ypes of aphasia therapy

	References	NHMRC Level of evidence
a. Treatment derived from cognitive neuropsychology models :- - word retrieval deficits - reading deficits - writing deficits	Brady et al., 2012 Wiseburn and Mahoney, 2009 Brady et al., 2012 Brady et al., 2012	I IV I I
b. Treatment of sentence comprehension and production impairments	Thompson et al., 2003	III-3
c. Discourse treatment	Boyle, 2011	IV
d. Augmentative and alternative communication	Baxter, Enderby, Evans, & Judge, 2012	IV
e. Constraint-induced language therapy	Brady et al., 2012	I
f. Gesture-based therapy	Rose, Raymer, Lanyon, & Attard, 2013	III-2

Rationales:
It has been demonstrated that therapy for word-retrieval and production disorders can be effective (de Jong-Hagelstein et al., 2011; Doesborgh et al., 2004; Wiseburn & Mahoney, 2009). The Wiseman & Mahoney systematic review presented evidence from a range of study designs including a substantial number of single case experimental designs (assigned a level of evidence of IV here). However, we still cannot predict which therapy will work for which impairment (Nickels, 2002). There is emerging evidence that impairment-focused therapy can impact on the conversations of people with aphasia (Carragher, Conroy, Sage, & Wilkinson, 2012). While these early findings are promising, investigations have been limited to naming therapies and the methods of data collection used have implications for ecological validity.

Treatment of Underlying Forms (TUF), which targets complex Wh-movement sentences, has been reported to result in improved production and comprehension of these structures and generalization to less complex Wh-movement constructions (Thompson, Shapiro, Kiran, & Sobecks, 2003).

Discourse treatment for word retrieval appears to be a promising approach. Further research is required to inform the true effectiveness of the approach. Positive outcomes were reported on measures of word retrieval across all studies in the Boyle (2011) review.

Some individuals with aphasia may benefit from high-technology AAC, further understanding is required to assist clinicians in being able to determine which clients are most likely to benefit and the types of AAC that are most effective. The use of low-technology AAC has not been well reported (Baxter et al., 2012).

Constraint induced language therapy is one potential approach to use within aphasia rehabilitation (Meinzer, Rodriguez, & Gonzalez Rothi, 2012). Based on current literature it is premature to conclude that there is a clear advantage of applying constraint principles to aphasia rehabilitation over other types of intensive intervention (Barthel, Meinzer, Djundja, & Rockstroh, 2008; Cherney, Patterson, Raymer, Frymark, & Schooling, 2008; Rose, 2013).

The current literature supports a benefit of combined gesture + verbal treatment for noun and verb production for some people with aphasia. Any additional benefit from gesture treatment for others remains uncertain (Rose et al., 2013).

Word retrieval therapy

STUDY # 1: Can impairment-focused therapy change the everyday conversations of people with aphasia? A review of the literature and future directions. Carragher, Conroy, Sage & Wilkinson (2012).

DETAILS: This review investigated impairment-focused studies which explored the impact of therapy on conversations of people with aphasia.
Five studies were included in the review. The studies investigated the effects of either noun retrieval or verb retrieval on conversation. The studies typically had a small sample sizes (N = 1 -2) with the exception of del Toro et al. (2009) who had 14 participants. These early studies provide promising results. Conversations of treated individuals did demonstrate an effect of therapy. This was reported across a number of outcomes including increased production of content words (Greenwood et al., 2010) and increased semantic specificity of nouns (del Toro et al., 2008). These were reported to be measures of informativeness (e.g. increased production of new information, increased informativeness of speech output) as well as measures of error production.

NOTES: The small number of participants and few samples of conversation must be taken into account in the interpretation of these studies. More research is required in order to replicate the findings of these early studies.

OVERALL CONCLUSION: “There is emerging evidence that impairment-focused therapy can impact on the conversations of PWA. While these early findings are promising, investigations have been limited to naming therapies and the methods of data collection used have implications for ecological validity” (pp895).

STUDY # 2: “Therapy for naming disorders: Revisiting, revising and reviewing" Nickels (2002)

DETAILS: This non-systematic review provides an update on a previous review (Nickels & Best, 1996) of word retrieval treatments. The review focuses on impairment-level treatments of spoken word production in aphasia. It provides in-depth discussion of the literature on various approaches such as: “reorganisation” approaches (such as facilitating intact processes to compensate for or support impaired processes); facilitation, repair and re-teaching approaches; and specific impairment-focused approaches such as those focusing on the remediation of semantic or post-lexical phonological impairments.

OVERALL CONCLUSION: “It has now be clearly demonstrated that therapy for word-retrieval and production disorders can be effective. However, we still cannot predict which therapy will work for which impairment - this is a conclusion that has been drawn several times (e.g. Hilis, 1993; Nickels & Best, 1996).”

Sentence Processing

STUDY: “Cognitive treatments of sentence processing disorders: What have we learned?” Mitchum, Greenwald & Berndt (2010)

DETAILS: This non-systematic review investigates 10 studies which aim to improve sentence comprehension. The review discusses various aspects of sentence processing in-depth, including; “thematic mapping”, generalisation patterns, and treatment of sentence production impairments.

OVERALL CONCLUSION: The outcomes indicate that treatments can induce a change in the pattern of sentence processing for some people with aphasia.

Discourse treatment

STUDY: Discourse treatment for word retrieval impairment in aphasia: The story so far. Boyle (2011)

DETAILS: This paper reviews studies of discourse treatment for word retrieval. Seven studies were included in the review. The included studies applied treatments to improve word retrieval during structured discourse production with people with aphasia. Treatment methods used in the investigations included “phonologic and orthographic cues, semantic feature analysis, contingency-based cueing hierarchies, and repeated conversational engagement” (pp1308). Structured narratives and structured conversations were used as the discourse context.

Positive outcomes were reported on measures of word retrieval across all studies. Changes to discourse macrostructure (in terms of discourse informativeness) were observed from treatment of linguistic processes. Treated vocabulary items did not improve in all cases. Some generalisation of word retrieval into conversation was observed in one study.

While further research is required to provide conclusions about treatment efficacy, the author did provide some early observations that may be clinically useful in the interim. It must be noted that these observations are based on studies of low level designs (case studies and single-participant studies) which had small sample sizes and no control groups. The author's observations were:

Alternate and augmentative communication (AAC)

STUDY: “Interventions using high-technology devices: a state of the art review”. Baxter, Enderby, Evans & Judge (2012)

DETAILS: This systematic review investigated interventions using high-technology AAC with people with communication difficulties (including but not limited to aphasia). A total of 65 studies (of various designs) were included in the review.
In relation to aphasia, 14 studies were identified which primarily investigated the use of computer software interventions. Some positive results were reported for the SentenceShaper To Go^TM portable device (e.g. correct word use and fluency) and the DragonNaturallySpeaking^TM program. For the DragonNaturallySpeaking^TM program, accuracy was reported to improve when used alongside SentenceShaper. Varying success was reported for CSpeak^TM Aphasia program (only one study included). The only speech generating device that was reported on was TouchSpeak^TM which showed positive results for some people with severe aphasia; many (43%) however, demonstrated no functional usage.

The authors reported evidence that high-technology AAC may be beneficial across a range of diagnoses including aphasia. Many studies though had a small sample size and low methodological quality.

OVERALL CONCLUSION: While some individuals with aphasia may benefit from high-technology AAC, further understanding is required to assist clinicians in being able to determine which clients are most likely to benefit and the types of AAC that are most effective.

Constraint-based approaches

Constraint-based approaches are intensive therapy approaches that focuses on forced verbal communication in relevant communicative contexts.

Gesture-based therapy

STUDY: A systematic review of gesture treatments for post-stroke aphasia. Rose, Raymer, Lanyon and Attard (2013)

DETAILS: This review investigated studies of symbolic and nonsymbolic gestural training in people with aphasia. The review included 23 studies (primarily single-case experimental designs). In total, 134 individuals participated across the studies. Mostly, the participants had moderate-severe nonfluent chronic aphasia.
The studies’ methodological quality was rated using the PEDro scale for the group designs (N = 4) and the scale for the single-case experimental designs (SCEDs) (N = 19). While the quality of the group designs was low, the majority of the SCEDs achieved high-quality scores (8-10/10).
While no significant effect was observed for gesture training alone, combined gesture + verbal treatment was reported to show positive effects for verbal production of verbs and nouns for some individuals. Further research is required to establish whether the effects of combined gesture + verbal are more efficacious than verbal treatment alone.

OVERALL CONCLUSION: “Comparative effect sizes support a benefit of combined gesture + verbal treatment for noun and verb production for some individuals with aphasia. Whether that benefit surpasses the results of verbal treatment alone is not well established. Symbolic gestures can be acquired by individuals with aphasia, although their communicative effectiveness requires further study. Overall, gestural training in aphasia, while generating some positive outcomes, is relatively understudied” (pp2-3).

Word retrieval therapy

Sentence Processing

Discourse treatment

Alternate and augmentative communication (AAC)

Constraint-based approaches

Gesture-based therapy

References:

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