Releasing the Constraints on Aphasia Therapy:
The Positive Impact of Gesture and
Multimodality Treatments
Miranda L. Rosea
Purpose: There is a 40-year history of interest in the use of
arm and hand gestures in treatments that target the reduction
of aphasic linguistic impairment and compensatory methods
of communication (Rose, 2006). Arguments for constraining
aphasia treatment to the verbal modality have arisen from
proponents of constraint-induced aphasia therapy
(Pulvermüller et al., 2001). Confusion exists concerning the
role of nonverbal treatments in treating people with aphasia.
The central argument of this paper is that given the state of
the empirical evidence and the strong theoretical accounts of
modality interactions in human communication, gesture-
based and multimodality aphasia treatments are at least as
legitimate an option as constraint-based aphasia treatment.
Method: Theoretical accounts of modality interactions in
human communication and the gesture production abilities of
C
onstraint-induced aphasia therapy (CIAT;
Pulvermüller et al., 2001) and its variants, con-
straint-induced language therapy (CILT; Maher
et al., 2006), constraint-induced aphasia therapy plus (CIAT
Plus; Meinzer, Djundja, Barthel, Elbert, & Rockstroh, 2005),
and intensive language action therapy (ILAT; Pulvermüller
& Berthier, 2008), have been shown to be efficacious in
promoting positive changes in formal tests of language
function and client perceptions of everyday communication
for many individuals with chronic aphasia. Constraint
aphasia therapies consist of four key elements: high intensity
of practice (30 hr over 10 days; massed practice), shaping of
responses (gradually increasing the complexity of spoken
targets in line with participant mastery), social imperative to
produce speech (game-based interactive tasks), and con-
straint of responses to the spoken modality only (visual
a
La Trobe University, Bundoora, Victoria, Australia
Correspondence to Miranda L. Rose: m.rose@latrobe.edu.au
Editor: Swathi Kiran
Associate Editor: Anastasia Raymer
Received July 30, 2012
Revision received September 16, 2012
Accepted September 25, 2012
DOI: 10.1044/1058-0360(2012/12-0091)
American Journal of Speech-Language Pathology N Vol. 22 N S227–S239 N May 2013 N ß American Speech-Language-Hearing Association
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individuals with aphasia that are harnessed in treatments are
reviewed. The negative effects on word retrieval of restricting
gesture production are also reviewed, and an overview of the
neurological architecture subserving language processing is
provided as rationale for multimodality treatments. The
evidence for constrained and unconstrained treatments is
critically reviewed.
Conclusion: Together, these data suggest that constraint
treatments and multimodality treatments are equally
efficacious, and there is limited support for constraining client
responses to the spoken modality.
Key Words: aphasia treatment, constraint, multimodality,
gesture, therapy
barriers and restriction/discouragement of nonverbal com-
pensatory communication). CIAT is based on constraint-
induced movement therapy (Taub, 2004) and principles of
neuroplasticity that aim to improve spoken communication
by preventing learned nonuse of oral communication (Taub,
Uswatte, Mark, & Morris, 2006) and harness the Hebbian
learning principle summarized as cells that fire together, wire
together (Kleim & Jones, 2009).
Constraint to the spoken modality was a strong feature
of early reports of CIAT and CIAT Plus. For example,
Pulvermüller et al. (2001) wrote that ‘‘aphasic patients often
use the communication channel that is accessible to them
with the least amount of effort: they gesticulate or make
drawings instead of using spoken language. Such strategies
need to be suppressed in Constraint Induced therapy in favor
of verbal communication’’ (p. 1,621). Pulvermüller et al. also
wrote that ‘‘all communication had to be performed by use
of spoken words or sentences: pointing or gesturing was not
permitted’’ (p. 1,622).
Meinzer et al. (2005) wrote in their CIAT Plus article
that ‘‘screens between players prevented them from seeing
each other’s cards and movements to enforce communication
by spoken language and to ‘constrain’ communication by
gestures’’ (p. 1,463). Finally, Maher et al. (2006) wrote that
‘‘if participants resorted to any of these strategies during the
therapy sessions, they were reminded to use only speech and
S227
 to ‘sit on their hands’ if necessary’’ (p. 846). More recently,
the notion of constraint has been refined and renamed focus,
although the emphasis on verbal communication as the sole
response modality, and restricting or minimizing nonverbal
communication, remains (Pulvermüller & Berthier, 2008).
Since the publication of the CIAT and CIAT Plus
studies, questions have arisen in clinical practice and in the
literature concerning the appropriateness of using well-
established nonverbal and multimodality treatments in
aphasia rehabilitation. Such treatments exploit the often
preserved drawing, gesture, reading, and writing abilities of
people with aphasia (PWA), either as compensation techni-
ques when spoken communication fails to be restored or as
direct crossmodal facilitation techniques to reestablish
language and speech. Such techniques include promoting
aphasics communicative effectiveness (PACE; Davis &
Wilcox, 1985), copy and recall treatment (CART; Beeson,
Rising, & Volk, 2003), drawing treatments (Farias, Davis, &
Harrington, 2006; Morgan & Helm-Estabrooks, 1987),
gesture treatments (Rose, 2006), American Indian sign
(Skelly, Schinsky, Smith, & Fust, 1974), and protocol-based
multimodality treatments such as multi-modality aphasia
treatment (M-MAT; Rose & Attard, 2011).
The central argument of my paper is that given the
state of the empirical evidence and the strong theoretical
accounts of modality interactions in human communication
and their documented neural underpinnings, gesture-based
and multimodality aphasia treatments are at least as
legitimate an option as constraint aphasia treatment. In
order to validate this argument, I first review the current
theoretical accounts of modality interactions in human
communication and the gesture production abilities of PWA
that are harnessed in treatments. Such theoretical accounts
help to explain the rich multimodality nature of human
communication in unimpaired speakers and the considerable
gesture production abilities of PWA. The theoretical
accounts also underpin the rationale for many gesture-based
and multimodality aphasia treatments. Next, I provide a
brief overview of the neurological architecture subserving
language comprehension and expression as further rationale
for aphasia treatments that explicitly harness multimodality
processing. Finally, I provide a critical summarized review of
the available evidence in constrained and unconstrained
treatments for chronic aphasia. Together, these data suggest
that constraint therapies and multimodality therapies are
equally efficacious, and there is limited support for
constraining client responses to the spoken modality.
Models of Gesture, Speech, and Language
Interaction
Before discussing models of gesture and speech
interaction, I want to clarify what is meant by the term
gesture in this context. In healthy speakers, the production of
arm and hand gestures is closely linked with speech
production, both in terms of the information that gestures
contain and the timing of their production with related key
words/phrases (Kendon, 1980; Morrel-Samuels & Krauss,
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1992). It is argued that gesture and speech are an integrated
multimodal communication system (Kita et al., 2007;
McNeill, 2005). Gesture production has been hypothesized
to have three possible functions: (a) to contribute to the
communication of meaning (e.g., when a person is showing
an interactant how to get from his or her current location to
another and produces directional gestures or in noisy
environments when pantomime dominates interaction;
Melinger & Levelt, 2004), (b) to help facilitate word retrieval
when difficulties are encountered (Krauss, Chen, &
Gottesman, 2000), and (c) to assist in thinking for speaking
when task demands are high (Kita & Davies, 2009).
Although controversy remains as to the exact function of
gestures, it is likely that these three accounts are not mutually
exclusive.
An understanding of different gesture types is impor-
tant to consider when using gestures in aphasia therapy. A
continuum of gesture types was proposed by Kendon (1980)
and was later refined by McNeill (1992; see Figure 1). The
gestures are defined along the continuum by the obligatory
presence or absence of speech, the presence of language-like
properties in the movements, whether gestures are idiosyn-
cratic or socially regulated, and the semiotic characteristics of
the movement. For example, gesticulation at the far left side
of the continuum is defined by its obligatory presence of
speech, lack of language-like properties, idiosyncratic nature,
and lack of semiotic characteristics.
The production of various gesture types is hypothe-
sized to be dependent on different underlying cognitive
processes. The sketch model of gesture and speech interac-
tion (de Ruiter, 2000) is based on the model of speech
production proposed by Levelt, Roelfs, and Meyers (1999;
see Figure 2). In the sketch model, gestures are produced as
a result of cognitive processing, whereby aspects of thought
are represented either in speech or in spatial units that are
realized as gestures. Well-rehearsed gestures such as emblems
(e.g., salute, OK signal) are produced from a stored gestuary,
whereas novel and idiosyncratic gestures such as iconics (e.g.,
unusual shape of a particular cake being discussed) and
pantomimes (e.g., action sequence depicting skier losing
control, hitting a tree, and falling over) are produced online
without reference to stored elements. Models such as the
Figure 1. Continuum of gestures proposed by Kendon (1980) and
adapted by McNeill (1992).
 Figure 2. The sketch model of speech and gesture interaction. Reprinted from Gesture and Speech Production (Doctoral dissertation), by J. P.
De Ruiter (1998). Catholic University of Nijmegen, The Netherlands. Reprinted with permission.

sketch model highlight the interaction of gesture and verbal
elements of expression. Other models of gesture and speech
interaction have been proposed and suggest possible frank
interaction between gesture and phonological processing
(Krauss et al., 2000) and the cognitive stages of thinking for
speaking and gesturing (Kita & Ozyurek, 2003; Kita et al.,
2007).
Gesture production in aphasic discourse. Recent inves-
tigations into the gesture production of PWA focusing on
discourse tasks (rather than gesture to command/limb
apraxia tasks) have found that PWA use gesture more
frequently than healthy control speakers do (Ahlsen, 1991;
Le May, David, & Thomas, 1988; Lott, 1999; Pedelty, 1987;
Sekine & Rose, 2012), and that the type of aphasia a person
has interacts with the variety of gestures that he or she
produces. In Lott’s (1999) study of 15 PWA (5 Broca’s,
5 Wernicke’s, 5 anomic) and 15 nonaphasic controls,
individuals with Broca’s aphasia produced the most iconic
and meaning-laden gestures (e.g., iconics, emblems, panto-
mimes), and all three groups with aphasia gestured more
than the controls both in total overall numbers and in a ratio
of gestures per 100 spoken words.
More recently, Sekine and Rose (2012) examined the
gestures produced by 98 PWA and 64 nonaphasic controls
during the Cinderella story retell task (MacWhinney,
Fromm, Forbes, & Holland, 2011) and found that signifi-
cantly more PWA gestured than controls. Further, the PWA
produced four gesture types during story retell that were
never produced by the control speakers: pointing to objects
in space, pointing to self, pantomime, and letter gestures.
Although all of the PWA used emblems and pointed to
objects in space, a significantly higher proportion of
individuals with Broca’s aphasia produced iconic, panto-
mime, and number gestures as compared to individuals with
other types of aphasia. Collectively, these results suggest
strengths in spontaneous gesture production in PWA. Even
in individuals with global aphasia, gestures have been shown
to play a vital role in enhancing message transfer and
maintaining discourse in co-constructed interaction
(Goodwin, 1995). Such gestural strength may well be utilized
in aphasia therapies.
Impacts of restricting gesture or producing gesture on
word production. One important consideration in employing
constraints on nonverbal communication concerns the role

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 of gesture in word retrieval and fluency in healthy speakers.
Several sources of evidence suggest that restricting gesture
production in healthy speakers leads to an increase in
disfluency, particularly for spatial content (Morsella &
Krauss, 2004; Rauscher, Krauss, & Chen, 1996), as well as a
reduction in successful word retrieval in tip-of-the-tongue
(TOT) states (Frick & Guttentag, 1998).
More recently, Pyers et al. (2010) found that restricting
gestures in 30 healthy speakers during a picture-naming task
by wearing gloves that were velcroed to a wooden board led
to less success in resolving TOT states as compared to
unrestricted matched participants. Further, there was con-
siderable variability in relation to the degree of impact that
the restriction had on the various individuals. A second study
by Pyers et al. examined the relationship between spatial
memory span, auditory working memory, and resolution of
TOT states. In this study, Pyers et al. found that individuals
with weaker auditory working memory relied more heavily
than individuals with strong auditory working memory on
gesture to aid them in the resolution of TOTs. These findings
may have significant implications for PWA who experience
high levels of word retrieval difficulty and commonly have
impaired auditory working memory.
A pilot study by Rose and Douglas (2001) investigated
the impact of PWA producing iconic gestures, pointing
gestures, cued articulation gestures, and visual imagery while
naming pictures. We showed an advantage for producing an
iconic gesture during naming attempts for individuals with
phonological-level word retrieval impairments. Further, in
an analysis of the conversations of 18 individuals with
chronic aphasia, Lanyon and Rose (2009) showed that these
individuals produced gestures significantly more frequently
during word retrieval failures, and that five individuals in the
sample with phonological-level word retrieval impairments
produced greater amounts of gesture were produced during
their resolved word retrieval events.
Taken together, these results suggest a positive role for
gesture production in word retrieval in PWA and potential
negative impacts if gesture is restricted. Such restriction has
been a feature of the majority of previous constraint
treatment studies.
Neurological Evidence for Gesture / Speech
Interaction and Principles of Neuroplasticity in
Aphasia Treatment
For more than a decade, the classic view of language
being mediated by a strictly encapsulated, modular proces-
sing system that is specialized for various linguistic
subsystems (e.g., syntax, semantics, phonology; e.g., Fodor,
1975; Patterson & Shewell, 1987) and strictly separated from
motor and sensory processing has been challenged by the
embodied view of language processing. In the embodied view
of language processing, there is frank interaction between
perception/action and higher cognitive processes such as
language and thought (Jirak, Menz, Buccino, Borghi, &
Binkoski, 2010). The gesture/speech interaction theoretical
models similarly suggest a rich and functional interplay
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between linguistic, perceptual, and gestural systems. Such
rich motor and linguistic interaction has been supported by
recent neuroscience, which emphasizes the co-activation of
related systems during various tasks (see Pulvermüller &
Berthier, 2008, for a detailed summary). For example, when
transcranial magnetic stimulation was applied to the left arm
or leg motor cortex of right-handed participants, processing
of verbs related to those body areas (e.g., arm: fold, beat,
grasp; leg: kick, hike, step) was faster than for unrelated
words and for the right hemisphere and sham control
conditions (Pulvermüller, Hauk, Nikulin, & Ilmoniemi,
2005). In a recent meta-analysis of studies examining
embodiment theory, Jirak et al. (2010) argued that there is
good evidence to support activation of primary motor,
supplementary motor, and premotor cortices during lan-
guage processing.
Such crossmodal interaction is interesting in the
context of aphasia and impaired linguistic systems, as we
might infer that a processing advantage could be afforded the
damaged linguistic system through motor activity. This is
certainly not a novel concept. Luria (1972) discussed
intersystemic facilitation and reorganization in the 1940s
following his detailed observational and behavioral work of
injured soldiers undergoing brain injury rehabilitation
following World War II. The strategy of restoring or
improving a damaged system by pairing it with an intact
system is well used in aphasia clinics throughout the world.
Interestingly, in their more recent constraint therapy
publications, Pulvermüller and Berthier (2008) advocated for
this language/action interaction and discussed its potential to
be harnessed positively in aphasia therapies. Where their
argument differs from mine is in the interpretation of the
concept of action and how action can be usefully employed in
aphasia treatments. In Pulvermüller and Berthier’s thorough
discussion of the neuroscience-based principles of aphasia
therapy, they take the evidence concerning language and
action cortical interaction and derive a principle of therapy
they term the behavioral relevance principle, stating that ‘‘it is
advantageous to practice language in relevant action
context’’ (p. 569). By this, they mean practicing speaking in a
social situation where there is an obvious and compelling
reason to speak (e.g., in a card-requesting game played
behind visual barriers). There seems little argument against
such a common-sense principle, but the neuroscience
evidence underpinning it can just as easily be interpreted in
an alternative principle that I term the multimodality
principle, stating that it is advantageous to practice language
in a rich multimodal context. Such practice is highly relevant
as it mimics real-life communication, which is multimodal.
Pulvermüller and Berthier (2008) go on to discuss the
negative role of learned nonuse in preventing positive
rehabilitation outcomes that have been well documented in
monkey and human studies of sensory-motor and limb
impairments and subsequent retraining (Taub et al., 2006).
They derive a further principle of aphasia therapy concerning
learned nonuse called the focusing principle. According to
Pulvermüller and Berthier, ‘‘it is advantageous to focus
patients on their remaining language abilities especially on
 those they avoid using’’ (p. 571). Unfortunately, as there are
no animal models that parallel the elaborate nature of
human language, there has not been direct neuroanatomical
or neurophysiologic investigations of learned nonuse in
language systems; rather, authors take what is known from
motor and sensory system research and infer from this to
human language and communication. Such inference is
probably imperfect given the simpler nature of the motor/
sensory neural systems as compared to the more elaborate
cognition/language neural systems.
However, even if there was a complete correspondence
between the animal and human models of the effects of
learned nonuse in motor/sensory systems and human
language systems, the argument put forward in constraint
therapies to constrain (focus) responses to verbal commu-
nication only fails to take into consideration cuing systems,
which aim to help reconstitute verbal communication and are
usually employed in nonconstrained aphasia treatments. The
early writings on constraint therapy, or communication
therapy as it was termed then (Pulvermüller & Roth, 1991),
compared it to PACE (Davis & Wilcox, 1985). Pulvermüller
and Roth (1991) rightly pointed out that although PACE
included therapeutic games/natural speech acts/communica-
tive interaction (e.g., clinician and client participate equally
as sender and receiver; exchange of new information between
clinician and client), PACE allows clients free choice of the
communication channel to convey messages (Davis, 2005),
whereas constraint therapy focuses on the verbal channel
exclusively. Further, the clinician feedback focuses on
message transfer success in PACE rather than on more direct
instruction, or direct reinforcement, for speech production.
By contrast, in many of the previously employed
nonverbal and multimodality treatments, and contrary to the
central tenet of PACE treatment, that aims at communica-
tion rather than speech, the aim of the activity/goal of these
multimodal therapies is in fact verbal communication, but
the client achieves the verbal response through multimodality
(or nonverbal) cuing support. Table 1 provides an overview
of the major features of various constraint and multi-
modality aphasia treatments. For example, in M-MAT
(Attard, Rose, & Lanyon, 2013; Rose & Attard, 2011), the
goal is verbal communication, not compensatory nonverbal
communication. Clients undertake intensive word produc-
tion practice with object and action picture card stimuli in a
group, social game activity (such as Bingo/Go Fish), with the
goal being spoken production of the target noun/verb/
phrase. Critically, the way in which that production is
facilitated is through a structured combination of

Table 1. Comparison of the basic features of constraint and multimodality aphasia therapies.

Name Goal Amount Intensity Responses allowed Cues provided

CILT/CIAT Verbal communication 30 hr 3 hr per day, Spoken only Picture to request/name

5 days
per week
CIAT Plus/ Verbal communication 30 hr 3 hr per day, Spoken only Pictures to request/name Written word
ILAT 5 days to read aloud
per week
M-MAT Verbal communication 30 hr 3.75 hr per Spoken primary; Pictures to request/name
day, 4 gesture, drawing, Written word to read aloud Spoken
days per and writing, word to copy
week secondary Gesture
Drawing
Writing
MOAT Verbal communication 30 hr 3 hr per day, Spoken, written Pictures to name Written word to read
5 days aloud Spoken word to copy
per week Semantic
Phonologic
Combined Verbal communication 20 hr 1 hr per day, Spoken and gestures Pictures to name
Verb + and gesture 2–3 days Written word to read aloud Spoken
Gesture communication per week word to copy
Gesture
PACE Communication: spoken Unspecified Variable Any communication Pictures to request/name
or nonverbal that is successful
CART Communication: written or Unspecified Variable Written and spoken Pictures to name
spoken Written words to copy and read
Instructions for correction
Drawing Communication: drawing Unspecified Variable Drawings and Pictures to name
or spoken spoken Drawings to copy Instructions for
drawing refinement

Note. CIAT = constraint-induced aphasia therapy (Pulvermüller et al., 2001), CILT = constraint-induced language therapy (Maher et al., 2006),
CIATPlus = constraint-induced aphasia therapy plus (Meinzer, Djundja, Barthel, Elbert, & Rockstroh, 2005), ILAT = intensive language action
therapy (Pulvermüller & Berthier, 2008), M-MAT = multi-modality aphasia treatment (Rose & Attard, 2011), MOAT = model oriented aphasia
therapy (Barthel, Meinzer, Djundja, & Rockstroh, 2008), PACE = promoting aphasics communicative effectiveness (Davis & Wilcox, 1985), CART
= copy and recall treatment (Beeson, Rising, & Volk, 2003).

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 multimodality cues: a related gesture, a drawing, a written
word, a word to be read aloud, and/or a spoken model to
copy. Such rich multimodality, intra- and intersystemic cuing
aims to recruit all available neural networks that were
previously involved in linguistic processing, thereby creating
a potent experience to assist language relearning/re-access. In
constraint therapies, the system of cues and assistance is
restricted to verbal repetition and to lowering the difficulty of
the naming task to high-frequency, easily accessible items
rather than exploiting the remaining language abilities
through phonologic, semantic, and orthographic cues.
So although it seems that there can be little argument
against a focusing principle (emphasizing language abilities/
production) in aphasia treatment, there appears scarce
evidence to support restricting cues that have previously been
demonstrated to assist verbal learning (Best, Herbert, Hickin,
Osborne, & Howard, 2002; Howard & Harding, 1998;
Howard, Patterson, Franklin, Orchard-Lisle, & Morton,
1985). Further, this argument against restriction/constraint
may be particularly pertinent for those individuals with
severe aphasia who have large areas of destruction in the
neural circuits that underpin language. As Luria (1972)
suggested so long ago, restitution of extensively damaged
systems is unlikely, and therapies aimed at compensatory
strategies are probably more practical. In the case where oral
language is not reinstated after treatment, at least in the
multimodality/nonverbal therapies, word retrieval practice
has occurred with alternative mechanisms (gesture, drawing,
writing), and these mechanisms could then be harnessed as
compensatory communication devices. If failure to re-
establish verbal communication occurs after constraint
therapies (e.g., Pulvermüller & Berthier [2008] wrote: ‘‘If … a
ceiling has been reached for certain patients, it may also be
fruitful to introduce alternative and augmentative commu-
nication strategies’’ p. 583), inefficient retraining of non-
verbal communication strategies will then need to be
initiated.
Comparative Evidence From CIAT, Gesture, and
Multimodality Aphasia Treatments
Table 2 provides a summary of the major aspects and
findings from studies published to date investigating the
impacts of CIAT on individuals with chronic aphasia.
Overall, the evidence suggests positive results from constraint
therapies, with statistically significant results obtained on
standardized measures of linguistic skills (e.g., Aachen
Aphasia Test [AAT; Huber, Poeck, Weniger, & Willmes,
1983]), particularly in the subskills of auditory comprehen-
sion and repetition. Obviously, in determining the efficacy of
a treatment, more is required than a statistically significant
change on an omnibus aphasia battery, and in questions of
comparative efficacy, effect sizes are required. Reports of
effect sizes from constraint studies using group statistics and
obtained from the AAT have been small to medium, apart
from Pulvermüller et al.’s (2001) initial report, which showed
a large effect size on the AAT composite score. Cherney and
colleagues (Cherney, Patterson, & Raymer, 2011; Cherney,
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Patterson, Raymer, Frymark, & Schooling, 2008) provided
further effect sizes in their systematic reviews of constraint
and intensive aphasia treatments. These are listed in Table 2.
Effect sizes for comprehension are generally higher than for
production.
However, effect sizes are only meaningful when the
measures they are calculated on are valid and reliable. In
order to better determine treatment efficacy, measures of the
clinical effectiveness of statistically significant changes,
ratings of discourse-level change, and client satisfaction seem
important. The large-N constraint studies reporting statisti-
cally significant changes in aphasia battery scores do not
include objective measures of discourse beyond client self-
perception of functional communication, and this is a
notable limitation. The few studies directly examining
discourse (Attard et al., 2013; Faroqi-Shah & Virion, 2009;
Goral & Kempler, 2009; Maher et al., 2006; Szaflarski et al.,
2008) have shown equivocal results. Further, several studies
have attempted to replicate the original findings from the
Pulvermüller et al. (2001) and Meinzer et al. (2005) studies in
a series of detailed single-subject designs but have not
obtained the same overall positive results of the earlier group
studies, with distinct individual variation in response to
treatment (Attard et al., 2013; Breier, Maher, Novak, &
Papanicolaou, 2006; Faroqi-Shah & Virion, 2009; Szaflarski
et al., 2008). Reports of negative responses to treatments are
important in terms of determining the participant charac-
teristics associated with good response. Meinzer et al.
reported that 15% (four) of their 27 participants did not
respond to CIAT. Unfortunately, Meinzer et al. did not
indicate which participants were the nonresponders, nor did
they indicate their characteristics. This latter point needs far
more attention in the research literature than is currently
provided by the constraint studies.
Table 3 summarizes findings from several gesture-
based therapy studies that have been published since a
comprehensive review (Rose, 2006). Overall, the evidence
suggests positive results from these multimodality therapies,
including some reference to generalization to untrained
stimuli and discourse, as well as long-term retention of
language gains. There are, however, individuals who do not
respond to the treatments, and these are listed. Effect sizes
are frequently in the medium to large range, and there
appears to be no negative impact of practicing gestures on
the acquisition of spoken nouns and verbs in the within-
subject comparison designs. Further, some studies have
demonstrated that training gesture actually provides a means
for communicating a word when spoken word production
continues to fail (Caute et al., 2013; Maher et al., 2006;
Marshall et al., 2012; Raymer et al., 2012).
Thus, a comparison of available outcomes from the
constraint and multimodality studies suggests no clear
advantage of constraint. This is particularly exemplified by
the Barthel, Meinzer, Djundja, and Rockstroh (2008) study
that directly compared outcomes from 27 individuals
receiving CIAT and CIAT PLus and 12 individuals
receiving a nonconstrained linguistically motivated
individual intervention (i.e., model-oriented aphasia
 Table 2 (p. 1 of 3). Summary of constraint therapy outcomes for individuals with chronic aphasia.

Aphasia
Author(s)/Date N severity Aphasia type Treatment type Outcome measures Results

Pulvermüller et al. (2001) 10 2 mild 6 Broca’s CIAT: 30 hr over 10 days AAT: Both groups improved; greater improvement
7 5 moderate 2 Wernicke’s Conventional therapy: 30 hr Token Test (1 t score) in CIAT group (17% vs. 2%).
3 severe 1 amnesic over 3–5 weeks Comprehension CIAT led to significant improvement in the
2 mild 1 transcortical Naming AAT Token Test (ES 2.18),a
4 moderate 1 4 Broca’s Repetition Comprehension and Naming but not
severe 2 Wernicke’s CAL repetition. Conventional therapy led to
1 conduction improvement on 1 test only. 30% increase
on CAL for the CIAT group, none for the
conventional therapy group.
Meinzer et al. (2004, 12 6 mild 4 Broca’s CIAT: 30 hr over 10 days, 3 hr AAT Significant difference on all subtests for both
2005) 15 5 moderate 2 amnesic per day CETI groups; stable at follow-up; no difference
1 severe 4 Wernicke’s CIAT Plus: 30 hr over 10 days, CAL between groups immediately post
4 mild 2 unclassified 3 hr per day, written 6 month follow-up treatment; no effect of TPO/severity; 17/27
10 moderate 6 Broca’s materials; action of individual participants significantly
1 severe 1 amnesic photographs; home improved on at least one AAT subtest;

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Pulvermüller Hauk,
Zohsel, Neininger, &
4 Wernicke’s practice with relative improvement in communicative
1 global effectiveness in CIAT Plus group at
3 unclassified 6 month follow-up.
ES: AAT – 0.34; Token Test – 0.8.a
9 2 mild 5 Broca’s CIAT: 30 hr over 10 days, 3 hr AAT: Statistically significant improvement in AAT
5 moderate 2 Wernicke’s per day Token Test Comprehension, Naming, and Token Test;

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Mohr (2005) 2 severe 1 amnesic Comprehension no signification change in Repetition
1 transcortical Naming ES: 0.25 Token Test, 0.46 AAT
Repetition Comprehension.a
Maher et al. (2006) 4 3 moderate PACE: 24 hr 4 days per week, WAB AQ Both groups significant improvement on WAB
5 1 severe 3 hr per day BNT AQ (ES CILT – 1.01),a BNT, Action Naming,
3 moderate CILT: 24 hr 4 days per week, Action Naming no difference between groups. Stable at
2 severe 3 hr per day ABA follow-up; Report of better discourse in
Story Retell CIAT group.
1 month follow-up 2 participants in CILT group frustrated at not
being allowed to write responses; 1 in
PACE group only talked.
Breier et al. (2006) 6 3 moderate 5 Broca’s CILT: 36 hr, 4 days per week, WAB AQ 2 individuals improved >5 points on WAB AQ,
3 severe 1 conduction 3 hr per day for 3 weeks; BNT 4 did not.
additions of phonemic, CIUs in treatment 1 participant made 9-point gain on BNT, 6
semantic, or repetition probes deteriorated.
cuing
Meinzer, Streiftau, & 10 CIAT Plus: 30 hr over 10 days, AAT: Both groups significantly improved. No
Rockstroh (2007) 10 3 hr per day, written Token Test difference between groups.
materials; action Comprehension
photographs; home Writing
practice with relative Naming
CIAT Plus delivered by trained Repetition
layperson: 30 hr over 10 CAL
days, 3 hr per day, written
materials; action

Rose: Multimodality and Constraint Treatments for Aphasia

photographs; home
practice with relative

S233
 S234
Table 2 (p. 2 of 3). Summary of constraint therapy outcomes for individuals with chronic aphasia.

Aphasia
Author(s)/Date N severity Aphasia type Treatment type Outcome measures Results

Barthel et al. (2008) 12 5 mild 8 Broca’s MOAT: 30 hr over 10 days, AAT: ES:
27 7 moderate 1 anomic 3 hr per day; individual Token Test Medium
Meinzer et al.’s 1 global linguistic, model-oriented Comprehension Large
(2005) 2 unclassified treatment based on Writing Medium
participants underlying linguistic Naming Small
strengths and weaknesses; Repetition Medium
ncludes functional role CETI Medium
playing and home practice CAL Medium
with relative 6 month follow-up Both groups significantly improved after
CIAT Plus: 30 hr over 10 days, treatment; stable at follow-up. Comparable
3 hr per day, written results for both groups except better
materials; action written language and perception of

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photographs; home everyday communication following MOAT.
practice with relative
Richter, Miltner, & 16 7 Broca’s CIAT: 30 hr over 10 days, 3 hr AAT: ES:
Straube (2008) 7 anomic per day Token Test not available
2 global Comprehension Medium
Spontaneous Medium

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speech Small
Semantics
Szaflarski et al. (2008) 3 1 moderate 2 nonfluent CIAT: 3 hr per day, 5 days for 1 BDAE 2 participants showed improved auditory
2 severe 1 fluent jargon week plus addition of BNT comprehension on BDAE; none showed
person-derived cues found Story retell improvement on expressive measures
to enhance word retrieval in Mini-CAL
testing
Berthier et al. (2009) 14 WAB AQ 23.2– 4 Broca’s CIAT with memantine WAB CIAT led to significant improvement in both
14 91.0 9 anomic CIAT only CAL groups, greater improvement with

American Journal of Speech-Language Pathology N Vol. 22 N S227–S239 N May 2013

WAB AQ 41.8– 1 conduction memantine.
84.4 5 Broca’s
4 anomic
2 conduction
2 transcortical
motor
Faroqi-Shah & Virion 4 2 mild 3 Broca’s CIAT: 24 hr over 10 days WAB AQ Improved WAB AQs but minimal changes
(2009) 2 moderate 1 agrammatic BNT computed over multiple tests; not
OANB Verbs maintained at follow-up; little change in
Story retell discourse measures.
Conversation
3 month follow-up
Kurland, Baldwin, & 1 Moderate- Wernicke’s PACE: 5 × 3 hr sessions per % correct on trained Significant improvement on naming trained
Tauer (2010) severe week for 2 weeks CILT: and untrained items in both conditions.
5×3 hr sessions per week items
for 2 weeks
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Table 2 (p. 3 of 3). Summary of constraint therapy outcomes for individuals with chronic aphasia.

Aphasia
Author(s)/Date N severity Aphasia type Treatment type Outcome measures Results

Goral & Kempler (2009) 1 CIAT: 20 hr over 4 × 75 minute BDAE No significant change on BDAE, CLQT.
sessions per week + salient CLQT Significant increase in verbs.
stimuli + focus on verbs Narratives Significant increase in social-communicative
Social- rating.
communicative
rating
Kurland, Pulvermüller, 2 Moderate- Transcortical motor PACE: 30 hr over 10 days, 3 hr Naming probes ES: Large in both PACE and CIAT; better from
Silva, Burke, & severe +AOS per day CIAT.
Andrianopoulos Broca’s +AOS CIAT: 30 hr over 10 days, 3 hr
(2012) per day
Attard, Rose, & Lanyon 2 Severe Broca’s CIAT Plus: 30 hr over 10 days, Naming probes ES: CH-large (CIAT), medium (M-MAT); MT:
(2013) CH 3 hr per day, written WAB AQ nil (CIAT), medium (M-MAT).
and materials; action BNT No significant differences between
MT photographs; home Scenario Test treatments. One participant strongly
practice with relative Story retell preferred M-MAT.
Rose: Multimodality and Constraint Treatments for Aphasia

M-MAT: 30 hr over 2 weeks, Conversation

3.75 hr per day, written CETI
materials; action 1 & 3 month follow-
photographs; home up
practice with relative;
gesture, drawing, writing
cues

Note. AAT = Aachen Aphasia Test (Huber, Poeck, Weniger, & Willmes, 1983); CAL = Communicative Activity Log (Pulvermüller et al., 2001); CETI = Communicative Effectiveness
Index (Lomas, Prickard, Bester, Elbard, Finlayson, & Zoghaib, 1989); TPO = time post onset; WAB AQ = Western Aphasia Battery—Revised (Kertesz, 2007) aphasia quotient; BNT =
Boston Naming Test (Kaplan, Goodglass, & Weintraub, 2000); ABA = Apraxia Battery for Adults (Dabul, 1999); BDAE = Boston Diagnostic Aphasia Examination (Goodglass, Kaplan, &
Baressi, 2000); OANB = Object and Action Naming Battery (Druks & Masterson, 2000); Mini-CAL = Reduced length communicative activity log (Szaflarski et al., 2008); CLQT =
Cognitive Linguistic Quick Test (Helm-Estabrooks, 2001); AOS = apraxia of speech. See text for further descriptions of CILT, CIAT, CIAT Plus, MOAT, M-MAT, PACE.
a
Effect sizes were derived from the Cherney et al. (2008) systematic review; Effect sizes provided by study report.
S235
 S236
Table 3. Summary of selected recent gesture therapy outcomes in individuals with chronic aphasia.

Aphasia
Author(s)/Date N severity Aphasia type Treatment type Outcome measures Results

Marshall et al. 14 Severe (<20% 15 × 1 hr sessions per week; Gesture treatment: Gesture and naming Nouns and gestures significantly
(2012) on CAT) 20 gestures, copy, hand shape assistance probes improved post treatments
Naming treatment: 20 nouns, repetition, 6 week follow up and maintained at 6-week
phonological cures follow-up; 11 better change in
naming; 3 better in gestures;
item specific changes.
Raymer et al. 8 Moderate- 4 Broca’s Errorless naming treatment (ENT): 20 × 1-hr Naming probe ES: Large on naming for ENT
(2012) severe 2TMA sessions, 2–3 times per week Gesture probe and GET treatments—no
1TSA Errorless gestural naming treatment (GET): 20 × 1- WAB–R difference.

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1 Wernicke hr sessions, 2–3 times per week BNT ES: Large for trained gestures.
CETI Maintained at 1 month.
FOQ–A
Boo & Rose 2 1 severe (GF) 2 Broca’s 10 × 1.5-hr sessions, 3 sessions per week for each Verb probes ES: Small to medium; GF: best
(2011) 1 moderate treatment WAB–R response to gesture + verbal;
(PF) Gesture + verbal: verb production with repetition, VAST PF best response for

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phonologic, semantic, and gesture cues Picture description repetition only. Maintained at
Semantic only: verb production with repetition, Conversation 1 month.
phonologic, semantic cues Increased verb production in
Gesture only: repetition and gesture cues conversation and narrative.
Repetition only: verb repetition with picture
Rose & Sussmilch 3 3 moderate 3 Broca’s 20 × 1.5-hr sessions, 3 sessions per week Verb probes MT- no response.
(2008) 1 semantic (MT) Gesture + verbal: verb production with repetition, WAB–R ES: Large on verb probes for KC
2 phonologic phonologic, semantic, and gesture cues VAST & MW; Gesture+Verbal better
(KC & MW) Verbal only: verb production with repetition, Picture description for MW; no difference for KC.

American Journal of Speech-Language Pathology N Vol. 22 N S227–S239 N May 2013

phonologic, semantic cues Conversation Generalization to verbs in
Gesture only: repetition and gesture cues conversation.
Raymer et al. 9 4 severe 6 Broca’s Gesture + verbal: repeat word and copy gesture, Noun and verb probes ES: Large for nouns (5/9), verbs
(2006) 5 moderate 2 Wenicke’s copy gesture alone, repeat word alone, name WAB–AQ (5/9).
1 conduction item BNT Gesture production improved for
10 sessions for nouns; 10 sessions for verbs nouns (8/9) and verbs (6/9).

Note. CAT = Comprehensive Aphasia Test (Swinburn, Porter, & Howard, 2004); TSA = transcortical sensory aphasia; TMA = transcortical motor aphasia; CETI = Communicative
Effectiveness Index (Lomas et al., 1989); FOQ–A = Functional Outcomes Questionnaire for Aphasia (Glueckauf, Blonder, Maher, Crosson, & Gonzalez-Rothi, 2003); VAST = Verb and
Sentence Test (Baastianse, Edwards, & Rispens, 2002).
 therapy; Barthel et al., 2008). Study results showed little
difference. Further, our head-to-head pilot comparison of
CIAT Plus and M-MAT, both treatments using group
format and socially motivated communication games/
activities, intensively provided (30 hr over 2 weeks), and
aiming at spoken targets but differing in the lack of verbal
constraint through the richness of multimodal cue provision,
showed an advantage for M-MAT in terms of client
preference (Attard et al., 2013): Participant CH expressed
strong preference for M-MAT, which allowed her
multiple modes for communication and produced less
frustration. Both participants disliked being behind the
visual barriers.
Conclusion
In this paper, I have argued that there is emerging
evidence supporting rich crossmodal neuronal interaction
between language and sensory/motor systems. Such interac-
tion supports rehabilitation strategies that harness these
distributed neural networks. Cuing strategies that employ
multimodal responses and inputs might harness such net-
works; a concept similar to Luria’s (1972) inter- and
intrasystemic reorganization. Evidence suggests that PWA
have considerable gesture production abilities and that these
have been effectively harnessed in treatments to promote
language recovery and communication, and that restricting
gesture production in PWA is likely to increase word
retrieval difficulty. Comparative evidence in constraint and
nonconstraint therapies for individuals with chronic aphasia
suggests no particular advantage for either type of therapy at
this time.
Multimodality therapies take advantage of other
mechanisms to support verbal production and provide
multimodality communication skills for social interaction
when word production fails. Taken together, it seems
that multimodality treatments are a valid option for
rehabilitation of individuals with chronic aphasia, and that
constraining participant responses to the verbal modality is
not strongly supported by current evidence. Clearly, there is
a compelling argument for further investigation into the
therapeutic power of treatment components such as inten-
sity, modality, and task specificity, along with the client
characteristics that interact with these variables.
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