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A Short History of the Past and Future of Aphasia Therapy Eine kurze Geschichte der Vergangenheit und Zukunft der Aphasietherapie Une histoire courte du passé et du futur du traitement de l’aphasie Chris Code, School of Psychology, University of Exeter, [email protected]

Abstract

In this paper I explore where aphasia therapy came from, where we are now and where aphasia therapy might develop in the future. We start with a survey of how thought language and speech were represented in the body from ancient to modern times. The ancient Egyptians (2000 – 3000 BC) thought that the heart was the seat of the «soul» and mental life and pre-Christian Greece and Rome development a theory of «fluids». Plato’s view that the mind was located in the head contrasted with Aristotle’s (384 – 322 BC) that it was located in the heart. Between 300 – 200 BC anatomical investigations of the brain developed and the ventricles of the brain is were where the soul was considered to reside. This view lasted well into the Middle Ages. It was not until the 15th c that basic treatment for aphasia began to develop based on the view that aphasia was a form of memory disorder. In the 18th c Gall developed his language and speech localisation theory and Broca, Hughlings Jackson and Bastian began to consider that recovery occurred because of some form of reorganisation, and treatment could be beneficial. But it was not until the First World War that Goldstein, Luria and the Viennese phoniatricians Hermann Gutzmann (1865 – 1922) (the father of aphasia therapy’) and Emil Froeschels developed the first systematic treatments. Between the wars the focus turned to the New World and a more behaviourist approach was developed. The return of localisation theory following World War II saw the development of approached based on the Boston School and «stimulation» approaches of Wepman and Schuell. In the latter part of the 20th c there developed approaches based on linguistics, psycholinguistics, modular cognitive models and psychosocial and social models.

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Zusammenfassung

In diesem Beitrag untersuche ich, wo die Ursprünge der Aphasie-Therapie liegen, wo wir heute stehen und wohin sich die Aphasie-Therapie zukünftig entwickeln kann. Wir beginnen mit einem historischen Überblick über die Repräsentation von Denken, Sprache und Sprechen im Körper. Die alten Ägypter (2000 – 3000 v. Chr.) glaubten, dass das Herz der Sitz von «Seele» und Verstand sei. Im vorchristlichen Griechenland und Rom wurde die Theorie der «Körper-Flüssigkeiten» entwickelt. Platons Idee, dass der Geist im Kopf lokalisiert sei, kontrastierte mit Aristoteles’ (384 – 322 v. Chr.) Annahme, dass er im Herzen angesiedelt sei. Zwischen 300 und 200 v. Chr. entwickelten sich die anatomischen Untersuchungen des Gehirns, und der Sitz der Seele wurde in den Gehirn-Ventrikeln vermutet. Diese Annahme hatte bis ins Mittelalter Bestand. Erst im 15. Jahrhundert wurden basale Behandlungsformen für Aphasie entwickelt, die auf der Ansicht der Aphasie als einer Form von Gedächtnisstörungen gründeten. Im 18. Jahrhundert entwickelte Gall seine Theorie der Lokalisation von Sprache und Sprechen. Broca, Hughlings Jackson und Bastian kamen später zu der Einsicht, dass die Rückbildung auf Reorganisationsprozessen beruhe und Behandlungen nutzbringend sein könnten. Aber erst im Ersten Weltkrieg entwickelten Goldstein, Luria und der Wiener Phoniater Hermann Gutzmann (1865 –1922) (der Vater der Aphasie-Therapie) und Emil Froeschels die ersten systematischen Behandlungsformen. Zwischen den Kriegen verlegte sich der Fokus Richtung Neue Welt und es wurden stärker behavioristisch geprägte Ansätze entwickelt. Die Rückkehr zur Lokalisationstheorie nach dem Zweiten Weltkrieg brachte neue Ansätze, die auf den Arbeiten der Bostoner Schule und der Stimulationsmethode von Wepman und Schuell basierten. Gegen Ende des 20. Jahrhunderts wurden Ansätze entwickelt, die auf linguistischen, psycholinguistischen oder modular kognitiven Modellen sowie psychosozialen bzw. sozialen Modellen basieren.

Résumé

Dans cet article, nous explorons d’où vient la thérapie de l’aphasie, où nous en sommes maintenant et comment la thérapie de l’aphasie pourrait se développer dans l’avenir. Nous commençons avec un aperçu de la manière dont la langue et la parole étaient représentées dans le corps depuis l’Antiquité jusqu’aux temps modernes. Les anciens Égyptiens (2000 – 3000 avant J.C.) pensaient que le cœur était le siège de l’«âme» et de la vie mentale. Les pré-chrétiens de Grèce et de Rome développèrent une théorie des «fluides». Platon estimait que l’esprit est situé dans la tête, par contre Aristote (384 – 322 avant J.C.), quant à lui, le supposait situé dans le cœur. Entre 300 – 200 avant J.C. se sont développées les premières investigations anatomiques du cerveau et les conceptions sur le siège de l’âme dans les ventricules. Ce point de vue a perduré une bonne partie du Moyen-Age. Ce n’est qu’à partir du 15e siècle qu’ apparaissent les débuts de traitement de l’aphasie basés sur l’idée que l’aphasie est une forme de trouble de mémoire. Au 18ème Gall

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développa sa théorie de localisation du langage et de la parole. Broca, Bastian Hughlings et Jackson ont commencé à supposer que la récupération est due à des processus de réorganisation cérébrale et que des traitements pouvaient avoir des effets positifs. Mais ce n’est qu’après la première Guerre mondiale que Goldstein, Luria, le phoniatre viennois Hermann Gutzmann (1865 – 1922) (le père de la thérapie de l’aphasie) et Emil Froeschels mettent au point le premier traitement systématique. Entre les deux guerres, l’accent s’est concentré vers le Nouveau Monde et se développe une approche plus behaviouriste. Le retour de la théorie de localisation après la Seconde Guerre mondiale mène au développement d’approches basées sur l’Ecole de Boston et les approches de stimulation de Wepman et de Schuell. Dans la dernière partie du 20e siècle, on observe des approches basées sur la linguistique, la psycholinguistique, modulaire, les modèles cognitifs et psychosociaux et les modèles sociaux.

The Ancient Past We need to understand the past so we can appreciate the present and the present is the realisation of events in the past. St Augustine (400 AD) outlined a first understanding of time past, time present and time future. He contended that we can only really know the present, because time past is only memory, even if it is recorded memory, and we know how unreliable memory can be, and time future is, by definition, impossible to know. An introduction to the early history of aphasia can be found in Tesak and Code (2008). We are reliant on the written records handed down to us from the past, and writing did not develop until 3500 BC in the Middle East, but the brain had no great importance in ancient Egyptian medicine and religion. For instance, in mummification all the organs were stored, but the Aphasie und verwandte Gebiete 1/ 2009

brain was pulled out through the nose with a hook and discarded. This is a reflection of the cardiocentric view where the heart was seen as the home of the soul, wherein resided a capacity for Good and Evil. The oldest reference to what we now call aphasia is in the Edwin Smith Papyrus (3000 and 2200 BC), a medical record of a number of cases of brain damage (Breasted, 1930). One record refers to a man who is «speechless» and states that the speechlessness is «an ailment not to be treated», but that the rubbing of ointment on the head and pouring a fatty liquid (possibly milk) into the ears is a beneficial therapy.

Theory of Fluids The causes of diseases in pre-Christian times were thought to be due to

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some imbalance of the bodily fluids or elements. A four-element theory was developed by different philosophers within natural philosophy (e.g., Empedocles, 504 – 433 BC), in an attempt to understand nature and the essence of human nature. Healing involved manipulating the balance of fluids: bloodletting, starvation, fluid deprivation, heat treatment, regurgitation, faecal evacuation and sweating. Deficits after brain injuries were interpreted as an accumulation of undesirable life fluids. Cranial drillings (trepanations) were sometimes attempts at the evacuation of undesirable fluids, and in some cases may have been effective. Element

Characteristic

Bodily fluid

Air Fire Earth Water

dry warm cold moist

yellow bile blood phlegm (mucus) black bile

Table 1

The Greco-Roman Period The connection between cognitive processing and a possible localisation in the structure of the human body emerged in Greco-Roman times and the question was posed, was the mind represented in the brain or in the heart? For Plato (428 – 347 BC) a tripar-

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tite soul corresponded to anatomically different parts of the body: reason and mind were located in the head but «higher» characteristics like pride, fear, courage, were in the heart; the lower characteristics of lust and desire were located in the liver or the abdomen. As human speech had been associated with the rational part of the soul since Pythagoras (580 – 428 BC), this was an important step for the examination of the relationship between speech, language and brain. Plato’s pupil Aristotle (384 – 322 BC) had a particularly significant impact in subsequent centuries on philosophy and the development of medicine. In contrast to his teacher Plato, he argued that the heart was the home of all cognitive, perceptual, and associated functions.

Ventricular Theory But the brain began to figure in GrecoRoman thought. Herophilos (335 – 280 BC) – the «father of anatomy», described the cortex, the cerebellum and the ventricles of the brain and the sensory and motor nerve trunks. It was with him that ventricular theory developed and where a connection was made between the «psyche» (soul) and the ventricles of the brain. Ventricular theory, or cell theory, dominated into the Middle Ages. Aphasie und verwandte Gebiete 1/ 2009

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Galen (130 – 200 AD) was the most significant brain anatomist until the 17th century. He dissected cows, monkeys, pigs, dogs, cats, rodents, and at least one elephant – but, apparently, no human bodies, which was prohibited in Rome. But he was a physician to the gladiators and so had extensive experience of wounds to the head and brain. Although a follower of Aristotle, he rejected Aristotle’s brain theory.

The Middle Ages The Middle Ages runs from the demise of the Roman Empire (400s) to the emergence of the Renaissance (1500s). During the Middle Ages Cell Theory developed from ventricular theory. A major difference was that the ventricles were understood in the as theoretical concepts rather than as anatomical structures and simply depicted as circles. Aphasic symptoms appear to result from damage to the third cell (the fourth ventricle) and conceptualized as memory disorders. The idea that aphasia was a memory disorder was to dominate until well into the 19th century. Antonio Guainerio (died 1440) hypothesised that the cause of aphasia was damage to the fourth ventricle (the third cell). Memory was impaired because the ventricle contains too much Aphasie und verwandte Gebiete 1/ 2009

phlegm. Nicolò Massa (1489 – 1569) described a man who lost his speech following a battle wound to the head and thought that a bone splinter was left in the brain. He located it and pulled it out and immediately the patient called out: «Ad Dei laudem, sum sanus!» (God be praised, I am healthy!). The Spaniard Francisco Arceo (1493 – 1573) described a worker hit on the head by a stone who was speechless for several days. Arceo remedied the fracture and some days later the patient began to speak again and apparently recovered fully through spontaneous recovery. Two prominent Renaissance anatomists who dismissed Galean ventricular theory were Andreas Vesalius (1514–1564) and Thomas Willis (1621–1675).

The 18th Century Enlightenment: Reason and Nature Isaac Newton (1642 – 1727) supposed, based on Aristotle’s teachings, that all human bodies contain a hidden, vibrating «ether» that moves through the nerves at the command of the will, from sensory organs to brain and then to muscles, which was described as «vibration theory». The philosopher John Locke (1632 – 1704) considered the human mind a collecting point for sensory perceptions that are pro-

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cessed, connected and associated with each other. David Hartley (1705 – 1757) considered that the cerebral gyri were responsible for memory and the will and attempted to explain memory through Locke’s association of ideas and Newton’s vibration theory which he combined in neurophysiology to produce associationism. René Descartes (1596 – 1650) famously believed that the soul was in the pineal gland, which lies outside the brain proper, so soul and body are separate in Cartesian dualism. This allowed the church to lift its ban on anatomical investigations.

The 18th Century Aphasia was an impairment of memory according to most in the 17th century. For instance, Johannes Jakob Wepfer (1620 – 1695) described at least 13 clear cases of language disorder with brain injuries which he attributed as memory loss. Johannes Schenck (1530 – 1598), rejected medieval ventricle theory and described a case with no memory problems despite damage to the fourth ventricle. He described cases of speech and language disorders, mostly openhead injuries, and observed that speech or language are often impaired although the tongue is not paralysed – one of the first to suggest that aphasia is a language disorder as opposed to a speech disorder.

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Johann Gesner (1738 – 1801) described KD in his book: «The language amnesia» where he laid the foundation for the first real theory of aphasia. Gesner separated language processing from speech programming and laid the foundations for a clear separation of general communicative competence, which was unimpaired in KD. He saw the cause of the aphasia as a selective disorder of memory caused by a «congestion» of the «nerve ducts», and (according to Benton, 1965) this was the first associationist aphasia theory – a precursor to the dominating associationist theories of the 19th century.

The 19th Century & the Birth of a Science of Aphasia Franz Josef Gall’s (1764 – 1828) organology (better known as phrenology) had a massive influence on ideas about aphasia, neuroanatomy and neuropsychology. Organology considered that the inner form of the cranium was determined by the external form of the brain and it was therefore possible to detect the strength of particular human «faculties» from the shape and size of the cranium. With Gall the foundations of cerebral localisation of function began as a serious idea. He was a particularly skilled anatomist and the first to recognise the imporAphasie und verwandte Gebiete 1/ 2009

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tance of the neocortex in localisation and described mental faculties («organs») that were localized in specific parts of the brain. The faculty for words which was part of the faculty for language, was in the frontal lobe. According to Gall, the faculty of language is innate, independent and autonomous of reason and intelligence, and its primary purpose was as a means of expression. This later communication this later formed part of the basis for «modularity», a significant feature of modern cognitive neuropsychology.

good comprehension, almost no speech and the speech automatisms tan tan and Sacre Nom de Dieu. Broca called this disorder aphemia, now mainly called apraxia of speech, and modern aphasiology was born. He proclaimed that the 3rd frontal convolution was the seat for articulated language.

An important follower of Gall in Paris was Jean Baptiste Bouillaud (1796 – 1881), who identified the connection between the separate loss of language and speech and frontal brain damage in patients he described and some seem to have what we would now call apraxia of speech.

In 1874 the scene moved to Germany, where a young physician, Carl Wernicke, wrote his thesis on «The Symptom-Complex of Aphasia», where he described cases with sensory aphasia due to lesions in the posterior left brain. With the anterior production aphasia of Broca (aphemia) and Wernicke’s posterior sensory aphasia, the basis for a fuller theory of language developed and Lichtheim (1885) detailed the Wernicke-Lichtheim model, which was to dominate aphasia theory in most of the world well into the 20th century.

Bouillaud’s son-in-law Ernest Auburtin (1825 –1893) was the significant figure in The Paris language localisation debates of 1861 – 1866. He accompanied Paul Broca (1824 – 1880), who had little experience of aphasia, in an examination of Broca’s patient Leborgne («Tan»), who Broca described at a subsequent meeting of the Paris Anthropology Society in 1861. Leborgne had a massive frontal lesion centred on the 3rd frontal convolution with

However, not everyone was seduced by the localisationist agenda. During the 1874 Berlin language debate, the localisationist Hitzig took an opposing view to Steinthal, probably the first real psycholinguist, who complained that the physicians’ descriptions of language and aphasia were too superficial and lacked necessary linguistic detail. In England, John Hughlings Jackson (1835 – 1911) too was opposed to

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localisation and supposed a reorganisation of function in the brain after damage. Positive (additions) symptoms can develop through failure of higher inhibition, as an expression of lower levels resulting from damage to levels higher up the hierarchy (e.g., cortical). Sigmund Freud (1891) too was a critic of the Wernicke-Lichtheim model and Henry Head (1926 ) launched an assault on what he called «the diagram makers». Many of the physicians at this time were very interested in the clinical management and treatment of aphasia; Broca and Henry Charles Bastian (1837 – 1915), for instance. Bastian (1898) and Henry Head described detailed testing of aphasia and their tests were used well into the second half of the 20th century.

The 20th century War has always produced advances in science and technology, and aphasia and neuropsychology are no exceptions. World War 1 produce, among others, Kurt Goldstein (1878 – 1965) who took a holistic view of aphasia through his organismic approach and was deeply concerned with rehabilitation and the psychosocial impact of aphasia. World War I saw the development of aphasia

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therapy from «speech gymnastics» (Howard & Hatfield, 1983) of the Viennese phoniatricians Hermann Gutzmann (1865 – 1922) «the father of aphasia therapy», and Emil Froeschels (1884 – 1973). They applied the techniques they knew from voice therapy, articulatory drills and primary school teaching techniques. In Britain too, treatment of aphasia was mainly developed by elocutionists and voice teachers. Bastian (1898) was an exception and emphasised the difference between compensation and restitution. He described therapy for aphasia based on the potential of reorganisation of the right hemisphere through the process of functional compensation, which he distinguished from functional restitution. During World War II A.R. Luria in Russia, developed a functional systems approach to the brain and language resulting in a new perspective on the organisation of cognition and language and a new classification of aphasia. He collected a mass of data from braininjured soldiers. His approach to treatment involved the re-organization of function where intact functional subsystems could be used to compensate for impaired sub-systems. Luria’s approach to assessment and treatment had a major impact in Eastern Europe, but also in the UK and particularly in Australia. Aphasie und verwandte Gebiete 1/ 2009

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The New World Takes The Lead With Weisenburg & McBride (1935) there was a shift in focus across the Atlantic and a new, behavioural, psychometric, anti-classification and antilocalisationist approach to aphasia developed. Following World War II in the USA between 1940 – 1960s Joseph Wepman and Hildred Schuell developed approaches for different aphasia types based heavily on significant auditory stimulation and repetition. For them the aphasic person has not lost language functions, but these functions have become inaccessible. Language competence has survived and it is language performance that is impaired and that can be regained with the right kind of stimulation. Therapy essentially entails facilitating and stimulating language use. Improvement, if it occurs, comes because the patient facilitates and integrates what he or she already knows and does not learn new vocabulary or grammatical forms.

Developments in the later 20th century (1970 – 1990) Frederick Darley and his students highlighted the importance of intensity, duration and timing of therapy input. Data began to emerge on the best candidates for treatment: age, education, time since onset and severity of the Aphasie und verwandte Gebiete 1/ 2009

damage began to emerge as important prognostic variables. A range of groupbased randomised clinical trials (RCTs) were conducted in the latter 20th century, but proved very difficult to design and carry out, mainly because of the heterogeneous nature of aphasia and the failure to systematise therapy appropriately. A cognitive neuropsychological model developed in the early 1980s that advocated single-case designs for therapy research (Coltheart, 1983) and good success with wellselected individuals was demonstrated. The development of the cognitive neuropsychological model emerged from the coming together of psycholinguistics, single-case methods and the information processing model, and a «theory-driven» approach to investigation of individuals was claimed to be preferable to attempts to compare mixed groups categorized according to the classical syndromes. Utilizing Jerry Foder’s ideas on modularity, an idea inspired by Gall’s faculties, the model assumes that components of cognition are organized in modules which are domain-specific (computations performed by a module are specific to that module only), associated with circumscribed brain structures, genetically determined and computationally autonomous and independent of other cognitive processes. The model became famous for its boxes and arrows to conceptualise processing which were used to represent the stages and

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routes involved in activities like reading single words aloud, writing single words to dictation and naming objects. The model can identify what is impaired and what is retained by detailed hypothesis-driven testing using psycholoinguistically controlled tests. It shares some features with the Wernicke-Lichtheim model, not least its focus on single word processing. The systematic nature of the approach had attractive features for clinical work with aphasia, and began to have a significant impact on aphasia therapy. The model came with a promising model of assessment for treatment, and an emphasis on the individual patient and their problems. Howard and Patterson (1990) outlined three strategies for therapy inspired by the model: re-teaching of the missing information, missing rules or procedures based on detailed testing, teaching a different way to do the same task and facilitating the use of impaired access routes. It will be observed that these broad approaches to treatment are not new and the model’s main contribution has been in systematising assessment and more clearly identifying the location of impairments in a hypothetical model. During the early 1980s too the psychosocial impact of aphasia began to be

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better recognised, although Goldstein had highlighted its importance before World War II. Towards the end of the 20th century the social disability that accompanies aphasia became increasingly recognised. Norman Geschwind re-introduced the Wernicke-Lichtheim model in the 1960s. This inspired a great deal of research activity in Boston, which became the major centre for aphasia, and the Boston Diagnostic Aphasia Examination was developed. Treatments were developed inspired by the Boston aphasia classification scheme mainly by Nancy Helm-Estabrooke and colleagues. Many of these approaches are designed for specific types of aphasia and use systematic behavioural training hierarchies organized into steps and levels, like Melodic Intonation Therapy (MIT), which aims to re-establish some speech in patients by reorganization of the speech production process using melodic intonation, and Visual Action Therapy (VAT) for Broca’s or Global impairments. An interest in more everyday functional communication developed at this time, and Martha Taylor Sarno and Audrey Holland were important in developing functional approaches to assessment and treatment. Approaches like PACE (Promoting Aphasics Communicative Efficiency) emphasised Aphasie und verwandte Gebiete 1/ 2009

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successful communication, not precise oral naming, or correct syntax. The main features of the approach are that the therapist and patient participate equally as sender and receiver of messages; interactions entail the exchange of new information; the aphasic person chooses the modality or methods of communication; feedback is based on the aphasic person’s success in communicating the message and encouraged to use writing, gesture, drawing, pointing. Reorganisational approaches developed based on surviving right hemisphere (RH) processing in the 1980s / 90s. These include MIT, which claims to utilise intact RH musical processing. Artificial languages were developed from work with chimpanzees which were made up of visual arbitrary shapes, or symbols. Remarkable success was reported with globally impaired patients being able to use the systems propositionally. There were attempts to directly influence cognitive processing in the RH and stimulate latent RH language processes using lateralisation techniques like dichotic listening and hemi-field viewing (Code, 1987). Most of our happiness and sadness comes from our interactions with others. How we perceive our interactions with others is what determines the quality of our life experience, our Aphasie und verwandte Gebiete 1/ 2009

psychosocial well-being. Our psychosocial life is grounded in our emotional experience, within a social context. The psychosocial impact of aphasia began to be increasingly recognised on aphasic people and on their families. In the latter part of the 20th century the «disability movement» were successful in supplanting the medical model, with a social model that interprets the repercussions of health conditions as having social consequences. In 1980 the World Health Organisation (WHO) introduced the terms impairment, disability and handicap to describe and categories disease. Speech and language therapists working with aphasia began to realise that aphasia too was not only an «impairment» to cognitive processes but also a social disability. The more recent draft of the International Classification of Impairments, Disabilities and Health –2 (1997) proposed three dimensions in the context of a health condition. Impairment is a loss or abnormality of body structure or of a physiological or psychological function whereas an activity limitation is where the extent of functioning at the level of the person is reduced or limited. Activities may be limited in nature, duration and quality. The term «disability» has been replaced by the term activity limitation. Participation is the nature and extent of a person’s involvement in life situations in relation to impairments, activities, health conditions and contex-

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tual factors. «Handicap» is replaced by participation restriction. It may be some time before these rather awkward terms replace the familiar impairment, disability and handicap. Linguists like M.A.K. Halliday had already developed models of language that saw language as having a social function as well as a cognitive / referential one. Language can be conversational and used to develop, cement and maintain relationships using different registers and styles depending on whether the relationship is with the boss, loved ones, or friends, and paralinguistic features like facial expression, body language and gesture make significant contributions to everyday communication. A language disability can have significant impact on relationships and can establish socio-communicative barriers within the aphasic person’s community. «The social model of disability sees the problem lying not in individuals» impairments but in society’s failure to accommodate different citizens’ needs, leading disabled people to meet social

barriers and oppression.’ (Jordan,1998). The main aim of a social approach to aphasic disability is to increase successful participation in authentic communication events, to focus on communication at the level of conversation, to provide communicative support systems within the speaker’s own community and to increase communicative confidence and empower speakers with aphasia (SimmonsMackie, N. 1998). So, what are the major trends emerging in the past 20 years? How have technical, social and economic changes influenced developments? Did things get better for people with aphasia in the 20th century? Katz et al. (2000) conducted an international survey across the English-speaking world, with data collected from clinical aphasia departments in the USA, Canada, Australia and the UK. Just some of the results relating to acute aphasia are summarised in table 2. The mean amount of therapy per week received at the acute stage was just 30 minutes for Australia and the UK,

Treatment Sessions at Acute Stage

Aus / UK North America

Mean 30 mins 60 mins

Sessions per Week 1– 5 16 – 20

Table 2

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with a range of 1 to 5 sessions only. For North America the mean was 60 minutes per week and with a broader range of 16 to 20 sessions. It should be noted that the North American data included the Veteran’s Administration Hospitals system. The figures for the UK and Australia in particular suggest that aphasic people, even in the acute stage, can expect no more than two and one half hours of therapy spread over five weeks. Yet there is evidence that intensive therapy, long in duration can improve outcome, especially, but not exclusively, in the early stages of recovery. Bhogal et al. (2003) conducted a meta-analysis of the randomised control trails that have been completed that have examined the effectiveness of aphasia treatment. They found a significant treatment effect in studies that provided 8.8 hours of weekly therapy for 11.2 weeks, studies that did not show a significant treatment effect provided less than 2hrs for 23 weeks. So studies that showed a positive effect of therapy provided more intensive therapy, but for less duration and the total hours (intensity) of therapy correlated significantly with improvement on test scores.

The 21st Century and the Future Is there a future for aphasia therapy? How might aphasia therapy develop Aphasie und verwandte Gebiete 1/ 2009

over the next 20 years or so? With the current financial climate, it seems unlikely that what we might hypothesise as the single most important variable, intensity of therapy, will change significantly. But are there any new approaches to therapy on the horizon? Our sketch of the past suggests that few new therapy techniques or approaches have been developed. The same techniques of stimulation, repetition, modelling, compensation, are common to many current studies of therapy. In recent years we have seen the emergence of some novel approaches to therapy, such as constraint induced therapy (CIT) and errorless learning. CIT studies have claimed remarkable success. Errorless learning therapy, that has reportedly shown promise in the treatment of memory disorders, appears to not induce any further improvement that error-full learning therapy. Any behaviour entails brain activity, and recovery of aphasic impairments we can assume entails changes in the brain seen as new dendritic growth, new synaptic connections or the reassembling of cells into new networks. Stem cell transplantation is in the early stages of development and promises new approaches to the problems of progressive brain damage and stroke. Recent research reports the development of pluripotent stem cells

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capable of becoming any of the 220 specialised cells of the body, including neurones. They are derived from human skin cells and can replicate indefinitely in culture (Yu et al., 2007). This exciting development circumvents the main ethical objection surrounding use of human embryos. We have learnt that such medical treatments will need to be carefully combined with behaviourally-based therapy. Pharmacological treatment studies of aphasia, while offering promise originally, have been disappointing, but this appears to be because the early studies failed to include appropriate language therapy (Small, 2000; Walker-Batson, 2000). Pharmacological treatment together with carefully and individually designed behavioural therapy will be combined in the coming years to examine to what extent they can enhance recovery. Connectionist networks are commonly utilised these days to examine hypothetical models of aspects of the language system, and the damaged

language system, on a computer, and have been successfully compared to the real-life aphasic impairments. These artificial models can be utilized in the future to simulate various approaches to therapy. Typically, a connectionist model can be «lesioned» in various ways, by reducing weights on units within the network or removing units in various ways. Networks lesioned to simulate types of aphasic impairment (e.g., paraphasia, agrammatism, anomia) could then provide the basis for testing approaches to therapy. Such questions as intensity of therapy, continuous repetition, errorful vs. errorless approaches, semantically based vs. phonologically based therapy, could be relatively cheaply and quickly tested before applying to real aphasic impairments. These are all guesses for the future. St Augustine was right about the future too: it’s impossible to know it, and the direction aphasia therapy takes over the next era or two could be entirely different.

Bibliographie Bastian, H. C. (1898) A Treatise on Aphasia and Other Speech Defects. London: H. C. Lewis. Bhogal, SK, Teasell, R. & Speechley, M. (2003) Intensity of Aphasia Therapy, Impact on Recovery. Stroke, 34. Breasted, J. H. (1930) The Edwin Smith Surgical Papyrus. Two Volumes. Chicago: University of Chicago Press. Code, C. (1987) Language, Aphasia, and the Right Hemisphere. London: Wiley.

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Coltheart, M. (1983) Aphasia therapy research: the single-case study approach. In: Code, C. & Müller, D.J. (Eds.) Aphasia Therapy. London: Edward Arnold, 193-202. Freud, S. (1891) Zur Auffassung der Aphasien. Eine kritische Studie. Leipzig u. Wien: Deuticke. Head, H. (1926) Aphasia and Kindred Disorders of Speech. 2 Volumes. Cambridge: Macmillan Company. Howard, D. & Hatfield, F. M. (1987) Aphasia Therapy: Historical and Contemporary Issues. Hove and London: Lawrence Erlbaum Associates. Howard, D. & Patterson, K. (1990) Methodological issues in neuropsychological therapy. In: Seron, X. & Deloche, G. (eds.) (1990) Cognitive Approaches in Neuropsychological Rehabilitation. London: Lawrence Erlbaum Associates. Jordan, L. (1998) Partners in care. Bulletin of the Royal College of Speech & Language Therapists. August. Katz, R., Hallowell, B., Code, C., Armstrong, E. Roberts, P., Pound, C. & Katz, L. (2000) A multi-national comparison of aphasia management practices. International Journal of Language & Communication Disorders, 35, 303-314. Simmons-Mackie, N. (1998) A solution to the discharge dilemma in aphasia: social approaches to aphasia management. Aphasiology, 12, 231-239. Small, S. (2000) The future of aphasia therapy. Brain & Language, 227-232. Teak, J. & Code, C. (2008) Milestones in the History of Aphasia: Theories and Protagonists. Hove, east Sussex: Psychology Press. Walker-Batson, D. Use of pharmacotherapy in the treatment of aphasia. Brain & Language, 252-254. Weisenburg, T. H. & Mcbride, K. E. (1935) Aphasia: a clinical and psychological study. New York: The Commonwealth Fund. Wernicke, C. (1874) Der Aphasische Symptomencomplex. Eine psychologische Studie auf anatomischer Basis. Breslau: Cohn & Weigert. Yu, J.Y., Vodyanik, M.A., Smuga-Otto, K., Antosiewicz-Bourget, J., Frane, J.L., Tian, S., Nie, J., Jonsdottir, G.A., Ruotti, V., Stewart, R., Slukvin, I.I., Thomson, J.A. (2007) Induced pluripotent stem cell lines derived from human somatic cells. Science, 318, 1

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Aphasie und verwandte Gebiete 1/ 2009

Chris Code School of Psychology University of Exeter [email protected]

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