dysphasia

• n.

• loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain(⇔dysarthria)

• 失語症、言語障害、不全失語症

同

aphasia

　

WordNet

1. an impairment of language (especially speech production) that is usually due to brain damage
2. impaired articulatory ability resulting from defects in the peripheral motor nerves or in the speech musculature
3. unable to speak because of a brain lesion
4. someone affected by aphasia or inability to use or understand language
5. related to or affected by aphasia; "aphasic speech"

PrepTutorEJDIC

1. 〈U〉〈C〉(…の)(量・額などの)不足,欠乏《+『of』(『in』)+『名』》 / 〈C〉不足分,不足量,不足額 / 〈C〉(精神・肉体などの)欠陥
2. 失語症患者 / 失語症の,失語症にかかっている

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2017/08/05 07:52:23」(JST)

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Not to be confused with Aphagia. For other uses, see Aphasia (disambiguation).

Aphasia
Pronunciation	/əˈfeɪʒə/, /əˈfeɪziə/ or /eɪˈfeɪziə/
Classification and external resources
Specialty	Neurology, psychiatry
ICD-10	F80.0-F80.2, R47.0
ICD-9-CM	315.31, 784.3, 438.11
DiseasesDB	4024
MedlinePlus	003204
eMedicine	neuro/437
MeSH	D001037

Dysphasia
Classification and external resources
Specialty	Neurology
ICD-10	F80.1, F80.2, R47.0
ICD-9-CM	438.12, 784.5

Aphasia is an inability to comprehend and formulate language because of damage to specific brain regions. This damage is typically caused by a cerebral vascular accident (stroke), or head trauma, however these are not the only possible causes. To be diagnosed with aphasia, a person's speech or language must be significantly impaired in one (or several) of the four communication modalities following acquired brain injury or have significant decline over a short time period (progressive aphasia). The four communication modalities are auditory comprehension, verbal expression, reading and writing, and functional communication.

The difficulties of people with aphasia can range from occasional trouble finding words to losing the ability to speak, read, or write; intelligence, however, is unaffected. Expressive language and receptive language can both be affected as well. Aphasia also affects visual language such as sign language. In contrast, the use of formulaic expressions in everyday communication is often preserved. One prevalent deficit in the aphasias is anomia, which is a deficit in word finding ability.

The term aphasia implies that one or more communication modalities in the brain have been damaged and are therefore functioning incorrectly. Aphasia does not refer to damage to the brain that results in motor or sensory deficits, which produces abnormal speech; that is, aphasia is not related to the mechanics of speech but rather the individual's language cognition (although a person can have both problems). An individual's "language" is the socially shared set of rules as well as the thought processes that go behind verbalized speech. It is not a result of a more peripheral motor or sensory difficulty, such as paralysis affecting the speech muscles or a general hearing impairment.

Signs and symptoms

People with aphasia may experience any of the following behaviors due to an acquired brain injury, although some of these symptoms may be due to related or concomitant problems such as dysarthria or apraxia and not primarily due to aphasia. Aphasia symptoms can vary based on the location of damage in the brain. Signs and symptoms may or may not be present in individuals with aphasia and may vary in severity and level of disruption to communication. Often those with aphasia will try to hide their inability to name objects by using words like thing. So when asked to name a pencil they may say it is a thing used to write.

• Inability to comprehend language
• Inability to pronounce, not due to muscle paralysis or weakness
• Inability to speak spontaneously
• Inability to form words
• Inability to name objects (anomia)
• Poor enunciation
• Excessive creation and use of personal neologisms
• Inability to repeat a phrase
• Persistent repetition of one syllable, word, or phrase (stereotypies)
• Paraphasia (substituting letters, syllables or words)
• Agrammatism (inability to speak in a grammatically correct fashion)
• Dysprosody (alterations in inflexion, stress, and rhythm)
• Incomplete sentences
• Inability to read
• Inability to write
• Limited verbal output
• Difficulty in naming
• Speech disorder
• Speaking gibberish
• Inability to follow or understand simple requests

Related behaviors

Given the previously stated signs and symptoms the following behaviors are often seen in people with aphasia as a result of attempted compensation for incurred speech and language deficits:

• Self-repairs: Further disruptions in fluent speech as a result of mis-attempts to repair erred speech production.
• Speech disfluencies: Include previously mentioned disfluencies including repetitions and prolongations at the phonemic, syllable and word level presenting in pathological/ severe levels of frequency.
• Struggle in non-fluent aphasias: A severe increase in expelled effort to speak after a life where talking and communicating was an ability that came so easily can cause visible frustration.
• Preserved and automatic language: A behavior in which some language or language sequences that were used so frequently, prior to onset, they still possess the ability to produce them with more ease than other language post onset.

Types

Acute

The following table summarizes some major characteristics of different acute aphasias:

Type of aphasia	Repetition	Naming	Auditory comprehension	Fluency
Receptive aphasia	mild–mod	mild–severe	defective	fluent paraphasic
Transcortical sensory aphasia	good	mod–severe	poor	fluent
Conduction aphasia	poor	mild	relatively good	fluent
Anomic aphasia	mild	mod–severe	mild	fluent
Expressive aphasia	mod–severe	mod–severe	mild difficulty	non-fluent, effortful, slow
Transcortical motor aphasia	good	mild–severe	relatively good	non-fluent
Global aphasia	severe	mod-severe	severe-profound	non-fluent
Mixed transcortical aphasia	moderate	poor	poor	non-fluent

• Individuals with receptive aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create new "words" (neologisms). For example, someone with receptive aphasia may say, "You know that smoodle pinkered and that I want to get him round and take care of him like you want before", meaning "The dog needs to go out so I will take him for a walk". They have poor auditory and reading comprehension, and fluent, but nonsensical, oral and written expression. Individuals with receptive aphasia usually have great difficulty understanding the speech of both themselves and others and are, therefore, often unaware of their mistakes. Receptive language deficits usually arise from lesions in the posterior portion of the left hemisphere at or near Wernicke's area.
• Individuals with transcortical sensory aphasia, in principle the most general and potentially among the most complex forms of aphasia, may have similar deficits as in receptive aphasia, but their repetition ability may remain intact.
• Individuals with conduction aphasia have deficits in the connections between the speech-comprehension and speech-production areas. This might be caused by damage to the arcuate fasciculus, the structure that transmits information between Wernicke's area and Broca's area. Similar symptoms, however, can be present after damage to the insula or to the auditory cortex. Auditory comprehension is near normal, and oral expression is fluent with occasional paraphasic errors. Paraphasic errors include phonemic/literal or semantic/verbal. Repetition ability is poor.
• Individuals with anomic aphasia have difficulty with naming. The patients may have difficulties naming certain words, linked by their grammatical type (e.g., difficulty naming verbs and not nouns) or by their semantic category (e.g., difficulty naming words relating to photography but nothing else) or a more general naming difficulty. Patients tend to produce grammatic, yet empty, speech. Auditory comprehension tends to be preserved. Anomic aphasia is the aphasial presentation of tumors in the language zone; it is the aphasial presentation of Alzheimer's disease.
• Individuals with expressive aphasia frequently speak short, meaningful phrases that are produced with great effort. Expressive aphasia is thus characterized as a nonfluent aphasia. Affected people often omit small words such as "is", "and", and "the". For example, a person with expressive aphasia may say, "Walk dog," which could mean "I will take the dog for a walk", "You take the dog for a walk" or even "The dog walked out of the yard". Individuals with expressive aphasia are able to understand the speech of others to varying degrees. Because of this, they are often aware of their difficulties and can become easily frustrated by their speaking problems.
• Individuals with transcortical motor aphasia have similar deficits as expressive aphasia, except repetition ability remains intact. Auditory comprehension is generally fine for simple conversations, but declines rapidly for more complex conversations. It is associated with right hemiparesis, meaning that there can be paralysis of the patient's right face and arm.
• Individuals with global aphasia have severe communication difficulties and will be extremely limited in their ability to speak or comprehend language. They may be totally nonverbal, and/or use only facial expressions and gestures to communicate. It is associated with right hemiparesis, meaning that there can be paralysis of the patient's right face and arm.
• Individuals with mixed transcortical aphasia have similar deficits as in global aphasia, but repetition ability remains intact.

Subcortical

• Subcortical aphasias characteristics and symptoms depend upon the site and size of subcortical lesion. Possible sites of lesions include the thalamus, internal capsule, and basal ganglia.

Causes

Regions of the left hemisphere that can give rise to aphasia when damaged

Aphasia is most often caused by stroke, but any disease or damage to the parts of the brain that control language can cause aphasia. Some of these can include brain tumors, traumatic brain injury, and progressive neurological disorders. In rare cases, aphasia may also result from herpesviral encephalitis. The herpes simplex virus affects the frontal and temporal lobes, subcortical structures, and the hippocampal tissue, which can trigger aphasia. In acute disorders, such as head injury or stroke, aphasia usually develops quickly. When caused by brain tumor, infection, or dementia, it develops more slowly.

There are two types of strokes: ischemic stroke and hemorrhagic stroke. An ischemic stroke happens when a person’s artery, which supplies blood to different areas of the brain, becomes blocked with a blood clot. This type of stroke happens 80% of the time. The blood clot may form in the blood vessel, which is called a thrombus, or the blood clot can travel from somewhere else in the blood system that is called an embolus. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures or bursts. Overall, people experience bleeding inside or around brain tissue. This type of stroke happens 20% of the time and is very serious. The most common causes of hemorrhagic stroke are weak vessels, traumatic injury, chronic high blood pressure hypertension, and an aneurysm.

Although all of the diseases listed above are potential causes, aphasia will generally only result when there is substantial damage to the left hemisphere (responsible for language function) of the brain, either the cortex (outer layer) and/or the underlying white matter.

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

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

Finally, certain chronic neurological disorders, such as epilepsy or migraine, can also include transient aphasia as a prodromal or episodic symptom. Aphasia is also listed as a rare side-effect of the fentanyl patch, an opioid used to control chronic pain.

Classification

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

However, no such broad-based grouping has proven fully adequate. There is a huge variation among patients within the same broad grouping, and aphasias can be highly selective. For instance, patients with naming deficits (anomic aphasia) might show an inability only for naming buildings, or people, or colors.

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

Classical-localizationist approaches

Cortex

Localizationist approaches aim to classify the aphasias according to their major presenting characteristics and the regions of the brain that most probably gave rise to them. Inspired by the early work of nineteenth century neurologists Paul Broca and Carl Wernicke, these approaches identify two major subtypes of aphasia and several more minor subtypes:

• Expressive aphasia (also known as "motor aphasia" or "Broca's aphasia"), which is characterized by halted, fragmented, effortful speech, but relatively well-preserved comprehension. Damage is typically in the anterior portion of the left hemisphere, most notably Broca's area. Individuals with Broca's aphasia often have right-sided weakness or paralysis of the arm and leg, because the left frontal lobe is also important for body movement, particularly on the right side.
• Receptive aphasia (also known as "sensory aphasia" or "Wernicke's aphasia"), which is characterized by fluent speech, but marked difficulties understanding words and sentences. Although fluent, the speech may lack in key substantive words (nouns, verbs, adjectives), and may contain incorrect words or even nonsense words. This subtype has been associated with damage to the posterior left temporal cortex, most notably Wernicke's area. These individuals usually have no body weakness, because their brain injury is not near the parts of the brain that control movement.
• Conduction aphasia, where speech remains fluent, and comprehension is preserved, but the person may have disproportionate difficulty where repeating words or sentences. Damage typically involves the arcuate fasciculus and the left parietal region.
• Transcortical motor aphasia and transcortical sensory aphasia, which are similar to Broca's and Wernicke's aphasia respectively, but the ability to repeat words and sentences is disproportionately preserved.

Recent classification schemes adopting this approach, such as the "Boston-Neoclassical Model", also group these classical aphasia subtypes into two larger classes: the nonfluent aphasias (which encompasses Broca's aphasia and transcortical motor aphasia) and the fluent aphasias (which encompasses Wernicke's aphasia, conduction aphasia and transcortical sensory aphasia). These schemes also identify several further aphasia subtypes, including: anomic aphasia, which is characterized by a selective difficulty finding the names for things; and global aphasia, where both expression and comprehension of speech are severely compromised.

Many localizationist approaches also recognize the existence of additional, more "pure" forms of language disorder that may affect only a single language skill. For example, in pure alexia, a person may be able to write but not read, and in pure word deafness, they may be able to produce speech and to read, but not understand speech when it is spoken to them.

Cognitive neuropsychological approaches

Although localizationist approaches provide a useful way of classifying the different patterns of language difficulty into broad groups, one problem is that a sizeable number of individuals do not fit neatly into one category or another. Another problem is that the categories, particularly the major ones such as Broca's and Wernicke's aphasia, still remain quite broad. Consequently, even amongst individuals who meet the criteria for classification into a subtype, there can be enormous variability in the types of difficulties they experience.

Instead of categorizing every individual into a specific subtype, cognitive neuropsychological approaches aim to identify the key language skills or "modules" that are not functioning properly in each individual. A person could potentially have difficulty with just one module, or with a number of modules. This type of approach requires a framework or theory as to what skills/modules are needed to perform different kinds of language tasks. For example, the model of Max Coltheart identifies a module that recognizes phonemes as they are spoken, which is essential for any task involving recognition of words. Similarly, there is a module that stores phonemes that the person is planning to produce in speech, and this module is critical for any task involving the production of long words or long strings of speech. Once a theoretical framework has been established, the functioning of each module can then be assessed using a specific test or set of tests. In the clinical setting, use of this model usually involves conducting a battery of assessments, each of which tests one or a number of these modules. Once a diagnosis is reached as to the skills/modules where the most significant impairment lies, therapy can proceed to treat these skills.

Progressive aphasias

Primary progressive aphasia (PPA) is a focal dementia that can be associated with progressive illnesses or dementia, such as frontotemporal dementia / Pick Complex Motor neuron disease, Progressive supranuclear palsy, and Alzheimer's disease, which is the gradual process of progressively losing the ability to think. Gradual loss of language function occurs in the context of relatively well-preserved memory, visual processing, and personality until the advanced stages. Symptoms usually begin with word-finding problems (naming) and progress to impaired grammar (syntax) and comprehension (sentence processing and semantics).<American Speech-Language-Hearing Association> People suffering from PPA may have difficulties comprehending what others are saying. They can also have difficulty trying to find the right words to make a sentence. There are three classifications of Primary Progressive Aphasia : Progressive nonfluent aphasia (PNFA), Semantic Dementia (SD), and Logopenic progressive aphasia (LPA)

Progressive Jargon Aphasia is a fluent or receptive aphasia in which the patient's speech is incomprehensible, but appears to make sense to them. Speech is fluent and effortless with intact syntax and grammar, but the patient has problems with the selection of nouns. Either they will replace the desired word with another that sounds or looks like the original one or has some other connection or they will replace it with sounds. As such, patients with jargon aphasia often use neologisms, and may perseverate if they try to replace the words they cannot find with sounds. Substitutions commonly involve picking another (actual) word starting with the same sound (e.g., clocktower - colander), picking another semantically related to the first (e.g., letter - scroll), or picking one phonetically similar to the intended one (e.g., lane - late).

Deaf aphasia

There have been many instances showing that there is a form of aphasia among deaf individuals. Sign language is, after all, a form of communication that has been shown to use the same areas of the brain as verbal forms of communication. Mirror neurons become activated when an animal is acting in a particular way or watching another individual act in the same manner. These mirror neurons are important in giving an individual the ability to mimic movements of hands. Broca's area of speech production has been shown to contain several of these mirror neurons resulting in significant similarities of brain activity between sign language and vocal speech communication. Facial communication is a significant portion of how animals interact with each other. Humans use facial movements to create, what other humans perceive, to be faces of emotions. While combining these facial movements with speech, a more full form of language is created which enables the species to interact with a much more complex and detailed form of communication. Sign language also uses these facial movements and emotions along with the primary hand movement way of communicating. These facial movement forms of communication come from the same areas of the brain. When dealing with damages to certain areas of the brain, vocal forms of communication are in jeopardy of severe forms of aphasia. Since these same areas of the brain are being used for sign language, these same, at least very similar, forms of aphasia can show in the Deaf community. Individuals can show a form of Wernicke's aphasia with sign language and they show deficits in their abilities in being able to produce any form of expressions. Broca's aphasia shows up in some patients, as well. These individuals find tremendous difficulty in being able to actually sign the linguistic concepts they are trying to express.

Prevention

Following are some precautions that should be taken to avoid aphasia, by decreasing the risk of stroke, the main cause of aphasia:

• Exercising regularly
• Eating a healthy diet
• Keeping alcohol consumption low and avoiding tobacco use
• Controlling blood pressure

Management

Most acute cases of aphasia recover some or most skills by working with a speech-language pathologist. Recovery and improvement can continue for years after the stroke. After the onset of Aphasia, there is approximately a six-month period of spontaneous recovery; during this time, the brain is attempting to recover and repair the damaged neurons. Improvement varies widely, depending on the aphasia's cause, type, and severity. Recovery also depends on the patient's age, health, motivation, handedness, and educational level.

There is no one treatment proven to be effective for all types of aphasias. The reason that there is no universal treatment for aphasia is because of the nature of the disorder and the various ways it is presented, as explained in the above sections. Aphasia is rarely exhibited identically, implying that treatment needs to be catered specifically to the individual. Studies have shown that, although there is no consistency on treatment methodology in literature, there is a strong indication that treatment in general has positive outcomes. Therapy for aphasia ranges from increasing functional communication to improving speech accuracy, depending on the person's severity, needs and support of family and friends. Group therapy allows individuals to work on their pragmatic and communication skills with other individuals with aphasia, which are skills that may not often be addressed in individual one-on-one therapy sessions. It can also help increase confidence and social skills in a comfortable setting.

A multi-disciplinary team, including doctors (often a physician is involved, but more likely a clinical neuropsychologist will head the treatment team), physiotherapist, occupational therapist, speech-language pathologist, physical therapist, dietician, and social worker, work together in treating aphasia. For the most part, treatment relies heavily on repetition and aims to address language performance by working on task-specific skills. The primary goal is to help the individual and those closest to them adjust to changes and limitations in communication.

Treatment techniques mostly fall under two approaches:

1. Substitute Skill Model - an approach that uses an aid to help with spoken language, i.e. a writing board
2. Direct Treatment Model - an approach that targets deficits with specific exercises

Several treatment techniques include the following:

• Copy and Recall Therapy (CART) - repetition and recall of targeted words within therapy may strengthen orthographic representations and improve single word reading, writing, and naming
• Visual Communication Therapy (VIC) - the use of index cards with symbols to represent various components of speech
• Visual Action Therapy (VAT) - typically treats individuals with global aphasia to train the use of hand gestures for specific items
• Functional Communication Treatment (FCT) - focuses on improving activities specific to functional tasks, social interaction, and self-expression
• Promoting Aphasic's Communicative Effectiveness (PACE) - a means of encouraging normal interaction between patients and clinicians. In this kind of therapy the focus is on pragmatic communication rather than treatment itself. Patients are asked to communicate a given message to their therapists by means of drawing, making hand gestures or even pointing to an object
• Melodic Intonation Therapy (MIT) - aims to use the intact melodic/prosodic processing skills of the right hemisphere to help cue retrieval of words and expressive language
• Other - i.e. drawing as a way of communicating, trained conversation partners

Semantic feature analysis (SFA) -a type of aphasia treatment that targets word-finding deficits. It is based on the theory that neural connections can strengthened by using using related words and phrases that are similar to the target word, to eventually activate the target word in the brain. SFA can be implemented in multiple forms such as verbally, written, using picture cards, etc. The SLP provides prompting questions to the individual with aphasia in order for the person to name the picture provided. Studies show that SFA is an effective intervention for improving confrontational naming.

Melodic Intonation Therapy is used to treat non-fluent aphasia and has proved to be effective in some cases. However, there is still no evidence from randomized controlled trials confirming the efficacy of MIT in chronic aphasia. MIT is used to help people with aphasia vocalize themselves through speech song, which is then transferred as a spoken word. Good candidates for this therapy include left hemisphere stroke patients, non-fluent aphasias such as Broca's, good auditory comprehension, poor repetition and articulation, and good emotional stability and memory. It has been hypothesized that MIT is effective because prosody and singing both rely on areas of the right hemisphere; it may be these right-hemisphere areas that are recruited for natural speech production after intensive training. An alternative explanation is that the efficacy of MIT depends on neural circuits involved in the processing of rhythmicity and formulaic expressions (examples taken from the MIT manual: “I am fine,” “how are you?” or “thank you”); while rhythmic features associated with melodic intonation may engage primarily left-hemisphere subcortical areas of the brain, the use of formulaic expressions is known to be supported by right-hemisphere cortical and bilateral subcortical neural networks.

More recently, computer technology has been incorporated into treatment options. A key indication for good prognosis is treatment intensity. A minimum of two–three hours per week has been specified to produce positive results. The main advantage of using computers is that it can greatly increase intensity of therapy. These programs consist of a large variety of exercises and can be done at home in addition to face-to-face treatment with a therapist. However, since aphasia presents differently among individuals, these programs must be dynamic and flexible in order to adapt to the variability in impairments. Another barrier is the capability of computer programs to imitate normal speech and keep up with the speed of regular conversation. Therefore, computer technology seems to be limited in a communicative setting, however is effective in producing improvements in communication training.

Intensity of treatment

The intensity of aphasia therapy is determined by the length of each session, total hours of therapy per week, and total weeks of therapy provided. There is no consensus about what “intense” aphasia therapy entails, or how intense therapy should be to yield the best outcomes. Overall, treatment is considered more intense when total therapy hours per week are increased, and on average, research suggests more intense therapy leads to better outcomes. For example, one study found that patients who were treated for 8.8 hours a week for 11.2 weeks progressed more than patients who were treated 2 hours a week for 22.9 weeks. Results of another study corroborate these findings. The researchers found that patients who received intensive therapy of 100 treatment hours over 62 weeks scored higher on language measures than the control group who received less intensive therapy. Therefore, although there is a general consensus that intense treatment encourages more improvement, there is not a straightforward definition of “intense” treatment.

Intensity of treatment should be individualized based on the recency of stroke, therapy goals, and other patient-specific characteristics such as age, size of lesion, overall health status, and motivation. Each individual reacts differently to treatment intensity and is able to tolerate treatment at different times post-stroke. Some patients cannot tolerate therapy directly after a stroke due to confusion or exhaustion, but may tolerate therapy better later. Intensity of treatment after a stroke should be dependent on the patient’s motivation, stamina, and tolerance for therapy. Level of intensity also depends on therapy goals; for certain goals non-intensive therapy is more beneficial. For example, non-intensive therapy has been found to be more effective than intensive therapy when targeting naming accuracy in patients with anomia. This is because more time in between sessions allows for rehearsal and reinforces long term learning.

Intensity of therapy is also dependent on the recency of stroke. Patients react differently to intense treatment in the acute phase (0–3 months post stroke), sub-acute phase (3–6 months post stroke), or chronic phase (6+ months post stroke). Intensive therapy has been found to be effective for patients with nonfluent and fluent chronic aphasia, but less effective for patients with acute aphasia. Patients with sub-acute aphasia also respond well to intensive therapy of 100 hours over 62 weeks. This suggests patients in the sub-acute phase can improve greatly in language and functional communication measures with intensive therapy compared to regular therapy. Research suggests that intense treatment is most beneficial in the sub-acute or chronic phase, rather than directly post stroke. More research needs to be done to examine the optimal time for providing intense therapy to all aphasic patients.

Intensive therapy can be alternatively characterized by the magnitude of the demands placed on a client within a session. Under this definition, intensive therapy includes a few specific techniques such as Constraint Induced Aphasia Therapy (CIAT) and Speech Intensive Rehabilitation Intervention (SP-I-R-IT). CIAT places high demands on the patient by restricting use of the strongest areas of the patient’s brain and requiring the weakest areas to work harder. Typical CIAT therapy sessions are intense and last for about 3 hours. One study found that when given intensive CIAT therapy, participant performance in verbal communication in everyday life significantly improved. Each participant in the study also showed improvement on at least one subtest within the Aachen Aphasia Test; which assesses language performance and comprehension in aphasia patients. These results suggest that intensive CIAT therapy is effective in patients with moderate, fluent aphasias in the chronic stage of recovery. SP-I-R-IT focuses heavily on speech production strategies and intervention. SPIRIT therapy has been found to be effective; patients participating in intensive SPIRIT therapy improved performance on standardized measures by 15% after 50 weeks of therapy.

Overall, intensity of aphasia treatment is an area that requires more research. Current research suggests that intense treatment is effective, although the definition of “intense” is variable. Most importantly, intensity of treatment should be determined on a case by case basis and should depend upon recency of stroke and the patient’s stamina, tolerance for therapy, motivation, overall health status, and treatment goals.

Prognosis

There are several outcomes that contribute to a patient's overall outcomes once diagnosed with aphasia including: neuroplasticity, age, overall health status, and patient motivation. Neuroplasticity is the brain's capability of change in response to the environment. Neuroplaticity underlies normal processes such as: typical development, learning & maintaining performance while aging, and the brain's response to a severe injury. Positive outcomes are most prominent when neuroplasticity is maximized for the aphasic patient, and is predicted by the patient's response to the other stated outcomes. The patient's age directly impacts the neuroplasticity the brain can allow, the younger the patient is, the greater plasticity is. Overall health status also greatly impacts outcomes in aphasic patients. If a patient has no underlying health problems, and is young, then they have better outcomes than someone who is older, has severe health issues (such as: obesity, heart disease, cancer, high blood pressure, etc.) in conjunction with aphasia. However, the most important factor affecting the outcomes of a patient with aphasia is a patient's motivation. In order to be successful, regardless of the contributing outcomes, the patient must be highly motivated in order to make the most efficient outcomes. If the patient is not motivated to make positive outcomes in their life after being diagnosed with any type of aphasia, their prognosis to make great improvements is much less than someone who is highly motivated to make positive changes in their life. All of these outcomes contribute to success in Wernicke's, Broca's, Global, and Conduction aphasia, and are detailed below:

Wernicke's aphasia

Wernicke’s Aphasia, considered a fluent aphasia, is often the result of trauma to the temporal region of the brain, specifically damage to Wernicke’s area. Trauma can be the result from an array of problems, however it is most commonly seen as a result of stroke Patients who have been diagnosed with Wernicke’s aphasia have fluent speech, but it is the meaning of their utterances that are most notably affected. While their sentence structure remains, the words patients use are often nonsensical

Comprehension is severely affected in patients with Wernicke’s aphasia. Wernicke’s area has been thought to be the center of language processing, specifically processing of meaning. While patients are still left with some comprehension, they are not able to repeat a sentence spoken to them or participate in an action requested by another speaker. A case study done by Ellis et al. discussed a patient who underwent several types of testing, one of which was a word-picture test. The conclusion of the test showed that while the patient understood what the image was, he had trouble retrieving the word and understanding the instructions. This case study suggests that it is language comprehension that is affected in Wernicke's aphasia and not a drop in intelligence.

Wernicke’s is considered a more severe form of aphasia, and is more commonly seen in older populations. Wernicke's area is in the left posterior temporal region of the brain, which is an important area for processing language comprehension. Wernicke’s aphasia has shown a high recovery rate and frequent evolution to other forms of aphasia. Though some cases of Wernicke’s aphasia have shown greater improvements than more mild forms of aphasia, people with Wernicke’s aphasia may not reach as high a level of speech abilities as those with mild forms of aphasia. Wernicke's aphasia is also referred to as receptive or fluent aphasia, due to the ability to speak grammatically and use appropriate prosody. However, much of what the person with aphasia says does not make sense, and oftentimes they will produce non-existent words and be unaware what they have said. People with Wernicke's aphasia have difficulties understanding the meaning of spoken words and sentences. Those with Wernicke's aphasia remain completely unaware of even their most profound language deficits.

Broca's aphasia

(Broca’s and Anomic):

The term Anomic Aphasia usually refers to patients whose only prevalent symptom is impaired word retrieval in speech and writing. Typically, the spontaneous speech of a person with anomic aphasia is fluent and grammatically correct but contains many word retrieval failures. These failures lead to unusual pauses, talking around the intended word, or substituting a different word for the intended word. Anomic aphasia is the mildest form of aphasia, indicating a likely possibility for better recovery. Patients with Broca’s aphasia may also have difficulty with word retrieval, or anomia. In addition, patients with Broca’s aphasia comprehend spoken and written language better than they can speak or write. These patients self-monitor, are aware of their communicative impairments, and frequently try to repeat or attempt repairs. The preceding factors discussed correlate with a good prognosis for patients with Broca’s aphasia. Many patients with an acute onset of Broca’s aphasia eventually progress to milder forms of aphasia, such as conduction or anomic.

Therapy for Expressive Aphasia (nonfluent) is beneficial, even for patients with severe nonfluent aphasia. A study conducted by Marangolo and co-workers (2013) administered conversational therapy to patients with severe nonfluent aphasia. The results of the study demonstrated a significant increase in the patient’s expressive language. The authors suggested that an intensive conversational therapy program should be considered for patients with moderately severe nonfluent aphasia in order to enhance the patient's quality of life and improve their language expression. In addition, although Anomic Aphasia is seen to be less severe than other aphasias, therapy is still imperative to help decrease the patient’s word finding deficits. A research study conducted by Harnish and co-workers (2014), provided intense treatment to patients with anomic aphasia. Results of the study concluded significant increases in the participant’s expressive language. These results suggest that an intensive intervention program for patients with anomic aphasia provides a surprisingly quick expressive language increase. Specifically, these patients relearned to correctly produce the problematic words after one to three hours of speech-language therapy.

Global aphasia

Global aphasia is considered a severe impairment in many language aspects since it impacts expressive and receptive language, reading, and writing. Despite these many deficits, there is evidence that has shown individuals benefited from speech language therapy. Even though each case is different, it has been noted that individuals with global aphasia had greater improvements during the second six months following the stroke when compared to the first 6 months. Intense and frequent speech-language therapy had been shown to be more effective, with the addition of daily homework. Improvement has also been shown when the individual was attentive, motivated, and information was presented in multiple ways.

In one study, 23 individuals that had previously received speech-language therapy, but had been dismissed because further recovery was not expected, participated in intense speech-language therapy. Results showed significant improvements in oral and written noun and sentence production, naming actions, and daily communication.

Even though individuals with global aphasia will not become competent speakers, listeners, writers, or readers, goals can be created to improve the individual’s quality of life. Collins (1991) suggests therapy targeting attainable goals that will have the greatest impact on an individual’s daily life, such as getting reliable yes/no answers or providing the patient gestures. Individuals with global aphasia usually respond well to treatment that includes personally relevant information, which is also important to consider for therapy.

Conduction aphasia

Conduction and transcortical aphasias are caused by damage to the white matter tracts. These aphasias spare the cortex of the language centers, but instead create a disconnection between them.

Conduction aphasia is caused by damage to the arcuate fasciculus. The arcuate fasciculus is a white matter tract that connects Broca’s and Wernicke’s areas. Patients with conduction aphasia typically have good language comprehension, but poor speech repetition and mild difficulty with word retrieval and speech production. Patients with conduction aphasia are typically aware of their errors. The awareness of errors and the milder nature of conduction aphasia compared to other types contributes to a positive outcome. Additionally, a case study completed on a 54-year-old man with a large infarct in the arcuate fasciculus indicated that severe conduction aphasia can be successfully treated. Despite his global deficits, he made a full recovery after 30 months.

Transcortical aphasias include transcortical motor aphasia, transcortical sensory aphasia, and mixed transcortical aphasia. Patients with transcortical motor aphasia typically have intact comprehension and awareness of their errors, but poor word finding and speech production. Patients with transcortical sensory and mixed transcortical aphasia have poor comprehension and unawareness of their errors. Despite poor comprehension and more severe deficits in some transcortical aphasias, small studies have indicated that full recovery is possible for all types of transcortical aphasia. Due to the limited research on outcomes for the specific subtypes of these aphasias, it is more important to focus on the other factors and severity of deficits in order to predict a reasonable outcome.

History

To better understand what aphasia is and how it affects both mental and physical aspects of speech, it is important to understand the history first. By knowing more about the history of this disorder, the better chance there is of ruling out potential misnomers of the disorder and possibly discovering new ways of thinking about treatment options. Although the cause for different types of aphasia's are mostly known, the best way to recover is still unknown. Many ancient cultures, such as the Egyptians, believed that the heart was where a person's soul was housed, therefore any issues of expression were caused by injury or tainting of the soul. The first recorded case of aphasia is from an Egyptian papyrus, the Edwin Smith Papyrus, which details speech problems in a person with a traumatic brain injury to the temporal lobe. During the second half of the 19th century, aphasia was a major focus for scientists and philosophers who were working in the beginning stages of the field of psychology.

Aphasia was non-medically described in early texts, such as the Bible and writings of Homer, but there was no further mention of what aphasia was or how it occurred at that time. In medical research, speechlessness was described as an incorrect prognosis, and there was no assumption that underlying language complications existed. The earliest recorded medical cases of aphasia were made back in the Middle Ages, were it was thought to be an imbalance of bodily fluids in the brain that caused the inability to speak one's mind. The first medical documents dating back to the late 19th century contain early descriptions of aphasia. Broca and his colleagues were some of the first to write about aphasia, but Wernicke was the first credited to have written extensively about aphasia being a disorder that contained comprehension difficulties. Despite claims of who reported on aphasia first, it was F.J. Gall that gave the first full description of aphasia after studying wounds to the brain, as well as his observation of speech difficulties resulting from vascular lesions.

Etymology

Aphasia is from Greek a- ("without") + phásis (φάσις, "speech").

The word aphasia comes from the word ἀφασία aphasia, in Ancient Greek, which means "speechlessness", derived from ἄφατος aphatos, "speechless" from ἀ- a-, "not, un" and φημί phemi, "I speak".

Notable cases

• Ralph Waldo Emerson
• Terry Jones
• Ronald Reagan – caused by late stages of Alzheimer's disease
• Lee Sedol

See also

• Agnosia
• Aphasiology
• Aprosodia
• Auditory processing disorder
• Lethologica
• Lists of language disorders
• Origin of speech

External links

Library resources about Aphasia

Resources in your library Resources in other libraries

• Aphasia at DMOZ
• Luria's Areas of the Human Cortex Involved in Language Illustrated summary of Luria's book Traumatic Aphasia
• Video clips showing patients with expressive-type aphasia
• A video clip with a patient exhibiting receptive aphasia

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 失語症患者へのアプローチ approach to the patient with aphasia
• 2. 失語症：予後および治療 aphasia prognosis and treatment
• 3. 前頭側頭型認知症：臨床的特徴および診断 frontotemporal dementia clinical features and diagnosis
• 4. 大脳皮質基底核変性症 corticobasal degeneration
• 5. アルツハイマー病の臨床的特徴および診断 clinical features and diagnosis of alzheimer disease

English Journal

• The Main Concept Analysis: Validation and sensitivity in differentiating discourse produced by unimpaired English speakers from individuals with aphasia and dementia of Alzheimer type.

• Kong AP1, Whiteside J1, Bargmann P2.
• Logopedics, phoniatrics, vocology.Logoped Phoniatr Vocol.2016 Oct;41(3):129-41. doi: 10.3109/14015439.2015.1041551. Epub 2015 Jun 10.
• PURPOSE: Discourse from speakers with dementia and aphasia is associated with comparable but not identical deficits, necessitating appropriate methods to differentiate them. The current study aims to validate the Main Concept Analysis (MCA) to be used for eliciting and quantifying discourse among na
• PMID 26059177

• 'I do the best I can': an in-depth exploration of the aphasia management pathway in the acute hospital setting.

• Foster AM1, Worrall LE1, Rose ML2, O'Halloran R2.
• Disability and rehabilitation.Disabil Rehabil.2016 Sep;38(18):1765-79. doi: 10.3109/09638288.2015.1107766. Epub 2015 Dec 17.
• PURPOSE: While research has begun to explore the management of aphasia across the continuum of care, to date there is little in-depth, context specific knowledge relating to the speech pathology aphasia management pathway. This research aimed to provide an in-depth understanding of the current aphas
• PMID 26680266

• Atomoxetine administration combined with intensive speech therapy for post-stroke aphasia: evaluation by a novel SPECT method.

• Yamada N1, Kakuda W1, Yamamoto K1, Momosaki R1, Abo M1.
• The International journal of neuroscience.Int J Neurosci.2016 Sep;126(9):829-38. doi: 10.3109/00207454.2015.1074226. Epub 2015 Aug 13.
• OBJECTIVES: We clarified the safety, feasibility, and efficacy of atomoxetine administration combined with intensive speech therapy (ST) for patients with post-stroke aphasia. In addition, we investigated the effect of atomoxetine treatment on neural activity of surrounding lesioned brain areas.MATE
• PMID 26335615

• The Hong Kong version of the Oxford Cognitive Screen (HK-OCS): validation study for Cantonese-speaking chronic stroke survivors.

• Kong AP1, Lam PH2, Ho DW3, Lau JK4, Humphreys GW5, Riddoch J5, Weekes B2.
• Neuropsychology, development, and cognition. Section B, Aging, neuropsychology and cognition.Neuropsychol Dev Cogn B Aging Neuropsychol Cogn.2016 Sep;23(5):530-48. doi: 10.1080/13825585.2015.1127321. Epub 2015 Dec 24.
• This study reports the validation of the Hong Kong version of Oxford Cognitive Screen (HK-OCS). Seventy Cantonese-speaking healthy individuals participated to establish normative data and 46 chronic stroke survivors were assessed using the HK-OCS, Albert's Test of Visual Neglect, short test of gestu
• PMID 26702642

Japanese Journal

• 口腔からみた摂食嚥下チームワークに必要なこと (第51回日本リハビリテーション医学会学術集会) -- (パネルディスカッション 摂食嚥下チームワーク)

• The Japanese journal of rehabilitation medicine 52(7), 411-413, 2015-07
• NAID 40020544165

• A Case of Tetanus Seen on Fiberscopic Examination that Led to Respiratory Arrest

• 耳鼻咽喉科臨床　補冊 144(0), 118-119, 2015
• NAID 130005110225

• Clinical Outcome of Palliative Radiotherapy in Patients with Head and Neck Cancer

• 耳鼻咽喉科臨床　補冊 144(0), 110-110, 2015
• NAID 130005110219

• 摂食嚥下チームワーク

• The Japanese Journal of Rehabilitation Medicine 52(7), 408-420, 2015
• NAID 130005094255

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Related Pictures

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★リンクテーブル★

リンク元	「100Cases 13」「失語症」「dysarthria」「alogia」「progressive aphasia」

「100Cases 13」

　　[★]

☆case13　手の筋力の低下

■glossary

brisk adj. (人・態度が)活発な、元気のよい、きびきびした。ぶっきらぼうな、素っ気ない。(商売が)活況の(⇔dull)。小気味のよい、(大気など)爽快な、気持ちのよい。(味などが)ピリッとする。鋭い。(飲料が)盛んに泡立つ

dysarthria n. difficulty in articulating words due to disease of the central nervous system　構音障害

dysphasia n. loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain　失語症、言語障害

multidisciplinary adj. 集学的な

gastrostomy 胃瘻造設術

feeding gastrostomy n. Surgery A procedure in which an opening is created in the anterior wall of the stomach to allow suction decompression and improved respiratory function by eliminating the need for a nasogastric feeding tube

■症例

67歳、男性　元大学講師(retired university lecturer)

主訴：左手の筋力低下と筋萎縮

現病歴：左手を使った労作後に左手の筋力が低下する(例えば、ドライバーを使った後など)。前腕の筋に疝痛をみとめる。発話はわずかに流暢であり(slight slurred)、水を飲んだあとで窒息しだす。服用薬はシンバスタチン、アスピリン、アテノロール。喫煙はしない。飲酒は週にワインのボトルを1本あける。

既往歴：高血圧が15年間続いている。3年前に心筋梗塞。

家族歴：妻と暮らしている。大きくなった2人の子供がいる。

・診察 examination

　血圧：146/88 mmHg。心血管系、呼吸器系、腹部に異常を認めない。上肢に萎縮を認める。特に左手に著しい萎縮を認める。両側の上腕の筋にいくらか線維性筋攣縮を認める。筋力は左で全般的に低下(globaly reduced)、右手でわずかに低下。筋緊張は正常。上腕二頭筋反射・上腕三頭筋反射は両側ともに活発に認められる(brisk)。感覚喪失(sensory loss)は認めない。わずかに構音障害を認める

■キーワード＆着目するポイント

　筋萎縮、線維性筋攣縮、感覚喪失なし

■解説

(第1パラグラフ)　疫学

・この男は運動ニューロン疾患。

・この疾患は原因不明の疾患で、脊髄、脳神経核、運動皮質に影響を及ぼす。

・この病気は普通50-70歳で出現する。

(第2パラグラフ) 症状

・筋力低下と筋萎縮は一側の手か腕にあらわれるのが一般的　←　両側性でないということか。

・筋力低下は運動後に最も顕著に表れる

・前腕の疝痛は疾患の初期に一般的である。

・患者は下肢の筋力低下あるいは構音障害や言語障害を訴えてやってくることがある。

・この病態の特徴的な生理的徴候は線維性攣縮(筋束の不規則で早い収縮。下位運動ニューロンの障害を示唆)　→　下肢の運動ニューロン損傷による筋肉の脱神経が原因

・反射は著明　→　皮質運動ニューロンの喪失による。

・感覚喪失はない

(第3パラグラフ)　鑑別

・進行例では診断は容易だが、初期ではmore problematic。

・疲労で悪化する四肢の筋力低下は「重症筋無力症」と混乱する。

・老人における失語症と構音障害の原因は、「脳血管障害による偽性球麻痺」であることがより一般的。

・上肢に感覚障害を伴わない筋萎縮、線維束攣縮を呈する他の疾患として「頚髄症」がある。

・「外傷」や「心尖部肺癌(パンコースト腫瘍)」による腕神経叢の損傷で腕に症状があらわれるかもしれない。

・末梢運動神経優位のニューロパチーは対側性の筋力低下と反射の低下というパターンを起こす。　←　？

(第4パラグラフ)　症状・経過

・運動ニューロン疾患は進行性で不治の病態

・足の痙性麻痺を発現する傾向がある

・球麻痺は失語症と構音障害を起こす

・肛門括約筋は普通影響を受けない

・知能は一般的に影響を受けない

(第5パラグラフ)　治療・管理

・この病態に対して治癒的な治療法はない

・発症から平均生存期間は2-4年

・医師は診断と予後について患者と家族に説明しなければならない。

・集学的なチームはサポートを提供しなければいけない。

・病気が進行して発話が悪くなったとき、コンピュータの使用で会話は補助されうる。

・feeding gastrostomyは十分なカロリーの摂取を可能にするために必要かもしれない。

・非侵襲的な呼吸器は呼吸不全を補助するために使われうる

・普通、気管支肺炎で死亡する

■運動ニューロン疾患とは？

運動ニューロン疾患 motor neuron disease MND

■参考文献

HIM = Harrison's Principles of Internal Medicine 17th Edition

CASES = 100 Cases in Clinical Medicine Second edition

IMD = 内科診断学第2版

「失語症」

　　[★]

英

aphasia

同

失語

関

感覚性失語症(ウェルニッケ失語症)、運動性失語症(ブローカ失語症)

dysphasia

流暢性と失語 (BET.250)

	非流暢性失語	流暢性失語
発語の量	少ない	正常または多い
発語に対する努力	努力を要する	正常
韻律	傷害されている	正常
句の長さ	短い	長い
統語障害	単語の羅列が多い(失文法)	言葉としてはつながっているがよく分からない(錯文法)
錯語	まれ	多い
言語促迫	減少	増加
障害部位	ブローカ野	ウェルニッケ野

「dysarthria」

　　[★]

• n

• difficulty in articulating words due to disease of the central nervous system　(⇔dysphasia)

構音障害

• Dysarthriaはかつては構音器官のレベルで生じる不完全な構音articulationの障害と定義された。しかし、その後、発声発語器官全体の(あるいはいずれかの)レベルで生じるspeechの障害として拡大して理解されるようになり、現在では広く共通の理解に至っている。すなわち、dysarthriaを「構音の障害」としてとらえる解釈は古典的定義であり、「speechの障害」としてとらえる解釈は今日の正しい定義である。(かつてわれわれはDysarthriaを「構音障害」と呼んでいた、といえる新たなる時代を迎えよう:小島氏への異論 西尾正輝　より抜粋)

　

「alogia」

　　[★]

アロギー、アロジア

関

acquired aphasia、aphasia、dysphasia、global aphasia、progressive aphasia、semantic aphasia

「progressive aphasia」

　　[★]

進行性失語症、進行性失語

関

acquired aphasia、alogia、aphasia、dysphasia、global aphasia、semantic aphasia