PII: S0911-6044(00)00018-X Copyright ©
2000 Elsevier Science Ltd. All rights reserved.
Aphasia therapy: past, present, and future
J. C. Marshall1
Neuropsychology Unit, University Department of
Clinical Neurology, Radcliffe Infirmary, Oxford OX2 6HE, UK Available online 6 September 2000.
J. C. Marshall1
For many years, aphasia therapy has been the poor relative of studies in the
neuropsychology of language. Like neurology itself (until quite recently),
aphasiology has been strong on diagnosis but weak on effective remediation. I
write "effective" remediation because speech and language therapists practiced
their trade for many years without fully realizing the necessity to submit
objective evidence of efficacy.
Consider the situation in the early 70 s of the last century. Darley 
summarized the state of the art as follows: "Studies of the effect of therapy on
the course of recovery from aphasia yield inconsistent results and permit no
generalization to the population of aphasic patients." A few years later,
Marshall, Holmes and Newcombe 
noted that some victims of aphasia recover a reasonable measure of communicative
competence and others do not, an undoubted fact that raised two basic questions:
"(1) Can the variables which account for the existence of different levels of
residual disability be found? (2) Can therapies be devised that will speed rate
of recovery and reduce the degree and scope of persisting impairment?" .
Although the questions were reasonably clear, the answers at that time were
Nonetheless, the 1970s and 80 s did eventually see the beginning of a
concerted effort to produce rational therapies and (even more important)
rational evaluations of efficacy. Albert, Sparks, and Helm 
had devised melodic intonation therapy (MIT), a technique that drew upon the
(musical) intonation capacities of the intact right hemisphere to improve verbal
expression after left hemisphere stroke. For the most part, the results obtained
in non-fluent aphasia were highly encouraging (see, for example, Laughlin et al.
Goldfarb and Bader ).
On a more general note, Enderby and David 
proposed a serious randomized trial of speech therapy for aphasia. The final
outcome (David, Enderby, and Bainton )
was somewhat mixed. Patients seen by professional speech therapists and
untrained volunteers seemed to recover at much the same rate; patients who
started treatment late made as much progress as those who started earlier. The
authors concluded that "the improvement in communication which occurred during
treatment may be due both to the appropriate stimulation which was based on
detailed and accurate speech therapy assessment, and to the regular support and
encouragement provided within the therapeutic relationship." An unkind critic
might suggest that therapy had been shown to be a placebo effect. A related
study (albeit without full randomization and with a very large non-random drop
out rate) was conducted by Basso, Capitani, and Vignolo .
They found that time between onset and the first examination was
negatively correlated with improvement. But like David et al. 
they reported that delay in obtaining language therapy after the onset of
language disorder did not reduce the efficacy of rehabilitation. Nonetheless,
Basso et al. 
wrote, somewhat alarmingly, that with respect to language rehabilitation, "the
relationship of type of aphasia to improvement was not significant." Unless the
particular type of therapy was closely matched to the specific deficits shown by
the patients, this latter finding is susceptible to a less encouraging
interpretation than that which the authors wish to uphold.
The issue of specificity was finally seen to be of crucial significance in
the 1980s and 90 s. Under the influence of the somewhat earlier cognitive
revolution in neuropsychology, a major reconsideration of both the structure of
language and speech rehabilitation itself, and of how to evaluate the results
thereof, was at last undertaken. In brief, it became clear that aphasia
therapies must be explicitly tailored to the pattern of impaired and preserved
performance in the individual patient. This single-case study approach
drew heavily upon arguments that had previously been advanced for why the
description and theoretical interpretation of neuropsychological symptoms
should, for the most part, be based upon the performance of individual patients
and case-series (Marshall and Newcombe ;
Newcombe and Marshall ).
Group studies based upon the polytypic syndromes of traditional aphasia
taxonomies are unlikely to be either theoretically revealing or practically
One consequence of this emphasis upon the individual is that randomized
controlled trials of aphasia therapy are not the best way to evaluate efficacy
although such large-scale trials could no doubt be improved by consideration of
effect size (as assessed by meta-analysis) rather than statistical significance
per se (Fitz-Gibbon ).
More importantly, longitudinal single-subject experimental designs are required
that can evaluate the efficacy of treatment in the individual. A number of such
protocols are now available, including reversal and withdrawal designs, multiple
baseline designs, and crossover treatment designs. Excellent discussions of
these issues can be found in Willmes and Deloche 
and Franklin .
Two key books that outline some preliminary results from the new approach are
Seron and Deloche 
and Berndt and Mitchum .
In order to know what the future may hold for best practise, I recommend the
papers that follow, based upon the Euroconference 2000: The Sciences of Aphasia:
From Therapy to Theory.
M. Albert, R. Sparks and N. Helm, Melodic intonation therapy for aphasia.
Archives of Neurology 29 (1973), pp. 130¯131.
A. Basso, E. Capitani and L.A. Vignolo, Influence of rehabilitation on language
skills in aphasic patients. Archives of Neurology 36
(1979), pp. 190¯196. MEDLINE
R.S. Berndt and C.C. Mitchum, Editors, Cognitive Neuropsychological
Approaches to the Treatment of Language Disorders, Lawrence Erlbaum, Hove,
M. Coltheart, Apahsia therapy: a single-case study approach. In: C. Code and
D.J. Muller, Editors, Aphasia Therapy, Arnold, London (1983).
F.L. Darley, The efficacy of language rehabilitation in aphasia. Journal of
Speech and Hearing Disorders 37 (1972), pp.
R. David, P. Enderby and D. Bainton, Treatment of acquired aphasia: speech
therapists and volunteers compared. Journal of Neurology, Neurosurgery, and
Psychiatry 45 (1982), pp. 957¯961. MEDLINE
P. Enderby and R. David, Proposed evaluation of speech therapy for acquired
aphasia. British Journal of Disorders of Communication
11 (1976), pp. 144¯148. MEDLINE
C.T. Fitz-Gibbon, In defence of randomised controlled trials, with suggestions
about the possible use of meta-analysis. British Journal of Disorders of
Communication 21 (1986), pp. 117¯124. MEDLINE
S. Franklin, Designing single case treatment studies for aphasic patients.
Neuropsychological Rehabilitation 7 (1997), pp.
R. Goldfarb and E. Bader, Espousing melodic intonation therapy in aphasic
rehabilitation: A case study. International Journal of Rehabilitation
Research 2 (1979), pp. 333¯342. MEDLINE
D. Howard, Beyond randomised controlled trials: the case for effective case
studies of the effects of treatment in aphasia. British Journal of Disorders
of Communication 21 (1986), pp. 89¯102. MEDLINE
S.A. Laughlin, M.A. Naeser and W.P. Gordon, Effects of three syllable durations
using the melodic intonation therapy technique. Journal of Speech and Hearing
Research 22 (1979), pp. 311¯320. INSPEC
J.C. Marshall, J.M. Holmes and F. Newcombe, Fact and theory in recovery from the
aphasias. In: Outcome of Severe Damage to the Central Nervous System (Ciba
Foundation Symposium 34), Elsevier, Amsterdam (1975).
J.C. Marshall and F. Newcombe, Putative problems and pure progress in
neuropsychological single case studies. Journal of Clinical
Neuropsychology 6 (1984), pp. 65¯70. MEDLINE
F. Newcombe and J.C. Marshall, Idealization meets psychometrics: The case for
the right groups and the right individuals. Cognitive Neuropsychology
5 (1988), pp. 549¯564.
T.R. Pring, Evaluating the effects of speech therapy for aphasics: developing
the single case methodology. British Journal of Disorders of
Communication 21 (1986), pp. 103¯115. MEDLINE
X. Seron and G. Deloche. Cognitive Approaches in Neuropsychological
Rehabilitation, Lawrence Erlbaum, Hove, UK (1989).
K. Willmes and G. Deloche, Methodological issues in neuropsychological
assessment and rehabilitation. Neuropsychological Rehabilitation
7 (1997), pp. 273¯277.
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