INTERVENTION FOR

PERSONS WITH
APHASIA
 INTRODUCTION
• Patients with aphasia may present some spontaneous language
improvement (so called “spontaneous recovery”), but systematic
therapeutic programs can significantly contribute to a more rapid and
complete language recovery.
• During the last decades, it has been observed that an increased number
of aphasia patients have had the opportunity to participate in
rehabilitation programs; this situation has resulted in a better quality of
life for a significant number of aphasic individuals.
 GENERAL GUIDELINES
Reduce the effects of the residual deficits on the personal, emotional,
social, family and occupational aspects of the client’s life.
Teach compensatory strategies
Counsel family members to help them cope with the residual defects.
Give a realistic prognosis that modifies the client’s and the family
members expectation.
Structure the treatment and let the client repeatedly practise the target
behaviour.
Develop a variety of client specific treatment procedures
Explicit the client’s strengths (eg: use stronger visual mode to
supplement for weaker auditory mode).
Judge when it is not useful or ethical to continue the treatment.
Observe them carefully.
Conduct a detailed assessment.
Choose client specific target behaviour that enhance functional
communication.
Sequence target behaviours in treatment.
Move from simple to complex tasks.
Use extra stimulus control initially.
Use modelling, pictures and objects.
Reduce stimulus control in small steps.
Arrange consequences that occur naturally.
Provide immediate response-contigent feedback.
Encourage the client to self monitor.
Train family members to evoke, prompt, reinforce and maintain
communicative behaviour.
AUDITORY COMREPHENSION
Factors that promote auditory comprehension.
More frequently used words.
Nouns rather than verbs, adjectives and adverbs.
Picturable verbs and other words.
Unambiguous pictures.
Shorter pictures.
Shorter sentence.
Active sentences
Personally relevant information.
Slower speech with frequent pauses.
Slower rate with words that are stressed.
Quieter environment.
Redundant messages.
• Connected speech rather than isolated words or sentences
• Limited response choices.
• Accompanied auditory stimuli with appropriate visual stimuli.
• Visibility of the speaker's face.
• Alerting stimuli presented before the evoking stimulus is presented.
Sequence of Auditory Comprehension Treatment
Comprehension of single words
• Body parts
• Objects
• Pictures of objects
• Clothing items
• Food items
• Action pictures
Comprehension of spoken sentence
• Simple sentences to more complex sentences.
• More redundant to less redundant sentences.
• Sentences with familiar information to those with unfamiliar information
Comprehension of spoken questions
• Concrete yes/no questions (‘Are you sitting in wheel chair?’)
• Abstract yes/no questions (‘Is a plant bigger than a tree?’)
• Simpler open ended questions
• More complex open ended questions
Comprehension of spoken direction
• Point to single objects or pictures (single verb)
• Point to object in sequence (point to the pen and then to the paper)
• Manipulate stimuli in sequence (point to the pen and then lift the paper)
• Manipulate objects according to directions (put the ball in the box)
Comprehension of discourse
• Turn taking
• Topic maintenance
• Switching roles between listener and speaker
 VERBAL EXPRESSION

TREATMENT OF NAMING
General consideration….
• High frequency words
• Name of manipulated objects
• Objects rather than pictures
• Realistic drawings rather than line or abstract drawing
• Phonemic cues
• Client-regulation of stimulus presentation
• Extra time to spend
• Longer (30sec or more) stimulus exposure time
• Simultaneous visual and auditory stimulus presentation
Confrontation naming
Place a picture in front of the client
Ask ‘what is this?’
Prompt correct response
Reinforce correct response
Use of cues:
Find a stimulus that evoke the response
Use a stronger cue that evokes the response
Use a stronger cue only when weaker cues do not evoke the response
Start with few cues and add more only when necessary
Use with different types of cues
Fade the cues so that natural stimuli come to evoke the response
TYPES OF CUES
1. MODELLING
Ask a question (‘what is this?’)
Immediately model the response (‘say a book’)
Let the client imitate
Reinforce the client for correct imitation
2. SENTENCE COMPLETION
Clinician: You write with a ……..?
Client: PEN

Clinician: You write with a ball-point ……..?

Client: PEN
SENTENCE COMPLETION
• Phonetic cues
Clinician: You write with a (pause) the word start with a P ?
Client: PEN
• Syllabic cues
Clinician: This is a spoo.....
Client: SPOON
• Silent phonetic cues : give articulatory posture without vocalization
Clinician: This is a ….. (Silent articulatory posture for P)
Client: PEN
• Functional description as cues : give a description of an object in
terms of its use as cues.
Clinician: This is a round object that you roll or kick. What you call it?
Client: BALL
• Description and demonstration of action as cues : ask the client to
first say what an object is used for and then name it.
Clinician: Tell me what you use this for and then tell me its name
• Patient description of function as cues : ask the client to first
demonstrate the function of an object and then name it.
Clinician: show me how you use this and then tell me the name
Client: demonstrate the action of drinking and then says “cup”
• Objects or pictures with their printed name
Clinician: Present a book/picture, printed word ‘book’ and then ask
the client “what is this?”
Client: BOOK
• Patient’s oral spelling as cues : ask the client to spell a word orally
say the word (Name)
• Patient’s spelling and writing as cues : ask the client to spell a
word, write it and then say it.
• Presentation of sound as cue : present a sound associated with an
object and then ask the client to name it.
3. DEBLOCKING
• Direct deblocking : present unrelated words along with the target
word (eg., clinician says several words along with ‘cup’ , then asks
the client to name the picture of a ‘cup’)
• Indirect deblocking : present a word typically associated with a
target word and then asking the client to produce it
The clinician doesn’t present the target word (eg., the clinician says
“women” to evoke the word “wife”)
 FUNCTIONAL COMMUNICATION

SPECIFIC TECHNIQUES AND PROGRAMS

Select words, phrases, and sentences that are most useful
*For client and his or her caregivers
*In expressing client's personal experiences, bodily needs,
emotions and thoughts
*In simple everyday social situations and conversational contexts
Design client specific treatment program in which we can shape
longer utterances
*Start with what the client can say
*Add other syllables to create words or words to create sentences
*Add additional words to create sentences
*Evoke variety of sentence structures
*Use special stimuli that are necessary
*Fade special stimuli out and fade in the naturalistic stimuli
*Reinforce the client production
*Move to conversational speech
*Implement maintenance program
 THE TRADITIONAL LANGUAGE ORIENED SCHOOL OF
APHASIA THERAPY
• In aphasia rehabilitation, impairment-disability-handicap, any one of
these three levels may be targeted for assessment, treatment, and
outcome evaluation.
• The assessment serves as a guide to treatment, which might target
several impairments concurrently or bypass the impairment level
altogether in favour of direct retraining or stimulation of the
compromised language.
• Both the target of treatment and the treatment techniques are tailored to
needs of the individual patient.
• The clinician may choose from several approaches.
For example:
*The ‘stimulation approach’ advocated by Schuell and colleagues uses
intensive auditory or multimodality input to elicit language production
through a variety of means (eg., repetition, phonemic cueing, reading) and in
a variety of contexts(linguistic and situational)
*Helm’s Elicited Language Program for Syntax Stimulation (HELPSS) uses
a combined delayed repetition/story elicitation procedure to stimulate
production of specific syntactic structures (e.g., yes-no questions: passive
voice constructions) in aphasics with grammatical disturbances.
• The common thread among these different approaches is the focus on
restoration of language skills as the route to improved functional
communication.

ASSESSMENT TREATMENT OUTCOME EVALUTION

HANDICAP

DISABILITY
TRADITIONAL LANGUAGE ORIENTED
IMPAIRMENT SCHOOL

The traditional language –oriented school of aphasia rehabilitation focuses

primarily on the impairments and disability levels.
• There are less evidence that these gains translate into reduced
handicap and enhanced quality of life. Indeed, the general view is that
language gains evident in the clinic do not generalize well to less
constrained task or setting.
• This is one problem with the traditional language oriented school of
aphasia therapy.
• A second is its weak theoretical base.
 THE FUNCTIONAL/PRAGMATIC SCHOOL OF APHASIA
THERAPY
• Functional approaches typically capitalize on the patient's strengths
and seek to train patient’s to use compensatory strategies when
communicating.
• Functional approaches may also use behavioural methodology to
achieve changes in pragmatic skills, as Doyle and co-workers
demonstrated in a study aimed at teaching Broca’s aphasics how to
make requests.
• The point of pragmatic treatment s to focus on communication skills
that can be used in everyday life.
• The most widely known pragmatic approach is Promoting Aphasics
Communicative Effectiveness(PACE) which fosters the
communication of new information
• Another pragmatic approach ‘Conversational Coaching’ develops
compensatory strategies in treatment sessions simulating
conversations that might take place outside the clinic and that include
conversation with unfamiliar listener to further extend generalization.
• Ultimately, the patient and his/her relatives are trained to use these
strategies to communicate with maximum effectiveness.
• In its pure form it emphasis on minimising handicap through
enhanced communication.
 ASSESSMENT TREATMENT OUTCOME EVALUTION
HANDICAP FUNCTIONAL/PRAGMATIC SCHOOL
DISABILITY

IMPAIRMENT

The functional/pragmatic school of aphasia rehabilitation focuses

primarily on the level of handicap.
 THE COGNITIVE NEUROPSYCHIOLOGY SCHOOL
• Practitioners of cognitive neuropsychology apply information-
processing models of normal cognition the analysis of disorders of
higher cortical function, including language.
• Cognitive neuropsychological assessments identify and measure
impairments.
• The basic idea is to pursue a more “rational” approach to treatment,
in which the goals of the treatment program are informed by theory
based assessment of the patient’s language capabilities.
 THE MODULAR TREATMENT APPROACH
• Most aphasic patients display multiple impairments in more than one
domain. The articular combination of impairment symptoms determines
the patient's clinical classification. But most impairment symptoms are not
restricted to a single clinical classification.
• For e.g., the lexical-semantic impairment that compromises word retrieval
is fund in patients with Broca’s, Wenicke’s and anomic aphasia.
• The basic idea behind the modular approach is that model-driven treatment
that target specific impairment may produce narrow gains, but when they
are cumulated over several treatment programs, the effect can be
substantial.
 MEDICAL INTERVENTION
The treatment of a patient with aphasia depends on he cause of the
aphasia syndrome.
Acute stroke treatment such as intravenous tPA, intra-arterial
interventional treatments now called mechanical thrombectomy, carotid
endartectomy and stenting, or even blood pressure manipulation may
help to alleviate deficit.
Surgery for subdural hematoma or brain tumour may be beneficial.
In infections such as herpes simplex, encephalitis antiviral therapy may
help the patient recover.
 LINGUISIC INTERVENTION

• Rehabilitation programs should be tailored to the specific linguistic needs of

each patient.
• Language includes two major dimensions: lexical and grammatical (Ardila,
2011, 2012).
• The first one is mostly impaired in the sensory aphasias, whereas a
disturbance of the second one is characteristic of Broca’s aphasia. Basso
(2003) specifically analyzes the rehabilitation of each one of these two
language levels. Her rehabilitation strategies for each one of these
components are presented below.
 REHABILITATION OF LEXICAL AND
SENTENCE DISORDERS
AUDITORY ANALYSIS SYSTEM
If the patient has difficulties in phoneme discrimination, pairs of
phonemes can be presented in order to say whether they are the same
or different. Initially both phonemes can be different in several
features, such as,
/p/ - /r/
And progressively the task moves to phonemes that are different in
only one feature, such as,
/b/ -/p/
ABSTRACT LETTER IDENTIFICATION
The patient is shown pairs of letters in different fonts and has to say
whether they represent the same letter or not. Initially, differences can
be obvious (e.g., R and r) and progressively they become more and
more similar (e.g., K and k). The task can become progressively more
complex, as pairs of letters and words are introduced.
INPUT LEXICON (COMPREHENSION)
 Comprehension disorders are mostly associated with Wernicke’s-
type fluent aphasias.
 A classical approach for the treatment of comprehension disorders
has been word-picture matching; this is when a word is orally
presented (e.g., pencil) and the patient is required to point to the
picture representing a pencil. However, this strategy does not
distinguish between input lexicon (decoding and integrating the
sequence of phonemes included in the word pencil); and semantic
system disorders (associating the word “pencil” with the
representation –meaning– of the word).
The task of choice for the evaluation of the input lexicons is the so-
called “lexical decision task”; that is, determining whether or not a
string of letters (or phonemes) corresponds to a real word or not.
Written stimuli can be used for the orthographic system and spoken
for the phonological system.
For example:
• CAR: Is it a real word or not? PAR: Is it a real word or not?
 Basso (2003) suggests that an exercise that the patient can do alone
is to look up in a small dictionary containing only frequently used
words, and focus on those that s/he is unsure about. The patient is
encouraged to look the orthographic form and to read the definition.
THE SEMANTIC SYSTEM
Damage to the semantic system will prevent the correct performance of
any task requiring the comprehension or production of words. The
semantic system is mostly impaired in Wernicke’s aphasia and
transcortical (extrasylvian) sensory aphasia.
Classification tasks are frequently used to treat the semantic deficits in
aphasia and restore the semantic representations of the words. Initially,
the patient can be requested to make classification of objects
represented in cards (for instance, animals, furniture, and fruits) without
using language.
 A name is then given to each category; and emphasis is made on the
features distinguishing each category. Further categories are
introduced, for instance, pets and wild animals; later, different
representations of the same animal (e.g., a cat) can be used to
emphasize the common features. This type of classification task can
also be developed using written words, instead of the direct visual
representation. The purpose is to restore the semantic field of the
words.
OUTPUT LEXICON

Difficulties in using vocabulary words can be due to defects in

storage (i.e., knowledge) or access (i.e., retrieval of the word).
According to Basso (2003), several criteria can be used to distinguish
storage and access disorders.
In most cases patients rehabilitated for anomia are required to
produce the target words, but the strategies used are different. Most
frequently cuing, both phonemic (the initial sounds) and semantic
(describing the meaning) has been used.
However, orthographic cuing (the initial letters included in the target
word) has also proven to be effective in facilitating naming. Other
strategies can also be useful; for instance, including the target word in a
“high probability sentence” (e.g., “I write with a…”).
CONVERSION RULES
Some so-called conversion rules have been analyzed in aphasia. These
conversion rules can be impaired in aphasia, and it is required to re-learn
these rules.
For instance:
• Input to output phoneme conversion impairment (prevents repeating
nonwords)
• Grapheme to phoneme conversions impairment (prevents reading
nonwords)
• Phoneme to grapheme conversions impairment (prevents writing nonwords
from dictation)
SENTENCE LEVEL
Difficulties in producing sentences represent the most salient diagnostic
sign of agrammatism associated with Broca’s aphasia. Indeed,
agrammatism is difficult to treat and represents a frequently long-term
sequel of motor and global aphasia. When treating agrammatic patients, it
is advisable to use words in grammatical contexts, not isolated (e.g., instead
of referring to “pencil” to refer to “the pencil”, “there is a pencil”, “the
pencil writes”, etc.).
• Thompson and Shapiro (2005) reported that the so-called Treatment of
Underlying Forms (TUF)
• Wisenburn et al. (2010): meta-analysis
TREATMENT OF APHASIA SPECIFIC
TYPES
BROCA’S APHASIA
• Increase length of utterance
• Increase complexity of responses
• Decrease grammatical errors
• Use modelling
• Model progressively longer utterance and ask the client to imitate
• Teach nouns and verbs on successive trials
• Provide immediate positive feedback
• Ask questions to evoke response
• Encourage pointing, gestures, drawing, writing and reading to improve verbal
expression
• Teach sign language system(if necessary)
GLOBAL APHASIA
• Eliminate distraction
• Face the client
• Reduce rate of speech of speaker
• Pause at syntactic junctures and between stimulus presentation
• Use appropriate stress and intonation
• Use short sentences
• Pause between sentences
• Use non-verbal cues to improve communication
• Select basic, simple, functional words and phrases for initial treatment
• Select words and phrases that express basic needs
• Accept any mode of response; verbal, gestural, visual
• Provide both auditory and visual stimulation
• Begin treatment with modelling and require immediate imitation
• Give the client time to respond
• Fade modelling and other additional stimuli
• Shape the response
• Provide manual guidance
• Give prompt, natural and social reinforcement
• Teach responses to simple questions
• Teach simple commands
• Teach simple description
• Move to basic conversation skills training
• Improve writing skills, teach gestures
TRANSCORTICAL MOTOR APHASIA
• Use imitation and naming to improve speaking
• Select pictures as stimuli
• Ask the client to form sentences with one of the words produced or
supplied
• Ask the client to expand the sentence with other words
• Reinforce all attempts in the right direction
WERNICKE’S APHASIA
Reduce impulsive and incessant talking
 Reduce distraction stimuli
 Ask the client to listen
 Use gestures or manual guidance to stop the client from talking
 Ask yes/no questions
 Accept only answers: not elaborated utterances
Expand utterance in a controlled manner
Treat auditory comprehension deficits