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Treatment of Poststroke Aphasia: Current Practice and New Directions Mackenzie E. Fama, MS, CCC-SLP1

Peter E. Turkeltaub, MD, PhD1,2

1 Department of Neurology, Georgetown University, Washington,

District of Columbia 2 MedStar National Rehabilitation Hospital, Research Division, Washington, District of Columbia

Address for correspondence Mackenzie Fama, MS, CCC-SLP, Department of Neurology, Georgetown University, 4000 Reservoir Rd. NW, Building D, Suite 165, Washington, District of Columbia (e-mail: [email protected]).

Abstract

Keywords

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stroke aphasia language rehabilitation

Aphasia is an acquired neurologic disorder that impairs an individual’s ability to use and/ or understand language. It commonly occurs after stroke or other injury to the brain’s language network. The authors present the current methods of diagnosis and treatment of aphasia. They include a review of the evidence for the benefits of speech–language therapy, the most widespread approach to aphasia treatment, and a discussion of newer interventions such as medication and brain stimulation. These methods hold much promise for improving patient outcomes in aphasia; however, additional research regarding the best approaches to aphasia treatment will greatly improve our clinical approach.

Approximately one million people in the United States are living with aphasia, an acquired neurologic disorder that affects the ability to use and/or understand language.1,2 Aphasia results from damage to any part of the language system in the brain; it is typically caused by stroke, tumor, or other brain injury. About two-thirds of individuals who experience a left-hemisphere stroke will develop aphasia and may have difficulty with any component of language, including word-finding, constructing grammatical speech, comprehending spoken words or sentences, reading, and/or writing.3–6 Although there is opportunity for both spontaneous recovery as well as therapeutic rehabilitation, approximately two-thirds of individuals with aphasia will experience a lifelong struggle with some aspects of communication.1,2 Living with aphasia can significantly affect life participation, and often has a negative impact on quality of life for both the patient and their family.7,8 Language is a symbolic system that is used by humans for social interaction and functional communication. The various components of language, including meaning (semantics),9 sounds (phonology),10 and structure (syntax/morphology),11 are subserved by specific networks of brain regions.12 Aphasia can result from any kind of injury or illness that affects these brain areas, which lie mostly in the left hemisphere. Language is left lateralized in approximately 95% of right-

Issue Theme Neurologic Rehabilitation; Guest Editors, Karunesh Ganguly, MD, PhD, and Gary M. Abrams, MD, FAAN

handed individuals13 and 75% of left-handed individuals.14,15 The remaining individuals exhibit either right hemisphere (crossed) or bihemispheric (mixed) dominance.14,15 Many neurologists consider the brain’s language network to be comprised of the Broca and Wernicke areas, with the arcuate fasciculus connecting them. However, the past few decades of research have revealed that language functions involve more extensive parts of the left temporal, parietal, and frontal lobes, along with subcortical gray matter structures.11,16,17 The nondominant hemisphere plays a smaller role in communication, contributing mostly to social or pragmatic aspects of language such as prosody and abstract language (e.g., humor or metaphor).18–20 Thus, damage to the nondominant hemisphere is unlikely to cause aphasia, but may cause difficulty with other cognitive–linguistic functions.21,22 The most common cause of aphasia is a stroke affecting the lateral aspects of the left cerebral hemisphere (e.g., a left middle cerebral artery infarct).3,23 Aphasia can also result from damage to subcortical regions in the left hemisphere,24–27 and rarely from right cerebellar lesions, likely due to the connections between the right cerebellum and the left cerebral cortex.28–30 Because networks involved in various language functions are distributed widely throughout the brain, there is a wide range of specific language deficits that can be observed in an individual suffering from aphasia.

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1396004. ISSN 0271-8235.

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Fama, Turkeltaub

These various impairments in spoken language production and/or comprehension may be accompanied by deficits in reading (alexia) and/or writing (agraphia).31,32 Additionally, although aphasia itself is a disorder of language and individuals with aphasia may have no other discernable cognitive or motor deficits, aphasia is often comorbid with deficits in executive function33,34 or with verbal and/or ideomotor apraxia.35,36 There is also a high incidence of depression in this population,37–39 with some estimates indicating that nearly two-thirds of patients with aphasia suffer from depression. Persons with aphasia are thus complex patients who benefit from thorough diagnostic assessment and careful development of a treatment plan that will maximize their ability to recover language function. Just as there is substantial variability in the symptoms and signs of aphasia, there is considerable variability in the course of recovery. As with other stroke-related deficits, recovery is fastest early on and slows down over time.23 Although the common wisdom is that all spontaneous recovery has occurred by 12 months after the injury,40 many studies have demonstrated that additional gains can be made after this time.41–45 In general, the initial severity of aphasia predicts the outcome.46–48 Other factors such as age, sex, premorbid language lateralization,49,50 and involvement of deep white-matter tracts51,52 also predict recovery to some degree, although our ability to predict early on who will recover well from aphasia is limited.23,48 Specific language deficits may improve at different rates, and the type of the aphasia may subsequently change over time.23,53 As a result, the treatment plan of an individual with aphasia will also change over time.

She had mild executive dysfunction, but no other focal deficits in nonlinguistic cognitive domains such as attention or memory. She received daily occupational, physical, and speech– language therapy (SLT) for 2 weeks in the rehabilitation hospital and then returned home to live with her husband and elderly mother. Her insurance covered outpatient sessions of SLT 3  /week for 6 weeks and then her family paid out of pocket for her to attend biweekly SLT sessions at a university clinic. Therapy sessions focused on increasing her functional communication skills through improved verbal output and alternative modalities such as gesture and picture-based communication boards. One year after the stroke, she began attending group SLT sessions at a communitybased aphasia center. Her speech comprehension greatly improved, but her expressive language continued to be restricted to output at the single-word or short-phrase (2–3 words) level with frequent perseverative errors. She also used facial expressions and gestures to augment her spoken output, but became frustrated with her decreased ability to use language effectively, often stating, “never mind” and abandoning her communication attempts. Her WAB-R54 aphasia quotient increased to 50.7, representing a diagnosis of moderate nonfluent aphasia. She was unable to return to work, spends the majority of her time at home, and is dependent on her family and friends for many activities of daily living. Communication is very effortful for her and she worries about being perceived as “stupid,” so she has withdrawn from her community and has very few social interactions.

Case Study

Aphasia is best managed by an interdisciplinary team with expertise in neurologic disorders, with a specific focus on speech, language, and cognition. Because aphasia is an evolving disorder and patients suffering from the disorder will experience some spontaneous recovery, effective management requires ongoing assessment of a patient’s current needs, goals, and opportunities for improvement.

A 52-year-old right-handed college-educated woman employed as a human resources manager presented to the emergency department by ambulance complaining of the sudden onset of right-sided weakness and difficulty speaking while at work. Her initial NIH (National Institutes of Health) stroke scale was 19. She received intravenous (IV) tissue plasminogen activator (tPA). A magnetic resonance angiogram (MRA) of the head/neck showed an occlusion of the superior branch of the left middle cerebral artery (MCA). Magnetic resonance imaging (MRI) showed acute infarction involving the posterior lateral frontal cortex and underlying white matter. The next day, her NIH stroke scale remained 19, and she was noted to have severe aphasia with little verbal output and severely impaired comprehension. After 9 days of medical management in the acute hospital, she was transferred to an inpatient acute rehabilitation hospital. Evaluation revealed a dense right-sided hemiparesis, dysphagia, dysarthria, and severe nonfluent aphasia characterized by single-word utterances with frequent perseverative and phonological errors. There was also difficulty understanding spoken language, particularly with sentence level comprehension. She also had apraxia of speech, alexia, and agraphia. Her overall aphasia quotient was 23.2 on the Western Aphasia Battery-Revised,54 consistent with severe aphasia.

Current Methods of Management

Diagnosis of Aphasia The first step in the management of aphasia requires the initial diagnosis of the disorder. Many acute care hospitals are now equipped with a dedicated stroke team, led by neurologists working closely with nursing staff, physical therapists, occupational therapists, and speech–language pathologists (SLPs). This team approach allows for rapid and effective diagnosis of stroke and related comorbidities, including aphasia as well as motor impairments, motor speech disorders such as verbal apraxia or dysarthria, and dysphagia. Early identification of aphasia is especially important because the patient’s ability to use and understand language impacts the care they receive from doctors, nurses, and other hospital staff as well as their disposition for discharge.5,55 In addition to general components of initial stroke diagnosis such as brain imaging, there are important components of assessment that are specific to an initial diagnosis of aphasia, including Seminars in Neurology

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Treatment of Poststroke Aphasia: Current Practice and New Directions

Treatment of Poststroke Aphasia: Current Practice and New Directions

• Interview with patient and family for determination of premorbid level of function • Behavioral language assessment for exploration of relative strengths versus areas of need: • Expressive language: Object naming, fluency, and content of spontaneous speech (picture description, storytelling) • Receptive language: Comprehension of single words and sentences, including questions and commands • Repetition tasks: Sentences and nonsense words or phrases to examine phonology and verbal working memory • Reading and writing • Assessment of motor speech abilities (e.g., evidence of apraxia or dysarthria) • Assessment of other cognitive faculties (e.g., memory, attention, executive function, ideomotor praxis) • Screening for depression A neurologist, a neuropsychologist, and/or an SLP may be involved in administration or interpretation of the assessments described above. Speech–language pathologists will likely utilize formal, comprehensive assessment batteries such as the Western Aphasia Battery-Revised54 or the Boston Diagnostic Aphasia Examination56 in addition to informal measures. Speech–language pathologists may also complete more targeted assessment for specific language skills, including semantics, phonology, syntax, and morphology, through structured assessments such as the Psycholinguistic Assessments of Language Processing in Aphasia, the Pyramids and Palm Trees Test, or the Boston Naming Test.57–59 Other cognitive skills can be assessed through nonverbal assessments such as Raven’s Colored Progressive Matrices60 or the Cognitive-Linguistic Quick Test,61 a comprehensive battery designed for assessing memory, visual-spatial skills, executive function, and attention in individuals with aphasia. Aphasia always affects one’s ability to use language, but the specific language impairments and the severity of them may vary widely across patients. The heterogeneity of aphasia stems from differences in etiology (e.g., site and size of lesion) as well as individual patient differences (e.g., age of onset, sex).6 For ease of understanding and communicating the various patterns of deficits that emerge, aphasia has been traditionally characterized as comprising of several different subtypes/syndromes, including Broca’s aphasia, Wernicke’s aphasia, global aphasia, and conduction aphasia among others. Although these traditional syndromes can be generally informative in framing the diagnostic process, they can be limited in practical applicability to treatment. Instead, it can be more helpful to focus on an individual’s relative strengths and weaknesses; for example, a patient may have difficulty comprehending or producing syntactically complex sentences, but have relatively preserved single-word comprehension, naming, and repetition. A more individualized approach to aphasia rehabilitation allows for more personalized therapy as compared with a syndrome-based approach to aphasia diagnosis and treatment. Seminars in Neurology

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Treatment of Aphasia The most widespread approach to rehabilitation for persons with aphasia is behavioral therapy with an SLP.41–43,62 Sessions of speech–language therapy (SLT) are most commonly one-on-one with a patient and SLP, but there is also opportunity for group therapy63 as well as incorporation of patients’ family members into functional therapeutic activities.45 In addition to providing activities to directly strengthen areas of need (such as improving verbal output), SLPs work to capitalize on preserved abilities and provide compensatory strategies or alternative and augmentative communication (AAC; e.g., paper-based communication boards or electronic devices) when appropriate. Although SLT has historically taken an impairment-based approach that focused on remediation of deficits, newer approaches to therapy may focus on life participation, with therapy goals uniquely targeted to an individual patient’s own goals.64–66 The setting and frequency of speech therapy sessions change throughout the stages of recovery. Speech–language pathologists can treat patients in acute care hospitals, rehabilitation hospitals, skilled nursing facilities, outpatient clinics, or at home.67 In the United States, the timing of each phase of recovery frequently follows a time course similar to that described in the case above, with the overall length of treatment for aphasia ranging from days to months, depending on the severity of the patient’s deficits and the health system in which he or she is being treated.68,69 A diagnosis of aphasia increases length of stay in stroke patients independent of other deficits.5,55 Evidence for the optimal timing and intensity of speech therapy will be discussed in the following section. Because there is a lack of data to support broad application of specific evidence-based treatment approaches to aphasia, SLPs require a substantial amount of knowledge and experience to develop an individualized plan for SLT. As such, neurologists should encourage patients with aphasia to work with an SLP with extensive training and experience in aphasia treatment. Moreover, to optimally improve functional outcomes, an interdisciplinary treatment team may be needed to address comorbidities (e.g., depression, hemiparesis, ideomotor apraxia) that may interact with aphasia.

Evidence-Based Compensatory and Restorative Treatments Studies investigating the value of SLT for aphasia have been undertaken for decades; however, converging evidence in favor of SLT has only recently emerged. One reason for the delay may be that randomized, double-blind, controlled trials, a gold standard for evidence-based practice, are especially difficult to conduct for SLT.6 One major limitation is that access to SLT has been the established standard of care for aphasia for quite some time in many parts of the world; it can be difficult to randomly assign patients suffering from the disorder to a no-treatment group during a potentially crucial phase of their recovery. Another limitation comes from the potential for bias in empirical research; blinding the

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researcher to treatment arms is difficult and blinding the patient is nearly impossible.42 A third major limitation arises from the heterogeneity in the disorder as well as in the treatment approaches used. For example, significant positive effects for individuals or for specific subpopulations of persons with aphasia may be overshadowed by attempts to generalize across entire groups of participants with various types of aphasia. Despite these limitations, evidence is emerging that establishes SLT as an effective method for enhancing language recovery after stroke. The American Speech–Language Hearing Association, the professional association for SLPs, defines the three components of evidence-based practice (EBP) for aphasia therapy as external scientific evidence, clinician expertise, and patient perspectives. Because of the aforementioned barriers to obtaining gold-standard scientific evidence in the field of aphasia, all three components of EBP are especially important in evaluating aphasia treatment approaches.

Acute Recovery (Up to 3 Weeks) The acute recovery phase is characterized by spontaneous recovery of function, as there is physiological restitution of the damaged brain.23,70 There is no strong evidence that SLT can boost the effects of spontaneous recovery in the first 3 weeks after stroke; in contrast, there is some evidence in the motor literature, based largely on animal research, that intensive intervention in the very early stages may adversely affect recovery.70,71 Although there is debate about what constitutes the acute phase (estimates range from 1 week–1 month), it has been demonstrated that intensive intervention in this initial acute phase can be counterproductive to ultimate motor recovery in humans as well.72,73 On the other hand, there is also evidence that complete disuse of impaired functions after stroke can be detrimental to later recovery of function. In the absence of specific evidence, however, a balanced approach to early intervention may be warranted. There is currently a push toward an increased focus on counseling and support in the highly acute phase of SLT, as opposed to immediate attempts at impairment-based intervention. Such an approach is based on reports from patients and families about the types of support they would have wanted in the early stages,74 although there is not yet prospective evidence regarding how this approach impacts outcomes or patient satisfaction.

Subacute Recovery (3 Weeks–12 Months) Spontaneous recovery often continues during the subacute phase, but this is more likely due to functional reorganization of the brain as opposed to the physiological restitution seen in the acute phase.75 Two recent Cochrane reviews have made significant strides toward establishing SLT as an effective treatment for aphasia, beginning in the subacute phase.42,43 The authors of the 2012 review note that the primary purpose of language is to convey meaning, so the primary outcome measure taken from the 39 studies included was functional communication, defined as “the ability to successfully communicate a message via spoken, written, or nonverbal mo-

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dalities (or a combination of these) within day-to-day interactions.”42 The general conclusions of these metaanalyses are that SLT facilitates improvement in functional communication, expressive language, and receptive language when compared with no SLT and that social stimulation alone is not as effective as participation in formal SLT. However, these effects are both modest in size. An earlier meta-analysis and multiple smaller studies have made strides to establish the efficacy of SLT on a smaller scale.41,76,77 One limitation of the meta-analyses is that they necessarily combine data across studies using considerably different types of SLT for aphasia. There are a variety of specific approaches to SLT for aphasia, but a major distinction can be drawn between methodologies that apply therapeutic restriction to the verbal modality, such as constraint-induced language therapy,78 constraint-induced aphasia therapy,79 and intensive language action therapy,80 and those that encourage use of nonverbal modalities. This latter group originally focused on the use of other communicative modalities (e.g., gestures) to compensate for verbal deficits, such as promoting aphasics’ communicative effectiveness (PACE)81 or drawing therapy.82 Evidence for each of these therapies indicates that at an appropriate intensity, they can be effective in improving communication skills in both subacute and chronic patients. Newer versions of nonverbal therapies use other communicative modalities not to compensate for deficits in verbal output, thereby replacing speech, but rather as a supportive cue for improving verbal ability83,84; emerging evidence supports their effectiveness.85,86 There are relatively few studies directly comparing these different types of SLT; the 2012 Cochrane review found that very few generalizable conclusions could be drawn from such studies.

Chronic Recovery (>12 Months) Traditional approaches to aphasia treatment suggested that the opportunity for recovery had largely ended by the time patients entered the chronic phase.53 Newer research, including the systematic reviews described above as well as case studies, indicates that this is not the case and that there is an opportunity for improvement of language function throughout the lifetime of an individual with aphasia.41–45 In contrast to research suggesting potentially negative impacts of early intensive treatment, evidence supports the benefits of high-intensity SLT in the chronic phase. A systematic review of previous studies by Bhogal et al in 2003 showed that positive evidence for the efficacy of SLT comes from studies with higher intensity of treatment (mean of 8.8 hours a week), whereas negative evidence comes from studies using SLT at lower intensities (mean of 2.0 hours a week).62 A systematic review by Allen et al in 2012 supported the importance of intensity in treatment for chronic aphasia; it also reviewed evidence that computer-based therapies, group language therapies, communication partner training, and constraint-induced therapy are effective approaches when initiated in the chronic phase (i.e., > 6 months after stroke).45 In addition to these more traditional approaches to SLT, the chronic phase of recovery is a time when patients may Seminars in Neurology

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Treatment of Poststroke Aphasia: Current Practice and New Directions

Treatment of Poststroke Aphasia: Current Practice and New Directions appreciate referrals to other resources, such as aphasia centers, mentorship programs, and stroke support groups. Although there are no randomized controlled trials to provide evidence for this type of treatment for chronic aphasia, some evidence for their benefit exists on a smaller scale (for a list of such resources, please see the website of the National Aphasia Association at http://www.aphasia.org).87,88 Overall, it has been established that speech–language therapy generally improves outcomes in patients with aphasia,41–43,45,62 but additional research is needed regarding specific approaches. Generally, there has been an expansion from the use of a strictly impairment-based treatment to the inclusion of treatments that incorporate aspects of the individual’s functional communication, such as multimodality approaches to treatment,84 and the Life Participation Approach to Aphasia,66 but more evidence is needed to support the efficacy of these approaches. Additionally, there has been much recent research on brain plasticity; this research has identified many principles of neuroplasticity that can be applied to stroke rehabilitation in general and aphasia in particular.70,89 These principles include timing, intensity, salience, “use it or lose it,” and generalization.71 The optimal parameters for these principles with respect to aphasia, including the most effective method for treating specific patterns of deficits in aphasia, have yet to be determined. Additional research is needed to investigate the relative efficacy of SLT for aphasia at different time points in recovery, and whether particular approaches to treatment may be most beneficial at specific times after the injury.

Interesting Developments in the Therapeutic Pipeline Neuroscience research on language and aphasia has expanded rapidly in recent decades, largely due to advances in neuroimaging and brain stimulation (also called neuromodulation) techniques. Insights from this research about the brain networks disrupted in aphasia and the subsequent reorganization of these networks over the course of recovery has driven interest in biologically based interventions for aphasia, including medications and brain stimulation. The basic rationale for the use of medications for aphasia is that strokes disrupt neurotransmitter pathways, and enhancement of neurotransmitter availability in partially disrupted pathways may mitigate deficits related to the disruption.2 Several medications have been studied in single cases, open-label studies, or small randomized controlled trials, either alone or in combination with SLT.2,90 The results have been promising for some medications, including piracetam (91–95, although see 96), acetylcholinesterase inhibitors,97–99 and memantine.100 In general, these studies have been too small in size or too crude in measuring aphasia outcomes to draw firm conclusions, and larger more definitive trials are needed. Additional studies are also needed to examine which patients benefit most from medications, the ideal timing of administration (e.g., during the acute or chronic phases), and the neurobiological basis of any beneficial effects. Seminars in Neurology

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Another new class of experimental treatments for aphasia attempts to focally modulate neuronal activity in a beneficial way. The aim of these approaches is either to directly improve language functions or to enhance plasticity, which may enable more successful natural recovery from aphasia or enhance learning and retention during SLT. The most common techniques use noninvasive mild direct current electrical stimulation (termed transcranial direct current stimulation [tDCS]) or repetitive magnetic pulses (transcranial magnetic stimulation [TMS]). Although the two techniques differ substantially in their characteristics and mechanisms, both can induce localized excitation or inhibition of neuronal populations that can last for minutes to hours after a short session,101–103 and both can enhance learning during motor or language training.104–109 Because both techniques induce focal neuromodulation, principled use of either tDCS or TMS for aphasia treatment requires a reasonable understanding of the neurobiological basis of aphasia recovery to guide selection of stimulation targets. The first neuromodulation studies for aphasia110–112 adopted a theoretical framework from the motor system often referred to as interhemispheric inhibition.113–116 This theory posits that homotopic areas of the two hemispheres compete with one another via transcallosal inhibitory fibers, and that a focal brain injury to one hemisphere releases the uninjured hemisphere from inhibition, causing it to overly suppress the injured side. Because optimal language recovery is thought to occur through restitution of function and reorganization within the injured left hemisphere,117 the theory of interhemispheric inhibition predicts that overinhibition from the right hemisphere limits successful left-hemisphere recovery in aphasia. Based on this theory, recovery from aphasia could be improved by enhancement of left-hemisphere activity, inhibition of the right hemisphere, or both. Indeed, most of the TMS and tDCS studies in aphasia to date have used one of these strategies either alone or in combination with SLT, often (but not always) based on the theory of interhemispheric inhibition.118–126 These studies, mainly observational series and small randomized clinical trials, have shown some beneficial effects of TMS or tDCS in both subacute and chronic aphasia.110–112,126–150 Benefits on several different language functions have been found, and in some studies, these effects last for months after a few weeks of treatment, even during the chronic phase when lasting effects of SLT without ongoing treatment are unusual.140,147,149 Insufficient evidence is available at this time to support one particular strategy of neuromodulation over others. Although these early findings regarding neuromodulation have generated a great deal of excitement in the aphasia community, the studies have been too small to draw firm conclusions, and not all studies have yielded positive results.151–154 Further, the trials to date have tended not to use functional communication outcomes, making the clinical relevance of the effects somewhat uncertain.152 At the same time, the theoretical framework of interhemispheric inhibition that many early studies were based on has fallen somewhat out of favor. Newer theories of aphasia recovery are more nuanced with regard to the role of the right hemisphere, posing mixed mechanisms of reorganization, some adaptive, and some

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Treatment of Poststroke Aphasia: Current Practice and New Directions

tion Grant 2012062. M.F. is supported by NIH Training Grant T32 NS041231.

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Conclusions Aphasia is a common and debilitating consequence of stroke and other insults to the brain. Patients suffering from aphasia have significant difficulty using and/or understanding language, an impairment that is likely to persist throughout the remainder of their lifetime and cause long-lasting effects on functional communication and health-related quality of life. There is some opportunity for improvement in language function in aphasia, both through spontaneous recovery as well as targeted interventions for language. There is evidence for the positive effects of behavioral therapy with a SLP, although the best timing, intensity, and methodological approaches for SLT are yet to be determined. Additional research in this area, as well as in newer interventions such as medications and brain stimulation techniques, will contribute to our ability to effectively treat patients with this debilitating disorder.

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Acknowledgments P.E.T. is supported by National Institutes of Health (NIH) Grant KL2TR000102 and Doris Duke Charitable Founda-

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potentially maladaptive, depending on the particular region, the specific language function in question, and the characteristics of the individual such as the premorbid lateralization of language and the size of the stroke.118,122,148,155,156 Other theories have posited that there is no reorganization in the right hemisphere per se, but only increased reliance on domain general cognitive systems in the right hemisphere in people with aphasia.157,158 Because the individual differences between patients with aphasia are so large, both anatomically and behaviorally, it is very likely that neurobiological reorganization differs between individuals. Understanding these individual differences will be key to developing maximally effective neuromodulatory treatments. As such, a great deal more work is needed to understand longitudinal changes in the organization of brain networks after strokes causing aphasia, and the relationships between these changes and behavioral recovery. Additional work is needed to understand the mechanism of long-term effects of TMS and tDCS, to delineate the population most likely to benefit from treatment, and to identify the ideal dose and timing of treatment, the ideal pairing between particular stimulation paradigms and SLT approaches, and the brain sites that provide the best response. The optimal approach likely varies from individual to individual, depending on stroke location or behavioral deficits.118,159,160 Collection of detailed behavioral and neurobiological outcome measures in neuromodulation trials will be essential in gaining a better understanding of the mechanisms of these treatments and how individual differences relate to any beneficial effects. This information, along with the development of other neuromodulatory techniques that are in early phases of human subjects testing, including high-intensity red light161 and focused ultrasound,162 has the potential to lead to more effective and long-lasting treatments for aphasia.

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Treatment of poststroke aphasia: current practice and new directions.

Aphasia is an acquired neurologic disorder that impairs an individual's ability to use and/or understand language. It commonly occurs after stroke or ...
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