1. health and fitness
2. therapy

Effect of treatment for bilingual individuals with aphasia:
A systematic review of the evidence
Yasmeen Faroqi-Shaha, Tobi Frymarkb, Robert Mullenb, Beverly Wangb
a
b
University of Maryland, College Park, MD, USA
National Center for Evidence-based Practice in Communication Disorders, American SpeechLanguage Hearing Association, Rockville, MD, USA
*Corresponding Author:
Tobi Frymark
National Center for Evidence-based Practice in Communication
Disorders
American Speech-Language Hearing Association
2200 Research Blvd, Rockville, MD 20850
301-296-8742 (o), 301-296-8588 (f)
tfrymark@asha.org
This is a preprint text of an article accepted for publication in the Journal of Neurolinguistics.
Please cite this article in press as: Faroqi-Shah, Y. et al., Effect of treatment for bilingual
individuals with aphasia: A systematic review of the evidence, Journal of Neurolinguistics
(2010), doi:10.1016/j.jneuroling.2010.01.002
Abstract
Language proficiency in bilingualism, and hence bilingual aphasia, is a multifaceted
phenomenon: influenced by variables such as age of onset, literacy, usage patterns, and
emotional valence. Although the majority of the world and growing US population is bilingual,
relatively little is known about the best practices for language therapy in bilingual aphasia. This
systematic review was undertaken to examine three crucial questions faced by speech-language
pathologists during clinical decision making: outcomes when language therapy is provided in the
secondary (less-dominant) language (L2), extent of cross-language transfer (CLT) and variables
that influence CLT, and outcomes when language therapy is mediated by a language broker.
Data from 14 studies (N=45 aphasic individuals) indicate that treatment in L2 leads to positive
outcomes (akin to L1 treatment); CLT was found to occur in most studies, especially when L1
was the language of treatment. Although limited by the methodological quality of included
studies, this systematic review shows positive findings for unilingual aphasia treatment and CLT.
Implications for clinical practice, models of language representation in bilinguals, and future
research directions are discussed.
Key Words: Aphasia; Bilingualism; Cross-Language Transfer; Multilingualism; SpeechLanguage Pathologist
1. Introduction
More than half the world (and a rapidly growing US demographic) is bilingual1. Hence
the occurrence of bilingual aphasia is more common than what can be gleaned from the
literature. Speech-language pathologists (SLPs) are increasingly likely to provide services to
bilingual aphasic clients (Ansaldo, Marchotte, Scherer, & Raboyeau, 2008; Centeno, 2009;
Paradis, 2001). Given that the overarching goal of language treatment for individuals with
aphasia is to achieve the maximum possible level of life participation, the goal of language
treatment in the bilingual client becomes the improvement of communication in both languages.
Providing language treatment to bilingual clients may pose challenges that are less
evident when providing treatment to monolingual clients with aphasia. The obvious logistical
challenges include access to bilingual assessment and treatment materials and availability of
bilingual SLPs, or two SLPs speaking the relevant languages. There is also an important and
largely unresolved conceptual challenge in the treatment of bilingual aphasia — whether to focus
on a single language or include both languages in treatment. Experts who recommend bilingual
therapy point out that inclusion of both languages ensures that the aphasic person is able to
utilize all possible communicative strategies available to him/her (akin to using gesture or
writing to aid verbal communication) (Ansaldo et al., 2008; Centeno, 2005; Kohnert, 2004). It is
also argued that the bilingual speaking environment is the most natural for some bilinguals; thus,
bilingual therapy is the best choice. However, some authors point out certain caveats and suggest
that bilingual therapy can lead to increased code mixing-code switching, or could suppress
1
We use the term bilingual as used by Grosjean (1994) to refer to all individuals who use two or more languages or
dialects in their daily communicative environment, irrespective of the context of use.
recovery of one language (Hemphill, 1976; Lebrun, 1988). In fact, there are reports of bilingual
treatments leading to improvement of only one language (Paradis, 1993).
From a neurolinguistic perspective, bilinguals possess an intermixed lexical and
morphosyntactic organization (Golesteni et al., 2006; Gollan, Montoya, Fennema-Notestine, &
Morris, 2005; Kroll & Stewart, 1994). The intermixed neurolinguistic organization is not only
used to make the case for bilingual therapy, but can also be used to argue that therapy in a single
language (henceforth unilingual therapy) will automatically transfer to the untrained language
because of stimulation of shared neural networks (Kohnert, 2009; Watamori & Sasanuma, 1978).
Unilingual therapy is also recommended for individuals who experience pathological code
mixing-code switching or who live in a primarily monolingual environment (Abutelabi & Green,
2008; Ansaldo, Ghazi Saidi, & Ruiz, 2009). However, this prediction of cross-language transfer
(CLT) with unilingual therapy has not been consistently borne out (e.g., Edmonds & Kiran,
2006; Faroqi & Chengappa, 1996; Filiputti, Tavano, Vorano, Luca, & Fabbro, 2002).
Discussions of variables that influence success of CLT have questioned whether the first
(L1) and second (L2) languages are equipotent in their prospects for language gains. One
proposal is that language proficiency may interact with CLT potential such that low proficiency
bilinguals are more likely than high proficiency bilinguals to experience CLT after unilingual
therapy in L2 (Edmonds & Kiran, 2006). This is because the L2 of low proficiency bilinguals
depends to a greater extent on borrowings from L1; while the L2 of high proficiency bilinguals is
relatively independent of L1 (Jared & Kroll, 2001). However, CLT effects with L2 therapy are
not always reported.
The foregoing discussion raises several pertinent questions that are unresolved. Namely,
do bilingual aphasic clients benefit from treatment provided in their L2? Does unilingual therapy
result in CLT? Do L1 and L2 differ in CLT potential? And do any factors (demographic,
linguistic, aphasia-related, or otherwise) help predict success with L2 therapy and CLT? A
cursory Medline search using the terms bilingualism and aphasia reveals 89 citations; the
majority of which characterize the nature and recovery pattern of bilingual aphasia (Fabbro,
2001; Green, 2005; Levy, Goral, & Obler, 1999; Lorenzen & Murray, 2008; Goral, Levy &
Obler, 2002; Obler & Mahecha, 1991) with only a small number focused specifically on the
impact of treatment. This superficial look at the literature does not provide straightforward
answers to the previously raised questions. Therefore a more comprehensive and meticulous
examination of the literature is warranted2.
This paper describes the findings of an evidence-based systematic review (EBSR)
conducted by the American Speech-Language-Hearing Association’s (ASHA’s) National Center
for Evidence-based Practice in Communication Disorders. The primary aim of this review is to
synthesize and analyze the existing data on aphasia treatment for bilingual individuals.
Knowledge of the current evidence is likely to assist SLPs in therapeutic decision making. In
addition, it is hoped that this review will serve to highlight the empirical strength of the current
evidence (or lack thereof) and identify unresolved questions in need of further research.
An essential first step in initiating a systematic review of the literature was to formulate
the questions for data extraction. In constructing the clinical questions, it was decided that the
impact of L1 therapy on L1 outcomes in bilingual individuals was not a crucial issue because this
is analogous to examining the efficacy of aphasia therapy in the native language of monolingual
2
It should be noted that a review article by Kohnert (2009) addressing CLT was published after the completion of
the present study. The authors were unaware of this article prior to the completion of the present review and
variations in clinical questions addressed, number of databases searched and study inclusion parameters led to a
minimal number of overlapping studies (5) reported.
clients. And there is ample evidence of the success of aphasia therapy (Beeson & Robey, 2006;
Holland, Fromm, DeRuyter, & Stein, 1996; Robey & Schultz, 1998). For this reason, we decided
to focus on the effect of L2 therapy. Our second focus was to examine the occurrence of CLT in
both directions (L1 to L2 and L2 to L1) and a third was to determine the effect of therapy that
was mediated by a language broker when the therapist and client spoke different languages.
Given that receptive and expressive language abilities can be relatively independent and
treatment does not always generalize across both modalities, we decided to examine treatment
effects on expressive and receptive language in separate analyses. Finally, we synthesized
pertinent variables such as age of participant, age of L2 acquisition, pre-morbid proficiency in
each language, language of the environment, aphasia characteristics, and time post onset to
determine factors that might impact outcomes. This resulted in the following eight questions in
three focus areas:
Focus A: Language therapy in the secondary language (L2)
1. What is the effect of treatment provided by an SLP in L2 on the receptive language skills in
the treated language (L2) for bilingual clients with neurologically-induced aphasia?
2. What is the effect of treatment provided by an SLP in L2 on the expressive language skills in
the treated language (L2) for bilingual clients with neurologically-induced aphasia?
Focus B: Cross-language transfer (CLT) of therapy outcomes
3. What is the effect of treatment provided by an SLP in L2 on the receptive language skills in
the untreated language (L1) for bilingual clients with neurologically-induced aphasia?
4. What is the effect of treatment provided by an SLP in L1 on the receptive language skills in
the untreated language (L2) for bilingual clients with neurologically-induced aphasia?
5. What is the effect of treatment provided by an SLP in L2 on the expressive language skills in
the untreated language (L1) for bilingual clients with neurologically-induced aphasia?
6. What is the effect of treatment provided by an SLP in L1 on the expressive language skills in
the untreated language (L2) for bilingual clients with neurologically-induced aphasia?
Focus C: Therapy outcomes with a language broker
7. What is the effect of services provided by a language broker in L1 on the receptive language
skills in the untreated language (L2) for bilingual clients with neurologically-induced
aphasia?
8. What is the effect of services provided by a language broker in L1 on the expressive
language skills in the untreated language (L2) for bilingual clients with neurologicallyinduced aphasia?
2. Method
2.1. Literature search
A literature search was conducted during July and August 2009. Research studies were
identified from 29 electronic databases using keywords pertaining to bilingualism or
multilingualism and aphasia (see A.1 for a complete list of databases and Supplementary
material for the expanded search terms). Inclusionary criteria that were used to determine
eligibility were: research studies published in peer-reviewed journals from 1980 to August 2009
with original data pertaining to the EBSR question(s), publications in English language (due to
ease of access and limited translation resources), and studies that included bilingual adults (ages
18 years or older) with neurologically-induced aphasia and described outcomes of language
intervention. As mentioned earlier, bilingual individuals included all individuals who spoke two
or more languages in their daily life, irrespective of manner and age of acquisition (Grosjean,
1992; Grosjean, 1994). Interventions included any SLP treatment conducted in primary (L1) or
secondary (L2) language targeting receptive and/or expressive language skills. Exclusion criteria
were studies that described individuals with cognitive deficits, studies that included participants
with heterogeneous etiologies (unless data could be separated), and interventions that were
pharmacological, or utilized augmentative and alternative communication.
Two authors (RM and TF) independently reviewed all citations for relevance based on
the predetermined inclusion criteria. References from all full-text articles and narrative reviews
were also hand-searched and when necessary, the study authors were contacted to obtain original
data or studies. Inter rater reliability between the two authors for study inclusion was determined
using the kappa statistic (Cohen, 1960). Study eligibility agreement between RM and TF was
good, K = .852. Disagreements were discussed and resolved by consensus. A third author (YF-S)
reviewed the full list of accepted and rejected bibliographies for completeness prior to final
inclusion/exclusion.
Figure 1 schematizes the literature search. Of the 174 citations reviewed, 36 were
identified for preliminary inclusion. After obtaining the full text of these articles, more than half
(64%; 23/36) were further eliminated. One study preliminarily accepted (Fabbro, Deluca, &
Vorano, 1996) could not be obtained despite attempted correspondence with authors. An
additional treatment study (Filiputti, et al., 2002) could not be included in our data analysis
because it only provided overall language measures (for morphology, syntax, etc.) that were
derived by combining expressive and receptive scores. Therefore, the data could not be evaluated
for a specific clinical question(s).
A total of 161 citations were excluded from the review; the majority of which did not
provide an intervention (50%, 81/161). Other reasons for exclusion were as follows: a) was not a
study or systematic review (23%, 37/161), b) not age or population under review (6%, 10/161),
c) did not provide original data or separate data from mixed populations or treatments (6%,
10/161), d) was not published in a peer-reviewed journal (7%, 12/161), e) did not target a
question (6%, 10/161) or f) could not obtain full-text (1%, 1/161); leaving a total of 13 citations.
One citation (Maragnolo, Rizzi, Peran, Piras, & Sabatini, 2009) provided data from two distinct
studies resulting in 14 studies for review. The list of excluded articles with reasons for exclusion
is provided as Supplementary material (see S2).
------------Insert Figure 1 about here---------Data extraction and coding
Methodological quality of included studies was independently appraised by RM and TF
on six indicators identified by ASHA’s levels of evidence scheme (ASHA, 2007). To minimize
bias, studies were evaluated on whether or not they provided an adequate description of study
protocol, whether assessors of outcomes were blinded to language of intervention, use of
adequate sampling/allocation procedures, evidence of treatment fidelity, report of significance (p
values) and report of precision (effect size and confidence intervals). Studies were not evaluated
on ASHA’s seventh quality indicator, use of intention to treat, as no controlled trials were found
in which this analyses was applicable. A description of quality indicators and corresponding
quality markers are provided as Supplementary material (see S.3). Level of agreement between
reviewers on study quality was good (K = 0.61 - 0.80; Landis & Koch, 1977). Each study was
examined for the question(s) which it addressed and relevant pre- and post-therapy data were
extracted. We computed statistical significance for the pre and post-treatment scores using the
McNemar’s change test (p<0.05, Seigel & Castellan, 1988)3. There were two primary reasons for
performing the statistical computations. Some studies failed to report any statistical measure
(e.g., Faroqi & Chengappa, 1996; Gil & Goral, 2004; Khamis, Verkent-Olenik, & Gil, 1996). A
few other studies reported parametric statistical tests whose assumptions of normality and
independence were not met by the study design and data. McNemar’s change test is a nonparametric test for paired nominal measures such as accuracy data, and has been used by several
aphasiologists to compute statistical significance of treatment-induced changes in behavioral
scores (Faroqi-Shah, 2008; Rochon, Laird, Bose, & Scofield, 2005). The use of a consistent
statistical measure makes comparisons of statistical significance across studies more valid. In
addition, one author (TF) extracted several key elements from each study to determine the
influence, if any, the participant’s linguistic, demographic and treatment characteristics have on
language outcomes. Variables included age, gender, level of education, medical diagnosis,
aphasia characteristics, time post onset, type, frequency, intensity and duration of treatment,
person administering intervention, L1 and L2 language, acquisition of secondary language, level
of pre-morbid proficiency in each language, and cognate relationships. Studies varied
considerably in the types of treatment administered and the extent to which the treatment
protocol was described. Broad categories of treatment types were coded on the basis of the focus
of the intervention. Categories included auditory-comprehension, word-semantic, wordphonology, sentence-syntax, and non-specific.
2.3. Operational definitions
3
The following on-line calculator was used: http://www.graphpad.com/quickcalcs/McNemar1.cfm
Unilingual treatment was operationally defined as the use of a single language at any
given treatment phase. Studies that used alternating treatments with a separate language for each
treatment phase were included. Studies that utilized both languages within a treatment phase or
used translation between languages were excluded. We operationally defined L1 as the first
acquired language as this was the criterion used by almost all the studies. It must be noted that in
some studies the individual with aphasia pre-morbidly used the L1 with a lower frequency or
proficiency than L2. Level of L1 and L2 proficiency was defined as high or low based on
author’s report (i.e. pre-morbid reading, writing and conversational levels). L2 was operationally
defined as the later acquired language, and it must be noted that this definition includes treatment
provided in a third or fourth acquired language. Early and late bilingualism was defined as L2
acquisition before or after five years of age respectively. Receptive language was defined as any
task that tapped input modalities (auditory or visual) such as auditory discrimination, lexical
decision, sentence comprehension, and picture identification. Expressive language was defined
as tasks that included verbal output such as picture naming, sentence production, synonym
generation, repetition, and picture description. Reading and writing tasks were excluded as these
involve multiple modalities. A language broker was operationally defined as a person who
lacked professional training (as an SLP or related profession) and served to mediate between an
SLP and bilingual client by interpreting (oral language) and translating (written language). Acute
and chronic aphasia were defined as within and after one year post-onset of the brain damage
respectively. Any treatment with a primary focus on improving auditory comprehension was
coded as auditory-comprehension. Treatments that focused on word retrieval were coded as
word-semantic or word-phonological based on whether semantic attributes or phonemic cueing
strategies were primarily used. The term sentence-syntax was used for treatments that focused on
sentence production, either with single sentences or discourse. Studies in which the treatment
description lacked sufficient detail for categorization were coded as non-specific.
3. Results
3.1. Overview
Table 1 summarizes the questions addressed, quality markers, study design and number
of participants for each of the studies included in this review; all of which were in the
exploratory stage of research (ASHA, 2007; See S3). The data included covers a total of 45
bilingual aphasic participants, with the majority of participants (N=30) contributed by a single
group study (Junque, Vendrell, Vendrell-Brucet, & Tobena, 1989). Eighty-six percent of the
studies (12/14) contributed data to more than one question and 79% (11/14) provided data across
more than one focus area. Of the 14 included studies, 12 addressed one or more questions in
Focus area A (language therapy in the secondary language) and 13 addressed one or more
questions in Focus area B (CLT of therapy outcomes). No study investigated outcomes with
language brokers (questions 7 & 8) and hence questions under Focus area C could not be
evaluated. Our systematic search of the literature found few studies (N = 6) pertaining to the
effects of SLP treatment on receptive language skills (questions 1,3,4). All included studies
addressed the effects of SLP treatment on expressive language skills (questions 2,5,6); the
majority of which (79%; 11/14) investigated the direct effect of SLP treatment in L2 on the
expressive language skills of the treated language (question 2). Eleven studies also examined
cross linguistic gains on expressive language skills as a result of SLP treatment provided in L2
(question 5) and five studies examined CLT of treatment provided in L1 (question 6).
----------------Insert Table 1 here---------------
Appraisal of methodological quality revealed that most (13/14) described individual
participant data as part of a case study or single subject design and had adequate description of
the study protocol. However, studies lacked in other quality markers such as random sampling,
blinding of assessors, and evaluation of treatment fidelity. Therefore the reader may note that the
interpretive strength of this review is somewhat limited by the quality of the component studies
(Dollaghan, 2007). In the following sections, the findings are presented under each focus area.
Data on demographic and linguistic variables is described last. Unless otherwise noted, reports of
statistical significance refer to this authors’ computation of significance using McNemar’s
change test (p<0.05).
3.2. Focus A: Language therapy in the secondary language (L2)
Five case studies investigated Question 1, the effect of unilingual treatment in L2 on
receptive language skills in L2 (Abutelabi, Rosa, Tettamanti, Green, & Cappa, 2009; Faroqi &
Chengappa, 1996; Gil & Goral, 2004; Kamis, Venkert-Olenik, & Gil, 1996; Miertsch, Meisel, &
Isel, 2009). These are listed in Table 2a. Although none of the studies reported effect size or
probability data, the participants in all five studies exhibited significantly increased performance
in L2 receptive language skills after SLP treatment was provided in L2 (McNemar’s change test,
p<0.05). Three of the studies described acute aphasic patients with primarily receptive
difficulties and the primary aim of therapy was to improve auditory comprehension (Abutelabi,
et al., 2009; Gil & Goral, 2004; Kamis et al., 1996). One study with a chronic patient also aimed
at improving auditory comprehension in addition to lexical retrieval (Miertsch, et al., 2009). The
Faroqi & Chengappa study (1996) differed from the above four studies in several aspects: the
patient had primarily expressive difficulties with relatively spared word level comprehension
(diagnosis of Broca’s aphasia as compared to Wernicke’s aphasia for the other four studies). The
therapy focused on syntactically complex sentences and used a combination of receptive and
expressive tasks.
It should be noted that studies differed considerably in the extensiveness of language
scores provided, and some studies listed only those pre- post- scores that differed significantly
(e.g., Miertsch et al., 2009), while other studies provided a more complete listing of scores (e.g.,
Abutelabi et al., 2009). Across studies, commercially available instruments such as the Bilingual
Aphasia Test (BAT; Paradis, 1987), Israeli Lowenstein Aphasia Test (ILAT; Schechter, 1965)
and/or custom-made measures were used. This confounds the interpretation of outcome
comparisons across studies. These caveats are addressed further in the discussion section.
---------------Insert Tables 2a and 2b about here--------------As shown in Table 2b, 12 studies contributed data relevant to Question 2, the effect of L2
treatment on L2 expressive language (Abutelabi et al., 2009; Edmonds & Kiran, 2006; Faroqi &
Chengappa, 1996; Gil & Goral, 2004; Goral, Levy & Kast, 2009; Khamis et al., 1996; Laganaro,
Di Pietro & Schnider, 2003; Marangolo et al., 2009 (study 1); Marangolo et al., 2009 (study 2);
Meinzer, Obleser, Flaisch, Eulitz, & Rockstroh, 2007; Miertsch et al., 2009; Penn & Beecham,
1992). Outcome measures included the Aechen Aphasia Test (AAT; Huber, Poeck, & Williams,
1984), BAT, ILAT; Boston Naming Test (BNT; Kaplan, Goodglass & Weintraub, 1983),
Snodgrass Naming Battery (SNB; Snodgrass & Vanderwart, 1980) and informal assessment
measures. Eight of these studies reported data from acute aphasic participants, seven of which
focused on word retrieval, and found statistically significant changes in word retrieval scores
(McNemar’s change test, p<0.05) (Abutelabi et al., 2009; Edmonds & Kiran, 2006; Gil & Goral,
2004; Khamis et al., 1996; Lagarno et al., 2003; Marangolo et al., 2009 study 1 and 2). One case
study of an acutely aphasic participant focused on discourse strategies and reported qualitative
data and so statistical comparisons could not be made (Penn & Beecham, 1992). Two studies of
chronic participants focused on word retrieval treatments and found statistically significant
improvements (Meinzer et al., 2007; Miertsch et al., 2009). The remaining two chronic studies
examined the efficacy of morphosyntactic and syntactic treatments respectively (Faroqi &
Chengappa, 1996; Goral et al., 2009). The morphosyntactic treatment changed one score
significantly (noun-verb agreement) while the syntactic treatment reported significant changes in
four sentence types.
3.3. Focus B: Cross-language transfer (CLT) of therapy outcomes
This section includes studies that provided treatment in L2 or L1 and examined pre-post
treatment measures in the untrained language (L1 and L2 respectively) for either receptive
(questions 3&4; see Table 3) or expressive (questions 5&6; see Table 4) language skills. Table
3a shows that, of the five studies that examined CLT from L2 to L1, three showed significant
improvement in receptive language skills (Faroqi & Chengappa 1996; Gil & Goral 2004; Khamis
et al., 1996) while one study reported a post-treatment decline in performance (Miertsch et al.,
2009). It is noteworthy that one of the studies with significant improvement involved chronic
participants (Faroqi & Chengappa, 1996). Two studies, listed in Table 3b, reported significant
CLT from L1 to L2 (Gil & Goral, 2004; Junque et al., 1989). The Junque et al., study (1989) is
noteworthy because it examined 30 acutely aphasic bilingual participants and found significant
improvement in single word identification. The magnitude of improvement in L2 was smaller
than that observed in the treated L1.
---------------Insert Tables 3a and 3b about here--------------As for expressive language outcomes, there are data from 11 studies examining L2 to L1
and four studies reporting L1 to L2 (Table 4; Abutelabi et al., 2009; Edmonds & Kiran, 2006;
Faroqi & Chengappa, 1996; Gil & Goral, 2004; Goral et al., 2009; Khamis et al., 1996;
Marangolo et al., 2009; Meinzer et al., 2007; Penn & Beecham, 1992; and Ansaldo et al., 2009;
Gil & Goral, 2004; Edmonds & Kiran, 2006; Junque et al., 1989 respectively). Five out of 11
studies found CLT to the untrained L1, of which three described acute participants and two
described chronic participants (Faroqi & Chengappa 1996; Khamis et al., 1996; Marangolo et al.,
2009; Miertsch et al., 2009). Four out of these five studies focused on word retrieval and one
study focused on sentence production. All four studies (35 participants total; one chronic and 34
acute) that examined CLT to the untrained L2 after L1 treatment reported significant
improvement (Ansaldo et al., 2009; Gil & Goral, 2009; Edmonds & Kiran, 2006; Junque et al.,
1989).
---------------Insert Tables 4a and 4b about here--------------3.4. Participant and language variables
Table 5 provides a detailed description of the 45 bilingual participants included across
studies (35 male, 10 female; age range = 21 to 80 years). Eighty-four percent of the participants
(38/45) exhibited stroke-induced aphasia with the remaining 16% presenting with other
neurologic impairments (6 hematomas, 1 traumatic brain injury). Aphasia type was characterized
as fluent (67%; 30/45), non-fluent (31%; 14/45) or mixed (2%; 1/45). Of those that reported
severity, three exhibited severe aphasia, one moderate to severe aphasia, 19 moderate and 15
mild or mild to moderate aphasia. Time post onset ranged from 2 weeks to 8 years; however
most participants (89%; 40/45) demonstrated acute aphasia. Comparing L2 and CLT expressive
and receptive outcomes (Tables 2-4) with these participant variables revealed no systematic
relationship of aphasia type, severity or time post onset. Data sets from both acute and chronic
participants reported positive treatment outcomes in several aspects, likewise there were
instances where both acute and chronic participants failed to show improvements.
---------------Insert Table 5 about here--------------Table 6 lists the language typologies and language histories of the participants in each
study. Language typologies were determined using the World atlas of language structures
(Haspelmath, Dryer, Gil, & Comrie, 2008). There were five studies in which L1 and L2 belonged
to the same language family (Abutelabi et al., 2009; Faroqi & Chengappa, 1996; Junque et al.,
1989; Khamis et al., 1996; Miertsch et al., 2009). Of these studies, CLT was reported in two out
of three for receptive language (Faroqi & Chengappa, 1996; Junque et al., 1989) and in four out
of five for expressive language (Faroqi & Chengappa, 1996; Junque et al., 1989; Khamis et al.,
1996; Miertsch et al., 2009). Nine participants were late bilinguals (age of L2 acquisition ≥ 5
years) and the remaining 36 were early bilinguals (acquisition ≤ 5 years). Age of acquisition did
not appear to impact L2 outcomes or CLT. Proficiency of language use was reported in the
majority of studies. Eight-four percent (38/45) of participants reported equal proficiency in L1
and L2.
---------------Insert Table 6 about here---------------
4. Discussion
The purpose of this evidence-based review was to examine language outcomes of
unilingual SLP treatments for bilingual individuals with aphasia. Eight clinical questions were
established a priori to tease apart expressive and receptive outcomes in the trained language and
CLT. Further analysis of patient-related, aphasia-related and linguistic aspects was conducted to
determine what variables, if any, impact treatment outcomes. The results of the systematic search
of literature from 1980 onwards yielded 14 exploratory studies from 13 citations pertaining to
one or more of the clinical questions; the majority of which provided data pertaining to
unilingual treatment in L2 on expressive language outcomes (N = 12). There was also a
preponderance of studies of acutely aphasic patients. No studies were found allowing us to
determine the impact of service provider (i.e. language broker) on treatment outcomes.
Although the limited number and methodological quality of the included studies warrants
caution when interpreting the results, this review revealed the following trends: therapy provided
in L2 yields positive receptive and expressive outcomes even in chronic bilingual aphasia, CLT
does occur in over half the participants, and, age of acquisition and language typology have little
differential effect on outcomes. This EBSR also illuminated that several variables are
confounded, and consequently need further research in order to clearly delineate their effects on
bilingual aphasia outcomes. The findings of this review and recommendations for future research
are discussed in the following paragraphs.
4.1. Clinical Implications
SLPs face the challenge of making treatment decisions that will facilitate and optimize
recovery of both languages of a bilingual aphasic individual. A recent survey of SLPs who
worked with adults in the United States revealed that a majority felt that their academic and
clinical training left them inadequately prepared for assessment and treatment of bilingual
aphasic clients (Centeno, 2009). Further, SLPs expressed dissatisfaction with the amount of
information available to guide treatment decisions. Given that a majority of the world (and a
rapidly growing US demographic) is bilingual, Centeno’s (2009) survey presents the rather
disturbing possibility that a significant proportion of the world’s aphasic clients’ communicative
needs may be compromised due to a limited knowledge base. Hence, it is imperative to propose
clinical recommendations based on this EBSR, bearing in mind the earlier cautionary note that in
most cases, the evidence was only modest.
The first clinically relevant finding of this EBSR is that all studies investigating the direct
impact of unilingual treatment in L2 showed improvement across receptive and expressive
language modalities. Given that the efficacy of aphasia treatment has been well-established
(Robey, 1998; Wisenburn & Mahoney, 2009), this finding with bilingual aphasia is not
surprising. It is recommended that when an SLP is faced with decisions about choice of language
for treatment, the L2 can be actively considered as a viable option. Of course, factors such as
client preferences and language of the environment should be considered. This EBSR failed to
reveal any consistent effect of L2 acquisition age or proficiency level as is evident from the
participant variables in Tables 5 and 6 (but see Edmonds & Kiran, 2006). Hence, until further
data emerge suggesting otherwise, SLPs may consider L2 therapy for early and late bilinguals
with moderate to high L2 proficiency. It should be stressed that these recommendations are not
to be interpreted as L1 treatment is undesirable, rather, that L2 treatment does not seem to have
any negative impact on outcomes (see also Kohnert, 2009 p.184 for a similar suggestion).
The benefits of cross linguistic transfer are less clear from this EBSR. Some unilingual
therapy studies found no generalization to the untrained language (Meinzer et al., 2007) while
others reported generalization (Edmonds & Kiran, 2006; Gil & Goral, 2004; Miertsch et al.,
2008). The recent review of 12 studies of bilingual aphasia treatment by Kohnert (2009) also
found mixed CLT effects.
These mixed CLT findings may be due to a plethora of factors such as differences
between treatment approaches, focus on different language domains such as lexical retrieval or
syntax, structural differences between languages, and patient-related variables such as pre-
morbid language proficiency, type of aphasia, relative severity of impairment in each language,
and extent/size of the neurological lesion. Interestingly, studies addressing receptive language
appeared to show more positive cross linguistic effects. The implications for clinical decision
making purposes then are that the current state of evidence does not provide any basis for SLPs
to predict if CLT will occur after unilingual treatment. Some authors have suggested that the
chances of CLT can potentially be increased by inclusion of activities such as translation
between L1 and L2, or stimuli with structural overlap between L1-L2, and help from family
members (Ansaldo et al., 2008; Kohnert, 2004; 2009). However, the studies included in the
present EBSR are inadequate in validating these suggestions and further research is warranted.
4.2. Future research needs
This EBSR revealed the rather appalling dearth of methodologically rigorous bilingual
aphasia treatment studies. It also identified multiple questions for future research although an
exhaustive list is beyond the scope of this paper. Foremost, at least to our knowledge, there is
virtually no research on the effectiveness of language brokers. Hence two clinical questions
could not be addressed in this EBSR. Given that language brokers are frequently utilized in
treatment of bilingual aphasic clients (Centeno, 2009), research on the extent of and factors
influencing outcomes with language brokers is crucial. The second major problem in the existing
corpus of studies is the over representation of studies with acutely aphasic patients that failed to
account for spontaneous neurological recovery. Future research will need to better delineate
spontaneous versus treatment-induced neural plasticity. Treatment-specific factors such as
effects of modality of treatment (expression, comprehension, reading), language domain (lexical,
morphosyntactic etc.), cross-linguistic similarity on CLT, and dose-response
(frequency/intensity) characteristics need to be examined. Other long recognized areas of
research are the influence of L2 acquisition age, pre-morbid proficiency, and daily usage
patterns.
4.3. Methodological considerations
Bilingual aphasia treatment studies at minimum, differ in languages used, types of
treatments used, types of outcome measures used, treatment schedules (intensity-frequency), and
types of participants (acute versus chronic aphasia; early versus late bilinguals; lesion location
and size). It is therefore difficult to delineate the impact of these variables on bilingual treatment
outcomes and to compare effects across studies. A further hurdle in this EBSR was not
necessarily the limited number of studies, but the limited methodological detail provided in some
of the studies. Several studies failed to mention crucial aspects such as the presence of
pathological code-switching, type of activities included in treatment, or the language of the
home/community. With a few exceptions, the overall methodological rigor of bilingual treatment
studies reviewed in this EBSR was below that of monolingual treatment studies of aphasia (e.g.,
compared to Cherney, Patterson, Raymer, Frymark, & Schooling, T., 2008). In light of these
issues, we conclude this EBSR by presenting a checklist for authors who plan to publish
bilingual aphasia treatment studies. This checklist is intended to recommend information that
should be included in order to make each bilingual treatment study transparent, replicable, and
interpretable. As the number of bilingual aphasic clients and hence the number of bilingual
treatment studies proliferates, this recommendation is crucial for clear scientific communication
that will aid future systematic reviews.
1. Research Questions. Akin to treatment studies of monolingual aphasic participants, a
clear articulation of the rationale for the treatment chosen, the experimental questions,
and the apriori hypotheses is warranted. This includes, but is not limited to, expectations
of within and across language outcomes in various domains such as word retrieval and
sentence formulation.
2. Experimental Design. The study design should be compatible with the experimental
question, with adequate consideration of non-treatment variables that may confound
treatment outcomes. These include, but are not limited to, neurological factors such as
spontaneous recovery in the early months and psychosocial factors such as the nature of
language stimulation outside the treatment setting and motivation to improve in a specific
language. Internal and external validity needs to be demonstrated (Thompson & Kearns,
1991). Given the importance of massed practice (that is, high intensity of treatment) on
aphasia therapy outcomes, it is imperative that authors justify their choice of treatment
dosage (Cherney et al., 2008; Kleim & Jones, 2008).
3. Participants. Participant(s)’ neurological, cognitive, linguistic, and demographic profiles
need to be explicit enough to enable comparison across studies. Details of pre-morbid and
post-morbid language background and language use history can be provided either with a
custom-made questionnaire or by using published questionnaires (Marian et al., 2007;
Munoz, Marquart, & Copeland, 1999; Paradis, 1989). Patterns of cognitive and linguistic
deficits, including relative severity differences across languages and domain general
therapy predictors (attention and (working) memory span), should be described. It has
been pointed out that aphasic symptoms could manifest differently across languages
because of typological differences. Studies examining CLT should specifically include
data on translation abilities, pathological language mixing, and the presence of bilingual
stimulation in the home/community environment. Description of the brain lesion should
be in sufficient detail to enable future examination of cross-study associations with
cognitive-linguistic deficit patterns, recovery patterns, and recovery predictors. This may
be achieved by a detailed narrative of radiological findings and/or inclusion of structural
magnetic resonance images (sMRI)4. If, as suggested by Ansaldo et al. (2008), lesion
location needs to be considered while choosing appropriate therapy for the bilingual
client (p. 554), lesion information is vital for future therapy decisions.
4. Treatment protocol and outcome measures. The treatment protocol should be in adequate
detail to be replicable, with specific information about the language of treatment,
feedback, choice of stimuli (cognate, phonological or syntactic overlap between
languages), treatment intensity-frequency, and the person administering the treatment
(monolingual, bilingual). It is highly recommended that outcome measures include
published tests to enable comparison across studies, as well as (custom-made) tests that
will demonstrate the direct effects of the treatment on trained and untrained domains. One
needs to be cognizant of the fact that researchers should report all measures, irrespective
of whether these change significantly after treatment (e.g., Abutelabi et al., 2009).
5. Interpretation. The results should be interpreted cautiously and within the context of
potential sources of bias, whether they arise from the study design, measurement
imprecisions, participant inconsistencies, or statistical analyses. Whenever possible,
authors should discuss the relative influence of bilingual variables (age of acquisition,
4
We thank an anonymous reviewer for highlighting the importance of including sMRI information.
level of proficiency, acceptability of code-mixing among unimpaired bilinguals in the
community), linguistic variables (especially similarities between languages),
aphasiological variables (including severity, deficit pattern, pathological code-mixing,
and cognitive aspects), neurological variables (lesion site-extent including subcortical
lesions and white matter involvement, multiple strokes), and sociocultural aspects on
treatment outcomes.
5. Conclusions
In conclusion, although modest evidence exists for positive treatment outcomes in L2 and
for CLT in bilingual aphasia, the results of this EBSR should be considered preliminary. Until
further data on bilingual treatment emerge, treatment decisions can be made based on the
findings of this EBSR complemented with clinical expertise, client preferences, and
consideration of sociocultural variables. It is evident from limited number of published bilingual
aphasia treatment studies that this research enterprise is still in its infancy and in need of
considerable systematic research. Investigations of bilingual aphasia treatment outcomes are
necessary not only for its obvious clinical importance, but also for the insights gleaned about
language representation and breakdown in the bilingual brain. Lesion-deficit correlations hold
the potential for refining neuroanatomical models of bilingual language representation.
Associations between language recovery and lesion characteristics (as well as cognitive
linguistic deficits) will contribute to our understanding of rehabilitation-dependent neural
plasticity.
Appendix
A.1 List of Electronic Databases Searched
AgeLine
The Aphasiology Archive
CINAHL
Cochrane Library
ComDisDome
Communications & Mass Media Complete
CSA Linguistics Language Behaviour Abstracts
CSA Neurosciences Abstracts
CSA Social Services Abstracts
Education Research Complete
ERIC
Evidence-Based Medicine Guidelines
GoogleScholar
Health Source: Nursing
HighWire Press
Latin America and Caribbean Health Sciences Literature
NHS Evidence: Health Information Resources
PsycBITE
PsycINFO
Psychology and Behavioral Sciences Collection
PubMed
REHABDATA
ResearchGATE
Science Citation Index
ScienceDirect
Social Science Citation Index
speechBITE
SUMSearch
TRIP Database
A.2 Additional Searches
The reference lists of all relevant articles identified were scanned for other possible studies.
All ASHA journals were searched through the HighWire Press website. Hand-search of
International Journal of Bilingualism and the Journal of Multilingual Communication Disorders.
Acknowledgements
This evidence-based systematic review was supported by ASHA’s National Center for Evidencebased Practice in Communication Disorders (NCEP). We thank the following individuals who
contributed to the preparation of this document: Hillary Leech, N-CEP’s Research Assistant who
helped with formatting, Mohan Singh and Emily Schuster, Research Assistants at the University
of Maryland, who helped with computations of McNemar’s change test. No author had any paid
consultancy or any other conflict of interest with this document and agreed to declare no
competing interests.
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* Studies that were included in the EBSR
Figure Caption: Figure 1. Flowchart outlining the study identification process
Table 1. Studies Included in EBSR by Questions Addressed, Quality Markers, and Number of Participants.
Quality indicators
Citation
Abutalebi, et al., 2009
Ansaldo et al., 2009
Question(s)
N
Study Design
Protocol
Description
1,2,3,5
1
Case study
+
Convenience
-
-
-
Case study
+
Convenience
-
+
-
6
1
Sampling
Treatment
Fidelity
Significance
Precision
Edmonds & Kiran, 2006
2,5,6
3
Single subject
+
Convenience
+
+
+
Faroqi & Chengappa,
1996
1-3,5
1
Case study
+
Convenience
-
-
-
Gil & Goral, 2004
1-6
1
Case study
+
Convenience
-
-
-
Goral, et al., 2009
2,5
1
Case study
+
Convenience
-
-
+/-
Junqué et al., 1989
4,6
30
Case series
+
Convenience
-
+
-
Khamis et al.,1996
1,2,3,5
1
Case study
+
Convenience
-
-
-
2
2
Single subject
+
Convenience
+
+
-
Maragnolo et al., 2009
(Study 1)
2,5
1
Case study
+
Convenience
-
+
-
Maragnolo et al., 2009
(Study 2)
2,5
1
Case study
+
Convenience
-
+
+
Meinzer et al., 2007
2,5
1
Case study
+
Convenience
-
-
-
Miertsch et al., 2009
1,2,3,5
1
Case study
-
Convenience
-
+
+
2,5
1
Case study
+
Convenience
-
-
-
Laganaro et al., 2003
Penn & Beecham, 1992
Note. + = Present; - = Absent
Table 2a. Outcomes of SLP Treatment in L2 on Receptive Language in L2 (Question 1)
Citation
Abutalebi et al., 2009
Intervention
Word-phonology during
Phase 1
Word- phonology + Wordsemantics during Phase 2
Faroqi & Chengappa
1996
Gil & Goral 2004
Khamis et al., 1996
Miertsch et al., 20091
Sentence-syntax
Auditory-comprehension
Treatment Schedule
Phase 1: 60 minute sessions
7 times weekly
6 weeks
Phase 2: 60 minute sessions
4 times weekly
16 weeks
60 minute sessions
32 sessions
Outcome(s) Measured
BAT
Pointing
Commands
Verbal-auditory discrimination
Syntactic comprehension
Lexical decision
Listening comprehension
Grammatical judgment:
Active sentences
Passive sentences
Object-clefts
Wh-questions
Relative clauses
Comprehension:
Active sentences
Passive sentences
Object-clefts
Wh-questions
Relative clauses
Pre
Post
9/10
5/10
9/18
76/86
24/30
4/5
10/10
10/10
18/18*
85/86*
30/30*
5/5
64%
60%
60%
72%
52%
100%*
100%*
98%*
100%*
96%*
75%
46%
40%
62%
66%
100%*
98%*
88%*
100%*
90%*
45 minute sessions
5 times weekly
4 weeks
ILAT
Answering questions
Picture identification
Commands
NR
42%
40%
NR
87%*
55%*
Multiple: auditorycomprehension + word +
discourse strategies
8 weeks
ILAT
Picture identification
Commands
92%
99%
100%*
100%
Word-semantic
45 minute sessions
2 hours daily
22 sessions
50%
100%*
BAT
Syntactic comprehension of
reversible noun phrases
Note. AAT=Aechan Aphasia Test; BAT=Bilingual Aphasia Test; ILAT= Israeli Lowenstein Aphasia Test; *McNemar’s change test, p<0.05
1
This study examined the effect of L3 treatment on L1, L2, and L3
Table 2b. Outcomes of SLP Treatment in L2 on Expressive Language in L2 (Question 2)
Citation
Abutalebi et al., 2009
Intervention
Treatment Schedule
Word-phonology during
Phase 1
Phase 1: 60 minute sessions
7 times weekly
6 weeks
Phase 2: 60 minute sessions
4 times weekly
16 weeks
BAT
Synonyms
Antonyms
Word repetition
Sentence repetition
Series
Naming
Semantic opposites
SNB
2 hour sessions
2 times weekly
BNT
BAT
Naming
Word Repetition
Semantic Categories
Semantic opposites
Synonyms
Antonyms I
Antonyms II
60 minute sessions
32 sessions
Word- phonology + Wordsemantics during Phase 2
Edmonds & Kiran, 2006
Participant 2
Faroqi & Chengappa, 1996
Gil & Goral, 2004
Goral et al., 2009
Word-semantic
Sentence-syntax
Auditory-comprehension
Sentence-syntax
Outcome(s) Measured
Pre
Post
8/20
8/10
30/30
7/7
0/3
8/20
8/10
57/144
19/20*
10/10
30/30
7/7
3/3
19/20*
10/10
122/144*
2/60
35/60*
0%
77%
60%
0%
20%
20%
20%
43%*
73%
80%*
70%*
100%*
60%*
40%*
Wh-marker production
Who
What
When
Where
40%
30%
40%
20%
100%*
100%*
100%*
100%*
45 minute sessions
5 times weekly
1 month
ILAT
Spontaneous speech
Elicited speech
Repetition
Naming
30%
0%
51%
8%
30%
0%
69%*
20%*
60 minute sessions
Treatment A
3 times weekly
9 sessions
Khamis et al., 1996
Lagarno et al., 2003
Multiple: auditorycomprehension + word +
discourse strategies
8 weeks
Word-phonology
Daily sessions
2 week intervals
6 weeks
60 minute sessions
5 times weekly
6 months
Noun-verb agr
Person-gender agr
Tense consistency
Preposition use
Syllables per minute
Treatment B
Noun-verb agreement
Person-gender agreement
Tense consistency
Preposition use
Syllables per minute
ILAT
Spontaneous speech
Automatic speech
Naming
57%
91%
85%
90%
38
73%*
100%
88%
93%
46
72%
95%
83%
72%
39
67%
93%
80%
85%*
40
80%
100%
50%
90%*
100%
70%*
4%
14%
20%
40%*
24%*
45%*
53%
73%
62%
70%*
83%*
66%*
AAT
Repetition
Naming
46%
60%
52%*
69%*
Naming
Participant 7
Computerized treatment items
Behavioral treatment items
Control items
Participant 10
Computerized treatment items
Behavioral treatment items
Control items
Marangolo et al., 2009
(Study 1)
Word-phonology
Marangolo et al., 2009
(Study 2)
Word-phonology
2 hour sessions
5 times weekly
2 weeks
Naming
35/48
47/48*
Meinzer et al., 2007
Word-semantic
3 hours daily
10 consecutive days
Naming
38/80
54/80*
Miertsch et al., 20091
Word-semantic
45 minute sessions
2 hours daily
BAT
Repetition of sentences
1/8
7/8*
22 sessions
Penn & Beecham 1992
Sentence-syntax
9 sessions
14 weeks
Words per minute
130
115
Compensatory strategy use:
+
Circumlocution
+
Fluency place holder
+
Turn taking
+
Prenominalization
+
Note. AAT=Aechan Aphasia Test; BAT=Bilingual Aphasia Test; BNT=Boston Naming Test; ILAT= Israeli Lowenstein Aphasia Test; SNB=Snodgrass Naming Battery;
* McNemar’s change test, p<0.05; + = Present; - = Absent
1
This study examined the effect of L3 treatment on L1, L2, and L3.
Table 3a. CLT of SLP Treatment in L2 on Receptive Language in L1 (Question 3)
Citation
Abutalebi et al., 2009
Intervention
Word-phonology during Phase 1
Word- phonology + Wordsemantics during Phase 2
Faroqi & Chengappa, 1996
Gil & Goral, 2004
Khamis et al., 1996
Miertsch et al., 20091
Sentence-syntax
Auditory-comprehension
Treatment Schedule
Phase 1: 60 minute sessions
7 times weekly
6 weeks
Phase 2: 60 minute sessions
4 times weekly
16 weeks
60 minute sessions
32 sessions
Outcome(s) Measured
BAT
Pointing
Commands
Verbal-auditory discrimination
Syntactic comprehension
Lexical decision
Listening comprehension
Grammatical judgment:
Active sentences
Passive sentences
Object-clefts
Wh-questions
Relative clauses
Comprehension:
Active sentences
Passive sentences
Object-clefts
Wh-questions
Relative clauses
Pre
Post
9/10
10/10
8/18
85/86
28/30
5/5
8/10
10/10
10/18
80/86
26/30
5/5
70%
54%
46%
64%
46%
100%*
100%*
92%*
92%*
84%*
56%
54%
44%
65%
54%
92%*
90%*
82%*
88%*
78%*
45 minute sessions
5 times weekly
4 weeks
ILAT
Answering questions
Picture Identification
Commands
Reading
20%
44%
48%
13%
53%*
98%*
65%*
48%*
Multiple: auditorycomprehension + word +
discourse strategies
8 weeks
ILAT
Picture identification
Commands
93%
92%
100%*
100%*
Word–semantic
45 minute sessions
2 hours daily
22 sessions
80%
60%*
Note. BAT=Bilingual Aphasia Test; ILAT=Israeli Lowenstein Aphasia Test
*McNemar’s change test, p<0.05
1
This study examined the effect of L3 treatment on L1, L2, and L3.
BAT
Syntactic comprehension of
reversible noun phrases
Table 3b. CLT of SLP Treatment in L1 on Receptive Language in L2 (Question 4)
Citation
Gil & Goral, 2004
Junque et al., 1989
Intervention
Auditory–comprehension
Unspecified
Note. ILAT=Israeli Lowenstein Aphasia Test; NR = not reported
* McNemar’s change test, p<0.05
a
t-test as reported by study authors (N=30)
Treatment
Schedule
45 minutes
5 times weekly
6 weeks
NR
Outcome(s) Measured
ILAT:
Commands
Picture identification
Reading
Object identification
Pre
Post
95%
80%
60%
92%
95%*
75%*
19.97%
22.47%a
Table 4a. CLT of SLP Treatment in L2 on Expressive Language in L1 (Question 5)
Citation
Abutalebi et al., 2009
Intervention
Treatment Schedule
Word-phonology
during Phase 1
Phase 1: 60 minute sessions
7 times weekly
6 weeks
Phase 2: 60 minute sessions
4 times weekly
16 weeks
BAT
Synonyms
Antonyms
Word repetition
Sentence repetition
Series
Naming
Semantic opposites
SNB
2 hour sessions
2 times weekly
BNT
BAT
Naming
Word repetition
Semantic categories
Semantic opposites
Synonyms
Antonyms I
Antonyms II
60 minute sessions
32 sessions
Auditorycomprehension
Sentence-syntax
Word- phonology
+ Word-semantics
during Phase 2
Edmonds & Kiran, 2006
Participant 2
Faroqi & Chengappa, 1996
Gil & Goral, 2004
Goral et al., 2009
Word-semantic
Sentence- syntax
Outcome(s) Measured
Pre
Post
4/5
4/5
30/30
7/7
3/3
9/20
7/10
35/90
4/5
3/5
30/30
7/7
3/3
8/20
7/10
34/90
0/60
0/60
0%
67%
100%
10%
20%
0%
60%
0%
67%
100%
10%
20%
0%
60%
Wh-marker production
who
what
when
where
30%
30%
40%
20%
100%*
100%*
100%*
90%*
45 minute sessions
5 times weekly
1 month
ILAT
Spontaneous speech
Elicited speech
Repetition
Naming
0%
51%
4%
19%
0%
51%
4%
19%
60 minute sessions
3 times weekly
9 sessions
Treatment A
Noun-verb agr
Person-gender agr
97%
100%
97%
100%
Khamis et al., 1996
Tense consistency
Preposition use
Syllables per minute
Treatment B
Noun-verb agr
Person-gender agr
Tense consistency
Preposition use
Syllables per minute
99%
93%
74
99%
96%
76
97%
100%
97%
97%
78
98%
100%
98%
96%
73
ILAT
Spontaneous speech
Automatic speech
Naming
80%
100%
53%
90%*
100%
79%*
44
61
49
67*
Multiple: auditorycomprehension +
word + discourse
strategies
8 weeks
Marangolo et al., 2009
(Study 1)
Word-phonology
60 minute sessions
5 times weekly
6 months
Marangolo et al., 2009
(Study 2)
Word-phonology
2 hour sessions
5 times weekly
2 weeks
Naming
27/48
46/48*
Meinzer et al., 2007
Word-semantic
3 hours daily
10 consecutive days
Naming
4/80
4/80
Miertsch et al., 20091
Word-semantics
45 minute sessions
2 hours daily
22 sessions
BAT
Repetition of sentences
50%
81%*
Penn & Beecham, 1992
Sentence-syntax
9 sessions
14 weeks
AAT
Repetition
Naming
Compensatory strategy use:
Circumlocution
Fluency place holder
Turn taking
Prenominalization
Note. AAT=Aechan Aphasia Test; BAT=Bilingual Aphasia Test; BNT=Boston Naming Test; ILAT= Israeli Lowenstein Aphasia Test; SNB=Snodgrass Naming
Battery; + = Present; - = Absent
*McNemar’s change test, p<0.05;
1
This study examined the effect of L3 treatment on L1, L2, and L3.
Table 4b. CLT of SLP Treatment in L1 on Expressive Language in L2 (Question 6)
Citation
Ansaldo et al., 2009
Gil & Goral, 2004
Edmonds & Kiran, 2006
Participant 1
Participant 2
Participant 3
Intervention
Treatment Schedule
Discourse
strategies +
Word–semantic
1 hour sessions
2 times weekly
3 months
Auditorycomprehension
45 minute sessions
5 times weekly
1 month
Word–semantic
2 hour sessions
2 times weekly
Word–semantic
Word-semantic
2 hour sessions
2 times weekly
2 hour sessions
2 times weekly
Outcome(s) Measured
WAB
Repetition
Object naming
Sentence completion
Responsive speech
ILAT
Repetition
Elicited speech
Naming
Writing
BNT
BAT
Naming
Word repetition
Semantic categories
Semantic opposites
Synonyms
Antonyms I
Antonyms II
BNT
BAT
Naming
Word repetition
Semantic categories
Semantic opposites
Synonyms
Antonyms I
Antonyms II
BNT
BAT
Naming
Pre
Post
84/100
30/60
6/10
4/10
90/100*
47/60*
7/10
7/10
74%
5%
31%
20%
96%*
40%*
51%*
50%*
41/60
48/60*
60%
93%
100%
20%
80%
80%
60%
62%
97%
80%*
40%*
80%
80%
100%*
2/60
35/60*
0%
77%
60%
0%
20%
20%
20%
41%*
73%
80%*
70%*
100%*
60%*
40%*
23/60
33/60*
88%
95%*
Word repetition
Semantic categories
Semantic opposites
Synonyms
Antonyms I
Antonyms II
Junque et al., 1989
Unspecified
NR
Naming
57%
100%
30%
20%
40%
40%
77%*
60%*
20%*
0%*
60%*
0%*
9.70
13.67a
Note. AAT=Aechan Aphasia Test; BAT=Bilingual Aphasia Test; BNT=Boston Naming Test; ILAT=Israeli Lowenstein Aphasia Test ; NR = not reported; WAB=Western Aphasia
Battery
*McNemar’s change test, p<0.05
a
t-test as reported by study authors (N=30)
Table 5. Participant variables
Aphasia
Type
Fluent
Aphasia
Severity
NR
TPO
Chronic (2y)
L CVA
Subcortical, including basal ganglia
and internal capsule
Fluent
Severe
Acute (2m)
10-12y
L CVA
NR
Non fluent
2 Moderate
1 Severe
Acute (8-9m)
F
17y
L CVA
Inferior frontal and basal ganglia
Non fluent
NR
Chronic (15m)
57y
M
>18y
L CVA
Fronto-parietal lobes
Mixed
Severe
Acute (2w4m)
1
49y
M
>18y
L CVA
Fronto-temporo-parietal lobes
Non fluent
NR
Chronic (7y)
Junque et al., 1989
30
M=60y
SD=9.9y
R=33-79y
23M
7F
NR
24 CVA; 6 H
NR
22 Fluent
8 Non fluent
17 Moderate
13 Mild
Acute (1-6m)
Khamis et al., 1993
1
21y
M
NR
TBI
Frontal lobe
Fluent
NR
Acute (2m)
Laganaro et al., 2003
2
P7=80y
P10=69y
2M
NR
L CVA
NR
Fluent
Moderate to
severe
Acute (NR)
Maragnolo et al., 2009
1
60y
F
NR
L CVA
Fluent
NR
Acute (2m)
Citation
Ansaldo et al., 2009
N
1
Age
56y
Gender
M
Education
>18y
Etiology/Site of lesion
L CVA
Subcortical including basal ganglia
Abutalebi et al., 2009
1
56y
M
12y
Edmonds & Kiran,
2006
3
P1=53y
P2=53y
P3=56y
2M
1F
Faroqi & Chengapppa,
1996
1
31y
Gil & Goral, 2004
1
Goral et al., 2009
Temporo-parietal, incl., STG, MTG,
SMG
Meinzer et al., 2007
1
35y
M
>18y
L CVA
Fronto-temporal-parietal lobes
Non fluent
Severe
Chronic (32m)
Miersch et al., 2009
1
48y
M
>18y
L CVA
Temporal lobe
Fluent
Mild to
moderate
Chronic (8y)
Penn & Beecham,
1992
1
38y
M
>18y
L CVA
Parietal lobe
Fluent
Mild
Acute (9m)
Note. F=Female; H=Hematoma; L CVA=Left cerebrovascular accident; M=Male; M=Mean’ m=Months; MTG= Middle Temporal Gyrus; N= participant Number; NR=Not reported;
P=Participant; R=Range; SD=Standard deviation; SMG= SupraMarginal Gyrus; STG=Superior Temporal Gyrus; TPO =Time post onset; w=Weeks; y=Years
Table 6. Language variables
Citation
L1
L2
L2 Acquisition
L1 Proficiency Level
L2 Proficiency Level
Ansaldo et al., 2009
Spanish
IE>Rom
English
IE>Ger
Late
High
High
Abutalebi et al., 2009
Spanish
IE>Rom
Italian
IE>Ro
Late
NR
High
Edmonds & Kiran, 2006
Spanish
IE>Rom
English
IE>Ger
P1 Late
P2 Early
P3 Early
P1 High
P2 Low
P3 Low
P1 High
P2 High
P3 High
Telugu
Dravidian>SouthCen
Kannada
Dravidian>South
Early
High
High
Gil & Goral, 2004
Russian
IE>Sla
Hebrew
AA>Sem
Late
High
High
Goral et al., 2009
Hebrew
AA>Sem
English
IE>Ger
Early
High
High
Junque et al., 1989
Catalan
IE>Rom
Spanish
IE>Rom
Early
High
High
Khamis et al. 1993
Arabic
AA>Sem
Hebrew
AA>Sem
Late
High
High
Laganaro et al., 2003
NR
French
IE>Rom
Late
NR
High
Marangolo et al., 2009
Flemish
IE>Ger
Italian
IE>Rom
Late
High
High
Meinzer et al., 2007
French
IE>Rom
German
IE>Ger
Early
High
High
Meirtch et al., 2009
German
IE>Ger
English (L2) IE>Ger
French (L3) IE>Rom
Late
NR
High
Penn & Beecham, 1992
Bantu
NC>Ban
English
IE>Ger
Late
High
NR
Faroqi & Chengapppa, 1996
Note. AA=AfroAsiatic; Ban=Bantoid; Early= < age 5; Ger=Germanic; IE=IndoEuroprean; Late= > age 5; NC=NigerCongo; NR=Note reported; Rom=Romance; Sem=Semitic;
Sla=Slavic; South=Southern; SouthCen=SouthCentral
Supplementary Materials
S1. Expanded Search Term
("Multilingualism"[Mesh] OR "Emigrants and Immigrants"[Mesh]) AND "Aphasia"[Mesh]
("Multilingualism"[Mesh] OR "Emigrants and Immigrants"[Mesh]) AND ("Language
Disorders/rehabilitation"[Mesh] OR "Speech Disorders/rehabilitation"[Mesh] OR "Rehabilitation
of Speech and Language Disorders"[Mesh]) AND ("Brain Injuries"[Mesh] OR ―Cerebrovascular
Disorders‖[Mesh] OR ―Dementia‖[Mesh])
("Multilingualism"[Mesh] OR "Emigrants and Immigrants"[Mesh]) AND ("Language
Disorders/rehabilitation"[Mesh] OR "Speech Disorders/rehabilitation"[Mesh] OR "Rehabilitation
of Speech and Language Disorders"[Mesh])
("Multilingualism"[Mesh] OR "Emigrants and Immigrants"[Mesh]) AND ("Brain
Injuries"[Mesh] OR ―Cerebrovascular Disorders‖[Mesh] OR ―Dementia‖[Mesh])
"Aphasia/rehabilitation"[Mesh] AND (multilingual* OR bilingual* OR trilingual* OR (english
language) OR l1 OR l2 OR second* OR (cross linguistic) OR (cross language))
"Aphasia/rehabilitation"[Mesh] AND (multilingual* OR bilingual* OR trilingual* OR l1 OR l2
OR ("cross linguistic") OR ("cross language") OR ("limited proficiency") OR second*)
("Aphasia"[Mesh] OR "Anomia"[Mesh]) AND (multilingual* OR bilingual* OR trilingual* OR
l1 OR l2 OR ("cross linguistic") OR ("cross language") OR ("limited proficiency") OR second*
OR dual OR broker OR interpreter OR transfer)
"Multilingualism"[MAJR] AND (interpreter OR broker)
aphasia AND (*lingual* OR l1 OR l2 OR ell OR dual OR second* OR proficien*) AND
(language AND (treatment OR therapy OR rehabilitation))
((bilingual* OR multilingual* OR trilingual* OR polyglot OR (english language learner) OR
(dual language) OR (l1) OR (l2)) AND aphasia) AND (treatment OR therapy OR rehabilitation
OR intervention)
"Aphasia"[Mesh] AND "Language"[Mesh] AND ("Reading"[Mesh] OR ―Speech‖[Mesh] OR
―Translating‖[Mesh] OR ―Writing‖[Mesh] OR ―Phonetics‖[Mesh] OR ―Semantics‖[Mesh] OR
―Vocabulary‖[Mesh]) AND (treatment OR therapy OR rehabilitation)
("Rehabilitation of Speech and Language Disorders"[Mesh] OR "Language
Disorders/rehabilitation"[Mesh] OR "Speech Disorders/rehabilitation"[Mesh]) AND
("Aphasia"[Mesh] OR "Anomia"[Mesh])
(MM "Aphasia+") AND (MH "Multilingualism")
Aphasi* AND (interpreter OR broker)
"multilingual"
((MM "Multilingualism") OR (MH ―Multilingualism‖)) AND ((MM "Aphasia+") OR (MH
―Aphasia+‖))
((XX "aphasia") OR (XX "aphasic")) AND (multilingual* OR bilingual* OR trilingual* OR
polyglot OR (english language learner))
DE "BILINGUALISM" AND DE "APHASIA"
(KW "multilingual/multicultural group" OR KW "multilingual" OR KW "bilingual") AND (KW
"aphasia")
((ZW "bilingual") or (ZW "bilingual aphasia") or (ZW "bilingualism") or (ZW "bilinguals") or
(ZW "multilingual") or (ZW "multilingual/multicultural group") or (ZW "multilingualism") or
(ZW "english language learners")) and ((ZW "aphasia") or (ZW "aphasia treatment"))
(DE "APHASIA" OR DE "AGRAMMATISM" OR DE "ANOMIA" OR DE "CONDUCTION
aphasia" OR DE "JARGON aphasia" OR DE "WORD deafness") and (DE "MULTILINGUAL
persons" OR DE "MULTILINGUALISM" OR DE "BILINGUALISM" OR DE
"MULTICULTURALISM")
((ZU "aphasia") or (ZU "aphasia -- treatment") or (ZU "aphasic persons")) and ((ZU
"multilingual persons") or (ZU "multilingualism") or (ZU "bilingualism"))
(DE "Aphasia" OR DE "Acalculia" OR DE "Agnosia" OR DE "Agraphia" OR DE "Dysphasia")
and (DE "Multilingualism" OR DE "Bilingualism")
(DE "APHASIA") AND (DE "BILINGUALISM" OR DE "CODE switching (Linguistics)" OR
DE "EDUCATION, Bilingual" OR DE "INTERFERENCE (Linguistics)" OR DE "LANGUAGE
attrition" OR DE "MULTILINGUALISM")
(DE "APHASIA") AND (DE "BILINGUALISM" OR DE "MULTILINGUALISM")
DE=("agnosia" or "aphasia" or "traumatic brain injury tbi") and ("bilingualism")
DE=("multilingualism" or "bilingualism" or "cultural background") and("speech therapy" or
"language therapy") and ("agnosia" or "aphasia" or "traumatic brain injury tbi")
DE=("aphasia") and ("bilingualism" or "code switching" or "cross cultural communication" or
"diglossia" or "indigenous languages" or "language contact" or "language diversity" or "language
proficiency" or "language use" or "languages" or "multilingualism" or "second language
learning" or "second languages" or "social factors" or "sociolinguistics" or "sprachbund")
DE=("aphasia") and ("bilingualism" or "code switching" or "cross cultural communication" or
"diglossia" or "indigenous languages" or "language contact" or "language diversity" or "language
proficiency" or "language use" or "languages" or "multilingualism" or "second language
learning" or "second languages" or "social factors" or "sociolinguistics" or "sprachbund") and
("speech therapy" or "therapy" or ―language therapy‖)
DE=aphasia and (bilingual* or multilingual* or polyglot or (english language learner) or (dual
language) or (l1) or (l2) or (cross linguistic))
TS=(((bilingual* OR multilingual* OR trilingual* OR polyglot OR (english language learner)
OR (dual language) OR (l1) OR (l2) OR (cross linguistic)) AND aphasia) AND (treatment OR
therapy OR rehabilitation OR intervention)) AND Language=(English)
DE=‖aphasia‖
DE=‖aphasia‖ AND (DE=‖bilingualism‖ or DE=‖multilingualism‖ or DE=‖English (Second
Language)‖ or DE=‖Second Language Learning‖)
("BILINGUAL" or "BILINGUALISM" or "BILINGUALS" or "MULTILINGUAL" or
"MULTILINGUALISM" or "POLYGLOT" or "CROSS-CULTURAL") and ("APHASIA" or
"APHASIC" or "APHASICS" or "APHASIOLOGICAL" or "APHASIOLOGY")
(aphasia OR aphasic) AND (bilingual OR multilingual OR trilingual OR multicultural)
(aphasia OR aphasic) AND (polyglot OR (english language learner) OR (dual language) OR
cross)
Supplementary Materials
S2. Bibliography of excluded studies and reasons for exclusion in systematic review
S2.1 Did not address one or more clinical question
April, R. S., & Han, M. (1980). Crossed Aphasia in a Right-handed Bilingual Chinese Man: A
Second Case. Arch Neurol, 37(6), 342-346.
Eviatar, Z., Leikin, M., & Ibrahim, R. (1999). Phonological processing of second language
phonemes: A selective deficit in a bilingual aphasic. Language Learning, 49(1), 121-141.
Filiputti, D., Tavano, A., Vorano, L., De Luca, G., & Fabbro, F. (2002). Nonparellel recovery of
languages in a quadrilingual aphasic patient. International Journal of Bilingualism, 6(4),
395-410.
Green, D. W., & Price, C. J. (2001). Functional imaging in the study of recovery patterns in
bilingual aphasia. Bilingualism: Language and Cognition, 4(2), 191-201.
Holland, A. L. (1983). Nonbiased assessment and treatment of adults who have neurologic
speech and language problems. Topics in Language Disorders, 3(3), 67-75.
Laganaro, M., & Overton Venet, M. (2001). Acquired alexia in multilingual aphasia and
computer-assisted treatment in both languages: issues of generalisation and transfer. Folia
Phoniatr Logop, 53(3), 135-144.
Polczynnska-Fiszer, M., & Mazaux, J. M. (2008). Second language acquisition after traumatic
brain injury: A case study. Disability and Rehabilitation, 30(18), 1397-1407.
Robey, R. R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. J Speech
Lang Hear Res, 41(1), 172-187.
Roger, P. (1998). Bilingual aphasia: The central importance of social and cultural factors in
clinically oriented research. Aphasiology, 12(2), 134 - 137.
Wender, D. (1989). Aphasic victim as investigator. Arch Neurol, 46(1), 91-92.
S2.2 Not a study or systematic review
Abutalebi, J., & Green, D. (2007). Bilingual language production: The neurocognition of
language representation and control. Journal of Neurolinguistics, 20(3), 242-275.
Abutalebi, J., Tettamanti, M., & Perani, D. (2009). The bilingual brain: linguistic and nonlinguistic skills. Brain Lang, 109(2-3), 51-54.
Ansaldo, A. I., Marcotte, K., Fonseca, R. P., & Scherer, L. C. (2008). Neuroimaging of the
bilingual brain: evidence and research methodology. PSICO, 39(2), 131-138.
Ansaldo, A. I., Marcotte, K., Scherer, L., & Raboyeau, G. (2008). Language therapy and
bilingual aphasia: Clinical implications of psycholinguistic and neuroimaging research.
Journal of Neurolinguistics, 21(6), 539-557.
Bates, E., & Wulfeck, B. (1989). Comparative Aphasiology: A Cross-Linguistic Approach to
Language Breakdown. Aphasiology, 3(2), 111-142.
Bates, E., Wulfeck, B., & MacWhinney, B. (1991). Crosslinguistic research in aphasia: An
overview. Brain Lang, 41, 123-148.
Centeno, J. G. (2008). Multidisciplinary evidence to treat bilingual individuals with aphasia.
Perspectives on Communication Disorders & Sciences in Culturally & Linguistically
Diverse (CLD) Populations, 15(3), 66-71.
Centeno, J. G., Anderson, R. T., Restrepo, M. A., Jacobson, P. F., Guendouzi, J., Müller, N., et
al. (2007). Ethnographic and Sociolinguistic Aspects of Communication: Research-Praxis
Relationships. The ASHA Leader, 12(9), 12-15.
Costa, A., La Heij, W., & Navarrete, E. (2006). The dynamics of bilingual lexical access.
Bilingualism-Language and Cognition, 9(2), 137-151.
Costa, A., Santesteban, M., & Cano, A. (2005). On the facilitatory effects of cognate words in
bilingual speech production. Brain Lang, 94(1), 94-103.
Faroqi-Shah, Y., & Thompson, C. K. (2007). Verb Inflections in Agrammatic Aphasia: Encoding
of Tense Features. Journal of Memory and Language, 56(1), 129-151.
Francis, N. (2008). Exceptional bilingualism. International Journal of Bilingualism, 12(3), 173193.
Fredman, M., & Miller, N. (2001). Communication disorders in multilingual populations...
selection of papers presented at the 2nd International Symposium on Communication
Disorders in Multilingual Populations which took place in South Africa in July 2000.
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Supplementary Materials
S3. ASHA levels of evidence scheme
Indicator
Description
Quality Marker
Study protocol
The complete description of study
protocol is provided in order to allow
replication of study protocol.
Adequate description of protocol.
Inadequate description of protocol.
Protocol not stated.
Blinding
The practice of keeping the participants
of the study or assessors unaware of the
group to which a participant has been
assigned.
The method(s) used to choose and
assign participants to the study.
Assessors blinded.
Assessors not blinded.
Blinding not stated
The procedure used to ensure that the
treatment protocol is delivered as
intended.
The likelihood that the study findings
occurred by chance.
Evidence of treatment fidelity.
No evidence of treatment fidelity
Precision
The size or magnitude of any
difference found between the treatment
under investigation and the control
condition.
Effect size and confidence interval
reported or calculable.
Effect size or confidence interval reported
or calculable.
Neither effect size nor confidence interval
reported or calculable.
Intention to treat
Participants in a randomized controlled
trial are analyzed according to the
group to which they were initially
assigned, regardless of whether or not
they dropped out, fully complied to the
treatment or crossed over and received
other treatment.
Analyzed by intention to treat.
Not analyzed by intention to treat.
Italics indicates highest quality marker
Sampling/allocation
Treatment fidelity
Significance
S3.1 Quality indicators used to evaluate included studies
Random sample adequately described.
Random sample inadequately described.
Convenience/hand-picked sample.
Not stated.
P values reported or calculable.
P values not reported or calculable.
S3.2 State of research
Exploratory research: Treatment approaches are developed and assessed in the context of
whether they show promise of being efficacious.
Efficacy research: Treatment approaches are rigorously tested under ideal, highly controlled
conditions to determine the outcomes that result.
Effectiveness research: If an intervention demonstrates positive outcomes in the highly
controlled setting of a clinical trial, then the controls are relaxed to test the intervention in a
―real-world‖ clinical setting.
Cost-benefit and/or public policy: Once an intervention has been shown to be both efficacious
and effective, research is conducted to study the political and economic environment in which
the intervention is best delivered.
S3.3 Supplementary material reference S3
ASHA Leader [homepage on the Internet]. Rockville (MD): American Speech-LanguageHearing Association; c1997-2009 [2007 Mar 12; cited 2009 August 31]. Mullen R. The state of
the evidence: ASHA develops levels of evidence for communication sciences and disorders.
Available from http://www.asha.org/Publications/leader/2007/070306/f070306b.htm.