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date: 18 February 2020

Principles of Aphasia Rehabilitation

Abstract and Keywords

This chapter reviews the broad literature on approaches to treatment of aphasia. Behavioral interventions for aphasia are influenced by perspectives from neuroscience that emphasize that neuroplasticity in rehabilitation is experience-dependent and potent. Several principles of neuroplasticity are reviewed, and examples are described from the aphasia treatment literature. Additional principles are considered regarding influences of error production and feedback in aphasia rehabilitation outcomes. Adjuvant treatments then are described that are meant to enhance behavioral treatment outcomes through pharmacologic and neuromodulatory interventions. Finally, life participation approaches are highlighted that encourage use of multi-modality communication for daily life activities along with training of communication partners. An interdisciplinary process is emphasized in which many professionals work together to provide individuals with aphasia the maximum benefits in language recovery, communication skills, and meaningful social engagement and quality of life.

Keywords: aphasia, rehabilitation, neuroplasticity, communication, neuromodulation, pharmacology, participation

One day out of the blue I had a stroke and in an instant my ability to talk was wiped out. I felt so isolated and confused because I could not communicate with people. I felt depressed and very anxious about how I could parent my children properly. I lost most of my old friends, as people lost patience with me. I felt trapped, with my confidence destroyed. I couldn’t carry on with my old life . . . .

(Carol Griffiths, 2014, Living with Aphasia: www.UKConnect.com)

Why Treat Aphasia?

Stroke is the single most disabling health condition in adulthood worldwide (Mozaffarian et al., 2016; Numminen et al., 2016; Wolfe, 2000; World Health Organization, 1997), and stroke survivors account for a substantial proportion of those living with aphasia (Berthier, 2005; Dickey et al., 2010; Laska, Hellblom, Murray, Kahan, & von Arbin, 2001). Further complicating this picture is the fact that, compared to stroke survivors who don’t have aphasia, those who have aphasia experience longer hospital stays and exhibit more intensive health service utilization (Ellis, Simpson, Bonilha, Mauldin, & Simpson, 2012). Fewer eventually return to work (Black-Schaffer & Osberg, 1990), and they participate in fewer activities and report lower quality of life as well as high distress (Hilari, 2011; Hilari, Needle, & Harrison, 2012). The social isolation of these persons with aphasia is profoundly life-altering and begins immediately upon aphasia (p. 308) onset and initial stroke hospitalization (O’Halloran, Grohn, & Worrall, 2012; O’Halloran, Worrall, & Hickson, 2011). The economic and social consequences are urgent and substantial, underscoring the need to place a premium on the development and delivery of treatments that can mitigate these debilitating outcomes (Pollock, St. George, Fenton, & Firkins, 2012).

Historical Perspective on Aphasia Treatment

Written descriptions of attempts to behaviorally treat aphasia can be traced back to the physician Galen (approx. 180 AD), who described bloodletting for aphasia, and to Celcus (approx. 100 BC) who recorded, among other ideas, that “. . . when one was unable to articulate . . . he must exercise himself to retain his breath, wash his head with cold water and then vomit . . .” (Finger, 1994, p. 418). Targets for treatment evolved from the spiritual (demonic possession) to the physiological (imbalance of four “humors”), with treatment modalities spanning from the wearing of charms to herbal potions, each attempting to address the purported mechanism of the deficit. Then and more recently, reports were anecdotal. For example, Goodglass (1985) cited an 1879 paper that describes a 49-year-old patient with aphasia who was treated repeatedly with applications of “a strong current to the man’s skin with an electric brush” (p. 308).

Modern-day history of behavioral treatments for aphasia is much more data-substantive, with turn-of-the-century case series beginning to emerge, such as those of Bateman (1890), Franz (1905; 1924), and Mills (1904) recounting case attributes, treatment methods, and outcomes. More extensive reports surfaced as the result of caring for returning wounded troops after World War I, with the early experiences in Germany of Kurt Goldstein (1942, 1948), in Russia subsequent to World War II by Luria (1970), and many in the United States, including Franz (1924) and Wepman (1951). Since that time, a considerable literature has examined effects of behavioral treatments aimed at impaired language functions in order to improve communication abilities of individuals with aphasia.

Behavioral Treatments Versus Natural Recovery

The nervous system is malleable and continually changing in response to life experiences, a concept often referred to as neuroplasticity.

Neuroplasticity can be broadly defined as the ability of the nervous system to respond to intrinsic and extrinsic stimuli by reorganizing its structure, function and connections . . . and can occur during development, in response to the environment, in support of learning, in response to disease, or in relation to therapy. Such plasticity can be viewed as adaptive when associated with a gain in function or as maladaptive when associated with negative consequences . . . .

(Cramer et al., 2011, p. 1592)

One example of the suspected contribution of experiential neuroplasticity to maladaptation can be found in discussions of addiction (e.g., Koob & Volkow, 2010). In contrast, most studies of adaptive neuroplasticity have focused on motor function recovery, which results in functional gains in both animals and humans (e.g., Adkins, 2015; Adkins et al., 2006; Buonomano & Merzenich, 1998; Johansson, 2000; Koski, Mernar, & Dobkin, 2004; Nudo, 2007, 2011; Nudo, Wise, SiFuentes, & Milliken, 1996). Evidence for restoration within cognitive (e.g., Corbetta, Kincade, Lewis, Snyder, & Sapir, 2005; Sturm et al., 2004) and affective (e.g., Eack et al., 2010) systems in humans can be found in the recent literature as well. What is clear from various strands of research is that experience is potent (Cramer, 2008). Carefully constructed experiences are needed to improve functions beyond what would happen through natural recovery alone. Because plasticity is experience-dependent, clinicians should attempt to provide rehabilitation experiences that contribute to adaptive and not maladaptive change (Cramer et al., 2011).

Adaptive Neuroplasticity Following Behavioral Aphasia Treatments

Do we have reason to believe that behavioral aphasia treatments can improve upon natural recovery after stroke by virtue of adaptive neuroplasticity? For more than 100 years, clinicians and researchers have contributed responses to this question, with the answer being a resounding “yes.” In their insightful review of the history of aphasia treatment, Cherney and Robey (2001) noted that early in the 20th century, several elaborate case reports and case series described methods that seemed to effect some amount of improvement in language abilities of individuals with aphasia. The need for effective rehabilitation methods exploded following World Wars I and II, when massive numbers of soldiers survived brain injuries and flooded medical systems. The fortunate consequence of this unfortunate (p. 309) circumstance was that larger numbers of individuals with aphasia participated in studies that reported that recovery was enhanced for those who engaged in some kind of behavioral therapy (Weisenburg & McBride, 1935). As scientific methods advanced in rigor, the era of group studies in medicine emerged, including those in behavioral aphasia treatment and recovery. Among the first controlled clinical trials were those of Wertz and colleagues (1981, 1986) who, with the support of the Veteran’s Affairs Rehabilitation Research Service throughout the United States, showed that treatment led to significant gains on standardized aphasia test scores. Among the considerable number of clinical trials that have taken place in the past 40 years, the vast majority of studies have reported that aphasia treatment is associated with superior outcomes when compared to no-treatment conditions (e.g., Hagen, 1973; Marshall et al., 1989; Poeck, Huber, & Willmes, 1989; Shewan & Kertesz, 1984).

Table 17.1 Results of Meta-analyses of Group Treatment Studies of Aphasia

Author

Number of studies included

Effect sizes

Treated

Untreated

Greenhouse et al., 1990

13

.80

Whurr et al., 1992

45

.59

Robey, 1994

21

1.25

.65

Robey, 1998

55

1.15 acute

.57 post-acute

.66 chronic

Brady et al., 2012

19

.30

Brady et al., 2016

27

.28

In the era of evidence-based medicine, efforts have been initiated to coalesce research evidence in the form of systematic reviews and meta-analyses. Whereas a literature review is conducted with general attempts to encompass a mass of literature, a systematic review is intended as a scientifically rigorous endeavor to identify every investigation that exists on a topic to address specific clinical questions (Grant & Booth, 2009). Several groups worldwide are now sponsoring efforts to synthesize research, including studies of rehabilitation for aphasia (e.g., Cochrane Reviews: www.cochrane.org/CD000425; American Speech-Language-Hearing Association: www.asha.org/public/Efficacy Summaries.htm; Academy of Neurologic Communication Disorders and Sciences: www.ancds.org/evidence-based-clinical-research; Speech Pathology Database for Best Interventions and Treatment Efficacy: www.speechpathologyaustralia.org.au/resources/speechbite). A number of systematic reviews have shown positive outcomes on standardized aphasia tests (Basso, 1992; Cherney, Patterson, Raymer, Frymark, & Schooling, 2008; Holland, Fromm, DeRuyter, & Stein, 1996). Of particular interest are meta-analyses that quantified the effects of aphasia treatments and reported medium to large effect sizes across reviews (Basso et al., 2011; Brady, Kelly, Godwin, & Enderby, 2012; Brady, Kelly, Godwin, Enderby, & Campbell, 2016; Greenhouse et al., 1990; Robey, 1994, 1998; Whurr, Lorch, & Nye, 1992). These findings (see Table 17.1) demonstrate the efficacy of aphasia treatment in general. The question thus evolved to “What is the best treatment; for whom; under what circumstances?”

Optimizing Relearning

Within this book, as chapters are organized by classical aphasia syndromes, a number of theoretically motivated, linguistically targeted treatments have been described as appropriate to the typical language impairments in each syndrome. We believe the advantage of this method in the overarching design of this book is that discussions by syndrome would allow the reader to recognize groupings through history; to share a common and accessible terminology that transcends time, settings, and professional perspectives; and to use the syndrome discussions to partition characteristic (p. 310) language attributes for more specific discussion (e.g., Broca’s aphasia and a discussion of grammar processing and dysfunction). We also believe that understanding detailed characteristics of language breakdown and remaining capabilities through a comprehensive assessment help guide the selection of potential language targets and strategic choices of methods for a given individual with aphasia, again as described in the chapters of this volume.

Discussions relevant to the various psycholinguistic subsystems of language in the context of aphasia syndromes are described in each of the prior chapters as though they were unique and independent, but in fact, difficulties with grammar, phonology, semantic underpinnings of words, reading, spelling, and so forth can occur in unique constellations in each person with aphasia. Because human communication is a multifaceted phenomenon supported by a complex set of processes (from psychological/linguistic to neurological; macro- to microstructures), and because any event which might disrupt this complex would be unique to the individual, restorative behavioral strategies with the goal of regaining effective communication in any one person with aphasia would need to be individualized. This would involve possibly bundling as well as staging a variety of treatments targeting various impaired linguistic mechanisms. While the evidence for such combinations and individualization represents a largely unexplored frontier, at this point we can examine more overarching questions of how normal learning generally occurs, extract suspected principles of how such learning can be optimized within the context of the rehabilitation experience, and consider how to apply those principles to relearning in the context of restorative behavioral therapies for aphasia (Rothi, Musson, Rosenbek, & Sapienza, 2008).

As noted in the NIH Blueprint for Neuroscience Research sponsored workshop in 2009, a behavioral experience can be potent and is influenced by experience attributes, is time-sensitive, and is impacted by intrinsic factors such as attention and motivation (Cramer et al., 2011). Kleim (2011), Nudo (2013) and others appropriately challenge us to use knowledge of the neural and behavioral signals that drive neural plasticity in order to develop “performance-enhancing” behavioral therapies. Similar mechanisms of brain plasticity occur across the lifespan and across varying forms of central nervous system (CNS) injury (disease, trauma, etc.), and this consistency “suggests that plasticity . . . uses a limited repertoire of events across numerous contexts” (Cramer et al., 2011, p. 1593). Kleim (2011) offers that, when relearning, “the brain will rely on the same fundamental neurobiological processes it used to acquire those behaviors initially. The basic rules governing how neural circuits adapt to encode new behaviors do not change after injury” (p. 522). Thus, a rehabilitation experience where individuals are expected to engage in linguistically rich activities might result in changed language behavior through learning-dependent, experiential neural plasticity; that is, relearning.

Accepting the premise that the act of verbal communication is an external representation of many underlying internal processes that can be examined from many levels of perspective, not least of which is a neural systems perspective, we looked to neural explanations of experience-dependent learning to seek principles of experience that might be applied to the context of restorative behavioral treatments for aphasia (Raymer et al., 2008). Turkstra, Holland, and Bays (2003) were among the first clinicians to draw attention to the implications of the neuroscience literature for clinical practice. Kleim and Jones (2008) were challenged to identify principles of experience-dependent neuroplasticity emanating from laboratory-based neuroscience studies using rodent models that they would recommend as “best candidates” for translation to humans. They offered ten possibilities, described in Table 17.2. While neuroscience studies in animal models surely have limits for the inferences that can be made for human language, principles garnered from these studies may have implications for aphasia rehabilitation practices. Some of these principles refer to factors that can be manipulated in the aphasia treatment context. Other principles guide outcomes that should be tracked in aphasia rehabilitation (transference and interference). Other possibilities exist beyond this set of ten principles, but this set often serves as a starting point for a discussion of principles emanating from neuroscience that have the potential to influence behavioral treatments in aphasia.

Use it, Use it, Use it

The first two principles offered by Kleim and Jones (2008) are “Use it or Lose it” and “Use it and Improve it” (see Table 17.2). Loss of function within the nervous system from disuse post–brain injury, or “learned non-use” as described by Taub, Uswatte, and Mark (2014), has been demonstrated for motor and sensory systems in animal models (Nudo, 2013). Compensatory skill-learning by the (p. 311) less-affected limb impedes later functional recovery in the more-affected limb (Allred & Jones, 2008; Allred, Maldonado, Hsu, & Jones, 2005; Jones et al., 2013; Kerr, Wolke, Bell, & Jones, 2013). These maladaptive effects were not seen in animals that were trained on a bimanual task (Kerr et al., 2013).

Table 17.2 Principles of Experience-Dependent Plasticity (after Kleim & Jones, 2008)

Principle

Description

1. Use It or Lose It

Failure to drive specific brain functions can lead to functional degradation.

2. Use It and Improve It

Training that drives a specific brain function can lead to an enhancement of that function.

3. Specificity

The nature of the training experience dictates the nature of the plasticity.

4. Repetition Matters

Induction of plasticity requires sufficient repetition.

5. Intensity Matters

Induction of plasticity requires sufficient training intensity.

6. Time Matters

Different forms of plasticity occur at different times during training.

7. Salience Matters

The training experience must be sufficiently salient to induce plasticity.

8. Age Matters

Training-induced plasticity occurs more readily in younger brains.

9. Transference

Plasticity in response to one training experience can enhance the acquisition of similar behaviors.

10. Interference

Plasticity in response to one experience can interfere with the acquisition of other behaviors.

In humans, functional loss in the early post-injury period has been shown to occur in the cognitive system as well (e.g., Coslett & Saffran, 1989). Thus much of the rationale for the class of rehabilitation therapies known as “constraint induced” (CI) therapies is based upon the principle of optimizing this latent residual capacity left behind by “learned non-use.” In parallel to optimizing this residual capacity using targeted post-injury activity/experience (Karni et al., 1998; Kleim, Barbay, & Nudo, 1998; Nudo Milliken, Jenkins, & Merzenich, 1996), recovery of function in the context of network changes incorporating inter- and intra-hemispheric adaptations is well documented (e.g., Jacquin-Courtois et al., 2013). Similar findings have been reported in humans in sensory (Taub et al., 2014), motor (Taub, Uswatte, & Morris, 2003), and cognitive (Corbetta et al., 2005; Saur et al., 2006) systems as well. An explosion of recent rehabilitation research has emphasized “use-dependent” or “experience-dependent” techniques based upon this principle of “use it,” focusing on massed practice of purposeful activity at maximal/optimal levels of an individual’s performance capacity, done in a manner that closely approximates normal performance and avoids compensation.

For individuals with aphasia, constraint induced language therapy (CILT) was developed by Pulvermüller and colleagues (2001) as a behavioral approach to overcome learned non-use and to promote use of verbal communication. Later the approach was broadened to be referred to as intensive language-action therapy (ILAT; Pulvermuller & Berthier, 2008). Because the treatment focuses on engaging expressive verbal language skills in the context of communicative interactions with partners in training, it is especially implemented in individuals with nonfluent forms of aphasia, as noted in the chapter on Broca’s aphasia (see Maher, Chapter 8). Systematic review of aphasia treatment studies has shown that the effects of CILT surpass those of comparison treatments on measures of general language, word retrieval, and auditory comprehension, as well as measures of communication participation (communication logs, rating scales) (Cherney et al., 2008; Cherney, Patterson, & Raymer, 2011).

In addition to CILT, any other aphasia treatments that facilitate language use during verbal production, auditory comprehension, reading, and writing activities can be conceived of as methods to overcome learned non-use. Thus many of the methods reviewed across the chapters in this book also would be considered as supporting use-dependent (p. 312) learning. Neuroscience evidence as well as evidence from aphasia rehabilitation suggest that language behavior must be engaged to overcome the natural propensity toward learned non-use.

Specificity in Training

Neuroscience researchers have shown that representational neural maps change in ways related to the specifics of the training experience (e.g., Wang, Conner, Rickert, & Tuszynski, 2011). In healthy human adults, expansions of hand, foot/ankle, or tongue motor maps have been shown to change in concert with skill learning in unilateral hand (Pascual-Leone, Wassermann, Sadato, & Hallett, 1995), leg (Perez, Lungholt, Nyborg, & Nielsen, 2004), or tongue movement task practice (Svensson, Romaniello, Arendt-Nielsen, & Sessle, 2003), respectively. Interestingly, the notion of the specificity of treatment effect has been borne out in the human stroke rehabilitation literature as well with Koski and colleagues (2004) showing expansion of motor maps correlated with motor improvements.

Additionally, researchers have shown that it is not as simple as repeating a behavior, but instead, that the effect of task practice is embellished when experiences are varied (Plautz, Milliken, & Nudo, 2000) and present opportunities for skill-building (Kleim et al., 2003), as opposed to repetitive or passively evoked responses. Thus it behooves the rehabilitation clinician to insure that the treatment plan is directed at achievement of carefully considered target behaviors. Kleim and Jones (2008) extend this notion by suggesting that in rehabilitation, one consideration might be that a specific modality of training may serve to influence subsequent training.

The concept of specificity in training can be applied to aphasia rehabilitation in several examples. Much of the extensive word-retrieval training literature employs picture-naming tasks where specific target vocabulary items are trained. Because the process of word retrieval engages both semantic and phonologic mechanisms for successful production of words, word-retrieval impairments can emanate from semantic or phonologic sources of breakdown (Harney in this volume; Reilly & Martin in this volume; Wilshire in this volume). Thus, word-retrieval treatments have been devised that focus on either semantic or phonologic attributes of words to target the impaired mechanism, a means to provide more specificity in training. The often-cited result across studies is that word-retrieval training effects are item-specific, as individuals with aphasia improve their ability to name trained pictures, with little generalization to untrained vocabulary (Raymer, 2015). Wilshire notes that in order to enhance effects, word-retrieval training should take place in a sentence context rather than during picture naming, as is the case in typical language use. Broader language gains, including improvements for word retrieval, have been reported in the outcomes of CILT (Cherney et al., 2008) or verb network strengthening treatment (Edmonds, Mammino, & Ojeda, 2014), where individuals engage lexical access while producing sentence-length utterances, rather than simply naming pictures. Yet, training of a limited set of functional “survival” vocabulary may be necessary in individuals with severe aphasia.

Likewise, in the treatment of acquired alexia and agraphia, specificity in training is a consideration. Several treatment approaches have been devised to address the multi-faceted patterns of breakdown that can be observed with disruption of distinct lexical and sublexical processes engaged in reading and spelling. The reading treatments reviewed by Riley, Brookshire, and Kendall (in this volume) and the spelling treatments reviewed by Beeson and Rising (in this volume) emphasize the connection between impaired processes and treatment approach to maximize training effects. Further, as Greenwald (in this volume) noted, writing treatment used as a compensatory method of communication for individuals with Wernicke’s aphasia may need to take place in a functional communicative context to encourage the use of writing as a communication modality.

Finally, the notion of specificity also implies that the outcomes measured following training should be specific to the intended goal. In studies of treatments such as CILT, in addition to treatment results documented in standardized aphasia test batteries or modality-specific tools (e.g., standardized tests of naming and auditory comprehension), outcomes pertaining to language use in daily communication activities, such as communication activity logs, discourse samples, or communication rating scales, also are documented (Maher et al., 2006; Meinzer, Djundja, Barthel, Elbert, & Rockstroth, 2005; Pulvermüller et al., 2001).

Repetition and Intensity Matter

When Kleim and Jones (2008) invoke the principle of repetition, they refer to the ongoing practice that takes place over time. The principle of intensity in training for them relates to the density or dosage of that practice within training sessions. In aphasia rehabilitation, CILT rehabilitation techniques are based upon the principle that relearning is optimized (p. 313) by repeated and intensive performances of target language behaviors (Pulvermüller et al., 2001).

To distinguish repetition and intensity in the context of aphasia rehabilitation, however, it is useful to consider the definitions of Warren, Fey, and Yoder (2007) as they discuss dosage as it pertains to intervention. “Dose” refers to “the number of properly administrated teaching episodes during a single intervention session” (p. 71). The definition of episode varies across tasks, types of interventions implemented, and therapists. “Dose frequency” is the number of sessions per time span, typically reported as sessions per week. “Total intervention duration” is the total span in days, weeks or months over which interventions are administered. Together, dose over dose frequency over total intervention duration leads to a “cumulative intervention intensity.” For example, a 30 minute session delivered 3 times per week for 12 weeks would equal a cumulative intervention intensity of 1080 minutes. The dose of episodes within a session is not often reported, however. In this parlance, “dose” is more of a corollary to Kleim and Jones’s (2008) principle that intensity matters within training sessions, while repetition matters across time in dose frequency and intervention duration.

In order to invoke long-term changes, aphasia treatment must incorporate many opportunities for the target language behavior, what we might refer to as a high-dose intervention (see Harnish in this volume). In their meta-analysis of the word-retrieval treatment literature, Snell, Sage and Lambon Ralph (2010) reported on the relationship between the number of words trained and naming outcomes, noting some negative correlation. This observation speaks to dose, as larger sets typically have a lower dose of exposure in training than smaller training sets. Yet, two systematic investigations of size of training sets showed that the same proportion of words were learned regardless of the size of training set, indicating that more words are learned when larger training sets are employed (Laganaro, Di Pietro, & Schnider, 2006; Snell et al., 2010). Harnish et al. (2014) demonstrated that aphasia treatment sessions can be structured with what they call saturated practice, in which individuals with aphasia have hundreds of opportunities to produce target words, thereby leading to rapid improvement in their word-retrieval outcomes after only three hours of training.

In the aphasia treatment literature, high intensity dose frequency tends to be referred to as “massed practice,” whereas lower intensity training is known as “distributed practice” (Dignam, Rodriguez, & Copland, 2016). As noted by Maher (in this volume), intensive training is a principle applied in CILT, as, not only are individuals with aphasia forced to use verbal utterances, but they are also provided training on an intensive massed schedule of 10–15 hours per week. In Robey’s (1998) meta-analysis of the aphasia treatment literature, larger effect sizes were reported when treatment was provided two or more hours per week, compared to less than 1.5 hours per week. Since then, several studies have directly compared massed versus distributed treatment schedules to evaluate intensity effects in aphasia treatment (Cherney et al., 2008, 2011). Across studies, some have varied dose frequency (sessions per week) while controlling total intervention duration, thus leading to differences in cumulative intervention intensity (Bakheit et al., 2007; Hinckley & Carr, 2005; Hinckley & Craig, 1998). Other studies have compared dose frequency administered at different intervention durations to equate cumulative intervention intensity (Dignam et al., 2015; Pulvermüller et al., 2001; Raymer, Kohen, & Saffell, 2006; Sage, Snell, & Lambon Ralph, 2011). Dose frequency studies typically compare training delivered in 4–5 sessions per week versus 1–2 sessions per week. Treatment gains following a short course of treatment tend to show advantages for a massed dose frequency schedule. Yet a less intensive, distributed treatment schedule may have better maintenance of results at follow-up, a finding reminiscent of a pattern reported often in the motor learning literature (Dignam et al., 2015). Differences in cumulative intervention intensities across studies ranging from 10–100 hours of total training may explain divergent findings. Over larger cumulative intervention intensities of greater than 50 hours of training, it appears that results tend to equalize across massed and distributed dose frequencies. What is clear across the literature is that greater cumulative intervention is better.

Time Matters

Neuroscience studies demonstrate that the timing of an intervention has considerable impact on the outcomes of that intervention (Turkstra et al., 2003). Timing of interventions in aphasia rehabilitation has also been considered. Historically, the presumption in rehabilitation has been that restorative treatments are more appropriate during acute phases of recovery, with reorganization approaches being added in subacute phases, and compensatory (p. 314) approaches applied in chronic phases of recovery (Barrett & Rothi, 2002; Nouwens et al., 2015). Robey’s (1998) meta-analysis seems to support that perspective, as treatment effects, while surpassing changes associated with no treatment, grow smaller over time from acute to chronic stages of aphasia recovery. But research examining patterns of aphasia recovery and treatment may refine that viewpoint.

Saur and colleagues (2006) showed through serial functional magnetic resonance imaging (fMRI) examinations of aphasia recovery (day 4 post-stroke, 2 weeks post-onset, greater than 4 months post-onset) that patterns of activation changed over time. The first epoch (day 4 post-stroke) showed complete breakdown of left hemisphere language-related activation. The second timeframe (2 weeks post-onset) showed activation of remaining left and newly formed right homologue language areas. Finally, in the chronic phase (4 months post-onset), participants showed normalization of language lateralization back to the left hemisphere. In their 2012 paper, Saur and Hartwigsen concluded that, with time, “aphasic patients may be able to resort to normative learning mechanisms in the chronic phase after stroke . . . (and) it can be assumed that model-based therapeutic strategies may be best applied in the chronic phase” (p. S21). Much of the aphasia treatment literature is conducted in the chronic phase of recovery, at least 4–6 months post–stroke onset and beyond, and impressive treatment effects are not uncommon in individuals who are years and even decades post–stroke onset (Kendall et al., 2007; Raymer et al., 2007). Less is known about the effects of aphasia treatment in the acute stage, as mixed findings are reported in several randomized controlled trials of aphasia treatment initiated within three days of stroke onset (Godecke et al., 2014; Laska, Kahan, Hellblom, Murray, & von Arbin, 2011). Further complicating this picture is the work of El Hachioui and colleagues (2013), who followed the language-recovery patterns of a group of individuals with aphasia at periodic time points, assessing different linguistic systems: semantics, syntax, and phonology. Findings indicated differing trajectories of recovery for the different linguistic systems, with phonology lagging significantly behind semantics and syntax. These observations suggest that the linguistically oriented treatments reviewed across chapters in this book might come into play at slightly different, as of yet unknown, timeframes in recovery.

Salience and Motivation Matters

Salience in human rehabilitation including that for aphasia can take on a number of different definitions. Things that are familiar, useful, functional, likeable, or interesting to the individual might be considered salient. Renvall, Nickels and Davidson (2013a,b) offer that functionality of words for aphasia treatment might be based upon how commonly they are used. Wilshire (in this volume) discusses the work of Marshall and Freed (2006), who demonstrated that personalized cues were more effective than generic cues in facilitating improvements in word retrieval. Beeson and Rising (in this volume) emphasize that target words for spelling treatments should have functional value for the person in training. In addition, how pleasant or unpleasant a stimulus may be to the individual can influence arousal and verbal expression, as noted by Leon, Rodriguez, and Rosenbek (in this volume).

Alternatively, salience may include the notion of reward and motivational state, which has a considerable influence on changes observed in the neuroscience training studies (Mosberger, de Clauser, Kasper, & Schwab, 2016). Less attention has been given to the influence of reward or motivation on aphasia treatment outcomes. Within right-hemisphere communication disorders, as noted by Leon and colleagues (in this volume), anosognosia, or lack of awareness of deficits, can be a detriment to rehabilitation outcomes. The type of feedback used during training may need to be adjusted to address the lower motivation to engage in treatment that might be seen in these individuals. Overall, reward and motivation are areas ripe for investigation for the effects on rehabilitation outcomes for aphasia and related communication disorders.

Age Matters

While neuroplasticity of the brain spans across the lifespan (Turkstra et al., 2003), there are limits to that potential as we age. Age of onset when a nervous system injury occurs has long been recognized for its influence on the prognosis for aphasia recovery, as children who incur brain injury with aphasia demonstrate considerably greater recovery than do adults (e.g., Bates et al., 2001). Within adulthood, age continues to be a potent mediating influence on stroke (Jorgensen et al., 1999), and aphasia recovery (Code, 2001), although the influence of age on aphasia treatment outcomes directly is not as evident (Ellis & Urban, 2016). Nevertheless, McClung, Rothi, and Nadeau (2010) included age, 50 years and younger vs. older than 50 years, as an (p. 315) intra-individual ambient factor that should be considered for its influence on rehabilitation outcomes.

Transference or Generalization

The corollary to what Kleim and Jones (2008) in neuroscience called transference is referred to in the aphasia literature as generalization. Transference has to do with effects of training that transcend the currently trained language stimuli, language behavior/task, or communicative context. As noted across chapters of this volume, to the extent that words or sentences engage common linguistic rules or principles, the likelihood of generalization of training effects is increased. Harney (in this volume) mentions the work of Kiran (Kiran, 2008; Kiran & Thompson, 2003), who has demonstrated that word-retrieval training for atypical category exemplars (e.g., artichoke) generalize to untrained typical category exemplars (e.g., carrot) because of common semantic features across stimuli. Maher (in this volume) refers to the work of Thompson and colleagues (Thompson & Shapiro, 2005; Thompson, Shapiro, Kiran, & Sobecks, 2003), who demonstrated that training of sentence production using syntactically complex stimuli (e.g., object cleft sentences) leads to improvements in untrained syntactically related stimuli (e.g., wh-questions) that share base syntactic structures.

Another form of generalization occurs across tasks that share psycholinguistic processing mechanisms. For example, Beeson and Rising (in this volume) mention the natural relationships in training involving writing and reading, such that training that focuses on spelling can generalize to improvements in reading or speech production for the trained words. Harnish (in this volume) described semantic treatments for anomia that influence both auditory comprehension and picture naming for the same words.

The overarching goal of aphasia treatment is transference or generalization from the immediate trained stimuli, tasks, or context to other untrained stimuli, tasks, or contexts, primarily to allow individuals with aphasia to engage in daily communication activities; that is, connected discourse. Many treatments discussed across chapters of this book lead to improvements in connected speech (e.g., CILT, Cherney et al., 2008; semantic feature analysis [SFA], Boyle, 2010; verb network strengthening treatment, Edmonds et al., 2014). As Harney notes (in this volume), some aphasia treatments lead to generalized improvements through remediation of the impaired language mechanism, while other approaches, such as SFA, have broader influence by teaching individuals a strategy to circumvent the impaired language system.

Interference

While a number of factors have potent positive influences on neuroplasticity, it is also possible for neuroplasticity to be maladaptive or harmful. Kolb, Muhammad, and Gibb (2011) note that pain, seizures, and drug addiction can be examples of maladaptive neuroplasticity. Perseverations so common in aphasia can be viewed as an interference phenomenon in this regard. As Greenwald (in this volume) noted, perseverations that are frequent in Wernicke’s aphasia are at times viewed as the lack of deactivation of prior productions of words that act as competitors in future attempts to say other words (Cohen & Dehaene, 1998).

Kleim and Jones (2008) include interference as a form of maladaptive neuroplasticity seen in rehabilitation. Interference occurs when training on one skill is detrimental to the potential benefit of training for subsequent skills. When Wilshire (in this volume) discussed conduction aphasia treatments, she mentions that one side effect of contextual priming treatment with phonologically similar pairings is phonologic confusion (e.g., Fisher, Wilshire, & Ponsford, 2009), which we might consider a form of interference effect. Fisher et al. proposed that one reason contextual priming ultimately works as an intervention method is that individuals implement error-monitoring mechanisms to overcome the interfering phonologic confusions that are often reported during this treatment approach. Another example of interference seen in the aphasia treatment literature is provided by Keane and Kiran (2015), who reported that a trilingual speaker with aphasia was trained in one language, which impeded progress in an untrained language.

To avoid interference among a set of impaired language mechanisms, attention might be given to sequencing treatments. Beeson and Rising in their chapter discuss writing interventions that occur in sequence, as advances in one mechanism of spelling (e.g., phonological) may need to take place prior to implementing more advanced spelling methods (e.g., interactive), which would otherwise be interfered with by the impaired mechanism.

Other Principles of Rehabilitation

In addition to the principles espoused by Kleim and Jones (2008), there are other factors that might be considered for their impact on aphasia treatment (p. 316) outcomes. Many of these principles can be applied in conjunction with the variety of treatments described across the chapters of this volume.

Sufficient Abilities

Cramer (2011) noted that “a behavior whose underlying brain regions are destroyed is less likely to improve than a behavior whose underlying regions are accessible to a restorative therapy” (p. S6). It is notable that functional gains post–motor therapy for hemiplegia (upper extremity) are greatest for those who begin treatment with some residual voluntary movement (Duncan et al., 2003; Kwakkel, 2006). A minimum level of motor function is a requirement stipulated for admission to constraint-induced motor therapy (Taub et al., 1993). However, those with precious little movement do respond to targeted as opposed to functional practice approaches (Taub et al., 2014).

In aphasia rehabilitation, there is some indication that a sufficient ability must be present for progress to take place—a leg to stand on, so to speak. It is not uncommon to find that the more severe the aphasia, the more limited the progress following treatment. For example, Crosson, Bohsali, and Raymer (in this volume) reported the work of Crosson and colleagues (2007), where, following intentional treatment for word retrieval, greater improvements in naming for trained and untrained probes were evident for groups with moderate–severe naming impairment compared to profound impairment. In a recent meta-analysis of randomized controlled trials of aphasia treatment, there was considerable variability of treatment effects across studies with little relationship to aphasia severity, which was attributed to methodologic variations across studies conducted in many different countries (Brady et al., 2016).

Error Production in Training

While it is a decades-old principle of learning, Wilson and colleagues (Wilson, Baddeley, Evans, & Shiel, 1994; Wilson & Evans, 1996) moved the principle of “errorless learning” into neurorehabilitation circles. They reported that individuals with memory impairments associated with brain injury or dementia can remember facts better when trained in an errorless format as compared to errorful trial-and-error practice. One notion is that the Hebbian principle—neurons that fire together wire together— implies that error production during training may be counterproductive and reinforce errors (Fillingham, Hodgson, Sage, & Lambon Ralph, 2003). In brain injury, declarative memory mechanisms (i.e., mesial temporal lobe) through which one can “learn from one’s mistakes” are often damaged. Errorless methods take advantage of intact neural networks (typically basal ganglia circuits) of implicit or procedural learning (Middleton & Schwartz, 2012) to improve memory for specific information.

The influence of error production on aphasia treatment outcomes also has been examined, especially in word-retrieval training paradigms. Chapters by Harnish and Greenwald (in this volume) both refer to errorless naming training studies by Fillingham, Sage, and Lambon Ralph (2005, 2006). When this effect has been examined systematically for naming treatments in aphasia, improvements are comparable in errorless and errorful training conditions, although participants often prefer errorless training methods perceived to be less frustrating. Likewise, in spelling remediation in individuals with acquired dysgraphia, errorless and errorful copy and recall approaches had similar positive outcomes, although some advantage was evident for errorful approaches at one-month follow-up (Raymer, Strobel, Prokup, Thomason, & Reff, 2010). This finding speaks to the integrity of declarative memory and frontal executive mechanisms that are integral to error awareness during aphasia rehabilitation.

Feedback Influences in Rehabilitation

The type of feedback provided during training events is another factor that has a potent influence on training outcomes, especially maintenance of those outcomes (Schmidt & Wrisberg, 2004). Feedback in the form of knowledge of performance (KP) provides information about why or how the response is in error, whereas knowledge of results (KR) feedback gives summary information about the accuracy of the performance. During acquisition phases of training, KP feedback is important and effective, but to promote maintenance of performance, feedback needs to evolve to KR. Harnish (in this volume) reviewed studies that showed that feedback has less effect on aphasia rehabilitation because associative learning takes place in language learning, although feedback increased the rate at which learning took place (Breitenstein, Kamping, Jansen, Schomacher, & Knecht, 2004). However, McKissock and Ward (2007) found that errorful naming training required KR feedback to be successful for improving naming performance compared to no feedback at all. In another example, Leon, Rodriguez and Rosenbek (in this volume) (p. 317) note that feedback played an important role in rehabilitation of prosodic impairments following right-hemisphere damage. In training individuals to overcome affective aprosodia, KP feedback was modified across steps of training to be delayed and intermittent in an effort to promote self-monitoring of prosodic productions and maintain training effects.

Adjuvants to Behavioral Training

An adjuvant is an agent, often pharmacologic, that acts to modify the effects of other agents. In aphasia rehabilitation, several drugs have been tried in an attempt to manipulate neurotransmitter systems needed to facilitate language recovery or to amplify behavioral language treatment effects (Berthier, Pulvermüller, Davila, Casares, & Gutierrez, 2011). Crosson, Bohsali, and Raymer (in this volume) report studies using the dopamine agonist bromocriptine administered to individuals with transcortical motor aphasia as an intervention to promote verbal generativity, with some positive findings in open-label trials (e.g., Albert et al., 1988; Gold, Van Dam, & Silliman, 2000; Raymer et al., 2001). Walker-Batson and colleagues (2001) reported that dextro-amphetamine, a noradrenergic agonist, enhanced aphasia treatment effects on a general test battery. In a systematic review of this literature, Greener, Enderby, and Whurr (2010) found few randomized controlled trials of pharmacologic interventions for aphasia. They reported the best results for a nootropic agent, piracetem, a drug that is not yet approved for use in the United States. Despite the unclear findings, some remain optimistic that drugs have the potential to enhance aphasia recovery when paired with intensive language treatment (Berthier et al., 2011).

Alternative adjuvants explored to enhance aphasia recovery are neuromodulators that use an electrical current in an effort to enhance treatment outcomes (Schlaug, Marchina, & Wan, 2011; Turkeltaub, 2015). The neuromodulatory approaches vary greatly in how, where (left or right hemisphere), when (before or after treatment), and how long they are administered, leading to a complex literature examining their impact on aphasia recovery or treatment effects. Turkeltaub’s (2015) review contrasts the approaches and effects of two main neuromodulatory techniques, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS).

In rTMS, a device is positioned above the skull to deliver a magnetic pulse that incites an electrical current over a targeted focal brain region in the left or right hemisphere. When administered at a low frequency, rTMS inhibits functions in the target brain region, whereas at a high frequency, it excites neuronal firing in the underlying region (Turkeltaub, 2015). Side effects can include headache, dizziness, or, in rare occasions, a seizure (Schlaug et al., 2011). Among the first to explore the influence of rTMS in aphasia rehabilitation were Naeser and colleagues (2012). Language treatment is administered before or after the rTMS session. Systematic reviews and meta-analyses of aphasia treatment studies employing rTMS demonstrate that improvements in language skills such as word-retrieval abilities occur when low frequency TMS is applied to right inferior frontal cortex (Gadenz, Moreira, Capobianco, & Cassol, 2015; Li, Qu, Yuan, & Du, 2015; Ren et al., 2014). Thus, the best effects are reported when rTMS is used to inhibit the right hemisphere during aphasia recovery.

An alternative portable, less expensive, and safe neuromodulator technique is tDCS, in which an electrical current is applied directly to the scalp to induce a broader signal. Anodal tDCS acts as an excitatory stimulus, and cathodal tDCS decreases the likelihood of cortical excitability (Schlaug et al., 2011). This technique can be administered before, during, or after language therapy. Reported side effects include tingling, burning, or itching sensations (Turkeltaub, 2015). A careful systematic review of 12 studies using tDCS for aphasia, including six studies incorporated in a meta-analysis of effects for a common picture-naming measure, showed little clear benefit of the technique (Elsner, Kugler, Pohl, & Mehrholz, 2015). In contrast, a meta-analysis of three tDCS studies administering cathodal tDCS to the right hemisphere reported positive improvements for naming in aphasia (Otal, Olma, Floel, & Wellwood, 2015). Cappon, Jahanshahi, and Bisiacchi (2016) conclude that more consistent methods need to be employed before any true benefits of tDCS for aphasia rehabilitation are known.

Life Participation Approaches in Aphasia Treatment

The World Health Organization International Classification of Functioning, Disability and Health (WHO ICF, 2001) integrates biomedical and psychosocial perspective on health and disability. The WHO ICF represents the interaction of three primary domains: body structure/function, (p. 318) activity/participation, and contextual factors. Much of the focus across chapters of this volume has been on language functions, including their assessment and treatment. As Patterson (in this volume) reviews assessment tools developed to address the social context of communication guided by the WHO ICF, so, too, does that framework lead to treatments devised to promote life-participation approaches to aphasia (LPAA; Chapey et al., 2008). The LPAA approaches can be categorized generally as functional/pragmatic in which individuals with aphasia are trained to use effective communication strategies, or social in which intervention aims to remove barriers in the communication context, typically through communication partners (Worrall, Papathanasiou, & Sherratt, 2013). Principles of neuroplasticity reviewed throughout this chapter have a potent influence on learning, maintenance, and generalization of communication strategies trained within these LPAA treatments. Importantly, treatments for language functions and life participation should be integrated throughout the recovery continuum to maximize communication outcomes for individuals with aphasia.

Table 17.3 Strategies to Enhance Communication in Individuals with Aphasia

Strategies when speaking to individuals with aphasia and auditory comprehension impairments:

1.

Speak slowly, with pauses between phrases of a sentence.

2.

Look directly at the person with aphasia; make eye contact.

3.

Write down key words to help the person understand the main concepts.

4.

Embellish speech with gestures, written words, or drawings.

5.

Speak at a natural loudness level with natural intonation.

Strategies for individuals with expressive communication impairments:

1.

Encourage the person to get out whatever words they can.

2.

Encourage the use of circumlocutions.

3.

Disregard mistakes as long as the idea is understood.

4.

Encourage the person to use alternative modes of communication, such as gestures, writing, or drawing, to express ideas.

5.

Write down what you think the person is trying to say to verify the message.

6.

Repeat what is understood so far.

7.

Provide a pointing board with pictures or letters to spell words they cannot say.

8.

Give the person with aphasia options if they are struggling to utter a specific word.

9.

Give the person with aphasia plenty of time to respond.

Functional Approaches in Aphasia Treatment

The term functional in this context refers to the use of language for daily communication activities (Armstrong, Ferguson, & Simmons-Mackie, 2013; Frattali, 1998). A number of treatment techniques take a broader approach to facilitating communication for individuals with aphasia to take part in daily conversations. Such approaches may use role-playing (e.g., conversational coaching; Hopper, Holland, & Rewega, 2002), multi-modality training (Rose, Mok, Carragher, Katthagen, & Attard, 2016), and practice with discourse-level text (e.g., script training; Cherney, Kaye, & Van Vuuren, 2014). A common thread across many functional treatment approaches is that individuals with aphasia are encouraged to implement any strategies to communicate, not just auditory-verbal alone.

A number of compensatory strategies can be implemented either to facilitate comprehension in light of impaired auditory skills or to support expression of thoughts and ideas despite impaired verbal expression abilities. Table 17.3 lists a number of strategies that can be used by individuals speaking (p. 319) to persons with aphasia to support comprehension or circumvent expression impairments. However, intervention may be needed so that persons with aphasia can become skilled in the use of compensatory strategies. One natural context for this to take place is within group aphasia therapy.

Group Therapy

In group aphasia treatment, several individuals with aphasia work together to engage in communication activities (Elman, 2011). The key purpose is for the participants to have opportunities for interchanges in which they can implement compensatory strategies to express or comprehend language as needed, in a safe, supportive environment. A natural outgrowth of such groups is a psychosocial benefit when individuals with common communication struggles work together to support and accept the new identity and deal with the complex emotions that aphasia has generated.

A number of studies have systematically explored the outcomes associated with aphasia group treatment as compared to treatment provided to individuals with aphasia (e.g., Elman & Bernstein-Ellis, 1999; Wertz et al., 1981). Systematic reviews of the literature have summarized findings across studies and report that outcomes of group aphasia therapy are commensurate with those of individualized treatment for language, communication, and quality of life measures (Brady et al., 2016; Layfield, Ballard, & Robin, 2013). Aphasia group training can benefit participants in the size of their social networks and community access as well (Lanyon, Rose, & Worrall, 2013).

Social Support for Aphasia

The WHO ICF model includes the environment as a consideration for its impact for an individual recovering from or living with a health condition, such as aphasia. The environment of an individual with aphasia includes many communication partners (e.g., family members, friends, healthcare providers) who may or may not naturally know how to communicate effectively with someone with aphasia. Therefore, communication partner training may be helpful to embellish the communicative context. A number of investigations have explored ways to support communication with different groups of communication partners, including families (Rautakoski, 2011), volunteers (e.g., Kagan, Black, Duchan, Simmons-Mackie, & Square, 2001), and medical providers (Legg, Young, & Bryer, 2005). While many partner-training studies provide education and counseling about aphasia, the majority of studies incorporate dyads where individuals with aphasia and their partners are trained to use specific communication strategies to facilitate better comprehension, expression, and repair of communication breakdown. Simmons-Mackie and colleagues (Simmons-Mackie, Cherney, Raymer, Holland & Armstrong, 2010; Simmons-Mackie, Raymer, & Cherney, 2016), in their systematic reviews of this extensive literature, reported that communication partner training leads to considerable improvements in the use of effective communication strategies by partners of individuals with aphasia and successful communication by individuals with aphasia. No changes in language measures were noted for persons with aphasia following communication partner training, however.

Conclusions

Treatment for aphasia is a complex process that requires the participation of a number of professionals in an interprofessional synergism to assure the best outcomes for individuals with aphasia (van de Sandt-Koenderman, van der Meulen, & Ribbers, 2012). While many of the approaches reviewed across the chapters of this text are language-oriented methods that aim to promote neuroplastic language recovery, other approaches focus on optimizing life participation of individuals with aphasia, using multi-modality communication methods and effective communication partners. We emphasize that these varied approaches are complementary, such that all may be implemented in an individual with aphasia as indicated with a consideration of the patterns of impairment, stage of recovery, neurologic indications, and personal factors. A number of principles of neuroplasticity can be considered for their modulatory effects of behavioral treatments for aphasia.

Fortunately, advances in technology now allow individuals with aphasia to take part in ongoing activities apart from traditional face-to-face individualized therapy. Telehealth practices may allow individuals with aphasia to benefit from treatment at a distance (Woolf et al., 2016). Computer programs and mobile applications on tablets or smartphones allow individuals with aphasia to participate in activities independently or with guidance from clinicians (Des Roches, Balachandran, Ascenso, Tripodis, & Kiran, 2015). Virtual reality applications are advancing to engage individuals with aphasia in rich communication interactions (Marshall et al., 2016).

(p. 320) The challenge persists for clinicians who work with individuals with aphasia to provide interventions that optimize outcomes. Research continues to explore methods to enhance behavioral treatments, advance technological applications, understand pharmacologic and neuromodulatory options, and implement psychosocial life-participation approaches. Other influences on successful recovery from aphasia are under investigation, such as exercise and motivation. Progress will continue in efforts to identify optimum treatment combinations that lead to the greatest language-recovery possible, the most effective communication skills, and the best quality of life and engagement for individuals with aphasia.

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