Aphasia rehabilitation

5.9 Aphasia rehabilitation:
     ● should target spoken production at the word level 
     ● can target spoken production at the sentence level (e.g., syntactic, thematic roles).

References: Brady et al., 2016: Cochrane review; Breitenstein et al., 2017: RCT; De Aguiar et al., 2016: Meta-analysis of 30 studies; Hickin et al., 2020: Scoping review of 37 studies (22 case studies, 7 case series that also reported group results, 6 single-case studies, 1 group study, and 1 pilot RCT).; Hickin et al., 2022: Systematic review of 33 studies (14 case series, 12 single-case studies, 5 case series with group results reported, 2 group studies); Nickels & Best, 1996: Narrative review; Poirier et al., 2023: Systematic review of 25 studies (all single- or multiple-case studies using SCED); Rose et al., 2013: Systematic review of 23 studies (4 group design, 19 SCED); Rose et al., 2022: RCT; Sze et al., 2021: Meta-analysis of 32 studies; Webster & Whitworth, 2012: Review of 26 studies; Wisenburn & Mahoney, 2009: Metaanalysis of 44 studies.

NHMRC Levels of Evidence: Word level: I; Sentence level: IV

Rationale: Word finding therapies have been found to be effective for people with aphasia in the short and longer term (De Aguiar et al., 2016; Hickin et al., 2020; Sze et al., 2021; Wisenburn & Mahoney, 2009; and in two high quality RCTs by Breitenstein et al., 2017 and Rose at al., 2022), although this is not always the case (Brady et al., 2016). Semantic, phonological, and mixed approaches have all shown benefits (Wisenburn & Mahoney, 2009), with research suggesting that word-form focused treatments (e.g., orthography or phonology) result in more treatment-specific effects, whereas semantic approaches result in higher degrees of generalisation to untreated items (Nickels & Best, 1996; Sze et al., 2021). Provision of the written word form facilitates rehabilitation of treated and untreated items (Sze et al., 2021). Combined gesture and verbal treatment and multimodality aphasia treatment for noun and verb production is beneficial for some people with aphasia (Rose et al., 2013; Rose et al., 2022).

Different components (including demographic, clinical, and treatment-related factors; De Aguiar et al., 2016) of word retrieval therapy may affect the outcome of this type of therapy, which may explain individually varying treatment outcomes reported across the literature. Participant baseline naming performance has not been found to be a strong predictor of treatment success for treated and untreated items, indicating that word retrieval therapy can benefit many people with aphasia with varying naming abilities (Sze et al., 2021). As generalisation to untreated items is generally limited (particularly for verbs; De Aguiar et al., 2016; Hickin et al., 2020; Webster & Whitworth, 2012), it is important to focus on personally relevant words when providing word finding therapy (Hickin et al., 2020; Webster & Whitworth, 2012). 

There is evidence in favour of the efficacy of therapy focusing on spoken production of sentences, with frequent reporting of treatment gains generalising to untrained items (Hickin et al., 2022; Poirier et al., 2023) and to sentence comprehension (Poirier et al., 2023). A systematic review (Poirier et al., 2023) that included single- and multiple-case studies found the evidence for a range of treatments, including Verb Network Strengthening Treatment (VNeST - Edmonds et al., 2009), Treatment of Underlying Forms (TUF – Thomson, 2001), and mapping therapies. The exact content of therapy will depend on the underlying cause of the sentence production impairment, which therefore needs to be assessed (Hickin et al., 2022; Poirier et al., 2023).

References: 

1. Brady, M.C., Kelly, H., Godwin, J., Enderby, P., & Campbell, P. (2016). Speech and language therapy for aphasia following stroke. The Cochrane Database of Systematic Reviews, 6(6). DOI: 10.1002/14651858.cd000425.pub4
2. Breitenstein, C., Grewe, T., Flöel, A., Ziegler, W., Springer, L., Martus, P., Huger, W., Willmes, K., Ringelstein, E.G., Haeusler, K.G., Abel, S., Glindemann, R., Domahs, F., Regenbrecht, F., Schlenck, K., Thomas, M., Obrig, H., De Langen, E., Rocker, R., Wigbers, F., Rühmkorf, C., Hempen, I., List, J. & Baumgaertner, A. (2017). Intensive speech and language therapy in patients with chronic aphasia after stroke: A randomised, open-label, blinded-endpoint, controlled trial in a healthcare setting. Lancet, 389 (10078), 1528-1538. DOI: 10.1016/S0140-6736
3. De Aguiar, V., Bastiaanse, R., & Miceli, G. (2016). Improving production of treated and untreated verbs in aphasia: A meta-analysis. Frontiers in Human Neuroscience, 10 (468). DOI: 10.3389/fnhum.2016.00468
4. Hickin, J., Cruise, M., & Dipper, L. (2020). A systematically conducted scoping review of the evidence and fidelity of treatments for verb deficits in aphasia: Verb-in-isolation treatments. American Journal of Speech-Language Pathology, 29(1S), 530-559. DOI: 10.1044/2019_AJSLP-CAC48-18-0234
5. Hickin, J., Cruise, M., & Dipper, L. (2022). A systematically conducted scoping review of the evidence and fidelity of treatments for verb and sentence deficits in aphasia: Sentence treatments. American Journal of Speech-Language Pathology, 31(1), 431-462. DOI: 10.1044/2021_AJSLP-21-00120
6. Nickels, L. & Best, W. (1996). Therapy for naming disorders (Part I): Principles, puzzles and progress. Aphasiology, 10(2). DOI: 10.1080/02687039608248397
7. Poirier, S., Fossard, M., & Monetta, L. (2023). The efficacy of treatments for sentence production deficits in aphasia: A systematic review. Aphasiology, 37(1). 122-142. DOI: 10.1080/02687038.2021.1983152
8. Rose, M.L., Raymer, A.M., Lanyon, L.E., & Attard, M.C. (2013). A systematic review of gesture treatments for post-stroke aphasia. Aphasiology, 27(9). 1090-1127. DOI: 10.1080/02687038.2013.805726
9. Rose, M. L., Nickels, L., Copland, D., Togher, L., Godecke, E., Meinzer, M., Rai, T., Cadilhac, D. A., Kim, J., & Hurley, M. (2022). Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia. Journal of Neurology, Neurosurgery & Psychiatry, 93, 573-581. DOI: 10.1136/jnnp-2021-328422
10. Sze, W.P., Hameau, S., Warren, J., & Best, W. (2021). Identifying the components of a successful spoken naming therapy: A meta-analysis of word-finding interventions for adults with aphasia. Aphasiology, 35(1), 33-72. DOI: 10.1080/02687038.2020.1781419.
11. Webster, J., & Whitworth, A. (2012). Treating verbs in aphasia: Exploring the impact of therapy at the single word and sentence levels. International Journal of Language & Communication Disorders, 47(6), 619-636. DOI: 10.1111/j.1460-6984.2012.00174.x
12. Wisenburn, B., & Mahoney, K. (2009). A meta‐analysis of word‐finding treatments for aphasia. Aphasiology, 23(11), 1338‐1352