Promoting Augmentative and Alternative Communication–Induced Language Recovery in Chronic Aphasia (PAIL-RcA): Theoretical Construct, Method, Protocol, and Treatment Resources

Abstract

Purpose:

The purpose of this tutorial is to provide a how-to so that clinicians can successfully implement augmentative and alternative communication (AAC) as a dual-purpose tool, one that successfully and simultaneously compensates for communication breakdowns and facilitates language recovery. Moreover, readers will understand two key principles of neuroplasticity as they apply to AAC implementation for people with aphasia (PWA), as well as the theory of intersystemic reorganization, by way of a novel treatment, Promoting AAC-Induced Language-Recovery in Chronic Aphasia (PAIL-RcA).

Method and Procedure:

Readers are provided a step-by-step overview of PAIL-RcA, as well as data sheets, cueing hierarchy, a family handout and prompt guides detailing how to successfully implement PAIL-RcA.

Conclusions:

PAIL-RcA is a novel AAC treatment for PWA that is theoretically driven, manualized, and proven feasible with freely available resources for clinical implementation. Although PAIL-RcA was developed for storytelling and is highlighted for use on an iPad, we encourage adaptation for implementation across a variety of AAC systems and communication purposes.

In aphasia rehabilitation, usual care is focused on helping people restore their prestroke language capacity (Dietz et al., 2020; Hersh, 1998), with SLPs reporting that augmentative and alternative communication (AAC) encompasses less than 2% of the functional poststroke communication measures treated across all rehabilitation settings (acute = 0.6%, inpatient = 0.5%, outpatient = 1.5%, skilled nursing = 1.4%; American Speech-Language-Hearing Association [ASHA], 2024). Inaccurate beliefs and practices about AAC for people with aphasia (PWA) continue to plague the field and likely restrict how AAC is integrated into aphasia rehabilitation (Dietz et al., 2020). For example, AAC is typically employed in a manner that limits PWA to communicating only about their most basic wants and needs—such as requesting food or using the restroom (which are often met through daily caregiving; Dietz et al., 2020; Hur & Kang, 2022; Weissling & Prentice, 2010). Another classic dogma is that AAC and restorative approaches are mutually exclusive (Dietz et al., 2020; Weissling & Prentice, 2010). There is also the idea that AAC only “works” for people with nonfluent aphasia and relatively good comprehension, often leading to an entire subset of PWA not receiving AAC services (Dietz et al., 2020; Weissling & Prentice, 2010). The current approach to AAC in aphasia rehabilitation offers an incomplete resolution for a complex need (Dietz et al., 2018, 2020).

Our recent feasibility study offered evidence against these long-held notions of AAC for PWA (Dietz et al., 2018). That is, AAC can be implemented for purposes beyond wants and needs, employed to support language recovery in people with chronic aphasia, and successfully adapted for people with all types and severity of aphasia (Dietz et al., 2018). Although the notion that AAC could be implemented as a dual-purpose tool was introduced in our 2018 feasibility paper and expanded in our 2020 viewpoint paper, we have yet to share how clinicians might achieve this goal in the clinic. In a medical model where clinicians are more crunched for time than ever (Gunning et al., 2017), it is imperative that clinicians have access to emerging interventions that are mindful of clinician needs and are offered in a digestible, clinic-ready format. As such, the purpose of this tutorial is to provide a how-to so that clinicians can successfully implement AAC as a dual-purpose tool, one that successfully, simultaneously compensates for communication breakdowns and facilitates language recovery. Moreover, readers will understand two key principles of neuroplasticity, as they apply to AAC implementation for PWA, by way of a novel treatment, Promoting AAC-Induced Language-Recovery in Chronic Aphasia (PAIL-RcA). We offer a step-by-step overview of this intervention, as well as our data sheets, cueing hierarchy, prompt guides, a family handout, and an outline of how to successfully implement PAIL-RcA. These resources can all be freely accessed here.

Harnessing Two Key Principles of Neuroplasticity During AAC Intervention

Kleim and Jones (2008) outlined 10 principles of experience-dependent neural plasticity and their significance for rehabilitation. This tutorial has been downloaded over 12,000 times and cited nearly 2,000 times (356 times in the past 2 years). This tutorial is “ … extremely highly cited and has received approximately 197 times more citations than average” (Dimensions, n.d.); these data speak to the continued relevance of this work well over 2 decades later. Of the 10 principles they outlined, we have identified two that are relevant to PAIL-RcA at this time: (a) “Use it or Lose It” and (b) “Use It and Improve It” (p. S227). Briefly, PAIL-RcA methodology explicitly instructs PWA how to successfully communicate using supports available on the iPad such as photographs, text, and speak buttons (SBs) during anomic events; however, there is also an equal emphasis on attempting to speak target words while referencing AAC supports. The notion that the PWA must always try to say the word (even if they are unsuccessful) is the foundation of the intervention and is based on the first two principles of experience-based neuroplasticity outlined by Kleim and Jones. The first is “Use It or Lose It: Failure to drive specific brain functions can lead to functional degradation” (p. S227). Translated to poststroke aphasia, if PWA do not (attempt) to speak, then the neural circuits that support language may result in further loss of function. This is often referred to as “learned non-use” (Pulvermüller & Berthier, 2008, p. 569) and interventions such as constraint-induced aphasia therapy (CIAT) were designed to avoid language non-use in PWA (Mozeiko et al., 2018). During classic CIAT intervention, the verbal modality is emphasized and AAC strategies are not allowed; further, clinicians provide cueing using only verbal modalities (interested readers are referred to the following article for detailed reading on the topic: Pulvermüller et al., 2001). Principle 2 is a close cousin to Principle 1: “Use It and Improve It: Training that drives a specific brain function can lead to an enhancement of that function” (p. S227). Essentially, this tells us that behavioral experiences, including rehabilitation, can facilitate plasticity. We have a growing and rich literature in aphasiology to document that PWA can recover language long into the chronic phases of the recovery (e.g., Edmonds et al., 2014; Efstratiadou et al., 2018). Taken together and applied to AAC treatment, it is critical that we ensure that PWA engage the native neural circuitry that supports language.

Neuroplasticity During PAIL-RcA

During our early work on the development of AAC interfaces, specifically visual scenes displays, we documented that PWA (and no significant motor speech impairment) spoke about 70% of the time when using AAC to retell personal narratives (Dietz et al., 2014; Griffith et al., 2014). We also observed increased on-topic comments, fewer communication breakdowns, higher rates of repairs during communication breakdowns (Dietz et al., 2014, 2018; Griffith et al., 2014), and a higher number of correct information units (CIUs; Nicholas & Brookshire, 1993) when they used AAC interfaces that included personally relevant photographs and text (Collier et al., 2014). This led us to develop an AAC intervention designed to harness the two aforementioned key principles of neuroplasticity (Kleim & Jones, 2008)—dubbed PAIL-RcA. In PAIL-RcA, we aim to engage the native neural circuitry that supports language by cueing the PWA to attempt to say the target words aloud as they use their AAC system (detailed in the PAIL-RcA Treatment Overview section, below). In time, we can imagine how the remaining experience-dependent neural plasticity principles (Kleim & Jones, 2008) could be incorporated into a model to boost outcomes of PAIL-RcA: (c) specificity, (d) repetition, (e) intensity, (f) time, (g) salience, (h) age, (i) transference, and (j) interference. For now, we will focus on “Use It or Lose It” and “Use It and Improve It” as outlined above. These key principles will be paired with intersystemic reorganization to form the basic tenets of PAIL-RcA.

Intersystemic Reorganization

First described by Luria in 1970, the intersystemic reorganization theory posits that a weak system can be restored/strengthened when paired with a stronger or intact system. Intersystemic reorganization requires a person to organize two functionally different systems into a new, related system. This theory has guided apraxia interventions (AOS) over the years (e.g., Knollman-Porter, 2008; Raymer et al., 2006; Rose, Attard, et al., 2013; Rubow et al., 1982). Indeed, a recent review identified the intersystemic reorganization theory as a prominent category of treatments, while acknowledging that many include the additional element of rate and rhythm (Munasinghe et al., 2023); we refer the interested reader to Munasinghe and colleagues' systematic review for an updated summary of this topic. Furthermore, the success of gestural facilitation training on motor planning improvements in people with AOS, as well as word retrieval, has also been attributed to intersystemic reorganization (Raymer et al., 2010). Indeed, gestures are a natural phenomenon of human communication (Kendon, 1994) that seem to have a facilitative word retrieval effect for healthy adults (van der Sluis & Krahmer, 2007). In fact, PWA produce more gestures compared to healthy controls during interactions (Lott, 1999) and more frequently during anomic events (Lanyon & Rose, 2009). These data suggest that PWA naturally use gestures to augment word retrieval and complement the findings of Raymer et al. (2010). Moreover, PWA have demonstrated significant improvements in communication and spoken language postmultimodal aphasia therapy (M-MAT; Rose, Attard, et al., 2013; Rose et al., 2022) to which the success may be attributed to Luria's theory of intersystemic reorganization via “ … crossmodal neuronal interaction between language and sensory/motor systems … ” (Rose, 2013; p. S237). The argument is that M-MAT harnesses the power of multimodal cueing (see below) and strengths of PWA and thereby facilitates improved communication and spoken language (Rose, 2013). To understand how experience dependent neuroplasticity and intersystemic reorganization apply to PAIL-RcA, it is important to first explore more deeply an important element of both aphasia rehabilitation and AAC practice: multimodal communication.

Multimodal Communication in Aphasia Treatment

In speech-language pathology, the term multimodal has a long history (Purdy & Van Dyke, 2011); however, it has been used broadly—as highlighted by Pierce et al. (2019). As a result, they propose a new framework to classify multimodal treatments: (a) multimodal therapy to improve verbal communication and (b) multimodal therapy to improve total communication (Pierce et al., 2019). Multimodal therapy to improve verbal communication is when at least one nonverbal modality is employed to facilitate natural speech (i.e., spoken/written expression and/or auditory/reading comprehension). In other words, this approach is helping PWA use nonverbal strategies as a “ … means to an end and not the primary goal” (p. 713). In contrast, multimodal therapy to improve total communication “ … target[s] nonverbal modalities as a communicative action in their own right … ” (p. 713). Moreover, it is common for PWA to use a combination of different non-verbal modalities while pairing them with spoken and/or written language to communicate their ideas. As defined by ASHA (n.d.-a), AAC refers to strategies a person uses to communicate, aside from talking—either as an alternative to speech or to augment or add to their spoken expression; as such, AAC inherently falls into the multimodal treatment for total communication (Pierce et al., 2019).

There are two types of AAC to consider: unaided and aided. Unaided AAC options do not require equipment, only the person's body; these include gestures (Beukelman & Light, 2020; Raymer et al., 2006; Rose, Attard, et al., 2013; Rose, Raymer, et al., 2013), writing in the air (Itaguchi et al., 2021), and facial expressions (ASHA, n.d.-a). Aided AAC can include low- or high-tech devices to support communication. Low-tech systems may include alphabet boards, communication boards, or communication books (Beukelman & Light, 2020). High-tech devices are available from a wide variety of specialized vendors with tailored language and graphic software systems and access method tools (eye gaze, head mouse, scanning, etc.); however, a plethora of communication apps are available for free and for purchase to download on personal mobile devices. These have speech and text output options, and may offer environmental controls, that can be personalized (Beukelman & Light, 2020). Whether a person uses aided (high- or low-tech) or unaided AAC, they may use these AAC strategies to self-cue natural speech.

Self-Cueing

As described above, self-cueing is a strategy that PWA may use to facilitate spoken language during anomic events or communication breakdowns. In addition to gestures, PWA are known to use text to self-cue by spontaneously pointing to the first letter of the target word via an alphabet board (Beukelman & Light, 2020; Garrett et al., 1989). Similarly, it is common for PWA to self-cue by writing, either in the air or on paper, the initial letter, or letters, of the target word (Wambaugh & Wright, 2007). Evidence also suggests that PWA use self-cueing strategies through drawing (Lyon, 1995; Purdy & Van Dyke, 2011). We posit that when PWA point to or write a letter, and/or draw to overcome an anomic event, they are tapping into two things at once: the “multimodality principle” (Rose, 2013, p. S230) and the tenets of intersystemic reorganization. The multimodality principle asserts that, since communication in the real world is multimodal, it is highly ideal for PWA to participate in multimodal language therapy. This is especially true in the 21st century where it is the norm to supplement our conversations with images from our phones or tablets, send photos with our text messages, and attend virtual meetings with real time transcription and visual supports—to name a few. Given the nature of human communication today, we propose that AAC intervention should be designed to teach PWA how to use their system as a dual-purpose tool, one that augments spoken language recovery, while simultaneously offering support as an alternative to spoken language during the unavoidable anomic events and communication breakdowns using a multimodal communication approach.

AAC as a dual-purpose tool. The literature reveals a history of language recovery following AAC treatment. Over the years, this has been documented as (a) reduced aphasia severity (Dietz et al., 2018; Hough & Johnson, 2009) improved: (b) reading/auditory comprehension (Hux et al., 2020; Knollman-Porter et al., 2022), (c) naming (Alam et al., 2023), (d) writing (Johansson-Malmeling et al., 2022), (e) spontaneous speech/discourse (Brock et al., 2017; Dietz et al., 2018), and/or (f) sentence formulation via AAC (Koul et al., 2008). These various interventions can be segmented into two distinct categories: (a) symbol learning and sentence formulation (Koul et al., 2005, 2008) and (b) total communication (Attard et al., 2013; Hough & Johnson, 2009; Huang et al., 2024; Johnson et al., 2008). By definition, AAC and multimodal communication (Pierce et al., 2019) focus on total communication; as such, the first category of articles contributes critical information to the scientific knowledge base regarding how PWA learn and interact with different AAC interfaces. The second provides insight into how PWA perform using AAC as a total communication tool and serves as a springboard for using AAC as a dual-purpose communication tool, as described above.

In 2008, Johnson and colleagues outlined a high-tech AAC protocol using a traditional grid display, with four levels of navigation that was personalized across three PWA. The intervention was adapted from Koul et al. (2005) and included the following four steps: Symbol Identification, Navigation, Scenario Role Play, and Sentences (sequencing several symbols). Posttreatment testing revealed improvements in comprehension, reading and writing, for all three participants and increases in the cortical quotient for two of the three participants. Moreover, positive changes were documented on the Communication Effective Index (Lomas et al., 1989) for all three participants. These findings were extended to a person with severe aphasia (Hough & Johnson, 2009) and documented the importance of the role of caregivers in assisting in generalizing skills beyond the therapeutic setting. Moreover, this study highlighted the importance of data collection and the need to tailor treatment frequency and intensity to ensure optimal outcomes. More recently, Huang et al. (2024) examined the impact of a low-tech AAC intervention, alongside usual care, during the early phase of stroke recovery (average time postonset = 2.5 months). PWA (fluent and nonfluent), across a wide variety of ages, received either 30 min of AAC + 30 min of usual care, or 60 min of usual care alone for 10 days. The usual care intervention was based on Schuell's stimulation approach (Huang et al., 2024). The low-tech AAC treatment was implemented, based on an adapted approach outlined by Johnson et al. (2008). The results revealed that the AAC + usual care group improved overall communication compared to those who received only usual care alone, as demonstrated on the Communication of Basic Needs domain of the Functional Assessment of Skills for Adults (Frattali et al., 1995). Moreover, compared to the usual care group, the AAC + usual care group also demonstrated significant improvements observed on the Aphasia Battery of Chinese (Gao et al., 1992), including spontaneous speech and the yes/no question subtest.

Over the years, the evidence has demonstrated two things: AAC successfully (a) supports communication (Beukelman et al., 2015) and (b) augments language recovery (Dietz et al., 2018) for PWA. By and large, AAC interventions to-date have yielded these results with a primary emphasis on communication. This brings us back to the notion of designing interventions that harness the full power of AAC by teaching PWA how to use AAC as a dual-purpose tool. As highlighted above, for AAC to be implemented as a dual-purpose tool, the intervention will teach PWA how to use the AAC system to augment spoken language recovery, while simultaneously teaching them how to use it as a communication support (i.e., an alternative to spoken language) during the unavoidable anomic events and communication breakdowns using a multimodal communication approach. This is how PAIL-RcA (Dietz et al., 2018) is structured, incorporating two key principles of neuroplasticity and integrating them into the intersystemic reorganization approach. This methodology, however, requires a shift in how AAC is employed. We posit that improvements in spoken language expression may be observed if a person can learn to use an AAC system to self-cue during anomic events (Dietz et al., 2018). Specifically, a person with aphasia can be instructed to use the intact visual and motor systems (Dietz et al., 2018) to enhance the weaker spoken language system (see quote from website below). Similarly, it is possible that the auditory system also supports this effort (e.g., self-cueing, spoken output of the device); however, our data have not yet substantiated this idea and further work in this area is warranted. The usual care approach to AAC is to replace spoken language, which can be classified as a “learned non-use” approach (Pulvermüller & Berthier, 2008, p. 569). This is a missed opportunity to actively promote language recovery through self-cueing and the coupling of the canonical language and visual processing neural networks (Dietz et al., 2018, 2020). Figure 1 provides an overview of how the theory of intersystemic reorganization can be applied to PAIL-RcA, as outlined on the website:

Figure 1.

Diagrammatic overview explaining how Luria's (1970) intersystemic reorganization can be applied to Promoting Augmentative and Alternative Communication–Induced Language Recovery in Chronic Aphasia to avoid learned non-use during treatment with people who have aphasia. ©2024 Aimee Dietz. All rights reserved. Reprinted with permission.

The relatively intact visual and motor modalities are exploited to strengthen the impaired spoken language modality via the novel performance act of AAC (via the embedded text and photos). PAIL-RcA is designed to teach PWA how to use AAC as a dual-purpose tool via self-cueing during the inevitable anomic events to support the PWA in avoiding learned non-use of spoken language. This is how we emphasize the augmentative, rather than the alternative aspects of AAC.

Bearing in mind the theory of intersystemic reorganization, it may now make sense why it is so important to correctly stimulate PWA during aphasia rehabilitation. When we do aphasia rehab, we are rewiring their brains (Dietz et al., 2018; Johnson et al., 2019; Schevenels et al., 2020); as such, how we manage their aphasia rehab could affect the rest of their recovery. Hebb coined a few phrases that may be helpful when thinking about avoiding learned non-use during AAC therapy. This is also referred to as Hebbian Learning: “Neurons that fire out of sync, lose their link” and “Neurons that fire together, wire together” (Bear et al., 2007, p. 716); these tie nicely back to Kleim and Jones' (2008) principles of experience-dependent neural plasticity, reviewed earlier. Even proponents of CIAT have said that AAC-type techniques are appropriate if they are not used as a substitute for language (Pulvermüller & Berthier, 2008).

PAIL-RcA Feasibility

To date, we have demonstrated feasibility of this PAIL-RcA treatment (Dietz et al., 2018) in participants who were in the chronic stages of their stroke recovery (16–170 months poststroke). Given that this treatment is a spoken discourse treatment, the inclusion criteria required the PWA to be able to speak five intelligible words and, if a motor speech disorder was present, we required that they had no more than a moderate dysarthria and/or apraxia of speech (AOS; using procedures adapted from Bunton et al. [2007] and Haley et al. [2012], respectively). We provided PAIL-RcA 3 times/week for 1 hr/day per session over 4 weeks, for a total of 12 hr of treatment, compared to a usual care group (n = 6) receiving the same intensity and frequency of treatment. PAIL-RcA evoked a reduced aphasia severity on the Western Aphasia Battery–Revised Aphasia Quotient (Kertesz, 2006), as well as large effects for increased counted words (Nicholas & Brookshire, 1993), increased CIUs (Nicholas & Brookshire, 1993), and T-units (Hunt, 1970), and a reduction in word mazes (Shadden, 1998) compared to usual care. Moreover, the PWA demonstrated improved communication via photograph expressive modality units (EMUs) via large effect size. The PWA in both the usual care and PAIL-RcA treatment groups demonstrated similar increased text box (TB) EMUs, which is not unexpected since usual care also classically employs text during treatment. Of note, not a single participant demonstrated SB EMUs; that is, they did not use the device to “speak” for them during the story retell testing sessions (posttreatment; Dietz et al., 2018), despite explicit training on how to use SB, as outlined below. We offer this as continued evidence that AAC does not promote learned non-use and that, whenever possible, PWA will use natural modalities to self-cue and communicate.

We continue to examine the effectiveness of PAIL-RcA, in face-to-face and tele-AAC formats and look forward to sharing those data in forthcoming publications. Below, we outline a feasible methodology for implementing AAC with PWA in a manner that supports the implementation of AAC as a dual-purpose tool, one that facilitates language recovery while supporting communication during the inevitable communication breakdowns.

PAIL-RcA Treatment Overview

Materials

PAIL-RcA was designed and employed face-to-face, on a high-tech AAC platform that supported visual scenes displays for adults as depicted in Figure 2. We also strongly encourage clinicians to employ the tried-and-true AAC Participation Model (Beukelman & Light, 2020, pp. 19–45; Beukelman & Mirenda, 2013, p. 109), which emphasizes the importance of planning for today and preparing for tomorrow, and refer them to several excellent resources for assessment (Beukelman & Light, 2020; Garrett & Lasker, 2007; Garrett et al., 2020).

Figure 2.

A comparison of a Visual Scene Display and traditional grid layout. ©2012 DynaVox Mayer-Johnson. All rights reserved. Reprinted with permission.

App selection and story co-construction . Together with the PWA, the clinician determines which app they will use and what content they will program into the iPad. For our research, we used an app tailormade by Tobii DynaVox; however, there are a plethora of apps that permit programming of photos, text, and speech output that could accommodate this protocol. For story development, we recommend a co-construction process to ensure that the voice of the PWA remains central and the content is personally relevant. The co-construction process is outlined in two of our previous papers (i.e., Dietz et al., 2014, 2018). Briefly, the first step of narrative co-construction is to gather contextualized photographs relevant to the life of the PWA. Ideally, these are personally relevant photographs that depict actions (people doing things) to spark richer conversation (Dietz et al., 2014; Griffith et al., 2014; McKelvey et al., 2007; Wallace et al., 2012). If possible, caregivers can jot down notes related to the events to share with clinicians. During the session, the clinician can use a computer, tablet, or other device to display the pictures and actively discuss the story around the photos with the PWA. This collaborative storytelling process helps the PWA, and clinician co-construct a rich narrative around each picture, including the vocabulary and content of the TBs.

During this app personalization and story development process, it is imperative that clinicians consider the cultural needs of the patients that they serve when setting up AAC systems. This is a complex matter that is increasingly important in a profession that is majority White and monolingual, serving a growing, diverse, bi- and multilingual population. The best way to approach this is with a mindset of cultural responsiveness, where one values diversity, seeks to further cultural knowledge, and works toward creation of community spaces where diversity is valued (Hopf et al., 2021). ASHA offers many resources to support clinicians' endeavor to be culturally responsive (ASHA, n.d.-b).

PAIL-RcA, as outlined below, was adapted for implementation on an iPad, with the goal of supporting PWA during a retell of a personal story. The overarching goal of PAIL-RcA is to instruct PWA how to use AAC as a dual-purpose tool by avoiding learned non-use. For ease of presentation, instructions are outlined for face-to-face implementation; however, we provide a summary of general and step-specific modifications implemented by our team for successful tele-AAC implementation of PAIL-RcA on our website.

Pretreatment

Tips and suggestions. Considering the busy schedule and time restraints of clinicians, a few things can be done to lighten the burden of implementing AAC. One option is to recruit a volunteer to assist with AAC programming and facilitation. Ideally, an AAC facilitator (Binger et al., 2012) is a family member or close friend who is familiar with the technology and is a comfortable communication partner. Another idea is to recruit a hospital volunteer who is dedicated to the rehabilitation unit, and perhaps the development of the AAC program. If there are university students nearby, perhaps it is possible to partner with the institution to create a unique volunteer program for their students, which could help generate interest in AAC. In this situation, there could be a minimum required hours per week that might also fulfill service requirements for classes or student clubs. These are but a few ideas.

Educational handout. To support understanding of PAIL-RcA, we have included a one-page educational handout for the PWA and their family. We recommend reviewing this handout with the PWA and family prior to beginning PAIL-RcA.

Prompts. The following sections provide an overview of how to implement PAIL-RcA; the detailed prompt guides for each step are available on the website. Please note that we encourage clinicians to adapt prompts as appropriate based on the needs of the PWA they serve. Providing augmented input with writing supports is also advised (Wallace et al., 2012). PWA can reply (when indicated) using any mode of communication available to them. In our experience, when provided with a slow rate, and visual supports, PWA are able to understand and respond to the prompts (n = 15, including manuscripts in preparation).

Data sheets. We have curated data sheets for each step that will help determine whether a PWA is ready to move to the next step or needs to remain on the current step at the end of each session. Clinicians only need to enter personalized content, which may be completed by AAC facilitators as outlined above. The data sheets include a legend for our cueing hierarchy, instructions for use and adaption, suggested mastery criterion, and how to proceed if a session ends in the middle of a round to help guide clinical decision making when implementing PAIL-RcA.

Cueing hierarchy. The PAIL-RcA cueing hierarchy is available on the website and includes the use of reminders, verbal, visual, and clinician models. When implementing cues, we recommend a least-to-most restrictive approach, beginning with minimal support and increasing assistance, as needed, to ensure success during the session, while promoting independence. Our experience indicates that pausing can also be a powerful clinical tool to promote opportunity to respond without cueing. However, this is highly individualized and requires clinical judgment to tease apart whether the PWA indeed requires time to process, or if a cue is needed to proceed.

While determining acceptable responses, it is important to bear in mind that the intention of PAIL-RcA is to learn how to use AAC as a dual-purpose tool by avoiding learned non-use via self-cueing—which begins in Step 1B. In this process, however, it is crucial that clinicians and PWA, alike, understand that it is acceptable if the PWA [is] only able to speak some of the words, or if they are unable to say all the words—so long as the PWA attempts to say the target as they point to the relevant elements in the TBs, photos, or as they click the SBs (outlined in Step 1B).

Technical adjustments. During the initial treatment session, the clinician works with the PWA to adjust the settings to select the preferred speaking voice, rate of speech, and loudness level. The pronunciation of specific words, such as names, is refined by entering alternate spellings. This is an important point to pause and consider additional cultural-linguistic needs such as relevance of important stories, voice, accent, pronunciation, spelling, and accent marks.

Treatment Protocol

The following sections outline the four steps of PAIL-RcA treatment. Table 1 is designed to be an organizational tool for clinicians; it summarizes the overarching goals outlined in the prompt guides as well as the materials and preparation reminders for each step of PAIL-RcA, which can be found on the PAIL-RcA website for easy reference. It is important to note that the length of time a person spends on each step varies from person-to-person, with some people spending a few days on a step, and others spending a few weeks (or more) on a step. So far, there is no clear, observable timetable for when people seem to progress from one step to the next. Our best advice is to remind PWA of the criteria and show them their in-therapy progress and to employ the mastery criteria on the data collection sheets to determine when to advance PWA to the next step.

Table 1.

An organization tool for clinicians that outlines the overarching goals and preparation reminders for each step of Promoting Augmentative and Alternative Communication–Induced Language Recovery in Chronic Aphasia (PAIL-RcA).

Overarching goals outlined in prompt guides	Materials and preparation reminders for each step
Step 1
The PWA will understand that the purpose of PAIL-RcA. The PWA will learn how to self-cue using AAC (to avoid learned non-use).	Cue Card 1 Cue Card 2 All participants begin here. Prepare data sheet
Step 2
The PWA will review the purpose of PAIL-RcA. The PWA will practice self-cueing using all elements of the AAC (i.e., photos, TBs, SBs), while retelling their personal story, in segmented story elements—after clinician demonstration of this skill.	Cue Card 1 Cue Card 2 Each TB is considered a segment. During the demonstration step, the clinician will model a pseudo-anomic event to explain how to use the interface elements to self-cue. We recommend practicing this skill, using the PWA's stories to ensure ease and comfort for both during the session. Determine the LEVEL appropriate for the PWA before proceeding. See Step 2 Prompt Guide for guidance. Prepare data sheet
Step 3
The PWA will practice how to retell their entire story using the iPad as a dual-purpose AAC tool—that simultaneously compensates for communication breakdowns and facilitates languages recovery. More specifically, the goal is to ensure that the PWA attempts use spoken language to retell story and uses the elements of the AAC (i.e., photos, TBs, SBs), ONLY during anomic events and/or communication breakdowns. The PWA begins to focus on pragmatics and interpersonal components of communication.	Cue Card 3 Cue Card 4 The LEVEL is based on what was determined in Step 2, for the PWA. See Step 2 Prompt Guide for guidance. Requires several stories; ensure the PWA has multiple stories programmed by this point. Step 3 requires a high-level of meta-linguistic processing and is quite a shift from Step 2 for the PWA. Prepare data sheet.
Step 4
The PWA practice retelling their story to people, aside from the clinician, while using the iPad as a dual-purpose tool. The PWA will maintain a conversational feel during the interaction. The PWA will identify what they did well and what can be improved upon during the video review of the story retell (4B).	CUE CARD 3 CUE CARD 5 Listener Guidelines (see Step 3) Ask a volunteer if they have 10–15 min to meet a person with aphasia and learn a little about their life. Engage a second volunteer or AAC facilitator to assist with the room setup and listener prep. Requires several stories (like Step 3); ensure that the PWA has multiple stories programmed by this point. Alternate stories each session. Determine who (clinician/PWA) will pause/play video ahead of the Session Review (Step 4B) prior to beginning to decrease disruptions during this phase. Prepare data sheet.

Note. PWA = people with aphasia; AAC = augmentative and alternative communication; TB = text box; SB = speak button.

©2024 Aimee Dietz. All rights reserved.

Step 1. AAC Orientation: Competence and Learning Self-Cueing

Step 1 is a foundational step; its mastery is crucial for success in the subsequent steps. All participants begin with this step, regardless of aphasia severity or type. This process may move quickly for people with milder aphasia; however, for those with more significant auditory comprehension challenges, this phase may take longer—and in fact it may be the only step they master. However, it is important not to underestimate the importance of this seemingly innocuous stage. A review of Light and McNaughton's (2014) communicative competence may be beneficial for readers interested in learning more about how to weave together the complex skills of knowledge and judgment with linguistic, operational, social, and strategic competence). In Step 1A, we review the treatment goal, emphasizing that we will be learning to use elements of the interface design as strategies for self-cueing during anomic events using Cue Card 1. In essence, this is where the PWA learn how to avoid learned non-use and the crucial skill of using AAC as a dual-purpose tool, as outlined above. We are ultimately emphasizing that the goal is to learn strategies, not to memorize the narratives. This emphasis throughout PAIL-RcA is what makes it an AAC, not a script training, intervention. We want to emphasize this difference here because we are often asked how the two are different; interested readers are pointed to the studies of Holland et al. (2002) and Youmans et al. (2005) for a quality review of script treatment in aphasia. When reviewing the purpose of PAIL-RcA, it is important to determine whether the PWA has any questions; otherwise, we have found PWA tend to hyperfocus on memorization—which as we just highlighted, is a different treatment altogether. This is emphasized in Step 1A, with a homework assignment to tell one person each day the purpose of the intervention. The PWA is encouraged to use Cue Card 1 as communication support, if needed. The reader will note in the prompt guides that there is a concerted effort to return to this notion throughout PAIL-RcA.

Next, in Step 1B, we begin the central work of instructing PWA about how to self-cue using AAC via Cue Card 2. We begin with photographs since they provide a concrete reference and are easily identifiable, then we move to TBs, and finish with the SBs. This is evident in the prompts provided. To be clear, we go through each element independently; however, since the prompts are identical for each, we have grouped them together. Essentially, in this part of Step 1, we ask the PWA, “Can you show me where your photographs/TBs/SBs are?” This will be challenging for some, and cueing will be required to support this skill. For others, it will be a quick check and a move on to the next part of this step, which is the beginning of learning how to self-cue. Here is where we instruct the critical metacognitive skill that the PWA will carry with them throughout PAIL-RcA, “If you wanted to say ____ but could not say the word(s), how could you use the photographs, TBs, SBs to say ____?” Some PWA will intuitively point to relevant aspects of the photographs or words in TBs; however, less intuitive—and preferred (Dietz et al., 2006)—to PWA —is how to use the SBs. To avoid learned non-use during treatment; PWA must learn how to simultaneously attempt to say the target whenever they experience an anomic event while using their AAC. This skill can take time, and reassurance is critical. We often say, “It is ok if you can only say some of the words. If you cannot say all the words, it is important to TRY to say the words.” This goal is achieved by walking through all the content words in the story using this procedure. Broadly speaking, content words include nouns and verbs depicted in the photos and TBs. Given that Step 1B establishes the foundation for learning how to avoid learned non-use, all PWA, regardless of severity level must complete both parts with the same criteria. Step 2 is where we have outlined two levels to ensure that PAIL-RcA accommodates people with varying degrees of aphasia types and severity.

Step 2. Demonstration and Practice: Segmented Story Elements

Building off the foundational skill of self-cueing with each element of the AAC interface (i.e., TBs, photos, and SBs), Step 2 advances this skill through a two-step process that moves the PWA toward the use of AAC as dual-purpose tool during a storytelling task. More specifically, the PWA learns how to implement self-cueing during a segmented story retelling process that begins with clinician modeling. There are two levels in Step 2 that provide flexibility to meet the needs of PWA—across a wide range of types and severities. For Level 1, the target for the PWA is for them to try to say ~80% of all the content words for each segment to receive full credit. Whereas for Level 2, the target is for the PWA to try to say ~80% of all words for each segment to receive full credit for Level 2. If the PWA achieves mastery in Level 1, they do not necessarily need to move on to Level 2, rather they progress to the next step. Broadly speaking, PWA who fall into Level 1 will be nonfluent; however, someone with fluent aphasia who has more severe comprehension challenges may also benefit from Level 1. People who benefit most from Level 2 are often fluent; however, this could be someone with nonfluent aphasia, who is fairly recovered and wishes to address syntax. There is no hard rule about which patient should go into Level 1 versus Level 2. Clinical judgment, together with patient goals, best guides this decision.

This step begins with a daily review of the purpose of PAIL-RcA and a reminder to practice telling at least one (ideally new) person the purpose of this intervention. Then, the first phase of Step 2 is clinician demonstration. Using Cue Card 2, the clinician explains that the PWA is going to start practicing sharing their story one part (segment) at a time. For purposes of PAIL-RcA, each TB is considered a segment. Next, they walk them through Cue Card 2 and how it will be used in this step. Finally, they demonstrate what the segmented story retell will look like. During this process, the clinician models a pseudo-anomic event to explain how to use the interface elements to self-cue. In our experience it is best to alert the PWA to the planned pseudo-anomic events and explain the purpose behind them before moving on. Next, the clinician demonstrates how to retell the story using Cue Card 2, segment by segment, inserting at least one pseudo-anomic event per segment. Our Step 2 Prompt Guide offers helpful verbiage for the clinician to explain a pseudo-anomic event and how to walk through the demonstration.

In Step 2B, the PWA practices segmented story retelling. The clinician introduces this by saying, “Now it is time for you to practice finding information on the iPad. Tell me about this part of the story” (pointing to the first segment of the story). The segmented story retelling begins with TBs, followed by photographs, and then SBs. That is, the PWA tells their story, segment by segment, while practicing using the TBs, photographs, and SBs to demonstrate their understanding of how to use each unique element during an anomic event. If the PWA successfully achieved their target, meaning, they attempted to say it, pointed to the target, and tried to say it again, they are encouraged for what they accomplished. The clinician points to Cue Card 2 (see Step 2B Prompt Guide) to emphasize what they are doing well and moves on to the next segment. If they cannot say it, but they tried, we always remind them that “It is ok if you can only say some of the words. If you cannot say all the words, it is important to TRY to say the words. We are practicing saying it and using the iPad so that you can tell your story even if your words won't come out.” The clinician walks the PWA through that segment using Cue Card 2 and makes note of what they need to work on during the next round of practice (or session) on the data sheet. For each round, the clinician takes the PWA through the targets for each TB, picture, and SB for EACH segment before moving to the next segment.

Step 3. Guided Practice: Retelling Entire Story

Once the PWA has mastered segmented story elements, they will practice how to retell their entire story using the iPad as a dual-purpose AAC tool. Here is where they will begin to focus on the pragmatic and interpersonal components of communication as well. Step 3 is multifaceted and requires a high-level of meta-linguistic processing. For Step 3, the LEVEL that the PWA begins is based on what was determined in Step 2, with the same expectations for spoken language.

Cue Card 3 is introduced in Step 3A, with the goal of aiding the PWA in learning to cue themselves only during anomic events and/or during communication breakdowns, using the element (i.e., TB, photo, or SB) that they feel is ideal in the moment. The clinician introduces this by saying, “Today we are going to begin practicing sharing your ENTIRE story using your speech. You will learn to use the iPad ONLY when you cannot say the words.” Again, the clinician models how to implement the cue card—forewarning the PWA that they will insert pseudo-anomic events to demonstrate the strategies. The clinician proceeds to retell the entire story using the TB elements during anomic events; the photos, the SBs—demonstrating at least one anomic event per element. The clinician emphasizes that SBs are a last resort to encourage use of natural modalities. After each retell, the clinician points out, “Do you see how I tried to say it first and used the pictures/TBs/SBs to help me find the words?” During Step 3A Demonstration, the clinician begins to stress the importance of pragmatics by commenting, “Notice too, how I am trying to have a conversation with you by looking at you when I tell the story.” The clinician demonstrates this for the PWA, for each TB on the interface, ensuring that they model a pseudo-anomic breakdown at least once per element—and use all elements of the interface twice, (i.e., words, photos, and SBs). Central to helping the PWA learn to use all AAC interface components is for the clinician to vary their use of the elements.

Step 3B begins after the clinician's second retell (see Step 3 prompt guide for more details). This is cued by saying, “Now, I want YOU to practice telling the story to me using your speech. When you have trouble saying the words, you can use the iPad either pointing to the words, or the pictures, or as a last resort the SBs.” The clinician reminds the PWA to provide enough detail so they could tell another person the story—and to make eye contact as well as to respond to their questions. It is at this point that the PWA really begins to work at the conversational level. To assist the clinician in this process, several tools are available in the Step 3 Prompt Guide to provide guidance; these include the Listener Guidelines, Trouble Implementing Steps, and Trouble Making it Conversational scripts. Clinicians may only need to use one of these tools—or they may interweave support from all three scripts to scaffold and support the PWA through this step.

Once the PWA is ready, they transition to Step 3C, where they learn to layer the AAC-supported storytelling skills onto various scenarios, such as telling their story to a friend, neighbor, or family member. This helps them understand how to deliver the story differently, depending on the context and the person. To introduce this, the clinician says, “Today we are going to begin practicing sharing your ENTIRE story using your speech. You will learn to use the iPad ONLY when you cannot say the right words.” They then demonstrate how to self-cue using Cue Card 3, alternating stories each session, which also aids with generalization for the PWA.

Additionally, at this point, the PWA is introduced to Cue Card 4 to support their ability to successfully use their pictures during the story retell. Essentially, the clinician walks the PWA through a “who, what, where, when” exercise to facilitate critical thinking about how the photos can augment their storytelling, either as communication supports, or to self-cue. After this exercise, the clinician says, “Again, we are going to practice sharing your ENTIRE story using your speech. You will learn to use the iPad ONLY when you cannot say the right words. I have some scenarios in which you could possibly use your iPad even after treatment, because the goal is that you will continue to use the strategies you have learned even after you leave therapy. Are you ready?” Once the PWA can demonstrate these skills effectively and efficiently, they move on to self-analysis, which prepares them for generalization of skills.

Step 4. Self-Analysis

Step 4 has three overarching goals. The first is for the PWA to practice retelling their stories to people aside from the clinician, while using the iPad as a dual-purpose tool. Here is where they gain practice with the crucial goal of trying to speak the target as they use the iPad to self-cue during communication breakdowns and/or anomic events by pointing to the relevant elements in the TBs, photos, or as they click the SBs during their story retell. A second goal is to maintain a conversational feel during the interaction. Finally, they learn to self-monitor what they did well, and what could be improved during a video self-analysis of the story retell with the clinician.

Step 4A requires some preplanning and setup. A volunteer is required (10–15 min) and the room must be set up to record the interaction to complete Step 4B. We recommend that busy clinicians engage the suggested volunteer for the room setup and to help recruit and to prep the listeners for this step. Listeners need a few minutes to review the listener guidelines (see Step 3) so that they understand how to encourage the PWA to lead the storytelling (e.g., tell me more), rather than to take over the conversation during anomic events; this time also allows for an introductory period before the story retell. The listener has a specific job, and they are told, “Your job is to learn all about _______'s (insert name of story). I want you to gain as much information as you can about the topic without introducing the information on the iPad (per the guidelines). When it is time to begin, I want you to say, ‘Tell me about your ______ story.’”

The PWA is advised, “Today you are going to share your ENTIRE story with ______. Remember, you should try to use your speech first. When you have trouble saying the words, you can use the iPad EITHER by pointing to the words, OR the pictures, OR as a LAST RESORT press the SBs.” While the clinician is pointing to Cue Card 3, then they are reminded, “Also, remember you are having a conversation, so be sure to pay attention to _______ and any questions/comments they make. Focus on the conversation.” Next, the listener and the PWA are then introduced, and conversation is facilitated. Once the dyad seems to be moving into a comfortable interaction, the clinician (or the AAC facilitator/volunteer) can cue them to begin the story: “I think it might be a good time to tell _______ about your ______ story. I want the two of you to chat for a few minutes.” During the retell, it is important to observe what the PWA does well and what could be improved upon, specifically as it relates to self-cueing, a conversational feel, and any other relevant notes. The prompt guide goes into detail and offers tips on how to do this to facilitate the session review and self-analysis for Step 4B. We recommend a 5- to 6-min conversation to collect a long enough video for Step 4B.

For Part B, the PWA is introduced to Cue Card 5 as they review the recording of their interaction with the listener. The recording is viewed 4 times, with distinctly different goals each time. During the first two viewings, the clinician highlights what the PWA did well and what they can improve on. To do this, they use their observation notes from the conversation and augment their input using the personalizable table from Step 4B. Things that the PWA does well that should be emphasized include attempting to say the words first, using the device only when they are “stuck,” engagement in conversation. Common areas that PWA need to improve on include (a) did not try to say the words before using the iPad, (b) only pointed to the pictures or words, (c) only looked at the iPad, and/or (d) did not look at their listener. During the final two viewings, the clinician hands over the reins to the PWA and it is their job to identify what they did well and what they can improve upon during the next conversation. This step allows for the PWA to recognize and reflect on specific times within a conversation that using the device for self-cueing could be beneficial. Given the wide variety of ability across comprehension and expression in PWA, we have as a preparation tip for this step that the clinician determines ahead of time, with the PWA, who will be playing/pausing the video. In our experience, it may surprise you who may wish to do this—or not. Furthermore, we have been able to run through this step with people who have anomic aphasia, Wernicke's aphasia, Broca's aphasia (with all severity levels), and even Global aphasia. We encourage clinicians to use the tools in the prompt guides (i.e., Cue Card 5 and the personalizable table) to augment input and to facilitate expression to support all PWA as they move to the step and, if necessary, to create new tools to meet the needs of your patients.

Clinical Implications

We acknowledge the limited trials and relatively small N that document the success of PAIL-RcA thus far. However, this tutorial represents the first AAC intervention in the aphasia literature that is theoretically driven, manualized, and proven feasible with freely available resources for clinical implementation. Moreover, we are actively working to disseminate more data to substantiate extant literature. We welcome feedback from clinicians based on your experiences implementing PAIL-RcA that would aid the effort to improve AAC for PWA. We also acknowledge that use of the device to “speak” for people with more significant AOS and reduced intelligibility would likely increase—and that PAIL-RcA might look very different for this population—this is an important area of focus for future research. We also recognize that the addition of a home program could bolster the already promising outcomes and encourage modifications to promote implementation of PAIL-RcA in a manner that promotes the Life Participation Approach to Aphasia (Chapey et al., 2000). This is another space ripe for strategic exploration.

PAIL-RcA, as outlined in this tutorial, was developed for implementation on a high-tech AAC system using visual scenes displays. Furthermore, this treatment and tutorial did not address navigation—a critical aspect of AAC intervention (Wallace & Hux, 2014). As with any AAC system, clinicians should consider the future organizational strategy and overall navigational approach for PWA (Beukelman et al., 2015). Visual scene displays may not be the interface design of choice for some PWA—some may use a traditional grid display. We also acknowledge that some PWA may only use low-tech AAC strategies. As such, we encourage clinicians to view the basic tenets of PAIL-RcA as system neutral, to employ AAC as a dual-purpose tool, one that augments spoken language recovery, while simultaneously offering supports as an alternative to spoken language during the unavoidable anomic events and communication breakdowns using a multimodal communication approach. Likewise, we encourage the use of AAC beyond storytelling interventions, such as treatments focused on basic needs or information sharing. To incorporate the principles of PAIL-RcA, clinicians could include instruction grounded in neuroplasticity, multimodal communication, and intersystemic reorganization, which can be adapted to a grid display by instructing the PWA to try to speak the target as they point to and/or select/speak the symbol cell and/or message window (depending on their goal) of a grid display. Ideally the symbol set would have accompanying text to facilitate this process. For low-tech AAC, the same idea applies; the PWA can be instructed to try to speak the target as they point to the picture, symbol, and/or related text in their communication book. Likewise, they can be encouraged to do the same when referencing drawings and writing (either saved or new) during communication exchanges. We fully acknowledge that the prompt guides would require adaptation if PAIL-RcA were to be employed via a different interface design, by means of low-tech AAC, or, even more so, if implemented for a communication purpose other than storytelling. Similar to high-tech AAC implementation, navigation must also carefully be planned for during low-tech AAC treatment for PWA (Weissling & Beukelman, 2006). Of course, clinical trials are required to validate the hypothesis that behavior would transfer as outlined above.

In closing, communication in the 21st century has evolved to be a multimodal process for most communicators. Technology has evolved to a point where it has virtually removed the stigma of disability for those who can afford iPads and tablets and supports the development of low-tech options. We hope that this tutorial has ignited ideas on how to integrate AAC as a dual-purpose tool, whether implementing PAIL-RcA in its native form as outlined here and on the website, or in a novel adaptation, employing its basic tenets as described herein.

Data Availability Statement

There are no data associated with this tutorial.

Funding Statement

This work was supported, in part, by the National Institute on Deafness and Other Communication Disorders (R15DC017280) “A Preliminary Study of the Neurobiology of AAC-Induced Language Recovery in Post-Stroke Aphasia” as well as an Institutional Training Award (KL2) from the University of Cincinnati (UC) and Cincinnati Children's Hospital Medical Center for Clinical and Translational Science and Training via the National Center for Research Resources and the National Center for Advancing Translational Sciences Grants 8 KL2 TR000078–05 and 8 UL1 TR000077–05. Portions of this tutorial were written while the first author was on research release at Georgia State University. This work reflects the opinion of the authors and not necessarily that of the National Institutes of Health or Georgia State University. This work was completed outside of any official capacity with the Veterans Affairs (VA). This work reflects the opinion of the authors, and the contents do not represent the views of VA or the U.S. government.