Laura Carbonero Sancho, a speech therapist with clinical experience in the treatment of adults with neurological disorders, explains in this article what aphasia is and the characteristics of each of its clinical profiles, while referring to speech therapy intervention methods.

What is aphasia?

Every year, an average of 4.5 million survivors of a stroke who have aphasia are estimated. According to the National Aphasia Association (NAA), aphasia is defined as the result of a stroke or brain injury that affects a person’s ability to communicate. In other cases, the gradual onset of a communication disorder with a neurological etiology is called Primary Progressive Aphasia (PPA).

Clinical profiles

Over the years, a classification of aphasia has been defined, which includes specific linguistic impairments that, according to the localizationist theory, correspond to the location of the brain lesion.

Types of aphasia

The National Aphasia Association (NAA) describes some characteristics of the types of aphasia:

• Global aphasia: severe communication impairment.
• Broca’s aphasia (non-fluent): language production is reduced, with numerous limitations in word access and/or production.
• Non-fluent mixed aphasia: in addition to difficulties in language production, there are also impairments in language comprehension.
• Wernicke’s aphasia (fluent): characterized by incoherent jargon. Severe difficulties in comprehension.
• Anomic aphasia: characterized by difficulty finding words. It often leads to frustration and results in a speech that is full of circumlocutions.
• Primary progressive aphasia: progressive deterioration of language skills.

In addition, it proposes a communication severity scale based on the difficulties presented by each person according to the aphasia profile.

States and principles of neuroplasticity

When brain damage occurs, researchers point out periods that correspond to the stages in which the person is after the injury.

• Acute phase: period from hospitalization to the following 3 months.
• Subacute phase: period from 3 to 6 months after the injury.
• Chronic phase: starting from 6 months after the injury.

Studies indicate the need to implement early rehabilitation in the acute phase, attending to the stability of clinical characteristics. In the case of people with aphasia, there are many studies indicating an early start to therapy.

Although these phases have been established, there is another aspect to consider of great relevance: the principles of neuroplasticity. These are always present as a strategic mechanism possessed by the brain to make changes, so they will influence the recovery of a person who has suffered a brain injury and must be taken into account when establishing a rehabilitation program.

Rehabilitation approaches to aphasia

Throughout the publications, within non-pharmacological therapies, emphasis is placed on two approaches that have commonly been used in the rehabilitation of people with aphasia.

• Disability-based therapy: aims to improve language functions by addressing specific aspects.
• Communication-based therapies: propose a more functional approach and address the entirety of interaction.

If we review the Evidence-Based Review of Stroke Rehabilitation (EBRSR), some intervention methods are included, among which I highlight:

• Traditional aphasia therapy mainly focused on linguistic deficits (naming, verbal fluency, speech, writing, oral/written comprehension, repetition, etc.).
• Constraint-induced aphasia therapy (CIAT) in which affected individuals are guided to use oral language forcefully during communicative situations.
• Lexical retrieval therapy uses associative learning procedures (semantic and phonological).
• Speech and language therapy facilitated by volunteers proposes training other non-speech therapists to implement communication programs.
• Social interaction therapy promotes the participation of individuals with aphasia in conversation training within a social environment.
• Music-based therapy utilizes musical elements (melody, rhythm, dynamics, timing) to enhance verbal production and improve verbal fluency.
• Technology-based therapy (computer-based) is an accessible and rapid method for patients requiring voluntary participation. It involves transferring communicative aspects to this rehabilitation pathway.

Intensive rehabilitation and the pragmatic approach

Speech therapy provides significant benefit in the communication of individuals with aphasia. Currently, research focuses on the clinical profile of the individual, the type of intervention performed, and its intensity.

Recent studies on aphasia rehabilitation demonstrate positive outcomes throughout treatment if it has a minimum dosage of 4 hours per week distributed over 3-5 days for a minimum of 3 months.

Communication aspects analyzed in some of the reviewed studies include general language, auditory comprehension, naming, and functional communication. These have been assessed using standardized scales or tests, allowing the establishment of a baseline for patients and quantifying changes throughout and after the intervention.

Previously, some of the intervention methods used have been discussed, but upon reviewing the literature, researchers confirm in their studies that there is an association between the functional/pragmatic approach and the benefits in the communicative capacity of individuals with aphasia.

The benefits of this approach are supported by studies that use social interaction as a means of rehabilitation. Verbal training programs such as PACE therapy, constraint-induced aphasia therapy, conversational training, or supported conversation have been used to demonstrate their effectiveness in people with aphasia, proving effective not only in communicative but also in social aspects (participation), promoting the well-being of individuals in the biopsychosocial sphere.

Conclusions

This article aims to gather information about the concept of aphasia, its typology, and language rehabilitation methods. Furthermore, emphasis is placed on the terms “intensive rehabilitation” and “pragmatic approach” as key aspects in intervention programs that have been studied in recent publications.

Therefore, speech therapists, as professionals trained in communication, should consider not only the pathology they are going to treat but also all aspects that can influence the functional communication of individuals with aphasia. Among the mentioned methods, those with the strongest evidence according to the clinical profile should be considered, and it will be recommended to design an individualized intervention program that includes practical and functional activities that take into account the principles of neuroplasticity.

Bibliography

• Brady MC, Ali M, et al. Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis. International Journal of Stroke. 2022;17(10):1067-1077. doi:10.1177/17474930221097477
• E. Noé, A. Gómez, M. Bernabeu et al., Guía: Principios básicos de la neurorrehabilitación del paciente con daño cerebral adquirido. Recomendaciones de la Sociedad Española de Neurorrehabilitación, Neurología, https://doi.org/10.1016/j.nrl.2021.06.009
• Evidence-Based Review of Stroke Rehabilitation (EBRSR) (2022). Introduction | EBRSR – Evidence-Based Review of Stroke Rehabilitation
• Palmer R, Pauranik A. Rehabilitación de los trastornos de la comunicación. 15 de enero de 2021. En: Platz T, editor. Vías clínicas en la rehabilitación de accidentes cerebrovasculares: recomendaciones de práctica clínica basadas en la evidencia [Internet]. Cham (CH): Springer; 2021. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK585589/ doi: 10.1007/978-3-030-58505-1_10
• REhabilitation and recovery of peopLE with Aphasia after StrokE (RELEASE) Collaborators. Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review-Based, Individual Participant Data Network Meta-Analysis. Stroke. 2022 Mar;53(3):956-967. doi: 10.1161/STROKEAHA.121.035216. Epub 2021 Dec 1. PMID: 34847708; PMCID: PMC8884127.
• Shrubsole, K., Worrall, L.E., Power, E., & O’Connor, D.A. (2017). Recommendations for post-stroke aphasia rehabilitation: an updated systematic review and evaluation of clinical practice guidelines. Aphasiology, 31, 1 – 24.

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