#### **5.2 Neurological examination**

A neurological examination is performed to see if there is evidence of dementia on a simple mental function screening (the mental status assessment) as well as signs of motor or sensory symptoms that indicate various forms of neurological illnesses could be causing dementia. The neurologist may also arrange tests, such as an MRI scan, to rule out the possibility of a stroke or tumor as the cause of the symptoms.

#### **5.3 Brain imaging studies**

This can be done with a CAT scan or an MRI scan. Both of these technologies create an image of the brain, allowing any structural abnormalities like a stroke, tumor, or hydrocephalus—all of which can cause dementia-like symptoms—to be recognized.

The CAT scan and MRI scans in the case of degenerative brain disease may reveal "atrophy," which indicates "shrinkage" of the brain tissue, or they may not show anything at all, especially in the early stages. In fact, the report is frequently returned as "normal." However, this just implies that no evidence of a tumor or stroke exists. It is unable to provide information on the microscopic degenerative changes that have occurred.

#### **5.4 Neuropsychological examination**

It provides a more thorough assessment of mental health. This is especially crucial in the early stages of sickness, when a standard screening examination may fail to discover the patient's difficulties. This takes several hours and consists of tests of mental talents, such as attention and focus, language learning and memory, visual perception, logic, and mood, conducted by paper and pencil or computer. The results can reveal whether there are any irregularities in thought or behavior, as well as their severity (mild, moderate, or severe). Because we normally test memory by telling someone something and then asking them to repeat it later, demonstrating that people with PPA have intact memory can be difficult. In an individual with PPA, it may be impossible to repeat back the information because of the aphasia.

As a result, it's critical that testing is done adequately to ensure that there is not an actual memory loss. To yet, the only way to objectively diagnose dementia is to undergo a neuropsychological evaluation. There are currently no dementia-specific blood tests or other physiological diagnostics available. This is especially helpful if the symptoms are modest or in the early stages.

#### **5.5 Psychiatric evaluation**

Sometimes there will also be a need for a psychiatric evaluation. This may be the case when it is not clear if the changes in behavior are due to depression or another psychiatric disturbance.

#### **5.6 Physiological evaluation**

PPA impacts not just the person who is afflicted with the disorder, but also those who are close to them. Relationships, the ability to continue working, the ability to execute numerous ordinary tasks, and the ability to convey even the most basic requirements are all affected by the disease. Although there are several resources accessible for people with memory loss, there are far fewer resources available for people with PPA, their relatives, and friends. A consultation with a social professional who is experienced with PPA can address these concerns and offer advice on how to deal with daily frustrations and problems.

#### **5.7 Speech and language evaluation**

Because the primary symptom of PPA is a reduction in language abilities, it's critical to figure out which aspects of language use are most affected, how badly they are affected, and what may be done to improve communication. A speechlanguage pathologist (SLP) examines various areas of language in-depth and might provide recommendations to improve communication. Family members should be included in treatment sessions to learn how to communicate more effectively.

#### **5.8 Formal assessment**

The following tests can be used to assess various functions in patients with PPA:

*Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

In the **Indian context**, the following tests prove to be valid:

#### **5.9 Informal assessment**

	- 1.Semantic memory:
		- Recognition of familiar faces.
		- Draw or color objects from memory, classify photographs using semantic criteria or match pictures of objects based on semantic similarity.
		- Executive functions, verbal fluency, and behavior: Impaired verbal fluency is frequently associated with executive function deficits such as abstraction (interpretation of proverbs, cognitive estimates, explaining similarities and differences), response inhibition, or motor sequencing (e.g. alternating hand movements).
		- The ability to create a list of common animals ("category fluency") or words beginning with a nominated letter ("phonological" or "phonemic fluency") can be used to measure verbal fluency.
	- Progressive Nonfluent Aphasia (PNFA) is indicated by decreased letter fluency.
	- The amount of words produced in one minute is used to determine the score.
	- 2.Spontaneous speech:
		- The patient can be asked to describe a scene in a photograph or drawing, and the system will analyze an extended sample of the patient's spontaneous (propositional) speech.
		- This is preferable to asking the patient to describe a typical day in their life.
	- Naming should be assessed both in response to pictorial items (confrontational naming) and in response to verbal descriptions (e.g., "a large grey animal with a trunk").
	- The performance of naming should be evaluated for both high and lowfrequency words (e.g., "shoe" versus "moat").
	- Examine if phonological (initial letter) or semantic (related item) cueing improves performance.
	- On confrontational naming tasks, visual perception deficits emerge as "visual" errors.
	- Circumlocutory reactions, semantic and phonological paraphasias can be noted.
	- Cueing with the first letter of the target word may help people with primary word retrieval and phonological encoding impairments (rather than primary verbal store faults).
	- Personal names might be particularly challenging.
	- Word-finding and language output difficulties coexist.
	- Can be measured at the level of individual words, which is dependent on both intact perceptual systems and the verbal knowledge store (vocabulary), and sentences, which is dependent on the ability to maintain verbal information online and understand grammatical relationships between words.
	- Can be proven at the bedside by testing phoneme pair discrimination (for example, "pat—tap," and "gat—cat").
	- Noun comprehension—asking the patient to point to items mentioned or described by the examiner, to provide a definition or other information regarding a target word (e.g., "What is a squirrel?"), or to choose between possible synonyms for a target word (e.g., does "trench" mean "hedge" or "ditch"?).

#### *Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

6.Sentence comprehension:

7.Speech repetition:

	- The patient should be asked to read a piece aloud that contains both irregular and non-words (e.g. proper nouns).
	- Once other linguistic functions have been established, this level can be judged with confidence.
	- Tasks that demand the development of novel verbal thought, such as the production of a statement including a target word (e.g. "boat") or the completion of an unfinished phrase, can be used to test the deficiency.
	- It is helpful to distinguish these from any linguistic loss, as well as to progress the clinical diagnosis in general.
	- The patient can be instructed to repeat a single syllable quickly (for example, "pa, pa, pa...") [19, 20]
	- Dysarthric patients' performance will be wrong if their rate or rhythm varies, although AOS patients' performance is normally normal.
	- AOS has a higher rate of sequencing mistakes.

#### *5.9.2 Assessments designed for differential diagnosis and tracking severity in PPA*

#### *Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

#### *5.9.3 Quality of life assessment*

#### **5.10 Probable intervention strategies**

	- 1.Neurologist (specialists in brain disorders who make the diagnosis and monitors its symptoms)
	- 2.Neuropsychologist (evaluate cognitive abilities through specialized paper and pencil tests).
	- 3.Psychiatrist (assist with behavioral and mood symptoms).
	- 4.Social worker (help families navigate the difficult decisions related to their diagnosis).

**Table 1.**

*Three representative domains of the progressive aphasia severity scale (PASS) [21].*

#### *Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

The goal is effective communication, not perfection as PPA is a progressive disorder. Early treatment, a specific plan, partner training, and long-term planning are all critical aspects of proper speech therapy treatment. Speech-language pathologists are uniquely competent to assess the present impact on communication, establish patient priorities, and build a treatment plan based on compensatory methods with a home program to preserve abilities as long as possible. We cannot stop PPA from progressing, but speechlanguage pathologists can help clients and families adjust their lives, compensate for their impairments, and keep the highest function and quality of life possible.

#### *5.10.2 Tips for treating primary progressive aphasia*

#### *<IP_ADDRESS> Practice priority vocabulary*

#### *<IP_ADDRESS> Teach scripts for primary progressive aphasia*

Depending on the severity of the PPA, vary the number and complexity of the scripts—the fewer and simpler the scripts, the more severe the PPA. Concentrate on

#### *Aphasia Compendium*

clarity and reduce frustration. When in doubt, keep the script simple—you are not trying to teach something new; instead, you are bolstering and compensating. Set priorities based on the client's priorities.

#### *<IP_ADDRESS> Train compensatory strategies for primary progressive aphasia*

Identifying and applying communication strengths can help you decide successful compensating measures and increase confidence, just as it can with aphasia or dementia. Modify hobbies and activities so that the person can compensate for linguistic difficulties. Labeling items in the environment is sometimes all that is required.

Clients should practice employing techniques, alternative communication, and scripts with the SLP, their family, and close friends in comfortable contexts. It will be easier to use them in public as a result of this.

#### *<IP_ADDRESS> Create a PPA business card*

Individualized information cards may be beneficial to clients who are still self-sufficient in the community. This card can be used to inform people that the individual has aphasia, as well as what tactics can help and who to contact in an emergency. This can come in handy if the individual is having trouble at the grocery store or library, or if they have a run-in with the cops. Cards can also be used as a script for ordering a cup of coffee or checking in for tea time.

	- Name
	- Explanation of the communication difficulty or diagnosis (consider including that they are not drunk or on drugs, as is often assumed)
	- Quick communication tip strategy that can help (e.g. "use short phrases", "speak slowly", "allow extra time to understand", "be patient").
	- Emergency contact person's name and phone number.

#### *<IP_ADDRESS> Train nonverbal communication*

Nonverbal skills become even more critical as PPA advances and communication abilities (especially verbal skills) deteriorate. Nonverbal communication is frequently easier to comprehend and produce. Teach care partners how to use gestures, eye contact, and body language and how to pay attention to them. Allow for more thinking time, have them write keywords, use visuals (photos, drawings, objects), shorten their phrases, and so on.

#### *<IP_ADDRESS> Voice banking and AAC*

When words fail, care partners can use AAC apps to help communicate their message. Early on in therapy, you can try out different AAC apps to discover which one or style the client enjoys, and then start customizing and training them before they are needed.

#### *<IP_ADDRESS> Plan for the future*

From the first day of treatment, the focus should be on a home program and compensating methods. Set up routines and experiment with multimodal and alternative communication as soon as possible, even before the client requires it. It will be easier to understand and acquire new strategies and routines early in the disease process, while more language and cognitive skills are still intact. Clients and families have more time to become comfortable with communication options and select what they like and do not like with earlier involvement. If at all possible, follow up with the client after discharge or check in with them every few months. PPA's home program and communication tactics will need to evolve as his or her life progresses.

#### *5.10.3 Phased treatment*

Clinicians need to consider important differences when managing speech and language impairments in the context of progressive disease [22].

In aphasia caused by stroke, clients show a static or gradually improving communication profile. But clients with PPA will eventually become mute or speak largely in jargon—using words that have some meaning to them but not to the listener.

Ultimately, with the disease's progression, patients will show increasing cognitive, behavioral, and motor deterioration.

Given this trajectory, PPA treatment should address a client's current profile of spared and impaired abilities, while also addressing the client's inevitable decline in communication and, in later stages, other domains.

Because of the evolving nature of PPA, a phased treatment approach, with recurring assessment and repeated treatment "doses" tailored to the client's current communication needs and challenges is recommended.

#### *<IP_ADDRESS> Phase 1—restitutive treatment in mild PPA*

#### *<IP_ADDRESS> Phase 2—toward aided communication in moderate PPA*

	- Treatment focuses on communication partner training and environmental modifications.
	- This phased treatment approach allows clinicians to draw from their experience treating aphasia while taking into account the inevitable decline associated with PPA.

#### *5.10.4 Promoting self-cueing strategies*

SLPs should focus on self-cueing strategies for lexical retrieval in the mild phases of PPA, which take advantage of the individual's residual skills [4]. During the examination, semantic, orthographic, and phonological self-cueing should all be tested in order to discover which method is most effective in prompting retrieval.

Family members can be taught to use cueing tactics like "Tell me about it" or "Can you think of what letter it starts with?" to help initiate self-cueing. The ultimate goal is for the person to be able to self-cue at the conversational level on their own. The SLP must be aware, however, when the family member is working too hard or seeing all interactions in therapy sessions.

#### *5.10.5 Script training*

Researchers have shown that conversational scripts can help people with stroke-induced aphasia improving their functional communication [23, 24]. The advantage of script training is the automaticity with which patients acquire skills by recalling memories of context-bound, skilled performance. When the same stimuli from the practice environment are available in a functional context, repeated practice of a specific task might improve automatic retrieval. The key to script training is to make sure that each person practices consistently and thoroughly. The SLP should consider the individual's requirements and interests, the style of the script (dialog or monolog), the number and duration of conversational turns, as well as the grammatical complexity and vocabulary choices when writing a script [25]. Families may purchase a script computer program such as Aphasia Scripts.

Examples of possible script topics include:

SLPs can frame a written goals based on the accuracy and rate of production (e.g., timing how long it takes to read the script while counting the number of errors). If the person is not motivated to practice the script outside of therapy sessions, he or she may not be a good candidate for script training.

#### *Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

#### *5.10.6 Facilitating receptive language*

Facilitating the use of Receptive Language Family training on ways to aid comprehension is critical for individuals with receptive language difficulties. Automatically speaking communication partners can make a difference in comprehension.

#### *5.10.7 Low-tech AAC*

The SLP's job is to determine the book's proper format, font size, and word/page length, and then instruct the individual and family members to keep adding pages.

Because some individuals with PPA may not independently use the book, training the family members on appropriate cueing strategies to initiate book use and facilitate navigation also should be targeted during treatment sessions.

#### *5.10.8 High-tech AAC devices*

Despite the lack of evidence on AAC intervention options for people with PPA, SLPs have effectively used high-tech AAC devices to help people with severe aphasia caused by stroke communicate [26]. Because people with PPA's other cognitive abilities deteriorate with time, it's crucial to keep in mind that a person's capacity to learn to utilize high-tech equipment may be limited and eventually hampered. The SLP's job is to figure out which devices if any, will best enable the client to convey

his or her needs and allow for social communication. The SLP should ask a series of questions to determine if a high-tech AAC is a good fit for someone with PPA.

#### **6. General suggestions for communicating with individuals with PPA**

\*Communication is usually most successful in a peaceful, calm, relaxed situation. Avoid talks when the television is on, and avoid circumstances where

#### *Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

numerous individuals are talking at the same time. Avoiding social circumstances is not necessary; rather, such activities should be encouraged. Maintain usual activities as much as feasible. When people are not tired, communication is usually the most effective.

### **Author details**

Yashaswini Channabasave Gowda1 and Hema Nagaraj2 \*

1 Junior Research Fellow, Department of Speech-Language Sciences, All India Institute of Speech and Hearing, Mysore, India

2 Assistant Professor, Department of Speech-Language Sciences, All India Institute of Speech and Hearing, Mysore, India

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Ferrano A, Jervis GA. Pick's disease. Archives of Neurology and Psychiatry. 1936;**36**:739-767

[2] Weintraub S, Rubin NP, Mesulam MM. Primary progressive aphasia: Longitudinal course, neuropsychological profile, and language features. Archives of Neurology. 1990;**47**(12):1329-1335

[3] Pick A. der linksseitigen Schläfenlappenatrophie. Monatsschrift für Psychiatrie und Neurologie. 1904;**16**:378

[4] Löwenberg K. Pick's disease: A clinicopathologic contribution. Archives of Neurology and Psychiatry. 1936;**36**(4):768-789

[5] Mesulam MM, Weintraub S. Primary progressive aphasia: Sharpening the focus on a clinical syndrome. In: Heterogeneity of Alzheimer's Disease. Berlin, Heidelberg: Springer; 1992. pp. 43-66

[6] Warrington EK. The selective impairment of semantic memory. The Quarterly Journal of Experimental Psychology. 1975;**27**(4):635-657

[7] Schwartz MF, Marin OS, Saffran EM. Dissociations of language function in dementia: A case study. Brain and Language. 1979;**7**(3):277-306

[8] Duffy JR, Petersen RC. Primary progressive aphasia. Aphasiology. 1992;**6**(1):1-15

[9] Martin A. Neuropsychology of Alzheimer's disease: The case for subgroups Alex Martin. Modular Deficits in Alzheimer-type Dementia. 1990;**143**:a006171

[10] Mesulam MM. Primary progressive aphasia. Annals of Neurology. 2001;**49**(4):425-432

[11] Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 1975;**12**(3):189-198

[12] Mckenna P, Warrington EK. Graded Naming Test: Manual. UK: NFERNelson; 1983

[13] Wechsler D. Wechsler Memory Scale-Revised. Berlin: Psychological Corporation; 1987

[14] Rey A. L'examen clinique en psychologie. Paris: Presses Universitaires de France; 1964

[15] Warrington EK, James M. Visual object recognition in patients with right-hemisphere lesions: Axes or features? Perception. 1986;**15**(3):355-366

[16] Howard D, Patterson K. The pyramids and palm trees test. In: A Test of Semantic Access from Words and Pictures. Bury St. Edmunds: Thames Valley Company; 1992

[17] Marshall JC, Newcombe F. Patterns of paralexia: A psycholinguistic approach. Journal of Psycholinguistic Research. 1973;**2**(3):175-199

[18] Graham NL, Patterson K, Hodges JR. The impact of semantic memory impairment on spelling: Evidence from semantic dementia. Neuropsychologia. 2000;**38**(2):143-163

[19] Dabul B. Apraxia Battery for Adults. Austin, Texas: Pro-Ed; 2000

[20] Duffy JR, Strand EA, Josephs KA. Motor speech disorders associated with primary progressive aphasia. Aphasiology. 2014;**28**(8-9):1004-1017

[21] Sapolsky D, Bakkour A, Negreira A, Nalipinski P, Weintraub S, *Primary Progressive Aphasia (PPA) DOI: http://dx.doi.org/10.5772/intechopen.104291*

Mesulam MM, et al. Cortical neuroanatomic correlates of symptom severity in primary progressive aphasia. Neurology. 2010;**75**:358-366. DOI: 10.1212/WNL.0b013e3181ea15e8

[22] Hinshelwood H, Henry M, Fromm D. Helping them hold on: Through phased treatment, speechlanguage pathologists can help clients with primary progressive aphasia function as normally as possible—For as long as they can. The ASHA Leader. 2016;**21**(10):44-51

[23] Youmans G, Holland A, Muñoz M, Bourgeois M. Script training and automaticity in two individuals with aphasia. Aphasiology. 2005;**19**(3-5):435-450

[24] Youmans G, Youmans SR, Hancock AB. Script training treatment for adults with apraxia of speech. American Journal of Speech-Language Patholog. 2011;**20**:23-27

[25] Cherney LR, Halper AS, Kaye RC. Computer-based script training for aphasia: Emerging themes from posttreatment interviews. Journal of Communication Disorders. 2011;**44**(4):493-501

[26] Beukelman DR, Fager S, Ball L, Dietz A. AAC for adults with acquired neurological conditions: A review. Augmentative and Alternative Communication. 2007;**23**(3):230-242

Section 2

## The Outcome and Treatment of Aphasias

#### **Chapter 5**

## Spontaneous Recovery and Intervention in Aphasia

*Chiaki Yamaji and Shinichiro Maeshima*

#### **Abstract**

The recovery of aphasia occurs immediately after the onset of the disease and lasts for several months or more. The speed and degree of improvement in aphasia vary depending on the time since onset, severity of aphasia, and each language modalities. It is assumed that there is a difference in the mechanism of aphasia recovery. The recovery process of the central nervous system observed in the first few days to weeks after the onset of aphasia is thought to involve the disappearance of cerebral edema, the absorption of necrotic tissue, angiogenesis, the development of the collateral circulation, and the resolution of hematomas, leading to the repair of damaged tissue. In the chronic phase, 1) recovery of damaged functional areas, 2) reconstruction of functions in the residual areas, and 3) compensatory functions by the contralateral hemisphere or activation of the contralateral cortex are assumed. In recent years, there have been many reports supporting the effectiveness of speech and language therapy interventions. Speech and language therapy should not only promote improvement of aphasia, but also take a comprehensive approach to improve the QOL of aphasia patients, such as acquisition of compensatory means of communication and family guidance.

**Keywords:** aphasia, spontaneous recovery, recovery process, speech language therapy, rehabilitation

#### **1. Introduction**

#### **1.1 What is spontaneous recovery?**

Spontaneous recovery from aphasia implies that impaired language functions improve without speech therapy interventions [1]. Several previous studies have investigated the duration for and degree of spontaneous recovery from aphasia. Culton evaluated the progress of improvement in language functions over a 2-month period four times at 2-week intervals using eight types of language tasks, such as naming and writing, in 11 patients with acute aphasia 2–4 weeks after the onset and in patients with chronic aphasia 11–48 months after the onset. Language therapy was not performed during the assessment period in both the groups. It has been reported that the acute aphasia group showed a more marked improvement. Particularly, the largest differences in the results of the language tasks were observed between the first and the second sessions, which indicated that the degree of improvement was most pronounced about 1 month following the onset of aphasia. It was also reported that improvements continued up to approximately 3 months after the onset [1]. Hartman (1981) evaluated language functions at the first visit and 30 days after the

onset using the Porch Index of Communicative Ability (PICA) in 44 patients with acute aphasia within 2 weeks after the onset. Comparison was made between the early group, which consisted of 20 patients who were administered the PICA within 6 days after the onset, and the late group, which consisted of 24 patients who were administered the PICA 7–14 days after the onset. Speech therapy was not administered in either of the two groups. As 42 of 44 patients showed improvements, it was reported that spontaneous recovery was achieved within 1 month. In particular, the early group showed more improvement in scores, showing most pronounced spontaneous recovery within 1–2 weeks. Moreover, given that the results of the final PICA were positively correlated with those of the initial PICA, it was argued that the degree of spontaneous recovery might be proportional to the severity of aphasia at the time of the onset [2]. Lomas & Kertesz evaluated language functions within 30 days and 3 months after the aphasia onset using the Western Aphasia Battery (WAB) in 31 patients with poststroke aphasia. Based on the initial WAB results, the patients were divided into the following four groups: the non-fluent/poor comprehension group, non-fluent/good comprehension group, fluent/poor comprehension group, and fluent/good the comprehension group. The two good comprehension groups exhibited improvements in general language functions, whereas the two poor comprehension groups displayed great improvements in comprehension and repetition [3]. Maeshima et al. evaluated language functions 1, 3, and 6 months after the aphasia onset using the Standard Language Test of Aphasia (SLTA) in 30 patients with poststroke aphasia who had not received speech therapy. Regardless of the age and gender, the SLTA scores improved 3 months after the onset in 18 patients; particularly marked improvements were noted in patients with moderate/mild aphasia. The SLTA scores improved 6 months after the onset in 14 patients irrespective of the severity. In terms of language tasks, such as writing, speech, and comprehension, improvements were observed in all tasks within 6 months. However, differences in the degree of improvement depending on the type and severity of aphasia were reported. Additionally, they reported that some patients were still followed 9–12 months later and that improvements were noted even in patients with severe aphasia [4]. Lendrem & Lincoln used PICA to evaluate 52 patients with poststroke aphasia who did not receive speech therapy 4, 10, 22, and 34 weeks after the onset. They reported that improvements in language functions continued until 34 weeks with the most pronounced improvement at 4–10 weeks. In particular, the results of the first PICA were correlated with the language functions after 6 months, suggesting that the degree of improvement is proportional to the severity of aphasia at the onset [5]. Sarno and Levita evaluated language functions using the Functional Communication Profile (FCP) in 28 patients with severe poststroke aphasia who did not receive speech therapy within 2 days, at 3 and 6 months after the onset. They reported that, as some subjects passed away, the number of the subjects decreased to 18 after 3 months and 14 after 6 months, and the improvements in the FCP were more pronounced at 3 months than 6 months after the onset [6].

Based on these reports, it is clear that spontaneous recovery from aphasia is possible in some cases. Age and gender do not seem to greatly affect the recovery. Although the degree of recovery differs depending on the severity of aphasia and language functions, improvements may be most pronounced 1–3 months after the onset and continue for 3–6 months or more.

#### **1.2 Mechanism involved in recovery of the central nervous system**

The recovery process of the central nervous system for a few weeks after the onset is believed to involve reduction of brain edema, necrotic tissue absorption, hematoma absorption, and formation of collateral circulation. Although recovery

#### *Spontaneous Recovery and Intervention in Aphasia DOI: http://dx.doi.org/10.5772/intechopen.100851*

of the central nervous system is limited after a long duration since the onset, language functions may continue to improve gradually.

Regarding the correlation between the recovery of language functions and the central nervous system recovery, Saur et al. conducted a study using functional magnetic resonance imaging (fMRI). They reported the following processes in acutephase middle cerebral artery (MCA) infarction: First, the activation of the remaining language-associated brain area is reduced, then activation occurs in the brain area related to language function improvement as well as in the surrounding area and the contralateral hemisphere, and finally normal activation ensues. Therefore, the reorganization of the central nervous system progresses in a stepwise manner [7].

Heiss et al., using positron emission tomography, investigated language functions 2 and 8 weeks after the onset in 23 patients with poststroke aphasia. In the group including patients with frontal lobe lesions and in that including patients with subcortical lesions, the right inferior frontal gyrus and the right superior temporal gyrus (STG) were activated at 2 weeks, and the left STG was activated at 8 weeks, showing considerable improvements in the language functions. Among patients with temporal lobe lesions, the left Broca's area and the supplementary motor area were activated at 2 weeks, and the bilateral precentral gyri and the right STG were activated at 8 weeks. However, the left STG did not activate, and improvements in the language functions were negligible. They reported that the recovery of language functions is preceded by compensation in the right hemisphere and that the preservation of the left STG is crucial for the reorganization of the neural network [8].

Mimura et al. performed single photon emission computed tomography (SPECT) to investigate the relationship between cerebral blood flow and language functions in patients with aphasia caused by left MCA lesions within 1 year and 7 years after the onset. They argued that increased blood flow in the left hemisphere was correlated with changes in language functions at 3–9 months and that functional recovery of the left hemisphere was essential for the improvement in language functions within 1 year. Changes in language functions after 7 years were correlated with increases in blood flow in the right hemisphere (especially in the frontal lobe and the thalamus). Functional compensation by the contralateral hemisphere may be involved in the longterm recovery of language functions [9].

These previous reports suggest that the mechanism of recovery involved in central nervous system reorganization may differ depending on the time from the onset. The mechanism for central nervous system recovery may possibly involve the recovery of damaged functional areas, reorganization of neurons in the remaining areas, or compensation by the contralateral hemisphere.

Pani et al. investigated the correlation between the right hemisphere and language functions in patients with chronic aphasia. They reported that fluency of speech was highly correlated with the volume of the middle temporal gyrus, precentral gyrus, and inferior frontal gyrus in the right hemisphere, as well as the volume of the fibers connecting the right and left supplementary motor areas. This may reflect a predisposition toward compensatory functions of the contralateral hemisphere [10].

#### **2. Improvement in language functions**

#### **2.1 Factors related to improvement in language functions**

#### *2.1.1 Age*

Many reports state that young people are more likely to show greater improvement in language functions than old people [11–14]. The underlying factor for

#### *Aphasia Compendium*

this difference is believed to be the difference in the plasticity of the brain associated with age. Previous studies using fMRI revealed that the left inferior frontal gyrus was activated in young subjects during verbal fluency tasks. Conversely, old subjects showed activation of the right inferior/middle frontal gyrus and poorer scores.

However, many reports conclude that there are no age-dependent differences in terms of improvement in language functions [1, 5, 16–24]. Therefore, no consensus has been reached on this matter. It is unlikely that language functions are related exclusively to age; hence, other factors, such as etiological causes (post-traumatic aphasia is prevalent in young people) and types of aphasia (Broca's aphasia is prevalent in young people), may also be related to language functions. Therefore, age-dependent differences may not have been apparent in studies that controlled these conditions. While age is an important factor for improving language functions, one must pay attention to the interpretation of correlation.

#### *2.1.2 Gender*

There are gender differences in terms of recovery from aphasia, and some reports showed that women were more inclined to recover than men [25, 26]. These differences may be attributed to the gender differences in the functional composition of the brain. Kansaku & Kitazawa conducted a study using fMRI and reported apparent gender-based differences in the activity of the anterior and posterior speech areas in vocabulary and story comprehension tasks, respectively [27]. Likewise, Shaywitz et al. also conducted a study using fMRI in which activation was found to be biased in the left inferior frontal gyrus in men in phonologic tasks, whereas broad areas including bilateral inferior frontal gyrus were found to be activated in women [28]. These reports indicate that gender plays a role in activating the brain areas with respect to language function. However, many reports argued that gender was not a factor for improving language functions [14, 16, 17, 19–21, 29]. Therefore, no definite correlation between gender and improvement in language functions has been established. Besides, other factors may also be related to gender. For instance, women are more susceptible than men to subarachnoid hemorrhage, which is an etiological factor conducive to improvement in language functions.

#### *2.1.3 Causative diseases*

Improvements in language functions are greater in patients with traumatic injury and in patients with brain hemorrhage than those in patients with brain infarction, respectively [29, 30]. This is attributable to differences in the extent of damage to the parenchyma in the cortical/subcortical tissue in the brain. Compared with brain infarction cases, brain hemorrhage cases achieve greater improvements through the absorption of hematoma and reduction of edema. However, severe aphasia may persist following traumatic injury and brain hemorrhage. Accordingly, prognoses may differ depending on the severity of brain damage. In addition, because of the differences in indications for thrombolysis or thrombectomy, it is difficult to predict the recovery of language function based on etiology alone today.

#### *2.1.4 Dominant hand*

The dominant hand is closely related to the language-dominant hemisphere, and 96%, 85%, and 73% of right-handed, ambidextrous, and left-handed people,

#### *Spontaneous Recovery and Intervention in Aphasia DOI: http://dx.doi.org/10.5772/intechopen.100851*

respectively, have the left hemisphere predominantly controlling language functions [31]. The incidence of aphasia caused by damage to the right hemisphere in non-right-handed people is believed to be 20–40% [32, 33]. As with right-handed people, most non-right-handed people develop aphasia triggered by damage to the left hemisphere. It has been reported that left-handed people develop aphasia more often than right-handed people [34, 35]. Smith reported that there were few left handers in patients with residual aphasia in the chronic phase [36].

These reports suggest that left-handed people are more susceptible to aphasia, but they tend to experience quick and larger improvements in language functions. The following are considered to be factors for good prognosis in left-handed patients with aphasia: A larger brain area responsible for language functions is conducive to restoring any remaining functions, and the presence of areas controlling language functions in both the hemispheres facilitates the activation of compensatory functions in the intact hemisphere [37, 38]. Meanwhile, some reports documented that left-handed patients with aphasia caused by damage to the left hemisphere had poor prognosis [39, 40]. Accordingly, there may be individual differences in the hemispheric dominance of language functions in non-righthanded people.

Among right-handed patients, some may have potential predispositions for left-handedness, such as a history of forced adjustment and familial factors. Information needs to be collected thoroughly in this regard.

#### *2.1.5 Severity of aphasia at the onset*

Many reports stated that the severity of aphasia at the onset affects prognosis [5, 11, 16, 17, 19–21, 23, 29, 41, 42]. All these reports argued that the language functions improve slowly and quickly in patients with severe and mild aphasia at the onset, respectively. As some reports indicate that the severity of aphasia is proportional to the severity of stroke, there is a possibility that the severity of brain damage also determines the severity and prognosis of aphasia.

Meanwhile, Lazar et al. reported that many patients with severe aphasia could still improve and that there were considerable variations in the degree of improvement in language functions and severity of aphasia 90 days after the onset. Therefore, they concluded that estimating prognosis based on the initial severity alone may be difficult [18]. Mohr et al. investigated language functions in three patients with global aphasia for 5 years and reported that improvements were observed in all the functions, except naming [43]. All reports indicated that language functions may improve even in patients with severe aphasia at the onset. They also suggested that the period required for improvement may differ depending on the patient.

#### *2.1.6 Types of aphasia at the onset*

While some reports state that types of aphasia affect the improvement in language functions, others indicated that there is no relationship between them [24]. Kertesz and McCabe reported that Broca's aphasia showed the largest improvement, followed by conduction aphasia. They stated that amnestic aphasia did not achieve large improvements because it was mild at the onset. Regarding long-term prognosis, patients with global aphasia showed poor prognosis, whereas patients with Broca's and Wernicke's aphasias exhibited moderately poor prognosis. Complete recovery was achieved in many patients with amnesic aphasia, conduction aphasia, and transcortical aphasia [29]. Demeurisse et al. investigated prognosis 6 months after aphasia onset in patients with three different types of aphasia: global, Broca's, and Wernicke's. They reported

#### *Aphasia Compendium*

that patients in the global aphasia group exhibited poorer improvements than those in the other two aphasia groups [41]. Bakheit et al. classified 75 patients with aphasia into the following groups based on the WAB classification: Broca's, Wernicke's, global, amnesic, and conduction aphasia, and administered the WAB at the onset and 4, 8, 12, and 24 weeks after the onset. Consequently, the Broca's aphasia group showed greater improvements than all the other groups, with the greatest improvement from the time of onset to 4 weeks after the onset [44]. Kertetsz reported that the rate of recovery differed depending on the type of aphasia, and patients with Broca's aphasia achieved the greatest improvement [19]. All these studies commonly reported that patients with Broca's aphasia had good prognoses, whereas patients with global aphasia showed poor prognoses. However, it should be noted that although patients with amnesic and conduction aphasias who had good WAB scores at the time of admission appeared to achieve less improvements due to a ceiling effect, their final scores tended to be higher than those of patients with Broca's aphasia who were known to show better improvements.

In a review, Watila and Balarabe cited the location and size of lesions, types of aphasia, and severity as the most critical factors for determining the recovery from aphasia. They concluded that, as all these factors are related each other, it would be difficult to investigate the independent factors [20]. The type of aphasia is somewhat consistent with the severity (e.g., amnestic aphasia is mild and global aphasia is severe). The location of lesions for non-fluent aphasia is different from that for fluent aphasia (anterior or posterior to the boundary of the central sulcus). Therefore, differences in aphasia types may be a factor encompassing these differences.

#### *2.1.7 Location and size of lesions*

Watila & Balarabe [20] and Plowman et al. [21] cited the location and size of lesions as factors contributing to the improvement in language functions in patients with poststroke aphasia. Maeshima et al. [45] investigated hemorrhage volume and language functions in 92 patients with putaminal hemorrhage. Consequently, they discovered that repetition difficulty was developed when the hemorrhage volume exceeded 20 mL, and non-fluent aphasia occurred when it exceeded 40 mL. The aforementioned causes of aphasia affect prognosis. However, prognosis may also differ depending on the location and size of lesions in the cortex or subcortex.

Regarding the location of lesions, Marchina et al. emphasized the importance of the arcuate fasciculus, stating that the degree of damage to the arcuate fasciculus is correlated with the improvement in spontaneous speech and naming [46]. The size of lesions represents the degree of damage to the area responsible for controlling language functions itself in the cortex. In the subcortex, improvements in language functions may be poor, despite the lesions being small, when the arcuate fasciculus is damaged.

As discussed above, many studies investigated factors contributing to the recovery of language functions, and all the cited factors were observed to interact and intertwine with each other. Because conditions were not controlled in previous studies, it is not easy to compare each of the factors; thus, no definite theory has been formulated. As most previous studies included patients who underwent speech therapy, it was difficult to clarify whether this was also related to spontaneous recovery.

#### **2.2 Effects of speech and language therapy interventions**

One of the effects of speech and language therapy interventions is the improvement in language functions, which is better than the improvement achieved by spontaneous

#### *Spontaneous Recovery and Intervention in Aphasia DOI: http://dx.doi.org/10.5772/intechopen.100851*

recovery. Nowadays, because speech therapy is provided worldwide to such patients, it is difficult to clearly distinguish between speech therapy-induced recovery and spontaneous recovery. To assess the efficacy of speech and language therapy, previous studies comparing trained and non-trained cases serve as good references.

There are few negative reports on the effectiveness of speech and language therapy. Lincoln et al. investigated changes in language functions in the speech therapy group and the no-therapy group 22 and 34 weeks after the onset. The results showed that language functions improved in both the groups and that no significant differences were observed in the degree of recovery between the two groups [47]. Levita compared improvements in language functions between the group that received speech therapy for 8 weeks and the no-therapy group in patients with aphasia 4–12 weeks after the onset. No differences were found between the two groups [48].

Many reports support the efficacy of speech and language therapy. Wertz et al. compared improvements in language functions in the following three groups: a group of patients who received speech therapy by speech therapists from the onset to week 12 and did not receive any therapy from week 12 to 24; a group of patients who received language practice by volunteers until week 12 and did not receive any practice from week 12 to 24; and a group of patients who did not receive any therapy until week 12 and received speech therapy by speech therapists from week 12 to 24. The results showed that, as of week 12, significant differences were observed between the groups that received language therapy by speech therapists until week 12 and the group that did not receive any language therapy until week 12 and that no significant differences were observed among all the groups at 24 weeks. They concluded that language therapy by speech therapists promotes improvements at the onset, and delayed interventions are still conducive to improvements [49].

Basso et al. investigated the factors affecting the improvement in the four language functions of speech, comprehension, reading, and writing, in the speech therapy group, which consisted of 162 patients who underwent speech therapy and the no-treatment group, which consisted of 119 patients who did not. In this study, although the duration from the onset to language function evaluation varied greatly, they compared the results of the language function evaluation for the first time and after 6 months, and reported that the implementation of language therapy was a factor responsible for improvements in all the language functions [24].

Maeshima et al. examined the language functions (writing, speech, and comprehension) in the speech therapy group, which consisted of 18 patients who received language therapy and the no-treatment group, which consisted of 18 patients who did not. They compared scores for each function and also compared the comprehensive language function scores calculated by summing each function scores between the two groups, 1, 3, and 6 months after the onset. No significant differences were observed in the language functions at 1 and 6 months after the onset between the two groups. However, many patients in the speech therapy group showed significant improvements at 3 months after the onset (**Figure 1**). Based on language function, many patients in the speech therapy group improved with regard to speech and writing at 3 months after the onset (**Figure 2**). These results indicate that improvements beyond spontaneous recovery may be achieved at an early stage following speech therapy interventions. In particular, it is easier to obtain the effects on the expressive aspect of language functions [50].

These reports suggest that early administration of speech therapy facilitates the recovery process beyond spontaneous recovery. The intervention effects may include improvements not only in passive language functions but also in active language functions that cannot be easily facilitated by daily voice–language communication.

**Figure 1.**

*Many patients in the speech therapy group showed significant improvements of language at 3 months after the onset.*

**Figure 2.**

*Many patients in the speech therapy group improved with regard to speech and writing at 3 months after the onset.*

In a literature review, Cicerone et al. stated that there was evidence supporting the efficacy of speech and language therapy for aphasia [51]. Conversely, while acknowledging the effectiveness of speech and language therapy, Mimura et al. argued in a review that scientific evidence was still insufficient because of the lack of evaluation of practice content's individuality and the effects in the no practice group [52]. In a Cochrane review, Brady et al. similarly stated that there was evidence supporting the effectiveness of speech therapy in improving functional communication, reading, writing, and expressive language, suggesting the efficacy of frequent and long-term speech therapy. However, they also argued that evidence *Spontaneous Recovery and Intervention in Aphasia DOI: http://dx.doi.org/10.5772/intechopen.100851*

was still insufficient because of small sample sizes and disunified practice methods [53]. Pickersgill and Lincoln (1983) asserted that although speech therapy interventions were expected to lead to early recovery, they would not expand the degree of final recovery. They appealed the early intervention effects of speech therapy, while simultaneously casting doubts regarding the argument that the interventions would also promote long-term recovery [23].

#### **2.3 Significance of speech therapy interventions**

As mentioned above, speech therapy interventions for aphasia improve language functions more than those by spontaneous recovery. Another significant effect is that these interventions help patients acquire communication techniques utilizing the remaining functions, thereby improving their quality of life.

Speech therapy approaches for aphasia are as follows: the therapeutic approach for functional deficits, the compensatory approach for disabilities, and the environment improvement approach for social disadvantages.

Examples of therapeutic approaches include Shuell's stimulus-facilitation approach [54], deblocking method [55], functional reorganization method [56], cognitive neuropsychological approach [57], semantic therapy [58], and melodic intonation therapy (MIT) [59]. They are considered effective for improving aphasia itself.

Meanwhile, examples of compensatory approaches for disabilities include acquisition practices for compensatory means, such as gesture practice, drawing practice, and practice for using other strategies, as well as practices for using compensatory means, such as the use of promoting aphasics' communicative effectiveness (PACE) and augmentative and alternative communication (AAC). In group therapy, patients with aphasia practice communicating effectively with other patients using available language and nonlanguage means [60, 61]. For patients with aphasia having communication difficulty at the onset, speech and language therapists must establish means of communication at early stages [62, 63].

Moreover, in addition to communication difficulty, patients with aphasia have various secondary problems in their daily lives, including difficulties in social connection, such as using financial institutions, public offices, public transportation systems, and commuting to the hospital. They also face problems, such as restrictions, in going to places for communicating with others and participating in leisure activities [64]. Simmons-Mackie et al. argued that encouraging the acquisition of communication partners promotes social participation among patients with aphasia and improves their communication skills. To resolve social and psychological issues among patients with aphasia, it is essential to promote family counseling and interactions with communication partners [65].

For rehabilitating patients with aphasia, it is desirable to appropriately approach the factors hindering communication and provide rehabilitation with a focus on life in the future.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Aphasia Compendium*

#### **Author details**

Chiaki Yamaji\* and Shinichiro Maeshima Graduate School of Rehabilitation, Kinjo University, Hakusan, Japan

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Spontaneous Recovery and Intervention in Aphasia DOI: http://dx.doi.org/10.5772/intechopen.100851*

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#### **Chapter 6**

## Treatment Approaches for Word Retrieval Deficits in Persons with Aphasia: Recent Advances

*Deepak Puttanna, Akshaya Swamy, Sathyapal Puri Goswami and Abhishek Budiguppe Panchakshari*

#### **Abstract**

Word retrieval deficit is found to be one of the most persistent symptoms reported among the constellation of symptoms exhibited by persons with aphasia (PWAs). This deficit restraints the persons with aphasia to perform with ease across day-to-day conversations. As a consequence, PWAs fail to communicate their desired ideas or thoughts. Word retrieval is an intricate process as it entails various levels of processing. In addition, word retrieval breakdown can occur at multiple levels (semantic level or lexical-semantic level, or phonological level). Thus, there is a need for speech-language pathologists (SLPs) to treat this deficit through effective treatment approaches. In recent decades, semantic feature analysis, verb network strengthening treatment, and phonological component analysis have received greater focus and importance in treating word retrieval deficits. Many studies confirmed that the use of these treatment approaches on PWAs possesses a pivotal role in remediating word retrieval deficits.

**Keywords:** word retrieval, lexical-semantic strengthening, semantic therapy, phonological therapy

#### **1. Introduction**

Word retrieval deficits remain one of the enduring symptoms in most PWAs [1]. Word retrieval deficits are events where the individual exhibits word-finding difficulty in conversation or while conveying their ideas or thoughts. The prevailing literature on word retrieval failures suggests that this deficit varies in their cognitive and neural underpinnings among discrete variants of aphasia. The SLP treating word retrieval deficits firstly needs to understand the nature of word retrieval breakdown (semantic or phonemic). These are ascertained *via* comprehensive naming assessments, and then based on the nature of word retrieval failures, appropriate treatment paradigms need to be employed.

#### **2. Pathophysiology of naming impairments**

The word retrieval process is an intricate process requiring two critical stages semantic and phonologic [2, 3]. The retrieval process is strongly influenced by the modality in which they receive the input. For instance, confrontation picture

naming involves object recognition as the primary input mechanism, followed by activation of the semantic system. The semantic system aids in storing the meaning and has associated information about the activated word. Finally, the semantic system activates modality-specific output lexicons for spoken, written words, and actions. With respect to spoken naming, lexical phonological output systems are activated. Subsequent to semantic and phonologic lexical retrieval stages, the post-lexical and articulatory process aids in the planning and execution of the verbal responses. These complex processes involved in word retrieval are likely to be affected in individuals with brain insult resulting in word retrieval impairment.

The word retrieval breakdown associated with PWAs is mediated by a distributed left hemisphere neural network (Hart & Kraut, 2007). There is a large body of evidence that suggests a lesion in the inferior temporal cortex is responsible for word retrieval impairments. Indeed, these impairments may vary with respect to the grammatical class and the impairments may be more for nouns than for verbs [4–6]. The lexical phonological output is mediated *via* the left superior temporal gyrus and inferior parietal cortex [1]. Lesions noted at the left frontal operculum result in non-fluent forms of aphasia, which result in difficulty in retrieving verbs than nouns [4–6]. Wilshire and Coslett [7] opine that word retrieval impairment can be accredited as an interface between syntactic and lexical processes. As far as the brain structure affected is concerned, the thalamus plays an indispensable role in word retrieval; as a result, lesions at the thalamus result in word retrieval impairment also [8].

#### **3. Treatment approaches**

Most of the treatment protocols developed for discrete variants of aphasia address the domains of linguistic deficit in aphasia. This implies that the protocol would be merely beneficial for semantically related deficits or phonological-based deficits. Traditionally, treatment rendered to PWAs relies on a symptomatic approach. Owing to the fact, aphasia is a multifaceted condition and entails the complex nature of the processing, and treatment for PWAs is explained along a continuum of naturalness [9].

One end of the continuum is the participation-based or socially oriented approach that primarily focuses on naturalness. Under this domain, the life participation approach [10] is streamlined as a socially oriented approach. LPAA aids in re-engagement of life to maximize an individual's quality of life and communication skills. The other hand of the continuum is the impaired-based approach. The impaired-based approach works on the premise of enhancing individuals' linguistic abilities. Subsequently, the treatment paradigms related to it were designed with the rationale of obviating the damaged processes.

#### **3.1 Impaired-based approach**

Impaired-based word retrieval paradigms are deployed to maximize the word retrieval abilities in contexts of speech and conversation. In the recent past, various types of word retrieval paradigms have been meticulously developed to remediate retrieval deficits. These are some of the seminal word retrieval paradigms, for instance, cueing hierarchy, phonological component analysis (PCA), semantic feature analysis (SFA), and Verb Network Strengthening Treatment (VNeST).

#### **3.2 Cueing hierarchies**

In cueing hierarchy paradigm, the SLP renders a series of discrete and potent cues to facilitate the targeted word. When PWAs retrieve the desired target word,

#### *Treatment Approaches for Word Retrieval Deficits in Persons with Aphasia: Recent Advances DOI: http://dx.doi.org/10.5772/intechopen.100828*

the clinician encourages to repeat the target word several times, or the clinician presents cues in reverse order until the PWA provides the desired response. While using cueing hierarchy in PWAs, SLPs must ensure the more and less effective cues pertaining to the individual. In this paradigm, the targeted word is elicited through both semantic and phonological cues.

However, few studies highlight the potent role of semantics over phonological cues or vice versa (e.g., [11–13]). A review study by Patterson (2001) was carried out to uncover the effectiveness of cueing hierarchy in remediating word retrieval failures. The consolidated reports by various studies posit that cueing hierarchy paradigm aids in showing ameliorated performance for the trained words with various levels of retrieval deficits (semantic or phonological).

There are few interesting studies, which appraised the effectiveness of cueing hierarchy paradigm by inculcating variations in the training. Marshall, Karow, Freed, and Babcock [14] compared the effect of personalized cues (i.e., a phrase developed by the individuals themselves) over phonological cues. The findings computed in the study showed that individuals using personalized semantic information (e.g., "Apple is red in color"? or the animal which eats flesh?) outperformed phonological cues alone. Furthermore, the cueing paradigm was trained and developed through software to provide more flexibility and to reach a large population who are deprived of receiving speech-language therapy services.

Over the recent decades, researchers have used a computerized version of cueing hierarchy paradigm. The finding of the study evinced ameliorated performance for the trained words in moderate–severe naming impaired individuals [15, 16].

#### **3.3 Phonological component analysis (PCA)**

PCA is one of the renowned treatment approaches to remediate word retrieval deficits [17]. This approach emphasizes the use of self-cueing. In PCA therapy, individuals are presented with a picture placing at the center of the chart, and then, they are asked to name the corresponding picture. Simultaneously, PWAs are asked to identify the phonological components such as rhyming words, the first sound, first sound associate, final sound, and the number of syllables with respect to the target word (**Figure 1**). While identifying the phonological cues, if individuals fail to produce desired responses, then they are given an array of choices (up to three choices). Out of these choices, individuals need to select one of the choices among three. Choices are presented *via* letter cards, and the clinician reads these choices aloud. The response elicited is noted in the chart. Once the response generation for each phonological component is complete, PWAs are able to retrieve the target item independently. When they generate the desired response, then positive feedback is provided. Considering the possibilities of errors, the clinician models the desired response and needs reiteration by PWAs.

The impact of PCA treatment on word retrieval skills per se has been studied in many research studies. The evidences from these studies seem to be conducive as they manifest ameliorated performance in trained items in most of the studies [18, 19]. On the other hand, the findings for PCA on untrained stimuli seem to be less robust. Thus, researchers posit poor generalization skills following PCA treatment [11, 18].

#### **3.4 Semantic feature analysis (SFA)**

#### *3.4.1 SFA for objects*

SFA intends to manifest ameliorated performance in lexical retrieval abilities per se in PWAs. This treatment systematically trains the target word by activating the

**Figure 1.** *Flowchart depicting the procedure of phonological component analysis (PCA) treatment.*

discrete semantic attributes, enhancing the semantic networks corresponding to the target word. In this treatment, the clinician places a target word picture card in the center of the chart. The chart comprises the discrete semantic features—superordinate category, use, action, physical properties, location, and association of the corresponding target word (**Figure 2**). In short, the clinician initially provides the target picture; subsequently, PWAs will be asked to retrieve the corresponding semantic attributes. If PWAs fail to name, then the clinician cues them to retrieve the desired responses. To provide semantic features, the clinician reads the printed cues and provides the relevant features both orally and in written forms. The semantic feature generation aids in distinguishing desired features versus undesired features of the target word. Initially, SFA training emphasizes maximal cueing by the clinician. Eventually, cueing is faded as the training progresses. The semantic features enhance the activation of the corresponding target word; consequently, PWAs name the items without any cues. If PWAs are not able to retrieve the target item and corresponding features, then the clinician delivers the name and features [20].

#### *3.4.2 SFA for verbs*

Semantic feature analysis treatment for verbs follows a slightly distinct protocol compared to noun training. In this treatment, a picture of the target action will be placed at the center of the chart. The PWA will be asked to retrieve the corresponding action. If they fail, the clinician cues the action verb using the following semantic features—(a) the agent/experiencer of the action ("Who usually does

*Treatment Approaches for Word Retrieval Deficits in Persons with Aphasia: Recent Advances DOI: http://dx.doi.org/10.5772/intechopen.100828*

**Figure 2.** *Flowchart depicting SFA treatment for noun.*

this?"), the theme/patient ("On what/ by whom is it performed?"), the location ("Where does this action happen?"), the purpose of the action ("Why does this happen?"), the means of carrying out the action ("What part of the body or what tool is used to make this happen?"), and the related objects or actions that reminded the participant of the target verb ("What does it make you think of?"). These features were introduced one at a time and in the same order mentioned above. The PWA's response will be noted down. If the PWA failed to provide the desired response, then the clinician prompts a response. The prompts can be either semantic or phonological. After generating all six semantic features, the PWAs are asked to name the target action without any prompts. Despite these prompts, if the PWA still fails to arrive at desired responses, then the clinician delivers the target action word. The PWA is asked to repeat the action word after the clinician models. Finally, they will be asked to construct a simple sentence using the verb; if they are unable to produce, then the clinician assists in constructing simple sentences or narrating the simple sentences for PWAs. The PWA is prompted to repeat after the clinician narrates the sentence (**Figure 3**).

Further, to document SFA treatment findings across various studies, a systematic review was conducted [21]. This review study pooled data from 21 studies consisting of 55 PWAs encompassed both fluent and nonfluent variants of aphasia. The findings revealed robust findings for 45 out of 55 PWAs for the trained items; 32 out of 55 PWAs were able to maintain the responses. In addition, 40% of PWAs were able to manifest generalization of response to the untrained stimuli. The SFA treatment manifested robust outcomes for fluent and mild–moderate severity of aphasia compared to nonfluent and severe forms of aphasia [22–25]. Overall, SFA is deemed as a viable treatment approach in the diminution of word retrieval deficits. In light of these findings, future studies on SFA should focus on observing or noting the generalization on untrained stimuli. A future implication would be that the treatment approach can be extended by documenting the improvement in the discourse genre.

**Figure 3.** *Flowchart depicting SFA treatment for verbs.*

#### **3.5 Verb network strengthening treatment (VNeST)**

VNeST was developed on the premise that if treatment paradigms utilized verbs as the core element then it can aid in the activation of a wide array of semantic networks. In addition, it may assist in the construction of simple active sentences. VNeST protocol constitutes a total of six steps to remediate word retrieval deficits [26]. These steps are as follows:

1.*Step one—Generation of Verb, Agent, and Patient*: In this step, the clinician probes PWAs to retrieve the verb with the relevant semantic cues. If they are unable to retrieve the target verb, then maximal cueing is provided. Subsequently, PWA will be probed to elicit relevant agents (doer of the action) and patients (receiver of the action) for the intended verb. If PWA fails to elicit the corresponding agent and patient pairs on their own, then they will be provided with a series of choices (maximum cues).

To illustrate, to retrieve the verb "Baking," the following semantic cues can be used: (a) This is usually done in the kitchen; (b) this is usually done using utensils/stove; (c) this is usually done to prepare bread, cake. For identification of the corresponding agent for the verb "Bake," individuals will be provided with choices (written cards) of photographer, farmer, and chef. PWA will be asked to identify the corresponding agent for the verb "Bake." Eventually, a similar cueing strategy will be carried out for the identification of the patient. In addition, PWA will be encouraged to produce agents and patients from their experiences. The rationale of step one is that eliciting a wide array of agent/patient pairs may promote the activation of discrete semantic networks corresponding to the verb.

2.*Step two—Reading the Agent/ Patient Pairs*: In this step, the PWA is prompted to read the generated agent/patient pairs corresponding verb. If they fail to read the simple sentence, then the choral reading strategy is employed.

*Treatment Approaches for Word Retrieval Deficits in Persons with Aphasia: Recent Advances DOI: http://dx.doi.org/10.5772/intechopen.100828*

The relevance of steps with respect to the activation system occurring in the VNeST protocol is depicted in **Figure 4**.

In order to understand the effectiveness of VNeST treatment, Edmonds [27] conducted a review study. A total of 19 English-speaking PWAs received VNeST treatment across different studies [26, 28–30]. These studies enrolled PWAs who evinced chronic aphasia with severity ranging between mild and severe form; PWAs showed no impairment or moderate impairment in cognitive-linguistic quick test and had good comprehension scores. Ten verbs were trained. The PWAs enrolled in these studies were trained for 4–15 weeks, twice a week (each session would last for 3–3.5 hours), wherein the majority of PWAs received training for 10 weeks on an average. On the other hand, Furnas and Edmonds [29] provided training thrice a week, with each session would last for 2 hours per session for the time interval

**Figure 4.** *Activation of the semantic network using VNeST treatment protocol. Edmonds [27].*

of six weeks. Outcomes of this review study served as the preliminary evidence. These studies posit that VNeST training reinforces lexical retrieval at a single word, sentence, and discourse genre across discrete variants of aphasia and with different levels of severity.

In addition, these studies evinced improvement in functional communication, per se. The studies based on VNeST showed ameliorated performance in noun and verb naming, sentence production, and discourse genre across the trained and untrained conditions. Despite these prominent findings, more research is warranted to strengthen these findings. The majority of the studies showed mixed findings while gauging the generalization effect. Equivocal findings were also noted across fluent and nonfluent aphasia and across different levels of severity. These literatures failed to evince the specific pattern or mechanism responsible for showing improvement in specific types of aphasia. Thus, the VNeST training has to be assessed in detail for each type of aphasia.

#### **4. Conclusions**

This chapter focuses on some of the word retrieval treatment approaches. These approaches are mainly intended to ameliorate word representation and also to activate the phonological encoding stage of word retrieval. While gauging the effectiveness of any treatment approach, several factors are to be looked upon, namely—(1) maintenance of word retrieval skills per se followed by therapy; (2) response generalization to the untrained conditions and different treatment settings. The treatments discussed in this chapter discerned fairly good generalization and response maintenance in almost all the approaches. However, relatively poor generalization skills are noted in the PCA. Poor responses can be attributed to being surface-level training and redundancy of cues. In cases of more severe word retrieval deficits, the treatment paradigms discussed may not be suitable for the initial phase of treatment. Instead, the clinician must start the treatment with more direct facilitative treatment and gradually progress to the treatment that entails selfgeneration of words. Owing to this, speech-language pathologists should consider severity before selecting the specific word retrieval treatment.

Commonly raised concern in the treatment-related studies is the superiority of one treatment approach over the other or anyone specific treatment approach is engendered to show maximal benefits. The answers to these questions are still at preliminary levels, and these need to be documented by conducting various research on these lines. To our understanding, in the current scenario, no particular treatment approach is deemed as superior over other treatment approaches at a more advanced level. However, based on the prevailing evidence, the VNeST approach can be claimed as the streamlined approach compared to SFA and PCA at the surface level in remediating word retrieval deficits.

 In some word retrieval treatments, improvement may be confounded to trained conditions, or improvement may be generalized to few untrained conditions. Owing to this, treatment paradigms selected should include strategies that would aid the PWAs to show improvement even in the functional communication per se.

*Treatment Approaches for Word Retrieval Deficits in Persons with Aphasia: Recent Advances DOI: http://dx.doi.org/10.5772/intechopen.100828*

### **Author details**

Deepak Puttanna1 \*, Akshaya Swamy2 , Sathyapal Puri Goswami2 and Abhishek Budiguppe Panchakshari3

1 Father Muller College of Speech and Hearing, Mangalore, India

2 All India Institute of Speech and Hearing, Mysore, India

3 Nitte College of Speech and Hearing, Mangalore, India

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[14] Marshall RC, Karow CM, Freed DB, Babcock P. Effects of personalised cue form on the learning of subordinate category names by aphasic and nonbrain-damaged subjects. Aphasiology. 2002;*16*(7):763-771

[15] Fink RB, Brecher A, Schwartz MF, Robey RR. A computer-implemented protocol for treatment of naming

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disorders: Evaluation of clinicianguided and partially self-guided instruction. Aphasiology. 2002;*16* (10-11):1061-1086

[16] Ramsberger, G., & Marie, B. (2007). Self-administered cued naming therapy: A single-participant investigation of a computer-based therapy program replicated in four cases. American Speech Language Pathology. 16:343-58

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#### **Chapter 7**

## The Importance of Aphasia Communication Groups

*Marina Charalambous and Maria Kambanaros*

#### **Abstract**

Chronic aphasia is linked to poor functional recovery, depression, and social isolation. In the exploration of the above factors, the role of aphasia communication groups has evolved. Aphasia communication groups for stroke survivors with chronic aphasia and their communication buddies are gaining clinical importance. Communication buddies can be family members, friends, carers, health professionals, and speech and language therapy students who serve as communication facilitators for each group member. Group members share experiences on stroke and aphasia by using technology/tablets and the total communication approach. The benefits or outcomes of group involvement are measured by assessment of functional communication, individual self-ratings of the impact of aphasia on communication, and quality of life after stroke. The use of the communication buddy system, total communication approach, and systematic evaluations enables therapists to measure the effectiveness and efficacy of communication groups in terms of functional communication, social inclusion, and quality of life.

**Keywords:** communication buddies, quality of life, aphasia communication groups

#### **1. Introduction**

Aphasia is an acquired communication impairment that impacts the ability to speak, understand, read, write, and carry out mathematical calculations [1]. It is caused by damage to the language networks in the brain usually after stroke but not only [2]. Aphasia is linked to poorer functional recovery [3], return to work [4], activities of daily living [5], depression [6], and social isolation [7].

Functional communication and social participation are impaired in aphasia, which brings about reduced confidence in communication [8]. This leads to reduced interactions with family and friends [9] and smaller social networks [10]. Although maintaining social interactions and friendship networks in the chronic phase of aphasia (greater than 6-months post brain injury) has been identified as an important goal in aphasia rehabilitation, this is not regularly addressed by aphasia clinicians [9].

Historical models of aphasia assessment and treatment have focused mainly on the person's linguistic competence [11]. Even though people with aphasia (PWA) may have successfully achieved their therapeutic goals in individual speech and language therapy sessions, they still struggle to use their new communication skills successfully in natural environments, e.g., with family members, close friends, and their therapist outside of the clinic/treatment environment [12]. Contemporary

rehabilitation approaches pay increasing attention to the pragmatic competence and the overall functionality of communication of PWA via aphasia communication groups (ACGs) [13].

In the context of the International Classification of Functioning, Disability and Health (ICF) [14], biopsychosocial models of disability, and particularly the Life Participation Approach to Aphasia Project Group [15], interest in ACGs is increasing in both research and clinical settings [16]. ACGs provide psychosocial benefits to PWA, including increasing social participation and peer support [17].

#### **1.1 Defining aphasia communication groups**

*Aphasia communication groups (ACGs) are defined as small groups of people with aphasia and their communication partners who interact with each other on a regular basis*. These groups include PWA who can communicate in any accessible way, are aware of each other's presence and perceive themselves, and are perceived by others, as being members of a group [18]. *ACGs* are described as informal groups meaning that they are more erratic and spontaneous, and less constrained by formal structures and power relationships compared to formal groups (committees, boards etc.) [19].

While ACGs can focus on the impairment-based characteristics of aphasia, the nature of the group setting tends to elicit functional, naturalistic forms of communication [20]. The actions and subject matter of each communication group vary enormously and depend mainly on the goals and aspirations of the group members. Group members develop close relationships with each other in a natural and supporting environment, which promotes meaningful conversations with people who empathize with their difficulties. *ACGs* work on the "barriers" that make communication challenging for the person with aphasia and their communication partners, and on what communication tools members could use to improve communication [21]. The different methodological approaches used in ACGs such as learning events, personal stories, and patient narratives foster functional communication, active engagement, and mutual support [22–24].

The primary *aim* of the *ACGs* is to provide support for PWA on learning about aphasia, communication opportunities to promote living well with aphasia, and improve quality of life [20]. Another common *goal* is the understanding that aphasia can be a life-long condition, and that aphasia is a "family issue," impacting not only the person with aphasia [21]. The main *pillar* of ACGs is to create a supportive and safe environment for meaningful communication and social endeavors that encompass interactive functional communication activities [21]. *ACGs* promote full participation and engagement in activities of interest and are inclusive to all PWA irrespective of degree and severity of aphasia [25]. In fact, ACGs have been likened to a "*rope team"* [26]. The term "rope team" comes from the sport of mountain climbing. The rope team will tether themselves together for safety to help prevent falls. By establishing a rope team, individuals with aphasia are provided with a positive atmosphere for participation and communication without fear of judgment. In aphasia rehabilitation, a rope team can consist of other healthcare professionals and caregivers, but, more importantly, others with aphasia.

#### **1.2 Communication quality in aphasia communication groups**

*ACGs* should seek to make improvements in the communication quality of PWA. Based on the *Communication Quality Guidelines* of the Royal College of Speech and Language Therapists (RCSLT) [27], this is fostered when groups are EASIER:

#### **1.3 Why are aphasia communication groups important to people with aphasia?**

Loneliness and social inaccessibility in chronic aphasia lead to poor community and public engagement [9]. Aphasia communication groups are an opportunity for social participation [28] that promote community integration, broaden friendship circles, and improve social connectedness [29]. Without prospects for *good communication,* PWA struggle to learn about their condition, to achieve personal goals, make friends, and interact meaningfully – all fundamental for citizenship and humanity and central to improving quality of life [27]. All these principles are offered to PWA in a communication group setting as they are given opportunities to exercise their human right on how to be involved with decisions about their care, make choices about their daily life, create opportunities to communicate their needs and thoughts, understand and express their necessities in relation to their health and wellbeing whilst being treated with respect and dignity [27].

*ACGs* are important to PWA as they have a common *purpose*: to become familiar with aphasia symptoms, to share personal experiences, support and encourage each other, and get trained on how to establish successful functional communication [25]. In a review by Attard and colleagues [30] on consumer perspectives on community ACGs, the findings revealed that group attendance formed positive relations for PWA with others, gave purpose in life, promoted environmental mastery, autonomy, personal growth, and self-acceptance. According to Lanyon and colleagues [31], PWA perceive community aphasia-group participation to be beneficial to their ability to live well with aphasia. Peer-to-peer communication strategies, shared roles and responsibilities, and consultation regarding group objectives and processes provide group members with the opportunity to become active contributors, demonstrate competence, and have positive influence over the group [31]. During the qualitative investigation of the factors impacting participation and integration of PWA in aphasia community groups, Lanyon and colleagues [31] revealed seven important features:

1.*Balanced interactional patterns*: reflects the balance and equal share in interactions between group members and leaders. It is associated with equal turntaking opportunities and the promotion of the appropriate sensitivity of the group leader toward group members.

Aphasia communication groups' positive participation promotes *patient involvement* (PI) and elevates discussions on how aphasia impacts activities of daily living, social integration, and participation [32]. Azios et al. [9] propose a *codesign* model of intervention and research on friendship maintenance within aphasia communication groups, as a means of addressing the issues of social isolation and other personal concerns of PWA. The *Quality of Communication Life Scale* [33] suggests that "the more positive the personal and environmental factors, the more successful the [person's] communication acts, the better the quality of communication life" (p. 2). Taking into consideration the perspectives, needs, and experiences of PWA, as service users in ACGs, it is critical to use PI approaches and activities that will accelerate translation to real-world activities and promote functional interventions and strategies for living successfully with aphasia (activity and participation level 0 [14]). Positive effects of ACGs where PWA are actively involved in decision making, build confidence in PWA to express their needs, whereas research evidence demonstrates positive health benefits of building interpersonal relationships and community while being part of an ACG [20].

### **2. Setting up an aphasia communication group**

#### **2.1 Establishing ground rules**

Before establishing an ACG, members should discuss and agree on the group's ground rules using a SIMPLE approach. The ACG and each group member should be:

**S**upportive – Ask caring questions; listen attentively to responses/others. **I**nspirational – Reassure others that life gets better and not to give-up. **M**otivational – Encourage action and acknowledge improvement. **P**ractical – Offer options, helpful tips, and information and access to resources. **L**ife-affirming – Not deny or devalue/trivialize the feelings of others. **E**ducational – Talk about what's worked for them and others; offer guidance/ counsel, but without giving prescriptive advice.

#### **2.2 Inclusion criteria**

The general inclusion criteria for *ACGs* are that PWA:

The inclusion criteria are usually adjusted according to the setting and the purpose of each ACG [21].

#### **2.3 Group features**

A successful group requires several features to be efficient: the members, the group, and the tasks/activities, the context [34]:

	- work cooperatively and not competitively.
	- support each other and show empathy.
	- get rewarded collectively and not individually.
	- are aware of the nature of the group process.
	- is relatively small (maximum five people).
	- is autonomous to address its activities and tasks.
	- has an effective leader/facilitator.
	- operates in the context of a supportive organization or community.
	- are accessible to all members.
	- are designed considering the individual skills of each member.
	- promote the active engagement of all members.
	- have precise objectives.
	- have a beginning and a defined end.
	- have measurable indicators of success.
	- The physical environment should be accessible.
	- Time schedule and agenda should be defined.
	- Resources should be allocated before enrolment.
	- External factors should be taken into consideration (traveling, financial issues).

#### **2.4 Total communication**

Group members practice total communication skills, i.e., gestures, singing, drawing, and writing, and/or a combination of all the above [20]. The main topics of discussion are learning about/refreshing knowledge on stroke and aphasia, linking the information to members' own experiences, asking questions, and discussing living with stroke and aphasia [21]. It is also important for members to share stories about life before the stroke [35]. Resources for total communication such as writing boards, notebooks, tables, communication books, aphasia friendly materials [36], and the Internet should be used to access information online [37].

#### **2.5 Virtual aphasia communication groups**

Group meetings can be established with face-to-face contact or digitally. Virtual group meetings and videoconferencing are a growing trend in aphasia rehabilitation with a major impact [38]. Online groups favor the person with mild to moderate aphasia, the member who is well motivated to participate and seeks interaction despite the means. In online ACGs, it is mandatory that members know how to operate a tablet, mobile phone, or a laptop independently and understand

*The Importance of Aphasia Communication Groups DOI: http://dx.doi.org/10.5772/intechopen.101059*

the ethics and procedures behind video conferencing [39]. Realistically, ACGs via video conferencing compared to face-to-face interaction need more time to plan and prepare. When technical problems occur, and they often do occur, they cause anxiety and frustration to the group. Some members become diverted into "fixing" the problem where others "switch off" from participating, factors that make the interaction dysfunctional. The experience of engaging in an online meeting is more mentally demanding as members must concentrate simultaneously on the content of the meeting, the visual material, and the constant input from several sources. Additionally, nonverbal cues are not detected easily, and the facilitator must be proactive in giving cues and prepare digital material to promote engagement.

#### **3. Setting client-centered goals in the aphasia communication groups**

According to Worrall and colleagues [40], goal setting in ACGs with PWA can be challenging because of members:

A further challenge is related to the *setting* that may reinforce a culture in which SLTs focus on the language impairment and are in control.

#### **3.1 SMART short-term goals**

At the beginning of each ACG, goals are discussed with the members of the group, which are more likely to be their long-term goals for aphasia rehabilitation in general. The facilitator along with the communication buddies needs to support the members of the group to break down these goals into SMART short-term goals that can be addressed in the group. These goals should be SMART: Specific, Measurable, Attainable, Relevant, and Time-based (**Figure 1**).

#### **3.2 The SMARTER framework**

In combination with the SMART goals, the SMARTER "Shared, Monitored, Accessible, Relevant, Transparent, Evolving, Relationship" framework encourages aphasia rehabilitation specialists engaged in group therapy to share the goal-setting process with the person with aphasia [41]. The procedure of setting SMARTER goals should be accomplished in a way that is accessible to the members of the group and ensures that the goals evolve with the needs of the clients. Within this framework, the person with aphasia is actively engaged in monitoring their own progress on the goals and each activity in the group ensuring transparency (see **Figure 2**).

**Figure 2.**

*The SMARTER framework based on Hersh et al. [41].*

All goals are relevant to the person with aphasia, and care is provided in a way that builds rapport within the group. Personalized and qualitative therapeutic objectives enable group members to gain more insight into their communication barriers, individually and within the group.

For ACGs to achieve a SMARTER goal setting, the facilitator must read through the framework extensively and then answer the questions for each domain reported below in **Table 1** c.

#### **Table 1.**

like?

*Specific questions involved in SMARTER goal setting framework as adapted from Hersh et al. [41].*

#### **4. The communication buddy system**

A communication buddy is a communication and conversation partner assigned for each person with aphasia within the group. Their main goal is to facilitate the understanding and output (not necessarily verbal) for PWA within the group. Communication buddies should establish mutual support, promote learning about aphasia, facilitate communication, and promote communication skills enhancement [21]. Pairing in groups is based on Bion's theory of "containment" or "container and contained." According to Bion, the *theory of containment* is the capacity

**Figure 3.** *The "essential" people that makeup ACGs.*

of one individual to receive in himself/herself projections from another individual, which he/she then can sense and use as communications (from him/her), transform them, and finally give them back (or convey back) to the subject in a modified form (see **Figure 3**) [42].

Communication buddies can be:

Communication buddies should be identified and assigned by the person with aphasia or by the setting where the group is taking place, e.g., students in a university setting. Communication access, social contact, and active participation are crucial elements in aphasia group work. The person with aphasia, the group facilitator, and the communication buddy must collaborate to find the means and strategies that are most useful for the particular client during communication breakdowns. These may include gestures, drawing, picture support, simplified text, writing keywords, clarification statements, verification questions, eliminating environmental distractors, and summarizing (see **Table 2**). It is mandatory to work closely as a team to identify and tailor these strategies to the person with aphasia.

#### **Table 2.**

*The means and strategies for communication recovery.*

#### **4.1 Communication partners training**

It is crucial that communication buddies, before their involvement with the group [41]:

It is mandatory that communication partners learn how to implement the communication strategies within the group, communicate their message in simplified and accessible ways and assist the person with aphasia to get their message across [43].

#### **5. Peer-led aphasia communication groups**

Peer-led support groups for PWA are run by a person with aphasia and/or family member, with the assistance of their communication buddies, which aim to increase social interaction and peer support [44]. Peer-led models in aphasia communication groups provide access to constant peer support and may address some of the limitations of professionally-led support groups that may use formal agendas and have a strict group structure [45].

Studies examining peer-led support groups in other chronic conditions, that is, cancer survivors, have shown peer-led support groups (72.1%) are greater in the community than professionally led support groups (27.9%) [46], and there is a larger preference for peer than professional health care leaders [47]. For example, by reducing professional resources and interventions, peer-led ACGs can provide extensive, long-term opportunities for functional communication, social contact, friendship, and peer support [48]. Aphasia Connect has successfully expanded the range of services available for PWA across the UK by utilizing PWA as service providers (group leaders) as well as receivers (group members) [49]. Additionally, members of peer-led ACGs share a greater sense of empowerment and ownership as they provide *and* receive support [45]. In most UK aphasia peer-led groups, PWA receive training and ongoing support from speech-language therapists and trained volunteers to co-facilitate and codesign support groups [48]. Similarly, in other community-based ACGs such as Speakability UK, professional facilitators support the initial development of self-assisted groups for PWA, for example by suggesting resources and tips, and provide additional support upon request from group members [47].

Tregea and Brown [45] found that the features that are important for the successful functioning of a peer-led aphasia support group are:

Additional factors that facilitated peer leaders to start and run groups include informational support, practical support, attracting new members, time, venue and organization, and a pleasant communicative personality [45].

#### **6. The role of the facilitator**

Aphasia communication group facilitators should not necessarily be qualified SLTs but individuals who have been trained by professional SLTs and/or the research team, in case the group is part of a randomized controlled trial (RCT), ahead of the intervention or trial, with a particular focus on meaningful and effective communication with PWA [49]. Facilitators should be provided the National Aphasia Guidelines [50] for communication with PWA and be trained on partner conversation skills [43]. Facilitators should assist PWA to co-facilitate the group, and complete checklists at the end of each group session to evaluate fidelity to group content [49]. In a recent pilot feasibility RCT by Tarrant et al. [51] examining group signing intervention in PWA, the facilitators identified several benefits that they attributed to the intervention, starting with the prospect for PWA to meet peers and share personal experiences and the development of warm, empathetic friendships.

In contemporary clinical aphasiology, facilitated conversation in aphasia communication groups is a popular exercise but only a small number of published studies have documented how interactions occur in such group settings [51, 52]. One aspect of ACGs that has been mentioned in the recent literature, but that has not yet been the focus of intensive study, is participation management [51]. Facilitators report that finding ways to help people with limited expressive language participate in the conversation and the group, in general, is one of the central challenges faced by the clinicians and volunteers who lead these groups [51–53].

The study of Archer and colleagues [52] documents common approaches to assisting PWA to participate meaningfully within the group discussions. Results revealed a set of conversational practices used by facilitators and by group members with verbal output difficulties. Archer et al. [52] stated that "these practices took the form of two sequences viz. floor transfers and question-answer series" (p. 15). The identified sequences contributed to promoting meaningful conversational participation by group members with non-fluent aphasia.

After a national survey of third sector ACGs facilitators in the UK by VandenBerg et al. ([54], p. 25), results revealed that the factors described as important to supporting members' attendance in aphasia support groups were as follows:

Also, in the same study ([54], p. 25), facilitators indicated that motivators for PWA's attendance were prioritized by their communication needs:

• "To get better at communicating" (16%);

*The Importance of Aphasia Communication Groups DOI: http://dx.doi.org/10.5772/intechopen.101059*

### **7. Evaluating the benefits of aphasia communication groups**

Aphasia communication groups offer many advantages over traditional individual therapy models in the chronic stage [55]:

Group evaluation has three fundamental purposes [57]:

To proceed with an evaluation process of the ACG, one could choose to evaluate all or any of the following areas [19]:

• The objectives: Were the goals appropriate to the needs of the group? Were the goals sufficiently adapted to the individual needs of the group members?

#### **8. The Aphasia Communication Team (TACT): a university-affiliated aphasia communication group**

The TACT is a university-affiliated ACG in the Republic of Cyprus. The number of strokes in Cyprus range between 1200 and 1400 yearly [58]. If one considers a third of all stroke survivors have aphasia, this means, there are roughly 400 new cases of aphasia each year. About 61% continue to experience communication problems 1 year after stroke leading to fewer friendships and smaller social networks [59]. In the exploration of all the above factors influenced by aphasia, the idea of The Aphasia Communication Team – TACT emerged. TACT delivers benefits to PWA, families, and speech-language therapy trainees. TACT aims to provide stroke survivors support for learning and communication opportunities to promote living well with aphasia. TACT works on the barriers (areas of weakness of the person with aphasia and conversation partners that make communication difficult) and on what communication tools members could use to improve communication. TACT has a broad outlook for living well with aphasia and improving quality of life. Another goal targeted is the understanding that aphasia can be a long-term condition and that aphasia is a "family issue"—not just for the person with aphasia [60]. TACT promotes full participation and engagement in activities of interest. TACT encourages a safe, positive, environment, and is inclusive to all.

The Cyprus Stroke Association recruits stroke survivors and TACT is held at the premises of the Rehabilitation Clinic of the Cyprus University of Technology once a week, for 2 hours. Two groups have been established so far, with five stroke survivors with chronic aphasia and five communication buddies, for each group. Communication buddies are speech and language therapy students who serve as communication facilitators of each group member. The groups are supervised and coordinated by academic and scientific staff from the Department of Rehabilitation Sciences.

*The Inclusion Criteria for participating in TACT is that* PWA:

Group members are assessed on psychometric measures (language, cognition, and quality of life) at the beginning and the end of each block of therapy. Therapy consists of a 12-week block of weekly sessions. The assessment procedure is based on the

#### *The Importance of Aphasia Communication Groups DOI: http://dx.doi.org/10.5772/intechopen.101059*

International Population Registry for Aphasia after Stroke (I-PRAISE) protocol [61] in combination with Attard et al's. [53] ICF-based assessment protocol. This is deemed necessary to measure improvement or change in behaviors post-therapy (see **Table 3**).

Group members are encouraged to share experiences by using technology and tablets. They also practice total communication skills, i.e., adding gestures, drawing, and writing to speech. The main topics of discussion are acquiring new knowledge on stroke and aphasia, linking the data to members' personal experiences, clarifying questions and misunderstandings about their condition, and sharing stories about their life before stroke, the incidence itself, and living with aphasia (see **Figure 4**).

Group member's outcomes consist of change or improvement in measures of functional communication, the overall severity of language impairment, auditory comprehension, spoken language (including naming), reading, and writing from

#### **Table 3.**

*ACGs outcome measures.*

**Figure 4.** *The main conversation "topics" for TACT members.*

#### *Aphasia Compendium*

baseline, overall communication self-rating, and quality of life after stroke. Data gathered via assessment procedures are digitalized for each individual member on a database using the RELEASE protocol [61]. The use of the communication buddy system, the involvement of the total communication approach, the systematic assessment, and the collection of individual patient data (IPD) sets enable the TACT team to measure the effectiveness and efficacy of group therapy interventions for people with chronic aphasia in terms of use of functional communication, social inclusion [14], and quality of life [31].

#### **9. Conclusion**

There is no doubt that Aphasia Communication Groups (ACGs) are of great benefit for people with chronic aphasia. ACGs are associated overall with improvement in communication, social networks, and community access. To achieve this, ACGs facilitators, participating members, and communication buddies should have equal involvement in the realization of the group.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Marina Charalambous1,2 and Maria Kambanaros1 \*

1 Rehabilitation Sciences Department, Cyprus University of Technology, Limassol, Cyprus

2 Laboratory of Cognitive and Neurological Sciences, University of Fribourg, Switzerland

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Importance of Aphasia Communication Groups DOI: http://dx.doi.org/10.5772/intechopen.101059*

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