Aphasia is an acquired neurogenic language disorder resulting from an injury to the brain—most typically, the left hemisphere. Aphasia involves varying degrees of impairment in four primary areas:
Depending on an individual's unique set of symptoms, impairments may result in loss of ability to use communication as a tool for life participation (Threats & Worrall, 2004).
A person with aphasia often has relatively intact nonlinguistic cognitive skills, such as memory and executive function, although these and other cognitive deficits may co-occur with aphasia.
A number of classification systems are used to describe the various presentations of aphasia. One of the most common is based on the pattern of impaired language abilities. Using this system, aphasia is categorized as either nonfluent or fluent, based on characteristics of spoken language expression (Davis, 2007; Goodglass & Kaplan, 1972). See ASHA's resource titled Classification of Aphasia [PDF] for descriptions of aphasia types using this classification system.
A person's symptoms may not fit neatly into a single aphasia type, and classification may change over time as communication improves with recovery. In addition, symptoms can co-occur with other speech and language impairments such as dysarthria and apraxia of speech, which can complicate classification.
The outcome 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 (Plowman, Hentz, & Ellis, 2012). Other predictors of long-term recovery include age, gender, education level, and other comorbidities (Laska, Hellblom, Murray, Kahan, & Von, 2001; Payabvash et al., 2010; Pedersen, Vinter, & Olsen, 2004).
Factors that may negatively affect improvement include poststroke depression (Berg, Palomäki H., Lehtihalmes M., Lönnqvist J., & Kaste, 2003) and social isolation after onset of aphasia (Hilari & Northcott, 2006; Vickers, 2010).
Incidence of aphasia refers to the number of new cases identified in a specified time period. It is estimated that there are 180,000 new cases of aphasia per year in the United States (National Institute on Deafness and Other Communication Disorders [NIDCD], 2015).
Prevalence of aphasia refers to the number of people who are living with aphasia in a given time period. NIDCD (2015) estimates that approximately 1 million people, or 1 in 250 in the United States today, are living with aphasia.
Aphasia after stroke is more common for older adults than younger adults (Ellis & Urban, 2016). Fifteen percent of individuals under the age of 65 experience aphasia after their first ischemic stroke; this percentage increases to 43% for individuals 85 years of age and older (Engelter et al., 2006).
No significant differences have been found in the incidence of aphasia in men and women. However, some data suggest that differences may exist by type and severity of aphasia. For example, Wernicke's aphasia and global aphasia occur more commonly in women, and Broca's aphasia occurs more commonly in men (Hier, Yoon, Mohr, & Price, 1994).
Aphasia symptoms vary in severity of impairment and impact on communication, depending on factors such as the location and extent of damage and the demands of the speaking situation.
A person with aphasia often experiences both receptive and expressive spoken language difficulties—each to varying degrees. He or she may have similar difficulties in written language (i.e., reading comprehension and written expression). As with spoken language, written language difficulties can vary in degree. For example, a person can have reading comprehension difficulties (alexia) with or without written expression difficulties (agraphia).
For individuals who speak more than one language, languages 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.
Common signs and symptoms of aphasia include the following:
Aphasia is caused by damage to the language centers of the brain. In most people, these language centers are located in the left hemisphere, but aphasia can also occur as a result of damage to the right hemisphere; this is often referred to as crossed aphasia, to denote that the right hemisphere is language dominant in these individuals.
Common causes of aphasia include the following:
Stroke is the most common cause of aphasia. According to the National Aphasia Association (n.d.), about 25%–40% of stroke survivors experience aphasia. Approximately 35%–40% of adults who are admitted to an acute-care hospital with a diagnosis of stroke are diagnosed with aphasia by the time they are discharged (Dickey et al., 2010; Pedersen, Jorgensen, Nakayama, Raaschou, & Olsen, 1995).
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, and treatment); 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:
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.
The clinician considers the following factors that may have an impact on screening and comprehensive assessment:
If the individual with aphasia wears prescription glasses or hearing aids, and prescriptions are still appropriate, the glasses or aids should be worn during assessment.
If additional hearing and/or visual deficits resulted from the neurological event—and physical or environmental modifications (e.g., large-print material, modified lighting, amplification devices) are not sufficient to compensate for these changes—then the individual should be referred for complete audiologic and/or vision assessments prior to testing.
When selecting the language of assessment for individuals who speak more than one language, it is important to consider the languages spoken, age of acquisition of each language, premorbid use of each language, and language(s) needed for return to daily activities.
There are times when one language remains intact or mildly impaired, whereas the second language is significantly impaired. Clinicians should gather data in all languages used in order to determine degree of impact. Assessment in only one language may be misleading.
Screening does not provide a detailed description of the severity and characteristics of aphasia but, rather, is a procedure for identifying the need for further assessment. Screening is an invaluable tool in the appropriate referral of persons with aphasia to speech-language pathology services and is an important first step in determining the need for treatment. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity.
Screenings are completed by the SLP or other professional. Standardized and nonstandardized methods are used to screen oral motor functions, speech production skills, comprehension and production of spoken and written language, cognitive aspects of communication, and hearing.
Screening may result in
Individuals identified with aphasia through screening are referred to an SLP for a comprehensive assessment of language and communication.
Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016b; WHO, 2001), comprehensive assessment is conducted to identify and describe
See the ASHA resource titled Person-Centered Focus on Function: Aphasia [PDF] for an example of assessment data consistent with ICF.
Assessment can be static (i.e., using procedures designed to describe current levels of functioning within relevant domains) and/or dynamic (i.e., 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, and ASHA's Preferred Practice Patterns for the Profession of Speech-Language Pathology: Spoken and Written Language Assessment—Adults.
Appropriate accommodations and modifications can be made to the testing process to reconcile cultural and linguistic variations. Documentation should include descriptions of these accommodations and modifications. Scores from standardized tests should be interpreted and reported with caution in these cases. See ASHA's Practice Portal pages, Bilingual Service Delivery; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.
See ASHA's Practice Portal page on Acquired Apraxia of Speech.
See ASHA's Practice Portal page on Augmentative and Alternative Communication.
Assessment may result in one or more of the following:
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, Transliterators, and Translators.
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
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 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, grouped by category. 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.
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.
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).
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:
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).
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:
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:
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).
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.
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:
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, Transliterators, and Translators, and Cultural Responsiveness.
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
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.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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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.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Aphasia (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Aphasia/.