A P H A S I O L O G Y

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Aphasiology
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Aphasia Therapy or The importance of being earnest
Anna Basso a; Alessandra Caporali a
a
Milan University, Italy.

Online Publication Date: 01 April 2001
To cite this Article: Basso, Anna and Caporali, Alessandra (2001) 'Aphasia Therapy
or The importance of being earnest', Aphasiology, 15:4, 307 - 332
To link to this article: DOI: 10.1080/02687040042000304
URL: http://dx.doi.org/10.1080/02687040042000304

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APHASIOLOGY, 2001, 15 (4), 307–332
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Aphasia Therapy
or
The importance of being earnest
Anna Basso and Alessandra Caporali
Milan University, Italy

Effectiveness of aphasia therapy, at least for some patients, is no longer under discussion but
the specific effect of most of the variables influencing recovery is unknown. In this paper we
address a question relative to the therapeutic regimen. Three pairs of patients with similar
age, educational level, sex, aetiology, lesion site, and type and severity of aphasia are
compared. Except for one of the control patients who was 2 months post-onset, all patients
were at least 6 months post-onset (range: 6–22 months) and had already been rehabilitated
when they entered the study. The three experimental subjects underwent a very long and
intensive therapeutic programme (2/3 hours per day, 7 days per week, for many months),
with the help of the family and volunteers. The control patients were rehabilitated daily (1
hour, 5 days a week) for similar periods of time. It is argued that the intensive treatment
achieved higher test scores and more prolonged recovery and that the experimental patients
made better use of their recovered language in daily life.

INTRODUCTION
It is now generally agreed that aphasia therapy can be effective, namely that an aphasic
patient will have better chances of recovery if he or she is rehabilitated. Experimental
evidence comes from group studies (Basso, Capitani, & Vignolo, 1979; Basso, Faglioni,
& Vignolo, 1975; Gloning, Trappl, Heiss, & Quatember, 1976; Hagen, 1973; Mazzoni et
al, 1995; Poeck, Huber, & Willmes, 1989) and single case studies (Byng, 1988; De Partz,
1986; Jones, 1986). The beneficial effect of therapy is also confirmed by results of meta-
analyses (Robey, 1994, 1998). In his 1998 study, Robey reviewed 55 reports on the
effectiveness of aphasia therapy and studied whether there is a difference between treated
and untreated patients. The reanalysis of the data showed a distinction between treated
and untreated patients, which exceeded the criterion value for a medium-sized effect.
However, the question is far from being settled because we still need to know which
patients (or, perhaps better, which impairments) can be profitably rehabilitated and how.
In a few single case studies both the impairment and the intervention have been described
in a sufficiently detailed way so as to be reproducible (Byng, 1988; De Partz, 1986;
Jones, 1986; Miceli, Amitrano, Capasso, & Caramazza, 1996). However, we do not know
whether other variables (such as the associated disorders or the therapeutic regimen) have
an effect on recovery and therefore we cannot be sure whether another patient showing

Address correspondenc e to: Anna Basso, Neurological Clinic, Via F. Sforza 35, 20122 Milan, Italy. Email:
abasso@micronet.it

# 2001 Psychology Press Ltd
http://www.tandf.co.uk/journals/pp/02687038.html DOI:10.1080/02687040042000304

308 BASSO AND CAPORALI

the same functional impairment (but different in other respects) would benefit from the

same intervention.
A theory of rehabilitation should comprise various aspects, the most important being
the intervention strategies themselves. Other important aspects are the characteristics of
the patient (such as age and education), the functional damage (impaired word
comprehension, impaired lexical reading, and so on), and the therapeutic regimen.
In this paper we shall address a question relative to the therapeutic regimen. In the
literature there are some descriptions of patients who have benefited from very brief
periods of therapeutic interventions (see, for instance, Byng, 1988; Marshall, Pound,
White-Thompson, & Pring, 1990; Penn, 1993). In the majority of cases these are chronic
patients who can be used as their own controls. After having received what is generally
called traditional therapy and having reached a plateau, they are offered a new method
and show recovery of the treated impairment. TC (Penn, 1993), for instance, was a
multilingual aphasic patient 9 months post-onset who ‘‘had a mild aphasia with relatively
intact receptive abilities, fluent output, and marked word-finding difficulty’’ (p. 36) when
a discourse-based therapy programme was implemented. The programme was carried out
in nine sessions after which ‘‘improvement in the target areas was noted in all languages
despite the fact that therapy was conducted only in English; the specific targeted
behaviors (. . .) were assessed as being markedly more appropriate across the tested
languages’’ (Penn, 1993, p. 40). BRB (Byng, 1988), a frequently cited case, was 6 years
post-onset (during which time he had been rehabilitated) when he received a specific
programme for mapping thematic roles onto grammatical relations. Therapy consisted of
two sessions a week apart and intervening homework. BRB showed marked improvement
in his comprehension of locative sentences (which had been the object of therapy) and of
simple reversible sentences, as well as in sentence production, which had not been
rehabilitated.
Unfortunately this has never been our experience. We have seen patients recover with
therapy, but following intensive treatment. Over the years we have been augmenting what
we considered the minimum duration and intensity of aphasia rehabilitation necessary for
recovery to show up in daily life, also in view of the fact that there is some experimental
evidence that to be effective rehabilitation must be intensive and protracted (see Basso,
1992 for a review).
The regimen we now offer to our patients generally consists of 1-hour daily sessions,
supported by intensive homework (2–3 hours per day) and protracted for many months
with control examinations every 3 months. The rationale for discontinuing the therapy is
no recovery between two successive control examinations.
This regimen in not easy to implement. We must first persuade the patient and his or
her family that this is necessary and then help them to find a way to implement the
necessary homework. With the help of the family, we try to identify a relative, a friend, or
a volunteer who can do it. We must also identify the objectives of the rehabilitation
programme that can be pursued by a lay person and the exercises that can be carried out
by the patient alone.
The focus of this paper is the regimen of aphasia therapy. The paper does not raise the
issue of the content of therapy nor does it discuss our approach, which is described in
some detail elsewhere (Basso, 1977, 1999). Briefly, we can say that in our aphasia unit
we adopt two rather different approaches. In those cases in which we can arrive at a
precise functional diagnosis with reference to a cognitive neuropsychologica l model of
normal processing, we endeavour to target the identified impairment/s and implement
what could be broadly defined as a cognitive neuropsychologica l approach. For severely

APHASIA THERAPY 309

damaged patients with an across-the-board impairment, less analytic approaches targeting

the disability itself can prove efficacious. By way of example, if a patient has an
understanding disorder that can be explained by, say, damage to the input lexicon, it
appears obvious to target the damaged lexicon. If, however, comprehension is severely
impaired and the patient fails all tasks, a cognitive diagnosis is still possible but it is not
really helpful in dictating what to do. We prefer to rehabilitate comprehension as a global
behaviour in more ecological settings such as a conversation. The principal function of
language is to permit communication among human beings and the main goal of
rehabilitation is to enable the patient to communicate through language. To communicate
the patient must be able to understand what his or her interlocutor is saying and to express
what he or she wants to say. In this sort of therapy, the therapist engages the patient in a
conversation which must be as similar as possible to a natural conversation the patient
may want to sustain in his or her daily life. Right from the beginning of the treatment the
patient’s participation must be similar to normal conversational behaviour. For each
patient we also identify specific goals (reduction of apraxia of speech, prevention of
agrammatism, recovery of word-finding abilities, reading aloud, and so on) with the aim
of setting the stage for a successive and more specific intervention. If we want to label
our intervention strategies, it can perhaps be suggested that for severe aphasic patients
our intervention can be considered loosely akin to the so-called stimulation approach (see
Howard & Hatfield, 1987, for a review).
In this paper we attempt to demonstrate that an intensive therapeutic regimen can
cause such a degree of recovery as to show up in the patient’s daily living. We are not
investigating the outcome of therapy for a well-defined task such as, for instance, naming
of 50 action pictures or reading of nonwords. We compare three pairs of patients matched
as far as possible for the variables known to influence recovery. They have all been re-
educated for long periods of time, the main difference being the intensity of the
rehabilitation: the three control patients were seen by the speech therapist for 1 hour 5
days per week, the three experimental patients were seen for 5 hours per week and were
also helped at home 2–3 hours per day.

PAIR 1: PATIENTS FC AND AM
Patient FC
FC was a 37-year-old right-handed mechanic with 13 years of education who suffered a
CVA in June 1997; his previous medical history was uneventful. He was admitted
unconscious to hospital where a CT-scan showed ischaemic damage to the left frontal-
temporal-parietal area surrounde d by oedema. Neurological assessment immediately
post-stroke indicated global aphasia and right hemiplegia. The patient recovered clear
consciousness in the following days and underwent motor rehabilitation. A MRI
performed in April 1999 showed a large temporal-parietal lesion with extensive
involvement of the white matter and the subcortical structures.
When discharged from the hospital in August, FC was admitted to a rehabilitation
clinic where he started language rehabilitation, 5 days a week, until November when he
went home. He continued language rehabilitation in the same clinic on an outpatient basis
four times per week during the first months, which reduced to three and then two times a
week. He had been dismissed from rehabilitation when first seen at the Aphasia Unit of
Milan University in February 1999, 20 months post-stroke, after being told that no further
recovery was possible.


The language examination (Ciurli, Marangolo, & Basso, 1996) at this time

demonstrated that it was not possible to classify FC’s language impairments into any
of the classical syndromes, and a diagnosis of mixed nonfluent aphasia (Goodglass &
Kaplan, 1983) was considered appropriate. He also showed verbal apraxia and acalculia
(on a written calculation test he scored 15/101; cut-off score: 74/101; Basso & Capitani,
1979). He had no oral apraxia (20/20; cut-off score: 17/20; De Renzi, Pieczuro, &
Vignolo, 1966) or ideomotor apraxia (67/72; cut-off score: 53/72; De Renzi, Motti, &
Nichelli, 1980). His speech was impoverished and scanty; few isolated words (generally
nouns) were produced with long pauses. Naming of object pictures was 60% correct,
naming of action pictures was 30% correct. FC did not try to express himself using
gestures or any other nonverbal means; he rarely looked at the interlocutor and appeared
to be concentrating on trying to find the words to make himself understood. When his
attention was caught, comprehension was sufficient for simple questions but severely
impaired on the Token Test (13/36; cut-off score: 29/36; De Renzi & Faglioni, 1978).
Reading comprehension was at the same level as auditory comprehension. Reading aloud
and repetition were possible for single words but not for sentences; writing was
impossible except for copying which was generally correct. He scored 34/36 on the
Raven’s Coloured Progressive Matrices (Figure 1). The Appendix reports his description
of the picture of a drawing room where a woman is knitting, a man is reading a
newspaper, a girl is watching television, a boy is playing with blocks and a cat with a ball
of wool.
FC had come to see us because he did not want to give up therapy. Mainly in
consideration of his young age, we thought this worthwhile notwithstanding two
important negative factors: the time elapsed since onset and the fact that the patient had
already been re-educated for 18 months. We discussed with FC and his wife the fact that
in our opinion his only chance of recovery depended on very hard and lasting work he
would have to do by himself, with a friend or a relative under our supervision, and
directly with us. Even in this case chances of recovery were rather poor because the
period of spontaneous recovery had finished long ago and he had already been re-
educated for a long period of time, although lately rehabilitation had been reduced. FC
and his wife agreed to do all they could. Because his wife worked and was away all day,
she could dedicate only an hour per day, in the evening, to her husband, with more time at
weekends. They found a young woman to work at home with him two more hours per day
and he received treatment at the Aphasia Unit for an hour daily. Initially his homework
consisted of sentence repetition and written action naming, tasks that a lay person can
easily handle. FC’s wife and assistant were shown how to work with the patient and they
regularly came to the clinic for supervision. Repetition was chosen because it could help
FC overcome his verbal apraxia (which was not very severe), give him confidence in his
capacity to produce sentences, and hopefully help prevent the production of agrammatic
sentences (Beyn & Shokhor-Trotskaya , 1966). Written naming was considered important
because of FC’s markedly reduced vocabulary, and actions instead of nouns were chosen
because he was inclined to use only nouns in speech and we thought that facilitating
retrieval of verbs could be helpful in preventing or reducing agrammatism.
The therapist reserved for herself that which we thought was more difficult to
delegate. During the evaluation it had become clear that FC had severe difficulties in
having a conversation; he was eager to speak (frequently without succeeding in making
the interlocutor understand what he was talking about) but would not pay attention to
what was said to him. This made it very difficult to help him express himself by asking
adequate questions. It was then decided that the therapist would involve the patient in a

APHASIA THERAPY 311

February 1999 (Ciurli et al. 1996) TT = 13/36 Rv = 34/36

100
90
80
70
60
50
40
30
20
10
0
N V S N V S N S N S N S N S N S
Oral Production Written Production Oral Written Repetition Reading Writing to
Comprehen. Comprehen. aloud dictation

October 1999 (Ciurli et al. 1996) TT = 13/36 Rv = 36/36

100
90
80
70
60
50
40
30
20
10
0

April 2000 (Ciurli et al. 1996) TT = 16/36 Rv = 50/60

100
90
80
70
60
50
40
30
20
10
0

TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences.

Figure 1. Percentage correct responses by FC at three subsequent evaluations: February, 1999, October, 1999;
April, 2000.

conversation, rapidly changing the subject of the conversation and getting the patient
accustomed to answering in any possible way.
A control evaluation 3 months later did not disclose much change, except for oral
action naming which was now 80% correct. We were not discouraged because we had not
expected much improvement in 3 months and therapy was continued.
At home he was required to read aloud (which he could do by himself) and to decline
verbs he had first retrieved in the infinitive form. With the therapist he now started to read


a short paragraph, imagine a scene that represented what he had read and, when he could

clearly see the scene in his mind’s eye, describe it. This was thought to help him speak
because the content of the message was already clear in his mind; at the same time the
therapist did not know in advance what he was going to say and therefore it had a
communicative value.
A second control examination in October 1999 (Ciurli et al., 1996) disclosed a
generalised although mild improvement in all language tasks. He was given a score of 5/
10 for his description of a picture (see Appendix) and he could write some words to
dictation and in a confrontation naming task. However, he still scored 13/36 on the Token
Test (Figure 1).
Rehabilitation continued without any important change and a final control
examination was carried on in April 2000, after 14 months of intensive language
therapy (Ciurli et al., 1996). Improvement was now evident in all tasks and his speech
output was more abundant and more informative. Confrontation naming of nouns was
85% correct and of actions 70% correct, and he could write to confrontation 70% of
nouns and 60% of actions. It was now possible for him to read and repeat short sentences.
Only his score on the Token Test was not much changed (16/36) (Figure 1). His
comprehension in a conversation, however, was quick and correct. His production was
more abundant and informative although still agrammatic with some correct sentences,
and he did not wait to be asked something but frequently introduced new topics. The
appendix reports his retelling of a typical day.

Patient AM
AM was a 37-year-old right-handed bookbinder with 8 years of formal education who
suffered a CVA in July 1988. On admission to the hospital the neurological examination
showed mild right hemiparesis and expressive aphasia. A CT scan performed in October
1988 disclosed a large left temporal-parietal lesion with deep extension to the basal
ganglia. AM started daily language rehabilitation in September, which was still going on
in June 1989, 11 months post-onset, when he was first examined at the Aphasia Unit.
The language examination (Basso & Vignolo, 1974) disclosed a mixed nonfluent
aphasia with severely reduced speech and verbal apraxia. His description of how to shave
is reported in the Appendix. Repetition and reading aloud were only mildly impaired for
words and nonwords but he could not repeat or read sentences. Writing was more
severely impaired than oral speech; he could sign and copy and he correctly wrote only
one of 20 words. Comprehension was adequate for oral and written words and sentences;
on the Token Test he scored 15/36. He had no oral (17/20) or ideomotor (69/72) apraxia
and scored 30/36 on the Raven’s Coloured Progressive Matrices. In the written
calculation test he scored 12/101 (Figure 2).
Rehabilitation in our unit was started, an hour daily, with the immediate objectives of
reducing AM’s verbal apraxia by having him repeat short sentences. It was also thought
that this could prevent or reduce agrammatism. In order to augment his speech output and
his vocabulary he was engaged in conversations above various subjects and asked to
describe pictures.
A control examination 6 months later, in December 1989 (Basso & Vignolo, 1974),
showed some recovery of speech production, which was now agrammatic but slightly
more fluent (see Appendix), and in writing of single words. His comprehension as
evaluated by the Token Test was much better (22/36). He scored 30/36 on the Raven’s
Coloured Progressive Matrices and 8/101 in the written calculation test (Figure 2). Daily

APHASIA THERAPY 313

June 1989 (Basso & Vignolo, 1974) TT = 15/36 Rv = 30/36

100
90
80
70
60
50
40
30
20
10
0
(n.t.) (n.t.)


December 1989 (Basso & Vignolo, 1974) TT = 22/36 Rv = 30/36

100
90
80
70
60
50
40
30
20
10
0
(n.t.) (n.t.)


June 1990 (Basso & Vignolo, 1974) TT =18/36 Rv = 33/36

100
90
80
70
60
50
40
30
20
10
0
(n.t.) (n.t.)


TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences; n.t. = not tested.

Figure 2. Percentage correct responses by AM at three subsequen t evaluations: June, 1989; December, 1989;
June, 1990.

rehabilitation was continued. Since AM’s speech production was still very slow, reduced,
and agrammatic, the main objective of therapy was to have the patient speak more
fluently with more verbs. Oral and written confrontation naming and retrieval of actions
were added, in the hope that a richer vocabulary would induce AM to speak more. The
language examination had shown that comprehension was superior to his speech
production. It was therefore not thought to be a problem and was not specifically
retrained. In June 1990, after a year of daily rehabilitation, a very mild across-the-board


recovery was detectable (Basso & Vignolo, 1974), except for the Token Test score which

was only 18. Confrontation naming was now 90% correct and written confrontation
naming 40%; reading aloud of sentences was 70% and repetition and writing to dictation
of sentences, although still severely impaired, were better than at first examination
(Figure 2). This degree of recovery, however, was apparently not sufficient to bring about
a change in his spontaneous production and did not show up in his daily life.
Communication was still very difficult (see Appendix) and AM did not try to speak with
members of his family or other people. Recovery showed up only in the rehabilitation
setting.
The patient was young and highly motivated, and we did not understand why he did
not use his speech outside the rehabilitation setting. Moreover, his speech therapist was
firmly convinced that she could obtain more from him. Rehabilitation was continued for a
year, 5 days a week with the only interruption the summer break, but without any further
recovery. Between June 1990 and July 1991 he was tested on three further occasions but
no amelioration was noted (in all testing sessions, for instance, the Token Test score was
18).
Figures 1 and 2 report percentage of correct responses by the two patients in the
language tasks. The two patients were examined with two different language
examinations (Basso & Vignolo, 1974; Ciurli et al., 1996). The two tests have been
devised for severe aphasic patients and all tasks are easily performed by normal subjects
with a ceiling effect. The stimuli used differ in the two batteries but the tasks are the same
and can easily be compared. The main difference between the two tests lies in the
sentence production task (see later).

Comparison
FC and AM were two men of similar age though their educational level was different (13
vs 8 years). They presented with very similar language disorder 20 and 11 months post-
onset when they started rehabilitation at the Aphasia Unit of Milan University. Both had
mild right hemiplegia without visual field defects. Comparison of their CT lesions
showed that they were similar although the cortical area involved in FC’s lesion was
slightly larger as was AM’s extension to the deep structures.
Both had previously been treated for aphasia with similar regimens. From their clinical
reports it would appear that initially they both had global aphasia which recovered to a
point that it could be reclassified as mixed nonfluent aphasia; in other words,
comprehension had partially recovered in both patients. Both presented with severely
reduced speech and mild verbal apraxia; agrammatism became evident in both patients
when their speech production became slightly more abundant.
To recapitulate, except for the educational level, FC and AM had similar demographic
characteristics, aetiology, aphasia profiles, and previous therapy regimen when we met
them.
Rehabilitation was then started with similar objectives: to reduce their verbal apraxia,
to augment speech output, and to prevent agrammatism. In neither case was
comprehension specifically rehabilitated: AM initially showed an important recovery
of comprehension and it was thought that conversation could be a sufficient stimulation
for FC’s comprehension. The therapy programmes were not much different and were
carried out by the same therapist. The only important difference was the amount of time
spent in therapy: 1 hour 5 days a week for AM, and no less than 2–3 hours 7 days per
week for FC. After a year, at testing AM’s comprehension, albeit still severely impaired,

APHASIA THERAPY 315

had recovered slightly more than FC’s, and FC produced much more and was more

communicative than AM. Direct comparison of their production poses a problem because
FC was asked to describe a picture and AM to explain how to shave, and procedural
language can be more difficult than description of a picture for aphasic patients.
However, FC’s production clearly shows a continuous recovery and AM’s production
does not change much (see Appendix). The difference between the two patients was
clearly evident in ecological situations. AM was reported never to start talking or
participate in a conversation even with his family members. FC talks more with more
people and although his comprehension is severely impaired on testing, he rarely has
problems comprehending what is said to him.
A second year of therapy did not result in any further recovery in AM; FC is still being
rehabilitated and there is no indication that a plateau has been reached.

PAIR 2: PATIENTS DT AND SB
Patient DT
At the beginning of March 1996 DT, a 35-year-old right-handed man with a degree in
architecture, suffered a subarachnoid haemorrhage caused by an existing arterio-venous
malformation. He was immediately admitted to the local hospital, where the neurological
examination showed intense rigor without focal neurological signs. An angiography
demonstrated a large aneurysm at the origin of the left communicating posterior artery.
Five days later DT was operated on and three days after the intervention he became
drowsy and showed a mild right hemiparesis and aphasia. Successive CT-scans showed a
progressive enlargement of the ventricles. Two weeks after the first intervention, he was
again operated on and a ventricular peritoneal shunt was positioned with progressive
recovery of consciousness. At the end of April he was discharged from hospital. The
neurological examination showed global aphasia without hemiparesis or hemianopia. In
September 1996 a CT scan showed a frontal hypodense lesion. He started aphasia
rehabilitation while in hospital, and it was still going on when he was first seen at the
Aphasia Unit at Milan University in September 1996, six months post-onset.
Language examination (Basso & Vignolo, 1974) disclosed global aphasia with severe
acalculia (12/101); oral (17/20) and ideomotor (71/72) apraxia were not present. His
spontaneous speech was scanty, apparently without verbal apraxia but totally
incomprehensible; he uttered short sequences of phonemes and sometimes such words
as ‘‘is, a, so’’ (see Appendix). Oral and written comprehension of words was possible
(75% and 85%) but it was severely impaired for short commands (30 and 40%
respectively). He scored 2/36 on the Token Test. Repetition, reading aloud, and writing to
dictation were all nil but he could copy some words. His score on the Raven’s Coloured
Progressive Matrices was 24/36 (Figure 3).
At that time it was not possible to involve the patient in a decision about rehabilitation
because he appeared not to realise how severe his deficit was and it was very difficult to
make him understand what was said to him, even when he himself was the subject of the
conversation. However, the family was very supportive and an aunt had plenty of time to
dedicate to the patient. As for DT, he had a rather passive attitude but was always willing
to do what he was asked. We therefore thought that we could rely on the family and
planned a therapeutic intervention that did not require DT to work alone. He lived rather
far from Milan but we decided, together with his family, that for the present time it was
better to come to Milan every morning and work at home in the afternoon, as we were not
convinced that a lay person could manage all the tasks we considered necessary.


September 1996 (Basso & Vignolo, 1974) TT =2/36 Rv =24/36

100
90
80
70
60
50
40
30
20
10
0
(n.t.) (n.t.)


June 1997 (Miceli et al., 1991) TT = 11/36 Rv = 29/36

100
90
80
70
60
50
40
30
20
10
0
(n.t.)


January 2000 (Miceli et al., 1991) TT = 19/36 (written = 31/36)
Rv = 36/36
100
90
80
70
60
50
40
30
20
10
0
(n.t.)


TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences;n.t. = not tested.

Figure 3. Percentage correct responses by DT at three subsequent evaluations: September, 1996; June, 1997;
January, 2000.

Because almost everything the patient tried to do resulted in a failure, it was
decided that the family should start with what can appear a very easy task: DT had
to repeat syllables or short words, whichever was more successful. In fact this proved
to be very difficult for DT and required a lot of skill and patience on the part of
his aunt. After he succeeded in repeating a few words and syllables, reading and
writing of syllables was introduced; mostly, however, these were accomplished by
repetition and copying.

APHASIA THERAPY 317

The therapist took on the difficult task of having DT say some content words that were

totally absent from his speech. She could not rely on such classical facilitation as repetition
or reading because DT could do neither. As for phonemic cueing it was sometimes, albeit
rarely, successful but its effectiveness was very short-lived. We gave up the idea of
obtaining a target content word in a convergent task, such as confrontation naming, and we
tried to elicit them in more divergent and open tasks, accepting any content word DT would
produce. For instance, we said a word and asked DT to say the first word that came into his
mind or to complete a sentence with any word he could think of. Any content word DT said
was repeated by the therapist and then included in a sentence, hoping that this would help
DT become conscious of what he had said, if by chance he had produced the word
automatically without really being aware of its meaning.
Comprehension exercises of words and sentences such as pointing to pictures were not
used. We decided that continuous verbal interactions with the therapist and his aunt
would provide sufficient stimulation and we argued that this would be a more dynamic
and ecological exercise.
A re-evaluation 3 months later showed slight improvement in repetition and reading
aloud that were now possible for some words and nonwords. Moreover, DT was now
more conscious of his difficulties and he was more motivated in his rehabilitation. This
allowed us to increase his homework. As he could now write some words he was also
asked to do written naming at home, especially action naming, with the help of his aunt.
Six months after starting rehabilitation he was again reassessed (Miceli, Laudanna, &
Burani, 1991). His speech output was severely reduced and anomic; he sometimes
omitted verbs and prepositions. Notwithstanding frequent omissions and phonemic
paraphasias, when speaking he could make himself understood, being very good at using
gestures, mime and drawings. He could name about 60% of object pictures and 30% of
action pictures. Comprehension was adequate in conversation but still severely impaired
on the Token Test (13/36). Repetition and reading aloud were still very severely
impaired.
DT had always been very keen to resume work, which he apparently could do. He was
a fashion designer for a glamorous Italian fashion house. His drawing capacity was
unaltered and he decided to go to work at least twice a week and come to Milan the other
3 days, working at home in the afternoons and the evenings. This regimen did not last
long and he soon resumed work 5 days a week coming to Milan once every 3–4 weeks.
After an initial period in which he gave up his commitment to rehabilitation because
working was both tiring and very involving for DT, his homework has always been
regular and intensive.
Reassessed in June 1997 (Miceli et al., 1991), 15 months post-onset and 9 months after
starting rehabilitation, he showed an across-the-board recovery but was still impaired in
all tasks. Some peaks of impairment were evident. Reading and repetition were
particularly difficult for him; he read very slowly, recognising one letter at a time.
However, if given enough time he could correctly read 70% of words and 50% of short
sentences. Repetition was made difficult, besides other reasons, by the fact that he had
difficulties identifying heard phonemes; the contrast voiced–voiceless, for instance, was
beyond his possibilities. His Token Test score was 11/36. However, his vocabulary was
richer, his production more abundant but still agrammatic. His comprehension in
conversation was fair, and his writing easier (Figure 3). The Appendix reports his
retelling of a typical day.
The same regimen was continued for the following two and a half years. Regular
control examinations showed slow but continued recovery. Treatment was changed

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