A Context-Based Approach to Treat Fluent Aphasia

Fluent aphasia can be particularly challenging to treat for both new and experienced clinicians alike. What complicates a speech-language pathologist’s job further is the lack of research for treatment in this area! Fortunately, there is some research and expert opinion available to help guide your intervention. The next time you think, “I have a client with fluent aphasia, what do I do?” you can feel more confident with the information here.

The Challenges of Fluent Aphasia

Fluent aphasia, also known as Wernicke’s aphasia or jargon aphasia, is characterized by a significant language comprehension impairment and near-effortless speech filled with the wrong words or even non-words. While this type of aphasia is often referred to as receptive aphasia (meaning problems with understanding language), individuals with fluent aphasia can have as much difficulty with expressive language as they do with receptive language. The difference is the listener who recognizes the problem more than the person speaking!

This clinical profile is further characterized by these unique attributes:

• Illusion of strong expressive skills - relatively spared grammar and clear articulation make it seem as if speech is normal until you listen closer

• Lack of awareness - no insight into the deficits or their severity; some with fluent aphasia may not believe they have a communication impairment and are confused as to why listeners don’t understand them

• Press of speech - copious amounts of unrestrained speech, often speaking over others and not stopping without being told to do so

• Jargon - speech is incomprehensible, filled with neologisms (non-words) and both semantic and phonemic paraphasias (words related to the intended word based on meaning or sounds)

What Does the Research Say about Treating Fluent Aphasia?

In short, not a lot. There is simply not much published research looking at treatments specifically addressing fluent aphasia, and many of the papers are single case studies offering weak evidence. We can learn from the available research that not all individuals respond positively, and treatments tend not to generalize past the stimuli used. This tells us two things.

1. Intervention needs to be highly specific and personalized

2. Data collection is critical to determine if a client is improving

When faced with a shortage of research evidence, we can take expert opinion into consideration.

Context-Based Approach

The esteemed Dr. Robert Marshall proposes a context-based approach to treat fluent aphasia, emphasizing this treatment as the starting point in the early stages of therapy. Specifically, Dr. Marshall reasons the context-based approach is ideal for clients with fluent aphasia to establish effective communication before a rapid discharge from acute and subacute care due to a lack of physical impairments. The context-based approach can assist in improving several areas of language, including comprehension, self-correction, efficiency in information exchange, and even caregiver training.

What is Context?

With this approach, context becomes the common denominator. Research shows a communicative context allows participants to make inferences and derive meaning from conversation. This will make clients with fluent aphasia more successful at communicating their intended message. 

There are two important facets to context that enhance comprehension for persons with aphasia: linguistic context, or the words used around the point to be understood, and paralinguistic context, or the non-linguistic factors that help to convey meaning such as prosody, facial expression, and intonation.

Establishing Communication Contexts and “Buy-In”

Due to a lack of awareness, it is often beneficial to find something the person with aphasia wants to communicate to get them invested in therapy. This could be anything from expressing a medical concern to asking a family member how their beloved pets are doing at home. Once they’ve communicated successfully with the help of the speech-language pathologist, it will be easier to engage the client in different topics of conversation and to establish new contexts.

Initially, the clinician may be responsible for establishing the context before beginning a conversation. There are several successful ways to do so, including using: 

• Shared knowledge learned from the medical chart

• Items found around the bedside, such as family photos

• Humor & emotion

• Life details provided by family members

Think creatively. If you both live in the same city, speak about notable landmarks or events. Find out about past work experience, how many grandchildren they have, or where they went to school. Maybe the client is wearing a logoed T-shirt of a sports team or other interest you can discuss. A little research can help you discover meaningful communication contexts to establish during intervention. 

Improving Comprehension

In the first several months post-stroke, it may be challenging to work on structured tasks to improve comprehension. Using a conversational context to improve understanding can promote functional communication and set a foundation for future speech therapy. The context-based approach for comprehension includes three variables.

1

Identifying & manipulating linguistic and temporal variables. The clinician/caregiver should:

• Highlight the main ideas during conversation

• Add stress and emphasis on important words

• State information simply and directly

• Use simple vocabulary

• Write down keywords to supplement auditory comprehension

• Be redundant by repeating, paraphrasing, and expanding to ensure the message is understood

• Speak slightly slower, but not unnatural or child-like

• Pause at appropriate syntactic boundaries

2

Supporting the client to take ownership of their comprehension

• Make sure the individual with aphasia is not just “pretending to understand”

  • Signs of this can include a lot of head-nodding and “uh-huh’s” with no attempt to communicate more

• Clinicians can encourage the client to take responsibility by modeling what they want the client to do:

  • Ask for repetition

  • Give the client a look to indicate you do not understand

  • Verify the information by rephrasing

  • Ask a rhetorical question

• Provide positive reinforcement of a client’s attempts to request repetitions and their use of verification methods

3

Training caregivers on how best to speak with the client

• The SLP must model and demonstrate how caregivers can best communicate with the client

Improving Verbal Expression

1

A common symptom, press of speech, makes verbal expression difficult for those with fluent aphasia. One effective way to decrease press of speech is using a “stop” strategy. The clinician can teach the client to listen to themselves, stop when an error occurs, and attempt to correct themselves. Initially, the SLP may need to signal the client to stop and request them to correct themselves. SLPs and caregivers should encourage short replies to avoid press of speech. When comprehension is too impaired for the “stop” strategy, the clinician should verify and rephrase the meaning of the intended utterance as best as possible.

2

Perseveration may also be a hindrance to successful communication in fluent aphasia. Perseveration, the act of repeating the same response when a new one is needed, is thought to be caused by slowness in consolidating or processing information. One technique to improve this is by providing increased time during conversational turns for the client to integrate the information. It may also be helpful to avoid quick changes in topics.

3

Anomia (word-finding difficulties) is often best dealt with using indirect approaches or compensating during the early-onset of fluent aphasia. Some helpful tips include:

• Taking your cues from the patient including filling in the intended word, if there is significant struggle, or encouraging total communication

• Using non-verbal means such as gestures, body movements, drawing, etc.

Promoting Self-Correction

Self-correction is a vital component of treatment for fluent aphasia. However, some individuals may have too severe comprehension deficits to initially target this approach. Within the context-based approach, one aspect to encourage self-monitoring is reinforcing the client when they are correcting their speech and language. Encouraging comments such as, “Nice job using a different word” or “I like the way you kept trying”, are good feedback tools for clients to gauge their success. Education regarding daily fluctuations in skills may be necessary, informing the client that consistency improves over time. 

Parting Thoughts

There is no guidebook or procedure to follow when using the context-based approach. This may make some clinicians hesitant to use this intervention. Ultimately, it takes practice and flexibility to make quick decisions that benefit the client. It’s important to remember the main goals of this approach in order to feel confident implementing the context-based approach.

• Improving the ability for the person with fluent aphasia to communicate with others after discharge

• Training family members as co-communicators and equipping them with strategies to use during breakdowns

• Encouraging the client to take ownership of their communication by improving awareness and the ability to self-correct

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ABOUT THE AUTHOR

Katie Brown, MA, CCC-SLP, CBIS

Katie is the owner and founder of Neuro Speech Solutions. She is passionate about providing person-centered treatment to her clients in order to meet their life participation goals. Katie is dedicated to helping other SLPs provide functional therapy through affordable materials and education courses.

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