CLINICAL TOPICS

Aphasia

Overview

Incidence and Prevalence

Signs and Symptoms

Causes

Roles and Responsibilities

Assessment

Treatment

See the Treatment section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Aphasia treatment is individualized to address the specific areas of need identified during assessment as well as the specific goals identified by the person with aphasia and his or her family. Additionally, treatment occurs in the language(s) used by the person with aphasia either by a bilingual SLP or with the use of trained interpreters, when necessary. In general, the aim of aphasia treatment includes

  • restoring language abilities by addressing all impaired communication modalities and focusing on training in those areas in which a person makes errors
  • strengthening intact modalities and behaviors to support and augment communication
  • compensating for language impairments by teaching strategies and by incorporating augmentative and alternative methods of communication if they help to improve communication
  • training family and caregivers to effectively communicate with persons with aphasia using communication supports and strategies, in order to maximize communication competence
  • facilitating generalization of skills and strategies in all communicative contexts
  • educating persons with aphasia, their families, caregivers, and other significant persons about the nature of spoken and/or written language disorders, the course of treatment, and prognosis for recovery.

Evidence Highlights

  • Evidence indicates that speech and language treatment is effective in improving functional communication, as well as receptive and expressive language skills in individuals with stroke-induced aphasia (Brady, Kelly, Godwin, & Enderby, 2012).

Expert Opinion

See the Treatment:  General Findings section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Because of the complexity and nature of aphasia, and based on the individual's language profile and values, interventions vary. There are many ways to organize treatment options, including by aphasia type or by primary signs and symptoms. However, since most individuals with aphasia present with a variety of communication deficits and bring different backgrounds and unique needs to the treatment situation, treatments here are organized using the framework proposed in the WHO's ICF framework (2001).

This framework considers two overarching components: health conditions and contextual factors. The health conditions component is most relevant to the treatment descriptions below, while the contextual factors must be considered for all patients throughout the treatment process. Health conditions include body functions and structures and activity and participation.

Framework for Outcome Measurement

Copyright 2008 by Aphasia Institute. Adapted with permission.

In the section below, some of the aphasia treatments described directly address body function impairments (e.g., difficulty formulating syntactically correct sentences, finding words, comprehending words or sentences), while others focus on communication activity and participation (e.g., working directly on functional tasks or situations in everyday activities such as answering the phone, completing paperwork, or ordering food). Regardless of the approach used, the ultimate goal of aphasia treatment is to maximize the individual's quality of life and communication success, using whichever approach or combination of approaches meets the needs and values of that individual.

The following are brief descriptions of both general and specific treatments for persons with aphasia. It is important to note that while the interventions below are categorized by a specific ICF domain (e.g., impairment-based treatment), the outcomes of treatment may extend across domains (Simmons-Mackie & Kagan, 2007). Where available, links to evidence and expert opinion regarding the intervention are provided. This list is not exhaustive nor does inclusion of any specific treatment approach imply endorsement from ASHA.

Language Impairment-Based Treatment

A treatment approach that addresses all communication modalities (spoken, written, and gestures) and focuses on training those areas in which a person makes errors.

Evidence Highlights

Evidence indicates

  • task-specific semantic therapy and task-specific phonological therapy improves semantic and phonological language activities, respectively, in aphasia (Teasell, Foley, & Salter, 2011)
  • cognitive linguistic treatment with both semantic and phonological elements may improve semantic and letter fluency (Teasell et al., 2011).

Expert Opinion

  • For individuals with expressive language difficulties, treatment may include tasks involving semantic processing (e.g., semantic cueing, semantic judgments, categorization and word-to-picture matching) (Taylor-Goh, 2005).
  • Intervention should include tasks that focus on spoken output or accessing phonological word forms such as phonemic cueing, cueing spoken output with written letters, repetition, rhyme judgment, and reading aloud (Taylor-Goh, 2005).

See the Language-Oriented Therapy ection of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Computer-Based Treatment

Treatment involving the use of software programs targeting various language modalities.

Evidence Highlights

  • Evidence indicates computer-based aphasia treatment can improve language skills at the impairment level and generalize to functional communication (Teasell et al., 2011).

See the Computer-Based Treatment section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Constraint Induced Language Therapy (CILT)

Intensive treatment approach focused on increasing verbal output. In contrast to many other approaches, CILT discourages the use of compensatory communication strategies, such as gestures or writing.

Evidence Highlights

Evidence indicates

See the CILT section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Melodic Intonation Therapy (MIT)

Treatment using intonation patterns (melody, rhythm, and stress) to increase the length of phrases and sentences. Reliance on intonation is gradually decreased over time. MIT targets improvement in spoken language expression.

Evidence Highlights

See the Melodic Intonation Therapy section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Reading Treatment

Treatment designed to improve decoding and comprehension of written language.

Expert Opinion

  • For individuals with reading impairments, treatment should focus on training the impaired component or incorporating strategies to compensate for impairment (e.g., semantic approach, improving speed and efficiency of letter identification) (Taylor-Goh, 2005).

See the Reading Treatment section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Syntax Treatment

Treatments designed to improve the grammatical structure of utterances, including

Treatment of Underlying Forms

An approach, grounded in linguistic theory, designed to improve sentence production for people with agrammatism that starts with training more complex sentence structures.

Verb Network Strengthening Treatment

A verb treatment approach designed to improve word retrieval in simple active sentences. Verbs are trained with pairs of related nouns to improve sentence production.

Chaining (Forward and Reverse)—an approach that breaks tasks/words/sentences into small parts and teaches the beginning (or end) part first.

Sentence Production Program for Aphasia—a prescribed treatment program designed to aid the production of specific sentence types.

Word Finding Treatment

Treatments designed to improve word finding in spontaneous utterances, including

Word Retrieval Cueing Strategies (semantic and cueing verbs)—an approach that provides additional information, such as the beginning sound of a word or contextual cues, to prompt word recall.

Gestural Facilitation of Naming—an approach that uses gestural interventions to facilitate verbalization.

Response Elaboration Training—a treatment approach designed to improve word finding and increase the number of content words used by a person with aphasia. The clinician elaborates on the person with aphasia's utterances to improve conversational abilities.

Semantic Feature Analysis Treatment—a word retrieval treatment where the person with aphasia identies important semantic features of a target word (e.g., building, books, quiet for "library"); this is thought to activate the semantic network and possibly aid in retrieval of nontargeted but related words.

Evidence Highlights

  • Evidence indicates that phonological and semantic cueing strategies improve naming accuracy and word retrieval skills (Teasell et al., 2011).

See the Word Finding Treatment section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Writing Treatment

An intervention designed to improve expression via written language.

Evidence Highlights

  • Evidence indicates that writing treatment in a group setting is less beneficial compared to individual treatment (Teasell et al., 2011).

Expert Opinion

  • For individuals with writing impairments, treatment should focus on the impaired component or incorporating strategies to compensate for impairment such as grapheme-to-phoneme training, use of anagrams, pictorial or first letters cues, or oral spelling (Taylor-Goh, 2005).

See the Writing Treatment section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Activities/Participation-Based Treatment

Multimodal Treatment

Treatment approaches focusing on the use of effective and efficient communication strategies via nonverbal and alternative means, including

Augmentative and Alternative Communication (AAC)—treatment involving the use of augmentative aids, such as picture and symbol communication boards and electronic devices, to help individuals with aphasia express themselves.

Visual Action Therapy—treatment used with individuals with global aphasia. This nonvocal approach trains persons with aphasia to use hand gestures to indicate specific items.

Promoting Aphasics' Communication Effectiveness (PACE)—treatment designed to improve conversational skills using any modality to communicate messages. Both the person with aphasia and the clinician take turns as message sender or receiver, promoting active participation from the person with aphasia.

Oral Reading for Language in Aphasia (ORLA)—treatment using auditory, visual, and written cues to assist the person with aphasia in reading sentences aloud.

Expert Opinion

See the Multimodal Treatment section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Partner Approaches

Treatment approaches engaging communication partners to facilitate improved communication in persons with aphasia, including

Conversational Coaching—treatment designed to improve communication between the person with aphasia and primary communication partners. The SLP serves as the "coach" for both partners.

Supported Communication Intervention (SCI)—an approach to aphasia rehabilitation that emphasizes the need for multimodal communication, partner training, and opportunities for social interaction. The three essential elements of SCI are incorporating augmentative and alternative communication, training communication partners, and promoting social communication, including participation in an aphasia group.

Social and Life Participation Effectiveness—an approach that focuses on the real-life goals of the person with aphasia, considering what the person can do with and without support. Intervention may also focus on others affected by aphasia, such as family members. Learn more.

Evidence Highlights

Evidence indicates

  • supported conversation for adults with aphasia (SCA) can enhance conversational skills and increase social participation for individuals with aphasia (Teasell et al., 2011).
  • Conversation partner training can improve communication activities/participation for individuals with chronic aphasia, with improvements maintained over time (Simmons-Mackie, Raymer, Armstrong, Holland, & Cherney, 2010).

Expert Opinion

See the Conversation Partner Training Approaches section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Pragmatic Treatment

Treatment designed to address social communication deficits, such as appropriate word choice, nonverbal communication, and understanding the rules of conversation.

Reciprocal Scaffolding

Treatment approach in which communication skills are addressed in natural, relevant situations where the person with aphasia takes on the role of instructor to "novices" during conversations about topics of interest to the person with aphasia. The relationship allows both parties to demonstrate and reinforce communication strategies.

Script Training

Treatment approach in which the clinician and person with aphasia construct a monologue or dialogue that is practiced intensely so that the person with aphasia can communicate about a topic of interest to them.

Service Delivery

In addition to determining the type of speech and language treatment that is optimal for the person with aphasia, consider other service delivery variables that may have an impact on treatment outcomes such as format, provider, dosage, and timing.

See the Service Delivery section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Format

Format refers to the structure of the treatment session (e.g., group vs. individual) provided to the person with aphasia.

Evidence Highlights

  • Evidence indicates that participation in group therapy may result in communicative and linguistic improvements for individuals with chronic aphasia (Teasell et al., 2011).

Expert Opinion

See the Format section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Provider

Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver).

Evidence Highlights

Evidence indicates that volunteers can serve as an effective adjunct to aphasia treatment for speech and language, provided that the volunteers are trained by a qualified professional and given access to relevant therapy materials and a therapeutic intervention plan developed by or under the direction of the professional therapist (Brady et al., 2012; Teasell et al., 2011).

Expert Opinion

  • SLPs should be involved in training volunteers working with individuals with aphasia. Training should focus on increasing volunteers' understanding of aphasia and use of communication techniques (Taylor-Goh, 2005).

See the Provider section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Dosage

Dosage refers to the frequency, intensity, and duration of service.

Evidence Highlights

Evidence indicates

  • an advantage of intensive speech and language treatment over less intensive, conventional speech and language therapy. Intensive treatment produced more significant benefits than conventional speech and language therapy (Bhogal, Teasell, & Speechley, 2003; Teasell et al., 2011).
  • mixed findings in support of more intensive language treatment for individuals with stroke-induced aphasia (Cherney et al., 2010).
  • support for more-intensive treatment over less-intensive treatment for improving language impairment outcomes for individuals with chronic aphasia. Findings remain mixed for communication outcomes at the level of activity/participation for individuals with chronic aphasia (Cherney, Patterson, & Raymer, 2011).

See the Dosage section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Timing

Timing refers to the timing of rehabilitation relative to the onset of aphasia.

Evidence Highlights

Expert Opinion

  • Individuals with persistent aphasia at 6 months should be referred for further speech and language treatment in a group or one-to-one setting (Taylor-Goh, 2005).

See the Timing section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Setting

Setting refers to the location of treatment (e.g., home, community-based).

Evidence Highlights

Evidence indicates

See the Setting section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Bilingual Considerations

In addition to the service delivery variables mentioned above, it is important to consider a person's language needs when selecting the language of intervention. Damage to the language center of the brain in bilingual individuals may produce aphasia across languages. Recovery of language may vary depending on the type of aphasia, how languages were acquired-simultaneously or sequentially-and the degree of proficiency and demands for the use of each language.

The goal of intervention might not be a full recovery of all language(s) used. For example, consider the patient/client with severe global aphasia who spoke English at work and Spanish at home and in the community. Return to work may not be feasible. English might be incorporated into treatment at a minimum; however, Spanish might be the primary focus to return the person to daily activities. It is essential to consider the linguistic demands on the patient/client.

Questions to consider when treating bilingual individuals with aphasia include the following:

  • How many languages does the person speak?
  • At what point did he or she learn English or a secondary language?
  • When and with whom does he or she use each language? For example, what language(s) are spoken at work, at home, and with family or friends?
  • What is the prognosis? How will that impact language(s) that are needed to communicate?

In addition to considering these questions, clinicians may need to consult with another professional, such as a bilingual SLP, a cultural/language broker (a person trained to help the clinician understand the person's cultural and linguistic background to optimize treatment), and/or an interpreter. An SLP will need to determine the language of treatment and its impact on cross-language generalization (i.e., improvement in the nontreated language). The language of intervention must involve the language that the person uses in the home. Demands for services in additional languages will depend on the person's ability to return to premorbid levels of functioning.

Evidence Highlights

  • Evidence from exploratory studies indicates that aphasia treatment provided in the secondary language (L2) yields positive results. Bilingual individuals with aphasia receiving unilingual services in L2 demonstrated improved receptive and expressive language outcomes. Mixed results were found for cross-linguistic transfer to the untreated language (Faroqi-Shah, Frymark, Mullen, & Wang, 2010).

 EXPERT OPINION

  • According to the Intercollegiate Stroke Work Party, individuals with aphasia whose first language is not English should be offered treatment and assessment in their primary language (Intercollegiate Stroke Working Party, 2012).

See the Bilingual Considerations section of the aphasia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Legal Requirements

In the United States, Title VI of the Civil Rights Act of 1964 (Title VI of the Civil Rights Act, 42 U.S.C §§ 2000 et seq.) ensures equal access to services regardless of language spoken. Therefore, health care organizations are required to seek the assistance of an interpreter for provision of service when there is not a client-clinician language match.

Executive Order 13166, issued by President Clinton on August 11, 2000, clarifies that all federal agencies shall develop and implement a system by which persons with limited English proficiency (LEP) can access services and shall ensure that persons with LEP have the opportunity to provide input to federally funded agencies (Moxley, 2002). Federal agencies that fail to meet these guidelines are at risk of facing a number of potential consequences, including losing federal funding if they are found to be discriminatory in practice (Limited English Proficiency, 2013).

Cultural Considerations

Views of the natural aging process and acceptance of disability vary by culture. Cultural views and preferences may not be consistent with medical approaches typically used in the U.S. health care system. It is essential that the clinician demonstrate sensitivity to family wishes when sharing potential treatment recommendations and outcomes. Clinical interactions should be approached with cultural humility.

Note: This section is under construction and will be developed in full detail based on the work of ASHA's Cultural Competence Practice Portal team.

Resources

References

Content Disclaimer: The Practice Resource Project, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.