Speech therapy in aphasia

Many people who have suffered a brain injury lose all or part of the ability to communicate: control speech movements, remember words, express thoughts, understand what they are told. Just as dysarthria is a muscular alteration of speech, aphasia is an alteration that affects language: understanding and expressing oneself. The loss of an essential capacity in human life such as communication, frequently associated with other motor or sensory deficits, has a strong impact on the affected person and his family.. The speech therapy intervention aims to improve the altered functions and help the acquisition of new compensatory communication skills. In this process, the family plays a primordial role and can learn specific strategies to favor the communication of the affected person. At the same time, medical advances are emerging that provide new procedures for the rehabilitation of language.

 

Aphasia is an alteration of the language due to an acquired brain injury , usually in the left hemisphere. The cause of the aphasia can be a stroke, a tumor, an infection or a traumatic brain injury. People with aphasia may have difficulties, both in expression, as in language comprehension, as well as in reading and writing. It is an alteration primarily of language; It should not be surprising that a person with severe aphasia is able to recognize his friends and remember facts of his life, as well as understand and remember what he sees, although he has difficulty in accurately understanding what is said.

 

Global aphasia, which is usually associated with hemiplegia, is the most serious form. Affected people can not express themselves beyond some automatisms (like hello, goodbye) or present stereotypes (the same word or syllable as the only verbal production). They can not write or, in most cases, communicate through gestures, because they suffer at the same time apraxia, which is the loss of the use of significant gestures. On the other hand, they have comprehension problems: they do not understand the language well, although they do understand visual information, such as the clock or the calendar.

 

However, they have preserved certain communication skills, such as facial expression and prosody (the intonation of language, which they use in their vocalizations or stereotypes), as well as a certain degree of comprehension in everyday contexts, and pragmatic skills, such as politeness and norms of social interaction.

 

People with Broca's aphasia (motor or expression aphasia), caused by injuries in the anterior areas of the dominant hemisphere, speak slowly, strained, with single words or grammatically simplified sentences and with difficulty in finding the words, at the same time as They often have difficulty understanding complex. Thus, different components of language may be altered: the articulatory (apraxia of speech), the grammatical (agrammatism, which manifests itself in difficulties not only of expression, but also of understanding sentences), and the lexicon (anomie).

 

On the contrary, in Wernicke's aphasia (of comprehension), caused by lesions in posterior areas, the speech is fluent and abundant, without articulatory difficulty but with multiple errors, which in the initial phase gives rise to an unintelligible jargon. At the same time, attention and listening are severely affected and often people affected can not follow a conversation because they do not understand it well, even if they manage to make themselves understood.

Aphasia, although it presents a certain spontaneous improvement in the first months, requires intensive and prolonged speech therapy rehabilitation. The improvement is usually partial. In recent years it has been proven, in different investigations, that there may be improvement in the chronic phase.

 

Aphasia has a strong impact on the quality of life. In more severe aphasias, the inability to communicate as before, motor limitations and emotional repercussions can reduce activity to such an extent that the person has little motivation to communicate. On the other hand, when there is a relationship with other people, news and activities of interest, there are more reasons to choose, propose, comment, comment or explain, either by verbal or non-verbal means, and with more or less support from the interlocutor.

 

People with less severe aphasia also suffer a very important impact in their lives. Despite being able to communicate with more or less effort in everyday situations, they may have difficulties outside the family and daily life. Even in cases of greater recovery, they may present problems such as following conversations with many people at the same time or using abstract language, which in their case is an obstacle to their reintegration into work and education.

 

 

The speech therapy intervention is framed in a global rehabilitation that includes medical, neuropsychological and social aspects. Start with an assessment to establish the diagnosis and determine which components of the language are affected and which are preserved. Next, the rehabilitation begins, with two objectives in parallel: to provide means to communicate more effectively and achieve the maximum possible recovery of the linguistic capacities. At the same time, a relationship is established that will help the patient and his family to be encouraged, to find new goals and to adapt to their new situation.

 

 

Unlike what happens in dysarthria, in the case of severe aphasia, alternative communication systems based on writing are not valid, because it is the written and oral language itself that is affected.

The person with severe aphasia can use a soffit or a communication notebook based on image plus word, with essential information : significant people, basic needs, calendar, activity schedule, frequented places and topics of interest. However, a person with severe aphasia will hardly take the initiative to express themselves in this way. The use of a communication notebook requires motivation, learning and collaboration from family members. Many aphasic people do not get used to these systems for several reasons: for example, because they have few opportunities to communicate, because of difficulties in their use, because their relatives already understand them by facial expression, intonation and some gesture in daily routines, or because it is a means of expression that seems strange to you. Resorting to supports, such as the mobile phone or the iPad, whose use is customary and socially normalized, which are manageable and easily implemented, can be interesting for alternative communication in aphasics.

Thus, it is essential in all cases to provide the aphasic person and their families with communication strategies: how to speak to ensure their understanding, how to help them express themselves and how to create opportunities to develop communication, taking advantage of their preserved skills. The main communication strategies for aphasia are cited in the attached table.

The evaluation of the language does not intend only to compile the errors, but to identify which the underlying processes are altered and, consequently, to establish a personalized rehabilitation plan, which should be revised as evolutionary changes are presented.. It is necessary, on the one hand, to improve the basic cognitive abilities, such as attention, and on the other, the language components altered at the phonological and articulatory, grammatical, lexical and semantic levels , in the modalities of oral comprehension, oral expression, reading and writing. It is done in sessions that can be individual, group and computerized. Recovery requires a lot of effort and is usually partial, although it is very variable from one case to another. Family participation can significantly increase the results of rehabilitation. Guidelines are given to the family to provide an environmental stimulation of the language and collaborate in the daily work necessary to optimize the recovery.

 

 

At the Institut Guttmann, the Chronic Motor Aphasia Treatment Program is currently being carried out, which combines two treatment modalities: EMT (Transcranial Magnetic Stimulation) and intensive logopedic rehabilitation.. EMT is a non-invasive and safe procedure that is used to modulate brain activity, enhancing the participation of undamaged areas of the left hemisphere in language recovery. The speech therapy treatment is planned in a personalized, intensive way, with demands on the use of language and restriction of non-verbal means. The results obtained so far lead us to a positive assessment of this new tool for the treatment of aphasia. This program is exposed in the following article within this magazine