Aphasia: Difference between revisions

Aphasia
Aphasia
Specialty	Neurology, neuropsychology, speech–language pathology

Aphasia
Aphasia
Pronunciation	/əˈfeɪʒə/, /əˈfeɪziə/ or /eɪˈfeɪziə/ ;
Specialty	Neurology, neuropsychology, speech–language pathology

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Aphasia is an inability to comprehend and formulate language because of damage to specific brain regions.^[1] 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.^[2] Expressive language and receptive language can both be affected as well. Aphasia also affects visual language such as sign language.^[1] In contrast, the use of formulaic expressions in everyday communication is often preserved.^[3] One prevalent deficit in the aphasias is anomia, which is a deficit in word finding ability.^[4]

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.^[5] 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.^[6]

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.^{[citation needed]}
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.^[7]

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^[8]

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.^[9] In rare cases, aphasia may also result from herpesviral encephalitis.^[10] The herpes simplex virus affects the frontal and temporal lobes, subcortical structures, and the hippocampal tissue, which can trigger aphasia.^[11] 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.^[2]^[12]

Substantial damage to tissue anywhere within the region shown in blue on the figure below can potentially result in aphasia.^[13] 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.^[14]^[15] The area and extent of brain damage or atrophy will determine the type of aphasia and its symptoms.^[2]^[12] 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.^[16]^[17]

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.^[18]

Epilepsy can also include transient aphasia as a prodromal or episodic symptom.^[19] Aphasia is also listed as a rare side-effect of the fentanyl patch, an opioid used to control chronic pain.^[20]

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.^[21]

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.^[22]

The Boston Classification

Major characteristics of different types of aphasia according to the Boston classification^[23]^[24]
Type of aphasia	Speech repetition	Naming	Auditory comprehension	Fluency
Broca's aphasia	Moderate–severe	Moderate–severe	Mild difficulty	Non-fluent, effortful, slow
Wernicke's aphasia	Mild–severe	Mild–severe	Defective	Fluent paraphasic
Conduction aphasia	Poor	Poor	Relatively good	Fluent
Mixed transcortical aphasia	Moderate	Poor	Poor	Non-fluent
Transcortical motor aphasia	Good	Mild–severe	Mild	Non-fluent
Transcortical sensory aphasia	Good	Moderate–severe	Poor	Fluent
Global aphasia	Poor	Poor	Poor	Non-fluent
Anomic aphasia	Mild	Moderate–severe	Mild	Fluent

Individuals with Wernicke's 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.^[25]
Individuals with Broca's 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 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.^{[citation needed]} Anomic aphasia is the aphasial presentation of tumors in the language zone; it is the aphasial presentation of Alzheimer's disease.^[26]
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.

Classical-localizationist approaches

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.^[27]^[28] 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 well-preserved comprehension relative to expression. Damage is typically in the anterior portion of the left hemisphere,^[29] 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.^[29]
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",^[27] 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.^[30] 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.^[31]^[32] 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,^[33]^[34] 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 neurodegenerative 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> The loss of language before the loss of memory differentiates PPA from typical dementias. 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.^[35]^[36]^[37] There are three classifications of Primary Progressive Aphasia : Progressive nonfluent aphasia (PNFA), Semantic Dementia (SD), and Logopenic progressive aphasia (LPA)^[37]^[38]

[[Jargon aphasia|Progressive Jargon Aphasia^{[citation needed]}]] 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 languages are, after all, forms of language that have been shown to use the same areas of the brain as verbal forms of language. 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.^[39]

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^[40]

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.^[12]

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.^[41] 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.^[42] 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.^[43]

Evidence dose not support the use of transcranial direct current stimulation (tDCS) for improving aphasia after stroke.^[44]

A person with aphasia will often be seen by a multi-disciplinary team due to the wide range of changes following the stroke. This exact team will depend on the individual's needs and may include a speech-language pathologist, doctor, clinical neuropsychologist, physiotherapist, occupational therapist, physical therapist, dietician, and social worker. Treatment is tailored to the individual's needs and goals and may include:

Compensatory treatment - aiming to develop strategies to compensate for the aphasia and to support communication, e.g., writing key words, using gesture, using a communication device or app;
Direct treatment - an approach that targets deficits with specific exercises, e.g., improving word finding^[41]
Conversation-focused treatment - working with the person with aphasia and others in their life on specific strategies to use in conversation, e.g., the person with aphasia might work on how to start a new topic of conversation
Life participation - this approach focuses on the impact of aphasia on the person's life, i.e., life goals, reducing barriers to make the environment 'aphasia friendly'

Specific 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^[45]
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^[46]
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^[47]
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^[48]
Other - i.e. drawing as a way of communicating, trained conversation partners^[41]

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.^[49] Studies show that SFA is an effective intervention for improving confrontational naming.^[50]

Melodic intonation therapy is used to treat non-fluent aphasia and has proved to be effective in some cases.^[51] 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.^[52] 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.^[3]^[53]

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.^[54] 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.^[54]

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.^[55] 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.^[56] However, a Cochrane review of speech and language therapy for people with aphasia revealed a more nuanced finding.^[57] The review found that treatments that are higher intensity, higher dose or over a long duration of time led to significantly better functional communication but people were more likely to drop out of high intensity treatment (up to 15 hours per week).^[57]

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.^[58]^[59] 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.^[56] Research suggests that intense treatment is most beneficial in the sub-acute or chronic phase, rather than directly post stroke.^[56]^[58]^[59] More research needs to be done to examine the optimal time for providing intense therapy to all aphasic patients.^[58]

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.^[60] 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.^[59] 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.^[56]

Individualized service delivery

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.^[58]^[61] Each individual reacts differently to treatment intensity and is able to tolerate treatment at different times post-stroke. ^[61] Intensity of treatment after a stroke should be dependent on the patient’s motivation, stamina, and tolerance for therapy.^[62]

Alternative therapy models

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.^[61] This is because more time in between sessions allows for rehearsal and reinforces long term learning.^[61] However, these results are variable, and the differences between non-intensive and intensive therapy trial results were significant, yet small. Furthermore, this conclusion did not reflect the entire group of participants. From this study, Sage et al. determined one participant who succeeded more with intensive therapy rather than non-intensive therapy despite being otherwise homogenous with the group.^[58]

Consistent with previous research, results from this study indicated that a distributed therapy model has a positive impact on word retrieval and naming in aphasia rehabilitation. ^[63] A distributed therapy model provides an efficacious and manageable alternative therapy model for individuals with aphasia.^[64] Research suggests that intense treatment is effective, but people are more likely to drop-out of high intensity treatments.^[57]

Prognosis

There are several factors that contribute to a person's chance of recovery including stroke size and location.^[65] Age, sex, and education have not been found to be very predictive.^[65]

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.^[66] Trauma can be the result from an array of problems, however it is most commonly seen as a result of stroke^[67] 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^[67]

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.^[68] 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.^[69] 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.^[69] 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.^[70] 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.^[71] Those with Wernicke's aphasia remain completely unaware of even their most profound language deficits.^[72]

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.^[73] 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.^[73] Anomic aphasia is the mildest form of aphasia, indicating a likely possibility for better recovery.^[74] 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.^[73] 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.^[75]

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.^[76] 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.^[77]

Global aphasia

Global aphasia is considered a severe impairment in many language aspects since it impacts expressive and receptive language, reading, and writing.^[78] Despite these many deficits, there is evidence that has shown individuals benefited from speech language therapy.^[79]

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.^[73] 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.^[73]

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.^[73] 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.^[80]

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.^[73] 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.^[81]

Outcomes

Spontaneous recovery

After a traumatic brain injury (TBI) or cerebrovascular accident (CVA), the brain undergoes several healing and re-organization processes, which may result in improved language function. This is referred to as spontaneous recovery. Spontaneous recovery is the natural recovery the brain makes without treatment, and the brain begins to reorganize and change in order to recover.^[73]

Specific to aphasia, spontaneous recovery varies among patients and may not look the same in everyone. Therefore, predicting recovery is difficult because of variability between patients.^[82] Some patients with aphasia may make what seems like a “full recovery” without any therapy due to spontaneous recovery, while other patients with aphasia will not appear to have made measurable progress. Research suggests that most spontaneous recovery occurs within the first 3 months after the stroke, as most patients’ language abilities will improve within the first 4-10 weeks CVA or TBI; less change occurs after this time period.^[83] Again, this varies from patient to patient, and recovery will not look the same in everyone.

One study found that treatment given in very early acute stages (2 weeks post onset) can enhance the effects of spontaneous recovery.^[84] Levels of improvement for any person with aphasia cannot be predicted based on sex, age, decade, or type of aphasia; however, the level of language abilities 6 months post stroke depend almost exclusively on severity.^[83]

Treatment

When addressing Wernicke’s aphasia, according to Bakheit et al. (2007), the lack of awareness of the language impairments, a common characteristic of Wernicke’s aphasia, may impact the rate and extent of therapy outcomes.^[85] Klebic et al. (2011) suggests that patients benefit from continuing therapy upon discharge from the hospital to ensure generalization.^[86] Robey (1998) determined that at least 2 hours of treatment per week is recommended for making significant language gains.^[87] Kurland et al. (2010) showed that a patient with chronic Wernicke’s aphasia benefited from treatment involving constraint-induced language therapy to improve naming tasks.^[88] The authors suggested that short, intensive therapy can significantly improve naming and auditory comprehension skills. For the patient in the study, intensive therapy initiated quicker recovery than the less intensive therapy he had experienced over the previous 2 years, which was only 1 hour weekly. Additionally, improvements made with therapy were likely to improve overall confidence in communication skills and functional independence.^[88] Spontaneous recovery may cause some language gains, but without speech-language therapy, the outcomes can be half as strong as those with therapy.^[87]

When addressing Broca’s aphasia, better outcomes occur when the patient participates in therapy, and treatment is more effective than no treatment for patients in the acute period.^[87] Two or more hours of therapy per week in acute and post-acute stages produced the greatest results.^[87] High intensity therapy was most effective, and low intensity therapy was almost equivalent to no therapy.^[87]

Patients with global aphasia are sometimes referred to as having irreversible aphasic syndrome, often making limited gains in auditory comprehension, and recovering no functional language modality with therapy. With this said, global aphasic patients may retain gestural communication skills that may enable success when communicating with conversational partners within familiar conditions. Process-oriented treatment options are limited, and patients may not become competent language users as readers, listeners, writers, or speakers no matter how extensive therapy is.^[73] However, patient’s daily routines and quality of life can be enhanced with reasonable and modest goals. For example, “provide the patient with a set of simple unequivocal gestures, which may include gestures to express yes or no”.^[73] A study conducted by Ho et. al. demonstrated that patients with global aphasia benefited from using communication symbols including remnants and pictographs to facilitate interactions. Patients also benefit from visual stimulants that activate emotional associations that will stimulate motivation and linguistic abilities of the speaker. When stimuli has a large degree of emotion, individual’s language performance improves.^[89] After the first month, there is limited to no healing to language abilities of most patients. There is a grim prognosis leaving 83% who were globally aphasic after the first month they will remain globally aphasic at the first year. Some patients are so severely impaired that their existing process-oriented treatment approaches offer signs of progress, and therefore cannot justify the cost of therapy.^[73]

Perhaps due to the relative rareness of conduction aphasia, few studies have specifically studied the effectiveness of therapy for patients with this type of aphasia. From the studies performed, results showed that therapy can help to improve specific language outcomes. One intervention that has had positive results is auditory repetition training. Kohn et al. (1990) reported that drilled auditory repetition training related to improvements in spontaneous speech, Francis et al. (2003) reported improvements in sentence comprehension, and Kalinyak-Fliszar et al. (2011) reported improvements in auditory-visual short-term memory.^[90]^[91]^[92] Berthier et al. (2014) expanded past repetition research by comparing two specific interventions.^[93] Patients in this study made considerable language gains after receiving distributed speech-language therapy (DSLT) and massed sentence repetition therapy (MSRT), while receiving donepezil medications. Research shows differing results as to whether language deficits persist in patients with conduction aphasia without therapy. Benson et al. (1973) reported that patients with conduction aphasia can often return to their former work.^[94] However, Bartha et al. (2003) reported that symptoms of conduction aphasia may be chronic.^[95] Leischner (1987) reported that symptoms of conduction aphasia may decrease to the point of resembling less severe anomic aphasia.^[96] Results from the study by Bartha et al. (2003) did not show a natural regression of symptoms.^[95]

Severity

The severity of the type of aphasia varies depending on the size of the stroke. However, there is much variance between how often one type of severity occurs in certain types of aphasia. For instance, any type of aphasia can range from mild to profound. According to Lendrem (1985), communication skills at 6 months following the occurrence of the stroke are heavily influenced by the severity.^[83] Other studies have discovered that regardless of the severity of aphasia, patients can make improvements due to spontaneous recovery and treatment in the acute stages of recovery.^[87] Klebic et al. (2011) found that patients with severe aphasia improved after receiving therapy for a year, consequently reducing the severity of their aphasia.^[86] Additionally, while most studies propose that the greatest outcomes occur in patients with severe aphasia when treatment is provided in the acute stages of recovery, Robey (1998) also found that those with severe aphasia are capable of making strong language gains in the chronic stage of recovery as well.^[87]^[83] This finding implies that persons with aphasia have the potential to have functional outcomes regardless of how severe their aphasia may be.^[87] While there is no distinct pattern of the outcomes of aphasia based on severity alone, global aphasia typically make functional language gains, but may be gradual since global aphasia affects many language areas.

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.^[97] 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.^[97] 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.^[98] 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.^[1]

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.^[99] The earliest recorded medical cases of aphasia were made back in the Middle Ages, where it was thought to be an imbalance of bodily fluids in the brain that caused the inability to speak one's mind.^[97] 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.^[100] 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.^[101]

Etymology

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

The word aphasia comes from the word ἀφασία aphasia, in Ancient Greek, which means^[40] "speechlessness",^[102] derived from ἄφατος aphatos, "speechless"^[103] from ἀ- a-, "not, un" and φημί phemi, "I speak".

Notable cases

Ralph Waldo Emerson^[104]
Terry Jones^[105]
Ronald Reagan^[106] – caused by late stages of Alzheimer's disease
Lee Sedol^[107]

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^ Godecke, E.; Ciccone, N.A.; Granger, A.S.; Rai, T.; West, D.; Cream, A.; Hankey, G.J. (2014). "A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke". International Journal Of Language & Communication Disorders. 49 (2): 149–161. doi:10.1111/1460-6984.12074.
^ Bakheit, A.M.O; Shaw, S; Carrington, S; Griffiths, S (2016). "The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke". Clinical Rehabilitation. 21 (10): 941–9. doi:10.1177/0269215507078452. PMID 17981853.
^ ^a ^b Klebic, Jasmina; Salihovic, Nevzeta; Softic, Rusmir; Salihovic, Denisa (2011). "Aphasia Disorders Outcome After Stroke". Acta Informatica Medica. 65 (5): 283–6. doi:10.5455/medarh.2011.65.283-286. PMID 22073852.
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^ Francis, Dawn; Clark, Nina; Humphreys, Glyn (2003). "The treatment of an auditory working memory deficit and the implications for sentence comprehension abilities in mild 'receptive' aphasia". Aphasiology. 17 (8): 723–50. doi:10.1080/02687030344000201.
^ Kohn, Susan E; Smith, Katherine L; Arsenault, Joan Kelly (1990). "The remediation of conduction aphasia via sentence repetition: A case study". International Journal of Language & Communication Disorders. 25 (1): 45–60. doi:10.3109/13682829009011962. PMID 1695853.
^ Berthier, Marcelo L; Dávila, Guadalupe; Green-Heredia, Cristina; Moreno Torres, Ignacio; Juárez y Ruiz De Mier, Rocío; De-Torres, Irene; Ruiz-Cruces, Rafael (2013). "Massed sentence repetition training can augment and speed up recovery of speech production deficits in patients with chronic conduction aphasia receiving donepezil treatment". Aphasiology. 28 (2): 188–218. doi:10.1080/02687038.2013.861057.
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External links

Library resources about
Aphasia

Aphasia at Curlie
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

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[85] Bakheit, A.M.O; Shaw, S; Carrington, S; Griffiths, S (2016). "The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke". Clinical Rehabilitation. 21 (10): 941–9. doi:10.1177/0269215507078452. PMID 17981853.

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[92] Kohn, Susan E; Smith, Katherine L; Arsenault, Joan Kelly (1990). "The remediation of conduction aphasia via sentence repetition: A case study". International Journal of Language & Communication Disorders. 25 (1): 45–60. doi:10.3109/13682829009011962. PMID 1695853.

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[94] Benson, D. Frank; Sheremata, W. A; Bouchard, R; Segarra, J. M; Price, D; Geschwind, N (1973). "Conduction Aphasia". Archives of Neurology. 28 (5): 339–46. doi:10.1001/archneur.1973.00490230075011. PMID 4696016.

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@@ Line 64: / Line 64: @@
 * 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.<ref>{{cite book|last1=Manasco|first1=M. Hunter|title=Introduction to Neurogenic Communication Disorders|date=2014|publisher=Jones & Bartlett Learning|location=Burlington, MA|pages=75–76}}</ref>
-===Types===
+====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.
-====Acute====
+==Causes==
+[[File:Aphasia.png|thumb|Regions of the left hemisphere that can give rise to aphasia when damaged<ref>{{cite journal|last1=Henseler|first1=I.|last2=Regenbrecht|first2=F.|last3=Obrig|first3=H.|title=Lesion correlates of patholinguistic profiles in chronic aphasia: comparisons of syndrome-, modality- and symptom-level assessment|journal=Brain|date=12 February 2014|volume=137|issue=3|pages=918–930|doi=10.1093/brain/awt374|pmid=24525451}}</ref>]]
+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.<ref>{{Cite web|title = Aphasia|url = http://www.asha.org/public/speech/disorders/Aphasia/|website = www.asha.org|access-date = 2015-11-18}}</ref> In rare cases, aphasia may also result from [[herpesviral encephalitis]].<ref>{{Cite journal  | last1 = Soares-Ishigaki | first1 = EC. | last2 = Cera | first2 = ML. | last3 = Pieri | first3 = A. | last4 = Ortiz | first4 = KZ. | title = Aphasia and herpes virus encephalitis: a case study | journal = Sao Paulo Med J | volume = 130 | issue = 5 | pages = 336–41 |year= 2012 | doi =  10.1590/S1516-31802012000500011| pmid = 23174874 }}</ref> The [[herpes simplex virus]] affects the frontal and temporal lobes, subcortical structures, and the hippocampal tissue, which can trigger aphasia.<ref>{{cite journal | title = Can herpes simplex virus encephalitis cause aphasia? | journal = Early Child Development and Care | date =  3 Jun 2010 | first1 = H | last1 = Naudé | first2 = E. | last2 = Pretorius | volume = 173 | issue = 6 | pages = 669–679 | doi = 10.1080/0300443032000088285 | url = http://www.tandfonline.com/doi/abs/10.1080/0300443032000088285#.UbKZCZxq95t | accessdate = 2013-06-08}}</ref>
+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.<ref name = "ASHA Aphasia" /><ref name = "medicinenet.com" >{{cite web | url = http://www.medicinenet.com/aphasia/article.htm | title = Aphasia | accessdate = 2011-05-23 | work = MedicineNet.com}}</ref>
+Substantial damage to tissue anywhere within the region shown in blue on the figure below can potentially result in aphasia.<ref>{{cite journal|last1=Henseler|first1=I|last2=Regenbrecht|first2=F|last3=Obrig|first3=H|title=Lesion correlates of patholinguistic profiles in chronic aphasia: comparisons of syndrome-, modality- and symptom-level assessment.|journal=Brain |date=March 2014|volume=137|issue=Pt 3|pages=918–30|pmid=24525451|doi=10.1093/brain/awt374}}</ref> Aphasia can also sometimes be caused by damage to subcortical structures deep within the left hemisphere, including the [[thalamus]], the [[Internal capsule|internal]] and [[external capsule]]s, and the [[caudate nucleus]] of the basal ganglia.<ref>{{cite journal|last1=Kuljic-Obradovic|first1=DC|title=Subcortical aphasia: three different language disorder syndromes?|journal=European Journal of Neurology|date=July 2003|volume=10|issue=4|pages=445–8|pmid=12823499|doi=10.1046/j.1468-1331.2003.00604.x}}</ref><ref>{{cite journal|last1=Kreisler|first1=A|last2=Godefroy|first2=O|last3=Delmaire|first3=C|last4=Debachy|first4=B|last5=Leclercq|first5=M|last6=Pruvo|first6=JP|last7=Leys|first7=D|title=The anatomy of aphasia revisited.|journal=Neurology|date=14 March 2000|volume=54|issue=5|pages=1117–23|pmid=10720284|doi=10.1212/wnl.54.5.1117}}</ref> The area and extent of brain damage or [[atrophy]] will determine the type of aphasia and its symptoms.<ref name="ASHA Aphasia" /><ref name="medicinenet.com" /> 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.<ref>{{cite journal|last1=Coppens|first1=P|last2=Hungerford|first2=S|last3=Yamaguchi|first3=S|last4=Yamadori|first4=A|title=Crossed aphasia: an analysis of the symptoms, their frequency, and a comparison with left-hemisphere aphasia symptomatology.|journal=Brain and Language|date=December 2002|volume=83|issue=3|pages=425–63|pmid=12468397|doi=10.1016/s0093-934x(02)00510-2}}</ref><ref>{{cite journal|last1=Mariën|first1=P|last2=Paghera|first2=B|last3=De Deyn|first3=PP|last4=Vignolo|first4=LA|title=Adult crossed aphasia in dextrals revisited.|journal=Cortex |date=February 2004|volume=40|issue=1|pages=41–74|pmid=15070002|doi=10.1016/s0010-9452(08)70920-1}}</ref>
+[[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.<ref>{{Cite web|title = Primary Progressive Aphasia|url = http://www.asha.org/Glossary/Primary-Progressive-Aphasia/|website = www.asha.org|accessdate = 2015-11-15}}</ref>
-The following table summarizes some major characteristics of different acute aphasias:
+[[Epilepsy]] can also include transient aphasia as a [[prodromal]] or episodic symptom.<ref>{{cite journal|last1=Blumenfeld|first1=H|last2=Meador|first2=KJ|title=Consciousness as a useful concept in epilepsy classification.|journal=Epilepsia|date=August 2014|volume=55|issue=8|pages=1145-50|doi=10.1111/epi.12588|pmid=24981294|pmc=4149314}}</ref> Aphasia is also listed as a rare side-effect of the [[fentanyl]] patch, an opioid used to control chronic pain.<ref>{{cite web |url=http://www.drugs.com/pro/fentanyl-transdermal.html#A02A9CB6-35CF-4F01-A980-C3733E0F861A |title=Fentanyl Transdermal Official FDA information, side effects and uses |format= |work=Drug Information Online |accessdate=}}</ref>
+==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.<ref>{{cite book |author1=Kolb, Bryan |author2=Whishaw, Ian Q. |title=Fundamentals of human neuropsychology |publisher=Worth |location=[New York] |year=2003 |pages= 502, 505, 511|isbn=0-7167-5300-6 |oclc=464808209 }}</ref>
+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.<ref>{{cite book|last1=Manasco|first1=M. Hunter|title=Introduction to Neurogenic Communication Disorders|publisher=Jones and Bartlett Learning|pages=7}}</ref>
+=== The Boston Classification ===
 {| class="wikitable sortable"
-|+ Major characteristics of different types of acute aphasia<ref name="Ref4 from the Broca's area article">{{Cite web|url=http://www.atlantaaphasia.org|title=What is Aphasia|accessdate=2008-12-01|publisher=Atlanta Aphasia Association |year=2006}}</ref>
+|+ Major characteristics of different types of aphasia according to the Boston classification<ref name="Ref4 from the Broca's area article">{{Cite web|url=http://www.atlantaaphasia.org|title=What is Aphasia|year=2006|publisher=Atlanta Aphasia Association|accessdate=2008-12-01}}</ref><ref>{{Cite book|url=https://link.springer.com/chapter/10.1007/978-1-4899-3458-1_2|title=Acquired Speech and Language Disorders|last=Murdoch|first=B. E.|date=1990|publisher=Springer, Boston, MA|isbn=9780412334405|pages=60–96|language=en|doi=10.1007/978-1-4899-3458-1_2}}</ref>
 ! Type of aphasia
 ! [[Speech repetition]]
@@ Line 77: / Line 95: @@
 ! Fluency
 |-
-| [[Expressive aphasia]]
+| [[Expressive aphasia|Broca's aphasia]]
 | Moderate–severe
 | Moderate–severe
@@ Line 83: / Line 101: @@
 | Non-fluent, effortful, slow
 |-
-| [[Receptive aphasia]]
+| [[Receptive aphasia|Wernicke's aphasia]]
 | Mild–severe
 | Mild–severe
@@ Line 126: / Line 144: @@
 |}
-*Individuals with '''receptive''' aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create new "words" ([[neologism]]s). 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.<ref>{{cite book|last1=Manasco|first1=Hunter|title=Introduction to Neurogenic Communication Disorders|date=2014|publisher=Jones & Bartlett Learning|pages=71}}</ref>
+*Individuals with '''Wernicke's''' aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create new "words" ([[neologism]]s). 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.<ref>{{cite book|title=Introduction to Neurogenic Communication Disorders|last1=Manasco|first1=Hunter|date=2014|publisher=Jones & Bartlett Learning|pages=71}}</ref>
+*Individuals with '''Broca's''' 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 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 [[insular cortex|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.{{citation needed|date=August 2012}} Anomic aphasia is the aphasial presentation of tumors in the language zone; it is the aphasial presentation of Alzheimer's disease.<ref>{{cite book | last1 = Alexander | first1 = MP | last2 = Hillis | first2 = AE | title = Aphasia | volume = 88 | edition = 1  | editors = Georg Goldenberg; Bruce L Miller; Michael J Aminoff; Francois Boller; D F Swaab | work = Handbook of Clinical Neurology | year = 2008 | pages = 287–310 | doi = 10.1016/S0072-9752(07)88014-6 | <!--accessdate = 2013-06-09 | -->isbn = 9780444518972 | oclc = 733092630}}</ref>
+*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.{{citation needed|date=August 2012}} Anomic aphasia is the aphasial presentation of tumors in the language zone; it is the aphasial presentation of Alzheimer's disease.<ref>{{cite book|title=Aphasia|last1=Alexander|first1=MP|last2=Hillis|first2=AE|work=Handbook of Clinical Neurology|year=2008|<!--accessdate = 2013-06-09 | -->isbn=9780444518972|editors=Georg Goldenberg; Bruce L Miller; Michael J Aminoff; Francois Boller; D F Swaab|edition=1|volume=88|pages=287–310|doi=10.1016/S0072-9752(07)88014-6|oclc=733092630}}</ref>
-*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==
-[[File:Aphasia.png|thumb|Regions of the left hemisphere that can give rise to aphasia when damaged<ref>{{cite journal|last1=Henseler|first1=I.|last2=Regenbrecht|first2=F.|last3=Obrig|first3=H.|title=Lesion correlates of patholinguistic profiles in chronic aphasia: comparisons of syndrome-, modality- and symptom-level assessment|journal=Brain|date=12 February 2014|volume=137|issue=3|pages=918–930|doi=10.1093/brain/awt374|pmid=24525451}}</ref>]]
-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.<ref>{{Cite web|title = Aphasia|url = http://www.asha.org/public/speech/disorders/Aphasia/|website = www.asha.org|access-date = 2015-11-18}}</ref> In rare cases, aphasia may also result from [[herpesviral encephalitis]].<ref>{{Cite journal  | last1 = Soares-Ishigaki | first1 = EC. | last2 = Cera | first2 = ML. | last3 = Pieri | first3 = A. | last4 = Ortiz | first4 = KZ. | title = Aphasia and herpes virus encephalitis: a case study | journal = Sao Paulo Med J | volume = 130 | issue = 5 | pages = 336–41 |year= 2012 | doi =  10.1590/S1516-31802012000500011| pmid = 23174874 }}</ref> The [[herpes simplex virus]] affects the frontal and temporal lobes, subcortical structures, and the hippocampal tissue, which can trigger aphasia.<ref>{{cite journal | title = Can herpes simplex virus encephalitis cause aphasia? | journal = Early Child Development and Care | date =  3 Jun 2010 | first1 = H | last1 = Naudé | first2 = E. | last2 = Pretorius | volume = 173 | issue = 6 | pages = 669–679 | doi = 10.1080/0300443032000088285 | url = http://www.tandfonline.com/doi/abs/10.1080/0300443032000088285#.UbKZCZxq95t | accessdate = 2013-06-08}}</ref>
-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.<ref name = "ASHA Aphasia" /><ref name = "medicinenet.com" >{{cite web | url = http://www.medicinenet.com/aphasia/article.htm | title = Aphasia | accessdate = 2011-05-23 | work = MedicineNet.com}}</ref>
-Substantial damage to tissue anywhere within the region shown in blue on the figure below can potentially result in aphasia.<ref>{{cite journal|last1=Henseler|first1=I|last2=Regenbrecht|first2=F|last3=Obrig|first3=H|title=Lesion correlates of patholinguistic profiles in chronic aphasia: comparisons of syndrome-, modality- and symptom-level assessment.|journal=Brain |date=March 2014|volume=137|issue=Pt 3|pages=918–30|pmid=24525451|doi=10.1093/brain/awt374}}</ref> Aphasia can also sometimes be caused by damage to subcortical structures deep within the left hemisphere, including the [[thalamus]], the [[Internal capsule|internal]] and [[external capsule]]s, and the [[caudate nucleus]] of the basal ganglia.<ref>{{cite journal|last1=Kuljic-Obradovic|first1=DC|title=Subcortical aphasia: three different language disorder syndromes?|journal=European Journal of Neurology|date=July 2003|volume=10|issue=4|pages=445–8|pmid=12823499|doi=10.1046/j.1468-1331.2003.00604.x}}</ref><ref>{{cite journal|last1=Kreisler|first1=A|last2=Godefroy|first2=O|last3=Delmaire|first3=C|last4=Debachy|first4=B|last5=Leclercq|first5=M|last6=Pruvo|first6=JP|last7=Leys|first7=D|title=The anatomy of aphasia revisited.|journal=Neurology|date=14 March 2000|volume=54|issue=5|pages=1117–23|pmid=10720284|doi=10.1212/wnl.54.5.1117}}</ref> The area and extent of brain damage or [[atrophy]] will determine the type of aphasia and its symptoms.<ref name="ASHA Aphasia" /><ref name="medicinenet.com" /> 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.<ref>{{cite journal|last1=Coppens|first1=P|last2=Hungerford|first2=S|last3=Yamaguchi|first3=S|last4=Yamadori|first4=A|title=Crossed aphasia: an analysis of the symptoms, their frequency, and a comparison with left-hemisphere aphasia symptomatology.|journal=Brain and Language|date=December 2002|volume=83|issue=3|pages=425–63|pmid=12468397|doi=10.1016/s0093-934x(02)00510-2}}</ref><ref>{{cite journal|last1=Mariën|first1=P|last2=Paghera|first2=B|last3=De Deyn|first3=PP|last4=Vignolo|first4=LA|title=Adult crossed aphasia in dextrals revisited.|journal=Cortex |date=February 2004|volume=40|issue=1|pages=41–74|pmid=15070002|doi=10.1016/s0010-9452(08)70920-1}}</ref>
-[[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.<ref>{{Cite web|title = Primary Progressive Aphasia|url = http://www.asha.org/Glossary/Primary-Progressive-Aphasia/|website = www.asha.org|accessdate = 2015-11-15}}</ref>
-[[Epilepsy]] can also include transient aphasia as a [[prodromal]] or episodic symptom.<ref>{{cite journal|last1=Blumenfeld|first1=H|last2=Meador|first2=KJ|title=Consciousness as a useful concept in epilepsy classification.|journal=Epilepsia|date=August 2014|volume=55|issue=8|pages=1145-50|doi=10.1111/epi.12588|pmid=24981294|pmc=4149314}}</ref> Aphasia is also listed as a rare side-effect of the [[fentanyl]] patch, an opioid used to control chronic pain.<ref>{{cite web |url=http://www.drugs.com/pro/fentanyl-transdermal.html#A02A9CB6-35CF-4F01-A980-C3733E0F861A |title=Fentanyl Transdermal Official FDA information, side effects and uses |format= |work=Drug Information Online |accessdate=}}</ref>
-==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.<ref>{{cite book |author1=Kolb, Bryan |author2=Whishaw, Ian Q. |title=Fundamentals of human neuropsychology |publisher=Worth |location=[New York] |year=2003 |pages= 502, 505, 511|isbn=0-7167-5300-6 |oclc=464808209 }}</ref>
-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.<ref>{{cite book|last1=Manasco|first1=M. Hunter|title=Introduction to Neurogenic Communication Disorders|publisher=Jones and Bartlett Learning|pages=7}}</ref>
 ===Classical-localizationist approaches===
@@ Line 179: / Line 175: @@
 [[frontotemporal dementia]] / [[Pick's disease|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> The loss of language before the loss of memory differentiates PPA from typical dementias. 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.<ref>{{cite journal |author=Mesulam MM |title=Primary progressive aphasia |journal=Ann. Neurol. |volume=49 |issue=4 |pages=425–32 |date=April 2001 |pmid=11310619 |doi=10.1002/ana.91 |url=}}</ref><ref>{{cite journal |vauthors=Wilson SM, Henry ML, Besbris M |title=Connected speech production in three variants of primary progressive aphasia |journal=Brain |volume=133 |issue=Pt 7 |pages=2069–88 |date=July 2010 |pmid=20542982 |pmc=2892940 |doi=10.1093/brain/awq129 |url=http://brain.oxfordjournals.org/content/133/7/2069.long#xref-ref-18-1|display-authors=etal}}</ref><ref name = "Harciarek  Kertesz 2011">{{cite journal |vauthors=Harciarek M, Kertesz A |title=Primary progressive aphasias and their contribution to the contemporary knowledge about the brain-language relationship |journal=Neuropsychol Rev |volume=21 |issue=3 |pages=271–87 |date=September 2011 |pmid=21809067 |pmc=3158975 |doi=10.1007/s11065-011-9175-9 |url=http://www.springerlink.com/content/3334m228j54ntq10/?MUD=MP}}</ref> There are three classifications of Primary Progressive Aphasia : [[Progressive nonfluent aphasia]] (PNFA), [[Semantic Dementia]] (SD), and [[Logopenic progressive aphasia]] (LPA)<ref name = "Harciarek  Kertesz 2011" /><ref name="Gorno-Tempini 2011">{{cite journal |vauthors=Gorno-Tempini ML, Hillis AE, Weintraub S |title=Classification of primary progressive aphasia and its variants |journal=Neurology |volume=76 |issue=11 |pages=1006–14 |date=March 2011 |pmid=21325651 |pmc=3059138 |doi=10.1212/WNL.0b013e31821103e6 |url=|display-authors=etal}}</ref>
-[[Jargon aphasia|Progressive Jargon Aphasia]] is a fluent or receptive aphasia in which the patient's [[Speech communication|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 [[noun]]s. 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 [[sound]]s. As such, patients with jargon aphasia often use [[neologism]]s, and may [[perseveration|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).
+[[Jargon aphasia|Progressive Jargon Aphasia{{citation needed|date=August 2012}}]]  is a fluent or receptive aphasia in which the patient's [[Speech communication|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 [[noun]]s. 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 [[sound]]s. As such, patients with jargon aphasia often use [[neologism]]s, and may [[perseveration|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===