3. INTRODUCTION
Language disorder that occurs in 10-30% of stroke
survivors
Chronic aphasia (ie, persisting for ≥6 months after stroke)
affects about 20% of all patients who have had a stroke
The presence of aphasia after stroke predicts the extent
of rehabilitation services required and likelihood of
failure to return to work.
Longer length of stay , in-hospital death, greater
disability were associated with presence of aphasia in
acute setting – Flowes et al 2015 Post stroke Aphasia
Frequency, Recovery and Outcomes: a systematic review
and meta-analysis
5. CEREBRAL
DOMINANCE
- Ninety-three percent of the population is right-
handed; with the left hemisphere being dominant for
language in 99% of right-handed individuals (Delaney,
1993)
- In left-handed individuals, 70% have language
control in the left hemisphere, 15% in the right
hemisphere, and 15% in both hemispheres (O'Brien,
1978).
- Therefore 97% of the population has language
control primarily in the left hemisphere.
- Language function is almost exclusively the domain of
the left hemisphere, except for 35% of left handers
(3% of population) who use the right hemisphere for
language function.
6. BROCA’S AREA
• Broadmanns area 44
• Located in posterior inferior frontal gyrus
• The anterior region of Broca’s area involved in
semantic processing
• The posterior region plays a central role in
processing syntax, grammar, and sentence structure
WERNICKE’S AREA
• Broadmanns area 22
• Area at posterior segment of the superior temporalgyrus
• Involved in language comprehension(sensory)
• Wernicke’s area contributes to phonological retrieval
7. ANGULAR GYRUS
• A region of the inferior parietal lobe, at the anterolateral
region of the occipital lobe
•Important element in processing concrete and abstract
concepts
•Role in verbal working memory during retrieval for
verbal information and in visual memory for when turning
written language into spoken language
•Involved in verbal coding of numbers
ARCUATE FASCICULUS
•A bundle of axons that connects the temporal cortex and
inferior parietal cortex to locations in the frontal lobe.
•Connecting Broca's and Wernicke's areas, which are involved in
producing and understanding language.
9. COMMUNICATION IN NON DOMINANT HEMISPHERE
- Annett (1975) demonstrated aphasia occurred after right hemispheric strokes in 30% of
left-handed people and 5% of right-handed people.
- Patients with nondominant hemispheric lesions often have associated communication
difficulties : have difficulty in utilizing intact language skills effectively, that is, the
pragmatics of conversation.
- The patient also may
not observe turn-taking rules of conversation
may have difficulty telling, or understanding, jokes (frequently missing the punchline)
Difficulty in comprehending ironic comments
May be less likely to appropriately initiate conversation.
This tends to result in social dysfunction that may negatively impact on family and social support systems
(Delaney, 1993).
10. TYPES OF COMMUNICATION DISORDER
Aphasia Dysarthria Apraxia
Cognitive
communication
difficulties
Dysphonia
11. Dysarthria refers to defective articulation but with the content of speech unaffected.
Key sounds that can be tested
“ta ta ta,” : tongue (lingual consonants);
“mm mm mm,” : lips (labial consonants);
“ga ga ga,” : larynx, phar- ynx, and palate (glottal consonants)
Subtypes : spastic, ataxic, hypokinetic, hyperkinetic, and flaccid
12. Dysphonia is a deficit in sound production
Can be secondary to respiratory disease, fatigue, or vocal cord
paralysis, which is seen both with neurologic conditions and after
intubation
The best method to examine the vocal cords is by indirect
laryngoscopy. Asking the patient to say “ah” while viewing the
vocal cords is used to assess vocal cord abduction. When the
patient says “e,” the vocal cords will adduct.
Patients with weakness of both vocal cords will speak in whispers
with the presence of inspiratory stridors.
13. Difficulties with listening, reading, writing, speaking because of
underlying cognitive
Cognitive linguistic deficits involve the pragmatics and
context of communication.
Examples :
• confabulation after a ruptured aneurysm of the
anterior communicating artery
• disinhibited or sexually inappropriate comments from a
patient with frontal lobe damage after a traumatic
brain injury.
Cognitive linguistic deficits are distinguished from fluent
aphasias (Wernicke aphasia) by the presence of relatively
normal syntax and grammar.
14. Apraxia is a disorder of voluntary movement where one cannot execute willed, purposeful activity
despite the presence of adequate mobility, strength, sensation, co-ordination, comprehension, and
motivation.
Roughly 30% of patients in the acute phase of stroke show evidence of apraxia (Donkervoort et al., 2000; Faglioni &
Basso, 1985).
15. APRAXIA CONT…
Anatomical Substrates of Apraxia : Although apraxia is more commonly associated
with strokes affecting the left parietal lobe, it may also occur in lesions to the right
parietal lobe, the temporal or frontal lobes, and even subcortical regions including
white matter and the basal ganglia (Leiguarda, 2001).
Recovery of Apraxia Post-Stroke : usually improves over time. Basso and colleagues
(1987) (as cited by van Heugten et al. (2000)) observed that recovery was related to
the site of lesion in that patients with anterior lesions demonstrated better recovery.
Recovery was NOT related to age, education, sex, type of aphasia and the initial
severity or the size of the lesion
16. IDEOMOTOR APRAXIA/ ATAXIA INTERVENTIONS:
APRAXIA TRAINING
- Some therapies revolve around creating strategies that a patient can employ to
help compensate for their apraxia impairment
- These strategies can be internal and external, and focus on teaching individuals how
to improve their functioning in activates of daily living, as opposed to remediation of
the underlying deficit (Donkervoort et al., 2001).
- Three RCTs were found evaluating apraxia training
20. DEFINITIONS
The AHCPR Post-Stroke Rehabilitation Clinical Practice Guidelines defines aphasia as “the loss of
ability to communicate orally, through signs, or in writing, or the inability to understand such
communications” (Klein, 1995).
Darley (1982) noted that aphasia is generally described as an impairment of language as a result
of focal brain damage to the language dominant cerebral hemisphere.
This serves to distinguish aphasia from the language and cognitive-communication problems
associated with non-language dominant hemisphere damage, dementia and traumatic brain injury
(Orange & Kertesz, 1998).
Chronic aphasia (ie, persisting for ≥6 months after stroke) affects about 20% of all patients who
have had a stroke
The presence of aphasia after stroke predicts the extent of rehabilitation services required and
likelihood of failure to return to work.
23. BOSTON CLASSIFICATION SYSTEM
AREA AFFECTED
Global aphasia: whole MCA
Mixed transcortical aphasia:
watershed area
Broca’s aphasia : posterior inf frontal
gyrus
Transcortical motor : ant superior to
Broca’s
Wernicke aphasia : posterior sup
temporal gyrus
Transcortical sensory aphasia :
Perisylvian speech structure
Conduction aphasia: arcuate
fascicules /deep to supra marginal
gyrus / insular
24. APHASIA : RISK FACTORS
Significant risk factors associated with development of aphasia include
i. older age :
reported that risk for aphasia increased significantly with age, such that each advancing year
was associated with 1-7% greater risk. While 15% of individuals under the age of 65
experienced aphasia, in the group of patients 85 years of age and older, 43% were aphasic
ii. greater severity of stroke and of disability
iii. cardioembolic origin and superficial middle cerebral artery stoke to be significant
risk factors for the development of aphasia
25. APHASIA – HOW OFTEN DO U SEE IT?
- APHASIA is one of the most common consequences of stroke in both the acute and
chronic phases. Acutely, it is estimated that from 21 – 38% of stroke patients are
aphasic (Berthier, 2005).
- A recent report based on data from the Ontario Stroke Audit (Ontario, Canada)
estimated that 35% of individuals with stroke have symptoms of aphasia at the time
of discharge from inpatient care (Dickey et al., 2010).
- Global aphasia is the most common type in the acute period affecting as many as
25-32% of aphasic patients, while other classic aphasias described within the Boston
system of classification are seen less frequently
26. Godefroy et al. (2002) reported approximately 25% of patients as having non-
classified aphasias, comprised mostly of disorders similar to anomic aphasia in
addition to some other impairments.
In that study, the presence of non-classified aphasia was significantly associated with
a history of previous stroke. Initial stroke severity and lesion volume have been
associated with initial severity of aphasia (Ferro et al., 1999; Laska et al., 2001;
Pedersen et al., 2004).
27. APHASIA : PROGNOSTICATION
Within the literature, most longitudinal studies have identified that the greatest
amount of spontaneous recovery occurs in the first 3 months following stroke.
After this, the rate of recovery slows and little additional spontaneous recovery can
be expected after the first 12 months (Ferro et al., 1999).
Pedersen et al. (2004) reported that during these first 12 months, aphasia of all
types (even global aphasia) tended to evolve to a less severe form.
While 61% of aphasic patients in the Copenhagen Aphasia Study still experienced
aphasia at one year post stroke, it was usually of a milder form.
Aphasia improves during the first year following the stroke event
A review by Ferro et al. (1999) reported that approximately 40% of acutely aphasic patients experience complete or almost
complete recovery by one year post stroke.
Maas et al. (2012) found that 86% of stroke patients presenting with aphasia symptoms in an emergency setting experienced
partial improvement within six months, 74% of whom had completely resolved.
28. FORMAL TESTS
FOR ACQUIRED
LANGUAGE
DISORDERS
Boston Diagnostic Aphasia Examination (BDAE)
Western Aphasia Battery (WAB)
Psycholinguistic Assessment of Aphasic Language Ability (PALPA)
The Revised Token Test (RTT)
The Comprehensive Aphasia Test (CAT)
Communicative Activities of Daily Living (CADL) (functional assessment tool)
Bedside Evaluation Screening Test for Aphasia (BEST-2)
Porch Index of Communication Ability (PICA) (functional assessment tool)
The Functional Communication Profile (functional assessment tool)
29. BOSTON DIAGNOSTIC APHASIA EXAMINATION
Produces a classification of the aphasic features observed in a particular patient.
Besides classifying aphasia it also provides a score of the severity of the aphasia, which
can be compared to aphasic patients in general
The BDAE is comprised of 8 subscales: Fluency, Auditory comprehension, Naming, Oral
reading, Repetition, Automatic speech, Reading comprehension, Writing
30. WESTERN APHASIA BATTERY
Similar to BDAE
Comprises 8 subscales: -
PART 1 – Spontaneous speech, Auditory verbal comprehension, Repetition, Naming and
word finding
PART 2 – Reading, Writing, Apraxia, Constructional, visuospatial and calculation tasks
Supplemental writing and reading tasks (WAB-R only)
31. THE COMPREHENSIVE APHASIA TEST
New English language aphasia battery ( created in 2005 by Swinburn, Porter and
Howard)
It’s main objectives are to
1. screen for associated cognitive deficits
2. assess language impairment in people with aphasia
3. investigate the consequences of the aphasia on the individual's lifestyle and emotional
well-being, and
4. monitor changes in the aphasia and its consequences over time
32. INTERVENTION
‘Reviewing and critiquing therapies for aphasia was challenging because of the
extensive number of heterogeneous studies, many of which relied on small samples
and were poorly designed or of overall low quality’
34. SPEECH AND
LANGUAGE
THERAPY
Mainstay treatment aim to improve language and functional communication
Improves language skills in individuals with all severities of aphasia post stroke
More intensive therapy over a short period of time VS less intensive therapy over
longer period of time (SK Bhogal et al., 2003)
Timing of SLT administration have critical implications for recovery. Study suggest
recovery more rapid in 3 months post stroke
Approach :
Impairment-based: focus to allow patient to comprehend and speak successfully
Eg: improve verbal production – naming, simple narrative, increase utterance
length, improve auditory comprehension – social questioning, self-related
question
Communication-based: assist patient to convey message with alternative means
of communication, involves compensatory strategies. Eg : AAC
38. CONSTRAINT INDUCED APHASIA THERAPY
Specialized form of language training to prevent ‘learn non use’
Based on 3 principles:
Use of intensive practice for short time intervals is preferred over long
term, less frequent training (intensive practice)
Constraints are used that force the patient to perform communication only
in the way that they normally avoids (constrain induction). Eg: constrained
using gesture
Therapy focuses on action relevant in everyday life (behavioural
relevance)
May be beneficial for improving repetition and writing (Wilssens et al.,
2015)
May NOT be beneficial for improving global speech and language and
social communication
45. SOCIAL INTERACTION
THERAPIES
- Conversation is important in social participation and plays a key
role in many social functions such as establishing and maintaining
relationships, sharing ideas and opinions or making plans.
- Interventions focused on the restoration of conversation and
socialization are not restricted to alleviating impairment of
language but also attempt to remove barriers to social
participation in the settings within which the individual with
aphasia lives and interacts with others (Lyon et al., 1997).
- Group therapy is a way to engage patients directly in the type
of social communication that a traditional speech-language
therapy aims to improve.
- Training conversation or communication partners within the
aphasic individual’s social setting is one way to promote
opportunities for restored access to conversation (Marshall et al.,
1989; Rayner & Marshall, 2003).
48. MUSIC-BASED THERAPY
Music and music-based therapies in the rehabilitation of speech
disorders, such as aphasia, have been used for over a century
This form of therapy has not been extensively studied in
randomized controlled trials, however, it shows promise as a
potentially effective treatment for this condition.
Music and speech production shared neural pathways
Based on observation that some person with aphasia “sing it
better than saying it”
Music-based speech-language therapies may be beneficial for
improving verbal fluency and repetition, but not social
communication, discourse, or global speech and language
compared to conventional therapy
51. REPETITIVE TRANSCRANIAL
MAGNETIC STIMULATION (RTMS)
- Painless and non-invasive method of
affecting neural activity through the
exogenous generation of an electromagnetic
field through a coil placed on the scalp, that
consequently induces a change in the electrical
fields of the brain (Peterchev et al. 2012).
- Can lead to changes in neuron activity,
synaptic transmission, and activation of neural
networks
- rTMS can be used to help modulate
interhemispheric competition, with low
stimulation frequencies (≤1Hz) decreasing
cortical excitability and inhibiting activity of
the contra-lesional hemisphere, while high
frequency (>1Hz) stimulation increases
excitability and have a facilitatory effect on
activity of the ipsilesional hemisphere (Dionisio
et al. 2018)
57. TRANSCUTANEOUS DIRECT
CURRENT STIMULATION
(TDCS)
- Another form of non-invasive brain stimulation
- This procedure involves the application of mild electrical
currents (1-2 mA) conducted through two saline-soaked, surface
electrodes applied to the scalp, overlaying the area of interest
and the contralateral forehead above the orbit.
- Anodal stimulation is performed over the affected
hemisphere and increases cortical excitability, while cathodal
stimulation is performed over the unaffected hemisphere and
decreases cortical excitability (Alonso-Alonso et al. 2007).
- In contrast to transcranial magnetic stimulation, tDCS does not
induce action potentials, but instead modulates the resting
membrane potential of the neurons (Alonso-Alonso et al.
2007).
61. tDCS
Applies low levels of direct, polarizing electrical currents (1-
2mA) to scalp through a pair of electrodes (large saline-
soaked sponges)
The current modulates resting membrane potential, making
neurons in cortex more or less likely to fire with subsequent
stimulation
Effects depends on the intended modulation:
Anodal stimulation: increase cortical excitability through
depolarization
Cathodal stimulation: induces inhibition through depolarization
10-30mins during SLT, effects last for minutes to hours after
the session
More practical, less expensive
SEs: transient tingling, itching, burning sensation at simulation
site
rTMS
Passes a series of rapid pulses at a predetermined frequency
through a coil of wire held to the scalp
The pulse produce rapidly changing magnetic field that cause action
potential or neuronal firing in the targeted region
Low stimulation frequency (≤1Hz) decreasing the cortical excitability
and inhibiting activity of the contralesional hemisphere
High frequency (>1Hz) stimulation increases excitability and have
facilitatory effect on activity of the ipsilesional hemisphere
Administered 10-30mins, effect last minute to hours after the
application
Repeated session produce longer lasting effect (months
posttreatment)
Concurrent SLT difficult to conduct due to limitation of movement
during stimulation
SEs: transient headache, dizziness, seizure
62. PHARMACOLOGICAL APPROACHES
TO APHASIA TREATMENT
No medications are currently approved for treatment of aphasia
Drugs approved for other neurological or neuropsychiatric disorders studied in aphasia in
open-label trials
Modulate the neurotransmitter systems facilitate synaptic plasticity improve language
function
- Catecholaminergic drugs; bromocriptine, levodopa, dextroamphetamine, amantadine
- Cholinergic drugs : donepezil, galantamine
- Nootropic drugs : piracetam
- Serotonic drugs. : fluvoxamine
- Acetylcholinesterase inhibitors, (rivastigmine, donepezil and galantamine)
- Amphetamines are central nervous system stimulants : methylphenidates
- Dopaminergic agonist Bromocriptine, levodopa
63. PIRACETAM
- Piracetam is a -
γ aminobutyrate derivative, a pharmacological
agent with a potential effect on cognition and memory
- Piracetam is thought to improve learning and memory by
facilitating release of acetylcholine and excitatory amino
acids, with increases in blood flow and energy metabolism
(Kessler et al., 2000).
- Three RCTs were found evaluating piracetam for aphasia
rehabilitation. 2 RCTs compared piracetam to a placebo (Szelies
et al., 2001; Huber et al., 1997). One RCT compared piracetam
to no drug therapy Enderby et al., 1994).
66. MEMANTINE
- Memantine is an antagonist of the N-methyl-D-aspartate
(NMDA) receptor.
- Therefore, it modulates brain activity by blocking glutamate
signalling.
- Its use has been evaluated among patients with Alzheimer’s
Dementia and those with vascular dementia
- In a review of memantine treatment for dementia, the drug was
able to improve language functions, as well as other cognitive
functions, activities of daily living and mood issues (McShane,
Sastre & Minakaran, 2006).
Two RCTs were found evaluating memantine for aphasia
rehabilitation. B
69. ALTERNATIVE MEDICINE : SCALP ACUPUNTURE
- According to Rabinstein and Shulman (2003), “Acupuncture is a therapy that involves
stimulation of defined anatomic locations on the skin by a variety of techniques, the most
common being stimulation with metallic needles that are manipulated either manually or that
serve as electrodes conducting electrical currents”.
- There is a range of possible acupuncture mechanisms that may contribute to the health
benefits experienced by stroke patients (Park et al. 2005). For example, acupuncture may
stimulate the release of neurotransmitters (Han & Terenius, 1982) and have an effect on the
deep structure of the brain (Wu et al. 2002).
- Lo et al. (2005) established acupuncture, when applied for at least 10 minutes, led to long-
lasting changes in cortical excitability and plasticity even after the needle stimulus was
removed.
- With respect to stroke rehabilitation, the benefit of acupuncture has been evaluated most
frequently for pain relief and recovery from hemiparesis, but some acupoints correspond to
language functions.
One RCT was found evaluating scalp acupuncture for aphasia rehabilitation. The single RCT
72. CASE DISCUSSION
MR Z is a 59 years old / Malay / Gentleman
Right Hand Dominant, Pre-morbidly ADL
independent
Retiree (Government)
Known case of Oligodendrioglioma
- p/w recurrent seizure episodes in 2019, done
tumor debulking in May 2019
- With occasional right sided weakness, no
bothering function, still able to walk
- No cognitive deficit
- No speech abnormalities premorbid
- No behavioral change
76. POST OP IMPAIRMENT
1. Right UL Monoplegia – good motor recovery
2. Global aphasia
- improved from global aphasia to expressive dysphasia
- able to communicate but still has word finding difficulties and initiation problems
- able to name, occasional word finding difficulties
- able to repeat short words but not long sentences
- writing impaired due to weak dominant hand but able to copy loosely with left hand
3. Cognition
- MOCA imporved slightly from 13/25 to 19/25 today ( exec function, attendtion, language)
unable to assess fully due to inability to write following weakness
78. WHAT WAS DONE FOR THE SPEECH?
Non pharmaco :
- early reviewed by Speech and Language Therapy. Attended inpatient – more frequent
review
- group therapy inptn and outptn
- role play
- noted always attending session alone despite came TCA with daughter
- expressed to be ‘malu’ to speak to strangers d/t his word finding difficulties
Pharmaco :
Given T Piracetam 1.2g TDS for 3/12
Unable to start pharamcological neurostimulant (e.g methyphenidate) for attention and
patient has history of seizure and residual tumour
79. SLT review in Aug 2022
a) Narrative skills:
- fair speech intelligibility when speaking slower
- Word-finding difficulties noted with short phrases most of the time
- needed prompts in sentence structure constructions noted
- pauses noted in words-retrieval and took time to respond most of the time
b) Semantic fluency:
- What's inside pictures were used
- Pt was able to tell 10 nouns for each picture 7/10 spontaneously and 3/10 with verbal prompts
- Response better with semantic prompts. Semantic paraphasia noted
- Word-finding difficulties noted occasionally
- slightly slow in response during word retrieval process
c) Conversation:
- Pt was able to share his experience verbally with minimal prompts. Prompts were given by
therapists to clarify /elaborate details
- Noted reduced speech intelligibility when speaking in fast rate
- Noted slightly slow in response when retrieving information/words
- syntactical errors noted minimally
- Pt training done
- Home program was given
#45:Low tech – alphabet boards, customised communication boards
High tech – smart phones tablets, specialized software
Compensatory method/approach – when verbal communication may not be feasible
Both low-tech and high-tech may require patient to touch / point / manipulate the device/modalities. (need to consider before deciding on types of AAC to ensure successful usage – eg those with incoordination, have difficulty to use communication board, may need assistant from communication partner)
#63:Major way stroke lesion cause aphasia is by interruption of neurotransmitter pathway that connect the brainstem and forebrain to language regions of the cerebral cortex and deep gray nuclei.
These pathways include dopaminergic, cholinergic, noradrenergic and serotonergic pathways.
Other neurotransmitters include glutamate and GABA
#86:Upper cut,at centrums emiovale
Omega signs : centra sulcus
- separate frontal n parietal lobe
- divide somatosensory cortex
#88:
residual tumour anterior 1.8 x 2.9 cm which apprae hyperintense at T2
