Aphasia is caused by damage to parts of the brain responsible for language, usually due to stroke or brain injury. How severe the aphasia is relates to how much a person’s language is affected. A person with mild aphasia might have word finding difficulties, problems explaining complex information, or difficulties understanding complex information. Even though the diagnosis is “mild”, there can still be significant communication disruption and people with mild aphasia report a loss of independence.
This evidence-based summary addresses treatments for people with mild aphasia. It focuses on five main treatment approaches that were either specifically designed for mild aphasia, or were modified for this group: word retrieval, sentence building, response elaboration, constrained summarising, and communication partner / conversation training.
Speech pathology intervention in mild aphasia: a quick snapshot of treatment options
| # | Treatment type | Description |
|---|---|---|
| #1 | Word retrieval | Semantic feature analysis within a picture description or procedure activity; orthographic and phonemic cueing within conversation |
| #2 | Sentences | Using joining words to create longer sentences, which convey more complex ideas |
| #3 | Response elaboration | Increasing the content and length of sentences using Modified Response Elaboration Training (M-RET) |
| #4 | Constrained summarisation | Attentive Reading with Constrained Summarisation (ARCS) |
| #5 | Communication partner training | Teaching the person with aphasia and a main communication partner to have better conversations, together. |
#1 Word retrieval
A common treatment for aphasia of all severities, including mild aphasia, is semantic feature analysis. This treatment helps a person with aphasia to strengthen word connections, with the goal of making those words easier to retrieve. It usually involves naming and describing WORDS, so it is a ‘word retrieval’ therapy.
During this treatment, the person with aphasia fills in a “feature analysis chart”. Objects have six features: category, action, use, location, properties, and associations. Actions have these six features: subject, purpose of action, part of body or tool used to carry out the action, description, usual location and associated objects or actions (Efstratiadou et al, 2018).
Usually, the person with aphasia is shown a picture of a single object or action, and they fill in the feature chart to describe it’s features. In mild aphasia, the treatment can be modified so that the person with aphasia is asked to describe a picture scene or tell a procedure. They then use use semantic feature analysis to address any word retrieval problems that happen during this talking. We call this semantic feature analysis within discourse.
What are semantic features?
Object naming
Action naming
Phonological and orthographic cueing
Another word retrieval treatment involves phonological and orthographic cueing. This sounds fancy, but it simply means that we use the first sound, letter, or syllable in a word to help a person with aphasia to retrieve it. So if the person was trying to say ‘rubbish’ we could say ‘r’, write ‘r’, or say/write ‘rub___’.
In mild aphasia, this treatment can be modified. The person with aphasia describes a picture or has a conversation on a topic that interests them. These tasks should includes words that the person with aphasia would like to treat. When word retrieval problems occur, sound and letter cues are used to help retrieve the word.
Example of a semantic feature analysis treatment in mild aphasia:
Two x 1-hour sessions per week for approximately 10 weeks
The person with aphasia describes two picture scenes as well as telling the steps in two familiar procedures. The speech pathologist makes a list of any words that are produced incorrectly during these 4 discourse tasks. These words are then treated using semantic feature analysis, ideally alternating between object and action targets. Approx 4 words may be treated per session.
The success of the treatment was measured in Peach & Reuter (2010) using:
- Communicative Effectiveness Index (CETI)
- Object and Action Naming Test
- Audio recordings of three picture descriptions, which were analysed for Content Information Units (CIU’s), # word finding behaviours, and informativeness (% CIU’s)
#2 Sentences
For some people with mild aphasia, the communication breakdown occurs when they are putting sentences together. The person with mild aphasia might use simple sentence joiners, such as “and, but”. The issue is that adults need to use a wide range of sentence joiners. We need words like “because, before, after, however, although” to fully express ideas and relationships.
In mild aphasia, there are a small number of treatment studies that have treated sentence formulation. These have involved teaching the person with mild aphasia to produce longer sentences so they can express more complex ideas. The person with mild aphasia might be taught to put two shorter sentences together to make a longer sentence. They learn to use sentence joining words such as ‘because, however, before’. These words can result in richer spoken language and conversations.
Example of a sentence treatment in mild aphasia:
One x 1-hour session per week for 16 weeks
The person with aphasia is given two short sentences and some sentence joiner options (such as ‘because, therefore’), and is asked to choose the joiner that will put the two sentences together to create a longer, sensible sentence. The usefulness of different sentence joiners is also discussed in real life terms (that is, how the person with mild aphasia might benefit from using the word ‘because’ in their life). As the person improves, they are asked to describe pictures and tell stories, with encouragement to use longer and more complex sentences. The person with mild aphasia completes home practice, which can be done using a computer or apps.
The success of the treatment was measured in Hickin, Mehta, and Dipper (2015) using:
- Comprehensive Aphasia Test (CAT)
- Cinderella narrative, analysed for local coherence, global coherence, story grammar elements, and # simple / complex sentences
- Quality of life questions
#3 Response elaboration
Response Elaboration Training (RET) is an established treatment for people with aphasia of different severities. The person with aphasia is asked to describe a picture, and then to elaborate on their description. When elaborating, the person with aphasia is encouraged to say more words and/or longer sentences.
The treatment has been modified for people with mild aphasia. Rather than describing pictures, the person with mild aphasia is asked to retell stories or describe the steps in a procedure. These are more complex tasks. It has the same loose approach as ‘standard’ RET, with treatment focused on what the person with aphasia says, and no right or wrong answers.
Example of a Modified-Response Elaboration treatment in mild aphasia:
Three x 1-hour sessions per week for approximately 5 weeks
The person with aphasia is asked to produce a procedure or a personal recount. There are slightly different steps depending on which task is being treated.
Personal recount:
- Person with aphasia tells a story (SP: “Tell me something about anything that you would like to talk about”).
- Speech pathologist reinforces what the person with aphasia says, e.g. “You went to the beach. That’s great.”
- Speech pathologist requests elaboration, e.g. “Why did you go to the beach?”
- Speech pathologist reinforces the elaboration, and models the longer sentences, e.g. “Right. You went to the beach because…..”
- Speech pathologist models the longer sentence again, and the person with aphasia is asked to repeat it.
- Wait 5 seconds, then the person with aphasia is asked to reiterate the elaborated response.
- In the event of no or inadequate response at any step, the speech pathologist provides options, e.g. “You could say something like… [noun phrase] or [verb phrase]” and waits for the person with aphasia to speak, before moving to the next step. If the person also has apraxia of speech, integral stimulation prompts may be used.
Procedural treatment:
- Person with aphasia tells a procedure (SP: ‘‘Tell me in detail how you would go about….’’).
- Follow the above steps, making sure requests for elaboration are specific to the procedure.
- In the event of no or inadequate response at any step, the speech pathologist provides options that are relevant to the procedure (rather than modelling noun and verb phrases) and waits for the person with aphasia to speak, before moving to the next step. If the person also has apraxia of speech, integral stimulation prompts may be used.
- When all treatment steps have been followed, the person with aphasia is asked to retell the whole procedure.
Examples of procedures to use in treatment:
- Tell me in detail how you would go about laying a cement pad.
- Tell me in detail how you would go about having a party.
- Tell me in detail how you would go about getting gas.
- Tell me in detail how you would go about making lemonade.
- Tell me in detail how you would go about buying a car.
- Tell me in detail how you would go about getting groceries.
- Tell me in detail how you would go about planting a tree.
- Tell me in detail how you would go about making the bed.
- Tell me in detail how you would go about shaving.
- Tell me in detail how you would go about making a tuna sandwich.
- Tell me in detail how you would go about washing a car.
- Tell me in detail how you would go about fixing a dripping faucet.
- Tell me in detail how you would go about getting the oil changed.
- Tell me in detail how you would go about seeing a doctor.
- Tell me in detail how you would go about moving to a new house.
- Tell me in detail how you would go about putting up a fence.
- Tell me in detail how you would go about getting ready for church.
- Tell me in detail how you would go about fixing breakfast.
- Tell me in detail how you would go about doing the laundry.
- Tell me in detail how you would go about giving a talk.
The success of the treatment was measured in Wambough, Nessler and Wright (2013) using:
- Audio recordings of a procedure and a personal recount (5 minutes), which were analysed for Content Information Units (CIU’s), informativeness (% CIU’s), and # novel words
- Narrative discourse, analysed for CIU’s and % CIU’s
#4 Constrained summarisation
Attentive Reading With Constrained Summarisation (ARCS) is a relatively newer treatment, which is suitable for people with mild aphasia. The person with mild aphasia reads a short news article with the intent to summarise it. They can summarise it verbally, in writing, or both. When summarising the article, the person with aphasia must follow 3 rules. These features of the treatment (intent and constraint) are borrowed from Constraint Induced Aphasia Therapy. ARCS is suited to people with mild aphasia because it involves a number of steps that can be challenging to the person’s language and thinking skills. First, the person must read a news article. Second, they must pay attention to key words in the article, and not get distracted by less relevant words. Third, they must hold these key words in their memory, as well as remembering the 3 summarisation rules, when they produce the summary. Fourth, they must say words relating to news and current affairs, which may be ‘low frequency words’ and harder for some people with aphasia to retrieve. And finally, the article summary must be precise, requiring the person to explain new ideas with as clear and specific expression as they can manage.
Example of a constrained summarisation treatment in mild aphasia:
Two x 1.5-hour sessions per week for 12 weeks
The speech pathologist selects a short news article (approx 200 words in length, year 6 reading level). The client is shown the article, and is directed to read the first few sentences.
- “Read only the outlined portion, and be prepared to summarise the information”. Any errors made while reading the article are corrected by the speech pathologist.
- “Read the sentences again silently to yourself, until you are sure you understood the material”.
- “Summarise what you have read but stick to these rules:”
- Summarise only what is written; no opinions or extra information; stay on topic.
- Use specific words (no words like “thing”, “stuff”, “he/she/it/they”).
- Use complete sentences.
- The person with aphasia now summarises the first few sentences of the story. The speech pathologist supports the person if word retrieval problems occur.
- Repeat steps 1-4, reading and summarising small sections of the article until it is complete.
- “Summarise the whole article, but stick to the rules”.
- “How complete was your summary?” Score on a rating scale from 1 (incomplete) to 5 (complete).
The success of the treatment was measured in Obermeyer and Edmonds (2018) using:
- Western Aphasia Battery – Revised
- Object and Action Naming Battery
- Audio recordings of three story retells, which were analysed for informativeness (% CIU’s), # complete sentences (% Content Units), and overall structure (% Main Concepts)
#5 Communication Partner / Conversation Training
Mild aphasia can have a significant impact on relationships and conversation. For this reason, some treatments include both the person with aphasia and an important communication partner, such as a family member or friend. In these treatments, the person with aphasia and their partner are taught skills to improve their conversations together. The partner can offer better communication support. The person with aphasia can improve their participation. This treatment is considered a form of ‘environmental modification’, because changing the way the partner communicates can have a positive impact on how the person with aphasia communicates.
Example of a conversation treatment in mild aphasia:
Two x 1-hour sessions per week for 7 weeks
The person with aphasia and their conversation partner have a series of 3 minute conversations on any topic, with the speech pathologist present. Each conversation is followed by self-reflection and feedback from the speech pathologist, focused on the client’s goals. The person with aphasia and their conversation partner do 15 minutes of home practice every day.
The success of the treatment was measured in Fox, Armstrong & Boles (2009) using:
- Audio recordings of a 10-minute conversation, analysed for skill and participation using Kagan scales, as well as quantity of verbal output (# words per conversation), and conversation balance (% total words per conversation)
- Individual goal setting and achievement
Summary
Mild aphasia is sometimes overlooked when treatments are being designed for people with aphasia. It makes sense that a lot of focus is given to people with significant difficulty understanding and using words (severe aphasia). However, people with mild aphasia still have problems communicating, and it still affects their lives. This article provides a snapshot of some evidence based treatments for those people with mild aphasia. It shows that there are a range of treatments available, so the speech pathologist can find a good match for an individual’s goals and needs.
The article is not a comprehensive analysis of treatment findings and study design. Speech pathologists are encouraged to do further reading into the treatment that interests them.
Where can I find out more about speech pathology intervention in mild aphasia?
To read more, take a look at these links:
References
- Efstratiadou, E. A., Papathanasiou, I., Holland, R., Archonti, A. and Hilari, K. (2018). A Systematic Review of Semantic Feature Analysis Therapy Studies for Aphasia. Journal of Speech, Language, and Hearing Research, 61, pp. 1261-1278. doi: 10.1044/2018_JSLHR-L-16-0330
- Richard K. Peach & Katherine A. Reuter (2010) A discourse-based approach to semantic feature analysis for the treatment of aphasic word retrieval failures, APHASIOLOGY, 24:9, 971-990, DOI: 10.1080/02687030903058629
- Alison Greenwood , Jennie Grassly , Julie Hickin & Wendy Best (2010) Phonological and orthographic cueing therapy: A case of generalised improvement, APHASIOLOGY, 24:9, 991-1016, DOI: 10.1080/02687030903168220
- Lucy Dipper, Jane Marshall, Mary Boyle, Nicola Botting, Deborah Hersh, Madeleine Pritchard & Madeline Cruice (2021) Treatment for improving discourse in aphasia: a systematic review and synthesis of the evidence base, Aphasiology, 35:9, 1125-1167, DOI: 10.1080/02687038.2020.1765305
- Julie Hickin, Beejal Mehta & Lucy Dipper (2015) To the sentence and beyond: a single case therapy report for mild aphasia, Aphasiology, 29:9, 1038-1061, DOI: 10.1080/02687038.2015.101047
- Sarah Fox , Elizabeth Armstrong & Larry Boles (2009) Conversational treatment in mild aphasia: A case study, Aphasiology, 23:7-8, 951-964, DOI: 10.1080/0268703080266952
- Richard Peach & Patrick Wong (2004) Integrating the message level into treatment for agrammatism using story retelling, Aphasiology, 18:5-7, 429-441, DOI: 10.1080/0268703044400014
- Nicholas, L. E., & Brookshire, R. H. (1993). A system for quantifying the informativeness and efficiency of the connected speech of adults with aphasia.Journal of Speech and Hearing Research, 36(2), 338-350. https://www.health.gov.au/topics/aged-care/advice-on-aged-care-during-covid-19/coronavirus-covid-19-helping-to-stop-the-spread
- Wambaugh, J. L., Nessler, C., & Wright, S. (2013). Modified response elaboration training: Application to procedural discourse and personal recounts. American Journal of Speech-Language Pathology, 22(2), S409-S425. https://doi.org/10.1044/1058-0360(2013/12-0063)
- Julie L. Wambaugh & Aida L. Martinez (2000) Effects of modified response elaboration training with apraxic and aphasic speakers, Aphasiology, 14:5-6, 603-617, DOI: 10.1080/026870300401342
- Obermeyer, J. A., Leaman, M. C., & Edmonds, L. A. (2020). Evaluating change in the conversation of a person with mild aphasia after attentive reading with constrained summarization-written treatment. American Journal of Speech-Language Pathology, 29(3), 1618-1628. https://doi.org/10.1044/2020_AJSLP-19-00078
- Obermeyer, J. A., & Edmonds, L. A. (2018). Attentive reading with constrained summarization adapted to address written discourse in people with mild aphasia.American Journal of Speech-Language Pathology, 27(1S), 392-405. https://doi.org/10.1044/2017_AJSLP-16-0200
- DeDe, G., & Hoover, E. (2021). Measuring change at the discourse-level following conversation treatment: Examples from mild and severe aphasia. Topics in Language Disorders, 41(1), 5-26. https://doi.org/10.1097/TLD.0000000000000243
