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Aphasia

The scope of this page is acquired aphasia in adults (18+). See the Aphasia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives. For research about neurodegenerative aphasia, see the Primary Progressive Aphasia Evidence Map.

Aphasia is an acquired neurogenic language disorder resulting from an injury to the brain, typically the left hemisphere, that affects the functioning of core elements of the language network. Aphasia involves varying degrees of impairment in four primary areas:

  • spoken language expression
  • written expression
  • spoken language comprehension
  • reading comprehension

Aphasia may also result from neurodegenerative disease. For example, primary progressive aphasia is a subtype of frontotemporal dementia in which language capabilities become progressively impaired. Discussion of neurodegenerative disease is beyond the scope of this page. For further information, please see ASHA’s Practice Portal page on Dementia, the Primary Progressive Aphasia Evidence Map, and the items listed in the Resources section at the end of this page.

Aphasia is often described as nonfluent or fluent, based on the typical length of utterance and amount of meaningful content a person produces. There are various subtypes of aphasia within these two categories based on differences in other aspects of expressive and receptive language skills. See the National Aphasia Association’s page on aphasia definitions for descriptions of aphasia types using this classification system. Clinicians should be aware that a person’s presentation may not fit into a single aphasia type and that the description of the aphasia type may change over time as communication improves with recovery.

The recovery arc of aphasia varies significantly from person to person. The most predictive indicator of long-term recovery is initial aphasia severity, along with lesion site and size (Benghanem et al., 2019; Hillis et al., 2018; Kristinsson et al., 2022; Plowman et al., 2012; Watila & Balarabe, 2015). Factors that may negatively affect improvement include poststroke depression (Berg et al., 2003) and social isolation after aphasia onset (Hilari & Northcott, 2006; Vickers, 2010).

Incidence of aphasia refers to the number of new cases identified in a specified time period.

Prevalence of aphasia refers to the number of people who are living with aphasia in a given time period.

It is estimated that roughly 100,000–180,000 people acquire aphasia each year in the United States (Ellis et al., 2010; National Aphasia Association, n.d.). Additional data suggest that 2–4 million people in the United States are living with aphasia (National Aphasia Association, n.d.; Simmons-Mackie, 2018).

Aphasia can occur because of traumatic brain injury (TBI), brain tumor, infection, dementia, or other neurodegenerative diseases. However, it is most commonly seen in individuals post-stroke. Data suggest that roughly 25%–50% of all strokes result in aphasia (Berthier, 2005; Dickey et al., 2010; Engelter et al., 2006; Flowers et al., 2016; Gialanella & Prometti, 2009; Grönberg et al., 2022) and that it is more common in older adults (Ellis & Urban, 2016; Engelter et al., 2006). Fifteen percent of individuals under the age of 65 years experience aphasia after their first ischemic stroke. This percentage increases to 43% for individuals 85 years of age and older (Engelter et al., 2006).

Very few statistics are available regarding the incidence and prevalence of TBI-induced aphasia. One study conservatively found that aphasia secondary to TBI occurred in 1% of veterans of the Iraq and Afghanistan wars (Norman et al., 2013), and two additional studies found that aphasia occurred in 13%–19% of individuals with TBI (Hoofien et al., 2001; Safaz et al., 2008). Simmons-Mackie (2018) estimates the prevalence of TBI-induced aphasia to be as low as 64,653 and as high as 1,228,421 based upon data extrapolated from these studies.

A study by Davie et al. (2009) estimated that the incidence of aphasia as a result of primary brain tumors ranged from 30% to 50%. Using these data, Simmons-Mackie (2018) estimates the prevalence rate of tumor-associated aphasia to be between 198,028 and 330,048.

Aphasia symptoms vary in severity of impairment and impact on functional communication, depending on factors such as the location and extent of damage and the demands of the communication environment. Aphasia may include deficits in verbal expression and auditory comprehension deficits as well as reading and writing deficits. Anomia, or difficulty retrieving words, is essentially universal across all individuals with aphasia (Laine & Martin, 2006). Alexia is the term for reading comprehension difficulties, and agraphia is the term used for written expression difficulties. Alexia and agraphia can occur together or in isolation.

Patterns in language impairment may also be impacted by language use and background (Goral & Lerman, 2020; Kuzmina et al., 2019). For example, individuals who speak more than one language may be affected by aphasia in different ways depending on when the language was learned, how often each language is used, and the overall degree of proficiency in each language. Please see ASHA’s resource on working with bilingual clients with aphasia.

Common signs and symptoms of aphasia can include any of the following:

  • impairments in spoken language expression including:
    • having difficulty retrieving words (i.e., anomia)
    • fluently combining nonmeaningful and/or real words to generate sentences or phrases that lack semantic meaning (i.e., jargon)
    • creating novel words that are not meaningful or recognizable to the listener (i.e., neologisms)
    • substituting sounds (e.g., “wishdasher” for “dishwasher”). These are known as phonemic paraphasias.
    • substituting words (e.g., “table” for “bed,” “bird” for “chicken”). These are known as semantic paraphasias.
    • omitting function words (e.g., “the,” “of,” and “was”). This is known as telegraphic speech.
    • lacking awareness of errors
    • making grammatical errors, such as omitting grammatical markers or using them incorrectly
    • speaking haltingly or with effort
    • speaking in single words or short fragmented phrases
    • making syntax errors, such as putting words in the wrong order
  • impairments in spoken language comprehension, including:
    • having difficulty understanding spoken utterances
    • requiring extra time to understand spoken messages
    • having difficulty understanding complex grammar (e.g., passive sentences such as “The dog was chased by the cat”)
    • having difficulty understanding long or rapidly presented speech (e.g., television program, complex conversation)
    • having difficulty understanding spoken language without supporting visual information (e.g., telephone, radio)
    • having difficulty interpreting nonliteral language (e.g., “It’s raining cats and dogs”)
    • lacking awareness of errors
  • agraphia, or impairments in written expression including:
    • having difficulty writing, typing, or copying letters, words, and sentences
    • writing single words only
    • substituting incorrect letters or words
    • spelling or writing nonmeaningful syllables or words
    • writing sentences with incorrect grammar or syntax
  • alexia, or impairments in reading comprehension, including:
    • having difficulty recognizing words by sight or comprehending written material of any length
    • having difficulty sounding out words or associating sounds with letters
    • misinterpreting the meaning of written words (e.g., interpreting “couch” as chair)
    • having difficulty reading function words (e.g., articles, prepositions, pronouns)

Aphasia is caused by damage to the language network of the brain. Aphasia typically results from left-hemisphere damage. However, in rare instances, aphasia can occur with a right-hemisphere lesion. This happens most often in people who are left-handed because left-handed individuals are more likely to have language networks that are bilateral or that are located in the right hemisphere (Szaflarski et al., 2002). When a right-hemisphere lesion causes aphasia in someone who is right-handed, this is referred to as crossed aphasia.

Common causes of aphasia include the following:

  • stroke
    • ischemic—caused by a blockage that disrupts blood flow to a region of the brain
    • hemorrhagic—caused by a ruptured blood vessel that damages the surrounding brain tissue
  • traumatic brain injury
  • brain tumors
  • brain surgery
  • brain infections

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with aphasia. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, treatment, and counseling); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016b).

Appropriate roles for SLPs include, but are not limited to, the following:

Assessment

  • Screening individuals who present with language and communication difficulties and determining the need for further assessment and/or treatment.
  • Diagnosing and documenting the presence or absence of aphasia.
  • Referring to other professionals to rule out other conditions and to facilitate access to comprehensive services.

Counseling and Education

  • Counseling people with aphasia and their care partners about communication and related issues and facilitating participation in social and community contexts.
  • Providing prevention information to individuals and groups known to be at risk for conditions that cause aphasia.
  • Educating other professionals and the public on the needs of people with aphasia and the role of SLPs in diagnosing and managing aphasia.
  • Connecting families with long-term resources for living with aphasia.

Treatment

  • Conducting thorough culturally and linguistically relevant services related to language and communication.
  • Developing person-centered treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria in collaboration with the patient and the treatment team.
  • Serving as an integral member of a collaborative team that includes physicians, other professionals (e.g., nurses and case managers, neuropsychologists, occupational and physical therapists, audiologists), and the patient and their care partners. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) and person- and family-centered care.
  • Implementing and supporting appropriate communication systems at all stages of recovery.

Other

  • Remaining informed of research in the area of aphasia and helping advance the knowledge base related to the nature and treatment of aphasia.
  • Advocating for individuals with aphasia and their families at the local, state, and national levels.

As indicated in the Code of Ethics (ASHA, 2016a), individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

See the Assessment section of the Aphasia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Assessment can be static (i.e., using procedures designed to describe current levels of functioning within relevant domains) and/or dynamic (i.e., an ongoing process using hypothesis testing procedures to identify potentially successful intervention and support procedures).

Assessment protocols can include both standardized and nonstandardized tools and data sources. See ASHA’s resource on assessment tools, techniques, and data sources as well as ASHA’s Preferred Practice Patterns for the Profession of Speech-Language Pathology: Spoken and Written Language Assessment—Adults.

When conducting screening and assessment for people with aphasia, SLPs consider several factors, including the following:

  • language(s) and dialect(s) used
  • concurrent motor speech impairment (i.e., dysarthria, apraxia)
  • presence of limb apraxia and/or oral apraxia
  • hearing status and auditory agnosia (inability to process sound meaning)
  • concurrent cognitive impairment
  • visual acuity deficits, visual agnosia, and visual field cuts
  • upper extremity hemiparesis (may affect the ability to write, point, and gesture)
  • presence of chronic pain from either preexisting or new conditions
  • presence or history of mental health disorders (e.g., anxiety, depression)
  • endurance and fatigue (testing may need to be broken into shorter sessions)

These factors may have an impact on screening and assessment and are considered during the evaluation. For example, if the individual with aphasia wears glasses (prescription or nonprescription), hearing aids, or dentures, then these devices should be worn during assessment if applicable prescriptions are still appropriate. Hearing and/or visual deficits may exist prior to the onset of aphasia or may be present as a result of the neurological event that caused aphasia. Physical or environmental modifications (e.g., large-print material, modified lighting, amplification devices) may assist SLPs with diagnosing language deficits in the presence of such co-occurring factors.

For people who use more than one language, it is important for the SLP to consider the age of acquisition of each language, the premorbid use of each language, and the language(s) needed for return to daily activities when selecting the language(s) and materials for assessment. Clinicians should gather data in all languages used to determine the degree of functional impact, keeping in mind that different languages may be impacted to varying degrees. Please see ASHA’s resource on working with bilingual clients with aphasia.

Documentation should include a description of any modifications and/or accommodations made to the testing process to reconcile cultural and linguistic variations, hearing and/or visual deficits, or other factors that may impact screening or comprehensive assessment. Any modifications and/or accommodations should also be considered when reporting assessment results (e.g., standardized scores may be impacted by modifications to assessment materials).

For further information, please see Murray and Chapey (2001) as well as ASHA’s Practice Portal pages on Adult Hearing Screening; Dysarthria in Adults; Acquired Apraxia of Speech; Bilingual Service Delivery; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness. See also ASHA’s resource on cognitive-communication.

Screening

Screening is a procedure for identifying the need for further assessment and does not provide a detailed description of the diagnosis, severity, and characteristics of aphasia. Screening is a valuable tool that helps health care providers make appropriate referrals to speech-language pathology services. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity.

Screenings are completed by the SLP, the speech-language pathology assistant, or other trained professionals. Standardized and nonstandardized methods are used to screen oral motor functions, speech production, expressive and receptive language, cognitive communication, and hearing.

Screening may result in

  • a recommendation for monitoring;
  • a recommendation for comprehensive speech, language, swallowing, or cognitive-communication assessments; and/or
  • a referral for other examinations or services.

Comprehensive Assessment

Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016b; WHO, 2001), a comprehensive assessment is conducted to identify and describe

  • impairments in body structure and function, including underlying weaknesses in expressive and receptive language that affect communication performance;
  • comorbid deficits, such as other health conditions and medications that can affect communication performance;
  • limitations in activity and participation, including changes in, and impact on, functional status in communication and interpersonal interactions;
  • environmental and personal factors that serve as barriers to, or facilitators of, successful communication and life participation; and
  • the impact of communication impairments on quality of life, functional limitations relative to the individual’s premorbid social roles, and the impact on their community.

See Person-Centered Focus on Function: Aphasia [PDF] for an example of assessment data consistent with the ICF. See also Counting What Counts: A Framework for Capturing Real-Life Outcomes of Aphasia Intervention [PDF] for a model of how to capture real-life outcomes in assessment and intervention.

Typical Components of Aphasia Assessment

Case History

Include information from medical records, self-reports/interviews, or clinician observations, such as the following:

  • medical history and recent medical status, including vision and hearing
  • mental health history
  • education and health literacy level
  • work history
  • hobbies and personal interests
  • cultural and linguistic backgrounds
  • typical communication environments (e.g., where, how, and why someone communicates)
  • knowledge of aphasia and communication strategies
  • perception of functional communication status
  • current status and the desired outcome of engagement with varied communication partners and home, vocational, and community-based activities
  • language(s) used in various communication environments
  • preferences and goals
Motor Speech Examination

Facilitate a differential diagnosis of apraxia and dysarthria through an assessment of articulatory processes, including rate, amplitude, accuracy, and consistency of movement. For further information, see ASHA’s Practice Portal pages on Acquired Apraxia of Speech and Dysarthria in Adults.

Language

Assess expressive and receptive skills in spoken/signed and written language of increasing complexity across a variety of contexts (e.g., social, educational, vocational). Language assessment supports aphasia classification and identifies facilitating strategies.

Specific language skills to consider include the following:

  • word, sentence, and paragraph comprehension (spoken/signed and written)
  • naming
  • repetition
  • spontaneous speech
  • discourse
  • word, sentence, and paragraph writing
  • gestures

See ASHA’s Practice Portal resource, Language in Brief for additional language domains to consider when testing. See also ASHA’s resource on assessment tools, techniques, and data sources.

Environmental and Personal Factors

Include factors that may impact treatment and recovery, such as

  • support from family, care partners, and the community;
  • communication partners’ knowledge of, and capacity to use, facilitating strategies;
  • feasibility and acceptance of compensatory strategies;
  • personal capacity to return to the previous level of engagement and communication ability;
  • social determinants of health that impact access to services; and
  • comorbidities such as cognitive impairments, visual and motor impairments, depression, and/or other chronic conditions.

Differential Diagnosis

The identification and differential diagnosis of co-occurring impairments (e.g., cognitive-communication deficits, dysarthria, or acquired apraxia of speech) aid in planning an appropriate treatment plan. Clinicians consider the severity and subtype of aphasia (e.g., Broca’s, Wernicke’s, anomic) in addition to the functional impact of the communication disorder when selecting intervention strategies and counseling patients and their care partners. Please see the National Aphasia Association’s page on aphasia definitions for further details.

Language and cognition are separate but overlapping skills. Deficits in one area may not impact the other; therefore, SLPs should remain aware that the presence of aphasia does not imply cognitive deficits. Please see ASHA’s Practice Portal pages on Acquired Apraxia of Speech and Dysarthria in Adults and ASHA’s resource on cognitive-communication for further information.

Assessment Results

Assessment may result in one or more of the following:

  • diagnosis of a language or other communication disorder (e.g., dysarthria, acquired apraxia of speech, cognitive-communication disorder)
  • description of the characteristics, severity, and functional impact of the language disorder
  • prognosis for change (in the individual or in relevant contexts)
  • recommendations for intervention, support, and community resources
  • a referral for other assessments or services

See the Treatment section of the Aphasia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Aphasia treatment is individualized to address the specific areas of need identified during assessment, including goals identified by the person with aphasia and their care partners.

Person- and family-centered care is a collaborative approach grounded in a partnership between the person with aphasia, their care partners and support network, and their 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, interests, and priorities in developing a treatment plan, including selecting targets and materials that are salient and culturally responsive to the individual. It represents 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.

This holistic, person-centered approach is consistent with the WHO’s (2001) International Classification of Functioning, Disability and Health (ICF) framework, with the overarching goal of intervention to help the individual achieve the highest level of 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 teaching new skills and compensatory strategies to both the individual with aphasia and their partner(s); 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., T. A. Rose et al., 2003, 2011).

See ASHA’s resource, Person-Centered Focus on Function: Aphasia [PDF], for an example of functional goals consistent with the ICF.

Community awareness of aphasia can be improved when clinicians provide education and outreach (Simmons-Mackie et al., 2011). Clinicians also foster such community support and integration by partnering with people with aphasia to reduce or remove communication barriers to accessing their communities. This may be addressed by supporting the individual’s communication skills, training conversational partners, and advocating for change and access to communication supports in the community. Examples include aphasia-friendly signage or menus in cafés, training first responders about supported communication strategies, and reducing background noise when possible.

Community aphasia groups can help support work that is done within the clinical setting. These groups can provide treatment and support for people with aphasia, which can improve linguistic functioning in a naturalistic setting (Elman, 2016; Elman & Bernstein-Ellis, 1999; Lanyon et al., 2013) and enhance social networks (Vickers, 2010). Community groups may also offer individuals and family members an opportunity to socialize; share ideas and feelings; receive support; and learn more about aphasia and aphasia resources, including opportunities to participate in research.

There are several models in use that consider the functional impact of aphasia. These models include the following.

The Living With Aphasia: Framework for Outcome Measurement (A-FROM) model was designed to identify important categories that represent the individualized functional impact of aphasia. A-FROM incorporates components of other models, including the ICF, into a simple program to organize outcomes. A-FROM uses the following domains, which overlap to represent an individual’s experience of living with aphasia (Kagan et al., 2008):

  • aphasia severity
  • participation/life habits
  • personal factors, including identity and emotions
  • environment

The Life Participation Approach to Aphasia (LPAA) considers an intervention that emphasizes achieving or reengaging in life (Chapey et al., 2000; Lyon, 1992). This is done by focusing on the specific life concerns of the person with aphasia, with the overall goal of strengthening daily participation in activities of choice. The LPAA often focuses on long-term management of aphasia. Although LPAA approaches have traditionally taken place at home and in the community, the principles can be applied in any setting and at any stage of recovery from aphasia. Clinicians may choose to incorporate LPAA principles alongside other restorative or compensatory treatments.

Planning Treatment

Social and Cultural Factors

Views on the natural aging process and understanding 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 clinicians acknowledge and incorporate the perspective of the person with aphasia and their care partner(s) when sharing potential treatment recommendations and outcomes. Clinical interactions should be approached with cultural responsiveness. Consider dialectal and cultural background when choosing stimulus items and providing models for expressive language.

Clinicians consider social determinants of health—the nonmedical factors that impact health outcomes—as they plan the evaluation and treatment for aphasia with clients and their care partners. Clinicians consider the impact of a person’s communication on their ability to

  • maintain their employment or participate in school;
  • access general and specialty care, including pharmacy and medical supply services; and
  • access the features of the neighborhoods where they live and receive care, including access to healthy food, exercise, and social supports within their communities.

The goal of treatment is often to improve people’s ability to communicate effectively in all the environments in which they live, work, play, and worship. For further information, please see Commission on Social Determinants of Health (2008).

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. SLPs consider the language(s) that an individual uses in their home as well as in other environments (e.g., social settings, work) when selecting the language(s) for treatment. Treatment occurs in the language(s) used by the person with aphasia—either by a bilingual SLP or through collaboration with interpreters, when necessary. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators. SLPs tailor treatment to meet the needs of each individual and to facilitate a return to functional communication. The goal of intervention might not be a full recovery of all the languages used.

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

  • How many languages does the person speak?
  • At what point did they learn English or another secondary language?
  • When and with whom do they use each language?
    • What language(s) are spoken at work, at home, and with family or friends?
    • What language(s), if any, do they use to read and/or write?
  • What languages and conversational environments are a priority for them?

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), an interpreter, and/or a translator. The clinician may need to provide additional training about what types of errors might be expected; what information would be important to note (e.g., paraphasias, neologisms, absence of functors); and what kind of prompting should be used or avoided. An SLP will need to determine the language(s) of treatment and its impact on cross-language generalization (i.e., improvement in the language that is not directly addressed).

See the following ASHA Practice Portal pages: Bilingual Service Delivery; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.

Treatment Techniques

Brief descriptions of both general and specific treatment options for individuals with aphasia are provided below. This information is not exhaustive, nor does inclusion of any specific treatment approach imply endorsement from ASHA. 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).

Treatment extenders—such as care partners, volunteers, and community members—may be trained to stimulate and support communication. This way, treatment extenders provide communication practice in the home and in the community; such practice encourages carryover of skills. Clinicians may also use technology tools, such as computer programs and apps, as part of a home program.

Expressive Language Treatments

Constraint-Induced Language Therapy (CILT) — a treatment approach that focuses on increasing spoken language output while discouraging (constraining) the use of compensatory communication strategies (e.g., gesturing and writing). CILT also involves high-intensity training via massed practice (Pulvermüller et al., 2001). The principles and techniques of CILT are derived from constraint-induced movement therapy in which the use of a less-affected limb is restrained while, at the same time, training movements of the affected limb using intensive treatment (Taub et al., 1993; Taub & Wolf, 1997).

Melodic Intonation Therapy (MIT) — a therapy program that uses melodic concepts (i.e., pitch, rhythm, and stress) to improve expressive language by engaging the right hemisphere of the brain. It is often used to treat individuals with severe nonfluent expressive language deficits who have relatively intact receptive language skills (Albert et al., 1973; Norton et al., 2009). Individuals begin by intoning simple phrases and then gradually increasing syllable length and length of utterance. Visual and tactile cues are given by the clinician, and phrases of social and functional importance to the individual (e.g., “I love you”) are practiced. Reliance on intonation is gradually decreased over time.

Phonological Components Analysis (PCA) — a phonologically based treatment approach modeled after semantic feature analysis (see below). In PCA, a participant is presented with a picture and is asked to complete five phonological tasks related to the word that the picture represents. The individual is asked to state the following:

  • words the word rhymes with
  • what sound the word starts with
  • another word that begins with the same sound
  • what sound the word ends with
  • the number of syllables in the word

If the individual is not able to complete one of the components above, then they are given a choice from a list of up to three. After the individual completes all the above elements, the clinician asks them to state the target word (Leonard et al., 2008, 2014; van Hees et al., 2013).

Response Elaboration Training (RET) — a treatment approach designed to improve spoken language by increasing the number of content words in persons with aphasia. The goal of RET is to generalize elaboration abilities so that the person can more fully participate in conversations with a communication partner (Kearns, 1986; Wambaugh et al., 2013).

A typical RET sequence consists of the following:

  1. The person with aphasia responds verbally to a prompt (e.g., picture stimulus).
  2. The clinician provides reinforcement and then shapes and models the person’s response.
  3. The clinician gives a “wh–” cue to elicit an elaborated response.
  4. The clinician reinforces attempts to elaborate and shapes and models the original response + the elaborated response.
  5. The person attempts to repeat the clinician’s combined model.
  6. The clinician elicits a delayed imitation of the combined model.

Semantic Feature Analysis (SFA) — 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,” they might be prompted with questions to provide information related to “stove” (e.g., “Where is it located?” “What is it used for?”). SFA is thought to improve word retrieval by activating the semantic network associated with the target word, thereby increasing the likelihood that a particular word will be retrieved (Boyle, 2004; Maher & Raymer, 2004).

Script Training — 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 the 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 et al., 2002).

Sentence Production Program for Aphasia (SPPA) — a treatment program designed to aid in the production of specific sentence types. The SPPA is based on the concept that the 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 per Helm-Estabrooks and Nicholas (2000):

  • 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.

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).

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 et al., 2009).

Word Retrieval Cuing Strategies (e.g., phonological and semantic cueing) — an approach that provides additional information, such as phonological cueing (providing the beginning sound of a word) or semantic cueing (providing contextual cues) to prompt word recall (e.g., Wambaugh et al., 2002; Webster & Whitworth, 2012).

Writing Treatments

Copy and Recall Treatment (CART) — a protocol that uses picture and/or written presentations of a given word to engage spelling and then reinforcing that spelling through repetition. A CART sequence consists of the following:

  1. The clinician shows a picture to a patient. If the participant spells the pictured word correctly, the clinician moves to the next item. If the participant spells it incorrectly, the clinician proceeds to Step 2.
  2. The clinician shows the patient a handwritten word of the item shown in Step 1 and asks the patient to copy the word three times.
  3. The clinician covers the written example, shows the picture again, and prompts recall of the spelling three times.
  4. If the patient cannot demonstrate recall after several trials, then move to the next word.

Please see Copy and Recall Treatment (CART) Protocol [PDF] for a complete description of this protocol.

Reading Treatments

Multiple Oral Re-Reading (MOR) — a treatment technique that involves re-reading text aloud—either for 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, relatively intact comprehension, and the ability to read aloud at the single-word level (see, e.g., Cherney, 2004; Kim & Russo, 2010; Moyer, 1979; Tuomainen & Laine, 1991).

Oral Reading for Language in Aphasia — a treatment that involves repeated practice reading sentences aloud with the clinician 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 et al., 1986).

Supported Reading Comprehension — approaches that incorporate 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 et al., 2014; Knollman-Porter et al., 2016; T. A. Rose et al., 2003, 2011).

Partner Approaches

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, care partner). Strategies can include drawing, gesturing, cueing, confirming information, and summarizing information. Strategies are chosen by the individual and their communication partner and are practiced in scripted conversations. The SLP serves as the “coach” for both partners (Hopper et al., 2002).

Supported Conversation for Adults With Aphasia — an approach to aphasia rehabilitation that emphasizes (a) the need for multimodal communication, (b) partner training, and (c) opportunities for social interaction. Per Kagan (2007), there are three underlying principles:

  1. Functional communication can be facilitated/improved by teaching strategies to communication partners.
  2. Communication is a dynamic process; tools and services for the person with aphasia must reflect this dynamic process.
  3. Communication includes social interaction and the exchange of information and ideas; opportunities for social interaction are emphasized.

Supporting Partners of People With Aphasia in Relationships and Conversation (SPPARC) — a participant-driven program that focuses on how people with aphasia and their communication partners act and react to each other during conversational exchanges. SPPARC is used to address communication breakdowns by recording and analyzing communication between conversational partners in a functional setting and then addressing issues in a clinical setting. This therapy approach has six steps (Lock et al., 2001), as follows:

  1. preparation
  2. recording the conversation
  3. preliminary viewing of the recording and transcription
  4. conversation assessment
  5. moving from assessment to training
  6. conversation training

Multimodal Treatments

Treatment approaches that use any modality to communicate a message. Multimodal treatments focus on using varied effective and efficient communication strategies and include the following.

Augmentative and Alternative Communication (AAC) — an area of clinical practice that supplements or compensates for impairments in speech-language production and/or comprehension, including spoken/signed and written modes of communication. AAC approaches incorporate low-tech strategies (e.g., photos, communication books) and high-tech devices to enhance communication. AAC focuses on using the individual’s residual language abilities and training communication partners to use “augmented input” to enhance comprehension and to offer written or visual choices to help individuals with aphasia indicate preferences, ideas, and feelings. Please see ASHA’s Practice Portal page on Augmentative and Alternative Communication for further information.

Gestural Facilitation of Naming — an approach that uses intact gesture abilities to facilitate the activation of word retrieval by taking advantage of the interactive nature of language and action (see, e.g., Raymer et al., 2006; Rodriguez et al., 2006; M. L. Rose, 2013; M. L. Rose et al., 2013, 2017).

Promoting Aphasics’ Communicative Effectiveness — a treatment designed to improve conversational skills. The individual with aphasia and the clinician take turns being the message sender and the message receiver. Picture prompts for conversational messages are hidden from the listener (similar to a barrier task), and the speaker uses their choice of modalities for conveying messages (Davis & Wilcox, 1981).

Reciprocal Scaffolding Treatment — a group treatment approach that addresses communication skills using natural language in meaningful social contexts. An individual with aphasia is given an opportunity to use premorbid knowledge and vocabulary to teach a skill to a group of “novices.” 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).

Visual Action Therapy (VAT) — a nonverbal treatment approach that trains individuals to use hand gestures to represent items that are not present (Helm-Estabrooks et al., 1982). 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.

Service Delivery

See the Service Delivery section of the Aphasia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

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 the following:

  • 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
  • setting—location of treatment (e.g., home, community-based, telepractice)

Treatment typically begins in the acute or rehabilitation inpatient setting and may continue in post-acute care. Treatment can occur in various formats or settings with the frequency, intensity, and duration of services based on the individualized treatment plan and progress. For example, in addition to one-on-one treatment, group treatment is often used to apply learned strategies in a more natural conversational context. Community-based programs (e.g., LPAA; Chapey et al., 2000) can be used to foster community integration and to provide peer support from other individuals with chronic aphasia. Intensive treatment/programs (e.g., intensive aphasia day treatment) may be used for a time-limited period.

Technology can also be incorporated into the delivery of services for aphasia when appropriate, 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.

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Aphasia page:

  • Joan M. Birchfield, MA, CCC-SLP
  • Mackenzie Fama, PhD, CCC-SLP
  • Kathryn L. Garrett, PhD, CCC-SLP
  • Katarina Haley, PhD, CCC-SLP
  • Jacqueline J. Hinckley, PhD, CCC-SLP
  • Rosalind C. Hurwitz, MS, CCC-SLP
  • Janet P. Patterson, PhD, CCC-SLP
  • Anastasia M. Raymer, PhD, CCC-SLP
  • Yasmeen F. Shah, PhD, CCC-SLP
  • Candace P. Vickers, PhD, MS, CCC-SLP
  • Gloriajean L. Wallace, PhD, CCC-SLP
  • Sarah E. Wallace, PhD, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Aphasia [Practice Portal]. Retrieved month, day, year, from https://www.asha.org/Practice-Portal/Clinical-Topics/Aphasia/

Content Disclaimer: The Practice Portal, 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.

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