The Neuroscience on the Web Series:
CMSD 636 Neuropathologies of Language and Cognition
CSU, Chico, Patrick McCaffrey, Ph.D.
Chapter 7. Specific Syndromes: The Nonfluent Aphasias
This is the most common of the nonfluent aphasias. In older literature, it is called verbal aphasia (Head, 1926), motor aphasia (Goldstein, 1933), and efferent motor aphasia (Luria, 1964) . It is named after Paul Broca (1865), a French physician. According to FitzGerald,1996, the principal output from Broca's area is to cell columns in the tongue and face areas of the precentral gyrus.
The lesion that causes Broca's aphasia affects the third frontal convolution (both the gyrus and the sulcus) of the left frontal lobe. This location is called Broca's area. It corresponds to Brodmann's areas 44 and 45. According to Brookshire (1997) it makes up the lower part of the pre-motor cortex. The damage often extends down into the white matter and, in some cases, extends posteriorly to the most inferior part of the motor strip (Goodglass and Kaplan (2001).
Speech is telegraphic , meaning that articles, conjunctions, prepositions, auxiliary verbs and pronouns (function words) and morphological inflections (e.g. plurals, past tense), are omitted. In addition, nouns, verbs, adjectives and adverbs (content words) may be retained. Output can be restricted to noun-verb combinations. There is often a concomitant apraxia of speech (AOS).
Sentence length is short. Average utterance length (MLU) is typically about 2. In extreme cases, the patient may only be able to produce single word utterances.
Syntax and morphology are affected; only the most basic and over-learned grammatical forms are produced (often limited to nouns and verbs).
Speech is labored and slow.
Melodic Contour is flat.
Articulatory Agility is impaired. Potential problems include:
Simplification of consonant clusters (e.g. t/st, p/spl).
Distortion of consonants.
Substitutions are infrequent.
A few paraphasias may occur. They will usually be literal .
Repetition is typically impaired, falling at about the middle of the Boston Diagnostic Aphasia Examination (BDAE) scale. (Repetition and spontaneous speech are impaired to about the same degree in Broca's aphasia.)
Word finding is impaired.
In Broca's aphasia auditory comprehension appears superior to expressive language, and usually falls within the 50th-90th percentile range on the Boston (McCaffrey, 2005). The patient's ability to understand grammer will be affected. So, while it can be said that auditory comprehension is good in comparison with expression, it is not normal. The knowledge of linguistic rules will be the same, but expression may be apraxic as well as aphasic.
In our clinic a Broca's aphasic patient when asked what his favourite food was he said: "Uh. uh. uh. choc. like. chocolate."
Note: I have frequently used the Token Test (DeRenzi & Vignolo, 1966), which assesses subtle receptive language dysfunction, to evaluate the auditory comprehension of Broca's aphasics and to differentiate between Broca's aphasia and apraxia of speech AOS. when the patient does well you know that s/he doesn't have aphasia. When s/he does poorly it is more difficult to make a diagnosis. The test which is also normed for children, has five parts involving the manipulation of objects of different colors, shapes, and sizes, and becomes progressively more difficult. It tests receptive language by requiring the patient to follow instructions like "Put the red square on the yellow circle." However you must be aware that words like "before" which are grammatical morphemes may be missed due to conceptual or semantic problems. Also, limb apraxia or colour blindness may not allow the patient to carry out the instructions, even though s/he understands them.
Hemiplegia/Hemiparesis of the right side is common (remember, the language center is in the left hemisphere for more than 90% of the population) The face and arm are most likely to be affected due to the organization of the motor strip.
Apraxia frequently accompanies this type of aphasia as it is likely caused by lesions to area 44/45. This poorly articulated speech shows up most frequently in longer words and phrases.
Broca's aphasics typically have low frustration tolerance. They are aware of their errors and may respond to them with a catastrophic reaction which might include weeping.
Broca's aphasics may receive a rating of 1 or 2 on the BDAE, especially soon after their strokes, due to the scarcity of their speech output. As they recover, they may be rated as 3, 4 or 5 (Goodglass and Kaplan, 1983).
Typically there is better recovery of language function in Broca's than in any of the other aphasia syndromes.
Transcortical Motor Aphasia
Lesions are typically smaller than those that cause Broca's aphasia and are superior to and often anterior to Broca's area. Broca's area itself is not affected, but the damage may extend down into the white matter including the white matter below Broca's area. Luria (1966) referred to this syndrome as dynamic aphasia.
Communication between Broca's area and the pre-motor or supplementary motor area (Brodmann's Area 6) is cut off. Because Wernicke's area and the arcuate fasciculus are spared, these patients have good repetition (Brookshire, 1997). This type of lesion may also sever links between Broca's area and the basal ganglia and/or the thalamus . There are motor areas in the thalamus and the basal ganglia that may have some kind of pre-motor function also. In addition, the damage could cause symptoms by affecting the link between Broca's area and the limbic system which also seems to be involved in memory (hippocampus) and speech and language.
Repetition is much better than other types of speech. In repetition , grammar and articulation are normal.
The patient will have great difficulty initiating and organizing responses in conversation, but will be unable to answer highly structured questions. For example someone with transcortical aphasia would probably not be able to answer question like "Why are you in the hospital?" but would be able to name their home town, answer yes/no questions, and name the days of the week. When faced with a question he/she cannot answer, the patient may appear "blocked" and produce fragmentary responses. Generally, with transcortical motor aphasia there is little or no paraphasia, fair to good articulation and fair to excellent auditory comprehension (Goodglass and Kaplan, 1983).
Articulation in general is fair to good.
Little or no paraphasia is present.
Confrontational naming is well-preserved. The patient will respond well to prompting with phonemic cues.
Auditory comprehension is fair to excellent.
According to Goodglass and Kaplan (2001) the fluent/nonfluent distinction is not especially applicable to this syndrome. Sometimes the patient will produce a grammatically correct, well-articulated sentence.
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Aphasia often arises as a result of damage to Broca's area or Wernicke's area.
Aphasia is a language disorder that results from damage to portions of the brain that are responsible for language. For most people, these are parts of the left side (hemisphere) of the brain. Aphasia usually occurs suddenly, often as the result of a stroke or head injury, but it may also develop slowly, as in the case of a brain tumor. The disorder impairs both the expression and understanding of language as well as reading and writing. Aphasia may co-occur with speech disorders such as dysarthria or apraxia of speech, which also result from brain damage.Who has aphasia?
Anyone can acquire aphasia, but most people who have aphasia are in their middle to late years. Men and women are equally affected. It is estimated that approximately 80,000 individuals acquire aphasia each year. About one million persons in the United States currently have aphasia.What causes aphasia?
Aphasia is caused by damage to one or more of the language areas of the brain. Many times, the cause of the brain injury is a stroke. A stroke occurs when blood is unable to reach a part of the brain. Brain cells die when they do not receive their normal supply of blood, which carries oxygen and important nutrients. Other causes of brain injury are severe blows to the head, brain tumors, brain infections, and other conditions of the brain.
Individuals with Broca’s aphasia have damage to the frontal lobe of the brain. These individuals frequently speak in short, meaningful phrases that are produced with great effort. Broca’s 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 Broca’s aphasia may say, “Walk dog” meaning, “I will take the dog for a walk.” The same sentence could also mean “You take the dog for a walk,” or “The dog walked out of the yard,” depending on the circumstances. Individuals with Broca’s 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 Broca’s aphasia often have right-sided weakness or paralysis of the arm and leg because the frontal lobe is also important for body movement.
In contrast to Broca’s aphasia, damage to the temporal lobe may result in a fluent aphasia that is called Wernicke’s aphasia. Individuals with Wernicke’s aphasia may speak in long sentences that have no meaning, add unnecessary words, and even create new “words.” For example, someone with Wernicke’s 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.” Individuals with Wernicke’s aphasia usually have great difficulty understanding speech and are therefore often unaware of their mistakes. These individuals usually have no body weakness because their brain injury is not near the parts of the brain that control movement.
A third type of aphasia, global aphasia, results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language.How is aphasia diagnosed?
Aphasia is usually first recognized by the physician who treats the individual for his or her brain injury, usually a neurologist. The physician typically performs tests that require the individual to follow commands, answer questions, name objects, and converse. If the physician suspects aphasia, the individual is often referred to a speech-language pathologist, who performs a comprehensive examination of the person’s ability to understand, speak, read, and write.How is aphasia treated?
In some instances, an individual will completely recover from aphasia without treatment. This type of “spontaneous recovery” usually occurs following a transient ischemic attack (TIA), a kind of stroke in which the blood flow to the brain is temporarily interrupted but quickly restored. In these circumstances, language abilities may return in a few hours or a few days. For most cases of aphasia, however, language recovery is not as quick or as complete. While many individuals with aphasia also experience a period of partial spontaneous recovery (in which some language abilities return over a period of a few days to a month after the brain injury), some amount of aphasia typically remains. In these instances, speech-language therapy is often helpful. Recovery usually continues over a 2-year period. Most people believe that the most effective treatment begins early in the recovery process. Some of the factors that influence the amount of improvement include the cause of the brain damage, the area of the brain that was damaged, the extent of the brain injury, and the age and health of the individual. Additional factors include motivation, handedness, and educational level.
Aphasia therapy strives to improve an individual’s ability to communicate by helping the person to use remaining abilities, to restore language abilities as much as possible, to compensate for language problems, and to learn other methods of communicating. Treatment may be offered in individual or group settings. Individual therapy focuses on the specific needs of the person. Group therapy offers the opportunity to use new communication skills in a comfortable setting. Stroke clubs, which are regional support groups formed by individuals who have had a stroke, are available in most major cities. These clubs also offer the opportunity for individuals with aphasia to try new communication skills. In addition, stroke clubs can help the individual and his or her family adjust to the life changes that accompany stroke and aphasia. Family involvement is often a crucial component of aphasia treatment so that family members can learn the best way to communicate with their loved one.
Family members are encouraged to:
Aphasia research is exploring new ways to evaluate and treat aphasia as well as to further understand the function of the brain. Brain imaging techniques are helping to define brain function, determine the severity of brain damage, and predict the severity of the aphasia. These procedures include PET (positron emission tomography), CT (computed tomography), and MRI (magnetic resonance imaging) as well as the new functional magnetic resonance (fMRI), which identifies areas of the brain that are used during activities such as speaking or listening. In-depth testing of the language ability of individuals with the various aphasic syndromes is helping to design effective treatment strategies. The use of computers in aphasia treatment is also being studied. Promising new drugs administered shortly after some types of stroke are being investigated as ways to reduce the severity of aphasia.Patients & Families Professionals
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