Differentiate the organization of language with respect to the role of phonological, lexical, syntactic, and semantic systems.
Understand the role of the motor speech system in the speech production process.
Discuss and characterize the classic aphasic syndromes.
Identify and explain the critical factors in the evaluation of recovery and rehabilitation of aphasia.
Identify and describe general approaches to aphasia rehabilitation and some specific treatment methods.
Identify etiologies of cognitive-communication disorders.
Compare and contrast deficits in executive function, pragmatic language, and motor speech in persons with cognitive-communication disorders.
Describe the primary types of dysarthria and rationales for dysarthria treatment.
Describe apraxia of speech and its treatment.
Gain an understanding of swallowing disorders.
Describe the goals and rationales for the use of augmentative communication systems.
Most people take the ability to produce and understand speech for granted and pay little attention to the nature and function of the processes involved in communication. Yet speech, like tool making, sets us apart from animals and is one of our most human behaviors. Even in primitive societies, humans have used the oral–motor speech code to share experiences, ideas, and feelings. Not all communities have developed writing and reading systems.
The use of speech for communication contributes to our identity as human beings and to the perception of "self." As a result, disruptions in the ability to communicate, whether caused by structural abnormalities (e.g., cleft palate), neurological conditions (e.g., stroke, Parkinson's disease), or nonorganic conditions (e.g., nonorganic articulatory disorders) may affect a person's daily life in important ways. For some, the acquisition of a communication disorder may have sufficient impact to cause an individual to withdraw from the workforce. For those whose communication disorders have persisted since childhood, the disorder may represent a significant vocational handicap. In other cases, a disorder that does not impede an individual's vocational life nonetheless interferes with everyday socialization. Communication disorders are complex, multifaceted behavioral impairments often associated so closely with a person's self-image as to threaten the quality of his or her life.
The term communication encompasses all of the behaviors, including speech, that human beings use to perceive and transmit information and interact with others. Speech comprises a delicate and rapid sequence of sensory and motor events requiring the coordinated activity of several parts of the body. The use of speech for communication involves many levels of human activity, ranging from the fine motor coordination of components of the oral–motor system to the subtle shades of meaning that occur at the cognitive/semantic level. Gestures, pantomime, and other nonverbal pragmatic language behaviors, such as turn taking, are also essential elements of communication.
Among unimpaired speakers, speech behavior varies greatly, yet the oral–motor system is efficient for the exchange of even complicated information. The range of variability is so wide that individuals generally produce different sound waves with different characteristics even when producing the same word. But listeners do not rely solely on information derived from speech waves. We also depend on cues, which are components of what is referred to as context. Context includes aspects of a communicative exchange such as the purpose of the activity, the location of the exchange, the knowledge of the participants, the roles of each participant, and the level of formality required by the situation.
This chapter addresses the neurogenic disorders of communication, a category of communication disorders represented by the majority of patients receiving speech-language pathology services in rehabilitation programs. The most common of these disorders are aphasia, a language (cerebral) disorder, dysarthria, a motor–speech disorder, and cognitive-communication disorders.
The field of speech-language pathology, which came into being in 1925 with the establishment of the American Speech-Language-Hearing Association (ASHA), is dedicated to the diagnosis and treatment of individuals with congenital or acquired communication disorders. Communication disorders in children and adults are estimated to have prevalence in the United States of 5% to 10% and a cost to the economy of $154 billion to $186 billion per year. The number of persons in the United States with communication disorders is estimated at 14 million.1,2 These statistics have increased by the addition of a large number of military personnel returning from active duty who may manifest a host of communication disorders, including hearing loss, speech-language disorders, and/or cognitive-communication disorders. A significant number of returning military personnel have cognitive-communication disorders secondary to traumatic brain injury (TBI), which include deficits in discourse, pragmatic language, and social communication.3,4,5,6
The National Institute on Deafness and Other Communication Disorders (NIDCD) reports that 6 to 8 million people in the United States have an acquired or developmental language disorder. It is estimated that about 100,000 persons acquire aphasia annually, and approximately 1 million people currently have aphasia.7 In addition, approximately 7.5 million people in the United States have voice disorders. The prevalence of articulation or speech sound disorders in children up to 6 or 7 years of age is estimated at 8% to 9%. By age 6 or 7, about 5% of children continue to present with speech disorders. It is also estimated that over 3 million Americans stutter.2
Approximately 28 million Americans have a hearing loss. Fifty-five percent of those with hearing impairments are older than 65 years of age, and 12 out of every 1,000 children younger than 18 have a hearing impairment.8,9 New technology has succeeded in providing the development of cochlear implants (CIs) for persons with profound hearing loss, which have been implanted in children as young as 6 months of age. CIs stimulate the surviving dendrites, spiral ganglion cells, and vestibulocochlear-nerve fibers in the inner ear, making auditory sensations available. Immediate benefits are reported following CI activation, including improvement in speaking, which generally increases over time.10
The speech-language pathologist (SLP) profession has grown rapidly. Affiliates (members and certificate holders) in the ASHA increased from 1,623 to 140,000 between 1950 and 2010. Speech-language pathology is a master's degree entry field. As of 2009, 47 states required a license to practice. The ASHA awards the Certificate of Clinical Competence (CCC) to SLPs who meet specified academic and clinical experience requirements, which includes a Clinical Fellowship Year (CFY), a 9-month period of supervision and mentoring by a speech and language pathologist holding ASHA certification. Fifty-seven percent of SLPs work in educational organizations, 37% in residential health care facilities, and approximately 15% in home health, private practice, and speech and hearing centers.11 The term SLP is the official designation of professionals in the field who hold the CCC. The term speech therapist, although no longer considered professionally appropriate, is a term that is often used informally.
In order for the presence and degree of speech or language pathology as it is manifest in a given person to be identified and measured, performance must be compared with a standard of "normal." One may choose as the standard (1) the language common to the cultural community of unimpaired persons in which the person lives, in which case an individual's verbal function would be compared with that of others in the same community of similar age, gender, education, and achievement, or (2) the person's verbal behavior before the onset of illness or trauma. The latter will vary from individual to individual and is based on premorbid educational achievement, specific cultural characteristics, personality, and other factors such as cognitive functioning. A person is verbally impaired when he or she deviates in any parameter of language and/or speech processing from the "normal" communication behavior of the community in which he or she functioned premorbidly.
A "normal" standard is implied in the terms impairment, disability, and handicap. This chapter uses the current World Health Organization (WHO) classification schema, in which the term disability is defined as the nature and extent of functioning, and the term handicap is defined as a person's involvement in life situations.12,13
THE ORGANIZATION OF LANGUAGE
When an individual generates an idea that he or she wishes to express, it is transformed into words and sentences by calling into play certain physiological and acoustic events. The message is converted into linguistic form. The listener, in turn, fits the auditory information into a sequence of words and sentences that are ultimately understood.
We refer to the system of symbols that are strung together into sentences expressing our thoughts and the understanding of those messages as language. In the first few years of life, infants and children gain a great deal of practice and experience in the use of language, until it becomes habitual and is used with different levels of conscious awareness.
Phonology refers to the study of the sound system of language. Words are made up of speech sounds or phonemes, which are generally classified as either vowels or consonants. Phonemes in and of themselves do not symbolize ideas or objects, but when put together they are the basic linguistic units that make words. Words comprise the lexicon, or vocabulary, of a language. English is comprised of 16 vowels and 22 consonants, which are combined into larger units called syllables.
A syllable usually consists of a vowel as a central phoneme surrounded by one or more consonants. There are between 1,000 and 2,000 syllables in English. Most languages have their own rules about how phonemes may be combined into larger units. For example, in English, syllables never start with the ng phoneme. The most frequently used words in English are sequences of from two to five phonemes. Some have as many as 10 phonemes or as few as one. In general, the most frequently used words have few phonemes. Even though only a small number of phoneme combinations are possible, new words are added to the English language every day. Although there are several hundred thousand English words, we use a repertoire of only about 5,000 to 10,000 words 95% of the time.
The grammar, or syntax, of a language determines the sequence of words that are acceptable in the formation of sentences. In English, for example, it is possible to say "The black box is on the table," but the sequence "Box black table on the" is unacceptable. Another example is "The old radio played well," which is syntactically correct, but "Old the well played radio" is not. The sentence "The boy walked to the store" is meaningful, but the sentence "The book walked to the store" is not. The language system that refers to the meanings of words is called semantics.
In addition to the phonological (sounds), lexical (vocabulary), syntactical (grammar), and semantic (meaning) language systems, we also utilize prosody (stress and intonation) to help make distinctions between questions, statements, expressions of emotional feelings, shock, exclamations, and so forth.
The speech organs consist of the lungs, trachea, larynx (which contains the vocal cords), pharynx, nose, and mouth. When considered together, these organs comprise a "tube" referred to as the vocal tract, which extends from the lungs to the lips. Moving the tongue, lips, and any other parts of the tract varies vocal tract shape. Changes in the configuration of the vocal tract act to modify the aerodynamic qualities of the air stream during speech (Fig. 28.1).
The primary function of the vocal organs relates to basic life-sustaining functions such as breathing and swallowing. These organs not only take on different roles for speech, but also function differently when engaged in speech production. For example, breathing for life-sustaining purposes is far more rapid than for speech production. A full cycle of inhalation/exhalation takes approximately 5 seconds, whereas while speaking we control the breathing rate according to the demands of the words and sentences we are producing, sometimes reducing the rate of breathing to as little as 15% devoted to inhalation. This is dictated in part by the fact that, when speaking, we generally take in enough air to vocalize a complete thought and we exhale the air gradually during the production of the thought.
The steady stream of air exhaled from the lungs is the source of energy for speech production, which is made audible by the rapid vibration of the vocal cords. During speech, we continuously alter the shape of the vocal tract by moving the tongue, lips, and other parts of the system. By moving parts of the vocal tract, thereby modifying its acoustic properties, we are able to produce different sounds. That is, by altering the shape of the vocal tract during phonation, we transform the air stream into a resonance chamber (Figs. 28.2 and 28.3).
Outlines of the vocal tract during articulation of various vowels.
Vocal tract configuration and corresponding spectra for three different vowels. The peaks of the spectra represent vocal tract resonances. The vertical lines for individual harmonics are not shown.
The larynx acts as a barrier to prevent food from entering the trachea and lungs by closing automatically during the act of swallowing, which is also helped by the action of the epiglottis. By opening and closing the flow of air from the lungs, the larynx acts as a valve between the lungs and the mouth. The laryngeal valve also acts to lock air into the lungs, which we do automatically when we perform heavy work using our upper extremities. The larynx is not a fixed, rigid organ, but because of its cartilaginous construction and corresponding connecting muscles and ligaments moves up and down during both swallowing and speaking.
The vocal cords, which create the sounds of speech, are located on either side of the larynx from the Adam's apple at the front to the arytenoid cartilages at the back. Recent neuroimaging research has reported findings that reflect the complexity of motor planning and control of vocal cord movement for voice production, showing that subcortical and cortical interactions control the movement of the vocal cords.14 We refer to the space between the vocal cords as the glottis. When the cords are pressed together, the passage of air is sealed off and the valve is shut. Because the cords are held together at the front where they articulate with the Adam's apple, the open glottis is V-shaped, opening only at the back. When we speak, we vibrate the vocal cords in a rhythmic fashion, opening and closing the air passage from the lungs to the oral/nasal cavities.
The frequency of sound produced by the vocal cords is directly related to their mass, tension, and length. The tension and length of the vocal cords is continuously altered while speaking. In normal speech, the range of vocal cord frequencies is from about 60 to 350 cycles per second (cps). Most people use a vocal cord frequency range that covers about one and a half octaves.
The pharynx is the area of the vocal tract connecting the larynx with the nose and mouth. We isolate the nasal cavity from the pharynx and back of the mouth by raising the soft palate. The most adjustable component of the vocal tract is the mouth, whose shape and size can be modified more than any other organ of the oral–motor system by changing the relative position of the palate, tongue, lips, and teeth. The lips are rounded, spread, or closed to alter the shape and length of the vocal tract or to stop airflow. The teeth and their relationship to the lips or tongue tip change the airflow. An important component of the teeth ridge is the alveolus, which is the area covered by the gums.
The term articulation refers to the articulating, or "meeting," of the various organs of the oral-pharyngeal cavity to produce the sounds of speech. Speech intelligibility refers to the adequacy of the acoustic signal produced by a speaker and represents a significant factor in understanding a speaker. A number of factors can influence judgments of intelligibility, such as the presence or absence of visual cues or of extraneous movements (i.e., tremor). The precision of the production of consonant sounds is one of the primary factors that contribute to speech intelligibility. Consonants are described by specifying their place and manner of articulation and whether they are voiced or unvoiced (Table 28.1). The "places" of articulation are the lips (labial), teeth, gums (alveolar), palate, and glottis. The manner of articulation refers to the plosive, fricative, nasal, liquid, and semivowel categories.
Table 28.1Classification of English Consonants by Place and Manner of Articulation ||Download (.pdf) Table 28.1 Classification of English Consonants by Place and Manner of Articulation
|Manner of Articulation |
|Place of Articulation ||Plosive ||Fricative ||Semivowel ||Liquids (including laterals) ||Nasal |
|Labial ||p b ||— ||w ||— ||m |
|Labiodental ||— ||f v ||— ||— ||— |
|Dental ||— ||_th ||— ||— ||— |
|Alveolar ||t d ||s z ||y ||l r ||n |
|Palatal ||— ||sh zh ||— ||— ||— |
|Velar ||kg ||— ||— ||— ||ng |
|Glottal ||— ||h ||— ||— ||— |
Plosive sounds, sometimes referred to as "stop" sounds, are those produced by building up air pressure in the oral cavity and suddenly releasing it (e.g., p, t). The blockage can occur by pressing the lips together or by pressing the tongue against either the gums or soft palate. There are plosive consonants that are labial, alveolar, or velar (consonants articulated with the back part of the tongue).
Fricatives are produced by making the air turbulent (e.g., f, v). Most consonants are produced with the soft palate raised, thereby closing off the flow of air to the nasal cavity, except for the nasals (e.g., m, n, ng), which are made by lowering the soft palate and blocking the oral cavity somewhere along its length. Liquids are sounds made with the soft palate raised: /r/, /l/.
Semivowels refer to those sounds produced by maintaining the vocal tract in a vowel-like position, then changing the position rapidly for the vowel that follows (e.g., w, y).
Speech sounds are affected by their context, that is, the sounds that immediately precede or follow. A speech sound wave is a continuous event rather than a sequence of discrete segments. The identification of a speech sound depends on relating acoustic features of the sound wave at different points in time.
A standard reference for the quality of vowels is the eight cardinal vowels (Fig. 28.4). This schema of the positions of the tongue for the production of the vowels of the language helps us visualize the tongue's movements during speech. It is, in a sense, a map of the tongue positions for vowel production. Tongue placement is described by specifying the location of the main body of the tongue at its highest point. For example, for the sound /ee/as in the word beat, the tongue tip is pointed in a high frontal configuration, whereas for the sound /ah/as in the word father, the highest point of the tongue is low and posterior in the oral cavity.
The cardinal vowels represented as a vowel quadrilateral. The cardinal vowels are extremely placed reference points for vowel articulation. Vowels on the same horizontal line are believed to have an equally high tongue height while vowels in the left–right position are assumed to be equally backed and fronted. Adapted from Ladefoged, P: A Course in Phonetics. Harcourt Brace Jovanovich, New York, 1975, with permission.
All vowel sounds and some consonant sounds are voiced. That is, the vocal cords vibrate during their production. When a sound is produced without vocal cord vibration, we say that it is unvoiced or voiceless (e.g., p, s). Table 28.1 shows that many consonant sounds are articulated in the same manner, and differ only with respect to voicing (e.g., p-b; s-z; f-v; k-g).
Speech behavior comprises a complex motor event that goes well beyond the skilled movements required of the oral–motor system. Yet we produce speech without thinking about it even while simultaneously involved in other activities. However, to transform thought into speech takes some voluntary, conscious behavior that allows us to take information stored in memory and translate it into a coherent production of words and utterances that follow certain grammatical rules.
In addition to its linguistic aspects, neurogenic communication disorders often involve coexisting mild to severe cognitive deficits that may not only aggravate the communication disorder but also make it difficult to differentiate cognitive from communication deficits. The communication disorder manifest in persons with right brain damage, which is addressed in this chapter, is an example of a disorder in which the cognitive component is a major issue.
The importance of the communication process and its underlying systems becomes apparent when we consider the two most common neurogenic communication disorders: aphasia and dysarthria. This chapter focuses primarily on aphasia and dysarthria but also considers verbal apraxia, dysphagia, cognitive-communication disorders, and the use of augmentative/alternate systems of communication.
An increase in the population of individuals with aphasia is anticipated by the projection that by 2050, 21% to 22% of the U.S. population will be over age 65.15 It has been estimated that there are over 1 million individuals with aphasia in the United States alone.2,16,17 In a survey of 850 patients in the first month post-stroke, aphasia was present in 177 patients.18 It is further estimated that there are more than 100,000 new patients with aphasia each year.11,19 The majority are currently older than 65 years of age and acquired aphasia as a result of a stroke. A smaller number are the result of head trauma and neoplasms. Aphasia is also often present in the early stages of Alzheimer's disease.20 Ellis et al19 report that the incidence of aphasia and its demographic characteristics has been generally consistent in the United States from 1997 to 2006.
Classification and Nomenclature
In this chapter, the term aphasia refers to the acquired communication disorder that is manifest in individuals who were previously capable of using language appropriately. It does not refer to developmental language disorders that may be present in individuals who never developed normal language and for whom the ability to use language may never reach age-appropriate performance levels.
In acquired aphasia, central nervous system (CNS) disease or trauma compromises certain structures in a focal rather than generalized fashion. The study of the neuroanatomical correlates of the aphasias has engaged neurologists since the late 19th century, and the correlation between aphasic syndromes and cerebral localization is relatively consistent. Recent advances in neuroradiological technology have provided many new methods for studying the neural substrates of language and language impairment.21,22
Aphasiologists generally agree that there are distinct major aphasic syndromes that adhere to specific profiles of impairment. This is not surprising, because the lesions that produce aphasia, particularly in the patient with cerebrovascular disease, tend to be located in brain loci that are especially vulnerable. It is not always possible, however, to classify patients according to these syndromes. Estimates of the proportion of cases that can be unambiguously classified range from 30% to 80%.23
The characteristics of an individual's speech production are used to determine aphasia classification. Speech output that is characterized as hesitant, awkward, interrupted, and produced with effort is referred to as non-fluent aphasia in contrast to speech output that is facile in articulation, produced at a normal rate, with preserved flow and melody, and is referred to as fluent aphasia. Fluency judgments are made during extended conversation with a patient and are defined as follows.
Fluent aphasia is characterized by impaired auditory comprehension and fluent speech that is of normal rate and melody. Fluent aphasia is usually associated with a lesion in the vicinity of the posterior portion of the first temporal gyrus of the left hemisphere. When fluent aphasia is severe, word and sound substitutions may be of such magnitude and frequency that speech may be rendered meaningless. Patients with fluent aphasia tend to have greatest difficulty in retrieving those words that are substantive (nouns and verbs). Since their lesions are located in the posterior portion of the brain, distant from motor areas, they also tend to have some degree of impaired awareness and are rarely physically disabled. There are several types of syndromes subsumed under the fluent aphasia classification (Table 28.2).
Table 28.2Classification by Aphasia Syndromes ||Download (.pdf) Table 28.2 Classification by Aphasia Syndromes
| ||Wernicke's Aphasia ||Broca's Aphasia ||Global Aphasia ||Conduction Aphasia ||Anomic Aphasia ||Transcortical Motor Aphasia ||Pure Word Deafness |
|Area of infarction ||Posterior portion of temporal gyrus ||Third frontal convolution ||Third frontal convolution and posterior portion of superior temporal gyrus ||Parietal oper-culum or posterior superior temporal gyrus ||Angular gyrus ||Supplementary motor areas ||Both Heschl's gyri or connection between Heschl's gyrus and posterior superior tempora gyrus |
|Spontaneous speech ||Fluent ||Nonfluent ||Nonfluent ||Fluent or nonfluent ||Fluent ||Nonfluent ||Fluent |
|Comprehension ||Poor ||Good ||Poor ||Good ||Good ||Good ||Poor |
|Repetition ||Poor ||Poor (but may be better than spontaneous speech) ||Poor ||Very poor ||Good ||Excellent ||Poor |
|Naming ||Poor ||Poor (but may be better than spontaneous speech) ||Poor ||Poor ||Very poor ||Poor ||Good |
|Reading comprehension ||Poor ||Good ||Poor ||Good to poor ||Good to poor ||Good ||Good |
|Writing ||Poor ||Poor ||Poor ||Poor ||Good to poor ||Poor ||Good |
The most common type of fluent aphasia is Wernicke's aphasia (also referred to as sensory aphasia and/or receptive aphasia). Wernicke's aphasia is usually the result of a lesion in the posterior portion of the first temporal gyrus of the left hemisphere. It is characterized by impaired auditory comprehension and fluently articulated speech marked by word substitutions. Reading and writing are usually severely impaired as well. Although patients with Wernicke's aphasia may produce what seem like complete utterances and use complex verb tenses, they often add a word or phrase and "augment" speech production. Speech is often produced at a rate greater than normal. Although the production of speech sounds is generally precise, patients with Wernicke's aphasia may reverse phonemes and/or syllables (hopspipal/trevilision) and may produce neologisms (nonsense words).
In the course of recovery Wernicke's aphasia may evolve into anomic aphasia. Anomic aphasia is characterized by a significant word-finding difficulty in the context of fluent, grammatically well-formed speech. Auditory comprehension is generally impaired, especially when listening to complex and/or rapid speech. Speech output may be somewhat vague and the patient may be proficient in producing circumlocutions to skirt the lack of specificity of language use.
Nonfluent aphasia is characterized by limited vocabulary, slow, hesitant speech, some awkward articulation, and restricted use of grammar in the presence of relatively preserved auditory comprehension. Nonfluent aphasia is associated with anterior lesions usually involving the third frontal convolution of the left hemisphere. Patients with nonfluent aphasia tend to express themselves in vocabulary that is substantive (nouns, verbs) and lack the ability to retrieve less substantive parts of speech (prepositions, conjunctions, pronouns). Patients with nonfluent aphasia tend to have good awareness of their deficit and usually have impaired motor function on the right side (right hemiplegia–paresis).
Broca's aphasia is a nonfluent type of aphasia also sometimes referred to as expressive aphasia, motor aphasia, and/or verbal aphasia. Broca's aphasia is the result of a lesion involving the third frontal convolution of the left hemisphere, the subcortical white matter, and extending posteriorly to the inferior portion of the motor strip (precentral gyrus). It is characterized by awkward articulation, restricted vocabulary, and restriction to simple grammatical forms in the presence of a relative preservation of auditory comprehension. Writing skills generally mirror the pattern of speech and reading may be less impaired than speech and writing. The patient may be limited to one- and two-word productions for expression and find it impossible to combine words into sentences. Articulation may be awkward and effortful (see later section titled Apraxia of Speech). Nonfluent Broca's aphasia is less common after TBI. Anomic disturbances predominate in aphasia secondary to TBI.
A severe aphasia with marked dysfunction across all language modalities and with severely limited residual use of all communication modes for oral–aural interactions is referred to as global aphasia. Global aphasia is not a type of aphasia but rather a designation of severity. The patient with global aphasia generally has extensive damage, which may be anywhere in the left hemisphere, and is sometimes bilateral.24 Global aphasia has been cited as among the most common types of aphasia in patients referred for speech rehabilitation services.25,26
Acquired aphasia in children as a result of cerebral damage caused by head injury, tumor, or stroke results in the same syndromes manifest in adults with aphasia.27,28,29,30 In children with aphasia secondary to TBI, anomic disturbances predominate and there is generally a reduction of output with hesitancy, difficulty initiating speech, and sometimes mutism.31 Follow-up studies report that a significant number of children with acquired aphasia are slow to develop language and academic skills. Since cerebral plasticity decreases across the developmental spectrum, the age of aphasia onset is a factor in determining the extent of recovery.30
Primary Progressive Aphasia
Primary progressive aphasia (PPA), a condition that was first described in 1982, is now a recognized diagnostic category.32,33 PPA is a slowly progressive isolated aphasia not due to stroke, trauma, tumor, or infection, which does not fit neatly into existing aphasia classification schemes. It can exist in the absence or relative absence of generalized intellectual and behavioral disturbances or cognitive impairment generally associated with dementia. Activities of daily living, judgment, insight, and behavior are usually preserved for at least 2 years and may remain unimpaired and isolated from the language impairment for as long as 20 years.34 About half of those with PPA eventually develop symptoms of a more pervasive dementia. Spontaneous recovery does not occur.
In its initial presentation, PPA is commonly reported and observed as being a speech or articulation disorder or difficulty in naming. PPA progresses at different rates and in its most severe form can result in the inability to speak. In these cases comprehension usually remains relatively preserved. However, in other cases initial difficulties with and a progressive decline in word retrieval skills and comprehension with relatively preserved speech production abilities is noted.35 The longer the duration of aphasia as an isolated symptom, the less likely that other signs of dementia will develop.
Language disturbances were recorded as early as 3500 BC, and attempts to "retrain" individuals with aphasia have been recorded throughout history.36 Some of the first documented cases of both natural recovery and intervention were the patients of Nicolo Massa and Francisco Arceo in 1558.37
In a landmark paper in the late 19th century, "Du siège de la faculté du langage articulé," Paul Broca was one of the first to discuss the possibility of retraining in aphasia.38 Dr. Charles K. Mills was the first to address recovery and rehabilitation in aphasia in an English-language publication. He reported the training of a patient with post-stroke aphasia whom he and Donald Broadbent treated, using methods largely determined by the patient, who began by systematically repeating letters, words, and phrases.39,40 Mills' observations and approach to aphasia rehabilitation, published over a century ago, are remarkably similar to much present-day practice and thought. Mills noted that not all patients benefit from retraining to the same degree and acknowledged that spontaneous recovery might have an influence on the course and extent of recovery.
World War I and its brain-injured combat survivors led to the establishment of treatment centers where patients with post-traumatic aphasia were treated, especially in Europe. Reports of aphasia rehabilitation experiences during and after the war in England and the United States were also published.41,42 One of the most comprehensive descriptions of the systematic treatment of a large number of patients with aphasia secondary to head trauma, of whom 90 to 100 were followed for a 10-year period, was provided by Kurt Goldstein in Frankfurt during the Second World War.43
Until World War II, reports of retraining civilians with post-stroke aphasia were rare. The aphasia literature was based almost exclusively on post-traumatic aphasia. In 1933, Singer and Low44 reported the case of a 39-year-old woman who suffered an apparent vascular infarct after a full-term delivery and showed continuous language improvement with consistent training over a 10-year period.
In a landmark 5-year study supported by the Commonwealth Fund, Weisenburg and McBride45 addressed the general topic of aphasia and commented on the effectiveness of reeducation. The study concerned 60 patients who were younger than 60 years of age, a majority of whom had suffered strokes, and concluded that reeducation increased the rate of recovery, assisted in facilitating the use of compensatory means of communication, and improved morale. Their work also documented the psychotherapeutic benefits of treatment.
Before World War II, aphasia and its concomitant neurological deficits in the patient with stroke were generally viewed as natural and necessary components of the aging process. The treatment of aphasia in the civilian population was not an option.
Many variables had an influence on making the treatment of aphasia the common practice that it is today. The advent of speech and language pathology as a health profession, the emergence of rehabilitation medicine as a medical specialty, the mass media explosion, a larger and more affluent middle class, an increase in the life span, the number of stroke and brain injury survivors, and public expectations of medicine in the age of technology are among them. The last has been particularly true in the industrialized world, where it is widely believed that there is a treatment for every human ill.46
Journals devoted to brain/language issues have become indispensable information sources for aphasiologists (e.g., Journal of Medical Speech and Language Pathology, Aphasiology, Brain and Language, and Cortex). The Academy of Aphasia, a scholarly society dedicated to the study of aphasia, was established in 1962. The National Aphasia Association (NAA) was founded in the United States in 1987 for the purpose of providing information to the public about aphasia, advocating for the aphasia community, and encouraging the establishment of a network of support groups called Aphasia Community Groups (ACGs).47
Several informational publications designed for use by the families and friends of patients with aphasia also appeared in the period following World War II.48,49,50,51,52,53 One of these, "Understanding Aphasia: A Guide for Family and Friends," is still widely read and has been published in 12 languages.53
Many measures of aphasia and related disorders have been developed for use in both clinical and research settings. In an inpatient setting, patients with aphasia are generally screened at bedside. The purpose of a bedside screening is to obtain a general idea of a patient's profile of deficits and preserved areas of language function as a basis for recommendations for more comprehensive testing and possible rehabilitation. However, a comprehensive examination is required to provide a baseline measure against which to gauge progress in the course of rehabilitation.
Comprehensive language tests designed to measure aphasic impairment generally contain specific domains of performance. In addition to the general requirements for the construction of tests, such as reliability, standardization, and demonstrated validity, certain factors are important in the design of tests intended to identify and measure aphasia. These include range of item difficulty, efficacy in measuring recovery, and ability to contribute to diagnostic classification.2,54 Aphasia tests are generally based on examinations of linguistic task performance and at a minimum include tasks of visual confrontation naming; a spontaneous or conversational speech sample that is analyzed for fluency of output, effort, articulation, phrase length, prosody, word substitutions, and omissions; repetition of digits, single words, multisyllable words, and sentences of increasing length and complexity; comprehension of spoken language of single words, of sentences that require only yes/no responses, and pointing on command; word retrieval (word finding) measuring the ability to generate words beginning with a particular letter of the alphabet or in a particular semantic category (animals); reading; and writing from dictation and spontaneously. Some widely used aphasia measures include the Boston Diagnostic Aphasia Examination (BDAE),23 the Neurosensory Center Comprehensive Examination for Aphasia (NCCEA),55 and the Western Aphasia Battery.56
In addition to measuring performance on specific linguistic tasks, an aphasia evaluation also requires an examination of functional communication. This is necessary because an individual's actual use of language in everyday life may not correspond to the degree of pathology measured by specific language task performance.57,58 Functional communication measures are generally rating scales with high interrater reliability. The Functional Communication Profile (FCP),59,60 Communicative Activities of Daily Living (CADL),61 Communicative Effectiveness Index,62 and ASHA's Functional Assessment of Communication Skills (ASHA FACS),63 which have high interrater reliability, are measures used for this purpose.
In addition to measures of language and functional communication, new tools have been developed to determine the impact of impaired communication skills on quality of life. The scope of SLP practice now encompasses all of the components and factors specified in the WHO framework.13,65,66,67,68 Specifically, concern for the effect of aphasia on family, social, and community life is the basis for more recently designed measures (e.g., Burden of Stroke Scale [BOSS], Functional Life Scale [FLS], Aphasic Depression Rating Scale [ADRS], Frenchay Activities Index, and Stroke and Aphasia Quality of Life Scale–39 [SAQOL-39]).68,69,70,71,72,73,74,75
If complete recovery from aphasia is to occur, it usually happens within a matter of hours or days following onset. Once aphasia has persisted for several weeks or months, a complete return to a premorbid state is usually the exception. It is the general consensus that language gains in aphasia take place earlier rather than later, and that time since onset is an important recovery variable.76,77,78,79,80,81
Most patients do not consider themselves recovered unless they have fully recovered to previous levels of language performance.46,82 When unrecovered patients are satisfied with their level of competence and consider themselves recovered, this is a psychological perception and should not be confused with an objective evaluation of communication abilities. For individuals with aphasia, the true test of rehabilitation outcome is their perception of the quality of their life. Measures of life function that include activity levels, socialization, mobility, and community reintegration can be used for this purpose.83,84
It is useful to distinguish between two separate recovery dimensions in aphasia: one that is objective and attempts to quantify the extent to which a person has regained language abilities; and another, which measures the recovery of functional communication.
The concept of a functional dimension of communication behavior emerged logically from the experience of treating patients with aphasia in rehabilitation medicine settings. Historically, rehabilitation medicine has acknowledged that the ability of patients to function in daily life (activities of daily living [ADL]) does not necessarily correlate with the degree of physical disability. Similarly, improvement in quantitative measures of language performance does not necessarily correlate with improvement in functional communication.46
The majority of patients experience a degree of natural recovery with or without intervention in the period immediately following onset. However, there is a lack of consensus about the duration of the spontaneous recovery period.85,86,87 Culton88 reported rapid spontaneous language recovery in the first month following the onset of aphasia, and a number of studies have concluded that the greatest improvement occurs in the first 2 to 3 months after onset.89,90,91,92,93 Of 850 patients surveyed in the first month following stroke, 177 presented with aphasia. In the 4 to 12 weeks following the stroke, aphasia improved in 74% of the patients and cleared in 44%.18 Butfield and Zangwill,94 Sands et al,95 and Vignolo89 reported that the recovery rate dropped significantly after 6 months. Others have found that spontaneous recovery occurs up to 6 months96 or 1 year.88,90 Sarno and Levita97 reported that the greater change took place within a 3-month rather than a 6-month post-onset period in a sample of patients with severe aphasia seen up to 6 months after stroke.
Recovery from aphasia after stroke is difficult to predict, especially during the early recovery stages.98 Severity and location of lesion have been reported as predictors of language recovery.99,100,101,102 However, these factors are very variable, making it difficult to generate a prognosis for individual patients.103
Most investigators have concluded that factors such as age, gender, and handedness do not affect recovery from aphasia.98,103,104,105 Although age has been reported as a significant prognostic factor,89,106,107,108 many do not support this view.90,104, 109,110,111,112,113 These wide discrepancies regarding the influence of age may relate to differences in sampling and methodology. In a study that compared aphasia recovery in the first post-stroke year between a middle-aged (50 to 64 years old) and older (65 to 80 years old) group, age did not emerge as a significant factor.83 In addition, educational level or occupational status before illness does not always correlate with recovery. However, Sarno and Levita97 reported that individuals with aphasia who were employed at the time of stroke recovered more than those who were unemployed. In the healthy aged, language performance declines significantly between the sixth and eighth decades.106,114,115 Gender does not appear to have an important influence on outcome,76,104,116 whereas hand edness may have an effect.117
It is generally agreed that posttraumatic aphasia has a better prognosis than aphasia secondary to vascular lesions.89,94 In fact, some cases of aphasia secondary to TBI have been reported to recover completely.91,118 The finding that traumatic aphasia carries a better prognosis than vascular aphasia may be influenced by the fact that patients involved in traumatic events are generally neurologically healthy whereas patients who have had strokes may have widespread vascular involvement.104
Both type and severity of aphasia appear to carry predictive value, with global aphasia having the poorest prognosis.76,119,120,121 Basso104 reported that when patients with fluent and nonfluent aphasia of the same severity were compared, there were no differences in degree of recovery. In 881 consecutive acute stroke admissions to a community-based hospital, it was possible to make valid prognoses within 1 to 4 weeks after stroke depending on the initial severity of aphasia.104
Not surprisingly, most studies report that patients with severe aphasia do not recover as much as those with mild aphasia.91,95, 120,121,122 Sarno and Levita76 found that people with fluent aphasia reached the highest level of functional communication, whereas patients with nonfluent and global aphasia made smaller gains in the 8- to 52-week post-stroke period. Global aphasia sometimes evolves to severe Broca's aphasia when there is significantly improved comprehension. Broca's aphasia may become anomic aphasia, and Wernicke's aphasia may evolve to anomic or conduction aphasia.76,91, 120,121,122,123,124 When persons with aphasia recover a great deal of language function they are usually left with residual anomia.
Patients whose computed tomography (CT) scans show large dominant hemisphere lesions, many small lesions, or bilateral lesions are less likely to recover than those with smaller or fewer lesions.82,120 Lesions in Wernicke's area or those that extend more posteriorly tend to lead to severe and persistent aphasia. The neu-roradiological correlates of aphasia recovery have been addressed by some investigators.93,125 Yarnell et al82 reported little prognostic value in angiographic and radioscintigram findings. Similarly, CT scans did not help in predicting who might profit from language retraining in a Norwegian study.86
More recent functional imaging studies of aphasia secondary to stroke have suggested that language recovery is dependent on several factors. The neuroplastic changes that are needed during recovery are thought to depend more heavily on left hemispheric changes in activity that slowly manifest over time.22 Following damage to the left hemisphere, rapid changes have been observed in temporal and frontal areas within the right hemisphere but may reflect maladaptive compensatory activity versus functional reorganization or recovery.126,127,128,129,130,131,132,133,134,135
Comprehension tends to recover to a greater degree than expression.26,89, 133,134,135,136 Although recovery of auditory comprehension involves bilateral temporal lobe activation, there does not seem to be a correlation between the activity of each hemisphere during this process.126,137,138,139 As technology advances and research continues, new insights into the mechanisms of recovery and treatment will emerge.140
The presence of depression, anxiety, and paranoia have been cited as negative factors in recovery,141,142,143 and premorbid personality traits have been identified as important prognostic factors. Eisenson and Herrmann felt that patients with outgoing personalities had a better prognosis than those with introverted, dependent, or rigid personalities.144,145,146
Efficacy of Treatment in Post-Stroke Aphasia
Many methodological problems have limited the number of studies that examine the efficacy of aphasia rehabilitation.147,148,149,150,151,152,153 Nevertheless, treatment accountability issues are compelling and a focus of professional concern.
Studies that investigate treatment effects, specific techniques, and approaches have been reported since the late 1950s.154 Vignolo,89 Hagen,155 and Basso et al90,119 utilized untreated control and treated groups and showed a positive treatment effect. Edmonds et al156 and Poeck et al157 also yielded positive treatment effects with treated and untreated groups. In addition, several reviews and examinations have revealed significant treatment effects (i.e., improvements in communicative ability) with intense intervention provided over a short period of time.158,159,160 Variables such as spontaneous recovery,91,161,162 age,109,163 duration, treatment inten sity,122,158,159,160 and timing of treatment164 and specific treatment techniques165,166,167 have been studied.
Although studies have varied in method and research focus, there have been strong indications for positive treatment effects.154 Some have maintained that single case studies rather than randomized, controlled trials are the most appropriate method for addressing treatment efficacy.168,169 Current research utilizing a standard approach to analyze data from single-subject designs are improving the ability to quantify treatment outcomes.96 A single case approach to the study of aphasia treatment efficacy has not escaped criticism but is far less frequent than criticism of studies based on groups of people with aphasia.96 Negative views of the group study model are based primarily on the view that individuals are unique, especially with respect to communication behavior.
The Academy of Neurologic Communication Disorders and Sciences (ANCDS) has issued evidence-based practice guidelines for neurogenic communication disorders.153,170,171 Until now, SLPs have depended on meta-analyses of efficacy studies reported for 45 studies published between 1946 and 1988 and for 55 studies that support better clinical outcome for patients who receive early, intensive treatment.152,172
Psychological and Related Factors
It has been observed that the variability of patients' psychological reactions is rarely determined by the type or location of their lesions but is an expression of the whole life experience of the person who has had a stroke.83,104,143,173,174
Depression, anxiety, premorbid personality, fatigue, and paranoia are often cited as deterrents to recovery and communication. The social isolation experienced by people with aphasia and their families has a profound impact on quality of life.83,151 The effect of aphasia on an individual's sense of "self" can be extremely negative, leading to a loss of self-esteem and feelings of helplessness. Also, the opportunity for "healing conversation," so essential to individuals who have suffered losses, is often unavailable to those with aphasia, which may be the result of inadequate social support.
In a study of patients with aphasia participating in a group psychotherapy program, Friedman175 investigated the nature of psychological regression with impaired reality testing in aphasia. Beyond the communication difficulties posed by aphasia, he observed that patients remained psychologically isolated. They did not maintain a consistent level of group participation and expressed intense feelings that they were very different from other people. Both withdrawal and projection were apparent as each patient acted in isolation and yet complained of these characteristic in others.
Aphasia treatment is rarely the same in any two settings. Literally hundreds of specific speech and language treatment techniques are cited in the aphasia literature. The lack of therapeutic uniformity has undoubtedly impeded an adequate number of carefully controlled studies on the effects of language retraining. Most methods derive essentially from traditional pedagogic practices, relying heavily on repetition.176
In general, treatment methods can be categorized as those that are largely indirect stimulation-facilitation and those that are essentially direct structured-pedagogic.78,118,141,177,178,179,180 The two principles that underlie most treatment methods reflect contrasting views of aphasia as either impaired access to language or a "loss" of language. The stimulation methods generally follow an impaired access model and pedagogic approaches are based on a theory of aphasia as a language loss.
In practice, however, much of aphasia treatment addresses the performance aspect of language in which repeated practice and "teaching" strategies are assumed to help restore impaired skills through a "task-oriented" approach (i.e., naming practice). One of the commonly used techniques involves self-cueing and repetition exercises that manipulate components of grammar and vocabulary. Another approach involves "stimulating" the patient to use residual language by encouraging conversation in a permissive setting where a patient's responses are unconditionally accepted and topics are of personal interest.179
The primary assumption that drives the treatment of aphasia is that language in the brain is not "erased," but that retrieval of its individual units has been impaired. Approaches to aphasia therapy have generally followed one of two models: a substitute skill model or a direct treatment model, both of which are based on the assumption that the processes that subserve normal performance need to be understood if treatment is to succeed.180 An example of the substitute skill model can be found in deaf individuals, some of whom use speech reading, a visual input rather than an auditory input, as an aid to comprehend spoken language. If a direct treatment model is followed, specific exercises individually designed to ameliorate specific linguistic deficits are the basis of treatment.
Significant progress and improvements of language and communication performance have been reported in those with aphasia who have received intensive and/or extended periods of language therapy.153,157,181,182 More recent re ports of intensive treatment programs have shown significant improvement of communication abilities several years post-stroke, when aphasia is in the chronic stage.167,182,183,184 Some benefits may also be received from pharmacological treatment with and without speech therapy.185,186,187,188,189,190,191,192 In addition, improvements have also been documented with the use of transcranial magnetic stimulation,193 functional magnetic resonance imaging,194 and transcranial direct current stimulation.195
Visual communication therapy (VIC) is an experimental technique designed for persons with global aphasia.196,197,198,199,200 It employs an index card system of arbitrary symbols representing syntactic and lexical components that patients learn to manipulate so as to (1) respond to a command and (2) express needs, wishes, or other emotions. The system attempts to circumvent the use of natural oral language, which is severely impaired and often unavailable to the patient with global aphasia. An adaptation and application of the VIC system, Computer-Aided Visual Communication system (C-VIC), was developed by Steele et al.198,199 Weinrich et al201 demonstrated that C-VIC training can lead to improved spoken language. Investigators conclude that the evidence supports the view that some patients who have severe aphasia can master the basics of an artificial language and that some of the cognitive operations entailed in natural language are preserved despite the severity of the impairment.
Visual Action Therapy (VAT) developed at the Boston Veterans Administration Medical Center by Helm-Estabrooks et al202,203 was designed to train people with global aphasia to use symbolic gestures representing visually absent objects. The tasks leading to this goal include associating pictured forms with specific objects, manipulating real objects appropriately, and finally producing symbolic gestures that represent the objects used (e.g., cup, hammer, razor).
In an attempt to utilize systematized gestural language to facilitate oral production, American Indian sign language has been modified in a method that combines common gestural sign with oral speech production (Amerind) for selected cases.204,205,206
Melodic Intonation Therapy (MIT) is based on the observation that language may not be available in spontaneous speech but can sometimes be provided in association with known melody, as the therapist gradually introduces spoken material with a melodic rhythm. The patient is encouraged to participate in the process.207,208,209
In the functional communication treatment (FCT) method developed by Aten et al,210,211 emphasis is placed on restoration of communication in the broadest sense. Treatment is designed to improve information processing in the activities necessary to conducting ADL, social interactions, and self-expression of both physical and psychological needs.210,211
Promoting Aphasics' Communicative Effectiveness (PACE), a technique intended to reshape structured interaction between clinicians and patients into more natural communicative exchanges, includes several pragmatic components common to natural conversation.212,213
Contextualized, constraint-induced language therapy (CILT) is an intensive form of language therapy that is usually administered over a short period of time. Treatment is conducted by an SLP in small groups of two to three persons with aphasia who are required to use and practice only those verbal skills that are difficult or impaired. Forms of communication that can be effective in total communication but are not verbal, including gesturing, drawing, or writing, are constrained.167,214,215
Maher et al215 compared PACE and CILT on the same schedule of intensity and found that both groups made significant improvements but differed in the types of communication behaviors that improved. Those who received CILT performed better on measures examining verbal behaviors and those who received PACE improved on nonverbal behaviors.
Some investigators have reported the use of writing216 or drawing as a potential means of communication.217,218,219,220 Others have developed interactive approaches to aphasia treatment. Examples include the communication partners approach of Lyon,217,218,219 a treatment plan designed to enhance communication and well-being in settings where the person with aphasia and the caregiver live; the supported conversation approach introduced by Kagan and colleagues,221,222,223,224,225 in which volunteers are trained as conversation partners to facilitate conversation by using all available modalities, thereby revealing the individual's competence and permitting a communicative interaction; and the social model of aphasia approach introduced by Simmons-Mackie,226,227,228,229,230,231,232,233,234 which focuses on the fulfillment of social needs and the encouragement of a greater conversational burden on the part of communication partners. Partners are trained to facilitate interaction by modifying some of their interactive behavior.
If an individual is unable to make himself or herself understood and has residual writing and spelling skills, aids that use the alphabet can provide a means of communication (e.g., an alphabet board). A communication book may consist of pictures or words arranged according to topics (e.g., foods, family members) in a notebook for easy access. The same type of material has also been adapted for computerized access in the form of tablet devices (e.g., iPad). Microcomputers were the basis for an approach that Seron et al235 found effective in treating patients with writing disorders associated with aphasia. With continued exposure to training, improvement in accuracy and recognition time in reading commonly used words236 and improvement in auditory comprehension were noted in a patient with aphasia who, when followed up at a later date, showed additional gains.237,238 Computer-generated phonemic cues were effective in improving naming in five patients with Broca's aphasia.239 An augmentative system was developed for a patient with Broca's aphasia;240 a word retrieval facilitation program was developed for individuals with aphasia;241 and Steele et al199 and Weinrich et al242 replicated and extended the findings of Gardner et al196 and Baker et al243 by training those with aphasia to use a computerized version of the VIC system.
Use of telecommunications, virtual clinicians, and computer-assisted treatments may lead to improvements in language and communication, especially when utilized as an adjunct to clinical therapy. Data suggest that these types of therapies may be effective for patients in various stages of recovery.244,245,246,247,248,249
Management of the Patient with Aphasia
The unfortunate reality is that once the condition of aphasia has stabilized, very few patients recover normal communication function, with or without speech therapy. Accordingly, aphasia rehabilitation should be viewed as a process of patient management in the broadest sense of the term. That is, the task is primarily one of helping the patient and his or her intimates adjust to the alterations and limitations imposed by the disability. Effective aphasia rehabilitation management requires the participation of several disciplines, including medicine, psychology, physical therapy, occupational therapy, social work, vocational counseling, and, most critically, aphasia therapy.
The selective and discriminating use of speech and language therapy to stimulate and support the patient through the various stages of recovery is an effective management tool.87,250,251 Experienced aphasia therapists recognize that while working on aphasic deficits, they are simultaneously dealing psychotherapeutically with a readjusting personality.143 Speech therapy, therefore, serves different purposes at different points along the way. Sometimes it allows patients to "borrow time," as Baretz and Stephenson252 have aptly stated. Occasionally depression lifts after speech therapy has been initiated, reflecting the supportive and nurturing nature of the therapeutic relationship rather than an objective improvement in recovery of speech and language.251
Aphasia recovery can be viewed as a dynamic process consisting of a series of stages like the stages of mourning described by Ku¨bler-Ross,253 through which the majority of patients evolve. Some, of course, never emerge from a state of severe depression.254,255 Ku¨bler-Ross253 and other authors have suggested that the stages through which someone with aphasia passes—including denial, rage, bargaining, and acceptance—could be characterized as attempts to overcome the sense of loss.
By directly addressing a patient's linguistic deficits and channeling attention and energies toward constructive goals, speech therapy may produce a noticeable reduction in depression. Therapy tasks in this instance act as an equivalent for work, which has long been recognized as an antidote for depression.
There is a great tendency to overestimate the capacity of individuals with aphasia to return to work, particularly if the verbal deficits are mild. Premature attempts to return to work can have a negative psychological impact. Professional rehabilitation counselors are best equipped to explore and evaluate a patient's vocational potential and carry out the long and arduous process of evaluating work performance and job requirements.
Experienced aphasia clinicians stress the importance of the patient's family in the rehabilitation process. Some of the potentially negative reactions of the family include overprotectiveness, hostility, anger, unrealistic expectations, overzealousness, lack of knowledge of the dimensions of the disorder, and inability to cope with practical difficulties. The apparently natural tendency of family members to minimize the patient's communication impairment, particularly in the early stages of recovery, requires understanding and tactful management.143
The quality of premorbid relationships generally tends to be intensified after a catastrophic event; those that were problematic may deteriorate further, whereas the bond between a loving couple may become stronger. The reversal of roles, changes in levels of dependency, and a changed economic situation, so often a consequence of chronic disability, can have a critical negative impact on the patient and his or her family.174
In a positive family milieu, patients are encouraged to develop regular daily routines as close to premorbid patterns as possible and are treated as contributing members of the family. Patients need to be allowed some sense of control. Including the patient in rehabilitation planning promotes restoration of feelings of self-worth. In this regard, the emphasis on function rather than complete recovery, pointing out success rather than performance failure, adds to a patient's sense of self. It is essential to listen to patients, particularly to their expressions of loss. Commiseration is often more comforting than optimistic prognostic statements.
Group speech therapy, stroke clubs, and other social groups that are frequently used resources can be effective tools in the management of some patients with chronic aphasia. The National Aphasia Association (NAA) was founded in the United States in 1987, following the lead of existing advocacy organizations established in Finland (1971), Germany (1978), the United Kingdom (1980), and Sweden (1981). The NAA provides an extensive array of educational and resource information appropriate for patients, families, and professionals on its website (www.aphasia.org). Knowledge that one is not alone often helps to reduce depression and loneliness.86,141
Group therapy with peers also provides a comfortable atmosphere in which patients can meet new friends and share feelings, although not all individuals with aphasia find it beneficial. A positive effect seems to be related to level of comprehension, time since onset, and personality factors. Although group therapy generally plays an important role in aphasia rehabilitation, it should be noted that much of its effectiveness depends on the skill and experience of the group leader.256,257
Aphasia rehabilitation remains eclectic and specifically tailored to the individual patient. Fundamental to this therapeutic philosophy is the acknowledgement and appreciation of the uniqueness of the individual. No two persons with aphasia are exactly alike in pathology, personality, linguistic deficits, reactions to catastrophic illness, life experience, spiritual values, or a host of other factors. The influence of these factors carries different weight and strength at different stages of recovery and they are all related to recovery outcome.
Those who manage the rehabilitation of patients with aphasia face many ethical–moral dilemmas. One of the principal issues is a result of the necessity in many settings to select those individuals who will receive treatment. Rehabilitation medicine services are not only scarce in many situations, but they are also not considered to be a right or entitlement. Services are usually provided on a selective basis to those individuals believed to have the potential to benefit. This process assumes that we know who can benefit.16,258,259,260,261 Many who are experienced in aphasia rehabilitation management hold the view that all people should be given a trial treatment period to determine their candidacy for further treatment and that trials should be provided at different points in the recovery course. Goal setting, the patient's right to self-determination, and the criteria appropriate in determining the termination of therapy are also important ethical issues.143,261
When the neural regions responsible for the cognitive processes that support communicative function are damaged, a broad spectrum of deficits can result. Many conditions can cause cognitive-communication disorders, including TBI, stroke (especially right hemisphere damage), dementia, brain tumors, aging, degenerative neurological disease, alcohol/drug abuse, and medications. Impairments of executive function, including difficulties with attention and memory, may interfere with a person's ability to transform thoughts and ideas into spoken and/or written language.262,263,264,265 Impaired memory can also affect word retrieval, topic maintenance, a person's ability to recall and integrate information, and the speed of processing information. In addition, organizing information, interpreting visual information, deficits in abstract reasoning, and decreased orientation to person, place, and time are common symptoms. Impairments in speech production, including reduced fluency and prosodic speech features (i.e., rate and rhythm of speech, stress within words to indicate meaning and within sentences to express variations of intent or meaning), are also common.266 Given the nature of these deficits, participating in social situations can be especially difficult.267 The difficulties may affect all modes of communication, including understanding, nonverbal and verbal expression, reading, and writing. These impairments can be debilitating and socially isolating, because they impair a person's ability to establish and maintain relationships with others.268,269
Impirements of certain aspects of pragmatic language (i.e., language use) and nonverbal communication (including difficulty in initiating, maintaining, and ending conversations), which may result in difficulties maintaining a topic and taking turns in discourse; being concise;270 understanding and expressing feeling through facial expressions; comprehending nonverbal methods of communication (i.e., gesturing); maintaining eye contact; engaging in conversation or narrative production that is self-focused; interpreting and expressing emotions appropriately; and reduced ability in understanding humor.
Examination of Cognitive-Communication Disorders
Many factors, including the heterogeneity of individuals, limitations of available standardized testing measures, performance differences in structured versus unstructured contexts, and environmental and personal factors, have made the examination of cognitive-communication disorders a challenging area in need of further study.271,272 A standardized test battery for the identification and measurement of cognitive-communication disorders does not exist and depends entirely on the knowledge, experience, and expertise of the examiner.
Treatment of Cognitive-Communication Disorders
Intervention depends on the type and severity of the cognitive-communication disorder and is usually based on a combination of behavioral, meta-cognitive, and counseling approaches. Patients with cognitive-communication disorders are especially challenging since they often have reduced insight and/or denial.269,273 The importance of providing speech-language pathology treatment using a team approach has been highlighted as an important element in the rehabilitation process. Such collaborative methods take into account each person's social network (e.g., family, friends, caregivers, and so forth.).263,264,274,275
The management of patients with cognitive-communication disorders begins with determining what environmental factors, if any, can be modified to provide the least visual or auditory distraction. Steps also need to be taken to establish a structured routine or daily schedule. These efforts help to reduce communication breakdowns and facilitate communicative success.274,275 The later stages of intervention emphasize the carryover of skills acquired in therapy to a variety of daily activities and contexts.263 Box 28.1 provides several suggested strategies to improve communication for patients with cognitive-communication disorders.
Box 28.1 Strategies for Improving Communication in the Presence of Cognitive-Communication Disorder
Use visual materials/aids to help orient the person to time (e.g., clocks and calendars)
Break long, complicated tasks into shorter tasks that are easier to follow
Establish eye contact to initiate and maintain conversation
When giving verbal directions, use simple sentences and repetitions as necessary
Accommodate the presence of visual field deficits by helping the person find compensatory means for reading and writing
Gently state when the topic in a conversation changes prematurely
The term dysarthria (sometimes called a motor speech disorder) refers to an impairment of speech production resulting from damage to the central or peripheral nervous system, which causes weakness, paralysis, or incoordination of the motor–speech system. Any one or all of the components of the motor–speech system (respiration, phonation, articulation, resonance, and prosody) may by compromised by neural damage. The type and degree of dysarthria depends on the underlying etiology, degree of neuropathology, coexistence of other disabilities, and the individual response of the patient to the condition. It is not unusual for dysarthria to coexist with aphasia in patients who have suffered cerebrovascular accident (CVA) or TBI. The severity of dysarthria may range from the production of occasionally imprecise consonant sounds to speech that is rendered totally unintelligible by the degree of impairment to the underlying systems. When patients are totally unintelligible as the result of severe motor–speech system impairment, they exhibit anarthria.
The incidence of dysarthria in the population of individuals with neurogenic disorders is approximately 46%, representing a significant proportion of the patients with communication impairments seen in medical settings.276 It is difficult to estimate the total number of people affected by dysarthria, because the condition results from a wide range of etiologies (e.g., progressive neurological diseases, TBI, and stroke). For example, approximately 1% of the population older than 60 suffers from Parkinson's disease,277 and about 89% of those with Parkinson's disease develop a motor speech disorder as the disease progresses.278
Dysarthria is generally reflected in deficits occurring in multiple motor–speech systems, but may sometimes occur in a single system (e.g., an impairment of soft palate movement resulting in hypernasality). It is most notably prevalent in cerebral palsy, TBI, CVA, demyelinating diseases (e.g., multiple sclerosis), neoplasm, and progressive neurodegenerative diseases, such as Parkinson's disease, Huntington's chorea, and amyotrophic lateral sclerosis.
There are five primary types of dysarthria: spastic, flaccid, ataxic, hypokinetic, and hyperkinetic. When two or more types coexist, the term mixed dysarthria is used. Coexisting physical disabilities are present in a majority of patients who manifest dysarthria.
Classification and Nomenclature
Spastic dysarthria is characterized by imprecise articulation, slow labored articulation, hypernasality, harsh to strained phonation, and monotonous pitch. Syllables may be given equal stress and inflection. There is often reduced control of exhalation, with shallow inhalations and slow breaths. Spastic dysarthria is the result of bilateral pyramidal system damage involving the corticobulbar tracts (upper motor neurons). The pathology may cause weakness and paresis of the face and tongue musculature on the side opposite to the lesion. There is a high incidence of spastic dysarthria among those with cerebral palsy.276
Flaccid dysarthria is characterized by slow/labored articulation, hypernasality, and hoarse, breathy phonation. Phrases may be short, inhalation is shallow, and the control of exhalation may be reduced. There is often a reduction in the variation of pitch and loudness with audible inspirations. Most of these deviant speech characteristics are related to muscular weakness and reduced muscle tone, which affects speech accuracy.
Ataxic dysarthria is characterized by disturbances of timing, movement, range, control, and coordination of the muscles of speech and respiration. Speech is imprecise, slow, and irregular. There may be intermittent periods of explosive inflection, syllable stress, and loudness patterns. Phonemes may be prolonged; pitch and loudness are monotonous. The lesions producing ataxic dysarthria are bilateral, generalized lesions involving the deep midline nuclei and pathways of the cerebellum. Patients with multiple sclerosis and TBI with cerebellar damage often manifest ataxic dysarthria.
Hypokinetic dysarthria is characterized by variable articulatory precision, slow rate of speech, harsh, hoarse voice quality, excessive and overly long pauses, prolonged syllables, and reduced phonation. Patients with Parkinson's disease, Parkinson's-plus syndromes, or parkinsonian-like symptoms often manifest hypokinetic dysarthria, usually caused by lesions of the substantia nigra.
Hyperkinetic dysarthria is characterized by variable articulatory precision, vocal harshness, prolonged sounds and intervals between words, monotonous pitch, and loudness. It is manifest in patients with Huntington's chorea, caused by lesions of the basal ganglia and/or their extrapyramidal projections.
Dysarthria treatment must be individually designed to account for the profile of impairment, as well as the variability of its disabling effects. The performance of components of the motor–speech system does not necessarily result in changes to the disabling effects of dysarthria, that is, the intelligibility or comprehensibility of speech.258,279 Goals that relate to the level of disability rather than normal speech are generally more realistic because they do not focus on normalcy, which is usually an unachievable goal, or improvement in the performance of a single component of the motor speech system, which may not, in the overall picture, be functionally important.
The ANCDS's initiative to develop evidence-based practice guidelines for neurogenic communication disorders170,171 has resulted in meta-analyses of efficacy and effectiveness reported for 51 studies published between 1966 and 2004.280 The focus of dysarthria treatment is sometimes based on an approach that emphasizes compensatory skills. These techniques tend to encourage the patient to minimize the overall disability by using strategies that may actually deviate from normal (i.e., slowing down the rate of speech production to increase intelligibility of consonant production).
Moreover, the overall aim of dysarthria treatment is to improve communicative effectiveness, which can be negatively affected if the speaker is in a noisy place. Patients and communication partners must be trained to seek the most optimal situations for communication interactions. One type of approach is to focus on one of the subsystems of speech production, such as velopharyngeal function.281 Other approaches include utilizing an approach that results in a spreading of effects and is centered around improving coordination of the subsystems of respiration, phonation, articulation, and resonance.282 Loudness, speaking rate, and prosodic features of speech (i.e., stress, intonation, rate, and rhythm of speech) have been investigated for their effectiveness in treating dysarthria.
Increasing the loudness of speech is a common target in the treatment of some types of dysarthria, especially Parkinson's disease. The majority of studies that have focused on loudness have examined the short- and long-term efficacy of the Lee Silverman Voice Therapy program (LSVT®/LOUD) for individuals with dysarthria due to Parkinson's disease. Treatment delivery is intensive and focused on high-effort speech and voice exercises to increase loudness, as well as a readjustment of the patient's perception of his or her own loudness levels when speaking.283,284 Exercise has been reported to stimulate the production of dopamine, thereby reducing symptom presentation.285 The program is based on several proposed exercise physiology principles that drive neuroplastic changes, including intensive practice, movement complexity, emotional saliency of tasks, timing of treatment (i.e., the earlier, the better), and continuous/daily exercise to slow disease progression.284 Studies that have examined this treatment method have also reported improvement in swallowing, articulation, and facial expression286,287,288,289 and have demonstrated its success in individuals with dysarthria due to stroke, TBI,291 multiple sclerosis,292 cerebral palsy,293 and Down syndrome.294
In addition to focusing on improving loudness, a variety of strategies are used to manipulate speech rate. Speakers tend to be more intelligible when they speak more slowly.295 The ANCDS review of studies that investigated the effectiveness of rate control techniques concluded that they are dependent on the type and severity of dysarthria and the specific intervention strategies employed. Further study is still needed to delineate an individual's candidacy for this type of technique, as well as what the carryover can be to the natural communication environment.280
A third focus of dysarthria treatment is the improvement of the prosodic aspects of speech (i.e., stress patterns within words and sentences, intonation to express meaning, and rate-rhythm interactions). A variety of strategies that target prosody have been implemented, including those using biofeedback and behavioral instruction. Few conclusions can be drawn about the effectiveness of prosody training because of the small number of examinations and wide range of subject characteristics and techniques used.280
A limited number of studies have also reported outcomes of therapy focused on providing people with feedback about speech clarity or instructing people with dysarthria to use "clear speech." A meta-analysis of investigations in this area reports a lack of evidence supporting the effectiveness of this approach.280
Many persons with motor–speech impairments have been able to increase their communicative effectiveness using augmentative and alternative communication aids (ACA). Low-tech aids, which only require batteries and electricity, include devices such as telephones and communication books. High-tech aids include specially adapted computers and switching systems, as well as speech-generating programs that are available on mobile devices such as laptop or tablet computers and a variety of smartphones.
Recommendations of ACA for persons with dysarthria depend on the severity of the communication disorder and the projected course of the disease and must be carefully selected and managed by the speech-language pathologist.
Some patients with nonfluent (Broca's) aphasia present with articulatory difficulty characterized by speech sound errors, slow speech rate, slow transitions between sounds, syllables, and words, and impaired prosody in the absence of impaired strength or coordination of the motor speech system.296,297,298,299 This profile of difficulty speaking is referred to as apraxia of speech (AOS) (or speech dyspraxia, verbal apraxia, cortical dysarthria, or phonetic disintegration). Additional behaviors that may be present in persons with AOS include difficulty initiating speech, articulatory struggling, periods of error-free speech production, and a greater number of sound production errors as utterance length increases. These characteristics may be so severe that the patient is barely intelligible but appears to be independent of difficulty in language processing. Unlike dysarthric speakers, individuals with AOS do not generally have deficits in performing nonspeech movements of the oral musculature. The possible independence of this deficit from the language disorder of Broca's aphasia remains controversial.
The disorder of articulation referred to as AOS is seldom, if ever, manifested in the absence of a coexisting Broca's aphasia, however mild. The speech dyspraxia component of this multifaceted communication disorder appears to be especially amenable to direct therapeutic intervention using approaches adapted primarily from traditional articulation therapy techniques, including stress and intonation drills. These approaches, designed to improve phonetic placement accuracy, typically depend on imitation, stress, and gradually shaping sounds currently available to patient until a desired sound is approximated, which is then drilled using kinesthetic, visual, and auditory cues. Generally, the stimuli used as the bases for these exercises are selected in a presumed order of difficulty, beginning with non-oral imitation, followed by sounds, words, phrases, and finally utterances.
Treatment of Apraxia of Speech
In an attempt to synthesize and assess available evidence from the literature, 59 studies were summarized and rated by the ANCDS. The most commonly used approaches are referred to as articulatory kinematic. These techniques aim to improve articulatory movements: modeling, imitation, repetition, shaping, electromagnetic articulography, and multimodal and articulatory placement cueing.299,300,301,302,303,304,305,306,307,308
Integral stimulation, a method originally introduced by Milisen,309 is a commonly used articulatory kinematic technique that involves imitation and emphasizes the importance of helping the patient focus his or her attention on auditory and visual models of speech. Rosenbek et al302 developed an eight-step continuum based on this approach that employs a hierarchy of cues in which the timing between the stimulus provided by the clinician and the response produced by the patient is varied.302
Sound production treatment, a five-step program based on the Rosenbek et al302 eight-step continuum, incorporates principles of motor learning such as repeated practice and verbal feedback and is an approach that has been systematically investigated more than any other AOS treatment.308,310,311,312
Visual spectrographic, and verbal feedback utilize different sensory modalities to facilitate speech production.304,306,307,313,314 The effect of the frequency and timing at which feedback is provided has been investigated and found to be important in the treatment of AOS.306,315
Rate and rhythm strategies are employed to improve speech sound accuracy by controlling the rate of speech and stress patterns within words and sentences.316 Ex ternal devices such as computer-generated pulses or programs, metronomes, pacing boards, and finger tapping are used to manipulate the rate of speech.317,318,319,320,321,322,323
The long-term nature of recovery of phonemic production in patients with verbal apraxia was confirmed in a study of a patient with Broca's aphasia who received speech therapy for 10 years. The errors that prevailed in the first post-stroke year were compared with performance at 10 years. The features of place and manner of production had improved; although voicing and addition errors (the addition of sounds) persisted, omission errors (the omission of sounds) were virtually eliminated.324
Alternative communication aid approaches are often recommended for persons with AOS. In most cases, the use of multiple communication modalities, such as writing, drawing, gesturing, and signing, is suggested as a facilitatory technique to enhance or substitute for impaired speech.325,326,327,328
Intersystemic facilitation or reorganization approaches use intact systems or preserved strengths or abilities of the patient to facilitate and improve accurate speech production.329 These approaches employ and combine strategies that can be included in more than one category, such as iconic or rhythmic gestures, vibrotactile stimulation, imitation, modeling, and ACA.330,331,332,333
The swallowing process is composed of a number of complex neuromuscular events. Normal swallowing requires that an individual be able to move food or liquid from the mouth (oral phase of swallowing), through the pharynx (pharyngeal phase of swallowing), and into the esophagus. In the oral swallow phase, food is collected in the oral cavity in a single mass, or bolus, which is then propelled into the pharynx and further propelled under pressure into the esophagus. During the oral phase of swallowing, the bolus is first held between the tongue and palate and then propelled by the tongue from the front to the back of the oral cavity. The bolus moves over the back of the tongue into the pharynx, triggering the pharyngeal swallow and the neuromuscular events that propel the bolus into the esophagus. Velopharyngeal closure, tongue base posterior motion, pharyngeal contraction, laryngeal elevation and closure, and upper esophageal opening occur to allow bolus passage into the esophagus. Airway protection involves closure of the airway entrance and airway. The vocal folds close and the epiglottis moves downward to prevent food from entering the trachea during this process.
Dysphagia is defined as a condition in which an individual has had an interruption in either eating function or the maintenance of nutrition and hydration.334 Many patients with neurogenic communication disorders also manifest deficits in swallowing (dysphagia). From 25% to 50% of individuals who have suffered strokes may have swallowing deficits ranging from mild to severe.176,335,336,337,338,339,340,341,342 In some cases dysphagia is only present in the acute phase with rapid recovery of swallowing function taking place in the first 3 weeks post-stroke.343 Swallowing deficits in post-stroke patients are often due to a combination of weakness and incoordination of the oral, pharyngeal, and laryngeal musculature, resulting in inefficient propulsion of a food bolus or liquid through the oral cavity, pharynx, and into the esophagus. Delayed triggering of swallowing is common after stroke.334 Oral or pharyngeal transit times may be slow. Reduced elevation or closure of the larynx may result in material being misdirected into the airway (aspiration). Dysphagia is also often present in patients with Parkinson's disease,344 Huntington's disease,345 the dystonias and dyskinesias,346,347 amyotrophic lateral sclerosis,348 multiple sclerosis,349 neoplasm,350 dementia,351 Alzheimer's disease,352 and other degenerative neurological conditions, as well as cerebral palsy.353 In addition, dysphagia is often present in TBI.354
A dysphagia examination usually begins at bedside and is followed by more objective, instrumental techniques if a pharyngeal phase swallowing disorder is suspected. The most frequently used instrumental technique to view swallowing physiology in a dysphagia examination is the modified barium swallow because it provides a radiographic view of the entire oropharyngeal swallow, including structural movement and bolus flow. Precise physiological swallowing disorders can be identified. In addition, the effects of therapeutic strategies on swallow physiology, safety, and efficiency can be examined. Another useful examination procedure is videoendoscopy. In most settings, the swallowing evaluation is carried out by the SLP.343
Dysphagia treatment is designed to improve swallowing efficiency for nutritional purposes and to increase swallowing safety. This can be accomplished by compensatory strategies and/or techniques designed to change swallowing physiology and reduce the risk of aspiration. Compensatory strategies include postural changes that affect the way food passes through the mouth and pharynx, dietary management, and placing food in the mouth in optimal positions. Postural techniques may also be introduced to reduce the possibility of aspiration.338,355 Specific exercises (and maneuvers) are used to increase the coordination, range of motion, strength, and sensory input of the muscles and structures involved in the oral and pharyngeal phases of swallowing.
These exercises are designed to improve initiation of tongue movement, lingual propulsion, laryngeal elevation, closure, and tongue base approximation to the posterior pharyngeal wall.356,357,358,359
The physical therapist can play an important role in positioning the patient for optimum swallowing and providing treatment to reduce muscle spasticity, improve muscle strength and coordination, and prevent primitive reflex patterns from interfering with swallowing.360,361,362,363,364 Box 28.2 provides an overview of implications for the physical therapist when treating patients with communication disorders. Table 28.3 presents Web-based resources for patients, families, and caregivers.
Box 28.2 Communication Disorders: Implications for the Physical Therapist
Physical therapists often work in settings where they may be the first to become aware of a patient's communication disorder. In such situations, a referral should be made to a speech-language pathologist (SLP) for evaluation. The physical therapist can contribute to the patient's improvement in communication function in two important ways: by providing physiological support for speech functions, and by stimulating and facilitating communication through successful, fulfilling interaction with the patient. In either case, the physical therapist will want to work closely with the SLP to ensure that their treatment goals and interventions are compatible.
The provision of physiological support for speech functions is especially relevant to the patient with pathology of the oral–motor system (e.g., dysarthria). The physical therapist will want to explore the influence of physiological support on the patient's speech in determining a comprehensive plan of care. Proper posture, for example, can help to inhibit reflexes that may trigger primitive movements. When overflow movements influence a patient's speech function, stabilization techniques may be indicated.
Control of respiration is essential to the improvement of vocalization and the phrasing of speech. The muscles of respiration can be strengthened along with exercises designed to increase head control, stability, and sitting balance. Proper posture and eye contact enhance the possibility that speech will be audible and clear.
When a patient is prescribed a communication board, the physical therapist contributes by determining a patient's sitting balance and tolerance, upper extremity motor control, and the best method for responding (e.g., pointing).
Strengthening exercises to increase the speech and range of motion of the tongue, lips, and general facial musculature and to improve coordination of the oral–motor system also increase the probability of intelligible speech and help the patient with dysarthria and dysphagia. Strategies to improve postural control are especially important for patients with dysphagia, who require individual treatment programs designed to facilitate swallowing and prevent aspiration.
Communication is a social activity and the physical therapy setting is a natural context for social interaction. The setting can be supportive by providing an atmosphere that is conducive to conversation and allows the patient to engage in a successful verbal interaction.
Patients who are neurologically compromised often have difficulty processing information in a distracting setting. Excessive noise, competing voices, and the presence of other stimuli can make communication particularly difficult. When possible, the physical therapist should strive to work with patients who are communicatively impaired in a closed environment that is free of distractions. Patients with communication impairments do best when they are positioned in such a way that face-to-face communication is possible, including the visualization of gestures and facial expressions. For this reason, room lighting needs to be sufficient.
Patients who manifest neurogenic speech-language disorders, especially those with aphasia, pose a considerable challenge to effective communication. The individual nature of each manifestation of aphasia argues for a close working relationship with the speech-language pathologist. This will ensure that the most effective communication strategies are used with each individual patient.
One of the greatest difficulties in addressing the needs of patients with acquired aphasia has to do with determining and accounting for the patient's level of auditory comprehension. Virtually all patients with aphasia have some degree of difficulty in comprehending spoken language. Physical therapists need to become skilled at recognizing and addressing auditory comprehension deficits because they can be a major deterrent to successful rehabilitation.
Misconceptions of the auditory comprehension level of a patient with aphasia can range from the assumption that a patient understands everything to the assumption that the patient comprehends nothing and must be excluded from conversation. A guiding principle to keep in mind is that auditory comprehension can vary greatly, depending on the context and complexity of the task at hand. Switching topics quickly, speaking too quickly, background noises, talking while a patient is engaged in physical activity, and conversing with more than one person at a time can impede the individual's ability to process auditory information. Sentences should be short and concise and the patient should be given sufficient time to process the information and formulate a response. Open-ended questions that require elaborate answers, such as "Tell me about your vacation" or "What do you think about the latest news?" are generally difficult for patients with aphasia to answer. It is best to ask questions that can be answered with "yes," "no," or another single word. Physical cues to comprehension such as gestures, facial expression, and voice inflection can facilitate and enhance a patient's understanding. It is important for the physical therapist to know that patients with aphasia often find it easier to respond to whole-body or axial commands ("stand up," "sit down") than distal commands ("point," "pick up").
It can be tempting to try to remedy a laborious communication situation by "talking down" to a patient with aphasia as if speaking to a child, or raising one's voice as if speaking to someone with impaired hearing. The best strategy is to speak a little more slowly, using language that is not too complex, and remaining consistent in giving instructions. This can be particularly important in the physical therapy setting, where verbal commands are a fundamental element in the patient–therapist interaction. At times, it may be necessary to repeat a sentence to be understood.
Rehabilitation team members almost universally overestimate the degree to which a person with aphasia understands spoken language. Physical therapists, when possible, should consult with the SLP for an indication of the patient's preserved auditory comprehension. It may be necessary to rephrase questions and supplement with body language to ensure comprehension.
The use of accompanying visual cues, such as gestures and facial expressions, can be extremely helpful for some patients. Others may understand best if a message is supplemented by written cues. Sometimes one can assist by asking questions that can be answered by yes or no in a "20 questions" format. When someone with aphasia is having trouble with verbal expression it usually helps to allow the patient extra time to speak. If the patient becomes visibly frustrated, it is desirable to remain calm and suggest that the patient wait and try again later.
During physical therapy interventions, patients with aphasia can be encouraged to produce single-word, repetitive speech that coincides with physical movements as a means of providing supplemental speech practice. Examples of this strategy include activities such as counting movements in series one to ten, and using words like up, down, left, and right while performing physical movements. The physical therapist, however, should always remain sensitive to the possibility of making speech demands that are beyond a patient's level of preserved communicative skill.
Table 28.3Speech and Language Disorder Web-based Resources for Patients, Families, and Caregivers ||Download (.pdf) Table 28.3 Speech and Language Disorder Web-based Resources for Patients, Families, and Caregivers
|Organization ||Website Address |
|The American Speech-Language-Hearing Association (ASHA) ||www.asha.org |
|The Academy for Neurologic Communication Disorders and Sciences (ANCDS) ||www.ancds.org |
|National Aphasia Association (NAA) ||www.aphasia.org |
Ever since World War II, SLPs have played an important role on the rehabilitation team in the management of patients with neurogenic speech-language disorders, especially aphasia and dysarthria. For the physical therapist, an understanding of normal and pathological communication behaviors can not only make this population of patients more interesting to work with, but can also enhance the quality of treatment he or she provides.
Communication using speech is a complex, species-specific behavior that consists of the coordinated interaction of cognitive, motor, sensory, psychological, and social skills. The neurogenic disorders of speech and language, specifically aphasia and dysarthria, dominate the population of patients with communication impairments in the rehabilitation setting. Viewed as a group, patients with neurogenic communication disorders comprise a relatively severely impaired segment of the disabled population.
The impact of neurogenic speech-language disorders on the self, family, community life, and vocational options makes these disorders especially challenging. The close relationship of one's verbal characteristics to personality and identity may cause even the mildest neurogenic communication disorder to affect the psychosocial domain. Current research is investigating the interaction of linguistic, cognitive, and psychosocial variables and their influence on the outcome of recovery and rehabilitation.
Describe the differences that distinguish nonfluent from fluent aphasic syndromes.
Discuss the components of a comprehensive language test designed to measure aphasic impairment.
Describe some critical factors that influence recovery from aphasia.
Describe the psychological sequelae that may have a negative effect on the outcome of aphasia rehabilitation.
List several causes of cognitive-communication impairments.
What neurological conditions are generally associated with dysphagia?
Describe augmentative communication systems and some specific techniques/devices that may enhance the treatment of aphasia.
How can the physical therapist contribute to the physiological support for speech?