Aphasia is a neurogenic acquired language disorder characterized by difficulties in understanding and producing spoken or written messages, resulting from lesions in the brain regions responsible for language processing. While aphasia predominantly occurs in adults, it may occasionally affect children due to cerebral disorders.[1] This disorder encompasses a wide range of communication challenges, impacting speech, comprehension, reading, and writing abilities. The most common cause of aphasia is stroke, although it can also arise from head trauma, brain tumors, or other neurological issues. The communicative impairments associated with aphasia can vary in severity, ranging from mild word-finding difficulties to a complete inability to communicate.[2]
Aphasia occurs in about 25 to 40% of individuals following a stroke. Each year, approximately 180,000 individuals in the United States are diagnosed with aphasia, and around two million individuals live with this condition. Despite being more common than Parkinson’s disease, cerebral palsy, and muscular dystrophy, awareness about aphasia remains surprisingly low.[3]
The symptoms of aphasia can vary based on the location and extent of brain damage, the severity of the impairment, and its impact on functional communication. Individuals with aphasia may experience various speech disorders, including anomia (difficulty in recalling words), jargon (producing meaningless sentences or expressions), phonemic paraphasias (incorrect vocalizations, such as saying “brus” instead of “brush”), semantic paraphasias (substituting one word for another within the same category, such as saying “paper” instead of “pen.”), and syntactic errors (arranging words in the incorrect order). Additionally, there may be deficits in auditory comprehension, manifesting as difficulty understanding spoken messages, the need for extra time to process information, struggles with long sentences that contain complex grammar or fast speech, inability to recognize errors in one’s speech and difficulty interpreting phrases with figurative meanings. Additionally, two other disorders commonly associated with aphasia are alexia, characterized by difficulties in reading comprehension, and agraphia, marked by impairments in written expression. These conditions may manifest independently or concurrently in individuals with aphasia.[4]
Aphasia can be classified based on several factors, including the anatomical location of the brain lesion, the ability to comprehend spoken language, and the fluency of speech. Currently, the classification that focuses on speech fluency is more widely accepted.[5] This categorizes aphasia into two main types: fluent and non-fluent aphasias. Non-fluent aphasias include Broca’s aphasia, transcortical motor aphasia, mixed transcortical aphasia, and global aphasia. On the other hand, fluent aphasias comprise Wernicke’s aphasia, transcortical sensory aphasia, anomic aphasia, and conduction aphasia.[6]
Speech and language therapists are essential in addressing the communication challenges faced by individuals with aphasia. They are responsible for screening and diagnosing those with aphasia, establishing and implementing appropriate intervention goals and strategies, and providing counseling to families.[7]
Speech and language therapists conduct comprehensive assessments to identify both the modalities where individuals with aphasia struggle to communicate and those where they find ways to compensate.[4] Aphasia assessment is the initial step in a structured intervention program.[8] Aphasia assessment tools can be categorized into two types: screening tests and comprehensive tests. The Gülhane Aphasia Test-2 (GAT-2) is a commonly used screening test in Türkiye by speech and language therapists.[9] For a comprehensive assessment, the Aphasia Language Assessment (ADD) test is utilized.[8] Additionally, the Turkish Version of the Comprehensive Aphasia Test (CAT-TR) is utilized.[10]
The primary goal of aphasia therapy is to enhance the individual’s impaired communication skills to the best possible level. Therapy must be tailored to each individual’s educational background, personal history, and cultural and linguistic differences. Therapists should concentrate on the areas of strength in individuals with severe aphasia while also recognizing the impaired regions that may be overlooked in those with mild aphasia. The goals of aphasia therapy can differ, focusing on either intervening disorder or enhancing functional language skills through compensatory strategies.[4]
The World Health Organization (WHO) defines health as complete physical, mental, and social well-being, not merely the absence of disease or disability.[11] Conventional therapy approaches often focus primarily on individuals' neurological, linguistic, and cognitive impairments, often overlooking aspects of well-being as defined by the WHO.[12] As a result, individuals with aphasia may struggle to carry over the skills they gain from therapy in real-life situations. Disorder-based therapy approaches classify aphasia as a language disorder, which leads to therapy content that is heavily language-oriented. In contrast, activity and participation-based approaches propose that aphasia is a psychosocial disorder. These approaches argue that communication skills and language are adversely affected and that therapy should target the barriers preventing individuals with aphasia from utilizing these skills in their daily lives.[13]
In this context, approaches prioritizing activity and participation, focusing on individuals’ involvement in life rather than solely on their impaired language skills, are gaining attention. In this review, we discuss both international and national literature on these activity and participation-based approaches and seek to raise awareness about aphasia among individuals with the condition and their communication partners in the society. Additionally, we aim to enhance the communication skills and quality of life of individuals with aphasia by guiding speech and language therapists on effective compensatory strategies. Furthermore, we intend to illuminate future research possibilities in this field. The review of national literature revealed a lack of prior research aligned with the objectives of this study. By compiling and analyzing studies that investigate the effectiveness of activity participation-based approaches for individuals with aphasia, this research would fill a significant gap in the field and serve as a valuable resource.
APHASIA THERAPY WITHIN THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH FRAMEWORK
Aphasia is a complex disorder which adversely impacts an individual’s ability to communicate, leading to difficulties in social interactions and a diminished quality of life. This condition can create challenges for both people with aphasia (PWA) and their family and friends.[14] The International Classification of Functioning, Disability, and Health (ICF), published by the WHO[15] provides a standardized language and framework for health professionals and researchers. The ICF framework consists of two main components: Functioning and Disability and Contextual Factors.[4] The Functioning and Disability component includes Body Structures and Functions, as well as Activity and Participation. The Contextual Factors component encompasses environmental and personal factors (Figure 1).[15]
Body structures and functions encompass the anatomical, physiological, and psychological states of an individual. Activity and participation refer to interactions in social life, as well as movement, production, care, and learning. Contextual factors include environmental influences, family dynamics, work settings, social clubs, beliefs, and cultural elements. Personal factors encompass aspects such as sex, race, education level, age, and temperament.[4]
According to this classification, there are two types of approaches used in aphasia intervention: Disorder-Based Approaches and Activity-Participation-Based Approaches.[4] This review study discusses activity and participation-based approaches.
Activity and participation-based approaches in aphasia
Activity and participation-based approaches aim to remove the communication barriers associated with aphasia. These approaches involve not only the individuals with aphasia, but also other participants in the intervention process. They focus on creating the necessary environmental conditions for effective communication. According to the ICF, the activity domain considers the context and environment in which an individual’s communication occurs, while the participation domain considers the conversation partner of the person with aphasia.[16]
According to the American Speech-LanguageHearing Association (ASHA), intervention programs that fall under Activity and Participation-Based Approaches are categorized as Conversation Partner Training and Multimodal Training.[4] The following section of the study would explore these intervention programs and review the effectiveness of these approaches as documented in both international and national literature.
Conversation partner training
Conversation partner training is an intervention method based on a social approach. This training is designed to enhance the social communication and life participation skills of PWA. This method focuses on training family members, neighbors, friends, health workers, volunteers, and students, namely “communication partners” who have contact with those affected by aphasia. The primary goal of this approach is to help individuals with aphasia recognize their role in social life and to encourage their participation in social activities which align with their interests.[17] The intervention programs associated with Conversation Partner Training are as follows:[4]
• Conversational Coaching (CC)
• Supported Conversation for Adults with Aphasia (SCA)
• Supporting Partners of People with Aphasia in Relationship and Conversation (SPPARC)
Conversational coaching
Conversational coaching was developed to provide information about stroke and aphasia to the relatives of individuals with aphasia, particularly in the early stages of the condition. It aims to support the recovery process during this initial period and, in the chronic stage, to teach verbal and nonverbal strategies that enhance communication between the PWA and their conversation partners.[18] This method is applied within a conversational context involving the PWA and their primary conversation partner. Engaging in daily living activities, such as answering the phone, relaying messages, describing interesting situations on television or radio, or sharing memories, can be challenging for the PWA and their partners. The main goal of CC is to equip the PWA with alternative strategies to convey their messages effectively and help their partner learn techniques that facilitate communication, ensuring a more effective interaction. This approach can alleviate frustrations and enhance future communication success.[18] The clinical rationale for this approach is as follows:[19]
1. Learning to live with aphasia takes time; it is unrealistic to expect immediate adjustments after a stroke.
2. Aphasia impacts not just the individual affected, but also all family members who are living with them.
3. Given the chronic nature of aphasia, individuals and their families must learn to integrate it into their daily lives.
In studies on CC, individuals with severe to moderate aphasia participated alongside healthy conversation partners. The CC sessions were conducted twice a week, lasting approximately 50 to 75 min each. The results indicated that CC was effective in several ways. There was a significant increase in the number of successfully communicated messages following the intervention. The PWA and their conversation partners reported improved perceptions of various communication methods. Additionally, there was a decrease in paraphasias in the speech of individuals with aphasia and positive effects on the quality of life for both individuals with aphasia and their conversation partners were observed.[20-22]
Supported conversation for adults with aphasia
The supported conversation for adults with aphasia is an evidence-based intervention program developed using data collected from interactions between volunteers and individuals with aphasia at the Aphasia Centre in North York, Canada.[23] This program aims to alleviate the psychosocial challenges associated with aphasia by fostering effective conversation partnerships. The program emphasizes the importance of training PWA and their communication partners, including family members, friends, neighbors, health professionals, and volunteers. By equipping both individuals with appropriate communication strategies and resources, SCA promotes a collaborative approach to communication, where the responsibility for effective interaction is shared. This method encourages both the PWA and their communication partner to support each other, thereby enhancing overall communication experiences.[24,25]
Individuals with aphasia may face barriers to their essential treatment due to challenges in communicating with healthcare personnel. These barriers can include difficulties in exchanging information, encountering negative attitudes from staff, or having communication partners who lack the necessary qualifications.[26] Of note, SCA promotes the idea that PWA have the right to communicate effectively. In this framework, a communication partner and appropriate speech resources serve as a “communication ramp” for individuals with aphasia. This concept is akin to the use of aids, such as wheelchairs or walkers, for individuals with physical disabilities who cannot fully regain their normal functions through therapy. For PWA, the communication ramp consists of a conversation partner and appropriate speech resources. The theoretical foundations of SCA include the following:[24]
1. It is essential to create opportunities for interaction with PWA to prevent them from being seen as cognitively or socially inadequate and to highlight their existing competencies.
2. Observations show that individuals with aphasia at the Aphasia Center are often hesitant to engage in conversations due to a fear of being perceived as incompetent or foolish.
3. These individuals should not be deprived of opportunities for communication, which are vital for their psychosocial well-being. This includes interactions with their doctors and being involved in decision-making in their daily lives.
4. The skills of speech partners, who play a key role in enhancing the communication access of individuals with aphasia, need to be improved.
Supported Conversation for Adults with Aphasia is based on “Accepting Competence” and “Revealing Proficiency”. Accepting competence refers to techniques which demonstrate the recognition that the PWA is naturally competent, while eliciting proficiency refers to techniques that facilitate the exchange of information, opinions, and feelings between the person with aphasia and conversation partners.[27]
The first step of SCA is a small group training workshop under the instruction of a speech-language pathologist experienced in this approach. The other steps are called practical training, apprenticeship, and continuing education. The training workshop prioritizes working with individuals with severe aphasia, who are thought to be most in need of the SCA approach and also aims to help conversation partners discover that they can have conversations with individuals with severe aphasia.[24]
In SCA researches, participants were predominantly individuals with severe Broca’s aphasia and their conversation partners, mostly students and healthcare professionals. The findings of the studies showed that SCA was effective in enabling individuals with aphasia and their partners to use more effective strategies in communication.[28,29]
Supporting partners of people with aphasia in relationship and conversation
Supporting partners of people with aphasia in relationship and conversation was developed in 2001 by Lock, Wilkinson, and Bryan from the Department of Speech and Language Therapy at University College London.[30] This program adapted Conversation Analysis (CA) techniques to use in clinical settings.[31] The CA techniques emphasize the importance of video feedback in the success of the therapy, aiming to train both the communication partner and the PWA to enhance speech and minimize behaviors that hinder communication.[32] According to the researchers, the theoretical justifications for SPPARC are as follows:[31]
1. Aphasia necessitates psychosocial adjustments for both PWA and their partners. Addressing the psychosocial needs of these partners is crucial for overcoming communication barriers.
2. The use of CA in aphasia therapy is believed to directly target the daily conversations of individuals with aphasia and their partners. This approach may lead to positive changes in their interactions.
The SPPARC intervention consists of two main components: the Supporting Program and the Communication Training Support Program. The Supporting Program aims to provide information about aphasia to the relatives of individuals affected by the disorder. It offers psychosocial support and facilitates interaction among family members facing similar challenges through group training sessions. These group sessions can only be led by a qualified professional, such as a speech-language pathologist, a social worker, or a clinical psychologist. The Supporting Program is conducted once a week for eight weeks, with each session lasting 30 to 35 min.[30]
Conversational analysis was utilized in aphasia therapy through the Conversational Training Program. Rather than analyzing participants’ speech based on individual words, sentences, or speech acts, the program focuses on their behaviors and interactions during conversations. The speech assessment in this intervention program is conducted in six steps.[31]
The SPPARC studies primarily involved individuals with mild to moderate aphasia and their healthy relatives. The results indicated that SPPARC, which consisted of sessions lasting between 45 min to 2 h, conducted one to two times a week throughout six to eight weeks, resulted in positive changes in the speech behaviors of the participants. Additionally, the Supporting Program helped reduce the caregiving burden for relatives of individuals with aphasia and improved their overall quality of life.[30,33,34]
Multimodal treatment
Multimodal treatment emphasizes the use of diverse and effective strategies, such as writing, drawing, reading, gestures, and music, to convey messages. The primary goal of these therapies is to enhance speech output, prioritizing methods which support this objective. However, when improvements in speech output are limited or unattainable, the use of compensatory techniques become a secondary goal.[35] Multimodal treatment includes various approaches and methods:[4]
• Gestural Facilitation of Naming (GFN)
• Visual Action Therapy (VAT)
• Promoting Aphasics’ Communicative Effectiveness (PACE)
• Augmentative and Alternative Communication (AAC)
Gestural facilitation of naming
Gestural facilitation of naming originated from a process known as “cross-systems gestural reorganization,” which utilizes existing gestural skills to restore functionality to a degraded language system.[36,37] There are various types of gestures, including deictic gestures, iconic gestures, pantomimes, and emblems. Compensatory communication primarily depends on iconic and pantomime gestures. Iconic gestures are symbolic movements, such as a thumbs-up signifying “okay” or a side-to-side wave of the hand representing a “greeting.” In contrast, pantomimes involve using gestures to symbolize actions, like eating with a fork or stirring tea.[38]
For individuals with aphasia, gestures are explored as an alternative and complementary method to verbal expression that can enhance communication skills[38] and reduce difficulties in finding words.[37] Research indicates that healthy individuals across all cultures and age groups commonly use gestures. They are considered innate, and interestingly, even those who are visually impaired tend to use gestures while speaking, despite not being able to see the gestures of others. It is also accepted that infants use gestures before they learn to talk, and these gestures can serve as predictors of language acquisition.[39] In this context, gestures can be a supportive communication method when verbal language fails.[38]
Individuals with aphasia who have damage to the left hemisphere often experience limb apraxia, which can hinder their ability to use gestures for effective communication. As a result, gesture training is an important focus in aphasia treatment in GFN.[38] Research has indicated that training in gesture use is effective for improving the recall of nouns and action words.[37]
In the GFN intervention, two modalities are used: “gestural” and “verbal”, which follow the same hierarchy. When needed, the verbal modality can be substituted with the written modality. The intervention comprises three steps, with each therapy session allocating equal time to each step:[40]
1. In the first stage of therapy, PWA are encouraged to associate gestures and words with corresponding pictures
2. The PWA is expected to produce the gesture or phrase that corresponds to the picture shown by the therapist
3. The PWA is also expected to generate goals that are unknown to the therapist. The therapist should first identify these goals from a field of irrelevant goals, followed by a field of relevant goals.
In the studies on Gestural Facilitation of Naming, most participants were individuals with Broca’s aphasia, alongside healthy individuals. Nearly 50% of the individuals with aphasia also demonstrated limb apraxia. The GFN approach consists of eight to 10 sessions, each lasting about 1 h, and is conducted one to two times a week. Research has shown that this approach is effective in improving word-finding skills for PWA.[41,42]
Visual action therapy
Individuals with global aphasia often experience significant difficulties with nonverbal expression skills, such as gesturing and drawing, as well as severe challenges in producing and understanding verbal and written language.[43] Visual Action Therapy is a therapeutic approach designed specifically for individuals with global aphasia. It focuses on conveying messages through single gestures, utilizing representative gestures instead of spoken words.[40]
The VAT consists of three programs, and each program is divided into three steps. Participants get points based on their answers: 1 point for completely correct answers, 0.5 points for partially correct answers, and 0 points for incorrect answers. The programs and steps of the VAT are outlined as follows:[43]
1. Matching objects with the picture they present
a. Placing objects on pictures
b. Placing pictures on objects
c. Pointing to and showing objects
d. Pointing to and showing pictures
2. Teaching the appropriate use of objects through modeling by the therapist
3. The therapist puts an action picture and an object in front of the client, and the client shows how to use the object as in the picture (This step is not scored).
4. The client finds and matches the action picture shown by the therapist from the seven objects in front of the client and uses that object appropriately
5. Showing the client that the pantomimed movements can represent objects (This step is not scored).
6. The client finds/points out which object from a set of seven objects the pantomime movements produced by the therapist point to.
7. When each picture is shown, the client describes the object by producing appropriate pantomime movements.
8. The therapist places two objects in front of the client and asks the client to pantomime hiding them. The therapist then removes one object from its hiding place and demonstrates its function. (This is intended for teaching purposes, not for scoring.)
9. The therapist presents two objects to the client and requests that the client pantomime hiding these objects. Afterward, the therapist asks the client to explain the function of the other hidden object using gestures while revealing one of the objects from its hiding place.
In the final stages of VAT, symbols and gestures are used instead of real objects, allowing individuals with aphasia to develop an alternative means of communication.[40]
Studies on VAT have been conducted with individuals primarily suffering from Global aphasia and Wernicke’s aphasia. These sessions typically lasted for an average of 10 weeks, occurring three to five times a week, with each session ranging from 30 to 45 min. The findings from these VAT studies indicate that individuals with severe aphasia can learn to employ alternative symbol strategies to facilitate communication.[44,45]
Promoting aphasics’ communicative effectiveness
Another compensatory method used in aphasia intervention is the Promoting Aphasics’ Communicative Effectiveness approach.[40] The PACE is appropriate for both fluent and non-fluent individuals who have various types and degrees of aphasia. The approach is based on two main assumptions:[46]
1. Most individuals with aphasia can communicate.
2. Natural speech can present communication challenges for these individuals.
The goal of the therapy is to enhance the ability of individuals with aphasia to communicate specific messages using all available communication skills during natural conversations with their therapist.[40] The PACE method is based on four key principles:[46]
1. Equal participation: Both the therapist and the client should have an equal number of turns as speaker and listener, adhering to the turn-taking rules commonly found in everyday conversation.
2. New information: It is crucial for the messages exchanged between the therapist and the client to contain new information. This allows the listener to focus more effectively on the incoming message.
3. Method selection: Communication partners are free to choose the method of communication they will use to convey their messages.
4. Natural feedback: The receiver of the message should provide feedback to ensure they understand the sender’s intent. Errors in language should not be emphasized.
The PACE method operates based on four key principles, where both the therapist and the client take turns describing a picture. During the activity, pictures are sequentially taken from a stack that is placed face down on the table. The individual describing the picture must use available communication methods to explain it to the listener. More importantly, the therapist should not be aware of which picture the client is attempting to describe.[40]
Most studies focusing on PACE have primarily involved individuals with Broca’s aphasia. Due to the varying durations of PACE application in the reviewed studies, it is not possible to make broad generalizations regarding its length of effectiveness. However, the findings suggest that PACE therapy is effective in enhancing the communication skills of individuals with aphasia.[47,48]
Augmentative and alternative communication
Over the last three decades, augmentative and alternative communication has become an important therapy option, particularly for individuals with severe aphasia.[49] This option includes various nonverbal communication methods that can supplement or replace spoken language, facilitating effective communication and rehabilitation for those with aphasia.[50]
Augmentative and alternative communication can be defined as any communication system that augments (adds to) or serves as an alternative (substitutes for) natural language, helping individuals achieve their communication goals.[51] It is considered augmentative when it supports a person’s existing speech, alternative when it replaces speech that is either dysfunctional or absent, and temporary when it is used by patients in intensive care.[4]
The AAC approaches are designed to utilize enhanced input to help individuals with aphasia effectively use and comprehend their existing language skills. They also aim to train communication partners through written and visual methods.[4] Various low-tech tools, such as communication notebooks, communication wallets, and communication boards featuring letters or photographs, are employed alongside high-tech options like software applications available on phones, tablets, or laptops.[51] While selecting these resources, it is of utmost importance to consider the individual’s cognitive abilities, attention span, visual acuity, and manual dexterity.[47]
Studies on AAC have primarily focused on individuals with global aphasia. The application of AAC approaches varies, and as a result, there are no definitive conclusions regarding the duration of use. However, research indicates that AAC is effective in supporting individuals with aphasia to manage their linguistic challenges and in developing skills that promote active participation in social life.[52-54]
In conclusion, this review compiled findings from national and international effectiveness studies on activity and participation-based approaches in the field of aphasia. Three main programs were introduced under the title of Conversation Partner Training: CC, SCA, and SPPARC. Additionally, several methods were categorized under the title of Multimodal Treatment: GFN, VAT, PACE, and AAC. Effectiveness studies for each of these approaches were included.
Within the realm of Conversation Partner Training, CC was found to be effective for individuals with aphasia and their spouses or caregivers. The SCA proved beneficial for others who communicate with individuals with aphasia, such as neighbors, friends, family members, healthcare professionals, and volunteers. In particular, the SPPARC was effective for individuals with aphasia and their family members.
Regarding the Multimodal Treatment, the study revealed that GFN and PACE methods were more effective for individuals with Broca’s aphasia, whereas the AAC method was beneficial for individuals with Global aphasia. The VAT method was effective for those with both Global aphasia and Wernicke’s aphasia.
Taken together, the results suggest that activity and participation-based studies effectively reveal the existing language proficiency of individuals with aphasia. They promote a more active participatory role in communication, reduce stress and depression symptoms in communication partners, lessen care burden, and establish more effective communication between individuals with aphasia and their partners. Ultimately, these approaches contribute to an improved quality of life for both individuals with aphasia and their partners.
FUTURE DIRECTIONS
This study serves as a general overview, and it is believed that conducting a systematic review of the current issue would provide valuable insights from the literature to professionals in the field of speech and language therapy.
The findings indicate a need for more research focused on activity and participation-based approaches. Only two studies on this topic were identified, particularly at the national level. It is recommended that additional research be conducted on activity and participation-based approaches, as they are crucial for developing diverse communication methods for individuals with aphasia. Such studies should aim to identify their competencies and help them communicate more effectively with their communication partners, across various types of aphasia and involving a larger number of participants.