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, including specific goals identified by the person with aphasia and his or her family.
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. See ASHA’s Practice portal page on Collaborating With Interpreters.
Consistent with the WHO’s (2001) ICF framework, the goal of intervention is to help the individual achieve the highest level of independent function for participation in daily living.
Intervention is designed to
- capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication across partners, activities, and settings;
- facilitate the individual’s activities and participation by (a) teaching new skills and compensatory strategies to both the individual with aphasia and his or her partner(s) and (b) incorporating AAC strategies if appropriate; and
- modify contextual factors that serve as barriers and enhance those that facilitate successful communication and participation, including accommodations such as large print, pictures, and aphasia-friendly formatting to support comprehension of written health materials (e.g., Rose, Worrall, & McKenna, 2003; Rose, Worrall, Hickson, & Hoffman, 2011).
See the ASHA resource, Person-Centered Focus on Function: Aphasia [PDF], for an example of functional goals consistent with ICF.
Person- and Family-Centered Care
Person- and family-centered care is a collaborative approach grounded in a mutually beneficial partnership among individuals, families, and clinicians. Each party is equally important in the relationship, and each party respects the knowledge, skills, and experiences that the others bring to the process. This approach to care incorporates individual and family preferences and priorities and offers a range of services, including counseling and emotional support, providing information and resources, coordinating services, and teaching specific skills to facilitate communication. See ASHA’s resource on person- and family-centered care.
Treatment can be restorative (i.e., aimed at improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for deficits not amenable to retraining).
From the perspective of the WHO’s (2001) ICF framework, approaches aimed at improving impairments focus on “body functions/structures.” Approaches aimed at compensating for impairments are directed at “activities/participation.” The outcomes of both treatment approaches may extend across domains (Simmons-Mackie & Kagan, 2007).
Listed below are brief descriptions of both general and specific treatment options for individuals with aphasia, listed in alphabetical order. This list is not exhaustive, nor does inclusion of any specific treatment approach imply endorsement from ASHA.
Specific treatment protocols will vary, based on each individual’s unique language profile and communication needs. The ultimate goal of treatment is to maximize quality of life and communication success, using the approach or combination of approaches that best meets the individual’s needs.
Community Support and Integration
Approaches that focus on providing community support and helping the individual participate more fully in community life include the following:
Community Aphasia Groups—treatment and support for people with aphasia that can improve linguistic functioning in a naturalistic setting (Elman & Bernstein-Ellis, 1999) and enhance social networks (Vickers, 2010). Groups also offer individuals and family members an opportunity to socialize, converse, share ideas and feelings, receive support, and learn more about aphasia and aphasia resources.
Life Participation Approach to Aphasia (LPAA)—a general philosophy and model of consumer-driven service delivery and not a specific clinical approach. LPAA largely takes place at home and in the community and focuses on long-term management of aphasia. It begins with an initial assessment and places the life concerns of the person with aphasia and others affected by it at the center of decision making (Chapey et al., 2000).
LPAA helps the person with aphasia reengage in life through daily participation in activities of his or her choice (Lyon, 1992). Motivation and a consistent, dependable support system are essential to full participation (Chapey et al., 2000).
Computer-based treatment involves the use of computer technology (e.g., touchscreen tablets) and/or software programs to target various language skills and modalities. Several currently available programs generate data about the individual’s progress on specific tasks; these data can be used in clinical documentation.
Constraint-Induced Language Therapy (CILT)
CILT is an intensive treatment approach focused on increasing spoken language output while discouraging (constraining) the use of compensatory communication strategies (e.g., gesturing and writing). In addition to “forced use” of verbal language, CILT involves high-intensity training via massed practice (Pulvermüller et al., 2001). The principles and techniques of CILT were derived from constraint-induced movement therapy(CIMT), in which the use of a less-affected limb is restrained while at the same time training movements of the affective limb using intensive treatment (Taub, Miller, Novack, & Cook, 1993; Taub & Wolf, 1997).
Melodic Intonation Therapy (MIT)
MIT uses the musical elements of speech (i.e., melody, rhythm, and stress) to improve expressive language. This approach capitalizes on intact functioning (singing) while engaging areas of the undamaged right hemisphere that are still capable of language. It is most often used to treat individuals with severe, nonfluent aphasia (Albert, Sparks, & Helm, 1973; Norton, Zipse, Marchina, & Schlaug, 2009). Individuals begin by intoning (singing) simple phrases and then gradually intoning phrases of increasing syllable length. Visual and tactile cues are given by the clinician, and phrases of social and functional importance to the individual are practiced. Reliance on intonation is gradually decreased over time.
Treatment approaches that focus on using effective and efficient communication strategies via nonverbal and alternative means include the following:
Augmentative and Alternative Communication (AAC) —a treatment that involves supplementing or replacing natural communication modalities (e.g., natural spoken language) with aided (e.g., picture communication symbols, line drawings, Blissymbols, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Aided symbols require some type of transmission device; unaided symbols require only one’s body to produce. Aided AAC includes speech-generating communication devices (Beukelman & Mirenda, 2013). Strategies and devices may be used temporarily or permanently and can be used in conjunction with natural communication modalities.
AAC approaches to severe aphasia (Garrett & Beukelman, 1992) focus on using the individual’s residual language abilities and training communication partners to use “augmented input” to enhance comprehension and to offer written choices to help individuals with aphasia indicate preferences, ideas, and feelings.
Promoting Aphasics' Communication Effectiveness (PACE)—a treatment designed to improve conversational skills. The individual with aphasia and the clinician take turns as the message sender or receiver. Picture prompts for conversational messages are hidden from the listener (similar to a barrier task), and the speaker uses his or her choice of modalities for conveying messages (Davis & Wilcox, 1981).
Visual Action Therapy (VAT)—a treatment used most often with individuals who have global aphasia. VAT is a nonverbal treatment approach that trains individuals to use hand gestures to indicate visually absent items. VAT incorporates a 12-step training hierarchy beginning with tracing (e.g., tracing objects), then matching objects, then producing pantomimed gestures for visible objects, and, finally, producing pantomimed gestures for absent objects. For a more detailed description of VAT, see Helm-Estabrooks, Fitzpatrick, & Barresi (1982).
Treatment approaches that engage communication partners to facilitate improved communication in persons with aphasia include the following:
Conversational Coaching—a treatment designed to teach verbal and nonverbal communication strategies to individuals with aphasia and their primary communication partners (e.g., spouse). Strategies can include drawing, gesturing, cueing, confirming information, and summarizing information. Strategies are chosen by the individual and his or her communication partner and are practiced in scripted conversations. The SLP serves as the “coach” for both partners (Hopper, Holland, & Rewega, 2002).
Supported Communication Intervention (SCI)—an approach to aphasia rehabilitation that emphasizes (a) the need for multimodal communication, (b) partner training, and (c) opportunities for social interaction. There are three underlying principles of SCI:
- Functional communication can be facilitated/improved by teaching strategies to communication partners.
- Communication is a dynamic process; tools and services for the person with aphasia must reflect this dynamic process.
- Communication includes social interaction and the exchange of information and ideas; opportunities for social interaction are emphasized (e.g., Kagan, Black, Duchan, & Simmons-Mackie, 2001).
Multiple Oral Reading (MOR)—a treatment technique for individuals with acquired disorders of reading (dyslexia or alexia). The technique involves re-reading text aloud— either a specific number of times or until a specific reading rate is reached—in an effort to improve whole-word oral reading in the context of a text passage. MOR is best suited for individuals with preserved letter-by-letter reading abilities and relatively good oral reading and comprehension at the single-word level. Treatment can be individualized by selecting text that is relevant and interesting to the individual (see, e.g., Cherney, 2004; Kim & Russo, 2010; Moyer, 1979; Tuomainen & Laine, 1991).
Oral Reading for Language in Aphasia (ORLA)—a treatment for individuals with aphasia that involves repeated practice reading sentences aloud with the clinician in an effort to improve reading comprehension via phonological and semantic reading routes. The use of connected discourse (sentences) rather than single words allows the individual to practice natural rhythm and intonation (Cherney, 1995; Cherney, Merbitz, & Grip, 1986).
Supported reading comprehension—approaches that focus on improving the reading comprehension of individuals with aphasia by incorporating aphasia-friendly text supports (e.g., drawings, personally relevant photographs, and reader-friendly formatting) and linguistic supports (e.g., headings and bolded text; see, e.g., Dietz, Knollman-Porter, Hux, Toth, & Brown, 2014; Knollman-Porter, Brown, Hux, Wallace, & Uchtman, 2016; Rose et al., 2003, 2011).
Reciprocal Scaffolding Treatment (RST)
RST is a group treatment approach that addresses communication skills using natural language in meaningful social contexts. An individual with aphasia, who has a particular skill, is given an opportunity to use premorbid knowledge and vocabulary in reciprocal teaching interactions with a group of “novices.” This reciprocal interaction is beneficial for all participants. The person with aphasia has an opportunity to convey knowledge to the novices, and the novices in turn learn a new skill and provide language models during realistic interactions (Avent & Austerman, 2003).
Script training is a functional approach to aphasia treatment that uses script knowledge (understanding, remembering, and recalling event sequences of an activity) to facilitate participation in personally relevant activities. Using this approach, the clinician and person with aphasia develop a scripted monologue or dialogue of an activity of interest and then practice it intensely until production of the scripted speech becomes automatic and effortless (Holland, Milman, Munoz, & Bays, 2002).
Syntax treatments are designed to improve the grammatical structure of utterances in individuals with sentence-level deficits. Syntax treatments include the following:
Sentence Production Program for Aphasia (SPPA)—a prescribed treatment program designed to aid in the production of specific sentence types. The rationale is that production of certain sentence types will improve if the person with aphasia hears and produces multiple sentences with the same syntactic form but different lexical content.
A story completion task is used to practice eight different sentence structures. There are two task levels:
- Level A—the clinician reads a story that includes the target sentence and then asks a question to elicit repetition of that sentence.
- Level B—the clinician reads the story without the target sentence and asks a question to elicit that sentence (Helm-Estabrooks & Nicholas, 2000).
Treatment of Underlying Forms (TUF)—a linguistic approach to treating sentence-level deficits in persons with agrammatic aphasia. TUF is designed to improve sentence production by training more complex sentence structures first, assuming that understanding the linguistic properties of these complex sentences will generalize to less complex sentences that share similar properties (Thompson & Shapiro, 2005).
Word-finding treatments are designed to improve word finding in spontaneous utterances. Word-finding treatments include the following:
Gestural Facilitation of Naming (GES)—an approach that uses intact gesture abilities to mediate activation of word retrieval by taking advantage of the interactive nature of language and action (see, e.g., Raymer et al., 2006; Rodriguez, Raymer, & Rothi, 2006; Rose, 2013; Rose, Mok, & Sekine, 2017; Rose, Raymer, Lanyon, & Attard, 2013).
Response Elaboration Training (RET)—a treatment approach designed to help increase verbal elaboration abilities of persons with aphasia. The ultimate goal of RET is to generalize elaboration abilities so that the person can more fully participate in conversation with a communication partner (Kearns, 1986).
A typical RET training sequence consists of the following:
- The person with aphasia responds verbally to a prompt (e.g., picture stimulus).
- The clinician provides reinforcement and then shapes and models the person’s response.
- The clinician gives a “wh–” cue to elicit an elaborated response.
- The clinician reinforces attempts to elaborate and shapes and models the original response + the elaborated response.
- The person attempts to repeat the clinician’s combined model.
- The clinician elicits a delayed imitation of the combined model.
Semantic Feature Analysis Treatment—a word retrieval treatment in which the person with aphasia identifies important semantic features of a target word that is difficult to retrieve. For example, if the person has difficulty retrieving the word stove, then he or she might be prompted with questions to provide information related to stove (e.g., Where is it located? [kitchen]; What is it used for? [cooking]).
SFA is thought to improve word retrieval by activating the semantic network associated with the target word, thereby raising the word’s threshold for being retrieved (Boyle, 2004; Maher & Raymer, 2004).
Verb Network Strengthening Treatment (VNeST)—an aphasia treatment to promote lexical retrieval in sentence context. VNesT targets verbs and their roles to activate semantic networks and to improve the production of basic syntactic structures (e.g., subject–verb–object). For example, the person with aphasia is given a verb (e.g., paint) and is asked to retrieve related agents and objects (e.g., artist–paints–picture and painter–paints–house; Edmonds & Babb, 2011; Edmonds & Mizrahi, 2011; Edmonds, Nadeau, & Kiran, 2009).
Word Retrieval Cuing Strategies (e.g., phonological and semantic cuing)—an approach that provides additional information, such as the beginning sound of a word (phonological cuing) or contextual cues (semantic cuing), to prompt word recall (e.g., Wambaugh, Doyle, Martinez, & Kalinyak-Fliszar, 2002; Webster & Whitworth, 2012).
Treatment Considerations: Cultural Factors
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.
Treatment Considerations: Linguistic Factors
Recovery of language may vary depending on the type of aphasia, how languages were acquired (simultaneously or sequentially), the degree of proficiency in each language, 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 individual with severe global aphasia who spoke English at work and spoke Spanish at home and in the community. His or her return to work may not be feasible. English might be incorporated into treatment at a minimum; however, Spanish might be the clinician’s primary focus to return the person to daily activities. It is essential to consider the linguistic demands on the individual.
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 another 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 prognosis 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.
See the following ASHA Practice Portal pages: Bilingual Service Delivery, Collaborating With Interpreters, and Cultural Competence.
See the Service Delivery section of the Aphasia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the optimal treatment approach for individuals with aphasia, other factors include the availability of specific types of services in a particular region, insurance coverage, pattern of recovery, and service delivery options including
- format—structure of the treatment session (e.g., group vs. individual);
- provider—person providing the treatment (e.g., SLP, trained volunteer, caregiver);
- dosage—frequency, intensity, and duration of service;
- timing—timing of intervention relative to the onset of aphasia; and
- setting—location of treatment (e.g., home, community-based).
In addition to individual treatment for aphasia, group treatment is often used as a format to apply learned strategies in a more natural conversational context. Intensive aphasia day treatment programs or time-limited residential programs are available in some areas. Community-based programs (e.g., Life Participation Approach to Aphasia [LPAA]; Chapey et al., 2000) are available in some areas to foster community integration and to provide peer support from other individuals with chronic aphasia. See LPAA description in the Community Support and Integration section above.
Technology has been incorporated into the delivery of services for aphasia, including computer-based treatment programs and the use of telepractice to deliver face-to-face services remotely. See ASHA’s Practice Portal Page on Telepractice.
Treatment extenders such as family members, volunteers, and community members may be trained to stimulate communication and use cuing strategies learned in structured treatment sessions. In this way, treatment extenders provide communication practice in the home and in the community; such practice encourages carryover of skills.
Timing of the beginning of treatment and treatment dosage are largely influenced by the patient’s setting and insurance coverage, rather than evidence for optimal benefit. Treatment typically begins with assessment in the acute or rehabilitation inpatient setting and may continue in postacute care. Evidence about neuroplasticity and the potential for continued functional gains with chronic aphasia (Marcotte et al., 2012) suggests that there are no absolute limits to the ability to benefit from intervention, despite the limitations of insurance coverage.