Aphasia Assessment and Treatment

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Stroke Rehabilitation

Aphasia Assessment and Treatment Janet Porcelli, MA, CCC-SLP*

Stroke is an appropriate name for a cerebrovascular accident (CVA). One minute one is in the mainstream oflife and the next minute one is struck down. Patients with aphasia often describe the first few days or week in the hospital as incredibly frightening. Strangers are speaking to them, asking questions and giving commands, but nothing makes sense. What language are they speaking? It sounds like English, but they cannot decipher the message. They attempt to respond but no one seems to understand. Or they open their mouths and nothing happens. Often through the encouragement of significant others and the speech-language pathologist, they take the risk of exploring their verbal strengths and weaknesses. The rehabilitation setting serves as the next catharsis, as this is the place where the pieces are put back together. Discharge time arrives but many of the problems still persist. Re-entry to their environment often does not provide the panacea that being in a familiar setting should provide. They are confronted with interfacing with their family, friends, and strangers in an altered state. How do they return to the mainstream of life? These are only some of the dilemmas with which patients, families, and professional caregivers are confronted. The ability to communicate is an act that appears voluntary and most of us accept as such, like eating and drinking. We rarely appreciate the complexity of language until it is taken away. LANGUAGE

Language has three highly interrelated and integrated components: cognition, linguistics, and communication. Each plays a significant role in acquiring and sharing information. Through the cogni-

* Director, Center for Communication Disorders, Moss Rehabilitation Hospital, Philadelphia, Pennsylvania Physical Medicine and Rehabilitation Clinics of North America-Vol. 2, No. 3, August 1991

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tive channel we acquire and retain knowledge of the world. It assists us in attending to salient features of a message, problem solving, and sequencing the steps in a process. It allows us to analyze our performance and that of others to monitor and change an outcome. Linguistics is the system of rules which governs language form and content. It is the sentences we elicit with the appropriate words. Communication is the use of this system to exchange thoughts and opinions. It involves a knowledge of how to converse with different partners in different situations to most effectively relay our message. 32

APHASIA It is estimated that one third of the individuals who survive stroke acquire aphasia. 4 It is usually due to a lesion in the left hemisphere, which is the dominant hemisphere for language in 85% of all individuals. It involves impairment in the ability to listen, speak, read, and write. Aphasia has been identified and defined by many, and the interested reader is directed to several references for an in-depth review. 6 ' 15 , lS, 4 1 , 42 For the purposes of this article, the most prevalent localization and behavioral approach is summarized. Goodglass and Kaplan differentiate aphasia into eight primary types and two types of subcortical aphasias. These classifications are based on where the lesion exists. 16 In global aphasia, all aspects of language are severely impaired. There is no distinctive pattern of preserved versus impaired components. The individual cannot use any of the verbal language modalities to communicate or understand. Broca' s aphasia is the common "anterior" or "nonfluent" aphasia with a lesion involving the third convolution of the left hemisphere. It is characterized by awkward articulation, restricted vocabulary, restricted grammar, and relative preservation of auditory comprehension. Written expression usually reflects spoken output, but reading is only mildly affected. The individual appears to understand most conversation and may follow multistep commands. Language output is extremely limited, resulting in frustration. Wernicke's aphasia usually depends on a lesion in the posterior portion of the first temporal gyms of the left hemisphere. Critical language features are impaired auditory comprehension and fluently articulated but paraphasic speech. Patients often do not initially recognize that their verbal messages cannot be interpreted. The ability to auditorily self-monitor their output has been lost. They often feel paranoid because people are speaking to them but they do not interpret the message. Word finding difficulty is the major feature of anomic aphasia. Unlike Broca's aphasia, this is in the context of fluent, grammatically well-formed speech. Their speech may seem empty, as the content words tend to be omitted. Conduction aphasia is a syndrome in which repetition is dispro-

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portionately severely impaired in relation to fluency in spontaneous speech. The major difficulty is the proper choice and sequencing of phonemes. In transcortical sensory aphasia, irrelevant paraphasia is well articulated with remarkable sparing of repetition. Memorized material like the Lord's Prayer is unusually preserved. Many of the features of Wernicke's aphasia are present. Transcortical motor aphasia also has a high repetition rating. Articulation is fair to good, with little to no paraphasia. Auditory comprehension is fair to excellent. Speech output is limited, as in Broca's aphasia. Mixed nonfiuent aphasia has elements of both Broca's and global aphasia. Output is sparse and auditory comprehension is more severely impaired. Anterior subcortical aphasias involve the anterior limb of the internal capsule and putamen. They are characterized by sparse output with severely impaired articulation and hypophonic speech. Posterior subcortical lesions involving the thalamus or neighboring white matter cause an aphasia that resembles Wernicke's aphasia. The major difficulty is word finding and paraphasia, whereas repetition and comprehension are spared. All of these classifications correspond to Geschwind' s organization of language in the left hemisphere. 16 Although many patients do not fit a particular diagnostic category, definitions do play a significant role in the communication of information in rehabilitation settings. Localization of lesion may affect the language diagnosis, and this information may assist professional caregivers in communicating more effectively with each other. Owing to the complexity of deficits in many patients and the presence of multiple lesions, the speech-language pathologist may choose a more behavioral approach to describe the aphasia. Darley defines aphasia as an impairment due to brain damage of the capacity to interpret and formulate language symbols. It is a multimodal loss or reduction in decoding conventional meaningful linguistic elements (morphemes and larger syntactic units) which is disproportionate to impairment of other intellectual functions. It is not attributable to dementia, sensory loss, or motor dysfunction. The patient exhibits reduced available vocabulary, a reduced ability to apply syntactic rules, reduced auditory retention span, and impaired efficiency in input and output channel selection. This definition should assist the speech-language pathologist in providing a more accurate description of the strengths and weaknesses of the language system. 6

THE ROLE OF THE SPEECH-LANGUAGE PATHOLOGIST The most common functions of the speech-language pathologist are the following: identification and selection of clients, assessment, intervention, administration, consultation, counseling, education, and

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research. Assessment and intervention are the most important. 4 Most individuals who have sustained a CVA to the dominant hemisphere exhibit some degree of impairment in speech and language. In some settings, screenings are done on all patients. Others depend on physician referral. Once individuals are identified, an in-depth evaluation is performed. The purpose is to make a diagnosis providing a description of the cognitive, linguistic, and communicative behaviors; to counsel the patient, family, and staff; and to make appropriate recommendations. Assessment Standardized tests and diagnoses are areas that have been well developed in the field of aphasia. Batteries utilized by the speechlanguage pathologist include the following: Boston Diagnostic Aphasia Examination, Porch Index of Communicative Ability, Minnesota Test for Differential Diagnosis of Aphasia, Western Aphasia Battery, Reading Comprehension Battery for Aphasia, and Boston Naming Test. A detailed assessment can be quite time consuming and is usually tailored to the rehabilitation environment and patient. All assessments should include the compilation of biographic, medical, and behavioral data (Table 1). This information may assist in differential diagnosis in order to separate aphasia from sensory deficits, apraxia, dysarthria, confusion, or dementia that the patient may be exhibiting. 45 A complete case history and family interview can provide a wealth of information for making appropriate recommendations. Premorbid status should assist in diagnosis and description of the functional impact of a newly acquired lesion. Personal information guides the clinician in establishing goals that apply to the individual's personal needs. Diagnostic tests and method of administration are usually dictated by the type and severity of communication impairment. Qualitative responses should be as carefully recorded as the quantitative information. A careful analysis of the performance on all language modalities of the individual then assists in providing critical information for treat-

Table 1. Case History Biographical Data Social history Educational background Vocational history Family interview Medical History Present medical history Results of neurodiagnostic tests Past medical history

Name, sex, age, address Marital status, significant others, living arrangements Level of schooling, premorbid reading and writing skills Occupational status and history Premorbid personality, skills, communication style, interests, leisure activities Onset date, diagnosis, course of hospitalization, complications, medications, sensory deficits MRI, CT, EEG, etc. Previous hospitalizations, diagnoses, CVAs, level of dysfunction, contributing health problems

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ment intervention (Table 2). A screening for cognitive and sensory deficits should also be done. An area of assessment which is often neglected is the evaluation of functional communication. There are few tools available commercially. The Functional Communication Profile can be included to provide a measure of how the individual relays information that is commonly requested in everyday life.38 The Communicative Abilities in Daily Living is another instrument that was developed to fill this void. Careful analysis of a variety of functional settings was done, with an evaluation of normal interaction expectation. 21 A limitation may be in requiring a patient to role play common everyday situations, a skill that can be difficult for many individuals. At least these batteries provide a method to achieve a baseline score of communication which can be used to measure change in a larger perspective than a languagespecific behavior over time. Discourse analysis is a method that is not a standard of practice for many because it is time consuming to analyze. It is a powerful tool for evaluating syntactic, semantic, and pragmatic competence. The Boston Diagnostic Aphasia Examination Profile of Speech Characteristics based on performance on the Cookie Theft Description plays a significant role in classifying the aphasia one exhibits. Many clinicians guess with fair reliability the parameters of melodic line, phrase length, articulatory agility, grammatic form, and paraphasia in running speech. Performance on a single picture description task may not be indicative of how the individual would communicate information that is highly relevant. Most formal test batteries have parameters for identifying and describing the type and severity of aphasia. These directives are usually based on the score for select language modalities and not on the effect of the communication impairment. Linebaugh advises caution in Table 2. General Language Assessment Auditory comprehension

Visual comprehension

Speech

Writing

Word identification/ discrimination Yes/no reliability for personal/general questions Ability to follow commands, length and complexity Sentence/paragraph level retention and understanding Ability to match symbols/letters Word identification skills Sentence/paragraph retention and comprehension Oral reading Functional reading skills Social/automatic speech Word/sentence repetition Confrontation/responsive naming Verbal agility, mean length of utterance, fluency rating Analysis of form and content Biographical information Letters, numbers: copying/dictation Word/sentence level Spontaneous sample

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the classification of mild aphasia when the communication deficit has significantly impacted on a return to premorbid status. What may be considered mild impairment in comparison to other aphasics may be severe for that individual. He suggests that descriptions are arbitrary when they relate to the functional needs of each individual. 30 The total person must be viewed in describing the effects of the disability on his or her well-being. The therapist must counsel the patient, family, and staff on the communication profile and attempt to provide compensatory strategies to improve communicative interactions . A recommendation for therapy is made if it is indicated, and a prognosis is given. A prognosis for improvement is a critical issue for the patient and family.

PROGNOSIS An assessment of the rate of recovery is important in the management of aphasia. Darley suggests that age, etiology, health, and months after onset influence change. In a prognostic variable approach, a clinician evaluates a patient's biographical, medical, and behavioral characteristics against how these variables are believed to influence change in aphasia.7 Demeurisse et al studied 75 patients with aphasia following stroke and found that the greatest improvement was observed during the first 3 months following onset. The rate of recovery was similar for expression and comprehension. Comprehension was usually less disturbed than expression regardless of the type of aphasia. 9 Sarno and Levi ta reported a marked recovery during the first 6 months, with the greatest improvement observed during the first 3 months. 39 Some reports indicate that a spontaneous and rapid recovery of speech is limited to the first month after onset. 5 Sands et al indicated a slight degree of recovery continuing over several years .37 All of these studies stressed the importance of the type of aphasia on the rate of recovery. The prognosis for Broca's and Wernicke's aphasa is similar, whereas global aphasia is notably different and improvement is rare. Marshall and Phillips studied 80 aphasic males who were homogeneous subject samples on 10 commonly recognized prognostic factors. These include age, occupational status, general health, time after stroke, severity of aphasia, auditory comprehension, self correction, speech fluency, first month's progress, and number of speech-language treatment sessions . The findings suggest that individuals likely to regain verbal communication are younger, in better general health, and ready for evaluation sooner after stroke. In addition, they are likely to exhibit less severe aphasia, have good auditory comprehension, and be fluent speakers. Severity of aphasia has been cited as a significant prognostic factor, and this study was no exception. 31 Porch et al attempted to develop a statistical production approach based on a multiple regression equation. They examined the usefulness of four predictors- gestural, verbal, graphic behavior, and agefor predicting change in aphasia and found that language performance

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was more important than age. Their results suggested that it is possible to generate formulas that produce a fairly accurate prognosis for change in communicative ability. 34 Lincoln and McGuirk attempted to use the Porch Index of Communicative Ability and duplicate Porch's results . No significant correlation of production to test scores was achieved, suggesting a limitation to the prediction method at this time. 29 Caution should be exercised in formulating prognosis during acute recovery. By 1 month after stroke, the factors that are important in predicting aphasia outcome can be reliably measured.

TREATMENT Treatment for aphasia includes traditional response manipulation of language deficits in all modalities, treatments for specific language and aphasia profiles, pragmatic treatment, and functional treatment. It is the responsibility of the treating clinician to provide the most effective and efficient intervention. The main objective should be to improve communicative ability as much as possible within the limits of the brain damage. For individuals who are more than a year after onset, trial therapy should be carefully documented to validate whether therapy is effecting change. The evaluation of the language status of the individual in conjunction with a consideration of his or her environmental milieu should determine the establishment of measurable short- and long-term goals. Many clinicians continue to treat the language deficit, whereas the focus must turn to the whole person. We need to change our value system from improving the quality of language to improving the quality of life. Re-evaluation of the status and goals must be done routinely and systematically to guide the focus of therapy. Wertz recommends complete evaluation on a 1-, 3-, 6-, and 10-month basis. 45 Many treatment approaches are available in the clinician's bag of tricks. Most therapists develop styles and techniques that have been effective for them and use materials with which they are comfortable. Most of these methods are a variation of the stimulation approach. This approach can be defined as a strong controlled auditory stimulation of the impaired symbol system in order to facilitate and maximize the patient's reorganization and recovery of language. Its principles are the basis of most clinical intervention. Duffy provides a complete discussion of its rationale and principles. 12 This is a summary of that discussion. First, it has been shown that sensory stimulation affects brain activity. Second, research indicates that repeated sensory stimulation is essential for organization, storage, and retrieval of patterns in the brain. Third, the auditory system is the primary mode oflanguage acquisition and serves as a feedback system to process and control information. Nearly all aphasics exhibit deficits of the auditory modality. The use of auditory stimulation is consistent with the definition of aphasia as a multimodality disturbance of language. This ap-

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proach is not a stimulus-response model as in teaching new information. The principles of remediation are those most often followed by clinicians . Intensive auditory stimulation is used. The stimulus presented must be at a level at which performance is only mildly impaired, that is, a level at which the individual is experiencing 80% success . The stimulus must be repetitive and should elicit a response. The adequacy of the response is consistently evaluated. Responses should be elicited, not forced, and a maximum number of responses should be elicited. Feedback about the accuracy of response should be provided only when it is beneficial. The intervention should be systematic and intensive. Sessions should begin with easy, familiar tasks. Materials should be varied and relevant to the patient, and new materials should be an extension of the old. 12 A small number of approaches are available for specific dysfunctions . Melodic intonation therapy has demonstrated effectiveness in working with aphasics with reduced verbal fluency and relatively intact auditory comprehension. 19 Visual action therapy is a systematic approach for global aphasics which initially operates on a prelinguistic level. Patients are to improve their ability to follow structured tasks, become aware of task expectations, and increase critical skills and are encouraged to produce representational gesture. 13 Voluntary control of involuntary utterances is a method developed by Helm-Estabrook which attempts to develop a functional vocabulary from the spontaneous utterances of the patient. 20 C-Vic research, the use of a variation of the Premack symbols, is being conducted to attempt to develop a visual communication system for the global aphasic. A pragmatic approach to intervention has the underlying principle of evaluating the relationship between language and the contexts in which language is used. Prutting and Kirchner35 designed a protocol that consists of 30 pragmatic aspects of language . It adheres to Levinson' s thesis that the range of pragmatic aspects exists on a continuum and includes both context-dependent aspects of language structure and principles of language usage that are relatively independent of language structure. The protocol is completed after observing an individual engaging in spontaneous, unstructured conversation with a communicative partner. It is recommended that clinicians observe 15 minutes of conversation directly or from a videotaped sample. The number of pragmatic aspects judged inappropriate for adults with left hemisphere lesions was 18%. Different profiles reflected differences in the subgroups but were predictable based on aphasia classification. In fluent aphasia, speech was often plentiful but deficient in content and intelligibility owing to high proportions of paraphasias and deficits in lexical access. The nonfluent patient produced speech limited to a few words characterized by agrammatic structure and high proportions of apraxic errors. In both cases the burden of communication lies with the listener. Nonverbal aspects of communication were well preserved. 35

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Methods of therapy which address functional communication are limited. We are in an era in which accountability for outcomes is being measured by intermediaries and health care agencies. Clinicians have often observed that the degree of communicative impairment is not always a direct reflection of language performance. Davis and Wilcox developed the Promoting Aphasics Communication Effectiveness approach to provide a systematic intervention strategy. In this therapy regimen the patient is encouraged to use all available tools to communicate a message. This may include but is not limited to drawing, the written word or part word, the spoken word, gestures, and facial expression in whatever combination is most effective. The clinician and patient take turns in describing situations (usually action pictures) that are visible only to the listener. The clinician can use his or her turn to model and shape desirable behavior as well as to provide feedback to the patient for effective problem solving and transmission of ideas. 8 There have been several published techniques for more critiCal evaluation of the communication output of the patient. More universal use of these tools on a systematic basis should assist in the evaluation of the functional effects of treatment as well as provide guidance in more effective planning of client-specific therapy. Yorkston and Beukelman systematically analyzed verbal descriptions by normal adults of the Cookie Theft Picture on the Boston Diagnostic Aphasia Examination. They found 57 variables that were common across all language samples. This may provide clinicians a more quantitative review of a patient's output as it compares to that of the normal population. 46 The Reporter Test is a variation of the Token Test in reverse. The evaluator moves the tokens while the patient is required to describe the action to another person who cannot see the movements. Not only can it assist in evaluating a breakdown in the information, but it provides an analysis of how the individual attempts to correct information that is miscommunicated.11 Chapey provides many practical guidelines. Questionnaires can be developed to describe possible barriers to communication which can assist the clinician in setting goals that address the unique needs of the individual. 4 Treatment is often discontinued when the patient plateaus in his or her ability to improve specific language modalities. Evaluation of how that person is functioning in his or her environment is not always done. Family members and significant others need to be included in the therapeutic process. This is the only way that clinicians can evaluate the listener-speaker dyad and shape behavior to ensure increased competence. In some instances family participation is discouraged because it appears to affect the patient's performance. These are the people in most cases who are spending the most time with the individual, and success of treatment may be measured only by improving their interaction. Families sometimes use the therapy as a respite from

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caring for their family member. Their role in the therapy process should be discussed, and they should be encouraged to become active participants. Intervention in real-life situations outside the clinical setting is another void that needs to be addressed. Periodic outings are a method of effectively judging communicative effectiveness. The use of less structured techniques should not be a problem if the clinician continues to set goals that are objective and measurable and the patient continues to demonstrate noticeable improvement. Both qualitative and quantitative changes should be documented on re-evaluation. Upon retest, many individuals may continue to score at the same level although their performance has improved. The response time may have decreased, errors may be more closely related to the target stimuli, and repair strategies of reauditorization and requests for repetition may be utilized without cueing. Careful recording of behavior and changes assists the clinician in appropriately terminating therapy. If the client has played an active role in goal setting, the end should not come as any surprise. Ideally, the patient has not only regained some language function but is armed with compensatory strategies to assist him or her in a more effective participation in life.

EFFICACY The efficacy of intervention continues to inspire debate. There are still some neurologists who believe that most improvement is due to spontaneous recovery. Aphasiologists contend that what they do does make a difference, especially when the individual continues to improve beyond 6 months after onset or, even more significantly, when change occurs many years after onset. I remember the aura of expectation many years ago when Darley at a national convention was to report his findings on the efficacy of treatment. There was an audible sigh of relief when he declared that speech therapy for the aphasic patient was efficacious. The data, however, were sparse and did not suggest that aphasia therapy was on solid ground. He concluded that the profession needed to produce more specific treatment regimens. Use of these specified regimens for specified periods of time in the aphasic population needed to be analyzed for results . Efficacy has been tested in single case treatment studies and group treatment with positive and negative results. Lincoln et al randomly allocated aphasic stroke patients to either a speech therapy group receiving individual treatment twice a week for 24 weeks of a no-treatment control group. The individuals were tested at 10, 22, and 34 weeks on the Porch Index of Communicative Ability and Functional Communication Profile. No significant differences were found between groups. The authors did indicate that many of the individuals in the treatment group attended only a portion of their sessions. Hagen found that individuals receiving 18 hours of speech

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therapy each week did significantly better on measures of language ability than a nontreatment group. This suggested that change was not entirely attributable to spontaneous recovery. 28 Hartman and Landau randomly assigned 66 right-handed aphasics who had suffered left hemisphere stroke to two modes of therapy-individual speech therapy two times per week and a supportive counseling therapy group. No significant differences in amount of improvement were noted between the two groups. A response from their colleagues criticized the interpretation of results due to what they observed were significant omissions in research design. 17 Prognostic variables of age, site of lesion, cause, severity of language deficit, educational level, and length and intensity of therapy were omitted, and results were judged only on quantitative test results. Complications do arise when designing and conducting treatment studies with aphasic patients. It becomes difficult to define a notreatment group. Ethical considerations contraindicate withholding treatment. Since therapy exists, the general feeling is that it must be offered. Random selection of a no-treatment group comprised of volunteers is fraught with questions about why one would elect not to have intervention. Wertz et al attempted to respond to the challenge by Darley via the VA Cooperative Study. Thirty-four patients were followed from 4 weeks after onset to 44 weeks of treatment. Patients were randomly assigned to treatment and no-treatment groups for 12-week intervals. Therapy was provided on an individual and group basis. The results demonstrated that both individual and group treatments were efficacious in managing aphasia for individuals who suffered a single left hemisphere thromboembolic infarct, with moderate-severe impairment, who were 3 months or less post onset and received at least 3 hours of treatment each week for a least 5 months. Benson concurs that speech therapy should be included in the neurologist's armamentarium for treatment of aphasia. He cited the emergence of specific treatment techniques (e.g., melodic intonation therapy, visual action therapy) as noteworthy and, like Darley, indicated the need for more single-case experimental designs to measure efficacy. 1 SUMMARY It is estimated that over 1 million people in the United States have some degree of aphasia. 4 With the growth in the geriatric population, this number is destined to increase. It is imperative that health care providers ensure that the best and most appropriate intervention is provided. Speech-language pathologists play a significant role in the evaluation and treatment of speech and language skills. They are able to diagnose and describe the language disorder and provide a prognosis and recommendations. Counseling is provided to the individual and significant others on the strengths and weaknesses of the language

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system as well as methods to facilitate improved communication. Short- and long-term goals can be established to improve communication status and address the personal needs of the client. Treatment needs to be tailored to the individual, with emphasis on improving functional communication as well as increasing language performance. The mandate for the future is clear. Speech-language pathologists need to establish data bases of information to evaluate the outcomes of their therapeutic intervention. Institutions providing services to the stroke population need to fund research for evaluating and developing specific treatment approaches as well as efficacy of intervention provided. The time has come to refine our standards of practice and address the mandate and challenges presented by Benson, Darley, and Wertz.

REFERENCES 1. Benson F: Aphasia rehabilition. Arch Neurol 44:646- 649, 1979 2. Borkowski J, Benton A, Spreen 0: Word fluency and brain damage. Neuropsychologia 5:135- 140, 1967 3. Brookshire R: An Introduction to Aphasia, ed 2. Minneapolis, BRK, 1978 4. Chapey R(ed): Language Intervention Strategies in Adult Aphasia, ed 2. Baltimore, Williams & Wilkins, 1986 5. Culton GL: Spontaneous recovery from aphasia. J Speech Hear Res 12:825- 832, 1969 6. Darley F: Aphasia. Philadelphia, WB Saunders, 1982 7. Darley F: The efficacy oflanguage rehabilitation in aphasia. J Speech Hear Disord 37:3-21, 1972 8. Davis G, Wilcox M: Incorporating parameters of natural conversation in aphasia treatment. In Chapey R(ed): Language Intervention Strategies in Adult Aphasia. Baltimore, Williams & Wilkins, 1981 9. Demeurisse G, Demo! 0, Derouck M, et al: Quantitative study of the rate of recovery from aphasia due to ischemic stroke. Stroke 11:5, 1980 10. DeRenzi E, Ferrari C: The Reporter's Test: A sensitive test to detect expressive disturbances in aphasics. Cortex 14:279- 293, 1978 11. DeRenzi E, Vignola L: The Token Test: A sensitive test to detect receptive disturbances in aphasics. Brain 85:665, 1962 12. Duffy JR: Schuell's stimulation approach to rehabilitation. In Chapey R(ed): Language Intervention Strategies in Adult Aphasia, ed 2. Baltimore, Williams & Wilkins, 1986 13. Estabrook NH: Severe apahasia. In Costello J, Holland A: Handbook of Speech and Language Disorders. San Diego, College Hill Press, 1986 14. Glass A, Gazzaniga M, Premack D: Artificial language training in global aphasias. Neuropsychologia 11:95- 103, 1973 15. Goldstein K: Language and Language Disturbances. New York, Grune & Stratton, 1948 16. Goodglass H, Kaplan E: The Assessment of Aphasia and Related Disorders, ed 2. Philadelphia, Lea & Febiger, 1983 17. Hartman J, Landau N: Comparison of formal language therapy with supportive counselling for aphasia due to acute vascular accident. Arch Neurol 44:646- 649, 1987 18. Head H: Hughlings Jackson on aphasia and kindred affections of speech. Brain 38:1- 27, 1915

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19. Helm N: Criteria for selecting aphasia patients for melodic intonation therapy. Paper presented to the American Academy for the Advancement of Science, Washington, DC, 1978 20. Helm N, Barresi B: Voluntary control of involuntary utterances: A treatment approach for severe aphasia. In Brookshire R(ed): Clinical Aphasiology. Proceedings of the Conference. Minneapolis, BRK Publishers, 1980, pp 308-315 21. Holland AL: Communicative Abilities in Daily Living. Baltimore, University Park Press, 1980 22. Jonns DJ(ed): Clinical Management ofNeurogenic Communicative Disorders. Boston, Little, Brown & Company, 1985 23. Kaplan E, Goodglass H, Weintraub S: Boston Naming Test. Philadelphia, Lea & Febiger, 1983 24. Kertesz A, McCabe P: Recovery patterns and prognosis in aphasia. Brain 100:1-18, 1977 25. LaPointe L: Aphasia therapy: Some principles and strategies for treatment. In Jonns DF (ed): Clinical Management ofNeurogenic Communicative Disorders. Boston, Little, Brown & Company, 1985, pp 179-241 26. LaPointe L, Horner J: Reading Comprehension Battery for Aphasia. Tigard, OR, CC Publications, 1979 27. Lincoln N, Jones A, Mulley G: Psychological effects of speech therapy. J Psychosom Res 29:467-474, 1985 28. Lincoln N, McGuirk E, Mulley G, et al: Effectiveness of speech therapy for aphasic stroke patients. Lancet 1:1197-1200, 1984 29. Lincoln N, McGuirk E: Prediction of language recovery in aphasic stroke patients using the Porch Index of Communicative Ability. Br J Disord Commun 21 :83-88, 1986 30. Linebaugh C: Mild aphasia. In Costello J, Holland A( eds): Handbook of Speech and Language Disorders. San Diego, College Hill Press, 1986 31. Marshall R, Phillips D: Prognosis for improved verbal communication in aphasic stroke patients. Arch Phys Med Rehabil 64:597-600, 1983 32. Muma JR, Hamre CE, McNeil MR: Theoretical models applicable to intervention in adult aphasia. In Chapey R (ed): Language Intervention Strategies in Adult Aphasia, ed 2. Baltimore, Williams & Wilkins, 1986 33. Porch B: Porch Index of Communicative Ability. Palo Alto, Consulting Psychologists Press, 1973 34. Porch B, Collins M, Wertz R, et al: Statistical predictions of change in aphasia. J Speech Hear Disord 37:3-21, 1972 35. Prutting C, Kirchner D: A clinical appraisal of the pragmatic aspects of language. J Speech Hear Disord 52:105-119, 1987 36. Richardson K, Globokar A, Pugh DB, et al: Aphasia therapy: More than just handholding [Letter]. Arch Neurol 46:249, 1989 37. Sands E, Sarno MT, Shankweiler D: Long term assessment of language function in aphasia due to stroke. Arch Phys Med Rehabil 50:202-207, 1969 38. Sarno MT: Functional Communication Profile. New York, Institute of Rehabilitation Medicine, New York City Medical Center, 1969 39. Sarno MT, Levi ta E: Natural course of recovery in severe aphasia. Arch Phys Med Rehabil 52: 175-178, 1971 40. Schuell H: Differential Diagnosis of Aphasia with the Minnesota Test, ed 2 rev. Minneapolis, University of Minnesota Press, 1973 41. Schuell H, Jenkins JJ, Jimenez PE: Aphasia in Adults. New York, Harper & Row, 1964 42. Wepman J: Aphasia: Language without thought or thought without language? ASHA 18:131-136, 1976 43. Wertz R: Communication deficits in stroke survivors: An overview of classification and treatment. Stroke 2l(Suppl 2):16-18, 1990 44. Wertz R: Language disorders in adults:State of the clinical art. In Costello J, Holland A( eds): Handbook of Speech and Language Disorders. San Diego, College Hill Press, 1986

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45. Wertz R, Collins M, Weiss D, et al: Veterans Administration Cooperative Study on Aphasia: A comparison of individual and group treatment. J Speech Hear Res 24: 580-594, 1981 46. Yorkston K, Beukelman D: An analysis of connected speech samples of aphasic and normal speakers. Speech Hear Disord 45:27-36, 1980 Address reprint requests to Janet Porcelli, MA, CCC-SLP Center for Communication Disorders Moss Rehabilitation Hospital 1200 West Tabor Road Philadelphia, PA 19141-3099