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There is no cure for DVD/CAS, but with appropriate, intensive intervention, people with the disorder can improve significantly.
DVD/CAS requires various forms of therapy which varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). In children with DVD/CAS, consistency is a key element in treatment. Consistency in the form of communication, as well as the development and use of oral communication are extremely important in aiding a child's speech learning process.
Many therapy approaches are not supported by thorough evidence; however, the aspects of treatment that do seem to be agreed upon are the following:
- Treatment needs to be intense and highly individualized, with about 3-5 therapy sessions each week
- A maximum of 30 minutes per session is best for young children
- Principles of motor learning theory and intense speech-motor practice seem to be the most effective
- Non-speech oral motor therapy is not necessary or sufficient
- A multi-sensory approach to therapy may be beneficial: using sign language, pictures, tactile cues, visual prompts, and Augmentative and Alternative Communication (AAC) can be helpful.
Although these aspects of treatment are supported by much clinical documentation, they lack evidence from systematic research studies. In ASHA's position statement on DVD/CAS, ASHA states there is a critical need for collaborative, interdisciplinary, and programmatic research on the neural substrates, behavioral correlates, and treatment options for DVD/CAS.
In addition to active speech therapy, pharmaceuticals have also been considered as a useful treatment for expressive aphasia. This area of study is relatively new and much research continues to be conducted.
The following drugs have been suggested for use in treating aphasia and their efficacy has been studied in control studies.
- Bromocriptine – acts on Catecholamine Systems
- Piracetam – mechanism not fully understood, but most likely interacts with cholinergic and glutamatergic receptors, among others
- Cholinergic drugs (Donepezil, Aniracetam, Bifemelane) – acts on acetylcholine systems
- Dopaminergic psychostimulants: (Dexamphetamine, Methylphenidate)
The most effect has been shown by piracetam and amphetamine, which may increase cerebral plasticity and result in an increased capability to improve language function. It has been seen that piracetam is most effective when treatment is begun immediately following stroke. When used in chronic cases it has been much less efficient.
Bromocriptine has been shown by some studies to increase verbal fluency and word retrieval with therapy than with just therapy alone. Furthermore, its use seems to be restricted to non-fluent aphasia.
Donepezil has shown a potential for helping chronic aphasia.
No study has established irrefutable evidence that any drug is an effective treatment for aphasia therapy. Furthermore, no study has shown any drug to be specific for language recovery. Comparison between the recovery of language function and other motor function using any drug has shown that improvement is due to a global increase plasticity of neural networks.
Treatment is usually carried out by speech and language therapists/pathologists, who use a wide range of techniques to stimulate language learning. In the past, there was a vogue for drilling children in grammatical exercises, using imitation and elicitation, but such methods fell into disuse when it became apparent that there was little generalisation to everyday situations. Contemporary approaches to enhancing development of language structure, for younger children at least, are more likely to adopt 'milieu' methods, in which the intervention is interwoven into natural episodes of communication, and the therapist builds on the child's utterances, rather than dictating what will be talked about. Interventions for older children, may be more explicit, telling the children what areas are being targeted and giving explanations regarding the rules and structures they are learning, often with visual supports.
In addition, there has been a move away from a focus solely on grammar and phonology toward interventions that develop children's social use of language, often working in small groups that may include typically developing as well as language-impaired peers.
Another way in contemporary remediation differ from the past is that parents are more likely to be directly involved, but this approach is largely used with preschool children, rather than those whose problems persist into school age.,
For school-aged children, teachers are increasingly involved in intervention, either in collaboration with speech and language therapists/pathologists, or as the main agents of delivery of the intervention. Evidence for the benefits of a collaborative approach is emerging, but the benefits of asking education staff to be the main deliverers of SLT intervention (the “consultative” approach) are unclear. When SLT intervention is delivered indirectly by trained SLT assistants, however, there are indications that this can be effective.
A radically different approach has been developed by Tallal and colleagues, who devised a computer-based intervention, FastForWord, that involves prolonged and intensive training on specific components of language and auditory processing. The theory underlying FastForword maintains that language difficulties are caused by a failure to make fine-grained auditory discriminations in the temporal dimension, and the computerised training materials are designed to sharpen perceptual acuity. However, a systematic review of clinical trials assessing FastForWord reported no significant gains relative to a control group.
In this field, Randomized controlled trial methodology has not been widely used, and this makes it difficult to assess clinical efficacy with confidence. Children's language will tend to improve over time, and without controlled studies, it can be hard to know how much of observed change is down to a specific treatment. There is, however, increasing evidence that direct 1:1 intervention with an SLT/P can be effective for improving vocabulary and expressive language. There have been few studies of interventions that target receptive language, though some positive outcomes have been reported.,
One technique that is frequently used to treat DVD/CAS is integral stimulation. Integral stimulation is based on cognitive motor learning, focusing on the cognitive motor planning needed for the complex motor task of speech. It is often referred to as the "watch me, listen, do as I do" approach and is founded on a multi-step hierarchy of strategies for treatment. This hierarchy of strategies allows the clinician to alter treatment depending upon the needs of the child. It uses various modalities of presentation, emphasizing the auditory and visual modes. Experts suggest that extensive practice and experience with the new material is key, so hundreds of target stimuli should be elicited in a single session. Furthermore, distributed (shorter, but more frequent) and random treatment, which mix target and non-target utterances, produces greater overall learning.
The 6 steps of the hierarchy upon which integral stimulation therapy for children is loosely organized are:"
- The child watches and listens and simultaneously produces the stimulus with the clinician.
- The clinician models, then the child repeats the stimulus while the clinician simultaneously mouths it.
- The clinician models and provides cues and the child repeats.
- The clinician models and the child repeats with no cues provided.
- The clinician elicits the stimulus without modeling, such as by asking a question, with the child responding spontaneously.
- The child produces stimuli in less-directed situations with clinician encouragement, such as in role-play or games".
In cases of acute AOS (stroke), spontaneous recovery may occur, in which previous speech abilities reappear on their own. All other cases of acquired AOS require a form of therapy; however the therapy varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). For severe forms of AOS, therapy may involve multiple sessions per week, which is reduced with speech improvement. Another main theme in AOS treatment is the use of repetition in order to achieve a large amount of target utterances, or desired speech usages.
There are various treatment techniques for AOS. One technique, called the Linguistic Approach, utilizes the rules for sounds and sequences. This approach focuses on the placement of the mouth in forming speech sounds. Another type of treatment is the Motor-Programming Approach, in which the motor movements necessary for speech are practiced. This technique utilizes a great amount of repetition in order to practice the sequences and transitions that are necessary in between production of sounds.
Research about the treatment of apraxia has revealed four main categories: articulatory-kinematic, rate/rhythm control, intersystemic facilitation/reorganization treatments, and alternative/augmentative communication.
- Articulatory-kinematic treatments almost always require verbal production in order to bring about improvement of speech. One common technique for this is modeling or repetition in order to establish the desired speech behavior. Articulatory-kinematic treatments are based on the importance of patients to improve spatial and temporal aspects of speech production.
- Rate and rhythm control treatments exist to improve errors in patients’ timing of speech, a common characteristic of Apraxia. These techniques often include an external source of control like metronomic pacing, for example, in repeated speech productions.
- Intersystemic reorganization/facilitation techniques often involve physical body or limb gestural approaches to improve speech. Gestures are usually combined with verbalization. It is thought that limb gestures may improve the organization of speech production.
- Finally, alternative and augmentative communication approaches to treatment of apraxia are highly individualized for each patient. However, they often involve a "comprehensive communication system" that may include "speech, a communication book aid, a spelling system, a drawing system, a gestural system, technologies, and informed speech partners".
One specific treatment method is referred to as PROMPT. This acronym stands for Prompts for Restructuring Oral Muscular Phonetic Targets, and takes a hands on multidimensional approach at treating speech production disorders. PROMPT therapists integrate physical-sensory, cognitive-linguistic, and social-emotional aspects of motor performance. The main focus is developing language interaction through this tactile-kinetic approach by using touch cues to facilitate the articulatory movements associated with individual phonemes, and eventually words.
One study describes the use of electropalatography (EPG) to treat a patient with severe acquired apraxia of speech. EPG is a computer-based tool for assessment and treatment of speech motor issues. The program allows patients to see the placement of articulators during speech production thus aiding them in attempting to correct errors. Originally after two years of speech therapy, the patient exhibited speech motor and production problems including problems with phonation, articulation, and resonance. This study showed that EPG therapy gave the patient valuable visual feedback to clarify speech movements that had been difficult for the patient to complete when given only auditory feedback.
While many studies are still exploring the various treatment methods, a few suggestions from ASHA for treating apraxia patients include the integration of objective treatment evidence, theoretical rationale, clinical knowledge and experience, and the needs and goals of the patient
Treatment for dysgraphia varies and may include treatment for motor disorders to help control writing movements. The use of occupational therapy can be effective in the school setting, and teachers should be well informed about dysgraphia to aid in carry-over of the occupational therapist's interventions. Treatments may address impaired memory or other neurological problems. Some physicians recommend that individuals with dysgraphia use computers to avoid the problems of handwriting. Dysgraphia can sometimes be partially overcome with appropriate and conscious effort and training. The International Dyslexia Association suggests the use of kinesthetic memory through early training by having the child overlearn how to write letters and to later practice writing with their eyes closed or averted to reinforce the feel of the letters being written. They also suggest teaching the students cursive writing as it has fewer reversible letters and can help lessen spacing problems, at least within words, because cursive letters are generally attached within a word.
Diagnosing dysgraphia can be challenging but can be done at facilities specializing in learning disabilities. It is suggested that those who believe they may have dysgraphia seek a qualified clinician to be tested. Clinicians will have the client self-generate written sentences and paragraphs, and copy age-appropriate text. They will assess the output of writing, as well as observe the client's posture while writing, their grip on the writing instrument, and will ask the client to either tap their finger or turn their wrists repeatedly to assess fine motor skills.
Children who demonstrate deficiencies early in their speech and language development are at risk for continued speech and language issues throughout later childhood. Similarly, even if these speech and language problems have been resolved, children with early language delay are more at risk for difficulties in phonological awareness, reading, and writing throughout their lives. Children with mixed receptive-expressive language disorder are often likely to have long-term implications for language development, literacy, behavior, social development, and even mental health problems. If suspected of having a mixed receptive-expressive language disorder, treatment is available from a speech therapist or pathologist. Most treatments are short term, and rely upon accommodations made within the environment, in order to minimize interfering with work or school. Programs that involve intervention planning that link verbal short term memory with visual/non-verbal information may be helpful for these children. In addition, approaches such as parent training for language stimulation and monitoring language through the "watch and see" method are recommended. The watch-and-see technique advises children with mixed receptive-expressive language disorder who come from stable, middle-class homes without any other behavioral, medical, or hearing problems should be vigilantly monitored rather than receive intervention. It is often the case that children do not meet the eligibility criteria established through a comprehensive oral language evaluation; and as a result, are not best suited for early intervention programs and require a different approach besides the "one size fits all" model.
Speech and language therapy is typically the primary treatment for individuals with aphasia. The goal of speech and language therapy is to increase the person’s communication abilities to a level functional for daily life. Goals are chosen based on collaboration between speech language pathologists, patients, and their family/caregivers. Goals should be individualized based on the person’s aphasia symptoms and communicative needs. In 2016, Wallace et al. found the following outcomes were commonly prioritized in therapy: communication, life participation, physical and emotional well-being, normalcy, and health and support services. However, available research is inconclusive about which specific approach to speech and language therapy is most effective in treating global aphasia.
Therapy can be either group or individual. Group therapies that integrate the use of visual aids allow for enhanced social and communication-skill development. Group therapy sessions typically revolve around simple, preplanned activities or games, and aim to facilitate social communication.
One particular therapy designed specifically for treatment of aphasia is Visual Action Therapy (VAT). VAT is a non-verbal gestural output program with 3 phases and 30 total steps. The program teaches unilateral gestures as symbolic representations of real life objects. Research on the effectiveness of VAT is limited and inconclusive.
One important therapy technique includes teaching family members and caregivers strategies for more effectively communicating with their loved ones. Research offers such strategies including, simplifying sentences and using common words, gaining the person's attention before speaking, using pointing and visual cues, allowing for adequate response time, and creating a quiet environment free of distractions.
Another approach to speech and language treatment is constraint-induced language therapy (CILT). CILT involves teaching the patient to use speech in small segments but avoid using gestures and familiar words . The speech language pathologist provides positive feedback throughout and ignores any mistakes made by the patient. The intensity with which this treatment is provided has been debated in the literature. One study, performed in 2015, compared the outcomes of patients with aphasia who received CILT for either 30 hours total over 2 weeks or 30 hours distributed over 10 weeks. Results showed that both groups made significant speech and language improvements. Overall, CILT is an effective treatment at a variety of intensities.
Research supporting the efficacy of pharmacological treatments for aphasia is limited. To date, no large scale clinical trials have proven benefits of pharmacological treatment.
Currently, there is no standard treatment for expressive aphasia. Most aphasia treatment is individualized based on a patient's condition and needs as assessed by a speech language pathologist. Patients go through a period of spontaneous recovery following brain injury in which they regain a great deal of language function.
In the months following injury or stroke, most patients receive traditional treatment for a few hours per day. Among other exercises, patients practice the repetition of words and phrases. Mechanisms are also taught in traditional treatment to compensate for lost language function such as drawing and using phrases that are easier to pronounce.
Emphasis is placed on establishing a basis for communication with family and caregivers in everyday life. Treatment is individualized based on the patient's own priorities, along with the family's input.
A patient may have the option of individual or group treatment. Although less common, group treatment has been shown to have advantageous outcomes. Some types of group treatments include family counseling, maintenance groups, support groups and treatment groups.
Due to advances in modern neuroimaging, scientists have been able to gain a better understanding of how language is learned and comprehended. Based on the new data from the world of neuroscience, improvements can be made in coping with the disorder.
Therapists have been developing multiple methods of improving speech and comprehension. These techniques utilize three general principles: maximizing therapy occurrences, ensuring behavioral and communicative relevance, and allowing patients to focus on the language tools that are still available in his or her repertoire.
Many of the following treatment techniques are used to improve auditory comprehension in patients with aphasia:
- Use common words
- Using concrete nouns is more effective than using adjectives, adverbs, or verbs
- Using action verbs that are easily imagined
- Concise and grammatically simple sentences as opposed to lengthy sentences
- Speaking slowly, repeating oneself several times when conversing with patients who are aphasic
- Using gestures
A relatively new method of language therapy involves coincidence learning. Coincidence learning focuses on the simultaneous learning of two or more events and stipulates that these events are wired together in the brain, strengthening the learning process. Therapists use coincidence learning to find and improve language correlations or coincidences that have been either damaged or deleted by severe cases of aphasia, such as transcortical sensory aphasia. This technique is important in brain function and recovery, as it strengthens associated brain areas that remain unaffected after brian damage. It can be achieved with intensive therapy hours in order to maximize time where correlation is emphasized.
Through careful analysis of neuroimaging studies, a correlation has been developed with motor function and the understanding of action verbs. For example, leg and motor areas were seen to be activated words such as "kick", leading scientists to understand the connection between motor and language processes in the brain. This is yet another example of using relationships that are related in the brain for the purpose of rehabilitating speech and comprehension.
Of huge importance in aphasia therapy is the need to start practicing as soon as possible. Greater recovery occurs when a patient attempts to improve their comprehension and speaking soon after aphasia occurs. There is an inverse relationship between the length of time spent not practicing and level of recovery. The patient should be pushed to their limits of verbal communication in order for them to practice and build upon their remaining language skills.
One effective therapy technique is using what are known as language games in order to encourage verbal communication. One famous example is known as "Builder's Game", where a 'builder' and a 'helper' must communicate in order to effectively work on a project. The helper must hand the builder the tools he or she may need, which requires effective oral communication. The builder succeeds by requesting tools from the assistant by usually using single word utterances, such as 'hammer' or 'nail'. Thus, when the helper hands the tool to the builder, the game incorporates action with language, a key therapy technique. The assistant would then hand the builder the requested tool. Success of the game occurs when the builder's requests are specific to ensure successful building.
Ultimately, regardless of therapy plan or method, improvement in speech does not appear overnight; it requires a significant time investment by the patient as well as a dedicated speech therapist seeking to ensure that the patient is focusing on the correct speech tasks outside of the clinic. Furthermore, the patient must collaborate with friends and family members during their free time in order to maximize the efficacy of the treatment.
Agraphia cannot be directly treated, but individuals can be rehabilitated to regain some of their previous writing abilities.
For the management of phonological agraphia, individuals are trained to memorize key words, such as a familiar name or object, that can then help them form the grapheme for that phoneme. Management of allographic agraphia can be as simple as having alphabet cards so the individual can write legibly by copying the correct letter shapes. There are few rehabilitation methods for apraxic agraphia; if the individual has considerably better hand control and movement with typing than they do with handwriting, then they can use technological devices. Texting and typing do not require the same technical movements that handwriting does; for these technological methods, only spatial location of the fingers to type is required. If copying skills are preserved in an individual with apraxic agraphia, repeated copying may help shift from the highly intentional and monitored hand movements indicative of apraxic agraphia to a more automated control.
Micrographia is a condition that can occur with the development of other disorders, such as Parkinson's disease, and is when handwriting becomes illegible because of small writing. For some individuals, a simple command to write bigger eliminates the issue.
- Anagram and Copy Treatment (ACT) uses the arrangement of component letters of target words and then repeated copying of the target word. This is similar to the CART; the main difference is that the target words for ACT are specific to the individual. Target words that are important in the life of the individual are emphasized because people with deep or global agraphias do not typically have the same memory for the words as other people with agraphia may. Writing can be even more important to these people as it can cue spoken language. ACT helps in this by facilitating the relearning of a set of personally relevant written words for use in communication.
- Copy and Recall Treatment (CART) method helps to reestablish the ability to spell specific words that are learned through repeated copying and recall of target words. CART is more likely to be successful in treating lexical agraphia when a few words are trained to mastery than when a large group of unrelated words is trained. Words chosen can be individualized to the patient, which makes treatment more personalized.
- Graphemic buffer uses the training of specific words to improve spelling. Cueing hierarchies and copy and recall method of specific words are used, to work the words into the short-term memory loop, or graphemic buffer. The segmentation of longer words into shorter syllables helps bring words into short-term memory.
- Problem solving approach is used as a self-correcting method for phonological errors. The individual sounds out the word and attempts to spell it, typically using an electronic dictionary-type device that indicates correct spelling. This method takes advantage of the preserved sound-to-letter correspondences when they are intact. This approach may improve access to spelling memory, strengthen orthographic representations, or both.
There is no curative treatment for this condition. Supportive management is helpful.
There is no method available to completely cure anomic aphasia. However, there are treatments to help improve word-finding skills.
Although a person with anomia may find it difficult to recall many types of words such as common nouns, proper nouns, verbs, etc., many studies have shown that treatment for object words, or nouns, has shown promise in rehabilitation research. The treatment includes visual aids, such as pictures, and the patient is asked to identify the object or activity. However, if that is not possible, then the patient is shown the same picture surrounded by words associated with the object or activity. Throughout the process, positive encouragement is provided. The treatment shows an increase in word-finding during treatment; however, word identifying decreased two weeks after the rehabilitation period. Therefore, it shows that rehabilitation effort needs to be continuous for word-finding abilities to improve from the baseline. The studies show that verbs are harder to recall or repeat, even with rehabilitation.
Other methods in treating anomic aphasia include Circumlocution Induced Naming therapy (CIN), wherein the patient uses circumlocution to assist with his or her naming rather than just being told to name the item pictured after given some sort of cue. Results suggest that the patient does better in properly naming objects when undergoing this therapy because CIN strengthens the weakened link between semantics and phonology for patients with anomia, since they often know what an object is used for but cannot verbally name it.
Anomia is often burdensome on the families and friends of those suffering from it. One way to overcome this burden is computer-based treatment models, effective especially when used with clinical therapy. Leemann et al. provided anomic patients with computerized-assisted therapy (CAT) sessions, along with traditional therapy sessions using treatment lists of words. Some of the patients received a drug known to help relieve symptoms of anomia (levodopa) while others received a placebo. The researchers found that the drug had no significant effects on improvement with the treatment lists, but almost all of the patients improved after the CAT sessions. They concluded that this form of computerized treatment is effective in increasing naming abilities in anomic patients.
Additionally, one study researched the effects of using "excitatory (anodal) transcranial direct current stimulation" over the right temporo-parietal cortex, a brain area that seems to correlate to language. The electrical stimulation seemed to enhance language training outcome in patients with chronic aphasia.
Treatment for all types of aphasia, including transcortical motor aphasia, is usually provided by a speech-language pathologist. The SLP chooses specific therapy tasks and goals based on the speech and language abilities and needs of the individual. In general for individuals with TMoA, treatment should capitalize on their strong auditory comprehension and repetition skills and address the individual's reduced speech output and difficulty initiating and maintaining a conversation. New research in aphasia treatment is showing the benefit of the Life Participation Approach to Aphasia (LPAA) in which goals are written based on the skills needed by the individual patient to participate in specific real-life situations (i.e. communicating effectively with nurses or gaining employment). Based on the specific needs of the patient, SLPs can provide a variety of treatment activities.
To improve word retrieval and initiation difficulties, clinicians may use confrontation naming in which the patient is asked to name various objects and pictures. Depending on the severity, they may also use sentence completion tasks in which the clinician says sentences with the final word(s) missing and expects the patient to fill in the blank. Limited research suggests that nonsymbolic limb movement on the left side (i.e. tapping the left hand on the table) during sentence production can increase verbal initiations. The use of the left arm in left space stimulates initiation mechanisms in the right hemisphere of the brain which can also be used for language allowing individuals to produce more grammatical sentences with higher fluency and more verbal initiation.
To increase speech output, the clinician may provide a set of pictures and prompt the patient to describe or elaborate on the events pictured. The clinician can also provide spoken or written words and prompt the patient to use the words in a sentence. Additionally, the clinician can ask questions based on the patient’s experiences, opinions, or general knowledge and prompt the patient to answer with phrases or sentences. To work on more connected speech, the clinician may ask the patient to describe procedures such as making a sandwich or doing laundry. A study found that syntax training in which sentence constructions are elicited on a hierarchy of difficulty produced gains in grammatically complete utterances and utterances that successfully communicated novel and accurate information.
To improve conversational skills, SLPs may engage the patient in structured conversations in which supports are provided to help the patient take appropriate conversational turns, maintain the topic of conversation, and formulate appropriate sentences. Clinicians often need to provide pragmatic guidelines so that the patient’s responses go beyond the clinician’s request and so the clinician does not do the majority of the talking. Research shows that conversation therapy can improve percent of complex utterances, the efficiency of the utterances for expressing ideas, and total time spent talking over more traditional stimulation therapy.
In order to improve the patient’s abilities to functionally communicate in their natural settings, the SLP will provide strategies and techniques to enhance their success in communicative settings (i.e. supplementing speech with nonverbal communication). Research supports the use of reduced syntax therapy to help patients overcome the non-fluent speech and agrammatism that often occurs with TMoA. Because agrammatism inhibits the patient's ability to form grammatically correct sentences, this type of treatment involves reducing these agrammatic deficits and teaching the patient to simplify linguistic structures while still conveying the message in order for language used to be more productive in conversation.
Additionally, they may train the patient’s communication partners to support the conversational abilities of the patient by facilitating the use of preserved cognitive and social functions. Research supports the use of various partner training programs such as Supported Conversation for Adults with Aphasia from the Aphasia Institute. In this program, the focus is put on acknowledging the patient’s competence and helping them to reveal that competence. Strategies include saying “I know you know” when appropriate, using gestures to supplement messages, limiting background noise, and given sufficient time for response.
From a neuroscience perspective, research has found that a dopamine agonist, bromocriptine, taken by mouth, has provided positive outcomes during intervention for non-fluent types of aphasia, such as TMoA or adynamic aphasia. Studies have found that bromocriptine increased neural networks which assist with the initiation of speech in individuals who possess non-fluent characteristics of speech.
In order to capitalize on neuroplasticity for treatment of all types of aphasia, timing, intensity, duration, and repetition of treatment should be taken into consideration. Research has found that aphasia treatment initiated during the earlier acute post-injury phase is more effective compared to treatment initiated in the chronic phase. With regard to intensity and duration of treatment, studies reported maximum recovery occurred with intense weekly therapy (approximately 8 hours per week) was delivered over a 2–3 month period. Other research shows that distributed therapy may be more beneficial than high intensity therapy. More research is needed to determine which is best, but it may be found that the ideal duration and intensity of therapy is variable depending on the patient and their needs.
When addressing Wernicke’s aphasia, according to Bakheit et al. (2007), the lack of awareness of the language impairments, a common characteristic of Wernicke’s aphasia, may impact the rate and extent of therapy outcomes. Klebic et al. (2011) suggests that people benefit from continuing therapy upon discharge from the hospital to ensure generalization. Robey (1998) determined that at least 2 hours of treatment per week is recommended for making significant language gains. Spontaneous recovery may cause some language gains, but without speech-language therapy, the outcomes can be half as strong as those with therapy.
When addressing Broca’s aphasia, better outcomes occur when the person participates in therapy, and treatment is more effective than no treatment for people in the acute period. Two or more hours of therapy per week in acute and post-acute stages produced the greatest results. High intensity therapy was most effective, and low intensity therapy was almost equivalent to no therapy.
People with global aphasia are sometimes referred to as having irreversible aphasic syndrome, often making limited gains in auditory comprehension, and recovering no functional language modality with therapy. With this said, people with global aphasia may retain gestural communication skills that may enable success when communicating with conversational partners within familiar conditions. Process-oriented treatment options are limited, and people may not become competent language users as readers, listeners, writers, or speakers no matter how extensive therapy is. However, people’s daily routines and quality of life can be enhanced with reasonable and modest goals. After the first month, there is limited to no healing to language abilities of most people. There is a grim prognosis leaving 83% who were globally aphasic after the first month they will remain globally aphasic at the first year. Some people are so severely impaired that their existing process-oriented treatment approaches offer signs of progress, and therefore cannot justify the cost of therapy.
Perhaps due to the relative rareness of conduction aphasia, few studies have specifically studied the effectiveness of therapy for people with this type of aphasia. From the studies performed, results showed that therapy can help to improve specific language outcomes. One intervention that has had positive results is auditory repetition training. Kohn et al. (1990) reported that drilled auditory repetition training related to improvements in spontaneous speech, Francis et al. (2003) reported improvements in sentence comprehension, and Kalinyak-Fliszar et al. (2011) reported improvements in auditory-visual short-term memory.
Most acute cases of aphasia recover some or most skills by working with a speech-language pathologist. Recovery and improvement can continue for years after the stroke. After the onset of Aphasia, there is approximately a six-month period of spontaneous recovery; during this time, the brain is attempting to recover and repair the damaged neurons. Improvement varies widely, depending on the aphasia's cause, type, and severity. Recovery also depends on the person's age, health, motivation, handedness, and educational level.
There is no one treatment proven to be effective for all types of aphasias. The reason that there is no universal treatment for aphasia is because of the nature of the disorder and the various ways it is presented, as explained in the above sections. Aphasia is rarely exhibited identically, implying that treatment needs to be catered specifically to the individual. Studies have shown that, although there is no consistency on treatment methodology in literature, there is a strong indication that treatment in general has positive outcomes. Therapy for aphasia ranges from increasing functional communication to improving speech accuracy, depending on the person's severity, needs and support of family and friends. Group therapy allows individuals to work on their pragmatic and communication skills with other individuals with aphasia, which are skills that may not often be addressed in individual one-on-one therapy sessions. It can also help increase confidence and social skills in a comfortable setting.
Evidence dose not support the use of transcranial direct current stimulation (tDCS) for improving aphasia after stroke.
Specific treatment techniques include the following:
- Copy and Recall Therapy (CART) - repetition and recall of targeted words within therapy may strengthen orthographic representations and improve single word reading, writing, and naming
- Visual Communication Therapy (VIC) - the use of index cards with symbols to represent various components of speech
- Visual Action Therapy (VAT) - typically treats individuals with global aphasia to train the use of hand gestures for specific items
- Functional Communication Treatment (FCT) - focuses on improving activities specific to functional tasks, social interaction, and self-expression
- Promoting Aphasic's Communicative Effectiveness (PACE) - a means of encouraging normal interaction between people with aphasia and clinicians. In this kind of therapy the focus is on pragmatic communication rather than treatment itself. People are asked to communicate a given message to their therapists by means of drawing, making hand gestures or even pointing to an object
- Melodic Intonation Therapy (MIT) - aims to use the intact melodic/prosodic processing skills of the right hemisphere to help cue retrieval of words and expressive language
- Other - i.e. drawing as a way of communicating, trained conversation partners
Semantic feature analysis (SFA) -a type of aphasia treatment that targets word-finding deficits. It is based on the theory that neural connections can strengthened by using using related words and phrases that are similar to the target word, to eventually activate the target word in the brain. SFA can be implemented in multiple forms such as verbally, written, using picture cards, etc. The SLP provides prompting questions to the individual with aphasia in order for the person to name the picture provided. Studies show that SFA is an effective intervention for improving confrontational naming.
Melodic intonation therapy is used to treat non-fluent aphasia and has proved to be effective in some cases. However, there is still no evidence from randomized controlled trials confirming the efficacy of MIT in chronic aphasia. MIT is used to help people with aphasia vocalize themselves through speech song, which is then transferred as a spoken word. Good candidates for this therapy include people who have had left hemisphere strokes, non-fluent aphasias such as Broca's, good auditory comprehension, poor repetition and articulation, and good emotional stability and memory. An alternative explanation is that the efficacy of MIT depends on neural circuits involved in the processing of rhythmicity and formulaic expressions (examples taken from the MIT manual: “I am fine,” “how are you?” or “thank you”); while rhythmic features associated with melodic intonation may engage primarily left-hemisphere subcortical areas of the brain, the use of formulaic expressions is known to be supported by right-hemisphere cortical and bilateral subcortical neural networks.
According to the National Institute on Deafness and Other Communication Disorders (NIDCD), involving family with the treatment of an Aphasic loved one is ideal for all involved, because while it will no doubt assist in their recovery, it will also make it easier for members of the family to learn how best to communicate with them.
The social approach involves a collaborative effort on behalf of patients and clinicians to determine goals and outcomes for therapy that could improve the patient's quality of life. A conversational approach is thought to provide opportunities for development and the use of strategies to overcome barriers to communication.The main goals of this treatment method are to improve the patient's conversational confidence and skills in natural contexts using conversational coaching, supported conversations, and partner training.
1. Conversational coaching involves patients with aphasia and their speech language pathologists, who serve as a "coach" discussing strategies to approach various communicative scenarios. The "coach" will help the patient develop a script for a scenario (such as ordering food at a restaurant), and help the patient practice and perform the scenario in and out of the clinic while evaluating the outcome.
2. Supported conversation also involves using a communicative partner who supports the patient's learning by providing contextual cues, slowing their own rate of speech, and increasing their message's redundancy to promote the patient's comprehension.
Additionally, it is important to include the families of patients with aphasia in treatment programs. Clinicians can teach family members how to support one another, and how to adjust their speaking patterns to facilitate their loved one's treatment and rehabilitation.
The intensity of aphasia therapy is determined by the length of each session, total hours of therapy per week, and total weeks of therapy provided. There is no consensus about what “intense” aphasia therapy entails, or how intense therapy should be to yield the best outcomes. A 2016 Cochrane review of speech and language therapy for people with aphasia found that treatments that are higher intensity, higher dose or over a long duration of time led to significantly better functional communication but people were more likely to drop out of high intensity treatment (up to 15 hours per week).
Intensity of therapy is also dependent on the recency of stroke. People with aphasia react differently to intense treatment in the acute phase (0–3 months post stroke), sub-acute phase (3–6 months post stroke), or chronic phase (6+ months post stroke). Intensive therapy has been found to be effective for people with nonfluent and fluent chronic aphasia, but less effective for people with acute aphasia.> People with sub-acute aphasia also respond well to intensive therapy of 100 hours over 62 weeks. This suggests people in the sub-acute phase can improve greatly in language and functional communication measures with intensive therapy compared to regular therapy.
Auditory comprehension is a primary focus in treatment for Wernicke's aphasia, as it is the main deficit related to this diagnosis. Therapy activities may include:
- Single-word comprehension: A common treatment method used to support single-word comprehension skills is known as a pointing drill. Through this method, clinicians lay out a variety of images in front of a patient. The patient is asked to point to the image that corresponds to the word provided by the clinician.
- Understanding Spoken Sentences: "Treatment to improve comprehension of spoken sentences typically consists of drills in which patients answer questions, follow directions or verify the meaning of sentences".
- Understanding Conversation: An effective treatment method to support comprehension of discourse includes providing a patient with a conversational sample and asking him or her questions about that sample. Individuals with less severe deficits in auditory comprehension may also be able to retell aspects of the conversation.
Through the use of compensation strategies, therapy and educational support, dyslexic individuals can learn to read and write. There are techniques and technical aids which help to manage or conceal symptoms of the disorder. Removing stress and anxiety alone can sometimes improve written comprehension. For dyslexia intervention with alphabet-writing systems, the fundamental aim is to increase a child's awareness of correspondences between graphemes (letters) and phonemes (sounds), and to relate these to reading and spelling by teaching how sounds blend into words. It has been found that reinforced collateral training focused on reading and spelling yields longer-lasting gains than oral phonological training alone. Early intervention that is done for children at a young age can be successful in reducing reading failure.
There is some evidence that the use of specially-tailored fonts may help with dyslexia. These fonts, which include Dyslexie, OpenDyslexic, and Lexia Readable, were created based on the idea that many of the letters of the Latin alphabet are visually similar and may, therefore, confuse people with dyslexia. Dyslexie and OpenDyslexic both put emphasis on making each letter more distinctive in order to be more easily identified. The benefits, however, might simply be due to the added spacing between words.
There have been many studies conducted regarding intervention in dyslexia. Among these studies one meta-analysis found that there was functional activation as a result.
There is no evidence demonstrating that the use of music education is effective in improving dyslexic adolescents' reading skills.
There is no cure for the condition. Management is through therapy.
Many researchers are investigating the characteristics of apraxia of speech and the most effective treatment methods. Below are a couple of the recent findings:
Sound Production Treatment:
Articulatory-kinematic treatments have the strongest evidence of their use in treating Acquired Apraxia of Speech. These treatments use the facilitation of movement, positioning, timing, and articulators to improve speech production. Sound Production Treatment (SPT) is an articulatory-kinematic treatment that has received more research than many other methods. It combines modeling, repetition, minimal pair contrast, integral stimulation, articulatory placement cueing, and verbal feedback. It was developed to improve the articulation of targeted sounds in the mid-1990s. SPT shows consistent improvement of trained sounds in trained and untrained words. The best results occur with eight to ten exemplars of the targeted sound to promote generalization to untrained exemplars of trained sounds. In addition, maintenance effects are the strongest with 1–2 months post-treatment with sounds that reached high accuracy during treatment. Therefore, the termination of treatment should not be determined by performance criteria, and not by the number of sessions the client completes, in order to have the greatest long-term effects. While there are many parts of SPT that should receive further investigation, it can be expected that it will improve the production of targeted sounds for speakers with apraxia of Speech.
Repeated Practice & Rate/Rhythm Control Treatments:
Julie Wambaugh’s research focuses on clinically applicable treatments for acquired apraxia of speech. She recently published an article examining the effects of repeated practice and rate/rhythm control on sound production accuracy. Wambaugh and colleagues studied the effects of such treatment for 10 individuals with acquired apraxia of speech. The results indicate that repeated practice treatment results in significant improvements in articulation for most clients. In addition, rate/rhythm control helped some clients, but not others. Thus, incorporating repeated practice treatment into therapy would likely help individuals with AOS.
After the initial diagnosis of speech delay, a hearing test will be administered to ensure that hearing loss or deafness is not an underlying cause of the delay. If a child has successfully completed the hearing test, the therapy or therapies used will be determined. There are many therapies available for children that have been diagnosed with a speech delay, and for every child, the treatment and therapies needed vary with the degree, severity, and cause of the delay. While speech therapy is the most common form of intervention, many children may benefit from additional help from occupational and physical therapies as well. Physical and occupational therapies can be used for a child that is suffering from speech delay due to physical malformations and children that have also been diagnosed with a developmental delay such as autism or a language processing delay. Children that have been identified with hearing loss can be taught simple sign language to build and improve their vocabulary in addition to attending speech therapy.
The parents of a delayed child are the first and most important tool in helping overcome the speech delay. The parent or caregiver of the child can provide the following activities at home, in addition to the techniques suggested by a speech therapist, to positively influence the growth of speech and vocabulary:
- Reading to the child regularly
- Use of questions and simple, clear language
- Positive reinforcement in addition to patience
For children that are suffering from physical disorder that is causing difficulty forming and pronouncing words, parents and caregivers suggest using and introducing different food textures to exercise and build jaw muscles while promoting new movements of the jaw while chewing. Another less studied technique used to combat and treat speech delay is a form of therapy using music to promote and facilitate speech and language development. It is important to understand that music therapy is in its infancy and has yet to be thoroughly studied and practiced on children suffering from speech delays and impediments.
Speech therapy is usually the most common treatment for asemia. Speech therapy allows the patient to be able to improve their speaking, comprehension, and writing skills. These patients have to learn all of these skills again since they are unable to understand or express anything. It usually depends on how long it takes for the speech therapy to work. If the condition is less severe, it will take less time, such as perhaps a couple of months to years. If the condition is more severe, it may take many years. The way speech therapy works is through speech practice as well as using special computer programs which let the patient practice their communication skills. By using simple and short sentences or writing down these phrases can aid the patients while going through therapy. Giving them enough time to communicate with their friends, family, or therapist will help them increase their skills and be able to manage them.
Complete success is usually achieved with treatment. However, sometimes only partial success is achieved and the patient cannot fully comprehend everything. With the partial restoration of some skills, the speech therapist may only focus on the skills which can be restored. In other cases, the therapist may work on the skills which may not retrieved and teach the patient how to handle those.
The methods of treatment are being evaluated and changed through several iterations to reach the most beneficial treatment for those with aprosodia. Although the biggest limitation on progress of aprosodia treatment is sample size, some significant data has been found to influence each subsequent phase of study. The Rosenbek lab at the University of Florida is currently in a new phase of treatment study based on combinations of the cognitive-linguistic and imitative therapies delivered in a randomized fashion in an effort to gain more insight into what most prominently affects aprosodia treatment.
Treatment of APD typically focuses on three primary areas: changing learning environment, developing higher-order skills to compensate for the disorder, and remediation of the auditory deficit itself. However, there is a lack of well-conducted evaluations of intervention using randomized controlled trial methodology. Most evidence for effectiveness adopts weaker standards of evidence, such as showing that performance improves after training. This does not control for possible influences of practice, maturation, or placebo effects. Recent research has shown that practice with basic auditory processing tasks (i.e. auditory training) may improve performance on auditory processing measures and phonemic awareness measures. Changes after auditory training have also been recorded at the physiological level. Many of these tasks are incorporated into computer-based auditory training programs such as Earobics and Fast ForWord, an adaptive software available at home and in clinics worldwide, but overall, evidence for effectiveness of these computerised interventions in improving language and literacy is not impressive. One small-scale uncontrolled study reported successful outcomes for children with APD using auditory training software.
Treating additional issues related to APD can result in success. For example, treatment for phonological disorders (difficulty in speech) can result in success in terms of both the phonological disorder as well as APD. In one study, speech therapy improved auditory evoked potentials (a measure of brain activity in the auditory portions of the brain).
While there is evidence that language training is effective for improving APD, there is no current research supporting the following APD treatments:
- Auditory Integration Training typically involves a child attending two 30-minute sessions per day for ten days.
- Lindamood-Bell Learning Processes (particularly, the Visualizing and Verbalizing program)
- Physical activities that require frequent crossing of the midline (e.g., occupational therapy)
- Sound Field Amplification
- Neuro-Sensory Educational Therapy
- Neurofeedback
However, use of a FM transmitter has been shown to produce significant improvements over time with children.