September 1, 2013 Features

More Than Words

When people with aphasia can’t find the right words, it can completely derail a conversation. Instruction in multimodal communication helps them slide more easily into other forms of expression when words fail them.

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As you prepare for your treatment session with "Blinn," a client who has severe aphasia, you're tickled when you catch sight of him trying to connect with another client in the waiting room. You've been working with him on using gestures to communicate meaning when he's unable to say the words. So, now you watch closely to see if he motions with his arms and hands after his attempts at saying keywords fail.

More Than WordsMuch to your disappointment, he doesn't.

It appears that Blinn is trying to tell the other client something about tonight's baseball game—you know from previous sessions that he's an ardent fan. Now he struggles to produce the word "baseball," but fails to use the swing-the-bat gesture he's been practicing with you. This puzzles you because you know he has mastered this gesture and a number of others that can help better communicate and bolster social closeness.

For speech-language pathologists who work with clients like Blinn, teaching use of gestures and other multimodal strategies is a major thrust of treatment. And the rise of new augmentative and alternative communication methods has only widened the spectrum of options. For example, in a chapter in the 2011 book "The Communication Disorders Casebook: Learning by Example," Aimee Dietz and her co-authors describe a person with severe aphasia who uses speaking, writing, a communication notebook and a speech-generating device. They also describe clients who use SGDs with unfamiliar communication partners, but who use natural speech and gestures with family and friends. For example, a client might select her order on an SGD when dining at a restaurant. But when chatting about last night's hockey game with a best friend, gestures and a little writing may work just as well.

The key is that multimodal communication allows people with moderate to severe aphasia to communicate flexibly across a wide range of people, topics and settings—and on this, the fields of aphasia and AAC generally agree. So returning to Blinn's case, why didn't he draw on his repertoire of gestures?

One possibility is the way in which he learned to use gestures did not allow him to shift easily among communication methods to repair breakdowns. Perhaps learning other modalities, such as pointing to a communication notebook or writing in an integrated manner, could boost his communication effectiveness. The fact is that the literature reveals little about how best to instruct people on using these modalities. Even less is known about how to instruct people in a way that encourages switching among modalities to repair communication breakdowns. Our team has been working to increase our knowledge base in both these areas, as we believe that people like Blinn can most effectively communicate when drawing from an arsenal of strategies. Our work so far backs this up—we'll explain how and share what we've learned.

The whole communication picture

In our research, we hypothesize that some people with aphasia may struggle to use alternative communication modalities because of their inability to switch among them. That is, when talking doesn't work, the person with aphasia is not able to switch to using gestures, despite being able to use gestures in structured situations. To help clients overcome this, we've developed Multimodal Communication Treatment,* an instructional technique designed to boost alternative modality use.

MCT's goal is to make verbal and nonverbal representations of a concept more automatic, facilitating switching among modalities. The technique promotes integration of nonverbal and verbal communication through simultaneous instruction: We instruct clients in speaking, gesturing, pointing, drawing or writing of a single concept before moving on to another one. We take care to preserve instruction in spoken expression to ease potential anxiety about it being sacrificed for instruction in alternative modalities.

Although we're investigating the specific MCT procedure in anew line of research, the general approach is this: First, the clinician shows the person with aphasia a picture. The clinician asks, "What are all the ways you can communicate this?" If the person answers using multiple modalities, the clinician reinforces this. If the person fails to use multiple modalities, the clinician provides a hierarchy of cues until the person draws on all target modalities. Early in treatment, people with aphasia usually struggle to produce many modalities independently. Thus, initial cues may include clinician modeling and client imitation. The clinician may also request that a client gesture or use some other modality or, later in treatment, may simply point to a person's hand to prompt gesture production. Cueing usually decreases over the duration of treatment.

In our first pilot study examining this treatment with people with chronic aphasia, one participant showed progress using and switching among modalities during an interactive communication task with a partner. During the task, the participant requested a picture containing two of the trained targets from a communication partner. The second participant had a more significant semantic impairment and did not perform as well during the interactive task. This participant then completed an additional treatment in which he sorted items into two groups based on a variety of concrete and abstract semantic features (for example, red versus yellow; animals versus vehicles; air versus ground). Following this treatment, he showed an increase in the accuracy of his modality production.

A second pilot study involving two patients confirmed that MCT can be used effectively during inpatient rehabilitation. Both patients increased their use of other modalities, while only one patient increased switching behavior to repair communication breakdowns. In a third study, a person with severe aphasia, including a significant semantic impairment, also improved his modality switching post-treatment when provided both MCT and a semantic feature treatment.

Steps to moving beyond words

Clearly, studies of MCT's principles, elements and benefits are preliminary and we need further research. But we believe its basic tenets can benefit people with aphasia when incorporated into practice. In short, these are:

  1. Assessment should guide intervention.
    Before beginning treatment, we assess clients to target the most effective modalities and involve clients and family members in their selection. For example, one person we worked with was a painter before his stroke, so we incorporated drawing into his intervention program. In assessing patients, we also consider limb apraxia and handedness, which could affect writing, drawing and gesturing. If a person can't functionally model a gesture,he or she will certainly never try using it outside of treatment. For example,gesturing the words "writing" or "pencil" may be difficult for some people who struggle with fine-motor movements. When a patient can use only one hand, we sometimes emphasize using one-handed gestures rather than two-handed gestures.We also suggest assessing clients' semantic abilities—using, for example, the Pyramids and Palm Trees and subtests of the Psycholinguistic Assessment of Language Processing in Aphasia—because intervention combining both semantic and multimodal treatment may best help some clients.
  2. Treatment should aid integration of verbal and nonverbal representations.
    Instead of instructing clients in, say, using gesture for a number of concepts before moving on to instruction in writing or drawing, clinicians instruct clients to integrate multiple modalities for a single concept. For example, when providing instruction on the word "cat," a clinician would encourage the person with aphasia to practice gesturing, drawing, writing and saying the word before providing instruction in another concept. Including spoken expression in this instruction increases the likelihood that clients will use other modalities when words fail. It also helps assure clients and families that spoken expression is not forgotten.
  3. Treatment should support comprehension.
    Many patients with aphasia benefit from augmented input or the simultaneous presentation of other modalities with spoken expression. Augmented input can help them understand instructions and perform treatment tasks. For example, we found that using photographs, written keywords and gestures helped a client understand directions and effectively perform a role-playing activity.
  4. Treatment should integrate existing evidence.
    Whenever possible, we incorporate evidence about how best to instruct people to learn particular modalities. For example, instruction in written expression may follow steps similar to those in Pélagie Beeson and colleagues' Copy and Recall Treatment protocol for providing instruction in written expression. The CART protocol provides structured modeling and opportunities for imitation.

Where to go from here?

Much research is still needed to examine elements of this treatment program and answer questions about candidacy and generalization. Key considerations to examine in future studies and in clinical practice have emerged from our results and experiences so far:

  • Manipulating the intensity (frequency and length) of intervention sessions could amplify treatment. The rehabilitation field is increasingly noting the value of intense treatment protocols involving significant repetition of target behaviors. Providing intensive multimodality treatment (for example, one to three hours daily for two weeks) may lead to rapid acquisition and maintenance of strategies.
  • Increasing treatment intensity could allow more time to be spent on other activities key to boosting functioning. For example, after completing the more traditional modeling and imitation, people with aphasia may benefit from practicing communication modalities in role-play situations to ease their use of different modalities in real-life situations.
  • Providing awareness training can boost self-awareness and self-monitoring in some people with neurological disorders. In addition to multimodal treatment, some people with aphasia may benefit from additional instruction to increase their awareness of communication breakdowns and their success at repairing these breakdowns. For example, the clinician may work with them on predicting and recognizing such breakdowns, and on how to address such difficulties.

With what we have learned through this line of research and its application to clinical practice, we can better understand Blinn's struggles to communicate with a fellow client about the baseball game. Through integrated instruction in alternative modalities, Blinn could likely gain a whole new level of communication confidence—because words would no longer be his only means of sharing his passion about baseball.


*The name of the treatment has varied across some of the published studies when minor modifications were implemented.

Sarah Wallace, PhD, CCC-SLP, is an assistant professor and researcher in the areas of aphasia and augmentative and alternative communication in the Speech-Language Pathology Department at Duquesne University in Pittsburgh. She serves on the coordinating committee of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders, and is an affiliate of SIG 12, Augmentative and Alternative Communication.

Mary Purdy, PhD, CCC-SLP, is a professor and researcher in the area of adult neurogenic communication disorders in the Department of Communication Disorders at Southern Connecticut State University. She is the associate coordinator of ASHA SIG 2 and is also an affiliate of SIG 13, Swallowing and Swallowing Disorders (Dysphagia).

cite as: Wallace, S.  & Purdy, M. (2013, September 01). More Than Words. The ASHA Leader.


Carr, S., & Wallace, S. E. (2013). Effects of semantic + multimodal communication program for switching behavior in severe aphasia. Paper presented at the Clinical Aphasiology Conference, Tucson, AZ.

Dietz, A., McKelvey, M., Schmerbach, M., Weissling, K., & Hux, K. (2011). Compensation for severe, chronic aphasia using augmentative and alternative communication. In S. S. Chabon & E. Cohn (Eds.). The Communication Disorders Casebook: Learning by Example (pp. 351–360). Boston: Allyn & Bacon/Merrill.

Purdy, M., Duffy, R. J., & Coelho, C. A. (1994). An investigation of the communicative use of trained symbols following multimodality training. Clinical Aphasiology, 22, 345–356.

Purdy, M. & Koch, A. (2006). Prediction of strategy usage by adults with aphasia. Aphasiology, 20, 337–348.

Purdy, M., & Van Dyke, J. A. (2011). Multimodal communication training in aphasia: A pilot study. Journal of Medical Speech-Language Pathology, 19, 45–58.

Wallace, S., & Purdy, M. (2013). The feasibility of a multimodal communication treatment for aphasia during inpatient rehabilitation. Paper presented at the Clinical Aphasiology Conference, Tucson, AZ.


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