Speech Therapy for Aphasia

Suddenly being unable to express thoughts, or to understand what family members say, is the after-effect of stroke that leaves patients and families most distressed. This condition is aphasia. The questions caregivers ask most often are usually not which treatments exist, but whether therapy for aphasia works, how long it takes to show results and whether it can be done at home. The answers depend less on any single special technique than on two factors that are often overlooked: a sufficient dose of therapy, and building training into real conversation situations. This article uses evidence to explain these two factors, and describes the targeted treatments (SFA, MIT, AAC) and communication strategies for each type of aphasia.

Language disorders and aphasia after stroke

Aphasia damages the ability to understand or express language, and the patient’s intelligence is not affected. The gap between knowing what to say and being unable to say it causes patients a great deal of frustration. A good outcome in rehabilitation is therefore more than a few extra words. It is the patient regaining the ability to talk with family and returning to daily life.

Three common types of aphasia

Aphasia is not a single condition. The types differ in their mechanisms and clinical features, and treatment has to be matched to them. If the treatment is not matched to the type, the best period for recovery can be lost.

Aphasia compared with dysarthria and apraxia of speech

Unclear speech can come from three quite different problems. Telling them apart gives the right direction for treatment. Aphasia is a disorder of language processing, whereas dysarthria and apraxia of speech involve control of speech movements.

Two factors in aphasia recovery: enough training and real-life settings

Many studies reach the same conclusion. The main factors in language improvement for people with aphasia are the total hours, weekly intensity and frequency of therapy, together with training designed around daily function, covering both understanding and expression, with home practice. The treatment method matters, but if the dose of therapy is too low, or the training is detached from real life, even a good method is unlikely to have the expected effect.

In clinical practice, however, there is a gap. Intensive outpatient therapy often leads patients to drop out because of the travelling it involves, which reduces the dose of therapy actually completed. Home visits build the training into the patient’s everyday conversation setting. They keep the training frequent, allow family members to be trained as communication partners and can be combined with independent home practice. This turns the dose that should be achieved into a dose that can be achieved.

Hours, frequency and course of speech therapy for aphasia

The RELEASE individual participant data network meta-analysis (959 participants, 25 trials) gives specific dose parameters, which can guide the planning of therapy.

Recovery time and course in aphasia

The common saying is that the first 6 months after stroke are the golden period, but a more accurate prediction of recovery depends on the severity at onset. The community study by Pedersen et al. (1995) found that the time taken for language function to level off varies with severity, and that the initial severity of aphasia is the only clinically meaningful prognostic indicator.

Treatment methods for different types of aphasia

For the three types above, different evidence-based treatments each have their own strength. SFA focuses on improving word retrieval, MIT helps patients with non-fluent aphasia to restart sentence expression, and AAC keeps up basic communication when language recovery is limited. Each is described below.

Semantic feature analysis (SFA): helping the patient retrieve words

SFA is one of the best-evidenced treatments for naming difficulty (anomia). A randomised controlled trial of 58 people with aphasia compared SFA with phonomotor treatment. After intensive treatment (56–60 hours over 6 weeks), both improved confrontation naming and reaction time straight away, and the SFA group kept shorter reaction times and functional gains during follow-up (Kendall et al., 2019). The core principle of SFA is to guide the patient to retrieve the semantic features around a target word, one at a time.

1. 1
   Set the target word

   First choose a word that the patient cannot say but uses often in daily life, for example “cup”.
2. 2
   Analyse the semantic features

   The therapist guides the patient step by step to think: what group does this object belong to, what is it for, what does it look like and where is it usually used? This helps the brain link up related memories.
3. 3
   Support word retrieval

   After these features are thought of, the patient is guided to say the word, which strengthens the brain’s response in retrieving words.
4. 4
   Repeat and generalise

   Repeated practice consolidates the effect. Research shows, though, that practised words help other, unpractised words only to a limited extent, so words used most often in daily life should be chosen first (Kendall et al., 2019).

Melodic intonation therapy (MIT): using melody and rhythm to support speech

MIT uses the patient’s remaining perception of melody and rhythm. A patient with non-fluent aphasia (such as Broca’s aphasia) first hums the sentence in a song-like way and then moves step by step to normal speech.

Augmentative and alternative communication (AAC): tools for everyday communication

If recovery of the patient’s language is limited, AAC can serve as a compensatory strategy so that the patient can keep expressing personal needs and take part in daily life. A systematic review found that high-tech AAC has the potential to improve communication function and social interaction, but it still faces obstacles in reaching mainstream clinical use, and better research and outcome reporting are needed (Russo et al., 2017).

AAC runs from low-tech to high-tech, and should be matched to the patient’s abilities and situation:

• Low-tech: communication boards and picture systems—These include communication boards, pointing boards, picture exchange systems, writing boards and gestures. They are simple to use and always available.
• High-tech: tablet communication apps—These include tablet communication apps, speech-output devices and text-to-speech software, which let the patient express a wider range of content.
• Use with a communication partner—AAC works better when family members nearby also know how to support it. The purpose of these tools is to help the patient and other people exchange messages in both directions.

Teaching family members to communicate with the patient

A speech therapist can provide only a few hours of therapy each week, and the patient spends most of the rest of the time with family. An updated systematic review of communication partner training included 25 studies, and all 25 reported that the training led to positive change. The authors concluded that communication partner training should be offered in clinical practice to improve partners’ skills in supporting communication with people who have chronic aphasia (Simmons-Mackie et al., 2016). Including family members in the treatment is therefore a core intervention, and an optional extra.

Benefits of home speech therapy for aphasia recovery

Back to the two factors stressed in this article, a sufficient dose and real-life situations. Home speech therapy has a structural advantage in both, because the therapy is built straight into the setting of the patient’s daily conversation and routines.

Frequently asked questions

Aphasia rehabilitation often needs other professional services to be carried out in full. You can read more about treatment for swallowing difficulty and how it deals safely with eating problems, and about the advantages of home speech therapy and how it uses generalisation to carry training results into real life. Our home speech therapy service covers all of these areas.