th e field o f A A C. In ad d itio n , the in v o lv em en t o f the clien t, his fam ily and sig n ifican t others, as co re team m e m ­ bers, is ce n tral to the p o sitiv e o u tco m e n o t o nly o f A A C im p lem e n ta tio n , b u t also o f th e re h a b ilita tio n p ro g ra m m e as a w hole. T h ere are tw o m a jo r categ o ries o f A A C s tra te g ie s , n a m e ly a id e d an d unaided. U n aid ed sy stem s refer to th o se sym bol system s w h ich ‘do n o t req u ire an y aid s o r d ev ice s fo r p r o d u c tio n ’ (L lo y d e t al, 1986:168). T h ese system s w o u ld in c lu d e g estu res, fin g er spelling, ey e -b lin k and fac ial ex p ressio n s. A id ed sym bol sy stem s refer to th o se sym bol sy stem s ‘th a t req u ire so m e ty p e o f ex te r­ n a l a s s is ta n c e , o r an aid o r d e v ic e (e.g. paper, p en cil, p ic tu res, ch arts, c o m ­ m u n ic atio n b o ard s, an d in som e cases e le c tro n ic d e v ic e s ) ’ (L lo y d e t al, 1986:168). A d v an ces in tech n o lo g y have m ad e av ailab le a ran g e co m p u ters and assistiv e co m m u n ic atio n dev ices w ith featu res th a t are ab le to im p a ct the c o m ­ p eten ce o f so m e users m arkedly. A A C u sers w ill nev er have o n ly o n e m eans o f co m m u n ic atio n . T h e ir co m m u n ic a tio n w ill, in co m m o n w ith reg u la r hum an c o m m u n ic a tio n , be m u ltim o d a l in nature. T his involves u sin g c o m b in a ­ tio n s o f s p e a k in g , g e s tu rin g , fa c ia l ex p ressio n s an d b ody lan g u ag e, w ritin g , ty p in g etc. U s e rs o f A A C sy ste m s sh o u ld th e re fo re in clu d e both the c o m ­ m u n icatio n m eans they have d ev elo p ed naturally, w ith o u t fo rm a l in terv en tio n , an d th o se m eans, strateg ies, an d te c h ­ n iq u es th a t can b e fac ilita te d o r tau g h t by c lin ic ia n s /e d u c a to r s . O n e o f th e ten ets o f A A C is ‘ th a t a p e r s o n c o m m u ­ n ic a tes is m ore im p o rta n t th a n h o w he c o m m u n ic a te s ’. In e s s e n c e th is d e s c rib e s a fu n c tio n a l a p p ro a c h in w hich th e u se r is e n c o u rag ed to use w h atev er m eans h e is has to convey his m essage. It m u st be stressed that, as speech is the m o st n o rm al an d m o st efficien t m eans o f co m m u n ic atin g , A A C in te r v e n tio n alw a y s e n c o u ra g e s an d facilitates verbal o u tput. T h e m yth th at th e in tro d u c tio n o f a u g m e n ta tiv e o r a lte rn a tiv e m e an s o f c o m m u n ic a tio n in h ib its th e d e v e lo p m e n t o f speech has been allay ed as th ese strateg ies have been show n to fac ilita te v erb al o u tp u t, as a re su lt o f d ec reasin g th e stress an d fru s­ tratio n cau sed by th e in a b ility to c o m ­ m u n ic ate (S ilv erm an 1995). AAC AND THE PHYSIOTHERAPIST L lo y d e t al (1997) d etails so m e o f the specific skills th e p h y sio th erap is t b rin g s to A A C assessm en t and in terv en tio n . T h ese in c lu d e d eterm in in g w h eth e r the p erso n has ad e q u ate m o to r co n tro l fo r un aid ed m eans o f co m m u n ic atio n such as m a n u a l sig n s o r c o m m u n ic a tio n d isp lay s; id e n tify in g b o d y site(s) and m o v e m en t p attern s th a t can be u sed to c o n tro l A A C devices; d eterm in in g the o p tim al p o sitio n o f b o th th e clien t and the device; d e sig n in g th e A A C system th a t b e s t m atches th e p e rs o n ’s m o to r ab ilities an d fo rm u latin g strategies to p ro m o te c o m p o n en ts o f m o v em en t to e n h a n c e m o to r c o n tro l o f th e A A C system . B e u k elm an and M ire n d a (1998) also d etail th e sig n ific an t ro le o f the p h y sio th erap ist in th e A A C team re fe r­ rin g to th e ir e x p e r tis e in a re a s o f m o b ility aids, m o to r c o n tro l an d le arn ­ ing, p o sitio n in g , m a in te n an c e o f m u scle SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) stren g th and ran g e o f m otion as w ell as train in g o f b alan c e an d co o rd in atio n . W h en faced w ith a clie n t w ith L N FS it is essen tial fo r th e p h y sio th erap is t to h av e th e k n o w led g e and sk ills to b e able to u se A A C strateg ies fu n ctio n ally to o p tim ise h er effectiv en ess as a therapist. A s the A A C u se r c o m m u n ic ate s w ith the p h y sio th erap ist she will b e c o m e m ore p ro fic ie n t in th e u se o f th e co m m u n ic a ­ tio n sy stem w h ich w ill fa c ilita te fu rth er in teractio n s. T h e im p o rta n ce o f this ro le m o d elin g sh o u ld n o t b e u n d erestim ated . S ig n ifica n t o th ers are o ften m o tiv ate d to use th e A A C sy stem s h av in g seen them b e in g u se d f u n c tio n a lly b y v a rio u s m em b ers o f the c o lla b o ra tiv e team . T his is h ig h lig h ted by A lan t and B o rn m an (1 9 9 4 :2 4 ) ‘T h e su ccess o f any c o m m u ­ nicatio n sy stem d ep en d s on th e c o n s is­ te n t and sp o n tan eo u s im p lem e n ta tio n o f th is sy stem acro ss all situ atio n s, fu n c ­ tions and p a rtn e rs’. K n o w le d g e o f A A C sy ste m s w ill en a b le p h y sio th erap ists to m ak e tim ely referrals. A n e x a m p le m ig h t b e a clien t w ith am yotrophic lateral sclerosis (ALS). O ften th e clie n t m ay co n s u lt p h y sio th e ­ rap ist long b efo re h e loses his ability to co m m u n ic a te . E arly e x p o s u re to th e field o f A A C w ill e n a b le th e clien t to m a k e in fo rm e d d e c is io n s a b o u t th e tech n iq u es an d strateg ies h e w o u ld like to use w hen he is no lo n g e r ab le to speak. S trategies such as ‘v oice b an k in g ’ (w h e re a clien t m ak es v o ice rec o rd in g s w h ich m ay la ter b e u sed as p a rt o f an A A C sy stem ) sh o u ld be in v estig ated . In ad d itio n b eco m in g fam iliar w ith the featu res o f assistiv e sp eech d ev ices and ad a p te d co m p u ters m ay w ell en h a n ce qu ality o f life d u rin g th e term in al stages o f th e d isease. T h e im p lem e n ta tio n o f an A A C sy stem sh o u ld th e re fo re n o t be reg a rd e d as a ‘last re s o rt’ b u t rath er b e c o m e an in teg ral p art o f th e c lie n t’s reh a b ilita tio n process. T h e m ain b ody o f A A C literatu re c le a rly re f le c ts th a t p h y s io th e ra p is ts h av e a critical ro le to play in the p ro v i­ sion o f A A C services. “T h e pro fessio n o f p h y sio th erap y has a sig n ific an t ro le to p lay in th e in terv en tio n o f p eo p le w ith little o r no fu n ctio n al sp eech as a sig n i­ fica n t p erc en ta g e o f th ese p e o p le are p h y sic ally sev erely c h a lle n g e d ” (A lan t 2 0 0 0 :2 7 ). In S o u th A fric a th e re are at p rese n t o nly fo u r p h y sio th erap ists w ith rec o g n ised q u alifica tio n s in th e field o f A A C . F o r p h y sio th erap is ts th ere is no form al train in g a v a ila b le a t u n d erg ra­ d u ate level. A cad em ic in stitu tio n s need to serio u sly c o n s id e r th e ex p o s u re o f p h y sio th erap y stu d en ts to th e p rac tice o f A A C to e q u ip them to in te ract w ith clien ts w ith sev ere c o m m u n ic atio n d iffi­ culties. A s w e m o v e to w ard s tra n sd isc i­ p lin ary team w o rk , train in g p ro g ram m es n eed to b e ad ap ted to ad d ress ch an g in g needs in se rv ic e delivery. T h o se tem p ted to le av e co m m u n ic a ­ tion in te rv en tio n to th e sp eech la n g u ag e p ath o lo g ist sh o u ld h ee d th e w o rd s o f J e a n -D o m in iq u e Bauby, the 4 2 -y ear-o ld ed ito r-in -c h ie f o f E lle m ag azin e, w ho su ffe re d a b ra in s te m s tro k e , w h ich resu lted in ‘lo ck ed in sy n d ro m e ’. In his book, ‘T h e D iv in g -B ell an d th e B u tter­ f ly ’, w h ich he ‘d ic ta te d ’ m ak in g use o f an a lp h ab e t b o ard an d in d ic atin g his c h o ic e o f e a c h in d iv id u a l le tte r by m ean s o f an e y e b lin k (th e only v o lu n ­ tary m o v e m e n t a t his d is p o s a l) he d escrib es his feelings: ‘T h e id e n tity b a d g e p in n e d to S a n d rin e ’s w h ite tu n ic says ‘S p eec h T h e ra p ist’ b u t it sh o u ld read ‘G u ard ian A n g e l’. S h e is th e o n e w ho se t up th e c o m m u n ic atio n co d e w ith o u t w h ich I w o u ld b e c u t o ff fro m th e w orld. B u t alas! W h ile m o st o f m y frien d s h av e ad o p ted the system , h ere a t the h o sp ital only S an d rin e an d o n e lady p sy c h o lo g ist u se it. So I u su ally h av e the sk im p iest arsen al o f facial ex p re ssio n s, w in k s and nods to ask p eo p le to sh u t th e door, turn on th e tap, lo w er th e v o lu m e on th e TV, o r flu ff up a p i!lo w ’(B audy, 1997:47). REFERENCES A la n t E & E m m e tt T 1995 B re a k in g the silence. C om m u n icatio n and e d u cation fo r c h ildren w ith severe handicaps. H SR C P ublishers, Pretoria A la n t E 2000 A u g m e n ta tiv e and A lternative C om m unication Intervention: A L ifespan Issue. P hysiotherapy: 56: 1-32 A lant E B ornm an J 1994 A u g m e n ta tiv e and A ltern a tiv e C o m m u n ic atio n . South A frican F am ily Practice: 15: 2 1 5-280 B auby J B 1997 T h e D iv ing-B ell and the Butterfly. F ourth E state L im ited, London B eukelm an D & A nsel B 1995. R esearch priorities in the field o f a u g m e n tativ e and a lte rn a tiv e C o m m u n ic a tio n . A u g m e n ta tiv e and A ltern a tiv e C om m u n icatio n . 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A u g m e n ta tiv e and A lternative C om m u n icatio n . 2: 165-171 L loyd L L F u lle r D R A rvidson H H 1997 A ugm entative and A lternative C om m unication. A H a n dbook o f P rin cip les and Practices. A llyn & B acon, M assachusetts. R ichardson. 1999 P rofessional developm ent. P h ysiotherapy: 85(9) 467-473 S ilv e rm a n 1995 C o m m u n ic a tio n fo r the speechless, 3rd edn. A llyn & B acon, N eedham H eights 20 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )