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Hearing and Communication Considerations in Function Based Rehabilitation

Original Editor - Ewa Jaraczewska based on the course by Ansunette Pelser

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Communication is an essential part of human connection and well-being. Through verbal and non-verbal exchanges, we can express our needs, share information and develop social connections. Speech and language conditions can significantly impact how we communicate, potentially resulting in frustration and isolation for patients. Understanding these conditions and incorporating communication-supportive strategies into daily patient interactions can enhance a person's healthcare experience and outcomes.

This article outlines a range of practical strategies for communication disorders that can be adapted to specific clinical contexts and client populations.

Speech and Language Conditions

Healthcare professionals may work with patients experiencing a range of communication issues, including communication disorders, speech disorders, language disorders, and problems related to hearing loss. Three common conditions, dysarthria, aphasia and apraxia, will be discussed in more detail below.[1]

Dysarthria

Dysarthria is a motor speech disorder.[2]

"A speech disorder is an impairment of the articulation of speech sounds, fluency and/or voice."- American Speech-Language-Hearing Association (ASHA)[3]

Dysarthria can have a sudden (e.g. stroke) or gradual (e.g. Alzheimer's disease) onset. It can develop at any age due to brain, spinal cord, cranial nerve or spinal nerve injury or dysfunction. Dysarthria can be a temporary condition or it can become chronic.[2]

Dysarthria impacts the articulators—the lips, tongue, cheeks, and hard and soft palate. It typically affects their strength and range of motion. The speech of people with dysarthria may sound slurred or imprecise. The degree of impairment can vary across structures. For example, cheek strength might be preserved while tongue function is affected.[1]

In this optional video, you can hear the speech of two individuals with spastic dysarthria:

[4]

Therapeutic Interventions for Dysarthria

In dysarthria, up to five speech subsystems can be affected, though the specific pattern varies depending on the type and cause of dysarthria. These subsystems include the respiratory, phonatory, resonance, articulatory, and prosodic systems.[5] Speech and language therapists create individualised treatment plans for each patient to target the affected subsystems.

The respiratory subsystem coordinates breathing during speech. When this system is affected, speech and language therapists might incorporate relaxation techniques and postural exercises into the person's daily routine.[5]

The phonatory subsystem (i.e. the larynx or voice box) produces sound. When affected, speech and language therapists might introduce exercises focusing on producing long vowels with pitch and volume variations, or controlled breath holding.[5]

The resonance subsystem manages how sound vibrations are shaped in the vocal tract when a person speaks. Practising prolonged vowels can help when this subsystem is impacted.[5]

The articulatory subsystem includes the structures used to produce speech sounds—lips, teeth, mouth, tongue and larynx. When articulation is affected, oral motor exercises, such as elevating the tongue tip against a tongue depressor or practising over-articulation, can help strengthen these structures.[5]

Finally, the prosodic subsystem controls the pitch, loudness, and timing of speech. To address issues with this subsystem, speech and language therapists might encourage patients to practise reading sentences aloud, emphasising different words each time.[5]

Strategies to Support Effective Communication for People with Dysarthria

Healthcare professionals can adopt several simple strategies to support effective communication with people with dysarthria. You can: (1) create a supportive communication environment by minimising external distractions like televisions, radios, and appliances; (2) inform friends and family that the person may need more time to speak but still has valuable contributions; (3) encourage the use of supplementary communication methods like writing, typing, communication boards, or apps, emphasising that these tools support verbal communication, (4) ask the person to repeat what they said or use different phrasing if you are having difficulty understanding them; and (5) allow sufficient time and reassure the person that you are committed to understanding while acknowledging the frustration they may be feeling.[1]

Aphasia

Aphasia is a communication disorder.[2]

"A communication disorder is an impairment in the ability to receive, send, process, and comprehend concepts of verbal, non-verbal, and graphic symbols system." American Speech-Language-Hearing Association (ASHA)[3]

Aphasia is an acquired condition that occurs due to damage in the language-dominant hemisphere of the brain.[2] Aphasia usually occurs after a stroke. Other causes include traumatic brain injury, brain tumours, and neurodegenerative conditions.[6]

Aphasia affects a person's ability to understand and / or express language. People with aphasia typically have difficulty accessing words and language. A person's presentation will vary depending on the type of aphasia they have.[1] If you are interested, you can learn more about the types of aphasia here.

Please watch the following optional videos if you would like to hear the speech of two people with different types of aphasia:

[7]
[8]


Therapeutic Interventions for Aphasia

"The ultimate aim of speech-language therapy for adults with aphasia is to enhance their life participation."[9]

Speech and language therapy aims to help people with aphasia (1) gain confidence and strategies to manage communication difficulties, (2) improve daily communication experiences, and (3) advocate for their needs.[9]

1. Gaining confidence and strategies to manage communication difficulties

When the linguistic, emotional, social and cognitive challenges associated with aphasia are effectively addressed, interventions and support systems can be enhanced, resulting in improved quality of life for people with aphasia.[10] Aphasia interventions aim to enhance communication and conversation.[11]

2. Daily communication experiences

Daily communication activities are crucial for individuals with chronic aphasia to maintain therapy gains. Therapeutic interventions should focus on sustaining the client’s functional communication within the community through, for example, group activities. Community group activities benefit clients by providing a sense of purpose, reducing social isolation, fostering support and friendships, increasing motivation, and improving mood and quality of life. People are more likely to continue these activities if they are meaningful and enjoyable. Research shows that integrating activities into a daily routine and facilitating interpersonal connections are more important than activity type.[12]

3. Empowering clients to advocate for their needs

Developing individualised communication strategies empowers people with aphasia to advocate for their needs. Speech and language therapists implement a range of techniques to enhance language and expressive abilities for individuals with aphasia. Individualised communication strategies include using alerting signals to gain and focus the attention of a client with aphasia, using simple language, and adding pictures and symbols to writing. It is also important to verify that the patient has understood a conversation. This might include asking yes or no questions, asking the client to paraphrase what has been said, or providing corrected feedback.[13]

Strategies to Support Effective Communication for People with Aphasia

All healthcare professionals can use supplementary interventions to help clients with aphasia communicate. These interventions may include using gestures, communication boards, and short and clear sentences and providing sufficient time for a person with aphasia to express themselves.[1]

Gestures can facilitate communication with a person with aphasia, as people with aphasia often rely on nonverbal cues. For example, pointing to the desired location when asking the patient to sit down. A person with aphasia should also be encouraged to use gestures to communicate their needs or wants. Another option is to use communication boards. These boards range from simple yes/no boards to more detailed boards with pictures or photographs. People with aphasia can point to an image to express their needs. Healthcare professionals can also use these boards to communicate with patients.[1]

"Lack of spoken or written language ability does not mean a person has nothing to communicate, and visual aids can bridge this gap."[1] - Ansunette Pelser, Speech and Language Therapist

We can also facilitate communication with a person with aphasia by using short, clear sentences and focusing on one idea per sentence. It is important to avoid speaking to them like they are a child (infantilising language) or speaking in a raised voice. Make sure you give individuals with aphasia sufficient time to express themselves, repeat back what they have said to ensure accuracy, and be honest if you are not able to understand their message. These strategies can be utilised during every conversation with a person with aphasia.[1]

Apraxia

Apraxia of speech is a motor speech disorder that affects the motor planning of the movements required for speech.[2]

Apraxia of speech typically has a sudden onset in middle or older age. It is caused by damage to the premotor frontal cortex (in either hemisphere), the corpus callosum, or the left inferior parietal lobe. In pure apraxia, a person's cognition is usually intact. They know what they want to say and can understand language, but their ability to plan speech production is affected.[2] Apraxia can, however, occur with aphasia, which results in additional language difficulties. In cases where aphasia co-occurs with apraxia of speech, it may be particularly difficult to determine whether speech sound errors are due to motor planning, related to apraxia of speech, or are phonemic paraphasias occurring in aphasia.[14]

Individuals with apraxia of speech may also experience motor apraxia in their arms and legs. Upper limb apraxia, in particular, can limit the types of communication tools a person could use.[1]

Apraxia of speech involves two speech subsystems: articulation and prosody. Sound coordination and sequencing are impacted, and speech may be inconsistent, distorted, or accompanied by groping mouth movements. Speech production becomes a conscious effort rather than an automatic process.[1]

Therapeutic Interventions for Apraxia

Speech and language therapists may choose from a range of treatment modalities when treating apraxia of speech. When deciding which approach to follow, a therapist may consider multiple factors, including (1) the severity of the apraxia of speech, (3) any co-occurring diagnoses, and very importantly, (3) the needs and preferences of the specific client.[15]

Articulatory-kinematic approaches are based on the principles of motor planning. These approaches focus on accurate speech movement and production, and require adherence to specific practice schedules, or blocks, with frequent and intense practice of targeted speech sounds. They may also incorporate sensory input. For example, a therapist may gently place their fingers on the client’s face, jaw or neck to give feedback on the articulatory position required to produce a specific speech sound.

Sensory cueing approaches focus on sensory inputs (auditory, visual, tactile, and proprioceptive) to teach movements for speech sounds. These are particularly helpful in cases where clients do not have sufficient intrinsic sensory feedback and are unable to identify how they are moving their articulators. These approaches may focus on a single sensory input or may use a multisensory approach, utilising different sensory inputs. Examples of sensory cues include placing fingers on the client’s articulators, as described previously, as well as using visuals, such as mirrors, drawings, models, or specialised software to help the client see how they are moving their articulators for different sounds.

Word- and phrase-focused approaches, such as script training, involve practising specific scripted phrases that are personally relevant or important to a client. These phrases are practised so that they become automatic and can be used in conversation with relative ease.

Rate and rhythm control approaches focus on intonation and prosody in order to improve speech production. Therapists may sing or intone words and phrases, modelling this for the client to imitate, gradually increasing the length of utterances. They may also use finger tapping or a metronome to assist in providing temporal cues which help to pace the production of speech sounds.

When treating apraxia of speech, it is recommended to adhere to the principles of motor learning, providing intensive treatment as early as possible to allow for repetitive practice of speech sound production.

Various augmentative and alternative communication (AAC) technologies can assist communication for people with apraxia, including speech-generating devices, apps, visual aids and communication boards.[16]

Supplementary Strategies to Support Effective Communication for People with Apraxia

Incorporating speech exercises into daily life can be beneficial for people with apraxia. This includes asking the person to read aloud, repeat phrases, or practise specific sounds. Support groups also offer opportunities for social interaction and emotional support, connecting individuals facing similar challenges to build confidence and share experiences.[16]

Please watch the following optional videos if you would like to hear the speech of people with apraxia:

[17]
[18]

Hearing Loss and Communication Challenges

Hearing impairment makes understanding speech difficult as language processing and speech rely on intact hearing. Untreated hearing loss can lead to difficulties in everyday communication. Noisy settings make conversation particularly difficult for people with hearing impairments.[19]

When working with individuals with an acquired brain injury, it's important to assess for potential hearing loss, which could result from damage to auditory processing areas in the brain (particularly the temporal lobe), trauma to the ear structures, or pre-existing conditions. If a hearing loss is suspected, a hearing assessment should be prioritised, as untreated hearing loss can significantly impact the effectiveness of speech and language therapy.[1]

You can read about hearing loss interventions in this optional article: Assistive Technology for Hearing.

Resources

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Pelser A. Hearing and Communication Considerations in Function-Based Rehabilitation Course. Physiopedia Plus, 2025.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Halpern H, Goldfarb RM. Language and motor speech disorders in adults. Jones & Bartlett Publishers; 2013.
  3. ↑ 3.0 3.1 Definitions of Communication Disorders and Variations. American Speech-Language-Hearing Association 1993. Available from https://www.asha.org/policy/rp1993-00208/?srsltid=AfmBOopOlztNRBeLfHa3C69au0NOHeM_4llMfa-6pqejP2ukYNUihcGf [last access 9.5.2025]
  4. ↑ neurosigns.org. Spastic dysarthria in ALS. Available from: https://www.youtube.com/watch?PZix1F6Gygk [last accessed 13/5/2025]
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Gison A, Ruggiero M, Tufarelli D, Proietti S, Moscariello D, Valente M. Intensive Speech Therapy for Hypokinetic Dysarthria in Parkinson's Disease: Targeting the Five Subsystems of Speech Production with Clinical and Instrumental Evaluation. NeuroSci. 2025 Jan 16;6(1):7.
  6. ↑ Le H, Lui F, Lui MY. Aphasia. [Updated 2024 Oct 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559315/
  7. ↑ tactustherapy. Broca's Aphasia (Non-Fluent Aphasia). Available from: https://www.youtube.com/watch?JWC-cVQmEmY [last accessed 13/5/2025]
  8. ↑ tactustherapy. Fluent Aphasia (Wernicke's Aphasia). Available from: https://www.youtube.com/watch?3oef68YabD0 [last accessed 13/5/2025]
  9. ↑ 9.0 9.1 Howe T, McCarron E, Rowe J. What helps confidence in communication - Perspectives of adults with aphasia: "Get maze…not stay out it". J Commun Disord. 2023 May-Jun;103:106334.
  10. ↑ Ayana Das R, Sanjay S, Shyju SS, Vibin AP, Abhishekh BP. Communication breakdown in patients with aphasia - a bird view of Indian context. Int J Health Sci Res. 2024; 14(8):330- 336.
  11. ↑ Simmons-Mackie N, Savage MC, Worrall L. Conversation therapy for aphasia: a qualitative review of the literature. Int J Lang Commun Disord. 2014 Sep-Oct;49(5):511-26.
  12. ↑ Menahemi-Falkov M, O’Halloran R, Hill AJ, Rose ML. “But if you do not keep doing it, you won’t maintain”. A qualitative study on speech-language pathologists' perspectives on maintenance of therapy gains in aphasia. Aphasiology 2024; 1–25.
  13. ↑ Stipinovich AM, Tönsing K, Dada S. Communication strategies to support decision-making by persons with aphasia: A scoping review. Int J Lang Commun Disord. 2023 Nov-Dec;58(6):1955-1976.
  14. ↑ Haley KL, Jacks A, Richardson JD, Harmon TG, Lacey EH, Turkeltaub P. Do People With Apraxia of Speech and Aphasia Improve or Worsen Across Repeated Sequential Word Trials? J Speech Lang Hear Res. 2023 Apr 12;66(4):1240-1251.
  15. ↑ Acquired Apraxia of Speech. Available from https://www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/#collapse_6 [last accessed 30.6.2025]
  16. ↑ 16.0 16.1 Munasinghe TU, Ariyasena ADK, Siriwardhana DD. Speech Therapy Interventions for Acquired Apraxia of Speech: An Updated Systematic Review. Am J Speech Lang Pathol. 2023 May 4;32(3):1336-1359.
  17. ↑ gina helms. Adult apraxia of speech. Available from: https://www.youtube.com/watch?bZ7pnmd9UHI [last accessed 13/5/2025]
  18. ↑ bbperegoy1. Speech example of apraxia of speech. Available from: https://www.youtube.com/watch?SfPBdzBKl8w [last accessed 13/5/2025]
  19. ↑ Humes LE, Dubno JR. A comparison of the perceived hearing difficulties of community and clinical samples of older adults. Journal of Speech, Language, and Hearing Research. 2021 Sep 14;64(9):3653-67.
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