Neurogenic communication disorders

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SEMINAR
ON
NEUROGENIC COMMUNICATION DISORDERS
Submitted by, Submitted to,
Aswathi. P Mrs. Resmi. G
2nd yr Msc Nursing Asst. Professor
Al-Shifa college of Nursing Al-Shifa college of Nursing
Perinthalmanna Perinthalmanna
Submitted on: 29-10-2015

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CENTRAL OBJECTIVE
On completion of class, students acquire knowledge regarding Neurogenic communication
disorders and applies this knowledge in their professional practice with a positive attitude.
SPECIFIC OBJECTIVE
On completion of class student,
 define neurogenic communication disorders
 mention the prevalence of neurogenic communication disorders
 list down the types of neurogenic communication disorders
 describe about aphasia
 explain dysarthria
 recognize apraxia of speech and aprosody
 discuss management of neurogenic communication disorders

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INTRODUCTION
Speech-language disorders that result from a stroke or other brain disorders or injury. A change in
speech is often the first sign that such an injury has occurred. This change may be so slight as to
be barely noticeable, or so severe that the patient is unable to speak. Many different types of
communication problems can result from a stroke or other brain injury. Treatment is geared to
their particular condition. Speech-language disorders are frequently the most devastating aspect of
a stroke. To help deal with this challenge, patients and family members receive individual
instruction on how to maximize communication, and are also provided with information about
community services and resources for patients with communication disorders.
ANATOMY & PHYSIOLOGY OF SPEECH GENERATION
Articulatory System
Articulation refers to movement of one structure against another. In this case we are referring to
“speech” structures.Also referred to as the Supra-LaryngealSystem (supra = above).
The system consists of a series of cavities,muscles, bones, and teeth.
The vocal tract
The vocal tract is an elongated assembly of tissue and organs that have a common origin and
function. The place where speech articulation occurs3 Cavities comprise the vocal tract:
 Nasal Cavity
 Oral Cavity
 Pharyngeal Cavity
The Articulators
The structures involved in the articulation of speech can be classified into two categories:
 Movable
 Fixed

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Speech production mechanism
Air enters the lungs via breathing
Air is expelled from the lungs, through the trachea, and cause to vocal cords to vibrate
Air ﬂow is chopped up into quasi-periodic pulses
The pulses are frequency-shaped by the oral cavity and the nasal cavity
Body parts involved in speech production: lungs, trachea, vocal cords within the larynx, velum
(soft palate), hard palate, tongue, teeth, lips, nasal tract.
Vocalization
 there are 3 primary organs involved in producing speech:
1. lungs, which act as an air reservoir
2. larynx, which generates the pulsatile quality of "voiced" sounds due to the actions
of the vocal folds
3. pharynx and the oral and nasal cavities, which filter the sounds, making them
characteristic of an individual's voice
 air expelled from the lungs (step 1 in table) accelerates as it passes through the glottis (the
constricted opening between the vocal folds) - the acceleration decreases the air pressure,
which causes the vocal folds to close until sufficient pressure builds up to force them open
again - the net result is an oscillation in air pressure (i.e., a sound wave) = step 2
o the fundamental frequency of the resulting speech sound is between 100 and 400
Hz; its exact pitch depends on gender, size and age

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the pathways from the vocal folds to the lips shape and filter the sound, based on their
natural resonances = step 3
o these resonances, called formants (F1, F2, F3 in diagram), determine the exact
characteristics of vowel sounds
the vocal folds participate in all vocalizations, but are primarily responsible for abrupt
changes in air flow responsible for consonant sounds
Cortical language areas
Many cortical (and non-cortical!) regions are involved in language processing. The primary
language pathway begins in Wernicke’s area (posterior temporal lobe), which receives
information from the auditory and visual cortices and assigns meaning (= language
comprehension). The arcuate fasciculus connects Wernicke’s area to Broca’s area (posterior
inferior frontal lobe). Broca’s area is responsible for the production of meaningful language.
Output from Broca’s area goes to motor cortex for initiation of the complex muscle movements
necessary for speech
Broca's area
Broca’s area is a region in the frontal lobe of one hemisphere. This region of the brain that
contains motor neurons involved in the control of speech. This area, located in the frontal part of
the left hemisphere of the brain, was discovered in 1861 by French surgeon Paul Broca, who
found that it served a vital role in the generation of articulate speech.
The Broca area lies specifically in the third frontal convolution, just anterior to the face area of the
motor cortex and just above the Sylvian fissure. It is made up of two areas: the pars triangularis
(Brodmann area 45) and the pars opercularis (Brodmann area 44). The Broca area is connected to
other regions of the brain, including the Wernicke area, by a neuronal tract known as the arcuate
fasciculus. In addition to serving a role in speech production, the Broca area also is involved in
language comprehension, in motor activities associated with hand movements, and in
sensorimotor learning and integration.
Damage to the frontal lobe can result in a speech disorder known as Broca aphasia, which is
characterized by deliberate, telegraphic speech with very simple grammatical structure, though

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the speaker may be quite clear as to what he or she wishes to say and may communicate
successfully.
Wernicke's area
It is also called Wernicke's speech area, is one of the two parts of the cerebral cortex linked. It is
involved in the understanding of written and spoken language. The Wernicke's area is classically
located in, the posterior section of the superior temporal gyrus (STG) in the left cerebral
hemisphere. This area encircles the auditory cortex on the Sylvian fissure (part of the brain where
the temporal lobe and parietal lobe meet). This area is neuro anatomically described as the
posterior part of Brodmann area .
 language processing involves many regions of the the brain, not just the classic areas
localized by Broca and Wernicke to the perisylvian cortex of the dominant (left)
hemisphere
 the exact regions can vary from person to person, and within the same person, in
unpredictable ways
o for example, bilingual patients do not necessarily use the same cortical regions to
produce the names of the same object in two different languages
 despite these qualifications, a general language pathway can be described:
o language input from visual or auditory cortex (1) goes first to Wernicke's area
(posterior temporal lobe) (2), which performs the final stages of language
comprehension
o Wernicke's area connects to Broca's area (posterior inferior frontal lobe) via the
arcuate fasciculus
o Broca's area (3) is responsible for production of meaningful language
o output from Broca's area goes to motor cortex (4) for control of the voluntary
muscles required to speak or write words
 this process of articulating specific words (i.e., issues of syntax and grammar) must be
merged with emotional context (i.e., prosody), which is processed by the corresponding
anatomical regions in the non-dominant (right) hemisphere

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 recent imaging studies have shown
that the inferior parietal lobule
(angular gyrus and supramarginal
gyrus = Geschwind's territory) is
connected by large bundles of nerve
fibres to both Broca’s area and
Wernicke’s area, providing by a
second, parallel route for language
production in addition to the general
language pathway
o the inferior parietal lobule is located at the junction of, and is connected to the
auditory, visual, and somatosensory cortexes
o cells in this region are multimodal (i.e., they respond to many different kinds of
stimuli)
o this lobule may help classify and label things, which is a prerequisite for forming
concepts and thinking abstractly
o the inferior parietal lobule is one of the last structures to mature, which may
explain why children typically do not begin to read and write until they are 5 or 6
years old.
TERMINOLOGIES
 Cluttering: A speech and fluency disorder characterized primarily by a rapid rate of
speech, which makes speech difficult to understand.
 Dysprosody: It is the rarest neurological speech disorder. It is characterized by alterations
in intensity, in the timing of utterance segments, and in rhythm, cadence, and intonation of
words. The changes to the duration, the fundamental frequency, and the intensity of tonic
and atonic syllables of the sentences spoken, deprive an individual's particular speech of
its characteristics.

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 Staccato Speech: An abrupt utterance, each syllable being enunciated separately; noted
especially in multiple sclerosis.
 Stuttering : Also called stammering or childhood-onset fluency disorder .It is a speech
disorder that involves frequent and significant problems with the normal fluency and flow
of speech.
 Scanning speech: Also known as explosive speech, is a type of ataxic dysarthria in which
spoken words are broken up into separate syllables, often separated by a noticeable pause,
and spoken with varying force. The sentence "Walking is good exercise", for example,
might be pronounced as "Walk (pause) ing is good ex (pause) er (pause) cise".
Additionally, stress may be placed on unusual syllables.
 Slurred speech: It is a symptom characterized by poor pronunciation of words,
mumbling, or a change in speed or rhythm during talking. The medical term for slurred
speech is dysarthria.
 Muteness :It is complete inability to speak.
DEFINITION
 Neurogenic speech disorders are defined as an inability to exchange information with others due to
nervous system impairment.
 Inability to exchange information with others because of hearing, speech, and/or language
problems caused by impairment of the nervous system (brain or nerves).
PREVALENCE
 54% are dysarthria – this is a motor speech disorder that can affect many aspects of
generating your voice and speech; these difficulties are due to communication difficulties
between the brain and your muscles
 25% are aphasia –Aphasia is a language disorder, not a speech disorder – persons with
aphasia often do also have speech disorders as well
 16% other cognitive-language disorders – dementia, TBI, amnesia fall into this category

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 4% have apraxia of speech – this is a speech disorder due to difficulty with motor
planning and programming; often the wrong sounds come out, and prosody (the up and
down lilt of a voice) is often affected – people with apraxia of speech may sound fairly
robotic
 1% have another neurogenic speech issue, such as mutism, acquired stuttering, and others
TYPES OF NEUROGENIC COMMUNICATION DISORDERS
1. aphasias: disturbance in formulation or comprehension of language
2. aprosody: difficulty in producing or understanding the emotional content of speech
3. apraxia of speech: inability to translate speech plans into motor activity
4. dysarthrias: disturbances in muscular control that affect speech production
APHASIA
Aphasia is from Greek a- ("without") + phásis ("speech"). The word aphasia comes from the word
aphasia, in Ancient Greek, which means "speechlessness", derived from aphatos, "speechless" from
ἀ- a-, "not, un" and phemi, "I speak"
 aphasia means "without language", but usually patients have some language capacity,
therefore "dysphasia" would be a more appropriate term
 usually refers to an acquired communication disorder that impairs a person's ability to
formulate and/or comprehend language, but does not affect other executive functions
 usually due to focal damage of the left cerebral hemisphere (25-40% of stroke survivors
have an aphasia)
Aphasia is the name given to a collection of language disorders caused by damage to the brain.
The term "aphasia" implies a problem with one or more functions that are essential and specific to
language function. It is not usually used when the language problem is a result of a more peripheral
motor or sensory difficulty, such as paralysis affecting the speech muscles or a general hearing
impairment.

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Aphasia can be so severe as to make communication with the patient almost impossible, or it can be
very mild. It may affect mainly a single aspect of language use, such as the ability to retrieve the
names of objects, or the ability to put words together into sentences, or the ability to read. More
commonly, however, multiple aspects of communication are impaired, while some channels remain
accessible for a limited exchange of information.
DEFINITION
 Aphasia is a communication disorder that results from damage or injury to language parts
of the brain. It's more common in older adults, particularly those who have had a stroke.
 Aphasia is an impairment of language, affecting the production or comprehension of
speech and the ability to read or write.
TYPES & CLINICAL FEATURES
 Aphasia may be mild or severe. With mild aphasia, the person may be able to converse,
yet have trouble finding the right word or understanding complex conversations. Severe
aphasia limits the person's ability to communicate. The person may say little and may not
participate in or understand any conversation.
Over a century of experience with the study of aphasia has taught us that particular components of
language may be particularly damaged in some individuals.. Some of the common varieties of
aphasia are:

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1. Broca's aphasia- Expressive aphasia ('non-fluent aphasia')
 In this form of aphasia, speech output is severely reduced and is limited mainly to short
utterances of less than four words.
 Vocabulary access is limited and the formation of sounds by persons with Broca's aphasia
is often laborious and clumsy.
 The person may understand speech relatively well and be able to read, but be limited in
writing.
 Broca's aphasia is often referred to as a 'non fluent aphasia' because of the halting and
effortful quality of speech.
Mixed non-fluent aphasia
 This term is applied to patients who have sparse and effortful speech, resembling severe
Broca's aphasia.
 However, unlike persons with Broca's aphasia, they remain limited in their
comprehension of speech and do not read or write beyond an elementary level.
 However, speech is far from normal. Sentences do not hang together and irrelevant words
intrude-sometimes to the point of jargon, in severe cases.
 Reading and writing are often severely impaired.
2. Wernicke's aphasia- Receptive aphasia ('fluent aphasia')
• Ability to grasp the meaning of spoken words is chiefly impaired, while the ease of
producing connected speech is not much affected.
• Therefore Wernicke’s aphasia is also referred to as ‘fluent aphasia’ or ‘receptive aphasia’.
• Reading and writing are often severely impaired. As in other forms of aphasia, individuals
can have completely preserved intellectual and cognitive capabilities unrelated to speech
and language.
• Persons with Wernicke’s aphasia can produce many words and they often speak
using grammatically correct sentences with normal rate and prosody.

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• However, often what they say doesn’t make a lot of sense or they pepper their sentences
with non-existent or irrelevant words.
• They may fail to realize that they are using the wrong words or using a non-existent word
and often they are not fully aware that what they say doesn’t make sense.
• Patients with this type of aphasia usually have profound language comprehension deficits,
even for single words or simple sentences. This is because in Wernicke’s aphasia
individuals have damage in brain areas that are important for processing the meaning of
words and spoken language. Such damage includes left posterior temporal regions of the
brain, which are part of what is knows as Wernicke’s area, hence the name of the aphasia.
• Wernicke’s aphasia and Wernicke’s area are named after the German neurologist Carl
Wernicke who first related this specific type of speech deficit to a damage in a left
posterior temporal area of the brain.
3.Global aphasia
 This is the most severe form of aphasia, and is applied to patients who can produce few
recognizable words and understand little or no spoken language.
 Persons with Global Aphasia can neither read nor write.
 Global aphasia may often be seen immediately after the patient has suffered a stroke and it
may rapidly improve if the damage has not been too extensive.
 However, with greater brain damage, severe and lasting disability may result.
 It is often seen right after someone has a stroke.
4.Conduction aphasias
 a form of fluent aphasia due to damage to the arcuate fasciculus or Gershwind's territory
the structure that transmits information between Wernicke's area and Broca's area.
 usually good auditory and verbal comprehension
 ability to repeat back words is disproprotionately impaired with lesions of the arcuate
fasciculus
 inability to come up with specific words is characteristic of lesions to Gershwind's
territory

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 fluency is limited to short runs of speech (may be frustrating to the patient)
5.Anomic aphasia
 This term is applied to persons who are left with a persistent inability to supply the words
for the very things they want to talk about-particularly the significant nouns and verbs.
 As a result their speech, while fluent in grammatical form and output is full of vague
circumlocutions and expressions of frustration.
 They understand speech well, and in most cases, read adequately.
 Individuals with Anomic aphasia have difficulty with naming.
 The patients may have difficulties naming certain words, linked by their grammatical type
(e.g., difficulty naming verbs and not nouns) or by their semantic category (e.g., difficulty
naming words relating to photography but nothing else) or a more general naming
difficulty. Patients tend to produce grammatic, yet empty, speech. Auditory
comprehension tends to be preserved.
 Anomic aphasia is the aphasia presentation of tumors in the language zone; it is the
aphasia presentation of Alzheimer's disease.
Types of anomic aphasia
There are three main types of anomia:
 Word selection anomia occurs when the patient knows how to use an object and can
correctly select the target object from a group of objects, and yet cannot name the object.
Some patients with word selection anomia may exhibit selective impairment in naming
particular types of objects, such as animals or colors.In the subtype known as color anomia,
the patient can distinguish between colors but cannot identify them by name or name the color
of an object. The patients can separate colors into categories, but they cannot name them.
 Semantic anomia is a disorder in which the meaning of words becomes lost. In patients with
semantic anomia, a naming deficit is accompanied by a recognition deficit. Thus, unlike
patients with word selection anomia, patients with semantic anomia are unable to select the
correct object from a group of objects, even when provided with the name of the target object.

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 Disconnection anomia results from the severing of connections between sensory and
language cortices. Patients with disconnection anomia may exhibit modality-specific anomia,
where the anomia is limited to a specific sensory modality, such as hearing. For example, a
patient who is perfectly capable of naming a target object when it is presented via certain
sensory modalities like audition or touch, may be unable to name the same object when the
object is presented visually. Thus, in such a case, the patient's anomia arises as a consequence
of a disconnect between his/her visual cortex and language cortices
6.Trans cortical sensory aphasia
 Individuals with Transcortical sensory aphasia, in principle the most general and
potentially among the most complex forms of aphasia, may have similar deficits as in
Receptive aphasia, but their repetition ability may remain intact.
7.Trans cortical motor aphasia
 Individuals with Transcortical motor aphasia have similar deficits as Expressive aphasia,
except repetition ability remains intact.
 Auditory comprehension is generally fine for simple conversations, but declines rapidly
for more complex conversations.
 It is associated with right hemiparesis, meaning that there can be paralysis of the patient's
right face and arm.
8.Primary Progressive Aphasia
 Primary Progressive Aphasia (PPA) is a rare neurological syndrome in which language
capabilities become slowly and progressively impaired, while other mental functions
remain preserved.
 Unlike other forms of aphasia resulting from stroke or traumatic brain injury, PPA is a
degenerative brain condition.
 It results from deterioration of brain tissue affecting areas of the brain that are important
for speech and language.

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9.Mixed trans cortical aphasia
 Individuals with Mixed transcortical aphasia have similar deficits as in global aphasia, but
repetition ability remains intact.
10.Crossed aphasia
A type of aphasia that occurs when a person's language centers are not in the expected
hemisphere. In most right-handed individuals, language centers are located in the left hemisphere.
This is also true for a majority of left-handed people, although there are exceptions for both
groups. An example of crossed aphasia would be a right-handed person who has a right
hemisphere stroke that results in aphasia.
11.Subcortical aphasia
 Subcortical aphasias Characteristics and symptoms depend upon the site and size of
subcortical lesion.
 Possible sites of lesions include the thalamus, internal capsule, and basal ganglia.
Presentation
The following table summarizes some major characteristics of different acute aphasias:
Type of aphasia Repetition Naming
Auditory
comprehension
Fluency
Receptive aphasia mild–mod
mild–
severe
Defective fluent paraphasic
Transcorticalsensory
aphasia
Good
mod–
severe
Poor Fluent
Conduction aphasia Poor Mild relatively good Fluent

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Type of aphasia Repetition Naming
Auditory
comprehension
Fluency
Anomic aphasia Mild
mod–
severe
Mild Fluent
Expressive aphasia
mod–
severe
mod–
severe
mild difficulty
non-fluent, effortful,
slow
Transcorticalmotor
aphasia
Good
mild–
severe
relatively good non-fluent
Global aphasia Poor Poor Poor non-fluent
Mixedtranscortical
aphasia
moderate Poor Poor non-fluent
CAUSES
Aphasia is most often caused by stroke. However, any disease or damage to the parts of the brain
that control language can cause aphasia. These include brain tumors, traumatic brain
injury, and progressive neurological disorders.
SIGNS AND SYMPTOMS
People with aphasia may experience any of the following behaviors due to an acquired brain
injury, although some of these symptoms may be due to related or concomitant problems such as
dysarthria or apraxia and not primarily due to aphasia.
 inability to comprehend language
 inability to pronounce, not due to muscle paralysis or weakness
 inability to speak spontaneously
 inability to form words

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 inability to name objects (anomia)
 poor enunciation
 excessive creation and use of personal neologisms
 inability to repeat a phrase
 persistent repetition of one syllable, word, or phrase (stereotypies)
 paraphasia (substituting letters, syllables or words)
 agrammatism (inability to speak in a grammatically correct fashion)
 dysprosody (alterations in inflexion, stress, and rhythm)
 incomplete sentences
 inability to read
 inability to write
 limited verbal output
 difficulty in naming
 speech disorder
 Speaking gibberish
 inability to follow or understand simple requests
DIAGNOSTIC MEASURES
 Usually, a doctor first diagnoses aphasia when treating a patient for a stroke, brain injury,
or tumor. Using a series of neurological tests, the doctor may ask the person questions.
The doctor may also issue specific commands and ask the person to name different items
or objects. The results of these tests help the doctor determine if the person has aphasia.
They also help determine the severity of the aphasia.
The speech-language pathologist (SLP) evaluates the individual with a variety tools to determine
the type and severity of aphasia. It includes assessment of:
 Auditory Comprehension: understanding words, questions, directions, and stories that are
spoken
 Verbal Expression: producing automatic sequences (e.g., days of the week), naming
objects, describing pictures, responding to questions, and having conversations

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 Reading and Writing: understanding or producing letters, words, sentences, and
paragraphs
 Functional Communication: using gestures, drawing, pointing, or other supportive means
of communication when he/she has trouble getting a point across verbally
Additionally, all individuals with aphasia may also have one or more of the following problems:
 Difficulty producing language:
o Experience difficulty coming up with the words they want to say
o Substitute the intended word with another word that may be related in meaning to
the target (e.g., "chicken" for "fish") or unrelated (e.g., "radio" for "ball")
o Switch sounds within words (e.g., "wish dasher" for "dishwasher")
o Use made-up words (e.g., "frigilin" for "hamburger")
o Have difficulty putting words together to form sentences
o String together made-up words and real words fluently but without making sense
 Difficulty understanding language:
o Misunderstand what others say, especially when they speak fast (e.g., radio or
television news) or in long sentences
o Find it hard to understand speech in background noise or in group situations
o Misinterpret jokes and take the literal meaning of figurative speech (e.g., "it's
raining cats and dogs")
 Difficulty reading and writing:
o Difficulty reading forms, pamphlets, books, and other written material
o Problems spelling and putting words together to write sentences
o Difficulty understanding number concepts (e.g., telling time, counting money,
adding/subtracting)
MANAGEMENT
Treatment for someone with aphasia depends on factors such as:
 Age
 Cause of brain injury

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 Type of aphasia
 Position and size of the brain lesion
For instance, a person with aphasia may have a brain tumor that's affecting the language center of
the brain. Surgery to treat the brain tumor may also improve the aphasia.
Treatment techniques mostly fall under two approaches:
1. Substitute Skill Model - an approach that uses an aid to help with spoken language, i.e. a
writing board
2. Direct Treatment Model - an approach that targets deficits with specific exercises
Several treatment techniques include the following:
 Visual Communication Therapy (VIC) - the use of index cards with symbols to represent
various components of speech
 Visual Action Therapy (VAT) - involves training individuals to assign specific gestures
for certain objects
 Functional Communication Treatment (FCT) - focuses on improving activities specific to
functional tasks, social interaction, and self-expression
 Promoting Aphasic's Communicative Effectiveness (PACE) - a means of encouraging
normal interaction between patients and clinicians. In this kind of therapy the focus is on
pragmatic communication rather than treatment itself. Patients are asked to communicate a
given message to their therapists by means of drawing, making hand gestures or even
pointing to an object.
 Melodic intonation therapy (MIT) - uses the intact melodic/prosodic processing skills of
the right hemisphere to help cue retrieval of words and expressive language
 Other - i.e. drawing as a way of communicating, trained conversation partners
Speech and language therapy techniques
The specific techniques used and the aims of the treatment will depend on each person's
circumstances. Some examples are described below.

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If person have difficulty understanding words, SLT may ask to carry out tasks such as matching
words to pictures or sorting words by their meaning. The aim of these tasks is to improve ability
to remember meanings and link them with other words.
If any difficulty expressing yourself, your SLT may ask you to practice naming pictures or judge
whether certain words rhyme. They may also ask to repeat words that they say, with prompting if
necessary. If able to complete tasks with single words, therapist will work on persons ability to
construct sentences.
Some techniques may involve working with a computer. Other methods may include group
therapy with other people with aphasia, or working with family members. This will allow person
to practice conversational skills, or rehearse common situations, such as making a telephone call.
An increasing number of computer based programmes and apps are available to help people with
aphasia improve their language abilities. However it's important to start using these alongside a
speech and language therapist.
Alternative methods of communication
An important part of speech therapy is finding different ways for to communicate. Therapist will
help to develop alternatives to talking, such as using gesture, writing, drawing or communication
charts.
Communication charts are large grids containing letters, words or pictures. They allow someone
with aphasia to communicate by pointing at the word or letter to indicate what they want to say.
For some people, specially designed electronic devices, such as voice output communication aids
(VOCAs), may be useful. VOCAs use a computer-generated voice to play messages aloud. This
can help if person have difficulty speaking but are able to write or type. There are also apps
available on smart phones and computer tablets that can do this.
Communicating with a person with aphasia

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 After speaking, allow the person plenty of time to respond. If a person with aphasia feels
rushed or pressured to speak, they may become anxious, which can affect their ability to
communicate.
 Use short, uncomplicated sentences and do not change the topic of conversation too
quickly.
 Avoid asking open-ended questions. Closed questions that have a yes or no answer can be
better.
 Avoid finishing a person's sentences or correcting any errors in their language. This may
cause resentment and frustration for the person with aphasia.
 Keep distractions to a minimum, such as background radio or TV noise.
 Use paper and a pen to write down key words or draw diagrams or pictures to help
reinforce your message and support their understanding.
 If you do not understand something a person with aphasia is trying to communicate, do
not pretend you understand. The person may find this patronising and upsetting.
 Use visual references, such as pointing, gesturing and using objects, to support their
understanding.
 If they are having difficulty finding the right word, prompt them – ask them to describe
the word, think of a similar word, try to visualize it, think of the sound the word starts
with, try to write the word, use gestures or point to an object.
Other treatments
Research is currently being carried out to study whether other treatments can benefit people with
aphasia. These include:
 medication – such as piracetam, bifemelane, piribedil, bromocriptine and idebenone
 transcranial magnetic stimulation – where an electromagnet placed on the scalp is
stimulated for a short time using an electric current to stimulate parts of the brain affected
by aphasia

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DYSARTHRIA
DEFINITION
speech disorders resulting from a lack of motor control over the speech generation mechanisms
due to damage to the central or peripheral nervous system i.e., not damage to vocal cords,
pharynx, etc.
TYPES OF DYSARTHRIA
Type Description
Flaccid – weak
muscles
 Sound too nasal (this is because the velum
is too weak to close appropriately)
 Very breathy (in fact you can often hear
someone with flaccid dysarthria inhale)
 Usually speak in short phrases
 Tire quickly but recover after resting
 Monopitch (pitch of voice does not change
much)
 Monoloudness (unchanged volume), and
reduced loudness
Spastic – overly
tight muscles
 Harsh, strained/strangled vocal quality
 Low pitch
 Slow rate
much)
reduced loudness Intermittent breathy

23
segments
Hypokinetic –
usually
associated with
Parkinson’s;
have a hard time
getting going
and sustaining
 Breathy voices
 Teloscoping of syllables (random syllables
get stretched out)
much)
 Reduced Stress, so you’re not sure what
the most important parts of a sentence are
reduced loudness
 Intermittent breathy segments
 Inappropriate silences
 Short rushes of speech
 Variable rate of speech (how fast they
talk), but overall increased overall rate
 Palilalia – repeating sounds or words
 Echolalia – repeating other people’s
sounds or words
Ataxic – hard to
get sounds out
due to the effort
of coordinating
the entire speech
process
 Slow rate
 Everything sounds stressed (not like the
psychological stress, but in terms of using
prosody to show importance in a sentence)
 Articulation of speech sounds breaks down
randomly and inconsistently
 Vowels are particularly off
 Too much volume variation
 Teloscoping of syllables (random syllables

24
get stretched out) and phonemes (specific
sounds)
Hyperkinetic –
usually due to
Basal Ganglia
damage,so
there’s an
excess of
movement
(common in
Huntington’s,
Dystonia, and
others)
 Can hear inhales and exhales, often very
sharply and suddenly
 Harshness vocal quality
 Low pitch
 Slow rate
 Vowels distorted
 Too much variation in volume
much)
 Variable rate of speech
 Prolonged pauses
 Tremor in voice
 Sometimes hypernasal
 Harder to understand the faster they talk
 Odd vocal noises
 Echolalia (repeating words and sentences
from other people)
 Coprolalia (cursing)
 Coming and going of strained voice and
breathy voice
 Articulation of speech sounds breaks down
randomly and inconsistently

25
CAUSES
 The causes of dysarthria can be many, including toxic, metabolic, degenerative diseases
(such as parkinsonism, ALS, Huntington's disease, Niemann-Pick disease, ataxia etc.),
traumatic brain injury, or thrombotic or embolic stroke.
 These result in lesions to key areas of the brain involved in planning, executing, or
regulating motor operations in skeletal muscles (i.e. muscles of the limbs), including
muscles of the head and neck (dysfunction of which characterises dysarthria).
 These can result in dysfunction, or failure of: the motor or somatosensory cortex of the
brain, corticobulbar pathways, the cerebellum, basal nuclei (consisting of the putamen,
globus pallidus, caudate nucleus, substantia nigra etc.), brainstem (from which the cranial
nerves originate), or the neuro-muscular junction (in diseases such as myasthenia gravis)
which block the nervous system's ability to activate motor units and effect correct range
and strength of movements.
SIGNS & SYMPTOMS
Signs and symptoms of dysarthria vary, depending on the underlying cause and the type of
dysarthria, and may include:
 Slurred speech
 Slow speech
 Inability to speak louder than a whisper or speaking too loudly
 Rapid speech that is difficult to understand
 Nasal, raspy or strained voice
 Uneven or abnormal speech rhythm
 Uneven speech volume
 Monotone speech
 Difficulty moving your tongue or facial muscles

26
DIAGNOSTIC MEASURES
A speech-language pathologist might evaluate speech to help determine the type of dysarthria.
This can be helpful to the neurologist, who will look for the underlying cause.
Besides conducting a physical exam, doctor might order tests, including:
 Imaging tests. Imaging tests, such as an MRI or CT scan, create detailed images of brain,
head and neck that may help identify the cause of speech problem.
 Brain and nerve studies. These can help pinpoint the source of symptoms. An
electroencephalogram measures electrical activity in brain. An electromyogram evaluates
electrical activity in nerves as they transmit messages to muscles. Nerve conduction
studies measure the strength and speed of the electrical signals as they travel through the
nerves to the muscles.
 Blood and urine tests. These can help determine if an infectious or inflammatory disease
is causing symptoms.
 Lumbar puncture (spinal tap). In this procedure, a doctor or nurse inserts a needle in
lower back to remove a small sample of cerebrospinal fluid for laboratory testing. A
lumbar puncture can help diagnose serious infections, disorders of the central nervous
system, and cancers of the brain or spinal cord.
 Brain biopsy. If a brain tumor is suspected, doctor may remove a small sample of brain
tissue to test.
 Neuropsychological tests. These measure thinking (cognitive) skills, ability to understand
speech, ability to understand reading and writing, and other skills. Dysarthria doesn't
affect cognitive skills and understanding of speech and writing, but an underlying
condition can.
COMPLICATIONS
Because of the communication problems dysarthria causes, complications can include:
 Social difficulty. Communication problems may affect relationships with family and
friends and make social situations challenging.

27
 Depression. In some people, dysarthria may lead to social isolation and depression.
MANAGEMENT
Speech and language therapy
Patients have speech and language therapy to help regain normal speech and improve
communication. Speech therapy goals might include adjusting speech rate, strengthening muscles,
increasing breath support, improving articulation and helping family members communicate with
patient.
Speech-language pathologist may recommend other communication methods (augmentative and
alternative communication systems) to help communicate, if speech and language therapy isn't
effective. These communication methods could include visual cues, gestures, an alphabet board or
computer-based technology.
Coping and support
 Speak slowly. Listeners may understand better with additional time to think about what
they're hearing.
 Start small. Introduce topic with one word or a short phrase before speaking in longer
sentences.
 Gauge understanding. Ask listeners to confirm that they know what you're saying.
 If you're tired, keep it short. Fatigue can make your speech more difficult to understand.
 Have a backup. Writing messages can be helpful. Type messages on a cellphone or hand-
held device, or carry a pencil and small pad of paper with you.
 Use shortcuts. Create drawings and diagrams or use photos during conversations, so you
don't have to say everything. Gesturing or pointing to an object also can help convey your
message.
Family and friends
If you have a family member or friend with dysarthria, the following suggestions may help you
better communicate with that person:

28
 Allow the person time to talk.
 Don't finish sentences or correct errors.
 Look at the person when he or she is speaking.
 Reduce distracting noises in the environment.
 Tell the person if you're having trouble understanding.
 Keep paper and pencils or pens readily available.
 Help the person with dysarthria create a book of words, pictures and photos to assist with
conversations.
 Involve the person with dysarthria in conversations as much as possible.
 Talk normally. Many people with dysarthria understand others without difficulty, so
there's no need to slow down or speak loudly when you talk.
LSVT (Lee Silverman voice treatment)
More recent techniques based on the principles of motor learning (PML), such as LSVT (Lee
Silverman voice treatment) speech therapy and specifically LSVT may improve voice and speech
function in PD. For Parkinson's, aim to retrain speech skills through building new generalised
motor programs, and attach great importance to regular practice, through peer/partner support and
self-management. Regularity of practice, and when to practice, are the main issues in PML
treatments, as they may determine the likelihood of generalization of new motor skills, and
therefore how effective a treatment is.
Augmentative and alternative communication (AAC) devices that make coping with a dysarthria
easier include speech synthesis and text-based telephones. These allow people who are
unintelligible, or may be in the later stages of a progressive illness, to continue to be able to
communicate without the need for fully intelligible speech.
APRAXIA OF SPEECH
Apraxia of speech is a motor speech disorder. The messages from the brain to the mouth are
disrupted, and the person cannot move his or her lips or tongue to the right place to say sounds
correctly, even though the muscles are not weak. The severity of apraxia depends on the nature of

29
the brain damage. Apraxia can occur in conjunction with dysarthria (muscle weakness affecting
speech production) or aphasia (language difficulties related to neurological damage). Apraxia of
speech is also known as acquired apraxia of speech, verbal apraxia, and dyspraxia.
Children can also have apraxia, referred to as childhood apraxia of speech.
CAUSES
Apraxia of speech is caused by damage to the parts of the brain that control coordinated muscle
movement. A common cause of acquired apraxia is stroke. Other causes include traumatic brain
injury, dementia, brain tumors, and progressive neurological disorders.
SYMPTOMS
Individuals with apraxia may demonstrate:
 difficulty imitating and producing speech sounds, marked by speech errors such as sound
distortions, substitutions, and/or omissions;
 inconsistent speech errors;
 groping of the tongue and lips to make specific sounds and words;
 slow speech rate;
 impaired rhythm and prosody (intonation) of speech;
 better automatic speech (e.g., greetings) than purposeful speech;
 inability to produce any sound at all in severe cases.
DIAGNOSIS
A speech-language pathologist (SLP) uses a combination of formal and informal assessment tools
to diagnose apraxia of speech and determine the nature and severity of the condition. The
assessment typically includes examinations of the individual’s oral-motor abilities, melody of
speech, and speech sound production in a variety of contexts.
MANAGEMENT

30
 Articulatory-kinematic treatments almost always require verbal production in order to
bring about improvement of speech. One common technique for this is modeling or
repetition in order to establish the desired speech behavior. Articulatory-kinematic
treatments are based on the importance of patients to improve spatial and temporal aspects
of speech production.
 Rate and rhythm control treatments exist to improve errors in patients’ timing of
speech, a common characteristic of Apraxia. These techniques often include an external
source of control like metronomic pacing, for example, in repeated speech productions.
 Intersystemic reorganization/facilitation techniques often involve physical body or
limb gestural approaches to improve speech. Gestures are usually combined with
verbalization. It is thought that limb gestures may improve the organization of speech
production.
 Finally, alternative and augmentative communication approaches to treatment of
apraxia are highly individualized for each patient. However, they often involve a
"comprehensive communication system" that may include "speech, a communication book
aid, a spelling system, a drawing system, a gestural system, technologies, and informed
speech partners".
 One specific treatment method is referred to as PROMPT. This acronym stands for
Prompts for Restructuring Oral Muscular Phonetic Targets, and takes a hands on
multidimensional approach at treating speech production disorders. PROMPT therapists
integrate physical-sensory, cognitive-linguistic, and social-emotional aspects of motor
performance. The main focus is developing language interaction through this tactile-
kinetic approach by using touch cues to facilitate the articulatory movements associated
with individual phonemes, and eventually words.
 One study describes the use of electropalatography (EPG) to treat a patient with severe
acquired apraxia of speech. EPG is a computer-based tool for assessment and treatment of
speech motor issues. The program allows patients to see the placement of articulators
during speech production thus aiding them in attempting to correct errors. Originally after
two years of speech therapy, the patient exhibited speech motor and production problems
including problems with phonation, articulation, and resonance. This study showed that

31
EPG therapy gave the patient valuable visual feedback to clarify speech movements that
had been difficult for the patient to complete when given only auditory feedback.
APROSODY
 Aprosodia is a neurological condition characterized by the inability of a person to
properly convey or interpret emotional prosody. Prosody in language refers to the ranges
of rhythm, pitch, stress, intonation, etc.
 Typically caused by dysfunction in areas of the non-dominant hemisphere that structurally
mirror Broca's and Wernicke's areas
o lesions to the temporal cortex of the right hemisphere result in difficulties
understanding emotional aspects of language
o lesions in the frontal cortex of the right hemisphere result in difficulties in
producing language with emotional context
 may be secondary to another disease, particularly if the disease produces a flattening of
affect (i.e., depression or schizophrenia)
 at present as a difficulty with social interactions
 since generation of the emotional component of speech is dependent on generation of
speech itself, damage to the left hemisphere can appear to affect prosody, but this can be
tested by reducing the articulation demands to simpler words or phonemes that can be
produced by the right hemisphere
 Treatment: Due to the rarity of reported aprosodia cases, only a few labs are currently
researching treatment methods of aprosodia. The largest study of treatments for aprosodia
consisted of only fourteen individuals, resulting in sample sizes too small to report
statistical significance when comparing one treatment to another. However, the data
gained from this study still yielded some results and is being used in the next iteration of
aprosodia research.

32
NURSING MANAGEMENT
The nurse will need to assess the patients communication system to determine which skills intact
or deficient
Assessment
 Speaking in response to open ended questions
 Using vocabulary , grammar and syntax correctly; note spontaneity, hesitancy in
pronunciation, and speed of speech
 Responding appropriately to written instructions that are one to three steps in complexity
 Responding appropriately to verbal instructions that are one to three steps in complexity
 Expressing ideas in writing
 Note difficulty in expressing thoughts verbally, finding the correct , forming words or
sentences
 Other abnormal finding include slurring of speech
Several factors associated with neurological illness can mask an accurate assessment of
communication skills
 Altered level of consciousness
 Decreased visual acuity
 Dysarthria
 Cognitive deficits
 Unfamiliarity with language

33
Impaired verbal communication
related to:
A. impaired function of the muscles that are used to produce speech;
B. ischemia in the dominant cerebral hemisphere (ischemia of Wernicke's area in the
temporoparietal cortex will result in receptive [fluent, sensory] aphasia; ischemia of
Broca's area in the frontal cortex will result in expressive [nonfluent, motor] aphasia).
Desired Outcome
The client will communicate needs and desires effectively.
Nursing Actions and Selected Purposes/Rationales
A. Assess client for impaired verbal communication (e.g. inability to speak, difficulty
forming words or sentences, difficulty expressing thoughts verbally, inappropriate
verbalization). Validate verbal responses with an assessment of nonverbal behavior in
order to determine if client is experiencing receptive aphasia.
B. Implement measures to facilitate communication:
1. answer call signal in person rather than using the intercommunication system
2. maintain a patient, calm approach; listen attentively and allow ample time for
communication
3. maintain a calm, quiet environment so that client can concentrate on
communication efforts, does not have to speak loudly, and is able to hear others
clearly
4. ask questions that require short answers, eyeblinks, or nod of head if client is
having difficulty speaking and/or is frustrated or fatigued
5. schedule rest periods before visiting hours and speech therapy sessions to
maximize communication ability during those times
6. when speaking to client, face him/her; speak slowly; use direct, short statements;
repeat key words; present only one idea or thought at a time; and avoid using
unrelated gestures

34
7. provide materials such as magic slate, pad and pencil, computer, word cards,
and/or picture board if appropriate; try to ensure that placement of intravenous line
does not interfere with client's use of these communication aids
8. consult speech pathologist or therapist regarding methods for dealing with speech
impairments; reinforce exercises and techniques recommended.
C. Inform significant others and health care personnel of techniques being used to facilitate
client's ability to communicate. Stress the importance of consistent use of these
techniques.
D. Encourage significant others and staff to talk to client even if he/she is unresponsive or
unable to communicate.
E. Consult appropriate health care provider (e.g. speech pathologist, physician) if client
experiences increasing impairment of verbal communication.
Disturbed Sensory Perception
Nursing Diagnosis
 Disturbed Sensory Perception
May be related to
 Altered sensory reception, transmission, integration (neurological trauma or deficit)
 Psychological stress (narrowed perceptual fields caused by anxiety)
Possibly evidenced by
 Disorientation to time, place, person
 Change in behavior pattern/usual response to stimuli; exaggerated emotional responses
 Poor concentration, altered thought processes/bizarre thinking
 Reported/measured change in sensory acuity: hypoparesthesia; altered sense of taste/smell
 Inability to tell position of body parts (proprioception)
 Inability to recognize/attach meaning to objects (visual agnosia)
 Altered communication patterns

35
 Motor incoordination
Desired Outcomes
 Regain/maintain usual level of consciousness and perceptual functioning.
 Acknowledge changes in ability and presence of residual involvement.
 Demonstrate behaviors to compensate for/overcome deficits.
Nursing Interventions Rationale
Review pathology of individual condition.
Awareness on the type and areas of involvement
aid in assessing specific deficit and planning of
care.
Observe behavioral responses: crying,
inappropriate affect, agitation, hostility,
agitation, hallucination.
Individual responses are variable, but
commonalities such as emotional lability,
lowered frustration threshold, apathy, and
impulsiveness may complicate care.
Establish and maintain communication with the
patient. Set up a simple method of
communicating basic needs. Remember to
phrase your questions so he’ll be able to answer
using this system. Repeat yourself quietly and
calmly and use gestures when necessary to help
in understanding.
Note: even an unresponsive patient may be able
to hear, so don’t say anything in his presence
you wouldn’t want him to hear and remember.
Eliminate extraneous noise and stimuli as
necessary.
Reduces anxiety and exaggerated emotional
responses and confusion associated with sensory
overload.
Speak in calm, comforting, quiet voice, using
short sentences. Maintain eye contact.
Patient may have limited attention span or
problems with comprehension. These measures

36
can help patient attend to communication.
Ascertain patient’s perceptions. Reorient patient
frequently to environment, staff, procedures.
Assists patient to identify inconsistencies in
reception and integration of stimuli and may
reduce perceptual distortion of reality.
Evaluate for visual deficits. Note loss of visual
field, changes in depth perception (horizontal
and/or vertical planes), presence of diplopia
(double vision).
Presence of visual disorders can negatively
affect patient’s ability to perceive environment
and relearn motor skills and increases risk of
accident and injury.
Approach patient from visually intact side.
Leave light on; position objects to take
advantage of intact visual fields. Patch affected
eye if indicated.
Helps the patient to recognize the presence of
persons or objects and may help with depth
perception problems. This also prevents patient
from being startled. Patching the eye may
decrease sensory confusion of double vision.
Assess sensory awareness: dull from sharp, hot
from cold, position of body parts, joint sense.
Diminished sensory awareness and impairment
of kinesthetic sense negatively affects
balance and positioning and appropriateness of
movement, which interferes with ambulation,
increasing risk of trauma.
Stimulate sense of touch. Give patient objects to
touch, and hold. Have patient practice touching
walls boundaries.
Aids in retraining sensory pathways to integrate
reception and interpretation of stimuli. Helps
patient orient self spatially and strengthens use
of affected side.
Protect from temperature extremes; assess
environment for hazards. Recommend testing
warm water with unaffected hand.
Promotes patient safety, reducing risk of injury.

37
Note inattention to body parts, segments of
environment, lack of recognition of familiar
objects/persons.
Agnosia, the loss of comprehension of auditory,
visual, or other sensations, may lead result to
unilateral neglect, inability to recognize
environmental cues, considerable self-care
deficits, and disorientation or bizarre behavior.
Encourage patient to watch feet when
appropriate and consciously position body parts.
Make patient aware of all neglected body parts:
sensory stimulation to affected side, exercises
that bring affected side across midline,
reminding person to dress/care for affected
(“blind”) side.
Use of visual and tactile stimuli assists in
reintegration of affected side and allows patient
to experience forgotten sensations of normal
movement patterns.
3. Ineffective Coping
Nursing Diagnosis
 Ineffective Coping
May be related to
 Situational crises, vulnerability, cognitive perceptual changes
Possibly evidenced by
 Inappropriate use of defense mechanisms
 Inability to cope/difficulty asking for help
 Change in usual communication patterns
 Inability to meet basic needs/role expectations
 Difficulty problem solving

38
Desired Outcomes
 Verbalize acceptance of self in situation.
 Talk/communicate with SO about situation and changes that have occurred.
 Verbalize awareness of own coping abilities.
 Meet psychological needs as evidenced by appropriate expression of feelings,
identification of options, and use of resources.
Assess extent of altered perception and related
degree of disability. Determine Functional
Independence Measure score.
Determination of individual factors aids in
developing plan of care/choice of interventions
and discharge expectations.
Identify meaning of the dysfunction and change
to patient. Note ability to understand events,
provide realistic appraisal of the situation.
Independence is highly valued in American
culture but is not as significant in some cultures.
Some patients accept and manage altered
function effectively with little adjustment,
whereas others may have considerable difficulty
recognizing and adjust to deficits. In order to
provide meaningful support and appropriate
problem-solving, healthcare providers need to
understand the meaning of the stroke/limitations
to patient.
Determine outside stressors: family, work,
future healthcare needs.
Helps identify specific needs, provides
opportunity to offer information and begin
problem-solving. Consideration of social
factors, in addition to functional status, is
important in determining appropriate discharge
destination.
Provide psychological support and set realistic To increase the patient’s sense of confidence

39
short-term goals. Involve the patient’s SO in
plan of care when possible and explain his
deficits and strengths.
and can help in compliance to therapeutic
regimen.
Encourage patient to express feelings, including
hostility or anger, denial, depression, sense of
disconnectedness.
Demonstrates acceptance of patient in
recognizing and beginning to deal with these
feelings.
Note whether patient refers to affected side as
“it” or denies affected side and says it is “dead.”
Suggests rejection of body part and negative
feelings about body image and abilities,
indicating need for intervention and emotional
support.
Acknowledge statement of feelings about
betrayal of body; remain matter-of-fact about
reality that patient can still use unaffected side
and learn to control affected side. Use words
(weak, affected, right-left) that incorporate that
side as part of the whole body.
Helps patient see that the nurse accepts both
sides as part of the whole individual. Allows
patient to feel hopeful and begin to accept
current situation.
Identify previous methods of dealing with life
problems. Determine presence of support
systems.
Provides opportunity to use behaviors
previously effective, build on past successes,
and mobilize resources.
Emphasize small gains either in recovery of
function or independence.
Consolidates gains, helps reduce feelings of
anger and helplessness, and conveys sense of
progress.
Support behaviors and efforts such as increased
interest/participation in rehabilitation activities.
Suggest possible adaptation to changes and
understanding about own role in future lifestyle.
Monitor for sleep disturbance, increased May indicate onset of depression (common after

40
difficulty concentrating, statements of inability
to cope, lethargy, withdrawal.
effect of stroke), which may require further
evaluation and intervention.
Refer for neuropsychological evaluation and/or
counseling if indicated.
May facilitate adaptation to role changes that are
necessary for a sense of feeling/being a
productive person. Note: Depression is common
in stroke survivors and may be a direct result of
the brain damage and/or an emotional reaction
to sudden-onset disability.
Other Nursing Diagnoses
1. Injury, risk for—general weakness, visual deficits, balancing difficulties, reduced
large/small muscle or hand-eye coordination, cognitive impairment.
2. Nutrition: imbalanced, less than body requirements—inability to prepare/ingest food,
cognitive limitations, limited financial resources.
3. Self-care deficit—decreased strength/endurance, perceptual/cognitive impairment,
neuromuscular impairment, muscular pain, depression.
4. Home Maintenance, impaired—individual physical limitations, inadequate support
systems, insufficient finances, unfamiliarity with neighborhood resources.
5. Self-Esteem, situational low—cognitive/perceptual impairment, perceived loss of control
in some aspect of life, loss of independent functioning.
6. Caregiver Role Strain, risk for—severity of illness/deficits of care receiver, duration of
caregiving required, complexity/ amount of caregiving task, caregiver isolation/lack of
respite.

41
CONCLUSION
Neurogenic speech disorders are defined as an inability to exchange information with others due
to nervous system impairment. To help deal with this challenge, patients and family members
receive individual instruction on how to maximize communication, and are also provided with
information about community services and resources for patients with communication disorders

42
REVIEW OF LITERATURE
Broca aphasia Pathologic and clinical
J. P. MOHR, M.D.,
Abstract
The speech disturbance resulting from infarction limited to the Broca area has been delineated; it
differs from the speech disorder called Broca aphasia, which results from damage extending far
outside the Brocas area. Nor does Broca area infarction cause Broca aphasia. The lesions in 20
cases observed since 1972 were documented by autopsy, computerized tomography, or
arteriogram; the autopsy records from the Massachusetts General hospital for the past 20 years
and the published cases since 1820 were also reviewed. The findings suggest that infarction
affecting the Brocas area and its immediate environs, even deep into the brain, causes a mutism
that is replaced by a rapidly improving dyspraxic and effortful articulation, but that no significant
disturbance in language function persists. The more complex syndrome traditionally referred to as
Broca aphasia, including Broca's original case, is characterized by protracted mutism, verbal
stereotypes, and agrammatism. It is associated with a considerably larger infarct which
encompasses the operculum, including the Broca area, insula, and adjacent cerebrum, in the
territory supplied by the upper division of the left middle cerebral artery.
The Relationship Between Apraxia of Speech and Oral Apraxia: Association or
Dissociation?
Sandra P. Whiteside1, Lucy Dyson1,
Abstract
Acquired apraxia of speech (AOS) is a motor speech disorder that affects the implementation of
articulatory gestures and the fluency and intelligibility of speech. Oral apraxia (OA) is an
impairment of nonspeech volitional movement. Although many speakers with AOS also display
difficulties with volitional nonspeech oral movements, the relationship between the 2 conditions
is unclear. This study explored the relationship between speech and volitional nonspeech oral

43
movement impairment in a sample of 50 participants with AOS. We examined levels of
association and dissociation between speech and OA using a battery of nonspeech oromotor,
speech, and auditory/aphasia tasks. There was evidence of a moderate positive association
between the 2 impairments across participants. However, individual profiles revealed patterns of
dissociation between the 2 in a few cases, with evidence of double dissociation of speech and oral
apraxic impairment. We discuss the implications of these relationships for models of oral motor
and speech control.
Complementary and alternative medical approaches to treating adult neurogenic
communication disorders: a review.
Laures J, Shisler R.
Abstract
PURPOSE:
This paper reviews studies investigating the effectiveness of treating adult neurogenic
communication disorders with complementary and alternative medicines (CAM). CAM is
gradually experiencing recognition as a viable treatment approach for a variety of disorders by
practitioners and patients. Some patients are using CAM as an adjunct to traditional rehabilitation.
Additionally, speech-language pathologists are increasingly using CAM in treating
communication disorders.
METHOD:
This review provides a description of various CAM techniques including acupuncture, hypnosis,
relaxation training, dreamwork, biofeedback and homeopathy/herbal medicine. Investigations
exploring the effectiveness of each of these approaches as they have been applied to aphasia,
motor speech disorders, and cognitive impairments are discussed.

44
RESULTS AND CONCLUSIONS:
Little scientific inquiry into the effectiveness of CAM in the treatment of aphasia, motor speech
disorders, and cognitive impairments has occurred. Many of the reviewed studies demonstrate
inconsistent results; use limited sample sizes; do not include quantitative measures of cognitive,
linguistic or motor speech skills; and are poorly reported. This review suggests that further
exploration of this area is required before any strong conclusions regarding effectiveness and
efficacy of these techniques can be made.
Dysarthria in Adults with Cerebral Palsy: Clinical Presentation, Communication, and
Classification
T. Schölderle, A. Staiger, R. Lampe, K. Strecker, W. Ziegler
Abstract
Background: Cerebral palsy (CP) is the most prevalent disorder in neuropediatrics. About 80% of
the patients show symptoms of dysarthria frequently resulting in major restrictions of everyday
communication. However, to date, there is no comprehensive description of the clinical features
of dysarthria and their specific impact on communicative variables (e.g., intelligibility). Adult
patients with CP have been neglected particularly in the relevant literature, even though there are
several reports indicating that limitations of activity and participation increase throughout
adulthood due to functional deficits of speech. Moreover, previous studies assume that the motor
subtypes of CP manifest in distinct symptom patterns of speech (dysarthria syndromes), which
reflect the underlying pathomechanism (spasticity, dyskinesia, and ataxia). This presumption is
not confirmed by empirical data. The aims of the study were (1) to systematically describe the
clinical presentation of dysarthria in adults with CP, (2) to identify dysarthric symptoms that
especially account for the communication deficits, and (3) to compare patient groups with
different CP types regarding their dysarthria syndrome and the overall severity of the speech and
communication disorder.
Methods: A total of 45 adults (age, median = 23 [18-56] years, 20 females) with different motor
subtypes of CP participated in the study. The Bogenhausen Dysarthria Scales provided a detailed

45
neurophonetic profile for each patient. In several listening experiments, we assessed two
communication-relevant parameters (intelligibility and naturalness). For dysarthria syndrome
classification, we applied a statistical approach.
Results: A pronounced severity of dysarthria became evident in the majority of patients. The most
prominent symptoms affected voice quality as well as articulatory precision and rate. We
documented substantial reductions of intelligibility and naturalness, which were predicted by
articulatory and prosodic features of dysarthria. Although the overall severity of the speech and
communication disorder differed between motor subgroups (with patients of the dyskinetic
variant of CP being more severely affected), we found dissociations between CP type and
dysarthria syndrome in several cases.
Conclusion: Adults with CP have to cope with significant limitations of communication as a
consequence of dysarthric speech. Diagnostics and treatment should therefore target
communication-relevant aspects to orient toward the patients’ everyday social interactions. The
motor subtype of CP provides only limited information about the clinical presentation of
dysarthria. For the interpretation of this result, factors associated with the early brain damage in
CP might be considered.
rTMS as a treatment for neurogenic communication and swallowing disorders
C. H. S. Barwood* and B. E. Murdoch
Recent years have seen the introduction of non-invasive brain stimulation techniques (e.g.
transcranial direct current stimulation and transcranial magnetic stimulation) utilized to target
neural-based pathologies, for therapeutic gain. The direct manipulation of cortical brain activity
by repetitive transcranial magnetic stimulation (rTMS) could potentially serve as an efficacious
complimentary rehabilitatory treatment for speech, language and swallowing disorders of a
neurological origin. The high prevalence of positive reports on communication and swallowing
outcomes support these premises. Nonetheless, experimental evidence to date in some areas is
considered rudimentary and is deficient in providing placebo-controlled substantiation of
longitudinal neuroplastic change subsequent to stimulation. The most affirmative therapeutic

46
responses have arisen from small placebo-controlled trials using low-frequency rTMS for patients
with non-fluent aphasia and high-frequency rTMS applied to individuals with Parkinson's disease
to improve motor speech performance and outcomes. Preliminary studies applying rTMS to
ameliorate dysphagic symptoms post-stroke provide positive swallowing outcomes for patients.
Further research into the optimization of rTMS protocols, including dosage, stimulation targets
for maximal efficacy and placebo techniques, is critically needed to provide a fundamental basis
for clinical interventions using this technique. rTMS represents a highly promising and clinically
relevant technique, warranting the future development of clinical trials across a spectrum of
communication and swallowing pathologies, to substantiate and expand on the methods outlined
in published reports
BIBLIOGRAPHY
 Ellen Barker “ Neuroscience nursing a spectrum of care “ 3rd edition, mosby publications
 Joanne V. Hickey “ the clinical practice of neurological and neurosurgical nursing”5th
edition , Lippincott publications
 Mary Kay Buder, Linda R Littlejohns, AANN core curriculum for neuroscience nursing,
4th edition , Saunders publications.
 Driksenheitkemper lewis(2004),”medical surgical nursing”,edition-6th,newdelhi , mosby
publication
 Suddarth’s and burner;”textbookof medical surgicalnursing”;edition-
10th,philadelphia,lippincott wikins publication
Journal references
 Neurology April 1978 vol. 28 no. 4 311
 Arch Clin Neuropsychol (2015) doi: 10.1093/arclin/acv051
 Disabil Rehabil. 2004 Mar 18;26(6):315-25
 Neuropediatrics2014 DOI: 10.1055/s-0034-1390517
 Acta Neurologica Scandinavica, Volume 127, Issue 2, pages 77–91, February 2013
Net references
 www.pubmed.com
 www.wikipedia.com

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