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APHASIA

Dani Rahmawati
Dept. of Neurology Diponegoro University
Carl Wernicke. Paul Broca

"Boston-Neoclassical Model". The most


prominent writers on this topic have been
Howard Goodglass and Edith Kaplan.
Definition
Aphasia (aphemia ) is condition characterized by either
partial or total loss of the ability to communicate verbally
or using written words.
A person with aphasia may have difficulty speaking,
reading, writing, recognizing the names of objects, or
understanding what other people have said.
Aphasia is caused by a brain injury, as may occur during
a traumatic accident or when the brain is deprived of
oxygen during a stroke. It may also be caused by a
brain tumor, a disease such as Alzheimer's, or an
infection, like encephalitis.
Aphasia may be temporary or permanent.
Aphasia does not include speech impediments caused
by loss of muscle control.
To understand and use language effectively, an
individual draws upon word memorystored information
on what certain words mean, how to put them together,
and how and when to use them properly.
For a majority of people, these and other language
functions are located in the left side (hemisphere) of the
brain. Damage to this side of the brain is most commonly
linked to the development of aphasia. (In 95 to 99% of
right-handed people, language centers are in the left
hemisphere, and up to 70% of left-handed people also
have left-hemisphere language dominance.)
Interestingly, however, left-handed people appear to
have language areas in both the left and right
hemispheres of the brain and, as a result, may develop
aphasia from damage to either side of the brain.
Stroke is the most common cause of aphasia in the
United States. Approximately 500,000 individuals suffer
strokes each year, and 20% of these individuals develop
some type of aphasia.
Other causes of brain damage include head injuries,
brain tumors, and infection. About half of the people who
show signs of aphasia have what is called temporary or
transient aphasia and recover completely within a few
days. An estimated one million Americans suffer from
some form of permanent aphasia.
As yet, no connection between aphasia and age, gender,
or race has been found.
Aphasia is sometimes confused with other
conditions that affect speech, such as dysarthria
and apraxia.
These condition affect the muscles used in
speaking rather than language function itself.
- Dysarthria is a speech disturbance caused by
lack of control over the muscles used in
speaking, perhaps due to nerve damage.
- Speech apraxia is a speech disturbance in
which language comprehension and muscle
control are retained, but the memory of how to
use the muscles to form words is not.
Causes and symptoms
According to the traditional classification
scheme, each form of aphasia is caused by
damage to a different part of the left hemisphere
of the brain.
This damage affects one or more of the basic
language functions: speech, naming (the ability
to identify an object, color, or other item with an
appropriate word or term), repetition (the ability
to repeat words, phrases, and sentences),
hearing comprehension (the ability to
understand spoken language), reading (the
ability to understand written words and their
meaning), and writing (the ability to
communicate and record events with text).
Symptoms
Any of the following can be considered symptoms of aphasia:
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
poor enunciation
excessive creation and use of personal neologisms
inability to repeat a phrase
persistent repetition of phrases
paraphasia (substituting letters, syllables or words)
agrammatism (inability to speak in a grammatically correct fashion)
dysprosody (alterations in inflexion, stress, and rhythm)
uncompleted sentences
inability to read
inability to write
Classification
Broca's aphasia, also called motor aphasia
Wernicke's aphasia
Global aphasia
Conduction aphasia, also called associative
aphasia
Anomic or nominal aphasia
Transcortical aphasia :
- transcortical motor aphasia,
- transcortical sensory aphasia, and
- mixed transcortical aphasia
Fluent, non-fluent and "pure"
aphasias
Fluent aphasias, also called receptive
aphasias,
Wernicke's aphasia, Transcortical sensory
aphasia, Conduction aphasia, Anomic aphasia
Nonfluent aphasias, also called expressive
aphasias
Broca's aphasia, Transcortical motor aphasia,
Global aphasia
"Pure" aphasias
Alexia, Agraphia, Pure word deafness
The cognitive neuropsychological model

A few less common subtypes include:


Subcortical motor aphasia
Subcortical sensory aphasia
Mixed transcortical aphasia
Acquired eleptiform aphasia (Landau
Kleffner Syndrome)
Primary and secondary aphasia

Primary aphasia is due to problems with


language-processing mechanisms.
Secondary aphasia is the result of other
problems, like memory impairments,
attention disorders, or perceptual
problems.
Broca's aphasia
also called motor aphasia, results from damage to the front portion
or frontal lobe of the language-dominant area of the brain.
Individuals with Broca's aphasia may be completely unable to use
speech (mutism) or may be able to use single-word statements or
even full sentences, though these sentences may require a great
deal of effort to construct.
Small words, such as conjunctions (and, or, but) and articles (the,
an, a), may be omitted, leading to a "telegraph" quality in their
speech.
Hearing comprehension is usually not affected, so they are able to
understand other people's speech and conversation and can follow
commands.
Often, they may experience weakness on the right side of their
bodies, which can make it difficult to write.
Reading ability is impaired, and they may have difficulty finding the
right word when speaking.
Individuals with Broca's aphasia may become frustrated and
depressed because they are aware of their language difficulties.
BROCA APHASIA
Wernicke's aphasia
is caused by damage to the side portion or temporal lobe
of the language-dominant area of the brain.
Individuals with Wernicke's aphasia speak in long,
uninterrupted sentences; however, the words used are
frequently unnecessary or even made-up. They have a
great deal of difficulty understanding other people's
speech, sometimes to the point of being unable to
understand spoken language at all.
Reading ability is diminished, and although writing ability
is retained, what is written may be abnormal.
No physical symptoms, such as the right-sided
weakness seen with Broca's aphasia, are typically
observed.
Also, in contrast to Broca's aphasia, individuals with
Wernicke's aphasia are not aware of their language
errors.
WERNICKE APHASIA
Global aphasia
is caused by widespread damage to the
language areas of the left hemisphere.
As a result, all basic language functions are
affected, but some areas may be more affected
than others. For example, an individual may
have difficulty speaking but may be able to write
well.
The individual may experience weakness and
loss of feeling on the right side of their body.
GLOBAL APHASIA
Conduction aphasia
also called associative aphasia, is rather uncommon.
Individuals with conduction aphasia are unable to repeat
words, sentences, and phrases.
Speech is fairly unbroken, although individuals may
frequently correct themselves and words may be skipped
or repeated. Although able to understand spoken
language, it may also be difficult for the individual with
conduction aphasia to find the right word to describe a
person or object.
The impact of this condition on reading and writing ability
varies.
As with other types of aphasia, right-sided weakness or
sensory loss may be present.
Anomic aphasia
or nominal aphasia primarily influences an
individual's ability to find the right name for a
person or object. As a result, an object may be
described rather than named.
Hearing comprehension, repetition, reading, and
writing are not affected, other than by this
inability to find the right name. Speech is fluent,
except for pauses as the individual tries to recall
the right name.
Physical symptoms are variable, and some
individuals have no symptoms of one-sided
weakness or sensory loss.
Transcortical aphasia
is caused by damage to the language areas of
the left hemisphere outside the primary
language areas. There are three types of
aphasia: transcortical motor aphasia,
transcortical sensory aphasia, and mixed
transcortical aphasia.
All of the transcortical aphasias are
distinguished from other types by the individual's
ability to repeat words, phrases, or sentences.
Other language functions may also be impaired
to varying degrees, depending on the extent and
particular location of brain damage.
Diagnosis
Following brain injury, an initial bedside assessment is
made to determine whether language function has been
affected.
If the individual experiences difficulty communicating,
attempts are made to determine whether this difficulty
arises from impaired language comprehension or an
impaired ability to speak.
A typical examination involves listening to spontaneous
speech and evaluating the individual's ability to
recognize and name objects, comprehend what is heard,
and repeat sample words and phrases.
The individual may also be asked to read text aloud and
explain what the passage means. In addition, writing
ability is evaluated by having the individual copy text,
transcribe dictated text, and write something without
prompting.
extensive examinations using in-depth, standardized
tests. Commonly used tests include the Boston
Diagnostic Aphasia Examination, the Western Aphasia
Battery, and possibly, the Porch Index of Speech Ability.
TADIR (Tes Afasia untuk Diagnosis Informasi
Rehabilitasi)
The results of these tests indicate the severity of the
aphasia and may also provide information regarding the
exact location of the brain damage. This more extensive
testing is also designed to provide the information
necessary to design an individualized speech therapy
program
Further information about the location of the damage is
gained through the use of imaging technology, such as
magnetic resonance imaging (MRI) and computed
tomography scans (CT).
Types of aphasia
The following table summarizes some major characteristics of different
types of aphasia :
Type of aphasia Repetition Naming Auditory comprehension Fluency

Wernicke's mildmod mildsevere defective fluent paraphasic

Transcortical sensory good modsevere poor fluent


Conduction aphasia poor poor relatively good fluent
Anomic aphasia (anomia) mild modsevere mild fluent
Broca's aphasia modsev. modsevere mild difficulty non-fluent,
effortful, slow
Transcortical motor aphasia good mildsevere mild non-fluent
Global aphasia poor poor poor non-fluent
Mixed transcortical aphasia moderate poor poor non-fluent -
Mixed non-fluent moderate moderate mild (worse
than Brocas non-fluent)
Alexia - - - - Alexia is a severe reading
impairment.
Agraphia - - - - Agraphia is a severe writing
impairment
Pure word deafness - - - -
APHASIA CLASS. Benson (1981)

Type of aphasia fluency repetition comprehension naming reading

Brocas aphasia NF - + - -

Wernicke aphasia F,P - - - -

Conduction aphasia F,P - + - +

Global aphasia NF - - - -

Transcortical motor NF + + - +

Transcortical sensory F,P + - - -

Transcortical mixed NF,P + - - -

Anomic aphasia F + + - +

Subcortical aphasia F,P + + + +


(talamic,striatal)
Continous..
Type of aphasia writing motor senso Visual Anatomical locus
ry field (dominant hemisphere)

Brocas aphasia - - + + Posterior inferior frontal

Wernicke aphasia - + Posterior superior temporal

Conduction aphasia - + - + Supramarginal gyrus

Global aphasia - - - - Perisylvian language area

Transcortical motor - + + frontal anterior, and/or


superior to brocas area
Transcortical sensory - + - - Parietal-temporal border
zone
Transcortical mixed - - - - Arterial border zone area

Anomic aphasia + + + +

Subcortical aphasia + - - - Subcortical nuclear or


tracts
Klasifikasi Kirshner
JENIS Bicara Arti Na Ulang Baca Tu Lesi di otak Darah
AFASIA spontan auditif ma lis
Broca NF/mutisme + - - + - Operkulum a.Serebri media
(motorik, lob.frontalis superior
ekspresif) (area broca)
Wernicke F/parafasia - - - - - Post girus temporalis a.Serebri media
sens.,res superior posterior
eptif,akus (area wernicke)
tis
Global NF/mutisme - - - - - Hemisfer kiri luas a.Serebri media
luas
Konduksi F/parafasia + +/- - + + Fasikulus arkuatus a. Serebri media
(sentralis)
Anomik F/sirkum + - + + + Girus angularis a.Serebri media
(nominal, lokasi cab.angularis
amnetis)
TKM NF/gagap + +/- + + + Lob.frontal; regio a.Serebri
(dinamis) frontal parasagit.sup; anterior
reg.frontal post.inf.
TKS F/parafasia/ - - ++ - +/- Border zone parietal Perbatasan
sirkumlokasi / temporal atau a.ser.med. Dan
keduanya a.ser.post.
Aleksia + < normal + +/- + - - Parieto temporal a.ser.med. Cab.
agrafia temporoparietal
aleksia normal + +/- + - + Oksipitalis medialis a.ser.post
EVALUATION / APHASIA TEST
CLINICAL ASPECT

Conversational speech ( konversasi/bicara


spontan)
Repetition (pengulangan)
Comprehension of spoken language
(pemahaman bahasa lisan)
Word finding (penamaan/penemuan kata)
Reading
writing
Treatment
the underlying cause of aphasia must be treated or
stabilized.
To regain language function, therapy must begin as soon
as possible following the injury.
Although there are no medical or surgical procedures
currently available to treat this condition, aphasia
resulting from stroke or head injury may improve
through the use of speech therapy.
For most individuals, however, the primary emphasis is
placed on making the most of retained language abilities
and learning to use other means of communication to
compensate for lost language abilities.
Speech therapy is tailored to meet individual needs, but activities and
tools that are frequently used include the following :

Exercise and practice. Weakened muscles are exercised by


repetitively speaking certain words or making facial expressions,
such as smiling.
Picture cards. Pictures of everyday objects are used to improve
word recall and increase vocabulary. The names of the objects may
also be repetitively spoken aloud as part of an exercise and practice
routine.
Picture boards. Pictures of everyday objects and activities are
placed together, and the individual points to certain pictures to
convey ideas and communicate with others.
Workbooks. Reading and writing exercises are used to sharpen
word recall and regain reading and writing abilities. Hearing
comprehension is also redeveloped using these exercises.
Computers. Computer software can be used to improve speech,
reading, recall, and hearing comprehension by, for example,
displaying pictures and having the individual find the right w
TERAPI FARMAKOLOGIK

Adjuvan
Tujuan :
- menghilangkan gejala yang mengganggu terapi dan
rehab. : gangguan atensi dan memori
atau depresi dan kecemasan
- memperbaiki gejala yang spesifik yang penting untuk
penampilan komunikatif pasien (bahasa
stereotipik,perseverasi,ekolalia,parafasia,mutisme)
Harus berdasarkan jenis gejala
Sebagian besar memanipulasi sistem neurotransmiter.
Manipulasi neurotransmiter monoaminergik pendekatan
prospektif.(dopamiergik,noradrenergik,serotonergik,kolinerg
ik )
Prognosis
The degree to which an individual can recover language
abilities is highly dependent on how much brain damage
occurred and the location and cause of the original brain
injury.
Other factors : age, general health, motivation and
willingness to participate in speech therapy, and whether
the individual is left or right handed.
Language areas may be located in both the left and right
hemispheres in left-handed individuals. Left-handed
individuals are, therefore, more likely to develop aphasia
following brain injury, but because they have two
language centers, may recover more fully because
language abilities can be recovered from either side of
the brain.
The intensity of therapy and the time between diagnosis
and the start of therapy may also affect the eventual
outcome.