Augmentative Communication

Clinical Issues

Susan Attermeier

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134755325
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Written by therapists experienced in working with nonspeaking clients and their families, this helpful book includes many issues pertinent to the assessment and training of augmented communicators. The field of augmentative communication, which is rapidly gaining recognition in all areas of rehabilitation, is thoroughly addressed here. A summary of the prerequisites for implementing a communication system will be particularly useful to anyone working with nonspeaking clients who do not yet have a method of communication. Included among the topics are assessing cognitive function in clients unable to take intelligence tests in standardized fashion, finding a match between the motor capabilities of the client and the motor demands of various aided and unaided communication systems, and promoting the involvement of the family in the development of a communication system. This indispensable resource also offers information about publication, equipment vendors, and the American Speech-Language-Hearing Association (ASHA), the primary leader in augmentative communication.

An Overview of Therapeutic Positioning for Multiply-Handicapped Persons, Including Augmentative Communication Users

Jane C. Mac Neela

SUMMARY. The body of literature related to adaptive equipment for positioning clients with neuro-musculoskeletal disorders has expanded slowly since the early 1970s. Much of this literature describes custom solutions to positioning problems for individual clients with cerebral palsy. Papers addressing the positioning needs for augmentative communication users remain sparse and superficial in scope. Furthermore, the literature on adaptive equipment solutions is substantially limited to clinicians’ perceptions and theoretical premises of the effectiveness of positioning devices. Few formal studies of the effects of positioning have been reported, and none of the studies have addressed the relationship of body positioning to the use of augmentative communication devices.

The purpose of this paper is to provide a review of the literature devoted to formal studies and guidelines for the use of therapeutic positioning for clients with multiple physical needs. Considerations for employing seating and positioning systems with clients using augmentative or alternative means of communication will also be addressed.

Clinicians and authors who serve multiply-handicapped children and adults with augmentative communication needs are aware of the importance of therapeutic positioning as it relates to effective means of expression. Klein commented that the client who requires an elaborate augmentative communication system is likely to be severely physically handicapped and have difficulty maintaining proper sitting posture.¹ Schurman added that sitting posture was especially important for the child using a headstick-pointing method to access a communication system, in that extraneous movement of the trunk and arms diminished the effective range of headstick-pointing by disturbing trunk balance.²

Despite the acknowldgement that body alignment is an important component for clients using augmentative communication systems, little has been written on this topic. Several authors have addressed this issue very briefly, without offering practical guidelines for integrating therapeutic positioning with communication devices.^1-4 No formal studies have addressed the relationship between optimal body alignment and use of augmentative communication devices.

Although supportive empirical data are lacking, the literature suggests that most clinicians believe therapeutic positioning plays an integral role in the physically handicapped client’s effective use of an augmentative communication device. Many centers serving handicapped clients offer an interdisciplinary staff and facilities for prescription, fabrication and adaptation of therapeutic positioning components, often interfaced with augmentative communication devices. Manufacturers of adaptive equipment have gradually expanded their product lines to include more versatile positioning components which promote improved function and comfort for these persons with multiple needs. These factors suggest that, in general, clinicians identify a positive relationship between therapeutic positioning and optimal functional use of augmentative communication systems for clients with significant physical deficits.

THERAPEUTIC POSITIONING AS IT RELATES TO FUNCTION

Much of the literature addressing therapeutic positioning describes the effects of improved alignment in terms of enhanced functional capabilities. If we assume that the use of communication devices is dependent on functional ability, improved body alignment could increase a given client’s communicative skills, whether he or she accesses a device via upper extremity pointing, use of a head-stick/light, or any other mode employing a body part.

Proposed Benefits and Purposes for Therapeutic Positioning

Many reasons for positioning clients having motor impairments have been reported in the literature. Among these various claims are proposed benefits for the musculoskeletal, cardio-respiratory, and nervous systems, in addition to improved functional abilities and ease of client care by others. The reader is encouraged to critique these claims carefully, giving consideration to the limited or absent proof for each postulate as offered in the subsequent literature review section of this paper.

The following list of these purposes is varied and quite extensive in scope. These have been grouped into two major sections: functionally and physiologically-based purposes. Postulates stated by individual authors may overlap those of others; wherever some discrepancy was noted, these related principles were cited separately for purposes of clarity.

The reasons for therapeutic positioning noted within this literature review included:

A. Functional Purposes:

1. to provide physical support/stability which promotes functional improvements⁵

2. to normalize muscle tone and facilitate more normal movement patterns, maximizing function with minimal movement pathology^5,6

3. to control abnormal movement patterns⁷

4. to facilitate components of normal movement in a developmental sequence by incorporating proper weight-bearing, weight shifting, rotation, and righting reactions^4-6

5. to promote more independent mobility^4,5,7-10

6. to provide comfort and relaxation in a more upright position^{3,6,7,8,10,11}

7. to allow maximal upper limb function^6,10-12

8. to facilitate communication via well-controlled upright positioning^3,7,8,12

9. to facilitate physical and occupational therapy by providing upright positions suitable for strengthening and coordination exercises⁷

10. to faciliate recreational and social activities, enhanced by more upright positioning^3,4,7,9

11. to promote the psychological benefits of the upright position by placing clients in more socially acceptable, “less handicapped” postures^4,7

12. to facilitate education via upright positioning in the classroom^3,7,12

13. to facilitate vocational activities⁷

14. to facilitate independence in self-care activities^4,7

15. to facilitate nursing care (feeding, toileting, bathing the upper body) via upright alignment^7,12

16. to allow ease of transportation of clients to and from schools, developmental centers, and community centers, by parents and attendants^10,11,12

B. Physiologic Purposes:

1. to prevent or correct joint contractures and skeletal deformities, and increase range of motion^5-8,10,11,13

2. to facilitate the sensation of good body alignment^4,5

3. to facilitate respiratory gas exchange⁷

4. to facilitate cardiac muscle function⁷

5. to promote general health and resistance to infection⁷

Although many of these statements seem to be theoretically sound, little proof of these premises has been provided via formal studies documented in the literature. Furthermore, the benefits of therapeutic positioning for oral or augmented communication have not been validated.

Formal Studies of Therapeutic Positioning

The practice of therapeutic positioning and seating is relatively recent in origin, and the literature on this topic seems to cover several areas. The most popular approach to documentation on this issue has been the case report method, citing custom-fitted solutions to individual client’s needs. Although these are helpful in sharing creative solutions to positioning problems, more formal studies of the effectiveness of positioning are needed. This section provides a review of the available formal studies related to therapeutic positioning. Readers are encouraged to consider that these studies contain the only evidence provided for validation of the aforementioned purposes for therapeutic positioning.

Within this review, the first three studies address functional gains following positioning intervention. The next two papers focus on the issue of therapeutic positioning applied to improve head control during feeding programs. The last two studies address more physiologic aspects of therapeutic positioning, evaluating the effects on pulmonary function and spasticity, respectively.

Hulme and associates¹⁴ described a rural, home-based model for provision of adaptive equipment to physically-handicapped clients throughout the state of Montana. Although the purpose of this paper was to describe the implementation of the project, the authors also cited several examples of the effectiveness of their interventions. These results were incidentally described in functional terms for individual clients, including improvements in head and trunk control, sucking and swallowing ability, finger feeding, and increased frequency and ease of mobility out of the home environment. Use of an objective rating scale for determining these improvements was not apparent.

In a follow-up study, Hulme and colleagues¹⁵ reported the perceived functional benefits for clients receiving adaptive equipment. By administering a post-hoc written questionnaire to clients’ caretakers, the investigators documented improvement in ability of 65.5% of the subjects to sit upright without leaning. Sitting tolerance also increased from a mean interval of 3-4 hours to a mean interval of 4-5 hours, following equipment intervention. Significant improvement was reported for eating manner, drinking manner, and ability to reach for and grasp an object. Also cited were improved independence in toileting, mobility in the home environment, and access to the community environment. The inter-relationship between adaptive seating and augmentative communication devices was not described in this functional review. The authors acknowledged that the documented functional improvements could not be attributed to adaptive equipment intervention alone, as many of the clients were concurrently involved in therapeutic training programs for motor and sensory skills, feeding, and upright mobility.

Trefler and co-workers¹⁶ completed a similar study to examine the effects of establishing a delivery program to provide ten physically-handicapped students with adaptive equipment for seating, communication, mobility, and personal care. Analysis of serial measures taken during an 18-month period revealed a significant increase to seven hours, for mean duration of upright head and trunk alignment, when eight of the students were positioned in their respective “therapeutic seating systems.” Significant improvement in gross arm control was also reported for the therapeutic seating condition. Progress in feeding skills was reported for students who received technical feeding aids. Influence of therapeutic seating on feeding skills was not discussed. The authors described a training program for improving motor skills required to operate the control switches (e.g., arm-slot control requiring only a gross placement of the arm within 1 of 5 “troughs,” and single-switch control requiring more accurate placement and activation by arm pressure on a single paddle) for powered technical aids. The trained students demonstrated two to four times more proficiency in operating two devices accessed by these two switches. Although the authors mentioned the provision of augmentative communication devices for some of the subjects in this study, the relationship between therapeutic positioning and use of such communication units was not addressed. The functional transfer of arm-placement training to implementation with communication devices was similarly not reported. Also, the authors did not clarify whether or not the students were positioned in their respective therapeutic seating systems during the arm-placement training, feeding training, and power wheelchair training.

O’Brien and Tsurumi¹⁷ compared head-righting abilities as an effect of sitting in an adapted wheelchair versus semi-prone positioning on a prone support device (angled 30 degrees from the horizontal). Each of the 26 clients’ wheelchairs had been custom-designed and fabricated “to bring the individu...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Foreword
• COMMENTS FROM THE GUEST EDITOR
• Augmentative Communication: An Interdisciplinary Challenge
• The Prerequisites to Augmentative Communication: Their Implications for Therapists and Early Interventionists
• Psychological Assessment of the Nonvocal, Physically Handicapped Child
• An Overview of Therapeutic Positioning for Multiply-Handicapped Persons, Including Augmentative Communication Users
• Motor Assessment for Unaided and Aided Augmentative Communication
• Augmentative Communication: Selection of an Initial Vocabulary
• Language vs. Communication in Training for Augmentative Communication System Use
• Supporting Families of Augmentative Communication Users
• Interaction Strategies
• APPENDIX I: RECORD FORMS FOR AUGMENTATIVE COMMUNICATION EVALUATION
• APPENDIX II: RESOURCES ON COMMUNICATION AND COMPUTER TECHNOLOGY