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The Aphasias. Woodford A. Beach, MS, CCC/SP Senior Speech-Language Pathologist Clinical Instructor, Otolaryngology MCVH&P of VCUHS May 3, 2002. Objectives. Define aphasia Review Boston aphasia classification Consider atypical aphasias Note other neurogenic communication disorders.

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the aphasias

The Aphasias

Woodford A. Beach, MS, CCC/SP

Senior Speech-Language Pathologist

Clinical Instructor, Otolaryngology

MCVH&P of VCUHS

May 3, 2002

objectives
Objectives
  • Define aphasia
  • Review Boston aphasia classification
  • Consider atypical aphasias
  • Note other neurogenic communication disorders
aphasia
Aphasia
  • acquired language disorder, that is a CNS disturbance of the capacity to interpret and formulate symbols for communicative purposes
  • secondary to focal brain damage
    • perisylvian region
    • dominant hemisphere
    • not due to diffuse or multifocal dysfunction
aphasia4
Aphasia
  • characterized by impairment in connected speech and conversation, auditory comprehension, repetition, naming, reading, & writing
dysarthria
Dysarthria
  • group of speech disorders
  • neurogenic
  • associated with CNS, PNS, muscle pathology
dysarthria8
Dysarthria
  • movement disorder
  • abnormal neuromuscular execution
    • affects speed, strength, timing, accuracy
    • affects respiration, phonation, resonance, articulation, and prosody

Darley, Aronson, & Brown 1975

apraxia of speech
Apraxia of Speech
  • disorder of motor planning
  • absence of aphasia & neuromotor deficits
  • characterized by symptom variability
    • mutism
    • difficulty initiating speech
    • problems in syllable transition
    • more difficulty in volitional than automatic
    • more difficulty in long than short
    • more difficulty in complex than simple
apraxia of speech10
Apraxia of Speech
  • Often
    • articulatory struggle
    • phoneme metathesis
    • syllable transposition

Duffy 1995

slide11
Aphasia is not language of confusion
  • Aphasia is not due to psychiatric disease
  • Aphasia is not due to primary cognitive dysfunction
  • it is focal, and not caused by multifocal or diffuse brain disease
assessment of aphasia formal
Assessment of Aphasia:Formal
  • Boston Diagnostic Aphasia Examination
  • Western Aphasia Battery
  • Burns Left Hemisphere Inventory
  • Boston Assessment of Severe Aphasia
  • Aphasia Diagnostic Profiles
  • Boston Naming Test
  • Minnesota Test for the Differential Diagnosis of Aphasia
assessment of aphasia informal
Assessment of Aphasia:Informal
  • Conversation & Connected Speech
    • fluent
    • hyperfluent (logorrhea or press of speech)
    • nonfluent
    • grammatic/paragrammatic/agrammatic
    • empty
    • appropriate without dyspragmias
assessment of aphasia informal16
Assessment of Aphasia:Informal
  • Conversation & Connected Speech
    • if there is only minimal speech
      • automatic series (counting, days of week)
      • singing
    • does the patient engage linguistically
assessment of aphasia informal17
Assessment of Aphasia:Informal
  • Auditory Comprehension
    • commands
      • 1 part axial
      • 1 part other
      • 2 part
      • 3 part
    • yes/no questions with known answer
      • orientation
      • bizarre
      • complex
assessment of aphasia informal18
Assessment of Aphasia:Informal
  • Repetition
    • repeat sentences
      • “No ifs, ands, or buts”
      • “They heard him speak on the radio last night”
    • repeat words
      • vary length and familiarity
assessment of aphasia informal19
Assessment of Aphasia:Informal
  • Word Retrieval
    • confrontation
      • name objects
      • name parts of objects
    • responsive
      • answer questions
    • verbal fluency
      • list words belonging to semantic class or beginning with common letter
assessment of aphasia informal20
Assessment of Aphasia:Informal
  • Word Retrieval Errors
    • paraphasias: word substitutions
    • circumlocutions: talk around target
    • neologisms: nonwords
    • stereotypy: restricted subpropositional forms (often yes & no)
    • frank dysnomia: no response or do not know
assessment of aphasia informal21
Assessment of Aphasia:Informal
  • Reading Comprehension
    • silent reading of command
    • silent reading of yes/no question
    • oral reading is not reading comprehension any more than dictation or copying are written expression
    • If reading comprehension compromised, assess oral reading
assessment of aphasia informal22
Assessment of Aphasia:Informal
  • Written Expression
    • generate sentence given stimulus word
    • automatic writing (e.g. signature) is not written expression
    • If writing impaired, assess taking dictation, then copying of words or figures
boston aphasia classification
Boston Aphasia Classification
  • Relative sparing vs relative impairment
  • Reading and writing always impaired
  • Differentiate aphasias in
    • fluency
    • auditory comprehension
    • repetition
    • naming
classic boston aphaisas
Nonfluent

Broca

Global

Transcortical Motor

Mixed Transcortical (isolation syndrome)

Fluent

Wernicke

Conduction

Anomic

Transcortical sensory

Classic Boston Aphaisas
disclaimers caveats re aphasia taxonomy
Disclaimers & caveats re: aphasia taxonomy
  • Receptive/expressive dichotomy invalid
    • all aphasias have an expressive component
    • all aphasias have a receptive component
  • If you are binary, use the fluent/nonfluent dichotomy
disclaimers caveats re aphasia taxonomy28
Disclaimers & caveats re: aphasia taxonomy
  • Other taxonomies exist
  • Some researchers argue that aphasia is a unary phenomenon
  • Metter showed that PET scans demonstrate metabolic hypodensities distal to site of lesion (is this diaschisis of von Monokow?)
  • Reliability dogs all taxonomies
disclaimers caveats re aphasia taxonomy29
Disclaimers & caveats re: aphasia taxonomy
  • Taxonomies often fail to capture characterististics of aphasia which are important therapeutically
  • e.g., Broca’s Aphasia
    • agrammatism
    • dysfluency
  • Labels are abbreviations. Describe Sxs!
disclaimers caveats re aphasia taxonomy30
Disclaimers & caveats re: aphasia taxonomy
  • Boston model fails to capture
    • natural course and evolution of aphasia
    • severity
    • localization consistently
  • Boston group admits:
    • “In many instances (30-40% of unselected cases), inspection of the speech characteristics leads directly to a diagnostic assignment” Albert et al. 1981
    • Therefore, are 60-70% aphasias mixed?
disclaimers caveats re aphasia taxonomy31
Disclaimers & caveats re: aphasia taxonomy
  • Research by Nina Dronkers (2000)
    • Chronic Broca’s
      • N=12 with Broca’s aphasia
      • 2 had lesions sparing Broca’s area
      • 10 others with Broca’s lesion had no persisting Broca’s aphasia
      • Chronic Broca’s Aphasia always involved insula
    • Chronic Wernicke’s
      • N= 7 with Wernicke’s aphasia
      • 2 had lesions sparing Wernicke’s
      • 7 others with Wernicke’s lesion had no persisting Wernicke’s aphasia
      • Chronic Wernicke’s always has large temporal lesion with destruction of posterior MTG
    • Data reflect structural lesions in chronic aphasias
localization of classical aphasias
Localization of Classical Aphasias
  • Broca: third left frontal convolution
  • Global: entire perisylvian region
  • Transcortical Motor: anterior watershed
  • Mixed Transcortical: anterior watershed & posterior watershed
localization of classical aphasias35
Localization of Classical Aphasias
  • Broca: third left frontal convolution
  • Global: entire perisylvian region
  • Transcortical Motor: anterior watershed
  • Mixed Transcortical: anterior watershed & posterior watershed
localization of classical aphasias37
Localization of Classical Aphasias
  • Broca: third left frontal convolution
  • Global: entire perisylvian region
  • Transcortical Motor: anterior watershed
  • Mixed Transcortical: anterior watershed & posterior watershed
localization of classical aphasias39
Localization of Classical Aphasias
  • Broca: third left frontal convolution
  • Global: entire perisylvian region
  • Transcortical Motor: anterior watershed
  • Mixed Transcortical: anterior watershed & posterior watershed
localization of classical aphasias41
Localization of Classical Aphasias
  • Wernicke: posterior, superior temporal lobe
  • Conduction: archuate fasciculus; inferior parietal lobe
  • Transcortical sensory: posterior watershed
  • Anomic: posterior: temporoparietal?
localization of classical aphasias43
Localization of Classical Aphasias
  • Wernicke: posterior, superior temporal lobe
  • Conduction: archuate fasciculus; inferior parietal lobe
  • Transcortical sensory: posterior watershed
  • Anomic: posterior: temporoparietal?
localization of classical aphasias45
Localization of Classical Aphasias
  • Wernicke: posterior, superior temporal lobe
  • Conduction: archuate fasciculus; inferior parietal lobe
  • Transcortical sensory: posterior watershed
  • Anomic: posterior: temporoparietal?
localization of classical aphasias47
Localization of Classical Aphasias
  • Wernicke: posterior, superior temporal lobe
  • Conduction: archuate fasciculus; inferior parietal lobe
  • Transcortical sensory: posterior watershed
  • Anomic: posterior: temporoparietal?
dorsolateral syndrome
Dorsolateral Syndrome
  • Reduced selective attention
  • lack of drive & awareness
  • reduced initiation
  • dynamic aphasia of Luria
  • Localize to frontal dorsolateral cortex
    • anterior and inferior to Broca’s area

Frattali 2000

aphasia in dls
Aphasia in DLS
  • decreased spontaneous speech
  • limits in amount and range of narrative
  • reduced verbal fluency
  • limited capacity to formulate propositions

Frattali 2000

dls and tma
DLS and TMA
  • TMA lesion is larger and less circumscribed.
  • Fewer behavioral manifestations

Frattali 2000

orbitomedial syndrome
Orbitomedial Syndrome
  • Deficit in exclusionary attention
  • utilization behavior
  • impulsive
  • poor inhibition
  • impaired moral judgment
  • localized to frontal orbomedial cortex

Frattili 2000

subcortical aphasia
Subcortical aphasia
  • Thalamic Aphasia
      • fluent with occasional dysfluency
      • paraphasias, neologisms, & word finding impaired
      • repetition intact
      • perseveration
  • Left caudate, putamen, ALIC Aphasia
      • limited spontaneous speech
      • intact repetition
      • mild anomia
      • relatively spared comprehension
atypical aphasias
Atypical Aphasias
  • Aphemia & Anarthria
  • Alexia without agraphia
  • Alexia with agraphia
  • Pure word deafness
  • Pure agraphia
atypical aphasias56
Atypical Aphasias
  • Gerstmann’s Syndrome
    • r/l disorientation
    • finger agnosia
    • dyscalculia
    • dysgraphia
  • Angular Gyrus Syndrome
    • anomia
    • alexia
    • Gerstmann’s Syndrome
nonaphasic language disorders
Nonaphasic Language Disorders
  • TBI
  • Minor hemisphere CVA
  • Dementias
  • Primary progressive aphasia
  • Diffuse & multifocal neurological deficits (encephalopathies)
  • Seizures
treatment in a nutshell
Treatment in a Nutshell
  • Aphasia therapy is efficacious
    • Robey
    • Frattali
  • It must exceed 2 hours per week (i.e., rehab frequency)
treatment in a nutshell60
Treatment in a Nutshell
  • Symptomatic
  • Multimodal
  • Gradually increasing in complexity
  • should focus on both deficits and compensatory strategies
  • should consider communicative handicap