The Speech Therapy Methods for Global Aphasia: A Narrative Review

Abstract

Introduction: Global aphasia due to extensive lesions in cortical, subcortical, and white matter of the left hemisphere is a severe acquired language disorder which disrupts all aspects of aural and written language. In the global aphasia, individual's interaction and his social community is generally affected and he needs ongoing rehabilitation, especially speech therapy. The purpose of this study was to investigate the common speech therapy methods for global aphasia and dissuss them based on exsiting evidence to introduce the most effective treatment. speech therapy methods have been reviewed to improve communication, expression, and comperhensive language in global aphasia. The results showed that some of them were effective and some were ineffective. Conclusion: The review suggests that alternative nonverbal, augmentative, and complementary communication methods in the people with global aphasia will produce better results and techniques such as remnant books, the Melodic Intonation Therapy (MIT), and SIPARI methods have been more effective than other methods

Full text

DOI: 10.22122/jrrs.v16i.3565 Published by Vesnu Publications
1- PhD Candidate in Speech Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran AND Department of Speech Therapy,
School of Rehabilitation Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
2- Department of Speech Therapy, School of Rehabilitation Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
3- Assistant Professor, Department of Speech Therapy, School of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
Corresponding Author: Fatemeh Fekar-Gharamaleki, Email: slp.fekar@yahoo.com
http://jrrs.mui.ac.ir
Journal of Research in Rehabilitation of Sciences/ Vol 16/ September 2020
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The Speech Therapy Methods for Global Aphasia: A Narrative Review
Fatemeh Fekar Gharamaleki1, Shima Zarei2, Azar Mehri3
Abstract
Introduction: Global aphasia due to extensive lesions in cortical, subcortical, and white matter of the left
hemisphere is a severe acquired language disorder which disrupts all aspects of aural and written language. In the
global aphasia, individual’s interaction and his social community is generally affected and he needs ongoing
rehabilitation, especially speech therapy. The purpose of this study was to investigate the common speech therapy
methods for global aphasia and dissuss them based on exsiting evidence to introduce the most effective treatment.
Materials and Methods: An electronic search in Web of Science, PubMed, Scopus, Medline, SID, Google Scholar,
Ovid, and Magiran databases for reviewing the common speech therapy methods was performed to obtain relevant
articles published from 1980 to 2020. The keywords used included “Global aphasia”, “Treatment methods”,
“Intervention”, “Speech therapy”, “Communication”, and “Therapy”.
Results: Among 19 related articles, 9 speech therapy methods have been reviewed to improve communication,
expression, and comperhensive language in global aphasia. The results showed that some of them were effective and
some were ineffective.
Conclusion: The review suggests that alternative nonverbal, augmentative, and complementary communication
methods in the people with global aphasia will produce better results and techniques such as remnant books, the
Melodic Intonation Therapy (MIT), and SIPARI methods have been more effective than other methods
Keywords: Commnication; Global aphasia; Language therapy; Speech therapy
Citation: Fekar Gharamaleki F, Zarei S, Mehri A. The Speech Therapy Methods for Global Aphasia: A Narrative Review.
J Res Rehabil Sci 2020; 16: 170-7.
Received: 02.06.2020 Accepted: 26.08.2020 Published: 05.09.2020
Introduction
Global aphasia is the most severe and common clinical
type of language disorder that results in severe
acquired communication deficits in all areas of
language, and these patients have impaired aural
perception and emotional tone, expressive language,
and severe receptive deficits (1-6). Individuals affected
by this complication have severe disorders in all
language modalities (7-9). According to the
classification system by Goodglass and Kaplan, speech
for people with global aphasia is usually limited to
expressing clichéd, obscure words and words that have
already remained in their minds. These patients have
difficulty even expressing simple words and have
difficulty reading skills (8). Except understanding
simple concepts and easy content, the auditory
comprehension in these individuals suffers a great
weakness. These patients seldom use gestures or
drawings spontaneously (9). In addition to speech and
language skills, they have limitations in other
communication skills such as initiation and use of body
and face gestures and tone of voice, but these problems
are inferior to those of speech and language (10-12).
Patients with global aphasia need communication
and language tools to communicate with others (12).
Most treatments for global aphasia include verbal
therapy or complementary-alternative communication
techniques such as the use of communication boards,
a glossary, and a notebook (13). In general, their
therapeutic output is of lower quality than that of
other types of aphasia, and some communication
problems remain even after the intervention (14).
Review Article
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Given the high prevalence of global aphasia and the
extent of damage in language modalities and patients’
need for communication, effective speech therapy
intervention is very important (1,6). So far, several
methods have been designed for patients with global
aphasia with different perspectives (6-10,12-17,19-21).
The preparation and collection of these interventions is
the first step towards describing and examining the
problems and obstacles to the progress of these
patients. The best method is to perform an intervention
that is cost-effective and accessible in any place and
time and for any language, which helps the patient the
most to communicate and use the remaining abilities
(10). In this regard, it is very important to review and
compare effective and efficient treatment methods.
Given that so far no study has been conducted to
collect and describe speech therapy methods in
individuals with global aphasia, the present study tried to
enhance the awareness and easier access of researchers,
therapists, nurses, caregivers, and anyone involved in
some way in the assessment and treatment of people
with global aphasia by collecting various therapeutic
interventions and examining them in more detail.
Therefore, understanding the existing treatment methods
with increasing insight can be applied in clinical and
research areas for patients with aphasia. In the present
study, in addition to reviewing common speech therapy
methods in subjects with global aphasia, the strengths
and weaknesses of each were clearly stated in order to
select the best, most cost-effective, and most efficient
treatment method appropriate to the patient’s condition.
The questions that arose after reviewing the studies and
treatment methods included what characteristics should
a treatment method have in order to be effective? In
other words, in today’s world, where early treatment and
increasing the quality of life (QOL) of patients are
among the most important indicators of intervention,
what is the best, most efficient, and most cost-effective
treatment method given the patient and family
conditions?
Materials and Methods
The aim of this study is to collect and review the
common methods of speech therapy in subjects with
global aphasia, details, conditions, and application of
the method, the length of the method and finally, the
extent of their effectiveness. The search process was
implemented in two general steps. First, in order to get
an inclusive list of speech therapy methods for
individuals with global aphasia, an extensive search
from 1980 to 2020 was performed in the Medline,
Scopus, PubMed, and Web of Science databases using
the Global Aphasia keyword with at least one of the
words “Language Therapy, Communication, Speech
Therapy, Intervention, Treatment Method”. In addition,
a search was made in the Scientific Information
Database (SID) and Magiran using the keywords
“Speech Therapy, Communication, and Global
Aphasia” in order to check which of the methods had
been performed and reported in our country. If the
above keywords were used in the title, abstract, or
keywords, the articles would enter the study. The
inclusion criteria included studies published in both
English and Persian. Thus, a list of speech therapy
methods in people with global aphasia was extracted.
In the second stage, in order to obtain more complete
information about the speech therapy methods, using
the name of the treatment method with at least one of
the words “Accuracy, Efficacy, Reliability”, the above
databases were referred again and the studies
containing these words in the title, abstract, or
keywords, entered the review. Finally, the effective
therapies on language and communication in patients
with global aphasia were included in the study. To
prevent bias, the articles were extracted by two
independent researchers and if the articles were not
included, the reason was mentioned. In cases where
there was disagreement between the two researchers,
the article was reviewed by a third person.
Results
Following studies and searches in various databases,
out of a total of 25 research and review articles, 19
ones that met the inclusion criteria, were selected.
Accordingly, 9 methods of speech therapy in this
field as well as their detailed information were
extracted in the next steps. The search for this
information included the name of the treatment
method, designer, patients’ language, year of
publication, related studies, and their positive and
negative results. Despite sending a request to the
corresponding author or editor of the publishing
journal for access to the full text of some of the
studies, they were removed from the review due to
lack of response. It should be noted that some of these
methods were old and their introduction dated back to
several decades ago; while these methods are not only
still important in the treatment of patients with global
aphasia, but the basis of many therapeutic tasks in
patients is also derived from these old methods. Since
the objective of this study was to collect all existing
methods and its approach did not consider only new
or widely used methods, these methods were also
discussed in the present study and their necessity,
importance, and use were explained in the relevant
section (Table 1).

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Table 1. Speech therapy methods in global aphasia
Name of the treatment method
Name of the designer
Type of method
Visual action
Helm-Estabrooks et al. (17)
Nonverbal
Melodic intonation therapy
Sparks and Holland (20)
Verbal
Nonverbal communication system
Johannsen-Horbach et al. (6)
Nonverbal
Drawing
Ward-Lonergan and Nicholas (13)
Nonverbal
Computerized language intervention system
McCall et al. (21)
Nonverbal
Picture books
Ho et al. (9)
Verbal
Hand and arm gestures
Rose (21)
Nonverbal
Music therapy
Jungblut et al. (22)
Verbal
Special therapies
Alexander and Loverso (7)
Verbal
Visual Action Therapy (VAT): This nonverbal
treatment was developed by Helm-Estabrooks et al. in
English. The VAT method enables subjects with
global aphasia to present symbolic movements for
mental stimuli which are not visually illustrated,
which is performed in three steps (17). At each stage,
a score of 1, 0.5, or 0 is given for completely correct
answers, corrected answers, and incorrect answers,
respectively (2). All instructions are presented non-
verbally (2,15).
In a study, eight 37- to 70-year-old men with
global aphasia, with right hemiplegia, were evaluated
using the VAT method 12 to 14 weeks after the onset
of the disease. Prior to initiation, all patients used
standard speech therapy techniques. The method was
performed in 30-minute sessions with an average of 5
sessions per week and the patients completed the
treatment program in 4 to 14 weeks (15).
In another study, the VAT method was
implemented on two adult men, 66 (A) and 81 (B)
years old. Both had normal intelligence and were
right-handed and had suffered from global aphasia
following a cerebrovascular accident (CVA) in the
left hemisphere, 12 and 16 months, respectively. The
patients went through 30 sessions of treatment each
for 55 minutes and the interval between sessions was
1-3 days (2). Finally, the positive effects of treatment
were reported in most stages for patient A and in half
of the stages for patient B, however the generalization
to untreated cases was very weak (2).
Melodic Intonation Therapy (MIT): This method
was first developed by Sparks and Holland in 1976 in
English to establish verbal communication in patients
with global aphasia with limited verbal output (20).
The MIT method is specifically for speech
improvement, but some experts have reported its
successful use in reducing nonfluency and
pronunciation errors. However, it is not effective for
patients with aural perception impairments
(5,6,16,17). In a study, a physiological model to
justify this method and its success was attributed to
the superiority of the right hemisphere for processing
music and melodic speech (18).
To understand the MIT method, one must first
distinguish between the tone of a sentence or
propositional phrases and the tone of the voice, which,
unlike singing, has a more limited range of musical
notes (16,18). In other words, a range of 3-4 notes is
required for sufficient variety in patterns (17). Each
stage of speech consists of 12 sentences or short
phrases related to the needs and background of the
patient. First, with the therapist training, the patient
produces a number of melodic sentences and phrases
as the unit length increases. During the treatment,
dependence on the therapist and reliance on the melody
decreases (2,3,17,18). To progress through the stages,
the patient must score 90% based on the average of 10
consecutive points, and at the end of treatment, the
patient is able to produce a melodic speech in his
sentences (18).
A review of recent research has been very
promising and shows that despite the advantages and
limitations, the MIT method has been successful for
patients with more verbal intensity (3,16-18).
Nonverbal Communication System: Bilsymbols
(NVC): This visual symbolization method was
designed by Johannsen-Horbach et al. in German and
consists of visual, imaginary, or exhibitive lines (6).
When using the NVC system, understandability of the
method is very important for aphasia-free
communication partners (4,18). In this regard, in
addition to very complete lexical content, the method
has some syntactic and grammatical structures and is
suitable and easily understood to meet the needs of
the patient (17). It is also effective for patients with
paralysis of the right half of their body (6).
Lane and Samples, treated four patients with
aphasia as a group, three of whom had global aphasia,
using the Bilsymbols symbolic system, with several
positive results. These subjects underwent routine
aphasia treatment for at least six months and 2
sessions per week, all of whom had moderate
intelligence quotients (IQs) (6). The NVC method
was then performed for each patient for at least two
months and 2 sessions per week. The unexpected
finding of the study was the correct expression of the

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word with its symbol, which was observed in 3
patients (4,6).
Drawing: This is one of the complementary-
alternative communication methods for patients with
global aphasia, developed by Ward-Lonergan and
Nicholas (13).
In the treatment proposed by Lyon and Sims,
strategies were developed to enhance drawing skills in
patients with global aphasia (14). Given their study,
5 patients underwent the Promoting Aphasics’
Communication Effectiveness (PACE) drawing
treatment program within three months. In this
program, interesting visual backgrounds were provided
to the patients to draw graphic drawings of them, with
positive results reported in the study (14,15).
The results of a case study were performed on a
person with global aphasia who was poor at drawing
before the injury. A 61-year-old right-handed man
who developed aphasia after a left hemisphere injury
was examined. His speech in singing, repetition, or
oral reading was indistinguishable, and he was unable
to communicate through writing or gestures, could
not write his name, and had impaired muscle
movements and inability to perform physical
activities. He had gone through common treatment
methods and due to the lack of proper effect, drawing
therapy was used (13). Despite some problems in the
spontaneous start of drawing, an important point after
treatment was that in the presence of a small stimulus
such as a pen and paper, the patient was able to draw
a picture to communicate (15).
Computerized language intervention system: This
system is a diagnostic and therapeutic tool developed
by McCall et al. in English (21). In this method, a
person with global aphasia constructs and writes
various phrases and sentences based on abstract rules
and grammar of language by manipulating symbols
related to nouns and verbs (3,22). This method is used
to improve the semantic aspects and perceptual skills,
but so far this hypothesis has not been confirmed that
it may increase the improvement of speech in patients
with global aphasia (21, 22).
Remnant and pictographic books method: This
method was designed by Ho et al. in English as a
complementary-alternative communication method to
improve communication in people with global aphasia
(9). Picture/touch books contain shapes, diagrams, and
objects, and are designed to be completely personal in
terms of vocabulary and content, and include tickets to a
recent sporting event, holiday photos, information about
religion, and personal interests (3,9,18). Remnant books
are similar to recovered-memory therapy (RMT) and
differs from Scrap.
Arm and Hand Gestures: This procedure was
performed by Rose in English (12). Sometimes
people with global aphasia spontaneously convey
communication concepts using gestures (18).
According to neuropsychological studies, the use of
motor skills and gestures in many people with aphasia
changes after brain injury, but their damage in
understanding and expressing movements is less than
language skills. Therefore, gestures are effective in
improving communication and speech production (5).
In other words, in this treatment, gestures are replaced
by damaged speech and are used to facilitate the
function of verbal communication (12).
In this regard, the study by Kurland et al. used the
Amer-Ind gestures, which was the method of
communication between Native Americans and Indian
Americans (18). Their study was performed on 6
people and was accompanied by good results and all
patients were able to produce words using gestures
(18). In another study of people with phonology and
coding problems and semantic deficits, all participants
had significant improvements in naming images (3,12).
Specific music therapy: This treatment method
was designed by Jungblut et al. (22) based on the
knowledge that in most patients with aphasia, even if
speech output is limited or speech clarity is low, the
patient is able to sing some familiar songs (23).
According to investigations on parallel processing
between speech and music, music can be used to treat
patients with global aphasia (24,28).
One of the methods of music therapy for aphasia is
SIPARI, the main components of which are singing,
intonation, prosody, atmung, rhythm, and
improvisation (23,24). The first stage, mental
preparation and internal singing is an important
educational element and expands the concept of
melody. The atmung exercises then enhance the vital
processes for prosody and prepare the individual for
prosody (24,25). Rhythmic exercises expand the
phonological capabilities of the left hemisphere, and
improvisation helps to improve patient communication
(18,19,21). Finally, therapy helps to establish
spontaneous verbal and non-verbal communication and
improve basic comprehension and expression skills
(26-28).
Music therapy was performed in 2000 on a 57-
year-old man with global aphasia due to cerebral
hemorrhage, alexia, agraphia, and hemiparesis (23). He
did not get an acceptable result after regular speech
therapy, so 3 years after the stroke, the SIPARI method
was started on him. After 20 months of treatment and
follow-up, the patient showed improvement in
spontaneous speech, repetition, and naming, and in the

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last assessment of clinical progress, his speech and
social relations performance and self-confidence
increased (24,25).
Specific treatments: These treatments were
introduced by Alexander and Loverso in English,
which included the results of a two-year scientific
experience of using speech therapy for 22 patients in
the age range of 40-75 years old with global aphasia
(7). According to their study, all participating patients
had left hemisphere infarction and aphasia, and were
right-handed and their mother tongue was English (7).
Initial assessments were performed for 2-5 weeks
after the stroke and treatment was performed in
accordance with the therapist’s decision and based on
the individual’s needs for 4-10 weeks and 6 days a
week in the form of individual, group, and family
education sessions. At the end of the treatment period
and based on the Western Aphasia Battery (WAB)
criteria, global aphasia was detectable in all patients
and none of them were able to speak clearly (3,7,18).
There are other case methods, including
Performance Assessment of Contributions and
Effectiveness (PACE) traditional speech therapy,
used to improve communication in individuals with
global aphasia (7,25-27). Additionally, there are
special therapies that are used to improve defects in
lexical content (27-29). Some complementary
methods are also applied in conjunction with speech
therapy, such as transcranial magnetic stimulation
(TMS), which is involved in improving naming
(3,26).
Discussion
The present study was conducted aiming to collect
and compare common methods of speech therapy in
patients with global aphasia and to address the
features, advantages, and limitations of the methods
and the results of relevant studies; nevertheless, some
of this information was not available in some
methods. This review study can be helpful in
providing readers with a comprehensive view of
speech therapy intervention methods such as
assignments used, target community, treatment areas,
implementation method or progress benchmark, etc.,
and can be a good source for getting knowledge on
the most widely used and important treatment
methods and their justification.
An undeniable fact is that the prognosis of patients
with global aphasia is very poor due to the extent of the
injury and the involvement of multiple cognitive,
speech, and language skills (1,6). These patients may
show improvements, but most of the aphasic features
remain and are detectable in them (7). However, in
evaluating and selecting treatment and determining the
prognosis, it should be noted that patients with aphasia
perform much better in real life than in clinical and
laboratory settings, and there is a chance of cure for
most patients (3,7). To choose the type of intervention,
indicators such as treatment duration, cost, availability,
results, and effects of treatment on the person’s QOL
should be considered (8).
Traditional rehabilitation therapies, despite being
expensive and time consuming, are not effective in
improving functional communication in these patients
(3,7,10). Thus, therapists and researchers alike place
great emphasis on the use of interventions related to
complementary-alternative communication systems
and family training (9,24-26). Studies on the
functional abilities of patients with aphasia have
shown that treatment based on nonverbal
communication skills is the most promising and best
treatment, which is confirmed by a review of studies
in recent years (21,23,25-27).
In patients improved by the VAT method, despite
improving the aural and reading capabilities and
performing pantomime in uneducated subjects, no
improvement was observed in speech language skills
(2,17) and there was a relative generalization of the
trained steps (2). Moreover, they did not use this
method to initiate communication (3,17,18).
The MIT method, with its emphasis on grammar
improvement, provides a relative improvement in oral
expression (19), and its best volunteers are patients
who have better aural comprehension than oral
expression (20). This method is useful for patients
with limited verbal output, but it cannot be said with
certainty that patients with severe global aphasia who
are disabled in all areas of communication will be
treated with this method (3,18-20).
The results of the SIPARI method reported
significant improvements in spontaneous speech,
indicating the successful generalization of the treatment
to semantic and syntactic levels in everyday
communication (30). In this way, rhythmic patterns
improve cognition and improve the ability to name and
repeat (26,27). Despite the favorable results, more
research is required to ensure the effectiveness of this
method.
Complementary-alternative communication
systems used for patients with global aphasia include
spontaneous communication methods such as
gestures and pantomime, and automatic
communication methods such as drawing, graphic
symbols, speech production gestures, and
computerized systems (2,6,9,12-18,21). Most
therapists tried to educate patients to be able to recall

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specific movements from marking systems, but failed
to have significant effects on everyday
communication (3,5,18). The study of pantomime
exercise indicated that the ability to communicate is
improved using movements (12). Using this method,
those around the patient also reported that after
training, the individuals appeared more confident in
social interactions and their ability to use spontaneous
movements increased (5,12).
Despite improved mental health and speech clarity
using the Bilsymbols method (6), other studies
suggested that this method may not be appropriate for
all patients (15); Because even in normal people, it is
difficult to understand the abstract message relative to
the objective one, and people with global aphasia
have additional problems in understanding the
meanings of abstract codes (1). Furthermore, for
individuals with severe hearing impairment,
symbolic-semantic information was more difficult to
understand and express, and they did not have the
cognitive ability to use symbols without the support
of communication partners (1,9).
The results of the computerized methods showed
that by manipulating the symbolic signs related to
nouns and verbs, the patient could express and write
different sentences and phrases based on syntactic
abstract rules (21,30,31), but so far, there has been no
more accurate evaluation confirming the hypothesis
that this method has been able to improve expression
in patients with global aphasia (3,21,22). The findings
showed that various types of communication symbols
with picture/touch and visual books improve the
relationships between patients and their
communication partners successfully (21). Patients
who used these books had better and more
communication and were more successful in
conveying their messages, and according to the
patients and communication partners, using this
method was enjoyable and promising (9).
A review of studies published in recent years
shows that in addition to choosing the proper
treatment method, other indicators also affect the
individual’s recovery and treatment success,
including the choice of appropriate, objective, high-
frequency words and words that are processed in the
right hemisphere (10,32-35). Another important
factor was the intensity of the treatment sessions.
Studies show that the effectiveness of intensive and
daily sessions is higher than regular sessions such as
2 days a week (16).
Limitations
In the present study, only articles published in both
English and Persian were reviewed and the ones in
other languages were not reviewed. On the other hand,
not all of these methods with different studies have
been performed in all languages and cultures, and
therefore their advantages and limitations cannot be
generalized.
In the extensive search conducted, there were few
studies comparing the outcome of treatment with at least
two different methods, and no study was found that
systematically discussed the scientific quality of articles
published on the applications of different treatment
methods. However, these methods make it possible to
conduct research on different patients with almost
similar conditions and to make a relative comparison of
the treatment method for each given language.
Recommendations
So far, limited studies have been conducted on
therapeutic interventions on patients with global
aphasia and their effects. Additionally, due to the
severity of defects and diversity of abilities and
problems in patients with global aphasia, it is
recommended to conduct more extensive research to
treat these patients in different languages and on more
samples, and speech therapists are recommended to
use clinical methods with more confidence and design
new effective therapies.
Conclusion
Review of various interventions suggests that non-
verbal methods are probably more effective and
among the alternative communication methods,
picture/touch books are more enjoyable for patients
and they can take them to different places with
themselves and on the other hand, these methods do
not need special training for communication partners
and are cost-effective. Besides, the MIT and SIPARI
methods in patients with healthy aural perception can
bring the patient to the spontaneous speech level. In
addition, learning these methods is much easier and
makes patients feel more satisfied.
Acknowledgments
The authors would like to appreciate all the
researchers whose treatment methods were used in
this review.
Authors’ Contribution
Fatemeh Fekar-Gharamaleki: Study design and
ideation, study financial, support, executive, and
scientific services, providing study equipment and
samples, data collection, analysis and interpretation of
results, specialized statistics services, manuscript

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preparation, specialized evaluation of the manuscript
in terms of scientific concepts, approval of the final
manuscript to be sent to the journal office,
responsibility for maintaining the integrity of the
study process from the beginning to publication, and
responding to the referees’ comments; Shima Zarei:
study financial, support, executive, and scientific
services, providing study equipment and samples,
data collection, analysis and interpretation of results,
specialized statistics services, manuscript preparation;
Azar Mehri: study financial, support, executive, and
scientific services, manuscript preparation.
Funding
The present study was conducted based on a review
of resources with approval code 65314 and ethics
code IR.TBZMED.REC.1399.637 under the financial
support of Tabriz University of Medical Sciences,
Tabriz, Iran.
Conflict of Interest
The authors declare no conflict of interest. Fekar-
Gharamaleki and Shima Zarei conducted basic studies
related to this project. Fekar-Gharamaleki has been
working as a faculty member at Tabriz University of
Medical Sciences since 2016. Shima Zarei has a
bachelor’s degree from Tabriz University of Medical
Sciences. Dr. Azar Mehri is an assistant professor at
Tehran University of Medical Sciences, Tehran, Iran.
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