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Aphasia

an acquired communication disorder caused by brain damage, characterized by an impairment of language modalities: speaking, listening, reading and writing
-is neurogenic
-acquired
-not a problem of sensation or intellect

Prevalence & Incidence

-over 1 million Americans have aphasia
-more than 100,000 new cases of aphasia annually
-aging of the US population (1/250 people)

Localization

Phrenology
-Gall believed that brain is a collection of separate organs, each governing a distinct mental faculty, with the parts of the brain at the surface playing a crucial role

Paul Broca

-Broca's area: premotor cortex, speech programming and planning

Carl Wernicke

-"sensory aphasia" impaired language comprehension due to damage to posterior region of brain
-Wernickes area-auditory association area, mental lexicon, grammatical rules

Anti-localization

-scientists that don't like to give brain structures specific function
-Flourens, Jackson, Pierre Marie
-the brain operates as an integrated whole
-the new localizationists were right somewhat more often than they were wrong

Language and Cerebral Dominance

-most adults: L hem for language
-some left-handers: more flexible about which hemisphere responsible for language
-less severe aphasia and recover better

Perisylvian Region

-the region surrounding the Sylvian fissure in the left hemisphere
-anterior language zone
-posterior language zone
-arcuate fasciculus and angular gyrus

Anterior Language Zone

-Perysylvian region in the L frontal lobe
-Broca's area: posterior inferior L frontal lobe
-function: planning and organizing expressive language actions (speech, writing and perhaps gestures)

Posterior Language Zone

-Perysylvian region in the L temporal love and in the L parietal lobe
-Wernicke's area: in the posterior superior superior left temporal lobe
-function: comprehending linguistic materials (store and retrieve mental representation of words
-formulating linguistic info with appropriate syntax and semantics
-interpreting info & help format new messages as well

Arcuate Fasciculus & Angular Gyrus

-arcuate fasciculus: linguistic info formulated in Wernickes area-->Broca's area
-angular gyrus (part of inferior parietal lobe) at the junction of temporal, parietal and occipital lobes
-reading (alexia) and writing (agraphia)

Impairments of Aphasia

-language comprehension
-spontaneous speech
-repetition
-reading
-writing

Auditory Comprehension

-How do spoken messages conduct?
-a spoken message (auditory output)
-Primary auditory cortices (L&R): acoustic info
-Wernickes area in left hemisphere (maps meaning onto speech signal and select vocab and syntax from memory
*R hemisphere consultation to interpret message intent

Spontaneous Speech

-Wernickes area
-Arcuate fasiculus
-Broca's area (speech programming) to primary motor cortex (execution of speech program)
-pyramidal system (corticobulbar tract) to cranial nerves (5,7,9,10,12 for speech muscles)
-Wernickes area and frontal love monitor speech output and repair speech errors (self-monitoring skills)

Repetition

-test entire language circuit
-acoustic info to primary auditory cortex (encoding)
-Wernickes area (encoding)
-arcuate fasciculus
-Brocas area to primary motor cortex
-Primary motor cortex to cranial nerves
-Wernickes area and frontal lobe monitor speech output and repair speech errors

Reading Comprehension

-printed materials
-visual cortices (if in RH, passing through corpus callosum) into LH
-Wernickes area (Client able to interpret linguistic info?)

Writing

-Wernickes area (formulate a message)
-arcuate fasciculus
-premotor cortex for hand and arm
-primary motor cortex for hand and arm
-pyramidal tract (corticospinal) for hand and arm
-Eyes and Wernickes area continue to edit and repair the written messages

Expressive vs. receptive

Brocas vs. Wernickes

Anterior vs. Posterior

(brain lesion) Brocas vs. Wernickes

Motor vs. Sensory

Brocas vs. Wernickes

Fluent vs. Nonfluent

Wernickes vs. Brocas

Non-fluent Aphasia Types

-Brocas
-Global
-Transcortical Motor Aphasia (TMA)

Fluent Aphasia Types

-Wernickes
-Conduction
-Transcortical sensory aphasia (TSA)
-Anomic aphasia, alexia, agraphia, agnosia, AOS, Dysarthria

Broca's Aphasia

-(nonfluent)
-lesion location: posterior-inferior frontal gyrus of the left hemisphere
-expressive aphasia, anterior aphasia, motor aphasia,
-right sided hemiparesis of hemiplegia
-if no paresis, more local damage toward bottom of motor cortex

Comprehension (Brocas)

-fair-good, difficulty in understanding complex syntactic structures

Speech (Brocas)

-telegraphic (use of primarily nouns and verbs), limited word output, short phrases and sentences, monotonous, apraxia of speech, dysarthria

Repetition (Brocas)

-labored, misarticulated, telegraphic (omits the grammatical elements of a sentence)

Fluency (Brocas)

-nonfluent, effortful, slow, halting

Word-retrieval (Brocas)

-impaired

Reading (Brocas)

-fair, slow reader

Writing (Brocas)

-at least as severely impaired as speech

Self-awareness (Brocas)

-aware of communication deficits

Global Aphasia

-(nonfluent)
-lesion location: large, perisylvian, widespread, destruction of the front-temporo-parietal regions

Comprehension (Global)

-poor

Speech (Global)

-profoundly impaired, stereotypic utterances

Repetition (Global)

-poor, literal and verbal paraphasias, perseveration

Fluency (Global)

-nonfluent

Word Retrieval (Global)

-poor

Reading & Writing (Global)

-impaired

Self-awareness (Global)

-poor

Stereotypic utterances

-repetitive utterances produced during an attempt to speak
-single, multiple or repeated syllables
-"hu hu" "kakie-kakie-kakie"
-Real words or phrases not related to context
-"it's a go-go"
-"how-dee-do"

Literal (phonemic) paraphasia

-incorrect sounds replace correct sounds (sound substitutions within words) "shooshbrush for toothbrush"

Verbal (semantic) paraphasia

-substitute one word to another
-pt. says "TV" for "book" or "fork" for "spoon"

Transcortical Motor Aphasia

-(nonfluent)
-lesion location: anterior superior frontal lobe in the language dominant hemisphere
-lesion at top of primary motor cortex, located higher than brocas lesion

Comprehension (TMA)

-Good

Speech (TMA)

-limited spontaneous speech, halting, agrammatic

Repetition (TMA)

-important to note
-preserved, echolalia, delayed in initiation

Fluency (TMA)

-reduced speech rate, nonfluent with some fluent utterances, unusual delays in inhibition

Word retrieval (TMA)

-variable, with delays in initiation

Reading (TMA)

-Good

Writing (TMA)

-Impaired

Wernicke's Aphasia

-lesion location: posterior superior temporal lobe
-receptive aphasia, posterior aphasia, sensory aphasia

Comprehension (Wern)

-poor

Speech (Wern)

-intact grammatical structures
-literal (phonemic) and verbal (semantic) paraphasias
-neologism, jargon-unintelligable speech.
-Think they make sense, no self awareness

Repetition (Wern)

-fluent, with verbal (semantic) paraphasias

Fluency (Wern)

-fluent, empty

Word-retrieval (Wern)

-poor, circumlocution, with verbal (semantic) paraphasias

Reading (Wern)

-difficulty recognizing meanings of printed words and sounds associated with written words

Writing (Wern)

-excessive but meaningless writing, fluent misspellings, and neologistic writing

Neologism

-production of nonsense words, usually without recognition of error
-impaired areas: lexical access to the word, semantic representation of the word, phonologic processing
-follow rules of language: stress, syllable structure, phonological rules
-speech that consists primarily of neologisms is called jargon
-Example: "Pass me the torkin" (salt)
-Aperam, unporter the merk so inper orzip"

Conduction Aphasia

-(fluent)
-lesion location: upper temporal lobe
-lower parietal lobe
-arcuate fasciculus

Comprehension (conduction)

-fair to good

Speech (conduction)

-literal (phonemic) paraphasias

Repetition (conduction)

-important to note
-impairment in the repetition of function words, longer words and longer phrases and sentences
-cannot repeat words

Fluency (conduction)

-fluent, less fluent than wernickes

Word retrieval (conduction)

-fair

Writing (conduction)

-impaired for most cases

Reading (conduction)

-variable reading problems

Self-awareness (conduction)

-alert, long strings of unsuccessful repair attempts

Transcortical Sensory Aphasia (TSA)

-(fluent)
-lesion location: posterior parietal lobe and parieto-occipital regions

Comprehension (TSA)

-generally poor. difficulty in following directions or answering simple yes/no questions

Speech (TSA)

-varies. spontaneous speech contains many paraphasias and neologisms, normal automatic speech (ex. counting)

Repetition (TSA)

-important to note
-intact repetition ability, echolalia and perseveration. pt. may offer an echo to long instructions provided by the clinician.

Fluency (TSA)

-fluent, empty

Word-Retrieval (TSA)

-poor

Writing (TSA)

-impaired

Reading (TSA)

-poor

Anomic Aphasia

-lesion location: varies. Appears as a result of diverse causes
-inferior temporal lobe is often involved

Comprehension (anomic)

-good. comprehension of complex and lengthy material may be compromised

Speech (anomic)

-empty speech, word retreival difficulties

Repetition (anomic)

-intact

Fluency (anomic)

-fluent

Word Retrieval (anomic)

-is the distinguishing feature from conduction aphasia
-pervasive word-finding difficulty, circumlocution, intact pointing to named objects

Reading and Writing (anomic)

-normal

Alexia

-the loss of previously acquired reading skills due to recent brain damage
-A=complete loss of an ability

Dyslexia

-a difficulty in learning to read
-2 types

Surface dyslexia

-rely on letter by letter decoding
-able to read regularly spelled words (radio, cap, hand)
-misread irregulary spelled words (neighbor)

Deep dyslexia

-rely on whole-word recognition
-misread words represent semantic errors (chair for table) or morphological errors (steal for stealth)

Alexia

-the loss or impairment of normally acquired reading skills

Agnosia

-impaired understanding of the meaning of certain stimuli
-often limited to one sensory modality
-no peripheral sensory impairment
-2 types

Auditory Agnosia

-bilateral damage to the auditory association areas
-normal peripheral hearing
-impaired understanding of the meaning of auditory stimuli

Auditory Verbal Agnosia

-(pure word deafness)
-bilateral temporal lobe lesions which isolate wernickes area
-normal peripheral hearing
-impaired understanding of spoken words
-pt. comprehends meanings of words in printed or written forms

Direct Reading Route

-whole word (visual representation of a word)
-familiar words usually processed through this route

Indirect Reading Route

-uses phonological analysis
-examples: chomps, toughfs, spemmed

Apraxia

-a disorder of volitional movement in the absence of muscle weakness, paralysis, or fatigue

Apraxia of speech (AOS)

-impairment with planning and programming for positioning and sequentially moving muscles for the volitional production of speech
-NOT caused by muscle weakness or neuromuscular slowness
-lesion: damage or injury to speech-motor programming areas (Brocas area and insula) in the dominant hemisphere

Characteristics of AOS

-INCONSISTENT articulation errors
-sound substitutions most common, distortions, and omissions
-more pronounced difficulty with consonants than vowels
-placement errors>voicing, manner (africates, fricatives are difficult), resonance
-easier automatic productions than volitional/purposive productions
-groping and silent posturing
-slower rate of speech, delayed initiation of speech, innappropriate pausing during speech
-less noticable stress patterns
-general awareness of speech problems

Dysarthria

-a neological speech motor impairment characterized by slow, weak, imprecise and/or uncoordinated movements of the speech musculature
-involving peripheral or CNS pathology (cerebral paulsy, stroke, traumatic brain injury, tumors, MS, Parkinsons)

Characteristics of Dysarthria

-respiratory, articulatory, phonatory, resonatory and prosodic disturbances caused by weakness, incoordination or paralysis of speech musculature
*CONSISTENT errors

Perseveration

-3 types
-inappropriate repetition or continuation of an earlier response after task requirements have changed
-person gets stuck on certain task
-could snowball through testing

Variables of perseveration

-nature of the task: intentional tasks difficult, automatic tasks less troublesome)
-order of tasks: "tell me names of fruits, tell me names of veggies" too similar
-rate of stimulus presentation (likely to occur if tasks presented too fast)
-word frequency(low frequency words difficult)
-semantic and phonemic relatedness (fork/spoon, too, two, to) Target words must sound and look different

Stuck-in-set perseveration

-inappropriate maintenance of a framework of response after introduction of a new task
-Example: 1st task, asked to draw. 2nd, write what you see..pt. began drawing.

Continuous perseveration

-inappropriate prolongation or continuation of a behavior without intervening response or stimulus
-Example: draw clock, draw long hand. pt. continued to draw lines over and over (w/o being intervened)

Recurrent perseveration

-inappropriate recurrence of a previous response following presentation of a new stimulus or after giving a different intervening response
-Example: naming task: 1. watch 2. gun "shot, oh, wrist, no" 3. Key 4. Jack "key" continues saying "key" for tasks

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