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Aphasia therapy: past, present, and future
Journal of Neurolinguistics 13 (2000) 227±229 www.elsevier.com/locate/jneuroling
Introduction
Aphasia therapy: past, present, and future 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 eective remediation. I write ``eective'' remediation because speech and language therapists practiced their trade for many years without fully realizing the necessity to submit objective evidence of ecacy. Consider the situation in the early 70s of the last century. Darley [5] summarized the state of the art as follows: ``Studies of the eect 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 [13] 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 dierent 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?'' [13]. Although the questions were reasonably clear, the answers at that time were anything but. Nonetheless, the 1970s and 80s did eventually see the beginning of a concerted eort to produce rational therapies and (even more important) rational evaluations of ecacy. Albert, Sparks, and Helm [1] 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-¯uent aphasia were highly encouraging (see, for example, Laughlin et al. [12]; Goldfarb and Bader [10]). On a more general note, Enderby and David [7] proposed a serious randomized trial of speech therapy for aphasia. The ®nal outcome (David, Enderby, and Bainton [6]) 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.'' 0911-6044/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 9 1 1 - 6 0 4 4 ( 0 0 ) 0 0 0 1 8 - X
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Introduction / Journal of Neurolinguistics 13 (2000) 227±229
An unkind critic might suggest that therapy had been shown to be a placebo eect. A related study (albeit without full randomization and with a very large non-random drop out rate) was conducted by Basso, Capitani, and Vignolo [2]. They found that time between onset and the ®rst examination was negatively correlated with improvement. But like David et al. [6] they reported that delay in obtaining language therapy after the onset of language disorder did not reduce the ecacy of rehabilitation. Nonetheless, Basso et al. [2] wrote, somewhat alarmingly, that with respect to language rehabilitation, ``the relationship of type of aphasia to improvement was not signi®cant''. Unless the particular type of therapy was closely matched to the speci®c de®cits shown by the patients, this latter ®nding is susceptible to a less encouraging interpretation than that which the authors wish to uphold. The issue of speci®city was ®nally seen to be of crucial signi®cance in the 1980s and 90s. Under the in¯uence 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 (Coltheart [4]) 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 [14]; Newcombe and Marshall [15]). Group studies based upon the polytypic syndromes of traditional aphasia taxonomies are unlikely to be either theoretically revealing or practically useful. One consequence of this emphasis upon the individual is that randomized controlled trials of aphasia therapy are not the best way to evaluate ecacy (Howard [11]; Pring [16]), although such large-scale trials could no doubt be improved by consideration of eect size (as assessed by meta-analysis) rather than statistical signi®cance per se (Fitz-Gibbon [8]). More importantly, longitudinal single-subject experimental designs are required that can evaluate the ecacy 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 [18] and Franklin [9]. Two key books that outline some preliminary results from the new approach are Seron and Deloche [17] and Berndt and Mitchum [3]. 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.
References [1] Albert M, Sparks R, Helm N. Melodic intonation therapy for aphasia. Archives of Neurology 1973;29:130±1.
Introduction / Journal of Neurolinguistics 13 (2000) 227±229
229
[2] Basso A, Capitani E, Vignolo LA. In¯uence of rehabilitation on language skills in aphasic patients. Archives of Neurology 1979;36:190±6. [3] Berndt RS, Mitchum CC, editors. Cognitive neuropsychological approaches to the treatment of language disorders. Hove, UK: Lawrence Erlbaum, 1995. [4] Coltheart M. Aphasia therapy: a single-case study approach. In: Code C, Muller DJ, editors. Aphasia therapy. London: Arnold, 1983. [5] Darley FL. The ecacy of language rehabilitation in aphasia. Journal of Speech and Hearing Disorders 1972;37:1±21. [6] David R, Enderby P, Bainton D. Treatment of acquired aphasia: speech therapists and volunteers compared. Journal of Neurology, Neurosurgery, and Psychiatry 1982;45:957±61. [7] Enderby P, David R. Proposed evaluation of speech therapy for acquired aphasia. British Journal of Disorders of Communication 1976;11:144±8. [8] Fitz-Gibbon CT. In defence of randomised controlled trials, with suggestions about the possible use of meta-analysis. British Journal of Disorders of Communication 1986;21:117±24. [9] Franklin S. Designing single case treatment studies for aphasic patients. Neuropsychological Rehabilitation 1997;7:401±18. [10] Goldfarb R, Bader E. Espousing melodic intonation therapy in aphasic rehabilitation: a case study. International Journal of Rehabilitation Research 1979;2:333±42. [11] Howard D. Beyond randomised controlled trials: the case for eective case studies of the eects of treatment in aphasia. British Journal of Disorders of Communication 1986;21:89±102. [12] Laughlin SA, Naeser MA, Gordon WP. Eects of three syllable durations using the melodic intonation therapy technique. Journal of Speech and Hearing Research 1979;22:311±20. [13] Marshall JC, Holmes JM, Newcombe F. Fact and theory in recovery from the aphasias. In: Outcome of severe damage to the central nervous system (Ciba Foundation Symposium 34). Amsterdam: Elsevier, 1975. [14] Marshall JC, Newcombe F. Putative problems and pure progress in neuropsychological single case studies. Journal of Clinical Neuropsychology 1984;6:65±70. [15] Newcombe F, Marshall JC. Idealization meets psychometrics: the case for the right groups and the right individuals. Cognitive Neuropsychology 1988;5:549±64. [16] Pring TR. Evaluating the eects of speech therapy for aphasics: developing the single case methodology. British Journal of Disorders of Communication 1986;21:103±15. [17] Seron X, Deloche G. Cognitive approaches in neuropsychological rehabilitation. Hove, UK: Lawrence Erlbaum, 1989. [18] Willmes K, Deloche G. Methodological issues in neuropsychological assessment and rehabilitation. Neuropsychological Rehabilitation 1997;7:273±7.
J.C. Marshall1 Neuropsychology Unit, University Department of Clinical Neurology, Radclie In®rmary, Oxford OX2 6HE, UK
Introduction
Aphasia therapy: past, present, and future 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 eective remediation. I write ``eective'' remediation because speech and language therapists practiced their trade for many years without fully realizing the necessity to submit objective evidence of ecacy. Consider the situation in the early 70s of the last century. Darley [5] summarized the state of the art as follows: ``Studies of the eect 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 [13] 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 dierent 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?'' [13]. Although the questions were reasonably clear, the answers at that time were anything but. Nonetheless, the 1970s and 80s did eventually see the beginning of a concerted eort to produce rational therapies and (even more important) rational evaluations of ecacy. Albert, Sparks, and Helm [1] 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-¯uent aphasia were highly encouraging (see, for example, Laughlin et al. [12]; Goldfarb and Bader [10]). On a more general note, Enderby and David [7] proposed a serious randomized trial of speech therapy for aphasia. The ®nal outcome (David, Enderby, and Bainton [6]) 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.'' 0911-6044/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 9 1 1 - 6 0 4 4 ( 0 0 ) 0 0 0 1 8 - X
228
Introduction / Journal of Neurolinguistics 13 (2000) 227±229
An unkind critic might suggest that therapy had been shown to be a placebo eect. A related study (albeit without full randomization and with a very large non-random drop out rate) was conducted by Basso, Capitani, and Vignolo [2]. They found that time between onset and the ®rst examination was negatively correlated with improvement. But like David et al. [6] they reported that delay in obtaining language therapy after the onset of language disorder did not reduce the ecacy of rehabilitation. Nonetheless, Basso et al. [2] wrote, somewhat alarmingly, that with respect to language rehabilitation, ``the relationship of type of aphasia to improvement was not signi®cant''. Unless the particular type of therapy was closely matched to the speci®c de®cits shown by the patients, this latter ®nding is susceptible to a less encouraging interpretation than that which the authors wish to uphold. The issue of speci®city was ®nally seen to be of crucial signi®cance in the 1980s and 90s. Under the in¯uence 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 (Coltheart [4]) 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 [14]; Newcombe and Marshall [15]). Group studies based upon the polytypic syndromes of traditional aphasia taxonomies are unlikely to be either theoretically revealing or practically useful. One consequence of this emphasis upon the individual is that randomized controlled trials of aphasia therapy are not the best way to evaluate ecacy (Howard [11]; Pring [16]), although such large-scale trials could no doubt be improved by consideration of eect size (as assessed by meta-analysis) rather than statistical signi®cance per se (Fitz-Gibbon [8]). More importantly, longitudinal single-subject experimental designs are required that can evaluate the ecacy 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 [18] and Franklin [9]. Two key books that outline some preliminary results from the new approach are Seron and Deloche [17] and Berndt and Mitchum [3]. 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.
References [1] Albert M, Sparks R, Helm N. Melodic intonation therapy for aphasia. Archives of Neurology 1973;29:130±1.
Introduction / Journal of Neurolinguistics 13 (2000) 227±229
229
[2] Basso A, Capitani E, Vignolo LA. In¯uence of rehabilitation on language skills in aphasic patients. Archives of Neurology 1979;36:190±6. [3] Berndt RS, Mitchum CC, editors. Cognitive neuropsychological approaches to the treatment of language disorders. Hove, UK: Lawrence Erlbaum, 1995. [4] Coltheart M. Aphasia therapy: a single-case study approach. In: Code C, Muller DJ, editors. Aphasia therapy. London: Arnold, 1983. [5] Darley FL. The ecacy of language rehabilitation in aphasia. Journal of Speech and Hearing Disorders 1972;37:1±21. [6] David R, Enderby P, Bainton D. Treatment of acquired aphasia: speech therapists and volunteers compared. Journal of Neurology, Neurosurgery, and Psychiatry 1982;45:957±61. [7] Enderby P, David R. Proposed evaluation of speech therapy for acquired aphasia. British Journal of Disorders of Communication 1976;11:144±8. [8] Fitz-Gibbon CT. In defence of randomised controlled trials, with suggestions about the possible use of meta-analysis. British Journal of Disorders of Communication 1986;21:117±24. [9] Franklin S. Designing single case treatment studies for aphasic patients. Neuropsychological Rehabilitation 1997;7:401±18. [10] Goldfarb R, Bader E. Espousing melodic intonation therapy in aphasic rehabilitation: a case study. International Journal of Rehabilitation Research 1979;2:333±42. [11] Howard D. Beyond randomised controlled trials: the case for eective case studies of the eects of treatment in aphasia. British Journal of Disorders of Communication 1986;21:89±102. [12] Laughlin SA, Naeser MA, Gordon WP. Eects of three syllable durations using the melodic intonation therapy technique. Journal of Speech and Hearing Research 1979;22:311±20. [13] Marshall JC, Holmes JM, Newcombe F. Fact and theory in recovery from the aphasias. In: Outcome of severe damage to the central nervous system (Ciba Foundation Symposium 34). Amsterdam: Elsevier, 1975. [14] Marshall JC, Newcombe F. Putative problems and pure progress in neuropsychological single case studies. Journal of Clinical Neuropsychology 1984;6:65±70. [15] Newcombe F, Marshall JC. Idealization meets psychometrics: the case for the right groups and the right individuals. Cognitive Neuropsychology 1988;5:549±64. [16] Pring TR. Evaluating the eects of speech therapy for aphasics: developing the single case methodology. British Journal of Disorders of Communication 1986;21:103±15. [17] Seron X, Deloche G. Cognitive approaches in neuropsychological rehabilitation. Hove, UK: Lawrence Erlbaum, 1989. [18] Willmes K, Deloche G. Methodological issues in neuropsychological assessment and rehabilitation. Neuropsychological Rehabilitation 1997;7:273±7.
J.C. Marshall1 Neuropsychology Unit, University Department of Clinical Neurology, Radclie In®rmary, Oxford OX2 6HE, UK