Often with bulbar-onset ALS, one may maintain the ability to point or gesture long after their speech ability and grip have disappeared. Both are easily designed by yourself. A letter board or Alphabet Board is a grid of letters and symbols that one points to in order to communicate. An icon board can be made to symbolize phrases or frequently used words. Hand signals could be regular Sign Language or gestures developed between the communicating parties to represent words or phrases.
Lip reading is also a low-tech but important resource.
March of Faces PALS and Trustee, Judy Repass of La Plata, MD who has survived ALS for over 20 years still communicates with her family and caregivers by lip reading. Communicating by lip-reading obviously means one still has the ability to control some of their facial muscles. A willing partner is essential when using this means of communication, but it can be so valuable in participating in all speech environments. Three clicks, Judy. Eye signals or eye movement is another low-tech alternative means.