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  • 1. Aphasia On this page: • What is aphasia? • Who has aphasia? • What causes aphasia? • What types of aphasia are there? • How is aphasia diagnosed? • How is aphasia treated? • What research is being done for aphasia? • Where can I get additional information? Areas of the brain affected by Broca’s and Wernicke’s aphasia What is aphasia? Aphasia is a disorder that results from damage to portions of the brain that are responsible for language. For most people, these are areas on the left side (hemisphere) of the brain. Aphasia usually occurs suddenly, often as the result of a stroke or head injury, but it may also develop slowly, as in the case of a brain tumor, an infection, or dementia. The disorder impairs the expression and understanding of language as well as reading and writing. Aphasia may co-occur with speech disorders such as dysarthria or apraxia of speech, which also result from brain damage. Who has aphasia? Anyone can acquire aphasia, including children, but most people who have aphasia are middle- aged or older. Men and women are equally affected. According to the National Aphasia Association, approximately 80,000 individuals acquire aphasia each year from strokes. About one million people in the United States currently have aphasia. Top What causes aphasia? Aphasia is caused by damage to one or more of the language areas of the brain. Many times, the cause of the brain injury is a stroke. A stroke occurs when blood is unable to reach a part of the brain. Brain cells die when they do not receive their normal supply of blood, which carries oxygen
  • 2. and important nutrients. Other causes of brain injury are severe blows to the head, brain tumors, brain infections, and other conditions that affect the brain. Top What types of aphasia are there? There are two broad categories of aphasia: fluent and non-fluent. Damage to the temporal lobe (the side portion) of the brain may result in a fluent aphasia called Wernicke’s aphasia (see figure). In most people, the damage occurs in the left temporal lobe, although it can result from damage to the right lobe as well. People with Wernicke’s aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create made- up words. For example, someone with Wernicke’s aphasia may say, “You know that smoodle pinkered and that I want to get him round and take care of him like you want before.” As a result, it is often difficult to follow what the person is trying to say. People with Wernicke’s aphasia usually have great difficulty understanding speech, and they are often unaware of their mistakes. These individuals usually have no body weakness because their brain injury is not near the parts of the brain that control movement. A type of non-fluent aphasia is Broca’s aphasia. People with Broca’s aphasia have damage to the frontal lobe of the brain. They frequently speak in short phrases that make sense but are produced with great effort. They often omit small words such as ”is,” ”and,” and ”the.” For example, a person with Broca’s aphasia may say, ”Walk dog,” meaning, ”I will take the dog for a walk,” or ”book book two table,” for ”There are two books on the table.” People with Broca’s aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated. People with Broca’s aphasia often have right-sided weakness or paralysis of the arm and leg because the frontal lobe is also important for motor movements. Another type of non-fluent aphasia, global aphasia, results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. There are other types of aphasia, each of which results from damage to different language areas in the brain. Some people may have difficulty repeating words and sentences even though they can speak and they understand the meaning of the word or sentence. Others may have difficulty naming objects even though they know what the object is and what it may be used for. Top How is aphasia diagnosed? Aphasia is usually first recognized by the physician who treats the person for his or her brain injury.Frequently this is a neurologist. The physician typically performs tests that require the person to follow commands, answer questions, name objects, and carry on a conversation. If the physician suspects aphasia, the patient is often referred to a speech-language pathologist, who performs a comprehensive examination of the person’s communication abilities. The examination includes the person’s ability to speak, express ideas, converse socially, understand language, read, and write, as well as the ability to swallow and to use alternative and augmentative communication. Top
  • 3. How is aphasia treated? In some cases, a person will completely recover from aphasia without treatment. This type of spontaneous recovery usually occurs following a type of stroke in which blood flow to the brain is temporarily interrupted but quickly restored, called a transient ischemic attack. In these circumstances, language abilities may return in a few hours or a few days. For most cases, however, language recovery is not as quick or as complete. While many people with aphasia experience partial spontaneous recovery, in which some language abilities return a few days to a month after the brain injury, some amount of aphasia typically remains. In these instances, speech-language therapy is often helpful. Recovery usually continues over a two-year period. Many health professionals believe that the most effective treatment begins early in the recovery process. Some of the factors that influence the amount of improvement include the cause of the brain damage, the area of the brain that was damaged, the extent of the brain injury, and the age and health of the individual. Additional factors include motivation, handedness, and educational level. Aphasia therapy aims to improve a person’s ability to communicate by helping him or her to use remaining language abilities, restore language abilities as much as possible, compensate for language problems, and learn other methods of communicating. Individual therapy focuses on the specific needs of the person, while group therapy offers the opportunity to use new communication skills in a small-group setting. Stroke clubs, regional support groups formed by people who have had a stroke, are available in most major cities. These clubs also offer the opportunity for people with aphasia to try new communication skills. In addition, stroke clubs can help a person and his or her family adjust to the life changes that accompany stroke and aphasia. Family involvement is often a crucial component of aphasia treatment so that family members can learn the best way to communicate with their loved one. Family members are encouraged to: • Simplify language by using short, uncomplicated sentences. • Repeat the content words or write down key words to clarify meaning as needed. • Maintain a natural conversational manner appropriate for an adult. • Minimize distractions, such as a loud radio or TV, whenever possible. • Include the person with aphasia in conversations. • Ask for and value the opinion of the person with aphasia, especially regarding family matters. • Encourage any type of communication, whether it is speech, gesture, pointing, or drawing. • Avoid correcting the person’s speech. • Allow the person plenty of time to talk. • Help the person become involved outside the home. Seek out support groups such as stroke clubs. Other treatment approaches involve the use of computers to improve the language abilities of people with aphasia. Studies have shown that computer-assisted therapy can help people with aphasia retrieve certain parts of speech, such as the use of verbs. Computers can also provide an alternative system of communication for people with difficulty expressing language. Lastly, computers can help people who have problems perceiving the difference between phonemes (the sounds from which words are formed) by providing auditory discrimination exercises. Top What research is being done for aphasia?
  • 4. Scientists are attempting to reveal the underlying problems that cause certain symptoms of aphasia. The goal is to understand how injury to a particular part of the brain impairs a person’s ability to convey and understand language. The results could be useful in treating various types of aphasia, since the treatment may change depending upon the cause of the language problem. Other research is attempting to understand the parts of the language process that contribute to sentence comprehension and production and how these parts may break down in aphasia. In this way, it may be possible to pinpoint where the breakdown occurs and help in the development of more focused treatment programs. Although different languages have many things in common when specific portions of the brain are injured, there are also differences. Scientists are trying to understand the common (or universal) symptoms of aphasia and the language-specific symptoms of the disorder. Other researchers are examining whether people with aphasia may still know their language but have difficulty accessing that knowledge. These studies may help with the development of tests and rehabilitation strategies that focus on specific characteristics of one language or multiple languages. Researchers are exploring drug therapy as an experimental approach to treating aphasia. Some studies are testing how drugs can be used in combination with speech therapy to improve recovery of various language functions. Researchers are also looking at how treatment of other cognitive deficits involving attention and memory can improve communication abilities. To understand recovery processes in the brain, some researchers are using functional magnetic resonance imaging (fMRI) to better understand the human brain regions involved in speaking and understanding language. This type of research may improve understanding of how these areas reorganize after brain injury. The results could have implications for both the basic understanding of brain function and the diagnosis and treatment of neurological diseases. What is aphasia? Aphasia is a disorder that results from damage to portions of the brain that are responsible for language. For most people, these are areas on the left side (hemisphere) of the brain. Aphasia usually occurs suddenly, often as the result of a stroke or head injury, but it may also develop slowly, as in the case of a brain tumor, an infection, or dementia. The disorder impairs the expression and understanding of language as well as reading and writing. Aphasia may co-occur with speech disorders such as dysarthria or apraxia of speech, which also result from brain damage. Who has aphasia? Anyone can acquire aphasia, including children, but most people who have aphasia are middle-aged or older. Men and women are equally affected. According to the National Aphasia Association, approximately 80,000 individuals acquire aphasia each year from strokes. About one million people in the United States currently have aphasia. What causes aphasia?
  • 5. Aphasia is caused by damage to one or more of the language areas of the brain. Many times, the cause of the brain injury is a stroke. A stroke occurs when blood is unable to reach a part of the brain. Brain cells die when they do not receive their normal supply of blood, which carries oxygen and important nutrients. Other causes of brain injury are severe blows to the head, brain tumors, brain infections, and other conditions that affect the brain. There are two broad categories of aphasia: fluent and non-fluent. Fluent aphasia Damage to the temporal lobe (the side portion) of the brain may result in a fluent aphasia called Wernicke's aphasia (see figure). In most people, the damage occurs in the left temporal lobe, although it can result from damage to the right lobe as well. People with Wernicke's aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create made-up words. For example, someone with Wernicke's aphasia may say, "You know that smoodle pinkered and that I want to get him round and take care of him like you want before." As a result, it is often difficult to follow what the person is trying to say. People with Wernicke's aphasia usually have great difficulty understanding speech, and they are often unaware of their mistakes. These individuals usually have no body weakness because their brain injury is not near the parts of the brain that control movement. Non-fluent aphasia A type of non-fluent aphasia is Broca's aphasia. People with Broca's aphasia have damage to the frontal lobe of the brain. They frequently speak in short phrases that make sense but are produced with great effort. They often omit small words such as "is," "and," and "the." For example, a person with Broca's aphasia may say, "Walk dog," meaning, "I will take the dog for a walk," or "book book two table," for "There are two books on the table." People with Broca's aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated. People with Broca's aphasia often have right-sided weakness or paralysis of the arm and leg because the frontal lobe is also important for motor movements. Another type of non-fluent aphasia, global aphasia, results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. There are other types of aphasia, each of which results from damage to different language areas in the brain. Some people may have difficulty repeating words and sentences even though they can speak and they understand the meaning of
  • 6. the word or sentence. Others may have difficulty naming objects even though they know what the object is and what it may be used for. How is aphasia diagnosed? Aphasia is usually first recognized by the physician who treats the person for his or her brain injury. Frequently this is a neurologist. The physician typically performs tests that require the person to follow commands, answer questions, name objects, and carry on a conversation. If the physician suspects aphasia, the patient is often referred to a speech-language pathologist, who performs a comprehensive examination of the person's communication abilities. The examination includes the person's ability to speak, express ideas, converse socially, understand language, read, and write, as well as the ability to swallow and to use alternative and argumentative communication. How is aphasia treated? In some cases, a person will completely recover from aphasia without treatment. This type of spontaneous recovery usually occurs following a type of stroke in which blood flow to the brain is temporarily interrupted but quickly restored, called a transient ischemic attack. In these circumstances, language abilities may return in a few hours or a few days. For most cases, however, language recovery is not as quick or as complete. While many people with aphasia experience partial spontaneous recovery, in which some language abilities return a few days to a month after the brain injury, some amount of aphasia typically remains. In these instances, speech-language therapy is often helpful. Recovery usually continues over a two-year period. Many health professionals believe that the most effective treatment begins early in the recovery process. Some of the factors that influence the amount of improvement include the cause of the brain damage, the area of the brain that was damaged, the extent of the brain injury, and the age and health of the individual. Additional factors include motivation, handedness, and educational level. Aphasia therapy aims to improve a person's ability to communicate by helping him or her to use remaining language abilities, restore language abilities as much as possible, compensate for language problems, and learn other methods of communicating. Individual therapy focuses on the specific needs of the person, while group therapy offers the opportunity to use new communication skills in a small-group setting. Stroke clubs, regional support groups formed by people who have had a stroke, are available in most major cities. These clubs also offer the opportunity for people with aphasia to try new communication skills. In addition, stroke clubs can help a person and his or her family adjust to the life changes that accompany stroke and aphasia. Family involvement is often a crucial component of aphasia treatment so that family members can learn the best way to communicate with their loved one.
  • 7. Family members are encouraged to: • Simplify language by using short, uncomplicated sentences. • Repeat the content words or write down key words to clarify meaning as needed. • Maintain a natural conversational manner appropriate for an adult. • Minimize distractions, such as a loud radio or TV, whenever possible. • Include the person with aphasia in conversations. • Ask for and value the opinion of the person with aphasia, especially regarding family matters. • Encourage any type of communication, whether it is speech, gesture, pointing, or drawing. • Avoid correcting the person's speech. • Allow the person plenty of time to talk. • Help the person become involved outside the home. Seek out support groups such as stroke clubs. Other treatment approaches involve the use of computers to improve the language abilities of people with aphasia. Studies have shown that computer- assisted therapy can help people with aphasia retrieve certain parts of speech, such as the use of verbs. Computers can also provide an alternative system of communication for people with difficulty expressing language. Lastly, computers can help people who have problems perceiving the difference between phonemes (the sounds from which words are formed) by providing auditory discrimination exercises. What research is being done for aphasia? Scientists are attempting to reveal the underlying problems that cause certain symptoms of aphasia. The goal is to understand how injury to a particular part of the brain impairs a person's ability to convey and understand language. The results could be useful in treating various types of aphasia, since the treatment may change depending upon the cause of the language problem. Other research is attempting to understand the parts of the language process that contribute to sentence comprehension and production and how these parts may break down in aphasia. In this way, it may be possible to pinpoint where the breakdown occurs and help in the development of more focused treatment programs. Although different languages have many things in common when specific portions of the brain are injured, there are also differences. Scientists are trying to understand the common (or universal) symptoms of aphasia and the language-specific symptoms of the disorder. Other researchers are examining whether people with aphasia may still know their language but have difficulty accessing that knowledge. These studies may help with the development of tests and rehabilitation strategies that focus on specific characteristics of one language or multiple languages. Researchers are exploring drug therapy as an experimental approach to treating aphasia. Some studies are testing how drugs can be used in combination with speech therapy to improve recovery of various language functions.
  • 8. Researchers are also looking at how treatment of other cognitive deficits involving attention and memory can improve communication abilities. To understand recovery processes in the brain, some researchers are using functional magnetic resonance imaging (fMRI) to better understand the human brain regions involved in speaking and understanding language. This type of research may improve understanding of how these areas reorganize after brain injury. The results could have implications for both the basic understanding of brain function and the diagnosis and treatment of neurological diseases. SOURCE: National Institutes of Health, National Institute on Deafness and Other Communication Disorders Aphasia: A Language Disorder Joseph Xiong "My most valuable tool is words, the words I can now use only with difficulty. My voice is debilitated - mute, a prisoner of a communication system damaged by a stroke that has robbed me of language," stated A. H. Raskins, one of approximately one million people in the United States who suffer from aphasia (1), a disorder which limits the comprehension and expression of language. It is an acquired impairment due to brain injury in the left cerebral hemisphere. The most common cause of aphasia is a stroke, but other causes are brain tumors, head injury, or other neuralgic illnesses. Of the estimated 400,000 strokes which occur a year, approximately 80,000 of those patients develop some form of aphasia (2). Another important observation is that within the United States, there are twice as many people with aphasia as there are individuals with Parkinson's disease (2). Yet, what is so astounding is the lack of public awareness about aphasia. Aphasia attacks an intricate part of a person's daily life - the simple act of communication and sharing. The disbursement of such a tool deprives an individual of education learned through their life, often leaving the ill fated feeling hopeless and alone. In considering the effects of aphasia, a deeper analysis of the two most common forms of aphasia will be examined: Broca's aphasia and Wernicke's aphasia. While both forms occur usually as a result of a stroke in the left hemisphere of the brain, their particular site of impairment produces different side effects in an individual's comprehension and speech. These regions have been further studied through experimental researches such as positron emission tomography (PET). Moreover, although there is currently no cure for the disorder, there are treatments and certain guidelines to follow when encountering an aphasic. In physiological terms, Broca's aphasia and Wernicke's aphasia occur in the left hemisphere of the brain, which is responsible for controlling the right side of the body along with speech and language abilities. Broca's aphasia affects the frontal lobe adjacent to the primary motor cortex, and Wernicke's aphasia affects the posterior portion of the first frontal lobe (3). A general distinction made between the two disorders are that Broca's aphasia limits speech, while Wernicke's aphasia limits comprehension. Broca's aphasia characterizes patients as people who has loss the production of complete sentence structures in speech and writing. Although the individual may retain the usage of nouns and verbs, the aphasic may have lost all forms of pronouns, articles, and conjunctions (3). Broca's aphasics struggle to speak more than one word at a time but shows signs of enormous effort; thus, patients with Broca's aphasia is characterized as "non-fluent aphasia" (4). Here is an example of a Broca's aphasic speech: Yes ... ah ... Monday ... er Dad and Peter H ... (his own name), and Dad ... er hospital ... and ah ... Wednesday ... Wednesday nine o'clock ... and oh ... Thursday ... ten o'clock, ah doctors ... two ... an' doctors ... and er ... teeth ... yah. (3) This passage shows the difficulty in interpreting a patient with Broca's aphasia. This particular aphasic may be trying to explain that he has a dental appointment at the hospital, or that his dad had an appointment. However, amazingly the Broca's aphasic
  • 9. comprehension level is less impaired. Case studies have shown that Broca's aphasics retained a good amount of their comprehension level. In an experiment to prove this, A. Caramaza and E.B. Zurif tested a Broca's aphasic comprehension level through sentence structures, whose nouns are irreversible as in the sentence: the girl is reading the yellow book. In this portion the aphasics tested rather well, because they managed to understand the sentence. However if the noun is reversible, such as the dog chased the cat, then their ability to recognize the sentence drops (3). This shows that Broca's aphasics retain a good majority of their comprehension level. Wernicke's aphasics have different types of symptoms. Individuals with Wernicke's aphasia speak extremely fluently but with no informative purpose (3). In this respect, Wernicke's aphasia is known as "fluent aphasia" (4). An example of a Wernicke's aphasic speaking is as follows: Well this is .... mother is away here working her work out o'here to get her better, but when she's looking, the two boys looking in other part. One their small tile into her time here. She's working another time because she's getting, too. (3) Clearly, the aphasic has problems expressing his thoughts to their audience. The sentence structure does not follow correct grammatical patterns, and ultimately, there is no meaning. Moreover, their comprehension level is more reduced than a patient with Broca's aphasia (3). In the same case studies by Caramaza and Zurif with Broca's aphasics, in which irreversible and reversible nouns were placed in sentences, Wernicke's aphasics tested poorly on both occasions (3). Thus, Wernicke's aphasics have lost a majority of their comprehension ability. N. Geschwind proposed a pattern for language function from examining the expressive behaviors of aphasics. He proposed that If a visual input is noticed, a message is sent to the visual center, the occipital lobe. This message then travels to Wernicke's area where the information is processed and linguistic words are formulated. The next step involves the message being sent to Broca's area, which translates the signal to motor commands that travels to muscles to induce a form of language expression. If another form of sensory is noted, the first signal travels to the sensory association center in the parietal lobe and follows the same pathway (3). Using this model as a guide to conceptualize the two forms of aphasia, the role of region specificity is enforced. If a patient has Broca's aphasia, although small levels of comprehension are impaired, forms of speech are near distinct. If a patient suffers from Wernicke's aphasia, their comprehension level is damaged but production of language is left remotely intact. Experimental studies also have been done to verify the region specificity. One such approach is positron-emission tomography (PET). In PET, an individual is injected with radioactive glucose into their blood stream and monitored for levels of radioactive glucose consumption throughout the brain region. Glucose consumption occurs in regions where the brain is active. In order to determine region specific properties, high glucose consumption regions are depicted in color code shown in a PET scan. Physicians use PET scans to determine the extremity of the disorder and define brain functions (5). Although, aphasics may never recover completely from their disorder, there are various techniques available for treating and increasing communication skills for an aphasic. Some specific techniques are (6): 1) imitating or repeating sounds; following commands 2) work on the functions they have retained 3) melotic - increase language skills through using music Another interesting approach is the use of alternative augmentative communication (AAC). The basis behind an augmentative approach is primarily based on symbols. The program known as Minspeak emphasizes the use of symbols that may have various meanings. These symbols are placed in context with one another tocreate an expression. An example is CUP, which could mean "drink", or the verb "to drink" with a action symbol. It could be linked in such an order: CUP + COW = "milk", or CUP + COW = "milk" + action symbol + CUP = "to drink." Another crucial point is that these images have to be transparent, if the patient does not know them, then he/she must be taught them (7).
  • 10. In considering the two types of aphasics and the forms of treatment, an aphasic may never recover from the disorder. In the case of Broca's aphasia where the effect is mainly speech oriented, the individual does not loose their comprehension level entirely. As for Wernicke's aphasia, the loss may have more relevance because an individual may loose their entire comprehension level. It is crucial to say that aphasia completely changes a person as a normal functioning human being. Although his physical attributes are present, depending on the severity of the disorder his mind may be lost. And even though treatments are available to help the aphasia regain some communication skills, what is lost is lost. It is as if the individual must start from the beginning again only to learn that the extent of what he/she learns is already limited.