Va Medica: Treatment Efficacy of Language and Calculation Disorders and Speech Apraxia: A Review of The Literature

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EUR J PHYS REHABIL MED 2011;47:101-21
Treatment efficacy of language

and calculation disorders
and speech apraxia: a review of the literature
A. BASSO 1, S. CATTANEO 1, L. GIRELLI 2, C. LUZZATTI 2, A. MIOZZO 3, L. MODENA 4, A. MONTI 5
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The aim of the study was to evaluate the efficacy of 1Instituteof Neurological Sciences
the treatment for language and calculation disorders Milan University, Milan, Italy
2Department of Psychology
and for speech apraxia in vascular subjects. Only ther-
apeutic methods that could be qualified as neuropsy- Milano Bicocca University, Milan, Italy
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chological were taken into account. For language dis-
orders, we searched the pertinent literature published
3Neurological Clinic, Brescia University, Brescia, Italy
4Azienda Ospedaliero-Universitaria S. Orsola-Malpighi
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from 1950 to August 31, 2007 by means of electronic Bologna, Italy
5Centro Interdipartimentale Mente/Cervello (CIMeC)
data banks and we took into consideration the Co-
Università degli Studi di Trento, Trento, Italy
chrane review, and papers in Cicerone et al. and Cap-
pa et al. systematic reviews. For acalculia we exam-
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ined the literature from 1980 by carrying out research

on electronic data banks; for speech apraxia, studies
emerged from a search of PUBMED. Aphasia therapy
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has been clearly demonstrated efficacious in groups of

subjects if sufficiently prolonged/intensive. Treatment
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for specific disorders (words and sentences process-

ing, reading, writing) studied in series of single pa- in the left half of the brain; these areas are respon-
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tients, though always efficacious, reaches a lower level sible for the ability to speak, understand, read, and
of recommendation due to the lack of RCT. Only a write. The terms “dyslexia” and “dysgraphia” refer
few studies tackled the problem of efficacy in case of to disorders of reading and writing. Due to the
IN
speech apraxia and calculation disorders. Results are

positive but data are scanty. Efficacy of aphasia ther- complexity of language, the term “aphasia” cov-
apy seems well established in group of subjects and ers heterogeneous disorders that may have little in
well-promising for speech apraxia and calculation dis- common. Indeed, the “ways” of being “aphasic” are
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orders. It is suggested, however, that the term “apha- infinite. The term “acalculia” refers to specific dis-
sia” covers widely different impairments and that RCT orders in processing numbers and in calculation.
are not the best instrument to evaluate efficacy; the The latter are almost always associated with apha-
importance of chronicity is underlined. sic disorders and rarely found in isolation. Speech
Key words: Aphasia - Dyslexia - Agraphia - Apraxia. apraxia is a motor speech programming disorder
that does not result from paresis of the muscles
that control the language movements. In this arti-
T he term “aphasia” refers to a more or less com-

plete loss of the ability to use the language due
to lesions in the cerebral areas, generally localized
cle, we report the data collected from the literature
on the efficacy of neuropsychological treatments of
aphasic disorders. Treatments that cannot be con-
sidered neuropsychological (such as, for instance,
Corresponding author: A. Basso, Department of Neurological
Sciences, via F. Sforza 35, 20122 Milan, Italy. Alternative and Augmentative Communication) are
E-mail: anna.basso@gmail.com not considered here.
tion of the Publisher.
Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 101

may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is
BASSO Treatment efficacy of language and calculation disorders and speech apraxia
No specific data on the incidence of aphasia are Results

available but an approximate count can be made
based on the incidence of stroke that varies from Heterogeneous treatments for groups of heterogene-
1.8/1 000 1 to 4.5/1 000 2 new cases per year. The ous patients
incidence of aphasia following stroke varies from
21% in some studies 3 to 38% in others.4 The problem of the efficacy of treatment for lan-
For the Italian population, these data indicate that guage disorders has been studied since the l950s.
incidence ranges from 22 000 to 99 000 new cases of Initially, the performance in two successive evalu-
aphasia per year. Pedersen et al.4 compared the in- ations of a group of treated patients was assessed
cidence of aphasia in acute and chronic cases (≥ six and improvement was attributed to the effect of re-
months) and found a reduction ranging from 38% ‑ habilitation, without considering the effect of spon-
acute phase ‑ to 18% ‑ chronic phase. taneous recovery. All these studies report more or
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less important recovery but their value is, to say the
least, limited due to the lack of a control group.
To rectify this problem, a group of untreated con-
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Methods
trol patients was subsequently introduced in numer-
To study the efficacy of neuropsychological treat- ous studies but given the great difficulties associated
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ments for vascular aphasic disorders, reading and with control groups, in many studies published in
writing, we searched the pertinent literature pub- the 1980s improvement obtained by patients treated
lished from 1950 to August 31, 2007 by means of by therapists was compared with improvement ob-
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electronic data banks. The bibliographical research
indicated 1 036 entries. We were unable to find 53 of
tained by patients treated by volunteers. Finally, in
recent studies, groups treated using different meth-
odologies have been compared. Table I presents the
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them. Of the 983 articles examined, 745 were discard-
ed for various reasons (such as non-vascular patients, main data reported in these studies: number of pa-
bare descriptions of methods, not neuropsychologi- tients treated and untreated (or treated by therapists
cal methods) and the remaining 238 were classified. and volunteers, or treated using different methods)
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Given the large body of work and the heterogene- duration and amount of treatment; results.
ity of aphasic disorders, we attempted to assemble As can be seen, the results are not clear cut: they
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the articles by the specific disorder treated. The first are “positive” (rehabilitation has a significant effect
works on treatment efficacy date back to the 1950s on recovery) in about half of the studies that have
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and l960s; these are group studies on heterogeneous a control group and in all studies comparing thera-
participants treated with global techniques and were pists and volunteers or patients treated using differ-
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considered apart (31 studies). ent methods (however, without a difference between
The approach used to study aphasia has changed the two groups); instead, no significant difference
profoundly over the past 30 years thanks to the con- was found between treated and untreated patients
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tribution of cognitive neuropsychology, and works in 50% of the studies comparing the two groups.
that tackled the problem of treatment efficacy used One common element in the studies that found
more adequate methodologies than those in earlier no positive effect of treatment was shortness of
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studies. More detailed evaluation techniques were treatment; indeed, treatment was always longer in
used that led to less general diagnoses than the syn- the positive studies. The issue concerning amount of
dromic ones (i.e., Broca or Wernicke aphasia) and it treatment was specifically tackled by Boghal et al.26
has been possible to re-group the subsequent works They considered all works published between 1975
in light of the patient’s specific damage. The stud- and 2002 in which recovery of a group of treated
ies (almost all of which were based on the study patients was compared with that of a group of non-
of single cases or series of single cases analyzed in treated patients and they identified those that pre-
detail) were sub-divided as follows: 61 referred to sented sufficient data for re-analysis (N.=10). Signifi-
the rehabilitation of single words, 45 of sentences, cantly more therapy sessions were carried out in the
20 of writing, 32 of reading. Finally, 37 referred to “positive” studies than in the “negative” ones, thus
specific treatments (PACE and MIT) or treatment us- confirming the importance of amount of treatment.
ing a computer and are not reported here. Moss and Nicholas 27 studied another variable:
102 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Treatment efficacy of language and calculation disorders and speech apraxia BASSO
Table I.—Summary of data of the 21 studies on treatment efficacy in group studies

Therapy length
N. of subjetcs
Authors (and N of sessions)
Results
(and subjects’ language) Treated Untreated Treated Untreated
(Method A) (Method B (Method A) (Method B
Vignolo (1964) 5 42 27 min 40 d; — No significant difference
(min 20)
Sands et al. (1969) 6 10 10 2 w-32 m — Mean recovery: 10 points percentile;
(n.r.) 3 subjects do not recover
Sarno et al. (1970) 7 10 11 3m — No significant difference
(80 1/2h)
Hagen (1973) 8 10 10 12 m — After 3 m only treated subjects con-
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(12h/w) tinue to recover
Levita (1978) 9 17 18 8w — No difference between groups
(5h/w)
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Deal and Deal (1978) 10 45 10 min 3 m — Better recovery for treated subjects
(27-254 ss) only if treatment starts before 3 MPO;
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Basso et al. (1979) 11 162 119 min 5 m (3 — A significant higher N of treated sub-
h/w) jects recover
Meikle et al. (1979) 12 17 14 max 80 w mean: 21w No significant difference
(therapists) (volunteers) (4 h/w)
Wertz et al. (1981) 13
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(individual
treatment)
35
(group treat-
ment)
44 w
(8 h/w)
44 w
(8 h/w)
Individual therapy more effective
than group therapy
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David et al. (1982) 14 48 48 max 20 w max 20 w (30 No significant difference
(therapists) (volunteers) (30 h) h)
Pickersgill and Lincoln (1983) 15 36 20 8w — No significant difference
(n.r.)
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Lincoln et al. (1984) 16 104 87 max 24 w — No significant difference

(2 h/w)
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Shewan and Kertesz (1984) 17 52 23 up to 12 m — No significant difference

(3 h/w)
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Wertz et al. (1986) 18 38 43 12 w 12 w No significant difference

(therapists) (volunteers) (8-10 h/w) (8—10 h/w)
Y
Hartman and Landau (1987) 19 30 30 6m 6m No significant difference

(therapists) (counseling) (2 h/w) (2 h/w)
Marshall et al. (1989) 20 31 37 12 w 12 w No significant difference
IN
(therapists) (family mem- (8-10 h/w) (8—10 h/w)

ber)
Poeck et al. (1989) 21 68 69 6-8 w — Significant recovery in treated sub-
(9 h/w) jects
M
Mazzoni et al. (1995) 22 13 13 6m — No difference at 4 m, significant dif-

(pairs) (pairs) (4-5 h/w) ference at 7 m
Pulvermüller et al.23 (German) 10 7 10 d 3-5 w Significantly better constraint induced
(constraint (traditional) (23-33 h) 20-54 h therapy
induced)
Meinzer et al. (2005) 24 12 15 10h/w x 2 w 2w Better recovery for subjects with con-
(constraint (constraint 20h 20 h straint induced therapy and writing
induced) induced+ writ-
ing)
Maher et al. (2006) 25 4 5 2w 2w All subjects recover but more sub-
(constraint (PACE) 24 h 24 h jects treated with constraint induced
induced) therapy
h: hour; d: days; w: week; m: month; n.r.: not reported; ss: sessions; PACE: Promoting Aphasic Communicative Effectiveness; min: minimum; max: maxi-
mum.

time from onset. They analyzed 23 works including them were chronic, seen more than six months from
a total of 57 patients subdivided into six groups ac- the morbid event. Most of the patients spoke Eng-
cording to the time between the morbid event and lish; several spoke French and others Finnish. Only
the beginning of treatment. Data indicate that the ef- seven patients spoke Italian.
fect of rehabilitation did not diminish with the pass- Patients presented various types and severity of
ing of the years, at least until the seventh year. aphasia; indeed, all of the classical types of aphasia
Finally, four meta-analyses were conducted on were represented. In some patients, localization of
the group studies 28-31 and two systematic reviews,32, the functional damage was identified according to
33 which were subsequently updated.34, 35 All meta- the model of the lexicon described in cognitive neu-
analyses confirmed the efficacy of rehabilitation. Fi- ropsychology (damage to the semantic system, the
nally, a very recent update of the Cochrane database phonological output lexicon, and the phonological
of systematic reviews 36 concludes: “Significant dif- buffer). The six patients with repetition deficits all
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ferences between the groups’ scores were few but presented conduction aphasia, probably resulting
there was some indication of a consistency in the from damage to the phonological output buffer.
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direction of results which favoured the provision of All patients were treated individually; however, in
SLT”. The systematic reviews were carried out by four studies the treated patients were part of hetero-
the American Society of Rehabilitative Medicine 32, geneous groups of more than ten individuals. All
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35 and the European Neurological Society.33, 34 Both
studies reported positive results even if not all pa-
reviews reach the conclusion that sufficient experi- tients improved.
mental evidence exists to recommend treatment of
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aphasia (such as Practice Standards in Cicerone et
al.’s work, that is, the maximum level of recommen-
Production
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dation; grade B according to Cappa et al.). Various methods were used to treat word produc-
To sum up: 1) when groups of treated and un- tion (repetition, reading aloud, phonological cues,
treated patients were compared, improvement was semantic cues, naming from definition, analysis of
always significantly greater in the treated patients, semantic traits, production of synonyms and an-
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unless treatment was short; 2) when the treatment tonyms, orthographical cues, anagrams, etc.) and
was short, the difference between treated and un- sometimes effectiveness of two treatments was com-
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treated patients was not significant; 3) the impor- pared. The number of items used varied from 13 to
tance of the amount of treatment is also confirmed 150; the number of sessions and/or the duration of
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by other studies: 4) the difference between patients treatment varied greatly (from 5 to 140 sessions; in
treated by therapists and patients treated by volun- some studies it was not specified). In two studies
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teers was never significant, but treatment was always the approach was clinical. In both studies treatment
short in these studies; 5) finally, there are indications (which lasted a year and three months respectively)
that distance from the morbid event does not influ- aimed at generalized recovery of production using
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ence rehabilitation efficacy. a large number of non-predefined stimuli. All of the

Although the experimental evidence is not defini- treatments described produced positive results.
tive, it clearly indicates a positive effect of rehabili- Many of these studies faced the problem of the
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tation and a grade B recommendation is given for generalization of improvement to non-treated stim-
generic treatments for groups of patients. uli; however, results were variable. When the diag-
nosis was made on the basis of the lexical model,
the expected result emerged, that is, generalization
Processing of single words
was found when the damage was at the level of the
We analyzed 61 papers published between 1973 buffer, but not when it was at the level of the lexical
and 2007. Only one of these studies 37 concerns components.
rehabilitation of word comprehension; 53 concern The evidence level is 3 in 46 studies and 2+ in 9
rehabilitation of oral production, one written pro- studies and the recommendation grade is C.
duction, and six works concern treatment of repeti- Number of studies (53), chronicity of the patients
tion. treated (192/215) and uniformity of the results (all
Overall, 222 patients were considered and 199 of studies reported positive results) are important fac-

tors for evaluating treatment validity and determin- in one case treatment was aimed at auditory dis-
ing the advisability of using these treatments in clini- crimination; exercises involved recognition of the
cal settings, which seems very high. initial/final phoneme of the word. Also in these
Table II reports type of treatment, number (and studies, both number of sessions (from 5 to about
chronicity) of treated subjects, number of therapy 100) and treatment duration were variable. All pa-
sessions and treated items and the evidence level for tients improved: in two cases, improvement oc-
each study. Due to the high number of the studies curred only on treated stimuli; in the others, a
concerning language functions, we have decided to reduction of errors was also found in spontane-
report detailed data only of the studies published ous production.
since 2000. The evidence level of all six studies is 3 and the
Thirty-four studies reported data on follow-up vis- recommendation grade is D.
its; duration ranged from a minimum of ten days to Three studies report data on the follow-up carried
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a maximum of seven months. Recovery was stable out at six weeks, at four and eight months after treat-
in 22 studies (with a follow-up ranging from five ment. All report good maintenance of the results ob-
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weeks to six months) and only partial in ten studies; tained during treatment.
total loss was reported in one study. Finally, in one The evidence level of all studies is 3 and the rec-
study results were not clear. ommendation grade is D.
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The evidence level is 3 in 28 studies and 2+ in 6
studies and the recommendation grade is C. Processing of sentences
Comprehension
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of comprehension and 39 on rehabilitation of pro-
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Behrmann and Lieberthal 37 treated a chronic glo- duction) published between 1979 and 2007.
bal aphasic individual with severe semantic damage.
Treatment aimed at the recovery of comprehension Production
of single words; they used 3 20-items sets pertaining
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to three different semantic categories and 160 con- Sentence production was studied in 115 patients.
trol items; recovery of treated and untreated items of Many spoke English, 12 spoke German, two spoke
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treated categories was significant but there was little Dutch and two Italian. Only 20 patients began treat-
generalization to untreated categories. ment in the sub-acute phase (within 6 months from
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The almost complete absence of works on the re- the morbid event); all others were chronic (from 7
habilitation of word comprehension (only one study months to 15 years).
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on a single aphasic patient) is probably due to the Five studies had small experimental groups (from
clinical observation that word comprehension is ini- 7 to 12 patients). In some studies, the type of aphasia
tially less impaired than word production and has was not specified; four patients presented Wernicke
IN
a more obvious and rapid spontaneous recovery. aphasia, one transcortical sensory aphasia and all
Therefore, clinicians rarely find it necessary to treat others Broca aphasia with agrammatism. All patients
comprehension of isolated words. Naturally, this is were treated individually. Duration of treatment and
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not true for severe aphasics but in these cases spe- number of sessions (from a minimum of two to a
cific treatment aimed at an isolated functional com- maximum of 110) were extremely variable.
ponent seems inadequate. Two main types of treatment were used: map-
Due to paucity of studies on the treatment of ping therapy and treatment based on the analysis
comprehension, no conclusions about its efficacy of movement using Wh-questions. Group studies
can be drawn. reported significant improvement of the group; al-
though all patients described improved individually,
in several cases the improvement was not signifi-
Repetition
cant. In general, for mapping therapy and treatment
The data on repetition are rather scanty; indeed, based on Wh-questions improvement was not lim-
six studies investigated a total of six patients. The ited to the items treated but generalized to the type
methods used were repetition and reading aloud; of sentence treated, to sentences with simple gram-

Table II.—Summary of the data of the studies on treatment efficacy for word production published since 2000.
Author Treatment N. of sbjs (cronicity) and N. items-Treatment length Evidence

(year of publication) aphasia type level
Marshall et al. (2001) 38 Phonol and individual cues 29 (chr: 1 to 16 y) mild 20 items; 3
aphasia 12 ss
Rieu et al. (2001) 39 Semantic (naming on definition) and 1A 2 40-item sets for each of the 3
phonol (repetition) treatment 2 treatm + 1 C set; 5 ss each
treatment
Hickin et al. (2002) 40 Phonol and orthographic cues 8 (chr: 3 to 8 y) various 100 items; 3
8 ss
Nickels (2002) 41 Reading, delayed copying on his 1 (chr: 12 m) A 102 items; 3
own, at home 18 ss
Rose et al. (2002) 42 Miming and verbal cues 1 (chr: 6m) conduct 80 items; 3
® A
7 ss
Wambaugh et al. (2002) 43 Hierarchical semantic and phonol 3 (chr: 26 to 136 m) 2A, 24 items; 3
cues 1W max 15 ss
T C
Conley and Coelho (2003) 44 Semantic features analysis 1 (chr: 8y) B 20 treated and 10 C items; 18 ss 3
Cornelissen et al. (2003) 45 Repetition and semantic priming 3 (chr: 2 to 14 y) A 50 treated and 50 C items; 9 ss 3
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DeDe et al. (2003) 46 Written auto-cues 1 (chr: 4 y) G 48 items; 3
13 ss
Kiran and Thompson (2003) 47 Semantic features analysis 4 (chr: 9 to 99 m) F 1 treated and 1 C semantic 3
category (24 items each); max
Renvall et al. (2003)

Boyle (2004) 49
48
IG E 1 semantic, 1 phonol, 1 other treatm.

Semantic features analysis
1 (chr: 30 y) A
2 (chr: 14 and 15 m): 1
20 ss
30 items for each treatment; 27 ss
13 and 20 items respectively
3
3
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A, 1 W, 12 ss
Kohnert (2004) 50 Written and oral naming 1 (chr: 12 m), NF bilingual 20 treated and 20 C items (20 3
English and 20 Spanish); 4 ss
Martin et al. (2004) 51 Contextual priming 2 (chr: 9 and 10 m): 1 B, 1 45 items; 3
conduct 9 ss
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Robson et al. (2004) 52 Pointing, phonol cues, writing 10 (chr: 6 to 45 m) A 30 proper and 30 common N; 5 ss 3
Fillingham et al. (2005) 53 Errorless: 3 repetition or reading 7 (chr) various 2 20-items treated and 1 C sets; 10 3
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before naming; ss each treatment

Errorful: phonol and orthogr cue
Fridriksson et al. (2005) 54 Delayed repetition and copy 3 (chr: 1, 12, 28 y): 1B, 2A 30 written and 30 oral items; 20 3
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and 30 ss
Linebaugh et al. (2005) 55 Hierarchical semantic and phonol 5A 20 item + 20 di C 3
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cues 20 to 25 ss
Renvall et al. (2005) 56 Contextual semantic/phonol priming 1: semantic damage 60 treated and 60 C items; 12 ss 3
Beeson and Egnor (2006) 57 Delayed copy and repetition 2 (chr: 5 y): 1 A, 1 40 items: 20 proper and 20 2+
conduct common N;
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20 ss
Davis and Harrington (2006) 58 Semantic decision (production 1W 60 items; 3
discouraged) 20 ss
Fillingham et al. (2006) 59 Errorless: 3 repetition or reading 11 (chr: > 6 m) various 30 items each for 2 treatment; 2+
before naming; 10 ss each
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Errorful: phonol and orthogr cue

McKissock and Ward (2007) 60 1st: repetition 5 (chr: > 2 y) A 30 items for each of 3 treatment; 3
2nd: naming + feedback 8 ss each
3rd: naming
Raymer et al. (2007) 61 Semantic and phonol questions 8 (7 chr); various 20 N and 20 V treated and 20 + 20 3
C; 10 ss
Renvall et al. (2007) 62 Semantic and phonol treatm 2 (chr: 4 and 7 y): 1 60 treated and 60 C items; 22 and 3
semantic and 1 phonol 30 ss respectively
damage
Vitali et al. (2007) 63 Phonological cues 1 (chr) A ? items; 3
4w
A: anomic; B: Broca; G: global; W: Wernicke; conduct: conduction; N: nouns; V: verbs; C: control; phonol: phonological; chr: chronic; h: hour; w: week; m: month;
ss: sessions.

Table III.—Summary of the data of the studies on treatment efficacy for sentence production published since 2000.
Authors Method N. of sbjs (chronicity) and Number of sessions Evidence level

aphasia type
Jacobs and Thompson (2000) 64 Wh-movement 4 (chr) agramm 8-19 ss 3

Murray and Karcher (2000) 65 Action ≥ sentence 1 (chr: 26 m) W 80 ss 3
Springer et al. (2000) 66 Reduced Syntax Therapy 8 (chr: 11 m-11 y) 8B, 3 G 3 h/ss x 12 w 2+
Raymer and Ellsworth (2002) 67 Use of gestures to facilitate sentence 1 TM 10 ss 3
production
Schneider and Thompson (2003) 68 Mapping therapy 7 (chr: 3-11 y) B 24 ss 2+
Thompson et al. (2003) 69 Mapping therapy 4 (chr: 1-11 y) B 11-30 2 h ss 3
® A
Murray et al. (2004) 70 Wh-movement 4 (chr:13-63 m): 1 MNF, 1 max 12 ss (repeatable) 2+
conduct, 2 F
T C
Peach and Wong (2004) 71 Story retelling, listen to his utterance 1 (chr: 3 y) agramm 30 ss 3
and improve it
H DI
Rochon et al. (2005) 72 Mapping therapy 3 (chr: 2-9 y) B 50 ss 3
Webster et al. (2005) 73 Action naming, Mapping therapy 1 (chr: 6 y) NF 60 ss in 12 w 2+
Wierenga et al. (2006) 74 Wh-movement 2 (chr: 8 and 53 m) agramm 32 ss 3
Murray et al. (2007) 75
IG E Wh-movement 1 (chr: 2 y) agramm 2 ss/w x w? 3

R M
B: Broca; G: global; W: Wernicke; conduct: conduction; agramm: agrammatism; NF: Non Fluent Aphasia; MNF: Mixed Non-Fluent aphasia; TM: Transcortical Motor;
N: nouns; V: verbs; C: control; Phonol: phonological; chr: chronic; h: hour; w: week; m: month; y: year; ss: sessions.
P A
matical structure, and to the evocation of verbs in Comprehension

spontaneous production.
O V
Comprehension was studied in six studies 76-81 for

The evidence level is 2+ in 11 studies and 3 in 28
a total of ten patients, all of whom were chronic and
studies and the recommendation level is C.
C ER
had Broca aphasia and agrammatism; four spoke

Number of studies (39), chronicity of patients
English and six French. The number of sessions was
treated (95/115), and uniformity of results (all stud-
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variable, that is, from 12 to about 75. Five of the

ies report positive results) are important factors in
six used the same methods of production (mapping
evaluating treatment validity and in determining
therapy and Wh-movement) and one study 81 used
IN
clinical advisability (at least in cases of Broca apha-

non-linguistic cognitive sequences. All studies re-
sia and agrammatism, which are by far the most nu- ported positive results.
merous), which seem clearly demonstrated. The evidence level is 2+ in one study 81 and three
Table III reports type of treatment, number (and
M
in the others and the recommendation grade is C.

chronicity) of treated subjects, number of therapy Data on follow-ups are provided only in two stud-
sessions and the evidence level for each of studies ies,78, 79 both of which are single-case studies. The
published since 2000. results obtained remained stable after one month in
Twenty-two studies also reported data relative to the first case and after seven weeks in the second.
follow-ups of variable duration, that is, from two The evidence level of the two studies is 3 and the
weeks to six months. Three studies reported partial recommendation grade is D.
loss of the improvement obtained during the treat-
ment of 12 patients. In all other cases (48 patients),
Reading
the results obtained were stable.
The evidence level is 3 in 19 studies and 2+ in 3 We evaluated 32 papers published between 1979
and the recommendation grade is C. and 2007. In all but a few studies, treatment was

Table IV.—Summary of the data of the studies on treatment efficacy for reading disorders published since 2000.
N. of sbs (chronicity) and N. of sessions/ Evidence

Authors Treatment aphasia type Treatment length level
Kiran et al. (2001) 85 G->Ph 2 (chr: 13 and 27 m) conduct 36 and 30 ss 3

and dyslexia
Friedman et al.(2002) 86 1- Homophones reading 2 (chr: 2 and 4 y) phonol 25 e 70 ss; 60 3
2- Sentence reading dyslexic
Friedman and Lott (2002)87 Byghraph->Syllable Therapy 2 (chr: 2 and 5 y) deep 355 ss in 31 m; 114 ss 3
dyslexic in 15 m
Mayer and Murray (2002) 88 MOR + working memory 1 (chr: 15 y) dyslexic 22 ss 3
® A
Peach (2002) 89 G->F 1 phonol dyslexia 10 ss 3
Yampolsky and Waters (2002) 90 Wilson’s Reading System G->F 1 (chr: 3 y) deep dyslexic 62 h 3
Kendall et al.(2003) 91 LiPS (modified) 2 (chr: 2 and 3 y) G,W 162 and 68 ss 3
T C
Ska et al.(2003) 92 Word reading and picture naming 1 (chr: 3 y) deep dyslexic 1 ss/w x 4 w 3
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Cherney (2004) 93 MOR 2 (chr: 24 m and 13 y) A and 56 and 24 ss 3
deep dyslexic
Orjada and Beeson (2005) 94 ORT and CART 1 (chr: 1 y) B 19 ss 3
Sage et al.(2005) 95 -Letter-form tracing 1 LbyL 7 + 7 ss 2+
Sperling et al. (2005) 96

IG E -LbyL reading
Repeated reading of functors 1 (chr: 7 m) PhTA 8 ss 3
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Viswanathan and Kiran (2005) 97 Sublexical conversion 1 A and pure alexic - 3
Kendall et al.(2006) 98 Phonol analysis -> via sublexical LiPS 1 (chr: 54 y) NF 74 ss in 6 m 3
Kim and Beaudoin-Parsons (2007) 99 Byghraph -> Syllable Therapy 1 (chr: 31 m) B 70 ss 2+
(and homework)
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A: anomic; B: Broca; G: global; W: Wernicke; NF: Non Fluent Aphasia; LbyL: Letter-by-letter reading; LiPS: Lindamood Phoneme Sequencing Program; ss: sessions;
ORT: Oral Reading Treatment; CART: Copy And Recall Treatment; MOR: Multiple Oral Reading; G: Grapheme; Ph: Phoneme; h: hour; d: day; w: week; m: month.
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based on the two-way reading model proposed by lish, it is possible to read almost all words using
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cognitive neuropsychology and, depending on the the sublexical route by applying the grapheme-to-
disorder, the two reading routes (i.e., lexical and phoneme conversion rules. Considering that treat-
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sub-lexical) were treated either separately or simul- ment of the sublexical route is effective in English,
taneously. Almost all patients spoke English, a lan- treatment of the sublexical route should produce
guage in which the relationship between phonol- even better results in Italian and, above all, allow
ogy and orthography is much more complex than for very broad generalization. The sublexical route
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in Italian. In fact, in Italian the relationship between was treated in 11 studies and the lexical route in
orthography and phonology is transparent, in the three. Seven studies considered the efficacy of a
sense that in almost all words phonology determines more global technique, that is, Multiple Oral Read-
orthography and vice-versa. By contrast, English has ing in the original 82 or in a slightly modified ver-
an opaque orthography, that is, knowing how to say sion.93 This technique involves repeated reading of
a word does not mean you will know how to write the same passage (often with exercises to carry out
it correctly and knowing the orthographic form of a at home). In two studies, the treated patients pre-
word does not mean you will know how to read it sented letter-by-letter dyslexia and the treatment
correctly. consisted of asking them to semantically judge
A direct consequence of this difference between words presented in tachistoscopic vision. Other
Italian and English is that in Italian, but not in Eng- works used less clearly identifiable treatments. Like

most of the works based on a cognitive model of Writing

functional damage, the studies considered single We analyzed 20 studies published between 1974
cases. and 2005. In all but a few studies, treatment was
Overall, 42 patients were treated: 34 were in the based on the two-way model of writing proposed
chronic phase (from 1 to 54 years after the morbid by cognitive neuropsychology and, depending on
event). the disorder, the two writing routes (lexical and sub-
Treatment duration was variable: from ten days to lexical) were treated either separately or simultane-
many months (31) and the therapy sessions (which ously. Almost all patients studied spoke English, a
had different durations) ranged from a minimum language in which the relationship between phonol-
of five to a maximum of 355. All treated patients ogy and orthography is much more complex than in
improved except for one chronic patient 83 who Italian; 17 patients spoke Italian.
was treated for only 10 days (his reading speed im- A total of 72 patients were studied: two were sub-
® A
proved but his coding operations did not change); acute and 70 chronic (between 6 months and 24
another chronic patient with letter-by-letter dyslexia years). Most studies presented single cases or series
T C
who had been asked to give a semantic judgment of two or three cases; four studies reported the re-
of words presented in tachistoscopic vision (six ses- sults of small groups (from 5 to 10 patients). Treat-
H DI
sions on 46 words) improved during the remaining ment duration was very variable, from a minimum
40 sessions in which he was treated with a different of six to a maximum of about 200 sessions, as was
technique, motor cross-cuing, which was not inves- duration of the single sessions (up to two hours per
tigated in this review.84 Due to the nature of the
IG E
studies (i.e., based on single cases), the evidence
level is 3 in 28 studies and 2+ in 4 studies and the
session).
Often the two writing routes (lexical and sub-lexi-
cal) were treated simultaneously; in other cases, the
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recommendation grade is C. treatment was directed toward the damaged compo-
Number of studies (32), chronicity of the pa- nent (orthographic lexicon or orthographic buffer).
tients treated (34/42), and uniformity of the results In some severe patients, an attempt was made to
(all but two patients improved) are important fac-
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reconstruct a small vocabulary to enable commu-

tors in evaluating treatment validity for reading. nication. Several patients in the groups showed no
Although various treatments were adopted, the
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improvement; all patients described in the other

results were positive for all types of treatment. studies improved.
It is important to consider separately efficacy of The evidence level is 3 in 16 studies and 2+ in 4
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recovery of mechanisms (such as grapheme-to- studies and the recommendation grade is C. Table
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phoneme conversion ability), which can then be V reports type of treatment, aphasia type, number
applied to any stimulus that respects the conver- (and chronicity) of treated subjects, number of ther-
sion rules (in this case, all words except for ir- apy sessions and the evidence level for each of the
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regular or loaned words) from the acquisition of studies published since 2000.
several specific items because in these cases gen- As already stated, number of works (20), chro-
eralization is impossible. nicity of patients treated (70/72), and uniformity of
Table IV reports type of treatment, aphasia type,
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results (positive in all studies) are important fac-

number (and chronicity) of treated subjects, number tors in evaluating the clinical relevance of treat-
of therapy sessions and the evidence level for each ment. Various treatments were used and the results
of the studies published since 2000. were positive for all types of treatment. Also in this
Only five studies report data on maintaining im- case, we have to consider separately the efficacy of
provement obtained during treatment over time in a the recovery of mechanisms (such as phoneme-to-
total of seven patients. Follow-up duration was vari- grapheme conversion ability), which can be applied
able (from two weeks to eight months) but the result to any stimulus that respects the conversion rules
was always the same: improvement was maintained (i.e., all words except for irregular or loaned words)
over time. from the acquisition of several specific items, each
The evidence level is 3 in all studies the recom- separately represented in the lexicon, in which case,
mendation grade is D. generalization is not expected.

Table V.—Summary of the data of the studies on treatment efficacy for writing disorders published since 2000.
Authors Treatment N. of subjects (chronicity) and N. of sessions Evidence

aphasia type level
Beeson et al. (2000) 100 Sublexical and lexical routes 1 (chr: 4y) A about 20 ss 3
Luzzatti et al. (2000) 101 Sublexical route 2 (chr: 4, 8y) B 17 m 2+
Carlomagno et al. (2001) 102 Sublexical and lexical routes 8 (chr. 6-9m) moderate 20-24 ss 3
aphasia
Robson et al.(2001) 103 Building of a personal vocabulary 10 (chr: 6-53m) jargon 12 ss 2+
aphasia
Beeson et al. (2002) 104 ACT+CART 4 (chr: 12-54m) 3 G, 1 A 11 ≥37 ss 3
® A
Rapp and Kane (2002) 105 Lexical route and delayed copy 2 (chr: 2-4y) dysgraphic 24 and 16 ss 3
Beeson et al. (2003) 106 CART 8 (chr: 24-84m), 7 B, 1W 12 ss (+ homework) 3
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Raymer et al. (2003) 107 Buffer and OOL 1 (chr:2y) dysgraphic 12 ss 3
Kiran S. (2005) 108 Sublexical route 3 (chr: 2, 13, 24y) mild W 20 ≥24 ss 2+
H DI
Rapp B. (2005) 109 Buffer and OOL 3 (chr: 2-4y) 2 dysgraphic, 1 14 ≥22 ss 2+
moderate aphasia
IG E
A: Anomic; B: Broca; W: Wernicke; ACT: Anagram and Copy Treatment; CART: Copy And Recall Treatment; OOL: Orthographic Output Lexicon; chr: chronic; h:
hour; m: months; y: years; ss: sessions.
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Ten studies reported data on follow-up visits; du- referred to single cases for a total of ten patients with
ration was extremely variable, that is, from three acalculia. The ability to transcode from one code
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weeks to two years. Hatfield and Weddell 110 car- to another (e.g., from Arabic numerals to numbers
ried out a control evaluation one month after the or from written number-words to phonology) was
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end of treatment and found that improvement was treated in five patients, re-learning of the number
not maintained; however, they provide no data on tables in three patients, multiplication procedures in
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individual patients and this outcome may not have two patients and calculation procedures in four pa-
been true for all nine patients treated. Robson et tients. In several cases, the calculation procedures
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al.103 reported the same negative finding in two out were treated after reacquisition of transcoding abil-
of four patients and Rapp and Kane 105 in one out ity. Many of the treated patients were aphasic (5 out
of two patients. In all other cases, the level reached of 8; in two cases it is not known). All studies re-
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was maintained (for two years in Rapp and Kane’s ported positive results.
study). In summary, 18 patients maintained the im- Given that these are single case studies, the evi-
provement, whereas 12 patients (counting all of Hat- dence level for all of them is 3 and the recommenda-
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field and Weddell’s patients) did not. tion grade is D.

The evidence level is 3 in 7 studies and 2+ in 3
and the recommendation grade is C. Speech apraxia
Table VI reports a summary of the results for each
of the disorder treated: word and sentence process- Speech apraxia (SA) is a motor speech program-
ing, reading and writing. ming disorder, which manifests following a unilat-
eral brain lesion, usually in the left hemisphere, and
Acalculia does not result from paresis of the muscles that con-
trol the movements required to produce language
We examined the literature from 1980 to the sounds.117 Originally the terms anarthria and pho-
present by carrying out research on electronic data netic disintegration were used to identify this deficit,
banks and identified seven studies.111-116 All works which is one of the symptoms that frequently char-

Table VI.—Summary of the results for each of the language disorder treated.
Number Years of publication Number of pts Methods Results

of papers
Words 53 1973-2007 268: 18 less than 6 mpo; Various: All studies report positive
(45 product, 1 comprehen, 250 chronic repetition, reading aloud, results
6 repetition cues, anagrams
Sentences 42: 37 product, 5 1979-2007 108 subjects: 25 less than Mapping therapy, All studies report positive
comprehen 6 mpo, WH-movement results
83 chronic
Reading 31 1979-2007 44: Mainly sublexical route or Only1 chronic subject did
6 less than 6 mpo MOR not improve
38 chronic
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Writing 20 1974-2007 72: only 1 was less than 6 Lexical and sub-lexical A few subjects did not
mpo routes improve
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acterizes Broca aphasia but which may also appear speech rate and/or rhythm; 3) intersystemic reor-
in its pure form. ganization; 4) alternative/augmentative communica-
Patients suffering from SA have difficulty in con- tion (AAC).
trolling the programming of their bucco-laryngo- (1) The articulatory kinematic techniques are
IG E
pharyngeal speech movements, which gives the
impression that they are struggling to produce the
intended to help the patient to acquire phonetic
knowledge of the movements required to produce
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intended sequence of sounds. The loss of the abil- language sounds and obtain voluntary control over
ity to program the action of the muscles involved the articulatory positions, first for the vowel sounds,
in language production is the principal mechanism then for the consonant-vowel (CV) syllables and fi-
P A
that underlies speech apraxia. Unlike dysarthria, SA nally for polysyllabic sequences and consonant clus-
affects only speech sound movements, leaving rela- ters. The rehabilitation techniques included in this
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tively intact the elementary non-articulatory motor category can be subdivided into two main groups,
abilities of the buccolingual and facial areas (in oth- in the first the treatment stimulates the production
of automated elements through facilitation,120, 121
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er words, there is no paresis of the face and mouth),

and has been known not to affect oral complex while in the second the treatment aims at breaking
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motor abilities and may occasionally be dissociated the automated processing schemes over which the
from oral apraxia. patient has lost control and at acquiring voluntary
There are no studies in the literature that focus control over speech production.122, 123 The ration-
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on defining the incidence of SA, which can only be ale of these procedures is the modelling of speech
estimated indirectly. Extracting information from the control through proprioceptive sensorial, tactile and
database of the Mayo Clinic, Duffy 118 showed that kinesthetic supports, which provide SA patients
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SA had been diagnosed in a relatively pure form in with input regarding the reciprocal position of the
4.6% of 3 417 cases of speech or language deficits articulators, tension, temporal sequence, manner
and it can be estimated that approximately 25% of of articulation and coarticulation.124 Two principles
aphasic patients suffer from mild to severe forms of usually associated with this technique are drilling
SA, i.e., with a prevalence of about 45 000 cases in and practice, using pairs of sound in minimal con-
Italy. trast.125, 126Although they originate from a common
hypothesis these two methods are based on two dia-
metrically opposite rehabilitation procedures: on the
Treatment
one hand the facilitation of and support for residual
According to Wambaugh et al.119 there are four automated abilities, on the other the inhibition of
main categories of treatment for SA, depending on automated elements and the reconstruction of the
the focus of training: 1) articulatory kinematics; 2) damaged capacity for speech on voluntary basis.

(2) The techniques which intervene on rhythm the impairment, severity of the aphasia if associated
assume that SA derives from a primary disorder of to the impairment) makes it extremely difficult to
a central rhythm control mechanism. However, this define a specific treatment program for standard ad-
hypothesis does not explain either the frequent dis- ministration for each patient.
sociation between SA and ideo-motor apraxia, or the In a subsequent phase of the current revision we
occasional dissociation between SA and oral aprax- analyzed the studies that tested the efficacy of SA
ia. The rationale behind these techniques is the as- treatments in single- or multiple-single-case studies.
sumption that training to regain control of rhythm The following aspects were considered in evaluat-
can re-establish appropriate temporal sequencing, ing the methodological adequacy of the studies: 1)
damaged in SA. an appropriate period of time left following the onset
(3) The techniques that aim at facilitating inter- of the disorder; 2) the use of statistical procedures to
systemic reorganization proceed on the basis that compare the changes observed on items being treat-
® A
the speech defect can be cured by multi-sensorial ed with those not being treated; 3) generalization
stimulation and activation of non-articulatory motor of the treatment to items not being treated, but with
T C
patterns. the same articulatory characteristics as those under
(4) The rationale behind the alternative/augmen- treatment; 4) stability of the recovery following sus-
tative communication (AAC) techniques is that SA pension of the treatment (follow-up); 5) extension
H DI
is impervious to all focused techniques and that, of the improvement to conversation (i.e., over and
therefore, functional recovery from the speech im- above the repetition and reading aloud exercises,
pairment must be based on an improvement of the which are normally used in the rehabilitation ses-
IG E
communication capacities through modalities other
than the oral one.
sions).
Three of the studies considered were classified as
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Class 2+, 7 as Class 3; 2 as Class 4 (Table VII).
All results come from patients with a chronic con-
Efficacy studies
dition (average=53,1±32; median=50; range 8-120
Twelve experimental studies on the efficacy of SA months from onset) and ischemic or hemorrhagic
P A
treatments have been examined. Each of these stud- etiology. The intensity of the treatment varied in
ies has investigated the degree of efficacy obtained weekly frequency, duration of the sessions and the
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in individual (and multiple) cases for a total of 17 overall number of sessions (average=42.3±44; me-
patients; we also found six revisions (including a Co- dian=26; range=5-150).
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chrane Review [see Appendix]) which have analyzed In at least 7 of the 13 cases treated in a minimum
the efficacy of diverse rehabilitation procedures. of 15 rehabilitation sessions, the recovery of the
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The studies emerged from a search of PUBMED, in- speech capacity generalised also to untreated items
serting the key words “apraxia of speech” “speech but with characteristics similar to the materials used
apraxia” “anarthria” “aphemia” crossed with the key in the treatment; the effects of the treatment lasted
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words: “rehabilitation” “recovery” “treatment”. for 1 to 6 months in at least 5 of the 6 cases in which
the stability of the treatment was tested after suspen-
Evidence sion (follow-up); generalisation to conversation was
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not tested in any of the studies examined.

The efficacy of the procedures adopted in the The 12 studies (with an overall count of 17 pa-
studies taken into consideration and the degree of tients) identified did not offer sufficient material for
recommendation have been evaluated on the basis a comparison of the efficacy of the procedures used
of the SPREAD classification criteria (www.spread.it). by the various authors. There would appear to be a
None of the studies we have selected corresponds to fair amount of documentation in favour of the artic-
the criteria of a randomized case-control trial. ulatory kinematic technique enriched when neces-
Given the absence of group studies, the SPREAD sary by the use of pacing with a metronome, while
criteria for verifying methodological appropriateness there would appear to be insufficient evidence in
do not appear suitable for a judgement on the ef- support of facilitations and intersystemic reorganiza-
ficacy of SA treatments. It has to be said that the tion, as well as for alternative/augmentative com-
variety of speech impairment symptoms (severity of munication. However, these conclusions are based

Table VII.—Overview of the studies on speech apraxia.
Authors Evidence Pt Follow-up Comments

level
Dworki et al. (1988) 127 3 1 Yes: efficacy Good recovery of accuracy and speed; recovery maintained even
maintained after suspension; did not extend to behavior that was not treated.
(4 wks)
Wambaugh et al.(1998) 128 2+/3 1 Yes: efficacy Selective efficacy for treated sounds; it extends to non treated
maintained clauses composed of sounds that were treated.
(6 wks)
Katz et al.(1999) 129 3 1 Yes: efficacy Effect on non-articulatory movements; little effect on articu-latory
maintained movements. Rehabilitation too short.
(1 month)
® A
Wambaugh et al. (1999) 130 2+ 1 Low level of Generalization, but little stabilization
maintenance (6
wks)
T C
Knock et al.(2000) 131 3 2 Yes: efficacy Pt-1: effects of treatment extends to items not included in the
maintained treatment; Pt-2: treatment did not generalize
(4 wks)
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Wambaugh and Martinez (2000) 132 3 1 Yes: efficacy Proven efficacy with little generalization; metronomic pacing
maintained associated with specific training is useful
(3 wks)
Bose et al. (2001) 133
Lustig and Tompkins (2002) IG E134

4
4
1
1
Maintenance not
evaluated
Yes: efficacy
Syntactic and speech rehabilitation associated; no statistical analysis
supplied; no clear evidence of treatment efficacy
Little evidence of efficacy; only clinical description
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maintained
(4-6 wks)
Maas et al. (2002) 135 3 2 Maintenance not Complex syllable training more effective than simple syllable
evaluated training; CV syllable training does not extend to clusters
P A
Wambaugh and Nessler (2004) 136 3(-) 1 Maintenance not Significant recovery of treated sounds. Little generalization
evaluated
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Schneider and Frens (2005) 137 3 3 Maintenance not Learning +; no generalization to patterns not included in the
evaluated treatment (same sounds); no variation vis-à-vis standard aphasia
tests
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Ballard et al. (2007) 138 2+ 2 P1: 6 months P2: Production of treated phonemes improved; extension to phonemes
6 wks not included in the treatment (only same manner); maintenance up
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to 1.5-3 months
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on an extremely limited number of cases, are not to endure for a significant period of time after the
quantified, and are not supported by statistical anal- treatment has been suspended. However, as all the
yses. One of the revisions that have been taken into studies described in the present paper refer to the
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consideration 119 did study a relatively larger number treatment of single cases, it is not possible to draw
of cases and came to relatively similar conclusions . any conclusions regarding the generalization of its
efficacy: in general the studies do not specify the
Synthesis criteria adopted for the inclusion and exclusion of
patients in their samples and do not describe any
Specific treatment of speech disorders has been cases of drop-outs and the reasons these patients
shown to improve production in patients with did not continue in the study. As a result, none of
chronic and medium to severe SA. The efficacy of the studies has been classified as Class 1, which cor-
the treatment would appear to depend on the inten- responds to a randomized clinical trial (RCT) and
sity with which it is administered and would appear consequently a B/C level recommendation has been
to extend to stimuli not being specifically treated assigned as under the circumstances it was not pos-
but with similar characteristics, and would appear sible to assign an A level recommendation. Further-

Table VIII.—Number of studies for each evidence level and the RCT and “aphasia”
recommendation grade for all functions investigated.
The RCT model, formulated and “normed” for
Evidence level drugs and considered the “gold standard”, is based
(numbers of papers)
Function treated Recommendation on several presuppositions. We are going to men-
2+ grade tion three presuppositions:
3
clinical conditions with a clearly definable diag-
Sentence comprehension 1 5 C nosis, prognosis, and “natural history” (which must
Sentence production 11 28 C not be extremely variable in terms of times and mo-
Word production 9 46 C
dalities of evolution);
Word repetition - 6 D
interventions with a clear “univocal” definition;
Reading 4 28 C
Writing 4 16 C
the non-dependence of the intervention outcome
® A
Acalculia - 7 D on the operator’s “competence”.
Speech apraxia 3 7 C None of these conditions are respected (and for
the most part cannot be respected) in studies on the
T C
efficacy of language rehabilitation and the use of
clinical trials to evaluate the efficacy of aphasia re-
H DI
more, while the effects of the treatment have been habilitation has been repeatedly criticized. The most
seen in the performance rendered on neurolinguis- frequent criticisms regard the difficulty of defining
tic tests, there has been no appropriate evaluation of univocally the damage to be treated (aphasia) and
IG E
the benefits of the treatment on the disorder in the
patients’ daily life.
the variability of the rehabilitative treatments adopt-
ed.139-141
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Diagnosis, prognosis and “natural history”
Discussion
The most shared definition of aphasia (“acquired
P A
According to the criteria of the SPREAD table, the language disorder following damage to specific cer-
first works carried out in groups of patients demon- ebral areas”) allows to identify people affected by
O V
strate that treatment (not better specified) of hetero- aphasia but does not allow to specify the language
geneous groups of aphasic patients is effective and disorders they present, because “language” is an ex-
tremely complex code that can be damaged in dif-
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recommended. On the basis of the studies consid-

ered and their evidence level, the recommendation ferent ways. Today, it is more correct to speak of
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grade is B. It is important to note that only when the “aphasias” or “aphasic disorders”.
treatment was brief the difference between groups The term “aphasia” is a sort of large umbrella un-
was not significant; furthermore, there are indica- der which we gather deficits that have nothing in
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tions that the effect of rehabilitation does not vary common either in terms of etiology (e.g., traumatic
even when treatment is begun several years after the or vascular), lesion site, verbal behaviours damaged
morbid event (within seven years). Data relative to (e.g., production, reading, comprehension, etc.), or
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the treatment of isolated words, sentences, reading, functional components damaged. We can get an idea
and writing were considered separately. Table VIII of the diversity of these different aphasic frames by
reports the number of studies for each evidence lev- comparing the following descriptions, made by four
el and the degree of recommendation for all func- different aphasic patients, of the same picture of a
tions considered. room in which a seated woman is knitting, a man is
Note that in the aphasiology literature it is impos- sitting in an armchair reading the newspaper, a little
sible to reach the maximum evidence levels and rec- boy is playing with blocks, a little girl is watching TV
ommendation grades of the SPREAD table because and a cat is playing with a ball of yarn.
of the almost complete absence of RCT. Neverthe- Patient 1: “What do we see here? And the the
less, for the reasons stated below we hold that RCT kids the share because I have difficulty here where
is not the most appropriate instrument for evaluat- pose the children who tie the girls here who bring
ing treatment efficacy of aphasic disorders. the plugs those for the usual lamps which however

don’t look at. Then we said that the children across are described in the literature that have in common
looked at the light and children did the reading for only the fact of “seeing a therapist”. Seron 142 and
the lamp plug. The girls moved the sight of the you Basso 143 tried to identify the underlying thread in
you young people who passed here the sight of the the vast literature on aphasia rehabilitation. The
children with all the plug of the children the sight of taxonomies proposed are very general and the ap-
the children and the closure”. proaches described only share some basic ideas,
Patient 2: “Normerugia dormore sircora sircore more on the nature of the disorder than on the way
mori clear good good here nustase sleep doce se- of dealing with it.
luta chestari chelone sostali iusta this cocchieri no
no nola these and enough enough”. Competence of the therapist
Patient 3: “The dog who plays with… I don’t
know its name… of the owner who’s knitting. Here Another important condition in clinical trials is
® A
is the television but it’s turned off the… how do you that the result of the treatment should not depend
say it… the behind, in sum… the girl who is watch- on the “competence” of the therapist. “Competence”
in this case not only concerns strictly cognitive as-
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ing and the father who is watching the… a younger
brother is playing with five cards plus the shorter pects but, above all, the therapist’s way of interact-
cards and one in hand. Here is… I don’t remember ing with the patients undergoing the intervention,
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how… another thing where they hold books but I especially if it is complex and if the interaction with
don’t remember it’s name and there are… one, two, the therapist (as occurs in treatment of aphasia) is a
ten books”. very important factor in the therapeutic relationship.
IG E
Patient 4: “Grandfather to read newspaper, little
girl TV, cine… little boy lego… not the grandfather, Amount of treatment: efficacy and therapy provision
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husband! Stitch, stitch, and cat, ball, wool”.
Another important aspect to define is amount of
Therefore, the disorder whose improvement we
treatment. The OTA (Office of Technology Assess-
wish to evaluate cannot be defined univocally be-
cause it is actually more than one disorder. ment) distinguishes between efficacy and effective-
P A
Regarding prognosis, certain data are very scanty ness. Efficacy is the likelihood that patients belong-
and the only universally recognized prognostic fac- ing to a particular population will be able to benefit
O V
tor is initial severity of the disorder, that is, the more from a medical technology applied to a given medi-
severe the initial deficit the less the possibility of cal problem in ideal conditions; effectiveness is
the likelihood that patients belonging to a specific
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recovery.
The natural history of the deficit is better known. population will be able to benefit from a medical
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Most patients undergo a certain degree of spontane- technology applied to a given problem in standard
ous recovery, but it is difficult to predict how much conditions.
will be recovered during the first months following In other words, a treatment may be efficacious if
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the morbid event. Recovery is clearly greater in the carried out in “ideal” conditions and not efficacious
first month and then slows down. After the first 6-8 if carried out in unfavorable conditions. Amount of
months, further spontaneous recovery is extremely treatment is an important element to consider in the
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rare. This must be emphasized because it helps to difference between “ideal” and “real” conditions.
resolve the difficult problem of the control group. Even if a drug is very efficacious, it is efficacious
If the deficit is stable and no longer susceptible to only if a sufficient amount is administered. By defi-
improvement in the absence of specific treatment, nition, an insufficient amount of a drug is insuffi-
any improvement obtained following treatment in cient and therefore not efficacious. One important
chronic subjects can be reasonably considered a di- difference between “positive” and “negative” group
rect effect of the treatment. studies comparing treated and untreated patients is
amount of treatment.
“Positive” group studies demonstrate that non-
Intervention
specific treatments can have a positive effect on
Treatment is not univocal; many different, more or groups of heterogeneous aphasic patients. Studies
less rational and more or less specific interventions that report “negative” results (in which treatment is

always short) simply show that in that specific case or two most correct studies from an experimental
the intervention was not efficacious; these are stud- perspective (an RCT, a meta-analysis, etc.) and to
ies on “therapy provision”, as repeatedly empha- ignore all of the remaining literature that can in no
sized also by the authors themselves. way modify the recommendation grade for that area.
Studies on “therapy provision” are not studies on Obviously, from the point of view of the clinician
treatment efficacy; in fact, they evaluate a service who must decide whether and which treatment to
provided for a group of individuals. In this type of use, several factors ignored by the SPREAD table
study, negative results should never be interpreted seem important for evaluating whether the evidence
as indicating rehabilitation ineffectiveness; much related to a given treatment warrants advising its
more simply, they “call into question the current use:
service”.140 — number of patients/authors;
A study by Lincoln et al.16 (one of the two works — chronicity of patients;
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considered by the Cochrane review and frequently — implementation.
reported as demonstrating that aphasia therapy is A result based on a large number of patients
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not efficacious) was criticized by many authors 144, should be more reliable than a result based on only
145for various reasons: the limited amount of treat- a few patients. To a lesser degree, even the fact that
ment, recruitment of patients with more than one different authors in different situations obtain the
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lesion, not having considered the various types of same result is important for evaluating whether a
aphasia, and not having defined the type of in- given treatment is really effective.
tervention. To all of these criticisms, Lincoln and The basic element ignored by the SPREAD table
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McGuirck 146 responded that they had considered
what “typically” occurs in a rehabilitation service in
is, however, patients’ chronicity. If the chronic deficit
is truly stable and no longer subject to spontaneous
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Great Britain and that this is what they wanted to improvement, there is no need for a control group.
verify. They added that longer treatment could have Indeed, an experimentally correct study of chronic
produced different results. patients could obtain the maximum recommenda-
In conclusion, conducting a clinical trial requires tion grade.
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the following: 1) defining the treatment; 2) defin- Some data on implementation are also important.
ing the functional damage for which it should work; These include the amount of treatment/drug that has
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3) establishing the duration and minimum intensity an obvious effect on results of the “cure” and in the
necessary; 4) evaluating its effectiveness in a single specific case of group treatment of aphasic patients
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case or a series of single cases. Nevertheless, it is it clearly separates works that have produced posi-
impossible to observe these conditions if we speak tive results from works that have produced negative
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of evaluating the rehabilitation efficacy of “aphasia”, ones.

which is too general a term. Evidence-based medicine enhances the value of
clinical trials, which are considered the only cor-
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SPREAD table rect base for demonstrating evidence of a treatment.

Well-conducted clinical trials, with clearly positive
The use of the SPREAD table as the only means results, would have an important political value. In-
M
to evaluate whether treatment of aphasic disorders deed, they would provide a strong argument to con-
is effective presents some drawbacks. Besides the vince local administrators and distributors of funds
great importance given to clinical trials, the way the of the usefulness of supporting language rehabili-
recommendation grade is calculated does not take tation. Actually, as we tried to illustrate above, the
into account other factors for evaluating whether a term “aphasia” is extremely general and covers very
given treatment should be recommended or not to heterogeneous disorders. Evidence deriving from
the clinician. this type of clinical trial does not allow identifying
According to the SPREAD table, the recommen- which of the treatments used was effective for which
dation grade is high (A), even if it is based on one type of aphasic disorder, nor which treatment was
study with few patients, as long as it concerns an ineffective and which disorders were not susceptible
RCT classified at the 1++ level. In fact, if the SPREAD to improvement.
table is used, it is only necessary to identify the one Given the great variety of deficits present in apha-

sic patients, studies are needed on the therapy of ment at the highest level of recommendation ‑ that
groups of subjects with very similar deficits that can of standard practice ‑ having identified two class I
be traced to a unique underlying functional damage. studies 147, 148 that evaluate the efficacy of treatments
This is more or less what we have done considering aimed at recovery of conversation.
separately treatment of words, sentences, writing,
and reading. Studies on the effect of treatment of
these disorders respond better to the requirements Conclusions
of therapists. The large number of studies, the fact
that practically all of them report positive results and In summary, evidence of therapy efficacy deriving
that the majority of patients treated are chronic, that from group studies seems strong enough, mostly if
is, well beyond the period of spontaneous recovery, it is integrated with the concept that in order to be
are all factors that allow us to hold that the evi- effective treatment has to be protracted and/or inten-
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dence level evaluated on the basis of the SPREAD sive. One of the two studies considered by the Co-
table (and the subsequent recommendation grade) chrane review reports a negative 16 and another 13 a
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are clearly inferior to the clinical advisability of the positive result. Note that the number of treatment ses-
treatments proposed. sions was clearly higher in the positive study whereas
many of the patients treated in the negative study did
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not finish the entire treatment and only half of the
Generalization to everyday life
patients underwent 24 therapy sessions. Unless treat-
One highly debated issue in aphasiology regards ment has the same effect as an immersion at Lourdes,
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generalization of results obtained during treatment
to language use in everyday life; in fact, it is of-
this finding is a foregone conclusion.
The efficacy of rehabilitative treatment in a group
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ten affirmed that no improvement has taken place of aphasic patients has been repeatedly affirmed
if there is no generalization to everyday life but the by systematic reviews and demonstrated by meta-
question seems poorly defined. If an aphasic patient analyses but almost all authors emphasize the im-
has damage at the level of word retrieval, it makes portance of going beyond this affirmation and iden-
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no sense to say that improvement must be demon- tifying more specifically which patients are most
strated at the level of sentences, for instance, which sensitive to treatment and which treatments are most
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were already correct but produced with frequent effective. We believe we have taken a step in this
pauses due to anomia. direction by considering separately results of studies
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The same line of reasoning holds for language on rehabilitation of less general disorders, such as
use. Some aphasic patients have disorders at the deficits in elaborating isolated words and sentences
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pragmatic level (i.e., the level of language use) and and in reading and writing.
others, although aphasic, have perfectly preserved Studies on treatment efficacy in each of these
ability to use their residual language in everyday life families of deficits are numerous and almost always
IN
situations. Therefore, the problem concerns the di- carried out in chronic patients who have passed the
agnosis. If damage is diagnosed at the level of lan- period of spontaneous recovery; moreover, results
guage use, improvement can be spoken of only if are almost always positive. Although they are not
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the patient improves at this level. If, on the contrary, flawless from an experimental point of view, these
the patient has no deficit in language use, there is studies unequivocally demonstrate the possibility of
no need to investigate generalization to everyday improvement in all these areas following treatment.
life. Unfortunately, the initial diagnosis does not al- Regarding rehabilitation of these deficits, the max-
ways take this level into account; in fact, attention imum evidence level possible using the SPREAD ta-
should be given to this point to initiate rational and ble is 2+ and the associated recommendation grade
aimed treatment. In this review, we did not consider is C. But the recommendation grades do not cor-
level of language use because pragmatic treatments respond with the clinical “recommendability” grade,
(except for those using the PACE technique) are which should take into account several elements that
usually poorly defined and cannot be considered are missing from the SPREAD table, that is, number
as neuropsychological treatments. In their 2005 up- of works and chronicity of patients, which are indis-
date, however, Cicerone et al.35 put this type of treat- pensable for evaluating real treatment efficacy.

Data on acalculia and speech apraxia are scanty 10. Deal JL, Deal LA. Efficacy of aphasia rehabilitation: preliminary
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The doubt still remains that the almost total absence D et al. Comparative trial of volunteers and professional treat-
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RH et al. Veterans Administration cooperative study on apha-
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To overcome some of the limits of the works con- tern of recovery of communication in aphasic stroke patients. J
Neurol Neurosurg Psychiatry 1983;46:130-9.
ducted up until now, in future studies data should 16. Lincoln NB, McGuirk E, Mulley GP, Lendrem W, Jones AC, Mith-
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be gathered on the natural history of the aphasic chell JRA. Effectiveness of speech therapy for aphasic stroke
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Va Medica: Treatment Efficacy of Language and Calculation Disorders and Speech Apraxia: A Review of The Literature

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EUR J ­PHYS REHABIL MED 2011;47:101-21

Treatment efficacy of language

ined the literature from 1980 by carrying out research

has been clearly demonstrated efficacious in groups of

for specific disorders (words and sentences process-

speech apraxia and calculation disorders. Results are

T he term “aphasia” refers to a more or less com-

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 101

No specific data on the incidence of aphasia are Results

102 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Table I.—Summary of data of the 21 studies on treatment efficacy in group studies

Lincoln et al. (1984) 16 104 87 max 24 w — No significant difference

Shewan and Kertesz (1984) 17 52 23 up to 12 m — No significant difference

Wertz et al. (1986) 18 38 43 12 w 12 w No significant difference

Hartman and Landau (1987) 19 30 30 6m 6m No significant difference

(therapists) (family mem- (8-10 h/w) (8—10 h/w)

Mazzoni et al. (1995) 22 13 13 6m — No difference at 4 m, significant dif-

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 103

ence rehabilitation efficacy. a large number of non-predefined stimuli. All of the

104 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 105

Author Treatment N. of sbjs (cronicity) and N. items-Treatment length Evidence

Renvall et al. (2003)

IG E 1 semantic, 1 phonol, 1 other treatm.

before naming; ss each treatment

Errorful: phonol and orthogr cue

106 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Authors Method N. of sbjs (chronicity) and Number of sessions Evidence level

Jacobs and Thompson (2000) 64 Wh-movement 4 (chr) agramm 8-19 ss 3

IG E Wh-movement 1 (chr: 2 y) agramm 2 ss/w x w? 3

matical structure, and to the evocation of verbs in Comprehension

Comprehension was studied in six studies 76-81 for

had Broca aphasia and agrammatism; four spoke

variable, that is, from 12 to about 75. Five of the

clinical advisability (at least in cases of Broca apha-

in the others and the recommendation grade is C.

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 107

N. of sbs (chronicity) and N. of sessions/ Evidence

Kiran et al. (2001) 85 G->Ph 2 (chr: 13 and 27 m) conduct 36 and 30 ss 3

Sperling et al. (2005) 96

108 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

most of the works based on a cognitive model of Writing

reconstruct a small vocabulary to enable commu-

improvement; all patients described in the other

results (positive in all studies) are important fac-

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 109

Authors Treatment N. of subjects (chronicity) and N. of sessions Evidence

field and Weddell’s patients) did not. tion grade is D.

110 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Number Years of publication Number of pts Methods Results

er words, there is no paresis of the face and mouth),

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 111

not tested in any of the studies examined.

112 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Table VII.—Overview of the studies on speech apraxia.

Authors Evidence Pt Follow-up Comments

Lustig and Tompkins (2002) IG E134

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 113

recommended. On the basis of the studies consid-

114 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE March 2011

Vol. 47 - No. 1 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 115

of evaluating the rehabilitation efficacy of “aphasia”, ones.

EUR J PHYS REHABIL MED 2011;47:101-21