Aphasia


Overview


Aphasia refers to a complete or partial loss of speech and language comprehension abilities due primarily to some form of damage in the brain's main language zones (temporal or frontal lobes). Depending on amount and location of trauma, aphasia ranges from mild to severe and can be seen in any age group but is rarest in children. Recovery from aphasia can be spontaneous or, if chronic, can improve through sustained speech language therapy intervention.

According to the American Speech-Language Hearing Association (ASHA), there are several major types of aphasia:
  • Expressive or difficulties using words and sentences (Broca'saphasia)
  • Receptive or difficulties understanding others (Wernicke'saphasia)
  • Globalor a combination of expressive and receptive difficulties
  • Anomia or mild difficulties finding words or expressing oneself


Broca's area: Frontal Lobe Wernicke's area: Temporal Lobe
Broca's area: Frontal Lobe Wernicke's area: Temporal Lobe












Health Impact


Typically, aphasia is a form of brain cell death caused by events such as dementia, stroke, infections, tumors or injuries to the head. Oxygen and blood flow interruption to the brain or aggravated drug use can also lead to aphasia. Certain genetic mutations while rare, are known to atrophy language control centers in the brain and can also cause aphasia.[1]

Once front-line medical conditions leading to aphasia are stabilized, the role of communication science disorders professionals (primarily speech language pathologists) is to treat aphasic patients with speech therapy protocols that focus on relearning and practicing lost language skills. When needed, alternative and augmentative communication methods and technology are also used to enhance therapeutic outcome of cerebrovascular accidents (CVAs). According to the America Speech-and-Hearing Association (ASHA) while aphasia is typically associated with overall language difficulties, reading and writing are more impaired than talking or understanding. Conversely, individuals with aphasia may also develop other physical problems such as dysarthria (weakening of facial muscles and respiratory system), apraxia (motor speech disorders), or swallowing problems.[2] According to the Mayo Clinic, less known risk factors for aphasia may also include individuals with language learning disabilities such as dyslexia. Although essentially related to language deficits similar to those in adult aphasia, in the learning disabled, the disorder is known as developmental dysphasia.[3]

In varying degrees, all aphasia types are mild to severe brain infarcts that lead to loss of human communication skills surrounding speech planning (Wernicke area) and delivery (Broca area) processes staged in the cerebral cortex. Specific language output and comprehension deficits along with various other motor problems occur according to range and severity of damage experienced mostly in the left hemisphere of the brain. According to Dr. Janet Patterson (CCC-SLP), in Broca's aphasia, accompanying paralysis of the body's right side is not uncommon and speech output is severely reduced to less than four words and minimal sentence production. While comprehension of language processes remain largely intact, Broca patients want to speak, but are minimally able to do so (non-fluent aphasia). In Wernicke's aphasia, patients are able to speak (fluent aphasia) yet comprehensible language output is severely compromised. Reading and writing are also affected. Wernicke aphasic patients know what they want to say but their verbal grammatical constructions appear nonsensical (Patterson). Physical paralysis is not common to Wernicke's aphasia since injury to brain area dealing with motor control remains largely unscathed. Global aphasia includes wide and severe damage to multiple areas of the brain and produces the most severe form of communication difficulties. There is no production of recognizable words. Auditory comprehension is virtually gone and reading and writing skills no longer exist (Patterson). The mildest form of aphasia is called anomia and refers to difficulties with producing concrete and easy to understand sentences. Noun and verbs constructions are problematic, but comprehension and reading capabilities tend to remain intact.[4] Although mild and not always noticeable, anomia is important because even mild speech impairments can affect identity and adversely interrupt social processes and interactions in society.

Across various types of aphasia, comorbidities such as dysarthria, swallowing problem disorders and apraxia often appear. Dysarthria is a weakening of the facial muscles and respiratory system in language production and apraxia refers to motor speech disorders which prevent the mouth from moving according to signals sent from the brain. A person with dysarthria, for example, could end up with slurred [or weak, breathy quality speech], [while an individual with apraxia] will make distorted sounds or [inadvertently] replace one sound for another.[5]

Illness can be psychologically and financially devastating, but for patients with communicative impairments, losing the basic human ability to communicate normally can produce feelings of profound social isolation and a loss of personal identity. Living unable to freely move or communicate due to aphasia can be a very significant life-altering experience. Depending on degree and severity, aphasics are often forced to endure highly debilitating and unimaginable psychological pain. The burden of illness is also felt by a patient's immediate circle: Family, friends and therapists. Oddly enough, according to Hermann and Wallesch, studies demonstrate that [while] aphasic patients and relatives suffer from considerable psychological strain, [patients and families tend to] estimate the probability of improvement [and] psychological adjustment as being significantly higher than speech therapists [do].[6]

Considering the vast impact of aphasia on identity change and the perception of identity after a stroke, anthropologist and neuro-physician, Doody along with various other social science scholars identify several core issues relevant to aphasia:

(1) The need to update the antiquated 19th century anatomical model of aphasia
(2) The impracticality of post-modern theory ambivalence in the face of painful human illness
(3) A patient's right to meaningful treatment according to circumstance
(4) Rejection of language literacy bias against patients with speech disorders[7]
(5) Social and communicative acts rather than impairment-based intervention
(6) Emphasis on life participation strategies[8]
(7) The value of the "insider perspective" or qualitative narrative in the sequelae of aphasia[9]
(8) Restoration of patient identity, effective therapies, and need for advocacy[10]

Cases of Aphasia



Movie trailer: The Diving Bell and the Butterfly
Based on a true story and released in Paris in 2007 as Le Scaphandre et le Papillon. At age forty-three,
after Elle magazine editor-in-chief Jean-Dominique Bauby suffered a massive and totally paralyzing stroke,
he survived to write a memoir by communicating with his speech therapist through the movements of
one trained eyelid. A testament and triumph of the human spirit before insurmountable odds.


Part I: Sarah Scott becomes an ischemic stroke victim at age 18 and develops expressive aphasia.


Part II: Sarah Scott after undergoing 16 months of speech therapy for expressive aphasia.


Stroke of Insight: Neuroanatomist Jill Bolte Taylor shares her extraordinary journey from brain
expert to stroke victim, and from despairing patient to lucky survivor.


Dianne Ackerman: The touching story and book memoir of a couple's recovery from devastating
loss to rehabilitation of language and love after a stroke.

Aphasia and Inequalities


The diagnosis and treatment of aphasia has been largely based on the culture and classic model of biomedicine and has certainly not been exempt from reductionist biomedical views. According to Papathanasiou, however, previously unstated assumptions [in biomedicine] have been identified, articulated and [are being] questioned:
  1. The mind and body are separate entities
  2. The mechanical factor: The body as machine
  3. Disease is a matter of biological change
  4. Bio-medical practice is [mostly] concerned with observation, hypothesis, control, experiment, and outcome.[11]

By referencing feminist critic, Nettleton (1995), Papathanasiou's illustrates (1) how the neglect of socio-cultural and contextual impacts [of aphasia] can lead to the exercise of professional medical practice in ways which users of healthcare construe as over-simplifying and excluding (2) agrees with Nettleton that health care is [silently] mediated by gender, ethnicity, and class.[12]


Reducing health disparities: The role of cultural and linguistic competence

As with any illness, the central question asked is whether the medicalization model used in aphasia diminishes patient
experiences with physical trauma and human pain. This central question is especially important since aphasics experience internal barriers that block external communication and make them unable to articulate suffering or give full and free expression (personal or political) to their illness. Often without access to voice and physically impaired, aphasics are likely to feel trapped by a profound experience of pathological and mind-boggling confinement.


Medical Anthropology Research


Medical and multidisciplinary experts from specialized tiers of communication science and various types of anthropology have become interested not only in the biological causes of aphasia, but also on aphasia's impact and the issues faced by those who live with it. According to linguistic anthropologist, Charles Goodwin, aphasia is a social as much as a physiological event and one that must be understood systematically and not in isolation from the social context.[13] Altogether, understanding aphasia beyond a pathological stance implies recognizing the critical dynamic that exists between identity, language and communication for those who fall ill.

In an approach towards treating the complexities of illness, bio-ethicists Guillemin and Gillam refer to the ethically important moments that surface between patients and practitioners. Together, these two researchers convincingly argue that while procedural ethics must govern research integrity, "ethics in [medical] practice" [should primarily involve reflexivity and] means acknowledging and being sensitized to the microethical dimension of research practice [and the] ethical tensions that arise.[14] At bird's eye view, researchers across numerous disciplines agree that a trend to encourage the humanization of aphasia must include:
  1. The signification of the socio-environmental context of aphasia
  2. The role of qualitative social research methods in exploring some aspects of aphasia
  3. Collaboration of research where subjects of research gain more influence in the nature of the research agenda
  4. Allowing outcome of qualitative social research to challenge the nature of medical intervention
  5. Emphasis on practitioner reflexivityrather than strict bio-objectivity
  6. Highlighting the critical relationship between identity and communication for people with aphasia
  7. Proper assessment and intervention management of aphasia for non-English speakers
  8. The right towards self-determination in the context of aphasia
  9. A move towards subjecting the culture of aphasiology to sustained and critical scrutiny[15]

In a significant contribution to the ethnography of aphasia, anthropologist Charles Goodwin documents how a man (Chil) able to speak only three words because of a severe stroke is nonetheless able to act as a competent speaker and indeed position himself as the teller of a complex story and does so by linking his limited talk and embodied action to the talk and action of others.[16] This suggests (1) a view of what it means to be a speaker that does not take as its point of departure the mental life and symbolic competence of the individual (2) focuses on the practices required to participate in the public processes of sign exchange that constitute talk as a primordial site for human social life.[17] The significance of early research (Burns, Blunder and Heilman,1991) and Goodwin's work in linguistics is the discovery of how, despite the ravages of aphasia, "[sheer] elocutionary force, sociolinguistic fluency, [and adaptive] conversational strategies" can manifest in ways that allow aphasics to successfully live and communicate with others.

The limitation of Goodwin's work is that there is growing empirical literature regarding how aphasia symptoms and outcomes may be related to cognitive strengths and weaknesses, including the integrity of memory skills.[18] What this implies is that while Goodwin rightly documented social meaning and effectively identified communication strategies in aphasic life, the fact that sixty-five year old Chil had been a well-educated attorney could have played a large cognitive role in how effectively Chil was able to still communicate (convey meaning) after suffering a stroke. Case in point would be to study and compare how stroke recovery can be impacted by patients' prior levels of education (cognitive history).


Applied Work


If Goodwin coined the term "social life of aphasia," speech pathologists Simmons-Mackie and Damico push the envelope by suggesting "flexible" methods of applied ethnography that certainly include observation, analysis of artifacts, interviews and recorded diaries, but also underscore the practical relevance of obtaining continual feedback on the relationship between patient and practitioners.[19] In applied speech therapy work, the anthropological devices covered by Simmons-Mackie and Damico can also be of great value in the challenging area of the clinical management, treatment and recovery of non-English speaking aphasic patients.

For allied health care professionals, the Royal College of Speech and Language Therapy in Britain suggests that sociology of medicine should be essential for three reasons: (1) Sociology makes a valid contribution to a holistic approach to care (2) provides tool that encourage reflexive practice (3) equips therapists to conduct empirical and qualitative research.[20] It seems evident that advancing social curriculum in medical fields is the ethical pathway to promoting comprehensive human health care.


Cultural and Linguistic Competency: Implications for research


Online Resources


Global stats
Aphasia
Asha
Research Guide
NIH
Treatment
Brain Injury Organization
Strokes
National Support Organization

Discussion Board


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Further Reading


Ackerman, D. (2011). One hundred names for love: A stroke, a marriage and the language of healing. New York, NY: W.W. Norton & Co.

Bauby, J.D. (1997). The diving bell and the butterfly. New York, NY: Knopf.

Bolte, J.T. (2006). Stroke of insight. New York, NY: Penguin Group.

Burns, A. (1), Blunder, L.X. (2), Heilman, K.M. (3). (1991). Sociolinguistics and aphasia. Journal of Linguistic Anthropology, 1(2), 165-177. doi: 10.1525/jlin.1991.1.2.165

Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York, NY: Penguin Group.

Goodwin, C. (2006). Human sociality as mutual orientation in a rich interactive environment: Multimodal utterances and pointing in aphasia. In Enfield, N.J. & Levinson, S.C. (Eds.), Roots of human sociality: Culture, cognition and interaction (97-125). New York, NY: Berg

Haley, K., Helm-Estabrooks, N., Caignon, D., Womack, J., & McCulloch, K (2009). Self-determination and life activity goals for people with aphasia. Annual Convention of the American Speech Language Hearing Association, New Orleans, LA

Haley, K. L., Helm-Estabrooks, N., Womack, J., Caignon, D., & McCracken, E. (2007). A pictorial, binary-sorting system allowing "self-determination" despite aphasia. American Speech Language Hearing Association, Boston, MA.

Haley, K. L., Womack, J.,& Helm-Estabrooks, N. (2007). Facilitating communication about life activities in individuals with aphasia. North Carolina Speech Hearing and Language Association, Raleigh, NC, March 28-31.

Haley, K. L., Jenkins, K., Hadden, P.C., Womack, J., Schweiker, C., & Hall, J. (2005). Strategies for Assessment of Life Participation in Persons with Aphasia. American Speech Language Hearing Association, San Diego, CA.

Haley, K., Jenkins, K., Hadden, C., Womack, J., Hall, J., & Schweiker, C. (2005). Sorting Pictures to Assess Participation in Life Activities. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders. October, 11-15.

Helm-Estabrooks, N., Haley, K. L., & Womack, J. (2007). A pictorial, binary-sorting system allowing “self-determination” despite aphasia. Academy of Aphasia, Washington DC, October 21-23 [Abstract]. In Brain and Language, 103, 201-202.

Levine, P. (2009). Stronger after stroke. New York, NY: Demos Medical Publishing.

Lovette, B. (2008). The LIV Card Sort: An investigation of use relative to cognitive and linguistic variables. Unpublished MS Thesis, University of North Carolina at Chapel Hill.

Willard, B. (2005). Feminist interventions in biomedical discourse: An analysis of the rhetoric of integrative medicine. Women Studies in Communication, 28 (1), 115-148. doi: 10.1080/07491409.2005.10162486

Womack, J., Haley, K. L., & Helm-Estabrooks, N. (2008). Assessing life participation in adults with post-stroke aphasia. Congress of Occupational therapists in European countries. Hamburg, Germany.

SLP & Anthro


Damico, J. (1), Mackie, N. (2). (2002). Qualitative research and speech language pathology: A tutorial for the clinical realm. American Journal of Speech Language Pathology, 12, 131-143. doi: 10.1044/1058-0360(2003/060)

Mackie, N. (1), Damico, J. (2). (2002). Contributions of qualitative research to the knowledge base of normal communication. American Journal of Speech Language Pathology, 12, 144-154. doi: 10.1044/1058-0360(2003/061)

Mackie, N. (1), Damico, J. (2). (1996). The contribution of discourse markers to communication competence in aphasia. American Journal of Speech Language Pathology, 5, 37-43.
Retrieved from http://ajslp.asha.org/cgi/content/abstract/5/1/37

Mackie, N., Damico, J. (2007). Access and social inclusion in aphasia: Interaction principles and applications. Aphasiology, 21 (1), 81-97. doi: 10.1080/02687030600798311

References


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  2. ^ Author unknown. (1997-2011). Aphasia. In American Speech-Language-Hearing Association. Retrieved from http://www.asha.org/public/speech/disorders/aphasia.htm
  3. ^ Rapin, I. (ab), Dunn, M. (b), Allen, D. (c). (2003). Developmental language disorders. In S.J. Segalowitz & Isabelle Rapin (Eds.), Handbook of Neuropsychology (2nd. ed., vol 8, part II). Amsterdam, The Netherlands: Elsevier, Science B.V.
  4. ^ Patterson, J. (Nd). Aphasia treatment program. Retrieved from http://class.csueastbay.edu/commsci/ATP%20website%201-4.htm
  5. ^ Patterson, J. (Nd). Aphasia treatment program. Retrieved from http://class.csueastbay.edu/commsci/ATP%20website%201-4.htm
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  7. ^ Doody, R., S. (1992). Aphasia: Some neurological, anthropological and postmodern implications of disturbed speech. (Doctoral Dissertation). Retrieved from University Microfilm International, Ann Arbor, MI. (9234359)
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  17. ^ Goodwin, C. (2004). A competent speaker who can't speak: The social life of aphasia. Journal of Linguistic Anthropology, 14 (2), 151-170.
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  20. ^ Earl, S. (2001). Teaching sociology within speech and language curriculum. Education for health: Change in Therapies and Practice, 14 (3), 383-391.