Vol. 6 nº 4 - Oct/Nov/Dec de 2012
Original Article Pages 223 to 235
 

Rehabilitation of language in expressive aphasias: a literature review
Reabilitação da linguagem nas afasias expressivas: uma revisão da literatura

Authors: Denise Ren da Fontoura1; Jaqueline de Carvalho Rodrigues2; Luciana Behs de Sá Carneiro3; Ana Maria Monção4; Jerusa Fumagalli de Salles5

PDF

Descriptors: rehabilitation, language disorders, review, aphasia.
Descritores:
reabilitação, transtornos da linguagem, revisão, afasia.

ABSTRACT:
OBJECTIVE: This paper reviews the methodological characteristics of studies on rehabilitation of expressive aphasia, describing the techniques of rehabilitation used.
METHODS: The databases Medline, Science Direct and PubMed were searched for relevant articles (January 1999 to December 2011) using the keywords Expressive / Broca / Nonfluent Aphasia, combined with Language or Speech Rehabilitation / Therapy / Intervention.
RESULTS: A total of 56 articles were retrieved describing rehabilitation techniques, including 22 with a focus on lexical processing, 18 on syntax stimulation, seven with the aim of developing speech and nine with multiple foci.
CONCLUSION: A variety of techniques and theoretical approaches are available, highlighting the heterogeneity of research in this area. This diversity can be justified by the uniqueness of patients' language deficits, making it difficult to generalize. In addition, there is a need to combine the formal measures of tests with measures of pragmatic and social skills of communication to determine the effect of rehabilitation on the patient's daily life.

RESUMO:
OBJETIVO: Revisar as características metodológicas dos estudos sobre a reabilitação da afasia expressiva, descrevendo as técnicas de reabilitação utilizadas.
MÉTODOS: Foram pesquisados artigos nas bases de dados Medline, Science Direct e PubMed (Janeiro de 1999 a Dezembro de 2011), utilizando as palavras-chave Expressive / Broca / Nonfluent Aphasia, combinado com Language or Speech Rehabilitation / Therapy / Intervention.
RESULTADOS: Foram encontrados 56 artigos descrevendo técnicas de reabilitação, incluindo 22 com foco no processamento lexical, 18 na estimulação da sintaxe, sete com objetivo de desenvolver a fala e nove com múltiplos focos.
CONCLUSÃO: Há variedade de técnicas e abordagens teóricas, destacando a heterogeneidade da investigação nesta área, que pode justificar-se pela singularidade dos deficits linguísticos dos pacientes, tornando-se difícil a generalização. Existe também necessidade de combinar as medidas formais de testes com medidas de habilidades pragmáticas e sociais da comunicação, para determinar o efeito da reabilitação na vida diária do paciente.

INTRODUCTION

Aphasia is defined as the impairment of expressive and/or receptive language, caused by brain damage, usually to the left hemisphere. It can be classified according to performances in oral and written language (comprehension, expression, naming, repetition).1,2 Among the types of aphasia, this analysis will focus on expressive aphasia (or nonfluent aphasia), highlighting the methods of language rehabilitation.

The World Health Organization proposes three levels of analysis concerning the functional consequences of chronic conditions such as aphasia: the Impairment, the Disability and the Handicap (WHO, 2001).3 Considering these three levels of analysis, three different lines of rehabilitation in aphasia may be characterized, namely: the Traditional School of Language-Oriented Aphasia Therapy, the Functional/Pragmatic School of Aphasia Therapy and the Cognitive Neuropsychology School.4

The Traditional School of Language-Oriented Aphasia Therapy focuses primarily on the levels Impairment and Disability. It is based on the type of aphasia and its symptoms, with a focus on intensive stimulation of language functions, through repetition, auditory and visual stimulation in linguistic and situational contexts. It addresses the restoration of language skills as a means of enhancing functional communication.4,5 The Functional/Pragmatic School of Aphasia Therapy is based on the interaction difficulties with the environment (Handicap). It encourages the patient to use compensatory strategies (verbal, written, gestural or graphical language), focusing on daily communication skills.6-8

The Cognitive Neuropsychology School is based on the impairment of the patient, focusing on functional recovery. The treatment is characterized by planning and structuring therapeutic goals through the theoretical basis for the assessment of the patient's language skills.7 Initially, the compromised cognitive functions are identified through neuropsychological assessment and subsequently the cognitive process that will be trained is defined.2,9

In the scientific literature, there are different therapeutic methods based on the above-mentioned three lines of rehabilitation. Thus, it is important to verify how these techniques are being researched and how they are consolidated. Review studies such as Cappa et al. (2003)10, Cicerone et al. (2005)11 and Cicerone et al. (2011)12 show the benefits of these interventions in language and communication. However, it is important to systematize the findings of this research, and identify its shortcomings and advances.

The main objective of this study was to review the methodological characteristics of studies on rehabilitation of expressive aphasias. More specifically, it was sought to: [1] characterize the study participants regarding the etiology of their aphasia, post-injury time, the study design and intervention time, [2] identify the design of surveys, [3] describe the therapeutic techniques used in the research and outcome in these cases. This systematic review is not exhaustive in terms of the knowledge of language rehabilitation in expressive aphasia, but intends to identify the most recent studies in this area.


METHODS

The databases Medline, Science Direct and PubMed were searched for scientific articles published from January 1999 to December 2011 using the keywords: on one side, Expressive Aphasia or Broca Aphasia or Nonfluent Aphasia and, on the other side, Language Rehabilitation, Language Therapy, Language Intervention, Speech Rehabilitation, Speech Therapy and Speech Intervention. This search, with all combinations of keywords above, retrieved 8,035 items, including duplicated studies repeated in more than one database.

To achieve the proposed objective of this review, only empirical studies that had some method of language intervention in expressive aphasic patients were sought. It is known that these patients may also have significant difficulties in language comprehension. However, these search criteria were determined so as to focus on studies describing only techniques for expressive language, excluding the motor aspects of speech (dysarthrias and dyspraxias).

All studies on language rehabilitation of children, bilingual patients, or in pathologies other than aphasia, studies concerning noncognitive therapy, such as drug treatment, neurosurgical intervention and transcranial stimulation, and those which were not written in Portuguese, Spanish or English, were excluded. From reading the abstracts of articles found, a total of 115 studies (excluding duplicates), whose aim was to report a rehabilitation technique for acquired expressive aphasia, were preselected. These studies were analyzed as a whole, with emphasis on method, results and conclusions.

Of the preselected studies, 56 were identified as meeting the study criteria where the remaining studies did not mention data on the effect of the technique in the Aphasia cases assessed. Based on the selected articles, a descriptive analysis was performed exploring the following aspects: design, sample profile, therapeutic procedures performed, duration of intervention and outcome in these cases. The rehabilitation techniques were organized according to lexical, syntactic and discourse language levels.


RESULTS

Concerning the methodological design of the analyzed articles, 39 (69.7%) were case studies, 11 (19.6%) of which were related to the description of a single case and 34 (60.7%) to multiple single-cases. Forty-six (82.1%) performed the research with group/case control.

Regarding the studied sample, patients' age in the analyzed studies ranged from 19 to 81 years old, and the etiology was predominantly stroke (53 articles or 94.6%) while only five (9%) were on traumatic brain injury, one (1.8%) studied simple herpetic encephalitis and another was of unknown etiology. The post-injury time until the beginning of intervention was variable where the majority of the articles used a period of at least six months after the first clinical manifestation of disease for the beginning of the intervention (Table 1).




The intervention time of the rehabilitation techniques ranged from two weeks to two years, but averaged one month of treatment. Intervention durations were found of 30 minutes, 50 minutes, one hour, one hour and a half, two hours and four hours (with interval). The number of sessions per week also varied, with cases from one to seven visits per week, but studies of two, three and five sessions per week (Table 1) were the most frequent.

The rehabilitation techniques identified in this review study incorporated several approaches, with 22 articles (39.3%) using techniques focused on lexical processing (Table 2); 18 articles (32.1%) focusing on syntax stimulation (Table 3), seven articles (12.5%) with the aim of developing discourse (Table 4) and nine articles (16%) with multiple foci (Table 5).










Only four articles (7.1%) set out to assess the efficacy of the therapeutic technique used. Efficacy refers to improvements concerning accurately conducted research, having a strictly selected sample from a clearly defined clinical population undergoing a specific treatment protocol delivered by a highly trained clinician, as explained by Cherney and Halper (2008). The techniques that showed therapeutic efficacy were applied in chronic patients (from 10 to 132 months post-onset), only one study group, while the others were case studies (Table 1). The following techniques demonstrated therapeutic efficacy for patients with nonfluent aphasia: Morphose-mantic Treatment14, Computer-Based Script Training,16 Oral Reading for Language in Aphasia (ORLA),17 and Linguistic Specific Treatment.22

The studies used a variety of different methods to measure therapeutic efficacy. Standardized testing was conducted pretreatment, posttreatment and weeks after the end of treatment with the following instruments employed, by frequency of studies: Western Aphasia Battery (WAB),14,16,17 Quality of Communication Life (QCL),16 Communication Activities of Daily Living-2 (CADL-2),16 and the Communicative Effectiveness Index (CETI).16

Narrative measures were obtained (baseline, treatment, and follow-up) in some studies, including rate of speech, mean length of utterance, proportion of sentences, proportion of grammatical sentences, proportion of verbs, open-closed class ratio, among other measures.14,22 Additionally, at the time of posttreatment assessment, Cherney and Halper (2008) conducted an exit interview with the participant and/or significant other in order to determine their perception of change resulting from the script training and their satisfaction with the treatment program.16

The other studies proposed to identify the effects of rehabilitation in patients by assessing the activation of neural networks (through neuroimaging techniques), describing the rehabilitation protocol used, and exploring the profile of patients after a specific rehabilitation technique, without mentioning therapeutic efficacy.


DISCUSSION

This paper reviewed studies on rehabilitation of expressive aphasia, investigating the methodological characteristics of these studies. Regarding design, most of the articles were found to be case studies. The use of this methodology aims to foster clinical innovations, study rare phenomena, develop new techniques, assess results for more refined techniques, provide clinical data for subsequent controlled investigations, address questions and to support theoretical views (Barlow and Hersen, 1984). Generally, single case studies are performed more frequently in rehabilitation due to the difficulty in forming homogeneous groups, having, as an alternative, the single-case experimental design (Wilson, 2009). Most articles selected used control/group cases to support the data, highlighting methodological control studies in the search for evidence of rehabilitation techniques of language.

With respect to samples used, most of the articles investigated the effect of rehabilitation in stroke patients - a feature also identified in the review study of Cicerone et al. (2005). Stroke is a major public health problem worldwide, causing care-dependent neurological patients to need rehabilitation, prompting clinical studies on this population. The worldwide prevalence of stroke is from 5 to 10 cases per 1000 inhabitants (Bonita et al., 1997) and the worldwide incidence is one to two cases per 1000 inhabitants (Thorvaldsen et al., 1995).

Regarding the period between the acquired brain injury and beginning of the rehabilitation process, this was found to vary considerably in studies, with the period of six months after the acquired injury being the most prevalent interval. Earlier than this period, measuring of therapeutic efficacy becomes more difficult. Within the first six months after the brain damage, a quick recovery of cognitive functions may occur as a result of the process of brain plasticity.23,24

Concerning aphasic patients, research has indicated that in the first few months after injury, spontaneous improvement in language skills may occur, and treatment may enhance recovery.25 Studies sought to avoid the period of spontaneous recovery, and so tended to assess cognitive-linguistic improvement promoted by interventions carried out at least six month after the injury. It is also evident that studies usually treat patients with chronic aphasia, suggesting the need to investigate whether these techniques are appropriate for acute aphasia.

Based on the articles investigated, the intervention time varied according to the technique applied, the goal of rehabilitation and patients' linguistic features. The number of rehabilitation sessions can also be an important factor in determining improvement in language, with intensive, prolonged care,25 planned on an individual basis,26 being the most prescribed. Although longer intensive therapy is preferred, individuals with chronic nonfluent aphasia may have improved their language skills with low-intensity ORLA treatment, and differences in modality-specific outcomes may have been anticipated based on the severity of the aphasia.17 The studies that showed therapeutic efficacy had intense weekly sessions or an extended number of sessions, corroborating the importance of intervention time.

Regarding the rehabilitation techniques presented in the studies, it is clear that, despite the fact that the techniques are diversified, most work with specific symptoms of expressive aphasia. The studies focused on improving lexical, syntactic, discourse processing or had multiple foci. However, most interventions focused on the lexicon. Thus, it is evident that most studies are using either a traditional approach or neuropsychologi-cal approach of language rehabilitation, with a minority incorporating a functional-pragmatic therapy approach.

The analyses also revealed evidence that the same rehabilitation technique is applied in different studies. The naming therapy through the Semantic Technique, for example, is implemented in one manner by Lorenz and Ziegler (2009)20 and Marcotte and Ansaldo (2010),27 and in another way by Kiran (2008),28 as illustrated in Table 1. Thus, there appears to be no single model of rehabilitation in aphasia; one reason for the difficulty measuring the effectiveness of treatment in these patients. On the other hand, it is noteworthy that the techniques for rehabilitation of language have been tested in different forms, enriching research in this area.

There is concern over methodological studies having control cases, as can be seen. However, few studies measure the efficacy of the techniques. To measure the effect of rehabilitation in patients, the studies used measures of semantic, phonological, lexical and syntactic abilities and verification of improvement in aspects of speech. Hence, studies typically train a specific language skill and monitor whether there was comparatively better performance of the patients on the tasks carried out before and after the intervention. However, these studies show positive results of rehabilitation in the therapeutic setting, but not in the patients' daily lives (generalization). To verify the effect of rehabilitation on patients' daily lives Cherney and Halper (2008),16 for example, emphasized qualitative changes in patients' verbal communication and independence at home, differences not observed in the neuropsychological tests applied, but in interviews given by the family. Given these characteristics, it is suggested that, in addition to the quantitative measures of neuropsychological tests (formal assessment), qualitative measures of the effect of rehabilitation (functional assessment) also be considered, through interviews, conversation recordings and observations of nonverbal communication, a method previously used in some studies.15,16,29

Besides observing the results of standardized tests after neuropsychological rehabilitation, many studies use measures of discourse as an alternative to check the effects of rehabilitation on patients' daily lives. Since the goal of rehabilitation in expressive aphasia is to improve expression (both verbal and non-verbal communication), it is important to develop methods of verifying improvement in communication among patients. None of the studies showed improvement after communicative interaction in the patient-caregiver dyad, which could also serve as evidence of improvements in language for everyday situations.

Finally, studies on rehabilitation have advanced in the search for evidence of improvement on neuroim-aging, showing specific brain changes after rehabilitation.27,30-32 Functional neuroimaging analysis in rehabilitation studies may determine whether the recovery is the result of brain reorganization within an existing scheme, if there has been recruitment of new areas within the neural network, or if there is plasticity in regions around the injured area.33 Adaptive brain plasticity seem to operate differently in each patient, despite the similarity of naming recovery profiles in anomia therapy, where recovery depends on the severity of the deficits of each patient.27 In addition, results highlight individual variability following language therapy, with brain activation changes depending on lesion site and size, language skill, type of intervention, and the nature of the neuroimage task.31

Breier et al. (2010)30 reported that one of the patients who received Melodic Intonation Therapy showed brain activation in language areas of the left hemisphere, suggesting some neuroregeneration and brain plasticity around the damaged area. By contrast, Schlaug et al. (2009)32 found an increase in the number of fibers of the right arcuate fasciculus in all participants after treatment (contralateral hemisphere of the lesion), suggesting probable recruitment of new areas for linguistic functioning within the neural network.

The results of this review of studies investigating expressive aphasia rehabilitation, have highlighted the use of a variety of techniques, theoretical approaches and methods, thus showing heterogeneity in methodology employed in this area. This diversity can be justified by the uniqueness and complexity of the patients' linguistic deficits. However, few studies have measured the effectiveness of rehabilitation techniques; thus, there is a need for further research with controlled methods for measuring therapeutic efficacy. Detailed description of techniques applied is also important, so as to enable replication of studies.

Clinical research on rehabilitation of expressive aphasia considers the linguistic aspects of communication in terms of words, phrases and discourse, choosing to evaluate and rehabilitate one of these aspects individually. However, the changes obtained by means of rehabilitation are sometimes observed only on the tests, and not in the patient's daily life. Thus, there is still a need to combine measures from formal tests with measures of pragmatic and social skills of communication to determine the effect of rehabilitation on the patient's daily life, aimed at enhancing their functional independence.

The aim of this study was to further the knowledge on expressive aphasia rehabilitation, while seeking to identify gaps and advances in this area. A description of the techniques in use can help clinicians select the most suitable for their patient. Only journal articles were evaluated: book chapters, short essays, theses and dissertations that could also report a systematic study on rehabilitation and contribute to this review were not included. For future research, databases of theses and dissertations, as well as new databases, should be included to encompass a broader range of studies in rehabilitation of expressive aphasia.

Acknowledgements. This review was supported by grants from the FCT - Fundação para a Ciência e a Tecnologia (Portugal).


REFERENCES

1. Goodglass H, Kaplan E, Barresi B. The Assessment of Aphasia and Related Disorders. 3nd ed. Philadelphia: Lippincott Williams & Wilkins; 2001:85.

2. Helm-Estabrooks N, Albert ML. Manual of Aphasia and Aphasia Therapy. Austin: Pro-Ed.;2003:281.

3. World Health Organization (2001). World Health Report 2001. Mental Health: New Understanding, New Hope.Geneva: World Health Organization.

4. Schwartz MF, Fink RB. Rehabilitation of aphasia. In: Feinberg TE, Farah MJ (Editors), Behavioral Neurology and Neuropsychology, 2nd ed. United States of America: McGraw-Hill Professional; 2003:179-195.

5. Basso A. The efficacy oh the impairment-based treatment. In: Halligan PW, Wade DT (Editors.), Effectiveness of rehabilitation for cognitive deficits. United States: Oxford University Press; 2005:185-194.

6. Code C. Multifactorial processes in recovery from aphasia: Developing the foundations for a multileveled framework. Brain Lang 2001;77:25-44.

7. Céspedes JMM, Ustárroz JT. Rehabilitación neuropsicológica. Madrid: Editorial Sínteses S. A.; 2008:01-238.

8. Haase VG, Lacerda SS. Neuroplasticidade, variação interindividual e recuperação funcional em neuropsicologia. Temas em Psicologia da SBP 2004;12:28- 42.

9. Mateer CA. Fundamentals of cognitive rehabilitation. In: Halligan PW, Wade DT (Editors.), Effectiveness of rehabilitation for cognitive deficits. United States: Oxford University Press; 2005: 21-29.

10. Cappa SF, Benke T, Clarke S, Rossi B, Stemmer B, van Heugten CM. EFNS guidelines on cognitive rehabilitation: report of an EFNS task force. Eur J Neurol 2003;10:11-23.

11. Cicerone KD, Dahlberg C, Malec JF, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Arch Phys Med Rehab 2005;86:1681-1692.

12. Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Arch Phys Med Rehab 2011;92:519-530.

13. Murray LL, Ray AH. A comparison of relaxation training and syntax stimulation for chronic nonfluent aphasia. J Commun Disord 2001;34:87-113.

14. Faroqi-Shah Y. A comparison of two theoretically driven treatments for verb inflection deficits in aphasia. Neuropsychologia 2008;46:3088-3100.

15. Cherney LR, Halper AS, Holland AL, Cole R. Computerized script training for aphasia: Preliminary results. Am J Speech Lang Pathol 2008;17:19-34.

16. Cherney LR, Halper AS. Novel technology for treating individuals with aphasia and concomitant cognitive deficits. Top Stroke Rehabil 2008;15:542-554.

17. Cherney LR. Oral reading for language in aphasia: Impact of aphasia severity on cross-modal outcomes in chronic nonfluent aphasia. Semin Speech Lang 2010a;31:42-51.

18. Kendall DL, Rosenbek JC, Heilman KM, et al. Phoneme-based rehabilitation of anomia in aphasia. Brain Lang 2008;105:1-17.

19. Biedermann B, Nickels L. The representation of homophones: More evidence from the remediation of anomia. Cortex 2008;44:276-293.

20. Lorenz A, Ziegler W. Semantic vs. word-form specific techniques in anomia treatment: A multiple single-case study. J Neuroling 2009;22:515-537.

21. Ballard KJ, Thompson CK. Treatment and generalization of complex sentence production in agrammatism. J Speech Lang Hear Res 1999;42:690-707.

22. Thompson CK, Shapiro LP, Kiran S, Sobecks J. The role of syntactic complexity in treatment of sentence deficits in agrammatic aphasia: The complexity account of treatment efficacy (CATE). J Speech Lang Hear Res 2003;46:591-607.

23. Cappa SF. Spontaneous Recovery in Aphasia. In: B. Stemmer & H. A. Whitaker (Editors), Handbook of Neurolinguistics. San Diego: Academic Press;1998:536-545.

24. Blomert L. Recovery from language disorders: Interaction between brain and rehabilitation. In: B. Stemmer, H. A. Whitaker (Editors), Handbook of Neurolinguistics. San Diego: Academic Press; 1998:548-557.

25. Carlomago S, Pandolfi M, Labruna L, Colombo A, Razzano C. Recovery from moderate aphasia in the first year poststroke: Effect of type of therapy. Arch Phys Med Rehabil 2001;82:1073-1080.

26. Wilson BA. Evidence for the effectiveness of neuropsychological rehabilitation. In: Wilson BA, Gracey F, Evans JJ, Bateman A (Editors), Neuropsychological Rehabilitation: Theory, Models, Therapy and Outcome. Cambridge: Cambridge University Press; 2009: 22-36.

27. Marcotte K, Ansaldo AI. The neural correlates of semantic feature analysis in chronic aphasia: Discordant patterns according to the etiology. Semin Speech Lang 2010;31: 52-63.

28. Kiran S. Typicality of inanimate category exemplars in aphasia treatment: Further evidence for semantic complexity. J Speech Lang Hear Res 2008;51:1550-1568.

29. LaFrance C, Garcia LJ, Labreche J. The effect of a therapy dog on the communication skills of an adult with aphasia. J Commun Disords 2007;40:215-224.

30. Breier JI, Randle S, Maher LM, Papanicolaou AC. Changes in maps of language activity activation following melodic intonation therapy using magnetoencephalography: Two case studies. J Clin Exp Neuropsychol 2010;32:309-314.

31. Cherney LR, Small SL. Task-dependent changes in brain activation following therapy for nonfluent aphasia: Discussion of two individual cases. J Int Neuropsychol Soc 2006;12: 828-842.

32. Schlaug G, Marchina S, Norton A. Evidence for plasticity in white-matter tracts of patients with chronic Broca 's aphasia undergoing intense intonation-based speech therapy. Ann N Y Acad Sci 2009;1169:385-394.

33. Grady CL, Kapur S. The use of neuroimaging in neurorehabilitative research. In Stuss DT, Winocur G, Robertson IH (Editors), Cognitive Neurorehabilitation. Cambridge: Cambridge University Press; 1999:47-48.

34. Adrián JA, González M, Buiza JJ, Sage K. Extending the use of Spanish Computer-assisted Anomia Rehabilitation Program (CARP -2) in people with aphasia. J Commun Disord 2011;44:666-677.

35. Best W, Schroder A, Herbert R. An investigation of a relative impairment in naming non-living items: Theoretical and methodological implications. J Neuroling 2006;19: 96-123.

36. Crosson B, Moore AB, Gopinath K, et al. Role of the right and left hemispheres in recovery of function during treatment of intention in aphasia. J Cogn Neurosc 2005;17:392-406.

37. Crosson B, Fabrizio KS, Singletary F, et al. Treatment of naming in nonfluent aphasia through manipulation of intention and attention: A phase 1 comparison of two novel treatments. J Int Neuropsychol Soc 2007;13:582-594.

38. Fridriksson J, Morrow-Odom L, Moser D, Fridriksson A, Baylis G. Neural recruitment associated with anomia treatment in aphasia. Neuroimage 2006;32:1403-1412.

39. Fridriksson J, Moser D, Bonilha L, et al. Neural correlates of phonological and semantic-based anomia treatment in aphasia. Neuropsycholo-gia 2007;45:1812-1822.

40. Fridriksson J, Baker JM, Whiteside J, et al. Treating visual speech perception to improve speech production in nonfluent aphasia. Stroke 2009;40:853-858.

41. Léger A, Démonet JF, Ruff S, et al. Neural substrates of spoken language rehabilitation in an aphasic patient: An fMRI study. Neuroimage 2002;17(1):174-183.

42. Vitali P, Abutalebi J, Tettamanti M, et al. Training-induced brain remapping in chronic aphasia: A pilot study. Neurorehabil Neural Repair 2007;21:152-160.

43. McCann C, Doleman J. Verb retrieval in nonfluent aphasia: A replication of Edwards & Tucker, 2006. J Neuroling 2011;24:237-248.

44. Marangolo P, Bonifazi S, Tomaiuolo F, et al. Improving language without words: First evidence from aphasia. Neuropsychologia 2010;48:3824-3833.

45. Martin N, Fink RB, Renvall K, Laine M. Effectiveness of contextual repetition priming treatments for anomia depends on intact access to semantics. J Int Neuropsychol Soc 2006;12: 853-866.

46. Parkinson BR, Raymer A, Chang YL, Fitzgerald DB, Crosson B. Lesion characteristics related to treatment improvement in object and action naming for patients with chronic aphasia. Brain Lang 2009;110:61-70.

47. Richards K, Singletary F, Rothi LJG, Koehler S, Crosson B. Activation of intentional mechanisms through utilization of nonsymbolic movements in aphasia rehabilitation. J Rehabil Res Dev 2002;39:445-454.

48. Rider JD, Wright HH, Marshall RC, Page JL. Using semantic feature analysis to improve contextual discourse in adults with aphasia. Am J Speech Lang Pathol 2008;17:161-172.

49. Hashimoto N, Frome A. The use of a modified semant ic features analysis approach in aphasia. J Commun Disord 2011;44:459-469.

50. Rochon E, Leonard C, Burianova H, et al. Neural changes after phonological treatment for anomia: An fMRI study. Brain Lang 2010;114: 164-179.

51. Cherney L. Oral reading for language in aphasia: Evaluating the efficacy of computer-delivered therapy in chronic nonfluent aphasia. Top Stroke Rehabil 2010b;17:423-431.

52. Dickey MW, Thompson CK. The resolution and recovery of filler-gap dependencies in aphasia: Evidence from on-line anomaly detection. Brain Lang 2004;88:108-127.

53. Jacobs BJ. Social validity of changes in informativeness and efficiency of aphasic discourse following Linguistic Specific Treatment (LST). Brain Lang 2001;78:115-127.

54. Thompson CK, den Ouden D, Bonakdarpour B, Garibaldi K, Parrish TB. Neural plasticity and treatment-induced recovery of sentence processing in agrammatism. Neuropsychologia 2010;48:3211-3227.

55. Koul R, Corwin M, Hayes S. Production of graphic symbol sentences by individuals with aphasia: Efficacy of a computer-based augmentative and alternative communication intervention. Brain Lang 2005;92:58-77.

56. Linebarger MC, Schwartz MF, Romania JR, Kohn SE, Stephens DL. Grammatical encoding in aphasia: Evidence from a "processing prosthesis". Brain Lang 2000;75:416-427.

57. Rochon E, Laird L, Bose A, Scofield J. Mapping therapy for sentence production impairments in nonfluent aphasia. Neuropsychol Rehabil 2005;15:1-36.

58. Ruiter MB, Kolk HJK, Rietveld TCM. Speaking in ellipses: The effect of a compensatory style of speech on functional communication in chronic agrammatism. Neuropsychol Rehabil 2010;20:423-458.

59. Stadie N, Schorder A, Postler J, et al. Unambiguous generalization effects after treatment of non-cationical sentence production in German agrammatism. Brain Lang 2008;104:211-229.

60. Straube T, Schulz A, Geipel K, Mentzel HJ, Miltner WH. Dissociation between singing and speaking in expressive aphasia: The role of song familiarity. Neuropsychologia 2008;46:1505-1512.

61. Weinrich M, Boser KI, McCall D. Representation of linguistic rules in the brain: Evidence from training an aphasic patient to produce past tense verb morphology. Brain Lang 1999;70:144-158.

62. Weinrich M, Boser KI, McCall D, Bishop V Training agrammatic subjects on passive sentences: Implications for syntactic deficit theories. Brain Lang 2001;76:45-61.

63. Cherney LR, Halper AS, Holland AL, Lee JB, Babbitt E, Cole R. Improving conversational script production in aphasia with virtual therapist computer treatment software. Brain Lang 2007;103:246-247.

64. Cherney LR, Halper AS, Kaye RC. Computer-based script training for aphasia: Emerging themes from post-treatment interviews. J Commun Disord 2011;44:493-501.

65. Beek S, Maxim J, Best W, Cooper F. Redesigning therapy for agrammatism: Initial findings from the ongoing evaluation of a conversation-based intervention study. J Neuroling 2011;24: 222-236.

66. Johnson RK, Hough MS, King KA, Vos P, Jeffs T. Functional communication in individuals with chronic severe aphasia using augmentative communication. Augment Altern Commun 2008;24:269-280.

67. Linebarger M, McCall D, Virata T, Berndt RS. Widening the temporal window: Processing support in the treatment of aphasic language production. Brain Lang 2007;100: 53-68.

68. Bakheit AMO, Shaw S, Carrington S, Griffiths S. The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke. Clin Rehabil 2007;21:941-949.

69. Basso A, Caporali A. Targeted intervention for multiple language disorders: A case study. J Neuroling 2004;17:383-401.

70. Breier JI, Juranek J, Maher LM, Schmadeke S, Men D, Papanicolaou AC. Behavioral and neurophysiologic response to therapy for chronic aphasia. Arch Phys Med Rehabil 2009;90: 2026-2033.

71. Meinzer M, Flaisch T, Breitenstein C, Wienbruch C, Elbert T, Rockstroh B. Functional re-recruitment of dysfunctional brain areas predicts language recovery in chronic aphasia. Neuroimage 2008;39:2038-2046.

72. Kim M, Tomaino CM. Protocol evaluation for effective music therapy for persons with nonfluent aphasia. Top Stroke Rehabil 2008;15):555-569.

73. Pinhasi-Vittorio L. The role of written language in the rehabilitation process of brain injury and aphasia: The memory of the movement in the reacquisition of language. Top Stroke Rehabil 2007;14:115-122.










1. Fonoaudióloga, Doutora em Ciências da Linguagem/Psicolinguística pela Universidade Nova de Lisboa (UNL), Mestre em Ciências da Saúde/Neurociências pela Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Especialista em Reabilitação Fonoaudiológica/ Voz pelo Instituto Metodista IPA e Pós Graduada em Neuropsicologia/ Linguagem pela PUCRS.
2. Psicóloga Clínica, Mestranda em Psicologia no Programa de Pós-Graduação em Psicologia, Universidade Federal do Rio Grande do Sul - UFRGS.
3. Fonoaudióloga Clínica.
4. Professora Auxiliar do Departamento de Linguística da Universidade Nova de Lisboa, Doutora em Psicolin-guística, Licenciada em Psicoterapia e Mestre em Neuropsicologia e Demencias.
5. Fonoaudióloga, Doutora em Psicologia, Professora Adjunta do Departamento de Psicologia do Desenvolvimento e da Personalidade, Instituto de Psicologia, Programa de Pós-Graduação em Psicologia, Universidade Federal do Rio Grande do Sul - UFRGS, Coordenadora do Núcleo de estudos em Neuropsicologia Cognitiva - NEUROCOG.

Denise R. Fontoura
Instituto de Psicologia - Rua Ramiro Barcelos, 2600 / sala 114
Porto Alegre RS - Brazil - 90035-003
E-mail: denisedafontoura@yahoo.com / jerusafs@yahoo.com.br

Received May 31, 2012
Accepted in final form August 13, 2012

Disclosure: The authors report no conflicts of interest.

 

Home Contact