Two million Americans live with some form of aphasia, a communication disorder caused by damage to one or more of the areas of the brain responsible for language, according to the National Aphasia Association. It's more common than Parkinson's disease, multiple sclerosis, and cerebral palsy, yet many people have never heard of it.
While it usually comes on suddenly, after a stroke or head injury, aphasia also can develop more slowly, resulting from a brain tumor or a neurologic disease like primary progressive aphasia, a type of frontotemporal dementia that involves the degeneration of the frontal lobes of the brain, including tissue related to speech and language.
“The most common cause of aphasia is stroke, which affects blood flow to the brain, or causes a rupture of blood vessels with bleeding into the brain,” says Jeffrey Binder, MD, professor of neurology and director of the stroke and neurobehavior programs at the Medical College of Wisconsin in Milwaukee. “About 30 percent of people who have a stroke experience aphasia.”
For most people, the areas responsible for language are located primarily on the left side of the brain. Regions typically damaged in aphasia are the left posterior frontal lobe, including Broca's area, which is responsible for speech production; the inferior parietal lobe; and the temporal lobe, including Wernicke's area, which is key to understanding language. How much a person can recover from aphasia depends on the extent of that damage. “The brain has backup systems, and sometimes the nearby tissue or mirror regions on the right side of the brain can fill in, at least partially—a process called neuroplasticity—but they are not usually as good as the primary systems,” says Steven C. Cramer, MD, FAAN, professor of neurology and endowed chair in rehabilitation medicine at the David Geffen School of Medicine at UCLA. “When there's minor damage, those backup systems can do an amazing job putting language function back together,” he says. “If there is massive damage, people probably will never fully recover the language ability they had before.”
Speech Therapy
The first step after a diagnosis of aphasia is speech therapy. “To be most effective it should be relatively intense,” says Argye Hillis, MD, professor of neurology and director of the Center of Excellence in Stroke Detection and Diagnosis at the Sheikh Khalifa Stroke Institute at Johns Hopkins University in Baltimore. “Studies suggest that at least three times a week is best, and a minimum of at least 20 hours, but the more the better.”
To assess impairment, speech therapists use a set of standardized tests across four primary domains of communication: understanding speech, producing speech, reading, and writing. Then they develop a plan for therapy based on each person's needs. Word retrieval is a common type of therapy for aphasia.
“Many people know the word they want to say, but they just can't bring it out,” says speech-language pathologist Donna Tippett, MA, MPH, associate professor of otolaryngology–head and neck surgery at Johns Hopkins University. “We have people work on stating the function of the object they're trying to name, or its location, or other associated words, or saying aspects of the object, like its color or size, to help make connections so that they can eventually access the word.”
The focus of therapy is on everyday communication, says speech-language pathologist Sabine Heuer, PhD, associate professor of communication sciences and disorders at the University of Wisconsin–Milwaukee. “Of course, everyone with aphasia wants to talk well again. But more specifically, they have daily routines—at work, at home, and in places where they gather, like church or sports organizations—with specific vocabularies that they use for those activities. We find out what people's needs are and connect those to functional practice.”
For example, Tippett currently has a patient with primary progressive aphasia whose son is getting married soon. “She wants to give a toast, so we do something called ‘script training’ to help her prepare to deliver that,” she says. “She also wanted to practice small talk, so we spent time thinking about topics that people might ask her about as well as questions she could ask others to engage in conversation at the wedding and rehearsal dinner. We have a ‘life participation’ approach to therapy.”
Group Therapy
In-person sessions can be augmented by home practice with activities like journaling, reading the newspaper, responding to mail, playing cards or board games, or playing aphasia-specific app-based games. And group therapy can be helpful. “Making connections with other people with aphasia can be very beneficial for language recovery and for mood and quality of life,” Dr. Hillis says. “People may get together to do activities like gardening or helping restaurants design aphasia-friendly menus,” she says. “There are also many book clubs for people with aphasia, which are excellent. People may read books that are a little simpler or more familiar and then discuss them.” (The National Aphasia Association has a search tool for support groups, as well as speech-language professionals and aphasia centers)
Brain Stimulation
Researchers are increasingly interested in noninvasive brain stimulation combined with speech therapy. Two of these techniques—transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS)—temporarily alter normal brain activity in the region being stimulated. “A few trials have shown some modest benefit with these techniques, but they are not standard yet,” says Dr. Binder.
Insurance
Unfortunately, most people with aphasia find that their insurance doesn't pay for as much speech therapy as they need. “There are very few services for people who've been living with chronic aphasia or who have exhausted their insurance plan's allotment of inpatient and outpatient therapy,” says Dr. Heuer. “I suggest people reach out to university programs and clinics that may have free or low-cost programs.”
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