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Curr Phys Med Rehabil Rep. 2014 June 1; 2(2): 114–120. doi:10.1007/s40141-014-0050-5.

Impairment and Functional Interventions for Aphasia: Having it

All
Elizabeth E. Galletta and
Department of Speech-Language Pathology and Audiology, Hunter College, The City University
of New York, 425 East 25th Street, P.O. Box 625, New York, NY 10010, USA

Kessler Foundation Research Center, West Orange, NJ, USA

Department of Physical Medicine and Rehabilitation, NJ Medical School, Rutgers-the State

University of New Jersey, Newark, NJ, USA

A. M. Barrett
Kessler Foundation Research Center, West Orange, NJ, USA
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Department of Physical Medicine and Rehabilitation, NJ Medical School, Rutgers-the State

University of New Jersey, Newark, NJ, USA

Kessler Institute of Rehabilitation, West Orange, NJ, USA

Elizabeth E. Galletta: elizabeth.galletta@gmail.com

Abstract
Aphasia, a cognitive-linguistic disorder secondary to stroke, is a frequent and often chronic
consequence of stroke with detrimental effects on autonomy and health-related quality of life.
Treatment of aphasia can be approached in a number of ways. Impairment-based approaches that
focus on training a specific linguistic form can be implemented. Additionally, functionally
oriented intervention such as supported conversation and aphasia groups are also frequently
utilized when providing a treatment program for an individual with aphasia. Creating a treatment
approach that includes both impairment and functional methodologies and considers how these
relate to the three domains proposed by the International Classification of Functioning Disability
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and Health (ICF)—body functions and structure, activity, and participation—can provide an
individual with aphasia an optimal treatment program that is person-centered and multi-faceted.

Keywords
Aphasia; Treatment; Intervention; International Classification of Functioning Disability and
Health (ICF); Impairment; Functional; Group therapy

© Springer Science + Business Media New York 2014

Correspondence to: Elizabeth E. Galletta, elizabeth.galletta@gmail.com.
Compliance with Ethics Guidelines
Conflict of Interest EE Galletta declares no conflicts of interest.
Human and Animal Rights and Informed Consent All studies by AM Barrett involving animal and/or human subjects were
performed after approval by the appropriate institutional review boards. When required, written informed consent was obtained from
all participants.
 Galletta and Barrett Page 2

Introduction
Aphasia, a cognitive-linguistic disorder that is a frequent and often chronic cognitive
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consequence of stroke, results in detrimental effects on autonomy and health-related quality

of life. It affects approximately 1 million people in the USA today. Commonly defined as
language impairment or loss, aphasia causes impairment of oral language production,
language comprehension, and other associated linguistic communication skills potentially by
modality (auditory, oral, visual, gestural), level of processing (phonology, morphology,
syntax, semantics), or impairment in other cognitive domains relevant to functional
communication (emotional communication, pragmatics, self-monitoring, theory of mind or
perspective-taking, aesthetics, and humor). Regardless of the classification used, for
individuals with aphasia, some or all aspects of linguistic competence are impaired.

With age as a major risk factor for ischemic stroke, and aging of the US population, aphasia
will become more common in the coming decades. Current behavioral treatment strategies
for aphasia, although beneficial in some cases, leave many stroke survivors with life-long
disability [1••]. We will discuss current approaches to aphasia therapy in the context of the
International Classification of Functioning Disability and Health (ICF) [2], a
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biopsychosocial model of health and disease that promotes the consideration of health
conditions among three domains of functioning: body functions and structure, activity, and
participation. See Fig. 1, below.

In the ICF model, the “body functions and structure” domain classifies the health condition
as impairment based, thus approaches to treatment that focus on the aphasia impairment
reflect this domain. With regard to aphasia, there are several impairment-based approaches
to behavioral intervention that focus on areas such as word finding [3] and grammar [4].
Moreover, neurophysiological clinical interventions for aphasia such as the use of
noninvasive brain stimulation as an adjuvant to behavioral treatment for aphasia [5–13•] fall
under the body functions and structure or the impairment-focused domain of the ICF.

The ICF domain labeled “activity” considers the life activities in which an individual
engages and how the health condition affects an individual’s activities. Examples of
activities that may be affected secondary to aphasia are talking on the telephone, asking for
directions to a location, or sharing a story. Aphasia treatment approaches that reflect this
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domain take into account the context and environment where communication occurs [14].
Lastly, the “participation” domain of the ICF classifies an individual’s participation in
society and the effects of aphasia on social roles and life situations such as attending a book
club or going to a community luncheon, for example. Reflecting this domain, the life
participation approach to aphasia therapy considers the conversational partner as a key part
of the treatment of aphasia [15, 16].

There are a variety of aphasia classification systems that range from considering aphasia as a
unitary disorder [17] to classifying aphasia as discretely distinct syndromes [18]. Treatment
approaches for aphasia may reflect the particular classification system the clinician prefers
and include, but are not limited to, “traditional” approaches, “cognitive neurolinguistic”
approaches, and/or “functional” approaches to aphasia intervention. For the purposes of this

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article, we will discuss current trends in aphasia treatment in the context of the ICF,
specifically describing approaches to aphasia intervention that are impairment-based,
reflecting the body functions and structure domain, and functionally oriented, reflecting the
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activity and participation domains of the ICF. Research-based treatments that address the
brain mechanism and neuroplasticity as well as functional reorganization of language in the
brain will be discussed under the section focused on impairment-based approaches to
aphasia treatment.

Impairment Based Aphasia Treatment

Word Retrieval
Word retrieval difficulty is a characteristic present in all people with aphasia regardless of
the applicable aphasia classification system. Therefore, treatment of word retrieval is a
common focus of intervention by nearly all clinicians implementing an impairment-based
treatment approach. Before focusing on word retrieval, determining whether word retrieval
difficulty reflects a semantic (meaning-based) or a phonological impairment (based on
auditory or articulatory word forms) will help guide the treatment session. Treatment
activities focused on training synonyms or antonyms, completion of fill-in the blank tasks,
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or tackling word description tasks are examples of activities included in a semantic approach
to treatment. A specific semantic approach, referred to as semantic feature analysis (SFA)
[3, 19, 20], focuses on training words with similar semantic features with the idea that
overlap among features may prime or reduce random activation in the semantic system, and
this might positively affect generalization. The SFA approach, in which features are
generated when presented with a picture surrounded by categories of semantic features, is
promoted as “semantic,” yet if the clinician offers phonemic cues or rhyming cues, for
example, this approach would then include both semantic and phonological training. Often,
clinicians implementing a semantic approach also provide phonemic cues at some point in
the session. This means that they are taking a semantic-phonological approach to treatment
of word retrieval.

As noted above, treatment approaches emphasizing word sounds (for example, rhyming
cues) and articulatory patterns and buccolingual movements would be considered
phonological. A phonomotor approach to word-finding treatment was reported by Kendall et
al. [21]. They hypothesized that training heard and produced speech sounds using various
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phonomotor tasks would enhance the neural connectivity supporting individual phonemes
and phoneme sequences, and result in fewer phonological naming errors in individuals with
aphasia. Ten people with chronic aphasia secondary to left hemisphere stroke were studied.
The phonomotor treatment stimuli consisted of phonemes in both real words and non-words
that were phonotactically legal in English, meaning the sound combinations were present
and acceptable in English (for example in English, the sound combination /caz/ is
phonotactically legal, whereas the sound combination /cza/ is not phonotactically legal). The
phonomotor treatment included a total of 60 h of intervention (1-h sessions, two sessions per
day, for 5 days a week over a treatment period of 6 weeks). The first stage of the treatment
focused on sounds in isolation and the next stage included treatment of sounds in various
combinations. There were two stages of treatment. Stage 1 included five tasks: exploration

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of sounds, motor description, perception tasks, production tasks, and graphemic tasks. Stage
2 included two additional tasks: a production and graphemic task and a perception and
graphemic task. The results revealed that participants showed statistically significant
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improvements in accuracy on trained items on post-treatment tests, but no improvement

occurred on untrained items. While this treatment description is research based, elements of
this approach may be present clinically when a therapist takes an impairment-based
phonemic approach to treatment of word retrieval deficits in aphasia by training certain
words of high importance to the patient (for example, the name of his street) using a sound-
based approach.

Brain Mechanism Influence

Although impairment-based behavioral treatments have promoted improved word
production in some people with aphasia, many continue to have speech and language
problems post-stroke even after they have received a course of behavioral treatment. The
majority of treatments reported in the literature result in improvement on trained stimuli, but
generalization to untrained material has unfortunately been limited [1, 21]. Thus, more
effective treatments are needed for the improvement of naturalistic, unconstrained speech,
language, and communication post stroke. Directly considering the stage of impaired
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language processing and what this means about likely underlying abnormalities of brain
function may help to target treatments and choose specific outcome measures to assess
treatment success, and thus optimize treatment outcomes. The functional reorganization of
language in people with aphasia may involve both intra- and interhemispheric interactions.
Functional imaging studies have provided information on brain mechanisms during aphasia
recovery. Specifically, imaging studies have indicated that activation of the language-
dominant left hemisphere regions during language-related tasks has consistently been shown
to have the most favorable influence on language outcomes [22– 25] and includes both the
reactivation of lesioned structures and also the recruitment of additional, perilesional areas.
For non-fluent aphasics, Broca’s area and surrounding structures are considered the key
region. In contrast, after a stroke, activation in contralesional homotopic right hemisphere
regions may be upregulated. Although the mechanisms of this increase in activation are
unclear, this activation may involve subcortical-cortical interactions [26] because of reduced
inhibition from the left hemisphere. Researchers are still clarifying why right hemisphere
activation accompanies language recovery in some people with aphasia [27–31] and under
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what circumstances right brain activation may be dysfunctional [33–36].

Constraint-Induced Methods
Constraint-induced language treatment (CILT) is a behavioral treatment approach for
aphasia with theoretical underpinnings based on knowledge about the brain mechanism.
CILT is modeled after constraint-induced movement treatment (CIMT) [37, 38], which
encourages forced use of the hemiparetic hand and arm in order to promote neuroplastic
changes in the lesioned hemisphere contralateral to the weak arm/hand, with the ultimate
goal of improved movement. CILT is an intervention strategy aimed at improving the
quality and quantity of verbal linguistic output of people with aphasia. The treatment
focuses on reducing the reliance on compensatory (substitutive) communication strategies,
such as writing and gesturing, in order to force the individual to utilize more extensive

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verbal means to communicate [39, 40]. It is possible that practicing oral language can
promote neuroplastic changes in the left hemisphere and support improved language
function. Oral verbal expression is required (and actually promoted using constrained
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techniques) for people with aphasia, who may previously have made extensive use of
nonverbal strategies or reading/writing to enhance communication effectiveness. The
premise is that substituting other behaviors for oral verbal language may reduce the capacity
for recovery of verbal linguistic neural networks; by eliminating the non-linguistic
behaviors, CILT may promote left hemisphere reactivation. Using CILT, the person with
aphasia is required to verbally communicate with another person, and constraints such as a
barrier (blocking view of the other person’s hands, anything in them, and their gestures) are
used to further promote verbal descriptions. Specifically, patients may not use gestures,
writing, or any other compensatory strategies; they must produce verbal oral expressive
language without the support of compensatory strategies. Often people with aphasia use
compensatory strategies spontaneously, and language therapy approaches over the years
have promoted a compensatory approach [41, 42]. Whereas people with chronic aphasia
may be in the habit of using these strategies, throughout the course of treatment using a
constraint-induced approach, clinicians aim to decrease use of compensatory strategies
allowing the individual to progress in terms of verbal output [40]. In addition to the focus on
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forced use, a main component of this technique is intensive practice. This involves utilizing
an extremely time-consuming and intense treatment regimen. Patients are typically seen for
treatment up to 3 h a day for up to 5 days a week [43].

While much of the research in the area of CILT involved people with chronic aphasia who
habitually used compensatory techniques for improved communication, a smaller focus of
clinical research in this area includes more recent stroke survivors. Not surprisingly, a
comprehensive literature review examining the effects of this treatment for adults with
aphasia [44] indicated the majority of the studies included chronic patients with aphasia.
Importantly, the same review reported separate categories for CILT and intensive aphasia
treatment in order to determine whether the effects of CILT were the result of the “forced
use” or the “massed practice” aspects of the treatment regimen. The authors looked at ten
studies and found that CILT did show some positive effects on improving language in
people with aphasia. However, the authors noted these benefits were about the same as other
types of intensive aphasia treatment regimens and claimed that further research must be
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conducted to fully understand the “constraint” piece of the treatment [44]. The major
question that is still unanswered regarding CILT is whether the constrained methods,
intensity of treatment, or the combination of both is what is responsible for the positive
outcomes and related neuroplastic brain mechanistic changes that are proposed.

Moreover, whether the habitual use of a compensatory mechanism approach to treatment

prior to CILT hinders the potential effect of CILT has not been widely studied. In a
population of recent stroke survivors in which compensatory strategies had not become
habitual, Kirmess and Maher [45] studied the effects of CILT in people with aphasia who
resided in a rehabilitation center the first 1–3 months post stroke. The improvements in
language function and patient satisfaction with this treatment were reported to be high. Not
surprisingly, expressive language improvements were greater than receptive language
improvements using this approach. It is possible that using CILT early on in the course of

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rehabilitation had a positive effect because a habitual pattern of communication post stroke
had not set in. However, using a constrained approach such as CILT early on in the course
of treatment post stroke may also be frustrating to recent stroke survivors. Taking into
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account the perspective and desires of the individual with aphasia should be considered
when determining the best treatment approach to be implemented for a person with aphasia
[2].

Noninvasive Brain Stimulation (NBS)

Promoting neuroplastic brain mechanism activation or reactivation of the left hemisphere is
thought to be an important aspect that contributes to improved language function post
stroke. Although this approach is not yet approved by the food and drug administration for
clinical use, research indicates that in addition to using a behavioral method such as CILT,
one way to modulate the functional reorganization of language-relevant areas in aphasia
may be use of non-invasive brain stimulation (NBS). Facilitating and inhibiting stimulation
protocols can be used to support optimal reactivation of the left hemisphere language
networks. Stimulating the right hemisphere Broca’s homolog using transcranial magnetic
stimulation (TMS), which may decrease activation in this region, can support leftward
lateralization and is associated with improved language recovery compared to sham
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stimulation in subacute stroke [46].

Transcranial direct current stimulation (tDCS), which, in contrast to TMS, can be conducted
simultaneously with language intervention for people with aphasia, has been implemented in
many aphasia rehabilitation studies. tDCS modulates cortical excitability by applying
constant low-intensity electrical currents through surface electrodes on the scalp. Several
studies have investigated tDCS in aphasia with promising results [5–12], although optimal
methods of administration have not yet been identified. In the future, this research treatment
may be used in conjunction with behavioral treatment for aphasia in standard and customary
clinical treatment protocols for aphasia to accelerate recovery.

Functionally Oriented Aphasia Treatment

Life Participation
The Life Participation approach to aphasia treatment is a functionally oriented approach that
focuses on improving the ability to perform communication activities of daily living [47].
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This approach promotes the idea that focusing on the real-life goals of people with aphasia
will allow the individual to reengage in life. The primary purpose of treatment is to reengage
in communication activities that relate to real-life experiences. The treatment goals are
highly specific to each individual’s needs. As the person with aphasia progresses from early
stages post stroke in the hospital setting to a discharge environment in a rehabilitation
community, a supported-living community, or the home environment, the goals for the
individual will likely change. A consumer-driven model of intervention focusing treatment
on activities that make real-life differences is the theme that prevails in the life participation
approach to aphasia intervention. An example of the life participation approach could
involve discharge planning for a patient who is leaving the hospital. As discharge planning
takes place for a new stroke survivor in an acute-care hospital, the individual with aphasia is

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included in the discharge planning meeting using supported conversation, and the stroke
survivor with aphasia contributes to the discharge planning. In relation to the ICF model,
this approach reflects both the activity and participation domains of the ICF.
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Supported Conversation
This approach to conversational treatment puts the person with aphasia in the lead of the
conversation, and the clinician follows the patient’s lead [16, 48]. The clinician provides
language facilitation in the context of the conversation, within the natural flow of the
conversational interaction. The conversational context is important for this approach, and
both the clinician and the patient need to be aware of the context in order for this approach
to work smoothly. Often a shared activity is the context of the conversation, allowing both
conversational participants to be aware of the context. This conversational treatment
approach can be used in individual treatment sessions or in the group therapy setting.

We wonder whether the supported conversation approach may provide both functional and
impairment-based support. Social conventions require code-switching, and this can be
challenging for people with aphasia [49]. It is possible that the supported conversation
approach reduces the need to code-switch from a comfortable-familiar communication mode
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to a formal-medical mode, easing the burden of communication and increasing available

lexical capacity.

Aphasia Groups
Group therapy for aphasia can theoretically take an impairment-based approach and focus
on training-specific linguistic forms in the group setting or a functional approach involving
the activities and participation domains of the ICF model. An aphasia group session that
incorporates CILT principles into the group is an example of an impairment-focused group
dynamic and reflects the body functions and structure domain of the ICF model. Although
an impairment-based approach to group treatment is possible, given the nature of group
dynamics and conversational interaction, functionally oriented group treatment is more
widely implemented. Conversational group therapy for people with aphasia that employs a
supported conversational approach to treatment is an example of a group treatment model
that reflects the activity and participation domains of the ICF.
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Because emotional communication enhances engagement and comprehension in aphasia

[50, 51], we feel that incorporating activity and participation is very important to derive
optimal benefit from group activities. Functionally oriented group activities will drive
spontaneous expressions of feelings and group conversational exchange of socially relevant
information with emotional content. This will not only help to target language that may be
more relevant and useful to the individual with aphasia, but it may allow for better retention
of learned material.

With advances in technology, individuals with communication disorders are increasingly

using tablet technology to support aphasia rehabilitation. The iPad (Apple, Inc.) can be
customized to individuals with aphasia to contain apps that are specifically relevant to a
person’s participation and activities [52•]. Using an iPad that has been specifically designed
for an individual with aphasia as well as including the individual with aphasia in the

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selection of apps for the iPad is a treatment activity that spans both group and individual
treatment modalities. Moreover, while this activity reflects the ICF activity and participation
domains, training naming within a specific category using the iPad could be viewed as an
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impairment-based approach to treatment of naming that reflects the body functions and
structure domain of the ICF. Broad implementation of the iPad in aphasia intervention could
include all three domains of the ICF: body functions and structure, activity, and
participation.

Conclusion
Aphasia therapy involves both impairment-based and functionally oriented approaches, as
well as a system that includes individual and group treatment. The ICF [2] provides a model
for classification of health conditions among three domains: body functions and structure,
activity, and participation. We suggest that none of these domains is superior to the others,
and an ideal program of treatment for aphasia considers each of these domains to provide the
individual with aphasia the opportunity to engage in treatment at a variety of levels. Future
directions in aphasia therapy are likely to continue to consider both impairment-based and
functionally oriented treatments, with the possible future use of neurophysiological
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approaches such as noninvasive brain stimulation (an impairment-based approach that

reflects the body functions and structure domain) in conjunction with behavioral language
therapy that includes training of linguistic forms in the context of conversation (ICF activity
domain). Treatment that is relevant to the individual with aphasia (ICF participation domain)
and treatment that includes the patient with aphasia as a partner in the treatment decision-
making process should be a part of standard and customary clinical care. The ICF model
provides a system that allows for classification of aphasia intervention that optimally
includes both impairment-based and functionally oriented components, and acknowledges
that all rehabilitation must be person-centered. The overarching goal of aphasia intervention
is improvement in language and communication, and we feel that implementing impairment-
based treatment as well as functionally oriented treatment, rather than treatment that reflects
only one or the other domains, may provide for the best outcomes for stroke survivors with
aphasia.

Acknowledgments
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AM Barrett has received research Grants from the National Institutes of Health and National Institute on Disability
and Rehabilitation Research.

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• Of importance

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Fig. 1.
The international classification of functioning model (reprinted with permission from the
World Health Organization) [2]
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