Handbook of Clinical Neurology, Vol.

110 (3rd series)

Neurological Rehabilitation
M.P. Barnes and D.C. Good, Editors
# 2013 Elsevier B.V. All rights reserved

Chapter 27

Rehabilitation of aphasia
ANNA BASSO 1*, MARGARET FORBES 2, AND FRANCOIS BOLLER 3
1
Department of Neuropsychology, Institute of Neurological Sciences, Milan University, Milan, Italy
2
Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA
3
Bethesda, MD, USA

INTRODUCTION approach (functional reorganization), the pragmatic ap-

The term aphasia refers to the more or less complete
loss of the ability to use language as the result of lesions
in cerebral areas generally localized in the left half of
the brain; these areas are responsible for the ability to
speak, understand, read, and write. Because language
is complex, the term aphasia covers heterogeneous
disorders that may have little in common. Indeed, it
can be argued that the ways of being aphasic are prac-
tically infinite. Besides varying from one person to an-
other, aphasia is far from static in any given patient and
is susceptible to changes, both spontaneously and as a
result of rehabilitation.
Unfortunately, the definition of aphasia does not say
much about characteristics of the loss: whether, for in-
stance, language is impaired in all of its aspects, or
whether there is a selective loss of one or more processes
(such as auditory comprehension or reading); or whether
aphasia is a single condition, or takes several forms that
may selectively impair one linguistic component (pho-
nology, syntax, semantics), leaving the others relatively
unimpaired. Even more ambiguous is the word rehabil-
itation, which is supposed to cover all the different treat-
ments intended to improve impaired function. The only
thing common to all aphasia treatments is that patient
and therapist try to communicate with each other. The
content of the communication and what the therapist
does in order to elicit a response from the patient vary
from place to place and from clinician to clinician.
Following a brief overview of the epidemiology and
the clinical characteristics of aphasia, this chapter will
present the major traditional approaches to rehabilitation.
They include the stimulation approach (also called
classic), the behavior modification approach, Lurias
proach, as well as the neurolinguistic approach. The sub-
sequent section illustrates some of the major current
approaches to aphasia rehabilitation, specifically the syn-
dromic approach (also called neoassociationist), the
cognitive neuropsychological approach, and the social ap-
proach. The chapter then provides examples of specific
methods. While all intervention strategies may be classi-
fied, more or less correctly, into one or another of the
above categories, it is not possible to mention the hun-
dreds of specific interventions to be found in the litera-
ture, some of which have been described only briefly
and in reference to a single case. The chapter concludes
with a review of efficacy studies on aphasia therapy.
EPIDEMIOLOGY
No specific data on the incidence of aphasia are available
but an approximate count can be inferred from the inci-
dence of stroke. This varies from 1.8/1000 (Di Carlo et al.,
2003) to 4.5/1000 (Wade et al., 1986) new cases per year;
overall prevalence is 65/1000 individuals (ILSAWG,
1997). With reference to the Italian population (approxi-
mately 58 million), these figures indicate an incidence of
105 000 to 261 000 new cases per year and a prevalence of
3.8 million individuals affected by stroke. For the USA,
the annual incidence is thought to be around 600 000
and the prevalence up to 4.6 million people. There is ev-
idence suggesting that the incidence of stroke has de-
creased over the past 50 years (Caradang et al., 2006).
The incidence of aphasia following stroke varies from
21% in some studies (Brust et al., 1976) to 38% in others
(Pedersen et al., 1995). For the Italian population, these
data indicate that incidence ranges from 22 000 (21%
of 1.8/1000) to 99 000 (38% of 4.5/1000) new cases of

*Correspondence to: Anna Basso, Department of Neuropsychology, Institute of Neurological Sciences, Milan University,
Milan, Italy. E-mail: anna.basso@gmail.com
326 A. BASSO ET AL.
aphasia per year. Kirshner and Jacobs (2009) note that re-
ports of incidence in the USA generally omit aphasia
caused by conditions other than stroke, but estimate that
approximately 170 000 new cases per year result from
stroke. Pedersen et al. (1995) compared the incidence
of aphasia in acute and chronic cases (
6 months) and
found a reduction ranging from 38% in the acute phase
to 18% in the chronic phase.
In addition to vascular etiology, traumatic brain inju-
ries due to traffic accidents, war, or other events also
cause a substantial number of brain injuries requiring spe-
cialized rehabilitation. Other etiologies of aphasia include
gunshot wounds, encephalitis, and anoxia, although they
account for a smaller number of cases. If no other med-
ical complications arise, the language of people with
aphasia resulting from these causes is expected to recover
to some extent. On the other hand, a number of conditions
such as CNS tumors and neurodegenerative diseases
(Alzheimer disease and especially primary progressive
aphasia) also cause language disturbances, but because
these diseases are progressive, further language decline
is expected rather than recovery, and therefore the
methods and goals of language treatment are quite dif-
ferent. For this reason, language problems due to these
etiologies will not be discussed in this chapter.
OVERVIEW OF THE HISTORYOF
APHASIA THERAPY
Examples of treatment for aphasia can be found, mainly
in German speaking countries, after World War I, but one
of the first systematic studies can be attributed to the sem-
inal work of Weisenburg and McBride (1935). Aphasia
therapy became common practice only after World War
II. At that time knowledge about aphasia was rather
scarce and treatment was not informed by a clear-cut the-
ory. Very different methods were put into practice but it is
possible to recognize some common threads, and the best-
known approaches will be very briefly mentioned. Any
taxonomy one proposes, however, will be an oversimpli-
fication, and the different categories tend to overlap.
The stimulation approach, the behavior modification
approach, the pragmatic approach, and the neurolinguis-
tic approach have more or less succeeded one another. In
contrast, Lurias functional approach was developed in a
different country and in a different culture. These ap-
proaches will be briefly discussed. The syndromic (or
neo-associationist) and the cognitive approaches, still
very popular, will be described in more detail, together
with the social (or consequences-based) approach.
Stimulation approach
A large number of very heterogeneous interventions
are generally grouped under this label. Followers of this
school maintained that language is a complex, holistic,
and indivisible function, not represented in the brain by
a number of discrete centers, but a property of the total
brain. The two principles of the stimulation approach are
the idea that aphasia is a unitary disorder varying in
severity but not in type, and the assumption that knowl-
edge about language is not lost but cannot be accessed
because of cerebral damage. Deriving directly from these
two principles is a global approach to treatment that var-
ies only according to the severity of the disorder and that
is based on the automatic-voluntary dissociation. The
required response is facilitated and automatically
obtained; facilitation is then progressively reduced until
the response is intentional. Wepman (1951), Schuell
(Schuell et al., 1964), and Darley (1982) are among the
most important representatives of this school.
Behavior modification approach
This approach stems from the application to aphasia
therapy of the principles of operant conditioning.
In the 1960s psychologists were quite interested in learn-
ing and some researchers investigated whether learning
in aphasic subjects followed the same rules as learning
in normal subjects. They concluded that the majority of
aphasic individuals are able to learn new materials using
the same strategies as normal subjects, but learning is less
efficient (Tikofsky and Reynolds, 1962, 1963; Edwards,
1965; Brookshire, 1971). Principles of operant condition-
ing and programmed instruction were then put to use in
aphasia therapy. The two most important techniques used
in programed instruction are shaping and fading and they
both assume that the required behavior or a similar one
exists in the patients repertoire of responses.
LURIAS FUNCTIONAL APPROACH
This is a good example of unity of theory and practice and
of a coherent therapeutic system. Luria (1963, 1970; Luria
et al., 1969) distinguished functional disturbances due to
the temporary loss of activity in some brain areas that can
rapidly resolve by themselves and do not require treat-
ment from the functional disturbances resulting from
the irreversible destruction of brain tissue. The damaged
function can never be restored to its previous form and
therapy must be directed towards the reorganization of
the function by transferring it to other brain structures
or functional systems. The patient must be taught to per-
form the damaged operation through new roundabout
methods by means of a partially new neural organization.
PRAGMATIC APPROACH
The pragmatic approach has evolved from the applica-
tion of linguistic knowledge to aphasia therapy. In the
 REHABILITATION OF APHASIA
stimulation approach the patient was required to use lan-
guage in standardized situations, such as confrontation
naming and picture description. With the appearance of
pragmatics aphasia therapists broadened their view of
successful responses in therapy, and began to take an in-
terest in patients capacity to communicate through any
channel, not only through spoken language. A number of
researchers demonstrated that aphasic patients capacity
to communicate is better preserved than their capacity to
express themselves through language (Wilcox et al.,
1978; Kadzielawa et al., 1981; Foldi et al., 1983) and a va-
riety of formal functional evaluations were developed
(Sarno, 1969; Holland, 1980). The best-known therapeu-
tic implementation is Promoting Aphasics Communica-
tive Effectiveness (PACE) (Davis and Wilcox, 1985).
NEUROLINGUISTIC APPROACH
Neurolinguistics is the branch of linguistics that analyzes
the language impairments that follow brain damage in
terms of the principles of language structure. The term
neurolinguistic is neutral about the linguistic theory it
refers to, but any linguistically based approach to apha-
sia therapy is based on the principle that language has an
internal organization that can be described by a system
of rules. The neurolinguistic approach stresses the role
of language in aphasia and analyzes it according to prin-
ciples of theoretical linguistics.
The first linguistically based typology of aphasic im-
pairments is probably that of Roman Jakobson (1964),
although Alajouanine and colleagues (1939, 1964) had al-
ready stressed the role of some linguistic phenomena in
aphasia. Many authors have underlined the importance
of linguistic theory for aphasia therapy (Hatfield,
1972; MacMahon, 1972; Hatfield and Shewell, 1983;
Lesser, 1989; Miller, 1989), but linguistic analyses were
not carried out in great detail until interest in aphasia
expanded beyond the field of neurology to disciplines
such as linguistics, speechlanguage pathology, and
psychology.
PRESENT APPROACHES
All the previously mentioned approaches have contrib-
uted in a more or less direct way to the present situation
in aphasia treatment in which it is possible to identify
three very different approaches to therapy: the neoasso-
ciationist or syndromic approach, the cognitive neuro-
psychological or impairment-based approach, and the
social or consequences-based approach.
Neoassociationist or syndromic approach
The neoassociationist approach (also called syndromic)
derives directly from the stimulation school and
327
similarly is highly heterogeneous. The neoassociationist
school flourished in the 1960s and 1970s in Boston with a
group of neurologists and psychologists (particularly
Norman Geschwind, Harold Goodglass, Frank Benson,
Edith Kaplan, and others) who have had a lasting and
important influence on clinical studies in aphasia. The
classic aphasia syndromes (Broca, Wernicke, conduc-
tion, transcortical, anomic, global) were redescribed
and reanalyzed in terms of more sophisticated linguistic
analyses and anatomical knowledge.
One of the most recent detailed descriptions of the
classic syndromes is that of Benson and Ardila (1996),
who define a syndrome as a cluster of symptoms plus
a specified brain lesion. They argue that although
limited and imperfect, the syndrome classification
originally developed by the nineteenth-century continen-
tal investigators remains basically accurate, replic-
able, and clinically useful (Benson and Ardila, 1996,
pp. 111112).
However, according to Albert et al. (1981) and Prins
et al. (1978), only approximately 20% of chronic aphasic
subjects can be reliably classified in one of the classic
syndromes. Poeck, considering the problem of aphasic
syndromes, argued that they are to a large extent, arte-
facts produced by the vascularization of the language
area and not natural combinations of symptoms that
necessarily co-occur (Poeck, 1983, p. 84). According
to Schwartz, aphasia syndromes are not real entities
because one cannot delineate for each category an
essence or idealized pattern which is invariant and
hence shared by all members of the group (Schwartz,
1984, p. 5).
Whatever the nature of the classic syndromes, they
are still very popular among clinicians and have been
the starting point for treatment for many years. A num-
ber of aphasia batteries, e.g., Boston Diagnostic Aphasia
Examination (BDAE) (Goodglass and Kaplan, 1983),
Revised Western Aphasia Battery (WAB) (Kertesz,
2007), and Porch Index of Communicative Ability (PICA)
(Porch, 1967), allow subject classification, and the syndro-
mic diagnosis has been considered a valid theoretical basis
for treatment. A person with global aphasia, for instance,
has severely damaged comprehension (as well as all other
verbal behaviors) and treatment of comprehension is ini-
tiated; a conduction aphasic person has disproportionately
impaired repetition, and treatment for repetition is initi-
ated; an anomic person has numerous anomias and treat-
ment for naming disorders is initiated. The relationship
between the symptom and the treatment is, however,
loose, and many different treatments for the same
impaired behavior have been suggested.
To illustrate, all of the following treatments for
naming disorders can be grouped under the umbrella
of the syndromic approach: semantic features analysis
328 A. BASSO ET AL.
(Kiran and Thompson, 2003); combined presentation of
the oral and written word to be named (errorless learn-
ing) or phonological and orthographic cues (errorful
learning) (Fillingham et al., 2006); delayed copy and re-
call (CART) plus repetition or repetition only (Beeson
and Egnor, 2006); semantic therapy designed to activate
the semantic network and minimize errors (production
was discouraged) (Davis et al., 2006); and repetition
combined with four yes/no questions about the seman-
tics or phonology of the word (Raymer et al., 2007). It
also encompasses novel approaches such as melodic in-
tonation therapy (MIT), which aims to harness the intact
musical skills of the right hemisphere to enable commu-
nication (Albert et al., 1973).
The underlying principles are not very different from
those underlying the stimulation approach. The basic
idea is that although language cannot be accessed, it is
not lost. Hence target responses are elicited by facilitat-
ing the patients production by any possible means.
Aphasia is no longer considered a unitary disorder, but
the linguistic analysis of verbal behaviors (reading, writ-
ing, comprehension, production) is still rather imprecise.
Many clinicians consider that the difficulty of a lan-
guage task is based solely on a hierarchy of linguistic
units: phonemes, morphemes, words, and sentences.
Compared to the stimulation approach, exercises are
more varied and tailored to the various syndromes;
therapists are more concerned with the formal aspects
of therapy (which could be a legacy of the behavior
modification approach) and the question of the efficacy
of rehabilitation is a central topic of research.
One limitation of this approach is that treatment ad-
dresses the superficial symptoms without trying to iden-
tify the underlying cause of the impaired behavior. As a
consequence it is not possible to establish whether a par-
ticular treatment is better or worse than a different one
and, even if it has been demonstrated that the treatment
has been effective, it is difficult to understand why and
therefore to rationally suggest it for other subjects. How-
ard and Hatfield (1987) argue, Too often. . .the relation-
ship between deficit and treatment is based on some
implicit idea of how treatment has its effects, which
has no good justification or scientific support (p. 106).
A global treatment that can be subsumed under the
heading of syndromic approach that avoids this criticism
is treatment based on the analysis of conversation. Con-
versation is the prototype of language use and the form
in which we all learn our native tongue; it is the most
common type of familiar discourse during which two
or more participants take turns speaking and listening.
A conversation is a collaborative endeavor in which par-
ticipants recognize a common goal. What the partici-
pants say at any moment is determined by the
common final goal, but what they communicate to
each other is more than the linguistic content of the sen-
tences themselves.
Treatment starts from an analysis of how conversation
evolves between two normal interlocutors and utilizes the
rules of conversation in order to build up a normal con-
versation with an aphasic individual. The aim of this treat-
ment is to train subjects with aphasia to use their residual
communicative capacity in the real world and to restore
their capacity to maintain a real conversation. This type
of therapy does not start from the symptoms, but from
the end-point of treatment and applies linguistic knowl-
edge about natural conversation (Basso, 2010).
The cognitive neuropsychological or
impairment-based approach
The classic anatomo-clinical approach provided knowl-
edge about the relationships between lesions and func-
tions, but in spite of the accumulation of knowledge,
the problem of inferring the structure of normal brain
functions from behavioral dysfunctions was far from
being resolved and some researchers were dissatisfied
with the methodology of clinical neuropsychology. Car-
amazza and McCloskey, for instance, wrote, It is not an
exaggeration to say that over one hundred years of re-
search on cognitive disorders has shed little light on
the nature of normal cognitive processes and the form
of their dissolution in conditions of brain damage
(Caramazza and McCloskey, 1988, p. 519).
In recent years, researchers have become less inter-
ested in the localization of cognitive functions in the
brain and more concerned about the nature of the cogni-
tive mechanisms. The basic aim of cognitive neuropsy-
chology was to provide a model of normal cognitive
processing and to explain impaired performance in
terms of damage to one or more components of the nor-
mal cognitive function. Cognitive neuropsychologists
argued for a functional approach to the study of the
mind explicitly independent of the study of the brain,
and introduced the use of information-processing
models, which provide a rational basis for the character-
ization of patterns of impaired performance in terms of
damaged subcomponents. They were interested in iden-
tifying the functional locus of the damage that caused
the symptoms by analyzing the patients performance
of various tasks in relation to a model of normal proces-
sing. The use of pathological data for the study of the
normal cognitive system requires some assumptions,
among which are the modularity and the subtraction
assumption.
The modularity assumption says that a complex cog-
nitive function consists of a series of functionally inde-
pendent subcomponents or modules that perform
different functions and interact with other parts of the
 REHABILITATION OF APHASIA
system; the subtraction assumption says that no new
cognitive structure is created as a consequence of the
lesion; pathological transformations of normal cognitive
functions obey constraints determined by the normal
structure of the system and can be inferred from the
analysis of the normal structure. The relevance of these
assumptions for treatment is evident. If a cognitive func-
tion (such as naming, for instance) consists of a series of
independent components that can be separately dam-
aged and no reorganization is possible, a detailed
diagnosis will locate the damage and therapy will be spe-
cifically directed to that component and not to unspeci-
fied naming disorders.
It is clear that the more explicit the reference model,
the more precise can be the diagnosis based on the model.
A functional diagnosis is different from a syndromic
diagnosis, such as Broca aphasia or Wernicke aphasia.
A syndromic diagnosis essentially involves classifying
the aphasia according to which cluster of symptoms it fits
best. A number of symptoms can generally be present in a
syndrome, but no particular one is necessary for the
diagnosis. In other words, taking Broca aphasia as an
example, the classic symptoms of reduced speech,
speech apraxia, and agrammatism are not always present
in subjects classified as having Broca aphasia.
A functional diagnosis, on the other hand, involves
determining the functional damage underlying the super-
ficial symptoms, and two subjects with the same func-
tional damage will show the same symptoms.
A precise and correct diagnosis, however, does not
dictate what to do. The contribution of cognitive neuro-
psychology to aphasia therapy is a negative contribu-
tion because the more precise the diagnosis the more
constrained the therapeutic choices rationally related
to the impairment. When the cause of an impaired behav-
ior is unknown, the choice of possible interventions is
very large but the opposite is true when the underlying
cause is known.
The past 30 years have seen important progress in our
understanding of the normal processing of single words.
In addition, there is now widespread consensus on a
dual-route model according to which reading and spell-
ing can be achieved through a lexical route, which allows
the correct pronunciation and spelling of stored words,
and a non-lexical route, which allows conversion of sub-
lexical units of phonemes or graphemes into sequences
of graphemes or phonemes, respectively. Only the
conversion mechanisms are dedicated to reading and spell-
ing; the lexical routes utilize parts of the lexicalsemantic
system that are also used in other tasks, such as auditory
comprehension and naming. The dual-route model has
prompted many of the more recent papers on therapy
for reading and writing disorders, and treatment is
generally focused on the impaired route (e.g., Beeson
329
et al., 2000; Luzzatti et al., 2000; Kiran et al., 2001; Peach,
2002; Rapp and Kane, 2002; Raymer et al., 2003; Sage
et al., 2005; Viswanathan and Kiran, 2005).
Sentence-level problems are very frequent in aphasia
but in contrast to the numerous treatments for naming
disorders, sentence-level disorders have only rarely
been tackled. Recently sentence-level treatments have
benefited from contributions from psycholinguistic
studies and the cognitive neuropsychological approach.
Two types of treatment are now rather common; one
based on the mapping hypothesis and another on the lin-
guistic theory of wh-movements.
According to the mapping hypothesis, the verbs se-
mantic information does not only specify the core mean-
ing of the verb, it also dictates the number of arguments
involved and their role in the event. Thus the core mean-
ing of rob is to deprive someone; it is a two-argument
verb and the thematic roles involved are an agent (caus-
ing the deprivation) and a patient (experiencing the rob-
bing). If an aphasic patient still understands the core
meaning of rob but has lost information about its the-
matic grid he or she will have nothing to map onto syntax
and will have problems understanding sentences such as
The thief robbed the old lady unless using knowledge
of the world where it is more probable for a thief to rob
an old lady than vice versa. The mapping hypothesis has
given rise to many therapy programs for comprehension
and production. Treatment is focused on emphasizing
the centrality of the verb and its relationship to the nouns
in the sentence, and attempts to link sentence structure
to sentence meaning (for review see Marshall, 1995;
Mitchum et al., 2000).
The second type of treatment is based on the linguistic
theory of wh-movement. According to linguistic theory
noncanonical sentences have two levels of representa-
tion: the underlying or d-structure (akin to the basic
Subject-Verb-Object pattern in the English language)
and the s-structure. Noncanonical sentences are derived
from the d-structure through application of rules which
involve movement of a constituent from its original
position into a new position in the s-structure (for
instance, the subject in the canonical sentence Martin
is eating the fruit moves from the front position and
takes the last position in the passive sentence the fruit
is eaten by Martin, a noncanonical sentence). One of the
two major types of movement is wh-movement. To form
a wh-question, wh-, which refers to a constituent that
occupies a certain position in the d-structure, is moved
to the front of the sentence. When movement occurs,
a trace (t) is left behind in the original position (Martin,
in the previous example). Most English interrogative
words start with wh- (who, what, where, why, etc.),
which explains the term wh-movement. Difficulty com-
prehending noncanonical sentences in English, such as
330 A. BASSO ET AL.
passives, object relatives, and certain forms of wh-
question, is a widely reported characteristic of agram-
matic aphasia.
Treatment involves meta-linguistic knowledge of
verb properties and movement, and takes into account
both the lexical and syntactic properties of sentences.
The first steps do not differ significantly from mapping
therapy, being mainly concerned with improving knowl-
edge of the thematic role information about verbs. Then
instructions concerning the movements of various sen-
tence constituents are provided and aphasic subjects
are trained to produce wh-movements (see Thompson
et al., 2003; Thompson and Shapiro, 2007).
The social or consequences-based approach
Clinicians have always stressed the fact that aphasia
has a significant impact on the whole life of individuals
suffering from the disorder, upsetting their relationships
with other family members, colleagues, and friends.
Aphasic individuals suddenly find themselves deprived
of their role, socially isolated, and unable to express their
wishes and emotions.
Recently the idea that disabled persons have a right to
an environment without barriers has taken root and
therapy has turned to the external environment, trying
to modify it to adapt it to the aphasic person. Examples
of this category are the Supporting Conversation for
Adults with Aphasia (Kagan, 1998; Kagan et al., 2001)
and the Conversational Coaching approaches (Holland,
1991; Hopper et al., 2002), which aim to teach effective
strategies to the normal interlocutor rather than to
modify the verbal behavior of the aphasic individual.
It is impossible to delineate the boundaries of the in-
terventions that can go under the name social or conse-
quences-based approach. They can run the gamut from
breathing therapy to improving the ability of the person
with aphasia to return to work. Some examples of the
differences between the social approach, which focuses
on changing the environment and the impairment-based
approach, which aims to rehabilitate the aphasia itself,
can be found in a recent book written by aphasia re-
searchers and clinicians (Martin et al., 2008). Two differ-
ent clinicians describe the suggested treatment for each
of five aphasic individuals, one clinician from the point
of view of the impairment-based approach and the other
from the social point of view that aims to minimize the
consequences of aphasia.
Table 27.1 summarizes the various approaches to
aphasia rehabilitation and their theoretical underpinnings.
EFFICACY OFAPHASIA THERAPY
The first group of studies on treatment efficacy, per-
formed in the 1950s and 1960s, reported positive results,
but included only rehabilitated subjects, and the possible
effect of spontaneous recovery was ignored (Butfield
and Zangwill, 1946; Marks et al., 1957; Leischner and
Lynk, 1967; Sands et al., 1969; Sarno and Levita, 1979).
The subsequent group of studies compared treated
and untreated subjects, thus taking into account sponta-
neous recovery, but results were equivocal because ther-
apy was found to have a significant effect on recovery in
some (Hagen, 1973; Basso et al., 1975, 1979; Gloning
et al., 1976; Shewan and Kertesz, 1984; Poeck et al.,
1989; Mazzoni et al., 1995), but not in others (Vignolo,
1964; Pickersgill and Lincoln, 1983; Lincoln et al.,
1984). The effect of rehabilitation has also been studied
by comparing results obtained by speech therapists and
volunteers (Meikle et al., 1979; David et al., 1982; Wertz
et al., 1986; Hartman and Landau, 1987; Marshall et al.,
1989). Treatment was always found to be effective, but
none of the studies that adopted this strategy found sig-
nificantly better results for the group of subjects treated
by speech therapists.
As can be seen, the results are not clear-cut: they are
positive (rehabilitation has a significant effect on re-
covery) in about half of the studies that have a control
group and in all studies comparing therapists and volun-
teers (however, without a difference between the two
groups). On the other hand, no significant difference
was found between treated and untreated patients in
about 50% of the studies comparing these two groups.
One common element in the negative studies was
brevity of treatment. Some researchers have specifically
tackled the issue of amount of treatment. With different
nuances, all of these studies report better recovery for
subjects who received more treatment (Brindley et al.,
1989; Denes et al., 1996; Hinckley and Carr, 2005; Basso
and Caporali, 2001). Furthermore, Bhogal et al. (2003)
considered all works published between 1975 and 2002
in which recovery of a group of treated patients was
compared with that of a group of nontreated patients,
and they identified those that presented sufficient data
for reanalysis (n 10). Significantly more therapy ses-
sions were carried out in the positive studies than in
the negative ones, thus confirming the importance
of amount of treatment.
Scientific evidence in support of efficacy of aphasia
therapy has come from meta-analyses and systematic
reviews. Four meta-analyses (Whurr et al., 1992; Robey,
1994, 1998; Rohling et al., 2009) and two systematic
reviews (Cicerone et al., 2000; Cappa et al., 2003),
which were subsequently updated (Cappa et al., 2005;
Cicerone et al., 2005), were conducted. All meta-
analyses confirmed the effectiveness of rehabilitation.
Finally, the latest Cochrane review (Kelly et al., 2010)
concludes Significant differences between the groups
scores were few but there was some indication of a
 REHABILITATION OF APHASIA
Table 27.1
Approaches to aphasia rehabilitation and their theoretical underpinnings
Stimulation Approach
Simulation of inaccessible language mainly through
comprehension exercises that vary only according to the
severity of the aphasic disorder
Behavior Modification Approach
Applies to aphasia therapy based on the principles of
operant conditioning and programed instruction. Shaping
and fading are the most important techniques. Stresses
methodology
Functional Reorganization Approach
Analysis of all the steps underlying the execution of
the impaired task and conscious execution of each
step, with external aids. Conscious substitution
of the impaired link with one from an undamaged
system
Pragmatic Approach
The main goal of therapy is to restore communicative
competence by whatever means: language, gestures, mimic,
drawing, and so forth
Neurolinguistic Approach
Scattered and rather vague suggestions to base therapy
on linguistic principles. Principles of Chomskys
competence-performance dichotomy and
transformation grammar have been used
Neoassociationist or Syndromic Approach
Therapy is still mainly based on stimulation, but more attention
is given to the level of the linguistic disorder (phonemic,
lexical, or syntactic) and therapy varies according to the type
of aphasia. Much research on aphasia therapy effectiveness
Cognitive Neuropsychological or Impairment-based
Approach
Therapy targets the damaged sub-component(s) of
language, as inferred from a model of normal language
processing
Social or Consequences-based Approach
Therapy aims to reduce whatever barriers prevent aphasic
people from using language and communication to
participate in life
Modified from Basso A (2003). Aphasia and its Therapy, by permission of Oxford University Press.
consistency in the direction of results which favoured
the provision of speech and language therapy (SLT).
However, since the therapeutic interventions were ex-
tremely varied (conventional, group treatment, com-
puter-mediated), the number of sessions was low in
five studies (max 48), and trained volunteers delivered
the treatment in two studies it is no wonder that signif-
icant differences were few. The most plausible
explanation is that some treatments delivered for
331
Holistic School
Language is a complex, indivisible psychological function, a
property of the total brain. Aphasia can only vary in severity;
in aphasia, language is not lost but inaccessible
Operant Conditioning
Human behavior is determined by external stimuli; verbal
behavior is not qualitatively different from other behaviors.
Only external stimuli and responses can be studied
scientifically
Luria
Language functions are based on a network of neurological
structures, each playing a different role but all contributing
to correct processing. Aphasia syndromes differ according
to the site of lesion, which interferes with a basic component
of a language function
Pragmatics
Stresses communication and studies the use of
language in context. Views aphasia as a communication
disorder
Neurolinguistics
Analyzes in terms of a linguistic theory the language
impairments that follow brain damage
Neoassociationism
Language is the sum of a number of faculties 
comprehension, production, reading, writing. Damage to
different areas of the brain differently affects verbal
behavior
Cognitive Neuropsychology
Language consists of a series of independent subcomponents
that perform different functions and interact with other
parts of the system. Impaired language performance is
explained in terms of damage to one or more of the
subcomponents in a model of normal language processing
Social Consequences
Aphasia, with its effects on both language and communication,
results in barriers to an individuals ability to participate in
life
sufficiently long times (or sufficient intensity) are effi-
cacious while others are not.
The American Society of Rehabilitative Medicine
(Cicerone et al., 2000, 2005) and the European Federa-
tion of Neurological Societies (EFNS) (Cappa et al.,
2003, 2005) independently conducted systematic re-
views. Cappa et al.s review (2003, 2005) concludes with
a grade B recommendation; Cicerone et al. (2000, 2005)
classify 11 studies in class I. Both reviews reach the
332 A. BASSO ET AL.
conclusion that sufficient experimental evidence exists
to recommend treatment of aphasia.
Moss and Nicholas (2006) studied another variable:
time from onset. They analyzed 23 studies including a
total of 57 patients subdivided into six groups ac-
cording to the time between the morbid event and the
beginning of treatment. Data indicate that the effect
of rehabilitation did not diminish with the passing of
the years, at least until the seventh year.
CONCLUSIONS
As this chapter illustrates, aphasia rehabilitation has un-
dergone many changes since it became widely practiced
after the World War II. Many of these changes have been
the result of increased knowledge in areas such as brain
functioning, learning theory, and the structure of
language. Others have resulted from changing social at-
titudes. Many disciplines, including neurology, linguis-
tics, speech-language pathology, cognitive psychology,
and others, have contributed to the knowledge base that
underlies aphasia rehabilitation. It is highly likely that
knowledge in these areas will continue to evolve, and that
aphasia therapy will continue to evolve as well. Although
it is now quite evident that aphasia therapy is effective, it
remains true that most aphasic people do not fully re-
cover their language. For those engaged in rehabilitation
of aphasia, the goal remains to provide the best possible
therapy based on current knowledge, while always at-
tending to the developing state of knowledge, and incor-
porating new knowledge into their treatment of aphasia.
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