There are two general categories of therapies, and most clinicians utilize both:
- Impairment-based therapies are aimed at improving language functions and consist of procedures in which the clinician directly stimulates specific listening, speaking, reading and writing skills.
- Communication-based (also called consequence-based) therapies are intended to enhance communication by any means and encourage support from caregivers. These therapies often consist of more natural interactions involving real life communicative challenges.
Decisions about approach depend on an individual's needs and wishes. Therapy for a very mild impairment is likely to differ from therapy for a very severe impairment. Also, therapy changes over time as the person with aphasia improves.
A person with aphasia initially wants to speak better and make sense of language spoken by others. Therefore, speech-language pathologists attempt to repair what is broken. Therapies focus an individual's attention on tasks that allow him or her to comprehend and speak as successfully as possible. A therapy session may be the only time of the day in which the mental mechanics of language are exercised with minimal frustration.
Seemingly limited time with a therapist may be supplemented with homework and computer programs. Computer software has been designed to exercise word-finding, comprehension, and real life problems such as exchanging money. Therapy time can be extended with professionally guided assistance from caregivers.
Clinical researchers have been developing therapies focused on specific area of language impairment such as retrieving verbs and formulating sentence structure. One example of experimental treatment includes the use of a virtual therapist speaking from a computer monitor. A great deal of clinical research has gone into providing evidence for the effectiveness of impairment-based therapies.
Although someone with aphasia wants mostly to speak better, communication may still be frustrating. Communication oriented treatments, in part, assist the person in conveying messages and feelings with alternative means of communicating. This orientation is also said to involve compensatory strategies. In addition, an individual is encouraged to use any remaining language ability that succeeds in conveying messages. Therefore, communication-based activities continue to be partly "language-based" and are likely to incorporate impairment-based objectives simultaneously.
Rehabilitation specialists are attending to the consequences of disability for quality of life. Speech-language therapists are enlisting group activities to facilitate a person's participation in daily life. We may hear these activities referred to as social approaches or participation-based approaches. Methods range from providing meaningful contexts within a rehabilitation facility to venturing outside of such facilities. These methods may emphasize a return to former activities and interactions, but also there are a few centers staffed by volunteers which effectively create a new community for people with aphasia.
Examples of Specific Therapies
There are many names for aphasia therapies. Some represent slight variations of fundamental procedures, and one could exaggerate by saying that there are as many methods as there are therapists. However, certain methods are somewhat unique and well-known, and clinical researchers are investigating new strategies or new wrinkles for established strategies. The following presents a few examples of specific therapies.
Contstraint-induced therapy (CIT): This therapy is modeled after a physical therapy for paralysis in which a patient is "forced," for example, to use an impaired side of the body, because the good side has been restricted or constrained. In applying this principle to communication functions, a person with aphasia may be constrained in using intact gesture in order to direct the individual to use impaired spoken language.
A second, and perhaps more well-known, component of this treatment is that it is more intensive than typical therapy schedules and it lasts for a relatively short duration. For example, the therapy may be administered for three hours daily for two weeks. Studies of CIT have been expanding beyond Germany and Houston, but it is not yet covered by insurance.
Constraint-induced therapy is almost the opposite of compensatory strategies in which the person with aphasia is encouraged to use intact abilities to communicate. It is likely that a therapist will employ both approaches.
Melodic Intonation Therapy (MIT): Developed by Robert Sparks in Boston, MIT is based on an observation that that some persons with aphasia "sing it better than saying it." The method is a series of steps in which an individual practices an artificially melodic production of sentences. It has been recommended for people with an expressive type of aphasia and good comprehension. We are careful to watch for the individual who speaks much better with melodic intonation but fails to carry this performance over to natural conversation.
Tele-rehabilitation: Established procedures are provided over the Internet with web cameras so that the therapist and person with aphasia can see and hear each other. Not yet widely available and not yet covered by Medicare, it is being developed by William Connors in Pittsburgh.
Specific Communication-based methods
PACE therapy (Promoting Aphasics' Communicative Effectiveness): This procedure is a slight variation of the basic picture-naming drill, but the adjustments introduce elements of conversation into the interaction. These adjustments include the person with aphasia and the therapist taking turns conveying messages, pictures for messages hidden from the listener, and a free choice of modalities for conveying messages. Developed by Jeanne Wilcox and Albyn Davis in Memphis, it appears to have been popular in Europe where most studies have been conducted.
Conversational coaching: Developed by Audrey Holland in Arizona, this strategy aims at increasing commuunicative confidence through the practice of scripted conversations. With assistance from Leora Cherney in Chicago, this method has been integrated into a computer program. Called "AphasiaScripts," it includes a virtual therapist to provide help for the person with aphasia.
Supported conversation: Originated by Aura Kagan in Toronto, Canada, supported conversation is a particular strategy for enhancing communicative confidence that is commonly found in community support groups. Volunteers are trained to engage in real conversations with persons who have aphasia. Similar therapies have been described, called "conversation therapy" or "scaffolded conversations."
A General Comment
There are many other therapies, and most of the therapies mentioned are continually being studied for their effectiveness. A speech-language pathologist tailors a therapy program to the wishes and abilities of the individual client, also considering the capacities of the rehabilitation facility and the availability of caregiver support.
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Written by G. Albyn Davis, Ph.D., CCC-SLP (Feb 2011)