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?

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.

Next: What are the types of aphasia?

Aphasia ( /fe/ or /fezi/) is an impairment of language ability. This class of language

disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write. Aphasia disorders usually develop quickly as a result of head injury or stroke, but can develop slowly from a brain tumor, infection, or dementia, or can be a learning disability such as dysnomia.
[1]

The area and extent of brain damage determine the type of aphasia and its symptoms. Aphasia types include Broca's aphasia, non-fluent aphasia, motor aphasia, expressive aphasia, receptive aphasia, global aphasia and many others (see Category:Aphasias). Medical evaluations for the disorder range from clinical screenings by a neurologist to extensive tests by a language pathologist.
[1]

Most aphasia patients can recover some or most skills by working with a speech and language therapist. This rehabilitation can take two or more years and is most effective when begun quickly. Only a small minority will recover without therapy, such as those suffering a mini-stroke. Patients with a learningdisorder aphasia such as dysnomia can learn coping skills, but cannot recover abilities that are congenitally limited.
[2]

Improvement varies widely, depending on the aphasia's cause, type, and severity. Recovery also depends on the patient's age, health, motivation,handedness, and educational level. [edit]Classification Classifying the different subtypes of aphasia is difficult and has led to disagreements among experts. The localizationist model is the original model, but modern anatomical techniques and analyses have shown that precise connections between brain regions and symptom classification don't exist. The neural organization of language is complicated; language is a comprehensive and complex behavior and it makes sense that it isn't the product of some small, circumscribed region of the brain. No classification of patients in subtypes and groups of subtypes is adequate. Only about 60% of patients will fit in a classification scheme such as fluent/nonfluent/pure aphasias. There is a huge variation among patients with the same diagnosis, and aphasias can be highly selective. For instance, patients with naming deficits (anomic aphasia) might show an inability only for naming buildings, or people, or colors. [edit]Localizationist
[3] [1]

model

Cortex

The localizationist model attempts to classify the aphasia by major characteristics and then link these to areas of the brain in which the damage has been caused. The initial two categories here were devised by early neurologists working in the field, namely Paul Broca and Carl Wernicke. Other researchers have added to the model, resulting in it often being referred to as the "Boston-Neoclassical Model". The most prominent writers on this topic have been Harold Goodglass and Edith Kaplan. Individuals with Broca's aphasia (also termed expressive aphasia) were once thought to have ventral temporal damage, though more recent work by Dr. Nina Dronkers using imaging and 'lesion analysis' has revealed that patients with Broca's aphasia have lesions to the medial insular cortex. Broca missed these lesions because his studies did not dissect the brains of diseased patients, so only the more temporal damage was visible. Dronkers and Dr. Odile Plaisant scanned Broca's original patients' brains using a non-invasive MRI scanner to take a closer look. Individuals with Broca's aphasia often have right-sided weakness or paralysis of the arm and leg, because the frontal lobe is also important for body movement. Video clips showing patients with Broca-type aphasia can be found here. In contrast to Broca's aphasia, damage to the temporal lobe may result in a fluent aphasia that is called Wernicke's aphasia (also termed sensory aphasia). These individuals usually have no body weakness, because their brain injury is not near the parts of the brain that control movement. A video clip with a patient exhibiting Wernicke's aphasia can be found here Working from Wernicke's model of aphasia, Ludwig Lichtheim proposed five other types of aphasia, but these were not tested against real patients until modern imaging made more in-depth studies available. The other five types of aphasia in the localizationist model are: 1. Pure word deafness 2. Conduction aphasia 3. Apraxia of speech (now considered a separate disorder in itself) 4. Transcortical motor aphasia 5. Transcortical sensory aphasia Anomia is another type of aphasia proposed under what is commonly known as the BostonNeoclassical model, which is essentially a difficulty with naming. A final type of aphasia, global aphasia, results from damage to extensive portions of the perisylvian region of the brain. An individual with global aphasia will have difficulty understanding both spoken and written language and will also

have difficulty speaking. This is a severe type of aphasia which makes it quite difficult when communicating with the individual. [edit]Other
[4]

ways to classify aphasia

Aphasia can also be classified as 1. Receptive 2. Intermediate 3. Expressive Receptive aphasias can be subdivided into A - pure word deafness (patient can hear but not understand words) B - alexia (patient can read but not understand words) C - visual asymbolia (written words are disorganized and can not be recognized). Intermediate - also called nominal amnestic aphasia. Expressive aphasia also known as Broca's aphasia or cortical motor aphasia (patient has difficulty in putting his thoughts into words) [edit]Fluent,

non-fluent and "pure" aphasias

The different types of aphasia can be divided into three categories: fluent, non-fluent and "pure" aphasias.
[5]

Fluent aphasias, also called receptive aphasias, are impairments related mostly to the input or reception of language, with difficulties either in auditory verbal comprehension or in the repetition of words, phrases, or sentences spoken by others. Speech is easy and fluent, but there are difficulties related to the output of language as well, such as paraphasia. Examples of fluent aphasias are:Wernicke's aphasia, Transcortical sensory aphasia, Conduction aphasia, Anomic aphasia
[5]

Nonfluent aphasias, also called expressive aphasias are difficulties in articulating, but in most cases there is relatively good auditory verbal comprehension. Examples of nonfluent aphasias are:Broca's aphasia, Transcortical motor aphasia, Global aphasia
[5]

"Pure" aphasias are selective impairments in reading, writing, or the recognition of words. These disorders may be quite selective. For example, a person is able to read but not write, or is able to write but not read. Examples of pure aphasias are: Pure alexia, Agraphia, Pure word deafness
[5]

[edit]Primary

and secondary aphasia

Aphasia can be divided into primary and secondary aphasia.

Primary aphasia is due to problems with language-processing mechanisms. Secondary aphasia is the result of other problems, like memory impairments, attention disorders, or perceptual problems.

[edit]Cognitive

neuropsychological model

The cognitive neuropsychological model builds on cognitive neuropsychology. It assumes that language processing can be broken down into a number of modules, each of which has a specific function. Hence there is a module which recognises phonemes as they are spoken and a module which stores formulated phonemes before they are spoken. Use of this model clinically involves conducting a battery of assessments (usually from the PALPA, the "psycholinguistic assessment of language processing in adult acquired aphasia ... that can be tailored to the investigation of an individual patient's impaired and intact abilities" http://www.psypress.com/palpa-9780863771668, last visited 1/21/2011), each of which tests one or a number of these modules. Once a diagnosis is reached as to where the impairment lies, therapy can proceed to treat the individual module. [edit]Acquired

childhood aphasia

Acquired childhood aphasia (ACA) is a language impairment resulting from some kind of brain damage. This brain damage can have different causes, such as head trauma, tumors, cerebrovascularaccidents, or seizure disorders. Most, but not all authors state that ACA is preceded by a period of normal language development.
[6]

Age of onset is usually defined as from infancy until but not including adolescence.

ACA should be distinguished from developmental aphasia or developmental dysphasia, which is a primary delay or failure in language acquisition.
[8] [7]

An important difference between ACA and

developmental childhood aphasia is that in the latter there is no apparent neurological basis for the language deficit.

ACA is one of the more rare language problems in children and is notable because of its contribution to theories on language and the brain.
[7]

Because there are so few children with ACA, not much is known

about what types of linguistic problems these children have. However, many authors report a marked decrease in the use of all expressive language. Children can just stop talking for a period of weeks or even years, and when they start to talk again, they need a lot of encouragement. Problems with language comprehension are less common in ACA, and don't last as long. [edit]Signs
[9]

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 inability to name objects poor enunciation excessive creation and use of personal neologisms inability to repeat a phrase persistent repetition of phrases 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

The following table summarizes some major characteristics of different types of aphasia: Type of aphasia Auditory comprehension

Repetition

Naming

Fluency

Presentation

Wernicke's aphasia

mildmod

mild severe

defective

Individuals with Wernicke's aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create new "words" (neologisms). For example, someone with Wernicke's aphasia may say, "You know that smoodle pinkered and that I want to get fluent him round and take care of him like you paraphasic want before", meaning "The dog needs to go out so I will take him for a walk". They have poor auditory and reading comprehension, and fluent, but nonsensical, oral and written expression. Individuals with Wernicke's aphasia usually have great difficulty understanding the speech of both

Type of aphasia

Repetition

Naming

Auditory comprehension

Fluency

Presentation

themselves and others and are therefore often unaware of their mistakes.

Transcortical sensory Good aphasia

mod severe

poor

fluent

Similar deficits as in Wernicke's aphasia, but repetition ability remains intact.

Conduction aphasia

Poor

poor

relatively good

fluent

Conduction aphasia is caused by deficits in the connections between the speechcomprehension and speech-production areas. This might be caused by damage to the arcuate fasciculus, the structure that transmits information between Wernicke's area and Broca's area. Similar symptoms, however, can be present after damage to the insula or to theauditory cortex. Auditory comprehension is near normal, and oral expression is fluent with occasional paraphasic errors. Repetition ability is poor.

Nominal or Anomic aphasia

Mild

mod severe

mild

fluent

Anomic aphasia is essentially a difficulty with naming. The patient 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.

Broca's aphasia

modsevere

mod severe

mild difficulty

Individuals with Broca's aphasia non-fluent, frequently speak short, meaningful effortful, phrases that are produced with great

Type of aphasia

Repetition

Naming

Auditory comprehension

Fluency

Presentation

slow

effort. Broca's aphasia is thus characterized as a nonfluent aphasia. Affected people often omit small words such as "is", "and", and "the". For example, a person with Broca's aphasia may say, "Walk dog" which could mean "I will take the dog for a walk", "You take the dog for a walk" or even "The dog walked out of the yard". Individuals with Broca's aphasia are able to understand the speech of others to varying degrees. Because of this, they are often aware of their difficulties and can become easily frustrated by their speaking problems. It is associated with right hemiparesis, meaning that there can be paralysis of the patient's right face and arm.

Transcortical motor Good aphasia

mild severe

mild

Similar deficits as Broca's aphasia, except repetition ability remains intact. Auditory comprehension is generally fine for simple conversations, but declines rapidly non-fluent for more complex conversations. It is associated with right hemiparesis, meaning that there can be paralysis of the patient's right face and arm.

Global aphasia

Poor

poor

poor

Individuals with global aphasia have severe communication difficulties and will be extremely limited in their ability to speak or comprehend language. They may be totally nonverbal, and/or only use non-fluent facial expressions and gestures to communicate. It is associated with right hemiparesis, meaning that there can be paralysis of the patient's right face and arm.

Type of aphasia

Repetition

Naming

Auditory comprehension

Fluency

Presentation

Mixed transcortical Moderate aphasia

poor

poor

non-fluent

Similar deficits as in global aphasia, but repetition ability remains intact.

Subcortical aphasias

Characteristics and symptoms depend upon the site and size of subcortical lesion. Possible sites of lesions include thethalamus, internal capsule, and basal ganglia.

Jargon aphasia is a fluent or receptive aphasia in which the patient's speech is incomprehensible, but appears to make sense to them. Speech is fluent and effortless with intact syntax and grammar, but the patient has problems with the selection of nouns. They will either replace the desired word with another that sounds or looks like the original one, or has some other connection, or they will replace it with sounds. Accordingly, patients with jargon aphasia often use neologisms, and may perseverate if they try to replace the words they can't find with sounds. Commonly, substitutions involve picking another (actual) word starting with the same sound (e.g. clocktower - colander), picking another semantically related to the first (e.g. letter - scroll), or picking one phonetically similar to the intended one (e.g. lane - late). [edit]Causes Aphasia usually results from lesions to the language-relevant areas of the frontal, temporal and parietal lobes of the brain, such as Broca's area, Wernicke's area, and the neural pathways between them. These areas are almost always located in the left hemisphere, and in most people this is where the ability to produce and comprehend language is found. However, in a very small number of people, language ability is found in the right hemisphere. In either case, damage to these language areas can be caused by a stroke, traumatic brain injury, or other brain injury. Aphasia may also develop slowly, as in the case of a brain tumor or progressive neurological disease, e.g., Alzheimer's or Parkinson's disease. It may also be caused by a sudden hemorrhagic event within the brain. Certain chronic neurological disorders, such as epilepsy or migraine, can also include transient aphasia as a prodromal or episodic symptom.
needed] [10] [citation

Aphasia is also listed as a rare side effect of the fentanyl patch, an opioid used to control chronic

pain.

[edit]Treatment There is no one treatment proven to be effective for all types of aphasias. The reason that there is no universal treatment for aphasia is because of the nature of the disorder and the various ways it is presented, as explained in the above sections. Aphasia is rarely exhibited identically, implying that treatment needs to be catered specifically to the individual. Studies have shown that although there isn't consistency on treatment methodology in literature, there is a strong indication that treatment in general has positive outcomes
[11]

A multi-disciplinary team, including doctors (often a physician is involved, but more likely a clinical neuropsychologist will head the treatment team), physiotherapist, occupational therapist, speechlanguage pathologist, and social worker, works together in treating aphasia. For the most part, treatment relies heavily on repetition and aims to address language performance by working on task-specific skills. The primary goal is to help the individual and those closest to them adjust to changes and limitations in communication
[11]

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 which 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. Other - i.e. drawing as a way of communicating, trained conversation partners
[11] [11]

More recently, computer technology has been incorporated into treatment options. A key indication for good prognosis is treatment intensity. A minimum of 2-3 hours per week has been specified to produce positive results
[12]

. The main advantage of using computers is that it can greatly increase intensity of

therapy. These programs consist of a large variety of exercises and can be done at home in addition to face-to-face treatment with a therapist. However, since aphasia presents differently among individuals,

these programs must be dynamic and flexible in order to adapt to the variability in impairments. Another barrier is the capability of computer programs to imitate normal speech and keep up with the speed of regular conversation. Therefore, computer technology seems to be limited in a communicative setting, however is effective in producing improvements in communication training
[12]

Several examples of programs used are StepByStep, Linguagraphica, Computer-Based Visual Communication (C-VIC), TouchSpeak (TS), and Sentence Shaper
[12]

Melodic intonation therapy is often used to treat non-fluent aphasia and has proved to be very effective in some cases
[13]

[edit]History

What are the types of aphasia?

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 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. 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. 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 usingfunctional 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