# Psycholinguistics/Aphasia Rehabilitation
## Introduction

According to the National Aphasia Association, aphasia affects about one in 250 people in the USA and is more common than Parkinson’s disease, muscular dystrophy or cerebral palsy. Considering the importance of communication in all aspects of life, getting help for a communication disorder is critical. Aphasia is an acquired disorder that usually occurs as a result of a stroke or other form of brain injury. In general terms it manifests itself in either an inability to produce or comprehend speech. The following article will outline the forms of therapy currently used today as well as discussing their efficacy for different types of aphasia.

## Historical Glimpses

Aphasia rehabilitation therapy really became popular after World War II as a result of the large number of veterans returning home with brain injuries. Initially the strategy was impairment-based treatment. This involved treating the actual physical symptoms, meaning that they focused on trying to get the patient to speak again as much a possible. This type of therapy is most effective if done in intensive one on one sessions. Later, as the number of patients increased and the number of therapists decreased the focus switched to providing consequences based treatment. This method of treatment recognizes the significant affects of aphasia on a person’s life and teaches patients coping mechanisms to deal with these issues. This could be done in groups and required fewer therapists. Today speech language therapists have recognized the need for both the impairment-based and the consequences-based treatments.

## The Focus Today

Today the approach towards aphasia rehabilitation is strongly influenced by the World Health Organization’s International Classification of Functioning, Disabilities and Health.
Figure 1 is a simplified version of the ICF similar to that seen in the book Aphasia Rehabilitation the Impairment and its Consequences by Martin, Thompson and Worrall. In general terms, this figure shows us how the affects of a given disability such as aphasia can be broken down into affects on the body, affects on participation in day to day activities and affects on the internal moral of the patient. Another external influence on aphasia rehabilitation today is the disability movement, which works towards promoting the acceptance of disabilities in society. The LPPA Project Group’s Life Participation Approach to Aphasia that was released in 2001 says that the primary focus of aphasia management should be life enhancement. Since those people with aphasia need to interact with their environment, it is important to not only work with the patient but also with those close to them in order to achieve the best quality of life. Aphasia rehabilitation today focuses on addressing these different areas and creating individual approaches based on personal goals.
Before beginning their treatment, patients are assessed using standardized tests such as the Western Aphasia Battery in order to determine the physical extent of their aphasia. The Western Aphasia Battery is a series of tests used to gauge the severity and extent of aphasia in adults. Speech language pathologists then communicate with the patient to determine what their personal goals are in the rehabilitation process. This is important because if for example the patient was never a great reader before acquiring aphasia, relearning that skill would not be as important him or her compared to someone who previously loved to read.

## Prognosis and Time Course for Recovery

The prognosis for aphasia recovery depends on the individual case and as with many neurological injuries, early intervention is very important. There are two general phases for the recovery of language. The early phase lines up with the period known as the spontaneous recovery period which peaks at about one month after the onset of aphasia and then flattens out to a plateau six to twelve months post onset. This is the period where maximum language recovery occurs and is why early intervention is so crucial. The long-term recovery phase continues for the rest of the patient’s life, although the degree of recovery varies greatly between patients with some getting better and others worse. Pederson et al. found that the degree of severity of the initial aphasia was directly related to the time course of recovery. Specifically they found that 95% of patients with severe aphasia had recovered maximum function in ten weeks while those with mild aphasia reached that point in only two weeks.

## Different Approaches
### Social Approaches:
#### Conversation Therapy

The goal of this therapy is to enhance conversational abilities. This means that it focuses on the ability to convey a message as well as the abilities of arguing, joke telling, gossiping and story telling. The sessions are usually one on one and really strive to boost the patient’s confidence.

#### Group Therapy

Group therapy has become an increasingly popular method of treatment. The focus of these sessions is to promote interactions between participants rather that working on discrete skills. Not only do patients get to practice their interactions but they get to meet other people in their situation. The sessions are monitored by a clinician who directs and promotes conversation.

#### Compensatory Strategies Training

The goal of this approach to aphasia intervention is to teach patients alternate methods of expressing themselves in real world settings. These include gestures, writing and the use of augmentative aids. It is again important with this approach that the family and friends are involved in the sessions so that everyone learns to be familiar with the strategies.

### Schuell’s Stimulation Approach:

This approach falls under the category of a traditional approach because it focuses on the impairment. According to Hildred Schuell, aphasia is a deficit that spans all language modalities. If a patient shows a deficit in one of these modalities it is a result of an underlying language problem. In this approach it is believed that the auditory system is of crucial importance because of its key role in both the acquisition and ongoing processing of language. Treatment is therefore focused on only the auditory system rather than on each system separately because it is believed that improvements there will spread to the other channels since they are all connected. The approach uses a very controlled repetition of auditory stimuli. Although the emphasis of the method is on the input, it is very important that responses are given. Here are a few examples of the tasks that might appear:
* Point-to Task: which is simply asking the patient to point to a specific object
* Yes-No Questions: asking questions like, “is Stephen Harper Prime Minister of Canada?”
* Reading Tasks: matching a word or sentence to a picture
With this method it is important not to start with tasks that are too difficult. The starting point should be where the deficits begin to appear.

### Context Based Treatment:

This approach to rehabilitation also falls under the impairment-based category and can be very effective for patients with Wernicke’s aphasia. This method requires a great deal of flexibility on the part of the clinician because it is all about creating contexts that are applicable to the patient. Because patients with fluent aphasia are often unaware that their speech is being misunderstood or that they misunderstand speech, early intervention is very critical. For this treatment creating an appropriate context is very important; it is best to choose a context that the patient is familiar with so they will be able to anticipate what might be coming next. In a session, context can be established with the clinician’s opening question such as: “I would like to talk to you about your children” or it can be established with the use of a prop such as a magazine. Once a context is established the clinician begins to ask the patient questions, if the patient needs help they will manipulate the timing and linguistic stress on certain words. If the patient has difficulty inhibiting their word flow, they are instructed to try and listen to themselves and to stop whenever there is an error in order to promote an awareness of their own mistakes.
Because this is a very time consuming and intensive method of treatment, it is imperative to get the support of the patient’s caregivers because these exercises can easily be done at home.

### Cognitive Neuropsychological Approach

This approach draws heavily on the use of models to understand how language processing works and where a particular aphasic patient has deficits.
Figure 2 is a schematic representation of the different stages of lexical processing. By looking at this diagram we can see that there are for example multiple routes to get to the “phonological output lexicon”, knowing this makes it more clear how a patient can be unable to understand the word apple from written cues and yet be able to read it aloud by sounding it out through the “letter-to-sound conversion pathway”. There are two basic principles behind cognitive neuropsychology. One is that everyone has the same cognitive processes and that brain damage does not result in new processes but merely alters which ones are used for certain tasks at certain levels. Speech language pathologists using this approach to aphasia rehabilitation must first determine which level of processing shows a deficit and then direct treatment towards improving that area or compensating for it.
The following is an example of a cognitive neuropsychological approach to treating a patient with impairments in lexical comprehension. The treatment was performed by Grayson and colleagues in 1997 and published in the “European Journal of Disorders of Communication”. The level of dysfunction was at the phonological and semantic stages of processing. The first part of the treatment addressed the semantic impairment and involved having the patient perform lexical tasks such as spoken or written word to picture matching. Example:
* Patient Hears: “a fruit”
* Correct Response: Patient points to a picture of an apple
Over the next few weeks of treatment they systematically increased the difficulty of the tasks. After four weeks the patient showed improvement in word to picture matching tasks but not in a phoneme discrimination task. However, when an extra four weeks of treatment were done with the addition of a phonological component to the semantic tasks the patient showed improvements in auditory word to picture tasks as well as a non-word phoneme discernment task.

### Computer Based Methods:

With all the advancements in computer technology today it is natural to see them implemented in a variety of clinical settings. With respect to aphasia rehabilitation, they can be implemented in a one of three manners. Either as the sole method of treatment, where the patient does the exercises alone and then has his or her performance reviewed later by a clinician. They can also be used to assist the clinician to present stimuli. There are also Augmentative Communication Devices, which are small portable computers that function as very advanced “pointing boards”. These ACDs use pictures, text, animation and digitized speech to help the aphasic patient communicate. One such program is the picture based “C-Speak Aphasia” which was developed by Nicholas and Elliot in 1998. In an experimental examination of the program’s efficacy, Nicolas et al. found that the majority of the patients studied were able to communicate better with the program. However, they highlighted the point that the degree to which the executive functioning skills were intact was a better determinate of the treatment’s success then the severity of the aphasia.
Although there is significant peer reviewed evidence supporting the use of computers in aphasia rehabilitation it is important to remember its limitations. These limitations include the fact that computers rely on pre-applied unchanging rules and that they cannot anticipate every possibility.

### Pharmacotherapy:

In the early days, the studies looking as the use of drugs in aphasia treatment centered on barbiturates because it was thought that people with aphasia would speak better if they were relaxed. More recent studies with animals have shown that a pharmacologically induced increase in brain catecholamine levels increases the effects of practice. Specifically d-Amphetaime was found to be an effective agent in these studies. Although there have been human studies on the effects of d-Amphetamine they are very hard to interpret because the anatomical and functional definitions of aphasia differ between studies and even between patients within a study. Another issue is that since aphasia in many cases appears alongside other disorders requiring pharmacological treatment, it is difficult to select patients for studies. To generalize, pharmacotherapy does not have the potential to replace behavioural or cognitive therapies for aphasia rehabilitation although it does have the potential to be used alongside these treatments in some capacity.

## Newest Trends
### Constraint Induced Language Therapy:

This method of treatment is very rigorous because it involves removing any coping mechanisms that the patient has developed such as gestures and pictures and only allows spoken communication. It essentially operates under the principle of “use it or lose it”. Sessions are usually intensive, three hours a day for ten days and implement the use of visual barriers between communication partners to prevent anything but verbal communication. Although this method of treatment has been proven effective, it is not recommended to be done at home because of the frustration it would cause for all parties involved.

### Book Clubs:

In 1999 the California Aphasia Clinic started its trademark Book Connection program. The program was started as a result of feedback from aphasic patients who expressed that the loss of the ability to read for pleasure had decreased their quality of life. Because there are so many different degrees to which aphasia can affect a person’s ability to read, the Book Connection program uses a series of adaptations to break down a book to help people be able to read. Their packages, which are sold to groups across North America include a facilitators guide, chapter outlines, chapter highlights, chapter key points, character sketches, and audio files. The book club then meets once a week to discuss what they have read. Participants gain both the benefits of group therapy sessions and have the opportunity to read and enjoy popular fiction. In a seminar given at the annual convention of the American Speech-Language-Hearing Association in 2005, it was presented by Elman et al. that book club members need not be at the same level and that there is a benefit to having a variety of abilities so long as all are motivated. A clinician whose role can vary between groups monitors the sessions.

### Intensive Therapy Program:

In 2002, the school of Human Communication Disorders at Dalhousie University in Halifax Nova Scotia developed their intensive InteRACT program for patients with aphasia. The program lasts for four and half weeks and requires that all participants have a communication partner and that they all live in the same residence building for the duration of the program. Having the participants live in the same residence building is very important to the success of the program because it allows the participants to learn from each other and to bond with people in similar situations. Participants receive four hours of individual therapy and one hour of group therapy per day for five days a week. In addition to this they all participate in a number of supplementary activities to enhance their treatment. Intensity has been proven very effective for aphasia treatment and the general message is go big or go home. For more information about this program see the InteRACT website.

## Conclusion

What the above article has attempted to do is to give an overview of the history and current treatments of aphasia. It is clear that there is not one great treatment of aphasia that everyone can agree on. This is because every case is different and requires individual attention. However the consensus is that one should not stick to one method of treatment and that both individual and group therapies are important in achieving the goal of a better quality of life.

## Learning Exercise
### Questions for Consideration:

* From reading the above chapter on aphasia rehabilitation, does it make sense why there are so many different approaches towards aphasia rehabilitation? Explain your reasoning.
* Treatment programs like the InteRACT program mentioned in the chapter are great but they currently are not receiving enough government funding. Do you think that aphasia programs should get more recognition and support from the government? Keep in mind how much aphasia can affect daily functioning and how many people are affected by it.
* Given what you have read in the chapter, why do you think it is important to provide a patient with both impairment based and consequence based treatment?

### Book Club Exercise

Create a chapter summary for a book of your choice, such as one might create for an aphasia book club. Take the first chapter of a book of your choice and:
* Create a point form chapter summary
* Make a list of the chapter highlights
* List all the characters who appear in that chapter
* Create two questions that will help direct the discussion on the chapter. Try and create ones that ask how the reader reacted personally to the chapter.

### Sample Book Club Exercise:

Exercise

## Aphasia Sites of Interest

* York-Durham Aphasia Centre
* California Aphasia Centre
* National Aphasia Association
* Toronto Aphasia Centre
* Canadian Association of Speech Language Pathologists and Audiologists
* Academy of Aphasia
* American Speech-Language-Hearing Association