Shifting of global aphasia to Wernicke's aphasia in a patient with intact motor function: a case report.

BACKGROUND: Global aphasia without hemiparesis (GAWH) is a rare stroke syndrome characterized by the dissociation of motor and language functions. Here, we present a case of GAWH with the patient later regaining speech fluency. CASE PRESENTATION: A 73-year-old man was admitted to our emergency department immediately after an episode of syncope. On arrival, we noted his global aphasia but without any focal neurologic signs. Computed tomography (CT) perfusion scans showed a large hypodense region over his left perisylvian area. Under the impression of acute ischaemic stroke, he received recombinant tissue plasminogen activator (rtPA) injection and was treated as an inpatient. The patient was later discharged with GAWH status and received regular speech rehabilitation. After 14 months of rehabilitation, the patient gradually recovered his language expression ability. The degree of aphasia was evaluated with the Concise Chinese Aphasia Test (CCAT), and we obtained brain single photon emission computed tomography (SPECT) scans to assess cerebral blood flow. CONCLUSION: A patient with severe impairments of Broca's and Wernicke's areas was able to talk fluently despite being unintelligible. SPECT revealed relative high level of radioactivity uptake in the right frontal lobe, suggesting the deficits in speech fluency could have been compensated by the right hemisphere. Although this is a single case demonstration, the results may strengthen the role of the right hemisphere in GAWH patients and suggests additional study that examines the possible benefits of stimulating activity at right homologous regions for recovering language function after global aphasia.

Auditory, Phonological, and Semantic Factors in the Recovery From Wernicke's Aphasia Poststroke: Predictive Value and Implications for Rehabilitation.

Background. Understanding the factors that influence language recovery in aphasia is important for improving prognosis and treatment. Chronic comprehension impairments in Wernicke's aphasia (WA) are associated with impairments in auditory and phonological processing, compounded by semantic and executive difficulties. This study investigated whether the recovery of auditory, phonological, semantic, or executive factors underpins the recovery from WA comprehension impairments by charting changes in the neuropsychological profile from the subacute to the chronic phase. Method. This study used a prospective, longitudinal observational design. Twelve WA participants with superior temporal lobe lesions were recruited 2 months post-stroke onset (2 MPO). Language comprehension was measured alongside a neuropsychological profile of auditory, phonological, and semantic processing and phonological short-term memory and nonverbal reasoning at 3 poststroke time points: 2.5, 5, and 9 MPO. Results. Language comprehension displayed a strong and consistent recovery between 2.5 and 9 MPO. Improvements were also seen for slow auditory temporal processing, phonological short-term memory, and semantic processing but not for rapid auditory temporal, spectrotemporal, and phonological processing. Despite their lack of improvement, rapid auditory temporal processing at 2.5 MPO and phonological processing at 5 MPO predicated comprehension outcomes at 9 MPO. Conclusions. These results indicate that recovery of language comprehension in WA can be predicted from fixed auditory processing in the subacute stage. This suggests that speech comprehension recovery in WA results from reorganization of the remaining language comprehension network to enable the residual speech signal to be processed more efficiently, rather than partial recovery of underlying auditory, phonological, or semantic processing abilities.

Exploring Treatment Fidelity in Persons With Aphasia Autonomously Practicing With Computerized Therapy Materials.

Purpose: Current computer technologies permit independent practice for people with cognitive-communicative disorders. Previous research has investigated compliance rates and outcome changes but not treatment fidelity per se during practice. Our aim was to examine adherence to procedures (treatment fidelity) and accuracy while persons with aphasia independently practiced word production using interactive, multimodal, user-controlled, word-level icons on computers. Method: Four persons with aphasia independently practiced single-word production after stimulation via user-initiated interactions in 3 conditions: (I) auditory stimulus with static representational drawing; (II) auditory stimulus with synchronized articulation video; and (III) users' choice between the 2 prior conditions. Sessions were video-recorded for subsequent analysis, which established emergently refined behavioral taxonomies using an iterative, mixed-methods approach. Results: In independent practice, users only sometimes adhere to modeled behaviors, other times improvising novel behaviors. The latter sometimes co-occurred with successful productions. Differences in success rates were noted between Conditions I and II across behaviors with Condition II generally favored. In Condition III, participants tended to choose the stimulus that resulted in highest success rates. Conclusions: During independent practice with technology, persons with aphasia do not necessarily comply with clinicians' practice instructions, and treatment fidelity does not determine success. Autonomy and choice in practice may reveal unanticipated dimensions for computerized aphasia treatment.

An analysis of topics and vocabulary in Chinese oral narratives by normal speakers and speakers with fluent aphasia.

This study analysed the topic and vocabulary of Chinese speakers based on language samples of personal recounts in a large spoken Chinese database recently made available in the public domain, i.e. Cantonese AphasiaBank ( http://www.speech.hku.hk/caphbank/search/ ). The goal of the analysis is to offer clinicians a rich source for selecting ecologically valid training materials for rehabilitating Chinese-speaking people with aphasia (PWA) in the design and planning of culturally and linguistically appropriate treatments. Discourse production of 65 Chinese-speaking PWA of fluent types (henceforth, PWFA) and their non-aphasic controls narrating an important event in their life were extracted from Cantonese AphasiaBank. Analyses of topics and vocabularies in terms of part-of-speech, word frequency, lexical semantics, and diversity were conducted. There was significant overlap in topics between the two groups. While the vocabulary was larger for controls than that of PWFA as expected, they were similar in distribution across parts-of-speech, frequency of occurrence, and the ratio of concrete to abstract items in major open word classes. Moreover, proportionately more different verbs than nouns were employed at the individual level for both speaker groups. The findings provide important implications for guiding directions of aphasia rehabilitation not only of fluent but also non-fluent Chinese aphasic speakers.

[Direct current electrical stimulation in the treatment of aphasia]. / Estimulacion electrica por corriente continua en el tratamiento de la afasia.

INTRODUCTION: Ictus is a medical condition with a high prevalence in Spanish population. One of its most common consequences is aphasia. Nowadays, aphasia is treated with both neuropsychological and pharmacological therapy. However, in recent years, transcranial direct current stimulation has been presented as a complement to classical therapies. AIMS: To familiarize the reader with transcranial direct current stimulation and to critically review the evidence on the benefits of this technique in aphasia rehabilitation. DEVELOPMENT: The first part of this paper describes what transcranial electrical stimulation is. Subsequently, an analysis of the efficacy of this technique in the treatment of aphasia is presented. To achieve this, we searched in PubMed database and found 19 different scientific papers, published between 2008 and 2016, which used transcranial electrical stimulation in the treatment of aphasia. CONCLUSIONS: These studies suggest that, when it is used in conjunction with speech therapy, transcranial direct current electrical stimulation is effective in the treatment of aphasia. In addition, its benefits are observed when a minimum of five sessions with intensities higher than 1 mA, stimulating perilesional areas, and in those patients with fluent aphasias. However, the reviewed studies also suggest that this technique is not a substitutive of speech therapy, but a way to prime the brain to it.

TITLE: Estimulacion electrica por corriente continua en el tratamiento de la afasia.Introduccion. Los ictus son un problema medico con una alta prevalencia en Espana, y la afasia es una de las secuelas mas comunes. Actualmente, la afasia se trata principalmente con terapia neuropsicologica y farmacologica. Sin embargo, en los ultimos anos, la estimulacion electrica transcraneal por corriente continua se ha presentado como un complemento a los tratamientos mas clasicos. Objetivos. Familiarizar al lector con la estimulacion electrica transcraneal por corriente continua y revisar de forma critica los beneficios de esta tecnica en la rehabilitacion de la afasia. Desarrollo. Tras describir en que consiste la estimulacion electrica transcraneal por corriente continua, posteriormente se analizan las evidencias existentes sobre los efectos de esta tecnica en el tratamiento de la afasia. Para ello se ha realizado una busqueda en la base de datos PubMed y se han revisado 19 estudios, publicados entre 2008 y 2016, en los que se utiliza la estimulacion electrica por corriente continua para el tratamiento de la afasia. Conclusiones. Estos estudios sugieren que la estimulacion electrica transcraneal por corriente continua es efectiva en el tratamiento de la afasia cuando se acompana de terapia neuropsicologica. Ademas, sus beneficios parecen ser mayores cuando se aplica durante al menos cinco sesiones con intensidades superiores a 1 mA, estimulando zonas perilesionales, y en pacientes con afasias fluentes. Los estudios tambien sugieren que esta tecnica no debe entenderse nunca como sustitutiva de la terapia neuropsicologica, sino como una forma de preparar al cerebro para esta.

Eficacia del tratamiento para la afasia de Wernicke en pacientes con sintomatología grave / Effective treatment for Wernicke's aphasia in patients with severe symptomatology

Introducción. La afasia es un trastorno del lenguaje que en la mayoría de los casos provoca una incapacidad para la comunicación, lo que implica un hándicap no solo para el paciente sino para el entorno familiar. La rehabilitación del paciente se considera, entonces, vital para suplir esta disfunción comunicativa. La terapia logopédica convencional es útil, pero en casos de afasias con graves alteraciones es lenta. Para subsanar este problema, en el ámbito de la afasia de Wernicke se desarrolló el «tratamiento para la afasia de Wernicke» (TAW), que se mostró efectivo en un conjunto específico de candidatos. Objetivo. Valorar el TAW en pacientes diagnosticados con afasia de Wernicke y que presentan una sintomatología grave, aunque no sean candidatos específicos al tratamiento original. Método. Se realizaron 12 sesiones del TAW con un paciente afectado por afasia de Wernicke y se comparó la actuación pre y postratamiento de este paciente con un grupo de pacientes con afasia de Wernicke (uno de ellos con igual etiología y localización) y otro grupo de pacientes con afasia sensorial transcortical (afasia de Wernicke tipo ii). Resultados. Los resultados muestran, en casi todos los ámbitos verbales analizados, una mejora mayor en el paciente que realizó el TAW respecto al resto de pacientes que siguieron una terapia logopédica convencional. Conclusiones. A partir de los resultados obtenidos se concluye que el TAW es un tratamiento terapéutico útil para toda clase de pacientes con afasia de Wernicke, y no solo para los candidatos propuestos en la rehabilitación inicial (AU)

Introduction. Aphasia is a language disorder which causes, in most cases, an inability to communicate, which implies a handicap not only for the patient but also for the family environment. Patient rehabilitation is considered vital to redress this communicative dysfunction. Conventional speech therapy is useful, but for cases of aphasia with severe disturbances it is too slow. To solve this problem, in the field of the Wernicke's aphasia was developed the Treatment for the Wernicke's aphasia (TWA), which it is showed effective in a specific set of candidates. Objective. To assess TWA in Wernicke's aphasia patients who had severe symptoms, although they were not candidates for the original conventional treatment. Method. 12 sessions of TWA were performed with a Wernicke's patient, and pre- and post-treatment results of the patient were compared with a group of Wernicke's patients (one with the same etiology and location) and with a group of transcortical sensory aphasia's patients (Wernicke aphasia type ii). Results. The results show, in almost all the analyzed verbal areas, a greater improvement in the patient who completed the TWA compared to patients who followed conventional speech therapy. Conclusions. From the results obtained in this study it can be concluded that the TWA is an useful therapeutic treatment for all classes of patients with Wernicke's aphasia, and not just for the candidates in initial rehabilitation (AU)

Development of a theoretically based treatment for sentence comprehension deficits in individuals with aphasia.

PURPOSE: Two new treatments, 1 based on sentence to picture matching (SPM) and the other on object manipulation (OM), that train participants on the thematic roles of sentences using pictures or by manipulating objects were piloted. METHOD: Using a single-subject multiple-baseline design, sentence comprehension was trained on the affected sentence type in 1 task-related protocol in 15 participants with aphasia. The 2 tasks were SPM and OM; the treatment stimuli were object relatives, object clefts, passives, and unaccusatives, as well as two control structures-object relatives with a complex noun phrase (NP) and active sentences with three NPs. RESULTS: The criteria for efficacious treatment was an increase in the level of performance from the pretreatment probes to the posttreatment probes for the treated structure such that accuracy rose from at or below chance to above chance and either (a) accuracy rose by 33% or (b) the effect size was 2.6. Based on these criteria, the success rate for training the target structure was 2/6 participants in the SPM condition and 4/7 participants in the OM condition. CONCLUSION: The outcome of this study illustrates the utility of this theoretically motivated and efficacious treatment for sentence comprehension deficits in individuals with aphasia.

Aphasia in border-zone infarcts has a specific initial pattern and good long-term prognosis.

BACKGROUND: While border-zone infarcts (BZI) account for about 10% of strokes, studies on related aphasia are infrequent. The aim of this work was to redefine specifically their early clinical pattern and evolution. METHODS: We prospectively studied consecutive patients referred to our stroke unit within a 2-year period. Cases of aphasia in right-handed patients associated with a MRI confirmed left-sided hemispheric BZI were included. These patients had a standardized language examination in the first 48 h, at discharge from stroke unit and between 6 and 18 months later. RESULTS: Eight patients were included. Three had anterior (MCA/ACA), two posterior (MCA/PCA), two both anterior and posterior, and one bilateral BZI. All our patients initially presented transcortical mixed aphasia, characterized by comprehension and naming difficulties associated with preserved repetition. In all patients, aphasia rapidly improved. It fully recovered within a few days in three patients. Initial improvement was marked, although incomplete in the five remaining patients: their aphasias specifically evolved according to the stroke location toward transcortical motor aphasia for the three patients with anterior BZI and transcortical sensory aphasia for the two patients with posterior BZI. All patients made a full language recovery within 18 months after stroke. CONCLUSIONS: We report a specific aphasic pattern associated with hemispheric BZI, including an excellent long-term outcome. These findings appear relevant to (i) clinically suspect BZI and (ii) plan rehabilitation and inform the patient and his family of likelihood of full language recovery.

Therapy for naming difficulties in bilingual aphasia: which language benefits?

BACKGROUND: The majority of the world's population is bilingual. Yet, therapy studies involving bilingual people with aphasia are rare and have produced conflicting results. One recent study suggested that therapy can assist word retrieval in bilingual aphasia, with effects generalizing to related words in the untreated language. However, this cross-linguistic generalisation only occurred into the person's stronger language (L1). While indicative, these findings were derived from just three participants, and only one received therapy in both languages. AIMS: This study addressed the following questions. Do bilingual people with aphasia respond to naming therapy techniques developed for the monolingual population? Do languages respond differently to therapy and, if so, are gains influenced by language dominance? Does cross-linguistic generalisation occur and does this depend on the therapy approach? Is cross-linguistic generalisation more likely following treatment in L2 or L1? METHODS & PROCEDURES: The study involved five aphasic participants who were bilingual in English and Bengali. Testing showed that their severity and dominance patterns varied, so the study adopted a case series rather than a group design. Each person received two phases of naming therapy, one in Bengali and one in English. Each phase treated two groups of words with semantic and phonological tasks, respectively. The effects of therapy were measured with a picture-naming task involving both treated and untreated (control) items. This was administered in both languages on four occasions: two pre-therapy, one immediately post-therapy and one 4 weeks after therapy had ceased. Testing and therapy in Bengali was administered by bilingual co-workers. OUTCOMES & RESULTS: Four of the five participants made significant gains from at least one episode of therapy. Benefits arose in both languages and from both semantic and phonological tasks. There were three instances of cross-linguistic generalisation, which occurred when items had been treated in the person's dominant language using semantic tasks. CONCLUSIONS & IMPLICATIONS: This study suggests that 'typical' naming treatments can be effective for some bilingual people with aphasia, with both L1 and L2 benefiting. It offers evidence of cross-linguistic generalisation, and suggests that this is most likely to arise from semantic therapy approaches. In contrast to some results in the academic literature, the direction of generalisation was from LI to L2. The theoretical implications of these findings are considered. Finally, the results support the use of bilingual co-workers in therapy delivery.

Low-frequency rTMS with language therapy over a 3-month period for sensory-dominant aphasia: case series of two post-stroke Japanese patients.

PURPOSE: To examine the safety and feasibility of therapeutic application of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with language therapy for post-stroke patients with sensory-dominant aphasia. SUBJECTS AND METHODS: Two post-stroke Japanese patients with sensory-dominant aphasia were studied. In both patients, 10 sessions of 20-minute low-frequency rTMS with 1 Hz to the Wernicke's area were provided throughout 6-day hospitalization, followed by weekly outpatient rTMS treatment for 3 months. The language therapy was also provided through the period of in- and out-patient treatment. Language function was evaluated using the Token test and the Standard Language Test of Aphasia (SLTA) at the start and end of the in-patient treatment and the end of the outpatient treatment. RESULTS: The therapeutic protocol was well tolerated throughout the in- and out-patient treatments, without any adverse effects. The scores of the Token test and certain sub-categories of SLTA increased in both patients after the in-patient rTMS treatment. Persistent improvement of the score was noted over the 3-month post-discharge period. CONCLUSIONS: The proposed protocol of long-term application of low-frequency rTMS to the Wernicke's area and language therapy is considered a safe and feasible therapeutic approach for post-stroke patients with sensory-dominant aphasia.

Aphasia and text writing.

BACKGROUND: Good writing skills are needed in almost every aspect of life today, and there is a growing interest in research into acquired writing difficulties. Most of the findings reported so far, however, are based on words produced in isolation. The present study deals with the production of entire texts. AIMS: The aim was to characterize written narratives produced by a group of participants with aphasia. METHODS & PROCEDURES: Eight persons aged 28-63 years with aphasia took part in the study. They were compared with a reference group consisting of ten participants aged 21-30 years. All participants were asked to write a personal narrative titled 'I have never been so afraid' and to perform a picture-based story-generation task called the 'Frog Story'. The texts were written on a computer. OUTCOME & RESULTS: The group could be divided into participants with low, moderate, and high general performance, respectively. The texts written by the participants in the group with moderate and high writing performance had comparatively good narrative structure despite indications of difficulties on other linguistic levels. CONCLUSIONS & IMPLICATIONS: Aphasia appeared to influence text writing on different linguistic levels. The impact on overall structure and coherence was in line with earlier findings from the analysis of spoken and written discourse and the implication of this is that the written modality should also be included in language rehabilitation.

Novel technology for treating individuals with aphasia and concomitant cognitive deficits.

PURPOSE: This article describes three individuals with aphasia and concomitant cognitive deficits who used state-of-theart computer software for training conversational scripts. METHOD: Participants were assessed before and after 9 weeks of a computer script training program. For each participant, three individualized scripts were developed, recorded on the software, and practiced sequentially at home. Weekly meetings with the speech-language pathologist occurred to monitor practice and assess progress. Baseline and posttreatment scripts were audiotaped, transcribed, and compared to the target scripts for content, grammatical productivity, and rate of production of script-related words. Interviews were conducted at the conclusion of treatment. RESULTS: There was great variability in improvements across scripts, with two participants improving on two of their three scripts in measures of content, grammatical productivity, and rate of production of scriptrelated words. One participant gained more than 5 points on the Aphasia Quotient of the Western Aphasia Battery. Five positive themes were consistently identified from exit interviews: increased verbal communication, improvements in other modalities and situations, communication changes noticed by others, increased confidence, and satisfaction with the software. CONCLUSION: Computer-based script training potentially may be an effective intervention for persons with chronic aphasia and concomitant cognitive deficits.

Application of neuroscience to technology in stroke rehabilitation.

The past decade has seen remarkable advances in our understanding of mechanisms that drive functional neuroplastic change after brain injury and the mirror neuron system that appears essential for language learning and communicative interaction. This article describes five neuroscience-based interventions available for clinical practice, with a discussion of the potential value of mirror neurons in stroke rehabilitation. Case-study data on three adults with aphasia who received various combinations of neuroscience-derived technological interventions are provided to inform the clinician of the potential advantages of technology as an adjunct to, not a substitution for, conventional therapeutic intervention.

Brain regions essential for improved lexical access in an aged aphasic patient: a case report.

BACKGROUND: The relationship between functional recovery after brain injury and concomitant neuroplastic changes is emphasized in recent research. In the present study we aimed to delineate brain regions essential for language performance in aphasia using functional magnetic resonance imaging and acquisition in a temporal sparse sampling procedure, which allows monitoring of overt verbal responses during scanning. CASE PRESENTATION: An 80-year old patient with chronic aphasia (2 years post-onset) was investigated before and after intensive language training using an overt picture naming task. Differential brain activation in the right inferior frontal gyrus for correct word retrieval and errors was found. Improved language performance following therapy was mirrored by increased fronto-thalamic activation while stability in more general measures of attention/concentration and working memory was assured. Three healthy age-matched control subjects did not show behavioral changes or increased activation when tested repeatedly within the same 2-week time interval. CONCLUSION: The results bear significance in that the changes in brain activation reported can unequivocally be attributed to the short-term training program and a language domain-specific plasticity process. Moreover, it further challenges the claim of a limited recovery potential in chronic aphasia, even at very old age. Delineation of brain regions essential for performance on a single case basis might have major implications for treatment using transcranial magnetic stimulation.

Contextual priming in semantic anomia: a case study.

The present case continues the series of anomia treatment studies with contextual priming (CP), being the second in-depth treatment study conducted for an individual suffering from semantically based anomia. Our aim was to acquire further evidence of the facilitation and interference effects of the CP treatment on semantic anomia. Based on the results of the study of , our hypothesis before the treatment was that our participant would show short-term interference and at most modest and short-term benefit from treatment. To acquire such evidence would not only be important for the choice of anomia treatment methods in individual patients, but would also prompt further development of the CP method. The CP technique used for our participant included cycles of repeating and naming items in three contextual conditions (semantic, phonological, and unrelated). As predicted, the overall improvement of naming was modest and short-term. Interestingly, the contextual condition that corresponded with the nature of our patient's underlying naming deficit (semantic) elicited immediate interference in the form of contextual naming errors, as well as short-term improvement of naming. Based on this and a recent study by , it appears that despite short-term positive effects, in its current form the CP treatment is not sufficient for those aphasics who have a semantic deficit underlying their anomia. The possible mechanism and directions for future research are discussed.

Evolution of phonemic word fluency performance in post-stroke aphasia.

UNLABELLED: In this longitudinal study, quantitative and qualitative changes in responses of people with aphasia were examined on a phonemic fluency task. Eighteen patients were tested at 3-month intervals on the letters F-A-S while they received comprehensive, intensive treatment from 3 to 12 months post-stroke. They returned for a follow-up evaluation at an average of 10 months post-intervention. Mean group scores improved significantly from beginning to end of treatment, but declined post-intervention. Patients produced a significantly greater number and proportion of modifiers (adjectives and adverbs) between the beginning and end of treatment, with no decline afterwards, implying that they had access to a wider range of grammatical categories over time. Moreover, patients used significantly more phonemic clusters in generating word lists by the end of treatment. These gains may be attributed to the combined effects of time since onset and the linguistic and cognitive stimulation that patients received in therapy. LEARNING OUTCOMES: Readers of this paper should (1) gain a better understanding of verbal fluency performance in the assessment of aphasia, (2) recognize the importance of analyzing qualitative aspects of single word production in aphasia, and (3) contribute to their clinical judgment of long term improvement in aphasia.

Functional MRI follow-up study of language processes in healthy subjects and during recovery in a case of aphasia.

BACKGROUND AND PURPOSE: The goal of this study was to develop a functional MRI (fMRI) paradigm robust and reproducible enough in healthy subjects to be adapted for a follow-up study aiming at evaluating the anatomical substratum of recovery in poststroke aphasia. METHODS: Ten right-handed subjects were studied longitudinally using fMRI (7 of them being scanned twice) and compared with a patient with conduction aphasia during the first year of stroke recovery. RESULTS: Controls exhibited reproducible activation patterns between subjects and between sessions during language tasks. In contrast, the patient exhibited dynamic changes in brain activation pattern, particularly in the phonological task, during the 2 fMRI sessions. At 1 month after stroke, language homotopic right areas were recruited, whereas large perilesional left involvement occurred later (12 months). CONCLUSIONS: We first demonstrate intersubject robustness and intrasubject reproducibility of our paradigm in 10 healthy subjects and thus its validity in a patient follow-up study over a stroke recovery time course. Indeed, results suggest a spatiotemporal poststroke brain reorganization involving both hemispheres during the recovery course, with an early implication of a new contralateral functional neural network and a later implication of an ipsilateral one.