Severe Non-fluent Aphasia Research Articles

The Case Study of the Augmentative and Alternative Communication (AAC) Intervention in Broca’s Aphasia Patients with AOS

배경 및 목적: 말실행증을 동반한 표현성 실어증 환자는 말 산출에 어려움을 보여 일상생활에서 의사소통에 심한 어려움을 보이지만 보완대체의사소통(augmentative and alternative communication; 이하 AAC)을 적용하면 기능적인 의사소통 능력을 향상시킬 수 있다. 본 연구는 3명의 실어증 환자를 대상으로 AAC를 적용한 과정과 경과를 보고하고, 실어증에 서 AAC의 적용가능성에 대해서 알아보고자 하였다. <BR> 방법: 고려대학교 안암병원 언어치료실에서 심한 표현성 실어증으로 치료를 받던 3명의 환자를 대상으로 2013년 3월부터 2013년 9월까지 AAC 프로그램인 마이토키를 사용하여 훈련하였다. 사례 1은 72세 남자로 파라다이스`한국판-웨스턴실어증검사에서 실어증지수 10.8점, 사례 2는 52세 여자로 실어증지수 28.8점이었으며, 우뇌 병변 후 발생한 교차성 실어증이었다. 사례 3은 40세 남자로 실어증지수 16.2점으로 대상자 모두 브로카 실어증이었으며, 말실행증을 동반하고 있었다. 각 사례에 대해 개별적인 프로그램에 따라 AAC를 적용하였고, 훈련과정에서 환자의 반응과 치료 전후 의사소통능력의 변화를 기술하였다. <BR> 결과: 사례 1와 2은 각각 15회기와 17회기의 AAC훈련을 적용하였고, 치료 상황에서 자발적으로 간단한 의사표현을 하는 데에는 훈련이 가능하였다. 그러나 일상생활에서 의사소통기능의 변화는 관찰되지 않았고 사지실행증과 보속증으로 인해 프로그램을 학습하고 조작하는데 지속적인 어려움을 보였다. 사례 3은 총 8회기의 치료를 시행하였으나, AAC에 대한 요구도가 낮아 훈련을 지속하지 못하고 언어 이해와 말 산출 능력의 향상을 위한 언어치료로 전환하여 시행하였다. <BR> 논의 및 결론: 많은 실어증 환자는 언어기능 외에도 집행기능을 포함한 인지기능의 손상을 흔히 동반하게 된다. 실어증 환자에서 성공적으로 AAC를 적용하기 위해서는 실어증의 심한 정도 외에도 환자의 동기와 요구도, 인지기능의 손상여부, 실행증의 유무 등에 대한 평가를 통해 환자를 선별하는 절차가 필요하며, 실어증 환자의 특성에 따라 체계적으로 적용할 수 있는 AAC 훈련방법의 개발과 적절한 치료 전후의 변화 측정, 치료사에 대한 전문적인 교육 등이 중요할 것으로 생각된다.

P 114. Anodal transcranial direct current stimulation in early treatment of post-stroke non-fluent aphasia

Introduction Neuroimaging studies suggests that increased level of cortical excitability in the stroke-affected left hemisphere is associated with better language improvement in aphasic patients. Recent neurostimulating studies showed that combination of behavioural therapy with excitatory anodal transcranial direct current stimulation (A-tDCS) of perilesional cortex in the language-dominant left hemisphere improve language performance in patients with chronic post-stroke aphasia. Objective The aim of this study was to investigate the impact of A-tDCS on language in aphasics in the early post-stroke rehabilitation period when most adaptive changes in cortical excitability are possible and most conventional therapies are conducted. We hypothesized that early reactivation of preserved language-related structures and their neighboring regions may facilitate the restoration of the neuronal language network manifested by better naming. Methods 24 patients with moderate or severe non-fluent aphasia were randomized to receive 15 consecutive daily sessions of A-tDCS (1 mA, 10 min; A-tDCS group = 14) or sham tDCS (1 mA, 25 s; sham tDCS group = 10) over Broca’s area followed by 45-min routine speech and language training. Naming ability was assessed before and after the rehabilitation, and three months later using Boston Naming Test. Naming accuracy and speed were chosen as outcome measures. Results Although both groups significantly improved after the therapy, there were no statistically significant differences between groups in either short-term or long-term tDCS effects when naming accuracy and naming time were analyzed. However, for response time A-tDCS group obtained higher effect sizes both post-treatment and at the 3-month follow-up. Conclusions The findings provide only a weak evidence of A-tDCS behavioural gains during early neurorehabilitation of post-stroke aphasia. Further research is needed to investigate the effectiveness of this kind of neuromodulation. Different modes and parameters of tDCS should be explored considering such important factors determining recovery from aphasia as type and severity of language impairment, lesion site and size, time since stroke, and degree of hemispheric language laterality.

How Conversational Therapy influences language recovery in chronic non-fluent aphasia

The study aimed to determine the efficacy of a Conversational Therapy approach in the treatment of chronic patients with moderately severe non-fluent aphasia. Eight patients completed a six week intensive language training. Every two weeks, each patient received rehabilitation using a different videoclip depicting everyday life. To elicit verbal communication, patients were required to observe each videoclip and to converse about it with the help of an experienced clinician. To measure any significant improvement in speech production all patients were tested before and after treatment. A significant increase in their ability to produce correct informative words (C-Units), verbs, nouns, adjectives, adverbs, as well as closed-class words (pronouns, articles and conjunctions) and well-formed sentences was found after therapy. Such improvement persisted at one week and one month after the end of the treatment. These results suggest that conversational therapy, applied through intensive language training, has a significant efficacy in the recovery of verbal communication in chronic non-fluent aphasic individuals. This approach should be considered for patients with moderately severe non-fluent aphasia, as it enhances not only the ability to use informative language but also its correct use in daily living.

When Traumatic Brain Injury Is Complicated by Personality Disorders

When Traumatic Brain Injury Is Complicated by Personality Disorders

When right is all that is left: plasticity of right‐hemisphere tracts in a young aphasic patient

Using an adapted version of Melodic Intonation Therapy (MIT), we treated an adolescent girl with a very large left-hemisphere lesion and severe nonfluent aphasia secondary to an ischemic stroke. At the time of her initial assessment 15 months after her stroke, she had reached a plateau in her recovery despite intense and long-term traditional speech-language therapy (approximately five times per week for more than one year). Following an intensive course of treatment with our adapted form of MIT, her performance improved on both trained and untrained phrases, as well as on speech and language tasks. These behavioral improvements were accompanied by functional MRI changes in the right frontal lobe as well as by an increased volume of white matter pathways in the right hemisphere. No increase in white matter volume was seen in her healthy twin sister, who was scanned twice over the same time period. This case study not only provides further evidence for MIT's effectiveness, but also indicates that intensive treatment can induce functional and structural changes in a right-hemisphere fronto-temporal network.

Formulaic Language and Language Disorders

The importance of formulaic language is recognized by many branches of the language sciences. Second language learners acquire a language using a maturationally advanced neurological substrate, leading to a profile of formulaic language use and knowledge that differs from that of the prepuberty learner. Unlike the considerable interest in formulaic language seen in second language learning, attention paid to this theme in clinical communicative disorders has been limited. Historically, verbal expressions preserved in severe nonfluent aphasia, including counting, interjections, and memorized phrases, have been referred to asautomatic speech. Closer examination of all forms of aphasic speech reveals a high proportion of formulaic expressions, while speech samples from persons with right hemisphere and subcortical damage show a significant impoverishment. These findings are supported by studies of persons with Alzheimer's disease, who have intact subcortical nuclei and abnormally high proportions of formulaic expressions, and Parkinson's disease, which is characterized by dysfunctional subcortical systems and impoverished formulaic language. Preliminary studies of schizophrenic speech also reveal a paucity of formulaic language. A dissociation between knowledge and use of the expressions is found in some of these populations. Observations in clinical adult subjects lead to a profile of cerebral function underlying production of novel and formulaic language, known as the dual processing model. Whereas the left hemisphere modulates newly created language, production of formulaic language is dependent on a right hemisphere/subcortical circuit. Implications of the dual process model for evaluation and treatment of language disorders are discussed.

Singing therapy can be effective for a patient with severe nonfluent aphasia

Patients with severe aphasia are rarely treated using speech therapy. We used music therapy to continue to treat a 79-year-old patient with chronic severe aphasia. Interventions 1, 2, and 3 were to practice singing a song that the patient knew, to practice singing a song with a therapist, and to practice saying a greeting using a song with lyrics, respectively. In addition, practice of uttering names of body parts was initiated using touch and rhythm. After intervention 1, the patient could sing spontaneously and repeat lyrics. After intervention 2, she could sing with the therapist, and sing spontaneously and repeat lyrics. After intervention 3, she could memorize words with meaning, say the words in context, and use them. The patient could utter the names of two body parts after therapy with touch and rhythm. These suggest that rehabilitation therapy can still be used in patients with severe cognitive impairment.

Multimodality in aphasic conversation

The use of gestures is one of the reasons for which some aphasics communicate better than they speak. For these aphasics as well as their partners, multimodality becomes a resource for the successful management of interaction. However, the successful employment of gesture implies multiple practices of adaptation, since there are important differences between gesture use in non-impaired and impaired aphasic interaction. In non-impaired faceto- face interaction, gestures mostly accompany language and support and influence its interpretation in various ways. Only rarely do gestures, body movements and the manipulation of artifacts take the lead, and even more rarely do they replace language entirely (Goodwin 1986, Heath 1982, 1992, Melinger &amp; Levelt 2004). Under conditions of severe non-fluent aphasia (as described here), gestures therefore are used for functions which they cannot easily fulfill. In the absence of language, gestures become a substitute (Goodwin 2000, 2003 and 2006a, b). This uncoupling of gestural communication from language usually results in complex and often lengthy collaborative sequences in which the participants set out to co-construct what the aphasic “gesturer” means, with the non-impaired speakers providing, in a way, the missing speech for the linguistically impaired speaker (cf. Damico et al. 2008, Goodwin 2000, 2003, 2006). As we will show, these processes of coconstruction are encumbered not by the aphasics’ deficient gestures, but rather the semiotic nature of gesturing itself. We will discuss examples of successful and unsuccessful gestural communication in aphasics and suggest some reasons why gestural communication fails sometimes, but why it helps in other cases. Our observations lend support to the idea that therapy has to respect the semiotic characteristics of gesturing and the interactional practices necessary for their management in order to enhance the successful employment of the visual modality.

Effects of cognate status and language of therapy during intensive semantic naming treatment in a case of severe nonfluent bilingual aphasia

As bilingualism becomes less exceptional in the world, and with the growing incidence of stroke and aphasia, a better understanding of how bilingualism affects aphasia recovery is increasingly important. The present study examined the effect of intensive semantic naming therapy in three phases (Spanish, English and mixed) on within- and across-language generalization for cognates and non-cognates, in a bilingual individual with chronic, severe expressive aphasia. We hypothesized that cognates would positively influence cross-linguistic generalization, which might be more likely to occur from L2 to L1. Results indicate relative increases in confrontation naming ability in the following conditions: trained versus untrained, L1 versus L2 or mixed and non-cognates versus cognates. This participant demonstrated a pattern of results consistent with a differential recovery pattern in which presentation of treatment in both languages and training of cognates may have promoted interference, thus increasing the activation threshold, and lowering performance under these conditions.

C-Speak Aphasia alternative communication program for people with severe aphasia: Importance of executive functioning and semantic knowledge

Learning how to use a computer-based communication system can be challenging for people with severe aphasia even if the system is not word-based. This study explored cognitive and linguistic factors relative to how they affected individual patients' ability to communicate expressively using C-Speak Aphasia (CSA), an alternative communication computer program that is primarily picture-based. Ten individuals with severe non-fluent aphasia received at least six months of training with CSA. To assess carryover of training, untrained functional communication tasks (i.e., answering autobiographical questions, describing pictures, making telephone calls, describing a short video, and two writing tasks) were repeatedly probed in two conditions: (1) using CSA in addition to natural forms of communication, and (2) using only natural forms of communication, e.g., speaking, writing, gesturing, drawing. Four of the 10 participants communicated more information on selected probe tasks using CSA than they did without the computer. Response to treatment was also examined in relation to baseline measures of non-linguistic executive function skills, pictorial semantic abilities, and auditory comprehension. Only nonlinguistic executive function skills were significantly correlated with treatment response.

Court Access for People with Aphasia

Court Access for People with Aphasia

Non-Invasive Brain Stimulation Enhances the Effects of Melodic Intonation Therapy

Research has suggested that a fronto-temporal network in the right hemisphere may be responsible for mediating melodic intonation therapy’s (MIT) positive effects on speech recovery. We investigated the potential for a non-invasive brain stimulation technique, transcranial direct current stimulation (tDCS), to augment the benefits of MIT in patients with non-fluent aphasia by modulating neural activity in the brain during treatment with MIT. The polarity of the current applied to the scalp determines the effects of tDCS on the underlying tissue: anodal-tDCS increases excitability, whereas cathodal tDCS decreases excitability. We applied anodal-tDCS to the posterior inferior frontal gyrus of the right hemisphere, an area that has been shown both to contribute to singing through the mapping of sounds to articulatory actions and to serve as a key region in the process of recovery from aphasia, particularly in patients with large left hemisphere lesions. The stimulation was applied while patients were treated with MIT by a trained therapist. Six patients with moderate to severe non-fluent aphasia underwent three consecutive days of anodal-tDCS + MIT, and an equivalent series of sham-tDCS + MIT. The two treatment series were separated by 1 week, and the order in which the treatments were administered was randomized. Compared to the effects of sham-tDCS + MIT, anodal-tDCS + MIT led to significant improvements in fluency of speech. These results support the hypothesis that, as the brain seeks to reorganize and compensate for damage to left hemisphere language centers, combining anodal-tDCS with MIT may further recovery from post-stroke aphasia by enhancing activity in a right hemisphere sensorimotor network for articulation.

Treatment-Induced Neuroplasticity Following Intensive Constrained and Unconstrained Language Therapy in a Case of Severe Non-fluent Aphasia

Treatment-Induced Neuroplasticity Following Intensive Constrained and Unconstrained Language Therapy in a Case of Severe Non-fluent Aphasia

From singing to speaking: facilitating recovery from nonfluent aphasia

It has been reported for more than 100 years that patients with severe nonfluent aphasia are better at singing lyrics than they are at speaking the same words. This observation led to the development of melodic intonation therapy (MIT). However, the efficacy of this therapy has yet to be substantiated in a randomized controlled trial. Furthermore, its underlying neural mechanisms remain unclear. The two unique components of MIT are the intonation of words and simple phrases using a melodic contour that follows the prosody of speech and the rhythmic tapping of the left hand that accompanies the production of each syllable and serves as a catalyst for fluency. Research has shown that both components are capable of engaging fronto-temporal regions in the right hemisphere, thereby making MIT particularly well suited for patients with large left hemisphere lesions who also suffer from nonfluent aphasia. Recovery from aphasia can happen in two ways: either through the recruitment of perilesional brain regions in the affected hemisphere, with variable recruitment of right-hemispheric regions if the lesion is small, or through the recruitment of homologous language and speech-motor regions in the unaffected hemisphere if the lesion of the affected hemisphere is extensive. Treatment-associated neural changes in patients undergoing MIT indicate that the unique engagement of right-hemispheric structures (e.g., the superior temporal lobe, primary sensorimotor, premotor and inferior frontal gyrus regions) and changes in the connections across these brain regions may be responsible for its therapeutic effect.

Double dissociation of letter and category fluency following left frontal and temporal lobe lesions

Background: A number of studies have suggested that temporal cortex is critical for the ability to generate exemplars belonging to a particular semantic category (i.e., category fluency), while frontal cortex is critical for generating words beginning with a particular letter (i.e., letter or phonemic fluency). However, previous studies have often focused on relative, quantitative differences in performance across groups of patients and primarily in the oral domain. Aims: The current study analysed verbal fluency data from two individuals with chronic aphasia, one with a large left temporal lobe lesion and a severe Wernicke's aphasia, and a second individual with a large left frontal lobe lesion and a moderately severe non-fluent aphasia. The goal of the study was to do both qualitative and quantitative analyses of letter and category fluency performance in these two individuals across oral and written fluency domains. Methods & Procedures: Participants were administered both oral and written versions of letter fluency (FAS) and category fluency conditions (fruits, animals, and supermarket items). Participants were given 90 seconds to generate as many items as possible, and their responses were scored for both overall output, as well as qualitative structure using a clustering analysis. Outcomes & Results: The individual with an extensive temporal lobe lesion generated a large number of exemplars on the letter fluency task. Some of these items were neologisms (e.g., frest, anth, and swink), but remarkably all adhered to the phonological constraints of the task. However, this individual was very poor at generating items belonging to semantic categories. In contrast, the individual with a large frontal lesion generated many exemplars on the category fluency task but only two items on the letter fluency task. The same pattern was replicated in the written domain in both individuals, and results from the clustering analysis paralleled these quantitative findings. Conclusions: This report describes two individuals with aphasia who exhibited a double dissociation between letter and category fluency performance in both oral and written domains. The current findings provide further evidence for the notion that left frontal cortex is critical for word retrieval based on phonology, while left temporal cortex is critical for word retrieval based on semantics. The findings have implications for the types of strategies that may be most effective in individuals with lesions to these brain regions critical for word retrieval.

Current trends in stroke rehabilitation. A review with focus on brain plasticity

Current understanding of brain plasticity has lead to new approaches in ischemic stroke rehabilitation. Stroke units that combine good medical and nursing care with task-oriented intense training in an environment that provides confidence, stimulation and motivation significantly improve outcome. Repetitive trans-cranial magnetic stimulation (rTMS), and trans-cranial direct current stimulation (tDCS) are applied in rehabilitation of motor function. The long-term effect, optimal way of stimulation and possibly efficacy in cognitive rehabilitation need evaluation. Methods based on multisensory integration of motor, cognitive, and perceptual processes including action observation, mental training, and virtual reality are being tested. Different approaches of intensive aphasia training are described. Recent data on intensive melodic intonation therapy indicate that even patients with very severe non-fluent aphasia can regain speech through homotopic white matter tract plasticity. Music therapy is applied in motor and cognitive rehabilitation. To avoid the confounding effect of spontaneous improvement, most trials are preformed ≥3 months post stroke. Randomized controlled trials starting earlier after strokes are needed. More attention should be given to stroke heterogeneity, cognitive rehabilitation, and social adjustment and to genetic differences, including the role of BDNF polymorphism in brain plasticity.

The efficacy of repetition, semantic, and gesture treatments for verb retrieval and use in Broca's aphasia

Background: Verb production difficulties are well documented in individuals with aphasia. Yet there remains limited evidence regarding the efficacy of treatments for verb retrieval in these individuals. While previous studies have generally demonstrated positive treatment outcomes in improving single-verb production on confrontation naming tasks, few studies have attempted to examine therapy outcomes in more natural communicative contexts. Aims: This study aimed to evaluate and compare the effects of repetition, semantic, and combined semantic and gesture treatments for verb retrieval and use in individuals with chronic Broca's aphasia. Methods & Procedures: Two individuals with severe and moderate Broca's aphasia participated in this single-participant, multiple-baseline across conditions design. Participant GF presented with mixed levels of verb retrieval deficits and significant apraxia of speech. Participant PF evidenced verb retrieval impairment arising primarily from the output phonological level. A total of 100 action pictures drawn from various sources were balanced for relevant linguistic factors and individual error rates during baseline naming. Treatments were carried out sequentially. Each treatment condition lasted for ten sessions. Semantic treatments involved the production of various features that were semantically associated with the target verb, including associated nouns, and the movement and location characteristics of the target verb. Gesture treatments involved the production of hand and arm movements representative of the target verb. Outcomes & Results: Both participants differed in their response to treatments. GF exhibited increased verb-naming accuracy following repetition-orthographic and combined semantic and gesture treatments; while PF displayed significant increase in naming accuracy following repetition-only and semantic treatment conditions. For both participants, treatments that resulted in significant increase in naming accuracy were shown to be equally efficacious. Both GF and PF also demonstrated increased verb production in narrative and conversation tasks. PF further evidenced improvements in sentence production on a picture description task post-treatment. Conclusions: These findings highlighted the responsiveness to therapy in two individuals with severe and moderate aphasia in the chronic stages. However, there was no significant change in specific lexical, syntactical and morphological linguistic production in conversation. Future research could explore the incorporation of single verb therapy in sentences and/or more natural communicative environments, to further enhance changes at the discourse level.

Drawing as a window to event conceptualisation: Evidence from two people with aphasia

Background: There is growing interest in how problems with “thinking for speaking” (Slobin, 1996) interact with language impairment in aphasia (Marshall, 2009). Evidence to date has come from language production tasks, or from non-linguistic input-focused tasks that bear little relation to the processes involved in event communication. The current study describes a novel approach using a non-linguistic communication task, the Event Drawing Task, to investigate event conceptualisation in two people with aphasia, only one of whom is hypothesised to have problems at this level. Aims: The study aims to identify similarities and differences between the event drawing performance of the two aphasic participants and a group of 12 non-brain-damaged controls. Intact event conceptualisation (participant “Bob”) would predict a similar performance to controls, while event conceptualisation problems (participant “Jack”) would predict differences from control performance. Methods & Procedures: “Bob” and “Jack” both had severe nonfluent aphasia resulting from a single stroke. A number of background language and event-processing assessments were carried out to gain a profile of their abilities. The Event Drawing Task required participants to communicate 32 short video clips of events using only drawing. Five theoretically motivated analyses were performed on the data from the Event Drawing Task, which targeted specific aspects of event conceptualisation. Patterns within control performance were identified, which formed the basis for detailed comparison with the performance of the two people with aphasia. Outcomes & Results: As predicted, Bob's performance on the Event Drawing Task mirrored that of controls in all analyses, while Jack's performance differed widely from the controls' on a number of parameters. Importantly, characteristics of Jack's event drawing performance provide further evidence for an event conceptualisation impairment. Conclusions: The findings confirm that event conceptualisation problems may be an additional source of deficit in aphasia. Furthermore, they suggest that these problems are likely to affect non-linguistic, as well as linguistic, forms of communication. This has both theoretical and clinical implications. It suggests that we need to consider “thinking for communication” more generally, in both the assessment and remediation of severe aphasia.

Recurring utterances (speech automatisms) without aphasia: A single case study

Background: Regarding the generation of recurring utterances (RUs), there are two lines of research in the literature. The first is that RUs occur in severe aphasia; that is, global aphasia or severe Broca's aphasia. The second is that RUs are a modality-specific and post-phonological speech disorder. Aims: The aims of this paper are (1) to describe and follow up on the characteristics of non-meaningful RUs observed in a patient, AY, who had no definite aphasic symptoms, and (2) to investigate the mechanism underlying the generation of AY's RUs neurolinguistically and neuroanatomically. Methods & Procedures: We studied and followed the language functions of AY, including her non-meaningful RUs, using the Japanese Standard Language Test for Aphasia (SLTA; Japanese Society of Aphasiology, 1977) and her conversations with her speech therapists. Outcomes & Results: The patient was found to present non-meaningful RUs without definite aphasic symptoms. Her speech disorder evolved into pure apraxia of speech about a year after onset. Conclusions: The results show that AY's non-meaningful RUs are a modality-specific and post-phonological speech disorder, which supports the hypothesis that RUs result from deficits in post-lexical subphonemic processing in the psycholinguistic or neurolinguistic model of speech production.

Omental therapy for primary progressive aphasia with tau negative histopathology: 3 year study

Objective: Omentum transposition surgery (OT) applied to various neurodegenerative disorders has produced clinically significant improvement, which may be due to omentally-derived factors. To evaluate the clinical effect of left hemisphere OT in a primary progressive aphasia (PPA) patient, 3 year follow-up data were analysed.Methods: Left hemisphere OT was performed on a 68-year-old male with PPA, characterized by moderate dementia and severe expressive aphasia with relatively preserved comprehension, object recognition and visual-spatial abilities. He was longitudinally assessed with cognitive, functional, behavioral and brain HMPAO SPECT measures pre-OT, at baseline and every 3–6 months for 34 months.Results: All measures improved above baseline for >20 months and persisted at or above baseline for 34 months. Cortical activity increased by a maximum of 21% underneath transposed omentum and in synaptically connected areas, and persisted in >50% of the cortex for at least 12 months. Subjectively, family members observed improved verbal and non-verbal communication.Conclusion: OT produced a sustained, beneficial treatment effect in PPA and warrants further clinical and basic research to identify explanatory factors.