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Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
Published in final edited form as:
Curr Phys Med Rehabil Rep. 2020 December ; 8(4): 478–492. doi:10.1007/s40141-020-00287-z.
Is Aphasia Treatment Beneficial for the Elderly? A Review of
Recent Evidence
Rachel Fabian, MS, CCC-SLP2,*, Lisa Bunker, PhD, CCC-SLP2,*, Argye E. Hillis, MD, MA1,2
1Department
of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine
2Department
of Neurology, Johns Hopkins University School of Medicine
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Abstract
Purpose: We review recent literature regarding aphasia therapy in the elderly. Relevant articles
from the last 5 years were identified to determine whether or not there is evidence to support that
various therapeutic approaches can have a positive effect on post-stroke aphasia in the elderly.
Recent findings: There were no studies examining the effects of aphasia therapy specifically in
the elderly within the timeframe searched. Therefore, we briefly summarize findings from 50
relevant studies that included large proportions of participants with post-stroke aphasia above the
age of 65. A variety of behavioral and neuromodulation therapies are reported.
Summary: We found ample evidence suggesting that a variety of behavioral and
neuromodulatory therapeutic approaches can benefit elderly individuals with post-stroke aphasia.
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Keywords
Stroke; aphasia; elderly; rehabilitation; treatment; therapy
Introduction
Stroke is a leading cause of long-term disability [1], disproportionately affecting older
adults; 70–77% of stroke patients are over 65 [2, 3], and about 17% are over 85 years-old
[4]. Very elderly patients have higher disability and receive less evidenced-based care [5, 6].
The greatest expected increase in stroke prevalence is among those over age 75 [7].
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Approximately 20–30% of strokes result in aphasia (neurogenic language impairment) [8,
9], and about 19% of stroke survivors over 65 continue to have aphasia at 6 months post
Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. http://www.springer.com/gb/openaccess/authors-rights/aam-terms-v1
Corresponding Author: Argye E. Hillis, MD, 600 N. Wolfe Street, Phipps 446, Baltimore, MD 21287, USA, Telephone:
01-410-955-2228, Fax: 01-410-614-9807, argye@jhmi.edu.
*These authors contributed equally to this work.
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been
accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept
up to date and so may therefore differ from this version.
Conflict of Interest
Lisa Bunker reports salary from Johns Hopkins University, provided by an NIH grant, during the conduct of the study. Argye Hillis
reports grants from NIDCD during the conduct of the study. Rachel Fabian declares no conflicts of interest relevant to this manuscript.
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stroke [10]. Aphasia can manifest as difficulty with comprehension, production, or both, in
any modality (i.e., spoken language, reading/writing, or gesture). An individual’s
independence can be significantly impacted by aphasia [11]. Communication is an essential
part of human connection and is critical for maximizing and maintaining quality of life.
Thus, remediation of aphasia after stroke aims to reduce language impairment and/or
increase functional communication, participation, and quality of life and reduce care burden.
Stroke survivors with aphasia are typically older than those without aphasia [9, 12], so it is
particularly important to understand the role of aphasia treatment in the older population.
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In this article we review the current literature regarding aphasia therapy in the elderly.
Relevant publications within the past 5 years were identified by searching for the general
terms elderly, aphasia, and therapy/rehabilitation in the following databases: PubMed,
Medline, ProQuest, ERIC and Google Scholar. Search results were limited to English
language publications from 2015 through March 19, 2020.
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Over 750 studies were screened for duplications and relevance (i.e., reports on the effects of
treatment for elderly persons with aphasia). There were no studies examining the effects of
aphasia therapy explicitly in the elderly within the timeframe searched. Therefore, we
focused on higher quality treatment evidence that included relatively large proportions of
participants above the age of 65 to draw meaningful conclusions (e.g., a single participant
above 65 in a group of 20 was not considered to provide meaningful evidence pertinent to
the older adult population and was therefore excluded). Likewise, small n or case studies are
difficult to interpret with regards to a population, as results can generally only be extended to
cases that are very similar. As such, all of the treatments discussed include multiple
participants above the age of 65 to support the generalization of results to the elderly
population. Thus, significant treatment effects theoretically could be extended to elderly
individuals if the other demographic variables match and the experimental rigor was high. It
should also be noted that, although aphasia can result from any neurological injury or even
progressive neurological disease, the most common cause of aphasia is stroke [9, 13, 14].
Likewise, treatment research exists almost exclusively for post-stroke aphasia. Therefore, the
articles included here report results for the post-stroke population. Generalization of
potential recovery to other etiologies cannot be assumed.
Fifty of the most relevant studies obtained from our search are included in this review.
Primary trends included traditional behavioral speech-language therapy (with and without
the use of advanced technological delivery modes), neuromodulation techniques, and
adjuvant pharmacological therapies. These studies are summarized in Tables 1 (behavioral
therapies) and 2 (neuromodulation therapies).
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Behavioral Speech-Language Therapy
For aphasia, behavioral speech and language therapy (SLT; i.e., the training/modification of
specific skills/behaviors) remains the current standard of care. SLT aims to improve an
individual’s ability to communicate by targeting the impairment specifically, training
compensatory behaviors for lost language skills, or facilitating the use of skills in a variety
of contexts.
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Face-to-face SLT continues to comprise a large proportion of intervention research. Recent
research has focused not only on the effectiveness of such treatments, but also on identifying
variables associated with greater response to therapy (e.g., intensity, generalization, delivery
mode, etc.), as well as eliminating barriers to implementation and participation (e.g., using
teletherapy as a means of reducing/eliminating the burden of travel to/from the clinic).
Intense Treatment
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Several studies have examined the optimal treatment intensity for acquisition and
maintenance of gains. For example, is intensive practice better than distributed practice? Or,
does highly intense treatment facilitate recovery better in the acute/subacute stage versus the
chronic stage? Intense treatment protocols have gained popularity in recent years for two
primary reasons: 1) highly intense practice is thought by some to be better for learning (i.e.,
acquisition and/or retention of behavior; e.g., see [15]) and/or 2) due to logistical barriers,
many persons with aphasia (PWA) in the chronic stage are more likely to be able to
participate when the overall time commitment is brief (i.e., weeks rather than months).
Synthesis and interpretation of “intense” treatment studies is challenging, as intensity is not
consistently defined or reported [29]. Thus, across most studies discussed here, it is
important to note that “intense” treatment is generally described as 3–4 hours/day, 5 days a
week, for 2–3 weeks.
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Intensive Language-Action Therapy (ILAT; also referred to as Constraint Induced Aphasia/
Language Therapy; see [16]) has been widely studied. Some studies examined the
effectiveness of ILAT (e.g., [17–19]), and others have compared ILAT to other intense
treatments [20–23]. In each study, ILAT was found to be effective at improving a variety of
language outcomes (e.g., naming, general language measures such as comprehensive
standardized assessments], communicative confidence, etc.), but not always above the
comparative treatments (e.g., [17, 23]). Wilssens and colleagues found the ILAT resulted in
improved production and phonology, while the compared lexical-semantic treatment
improved comprehension/semantics for persons with fluent aphasia [22]. In cross-over
studies where participants received both treatments, ILAT was always found to be effective,
but outcomes differed based on order of administration [20, 21]. For example, participants
receiving ILAT first demonstrated greater overall gains than those receiving ILAT second,
suggesting that ILAT may be particularly effective in early intervention [21]. However, these
comparison studies generally did not clearly report protocols for the comparative treatments,
thus it is difficult to know if both treatments were targeting the same communicative
functions/skills. Differential responses may have been due to the two treatments modifying
different behaviors that were not equally captured by the outcome measures. Additional
investigation is needed to understand if, and how, ILAT may be more effective than other
behavioral intervention options, but ILAT generally results in favorable changes.
Another popular intense treatment approach is that of intensive comprehensive aphasia
programs (ICAPs), where PWA will come to an aphasia clinic for a defined period of time to
receive a comprehensive program of treatment including impairment-based and functional
interventions across any/all modalities. Interventions are often delivered through a variety of
approaches (e.g., individual/group therapy, partner training, self-practice, etc.). ICAPS have
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been reported to result in significant gains on overall aphasia severity ratings, impairmentbased measures, and qualitative ratings of communication and participation/quality of life
(QOL) [24, 25]. Positive outcomes were reported across aphasia types and severities. It is
important to note that ICAPs are generally delivered at an even greater intensity than most
other treatments described as “intense.” That is, the ICAPs reported by Babbitt et al. and
Hoover et al. included 30 hours of treatment per week over four weeks, for a total of 120
hours [24, 25].
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While many researchers and clinicians believe that high-intensity treatment is particularly
effective, the effects of intense treatment are not fully understood. Recent investigations have
evaluated effects of intense treatment compared to less- or non-intense treatment. Woldag et
al. found no difference on standardized assessments between ILAT and non-intense
“traditional” treatment, but the compared treatment was only vaguely described and tailored
to individual impairments (i.e., treatment ingredients and targets were different for each
individual, thus collective positive change for the group may have been confounded) [23].
Stahl compared highly intense to moderately intense ILAT (i.e., 4 compared to 2 hours/day)
and likewise found both intensities resulted in equivalent gains, with no difference between
the two groups [26]. Positive results with less intense ILAT have also been reported in
several other studies [27, 21]. In an examination of Aphasia Language and Impairment
Functioning Therapy (Aphasia LIFT) [28], two groups were compared receiving the same
total amount of treatment, but either condensed into three weeks, or distributed over eight
weeks. While most outcomes were equal across groups, the primary outcome (naming
accuracy) showed greater improvement with the distributed schedule. Thus, while intensive
treatment schedules have been shown to be effective, evidence has not demonstrated that
intense treatment is more effective than non-intense treatment, partly due to considerable
differences in how intensity is defined and reported across studies [29].
Generalization
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Ideally, all treatment would result in generalization to performance of learned skills/
behaviors beyond the specific items/contexts practiced in treatment. However, reliable
generalization effects have been largely absent from current treatment evidence. Some
treatment studies have focused on identifying the nature of generalized effects. For example,
in naming treatments, training more complex or difficult items/tasks has been shown to
generalize to less complex or difficult items [30]. Dignam found that a hybrid approach
(combination of individual, group, and computerized treatment) resulted in generalized
naming improvement [28]. Other studies have shown generalization to untrained stimuli by
training underlying language processes such as phonological sequencing, [31] but the
observed generalization was not associated with any participant variables [32]. Semantic
Feature Analysis continues to be a popular and effective choice for naming treatment [33]
and has been shown to generalize to untrained items [34]; see [35] for review. In Semantic
Feature Analysis, greater gains have been associated with greater dosage (i.e., number of
trials; [35]), baseline language performance [35], and the number of features generated [34].
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Functional Approaches
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Despite the demonstration of generalization to untrained items and contexts, a significant
impact on functional communication is often not readily apparent. To promote more
functional outcomes, some investigators have targeted individual impairment/participation
goals in a group setting, such as conversation. Conversation treatment [36] has resulted in
improved functional communication [37, 38] and is more effective in dyads rather than
larger groups [38]. Conversation treatment was also reported to be very motivating for PWA
and their partners [37].
Delivery Modes
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Cost and access to aphasia intervention continues to be a challenge for PWA, particularly in
subacute or chronic stages when individuals have returned home and treatment is no longer
covered by insurance, or travel to an outpatient clinic is difficult. Teletherapy allows remote
delivery of behavioral interventions as an alternative to the standard face-to-face delivery.
Remote delivery has been demonstrated to be successful in both impairment-specific
training [39] and functional communication [40]. In one study, remote and face-to-face
delivery did not have significantly different effects on measured outcomes (naming in
various contexts) [39]. In a novel virtual reality application allowing for client and clinician
to interact in a virtual environment, improvements in functional communication and verbal
fluency for trained categories was reported, but could not be reliably attributed to treatment
[41]. The same study, however, did not show improved socialization or communicative
confidence, suggesting that a virtual environment may not be an ideal setting for some
aspects of communicative function. Additional research is needed to understand the potential
role of virtual reality and other remote delivery methods.
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Another approach to expanding access the use of computer-/tablet-based intervention tasks
in addition to, or in place of, traditional face-to-face services. The use of software
applications as an adjuvant therapy have had mixed results. While some studies have shown
improved outcomes compared to the traditional treatment alone (e.g., [42]), others have
found traditional delivery alone to result in better outcomes [43]. Hybrid models, combining
individual, group, and computerized treatment—with individualized treatment plans and
treatment ingredients—have also been shown to improve verbal/functional communication
[28, 44, 45] and activity/participation [28, 45].
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In the case of computerized treatment delivered [almost] exclusively through selfadministration (e.g., through an app such as Listen In [46]), significant gains have been
reported in naming trained items [47–49], with some generalization to untrained contexts
[50], and for auditory comprehension [46]. When compared to “standard” care, reported
gains with computerized treatment have exceeded those for “standard” treatment [46, 47].
Unfortunately, treatment protocols and compliance are often not well described/reported for
such studies. Additional investigation is needed to determine the benefits of computerized
treatment alone, and in addition to, face-to-face delivery.
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Neuromodulation Techniques
Another recent trend in aphasia therapy research is investigation of the potential therapeutic
role that noninvasive brain modulation techniques such as transcranial direct current
stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) could have for
augmenting outcomes of behavioral SLT. tDCS and rTMS have already been shown to be
beneficial in the treatment of aphasia. For detailed reviews of trends in non-invasive brain
stimulation for aphasia, see [51, 52].
Transcranial Direct Current Stimulation
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tDCS delivers a weak electrical current (usually 1 or 2 mA) via two electrodes placed on the
outside of the scalp. This stimulation is believed to enhance or diminish cortical excitability
depending on the application of the anodal (positive) or cathodal (negative) electrode,
respectively [53]. tDCS studies identified in our search generally reported a stimulus or
sham application for 20 minutes—typically, during the first 20 minutes of the concurrent
SLT. The stimulation sites, quantity of sessions, and type of concurrent language tasks varied
among the studies (see Table 2).
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Anodal-tDCS (A-tDCS) applied to the left hemisphere has been shown to positively impact
language recovery in PWA in the chronic stage [54–56]. In contrast, positive effects were not
found for individuals who underwent A-tDCS in the subacute stage [57]. In the latter,
participants in both stimulus conditions showed improved naming with no statistical
difference between tDCS and sham. Lack of a statistical difference between groups,
however, may be explained by only 5 treatment sessions, gains in the experimental group
that were not large enough to be identified above and beyond spontaneous recovery, or by
differences between groups (e.g., 23% hemorrhagic stroke in the experimental group versus
6% in the control group).
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A current aim of tDCS research is investigating optimal placement of electrodes. For
example, is it better to apply positive or negative stimulation, and is such stimulation most
effective when applied to perilesional or contralesional areas, to specific anatomical
locations regardless of lesion location, or to areas of high activation individually identified?
When comparing two configurations of A-tDCS (application over left inferior frontal gyrus
[IFG] and over left posterior superior temporal gyrus [STG]) and sham stimulation, postintervention performance was highest for the active IFG condition, suggesting that
placement of stimulation can impact outcomes [58]. Additionally, application of A-tDCS
over left primary motor cortex also demonstrated positive effects on language recovery [56].
Cathodal tDCS (C-tDCS; applied over the right hemisphere) has also demonstrated
therapeutic effects (e.g., improved response times for noun naming [59] and improved verb
naming [60]), suggestive that C-tDCS over the right hemisphere may also induce therapeutic
effects.
A-tDCS and C-tDCS often utilize a reference electrode over the supraorbital region, but
other modes of delivery being investigated include application of both anodal and cathodal
electrodes to areas hypothesized to be pertinent to language (e.g., both activation of left
hemisphere regions and inhibition of right hemisphere regions concurrently). This
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configuration has resulted in improvement in treated and untreated verb production;
however, there was no difference between tDCS and sham conditions [61]. The stimulation
site in this study was perilesional and thus slightly different for each participant, which may
have contributed to the lack of a group effect. The sample size was also small, so it is
difficult to draw strong conclusions.
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Other important factors investigated in recent years include more precisely localized delivery
of stimulation and the ideal current level. Investigators have attempted to increase precision
of the stimulation site through methods such as high definition tDCS (HD-tDCS).
Traditional tDCS electrodes are typically about 4×5cm in size; HD-tDCS electrodes are
about 10mm in diameter allowing for a more focused delivery of current. To date, it is
unclear that HD-tDCS is more effective than conventional sponge-based tDCS, but its
feasibility has been shown, with effects at least comparable to conventional sponge-based
tDCS [62]. Additionally, cathodal HD-tDCS applied to the right homologue of Broca’s area
has resulted in improved verb naming with 2mA current delivery, but not with 1mA [60],
suggesting that current delivery can also impact outcomes. However, 1 mA current is often
used as it is less likely to induce scalp pain compared with 2mA [54], another important
factor in the clinical setting.
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Investigators are also aiming to identify which patients are the best candidates for tDCS (i.e.,
who benefits the most) with regard to characteristics such as lesion location, aphasia type,
and impairment severity. Some lesion locations have been associated with poorer response to
tDCS condition (i.e., left basal ganglia, insula, and longitudinal fasciculus [63]). In addition
to identifying who will benefit most, investigators are seeking to identify the best dosage for
tDCS intervention (e.g., does increasing the frequency and intensity improve outcomes?).
Positive results were observed for an intensive intervention (two 1.5-hour SLT sessions per
day with tDCS application during the first 20 min of each session) [56]. Effects from this
dosage seemed comparatively larger than other studies, possibly related to receiving 40
minutes of tDCS per day which is twice that of most other protocols. Continued
investigation along these lines of inquiry are needed.
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Another novel trend in tDCS research is investigating the potential therapeutic role that
tDCS may have to augment SLT when applied to the cerebellum, as this configuration
targets tracts involved in language processing and can be applied without the need to
consider the cerebral lesion location or identify activation sites prior to tDCS application.
Cerebellar tDCS had a positive effect on language skills and improved functional
connectivity in healthy younger adults [64] and in a case study of an individual with chronic
post-stroke aphasia and large bilateral cortical strokes [65]. Positive effects were recently
observed in a study that included multiple participants in the elderly age range [66],
suggesting that this configuration could have therapeutic effects on elderly adults with
chronic post-stroke aphasia. In the latter study, significant improvement was observed in
verb generation but not in verb naming, indicating that cerebellar tDCS may be most
effective for tasks that also require nonlinguistic strategies, as in verb generation.
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Repetitive Transcranial Magnetic Stimulation
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Repetitive transcranial magnetic stimulation (rTMS) consists of the presentation of a low
frequency (e.g., 1–5 Hz) or a high frequency (e.g., 10–20 Hz) magnetic pulse aimed at a
targeted neurological location in order to inhibit or excite the residual function of that area
[67]. In aphasia treatment applications, stimulation is delivered to the left hemisphere
language networks or corresponding right hemisphere homologues. Using fMRI to examine
activation and connectivity, rTMS has been shown to recruit residual language areas while
reducing involvement of the right hemisphere during language tasks [68].
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As with other neuromodulation techniques, various rTMS applications/ specifications (e.g.,
inhibitory versus excitatory stimulation, stimulation site, frequency [i.e., low versus high
frequency], and dosage) have been used. While promising results of the effects of rTMS for
post-stroke aphasia have been reported [67, 69–75], the ideal application parameters have
not been identified. Site of application appears to have an impact on treatment outcomes in
subacute post-stroke global aphasia. Ren and colleagues compared the effects of rTMS when
applied to two different sites: right posterior IFG and right posterior STG [67]. Repetition
and severity scores improved for both sites; however, application to posterior STG was
associated with significant increases in auditory comprehension, and application to posterior
IFG was associated with increases in fluency and content accuracy. Varying frequency (i.e.,
low versus high frequency) also affects outcomes. In a study comparing low frequency (LFrTMS;1 Hz) to high frequency (HF-rTMS; 10 Hz), positive immediate and long-term (i.e., 2month follow-up) effects were observed only in those who received LF-rTMS. The HFrTMS group only demonstrated improvement at two months post-treatment, and the effects
were greater overall for LF-rTMS than HF-rTMS [74]. Additional research is needed to
understand the differential effects of varying application sites and frequency of rTMS.
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Investigators are also seeking to identify the optimal timing of rTMS intervention after
stroke and to understand who will benefit most from rTMS. Positive effects have been
reported in chronic post-stroke aphasia [74]; however, LF-rTMS over the right IFG in
subacute stroke has demonstrated mixed results [67, 75]. Rubi-Fessen and colleagues found
no difference between active rTMS and sham stimulation in the subacute period for half of
the measured outcomes [75]. Neural responsiveness to treatment may differ at different
stages of recovery [76].
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Mixed results across studies could also be in part due to other factors, such as differences in
post-stroke language laterality (based on fMRI activation) [77] or different underlying
deficits. For example, investigators found that inhibitory rTMS over the right pars
triangularis facilitated phonological access during word retrieval, suggesting that impairment
at this stage of production may optimally respond to this approach [71].
Pharmacological Therapies
Investigations of the potential role of medications on enhancing aphasia recovery have been
scattered across the literature over the past few decades, but none have been adequately
replicated. Search results yielded one current study relevant to the elderly: an investigation
of effects of combination therapies (i.e., pharmacotherapy plus behavioral SLT plus
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neuromodulation techniques) which showed promising results [78]. Changes in language
measures post-intervention were significantly higher for those who received
dextroamphetamine compared to those who received a placebo in conjunction with
behavioral SLT and tDCS. However, more research is needed before these treatments can be
recommended. For detailed review of current trends in pharmacological interventions, see
[79].
Discussion and Limitations
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Since no studies identified in our search results explicitly studied the effects of aphasia
therapy in the elderly population, we reviewed the most relevant studies, based on inclusion
of older participants and quality of the evidence. Therefore, the results, as they pertain to the
elderly, need to be examined judiciously. Most studies were relatively small, and
generalizability to the population as a whole is tentative.
While results of these studies are not directly applicable to the rehabilitation potential of
older adults, there is ample evidence that older adults are still capable of responding to
treatment given the ample number of participants above the age of 65 across these studies.
While advanced age is a factor that contributes to a reduction in neural plasticity [76],
increased brain atrophy [80], and physiological changes [81], there is mixed evidence that
age actually predicts post-stroke aphasia outcomes [12]. In a recent review examining age
and aphasia recovery, 12 of 17 studies reported that advanced age did not influence clinical
recovery patterns or outcomes [12], suggesting both that: 1) many elderly adults have
comparable capacity for response to treatment as younger adults, and 2) more research is
needed to understand the effects that aging has on response to aphasia therapy.
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Conclusions and Future Directions
Additional research is needed to elucidate the mechanisms by which aphasia therapies
enhance language performance in the elderly. Larger studies are needed to yield meaningful
results. In the absence of larger studies, meta-analyses could be beneficial, but are severely
limited by differences in outcome measures, delivery methods, frequency, duration, and
dosages across studies. Future studies would benefit from some standardization of these
areas in order to fully analyze the outcomes on a larger scale. Likewise, future study
protocols on neuromodulation techniques should continue to include current strength,
electrode size, electrode placement site and stimulation duration to allow investigators to
compare results between studies.
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Investigations specifically comparing treatment response across age groups are also needed.
While training-induced neural plasticity reduces with age [76], older adults have responded
positively to SLT (as indicated by investigations reported here as well as many not included
in this review). It would be valuable to examine the effects of aging specifically on the
outcomes of post-stroke aphasia with regard to specific interventions. The overarching goal
for aphasia therapy research is to identify the most effective interventions that capitalize on
principles of neural plasticity and neurorehabilitation and employ optimal intervention
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technique, timing, frequency and dosage to maximize language outcomes and improve
quality of life for individuals of all ages.
Acknowledgements/Funding:
The authors’ work was supported by NIH (NINDS), through R01 DC05375.
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have positive effects on language outcomes of post-stroke aphasia.
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56**. Meinzer M, Darkow R, Lindenberg R, Flöel A. Electrical stimulation of the motor cortex
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language outcomes when applied to the left primary motor cortex, which could be helpful when
aiming to identify a viable tDCS application site outside of the primary language areas for the
treatment of post-stroke aphasia.
57**. Spielmann K, van de Sandt-Koenderman WME, Heijenbrok-Kal MH, Ribbers GM. Transcranial
direct current stimulation does not improve language outcome in subacute poststroke aphasia.
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one of few recent studies where language outcomes following tDCS and sham were equivalent,
bringing into question the efficacy of tDCS to enhance language measures in subacute aphasia.
58**. Spielmann K, van de Sandt-Koenderman WM, Heijenbrok-Kal MH, Ribbers GM. Comparison
of two configurations of transcranial direct current stimulation for aphasia treatment. J Rehabil
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tDCS application to left IFG and left STG, investigators found that improvement was highest in
left IFG condition.
59. Silva FRD, Mac-Kay A, Chao JC, Santos MDD, Gagliadi RJ. Transcranial direct current
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60*. Fiori V, Nitsche MA, Cucuzza G, Caltagirone C, Marangolo P. High-definition transcranial direct
current stimulation improves verb recovery in aphasic patients depending on current intensity.
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2 mA cathodal high definition tDCS applied to right Broca’s homologue, investigators observed
improved naming following 2mA only.
61. de Aguiar V, Bastiaanse R, Capasso R, Gandolfi M, Smania N, Rossi G, et al. Can tDCS enhance
item-specific effects and generalization after linguistically motivated aphasia therapy for verbs?
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62*. Richardson J, Datta A, Dmochowski J, Parra LC, Fridriksson J. Feasibility of using highdefinition transcranial direct current stimulation (HD-tDCS) to enhance treatment outcomes in
persons with aphasia. NeuroRehabil. 2015;36(1):115–26. Doi:10.3233/nre-141199.This study
demonstrated that high definition tDCS was feasible, and its effects were at least comparable to
conventional sponge-based tDCS.
63**. Campana S, Caltagirone C, Marangolo P. Combining voxel-based lesion-symptom mapping
(VLSM) with A-tDCS language treatment: Predicting outcome of recovery in nonfluent chronic
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Results suggest that individuals could have poorer response to A-tDCS when they have damage
to certain left hemispheric structures.
64. Turkeltaub PE, Swears MK, D’Mello AM, Stoodley CJ. Cerebellar tDCS as a novel treatment for
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65. Sebastian R, Saxena S, Tsapkini K, Faria AV, Long C, Wright A, et al. Cerebellar tDCS: A novel
approach to augment language treatment post-stroke. Front Hum Neurosci. 2017;10:695.
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66*. Marangolo P, Fiori V, Caltagirone C, Pisano F, Priori A. Transcranial cerebellar direct current
stimulation enhances verb generation but not verb naming in poststroke aphasia. J Cogn
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first study to demonstrate that tDCS application to the cerebellum could have a positive impact
on certain language skills in those with post-stroke aphasia in the elderly age range.
67**. Ren C, Zhang G, Xu X, Hao J, Fang H, Chen P, et al. The Effect of rTMS over the different
targets on language recovery in stroke patients with global aphasia: A randomized shamcontrolled study. Biomed Res Int. 2019;2019:4589056. Doi:10.1155/2019/4589056. [PubMed:
31467892] This demonstrated that rTMS over different regions could result in differential
language outcomes.
68**. Griffis JC, Nenert R, Allendorfer JB, Szaflarski JP. Interhemispheric plasticity following
intermittent theta burst stimulation in chronic poststroke aphasia. Neural Plast.
2016;2016:4796906. Doi:10.1155/2016/4796906. [PubMed: 26881111] Utilizing fMRI
techniques, investigators found increased left IFG activation and reduced right IFG activation
following intermittent theta burst stimulation applied to residual language-responsive cortex.
They also found a negative correlation between changes in right IFG activation and increased
fluency.
69. Sebastianelli L, Versace V, Martignago S, Brigo F, Trinka E, Saltuari L, et al. Low-frequency rTMS
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70. Ren C-L, Zhang G-F, Xia N, Jin C-H, Zhang X-H, Hao J-F, et al. Effect of low-frequency rTMS on
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71. Harvey DY, Mass JA, Shah-Basak PP, Wurzman R, Faseyitan O, Sacchetti DL, et al. Continuous
theta burst stimulation over right pars triangularis facilitates naming abilities in chronic post-stroke
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72. Haghighi M, Mazdeh M, Ranjbar N, Seifrabie MA. Further evidence of the positive influence of
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73**. Hara T, Abo M, Kakita K, Mori Y, Yoshida M, Sasaki N. The effect of selective transcranial
magnetic stimulation with functional near-infrared spectroscopy and intensive speech therapy on
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homologue to have comparable positive effects when using low frequency for those who
demonstrated left hemisphere activation and high frequency for those who demonstrated right
hemisphere activation during fNIRS language task, which may elucidate when low and high
frequency are most appropriate.
74**. Hu XY, Zhang T, Rajah GB, Stone C, Liu LX, He JJ, et al. Effects of different frequencies of
repetitive transcranial magnetic stimulation in stroke patients with non-fluent aphasia: A
randomized, sham-controlled study. Neurol Res. 2018;40(6):459–65.
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to have a greater impact on language recovery than high frequency rTMS during right
hemisphere rTMS application when participants with post-stroke aphasia were randomly
assigned to receive one or the other.
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repetitive transcranial magnetic stimulation on subacute aphasia therapy: Enhanced improvement
of functional communication and basic linguistic skills. A randomized controlled study. Arch
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repetitive transcranial magnetic stimulation combined with intensive speech therapy on cerebral
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Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any
of the authors.
Author Manuscript
Author Manuscript
Author Manuscript
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
Author Manuscript
Author Manuscript
N = 156
53.2 (9.6)
N = 32
51.7 (14.6)
N = 46
64.3 (11.9)
N = 34
58.5 (10.9)
N = 19
53.5 (11.7)
N = 19*
54 (11.34)
*Likely same cohort as
Duncan et al. (2016)
although age
demographics are
reported as slightly
different
N = 35
61 (12)
N = 17
59(15)
De Luca, et al.
(2018) [47]
DeDe, et al. (2019)
[38]
Dignam, et al.
(2015) [28]
Duncan, et al. (2016)
[48]
Duncan & Small
(2017) [50]
Fleming, et al. (in
revision) [46]
Gravier, et al. (2018)
[34]
N = 74
54.1 (16.3)
Babbitt, et al. (2015)
[24]
Breitenstein, et al.
(2017) [44]
# of Participants; Mean
Age (SD) in years
Authors
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
Single group pre-posttest design (multiple
baseline)
Randomized, repeated
measure crossover
design
Single group pre-posttest design
Single group pre-posttest design
Parallel-group, prepost-test design
RCT of 2 experimental
groups and control
group
RCT of experimental or
control groups
RCT of treatment or
waitlist (i.e., no
treatment)
Single group pre-posttest design
Design
Semantic Feature Analysis
(SFA)
Self-administered
computerized auditory
comprehension treatment
(Listen-In)
Computerized imitationbased naming therapy (i.e.,
IMITATE)
Computerized imitationbased naming therapy (i.e.,
IMITATE)
Aphasia Language and
Impairment Functioning
Therapy (LIFT) at 2 different
intensities
Conversation therapy in
dyads or groups of 6–8
people
Computerized naming
treatment compared to
“standard” treatment
Individualized,
comprehensive targets—
hybrid delivery (1:1, group,
computerized)
Intensive Comprehensive
Aphasia Program (ICAP) in
individual and group sessions
Intervention
2 2-hour sessions/day x 4–5 days/
week x 4 weeks
Target of 100 hours cumulative
treatment over 12 weeks (mean =
85 hours)
6 30-minute sessions/week x 6
weeks
6 30-minute sessions/week x 6
weeks
Intense group: 5 3+ hour sessions/
week x 3 weeks Distributed group:
3–4 1–2-hour sessions/week x 8
weeks Both groups received a total
of 48 hours of treatment
2 1-hour sessions/week x 10 weeks
3 45-minute sessions/week x 8
weeks
10+ hours/week x 3 weeks
30 hours/week x 4 weeks
# of Sessions & Duration
Author Manuscript
Studies Utilizing Behavioral Speech Language Therapy
Significant improvement for treated and
untreated items; response was predicted by the
number of features generated (but not number
of trials or total treatment time)
Statistically significant gains on word and
sentence comprehension measures
Significant improvement on narrative accuracy
with treatment; positive response was predicted
by number of sessions completed
Significant improvement on standardized
assessment; response was predicted by pretreatment variability (i.e., greater variability
resulted in greater treatment gains)
Most outcomes were equal between practice
schedules except for naming, which was better
for the distributed group both immediately after
treatment and at 1-month post.
Both experimental groups showed improvement
over the control group, with up to 11 months
retention. Dyads (groups of 2) showed greater
improvement than larger treatment groups.
All measured language outcomes improved for
the experimental group, with retention at 3
months, compared to the “standard” treatment.
“Standard” treatment is not well enough
described for reliable comparison
Treatment, compared to no treatment, resulted
in statistically significantly improvement on
verbal communication measures.
Examination of outcomes by participant
characteristics
Results
Author Manuscript
Table 1:
Fabian et al.
Page 17
N = 27
56 (2.7)
N = 26*
56 (14.5)
*Same cohort as Kendall
et al. (2015)
N = 8 (plus 8
conversational partners)
57.63 (10.21)
N = 26
56 (15)
N = 20
52.85 (12.0)
N = 21
66.4 (8.4)
N = 20
63.65 (10.1)
N = 20
57.8 (11.6)
N = 19*
54.6 (12.2)
*subset of cohort
reported by Szaflarski et
al. 2015
N=4
59.75 (18.66)
N = 240
64.6 (13.0)
Pompon, et al.
(2017) [32]
Johnson, et al.
(2017) [37]
Kendall, et al. (2015)
[31]
Kesav, et al. (2017)
[43]
Kurland, et al.
(2018) [49]
Macoir, et al. (2017)
[40]
Marshall, et al.
(2016) [41]
Nenert, et al. (2017)
[17]
Nickels & Osborne
(2016) [27]
Palmer, et al. (2019)
[42]
Author Manuscript
Hoover, et al. (2017)
[25]
Author Manuscript
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
RCT of 2 experimental
groups and an
attentional control
Single-case
experimental design
RCT of treatment group
and control
Quasi-RCT of
treatment group and
waitlist control (i.e., no
treatment)
Single group pre-posttest design
Single group pre-posttest design
RCT of 2 experimental
groups
Open-trial design of
immediate and delayed
treatment
Qualitative study
Single group pre-posttest design
Delayed treatment
within-participants
design
Design
“Standard” treatment alone
compared to “standard”
treatment plus selfadministered computerized
naming treatment
(StepByStep)
Constraint Induced Language
Therapy (CILT)
Intense Language Action
Therapy (also called
Constraint Induced Language
Therapy)
Virtual reality treatment
(EVA Park) with
individualized goals
Promoting Aphasics’
Communicative Effectiveness
delivered remotely
Self-administered computerbased naming treatment
“Standard” treatment alone
(various tasks and treatment
protocols such as MIT or
PACE) compared to
“standard” treatment plus
additional comprehensive
computer-based practice
Phonomotor treatment
Conversation therapy
Phonomotor treatment
Intensive Comprehensive
Aphasia Program (including
individual and group therapy)
Intervention
“Standard” treatment only (Group
1) delivered at same intensity as
previous care “Standard” plus
computerized (Group 2) target
practice: daily 20- to 30-minute
2 1.5-hour sessions/week x 4 weeks
10 4-hour sessions over 2 weeks
5 1-hour sessions/week x 5 weeks
with clinician plus 1 hour/week in
group session; unlimited amount of
self-practice
9 sessions over 3 weeks (session
duration not reported)
Target practice: 5–6 20-minute
sessions/week x 24 weeks (actual
practice time not reported)
“Standard” group (non-intense): 3
1-hour sessions/week x 4 weeks
Experimental group (intense): 6 1hour sessions/week x 4 weeks (half
“standard,” half computer-based)
2 1-hour sessions/day x 5 days/
week x 6 weeks
8 weeks duration. Session length
and frequency not reported
2 1-hour sessions/day x 5 days/
week x 6 weeks
30 hours/week x 4 weeks
# of Sessions & Duration
Author Manuscript
# of Participants; Mean
Age (SD) in years
Significantly improved naming for the addition
of computerized practice compared to
“standard” treatment, which was retained up to
6 months post. However, changes were limited
to trained items, and did not generalize to
natural contexts.
Examined response to CILT when administered
by a volunteer facilitator. Positive responses
were seen for 3/4 participants
Examination of cortical changes following
ILAT; no significant changes were observed
Functional communication and verbal fluency
measures improved compared to no treatment,
but self-ratings and socialization did not
change. Authors could not reliably attribute
changes to the treatment
Communicative effectiveness was significantly
improved with treatment.
Positive outcomes were reported, which were
mediated by severity, compliance, and amount
of training to utilize training platform.
Both groups resulted in significant
improvement on standardized assessment, but
more so in the control group (“standard”
treatment only). Besides computerized practice,
groups differed in intensity, demographic makeup and subsequent treatment tasks, so
differences may not be related to the addition of
computerized treatment.
Treatment resulted in generalization to naming
of untrained words and phonological processes.
Transcript analysis indicated seven themes
reflecting potential mechanisms of change
associated with conversation therapy
Examination of predictive variables; no
participant variables were found to predict
response to phonomotor treatment.
Significant change seen on all impairmentbased measures and some functional
communication and quality of life measures.
Results
Author Manuscript
Authors
Fabian et al.
Page 18
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
N = 18
51 (12)
N = 30
60.1 (15.3)
N = 24
54.5 (12.0)
N = 17
60.8 (9.4)
N=9
72.4 (9.4)
N=9
66.6 (9.0)
N = 60
68.2 (11.7)
N = 20
59.2 (13.1)
Stahl, et al. (2016)
[20]
Stahl, et al., (2018)
[26]
Szaflarski, et al.
(2015) [18]
Vuksanovic, et al.
(2018) [21]
Wenke, et al. (2018)
[45]
Wilssens, et al.
(2015) [22]
Woldag, et al. (2017)
[23]
Woolf, et al. (2016)
[39]
Quasi-RCT of 3
experimental groups
and an attention control
RCT of 3 experimental
groups
Small parallel-group
design
Small parallel-group
design
RCT crossover design
of 2 experimental
groups
RCT of treatment group
compared to control
(i.e., no treatment)
RCT of 2 treatment
groups
RCT crossover design
of 2 treatment groups
Single-case
experimental design
Meta-analysis of
single-case
experimental data
Intervention
Teletherapy (from two
different sites, i.e., Groups 1
and 2) and face-to-face
therapy
Intense Language Action
Therapy (ILAT), intense
“traditional” group treatment,
and non-intense clinically
“typical” approach
Constraint Induced Language
Therapy (CILT) and a lexical
semantic treatment
Hybrid model: face-to-face,
group, and computerized
treatment (various targets/
tasks)
Constraint Induced Language
Therapy (CILT) and
stimulation aphasia therapy
(SAT)
Intense Language Action
Therapy (ILAT)
Intense Language Action
Therapy (ILAT)
Intense Language Action
Therapy (ILAT) and intensive
naming treatment
Naming treatment targeting
abstract words
Semantic Feature Analysis
(SFA)
Note: # = number; Tx = treatment; Exp. = experimental; RCT = randomized control trial.
N = 10
59.4 (10.01)
Sandberg, et al.
(2015) [30]
N = 36
60.1 (10.5)
Author Manuscript
Quique, et al. (2018)
[35]
Author Manuscript
Design
2 1-hour session/week x 4 weeks
ILAT and intense traditional groups:
5 3-hour sessions/week x 2 weeks
Non-intense “typical” group: 2 30minute sessions/day x 10 sessions
over two weeks plus 2 1-hour group
sessions/week x 2 weeks
4 or 5 2–3-hour sessions/week x 2
weeks
Intense group: 8 hours/week x 8
weeks Non-intense group:4 hours/
week x 8 weeks
Each block: 5 1-hour sessions/week
x 4 weeks
4 hours/day x 10 days over 2 weeks
Intense: 4 hours/day 3x/week x 2
weeks Moderately intense: 2
hours/day 3x/week x 2 weeks
3.5 hours/day x 6 consecutive days
2 2-hour sessions/week, treated to
criterion performance
Variable schedules
sessions x 6 months (actual average
of 28 hours total)
# of Sessions & Duration
Author Manuscript
# of Participants; Mean
Age (SD) in years
Naming improved with all three experimental
groups with no significant differences between
face-to-face delivery and teletherapy.
Significant improvements were found for all
three groups with no differences between
groups
Both groups showed positive responses to
treatment, but CILT resulted in changes in
production/phonology while the lexical
semantic treatment resulted in changes in
comprehension/semantics.
Group differences were not examined; clinically
meaningful changes were seen for both
treatment groups.
Both treatments resulted in statistically
significant gains, but improvements were
greater for those receiving CILT first; naming
improvements were greatest with CILT
Subjective ratings of communication were
significantly different after treatment; other
measures trended toward significance.
Both groups made significant improvements,
with no differences between groups (i.e.,
intensity of treatment)
ILAT was effective regardless of order
administration, but the compared naming
treatment was only effective when administered
first (in cross-over design)
Increased connectivity associated with trained
abstract words seen in different networks than
for untrained concrete words.
Improved naming of trained and untrained
items, with greater response associated with
higher dosages and pre-treatment language
abilities.
Results
Author Manuscript
Authors
Fabian et al.
Page 19
Author Manuscript
N = 20
57.1 (10.3)
N=9
57 (12.7)
N = 20
62 (5.9)
N = 74
60 (10)
N = 10
56.4 (16.8)
N = 12
58 (7.8)
N = 26
60 (11.8)
Campana, et al.
(2015) [63]
de Aguiar, et al
(2015) [61]
Fiori, et al.
(2019) [60]
Fridriksson, et
al. (2018) [54]
Keser, et al.
(2017) [78]
Marangolo, et al.
(2018) [66]
Meinzer, et al.
(2016) [56]
# of Participants;
Mean Age (SD) in
years
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
Double-blind
randomized shamcontrolled clinical
trial
Double-blind
randomized
crossover
Double-blind
randomized
placebo-controlled
crossover;
Feasibility study
Double-blind,
randomized,
sham-controlled
clinical trial;
Futility design
Double-blind
randomized
crossover
Double-blind
randomized
crossover
Double-blind
randomized
crossover
Design
A-tDCS (1mA) + intensive
computer-assisted naming
SLT
Cerebellar C-tDCS (2mA) +
SLT for verb improvement
Combination of
pharmacological
(dextroamphetamine or
placebo), A-tDCS (1.5 mA),
plus SLT (Melodic
Intonation Therapy)
A-tDCS (1mA) +
computerized anomia SLT
Cathodal High Definition
tDCS at two intensities (1mA
vs. 2 mA) + verb naming
task
tDCS (1mA) + SLT focusing
on verb inflection and
sentence construction
(ACTION)
A-tDCS (2mA) +
conversational SLT
Intervention
16 sessions over 8 days; tDCS for the
first 20 minutes of two 1.5-hour
intensive naming SLT sessions per
day
5 consecutive daily sessions per
condition: (2 active tDCS conditions
and 2 sham conditions); 20 minutes
of tDCS during SLT session (SLT
session time not reported)
2 sessions (1 per condition); 20minutes of tDCS plus 40 minutes of
SLT combined with
dextroamphetamine or placebo
15 sessions over 3 weeks; 20-minutes
of tDCS during 45-minute SLT
session
10 sessions per condition over 2
weeks; 20-minutes of tDCS during
verb naming task (time for verbnaming task not reported)
10 sessions per condition over 2
weeks; 20 minutes of tDCS during 1hour SLT session
10 sessions per condition over 2
weeks; 20-minutes of tDCS during 1hour SLT session
# of Sessions & Duration
Transcranial Direct Current Stimulation (tDCS)
Author Manuscript
Authors
Author Manuscript
Studies Utilizing Neuromodulatory Therapy
Left primary motor
cortex
Right cerebellum
Right IFG
Left temporal lobe
region with greatest
activation during
fMRI naming task
Right Broca’s
homologue
Perilesional,
differed by
individual
Left IFG
Sites Targeted
Improvement in both groups, but
more so in A-tDCS group;
generalization to untrained items
significantly better in the tDCS group
post treatment and at 6 months;
functional communication
significantly better post treatment and
at 6 months for tDCS group
Improvement in verb generation, but
little improvement in verb naming
post treatment
Dextroamphetamine + tDCS group
showed statistically significant
changes on WAB AQ compared to
placebo
Greater improvement with A-tDCS
compared to sham
Significant improvement in verb
naming following 2mA intensity only
Improvement in verb production
(treated and untreated), but no
difference between tDCS and sham
(both improved)
Significant improvement in picture
description, noun naming and verb
naming with active condition. Poorer
response to A-tDCS observed with
damage to certain left hemispheric
structures (e.g., basal ganglia, insula,
superior and inferior longitudinal
fasciculi)
Results
Author Manuscript
Table 2:
Fabian et al.
Page 20
N =14
52.38 (17.26)
N = 13
53.2 (11.3)
N = 58
58.9 (10.0)
N = 21
53(11)
# of Participants;
Mean Age (SD) in
years
N=8
54.4 (12.7)
N = 12
61.1 (9.3)
N = 50
60.3 (12.1)
Silva, et al.
(2018) [59]
Spielmann, et al.
(2018) [58]
Spielmann, et al.
(2018) [57]
Woodhead, et al.
(2018) [55]
Authors
Griffis, et at.
(2016) [68]
Haghighi, et al.
(2017) [72]
Hara, et al.
(2015) [77]
N=8
60.6 (8.9)
Author Manuscript
Richardson, et
al. (2015) [62]
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.
Parallel group prepost-test design
Double-blind
randomized shamcontrolled clinical
trial
Single group prepost-test design
Design
Baselinecontrolled
repeated-measures
double-blinded
crossover
Double-blind
randomized shamcontrolled clinical
trial
Double-blind
randomized
crossover
Double-blind
randomized shamcontrolled clinical
trial
Single-blind
randomized
crossover
Design
Author Manuscript
# of Participants;
Mean Age (SD) in
years
Author Manuscript
Authors
Two 4-week blocks of SLT (1 block
with active tDCS and 1 with sham).
Each block included 34 hours of SLT
and 11 stimulation sessions
5 daily sessions/week x 1 week; tDCS
during first 20 minutes of 45-minute
SLT session
3 sessions (1 sham, 1 tDCS over L
IFG and 1 tDCS over L posterior
STG) over 2–4 weeks with a 3-day
minimum interval between each; 20minutes of tDCS during 30-minute
SLT session
5 consecutive daily sessions of 20
minutes of tDCS
5 consecutive daily sessions per
condition; 20 minutes of tDCS during
final portion of 25-minute SLT
session
# of Sessions & Duration
LF-rTMS (1 Hz) + intensive
constraint-induced SLT
LF-rTMS (1 Hz) + SLT
HF-rTMS (50 Hz;
intermittent theta burst)
Intervention
One 40-minute rTMS session + 10
60-minute intensive constraintinduced SLT sessions during 11-day
hospitalization
10 30-minute rTMS sessions and 10
45-minute SLT sessions over 2 weeks
10 sessions over 2 weeks; HF-rTMS
delivered for 200-second period
# of Sessions & Duration
Repetitive Transcranial Magnetic Stimulation (rTMS)
A-tDCS + SLT via training
app (iReadMore)
tDCS (1mA) + word-finding
SLT
A-tDCS (1mA) + wordfinding SLT
C-tDCS (2mA)
Conventional-tDCS (1mA)
vs High Definition-tDCS +
computerized anomia SLT
Intervention
IFG (for nonfluent
aphasia) or STG
(for fluent aphasia)
in left or right
hemisphere based
on fMRI activation
Right inferior
posterior frontal
gyrus
Residual languageresponsive cortex in
or near Left IFG
(identified via fMRI
task)
Sites Targeted
Left IFG
Left IFG
Left IFG and Left
STG
Right hemisphere
homolog to Broca’s
area
Left perilesional
cortex with highest
activation during
fMRI naming task
Sites Targeted
rTMS was not as effective for
individuals whose language laterality
had shifted to the non-lesioned
hemisphere
Significant improvement in speech
and language for all participants, but
more so for rTMS compared to sham
Increased left IFG activation and
reduced right IFG activation postintervention
Results
Increased reading accuracy for trained
words with iReadMore and slight
enhancement of reading accuracy for
trained and untrained words with AtDCS
Improved naming reported for all
participants; no difference between
tDCS/sham on any measure.
Improvement on trained items only;
increase was highest in the active LIFG condition
Significant improvement in time for
correct responses with strategy
Naming accuracy and response times
improved with both conditions.
Accuracy of trained items was higher
for High Definition-tDCS, but not
statistically significant.
Results
Author Manuscript
Transcranial Direct Current Stimulation (tDCS)
Fabian et al.
Page 21
Author Manuscript
N = 11
55.5 (14.8)
N = 40
48.3 (10.6)
N = 45
64 (12.2)
N = 30
68.8 (7.3)
Harvey, et al.
(2019) [71]
Hu, et al. (2018)
[74]
Ren, et al.
(2019) [67]
Rubi-Fessen, et
al. (2015) [75]
Randomized,
blinded, shamcontrolled trial
Double-blind
randomized shamcontrolled clinical
trial
Randomized,
sham controlled
trial
Double-blind
randomized
crossover
Parallel group prepost-test design
LF-rTMS (1 Hz) + SLT
LF-rTMS (1 Hz) + SLT
HF-rTMS (10 Hz) vs. LFrTMS (1 Hz) + conventional
treatment, including SLT
Continuous theta burst
stimulation, an inhibitory
form of rTMS (5 Hz)
rTMS (1 Hz or 10 Hz
depending on site of
activation on fNIRS) + SLT
Intervention
10 sessions (20 minutes rTMS
followed by 45 minutes of SLT per
session) over 2 weeks
15 sessions (20 minutes rTMS
followed by 30-minutes of SLT per
session) over 3 weeks
10 total daily sessions of 10 minutes
of rTMS + 30-minute daily SLT
sessions (total duration in weeks, not
specified)
1 40-second session of continuous
theta burst stimulation to target site
and 1 40-second session to control
site
10 sessions consisting of 40-minute
rTMS followed by 60 minutes of
intensive SLT during 11-day
hospitalization
# of Sessions & Duration
Right Broca’s
homologue
Right pars
triangularis of the
IFG or posterior
STG
Right hemispheric
Broca’s area
homologue
right pars
triangularis vs
vertex (control site)
Right Broca’s
homologue
(opposite of
languagecompensatory
hemisphere)
Sites Targeted
Significant improvement in 10
measures of basic linguistic skills and
in functional communication
Significant improvement in repetition,
spontaneous speech, and Aphasia
Quotient in the IFG group;
Significant improvement in auditory
comprehension, repetition, and
Aphasia Quotient in the STG group;
LF-rTMS group demonstrated greater
overall improvement; positive
immediate and long-term effects were
observed for LF-rTMS; HF-rTMS
group only demonstrated gains 2
months post-treatment
Improved naming of inconsistent, but
not wrong, items for individuals with
more severe baseline naming
impairment found with experimental
group
Both groups showed significant
improvement of pre/post testing, no
difference between the groups;
imbalance of activation before
treatment was resolved after
treatment, per fNIRS
Results
Note: # = number; SLT = speech-language therapy, tDCS = transcranial direct current stimulation, rTMS = repetitive transcranial magnetic stimulation; A-tDCS = anodal tDCS; C-tDCS = cathodal tDCS;
LF=low frequency; HF= high frequency; IFG = inferior frontal gyrus; STG = superior temporal gyrus; fMRI – functional magnetic resonance imaging; fNIRS = functional near infrared spectroscopy; mA =
milliamp; min. = minute; vs = versus
N=8
65.6 (11.9)
Hara, et al.
(2017) [73]
Design
Author Manuscript
# of Participants;
Mean Age (SD) in
years
Author Manuscript
Authors
Author Manuscript
Transcranial Direct Current Stimulation (tDCS)
Fabian et al.
Page 22
Curr Phys Med Rehabil Rep. Author manuscript; available in PMC 2021 December 01.