Aphasia: A Look Into Two Therapy Methods

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Table of Contents

Therapy
Brief notes
References
APPENDIX A

Paul Broca’s post-mortem study of two aphasic individuals changed the way that the medical world looked at certain brain abnormalities (Pinel, 2006). Prior to that study, they attributed these abnormalities to the malfunction of the whole brain rather than just parts of it.

Aphasia (from Greek a “not” and phanai “saying”) is a discrepancy in the ability to produce or comprehend language, which results from brain damage (Pinel, 2006). This brain damage may be because of tumours, blood vessel ruptures and penetrating head wounds (Atkinson, Atkinson, Smith, Bem, & Nolen-Hoeksema, 2000). Aphasia can either be temporary or permanent. Broca’s and Wernicke’s aphasia are the most commonly observed.

Broca’s aphasia results from the damage of Broca’s area that lies in the frontal lobe. Broca’s area is a small part in the inferior portion of the left prefrontal cortex. This is also the centre for speech production. According to Broca’s hypothesis, this area stores articulation programs, including articulatory codes (Atkinson et al., 2000); when these programs stimulate the adjacent area of the precentral gyrus, which is the control centre for facial and oral cavity muscles, then speech is produced. The angular gyrus, which is the adjacent area of the precentral gyrus, corresponds the written form of the word to its auditory code (Atkinson et al., 2000). The symptoms of Broca’s aphasia are mainly expressive, that means, described by normal comprehension in both spoken and written language and also by speech that maintains its meaning in spite being slow, disorganized, disoriented and feebly articulated (Pinel, 2006). It should be stressed that this people can still fully understand both or either spoken or written language.

This is an example of a speech of a person with Broca’s aphasia from Gardner (as cited in Atkinson, Atkinson, Smith, Bem, & Nolen-Hoeksema, 2000, p. 308):

“An aphasic person is being interviewed about how he lost his speech: “Head, fall, Jesus Christ, me not good, str, str…oh Jesus…stroke”, and what he have been doing in the hospital: “…Me go, er, uh, P.T. nine o’cot, speech…two times…read…wr…rip, er, rike, er write…practice…get-ting better.”

From these examples we can observe that their speech is full of halts and hesitation, which can be observed even in very simple sentences. Their speech is mainly consisted of content or key words and contains hardly any grammatical morphemes and composite sentences (Atkinson et al., 2000). Also, they express nouns in the singular, and articles, conjunctions, adjectives and adverbs are more likely to be excluded. This means that Broca’s aphasia is partly a disruption of syntax (Caramazza & Zurif, 1976). There is no total disruption of syntax because aphasics are capable of managing specific kinds of syntactic analysis (Grodzinski, 1984).

Another form of aphasia, Wernicke’s aphasia is characterized by damage in the Wernicke’s area. In 1874, Carl Wernicke concluded that there exists a language area in the part posterior to the primary auditory cortex located in the left temporal lobe. Subsequently called the Wernicke’s area, this is the cortical area of the comprehension of language. Wernicke’s aphasia is characterized as receptive—poor comprehension of both written and spoken language and meaningless speech yet still maintain the basic structure, intonation, and rhythm of normal speech (Pinel, 2006). People with this kind of aphasia can hear words, but they don’t understand them by their meanings. They can produce a series of words normally and with fitting articulation. However, they commit errors in usage and this results to meaningless speech (Atkinson et al., 2000). Word salad became the term for the normal-sounding but nonsense speech of someone with Wernicke’s aphasia (Pinel, 2006).

An example of a speech of Wernicke’s aphasia given by Gardner (as cited in Atkinson et al., 2000) also provided an example of a condition of Wernicke’s aphasia:

“Boy, I’m sweating. I’m awful nervous, you know, once in a while I get caught up. I can’t mention the tarripoi, a month ago, quite a little. I’ve done a lot well, I impose a lot, while, on the other hand, you know what I mean, I have to run around, look it over, trebin and all that sort of stuff.”

In contrast to Broca’s aphasia, Wernickes aphasic language sustains the syntax but is outstandingly devoid of substance (Atkinson et al., 2000). There are difficulties in finding the appropriate noun and words are normally invented. This implies that unlike Broca’s aphasia, Wernicke’s aphasia includes disruption of words and concepts. Damage in the Wernicke’s area interrupts production of speech but has less or no effect on the comprehension of spoken or written language (Atkinson et al., 2000).

Therapy

There are various therapeutic approaches to patients with aphasia. For this paper, we will be presenting therapies, which don’t have extensive array of available resources and evidences for further studies. This is to pave way for further researches on these interventions and to provide opportunities for better dissemination of information about these techniques. The animal-assisted and phonological therapy are two of the interventions which are provided with less research and needs further investigation regarding their efficacy in increasing the remediation of language impairment of aphasic individual resulting from brain damage. It is proposed that clinicians utilize these methods for therapy of aphasic individuals.

The whole course of intensive therapy has been found to contribute to the alteration in the patient’s interaction towards people as much as it changed when he suffered from the impairment. The change includes a more active part, which entailed greater effort and more communication (Kendall et al., 2006).

Animal-assisted therapy

Florence Nightingale (as cited in Macauley, 2006, p. 358), one of the most important figures in the field of nursing, observed the advantages of using animals in different therapy methods. She emphasized that animals are great companion for a sick person. Since aphasic individuals are more likely to experience anxiety, frustration, panic, depression, and other mood disorders (Chapey, 2001), animals can help lessen these problems.

Animal-assisted therapy has also been used in different clinical, occupational, counselling and mental health programs in the United States and other countries (Macauley, 2006). Boris Levinson, in his 1962 paper The dog as a ‘co-therapist’, described how the presence of his dog has contributed to the progress of the therapy and counselling sessions. Eventually, he concluded that animals could help inhibited children to open up during these therapy sessions.

Individuals with aphasia have sudden speech impairments that may lead to their inhibition to cooperate and respond to therapy and counselling sessions and even to their family and friends (Macauley, 2006). For this reason, this therapy is focused on improving the person’s mood and socialization through the intervention of animals. Animals are proven to successfully show unconditional acknowledgement despite the language difficulty of the individual, which in turn may lead to building his confidence (Barba, 1995).

The Delta Society promotes the bond between humans and animals (Macauley, 2006). They defined animal-assisted therapy as a goal-directed technique in which an animal is screened to meet certain criteria in order to identify if they are qualified to be part of the treatment process (the animal is called by the Society as Pet Partner ®). AAT is directed and/or carried out by a health professional with focused expertise. Animal-assisted therapy is intended to advance improvement in the physical, emotional, social and cognitive functioning of an individual.

In this study regarding animal-assisted therapy by Macauley (2006), Pet Partners® are trained to tolerate the different devices used by patients (canes, wheelchairs, etc.), loud noises and clumsy movements by patients. It is also ensured that the animal is healthy and is free from any disease or parasites that may be transferred to the patient.“The participants of this study on effectiveness of animal-assisted therapy for aphasia were three men with aphasia originating from left-hemisphere strokes. The men received one semester of traditional speech-language therapy followed by one semester of animal-assisted therapy”. Both therapies were reported to be effective considering that the participants achieved their goals. Nevertheless, there are no significant differences between results of tests conducted after the traditional therapy and animal-assisted therapy. Looking into the personal satisfaction of the patients, however, implied that the participants felt a lighter environment and enjoyed the sessions of animal-assisted therapy than that of the traditional therapy. They also conveyed that they were more motivated in the animal-assisted therapy.

Phonological Therapy

“Phonological therapy is usually done 3–4 days/week, 1–2 hours/day for a total of

74 hours of therapy session over 6 months”. “The program is organized hierarchically and divided into three stages: (1) oral awareness training, (2) simple non-word training (the use of single syllables), and (3) complex non-word training (the use of 2–3 syllables)” (Kendall et al., 2006). Prior and after the program, the patient is engaged by the therapist in a series of conversations which are mainly about everyday events and family matters. This is considered an informal form of the forced-use language therapy (Maher et al., 2003; Pulvermuller et al., 2001).

“The first stage (oral awareness training) included the provision of visual feedback of the subject’s mouth movements from a mirror, as well as the verbal labels of the movements of articulators, articulators’ line drawings and voicing characteristics”. Through this method (including visual, oral tactile-kinaesthetic, and auditory perception), the patient will have a deeper assessment of separate phonemes (Kendall et al., 2006).

The second stage involved training phonological awareness of vowel, consonant-vowel, and consonant-vowel-consonant syllables. The awareness acquired in the previous stage is necessary to carry out the second stage. This stage also utilized mirrors and graphic images while the phonemes are being repeated by the patient. As the description of the name implies, the third stage is a complex form of the second stage, which includes words (and even non-words) composed of 2-3 syllables (Kendall et al., 2006).

Phonological treatment can improve reading acquirement through the phonological path subsequent to the brain damage (Kendall et al., 2006). Reading using the phonological route entails basic information of the logical relationships between series of phonemes and graphemes. Through the first stage of the therapy, phonemes are defined as isolated units deliberately comprehensible from conceptual presentations, which are considered the basis for phonological awareness. “The stage two of phonological therapy unequivocally trains the acoustic to articulatory sequence knowledge. Although reading via the phonological route benefits from sequence knowledge in the acoustic to articulatory pattern associator, it apparently entails additional exercise of sequence knowledge in the orthographic to articulatory motor pattern associator, which is the main objective of stage three of the phonological therapy” (Kendall et al., 2006).

It should be taken into consideration that most of the literature on phonological therapy focus more on other speech impairments and less on aphasia. It is also proposed that clinicians and researchers use this therapy in order to come up with a rich collection of literature and evidences supporting their effectiveness in dealing with aphasic patients. The technique is very promising in its organized stages, which can further be improved by further and extensive research.

The animal-assisted and phonological therapies are helpful in addressing the conditions of people with aphasia. With proper execution and support from family members, these will both be effective means of progressing the comprehension skills of patients and even their socialization skills. It should also be noted that aphasia is a complex disorder and the interventions that are useful in advancing comprehension for one patient may not yield the same outcomes with another patient (Marshall, 2004).

Brief notes

Aphasia is a result of damage in specific areas of the brain (left hemisphere).
This damage may be due to tumours, head injury, trauma, and infection.
Aphasia can be temporary or permanent
The damage can affect the person’s ability to read, write, understand, recognize, speak and interpret language
Pathways of language for the production and comprehension of language is damaged
The speech of the patient can be characterized as hesitant and disrupted concept.
They could articulate invented and nonsense words.
Their speech usually contains keywords (mostly nouns) and a lot of pauses.
Different therapies can be done in order to alleviate the impairment
The most common of these therapies is the speech therapy, which comes in various forms
Other forms of therapy include the phonological therapy, which is based on the verbalization of phonemes
Animal-assisted therapy includes the participation of animals to encourage patients by giving unconditional acceptance and comfort

References

Atkinson, R., Atkinson, R., Smith, E., Bem, D., & Nolen-Hoeksema, S. (2000). Hilgard’s Introduction to Psychology. Harcourt Inc.
Barba B.E. (1995). The positive influence of animals: Animal-assisted therapy in acute care. Clinical Nurse Specialization, 9(4), 199–202.
Blonder L.X. (2000). Language use. In: Nadeau SE, Gonzalez Rothi LJ, Crosson BA, editors. Aphasia and language: Theory to practice. New York (NY): Guilford Press, p. 284–95.
Carmack BJ, Fila D. (1989). Animal-assisted therapy: A nursing intervention. Nursing Management, 20(5), 96–101.
Chapey, R. (ed).(2001). Language Intervention Strategies in Adult Aphasia. 4th edition Baltimore: Williams & Wilkins.
Gammonley, J., Howie, A.R., Kirwin, S., Zapf, S.A., Frye, J., Freeman, G., Stuart-Russell R. (1997). Animal-assisted therapy: Therapeutic interventions. Bellevue (WA): Delta Society.
Kendall, D. (2006). Treatability of different components of aphasia–Insights from a case study. Journal of Rehabilitation Research & Development, 43(3), 323-335.
Levinson B.M. (1962). The dog as a “co-therapist”. Mental Hygiene,46, 59–65.
Levinson B.M. (1969). Pet-oriented child psychotherapy. Springfield (IL): Thomas Publisher.
Macauley, B. (2006). Animal-assisted therapy for persons with aphasia: A pilot study. Journal of Rehabilitation Research and Development, 43(3), 357-366.
Maher LM, Kendall DL, Swearengin JA, Pingle K, Holland A, Gonzalez Rothi LJ. (2003). Constraint induced language therapy for chronic aphasia: Preliminary findings [abstract]. Journal of International Neuropsychology Society, 9(2), 192-215.
Marshall, R.C. (2004). Functional Strategies to Enhance Auditory Comprehension of Persons with Aphasia for Neurologic Physical Therapists. Journal of Neurologic Physical Therapy. FindArticles.com. Web.
Pinel, J. (2006). Biopsychology. New York: Allyn & Bacon.
Pulvermuller F, Neininger B, Elbert T, Mohr B, Rockstroh B, Koebbel P, Taub E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32(7), 1621–1626.
Riede D. (1987). The relationship between man and horse with reference to medicine throughout the ages. People, Animal, Environment, 5(2), 26–28.
Thompson CK. (2001) Treatment of underlying forms: A linguistic specific approach for sentence production deficits in agrammatic aphasia. In: Chapey R, editor. Language intervention strategies in aphasia and related neurogenic communication disorders. 4th ed. Philadelphia (PA): Williams & Wilkins, p. 605–25.

APPENDIX A

Table 1: Summary of Evidences for Animal-assisted therapy

Animal-assisted Therapy article	Evidence of Efficacy
Levinson B.M. (1962). The dog as a “co-therapist”. Mental Hygiene, 46, 59–65.	Levinson observed significant progress when his dog Jingles was present during therapy or counseling sessions. From this observation he compared the sessions where Jingle was present with sessions where Jingles was not there. The results show that patients are more motivated when the dog is present during the therapy. This led to his conclusion that many children who don’t disclose to other people regarding certain matters would positively interact and play with the dog. This became one of the bases for the formulation of the animal-assisted therapy to address problems of aphasic individuals.
Levinson B.M. (1969). Pet-oriented child psychotherapy. Springfield (IL): Thomas Publisher.
Riede D. (1987). The relationship between man and horse with reference to medicine throughout the ages. People, Animal, Environment, 5(2),26–28.	History tells us that interaction with animals improve emotional, functional, physical and mental state of the individual. Since aphasia includes difficulties in these aspects, it strongly suggests the significance of having animals intervene in therapeutic techniques.
Gammonley J, Howie AR, Kirwin S, Zapf SA, Frye J, Freeman G, Stuart-Russell R. (1997). Animal-assisted therapy: Therapeutic interventions. Bellevue (WA): Delta Society.	There are numerous healthcare fields, including clinical psychology, nursing; counseling, and occupational, speech and physical therapies, which incorporate the use of animals during sessions because of their effectiveness in motivating the individual to participate and respond more positively to interventions.
Carmack BJ, Fila D. (1989). Animal-assisted therapy: A nursing intervention. Nursing Management, 20(5), 96–101.	Animal-assisted therapy in hospitals are found to have lessened stress among patients and provided both health benefits (psychological and physiological) to the patients.

Table 2: Summary of Evidences for Phonological Therapy

Phonological Therapy article	Evidence of Efficacy
Maher LM, et al. (2003). Constraint induced language therapy for chronic aphasia: Preliminary findings [abstract]. Journal of International Neuropsychology Society, 9(2), 192-215.	Prior and after the program, the patient is engaged by the therapist in a series of conversations which are mainly about everyday events and family matters. This is considered an informal form of the forced-use language therapy. It can be considered a healthier way of dealing with patients because a free flowing conversation is encouraged. The stream of thoughts can help in the further development of their comprehension skills and may pose positive results for them.
Pulvermuller F, et al. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32(7), 1621–1626.
Thompson CK. (2001) Treatment of underlying forms: A linguistic specific approach for sentence production deficits in agrammatic aphasia. In: Chapey R, editor. Language intervention strategies in aphasia and related neurogenic communication disorders. 4th ed. Philadelphia (PA): Lippincott Williams & Wilkins, p. 605–25.	In relation to production of spoken language, comprehension and reading, the “potential for generalization to all words if the full repertoire of phoneme articulations and phonological sequences could be trained or the generalization to all words that occurs when selected grammatical manipulations are trained”
Blonder L.X. (2000). Language use. In: Nadeau SE, Gonzalez Rothi LJ, Crosson BA, editors. Aphasia and language: Theory to practice. New York (NY): Guilford Press, p. 284–95.	Aphasia may lead to a significant change in patients’ levels in their social milieu. Even if in a position of leadership before, an aphasic individual may be demoted to a more passive role with less verbal communication. A therapy successful in increasing the patient’s confidence in communicative ability and social capacity may result to increased efforts at spoken communication, which can be the basis for what essentially is a continuation of language therapy after the formal speech therapy.

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