INTRODUCTION

Aphasia Rehabilitation: More Than Treating the

Language Disorder
Mieke E. van de Sandt-Koenderman, PhD, Ineke van der Meulen, PhD, Gerard M. Ribbers, MD, PhD
ABSTRACT. van de Sandt-Koenderman ME, van der Meulen I,
Ribbers GM. Aphasia rehabilitation: more than treating the
language disorder. Arch Phys Med Rehabil 2012;xx:xxx.
This supplement focuses on the neurorehabilitation of lan-
guage disorders. It offers a broad survey of this eld, with
state-of-the-art contributions from various disciplines. In doing
so, it aims to show that treating the devastating consequences
of neurological language disorders requires a prolonged inter-
disciplinary effort.
Key Words: Aphasia; Cerebrovascular Accident; Rehabilitation-
Rehabilitation of Speech and Language Disorders.
2012 by the American Congress of Rehabilitation
Medicine
R
EHABILITATION MEDICINE emerged in the late 19th
century, when patients with rheumatic diseases were pas-
sively undergoing physical therapy applications such as bal-
neotherapy and electrotherapy. In the 20th century, as a result
of the rst and second world wars, the focus of rehabilitation
medicine shifted to patients with spinal cord injuries, am-
putations, and polytrauma. In the second half of the century,
because of increasing numbers of patients surviving brain
injury, there was a growing need to develop effective neu-
rorehabilitation programs. Besides treating neurologic dis-
orders of the locomotor apparatus and dealing with medical
complications, neurorehabilitation had to focus on behav-
ioral, cognitive, and linguistic consequences of acquired
brain injuries. Initially neurorehabilitation was based on
pragmatism rather than on research. However, since these
early days, signicant scientic progress has been made in
neurorehabilitation. Today, with stroke as a major cause of
adult disability,
1
neurorehabilitation has become a main
topic in rehabilitation medicine.
The theme of this Archives of Physical Medicine and Reha-
bilitation supplement is Rehabilitation of Neurological Lan-
guage Disorders, with a specic focus on aphasia, a chronic
and severely disabling condition that affects the patients com-
munication and has a disruptive effect on social participation.
In 80% to 90% of patients, aphasia is caused by a stroke.
2
The
reported incidence in stroke populations ranges from 18% to
38%. Because of a higher mortality risk of aphasic patients,
3
and to rapid recovery in the rst months,
4
the percentage of
aphasic patients decreases over time. At 3-months postonset,
20% to 25% have aphasia. Aphasic patients need more reha-
bilitation services, are older, and have more severe disability
than nonaphasic stroke survivors. Independently of age and
comorbidity, the presence of aphasia predicts longer hospital
stays, increased use of rehabilitation services, and a lower
chance of returning home after rehabilitation.
5,6
When com-
pared with stroke patients without aphasia, aphasic patients
report a lower quality of life, are more distressed, and partic-
ipate in fewer activities.
7
Linguistically, aphasia is a heterogeneous phenomenon. Se-
verity ranges from a complete inability to produce and under-
stand language to mild problems of word nding. Across
aphasia types, specic linguistic processes may show selective
disorders, such as a semantic disorder (of processing word
meaning), a phonologic disorder (of processing word sounds),
and a syntactic disorder (of processing sentence structure).
Each has a different effect on verbal communication, resulting
in diverse patterns of communicative functioning in aphasic
patients. A semantic disorder, for instance, has more impact on
verbal communication than a phonologic disorder.
8,9
Further-
more, there is variation across the 4 modalities of language:
speaking, writing, auditory comprehension, and reading com-
prehension.
Concomitant nonlinguistic cognitive decits of memory, vi-
sual processing, or executive functioning and mood disorders
may complicate the picture and present a barrier for successful
treatment.
10-15
The rehabilitation of aphasia has a long and rich tradition.
The rst descriptions of aphasia date back to around 2800 BC,
and Paul Broca already discussed some treatment strategies in
1865. It took until after the rst world war before the rst
concise discussion of aphasia therapy was published in the
U.S., by Theodore Weisenburg and Katherine McBride in
1935.
16
After the second world war, treatment of aphasia
became more common, due to the need to treat war-wounded
head injury patients. In Russia, Alexander Luria developed a
treatment program for speech reeducation, based on his ideas
on the organization of higher cortical functions. Since that
time, the evidence of aphasia treatment has continued to grow.
Notwithstanding the heterogeneity of the disorder, dictating an
individually tailored interdisciplinary treatment approach, to-
days knowledge of the effect of specic treatment approaches
for patients with specic disorders is considerable.
17-20
Communication is the key to social participation. The ulti-
mate goal of aphasia rehabilitation is a social one: to optimize
the communication between the person with aphasia and his or
her environment. In line with the International Classication of
Functioning, Disability and Health, different behavioral treat-
ment approaches can be identied. The disorder-oriented ap-
proach aims at restoring linguistic processing by providing
linguistic treatment. The functional treatment approach aims at
achieving an optimal level of communication, given the lin-
guistic decits, whereas the participation-oriented treatment
emphasizes on dealing with the consequences of aphasia by
removing social barriers. Relatively new is the application of
pharmacologic or electrophysiologic treatments. These are
From the Rotterdam Neurorehabilitation Research, Rijndam Rehabilitation Centre
(van de Sandt-Koenderman, van der Meulen, Ribbers); and the Department of
Rehabilitation Medicine, Erasmus MC (van de Sandt-Koenderman, van der Meulen,
Ribbers), Rotterdam, The Netherlands.
No commercial party having a direct nancial interest in the results of the research
supporting this article has or will confer a benet on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Mieke van de Sandt-Koenderman, PhD, Rijndam Rehabilitation
Centre, PO Box 23181, 3001 KD Rotterdam, The Netherlands, e-mail:
m.sandt@rijndam.nl.
0003-9993/12/xxx-00885$36.00/0
doi:10.1016/j.apmr.2011.08.037
1
Arch Phys Med Rehabil Vol xx, Month 2012
thought to enhance the brains responsiveness to disorder-
oriented behavioral treatment.
The 3 behavioral treatment approaches each have their own
advocates in the literature. Most clinicians working in the eld
of aphasia rehabilitation will agree that all approaches are
important, and that aphasia rehabilitation is more than the
application of either disorder-oriented, or functional or social
treatment. It is a long and complex process in which all 3
approaches have to be combined, complementing each other,
rather than being mutually exclusive and involving the patients
as well as their proxies. The many therapy methods represent-
ing each of the 3 approaches constitute the building blocks for
this complex process of rehabilitation that has to be tailored to
individual needs and capacities. Hence, from the start of the
process, the clinician has to decide on the goal and method,
taking into account linguistic, cognitive, medical, and psycho-
social determinants. The intermediate results should be moni-
tored carefully, and put into perspective with the ultimate goal:
improvement of communication and social participation. At
several points in time during the rehabilitation process, the
therapist and the patient will encounter a crossroads, where it
has to be decided which path to follow next.
Taking a clinical perspective, this supplement offers a broad
survey of aphasia rehabilitation, with state-of-the-art contribu-
tions from various disciplines: speech and language rehabilita-
tion, neurology, psychology, and linguistics.
The 2 contributions on disorder-oriented treatment illustrate
the variation in techniques in the eld. Melodic intonation
therapy, developed in Boston in the 1970s, uses melody and
rhythm to improve uency in nonuent aphasia. This technique
is still used, and the mechanisms underlying its success are
under discussion even today (see van der Meulen et al
21
within
this issue). Word nding problems are common to all aphasia
types. Consequently, treatment programs for word nding are
widely used. Controlling the linguistic characteristics of the
training material appears to be crucial for treatment success
(see Conroy et al
22
within this issue), as has been shown for
many disorder-oriented treatment programs for syntactic, se-
mantic, and phonologic disorders as well.
There is considerable knowledge about treating the specic
linguistic disorders seen in aphasic patients. Much less, how-
ever, is known about treating the communication disorders
resulting from right hemisphere stroke. In healthy speakers,
language is subserved by a complex bilateral neural network.
Interestingly, aphasia iswith only a few exceptionscaused
by left hemisphere damage. However, in the absence of apha-
sia, right hemisphere damage may cause specic language and
communication problems that need to be addressed in stroke
rehabilitation (see Tompkins et al
23
within this issue).
Two important issues for clinical aphasia rehabilitation are
the timing of treatment and the intensity required. The impor-
tance of a high treatment intensity is well supported,
24-26
whereas the evidence for early treatment is less well-estab-
lished. The importance of treatment intensity is further sup-
ported by the positive studies of applying constraint-induced
treatment techniques in aphasia rehabilitation (see Meinzer et
al
27
within this issue). Constraint-induced treatment techniques
are well-known in the eld of motor disorders, for example for
arm use in chronic stroke patients with hemiparesis.
28
Massed
practice, for example, 3 to 4 hours per day during 2 weeks, is
1 of the main principles of constraint-induced motor and lan-
guage treatment, and its success is in line with the reviews
indicating that treatment intensity is a key factor.
24-26
The fast developing neuroimaging techniques are promising
tools to unravel the complex language network in the brain and
the underlying mechanisms of neurobiologic recovery (see
Saur et al
29
and Smit et al
30
within this issue). Such information
is vital to further the development of language therapy, without
which the inuence of the many factors that play a role in the
recovery of language function remains unclear.
Noninvasive magnetic or electrophysiologic brain stimula-
tion provides a promising new tool for neurorehabilitation.
Stimulation or inhibition of specic brain regions is targeted at
enhancing recovery and preventing maladaptive reorganization
(see Naeser et al
31
within this issue).
Contextual factors are important determinants of effective
communication (see OHalloran et al
32
within this issue) and
quality of life (see Hilari et al
33
within this issue). This supports
the notion that aphasia rehabilitation should also incorporate
elements of the social treatment approach. More and more it is
recognized that the communication partner should be involved
in aphasia rehabilitation (see Wilkinson et al
34
within this
issue).
This supplement illustrates that a prolonged interdisciplin-
ary effort is required to deal effectively with the devastating
consequences of neurologic language disorders. Cross-bor-
der knowledge in the team members is pivotal to achieve the
optimal synergy in doing so. Not only the speech and
language therapist, but also the physical and occupational
therapists, the social worker, psychologist, nursing staff, and
caregivers are involved. This notion is underlined by pub-
lishing this supplement, and although necessarily incom-
plete, it offers a broad overview on the domain.
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