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Chapter 21

Global Aphasia: Identification and Management

Richard K. Peach Mackie, & Square, 2001). The prognosis for recovery of
premorbid speech-language abilities is, indeed, poor follow-
ing global aphasia, but these individuals do make significant
improvements in communication skills with treatment dur-
OBJECTIVES ing the first year post-onset (Nicholas, Helm-Estabrooks,
Ward-Lonergan, & Morgan, 1993) and beyond (Naeser
Following the completion of this chapter, the reader will be et al., 2005). Those improvements also occasionally exceed
able to identify the features of global aphasia, its etiology, the outcomes observed in patients with other types of apha-
the patterns of evolution and outcome in global aphasia, and sia (i.e., Broca’s and Wernicke’s aphasia) that are associated
some factors that are related to recovery from this syn- with better prognoses for improvement (Basso & Farabola,
drome. The reader also will be able to provide a rationale for 1997; Kertesz & McCabe, 1977). Identification of new treat-
early intervention with these patients, describe contempo- ments yielding limited but nonetheless positive communica-
rary goals for assessment, and develop treatment plans that tion benefits for these individuals is therefore an important
exploit the residual language capacity and/or other func- advance, particularly when considered in the context of the
tional abilities of patients with global aphasia. Finally, the historically pessimistic views associated with this clinical
reader will be able to identify current testing measures and group.
both impairment-based and socially oriented treatment pro- The central questions regarding outcomes following
grams that emphasize improved language and functional global aphasia concern discovering the patient characteris-
communication and are appropriate for assessing and treat- tics that can be associated with various prognoses and apply-
ing patients with global aphasia. ing these in treatment planning (Peach, 1992). Some recent
studies have attempted to do this by examining outcomes
with regard to the patterns of lesion sites producing global
aphasia (Basso & Farabola, 1997; Kumar, Masih, & Pardo,
Positive developments regarding the rehabilitation of per- 1996; Naeser, 1994; Okuda, Tanaka, Tachibana, Kawabata,
sons with global aphasia have continued to appear in the lit- & Sugita, 1994). Others have investigated the role of an [Au1]
erature since publication of the last version of this chapter. accompanying hemiplegia (Keyserlingk, Naujokat,
Clinicians and families therefore have reasons to be guard- Niemann, Huber, & Thron, 1997; Nagaratnam, Barnes, &
edly optimistic concerning the communication outcomes Nagaratnam, 1996). Still others have employed positron-
from this condition. Among these developments are an emission tomography to identify predictors that might
improved understanding of the cerebral mechanisms under- account for the large amount of variability observed in
lying recovery of auditory comprehension following global recovery from aphasia generally and from global aphasia
aphasia (Zahn et al., 2004); novel approaches to treating specifically (Heiss, Kessler, Karbe, Fink, & Pawlik, 1993; [Au2]
naming, including phonologic treatment (Biedermann, Okuda et al., 1994).
Blancken, & Nickels, 2002) and transcranial magnetic stim- These developments are encouraging especially, because
ulation (Naeser et al., 2005); and extended application of the largest percentage of patients with aphasia referred for
computer-based communication systems to produce sen- speech-language services is composed of those presenting
tences of varying syntactic complexity (Koul, Corwin, & with global aphasia (Sarno & Levita, 1981). Despite the poor
Hayes, 2005; McCall, Shelton, Weinrich, & Cox, 2000). prognosis for recovery of oral language skills following
The emergence of social approaches for language and com- global aphasia, clinicians now have more tools than ever to
munication treatment, some of which have demonstrated make informed decisions regarding both whether and how to
efficacy, also provides an important dimension to rehabilita- treat individuals with global aphasia and the impact that this
tion for global aphasia (Kagan, Black, Duchan, Simmons- treatment will have on the patients’ communication skills.

565
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566 Section IV ■ Traditional Approaches to Language Intervention

FEATURES (superotemporal) areas (Kertesz, 1979) or, alternatively,

both the prerolandic and postrolandic speech zones
Incidence (Goodglass & Kaplan, 1983. The subjects with global apha- [Au3]

Global aphasia may be one of the most frequently occurring sia described by Murdoch, Afford, Ling, and Ganguley
types of aphasia. Previously, incidence rates of between 10% (1986) exhibited large lesions extending from the cortical
and 40.6% have been reported for global aphasia (Basso, surface inferiorly to subcortical areas, including the basal
Della Sala, & Farabola, 1987; Brust, Shafer, Richter, & ganglia, internal capsule, and thalamus. Basso and Farabola’s
Bruun, 1976; Collins, 1986; De Renzi, Faglioni, & Ferrari, (1997) subject with global aphasia had damage to the left
1980; Eslinger & Damasio, 1981; Kertesz, 1979; Kertesz & frontal operculum, Wernicke’s area, the premotor area, the
Sheppard, 1981). Some recent reports, however, suggest supramarginal gyrus, inferior and superior parietal lobules,
that the incidence rate during the acute stage may be even angular gyrus, and Heschl’s gyri. All of these global apha-
higher. Scarpa, Colombo, Sorgato, and De Renzi (1987) sia–producing lesions involved the cortex and were exten-
reported an incidence of 55.1% in an acute sample. All of sive, dominating the left hemisphere. Numerous exceptions
the 108 patients with aphasia included in the study by Scarpa have been reported in the literature, however, suggesting
and colleagues (1987) were assessed between 15 and 30 days that such an extensive lesion may not be necessary to pro-
post-onset and were right-handed with a single, left hemi- duce a global aphasia.
sphere lesion. When these data are combined, they provide Mazzocchi and Vignolo (1979) found global aphasia in
evidence indicating that patients with global aphasia are 3 of 11 cases following lesions that were confined to anterior
prominent among patients with aphasia as a whole. As a regions. In four additional cases, the lesions were deep and
result, they constitute a significant demand on the resources confined to the insula, the lenticular nucleus, and the inter-
of clinical aphasiologists from the acute stages of illness nal capsule. Varying lesion effects also were described by
through the time of maximal recovery. Cappa and Vignolo (1983). Basso, Lecours, Moraschini, and
Vanier (1985) observed global aphasia following discrete
lesions confined to anterior (sparing of postrolandic centers)
Characteristics
or posterior cortical sites. Alexander (2000) suggests that the
Age and Sex comprehension deficit in patients with lesions limited to the
frontal lobe may be the result of inattention, underactiva-
Discrepancies appear in the literature with regard to age and
tion, unconcern, poor problem solving, or perseveration
global aphasia. Some studies suggest no effect of age on global
interacting with modest phonologic and/or semantic deficits
aphasia (Habib, Ali-Cherif, Poncet, & Salamon, 1987; Scarpa
to produce more profound functional comprehension
et al., 1987; Sorgato, Colombo, Scarpa, & Faglioni, 1990),
deficits. Lüders and colleagues (1991) produced global
whereas others report differences only with patients demon-
aphasia during electrical stimulation of the basal temporal
strating Broca’s aphasia (i.e., patients with Broca’s aphasia
region. This region has its white matter in contact with the
tend to be significantly younger than those with global apha-
white matter deep to Wernicke’s area, thereby favoring close
sia). This difference appears to hold true not only for Western
interaction between these two areas. Sugiu, Katsumata,
patients with stroke but also for Indian patients with stroke
Ono, Tamiya, and Ohmoto (2003) observed global aphasia
(Bhatnagar et al., 2002). The older patients in the sample of
in a patient with a subarachnoid hemorrhage of the inter-
Sorgato and colleagues (1990), however, did tend to show
hemispheric fissure identified by computed tomography
atypical aphasias, including global aphasia from brain damage
(CT) and a small ischemic lesion in the territory of the dis-
that was restricted to either anterior or posterior areas.
tal left anterior cerebral artery identified by magnetic reso-
With regard to sex, there appears to be no observable dif-
nance imaging (MRI). Angiography demonstrated an ante-
ference in the distribution of global aphasia (Habib et al.,
rior communicating artery aneurysm and severe vasospasm
1987). Davis (1983) suggested a general bias toward males in
of the A1 segment of the anterior cerebral artery, the M1
the data generated among the VA Medical Centers because
segment of the middle cerebral artery, and the distal internal
of the nature of the population seen at these hospitals.
carotid artery. Conversely, Basso and colleagues (1985)
Further studies, including more representative patient dis-
reported other forms of aphasia following lesions that would
tributions, may be necessary for reliable data regarding the
have been suggestive of global aphasia.
influence of sex on global aphasia. Nonetheless, age and sex
Global aphasia also has been described in patients with
may not be considered to have a differential effect on the
lesions restricted to subcortical regions. Alexander, Naeser,
incidence of global aphasia.
and Palumbo (1987) found global aphasia in association with
one lesion or with a series of primarily subcortical lesions
Site of Lesion
that collectively damaged the striatum-anterior limb of the
Cerebrovascular lesions producing global aphasia have been internal capsule; the anterior, superior, anterosuperior, and
described as involving Broca’s (posterofrontal) and Wernicke’s extraanterior periventricular white matter; and the temporal
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Chapter 21 ■ Global Aphasia: Identification and Management 567

isthmus. Yang, Yang, Pan, Lai, and Yang (1989) also identi- functioning in global aphasia suggests that the loss for these
fied global aphasia in patients with lesions involving the patients may be viewed more appropriately as a variable mix
internal capsule, basal ganglia, thalamus, and anteroposte- of competence and performance deficits.
rior periventricular white matter. Okuda and colleagues
(1994) described four patients with global aphasia who had Comprehension
lesions in the putamen, posterointernal capsule, temporal
Patients with global aphasia may have considerable single-
isthmus, and periventricular white matter of the left hemi-
word comprehension (Alexander, 2000). Several isolated
sphere. Kumar and colleagues (1996) observed global apha-
areas of relatively preserved comprehension following global
sia in their patient following a left thalamic hemorrhage.
aphasia also have been identified in the literature. These
Ferro (1992) as well as Basso and Farabola (1997) investi-
include recognition of specific word categories (McKenna &
gated the influence of lesion site on recovery from global
Warrington, 1978; Wapner & Gardner, 1979), familiar envi-
aphasia. Ferro initially examined 54 subjects during either
ronmental sounds (Spinnler & Vignolo, 1966), and famous
the first month (34 subjects), third month (7 subjects), or
personal names (Van Lancker & Klein, 1990; Yasuda & Ono,
sixth month post onset (13 subjects). He then followed-up
1998; but see also Forde & Humphreys, 1995, for a report of [Au4,5]
each patient at 3, 6, and 12 months and then yearly there-
relatively impaired access to personal names following global
after when possible. The lesions in his group of subjects with
aphasia). In the case of famous personal names, Yasuda and
global aphasia were grouped into five types with differing
Ono (1998) found a distinct advantage for comprehending
outcomes. Type 1 included patients with large pre- and
these items when reading versus listening. They attributed
postrolandic middle cerebral artery infarcts; these patients
this finding to the nonsemantic, referential nature of per-
had a very poor prognosis. The remaining four groups were
sonal names and to the probable processing of these stimuli
classified as follows: type 2  prerolandic; type 3  subcor-
in the patients’ intact right hemispheres. Subjects with global
tical; type 4  parietal, and type 5  double frontal and pari-
aphasia also show relatively better comprehension for per-
etal lesion. Patients in these latter groups demonstrated
sonally relevant information (Wallace & Canter, 1985; Van
variable outcomes, improving generally to Broca’s or
Lancker & Nicklay, 1992).
transcortical aphasia. Complete recovery was observed in
Wallace and Stapleton (1991) analyzed the responses of
some cases with type 2 and type 3 infarcts. In contrast to
subjects with global aphasia on the auditory comprehension
these findings, Basso and Farabola investigated recovery in
portion of the Boston Diagnostic Aphasia Examination
three cases of aphasia based on the patients’ lesion patterns.
(Goodglass & Kaplan, 1983), or BDAE, to identify patterns
One patient had global aphasia from a large lesion involving
of preserved and impaired performance. Their results gen-
both the anterior and posterior language areas, whereas two
erally supported previous claims that distinct patterns of
other patients had Broca’s and Wernicke’s aphasia from
preserved components are absent in global aphasia;
lesions restricted to either the anterior or posterior language
nonetheless, two or three of their subjects did show evidence
areas, respectively. The patient with global aphasia was
of differential performance both within and across tasks.
found to recover better than his two aphasic counterparts,
Interestingly, the scores for each of these subjects were col-
but his overall outcome was considered to be outstanding.
lected during the acute stage of their recovery. The authors
Based on these observations, Basso and Farrabola concluded
speculate that differential auditory comprehension perfor-
that group recovery patterns based on aphasia severity and
mance during acute aphasia may be a useful prognostic
site of lesion may not be able to account for the improve-
indicator.
ment that occasionally is observed in individual patients.
Expression
Language
It has been suggested that patients with global aphasia may
The hallmark of global aphasia is impaired language com- be most severely impaired in their expressive abilities. This
prehension (up to the 30th percentile on the Boston may be a result of the greater contributions of the right
Diagnostic Aphasia Examination [Alexander, 2000]) with hemisphere for comprehension than for expressive behav-
concomitant deficits in expressive abilities (Damasio, 1991; iors (Collins, 1986). The verbal output of many patients
Davis, 1983; Kertesz, 1979) in the context of almost univer- with global aphasia primarily consists of stereotypic recur-
sal buccofacial and limb apraxia (Alexander, 2000). Wallace ring utterances or speech automatisms (Kertesz, 1979).
and Stapleton (1991) suggested that, traditionally, the lin- Some authors have concluded that stereotypic recurring
guistic deficit in global aphasia has been interpreted as a loss utterances are unique to global aphasia (Poeck, De Bleser, &
of language competency (i.e., the knowledge of linguistic Keyserlingk, 1984). Because of this and complementary evi-
rules and operations). According to these authors as well as dence, Selnes and Hillis (2000) speculate that Tan, a patient
others (Rosenbek, LaPointe, & Wertz, 1989), the recent with Broca’s aphasia whose speech was limited to repetitions
clinical evidence demonstrating preserved areas of language of the syllable “tan,” actually may have presented with an
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568 Section IV ■ Traditional Approaches to Language Intervention

atypical global aphasia rather than the historically accepted specific relationship exists in aphasia between cognitive non-
diagnosis of Broca’s aphasia. verbal impairment and breakdown of the semantic-lexical
Stereotypes have been described as being either nondic- level of integration of language” (p. 48).
tionary verbal forms (unrecognizable) or dictionary forms Rossor, Warrington, and Cipolotti (1995) demonstrated [Au7]
(word or sentence) (Alajouanine, 1956). Blanken, Wallesch, relatively preserved calculation skills in a patient with global
and Papagno (1990) examined 26 patients demonstrating aphasia secondary to progressive atrophy of the left tempo-
the nondictionary forms of speech automatisms. Of these ral lobe. Together with previous reports of selective impair-
cases, 24 were classified as having global aphasia. The other ment of calculation in patients with intact language skills,
patients demonstrated signs more closely associated with the authors posited that this double dissociation reflects a
Broca’s and Wernicke’s aphasia. Although speech automa- functional independence between the two domains of
tisms frequently were associated with comprehension dis- behavior (i.e., that calculation skills are not dependent on
turbances, the observed variability in language comprehen- the language processing system). Because selective impair-
sion among these patients suggests that speech automatisms ment of calculation skills has been associated with left pari-
cannot be used to infer the presence of severe comprehen- etal lesions, the authors also suggested that lesions produc-
sion deficits. Blanken and colleagues. (1990) proposed that ing language disturbances that spare the parietal lobe may be
speech automatisms relate only to speech output and do not associated with preserved calculation skills.
necessarily indicate the presence of severe comprehension
deficits.
Communication
Recurring utterances among individuals with global aphasia
Cognition
was addressed previously. Those who exhibit only recurring
The cognitive abilities of patients with brain damage often are consonant-vowel syllables (e.g., “do-do-do” or “ma-ma-ma”)
assessed by administration of the Raven’s Colored Progressive often give the impression of somewhat preserved commu-
Matrices (Raven, 1965), or RCPM, a nonverbal test of analog- nicative abilities in that they may make use of the supraseg-
ical reasoning. Conflicting results have been reported regard- mental aspects of speech (Collins, 1986). The use of
ing the performance of subjects with aphasia relative to that of suprasegmentals in conversational turn taking may appear to
patients with left brain damage but without aphasia. Some indicate that the patient with aphasia is producing utter-
studies have found that subjects with aphasia perform at lower ances with some communicative intent. deBlesser and Poeck
levels (Basso, Capitani, Luzzati, & Spinnler, 1981; Basso, De (1984) studied a group of patients with global aphasia and
Renzi, Faglioni, Scotti, & Spinnler, 1973; Colonna & Faglioni, found that they did not exhibit prosodic variability to the
1966), but others have failed to show any significant difference extent necessary for conveying communicative intent. The
between these two groups (Arrigoni & De Renzi, 1964; Piercy utterances used for analysis, however, were limited to those
& Smith, 1962). Collins (1986) has reported significant posi- elicited during formal testing, and they may not have
tive correlations between the language ability of subjects with reflected the spontaneous use of inflection to convey intent
global aphasia and their performance on the RCPM. The sub- (Collins, 1986). deBlesser and Poeck (1985) subsequently
jects in the Collins study were in the early stages of recovery, analyzed the spontaneous utterances of a group of subjects
and eventually, these subjects achieved RCPM scores similar with global aphasia and output limited to consonant-vowel
to those of subjects with less severe aphasia. recurrences. Utterances were sampled during interviews in
Using a modified version of the RCPM to minimize the which the examiner asked a series of open-ended questions,
potential effect of unilateral spatial neglect, Gainotti, and the length of the utterances and their pitch contours
D’Erme, Villa, and Caltagirone (1986) compared acute and were analyzed for variability. The authors concluded that
chronic subjects with varying types of aphasia to normal both length and pitch appeared to be stereotypic and that
[Au6] controls, subjects with right hemisphere damage, and sub- the prosody of these patients did not seem to reflect com-
jects with left hemisphere damage but without aphasia. In municative intent. The appropriateness of these consonant-
this study, the subjects with aphasia performed worse than vowel recurring utterances with regard to turn taking
the subjects in the other groups. Further, the patients with remains questionable. These findings highlight the marked
global aphasia and with Wernicke’s aphasia scored the poor- discrepancy that exists between research outcomes and clin-
est in comparison to those in the other aphasic groups ical reports. deBlesser and Poeck (1985) suggest that the
(anomic, Broca’s, and conduction). These results were simi- contributions to conversation for which these patients are
lar to those obtained by Kertesz and McCabe (1975). credited may, in fact, be the result of the communicative
Gainotti and colleagues. (1986) did not obtain differences partner’s need for informative communication rather than
relative to the severity of aphasia, but they did link poor per- the patient’s use of prosodic elements to convey intent.
formance on the RCPM to the presence of receptive semantic- In a study by Herrmann, Koch, Johannsen-Horbach, and
lexical disturbances. Gainotti colleagues conclude that “a Wallesch (1989), a group of patients with chronic and severe
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Chapter 21 ■ Global Aphasia: Identification and Management 569

nonfluent aphasia were described in terms of their communi- and Chaudhary suggest this might be the result of heavy
cation strategies and communicative efficiency. The patients reliance on verbal responses for establishing a diagnosis of
presented with either severe Broca’s or global aphasia (50%). depression. Also, patients with global aphasia tend to be
[Au8] The results showed that the efficiency of the patients’ com- excluded from treatment studies because of their severe
munication depended on the type of question to which they comprehension deficits. In a case report of a patient with
were asked to respond. As might be expected, superior per- chronic global aphasia hospitalized for deteriorating mental
formance was observed for responses to yes/no questions status, these authors describe positive benefits from admin-
(e.g., “Did your illness occur suddenly?”) when compared to istration of the psychostimulant methylphenidate for treat-
interrogative pronoun questions (e.g., “How long have you ment of his major depression. From a pre-treatment state
had language problems now?”) and narrative requests (e.g., characterized by drowsiness and lethargy, sad affect, and an
“Tell me what happened to you after you took ill.”). inability to participate in his care, the patient improved
Herrmann and colleagues (1989) reported that the patients within 72 hours of achieving a therapeutic dose (15 mg/day)
used mostly gesture in their responses to the yes/no ques- to become more alert, smiling, attentive, and actively
tions. The other types of questioning require increased ver- involved in his care. These changes resulted in his improved
bal output and, thus, created the need for more complex candidacy for rehabilitation, and on referral, he reportedly
communicative responses from the patients. made significant gains in speech-language treatment that
In examining the communication strategies utilized, included producing single words, following simple com-
Herrmann and colleagues (1989) found that patients rarely mands, and imitating gestures. Discontinuation of his med-
took the initiative or expanded on topics. The most frequent ications, including the methylphenidate, secondary to two
strategies reported by these authors were those enabling the generalized tonic-clonic seizures resulted in a return to his
patients to secure comprehension (e.g., indicating compre- previous apathetic state within a week.
hension problems or requesting support for establishing
comprehension). Herrmann and colleagues concluded that
patients with global aphasia rely most heavily on nonverbal
ETIOLOGY
communication. As described, the majority of lesions producing global apha-
[Au9] Marshall and colleagues (1997) also investigated the effi- sia are extensive and involve both pre- and postrolandic
ciency of different communication strategies used by three areas. The blood supply for these areas is via the middle
patients with severe aphasia: A patient with Broca’s aphasia cerebral artery, which is the largest branch of the internal
communicated primarily through writing and drawing; a carotid artery, branching at the point of the sylvian fissure.
patient with Wernicke’s aphasia communicated primarily Because of the extent of the lesion, global aphasia most com-
through speaking; and a patient with global aphasia and monly results from a cerebrovascular event, the locus of
apraxia of speech communicated primarily through gestur- which is in the middle cerebral artery at a level inferior to
ing with a few single words. Marshall and colleagues the point of branching. When accompanied by hemiplegia,
assessed each patient’s communicative efficiency and the the event causing global aphasia tends to be thrombotic
degree of communicative burden assumed by a partner dur- more than embolic (Collins, 1986). The stroke mechanism
ing a declarative message exchange task that was evaluated causing global aphasia without hemiparesis, however, is het-
using a visual analogue scale. The investigators also analyzed erogeneous (Bang et al., 2004; Hanlon, Lux, & Dromerick,
the effects of context and shared knowledge on efficiency in 1999). Greater late recovery may be associated with large
communicative interactions by varying the extent of the hemorrhages (Alexander, 2000).
raters’ awareness of the message contents (e.g., no knowl- Not all occurrences of global aphasia are the result of a
edge or partial or full knowledge). Their results demon- cerebrovascular event in the middle cerebral artery.
strated that the efficiency of communication by the patient Interestingly, Wells, Labar, and Solomon (1992) reported a
with global aphasia approximated that of the most efficient temporary case of global aphasia because of simple partial
patient (i.e., the patient with Broca’s aphasia). Also, the bur- status epilepticus. The aphasia lasted during a period in
den imposed by his gestural strategy was nearly as low as the which periodic lateralized epileptiform discharges occur.
writing and drawing of the patient with Broca’s aphasia. Wells and colleagues reported that the patient’s language
These findings support the effectiveness of the nonverbal returned to near normal during the 24 hours following the
strategies used by patients with global aphasia and further seizures. A case of rapidly developing global aphasia and
reinforce their training as a target of rehabilitation. personality change in a young woman secondary to demyeli-
nating disease also is described in the case records of the
Massachusetts General Hospital (Anonymous, 1996). An
Affect
MRI scan of the brain with gadolinium showed multiple
Depression following aphasia has been “underrecognized enhancing white matter lesions predominating in the sub-
[Au10] and undertreated” (Masand & Chaudhary, 1994). Masand cortical and periventricular white matter, the posterior limb
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570 Section IV ■ Traditional Approaches to Language Intervention

of the left internal capsule, and the corona radiata and cen- period between 6 and 12 months or more post-onset
trum semiovale bilaterally. Treatment with corticosteroids (Kertesz & McCabe, 1977; Nicholas et al., 1993; Sarno &
resulted in minimal improvements; administration of cyclo- Levita, 1979, 1981). In the study by Kertesz and McCabe
phosphamide, an anti-inflammatory/immunologic agent, (1977), significantly greater improvement was noted in
produced steady improvement. No other information was treated versus untreated patients with global aphasia during
provided regarding her speech-language outcome. Katz, this period, although the authors attributed this gain at least
Shetty, Gobin, and Segal (2003) reported a case of transient partially to subject heterogeneity. In the studies by Sarno
global aphasia resulting from a giant dural arteriovenous fis- and Levita (1979, 1981), improvement was most accelerated
tula of the superior sagittal sinus that resolved after fistula between 6 and 12 months poststroke. Nicholas and col-
embolization. Global aphasia also was reported following a leagues (1993) found different patterns of recovery for lan-
ruptured anterior communicating artery aneurysm and guage and non-language skills following longitudinal
vasospasm (Sugiu, Katsumata, Ono, Tamiya, & Ohmoto, administration of the Boston Assessment of Severe Aphasia
2003). His symptoms improved following endovascular (Helm-Estabrooks, Ramsberger, Morgan, & Nicholas,
treatment of the aneurysm. 1989), or BASA, an instrument developed specifically to
evaluate communication performance in patients with
severe aphasia. Substantial improvements in praxis and oral-
RECOVERY gestural expression were noted only during the first 6 months
The outlook for recovery from global aphasia tends to be post-onset, whereas similar improvements in auditory and
bleak. For this reason, the term “global aphasia” may be reading comprehension were observed only between 6 and
more prognostic than descriptive (Peach, 2004). Kertesz and 12 months post-onset. Based on these findings, the authors
McCabe (1977) reported that the group of subjects with stressed the need for analyzing subsets of communication
global aphasia in their study generally demonstrated limited skills rather than overall scores to evaluate recovery from
language recovery, a pattern similar to that reported by global aphasia.
Wapner and Gardner (1979). When assessing the language
recovery that does occur, better improvement is demon-
Evolution
strated in comprehension than in expression (Lomas &
Kertesz, 1978; Prins, Snow, & Wagenaar, 1978). With The majority of patients with global aphasia will not recover
regard to recovery of nonverbal cognitive abilities, Kertesz to less severe forms of the disorder. Some patients, however,
and McCabe (1975) found a precipitous and parallel rate of will improve to the extent that they evolve into other apha-
improvement for RCPM and language performance during sic syndromes. A number of studies have documented these
the first 3 months post-onset. During the next 3 months, changes using a variety of assessment instruments and test-
performance on the RCPM continued to increase substan- ing schedules.
tially, surpassing language performance that was only mildly Six studies used the Western Aphasia Battery (Kertesz,
improved from levels attained at the end of the first 3 months. 1982), or WAB, to assess language performance during the
Patients appeared to reach a plateau in both RCPM and lan- acute period of recovery and at regular intervals for up to
guage performance during the period between 6 and 12 month 1 year (or more) post-onset. Kertesz and McCabe (1977)
post-onset. Overall, performance on the RCPM by the tested 93 subjects with aphasia between 0 and 6 weeks post-
patients with global aphasia did not exceed approximately onset and found that 5 of their 22 subjects with global apha-
50% of the maximum attainable score. sia progressed to other syndromes, including Broca’s,
In relation to the recovery observed in other types of transcortical motor, conduction, and anomic aphasia after
aphasia, Kertesz and McCabe (1977) described patients with 1 year or more. Siirtola and Siirtola (1984) classified subjects
global aphasia as having the lowest recovery rate. With with aphasia within the first 2 weeks after hospitalization. At
regard to the temporal aspects of recovery in global aphasia, 1 year post-onset, 6 from among 14 subjects with global
differences have been reported depending on whether the aphasia had evolved to other syndromes, including Broca’s,
subjects were receiving speech and language treatment. For conduction, anomic, and Wernicke’s aphasia, or, in the case
patients with global aphasia not receiving treatment, of one subject, had recovered completely. For 1 year,
improvement appears to be greatest during the first months Holland, Swindell, and Forbes (1985) followed 15 patients
post-onset (Kertesz & McCabe, 1977; Pashek & Holland, who had been classified as having global aphasia immedi-
1988). Siirtola and Siirtola (1984) observed the greatest ately after stroke. In this study, classifications were based on
improvement in their untreated subjects during the first results obtained from the WAB as well as from clinical
6 months post onset. impressions. Several patterns were observed at the end of
Patients with global aphasia receiving treatment, how- the first year: Two patients (in their 30s) returned to normal
ever, demonstrate substantial improvements during the first language functioning, two (in their 40s) evolved to Broca’s
3 to 6 months but also continued improvement during the aphasia, two (59 and 61 years of age) evolved to anomic
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Chapter 21 ■ Global Aphasia: Identification and Management 571

aphasia, two (in their 70s) evolved to Wernicke’s aphasia, Laska, Hellblom, Murray, Kahan, and Von Arbin (2001)
and two (in their 80s) remained global aphasic. The five studied the natural course of aphasia during the acute phase
remaining subjects died during the course of the study. and at 3, 6, and 18 months after stroke onset in 119 consec-
Pashek and Holland (1988) described the evolution of 11 utive, unselected patients. The median time for acute testing
subjects with global aphasia from among a larger group of was 5 days (range, 0–30 days); 90% of all patients were
32 subjects who were followed for at least 6 months. tested within 11 days. Clinical tests included the “Grunntest
Language performance was assessed by repeated administra- for aphasi” (Reinvang, 1985, as cited in Laska et al., 2001), a [Au11]
tion of the WAB, these subjects with aphasia were classified test that the authors described as being similar to the WAB;
on the basis of descriptive criteria rather than WAB typol- the Amsterdam-Nijmegen-Everyday-Language-Test, or
ogy. All subjects were evaluated within the first 5 days after ANELT, which is a measure of functional verbal communi-
stroke. Four of these patients evolved to less severe syn- cation; and the Token Test. A subjective ranking of aphasia
dromes, including Broca’s, Wernicke’s, and anomic aphasia. severity also was obtained. Recovery was determined by the
Two patients evolved to a less severe but unclassifiable apha- degree of change in ANELT scores. A vast majority of the
sic syndrome. One subject recovered normal language, and patients had either global, Wernicke’s, or conduction apha-
two subjects demonstrated symptoms of dementia. Mark, sia. Improvements were observed in all types of aphasia,
Thomas, and Berndt (1992) reported the 1-year outcomes of including global aphasia. A positive correlation was found
13 patients initially classified as having global aphasia at 7 to for initial severity and degree of recovery. Of six patients
10 days post-onset. One patient was no longer aphasic, who were diagnosed initially with global aphasia and were
whereas seven patients recovered to a less severe form of available at least three times during 18 months, four evolved
aphasia. Among the latter, two patients recovered to to mixed nonfluent aphasia, one to conduction aphasia, and
Wernicke’s aphasia, two recovered to conduction aphasia, one to mixed fluent aphasia (the category of mixed aphasias
and three recovered to anomic, Broca’s, and transcortical on the Reinvang test includes the presence of two or more
motor aphasias, respectively. Finally, 9 of 13 patients with aphasic syndromes).
global aphasia followed by McDermott, Horner, and One apparent explanation for the discrepancies among
DeLong (1996) evolved to other forms of aphasia. Seven of these studies might be the greater instability of language
these patients evolved to Broca’s aphasia, and two evolved to scores and, therefore, aphasia classifications obtained during
Wernicke’s aphasia. the first 4 weeks after stroke versus those obtained after the
Nicholas and colleagues (1993) assessed 17 patients with first month post-onset. McDermott and colleagues (1996)
global aphasia as well as seven other patients with severe found greater magnitude-of-change scores and frequencies
aphasia for 2 years after the onset of their aphasia to describe of aphasia type evolution in subjects tested during the first
the patterns of recovery. Patients were scheduled for testing 30 days post-onset versus those tested during the second
with the BASA at 1 to 2 months after the onset of their apha- 30 days post-onset. Aphasia tends to be more severe during
sia and at every 6-month anniversary of their strokes there- the acute stage, giving observers an initial impression of
after up to 24 months. Of the patients with global aphasia global aphasia. This symptomatology may be fleeting, how-
initially, four changed classification during this period, and ever, and result in a seemingly greater potential for patients
the remaining 13 continued to be classified as having global to evolve to a less severe aphasic syndrome following this
aphasia. For the patients who did evolve, one changed to a early period (Table 21–1).
mild Wernicke’s aphasia and changed to mixed nonfluent Holland and colleagues (1985) as well as Pashek and
aphasia. Holland (1988), however, found that patients with global
Sarno and Levita (1979) investigated recovery from aphasia who do progress to some other form of aphasia
global aphasia using selected subtests of the Neurosensory demonstrate changes that extend into the first months post-
Center Comprehensive Examination for Aphasia (Spreen & onset. In some cases, the global aphasia may not begin to
Benton, 1977) and the Functional Communication Profile evolve until after the first month has passed. In addition,
(Sarno, 1969), or FCP. Classification of aphasia was based on Reinvang and Engvik (1980) initially assessed their subjects
clinical impressions as well as language test scores. In the with aphasia between 2 and 5 months after their injuries
study by Sarno and Levita (1979), the earliest language (mean, 3 months) and found that four of the seven subjects
observations were collected at 4-weeks post-onset, with a with global aphasia had evolved to a less severe Broca’s, con-
variation of no greater than plus or minus 1 week. Repeated duction, or unclassifiable syndrome at retesting. The retest-
testing was continued until 1 year after the stroke. In con- ing was completed no sooner than 1 month after initial test-
trast to the above studies, none of these 14 subjects with ing, with a mean time of 7.5 months after injury and a range
global aphasia evolved to another type of aphasia by the end of 3 to 30 months. Based on these findings, the discrepancies
of the year. Similar results were observed in a follow-up in recovery from global aphasia reported in these studies do
study of seven subjects with global aphasia (Sarno & Levita, not appear to be the result simply of the time at which the
1981). initial language observations were recorded. Apparently,
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572 Section IV ■ Traditional Approaches to Language Intervention

TABLE 21–1

Proportion of Subjects with Global Aphasia Evolving to Less Severe Aphasic Syndromes or Normal Language
with Time of Initial Testing after Cerebral Injury

Study Subjects (n) Initial Testing % Evolveda

Holland, Swindell, & Forbes (1985) 10 Immediately 80

Pashek & Holland (1988) 11 0–5 days 64
Laska, Hellblom, Murray, Kahan, &Von Arbin (2001) 6 0–30 days 100
Mark, Thomas, & Berndt (1992) 13 7–10 days 62
Siirtola & Siirtola (1984) 14 0–2 weeks 43
Kertesz & McCabe (1977) 22 0–6 weeks 23
McDermott, Horner, & DeLong (1996) 13 0–6 weeks 69
Sarno & Levita (1979) 11 4 weeks 0
Sarno & Levita (1981) 7 4 weeks 0
Nicholas, Helm-Estabrooks, Ward-Lonergan, & Morgan (1993) 17 1–2 months 24
Reinvang & Engvik (1980) 7 2–5 months 57
a
End-stage assessments were completed between 6 to 12 months post-injury in all studies except Kertesz & McCabe (1977), Reinvang & Engvik (1980), Nicholas et al. (1993),
McDermott and colleagues (1996), and Laska and colleagues (2001). Only 10 of the subjects with global aphasia studied by Kertesz and McCabe (1977) were assessed at 1 year
or more post-onset. Specific data for the subjects with global aphasia of Reinvang & Engvik (1980) were not reported; the mean time post-onset for the end-stage observations
of all subjects with aphasia in their study was 7.5 months, with a minimum time of 3 months post-onset. Fifteen of the 17 subjects with global aphasia followed by Nicholas
and colleagues (1993) were assessed at 24 months post-onset; final testing for the remaining two subjects was completed at 18 months post-onset. Re-evaluation for the 13 sub-
jects with global aphasia tested by McDermott and colleagues (1996) occurred approximately between 1 and 6 months post-onset, with a minimum intervening period of at
least 30 days. The patients of Laska and colleagues (2001) received follow-up at 18 months post-onset of their aphasia.

evolution from global aphasia is the result of a complex The variability in evolution patterns and age effects identi-
interaction among a number of heretofore incompletely fied by these authors is intriguing and suggests the need for
understood factors. further large-scale research studies in this area.

Hemiplegia
Prognostic Factors
Occasionally, global aphasia occurs without an accompany-
Age
ing hemiparesis (Bogousslavsky, 1988; Ferro, 1983; Van
Following global aphasia, a patient’s age appears to have an Horn & Hawes, 1982). Motor abilities may be preserved fol-
impact on recovery: The younger the patient, the better the lowing dual discrete lesions occurring in the frontal and
prognosis (Holland et al., 1985; Pashek & Holland, 1988). temporoparietal regions, a single frontotemporoparietal
Age also may relate to the type of aphasia at 1 year post- lesion, or a single temporoparietal lesion. Absence of a
stroke. For example, in the study reported by Holland and hemiparesis in global aphasia may be a positive indicator for
colleagues (1985), younger patients with global aphasia recovery (Legatt, Rubin, Kaplan, Healton, & Brust, 1987;
evolved to a nonfluent Broca’s aphasia, whereas older Tranel, Biller, Damasio, Adams, & Cornell, 1987). Tranel
patients evolved to increasingly severe fluent aphasias with and colleagues (1987) described patients with global aphasia
advancing age. The oldest patients remained global aphasic with dual discrete lesions (anterior and posterior cerebral)
(see above). that spared the primary motor area. The global aphasia of
Whether age can be considered a prognostic indicator these patients aphasia improved significantly within the first
has yielded differing conclusions. Advanced age has been 10 months post-onset. Deleval, Leonard, Mavroudakis, and
found to have a negative influence on recovery (Holland & Rodesch (1989) reported two cases of global aphasia without
Bartlett, 1985; Holland, Greenhouse, Fromm, & Swindell, hemiparesis following discrete prerolandic lesions.
1989; Marshall & Phillips, 1971; Sasanuma, 1988) and to be Although both of these patients exhibited mild right arm
an insignificant predictor of recovery (Hartman, 1981; weakness initially, this motor disturbance cleared within 48
Kertesz & McCabe, 1977; Sarno, 1981; Sarno & Levita, hours of onset. The patients reported by Deleval and col-
1971). Pashek and Holland (1988) noted specifically that age leagues (1989) showed rapid recovery yet continued to
appeared to predict a poor prognosis for change in global exhibit what the authors referred to as a residual motor
aphasia but also identified a number of exceptions to this aphasia. The patient described by Basso and Farabola (1997)
rule. Thus, age cannot be considered an absolute predictor. experienced global aphasia and a right hemiparesis that
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Chapter 21 ■ Global Aphasia: Identification and Management 573

cleared within a few days following a single, left frontotem- recovered to a pattern most like transcortical motor aphasia,
poral lesion. Although severely aphasic at the initiation of with relative preservation of repetition and improved com-
treatment 40 days post-onset, the patient’s language out- prehension and naming. Cluster 3 included four patients
come 2.5 years later was described as “outstanding.” with a mean AQ of 13.9. These patients demonstrated low-
Nagaratnam and colleagues (1996) examined language level, dysfluent speech; marked comprehension impairment;
recovery at 3 months poststroke in 12 patients diagnosed minimal or no repetition; and severely defective naming
with global aphasia without hemiparesis 4 to 8 days post- characterized by perseverative monosyllabic utterances.
onset. Eight patients with single lesions in either anterior Lesioning of the left pre- and postcentral gyri involving the
language cortex or posterior language cortex recovered to central and posterior parietal vascular territories was found.
no more than mild levels of impairment. Four patients with At follow-up, increased speech fluency and improved com-
lesions in both anterior and posterior language areas contin- prehension were observed, accompanied by inconsistent
ued to have severe language impairments. changes in repetition and naming. All members of this
Global aphasia without hemiparesis does not necessarily group evolved to a pattern of Wernicke’s aphasia. Degree of
result in extensive language recovery. Keyserlingk and col- recovery was related to group subtype.
leagues (1997) found that chronic patients with global apha-
sia and no history of hemiparesis secondary to a single, large
Neuroimaging Patterns
lesion of the left perisylvian region did not fare any better
with regard to language outcome than did their counterparts Both CT and functional MRI (fMRI) have been used to esti-
with global aphasia and hemiparesis from the time of onset. mate outcome from global aphasia. In a two-part study,
The critical difference between the two groups for motor, Pieniadz, Naeser, Koff, and Levine (1983) investigated the
but not language, function depended on the degree to which relationship between hemispheric asymmetries and recovery
the patients’ lesions extended into the subcortical white mat- from aphasia. The first part of the study involved the analy-
ter and nuclei. Eight of the 11 patients studied by Bang and sis of hemispheric asymmetry in a large group of subjects
colleagues (2004) showed minimal improvement 8 weeks with aphasia and in a group of control subjects without
after stroke onset. Three patients demonstrated the classical aphasia. The results demonstrated significant similarity and
pattern of dual lesions in the left inferior frontal gyrus and consistency in hemispheric asymmetry for both groups. The
the superior temporal gyrus, five patients exhibited single most frequent asymmetry involved left-greater-than-right
lesions of either the left inferior frontal gyrus or the superior occipital width. Frontal width was greater in the right hemi-
temporal gyrus, and three patients had a subcortical or corti- sphere than in the left hemisphere. Length also was greater
cal lesion outside the perisylvian area. Language recovery in the left occipital region. For frontal length, the hemi-
could not be predicted by lesion location. spheres were typically equal.
Hanlon, Brown, and Gerstman (1999) found three dis- In the second part of the study by Pieniadz and colleagues
tinct subtypes of global aphasia in 10 patients without hemi- (1983), recovery patterns were examined in a group of sub-
paresis. The subtypes were associated with different patterns jects with global aphasia. These researchers found larger
of language outcome 10 to 12 weeks after their strokes. The right occipital widths and lengths on CT scans for subjects
auditory-verbal subtest scores and the aphasia quotient (AQ) demonstrating superior recovery of single-word compre-
from the WAB were entered into a cluster analysis to define hension, repetition, and naming. Pieniadz and colleagues
the groups. Lesion patterns also were identified. Four suggested that these atypical asymmetries may indicate right
patients with a mean AQ of 2.3 comprised cluster 1; these hemisphere dominance for language. Evaluation of hemi-
were the most severely impaired patients and were charac- spheric asymmetries may be used, therefore, to predict
terized by dense, nonfluent speech with severe initiation recovery of single-word functions, with atypical patterns
deficits, marked comprehension impairment, no repetition, suggesting superior long-term gains.
and grossly defective naming. Their lesions primarily Naeser, Gaddie, Palumbo, and Stiassny-Eder (1990) used
involved the left superior temporal gyrus. Patients in this CT to compare lesion location and language recovery in a
cluster showed minimal or no change in language scores at group of subjects with global aphasia. The primary foci in
follow-up and remained globally aphasic. Cluster 2 con- their study were recovery of comprehension abilities and
sisted of two patients with a mean AQ of 34.9 who were differentiation between temporal lobe lesions involving
characterized by dense, nonfluent spontaneous speech; Wernicke’s area and those restricted to the subcortical tem-
moderate comprehension impairment; minimal capacity for poral isthmus. The subjects had either frontal, parietal, and
naming monosyllabic, high-frequency nouns; and limited temporal lobe lesions or lesions involving the frontal and
repetition. The left inferior frontal gyrus and adjacent sub- parietal lobes with temporal lobe lesions restricted to the
cortical white matter, primarily involving the territory of the subcortical temporal isthmus. The results of this study
precentral, central, lenticulostriate, and insular branches of showed significantly better recovery of auditory compre-
the middle cerebral artery, were lesioned. These patients hension for the group without damage to Wernicke’s area
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574 Section IV ■ Traditional Approaches to Language Intervention

(lesions limited to subcortical temporal isthmus). Over the Language Scores

course of 1 to 2 years, the majority of these subjects report-
edly obtained auditory comprehension scores on the BDAE Collins (1986) has used scores obtained from patients with
(Goodglass & Kaplan, 1983) that were consistent with only global aphasia on the Porch Index of Communicative Ability
mild to moderate comprehension deficits (Naeser et al., (Porch, 1981), or PICA, to predict recovery. According to
1990). None of the subjects in this study made significant Collins (1986), patients with global aphasia invariably obtain
gains in speech output. scores below the 25th percentile. High intra- and intersub-
A group of patients with severe global aphasia and test variability, however, suggest at least the potential for
extreme loss of both verbal and nonverbal communication recovery. Variability in this instance is defined as the differ-
(including comprehension) was studied by De Renzi, ence between the mean score for a PICA subtest and the
Colombo, and Scarpa (1991). These authors found a variety highest score within that subtest. A total variability score is
of lesion patterns, only 35% of which involved the entire derived by adding the variability scores for all PICA sub-
language area. Attempts to correlate specific types of lesions tests. Variability scores of greater than 400 suggest excellent
with some recovery of language abilities were unsuccessful. potential for recovery, whereas scores of less than 200 sug-
For the patients who showed some comprehension improve- gest poor potential for recovery.
ment, no common lesion pattern was found. Using medical and PICA data, Collins (1986) suggests
Mark and colleagues (1992) evaluated CT scans of that patients with global aphasia demonstrating some vari-
patients with global aphasia in a routine acute-care setting to ability within subtests and variability scores of around 100,
assess their viability of such scans for predicting language but relatively flat scores across all modalities, have a poor
performance at 1-year post-onset. The scans were measured prognosis for recovery. Imitation, copying, and matching
for lesion volume, total occipital asymmetry, and the cere- may be better than other test behaviors. Patients with vari-
bral volume occupied by the lateral ventricles and correlated ability scores of much greater than 100 and with greater
with WAB (Kertesz, 1982) AQ and auditory comprehension divergence among modality scores have a fair prognosis for
scores. No clear relationship was found between acute imag- recovery. Performance generally is characterized by mostly
ing of the patients’ lesions and their aphasia outcomes. correct object matching, good copying skills, the ability to
Zahn and colleagues (2004) used fMRI to investigate the name one or two of the objects, and production of some dif-
underlying mechanism for recovery of auditory comprehen- ferentiated responses on the verbal subtests. Significant
sion following global aphasia. Seven patients with large increases in overall variability relative to the previous two
lesions following left middle cerebral artery infarction were categories and occasionally higher scores (seven or above) on
identified using the Aachen Aphasia Test or the Aachen auditory comprehension, reading, and naming subtests are
Aphasia Bedside Test during the acute or subacute stages of consistent with a good prognosis for recovery. One patient
their illnesses. Different degrees of auditory comprehension described by Collins (1986) achieved a variability score of
recovery were demonstrated among these patients at follow- greater than 400 while still performing at the 9th percentile.
up 6 to 12 months later. A functional activation paradigm The recommendations of Collins should be tempered by
was used that allowed differentiation of anatomical patterns subsequent work. Wertz, Dronkers, and Hume (1993) tested
associated with processing of auditory word form versus the influence of PICA intrasubtest variability on prognosis
meaning. When compared to normal subjects, no differ- for improvement in aphasia. Negative and nonsignificant
ences were observed in the patients having global aphasia correlations were obtained between variability scores at
with regard to the lateralization or the general regions of 1 month post-onset and improvement in PICA overall per-
activations. The left extrasylvian temporal cortex and right formance at 6 and 12 months post-onset. In addition, no sig-
posterior parietal cortex were the most consistently acti- nificant differences in improvement were found at 6 and
vated regions. The extrasylvian temporal activations were 12 months post-onset between two groups with high vari-
thought to represent correlates of recovery of lexical-seman- ability (score greater than 350) and low variability (score less
tic processing. The authors concluded that comprehension than 300) at 1 month post-onset. Wertz and colleagues con-
recovery occurs via functional compensation by spared parts cluded that intrasubtest variability has no influence on prog-
of the partially damaged semantic word processing system nosis. For other measures of aphasia, it generally appears
(redundancy recovery). The results did not support other that a lack of variability between auditory comprehension
mechanisms for recovery that have been proposed, such as scores and other language scores may be viewed as a nega-
reactivation of functionally connected areas, substitution of tive indicator. The more performance differs among tasks,
previously nonactive areas, or transfer of function to right the better the outlook. Further, higher test scores (i.e., less
hemisphere homologues. Right hemisphere contributions, severe impairment) are consistent with a better prognosis.
however, may be substantial for lexical-semantic processing Within auditory comprehension scores, patients with global
of words presented visually, particularly when phonologic aphasia who provide yes/no responses to simple questions,
processing is severely impaired (Gold & Kertesz, 2000). regardless of their accuracy, seem to have a better outcome
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Chapter 21 ■ Global Aphasia: Identification and Management 575

at 1 year post-onset compared with those who cannot grasp (Naeser et al., 1990). Recent evidence derived from fMRI
the yes/no format (Mark et al., 1992). studies of patients initially diagnosed with global aphasia has
demonstrated that activation of regions associated with
lexical-semantic processing in normal subjects (left extratem-
INTERVENTION poral and right posterior parietal cortex) is associated with
good recovery of auditory comprehension at 6 months or
Before discussing clinical intervention for global aphasia, a
greater following global aphasia (Zahn et al., 2004).
few introductory remarks are provided in support of the
Recovery of spontaneous speech in severely nonfluent
management strategies that follow. The issues addressed
patients with stroke and left middle cerebral artery infarc-
here include some influences regarding the timing of inter-
tion can be estimated from the extent of lesion in two sub-
vention for global aphasia, the nature of the language assess-
cortical white matter areas: the medial subcallosal fasciculus
ment, and the behavioral targets of treatment.
(initiation of spontaneous speech), and the middle third of
the periventricular white matter (motor/sensory aspects of
Influences Regarding the Timing of Intervention spontaneous speech) (Naeser, Palumbo, Helm-Estabrooks,
Stiassny-Eder, & Albert, 1989). For patients with lesions
As described previously, the prognosis for recovery from
outside the left middle cerebral artery, Naeserand colleagues
global aphasia generally is poor (Kertesz & McCabe, 1977).
(1989) suggest examining other specific structures as well
Nonetheless, approximately one-fourth to three-fourths or
(e.g., supplementary motor area and cingulate gyrus).
more of these patients with global aphasia will recover to a
These findings provide a promising approach to progno-
less severe aphasia or even to a normal condition by the end
sis for global aphasia, but their application appears to war-
of the first year after their stroke. Do these findings argue
rant discretion on several accounts when making decisions
against early intervention for global aphasia? Should practi-
regarding early intervention for global aphasia. For exam-
tioners withhold assessment and treatment for these patients
ple, the findings of Naeser and colleagues (1989) are limited,
until a stable language profile is achieved? Clinicians have
because many of the patients in their most severe subject
opposed withholding early treatment (Collins, 1986; Peach,
groups were not global aphasic. In addition, exceptions to
2001), and a number of reasons exist to continue to do so.
expected patterns of recovery exist even in patients who
meet the suggested neuroanatomical profiles (Naeser et al.,
Prognostic Limitations
1989). Finally, the lack of clear patterns on CT scans that
Primary among the reasons for advocating early interven- could be associated with recovery from global aphasia in
tion is the inability to identify accurately those patients with other studies (De Renzi et al., 1991; Mark et al., 1992) sug-
global aphasia who will evolve to less severe syndromes and gests that these approaches are in need of further data before
those who will not. Even if it could be established that with- they can be applied rigorously.
holding early treatment from patients who have a high or Besides CT, a patient’s levels of alertness or attention at
low probability for good recovery is an acceptable clinical the outset of global aphasia also might be assessed to predict
practice, current methodologies prevent clinicians from superior recovery. Patients who initially are more alert or
accurately identifying the recovery potential for these have better attention appear to show greater recovery from
patients to make such decisions. Global aphasia cannot be their global aphasia (Kertesz & McCabe 1977; Sarno &
reliably discriminated in the early stage (Wallesch, Bak, & Levita, 1981). Because the evidence for these latter findings
Schulte-Monting, 1992), and any general conclusions about is primarily anecdotal, however, its application as a clinical
recovery in individual patients are “premature” (Basso & guideline is tenuous until additional information becomes
Farabola, 1997). Conflicting findings with regard to many of available. These observations, along with differing profiles
the factors identified above continue to present problems for in the evolution of global aphasia, underscore the fact that
estimating clinical prognosis. patients with global aphasia are a heterogeneous group. It is
Information derived from technologic applications may evident that research is needed to identify the particular fac-
assist with this problem. In one study, the potential for recov- tors and the way that they interact to account for better
ery of auditory comprehension following global aphasia was recovery. Clinicians might then more accurately identify the
estimated by examining the lesion site patterns on CT scans subgroups of patients with global aphasia who will demon-
for these patients. As described earlier, better recovery was strate substantial language recovery and those who will not.
predicted at 1 to 2 years post-onset in patients whose tempo- This information can then be applied in management deci-
ral lesions spared Wernicke’s area and involved only the sub- sions regarding treatment (Ferro, 1992; Sarno, Silverman &
cortical temporal isthmus. Patients with temporal lesions Sands, 1970).
that included more than half of Wernicke’s cortical area, In the absence of accurate techniques for predicting
however, were expected to demonstrate moderate to severe recovery from global aphasia, the most powerful reasons for
comprehension deficits at 1 to 2 years after their injuries providing early treatment are (1) the latent recovery
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576 Section IV ■ Traditional Approaches to Language Intervention

observed in those patients who receive acute speech and lan- first goals of treatment also focus on establishing some
guage treatment and (2) the greater effects generally means of communication, no matter how simple. Some
observed in patients with aphasia when treated during the methods to accomplish this would include establishing reli-
acute period of recovery. As a group, patients with global able yes/no responding or a basic vocabulary of functional
aphasia receiving early treatment show continued language items through oral or gestural means, such as head nodding,
improvement during the period between 6 and 12 months eye blinking, and pointing to pictures or specific icons.
post-onset (Kertesz & McCabe, 1977; Nicholas et al., 1993; Interestingly, the activities associated with establishing these
Sarno & Levita, 1979, 1981) that is not observed in communication systems may, in and of themselves, be con-
untreated patients (Pashek & Holland, 1988; Siirtola & sidered stimulatory for language. Clinicians also provide
Siirtola, 1984). In addition, meta-analyses of the aphasia information to family, friends, and health-care staff during
treatment literature have provided convincing evidence that this phase regarding the patient’s particular language profile
outcomes for patients with severe aphasia are much greater (i.e., preserved versus deficient areas), prognosis, and suit-
when treatment is begun immediately after onset rather able ways to improve communication with the patient. Early
than during the post-acute period (Robey, 1998). Until more intervention in global aphasia therefore has the multiple
is known about the individual patient with global aphasia, purposes of language stimulation directed toward cerebral
these data suggest that clinicians should continue to inter- reorganization and recovery, identification of successful
vene at the earliest opportunity to assist these patients at a communication strategies, and patient, family, and staff
time when such treatments may be most crucial to long- counseling. None of these activities can—or should—be
[Au12] term recovery. deferred until a stable language profile is achieved.

Treatment Objectives Goal Revisions

A second reason for early intervention in global aphasia con- Patients with global aphasia do demonstrate varying
cerns the purpose of treatment. In deliberating this issue, improvements in linguistic, extralinguistic, and nonverbal
consider a scenario in which the clinical limitations communicative functioning (Kenin & Swisher, 1972; Mohr,
described above no longer applied in predicting recovery Sidman, Stoddard, Leicester, & Rosenberger, 1973; Prins,
from global aphasia. With full awareness of whether a Snow, & Wagenaar, 1978; Sarno & Levita, 1979, 1981;
patient will experience a good versus a minimal recovery, Wapner & Gardner, 1979). As discussed, these improve-
which outcome would suggest the need for early treatment? ments may result in recovery to a less severe form of aphasia
For patients who are expected to evolve to a less severe in some cases, whereas in others, the changes may be insuf-
aphasia, might treatment be deferred to obtain the more sta- ficient even at 1 year post-onset to suggest reclassification
ble language profile that might subserve a more effective to another form of aphasia (Sarno & Levita, 1979, 1981).
long-term management plan, or might treatment be initi- For this latter group, improvement can be anticipated in at
ated immediately to accelerate the patient’s anticipated least one of these categories, especially that of functional
recovery? For patients who are not expected to demonstrate communication.
substantial recovery, might treatment be withheld because Most, if not all, clinical aphasiologists recognize the
of the poor prognosis to allocate clinical and financial dynamic nature of aphasia. Early testing therefore is viewed
resources more effectively, or might these patients become only as a measure of the patient’s language functioning at a
primary candidates for treatment to develop a functional single point in time that will be used to establish a baseline
communication system from the outset of their aphasia that for intervention during the acute period. Because of recov-
will provide the primary means through which they subse- ery, frequent probes for improvement in treated and
quently will communicate? When considering the purpose untreated behaviors during this early period as well as re-
of treatment in either case, the arguments for early inter- evaluation using formal instruments is not only encouraged,
vention with patients who have global aphasia, no matter it is expected.
their outcome, are more compelling than otherwise. The Withholding early treatment while awaiting more stable
recovery patterns per se following global aphasia therefore language profiles to improve treatment planning does not
do not provide an adequate rationale for postponing treat- acknowledge that establishing and revising short-term treat-
ment of aphasia for these patients. ment goals are inherent principles of aphasia rehabilitation.
Global aphasia will be greatest during the acute phase of Whether treatment is provided before or after the first
recovery. Often, as alluded to above, treatment during this month post-onset, this process will be repeated regularly
phase focuses on the remediation of language deficits via throughout the term of the patient’s rehabilitation, regard-
stimulation of disrupted cognitive processes. Depending on less of the type of aphasia. There is little sense, therefore, in
the degree to which the condition renders the patient unable declaring this process to be less valid in global aphasia when
to communicate even the most basic of needs, however, the treatment is initiated before the first month after injury.
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Chapter 21 ■ Global Aphasia: Identification and Management 577

Clinicians have much to offer patients with global aphasia mal or informal) is seen as simply augmenting the other. For
and their families during the acute period of recovery. When the patient with global aphasia, both types are deemed
patients improve, the treatment objectives reflect this mandatory for adequately describing communication func-
[Au13] change; when they fail to change, concerted rehabilitative tioning. A host of procedures are available to accomplish
efforts continue in the areas of the patients’ greatest func- these objectives. These will be reviewed in the following
tional communicative needs. sections.

Nature of the Assessment Behavioral Targets for Treatment

Assessment of individuals with aphasia encompasses more Because the impairment in aphasia is, first and foremost, a
than simple diagnosis. Ideally, assessment provides a profile linguistic one, the primary target for treatment traditionally
not only of the patient’s areas of weakness but also of his or has been that of language performance. As a result, the suc-
her strengths. Reasonable treatment plans require both cess of intervention most often has been evaluated by the
types of data. Formal tests provide one method for gathering extent of changes occurring exclusively in the patient with
such data and, in addition, facilitate discussion of patient aphasia’s grammatical and lexical behaviors. In such an
findings among colleagues. To that end, Collins (1986, p. 62) approach, the potential for these changes is diminished with
provides a summary of the severity ratings for a number of increases in the initial severity of the language impairment.
these tests that are suggestive of global aphasia. Sometimes, Too often, this approach has resulted in underestimation of
however, formal tests may be inadequate for treatment plan- what has been accomplished regarding recovery of commu-
ning (Rosenbek et al., 1989), especially in the case of nication skills.
severely impaired patients, such as those with global aphasia. Nowhere might this problem be more prevalent than in
Little can be gained about patients’ preserved areas of com- the case of the patient with global aphasia. From the time
municative functioning from scores that are consistently that Sarno and colleagues (1970) suggested that patients
near the floor for a given test. For these patients, informa- with stroke and severe aphasia do not benefit from speech
tion regarding their residual communicative capacities may and language treatment, many health-care providers have
be more readily available from a variety of informal (i.e., taken a rather pessimistic view with regard to rehabilitation
nonstandardized) measures. Such measures consist of outcomes in this group of patients. The conclusions of
patient observation to determine functional communication Sarno and colleagues, however, and of others like them,
and the diverse methods for cueing behaviors that, when were based solely on statistical comparisons of pre- and
logically varied, allow a practical test of approaches that post-treatment language scores and failed to account for
result in the most favorable responses. Methods that are suc- positive changes that may have occurred in other communi-
cessful in eliciting target behaviors are incorporated into cation behaviors. In a subsequent study involving patients
treatment and provide an initial approach for developing with global aphasia, Sarno and Levita (1981) examined the
subsequent behaviors. changes occurring not only in language scores but also in
Contemporary approaches include both formal and communication performance as assessed by the FCP.
informal measures of assessment to establish a communica- Clinically significant improvements in the patients’ lan-
tion profile for the patient with global aphasia. From a prac- guage scores were observed that, nonetheless, were insuffi-
tical point of view, initial contact with the patient should be cient to warrant reclassification to another aphasic syn-
preceded by a review of medical records and interviews with drome. Inspection of nonverbal communication abilities
knowledgeable others to glean information about the revealed recovery of alternate skills (e.g., gesture, pan-
patient’s communicative status. To the degree possible, a tomime, and other extralinguistic behaviors) that exceeded
formal language assessment should be completed using a the reported language changes. According to Sarno and
standardized aphasia battery, sampling behaviors across Levita (1981), these improvements resulted in limited but
tasks at least minimally in each language domain (i.e., speak- effective communication by the end of the first year after
ing, listening, reading, and writing), and describing the stroke. Nicholas and colleagues (1993) also found signifi-
patient’s responses to each item. Given this baseline, assess- cant improvements in the communication skills of their
ment continues through what might be viewed as diagnostic patients with global aphasia during the first year poststroke,
treatment to identify the conditions that further promote even though the majority of those patients did not change
successful language performance. Included here would be an classification.
analysis of patient responses during interviews focusing on These findings have given way in many instances to social
familiar topics or in selected situations and the evaluation of approaches that exploit the residual language capacity
hierarchical cues within language tasks. and/or other functional abilities of these patients as well as
In this “qualitative” approach, as described by Helm- the skills of conversation partners to improve communica-
Estabrooks (1986), neither type of language assessment (for- tion and the patient’s quality of life. Clinicians no longer
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578 Section IV ■ Traditional Approaches to Language Intervention

attend exclusively to improving propositional speech in TABLE 21–2

patients with global aphasia during or after the acute period
of recovery. Such an emphasis is apparent in many of the Formal and Informal Measures for Assessment
treatment methods that have been developed recently for of Global Aphasia
such patients.
Au: T4
Formal Assessment and T5 ok.
General Language Pl. check
ASSESSMENT Aphasia Diagnostic Profiles
Aphasia Language Performance Scales
Assessment of communication functioning in patients with Boston Assessment of Severe Aphasia
global aphasia is best achieved using both formal and Boston Diagnostic Aphasia Examination
informal measures. These measures are summarized in Examining for Aphasia–Third Edition
Table 21–2. Language Modalities Test for Aphasia
Minnesota Test for Differential Diagnosis of Aphasia
Neurosensory Center Comprehensive Examination
Formal Test Measures for Aphasia
Porch Index of Communicative Ability
General Language
Sklar Aphasia Scale-Revised
The language features of global aphasia were described in a Western Aphasia Battery
previous section. Some standardized aphasia test batteries Modality-Specific
that specifically address global aphasia in their classification Auditory Comprehension Test for Sentences
schemes include Aphasia Diagnostic Profiles (Helm- Boston Naming Test
Estabrooks, 1992), the BDAE(Goodglass, Kaplan, & Barresi, Functional Auditory Comprehension Test
2001), the Language Modalities Test for Aphasia (Wepman Gray Oral Reading Tests–Fourth Edition
Object and Action Naming Battery
& Jones, 1961), the Minnesota Test for Differential Diagnosis
Psycholinguistic Assessments of Language Processing
of Aphasia (irreversible aphasia syndrome) (Schuell, 1974),
in Aphasia
the Sklar Aphasia Scale (Sklar, 1983), and the WAB(Kertesz, Reading Comprehension Battery for Aphasia–Second Edition
1982). Additional batteries that comprehensively assess lan- Test of Adolescent/Adult Word Finding
guage performance to provide the clinical data for establish- Token Test
ing a diagnosis of global aphasia include the Aphasia Revised Token Test
Language Performance Scales (Keenan & Brassell, 1975), Functional Communication
Examining for Aphasia–Third Edition (Eisenson, 1994), the ASHA Functional Assessment of Communications Skills
Neurosensory Center Comprehensive Examination for for Adults
Aphasia (Spreen & Benton, 1977), the PICA(Porch, 1981), Assessment of Language-Related Functional Activities
and Psycholinguistic Assessments of Language Processing in Communication Activities of Daily Living–Second Edition
Aphasia (Kay, Lesser, & Coltheart, 1992). For Spanish speak- Functional Communication Profile
ers, the Multilingual Aphasia Examination-Spanish (Rey, Informal Measures
Sivan, & Benton, 1991) can be used. The performance pat- General Language
tern for patients with global aphasia on any of the tests iden- Auditory Comprehension Assessment (Edelman, 1984)
Behavioral Assessment (Salvatore & Thompson, 1986)
tified above generally is one of severe impairment in all
language abilities. Functional Communication
Assessment of Communicative Effectiveness in Severe Aphasia
Some modality-specific assessment instruments also
(Cunningham et al., 1995)
might be appropriate in the evaluation of patients with
Communicative Effectiveness Index (Lomas et al., 1989)
global aphasia. These tests include the following: for audi- Functional Rating Scale (Collins, 1986)
tory comprehension, the Token Test (De Renzi & Vignolo, Natural Communication (Holland, 1982)
1962), the Auditory Comprehension Test for Sentences
(Shewan, 1979; Shewan & Canter, 1971), the Revised Token Key: ASHA  American Speech-Language-Hearing Association.
Test (McNeil & Prescott, 1978), and the Functional
Auditory Comprehension Task (LaPointe & Horner, 1978;
LaPointe, Holtzapple, & Graham, 1985); for reading com- Action Naming Battery (Druks & Masterson, 2000), and the
prehension, the Reading Comprehension Battery for Test of Adolescent/Adult Word Finding (German, 1990).
Aphasia-Second Edition (LaPointe & Horner, 1998) and the Unlike the foregoing instruments, the BASA (Helm-
Gray Oral Reading Tests-Fourth Edition (Wiederholt & Estabrooks, Ramsberger, Morgan, & Nicholas, 1989) was
Bryant, 2001); and for naming, the Boston Naming Test developed “for the specific purpose of identifying and quan-
(Kaplan, Goodglass, & Weintraub, 2001), the Object and tifying preserved abilities that might form the beginning
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Chapter 21 ■ Global Aphasia: Identification and Management 579

steps of rehabilitation programs for severely aphasic The ASHA FACS contains 43 items that assess functional
patients” (p. 1). The BASA assesses performance on 61 items communication in four areas: social communication; com-
in 15 areas: social greetings and simple conversation; per- munication of basic needs; reading, writing, and number
sonally relevant yes/no question pairs; orientation to time concepts; and daily planning. A seven-point quantitative
and place; buccofacial praxis; sustained phonation and scale rates the frequency of behaviors. A five-point qualita-
singing; repetition; limb praxis; comprehension of number tive scale rates the adequacy, appropriateness, and prompt-
symbols; object naming; action picture items; comprehen- ness of an individual’s responses as well as the relative shar-
sion of coin names; famous faces; emotional words, phrases, ing of communication burden with the partner. The ASHA
and symbols; visuospatial items; and signature. Responses FACS has been found to be reliable and valid for use with
are scored for response modality (verbal, gestural, or both), adult aphasia resulting from left hemisphere stroke and
communicative quality (fully communicative, partially com- adult cognitive communication disorders resulting from
municative, noncommunicative, unintelligible, irrelevant, traumatic brain injury. It is available in both a paper-and-
incorrect, unreliable, or task refused or rejected), affective pencil version and a computerized version.
quality, and perseveration. Raw scores are summed accord- The ALFA consists of 10 subtests, including telling time,
ing to seven clusters of items: auditory comprehension, counting money, addressing an envelope, solving daily math
praxis, oral-gestural expression, reading comprehension, problems, writing a check/balancing a checkbook, under-
gesture recognition, writing, and visuospatial tasks. Norms standing medicine labels, using a calendar, reading instruc-
are provided to convert the total raw score and item cluster tions, using the telephone, and writing a phone message.
raw scores to standard scores and percentile ranks. “Because The subtests probe auditory comprehension, verbal expres-
an important goal of the BASA is to help determine whether sion, reading and writing, as well as cognitive and motor
a severe case of aphasia may be classified as global,” (p. 42) skills. The test yields a raw score for each subtest that is
two separate sets of norms are provided, one for cases of associated with a rating of independent functioning levels
severe aphasia and one for global aphasia. for two populations (below and above 65 years of age). The
ALFA was standardized on 495 patients between the ages of
20 and 96 years with neurological histories as well as a group
Functional Communication
of 150 normal adults.
Measures for the formal assessment of functional communi-
cation include the FCP (Sarno, 1969); Communication
Activities of Daily Living–Second Edition (Holland, Fratalli, Informal Measures
& Fromm, 1998), or CADL-2; the American Speech-
General Language
Language-Hearing Association Functional Assessment of
Communication Skills for Adults (Fratalli, Holland, & As described previously, informal measures of language
Thompson, 1995), or ASHA FACS; and the Assessment of assessment are conducted following formal assessment with
Language-Related Functional Activities (Baines, Martin, & a standardized battery to identify the conditions that further
Heeringa, 1999), or ALFA. The FCP assesses 45 communi- promote successful language performance. Such measures
cation behaviors in a conversational situation that are con- aim to identify isolated areas of preserved performance, such
sidered to be common functions of everyday life. Behaviors as those listed above as features of comprehension.
are rated as normal, good, fair, or poor and are transformed Hierarchical cues are used to evaluate such residual areas
to raw scores within five dimensions: movement, speaking, within language tasks.
understanding, reading, and other behaviors. The raw Salvatore and Thompson (1986) provide an example of
scores are converted to a percentage and a weighted score informal assessment procedures designed to assess verbal and
representing the patient’s performance relative to normal nonverbal communication systems in patients with global
behavior for that dimension. An overall score is obtained by aphasia. The model used in their approach employs one
summing the weighted scores to represent the patient’s per- stimulus to evoke a variety of responses. When stimuli are
centage of normal communication. presented to evoke all levels of responding, stimulus-
The CADL-2 includes 50 items that assess communica- response relations that are preserved and those that are
tion skills in structured, simulated daily activities. It includes impaired are identifiable. For example, patients may be asked
a series of context-dependent items that evoke a variety of to provide several responses to a pictured stimulus, including
speech acts and verbal interchanges as well as other items matching it to an identical picture and both writing and say-
that assess functional reading, writing, and math. Responses ing its name. Responses are analyzed in different modes,
can be communicated by a variety of verbal and nonverbal including gesturing, drawing, reading, writing, and verbaliz-
means and are scored as correct, adequate, or wrong. The ing. A matrix is developed to categorize the various relations
CADL-2 has high inter- and intrarater reliability and that are tested. The results of the assessment provide impor-
includes standard scores and performance norms. tant information that provides a basis for treatment.
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580 Section IV ■ Traditional Approaches to Language Intervention

Edelman (1984) provides an outline for the assessment of conclude that the CETI is an instrument that is capable of
comprehension in global aphasia that specifically takes into measuring the functional changes occurring during the
account research findings identifying areas of residual func- recovery of patients with aphasia that have been difficult to
tion in global aphasia and factors that facilitate understand- measure previously.
ing. The suggested framework permits a systematic evalua- Cunningham, Farrow, Davies, and Lincoln (1995) devel-
tion of understanding, both contextually and acontextually, oped the Assessment of Communicative Effectiveness in
while manipulating variables found to be facilitative. Severe Aphasia, or ACESA. It consists of two sections: a
Performance is assessed using commands and questions at structured conversation, and an assessment of the patient’s
simple linguistic levels. Commands are divided into two sec- ability to convey information about objects and pictures.
tions. Those relating to the self involve whole-body move- Gesture, facial expression, speech, symbolic noise, and into-
ments, limb movements, and orofacial movements, and nation are accepted ways for conveying information.
those relating to objects in the environment are divided into Communicative effectiveness is rated using separate scales
object recognition and object manipulation. These tasks are of recognizability for verbal and nonverbal responses. In an
assessed respectively in a natural verbal context (e.g., “Have initial study to test the reliability of the instrument, test-
you any water?”; “Can you pass the tissues?”) and acontextu- retest reliability and intrarater reliability were found to be
ally (e.g., “Show me the comb”; “Pick up the comb”). good. The authors therefore suggested that the tool can be
Questions require affirmation or negation only, and they useful for assessing change in communicative effectiveness
include those relating to self as well as those of less personal when it is scored by the same person. Low interrater relia-
saliency. Responses are accepted when communicated either bility, however, suggested that the tool needs further modi-
verbally or nonverbally. In addition, hierarchical cueing, fications before it can be used confidently for other clinical
consisting of repetition, utterance expansion, and gestural and/or research purposes.
accompaniment, is incorporated and scored using a modi- Finally, a less systematic—but often effective—assess-
fied PICA system. ment of functional communication can be derived from
patient interviews or questionnaires completed by individu-
als who are familiar with the patient who has global aphasia.
Functional Communication
Collins (1986) reviews several of these questionnaires and
A number of informal procedures that can be used to sys- provides one such example, an adaptation of the FCP called
tematically evaluate the functional communication of the Functional Rating Scale.
patients with global aphasia also have appeared in the litera-
ture. Holland (1982) developed a procedure to score obser-
vations of natural communication in normal family interac-
tions. The categories of behaviors included verbal and
TREATMENT
nonverbal output, reading, writing, math, and other com- Given the generally poor outcome in chronic global aphasia
municative behaviors, such as talking on the phone and (Kertesz & McCabe, 1977; Sarno & Levita, 1981) and the
singing. The verbal behaviors were further subcategorized negative results that have been reported for treatment pro-
to capture the form, style, conversational dominance, cor- grams aimed specifically at remediating verbal skills (Sarno
rectional strategies, and metalinguistics of the production. et al., 1970), treatment for these patients may emphasize func-
Holland’s procedure is “primarily concerned with the fre- tional and/or social approaches that attempt to improve par-
quency and form of successful and failed verbal and nonver- ticipation in communication activities as well as impairment-
bal communicative acts” (p. 52). based approaches that attempt to reduce the severity of the
Lomas and colleagues (1989) constructed the Com- language impairment (Peach, 1993). Functional (patient-
municative Effectiveness Index, or CETI, using commu- oriented) and social (partner-oriented) approaches use
nicative situations provided by patients with aphasia and strategies that exploit the patient’s residual linguistic and
their families that were thought to be important in day-to- non-linguistic cognitive skills to increase successful commu-
day life. The CETI quantitatively assesses the performance nication (Herbert, Best, Hickin, Howard, & Osborne,
of those with aphasia over time in 16 situations using judg- 2003). Impairment-based approaches use structured meth-
ments provided by spouses or significant others. Performance ods that are carefully controlled for levels of difficulty to
is rated relative to the person with aphasia’s premorbid abil- provide a context that will facilitate successful language res-
ities using a visual analogue scale. The situations range from ponses and shape succeeding language behaviors of increas-
getting somebody’s attention to describing or discussing ing complexity. Functional and social approaches tend to
something in depth. The index was found to be internally predominate during the chronic phase of the condition, but
consistent, to have acceptable test-retest and interrater all approaches may—and should—be used during the course
reliability, and to be a valid measure of functional communi- of recovery from global aphasia (Peach, 2001). Table 21–3
cation when compared with other measures. The authors provides a summary of these approaches.
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Chapter 21 ■ Global Aphasia: Identification and Management 581

TABLE 21–3 may underlie subsequent association of meaning with the

name of the pictures (Peach, 1993). Complexity may be
Treatment Approaches for Global Aphasia increased within this task by (a) increasing the size of the
response field; (b) moving from pairing real objects to real-
Impairment-Based Approaches istic pictures of objects to line drawings of the objects; (c)
Auditory Comprehension matching objects to pictures and pictures to objects, a tech-
Matching pictures nique incorporated in Visual Action Therapy (Helm-
Eliciting appropriate responses Estabrooks, Fitzpatrick, & Barresi, 1982); and (d) using sets
Playing cards of pictures that represent nouns with decreasing frequency
Verbal Expression of occurrence in language usage. As performance improves,
Associating meaning with speech movements these tasks may be followed by word recognition for objects,
Conversational prompting
pictures, or body parts and responding to simple questions.
Voluntary control of involuntary utterances
Marshall (1986) provides an approach to treating audi-
Phonologic treatment for naming
Transcranial magnetic stimulation for naming tory comprehension in patients with global aphasia that is
presented in four phases: (a) eliciting responses, (b) eliciting
Functional (Patient-Oriented) Approaches
Gestural Programs differentiated responses, (c) eliciting appropriate responses,
Amer-Ind Code and (d) eliciting accurate responses. In the first phase, clini-
Visual action therapy cians focus on attending, pointing, and yes/no responding;
Pantomime at a minimum, the clinician should help patients to express
Limited manual sign systems themselves through head nods, smiles, or frowns. Patients
Non-Speech Communication Aids who cannot respond to spoken messages may engage in
Non-electronic visual matching or orientation tasks. They also may be pro-
Preparatory training vided spoken messages accompanied by gestures. Questions
Communication boards and statements about personally relevant topics may com-
Blissymbols prise one of the best ways to elicit responses during this
Drawing phase. In the second phase, the materials and techniques to
Electronic
elicit responses are not unlike those used in the first phase.
Computer-aided visual communication
At this time, however, the clinician accepts and reinforces
Lingraphica
Gus multimedia speech system any response that is different from the previous response
Promoting Aphasics’ Communicative Effectiveness given for those stimuli (e.g., varied facial expressions, head
Social (Partner-Oriented) Approaches nods, gestures, and stereotypic utterances). To do this, the
Supported Conversation for Adults with Aphasia clinician records the patient’s responses to a standard set of
Conversational coaching simple questions, looking for a variety of responses both
Partner training between stimuli and from session to session. With progress,
Reciprocal scaffolding patients will move into the third phase, demonstrating
appropriate responses with occasional accurate responses,
Key: Amer-Ind  American-Indian.
such as pointing to a calendar when asked to show the date,
saying “yes” instead of “no,” and shrugging the shoulders
when asked how they are feeling. Other appropriate
Impairment-Based Approaches responses consist of performing one command for another
or production of jargon in response to a question or request
Auditory Comprehension
for information. Marshall suggests that, for some patients,
Collins (1986, 1997) suggests that a realistic goal for treat- appropriate responses may represent their best performance
ment with the patient who has global aphasia consists of and, therefore, should be encouraged by clinicians and oth-
improving auditory comprehension, supplemented with ers in the patient’s environment. Finally, in the fourth phase,
contextual cues, to permit consistent comprehension of one- clinicians seek accurate responses to such tasks as object and
step commands in well-controlled situations. For the most picture identification, following commands, and responding
severe comprehension deficits, picture matching, accompa- to yes/no and “wh-” questions. Nonverbal responses may be
nied by the clinician’s production of the name of the items to facilitated with accompanying props, including pages with
be matched, may provide the most basic level of auditory words and numbers written on them; a clock with movable
stimulation. Even in those cases when the patient has no hands; a calendar; a road atlas; lists of families, relatives, and
understanding of the auditory stimulus accompanying the friends; and a communication notebook.
pictures, the response elicited by the matching task is assumed Collins (1986, 1997) has designed a program to treat
to evokes auditory representations of the visual stimuli that auditory comprehension using playing cards. This approach
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582 Section IV ■ Traditional Approaches to Language Intervention

is based on the observation that patients with global aphasia communication for patients with global aphasia. It also may
often can recognize names that contain two salient features provide a suitable means for overcoming some of the prob-
(e.g., “queen of hearts”), differentiate cards by suit, and lems traditionally associated with the generalization of
place cards in a sequence when they are unable to perform trained responses to conversational contexts.
similarly with other stimuli. Although not all patients The verbal output of many patients with global aphasia
achieve the highest levels of performance, Collins suggests consists primarily of stereotypic recurring utterances or
that portions of the program are useful at some stage for speech automatisms. For many of these patients, productive
most patients. usage of single words or phrases may not be a realistic goal.
The treatment program Voluntary Control of Involuntary
Utterances (Helm & Barresi, 1980; Helm-Estabrooks &
Verbal Expression
Albert, 2004), or VCIU, can be used with these patients to
Despite conclusions that traditional treatment focused on bring these stereotypies into more productive usage. In this
verbal communication skills may be ineffective for global program, words that are involuntarily and inappropriately
aphasia (Salvatore & Thompson, 1986; Sarno & Levita, produced in the contexts of testing and treatment are identi-
1981), short-term attempts to establish or expand verbal fied and used as later targets in treatment. Patients are trained
expression in patients with global aphasia may be a legiti- in the words in a sequence, including oral reading, confronta-
mate therapeutic activity during both the acute and chronic tion naming, and finally, conversational usage, until a vocabu-
phases of recovery (Rosenbek et al., 1989). Rosenbek and lary of between 200 and 300 words is established. [Au14]
colleagues (1989) do this by first attempting to associate Two studies have investigated treatments for improving
meaning with speech movements. To do this, patients use naming ability in patients with global aphasia. To test theo-
available methods (e.g., showing fingers, pointing, gestur- ries regarding the psycholinguistic representation of homo-
ing, writing, matching, and selecting objects) to confirm the phones as well as the effectiveness and generalization of
meaning of any successfully elicited verbalizations. Included phonologic treatment, Biedermann and colleagues (2002)
among these may be serial productions, imitated words and treated naming to confrontation using phonologic cues in a [Au15]
phrases, or automatic, meaningful responses to conversa- 59-year-old man with global aphasia 13 years poststroke. The
tions relating to a variety of topics. As described previously, cuing hierarchy consisted of (a) an initial cue (consonant 
conversational topics that are personally relevant will schwa or vowel), (b) tapping the syllable number of the word,
improve performance (Van Lancker & Klein, 1990; Van and (c) repetition. The design included four conditions:
Lancker & Nicklay, 1992; Wallace & Canter, 1985). Patients homophones, semantically related words, phonologically
who succeed in these tasks are taught to produce at least a related words, and unrelated words. Item-specific, short-
small repertoire of useful spoken or spoken plus gestured term improvements were observed for treated items; no gen-
responses. They suggest that these items include at least one eralization to untreated items, except for homophones,
greeting, the words “yes” and “no,” a few proper names, sin- occurred. These results were consistent with previous studies
gle words that express important needs, and perhaps, one or of aphasia that have found poor generalization to untreated
more phrases, especially if they appear in the patient’s spon- items following phonologic treatment.
taneous verbal productions. Imitation, either alone or sup- Naeser and colleagues (2005) used transcranial magnetic
plemented by gestures and reading, is used to establish these stimulation (TMS) to treat the naming abilities of a 51-year-
responses (for a detailed approach to establishing an old woman with severe nonfluent/global aphasia who was
unequivocal yes/no response, see Collins, 1986, 1997). 6.5 poststroke. TMS is a noninvasive procedure that uses
Imitated responses are then practiced in more functional magnetic fields to generate electrical currents over discrete
contexts using questions or practical situations to facilitate brain regions. These lead to neuronal depolarization that
response generalization. can excite or inhibit the cortex. Functional imaging studies
Conversational prompting, a method reported by have suggested an anomalous right frontal response in
Cochran and Milton (1984), uses modeling, expansion, and patients with left frontal damage that is thought to interfere
feedback to develop the verbal responses of patients with with language recovery. Naeser and colleagues therefore
severe aphasia in conversational contexts. Props and written applied repetitive TMS (rTMS) to reduce the cortical
cues are provided to facilitate verbal expression. Ten conver- excitability of right pars triangularis in this patient and effect
sational levels are identified, ranging from concrete, struc- improvements in language functioning. She received ten 20-
tured contexts (e.g., manipulating objects or acting out and minute, 1-Hz rTMS treatments 5 days a week for 2 weeks.
describing sequences) to more open contexts (e.g., struc- Language testing at 2 and 8 months post-treatment demon-
tured interview or structured discussion). A cueing hierar- strated modest improvements in naming on the Boston
chy is described to promote language retrieval. With its Naming Test and the BDAE. Improvements at 1 year post-
emphasis on conversational interaction, this technique may treatment were considered to be substantial enough to war-
be particularly useful in developing contextually appropriate rant referral for further speech-language treatment. This
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Chapter 21 ■ Global Aphasia: Identification and Management 583

patient continued to improve, especially in auditory com- ments not only in the area of pantomime, as indicated by
prehension and in the voluntary use of words and phrases formal assessments, but also in the areas of auditory and
appropriate to her environment. reading comprehension, verbal repetition, and graphic
copying.
Conlon and McNeil (1991) proposed that the efficacy of
Functional (Patient-Oriented) Approaches VAT has not been established because of experimental limi-
Gestural Programs tations in the original work of Helm-Estabrooks and col-
leagues (1982). Therefore, they investigated the effects of
American-Indian Code VAT on the communication abilities of two patients with
Gestural programs constitute a sizeable portion of the func- global aphasia. Using a modified program for experimental
tional treatment approaches for global aphasia. Probably the purposes, positive treatment effects were observed on most
best known of the gestural programs is American-Indian steps of the program for their first subject and on about half
(Amer-Ind) Code (Rao, 2001; Skelly, 1979). Amer-Ind Code the steps for their second subject. These results generally
is adapted from Amer-Ind sign, a gestural system based on were consistent with those of Helm-Estabrooks and col-
the concepts underlying words rather than on the word leagues (1982), but generalization of these effects to
themselves (Skelly, Schinsky, Smith, Donaldson & Griffin, untreated items was not observed. This lack of generaliza-
1975). According to Rao and Horner (1980), Amer-Ind tion suggested that the learned behaviors did not influence
Code is concrete, pictographic, highly transmissible, easily performance on untreated but similar behaviors. Conlon
learned, agrammatical, and generative. The system can be and McNeil (1991) determined that VAT is not effective in
applied in aphasia rehabilitation as an alternative means of achieving the program’s stated purpose of establishing “sym-
communication, as a facilitator of verbalization, and as a bolic representation” as defined by Helm-Estabrooks and
deblocker of other language modalities (Rao, 2001). A few colleagues (1982). These authors concluded that further [Au16]
reports have demonstrated the usefulness of Amer-Ind Code research is needed before VAT can be confidently recom-
as an alternative means of communication (Rao 1995; Rao mended for the treatment of patients with global aphasia.
et al., 1980; Tonkovich & Loverso, 1982). The approach also Some other gestural programs include pantomime; lim-
might be combined with other nonverbal means of commu- ited manual sign systems for hospitals and nursing homes,
nication (e.g., drawing) (see below) to increase a severely such as manual shorthand, manual self-care signals, or a
affected patient’s communicative effectiveness (Rao, 1995). hand-talking chart; gestures for “yes” and “no”; eye-blink
The greatest utility of the technique, however, appears to be encoding; and pointing (Silverman, 1989). Silverman (1989)
as a facilitator of verbalization, though reports of its effec- offers a number of suggestions for the selective use of each
tiveness vary (Hanlon et al., 1990; Hoodin & Thompson, of these approaches. For example, pantomime may be
1983; Kearns, Simmons, & Sisterhen, 1982; Rao & Horner, appropriate for the patient with aphasia who cannot use
1978; Raymer & Thompson, 1991; Skelly, Schinsky, Smith, Amer-Ind Code. Limited manual sign systems may be used
Donaldson, & Griffin, 1974). Rosenbek and colleagues initially, on an interim basis, until other communication sys-
(1989) describe a treatment program for gestural reorgani- tems can be developed, but ultimately, these limited systems
zation that uses Amer-Ind Code as the primary system of may provide the only means of communication in the most
gestures and has, as its end goal, verbalization without ges- severely impaired patients (see, e.g., Coelho, 1990, 1991).
tural accompaniment. Pointing is desirable for the patient who is going to use a
communication board.
Visual Action Therapy
Non-Speech Communication Aids
Visual Action Therapy (Helm-Estabrooks & Albert, 2004;
Non-speech aids include those that assist communication by
Helm-Estabrooks et al., 1982; Helm-Estabrooks, Ramsberger,
both non-electronic and electronic means. Strategies using
Brownell, & Albert, 1989; Ramsberger & Helm-Estabrooks,
non-electronic assistance include transmission of messages
1989), or VAT, uses gestures to reduce apraxia and improve
by communication boards, manipulation of symbol sequences,
the patient’s verbal expression or ability to use symbolic
and drawing. One of the most prominent strategies in the
gestures as a means of communication. Three programs
rehabilitation of patients with global aphasia using elec-
constitute the approach: proximal limb, distal limb, and buc-
tronic means is computer-aided visual communication
cofacial VAT. A hierarchical procedure is used in each pro-
(C-ViC) (Weinrich, Steele, Carlson, et al., 1989).
gram to “move the patient along a performance continuum
from the basic task of matching pictures and objects to the
Preparatory Training
communicative task of representing hidden items with self-
initiated gestures” (Helm-Estabrooks & Albert, 2004, p. 255). Alexander and Loverso (1993) developed a specific program
The authors suggest that the method produces improve- for the treatment of global aphasia that supports the capacity
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584 Section IV ■ Traditional Approaches to Language Intervention

to make categorical and associational semantic discrimina- and training occurred during a coffee hour in a nursing
tions while being sufficiently easy to allow an understanding home care unit. Pictures were divided into three sets for
of the nature and purpose of the tasks. Those authors contend communicating social responses, requests for food and other
that therapy of this sort establishes a necessary precondition items, and personal information. Stimulus presentations
for subsequent treatment with communication programs were followed by a 5-second response interval. If an accurate
using iconic/substitutional language (e.g., communication response was not observed, cues consisting of a verbal cue, a
boards or C-ViC). Twenty-four common everyday objects, model, and a physical assist were provided. Subjects received
realistic pictures of those objects, and realistic pictures of the response-contingent verbal feedback. Generalization train-
locations in which those objects would be found were used as ing was conducted using a role-playing procedure in the
treatment stimuli. The stimuli were described as being repre- treatment room with a script employed during the coffee-
sentationally similar to those adopted for communication hour probes or within the coffee-hour setting. Maintenance
boards or C-ViC. Eight hierarchically-arranged treatment data were collected for up to 6 months.
levels were identified, beginning with object-to-object match- Following treatment, requesting and personal informa-
ing in a field of one and increasing to picture sorting into loca- tion responses were acquired, but not social responses. No
tively related groups. Two of five patients with global aphasia response generalization to untrained responses was
who were studied reached the proposed goal of treatment— observed, nor was generalization of board use seen during
namely, demonstration of semantic capacity across categorical the coffee hour. Of the two procedures for training general-
and associational boundaries. The remaining patients with ization, only training within the actual coffee-hour setting
global aphasia were unable to recognize the nature of the resulted in generalized use of all responses except for social
response required at more complex levels. The authors con- responses. Based on these results, the authors recommended
cluded that, even if only 40% of the cases respond successfully that (a) communication boards include primarily pictures
to the program, these patients constitute the appropriate that communicate specific content items and (b) treatment
group for substituted language systems. for the use of picture communication boards take place in
Salvatore and Nelson (1995) described a training model the natural environments where the board is to be used.
for establishing equivalence relationships among visual Ho, Weiss, Garrett, and Lloyd (2005) speculated that the
stimuli that may have potential for use with gestural-assisted failure of symbol use to generalize to functional communi-
programs like those described below. In their study, four cation following global aphasia might be a result of (a) the
subjects with severe aphasia learned novel symbolic relation- difficulty individuals with global aphasia have extracting
ships and generalized these to untrained relationships. The meaning from symbols referring to abstract concepts, (b) a
authors suggested that demonstrations of such generaliza- correlation between the severity of the language impairment
tion may be used as an indicator of the patient’s ability to and the ability to use symbols, and (c) the absence of the
benefit from further treatment efforts. cognitive ability to initiate symbol use without the support
of conversational partners. To overcome these challenges,
they suggested using remnants (actual objects or pho-
Communication Boards
tographs depicting recent or past events) that have personal-
Communication boards vary in type and complexity. For ized value in conversational interactions with persons who
severely impaired patients, a typical board will contain per- have global aphasia. In a study using a combination ABA and
sonally relevant words and pictures, numbers, and the alpha- alternating treatment single-subject design with two
bet. Specific treatment is required for effective use of the patients who had global aphasia, the authors demonstrated
board. Collins (1986, 1997) suggests a training procedure in that the participants initiated more topics and had fewer
which target items are identified in isolation, then after an unrepaired communication breakdowns during conversa-
imposed delay, and finally, from among increasing numbers tion when either remnants or pictographs were used versus
of foils until a temporary ceiling is obtained for the number when no symbols were available. Participants demonstrated
of items contained on one board. Alternative boards con- more pointing behavior, however, with remnants than with
taining pictures within only one domain (e.g., family or pictographic symbols. The subjective evaluations of the
familiar objects) may be used to increase the number of communication partners also favored the remnants over the
items available to the patient. pictographs. The authors concluded that their results sup-
Bellaire, Georges, and Thompson (1991) investigated the port the use of communication books with individuals who
acquisition, generalization, and maintenance effects of pic- have aphasia.
ture communication board training. Although their two
subjects did not have global aphasia, their findings have
Blissymbols
potential application to the treatment of this population.
Treatment and acquisition probes were administered in a Johannsen-Horbach, Cegla, Mager, Schempp, and Wallesch
traditional treatment room, whereas generalization probes (1985) assessed the benefits of treating four patients with
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Chapter 21 ■ Global Aphasia: Identification and Management 585

global aphasia using Blissymbols, a visual symbol system of program entitled Back to the Drawing Board (BDB) to teach
pictograms and ideograms. All patients had previously patients to communicate messages through sequential draw-
received at least 6 months of traditional therapy for aphasia ings. Patients are trained to draw cartoons from memory
without significant improvement in expressive language. For using verbal instruction, demonstration, and practice through
the procedures using Blissymbols, patients received individ- copying. The cartoons range from one to three panels.
ual treatment twice per week for a period of at least 2 Criterion performance consists of reproducing a recognizable
months. The program was designed (a) to provide a basic drawing that contains the critical details relevant to the
lexicon of nouns, verbs, adverbs, and function words; (b) humorous aspects of the cartoon. Treatment outcome is eval-
teach the production and comprehension of simple sentence uated by increased accuracy in the patients’ drawings of nine
in the symbol language; and (c) acquaint relatives with the “accidents of living.” Morgan and Helm-Estabrooks (1987)
symbol system to use in communicating with the patients. provide an operational definition of accuracy to facilitate
Symbols were introduced verbally along with simultaneous comparison and interpretation of the drawings. Their post-
presentation of pictures or objects or the pantomime of the treatment results for two patients indicated an improved abil-
therapist. Training consisted of associating symbols and pic- ity to convey information through the use of drawing alone.
tures for nouns, verbs, and function words in multiple- Lyon and Sims (1989) undertook a study to determine the
choice arrays and, subsequently, incorporating these items degree to which patients with severe aphasia can communi-
into Blissymbol sentences. cate through drawing and to evaluate the effectiveness of a
All patients acquired a symbol lexicon; three patients pro- treatment program emphasizing drawing-aided communi-
duced Blissyntactically correct sentences in response to pic- cation. Eight patients with aphasia and eight comparable,
tures. Two of the patients successfully used the symbols in normal adults participated in the study. The eight subjects
their communication with their relatives. In an important with aphasia were enrolled in a treatment program focused
related finding, three patients evidenced the ability to artic- on refining primary drawing skills (form, visual organiza-
ulate the correct words while pointing to the corresponding tion, detail, and perspective) within defined communicative
symbols, and one patient articulated grammatical sentences. contexts. Verbal and graphic cueing and requests for
Variable outcomes with regard to continued use of the sym- enlargement of distorted parts were used to improve the rec-
bols by these four patients were reported. ognizability of the drawings. The drawings were then placed
The success of some patients with severe aphasia in com- in a communicative interaction between the patient and a
municating using novel visual symbol systems has been inter- trained interactant who used specific strategies to optimize
preted as evidence for the superiority of such systems relative communicative effectiveness.
to the surface forms of natural language. To test this assump- Communicative effectiveness was assessed using a 40-item
tion, Funnell and Allport (1989) investigated the ability of drawing outcome measure to evaluate pre- and post-treat-
two patients with severe aphasia (neither of whom appeared ment performance both with and without the use of draw-
to have global aphasia) to use Blissymbols to communicate in ings. A scale of communicative effectiveness was designed to
conversational situations. By performing detailed analyses of rate performance on the outcome measure, and a second
the patients’ abilities to process isolated words during listen- scale was designed to rate the recognition of drawings. Pre-
ing, speaking, reading, and writing, the authors were able to and post-treatment performance on the PICA also was used
compare the patients’ use of Blissymbols to their processing to measure communicative effectiveness.
of similar forms in natural language. Funnell and Allport Following drawing treatment, substantial gains were
found that the performance of the patients with aphasia using observed in the communicative effectiveness of subjects with
Blissymbols was entirely consistent with their processing of aphasia compared to their pretreatment levels. Performance
spoken and written words, and that the use of Blissymbols further improved following treatment to 88% of the com-
did not provide a channel for communication that was inde- municative effectiveness score attained by the normal adults.
pendent of natural language processes. Further inquiry will The subjects with aphasia also improved in the recognizabil-
be necessary to determine whether these findings can be ity of their drawings following treatment, achieving 65% of
applied to patients with global aphasia who have more the normal adults’ scaled value. Based on these data, the
severely impaired natural language abilities than those of the authors concluded that drawing serves as an important facil-
subjects participating in the study by Funnell and Allport. itator of communication by providing to patients with apha-
sia a fixed representation of a concept that is readily available
for subsequent modification.
Drawing
Kearns and Yedor (1992) have pointed out that specific
Drawing has received considerable attention both as a com- programming may be needed in some cases to establish
municative medium and as a means to deblock verbal and spontaneous use of drawing for communicative purposes.
written communication. Morgan and Helm-Estabrooks Ward-Lonergan and Nicholas (1995) described such a pro-
(1987; see also Helm-Estabrooks & Albert, 2004) designed a gram for their patient with global aphasia. The program
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586 Section IV ■ Traditional Approaches to Language Intervention

began with BDB (Morgan & Helm-Estabrooks, 1987), pro- or later poststroke. The C-ViC training was initiated no ear-
gressed to the less structured conversational framework em- lier than 3 months after aphasia onset and was continued
ployed in Promoting Aphasics’ Conversational Effectiveness twice weekly for 6 months to 1 year. Outcomes were based
(Davis & Wilcox, 1981) (see below), and concluded with an on a rating scale that was developed to assess the quality of
unstructured, interactive approach they identified as Func- C-ViC–generated sentences.
tional Drawing Training. The patient made substantial The findings from this study suggested that the lesion site
progress during the course of the program, and although pattern associated with the best response (i.e., initiates com-
spontaneous initiation of communicative drawing was still munication) using C-ViC spares large portions of either
lacking at the end of the treatment, the patient was able to posterior systems that include Wernicke’s area and the tem-
communicate effectively through drawing when given lim- poral isthmus or anterior systems that include the supple-
ited encouragement. mentary motor area and the cingulate gyrus. Moderate
responses (i.e., responds to questions but does not initiate
interactions) were found following lesions that spared poste-
Computer-Aided Visual Communication
rior systems but involved anterior systems. Patients who
Computer-aided visual communication (Steele, Kleczewska, demonstrated no response to the program had bilateral
Carlson, & Weinrich, 1992’ Steele, Weinrich, Kleczewska, lesions that included variable lesions in either left posterior
Carlson, & Wertz, 1987; Steele, Weinrich, Wertz, Kleczewska, or posterior and anterior systems. The authors also found,
& Carlson, 1989; Weinrich, Steele, Kleczewska, et al., 1989) however, that prediction of outcome was optimized when
provides another approach to establishing alternative com- these lesion site patterns were combined with behavioral
munication in severely impaired patients. Using procedures results obtained from pre-treatment testing with the BASA
similar to those of visual communication (Gardner, Zurif, (Naeser et al., 1998).
Berry, & Baker, 1976) but in a microcomputer environment, Similar to that reported with gestural strategies, verbal
C-ViC is an iconographic system in which patients construct facilitation has been noted (personal observation) during
communications by selecting symbols from six “card decks” C-ViC training that produces successful naming that is not
and arranging them according to certain syntactic conven- seen in these same patients in other communicative contexts
tions. The card decks contain interjections, animate nouns, (e.g., conversation or formal testing). The ultimate goal of
verbs, prepositions, modifiers, and common nouns. The C-ViC is not verbalization without computer assistance (as
program has been used successfully to train comprehension might be the case with some of the foregoing gestural strate-
of a variety of lexical categories (e.g., verbs and preposi- gies), but these observations suggest that C-ViC is a power-
tions), although generalization to oral production of these ful verbal reorganizer that may enhance the language pro-
[Au17] items has been limited (Weinrich et al., 1989, 1993). Formal duction of patients using this tool.
[Au18] procedures have been developed that extend training from
introductory phases which teach the patient to follow simple
Lingraphica
commands to later phases designed to transfer C-ViC com-
munication skills to use in a home setting (Baker & The Lingraphica is a speech-generating device combining
Nicholas, 1992). One patient with global aphasia was able to images, animation, text, and spoken words to provide
accurately select the lexical items for a message as well as computer-based communication. It contains a large number
apply simple syntactic rules to produce basic constructions of words represented by icons and can be customized with a
(subject-verb, irreversible and reversible subject-verb-object) user’s special words and pictures. The user selects icons to
(McCall et al., 2000). This patient demonstrated great diffi- express a thought or need, which the device then turns into
culty in multi-sentence production, however, and positive audible words or sentences. The Lingraphica also is loaded
gains that were observed over the protracted period with a wide range of practice materials that can be used in
required for this training did not generalize to standardized the clinic under the direction of a speech-language patholo-
assessment measures. gist or independently at home.
Naeser and colleagues (1998) investigated the lesion site Three studies have demonstrated positive effects for
patterns for 17 patients with severe aphasia who had under- chronic patients with a wide range of types and severities of
gone C-ViC training to determine whether these patterns aphasia following treatment using the Lingraphica System.
were predictive of communication outcomes following C-ViC Aftonomos, Steele, and Wertz (1997) studied the responses
treatment. Although some of their patients did not have to computer-based treatment of 23 patients with aphasia who
global aphasia, all of the patients did present with little or no were 6 months to more than 15 years post-onset and who had
spontaneous speech and impaired auditory comprehension. been discharged from previous courses of speech-language
Before treatment, all patients were tested with the BASA treatment. All patients received 1-hour treatment sessions
(Helm-Estabrooks, Ramsberger, Morgan, & Nicholas, with a speech-language pathologist using the Lingraphica
1989) and underwent non–contrast enhanced CT at 3 months System and, with the exception of one patient, used the
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Chapter 21 ■ Global Aphasia: Identification and Management 587

system at home for practice between clinical treatment ses- skills determine the number of symbols that are displayed in
sions. Comparison of pre- and post-treatment scores on a each screen, and each symbol can be programmed to pro-
variety of formal language instruments demonstrated signifi- duce a spoken message.
cantly improved performance in multiple modalities. Koul and colleagues (2005) investigated the effect of Gus
Aftonomos, Appelbaum, and Steele (1999) extended the intervention on the production and generalization of
previous work by assessing the outcomes of computer-based graphic symbol sentences of varying grammatical complex-
treatment on functional communication as well as formal ity in 10 patients with severe aphasia, 2 of whom had global
language tests. Sixty subjects, consisting of 14 patients less aphasia. The motivation for the study was to evaluate the
than 6 months post-onset and 46 patients more than extent to which patients with severe aphasia can use elec-
6 months post-onset, were administered the WAB and tronic communication aids to support or replace spoken lan-
CETI before the initiation of treatment. Treatment con- guage. The first patient with global aphasia was unable to
sisted of 1-hour sessions using the Lingraphica clinical exer- produce even the most syntactically simple sentences (two
cises but with a focus on improving the patients’ functional word agent  action or action  object constructions). The
communication outside the clinic. The number of treatment second patient was able to achieve criterion for two out of six
sessions ranged from 10 to 132. Post-treatment group Level I constructions and one Level II construction (mor-
results demonstrated significant improvements for all sub- phologic inflections [e.g., boy reading]); he did not achieve
tests of the WAB and for the CETI. The acute and chronic the criteria for any of the more complex constructions. No
aphasic groups each made significant improvements on both generalization was observed for any of the sentences that
of the test measures, and all of the patients grouped by apha- were probed. That even one of the two patients with global
sia category, except for patients with Wernicke’s and aphasia was able to use the computer-based system to pro-
transcortical motor aphasia, made significant improvements. duce sentences of varying syntactic complexity was viewed
Eleven patients with global aphasia included in this group by the authors as evidence for the effectiveness of this
had a mean AQ improvement of 6.2 points. approach following global aphasia when compared to the
Finally, Aftonomous, Steele, Applebaum, and Harris patients’ natural language.
(2001) reported outcome data for both the impairment and
functional levels following treatment with the Lingraphica
Promoting Aphasics’ Communicative Effectiveness
System. Fifty patients, including six with global aphasia,
completed at least 1 month of treatment, after which pre- The last functional approach to be considered here is
and post-treatment scores on all items of the WAB and Promoting Aphasics’ Communicative Effectiveness, or
CETI were compared. Participants were found to have PACE, treatment (Davis, 1980, 1986, 2005; Davis &
improved significantly on all language subtests of the WAB, Wilcox, 1981, 1985; Wilcox & Davis, 1978). Despite having
on the WAB AQ, and for all items of the CETI following attributes such as direct language stimulation and real-life
treatment. Patients with global aphasia made the second least conversation (Davis, 2005), its inclusion here (as in previous
gains (behind patients with anomic aphasia) at the impair- versions of this chapter) is based on the limited language of
ment level and the third least gains in functional communi- persons with global aphasia and the potential for using this
cation. When analyzed by patient severity, those with the procedure as a means to promote nonverbal, functional
most and least severe aphasias made the smallest, although options for communication.
still statistically significant, gains at the impairment level, Because PACE procedures allow patients to freely choose
whereas those with the most severe aphasias made the great- the channels through which they will communicate, the
est gains in functional communication. The authors attrib- technique provides opportunities for patients to use either a
uted the latter outcome to commonly observed “ceiling verbal strategy or any of the nonverbal strategies described
effects” in less impaired patients following treatment. above, with or without verbal accompaniment, to convey
messages. In this way, the approach emulates natural con-
versation by allowing participants to exchange information
Gus Multimedia Speech System
through multiple modalities.
Gus is a computer-based graphic symbol communication In addition to free selection, some of the other character-
system that offers graphic and orthographic symbols along istics of natural conversation that provide guiding principles
with synthetic speech output (Koul et al., 2005). The pro- for PACE treatment include the following: (a) Clinician and
gram presents symbols in a dynamic display format that patient participate equally as senders and receivers of mes-
allow the symbols to be presented across screens logically sages, (b) the interaction incorporates the exchange of new
(e.g., superordinate categories in a first screen that explode information between clinician and patient, and (c) the clini-
into subordinate categories in a second screen, followed by cian’s feedback is based on the patient’s success in communi-
specific items in that category in a third screen). The cating a message (Davis & Wilcox, 1985). PACE treatment
patient’s cognitive, linguistic, motor, and visuoperceptual also uses a multidimensional scoring system to better
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588 Section IV ■ Traditional Approaches to Language Intervention

capture the full range of behaviors that may be observed in included gesture, writing key words, and drawing accom-
this interactive approach. Generalization of language gains panied by pictographic resources. Two rating scales were
observed following PACE treatment has been demonstrated developed to measure the amount of support provided by
on formal language assessment instruments. Given its the conversation partner and the level of participation by the
emphasis on the pragmatic aspects of language, PACE is adult with aphasia. Trained volunteers scored significantly
well suited as a means to incorporate compensatory strate- higher than untrained volunteers on ratings of acknowledg-
gies into communication treatment. An additional strength ing and revealing competence in their partners with aphasia.
of the approach, however, lies in its use as a framework for The adults with aphasia in the experimental group also per-
incorporating traditional language stimulation techniques formed significantly higher than their counterparts in the
into a communicatively dynamic context. control group on measures of social and message exchange
skills, even though they had not participated in the training.
These results were interpreted as support for the efficacy of
Social (Partner-Oriented) Approaches
this particular approach to aphasia rehabilitation.
Social approaches (covered in greater detail elsewhere in
this volume) target communication partners or other ways
to reduce communication barriers in addition to improving
FUTURE TRENDS
language or compensatory functional language (LPAA Clearly, future clinical research must better identify the con-
Project Group, 2001; Simmons-Mackie, 2001). As such, ditions under which treatment for global aphasia is maxi-
they may be particularly appropriate for individuals with mally effective. To do so, several issues must receive further
global aphasia, given their poor prognosis for language exploration. One of these concerns outcome from global
recovery. One particularly good example of this approach is aphasia and includes (a) identifying the factors that differen-
Supported Conversation for Adults with Aphasia (Kagan, tially account for evolution in some patients with global
1998; Kagan et al., 2001), or SCA. Others have included aphasia to less severe aphasic syndromes, (b) establishing or
[Au19] conversational coaching (Hopper & Holland, 2002), recip- refining prognostic indicators or profiles that can reliably
rocal scaffolding (Avent & Austermann, 2003), partner predict outcome in global aphasia, and (c) specifying the rela-
[Au20] training (Simmons-Mackie, 2004), and the use of autobio- tionships between site and extent of lesion for outcome in
graphical reports (Pound, Parr, & Duchan, 2001). global aphasia. A second issue concerns how this outcome
The SCA program teaches techniques to conversation information can be better applied to management decisions
partners that will help them better reveal the competence of for patients with global aphasia. Naeser (1994) provides one
people with aphasia (Kagan, 1998). It builds on the assump- example of the use of outcome information obtained during
tion that many adults with aphasia can capitalize on pre- the acute phase of recovery for these purposes. This
served cognitive and social abilities to participate in conver- approach must be further developed to improve specificity
sation. The SCA program involves training conversation and accuracy. Third, clinicians must continue to identify spe-
partners to acknowledge the competence of individuals with cific assessment and treatment approaches that are sensitive
aphasia and help them reveal what they think, know, and feel. to the capabilities of patients with global aphasia and produce
Kagan and colleagues (2001) investigated the efficacy of reasonable outcomes in functional communication relative to
SCA in a single-blind, randomized, controlled, pre-post the time and effort expended during the rehabilitation
design study. Forty dyads consisting of a volunteer conversa- process. Finally, greater emphasis will be placed on improv-
tion partner and an adult with moderate to severe aphasia ing not just communication, but the overall quality of life of
were divided evenly between a control and an experimental the patient with global aphasia. Rehabilitation programs will
group. Fifteen percent of the participants with aphasia were incorporate increasingly sensitive measures to evaluate the
diagnosed with global aphasia. The groups participated in psychosocial outcomes of treatment. Common practice will
videotaped semistructured interviews with or without SCA extend the continuum of care for these patients to support
training. The SCA training focused on acknowledging and groups and other community organizations following the
revealing the competence of adults with aphasia through sup- completion of formal speech and language treatment.
ported conversation. For example, the topics for acknowl-
edging competence included keeping talk as natural as possi-
ble, avoiding patronization, and explicitly indicating that KEY POINTS
competence of the person with aphasia is not in question;
those for revealing competence included ensuring the person 1. Global aphasia may be one of the most frequently
with aphasia understands what is being communicated and is occurring types of aphasia; age and sex do not appear
given the opportunity to express what he or she knows, to have a differential effect on the incidence of global
thinks, or feels and verifying that the conversation is on track aphasia.
from perspective of person with aphasia. The techniques
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Chapter 21 ■ Global Aphasia: Identification and Management 589

2. Global aphasia may result from extensive cortical 12. In the absence of accurate techniques for predicting
lesions of the dominant hemisphere, lesions confined recovery from global aphasia, the most powerful rea-
to either the anterior or posterior cortex, or lesions sons for providing early treatment are the latent
restricted to subcortical regions. Patients with global recovery observed in patients who receive acute
aphasia and large pre- and postrolandic middle cere- speech and language treatment and the greater
bral artery infarcts generally have a poor recovery, effects that are observed for patients with aphasia in
but some individual patients with this lesion pattern general when treated during the acute period of
may demonstrate outstanding outcomes. recovery.
3. Patients with global aphasia have several isolated 13. Early intervention in global aphasia has the multiple
areas of relatively preserved comprehension, includ- purposes of language stimulation directed toward
ing specific word categories, familiar environmental cerebral reorganization and recovery, identification
sounds, famous personal names, and personally rele- of successful communication strategies, and patient,
vant information. The verbal output of these patients family, and staff counseling.
consists primarily of stereotypic recurring utterances 14. Contemporary approaches to assessment include
or speech automatisms. both formal and informal measures to establish a
4. Nonverbal cognitive impairment is correlated with communication profile that documents not only the
the degree of language impairment in global aphasia. patient’s areas of weakness but also the patient’s
5. Patients with global aphasia rely most heavily on strengths.
nonverbal communication that may be nearly as 15. Treatment for global aphasia exploits the residual
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[Au1][AU: Please provide full citation for “Okuda et al., 1994” in the References.]
[Au2][AU: Please provide full citation for “Heiss et al., 1993” in the References.]
[Au3][AU: Please provide full citation for “Goodglass & Kaplan, 1983” in the References.]
[Au4][AU: Please provide full citation for “Yasuda & Ono, 1998” in the References.]
[Au5][AU: Please provide full citation for “Forde & Humphreys, 1995” in the References.]
[Au6][AU: Please clarify. Do you mean subjects with right hemisphere damage without aphasia?]
[Au7][AU: Please provide full citation of “Rossor, Warrington, & Cipolotti, 1995” in the References.]
[Au8][AU: Please clarify. Do you mean 50% each, or do you mean 50% in total showed Broca’s or global aphasia?]
[Au9][AU: Please provide full citation for “Marshall and colleagues (1997)” in the References.]
[Au10][AU: Please provide full citation for “Masand & Chaudhary, 1994” in the References.]
[Au11][AU: Please provide full citation for “Reinvang, 1985” in the References.]
[Au12][AU: Please clarify the sentence beginning “Until more is known...” Do you mean that in each case, the clinician should intervene at the earliest opportunity unless some-
thing specific to the individual patient contradicting this approach becomes known?]
[Au13][AU: Please clarify. By “when they fail to change,” do you mean when the patients fail to improve? When the treatment objectives fail to reflect the change in the patient?]
[Au14][AU: Please clarify. Is the sentence “Patients are trained in...” OK as edited for clarity and flow?]
[Au15][ AU: Please clarify. By “treated naming to confrontation,” do you mean “used confrontation in a naming exercise”?]
[Au16][AU: Please clarify. Does “These authors” refer to Conlon and McNeil (1991)?]
[Au17][AU: Please clarify. Is this Weinrich Steele, Carlson, et al., 1989, or Weinrich, Steele, Kleczewska, et al., 1989?]
[Au18][AU: Please provide full citation for “Weinrich et al., 1993” in the References.]
[Au19][AU: Is this “Hopper, Holland, & Rewega, 2002,” as given in the References? If not, please provide full citation.
[Au20][AU: Please provide full citation for “Simmons-Mackie, 2004” in the References.]
[Au21][AU: Please cite reference in text.]
[Au22][AU: Please cite reference in text.]
[Au23][AU: Please cite reference in text.]
[Au24][AU: Please cite reference in text.]