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Aphasia

In aphasia (sometimes called dysphasia),[a] a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions.[2] The major causes are stroke and head trauma; prevalence is hard to determine but aphasia due to stroke is estimated to be 0.1–0.4% in the Global North.[3] Aphasia can also be the result of brain tumors, epilepsy, autoimmune neurological diseases,[4] brain infections,[5] or neurodegenerative diseases (such as dementias).[6][7]

Not to be confused with aphakia, aphagia, or aphantasia.

To be diagnosed with aphasia, a person's language must be significantly impaired in one (or more) of the four aspects of communication. Alternatively, in the case of progressive aphasia, it must have significantly declined over a short period of time. The four aspects of communication are spoken language production and comprehension and written language production and comprehension; impairments in any of these aspects can impact on functional communication.


The difficulties of people with aphasia can range from occasional trouble finding words, to losing the ability to speak, read, or write; intelligence, however, is unaffected.[7] Expressive language and receptive language can both be affected as well. Aphasia also affects visual language such as sign language.[2] In contrast, the use of formulaic expressions in everyday communication is often preserved.[8] For example, while a person with aphasia, particularly expressive aphasia (Broca's aphasia), may not be able to ask a loved one when their birthday is, they may still be able to sing "Happy Birthday". One prevalent deficit in all aphasias is anomia, which is a difficulty in finding the correct word.[9]: 72 


With aphasia, one or more modes of communication in the brain have been damaged and are therefore functioning incorrectly. Aphasia is not caused by damage to the brain resulting in motor or sensory deficits, thus producing abnormal speech – that is, aphasia is not related to the mechanics of speech, but rather the individual's language cognition. However, it is possible for a person can have both problems, e.g. in the case of a hemorrhage damaging a large area of the brain. An individual's language abilities incorporate the socially shared set of rules, as well as the thought processes that go behind communication (as it affects both verbal and nonverbal language). Aphasia is not a result of other peripheral motor or sensory difficulty, such as paralysis affecting the speech muscles, or a general hearing impairment.


Neurodevelopmental forms of auditory processing disorder are differentiable from aphasia in that aphasia is by definition caused by acquired brain injury, but acquired epileptic aphasia has been viewed as a form of APD.

Self-repairs: Further disruptions in fluent speech as a result of mis-attempts to repair erred speech production.

[12]

Struggle in non-fluent aphasias: A severe increase in expelled effort to speak after a life where talking and communicating was an ability that came so easily can cause visible frustration.

Preserved and automatic language: A behavior in which some language or language sequences that were used so frequently prior to onset are still produced with more ease than other language post onset.

Causes[edit]

Aphasia is most often caused by stroke, where about a quarter of patients who experience an acute stroke develop aphasia.[39] However, any disease or damage to the parts of the brain that control language can cause aphasia. Some of these can include brain tumors, traumatic brain injury, epilepsy and progressive neurological disorders.[40] In rare cases, aphasia may also result from herpesviral encephalitis.[41] The herpes simplex virus affects the frontal and temporal lobes, subcortical structures, and the hippocampal tissue, which can trigger aphasia.[42] In acute disorders, such as head injury or stroke, aphasia usually develops quickly. When caused by brain tumor, infection, or dementia, it develops more slowly.[7][43]


Substantial damage to tissue anywhere within the region shown in blue (on the figure in the infobox above) can potentially result in aphasia.[1] Aphasia can also sometimes be caused by damage to subcortical structures deep within the left hemisphere, including the thalamus, the internal and external capsules, and the caudate nucleus of the basal ganglia.[44][45] The area and extent of brain damage or atrophy will determine the type of aphasia and its symptoms.[7][43] A very small number of people can experience aphasia after damage to the right hemisphere only. It has been suggested that these individuals may have had an unusual brain organization prior to their illness or injury, with perhaps greater overall reliance on the right hemisphere for language skills than in the general population.[46][47]


Primary progressive aphasia (PPA), while its name can be misleading, is actually a form of dementia that has some symptoms closely related to several forms of aphasia. It is characterized by a gradual loss in language functioning while other cognitive domains are mostly preserved, such as memory and personality. PPA usually initiates with sudden word-finding difficulties in an individual and progresses to a reduced ability to formulate grammatically correct sentences (syntax) and impaired comprehension. The etiology of PPA is not due to a stroke, traumatic brain injury (TBI), or infectious disease; it is still uncertain what initiates the onset of PPA in those affected by it.[48]


Epilepsy can also include transient aphasia as a prodromal or episodic symptom.[49] However, the repeated seizure activity within language regions may also lead to chronic, and progressive aphasia. Aphasia is also listed as a rare side-effect of the fentanyl patch, an opioid used to control chronic pain.[50]

Diagnosis[edit]

Neuroimaging methods[edit]

Magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) are the most common neuroimaging tools used in identifying aphasia and studying the extent of damage in the loss of language abilities. This is done by doing MRI scans and locating the extent of lesions or damage within brain tissue, particularly within areas of the left frontal and temporal regions- where a lot of language related areas lie. In fMRI studies a language related task is often completed and then the BOLD image is analyzed. If there are lower than normal BOLD responses that indicate a lessening of blood flow to the affected area and can show quantitatively that the cognitive task is not being completed.


There are limitations to the use of fMRI in aphasic patients particularly. Because a high percentage of aphasic patients develop it because of stroke there can be infarct present which is the total loss of blood flow. This can be due to the thinning of blood vessels or the complete blockage of it. This is important in fMRI as it relies on the BOLD response (the oxygen levels of the blood vessels), and this can create a false hyporesponse upon fMRI study.[51] Due to the limitations of fMRI such as a lower spatial resolution, it can show that some areas of the brain are not active during a task when they in reality are. Additionally, with stroke being the cause of many cases of aphasia the extent of damage to brain tissue can be difficult to quantify therefore the effects of stroke brain damage on the functionality of the patient can vary.


Neural substrates of aphasia subtypes


MRI is often used to predict or confirm the subtype of aphasia present. Researchers compared 3 subtypes of aphasia- nonfluent-variant primary progressive aphasia (nfPPA), logopenic-variant primary progressive aphasia (lvPPA), and semantic-variant primary progressive aphasia (svPPA), with primary progressive aphasia (PPA) and Alzheimer's disease. This was done by analyzing the MRIs of patients with each of the subsets of PPA.[52] Images which compare subtypes of aphasia as well as for finding the extent of lesions are generated by overlapping images of different participant's brains (if applicable) and isolating areas of lesions or damage using third-party software such as MRIcron. MRI has also been used to study the relationship between the type of aphasia developed and the age of the person with aphasia. It was found that patients with fluent aphasia are on average older than people with non-fluent aphasia. It was also found that among patients with lesions confined to the anterior portion of the brain an unexpected portion of them presented with fluent aphasia and were remarkably older than those with non-fluent aphasia. This effect was not found when the posterior portion of the brain was studied.[53]


Associated conditions


In a study on the features associated with different disease trajectories in Alzheimer's disease (AD)-related primary progressive aphasia (PPA), it was found that metabolic patterns via PET SPM analysis can help predict progression of total loss of speech and functional autonomy in AD and PPA patients. This was done by comparing an MRI or CT image of the brain and presence of a radioactive biomarker with normal levels in patients without Alzheimer's Disease.[54] Apraxia is another disorder often correlated with aphasia. This is due to a subset of apraxia which affects speech. Specifically, this subset affects the movement of muscles associated with speech production, apraxia and aphasia are often correlated due to the proximity of neural substrates associated with each of the disorders.[55] Researchers concluded that there were 2 areas of lesion overlap between patients with apraxia and aphasia, the anterior temporal lobe and the left inferior parietal lobe.[56]


Treatment and neuroimaging


Evidence for positive treatment outcomes can also be quantified using neuroimaging tools. The use of fMRI and an automatic classifier can help predict language recovery outcomes in stroke patients with 86% accuracy when coupled with age and language test scores. The stimuli tested were sentences both correct and incorrect and the subject had to press a button whenever the sentence was incorrect. The fMRI data collected focused on responses in regions of interest identified by healthy subjects.[57]  Recovery from aphasia can also be quantified using diffusion tensor imaging. The accurate fasciculus (AF) connects the right and left superior temporal lobe, premotor regions/posterior inferior frontal gyrus. and the primary motor cortex. In a study which enrolled patients in a speech therapy program, an increase in AF fibers and volume was found in patients after 6-weeks in the program which correlated with long-term improvement in those patients.[58] The results of the experiment are pictured in Figure 2. This implies that DTI can be used to quantify the improvement in patients after speech and language treatment programs are applied.

Classification[edit]

Aphasia is best thought of as a collection of different disorders, rather than a single problem. Each individual with aphasia will present with their own particular combination of language strengths and weaknesses. Consequently, it is a major challenge just to document the various difficulties that can occur in different people, let alone decide how they might best be treated. Most classifications of the aphasias tend to divide the various symptoms into broad classes. A common approach is to distinguish between the fluent aphasias (where speech remains fluent, but content may be lacking, and the person may have difficulties understanding others), and the nonfluent aphasias (where speech is very halting and effortful, and may consist of just one or two words at a time).[59]


However, no such broad-based grouping has proven fully adequate, or reliable. There is wide variation among people even within the same broad grouping, and aphasias can be highly selective. For instance, people with naming deficits (anomic aphasia) might show an inability only for naming buildings, or people, or colors.[60] Unfortunately, assessments that characterize aphasia in these groupings have persisted. This is not helpful to people living with aphasia, and provides inaccurate descriptions of an individual pattern of difficulties.


It is important to note that there are typical difficulties with speech and language that come with normal aging as well. As we age, language can become more difficult to process resulting in a slowing of verbal comprehension, reading abilities and more likely word finding difficulties. With each of these, though, unlike some aphasias, functionality within daily life remains intact.[9]: 7 

Exercising regularly

Eating a healthy diet, avoiding cholesterol in particular

Keeping alcohol consumption low and avoiding tobacco use

Controlling blood pressure

[90]

Going to the emergency room immediately if you begin to experience unilateral extremity (especially leg) swelling, warmth, redness, and/or tenderness as these are symptoms of a deep vein thrombosis which can lead to a stroke

[91]

Aphasia is largely caused by unavoidable instances. However, some precautions can be taken to decrease risk for experiencing one of the two major causes of aphasia: stroke and traumatic brain injury (TBI). To decrease the probability of having an ischemic or hemorrhagic stroke, one should take the following precautions:


To prevent aphasia due to traumatic injury, one should take precautionary measures when engaging in dangerous activities such as:


Additionally, one should always seek medical attention after sustaining head trauma due to a fall or accident. The sooner that one receives medical attention for a traumatic brain injury, the less likely one is to experience long-term or severe effects.[93]

Copy and recall therapy (CART) – repetition and recall of targeted words within therapy may strengthen orthographic representations and improve single word reading, writing, and naming

[100]

Visual communication therapy (VIC) – the use of index cards with symbols to represent various components of speech

Visual action therapy (VAT) – typically treats individuals with global aphasia to train the use of hand gestures for specific items

[101]

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 people with aphasia and clinicians. In this kind of therapy, the focus is on pragmatic communication rather than treatment itself. People are asked to communicate a given message to their therapists by means of drawing, making hand gestures or even pointing to an object

[102]

Melodic intonation therapy (MIT) – aims to use the intact melodic/prosodic processing skills of the right hemisphere to help cue retrieval of words and expressive language: 93 

[9]

Centeredness Theory Interview (CTI) - Uses client centered goal formation into the nature of current patient interactions as well as future / desired interactions to improve subjective well-being, cognition and communication.

[103]

Other – i.e. drawing as a way of communicating, trained conversation partners

[97]

Outcomes[edit]

If the symptoms of aphasia last longer than two or three months after a stroke, a complete recovery is unlikely. However, it is important to note that some people continue to improve over a period of years and even decades. Improvement is a slow process that usually involves both helping the individual and family understand the nature of aphasia and learning compensatory strategies for communicating.[119]


After a traumatic brain injury (TBI) or cerebrovascular accident (CVA), the brain undergoes several healing and re-organization processes, which may result in improved language function. This is referred to as spontaneous recovery. Spontaneous recovery is the natural recovery the brain makes without treatment, and the brain begins to reorganize and change in order to recover.[66] There are several factors that contribute to a person's chance of recovery caused by stroke, including stroke size and location.[120] Age, sex, and education have not been found to be very predictive.[120] There is also research pointing to damage in the left hemisphere healing more effectively than the right.[39]


Specific to aphasia, spontaneous recovery varies among affected people and may not look the same in everyone, making it difficult to predict recovery.[120]


Though some cases of Wernicke's aphasia have shown greater improvements than more mild forms of aphasia, people with Wernicke's aphasia may not reach as high a level of speech abilities as those with mild forms of aphasia.[121]

Prevalence[edit]

Aphasia affects about two million people in the U.S. and 250,000 people in Great Britain.[122] Nearly 180,000 people acquire the disorder every year in the U.S.,[123] 170,000 due to stroke.[124] Any person of any age can develop aphasia, given that it is often caused by a traumatic injury. However, people who are middle aged and older are the most likely to acquire aphasia, as the other etiologies are more likely at older ages.[125] For example, approximately 75% of all strokes occur in individuals over the age of 65.[126] Strokes account for most documented cases of aphasia:[127] 25% to 40% of people who survive a stroke develop aphasia as a result of damage to the language-processing regions of the brain.[6]

Further research[edit]

Research is currently being done using functional magnetic resonance imaging (fMRI) to witness the difference in how language is processed in normal brains vs aphasic brains. This will help researchers to understand exactly what the brain must go through in order to recover from Traumatic Brain Injury (TBI) and how different areas of the brain respond after such an injury.[134]


Another intriguing approach being tested is that of drug therapy. Research is in progress that will hopefully uncover whether or not certain drugs might be used in addition to speech-language therapy in order to facilitate recovery of proper language function. It's possible that the best treatment for Aphasia might involve combining drug treatment with therapy, instead of relying on one over the other.[135]


One other method being researched as a potential therapeutic combination with speech-language therapy is brain stimulation. One particular method, Transcranial Magnetic Stimulation (TMS), alters brain activity in whatever area it happens to stimulate, which has recently led scientists to wonder if this shift in brain function caused by TMS might help people re-learn language. Another type of external brain stimulation is transcranial Direct Current Stimulation (tDCS), but existing research has not shown it to be useful for improving aphasia after a stroke.[110]

National Aphasia Association

at Curlie

Aphasia