Aphasia

Aphasia is an acquired neurogenic language disorder resulting from an injury to the brain,
typically the left hemisphere that affects the functioning of core elements of the language
network. Aphasia involves varying degrees of impairment in four primary areas:

 spoken language expression

 written expression
 spoken language comprehension
 reading comprehension

Aphasia may also result from neurodegenerative disease. For example, primary progressive
aphasia is a subtype of frontotemporal dementia in which language capabilities become
progressively impaired.
Aphasia is often described as nonfluent or fluent, based on the typical length of utterance and
amount of meaningful content a person produces. There are various subtypes of aphasia within
these two categories based on differences in other aspects of expressive and receptive language
skills. Clinicians should be aware that a person’s presentation may not fit into a single aphasia
type or subtype, and should use care if designating a type or subtype. Aphasia’s presentation may
also change over time as communication improves with recovery.
The recovery arc of aphasia varies significantly from person to person. The most predictive
indicator of long-term recovery is initial aphasia severity, along with lesion site and size.

Incidence and Prevalence

Incidence of aphasia refers to the number of new cases identified in a specified time period.
Prevalence of aphasia refers to the number of people who are living with aphasia in a given time
period.
It is estimated that roughly 100,000–180,000 people acquire aphasia each year in the United
States (Ellis et al., 2010; National Aphasia Association, n.d.). Additional data suggest that 2–4
million people in the United States are living with aphasia (National Aphasia Association, n.d.;
Simmons-Mackie, 2018).
Aphasia can occur because of traumatic brain injury (TBI), brain tumor, infection, dementia, or
other neurodegenerative diseases. However, it is most commonly seen in individuals post-stroke.
Data suggest that roughly 25%–50% of all strokes result in aphasia and that it is more common
in older. Fifteen percent of individuals under the age of 65 years’ experience aphasia after their
first ischemic stroke. This percentage increases to 43% for individuals 85 years of age and older
(Engelter et al., 2006).
Very few statistics are available regarding the incidence and prevalence of TBI-induced aphasia.
One study conservatively found that aphasia secondary to TBI occurred in 1% of veterans of the
Iraq and Afghanistan wars (Norman et al., 2013), and two additional studies found that aphasia
occurred in 13%–19% of individuals with TBI (Hoofien et al., 2001; Safaz et al., 2008).
Signs and Symptoms
Aphasia symptoms vary in severity of impairment and impact on functional communication,
depending on factors such as the location and extent of damage and the demands of the
communication environment. Aphasia may include deficits in verbal expression and auditory
comprehension deficits as well as reading and writing deficits. Anomia, or difficulty retrieving
words, is essentially universal across all individuals with aphasia (Laine & Martin,
2006). Alexia is the term for reading comprehension difficulties, and agraphia is the term used
for written expression difficulties. Alexia and agraphia can occur together or in isolation.
Common signs and symptoms of aphasia can include any of the following:

 impairments in spoken language expression including:

o having difficulty retrieving words (i.e., anomia)
o fluently combining nonmeaningful and/or real words to generate sentences or
phrases that lack semantic meaning (i.e., jargon)
o creating novel words that are not meaningful or recognizable to the listener
(i.e., neologisms)
o substituting sounds (e.g., “wishdasher” for “dishwasher”). These are known
as phonemic paraphasias.
o substituting words (e.g., “table” for “bed,” “bird” for “chicken”). These are
known as semantic paraphasias.
o omitting function words (e.g., “the,” “of,” and “was”). This is known
as telegraphic speech.
o lacking awareness of errors
o making grammatical errors, such as omitting grammatical markers or using them
incorrectly
o speaking haltingly or with effort
o speaking in single words or short fragmented phrases
o making syntax errors, such as putting words in the wrong order
 impairments in spoken language comprehension, including:
o having difficulty understanding spoken utterances
o requiring extra time to understand spoken messages
o having difficulty understanding complex grammar (e.g., passive sentences such as
“The dog was chased by the cat”)
o having difficulty understanding long or rapidly presented speech (e.g., television
program, complex conversation)
o having difficulty understanding spoken language without supporting visual
information (e.g., telephone, radio)
o having difficulty interpreting nonliteral language (e.g., “It’s raining cats and
dogs”)
o lacking awareness of errors
 agraphia, or impairments in written expression including:
o having difficulty writing, typing, or copying letters, words, and sentences
o writing single words only
o substituting incorrect letters or words
o spelling or writing nonmeaningful syllables or words
 o writing sentences with incorrect grammar or syntax
 alexia, or impairments in reading comprehension, including:
o having difficulty recognizing words by sight or comprehending written material
of any length
o having difficulty sounding out words or associating sounds with letters
o misinterpreting the meaning of written words (e.g., interpreting “couch” as chair)
o having difficulty reading function words (e.g., articles, prepositions, pronouns)

Causes
Aphasia is caused by damage to the language network of the brain. Aphasia typically results
from left-hemisphere damage. However, in rare instances, aphasia can occur with a right-
hemisphere lesion. This happens most often in people who are left-handed because left-handed
individuals are more likely to have language networks that are bilateral or that are located in the
right hemisphere (Szaflarski et al., 2002). When a right-hemisphere lesion causes aphasia in
someone who is right-handed, this is referred to as crossed aphasia.
Common causes of aphasia include the following:

 stroke
o ischemic—caused by a blockage that disrupts blood flow to a region of the brain
o hemorrhagic—caused by a ruptured blood vessel that damages the surrounding
brain tissue
 traumatic brain injury
 brain tumors
 brain surgery
 brain infections

Roles and Responsibilities

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis,
and treatment of persons with aphasia.
Appropriate roles for SLPs include, but are not limited to, the following:

Assessment
 Screening individuals who present with language and communication difficulties and
determining the need for further assessment and/or treatment.
 Diagnosing and documenting the presence or absence of aphasia.
 Referring to other professionals to rule out other conditions and to facilitate access to
comprehensive services.

Counseling and Education

 Counseling people with aphasia and their care partners about communication and related
issues and facilitating participation in social and community contexts.
  Providing prevention information to individuals and groups known to be at risk for
conditions that cause aphasia.
 Educating other professionals and the public on the needs of people with aphasia and the
role of SLPs in diagnosing and managing aphasia.
 Connecting families with long-term resources for living with aphasia.

Treatment
 Conducting thorough culturally and linguistically relevant services related to language
and communication.
 Developing person-centered treatment plans, providing treatment, documenting progress,
and determining appropriate dismissal criteria in collaboration with the patient and the
treatment team.
 Serving as an integral member of a collaborative team that includes physicians, other
professionals (e.g., nurses and case managers, neuropsychologists, occupational and
physical therapists, audiologists), and the patient and their care partners.
 Implementing and supporting appropriate communication systems at all stages of
recovery.

Assessment
See the Assessment section of the Aphasia Evidence Map for pertinent scientific evidence,
expert opinion, and client/caregiver perspectives.
Assessment can be static (i.e., using procedures designed to describe current levels of
functioning within relevant domains) and/or dynamic (i.e., an ongoing process using hypothesis
testing procedures to identify potentially successful intervention and support procedures).
Assessment protocols can include both standardized and nonstandardized tools and data sources.
When conducting screening and assessment for people with aphasia, SLPs consider several
factors, including the following:

 language(s) and dialect(s) used

 concurrent motor speech impairment (i.e., dysarthria, apraxia)
 presence of limb apraxia and/or oral apraxia
 hearing status and auditory agnosia (inability to process sound meaning)
 concurrent cognitive impairment
 visual acuity deficits, visual agnosia, and visual field cuts
 upper extremity hemiparesis (may affect the ability to write, point, and gesture)
 presence of chronic pain from either preexisting or new conditions
 presence or history of mental health disorders (e.g., anxiety, depression)
 endurance and fatigue (testing may need to be broken into shorter sessions)

These factors may have an impact on screening and assessment and are considered during the
evaluation. For example, if the individual with aphasia wears glasses (prescription or
nonprescription), hearing aids, or dentures, then these devices should be worn during assessment
if applicable prescriptions are still appropriate. Hearing and/or visual deficits may exist prior to
the onset of aphasia or may be present as a result of the neurological event that caused aphasia.
Physical or environmental modifications (e.g., large-print material, modified lighting,
amplification devices) may assist SLPs with diagnosing language deficits in the presence of such
co-occurring factors.

Screening
Screening is a procedure for identifying the need for further assessment and does not provide a
detailed description of the diagnosis, severity, and characteristics of aphasia. Screening is a
valuable tool that helps health care providers make appropriate referrals to speech-language
pathology services. Screening is conducted in the language(s) used by the person, with
sensitivity to cultural and linguistic diversity.
Screenings are completed by the SLP, the speech-language pathology assistant, or other trained
professionals. Standardized and nonstandardized methods are used to screen oral motor
functions, speech production, expressive and receptive language, cognitive communication, and
hearing.
Screening may result in

 a recommendation for monitoring;

 a recommendation for comprehensive speech, language, swallowing, or cognitive-
communication assessments; and/or
 a referral for other examinations or services.

Comprehensive Assessment
Consistent with the World Health Organization’s (WHO) International Classification of
Functioning, Disability and Health (ICF) framework (ASHA, 2016; WHO, 2001), a
comprehensive assessment is conducted to identify and describe

 impairments in body structure and function, including underlying weaknesses in

expressive and receptive language that affect communication performance;
 comorbid deficits, such as other health conditions and medications that can affect
communication performance;
 limitations in activity and participation, including changes in, and impact on,
functional status in communication and interpersonal interactions;
 environmental and personal factors that serve as barriers to, or facilitators of,
successful communication and life participation; and
 the impact of communication impairments on quality of life, functional limitations
relative to the individual’s premorbid social roles, and the impact on their community.

Typical Components of Aphasia Assessment

Case History
Include information from medical records, self-reports/interviews, or clinician observations, such
as the following:
  medical history and recent medical status, including vision and hearing
 mental health history
 education and health literacy level
 work history
 hobbies and personal interests
 cultural and linguistic backgrounds
 typical communication environments (e.g., where, how, and why someone
communicates)
 knowledge of aphasia and communication strategies
 perception of functional communication status
 current status and the desired outcome of engagement with varied communication
partners and home, vocational, and community-based activities
 language(s) used in various communication environments
 preferences and goals

Motor Speech Examination

Facilitate a differential diagnosis of apraxia and dysarthria through an assessment of articulatory
processes, including rate, amplitude, accuracy, and consistency of movement. For further
information, see ASHA’s Practice Portal pages on Acquired Apraxia of Speech and Dysarthria in
Adults.
Language
Assess expressive and receptive skills in spoken/signed and written language of increasing
complexity across a variety of contexts (e.g., social, educational, vocational). Language
assessment supports aphasia classification and identifies facilitating strategies.
Specific language skills to consider include the following:

 word, sentence, and paragraph comprehension (spoken/signed and written)

 naming
 repetition
 spontaneous speech
 discourse
 word, sentence, and paragraph writing
 gestures

Environmental and Personal Factors

Include factors that may impact treatment and recovery, such as

 support from family, care partners, and the community;

 communication partners’ knowledge of, and capacity to use, facilitating strategies;
 feasibility and acceptance of compensatory strategies;
 personal capacity to return to the previous level of engagement and communication
ability;
 social determinants of health that impact access to services; and
  comorbidities such as cognitive impairments, visual and motor impairments, depression,
and/or other chronic conditions.

Differential Diagnosis
The identification and differential diagnosis of co-occurring impairments (e.g., cognitive-
communication deficits, dysarthria, or acquired apraxia of speech) aid in planning an appropriate
treatment plan. Clinicians consider the severity and subtype of aphasia (e.g., Broca’s,
Wernicke’s, anomic) in addition to the functional impact of the communication disorder when
selecting intervention strategies and counseling patients and their care partners.
Assessment Results
Assessment may result in one or more of the following:

 diagnosis of a language or other communication disorder (e.g., dysarthria, acquired

apraxia of speech, cognitive-communication disorder)
 description of the characteristics, severity, and functional impact of the language disorder
 prognosis for change (in the individual or in relevant contexts)
 recommendations for intervention, support, and community resources
 a referral for other assessments or services

Treatment
See the Treatment section of the Aphasia Evidence Map for pertinent scientific evidence, expert
opinion, and client/caregiver perspectives.
Aphasia treatment is individualized to address the specific areas of need identified during
assessment, including goals identified by the person with aphasia and their care partners.
Person- and family-centered care is a collaborative approach grounded in a partnership
between the person with aphasia, their care partners and support network, and their clinicians.
Each party is equally important in the relationship, and each party respects the knowledge, skills,
and experiences that the others bring to the process.

Planning Treatment
Social and Cultural Factors
Views on the natural aging process and understanding of disability vary by culture. Cultural
views and preferences may not be consistent with medical approaches typically used in the U.S.
health care system. It is essential that clinicians acknowledge and incorporate the perspective of
the person with aphasia and their care partner(s) when sharing potential treatment
recommendations and outcomes. Clinical interactions should be approached with cultural
responsiveness. Consider dialectal and cultural background when choosing stimulus items and
providing models for expressive language.

Linguistic Factors
Recovery of language may vary depending on the type of aphasia, how languages were acquired
(simultaneously or sequentially), the degree of proficiency in each language, and demands for
the use of each language. SLPs consider the language(s) that an individual uses in their home as
well as in other environments (e.g., social settings, work) when selecting the language(s) for
treatment. Treatment occurs in the language(s) used by the person with aphasia—either by a
bilingual SLP or through collaboration with interpreters, when necessary.
In addition to considering these questions, clinicians may need to consult with another
professional, such as a bilingual SLP, a cultural/language broker (a person trained to help the
clinician understand the person’s cultural and linguistic background to optimize treatment), an
interpreter, and/or a translator. The clinician may need to provide additional training about what
types of errors might be expected; what information would be important to note (e.g.,
paraphasias, neologisms, absence of functors); and what kind of prompting should be used or
avoided.

Treatment Techniques
Brief descriptions of both general and specific treatment options for individuals with aphasia are
provided below. This information is not exhaustive, nor does inclusion of any specific treatment
approach imply endorsement from ASHA. Treatment can be restorative (i.e., aimed at
improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for
deficits not amenable to retraining).
Expressive Language Treatments
Constraint-Induced Language Therapy (CILT) — a treatment approach that focuses on
increasing spoken language output while discouraging (constraining) the use of compensatory
communication strategies (e.g., gesturing and writing). CILT also involves high-intensity
training via massed practice (Pulvermüller et al., 2001). The principles and techniques of CILT
are derived from constraint-induced movement therapy in which the use of a less-affected
limb is restrained while, at the same time, training movements of the affected limb using
intensive treatment (Taub et al., 1993; Taub & Wolf, 1997).
Melodic Intonation Therapy (MIT) — a therapy program that uses melodic concepts (i.e.,
pitch, rhythm, and stress) to improve expressive language by engaging the right hemisphere of
the brain. It is often used to treat individuals with severe nonfluent expressive language deficits
who have relatively intact receptive language skills (Albert et al., 1973; Norton et al., 2009).
Individuals begin by intoning simple phrases and then gradually increasing syllable length and
length of utterance. Visual and tactile cues are given by the clinician, and phrases of social and
functional importance to the individual (e.g., “I love you”) are practiced. Reliance on intonation
is gradually decreased over time.
Phonological Components Analysis (PCA) — a phonologically based treatment approach
modeled after semantic feature analysis (see below). In PCA, a participant is presented with a
picture and is asked to complete five phonological tasks related to the word that the picture
represents. The individual is asked to state the following:

 words the word rhymes with

 what sound the word starts with
  another word that begins with the same sound
 what sound the word ends with
 the number of syllables in the word

If the individual is not able to complete one of the components above, then they are given a
choice from a list of up to three. After the individual completes all the above elements, the
clinician asks them to state the target word (Leonard et al., 2008, 2014; van Hees et al., 2013).
Response Elaboration Training (RET) — a treatment approach designed to improve spoken
language by increasing the number of content words in persons with aphasia. The goal of RET is
to generalize elaboration abilities so that the person can more fully participate in conversations
with a communication partner (Kearns, 1986; Wambaugh et al., 2013).
A typical RET sequence consists of the following:

1. The person with aphasia responds verbally to a prompt (e.g., picture stimulus).
2. The clinician provides reinforcement and then shapes and models the person’s response.
3. The clinician gives a “wh–” cue to elicit an elaborated response.
4. The clinician reinforces attempts to elaborate and shapes and models the original
response + the elaborated response.
5. The person attempts to repeat the clinician’s combined model.
6. The clinician elicits a delayed imitation of the combined model.

Semantic Feature Analysis (SFA) — a word retrieval treatment in which the person with
aphasia identifies important semantic features of a target word that is difficult to retrieve. For
example, if the person has difficulty retrieving the word “stove,” they might be prompted with
questions to provide information related to “stove” (e.g., “Where is it located?” “What is it used
for?”). SFA is thought to improve word retrieval by activating the semantic network associated
with the target word, thereby increasing the likelihood that a particular word will be retrieved
(Boyle, 2004; Maher & Raymer, 2004).
Script Training — a functional approach to aphasia treatment that uses script
knowledge (understanding, remembering, and recalling event sequences of an activity) to
facilitate participation in personally relevant activities. Using this approach, the clinician and the
person with aphasia develop a scripted monologue or dialogue of an activity of interest and then
practice it intensely until production of the scripted speech becomes automatic and effortless
(Holland et al., 2002).
Sentence Production Program for Aphasia (SPPA) — a treatment program designed to aid in
the production of specific sentence types. The SPPA is based on the concept that the production
of certain sentence types will improve if the person with aphasia hears and produces multiple
sentences with the same syntactic form but different lexical content.
A story completion task is used to practice eight different sentence structures. There are two task
levels per Helm-Estabrooks and Nicholas (2000):

 Level A — The clinician reads a story that includes the target sentence and then asks a
question to elicit repetition of that sentence.
  Level B — The clinician reads the story without the target sentence and asks a question
to elicit that sentence.

Treatment of Underlying Forms (TUF) — a linguistic approach to treating sentence-level

deficits in persons with agrammatic aphasia. TUF is designed to improve sentence production by
training more complex sentence structures first, assuming that understanding the linguistic
properties of these complex sentences will generalize to less complex sentences that share
similar properties (Thompson & Shapiro, 2005).
Verb Network Strengthening Treatment (VNeST) — an aphasia treatment to promote lexical
retrieval in sentence context. VNeST targets verbs and their roles to activate semantic networks
and to improve the production of basic syntactic structures (e.g., subject–verb–object). For
example, the person with aphasia is given a verb (e.g., “paint”) and is asked to retrieve related
agents and objects (e.g., “artist–paints–picture” and “painter–paints–house”; Edmonds & Babb,
2011; Edmonds & Mizrahi, 2011; Edmonds et al., 2009).
Word Retrieval Cuing Strategies (e.g., phonological and semantic cueing) — an approach
that provides additional information, such as phonological cueing (providing the beginning
sound of a word) or semantic cueing (providing contextual cues) to prompt word recall (e.g.,
Wambaugh et al., 2002; Webster & Whitworth, 2012).
Writing Treatments
Copy and Recall Treatment (CART) — a protocol that uses picture and/or written
presentations of a given word to engage spelling and then reinforcing that spelling through
repetition. A CART sequence consists of the following:

1. The clinician shows a picture to a patient. If the participant spells the pictured word
correctly, the clinician moves to the next item. If the participant spells it incorrectly, the
clinician proceeds to Step 2.
2. The clinician shows the patient a handwritten word of the item shown in Step 1 and asks
the patient to copy the word three times.
3. The clinician covers the written example, shows the picture again, and prompts recall of
the spelling three times.
4. If the patient cannot demonstrate recall after several trials, then move to the next word.

Please see Copy and Recall Treatment (CART) Protocol [PDF] for a complete description of this
protocol.
Reading Treatments
Multiple Oral Re-Reading (MOR) — a treatment technique that involves re-reading text aloud
—either for a specific number of times or until a specific reading rate is reached—in an effort to
improve whole-word oral reading in the context of a text passage. MOR is best suited for
individuals with preserved letter-by-letter reading abilities, relatively intact comprehension, and
the ability to read aloud at the single-word level (see, e.g., Cherney, 2004; Kim & Russo, 2010;
Moyer, 1979; Tuomainen & Laine, 1991).
Oral Reading for Language in Aphasia — a treatment that involves repeated practice reading
sentences aloud with the clinician to improve reading comprehension via phonological and
semantic reading routes. The use of connected discourse (sentences) rather than single words
allows the individual to practice natural rhythm and intonation (Cherney, 1995; Cherney et al.,
1986).
Supported Reading Comprehension — approaches that incorporate aphasia-friendly text
supports (e.g., drawings, personally relevant photographs, and reader-friendly formatting) and
linguistic supports (e.g., headings and bolded text; see, e.g., Dietz et al., 2014; Knollman-Porter
et al., 2016; T. A. Rose et al., 2003, 2011).
Partner Approaches
Treatment approaches that engage communication partners to facilitate improved communication
in persons with aphasia include the following.
Conversational Coaching — a treatment designed to teach verbal and nonverbal
communication strategies to individuals with aphasia and their primary communication partners
(e.g., spouse, care partner). Strategies can include drawing, gesturing, cueing, confirming
information, and summarizing information. Strategies are chosen by the individual and their
communication partner and are practiced in scripted conversations. The SLP serves as the
“coach” for both partners (Hopper et al., 2002).
Supported Conversation for Adults With Aphasia — an approach to aphasia rehabilitation
that emphasizes (a) the need for multimodal communication, (b) partner training, and (c)
opportunities for social interaction. Per Kagan (2007), there are three underlying principles:

1. Functional communication can be facilitated/improved by teaching strategies to

communication partners.
2. Communication is a dynamic process; tools and services for the person with aphasia must
reflect this dynamic process.
3. Communication includes social interaction and the exchange of information and ideas;
opportunities for social interaction are emphasized.

Supporting Partners of People With Aphasia in Relationships and Conversation

(SPPARC) — a participant-driven program that focuses on how people with aphasia and their
communication partners act and react to each other during conversational exchanges. SPPARC is
used to address communication breakdowns by recording and analyzing communication between
conversational partners in a functional setting and then addressing issues in a clinical setting.
This therapy approach has six steps (Lock et al., 2001), as follows:

1. preparation
2. recording the conversation
3. preliminary viewing of the recording and transcription
4. conversation assessment
5. moving from assessment to training
6. conversation training
Multimodal Treatments
Treatment approaches that use any modality to communicate a message. Multimodal treatments
focus on using varied effective and efficient communication strategies and include the following.
Augmentative and Alternative Communication (AAC) — an area of clinical practice that
supplements or compensates for impairments in speech-language production and/or
comprehension, including spoken/signed and written modes of communication. AAC approaches
incorporate low-tech strategies (e.g., photos, communication books) and high-tech devices to
enhance communication. AAC focuses on using the individual’s residual language abilities and
training communication partners to use “augmented input” to enhance comprehension and to
offer written or visual choices to help individuals with aphasia indicate preferences, ideas, and
feelings. Please see ASHA’s Practice Portal page on Augmentative and Alternative
Communication for further information.
Gestural Facilitation of Naming — an approach that uses intact gesture abilities to facilitate the
activation of word retrieval by taking advantage of the interactive nature of language and action
(see, e.g., Raymer et al., 2006; Rodriguez et al., 2006; M. L. Rose, 2013; M. L. Rose et al., 2013,
2017).
Promoting Aphasics’ Communicative Effectiveness — a treatment designed to improve
conversational skills. The individual with aphasia and the clinician take turns being the message
sender and the message receiver. Picture prompts for conversational messages are hidden from
the listener (similar to a barrier task), and the speaker uses their choice of modalities for
conveying messages (Davis & Wilcox, 1981).
Reciprocal Scaffolding Treatment — a group treatment approach that addresses
communication skills using natural language in meaningful social contexts. An individual with
aphasia is given an opportunity to use premorbid knowledge and vocabulary to teach a skill to a
group of “novices.” The person with aphasia has an opportunity to convey knowledge to the
novices, and the novices, in turn, learn a new skill and provide language models during realistic
interactions (Avent & Austerman, 2003).
Visual Action Therapy (VAT) — a nonverbal treatment approach that trains individuals to use
hand gestures to represent items that are not present (Helm-Estabrooks et al., 1982). VAT
incorporates a 12-step training hierarchy beginning with tracing (e.g., tracing objects); then
matching objects; then producing pantomimed gestures for visible objects; and, finally,
producing pantomimed gestures for absent objects.