Aphasia Rehabilitation

Broca aphasia is the classic form of frontal lobe language dysfunction with dominant hemisphere lesions. It is characterized by a nonfluent, effortful, slow, and halting speech. This language dysfunction is typically of reduced length, that is, few words with reduced phrase length, simplified grammar, and impaired naming. Repetition is characteristically intact. These individuals often have associated apraxia (buccofacial, speech, and of the nonparalyzed limb) and right-sided weakness of the face and hand.

Wernicke aphasia is the classic example of language dysfunction occurring with a left superior temporal gyrus stroke, often secondary to left middle cerebral artery emboli. Typically, such patients have fluent spontaneous speech with phonemic (mixed syllables) and verbal (incorrect words) paraphasic errors sometimes referred to as a word salad. Often these individuals exhibit naming and repetition problems associated with comprehension, reading, and writing impairments. Sometimes these patients are not completely aware of their various limitations; however, when they are cognizant of these same problems, this can be extremely frustrating, leading to emotional lability. Less commonly, the temporal lobe may be disconnected from other or both auditory cortices. This may result in certain circumscribed language function disorders referred to as a disconnection syndromes. Pure word deafness is defined as loss of pure language word recognition while retaining one’s ability to normally hear and interpret meaningful nonverbal sounds such as a dog barking or a telephone ringing.

Global aphasia occurs with a more extensive dominant hemisphere cerebral infarction, leading to marked functional damage (see Plate 9-46). Here the patient may initially be unable to express any language function. As improvement begins, the damage may remain more pronounced in the frontal or temporal parietal cortex, with either a Broca- or Wernicke-type deficit emerging as the primary residual language impairment.

Prognosis for recovery from aphasia depends on the location and extent of lesion. Most patients improve to some extent, with greatest gains in the first few months, although there is significant treatment response with speech therapy regardless of the time postonset. Most communication therapy is provided through a multifactorial model and may include both context- and skillbased approaches combining multiple sensory stimuli, such as pictures and music, focus on semantics and repetition, and using emotional and social components in speech. Intensity of therapy, rather than the method, seems to be more important in the recovery response.

Constraint-induced aphasia therapy, a high-intensity treatment approach that restricts the use of nonverbal communication, has recently shown significant positive results in some patients with chronic aphasia. This rehabilitation language therapy is directed at a few individuals with a chronic aphasia entered into a group therapy program. These patients are encouraged to increasingly use verbal responses, emphasizing more expansive word output over time with hopes of maintaining these changes in treated individuals having chronic aphasia. Alternative compensatory means to attempt to communicate without language function are very much discouraged, for instance, writing, drawing, and various simple gestures during group therapy sessions. This modality demands a very significant daily time commitment of 2 to 3 hours per session, often taking place over a matter of months. The overall goal is to promote improved verbal language output. Initial reviews suggest that this very intensive therapeutic program is more effective for patients with nonfluent frontal Broca-type aphasias.

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