Editing Expressive aphasia (section)

==Treatment==
Currently, there is no standard treatment for expressive aphasia. Most aphasia treatment is individualized based on a patient's condition and needs as assessed by a speech language pathologist. Patients go through a period of spontaneous recovery following brain injury in which they regain a great deal of language function.<ref name=":8" />

In the months following injury or stroke, most patients receive traditional treatment for a few hours per day. Among other exercises, patients practice the repetition of words and phrases. Mechanisms are also taught in traditional treatment to compensate for lost language function such as drawing and using phrases that are easier to pronounce.<ref name="Meinzer">{{cite journal|title=Extending the Constraint-Induced Movement Therapy (CIMT) approach to cognitive functions: Constraint-Induced Aphasia Therapy (CIAT) of chronic aphasia|journal=NeuroRehabilitation|year=2007|first=Marcus|last=Meinzer|author2=Thomas Elbert|author3=Daniela Djundja|author4=Edward Taub|pmid=17971622|volume=22|issue=4|pages=311–318|doi=10.3233/NRE-2007-22409}}</ref>

Emphasis is placed on establishing a basis for communication with family and caregivers in everyday life. Treatment is individualized based on the patient's own priorities, along with the family's input.<ref name=":1" /><ref name="Aphasia">{{cite web|title=Aphasia - Treatment|url=http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934663&section=Treatment|website=ASHA Practice Portal|publisher=American Speech-Language-Hearing Association|access-date=August 7, 2017}}</ref>

A patient may have the option of individual or group treatment. Although less common, group treatment has been shown to have advantageous outcomes. Some types of group treatments include family counseling, maintenance groups, support groups and treatment groups.<ref>{{Cite journal |last1=Fama |first1=Mackenzie E. |last2=Baron |first2=Christine R. |last3=Hatfield |first3=Brooke |last4=Turkeltaub |first4=Peter E. |date=August 2016 |title=Group Therapy as a Social Context for Aphasia Recovery: A pilot, observational study in an acute rehabilitation hospital |journal=Topics in Stroke Rehabilitation |volume=23 |issue=4 |pages=276–283 |doi=10.1080/10749357.2016.1155277 |issn=1074-9357 |pmc=4949973 |pmid=27077989}}</ref>

===Augmentative and Alternative Communication===
{{Organize section|date=February 2024}}
Augmentative and Alternative Communication (AAC) refers to a set of tools and strategies that support or replace verbal communication for individuals with communication disorders, such as Broca's aphasia or other conditions that affect speech and language abilities. AAC is designed to enhance communication and may be used as a temporary or permanent solution, depending on the individual's needs. Here are some key aspects of AAC:

# Communication Aids:
#* Low-Tech AAC: This includes simple, non-electronic communication aids such as communication boards, picture books, or communication charts. Users can point to or select symbols or pictures to convey their messages<ref name="sciencedirect.com" />
#* High-Tech AAC: Involves electronic devices such as speech-generating devices (SGDs) or tablet-based communication apps. These devices use synthesized speech or recorded messages to facilitate communication. Users can select words, phrases, or symbols on a screen to express themselves.
# Symbols and Representations:
#* Symbols used in AAC can vary and may include pictures, icons, words, or a combination of these. Symbols are chosen based on the individual's cognitive and language abilities.
# Types of AAC Systems:
#* Unaided AAC: Relies on the user's body to convey messages without external tools, such as using gestures, facial expressions, or sign language.
#* Aided AAC: Involves external tools or devices, such as communication boards, speech-generating devices, or computer-based systems.
# Vocabulary and Language Systems:
#* Core Vocabulary: Focuses on essential words that are frequently used across various contexts. Core vocabulary systems aim to provide users with a versatile set of words to express a wide range of messages.
#* Fringe Vocabulary: Includes specific words related to an individual's unique needs, interests, or daily activities. Fringe vocabulary supplements core vocabulary to make communication more personalized.<ref name=":5" />
# Customization and Individualization:
#* AAC systems are highly customizable to meet the unique needs of each user. Therapists work with individuals and their families to tailor the system to the user's abilities, preferences, and communication goals.
# Training and Support:
#* Users of AAC systems, as well as their caregivers and support networks, receive training to effectively use the communication tools. Training may involve learning how to navigate electronic devices, program personalized messages, or understand the meaning of symbols.
# Integration with Therapy:
#* AAC is often integrated into speech and language therapy sessions. Therapists use AAC tools to facilitate communication practice and help individuals with communication disorders improve their language skills.<ref name="Nakai_2017" />
# Social and Emotional Aspects:
#* AAC not only addresses the functional aspects of communication but also considers the social and emotional dimensions. It plays a crucial role in helping individuals with communication disorders participate more fully in social interactions and express their thoughts and feelings.

AAC is a dynamic and evolving field, and advancements in technology continue to enhance the range and effectiveness of communication tools available for individuals with speech and language challenges. The selection of AAC strategies depends on factors such as the individual's abilities, preferences, and the specific nature of their communication disorder.

===Melodic intonation therapy===
[[Melodic intonation therapy]] was inspired by the observation that individuals with non-fluent aphasia sometimes can sing words or phrases that they normally cannot speak. "Melodic Intonation Therapy was begun as an attempt to use the intact melodic/prosodic processing skills of the right hemisphere in those with aphasia to help cue retrieval words and expressive language."<ref>{{cite journal|title=A Case Study of the Efficacy of Melodic Intonation Therapy|journal=Music Perception |volume=24|issue=1 |year=2006 |pages=23–36 |issn=0730-7829 |doi=10.1525/mp.2006.24.1.23 |author=Wilson Sarah J|url=http://espace.library.uq.edu.au/view/UQ:186051/UQ186051_OA.pdf }}</ref> It is believed that this is because singing capabilities are stored in the right hemisphere of the brain, which is likely to remain unaffected after a stroke in the left hemisphere.<ref name='Schlaug'>{{cite journal|doi=10.1525/mp.2008.25.4.315|title=From Singing to Speaking: Why singing may lead to recovery of expressive language function in patients with Broca's Aphasia|journal=Music Perception|year=2008|first=Gottfried|last=Schlaug|author2=Sarah Marchina|author3=Andrea Norton|volume=25|issue=4|pages=315–319|pmid=21197418|pmc=3010734}}</ref> However, recent evidence demonstrates that the capability of individuals with aphasia to sing entire pieces of text may actually result from rhythmic features and the familiarity with the lyrics.<ref name='Stahl a'>{{cite journal|last1=Stahl|first1=Benjamin|last2=Kotz|first2=Sonja A.|last3=Henseler|first3=Ilona|last4=Turner|first4=Robert|last5=Geyer|first5=Stefan|title=Rhythm in disguise: why singing may not hold the key to recovery from aphasia|journal=Brain |volume=134|issue=10 |year=2011 |pages=3083–3093 |issn=0006-8950|doi=10.1093/brain/awr240 |pmid=21948939 |pmc=3187543}}</ref>

The goal of Melodic Intonation Therapy is to utilize singing to access the language-capable regions in the right hemisphere and use these regions to compensate for lost function in the left hemisphere. The natural musical component of speech was used to engage the patients' ability to produce phrases. A clinical study revealed that singing and rhythmic speech may be similarly effective in the treatment of non-fluent aphasia and apraxia of speech.<ref name='Stahl b'>{{cite journal|last1=Stahl|first1=Benjamin|last2=Henseler|first2=Ilona|last3=Turner|first3=Robert|last4=Geyer|first4=Stefan|last5=Kotz|first5=Sonja A.|title=How to engage the right brain hemisphere in aphasics without even singing: Evidence for two paths of speech recovery|journal=Frontiers in Human Neuroscience |volume=7 |issue=35 |year=2013 |pages=1–12 |issn=1662-5161 |doi=10.3389/fnhum.2013.00035|pmid=23450277|pmc=3583105|doi-access=free }}</ref> Moreover, evidence from [[randomized controlled trial]]s is still needed to confirm that Melodic Intonation Therapy is suitable to improve propositional utterances and speech intelligibility in individuals with (chronic) non-fluent aphasia and apraxia of speech.<ref name='van der Meulen a'>{{cite journal|last1=van der Meulen|first1=I.|last2=van de Sandt-Koenderman|first2= M. W.|last3=Heijenbrok-Kal|first3=M. H.|last4=Visch-Brink|first4=E. G.|last5=Ribbers|first5=G. M.| title=The efficacy and timing of Melodic Intonation Therapy in subacute aphasia.|journal=Neurorehabil. Neural Repair|year= 2014|volume=28|issue=6|doi=10.1177/1545968313517753|pmid=24449708|pages=536–544|s2cid=6495987}}</ref><ref name='Zumbansen a'>{{cite journal|last1=Zumbansen|first1=Anna|last2=Peretz|first2=Isabelle|last3=Hébert|first3=Sylvie| title=Melodic Intonation Therapy: Back to Basics for Future Research.|journal=Frontiers in Neurology|year= 2014|volume=5|issue=7|pages=7|doi=10.3389/fneur.2014.00007|pmid=24478754|pmc=3904283|doi-access=free }}</ref>

Melodic Intonation Therapy appears to work particularly well in patients who have had a unilateral, left hemisphere stroke, show poor articulation, are non-fluent or have severely restricted speech output, have moderately preserved auditory comprehension, and show good motivation. MIT therapy on average lasts for 1.5 hours per day for five days per week. At the lowest level of therapy, simple words and phrases (such as "water" and "I love you") are broken down into a series of high- and low-pitch syllables. With increased treatment, longer phrases are taught and less support is provided by the therapist. Patients are taught to say phrases using the natural melodic component of speaking and continuous voicing is emphasized. The patient is also instructed to use the left hand to tap the syllables of the phrase while the phrases are spoken. Tapping is assumed to trigger the rhythmic component of speaking to utilize the right hemisphere.<ref name='Schlaug' />

[[FMRI]] studies have shown that Melodic Intonation Therapy (MIT) uses both sides of the brain to recover lost function, as opposed to traditional therapies that utilize only the left hemisphere. In MIT, individuals with small lesions in the left hemisphere seem to recover by activation of the left hemisphere perilesional cortex. Meanwhile, individuals with larger left-hemisphere lesions show a recruitment of the use of language-capable regions in the right hemisphere.<ref name="Schlaug"/> The interpretation of these results is still a matter of debate. For example, it remains unclear whether changes in neural activity in the right hemisphere result from singing or from the intensive use of common phrases, such as "thank you", "how are you?" or "I am fine." This type of phrases falls into the category of [[formulaic language]] and is known to be supported by neural networks of the intact right hemisphere.<ref name='Stahl c'>{{cite journal|last1=Stahl|first1=Benjamin|last2=Kotz|first2=Sonja A.|title=Facing the music: Three issues in current research on singing and aphasia|journal=Frontiers in Psychology |volume=5 |issue=1033 |year=2013 |pages=1–4 |issn=1664-1078 |doi= 10.3389/fpsyg.2014.01033|pmid=25295017|pmc=4172097|doi-access=free }}</ref>

A pilot study reported positive results when comparing the efficacy of a modified form of MIT to no treatment in people with nonfluent aphasia with damage to their left-brain. A randomized controlled trial was conducted and the study reported benefits of utilizing modified MIT treatment early in the recovery phase for people with nonfluent aphasia.<ref>{{cite journal|last1=Conklyn|first1=D|last2=Novak|first2=E|last3=Boissy|first3=A|last4=Bethoux|first4=F|last5=Chemali|first5=K|title=The Effects of Modified Melodic Intonation Therapy on Nonfluent Aphasia: A Pilot Study|journal=Journal of Speech, Language, and Hearing Research|date=2012|volume=55|issue=5|pages=1463–1471|doi=10.1044/1092-4388(2012/11-0105)|pmid=22411278}}</ref>

Melodic Intonation Therapy is used by music therapists, board-certified professionals that use music as a therapeutic tool to effect certain non-musical outcomes in their patients. Speech language pathologists can also use this therapy for individuals who have had a left hemisphere stroke and non-fluent aphasias such as Broca's or even apraxia of speech.

{{Further|Music therapy for non-fluent aphasia}}

===Constraint-induced therapy===
Constraint-induced aphasia therapy (CIAT) is based on similar principles as [[constraint-induced movement therapy]] developed by Dr. [[Edward Taub]] at the University of Alabama at Birmingham.<ref name='Meinzer' /><ref name='Pulvermuller'>{{cite journal|title=Constraint-Induced Therapy of Chronic Aphasia following Stroke|journal=Stroke|year=2001|first=Friedemann|last=Pulvermuller|pmid=11441210|volume=32|issue=7|pages=1621–1626|url=http://stroke.ahajournals.org/cgi/content/full/32/7/1621|doi=10.1161/01.STR.32.7.1621 |display-authors=etal|citeseerx=10.1.1.492.3416|s2cid=673662}}</ref> Constraint-induced movement therapy is based on the idea that a person with an impairment (physical or communicative) develops a "learned nonuse" by compensating for the lost function with other means such as using an unaffected limb by a paralyzed individual or drawing by a patient with aphasia.<ref name='Pulvermuller2'>{{cite journal|doi=10.1080/02687030701612213|title=Aphasia therapy on a neuroscience basis|journal=Aphasiology|year=2008|first=Friedemann|last=Pulvermuller|author2=Marcelo Berthier|pmid=18923644|volume=22|issue=6|pmc=2557073|pages=563–599}}</ref> In constraint-induced movement therapy, the alternative limb is constrained with a glove or sling and the patient is forced to use the affected limb. In constraint-induced aphasia therapy the interaction is guided by communicative need in a language game context, picture cards, barriers making it impossible to see other players' cards, and other materials, so that patients are encouraged ("constrained") to use the remaining verbal abilities to succeed in the communication game.<ref name='Pulvermuller' />

Two important principles of constraint-induced aphasia therapy are that treatment is very intense, with sessions lasting for up to 6 hours over the course of 10 days and that language is used in a communication context in which it is closely linked to (nonverbal) actions.<ref name='Meinzer' /><ref name='Pulvermuller' />  These principles are motivated by neuroscience insights about learning at the level of nerve cells (synaptic plasticity) and the coupling between cortical systems for language and action in the human brain.<ref name='Pulvermuller2' /> Constraint-induced therapy contrasts sharply with traditional therapy by the strong belief that mechanisms to compensate for lost language function, such as gesturing or writing, should not be used unless absolutely necessary, even in everyday life.<ref name='Meinzer' />

It is believed that CIAT works by the mechanism of increased [[neuroplasticity]]. By constraining an individual to use only speech, it is believed that the brain is more likely to reestablish old neural pathways and recruit new neural pathways to compensate for lost function.<ref>{{Cite journal |last1=Balardin |first1=Joana Bisol |last2=Miotto |first2=Eliane Correa |date=December 2009 |title=A review of Constraint-Induced Therapy applied to aphasia rehabilitation in stroke patients |journal=Dementia & Neuropsychologia |volume=3 |issue=4 |pages=275–282 |doi=10.1590/S1980-57642009DN30400003 |issn=1980-5764 |pmc=5619412 |pmid=29213640}}</ref>

The strongest results of CIAT have been seen in patients with chronic aphasia (lasting over 6 months). Studies of CIAT have confirmed that further improvement is possible even after a patient has reached a "plateau" period of recovery.<ref name='Meinzer' /><ref name='Pulvermuller' /> It has also been proven that the benefits of CIAT are retained long term. However, improvements only seem to be made while a patient is undergoing intense therapy.<ref name='Meinzer' /> Recent work has investigated combining constraint-induced aphasia therapy with drug treatment, which led to an amplification of therapy benefits.<ref name='Berthier'>{{cite journal|doi=10.1002/ana.21597|title=Memantine and constraint-induced aphasia therapy in chronic poststroke aphasia|journal=Annals of Neurology|year=2009|first=Marcelo|last=Berthier|volume=65|issue=5|pages=577–578|pmid=19475666|s2cid=31528532|display-authors=etal}}</ref>

===Medication===
In addition to active speech therapy, pharmaceuticals have also been considered as a useful treatment for expressive aphasia. This area of study is relatively new and much research continues to be conducted.

The following drugs have been suggested for use in treating aphasia and their efficacy has been studied in control studies.
* [[Bromocriptine]] – acts on [[Catecholamine]] Systems<ref name='de Boissezon'>{{cite journal|doi=10.1016/j.bandl.2006.07.004|title=Pharmacotherapy of aphasia: Myth or reality?|journal=Brain and Language|year=2007|first=de Boissezon|last=Xavier|author2=Patrice Peran|pmid=16982084|volume=102|issue=1|pages=114–125|s2cid=38304960}}</ref>
* [[Piracetam]] – mechanism not fully understood, but most likely interacts with cholinergic and glutamatergic receptors, among others<ref name='de Boissezon' />
* [[Cholinergic]] drugs ([[Donepezil]], [[Aniracetam]], [[Bifemelane]]) – acts on [[acetylcholine]] systems<ref name='de Boissezon' />
* [[Dopaminergic]] [[psychostimulants]]: ([[Dexamphetamine]], [[Methylphenidate]])<ref name='de Boissezon' />

The most effect has been shown by piracetam and amphetamine, which may increase [[Neuroplasticity|cerebral plasticity]] and result in an increased capability to improve language function. It has been seen that piracetam is most effective when treatment is begun immediately following stroke. When used in chronic cases it has been much less efficient.{{sfn|Berthier|2005}}

Bromocriptine has been shown by some studies to increase verbal fluency and word retrieval with therapy than with just therapy alone.<ref name='de Boissezon' />  Furthermore, its use seems to be restricted to non-fluent aphasia.<ref name='Berthier' />

Donepezil has shown a potential for helping chronic aphasia.<ref name='Berthier' />

No study has established irrefutable evidence that any drug is an effective treatment for aphasia therapy.<ref name='de Boissezon' /> Furthermore, no study has shown any drug to be specific for language recovery.<ref name='Berthier' />  Comparison between the recovery of language function and other motor function using any drug has shown that improvement is due to a global increase plasticity of neural networks.<ref name='de Boissezon' />

===Transcranial magnetic stimulation===
In [[transcranial magnetic stimulation]] (TMS), magnetic fields are used to create electrical currents in specified [[cerebral cortex|cortical]] regions. The procedure is a painless and noninvasive method of stimulating the cortex. TMS works by suppressing the inhibition process in certain areas of the brain.<ref name='Naeser'>{{cite journal|doi=10.1016/j.bandl.2004.08.004|title=Improved picture naming in chronic aphasia after TMS to part of right Broca|journal=Brain and Language|year=2004|first=Naeser|last=Margaret|author2=Paula Martin|author3=Marjorie Nicholas|author4=Errol Baker|pmid=15766771|volume=93|issue=1|pages=95–105|s2cid=9348149}}</ref> By suppressing the inhibition of neurons by external factors, the targeted area of the brain may be reactivated and thereby recruited to compensate for lost function. Research has shown that patients can demonstrate increased object naming ability with regular transcranial magnetic stimulation than patients not receiving TMS.<ref name="Naeser"/> Furthermore, research suggests this improvement is sustained upon the completion of TMS therapy.<ref name='Naeser' /> However, some patients fail to show any significant improvement from TMS which indicates the need for further research of this treatment.<ref name='Martin'>{{cite journal|doi=10.1016/j.bandl.2009.07.007|title=Overt Naming fMRI Pre- and Post- TMS: Two Nonfluent Aphasia Patients, with and without Improved Naming Post- TMS|journal=Brain and Language|year=2009|first=Paula|last=Martin|author2=Margaret Naeser|author3=Michael Ho|author4=Karl Doron|author5=Jacquie Kurland|pmid=19695692|volume=111|issue=1|pmc=2803355|pages=20–35}}</ref>

===Treatment of underlying forms===
Described as the linguistic approach to the treatment of expressive aphasia, treatment begins by emphasizing and educating patients on the thematic roles of words within sentences.<ref name="TUF">{{cite journal |vauthors=Thompson CK, Shapiro LP |title=Treating agrammatic aphasia within a linguistic framework: Treatment of Underlying Forms |journal=Aphasiology |volume=19 |issue=10–11 |pages=1021–1036 |date=November 2005 |pmid=17410280 |pmc=1847567 |doi=10.1080/02687030544000227 }}</ref> Sentences that are usually problematic will be reworded into active-voiced, declarative phrasings of their non-canonical counterparts.<ref name="TUF" /> The simpler sentence phrasings are then transformed into variations that are more difficult to interpret. For example, many individuals who have expressive aphasia struggle with Wh- sentences. "What" and "who" questions are problematic sentences that this treatment method attempts to improve, and they are also two interrogative particles that are strongly related to each other because they reorder arguments from the declarative counterparts.<ref name="TUF" /> For instance, therapists have used sentences like, "Who is the boy helping?" and "What is the boy fixing?" because both verbs are transitive- they require two arguments in the form of a subject and a direct object, but not necessarily an indirect object.<ref name="TUF" /> In addition, certain question particles are linked together based on how the reworded sentence is formed. Training "who" sentences increased the generalizations of non-trained "who" sentences as well as untrained "what" sentences, and vice versa.<ref name="TUF" /> Likewise, "where" and "when" question types are very closely linked. "What" and "who" questions alter placement of arguments, and "where" and "when" sentences move adjunct phrases.<ref name="TUF" /> Training is in the style of: "The man parked the car in the driveway. What did the man park in the driveway?"<ref name="TUF" /> Sentence training goes on in this manner for more domains, such as clefts and sentence voice.<ref name="TUF" />

Results: Patients' use of sentence types used in the TUF treatment will improve, subjects will generalize sentences of similar category to those used for treatment in TUF, and results are applied to real-world conversations with others.<ref name="TUF" /> Generalization of sentence types used can be improved when the treatment progresses in the order of more complex sentences to more elementary sentences. Treatment has been shown to affect on-line (real-time) processing of trained sentences and these results can be tracked using fMRI mappings.<ref name="TUF" /> Training of Wh- sentences has led improvements in three main areas of discourse for aphasics: increased average length of utterances, higher proportions of grammatical sentences, and larger ratios of numbers of verbs to nouns produced.<ref name="TUF" /> Patients also showed improvements in verb argument structure productions and assigned thematic roles to words in utterances with more accuracy.<ref name="TUF" /> In terms of on-line sentence processing, patients having undergone this treatment discriminate between anomalous and non-anomalous sentences with more accuracy than control groups and are closer to levels of normalcy than patients not having participated in this treatment.<ref name="TUF" />

===Mechanisms of recovery===
Mechanisms for recovery differ from patient to patient. Some mechanisms for recovery occur spontaneously after damage to the brain, whereas others are caused by the effects of language therapy.<ref name='Berthier' /> [[FMRI]] studies have shown that recovery can be partially attributed to the activation of tissue around the damaged area and the recruitment of new neurons in these areas to compensate for the lost function. Recovery may also be caused in very acute lesions by a return of blood flow and function to damaged tissue that has not died around an injured area.<ref name='Berthier' /> It has been stated by some researchers that the recruitment and recovery of neurons in the left hemisphere opposed to the recruitment of similar neurons in the right hemisphere is superior for long-term recovery and continued rehabilitation.<ref name='Heiss'>{{cite journal|doi=10.1002/1531-8249(199904)45:4<430::AID-ANA3>3.0.CO;2-P|title=Differential capacity of left and right hemispheric areas for compensation of poststroke|first5=H|last5=Karbe|first4=M|last4=Ghaemi|first3=A|last3=Thiel|first2=J |journal=Ann Neurol|last2=Kessler|year=1999|first1=W-D|last1=Heiss|volume=45|pmid=10211466|issue=4|pages=430–438|s2cid=13377946 }}</ref> It is thought that, because the right hemisphere is not intended for full language function, using the right hemisphere as a mechanism of recovery is effectively a "dead-end" and can lead only to partial recovery.<ref>{{cite journal|last1=Heiss|first1=W-D|last2=Thiel|first2=A|date=2006|title=A proposed regional hierarchy in recovery of post-stroke aphasia|url=https://www.sciencedirect.com/science/article/abs/pii/S0093934X06000484|journal=Brain and Language|volume=98|issue=1|pages=118–123|doi=10.1016/j.bandl.2006.02.002|pmid=16564566 |s2cid=22877982 |access-date=2024-02-21}}</ref>

There is evidence to support that, among all types of therapies, one of the most important factors and best predictors for a successful outcome is the intensity of the therapy. By comparing the length and intensity of various methods of therapies, it was proven that intensity is a better predictor of recovery than the method of therapy used.<ref name='Sanjit'>{{cite journal|doi= 10.1161/01.STR.0000062343.64383.D0|pmid= 12649521|title= Intensity of Aphasia Therapy, Impact on Recovery * Aphasia Therapy Works!|journal=Stroke|year=2003|first=Bhogal|last=Sanjit|author2=Robert Teasell|author3=Mark Speechley|author4=Martin Albert|volume=34|issue=4|pages=987–993|doi-access=free}}</ref>