Mind-body and creative arts therapies for people with aphasia: a mixed-method systematic review

Figures & data

Table 1. SPIO inclusion/exclusion criteria

	Inclusion criteria	Exclusion criteria
Study design	Any, except those in exclusion criteria.	Systematic review, literature review, and case report.
Population	Adults (18^+) with a diagnosis of aphasia following stroke, traumatic brain injury, and Primary Progressive Aphasia.	Presence of neurological diseases (e.g., Parkinson’s Disease and Motor Neurone Disease). Presence of significant neurological co-morbidities
Intervention	Mind-body therapies: approaches implementing different types of behavioural exercises to promote the connection between mind and body. Any mind-body intervention intended as approach except those in exclusion criteria Creative arts intervention; therapeutic approaches using art-based activities to facilitate self-expression through the creative arts intervention – except those in exclusion criteria	Mind-body intervention involving manipulation, mobilisation, body sensors, movement, and posture re-education (e.g., acupuncture,chiropractic, and osteopathic manipulation, biofeedback, etc.) Hypnotherapy Melodic-Intonation Therapy or SLT-based interventions Movement therapy other than a form of dance therapy
Outcomes	Any outcome related to global well-being and/or aspects of well-being (e.g., mood disorders, confidence, social participation, quality of the life, cognition,communication, fatigue,etc.)

Figure 1. Flowchart showing the review data selection process adapted from the PRISMA 2020 flow diagram template for systematic reviews (adapted from Page et al., 2021a).

Table 2. Characteristics of included interventions.

Author/s (year)	Intervention type	Dosage and intensity	Setting	Communication support	Comparative intervention	Follow-up
*Biedermann et al. (2019)	Meditation	1-hour sessions twice weekly for over 9 weeks	Group Face-to-face	Some visually guided practices	No	Weeks 1–2-3 post-intervention
*Crielesi et al. (2019-Study 2)	Adapted Mindfulness-based Cognitive Therapy	2-hour sessions once weekly for over 8 weeks	Group Face-to-face	Some variations to MBCT protocol; use of supported conversation strategies; materials with simplified language and font size adjustments. Changes made by the practitioner	No	No
*Dickinson et al. (2017)	Mindfulness-Based Stress Reduction	1.5-/2-hour sessions, once weekly for over 4 weeks	1:1 Face-to-face	Reduced length of the course (from 8 to 4 weeks), changes from group to 1:1 setting, individualised programme, supported conversation strategies (adaptations made by the clinical psychologist trained by an SLT)	No	3-week follow-up
*Laures-Gore and Marshall (2016)	Mindfulness meditation (modelled after Kabat-Zinn, 1982, Zeidan et al., 2010, and Wenk-Sormaz, 2005)	Up to 30 min once daily over 4 consecutive days + independent 30-min practice on the 5^th day	1:1 Face-to-face	Reduced course length and speech rate; questions to verify participants’ instruction comprehension	No	1-week follow-up
*Marshall et al. (2018)	Aphasia Mindfulness Meditation (MM)	Up to 30 min once daily over 4 consecutive days + independent 30-min practice on the 5^th day	Group Face-to-face	Aphasia-specific programme developed by an SLT; reduced session duration (30 min), reduced programme content (breath and present moment awareness), language simplifications, pictorial instruction sheet, and nonverbal strategies to support communication (gestures and visual cues)	Yes	1-week follow-up
*Marshall et al. (2014)	Unilateral Nostril Breathing (UNB)	10-week program 1 h of guided instruction once weekly + up to 40 min of daily practice + 6 weeks of individual UNB	Group Face-to-face	Not reported	Yes	No Measures repeated at week-4 (end of first intervention period) and week 10 (end of second intervention period)
*Merriman et al. (2015)	Mindfulness-based Cognitive Therapy	Not specified	Group Face-to-face	Hand-outs with audio version; stickers for object as reminder of mindful activity; modified movement exercises to allow participants to remain seated and focus on the upper body; reduced exercise duration	No	No
*Orenstein et al. (2012)	Mindfulness Meditation	Phase B: The session duration gradually increased from 5 up to 30 min over a minimum of four sessions Phase A2: 5 sessions, 30 min each, no guided practice	1:1 Face-to-face	Not reported	No	No
*Panda et al. (2020)	Informal lunch meditation	2-hour sessions once weekly for over 6 weeks	Group Face-to-face	Reduced course duration; structured sessions; Trainer = expert aphasiologist; some aphasia-friendly documentation (aphasia-friendly consent form and info sheet)	No	No
*Wantsala et al. (2010)	Mindfulness-based Stress Reduction	1-hour sessions once weekly for over 8 weeks	1:1 Face-to-face	Not reported	No	No
*Yeates (2019)	Taiji	Not specified Over 6 months	Group Face-to-face	Visual and kinaesthetic teaching; Tactile feedback, short instruction, and use of keywords	No	No Measures repeated every 4 weeks over 6 months during intervention delivery
*Andrew, 2015	Observational drawing	2-hour sessions once weekly over 8 consecutive weeks	Group Face-to-face	Information was delivered in an aphasia-friendly format with illustrated handouts	No	No
*Castka et al. (2009)	Musical production/performance	2-hour sessions once weekly for 12 weeks + final performance	Group Face-to-face	Aphasia-friendly scripts, adapted musical score, and choreography created by SLTs	No	No
*Cherney et al. (2011)	Drama class	90 minutes once weekly for over 18 weeks + 3 rehearsals + 1 dress rehearsal	Group Face-to-face	Supported conversation strategies to facilitate communication among the participants	No	No
*Croteau et al. (2008)	Theatre workshop	Duration not specified once weekly over a year	Group Face-to-face	SLT-led workshops together with a theatre professional	No	No
*Duarte et al. (2020)	Clowning	3-hour sessions once weekly over 6 months	Group Face-to-face	Facilitator provided instruction according to participants’ needs and initiatives	No	No
*Gadberry and Ramachandra (2015)	Music Therapy (based on Tomaino’s protocol)	45 min each 17 sessions	1:1 Face-to-face	Not reported	No	No
Kim et al. (2008)	Art therapy	40 min twice weekly over 75 days	1:1 Face-to-face	Not reported	No	No
*Mantie-Kozlowski et al. (2020)	Therapeutic songwriting	13 sessions of 55 min each twice weekly for over 8 weeks	1:1 Face-to-face	Therapy delivered by a language pathology graduate student. One of the songwriting techniques was modified (pt to select phrases for lyrics from materials) Conversational repair strategies used during the sessions	No	No
*Mantie-Kozlowski et al. (2018)	Sing-along group	10 sessions of 90-min sessions each twice monthly	Group Face-to-face	Large font size, song text contained to one page (whenever possible), attempts made to include participants’ preferences and musical needs	No	No
*Tamplin et al. (2013)	Community choir singing	2-hour sessions once weekly for over 20 weeks	Group Face-to-face	Vocal warm-ups, song lyrics, and musical arrangements adapted by a music therapist	No	No
*Zumbansen et al. (2017)	Choir sessions	2-hour sessions once weekly for over 6 months	Group Face-to-face		Yes	No

Table 3. Summary of measures used for each well-being-related outcome identified.

Outcome	Measurement tool	n = studies that have used this tool (study reference/s)
Attention	Connor’s Continuous Performance Task-II (CPT-II), Conners, 2004)	2 (Marshall, 2018; *Laures-Gore & Marshall, 2016)
	Centre for Research on Safe Driving-Attention Network Test (CRSD-ANT, Weaver et al., 2013)	2 (Marshall, 2018; *Laures-Gore & Marshall, 2016)
	Subtests of Test of Everyday Attention (Robertson et al., 1994)	2 (*Biedermann et al., 2019; *Andrew, 2015)
	Psycholinguistic Assessments of Language Processing in Aphasia (PALPA, Kay et al., 1996) 8 and 13 subtests	1
	Rating Scale for Attentional Problems (RSAP; Ponsford & Kinsella, 1991)	1 (*Merriman et al., 2015)
	Test of Attention Matrices (TAM; Spinnler & Tognoni, 1987)	1 (*Crielesi et al., 2019)
Language	Revised Token Test (RTT, McNeil & Prescott, 1978)	3 (*Marshall et al., 2018; *Laures-Gore & Marshall, 2016; Marshall et al.,2014)
	Comprehensive Aphasia Test (CAT, Swinburn et al., 2004) subtests	3 (*Dickinson et al., 2017; Andrew, [2015])
	Western Aphasia Battery-R (WAB-R, Kertesz, 2006)	2 (*Marshall et al., 2018; *Laures-Gore & Marshall, 2016)
	Narrative Story Cards (Helm-Estabrooks, 2001, 2003)	2 (*Marshall et al., 2018; Laures-Gore& Marshall, 2016)
Language	Boston Naming Test (BNT, Kaplan et al., 2001)	2 (Manti-Kozolowski et al. 2020; Wantasala et al., 2010)
	1–3 Syll. Test (as cited in *Biedermann et al., 2019);	1 (*Biedermann et al., 2019)
	Battery for Assessment of Plural Processing in Aphasia (BAPPA), for frequency (Biedermann et al., 2014a) and regularity (Biedermann et al., 2014b)	1 (*Biedermann et al., 2019)
	Object and Action Naming Battery (OANB, Druks & Masterson, 2000)-selected verb and noun picture naming subtest	1 (*Dickinson et al., 2017)
	Aphasia Diagnostic Profiles (ADP, Helm-Estabrooks, 1992) subtests	1 (*Marshall et al., 2018; *Laures-Gore & Marshall, 2016)
	Non-linguistic dual-task modelled after Erickson et al. (1996)	1 (Ornestein et al., 2012)
	Cognitive Linguistic Quick Test (CLQT, Helm-Estabrooks, 2001)-word Generation subtest	1 (Wantasala et al., 2010)
Mood	Benton Controlled Oral Word Association Test (COWAT, Benton; 1967)	1 (*Marshall et al., 2014)
	Korean-Western Aphasia Battery (K-WAB, *Kim et al., 2004)	1 (*Kim et al., 2008)
	Adjective Check List (ACL, Gough & Heilbrun, 1983)	1 (*Croteau et al., 2008)
	Montréal-Toulouse Aphasia Battery (MT86, Nespoulous et al., 1992)-automatised series, auditory comprehension, repetition, and naming subtests	1 (*Zumbansen et al., 2017)
	Boston Diagnostic Aphasia Examination (BDAE , Goodglass et al., 2001) subtests	1 (Ornesein et al., 2012)
	Informal language measures: description task, connected speech, and correct information units-CIU analysis	1 (Ornestein et al., 2012)
	Visual Analog Mood Scale (VAMS, Stern, 1997)	3 (*Crielesi et al., 2019: Study 2; *Zumbansen et al., 2017; *Tamplin et al., 2013)
Mood	Hospital Anxiety and Depression Scale (HADS, Zigmond & Snaith, 1983)	2 (*Yeates, 2019; *Merriman et al., 2015)
	Beck Depression Inventory Revised (BDI-II, Beck et al., 1996)	2 (*Crielesi et al., 2019; Marhsall et al., 2014)
	Stroke Aphasia Depression Questionnaire-10 items (SADQ-10; Sutcliffe & Lincoln, 1998)	1 (*Crielesi et al., 2019)
	State-Trait Anxiety Inventory (STAIX, Spielberger, 1983)	1 (*Crielesi et al., 2019)
	Mood state (Stern, 1999)	1 (Wantasala e t al., 2010)
	Profile of Mood States (POMS, McNair et al., 1971)	1 (*Gadberry & Ramachandra, 2015)
	Beck’s Anxiety Measure (Beck et al., 1988)	1 (*Dickinson et al., 2017)
	Beck Anxiety Inventory (BAI, Beck & Steer, 1993)	1 (*Marshall et al., 2018)
Communication	Communication Confidence Rating Scale for Aphasia (CCRSA; Babbitt & Cherney, 2010)-subtests	1 (*Cherney et al., 2011)
	Communicative Effectiveness Index (CETI, Lomas et al., 1989)	1 (*Croteau et al., 2008)
	Stroke Impact Scale-3 (SIS-3, Duncan et al., 1999)—communication subscale	1 (*Tamplin et al., 2013)
	Test Lillois de Communication (Rousseaux et al., 2001)	1 (*Zumbansen et al., 2017)
	Assessment of Life Habits (LIFE-H, Fougeyrollas & Noreau, 1998)	1 (*Croteau et al., 2008)
Cognition	Cognitive Linguistic Quick Test-Plus (CLQT+, Helm-Estabrooks, 2001)	2 (Manti-Kozwoloski et al., 2020)
	Korean-Mini Mental Status Examination (K-MMSE, as cited in *Kim et al., 2008)	1 (*Kim et al., 2008)
	Korean-Wechsler Adult Intelligence Scale (K-WAIS, as cited in *Kim et al., 2008)	1 (*Kim et al., 2008)
	Stroke Impact Scale-3 (SIS-3, Duncan et al., 1999)—cognition subscales	1 (*Tamplin et al., 2013)
Other well-being aspects	Global well-being
	Subjective Well-being Scale (SWBS, Albuquerque & Tróccoli, 2004)	1 (*Duarte et al., 2020)
	Burden of Stroke Scale (BOSS, Doyle et al., 2003) subtests	1 (*Cherney et al., 2011)
	QoL
	Stroke and Aphasia Quality of Life Measure-39 (SAQOL-39; Hilari et al., 2003)	2 (*Duarte et al., 2020; Wantasala et al., 2010)
	WHO Quality of Life – Bref (WHO QoL-Bref, The Whoqol Group, 1998)	1 (*Merriman et al., 2015)
	Quality of Life after Brain Injury (QOLiBRI, Von Steinbüchel et al., 2010)	1 (*Yeates, 2019)
Other well-being aspects	ASHA Quality of Communication Life (ASHA QCL; Paul et al., 2004)	1 (Manti-Kozolowski et al., 2020)
	Stroke Impact Scale-3 (SIS-3, Duncan et al., 1999)—Global Impact Subscale	1 (*Tamplin et al., 2013)
	Psychological outcomes
	General Health Questionnaire-12 (GHQ-12)	1 (*Tamplin et al., 2013)
	Sickness Impact Profile (SIP, Bénaim et al., 2003)	1 (*Zumbansen et al., 2017)

Figure 2. Revised effect direction plot for quantitative studies including sign test p-values for well-being outcomes, study design, and quality (adapted from Boon & Thomson, 2021) .

Figure 3. Thematic synthesis process adapted from Suškevičs et al. 2019.

Figure 4. Review analytical themes.

Box 1. Example of search string using boolean operators

(Aphasia OR dysphasia OR aphasic OR

(Aphasia OR dysphasia OR aphasic OR dysphasic OR primary progressive aphasia OR PPA OR word finding difficulties OR agrammatism OR agrammatic) AND ((mind-body therapies OR meditation OR Mindfulness OR mindfulness-based stress reduction OR mindfulnessbased cognitive therapy OR mindfulness-based interventions OR MBSR OR MBCT OR MBI OR Yoga OR Tai JI OR Tai Chi OR relaxation OR relaxation therapy OR breathing exercises) OR ((creative arts therapies OR expressive arts therapies OR art therapy OR music therapy OR music intervention OR psychodrama OR dance therapy OR movement therapy))

Table 4. Theoretical framework: pwa’s perspective on mind-body and creative arts interventions

Synthetised findings	Descriptive themes		Original findings
Positive impact on self	Positive experience Needed activity Relevant experience New self		Enjoying the course (Andrew [2015], Duarte et al., 2020; Tamplin et al., 2013), feeling good (Duarte et al., 2020), feeling that they have learnt something useful (Andrew [2015]), having a lot of fun (Duarte et al., 2020), and experience perceived as positive (Crielesi et al., 2019: Study 2) ‘Described his need for an activity like Taiji in his life’ (Yeates, 2019), making forget many [negative things] (Duarte et al., 2020) Opportunity to (…) return to a valued, meaningful, and rewarding experience (Duarte et al., 2020, Mantie-Kozlowski et al., 2018), Felling like someone else (Duarte et al., 2020), perceived improvements in communication (Cherney et al., 2011, Dickinson et al., 2019, Gadberry & Ramachandra, Tamplin et al., 2013), mood (Panda et al., 2020; Biedermann et al., 2019; Dickinson et al., 2017; Tamplin et al., 2013; Orenstein et al., 2012; Cherney et al., 2011), motivation (Tamplin et al., 2013), confidence (Mantie-Kozlowski et al., 2020; Tamplin et al., 2013), self-acceptance (Biedermann et al.,2019; Panda et al., 2020), self-control (Panda et al., 2020; Croteau et al., 2008;), sense of self (Duarte et al., 2020; Tamplin et al., 2013), emotion management (Panda et al., 2020), and resilience (Panda et al.,2020)
Empowering multifaceted experience	A non-impairment-focused activity A learning opportunity A social engagement opportunity A space for a break A time for connection Ease of implementation		Not stroke-related (Panda et al., 2020); not aphasia-focused; strength-based skills (Panda et al., 2020; Biedermann et al., 2019), [activity] which do not require verbal output; [activity] to shift away from stroke symptoms (Panda et al., 2020); inclusion in a group activity not defined by language expression competence (Yeates, 2019)
			Opportunity to discover a talent, to learn a new skill (Catska et al., 2008); enjoyment in learning a new skill (Biedermann et al., 2019) Social, leisure, and activity opportunity not dependent on verbal communication (Yeates, 2019); group as opportunity for social engagement (Panda et al., 2020) A break, a way to escape hectic quotidian (Panda et al., 2020); deeply immersive experience (Panda et al., 2020) Meditation as a prayer (Panda et al., 2020); meditation interrelated with nature (Panda et al., 2020) ‘Easy to learn’ and ‘easy to carry out on a daily basis’ (Orenstein et al., 2012)
The relevance of needs-centred adjustments	Facilitators Need of practice and time Group presence Facilitators’ role Openness to individual preferences Intervention adjustments		Gradual, practiced process; importance of practice (Panda et al., 2020) Group useful to share experiences and explore ways of coping with negative feelings (Crielesi et al., 2019: Study 2; Merriman et al., 2015); collaborate, coach, and support each other (Panda et al., 2020; Tamplin et al., 2013; Catska et al., 2008). Group associated with pleasure and hope resulting from observing peers’ successes (Tamplin et al., 2013; Catska et al., 2008); group seen as resource for comparison and for bonds (Panda et al., 2020; Crielesi et al., 2019; Tamplin et al., 2013); source of sense of belonging (Tamplin et al., 2013)—importance of having a shared context (Panda et al., 2020); positive and important component—importance of the group for engagement with activity and practice (Panda et al., 2020); reason for continuing attendance (Panda et al., 2020; Tamplin et al., 2013) Role of the facilitator was crucial to support learning journey (Panda et al., 2020) Individually unique preferences increased [participants’] ease of entering the meditative state (Panda et al., 2020) Adaptations to mindfulness exercises are necessary (Merriman et al., 2015): shorter meditation may improve participants’ engagement with practising; adapting the body scan to focus on individual harms might improve its accessibility for stroke survivors; need to modify the pace of the intervention and the exercise duration
The relevance of needs-centred adjustments continued		Customised resources Partner’s presence Barriers Language tasks Cognitive difficulties Physical impairment Initial learning phase		Prepared scripts allowed for repetitive linguistic practice (Catska et al., 2008); the ease of revisiting the content through the audio and visual handouts enhanced their understanding and memory of the practice (Merriman et al., 2015) Participants reported that the group experience might have been improved by including partners (Merriman et al., 2015) as partners could benefit from it and also promote practice Difficulties with generating own lyrics due to word finding difficulties (Manti-Kozlowski); difficulties with written tasks, e.g., diary (Merriman et al., 2015) Longer meditation difficulty due to attentional difficulties or fatigue (Merriman et al., 2015) Body scan challenging for participants with hemiplegic arms because it was on both arms simultaneously, and participants experienced hugely variations between both arms (Merriman et al., 2015) The process of learning meditation was reported to be initially difficult (Panda et al., 2020), initially difficult to learn Tai Ji movements (Yeates, 2019), and worry about the first session (Yeates, 2019)

Table 5. Summary of findings for included studies

MIND-BODY INTERVENTIONS
Single-subject studies
Author/s (year) Country	Participant details	Intervention type, setting, duration, and aphasia-friendly modifications	Data collection methods and time; Outcome(s) of interest	Key Findings	Quality
Biedermann et al. (2019; poster) Australia	Number: 7 Age: 62 years (mean) Gender: M=6; F=1 Ethnicity: n/r Aphasia type: Broca n = 4; Anomic n = 3 Aphasia severity: n/r Aphasia aetiology: n/r Time post-onset: > 1 year Educational level: n/r Marital status: n/r Living status: n/r	Intervention: Meditation Setting: group, face-to-face Duration: twice, for 1 hour sessions over 9 weeks Aphasia-friendly modifications: some practices were visually guided, maximum practice length = 30 min	Mixed-methods Data collection methods: pretest-post-test (2 baselines, 2 post-tests), semi-structured interviews+ weekly and exit questionnaire(s) Outcomes: attention, language (spoken word finding), communication and social participation, and meditation impact	Feasibility: Enjoyment in learning a new skill Effectiveness Attention: 3/7 pwa improved in switching visual attention; 1/7 pwa improved in selective auditory attention; 1/7 pwa improved in sustained auditory attention Language: no significant gains in spoken word production; 2/7 showed improvement on running language measures; Meditation impact: 1/7 showed a positive impact on everyday life communication and social participation. Themes relaxed & calm, positive sense of self, self-accepting, and enjoyment in learning a new skill that is strength-based	Medium 7/11 (SCED Scale)
Key ax: assessment; F: female; M: male; MBCT: Mindfulness-based Cognitive Therapy; MBSR: Mindfulness-based Stress Reduction; n/r: not reported; QoL: Quality of Life
Crielesi et al., 2019: Study 2 Italy	Number: 4 Age: 47–78 years (range) Gender: M = 2; F = 2 Ethnicity: n/r Aphasia type: homogenous production Aphasia severity: medium-light production deficit; (impaired comp excluded) Aphasia aetiology: stroke Time post-onset: at least 6 months Educational level: n.d., 4, 11, and 15 years Marital status: married n = 2; n/r n = 2 Living status: living alone n = 2; with spouse n = 2	Intervention: Mindfulness-based Cognitive Therapy (MBCT)-adapted Setting: group, face-to-face Duration: once weekly for 2 hours over 8 weeks + home practice Aphasia-friendly modifications: Some variations to the MBCT protocol; supported conversation strategies to facilitate communication; materials with simplified language and adjusted font size. Changes made by the practitioner	Mixed-methods Data collection methods: pre-test-post-test (baseline, 4-week post-intervention), session video-recordings, and debriefing session 4-week post-intervention Outcomes: psychological well-being and attention-related cognitive functions	Feasibility: experience perceived as positive (n = 4) Effectiveness improvements in QoL, decrease of anxiety and depression, and improvements in cognitive measures Participant-reported improvements for: participation (n = 4), interpersonal relationships (n = 4), QoL (n = 3), being in the present moment (n = 3), anxiety reduction (n = 2), attention (n = 2), communication (n = 2), anger management (n = 1), and sense of calm (n = 1)	Medium 5/11 (SCED Scale)
Dickinson et al. (2017) New Zealand	Number: 1 Age: 59 years Gender: F Ethnicity: European Aphasia type: Broca Aphasia severity: severe Aphasia aetiology: n/r Time post-onset: 3 years Educational level: n/r Marital status: n/r Living status: ‘often alone’ Other factors: apraxia and anxiety (reported by her son)	Intervention: Mindfulness-Based Stress Reduction Programme (MBSR) Setting: 1:1, face-to-face Duration: once weekly for 1.5–2 hours over 4 weeks + home practice Aphasia-friendly modifications: Reduced length of the course (from 8 to 4 weeks), changes from group to 1:1 setting, individualised programme, supported conversation strategies (adaptations made by the clinical psychologist trained by an SLT)	Mixed-methods Data collection methods: pre-test-post-test (baseline, weeks 1 and 3 post-intervention) and observation Outcomes: anxiety, communication, and disability/impact of aphasia	Feasibility: n/r Effectiveness Anxiety: decline (from moderate to low) Spoken and written comprehension: no significant improvement; Confrontation naming: significant improvements for nouns (p = 0.012) and verbs (p = 0.016); Repetition: significant improvement (p = 0.021); Word fluency: no improvements in generative naming; improvements in picture description task Disability: non-significant improvements Improved communication ability with increased verbal output and changes in emotional state (e.g., decline in crying)	Medium 5/11 (SCED Scale)
Laures-Gore and Marshall (2016) USA	Number: 1 Age: 60 years Gender: F Ethnicity: African-American Aphasia type: conduction Aphasia severity: WAB quotient = 70.4 Aphasia aetiology: left hemisphere stroke Time post-onset: 14 years Educational level: n/r Marital status: n/r Living status: n/r	Intervention: Mindfulness meditation (Kabat-Zinn, 1982, Zeidan et al., 2010, and Wenk-Sormaz, 2005) Setting: 1:1, face-to-face. Duration: once daily for up to 30 min over 4 consecutive days + home practice followed by independent 30-min practice on the 5^th day Aphasia-friendly modifications: reduced course length and speech rate; questions to verify participants’ instruction comprehension	Quantitative methods Data collection methods: pre-test-post-test (2 ax at baseline, 1 ax day 5, and 1 ax week 1); psychophysiological data collected pre-/during/post-intervention Outcomes: language (word productivity, auditory comprehension, verbal fluency, and length of utterance), attention, and psychophysiological data (heart rate and cortisol level)	Feasibility: n/r Effectiveness Changes in some psychophysiological and behavioural measures: Heart rate: some changes; Cortisol level: no changes in pattern Word productivity: most notable gains immediately after MM training and MM during the 3^rd ax; auditory comprehension: little changes; verbal fluency and length of utterance: small increases for naming, fluency, and generative naming; decreased performance in Personal Information Attention: small decreases in inattentiveness and impulsiveness; no changes in vigilance	Medium 6/11 (SCED Scale)
Merriman et al. (2015) UK	Number: 4 Age: 47–62 years (range) Gender: M = 3; F = 1 Ethnicity: n/r Aphasia type: dysphasia with reduced reading and writing abilities n = 1 Aphasia severity: n/r Aphasia aetiology: right hemisphere ischaemic stroke n = 3; left hemisphere stroke Time post-onset: 2 years n = 1, 3 years n = 1, and ≥ 1 year n = 2 Educational level: n/r Marital status: n/r Living status: n/r	Pilot study Intervention: Mindfulness-based Cognitive Therapy (MBCT) Setting: group, face-to-face Duration: not specified Aphasia-friendly modifications: n/r Stroke-friendly modifications: handouts with audio version, stickers for objects to act as a reminder of mindful activity, movement exercises modified to allow participants to remain seated and focus on the upper body, and reduced exercise duration	Mixed-methods Data collection: pre- and post-intervention interviews; psychometric ax Outcomes: psychological measures, mindfulness skills, anxiety and depression, attention, stroke survivors’ experience of MBCT, and MBCT feasibility	Feasibility Materials: ease of revisiting content with resources provided; difficulties with writing task (n = 4) Mindfulness practice: long practices resulted in challenging (n = 3), reduced motivation to practice at home (n = 1), and Body Scan challenging for participants with hemiplegic arms (n = 3) Effectiveness For participant with dysphasia: Psychological measures: no observable difference Mindfulness skills: decrease in anxiety and depression: improvements Attention: improvements	Medium 5/11 (SCED Scale)
Orenstein et al. (2012) USA	Number: 3 Age: 53 years (mean); 49–59 years (range) Gender: M = 2; F = 1 Ethnicity: n/r Aphasia type: borderline Wernicke n = 1, Wernicke n = 1, anomic n = 1 Aphasia severity: mild n = 2, moderate n = 1 Aphasia aetiology: left-hemisphere brain damage n = 3 Time post-onset: 61, 36, and 96 months Educational level: n/r Marital status: n/r Living status: n/r	Intervention: Mindfulness Meditation Setting: 1:1, face-to-face; Duration: Phase B: length increased gradually from 5 min up to 30 min over a minimum of four sessions + home practice Phase A2: 5 sessions, 30 min each, no guided practice Aphasia-friendly modifications: n/r	Mixed-methods Data collection methods: data collected pre-/during/post-intervention, participants’ feedback Outcomes: divided attention, sense of effort (SOE), language, and participants’ experience	Feasibility: n/r Effectiveness Divided attention: no observed changes Language: no significant improvements Sense of effort: no observed changes Participants reported MM as easy to learn and carry out on a daily basis and a feeling of relaxation associated with MM	Medium 5/11 (SCED Scale)
Panda et al. (2020) Australia	Number: 5 Age: 65.4 years (mean); 50-72 (range) Gender: M = 3; F = 2 Ethnicity: n/r Aphasia type: n = 3 fluent (anomic), n = 2 non-fluent (Broca) Aphasia severity: n = 3 mild, n = 2 moderate Aphasia aetiology: stroke Time post-onset: 14, 7, 6, and 5 (x2) years Educational level: n/r Marital status: n = 3 spouse, n = 2 no spouse Living status: living with spouse n = 3, living alone n = 2	Intervention: Informal lunch meditation Setting: group, face-to-face Duration: once weekly for 2 hours over 6 weeks Aphasia-friendly modifications: trainer= expert aphasiologist, reduced course duration, structured sessions, aphasia-friendly consent form and info sheet, and supported conversation strategies offered during interviews	Qualitative methods Data collection methods: post-test semi-structured interviews Outcomes: lived experience of meditation	Feasibility: Learning meditation initially difficult; time needed to develop meditation skills; facilitator essential for learning; not stroke-related activity; language output not required; a ‘break’ and ‘deeply immersive experience’; Importance of being part of a group Effectiveness pwa reported that meditation helped them to develop self-acceptance and manage negative emotions, and this contributed to their recovery journey Meditation as a tool to overcome fear of another stroke, to develop resilience, and to feel relaxed/calmed/reduce stress/to feel more alert	High 10/10 (CASP Qualitative Checklist)
Wantsala et al. (2010; poster) USA	Number: 1 Age: 29 years Gender: F Ethnicity: n/r Aphasia type: Broca Aphasia severity: mild with significant word finding difficulties Aphasia aetiology: left hemisphere stroke Time post-onset: 6 months Educational level: n/r Marital status: n/r Living status: n/r	Intervention: Mindfulness-Based Stress Reduction (MBSR) training Setting: 1:1, face-to-face; Duration: once weekly for 1 h over 8 weeks (+ home practice) Aphasia-friendly modifications: n/r	Quantitative methods Data collection methods: pre-test-post-test (baseline, week 8) Outcomes: language production, mood, quality of life, stress symptoms	Feasibility: n/r Effectiveness Improved naming and mood	Low 4/11 (SCED Scale)
Yeates (2019) UK	Number: 1 Age: 44 years Gender: M Ethnicity: n/r Aphasia type: expressive, relatively intact comprehension Aphasia severity: n/r Aphasia aetiology: left middle cerebral artery infarction Time post-onset: 6 years Educational level: n/r Marital status: n/r Living status: n/r	Design: Single subject Intervention: Taiji Setting: group, face-to-face; Duration: over 6 months + home practice, not specified Aphasia-friendly modifications: visual and kinaesthetic teaching Stroke-specific modifications: adjustments for balance, hemiplegia, fatigue, attention, dyspraxia, communication, memory, and disorientation e.g., chair-based sequences, therapy bands, reduced sequence length, regular breaks, and short instruction	Mixed-methods Data collection methods: pre-test-post-test (baseline, repeated every 4 weeks); focus group interviews Outcomes: anxiety, depression, fatigue, QoL, and experience	Feasibility: Intervention perceived as a meaningful social activity Effectiveness Anxiety: constant, no changes Fatigue: constant, no changes QoL: higher scores	Low 4/11 (SCED Scale)
Marshall et al. (2018) USA	Number: 8 Age: 38–73 years (range) Gender: M = 5; F = 3 Ethnicity: Caucasian n = 6; African-American n = 2 Aphasia type: anomic (n = 6); Broca (n = 1); conduction (n = 1) Aphasia severity: n/r Aphasia aetiology: n/r Time post-onset: 1 year 3 months – 5 years Educational level: 12^th grade – doctorate Marital status: n/r Living status: n/r	Design: Within-subjects repeated-measure wait list control design Intervention: Aphasia Mindfulness Meditation n = 5; waiting list n = 3 (mind wandering) Setting: group, face-to-face Duration: once daily for up to 30 min over 5 days Aphasia-friendly: programme developed by SLT; reduced session duration (30 min), reduced content, language simplification, pictorial instruction sheet, and non-verbal strategies	Quantitative methods Data collection methods: pre-test-post-test (2 ax at baseline, 1 ax day 5, and 1 ax week 1); psychophysiological data collected pre-/during/post-intervention Outcomes: language (word productivity, auditory comprehension, verbal fluency, and length of utterance), attention, and psychophysiological data (heart rate and cortisol level)	Feasibility: n/r Effectiveness Little or no changes Language measures: no sig differences between groups or over time. Attention: no sig differences between groups or over time; significant decrease in commission over time for both groups; sigincrease in detectability over time for both groups Heart rate: average beats per minute (BPM) did not change over the sessions; HRV significantly lower on average in the control group Cortisol level: sig differences in average cortisol between sessions 1 and sessions 2–4 for the control group; no sigdifferences across sessions for the training groups	Medium-high 7/9 (JBI Critical Appraisal Checklist for Quasi-Experimental Studies)
Marshall et al. (2014) USA	Number: 11 Ethnicity: native English speakers Time post-onset: 4 months-6 years Educational level: n/r Marital status: n/r Living status: n/r Intervention Group (IWA) Number: 6 Gender: M = 5; F = 1 Age: 58.2 years (mean); 52–74 years (range) Aphasia type: Broca n = 3, Wernicke n = 1, Borderline fluent n = 1; transcortical n = 1 Aphasia severity: ADP scores: 95–110	Design: Within-subjects repeated-measures design Intervention: Unilateral nostril breathing (UNB) n=6. Control group (LHD)n=5 Setting: group, face-to-face Duration: 10-week program (once weekly for 1 h of guided instruction + up to 40 min of daily practice followed by 6 weeks of individual UNB) Aphasia-specific modifications: n/r	Quantitative methods Data collection: pre-test-post-test (at baseline, weeks 4, and 6). Outcomes: language, attention, spatial abilities and depression, and anxiety	Feasibility: n/r Effectiveness No effect of UNB treatment found to last through week 10 of the study Language: LHD group with sig higher scores than the IWA. IWA showed sig positive changes from baseline to week 4. For both groups, performance on language comprehension, attention, and spatial abilities tasks did not sigchange Anxiety: for both groups, anxiety was less after 4 weeks of guided practice than at baseline	Medium-high 7/9 (JBI Critical Appraisal Checklist for Quasi-Experimental Studies)
Marshall et al. (2014)-continued USA	Aphasia aetiology: brain damage Control group (LHD) Number: 5 Age: 52.4 years (mean); 31–66 years (range) Gender: M= 4; F=1 Characteristics: left-hemisphere stroke with no aphasia
Key sig: significant/significantly

Table

CREATIVE ARTS INTERVENTIONS
Single-subject studies
Author/s (year) Country	Participant details	Intervention type setting, duration, and aphasia-specific modifications	Data collection methods and time; Outcome(s) of interest	Key Findings			Quality
Andrew [2015] UK	Number: 6 Age: 52.33 years (mean); 44–59 (range) Gender: M = 5; F = 1 Ethnicity: n/r Aphasia type: word finding difficulties n = 6, receptive difficulties n = 5, planning utterances difficulties n = 3 Aphasia severity: mild-severe Aphasia aetiology: stroke Time post-onset: 6 months-4 years	Intervention: Observational drawing Setting: group, face-to-face Duration: 8 2-hour sessions, over 8 consecutive weeks Aphasia-specific modifications: information was delivered in an aphasia-friendly format with illustrated handouts	Mixed-methods Data collection methods: pre-test-post-test, interview Outcomes: language, cognition, QoL, and acceptability	Feasibility: high acceptability Effectiveness QoL was the area with most gains observed, followed by mood, confidence, and concentration Visual attention: not overall improvements Language: gains in semantic information gathering.			Medium 5.5/11 (SCED Scale)
Andrew [2015]-continued	Educational level: finished education between ages of 13 and 21. Degree (n = 1). Marital status: n/r Living status: n/r
Castka et al. (2009) Not specified	Number: 23 but data collected for n = 19 (n = 11 ‘veterans’; n = 8 first-time members) Age, gender: n/r Ethnicity: n/r Aphasia severity, aetiology: n/r Time post-onset: n/r Educational level: n/r Marital status: n/r Living status: n/r	Intervention: Musical production/performance Setting: group, face-to-face Duration: Once weekly for 2 hours, 12 weeks of rehearsal + final performance Aphasia-friendly modifications: aphasia-friendly scripts, adapted musical score and choreography created by SLTs	Qualitative methods Data collection methods: pre- and post- participation survey for participants; feedback from participants and carers Outcome: benefits of participations Measures: bespoke survey; not specified	Feasibility: n/r Effectiveness Benefits: challenging oneself, having fun, performing for a group, team-work, returning to performing (first-time members); increased confidence (‘veterans’) Themes: 1. Psychosocial (empowerment, teamwork opportunity, enjoyment, and hope). 2. Linguistic (promotion of spontaneous communication, improvisation, andmultimodal strategies use). 3. Recreational (meaningful activity and no experience required)			Low 1/9 (CASP Qualitative Checklist)
Cherney et al. (2011) USA	Number: 7 Age: 56.7 years (mean) Gender: M = 5; F = 2 Ethnicity: white n = 12, black n = 2 Aphasia type: Broca (n = 4), anomic (n = 3) Aphasia severity: moderate n = 4; mild n = 3 Aphasia aetiology: stroke, n = 6; gunshot n =1 Time post-onset: 6.1 years (range:11 months to 27 years). Educational level: 15.7 years (mean) for 7 participants Marital status: n/r Living status: n/r	Intervention: Drama class (theatre experience and performance) Setting: group, face-to-face Duration: once weekly for 90 minutes over 18 weeks + 3 rehearsals + 1 dress rehearsal Aphasia-specific modifications: SLT and drama therapist used supported conversation strategies to facilitate communication among the participants	Mixed-methods Data collection methods: patient-reported outcomes pre-test/post-test (baseline and week 18 post-intervention) Outcomes: mood and communication confidence	Feasibility: n/r Effectiveness Perceived improvements in communication and mood Medium effect sizes: communication-burden; communication-distress; mood-positive items Small effect sizes: Social Relations-Distress, Social Relations-Distress, Mood-negative items, Mood-Distress, and CCRSA.			Medium 7/11 (SCED Scale)
Gadberry & Ramachandra 2015 USA	Number: 1 Age: 69 Gender: M Ethnicity: n/r Aphasia type: Broca Aphasia severity: n/r Aphasia aetiology: acute ischaemic stroke Time post-onset: >1 year Educational level: high school Marital status: n/r Living status: n/r	Intervention: Music Therapy (Tomaino’s protocol) Setting: 1:1, face-to-face Duration: 17 sessions of 45 min each Aphasia-specific modifications: not specified, apart from observing pt reactions to songs during the song selection phase	Mixed-methods Data collection methods: baseline data, observation, pre- and post-test Outcomes: communication and mood	Feasibility: n/r Effectiveness Communication: increased verbalisations; renewed interest in using AAC; increased in communication initiative Mood: reduction in anxiety and depression			Low 4/11 (SCED Scale)
Duarte et al. (2020) Brazil	Number: 1 Age: 67 years Gender: F Ethnicity: n/r Aphasia type: resolved expressive aphasia; deficit in oral phrases comprehension Aphasia severity: moderate severe Aphasia aetiology: 2 strokes Time post-onset: >1 year Educational level: incomplete elementary education Marital status: has a partner Living status: living alone Others: depression, smoking, and alcoholism	Intervention: Clowning session Setting: group, face-to-face Duration: once weekly for 3 hours over 6 months Aphasia-specific modifications: facilitator provided support according to participants’ needs and initiatives	Mixed-methods Data collection methods: pre-test-post-test, interview Outcomes: well-being and QoL	Feasibility: experience perceived as positive; participant reported to feel more relaxed and comfortable with herself Effectiveness Improvements in all investigated components of well-being and QoL			Medium 5.5/11 (SCED Scale)
Kim et al. (2008) Korea	Number: 1 Age: 59 years Gender: F Ethnicity: n/r Aphasia type: Broca Aphasia severity: 9^th percentile on Korean WAB- very limited linguistic communication Aphasia aetiology: subarachnoid haemorrhage from a cerebral aneurysm rupture Time post-onset: 18 months Educational level: n/r Marital status: n/r Living status: n/r	Intervention: Art therapy Setting: 1:1, face-to-face Duration: twice weekly for 40 min over 75 days Aphasia-specific modifications: n/r	Quantitative methods Data collection methods: pre-test-post-test Outcomes: cognition, language, spatial perception, and functioning	Feasibility: n/r Effectiveness Cognitive function: improvement in all areas; improved visual perception, capability and motor function; improved disorientation, 3-step oral commands performance, and geometric figures drawing; improved attention, construction, conceptualization, and memory. Language: not many improvements, apart from slight improvements in the understanding category			Low 4.5/11
Manti-Kozolowski et al. (2020)	Number: 1 Age: 64 Gender: F Ethnicity: n/r Aphasia type: expressive and receptive difficulties Aphasia severity: severe Aphasia aetiology: PPA Time post-onset: >1 year Educational level: n/r Marital status: n/r Living status: living with her brother	Intervention: Therapeutic songwriting Setting: 1:1, face-to-face Duration: 13 sessions in total, twice weekly for 55 min over 8 weeks Aphasia-specific modifications: Therapy delivered by a language pathology graduate student. One of the song writing techniques was modified (pt to select phrases for lyrics from materials) Conversational repair strategies used during the session.	Mixed-methods Data collection methods: pre-test-post-test, clinician’s field notes. Outcomes: perception of meaningfulness of song writing activity and quality of communication life	Feasibility: activity perceived as enjoyable and satisfying song writing techniques were described by the pt as “meaningful”, “valuable”, and “rewarding” and that the activity “allowed for self-reflection Effectiveness Positive impact on confidence Higher scores for feeling “included”, “seeing the funny things in life”, and were more “confident in her ability to communicate”			Low 4/11 (SCED Scale)
Mantie-Kozlowski et al. (2018) USA	Number: 5 Age: 60–69 (range) Gender: M = 3; F = 2 Ethnicity: Caucasian n = 3, Hispanic n = 1, African-American n = 1 Aphasia type: non-fluent aphasia (n = 3), mixed nonfluent aphasia (n = 1), apraxia of speech (n = 1) Aphasia severity: severe n = 4, moderate-severe n = 1 Aphasia aetiology: left hemisphere CVA n = 4; Surgical removal of benign left frontal lobe neoplasm n = 1	Feasibility study Intervention: Sing-along group Setting: group, face-to-face Duration: 10 90-min sessions twice monthly Aphasia-specific modifications: large font size, song text contained to one page (whenever possible), attempts made to include participants’ preferences, and musical needs	Qualitative methods pwa-Data collection methods: pre-/post- participation interviews; post-participation questionnaire, and observations Outcomes: attitude toward their caregiver, musical background, feasibility, caregiver involvement, personal and believed caregivers’ feeling about sing-along group, Likert scale, and songs enjoyment	Feasibility: pwa and carers reported that the location was accessible, and frequency and duration of the meetings appropriate; participants enjoyed sing-along sessions. Effectiveness Familiar and non-worded songs were associated with a less frustration for pwa. However, both pwa and caregivers expressed preference for familiar and worded over novel and non-worded songs. Caregiver involvement: no discernible patterns in pwa’s responses; slight preference for caregiver involvement, but this seemed to be related to desire to be in a larger group			High 8/9 (CASP Qualitative Checklist)
Mantie-Kozlowski et al. (2018)-continued USA	Time post-onset: 18–57 months Educational level: n/r Marital status: n/r Living status: n/r Caregivers N = 5 Age = 42–69 (range) Gender = M = 2; F = 3		Caregivers-Data collection methods: pre-/post-participation interviews, pre-/post-test, post-experience questionnaire, observations Outcomes: level of burden, strain, musical background, sing-along experience, and feasibility

Table

Quasi-experimental studies
Author/s (year) Country	Participant details	Intervention type setting, duration, and aphasia-specific modifications	Data collection methods and time; Outcome(s) of interest	Key Findings	Quality
Croteau et al. (2008) (poster) Canada	Experimental group Number: 7 pwa with their significant others Age: 56 (mean) Gender: n/r Ethnicity: n/r Aphasia type: n/r Aphasia severity: 2.6 (BDAE) Aphasia aetiology: CVA Time post-onset: 5 years (mean), at least >1 year Educational level: 13 years Marital status: n/r	Intervention: Theatre workshop Setting: group, face-to-face Duration: once weekly sessions over a year Aphasia-specific modifications: SLT-led workshops together with a theatre professional	Mixed-methods Data collection methods: pre-/post-test, interview (for the experimental group) Outcomes: social participation, communication, personality changes	Feasibility: n/r Effectiveness Social participation: pwa had significant increase for fitness, personal care, communication, and community life; significant decrease for recreation scales. Pwa who participated in the workshop had less time for other activities. For significant others, significant increase of satisfaction on: mobility, responsibility, interpersonal relationships, community life, and recreation. No significant change in performance for life habits. No significant change in the control group Communication: significant others perceived a statistically meaningful increase in the ability of pwa at getting involved in a group conversation about themselves. No change in the control group Personality changes: significant increase on: “nurturance”, “self-control”, and “A-3” (affiliative, respectful of others’ rights and wishes, and conciliatory in social style); significant decrease on the “critical parent scale”→ pwa described as more able to take care of others, more able to take into consideration other people, more accommodating and tolerant of the weakness of others, and more able to have self-control	Medium-high 7/9 (JBI Critical Appraisal Checklist for Quasi-Experimental Studies)
Croteau et al. (2008)-continued (poster) Canada	Living status: n/r Control group Number: 5 pwa with their significant others Age: 62 (mean) Gender: n/r Ethnicity: n/r Aphasia type: n/r Aphasia severity: 3.6 (BDAE) Aphasia aetiology: CVA Time post-onset: 5 years (mean), at least >1 year Educational level: 10 years Marital status: n/r Living status: n/r			Control group: a significant decrease on: “achievement” and “self-confidence” → Pwa not involved in activities tended to lose self-confidence and the need to achieve over time. Three adjectives showed a decrease of more than 50% on the post-test: “obliging”, “dissatisfied”, and “high-strung”. → pwa less obliging. They might have had less time at home to help out. Control group: Four adjectives showed an increase of more than 50%: “headstrong”, “thrifty”, “tense”, and “unemotional”→ pwa described less positively at the post-test.
Tamplin et al. (2013) Australia	Number: 13 Age: 58.3 years (mean); 37–82 (range) Gender: M = 10; F= 3 Ethnicity: n/r Aphasia type: non-fluent Broca with receptive difficulties n = 10; Wernicke n = 3 Aphasia severity: mild-moderate Aphasia aetiology: stroke Time post-onset: n/r Educational level: Secondary school n =6, Certificate/Diploma n = 3, Bachelor /H igher Degree n = 4 Marital status: married n = 11, single n = 1, divorced n = 1 Living status: n/r	Pilot study Intervention: Community choir singing Setting: group, face-to-face 5:1 proportion of stroke survivors singing to healthy others Duration: one weekly for 2 h over 20 weeks (90 min of singing/vocal exercises + 30 min of coffee break for rest and socialization) Aphasia-friendly modifications: vocal warm-ups, song lyrics, and musical arrangements adapted by a music therapist	Mixed-methods Data collection methods: pre-test-post-test (weeks 12 and 20), semi-structured interviews with participants able to communicate verbally to some extent (n =), and caregivers (n = 5) Outcomes: mood; stroke impact on communication, cognition, and global recovery; and social participation and experience	Feasibility: n/r Effectiveness Mood: possible reduction in adverse mood symptoms sustained to week 20; high degree of variability across participants, reduction in feeling of being ‘Tired’; increase in feelings of being Afraid’ Communication: small increase in scores Cognition: reduction in perceived thinking and memory scores Global recovery: increase in scores Social participation: reduction Most frequently reported benefits for choir participants were increases in confidence (n = 29), development of peer support networks (n = 26), and enhanced mood (n = 25); increase in participants’ motivation both within and outside of the choir (n = 15); some changes in communication abilities (n = 14)	Medium 5/9 (JBI Critical Appraisal Checklist for Quasi-Experimental Studies)

Table

RCT
Author/s (year) Country	Participant details	Intervention type setting, duration, and aphasia-specific modifications	Data collection methods and time; Outcome(s) of interest	Key Findings			Quality
Zumbansen et al. (2016) Canada	Number: 22 Ethnicity: Francophone Aphasia aetiology: stroke n = 21, brain tumour n = 1 Time post-onset: 1.0–35.3 years Educational level: 6–23 years Marital status: n/r Living status: n/r Intervention Group Number: 7 Age: 64.3 years (mean); 54–69 years (range) Gender: M=2; F= 5	Intervention Group: Choir sessions Control Group: drama Classes; waiting list: no intervention Setting: group, face-to-face Duration: once weekly for 2 h over 6 months	Quantitative methods Data collection: pre-test-post-test Outcomes: functional communication, speech and language skills (motor-speech ability; automatised series, repetition, naming, connected speech, and comprehension), mood, and QoL	Feasibility: n/r Effectiveness No significant differences between groups in any outcome measure Significant positive correlation found between attendance to any social activity and functional communication improvements			High 8/11 (CASP RCT Checklist)
Zumbansen et al. (2016)-continued Canada	Aphasia type: Transcortical sensory n = 3; mix n = 3, transcortical motor n = 1 Aphasia severity: severe n = 2, moderate n = 4, mild-moderate n = 1 Control group Number: 8 Age: 54.0 years (mean); 28–82 years (range) Gender: M = 5; F = 3 Aphasia type: mix n = 3, Broca n = 1, conduction n = 1, global n = 1, anomic n = 1, transcortical motor n = 1
	Aphasia type: moderate n = 5, severe n = 2, mild-moderate n = 1 Waiting list Number: 7 Age: 54.0 years (mean); 39–69 years (range) Gender: M = 2; F = 5 Aphasia type: mix n = 4; Wernicke n = 1, conduction n = 2 Aphasia severity: moderate n = 3, mild-moderate n = 2, severe n = 1, moderate-severe n = 1

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