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Although qualitative and quantitative studies exist, there is little consensus on the proper method to assess for apraxia. The criticisms of past methods include failure to meet standard psychometric properties as well as research-specific designs that translate poorly to non-research use.
The Test to Measure Upper Limb Apraxia (TULIA) is one method of determining upper limb apraxia through the qualitative and quantitative assessment of gesture production. In contrast to previous publications on apraxic assessment, the reliability and validity of TULIA was thoroughly investigated. The TULIA consists of subtests for the imitation and pantomime of non-symbolic (“put your index finger on top of your nose”), intransitive (“wave goodbye”) and transitive (“show me how to use a hammer”) gestures. Discrimination (differentiating between well- and poorly performed tasks) and recognition (indicating which object corresponds to a pantomimed gesture) tasks are also often tested for a full apraxia evaluation.
However, there may not be a strong correlation between formal test results and actual performance in everyday functioning or activities of daily living (ADLs). A comprehensive assessment of apraxia should include formal testing, standardized measurements of ADLs, observation of daily routines, self-report questionnaires and targeted interviews with the patients and their relatives.
As stated above, apraxia should not be confused with aphasia; however, they frequently occur together. It has been stated that apraxia is so often accompanied by aphasia that many believe that if a person displays AOS; it should be assumed that the patient also has some level of aphasia.
There is no one definitive test for ideomotor apraxia; there are several that are used clinically to make an ideomotor apraxia diagnosis. The criteria for a diagnosis are not entirely conserved among clinicians, for apraxia in general or distinguishing subtypes. Almost all the tests laid out here that enable a diagnosis of ideomotor apraxia share a common feature: assessment of the ability to imitate gestures. A test developed by Georg Goldenberg uses imitation assessment of 10 gestures. The tester demonstrates the gesture to the patient and rates him on how whether the gesture was correctly imitated. If the first attempt to imitate the gesture was unsuccessful, the gesture is presented a second time; a higher score is given for correct imitation on the first trial, then for the second, and the lowest score is for not correctly imitating the gesture. The gestures used here are all meaningless, such as placing the hand flat on the top of the head or flat outward with the fingers towards the ear. This test is specifically designed for ideomotor apraxia. The main variation from this is in the type and number of gestures used. One test uses twenty-four movements with three trials for each and a trial-based scoring system similar to the Goldenberg protocol. The gestures here are also copied by the patient from the tester and are divided into finger movements, e.g. making a scissor movement with the forefinger and middle finger, and hand and arm movements, e.g. doing a salute. This protocol combines meaningful and meaningless gestures. Another test uses five meaningful gestures, such as waving goodbye or scratching your head and five meaningless gestures. Additional differences in this test are a verbal command to initiate the movement and it distinguishes between accurate performance and inaccurate but recognizable performance. One test utilizes tools, including a hammer and a key, with both a verbal command to use the tools and the patient copying the tester's demonstrated use of the tools. These tests have been shown to be individually unreliable, with considerable variability between the diagnoses delivered by each. If a battery of tests is used, however, the reliability and validity may be improved. It is also highly advisable to include assessments of how the patient performs activities in daily life. One of the newer tests that has been developed may provide greater reliability without relying on a multitude of tests. It combines three types of tool use with imitation of gestures. The tool use section includes having the patient pantomime use with no tool present, with visual contact with the tool, and finally with tactile contact with the tool. This test screens for ideational and ideomotor apraxia, with the second portion aimed specifically at ideomotor apraxia. One study showed great potential for this test, but further studies are needed to reproduce these results before this can be said with confidence. This disorder often occurs with other degenerative neurological disorders such as Parkinson's disease and Alzheimer's Disease. These comorbidities can make it difficult to pick out the specific features of ideomotor apraxia. The important point in distinguishing ideomotor apraxia is that basic motor control is intact; it is a high level dysfunction involving tool use and gesturing. Additionally, clinicians must be careful to exclude aphasia as a possible diagnosis, as, in the tests involving verbal command, an aphasic patient could fail to perform a task properly because they do not understand what the directions are.
Developmental Verbal Dyspraxia can be diagnosed by a speech language pathologist (SLP) through specific exams that measure oral mechanisms of speech. The oral mechanisms exam involves tasks such as pursing lips, blowing, licking lips, elevating the tongue, and also involves an examination of the mouth. A complete exam also involves observation of the patient eating and talking. Tests such as the Kaufman Speech Praxis test, a more formal examination, are also used in diagnosis.
A differential diagnosis of DVD/CAS is often not possible for children under the age of 2 years old. Even when children are between 2–3 years, a clear diagnosis cannot always occur, because at this age, they may still be unable to focus on, or cooperate with, diagnostic testing.
Psycholinguistics pertain to the psychological and neurobiological components that allow humans to acquire, utilize, comprehend, and produce language. The tests most commonly used for psycholinguistic testing include the Dutch version of , syntactic comprehension test, and the Token test. Psycholinguistics allow physicians to narrow down and rule out other disorders that may be similar to FCMS when diagnosing a patient.
Neuropsychology is the study of neurobiology and psychology. Neuropsychological tests are utilized for the purpose of observing an individuals’ abilities in cognitive functioning, reasoning, and memories. The tests most commonly used for neuropsychological testing include WAIS-III, Stroop test, Bourdon Wiersma test, and the Rey-Osterrieth complex figure test. These tests allow physicians to evaluate the degree to which the bilateral lesions in the operculum have been affected, and allow for the determination of proper treatment.
The prognosis for individuals with apraxia varies. With therapy, some patients improve significantly, while others may show very little improvement. Some individuals with apraxia may benefit from the use of a communication aid.
However, many people with apraxia are no longer able to be independent. Those with limb-kinetic and/or gait apraxia should avoid activities in which they might injure themselves or others.
Occupational therapy, physical therapy, and play therapy may be considered as other references to support patients with apraxia. These team members could work along with the SLP to provide the best therapy for people with apraxia. However, because people with limb apraxia may have trouble directing their motor movements, occupational therapy for stroke or other brain injury can be difficult.
No medication has been shown useful for treating apraxia.
Expressive aphasia is classified as non-fluent aphasia, as opposed to fluent aphasia. Diagnosis is done on a case by case basis, as lesions often affect the surrounding cortex and deficits are highly variable among patients with aphasia.
A physician is typically the first person to recognize aphasia in a patient who is being treated for damage to the brain. Routine processes for determining the presence and location of lesion in the brain include Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scans. The physician will complete a brief assessment of the patient's ability to understand and produce language. For further diagnostic testing, the physician will refer the patient to a speech-language pathologist, who will complete a comprehensive evaluation.
In order to diagnose a patient who is suffering from Broca’s aphasia, there are certain commonly used tests and procedures. The Western Aphasia Battery (WAB) classifies individuals based on their scores on the subtests; spontaneous speech, auditory comprehension, repetition, and naming. The Boston Diagnostic Aphasia Examination (BDAE) can inform users what specific type of aphasia they may have, infer the location of lesion, and assess current language abilities. The Porch Index of Communication Ability (PICA) can predict potential recovery outcomes of the patients with aphasia. Quality of life measurement is also an important assessment tool. Tests such as the Assessment for Living with Aphasia (ALA) and the Satisfaction with Life Scale (SWLS) allow for therapists to target skills that are important and meaningful for the individual.
In addition to formal assessments, patient and family interviews are valid and important sources of information. The patient’s previous hobbies, interests, personality, and occupation are all factors that will not only impact therapy but may motivate them throughout the recovery process. Patient interviews and observations allow professionals to learn the priorities of the patient and family and determine what the patient hopes to regain in therapy. Observations of the patient may also be beneficial to determine where to begin treatment. The current behaviors and interactions of the patient will provide the therapist with more insight about the client and his or her individual needs. Other information about the patient can be retrieved from medical records, patient referrals from physicians, and the nursing staff.
In non-speaking patients who use manual languages, diagnosis is often based on interviews from the patient's acquaintances, noting the differences in sign production pre- and post- damage to the brain. Many of these patients will also begin to rely on non-linguistic gestures to communicate, rather than signing since their language production is hindered.
Given the complexity of the medical problems facing ideomotor apraxia patients, as they are usually suffering from a multitude of other problems, it is difficult to ascertain the impact that it has on their ability to function independently. Deficits due to Parkinson's or Alzheimer's disease could very well be sufficient to mask or make irrelevant difficulties arising from the apraxia. Some studies have shown ideomotor apraxia to independently diminish the patient's ability to function on their own. The general consensus seems to be that ideomotor apraxia does have a negative impact on independence in that it can reduce an individual's ability to manipulate objects, as well as diminishing the capacity for mechanical problem solving, owing to the inability to access information about how familiar parts of the unfamiliar system function. A small subset of patients has been known to spontaneously recover from apraxia; this is rare, however. One possible hope is the phenomenon of hemispheric shift, where functions normally performed by one hemisphere can shift to the other in the event that the first is damaged. This seems to necessitate, however, that some portion of the function is associated with the other hemisphere to begin with. There is dispute over whether the right hemisphere of the cortex is involved at all in the praxis system, as some evidence from patients with severed corpus callosums indicates it may not be.
Although there is little that can be done to substantially reverse the effects of ideomotor apraxia, Occupational Therapy can be effective in helping patients regain some functional control. Sharing the same approach in treating ideational apraxia, this is achieved by breaking a daily task (e.g. combing hair) into separate components and teaching each distinct component individually. With ample repetition, proficiency in these movements can be acquired and should eventually be combined to create a single pattern of movement.
Assessment will usually include an interview with the child’s caregiver, observation of the child in an unstructured setting, a hearing test, and standardized tests of language and nonverbal ability. There is a wide range of language assessments in English. Some are restricted for use by speech and language professionals (therapists or SALTs in the UK, speech-language pathologists, SLPs, in the US and Australia).
A commonly used test battery for diagnosis of SLI is the Clinical Evaluation of Language Fundamentals (CELF).
Assessments that can be completed by a parent or teacher can be useful to identify children who may require more in-depth evaluation.
The Grammar and Phonology Screening (GAPS) test is a quick (ten minute) simple and accurate screening test developed and standardized in the UK. It is suitable for children from 3;4 to 6;8 years;months and can be administered by professionals and non-professionals (including parents) alike, and has been demonstrated to be highly accurate (98% accuracy) in identifying impaired children who need specialist help vs non-impaired children. This makes it potentially a feasible test for widespread screening.
The Children’s Communication Checklist (CCC–2) is a parent questionnaire suitable for testing language skills in school-aged children.
Informal assessments, such as language samples, may also be used. This procedure is useful when the normative sample of a given test is inappropriate for a given child, for instance, if the child is bilingual and the sample was of monolingual children. It is also an ecologically valid measure of all aspects of language (e.g. semantics, syntax, pragmatics, etc.).
To complete a language sample, the SLP will spend about 15 minutes talking with the child. The sample may be of a conversation (Hadley, 1998), or narrative retell. In a narrative language sample, the SLP will tell the child a story using a wordless picture book (e.g. "Frog Where Are You?", Mayer, 1969), then ask the child to use the pictures and tell the story back.
Language samples are typically transcribed using computer software such as the Systematic Analysis of Language Software (SALT, Miller et al. 2012), and then analyzed. For example, the SLP might look for whether the child introduces characters to their story or jumps right in, whether the events follow a logical order, and whether the narrative includes a main idea or theme and supporting details.
Ideational apraxia is a difficult disorder to diagnose. That is because the majority of individuals who have this disorder almost always have some other type of dysfunction such as agnosia or aphasia. The tests used to make an IA diagnosis can range from easy single object tasks to complex multiple object tasks. When being tested a patient may be asked to view twenty objects. They then have to demonstrate the use of each single object following three different ways of presenting the stimuli. The patient must then perform complex test where the examiner describes a task such as making coffee and the patient must show the sequential steps that makes a cup of coffee. The patients are then scored on how many errors are seen by the examiner. The errors of the patients in performing the MOT were scored according to a set of criteria partly derived from De Renzi and Lucchelli.
Following are some precautions that should be taken to avoid aphasia, by decreasing the risk of stroke, the main cause of aphasia:
- Exercising regularly
- Eating a healthy diet
- Keeping alcohol consumption low and avoiding tobacco use
- Controlling blood pressure
Apraxia of speech can be diagnosed by a speech language pathologist (SLP) through specific exams that measure oral mechanisms of speech. The oral mechanisms exam involves tasks such as pursing lips, blowing, licking lips, elevating the tongue, and also involves an examination of the mouth. A complete exam also involves observation of the patient eating and talking. SLPs do not agree on a specific set of characteristics that make up the apraxia of speech diagnosis, so any of the characteristics from the section above could be used to form a diagnosis. Patients may be asked to perform other daily tasks such as reading, writing, and conversing with others. In situations involving brain damage, an MRI brain scan also helps identify damaged areas of the brain.
A differential diagnosis must be used in order to rule out other similar or alternative disorders. Although disorders such as expressive aphasia, conduction aphasia, and dysarthria involve similar symptoms as apraxia of speech, the disorders must be distinguished in order to correctly treat the patients. While AOS involves the motor planning or processing stage of speech, aphasic disorders can involve other language processes.
According to Ziegler et al., this difficulty in diagnosis derives from the unknown causes and function of the disorder, making it hard to set definite parameters for AOS identification. Specifically, he explains that oral-facial apraxia, dysarthria, and aphasic phonological impairment are the three distinctly different disorders that cause individuals to display symptoms that are often similar to those of someone with AOS, and that these close relatives must be correctly ruled out by a Speech Language Pathologist before AOS can be given as a diagnosis. In this way, AOS is a diagnosis of exclusion, and is generally recognized when all other similar speech sound production disorders are eliminated.
Two classes of errors are used to develop a diagnosis:
Class I: Sequence errors
- Action addition (AA) is a meaningful action step that is not necessary for accomplishing the goal of the MOT action (e.g., removing the filter of the orange squeezer in order to pour the liquid);
- Action anticipation (A) is an anticipation of an action that would normally be performed later in the action sequence (e.g., blowing the match out before using it);
- Step omission (SO) is an omission of a step of the multiple-actions sequence (e.g., inserting the filter in the coffee machine without pouring some water);
- Perseveration (P) is a repetition of an action step previously performed in the action sequence.
Class II: Conceptual errors
- Misuse (Mis) errors that can be differentiated into two further types:
1. (Mis1) the first type of misuse involves a well-performed action that is appropriate to an object different from the object target (e.g., hammering with a saw);
2. (Mis2) the second type involves an action that is appropriate at a superordinate level to the object at hand but is inappropriately specified at the subordinate level (e.g., cutting an orange with a knife as if it were butter).
- Mislocation (Misl) which can be further differentiated into two error subtypes:
1. (Misl1) the first type is an action that is appropriate to the object in hand but is performed in completely the wrong place (e.g., pouring some liquid from the bottle onto the table rather than into the glass);
2. (Misl2) the second type involves the correct general selection of the target object on which to operate with the source object or instrument in hand but with the exact location of the action being wrong (e.g., striking the match inside the matchbox).
- Tool omission (TO) is an omission in using an obligatory tool where the hand is used instead (e.g., opening a bottle without using a bottle opener);
- Pantomiming (Pant) is where the patient pantomime show the object should be used instead of using it;
- Perplexity (Perpl) Is a delay or hesitation in starting an action or subcomponents of an action;
- Toying(T) consists of a brief but repeated touching of an object or objects on the table.
As the examiner observes the patient for each task they mark off which errors were committed. From this criteria the examiner will be able to focus on severity of the dysfunction. It is important to express that the motor movement is not lost in patients with IA. Yet, at first glance their movements may appear to be awkward because they are unable to plan a sequence of movements with the given object.
There is no cure for DVD/CAS, but with appropriate, intensive intervention, people with the disorder can improve significantly.
DVD/CAS requires various forms of therapy which varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). In children with DVD/CAS, consistency is a key element in treatment. Consistency in the form of communication, as well as the development and use of oral communication are extremely important in aiding a child's speech learning process.
Many therapy approaches are not supported by thorough evidence; however, the aspects of treatment that do seem to be agreed upon are the following:
- Treatment needs to be intense and highly individualized, with about 3-5 therapy sessions each week
- A maximum of 30 minutes per session is best for young children
- Principles of motor learning theory and intense speech-motor practice seem to be the most effective
- Non-speech oral motor therapy is not necessary or sufficient
- A multi-sensory approach to therapy may be beneficial: using sign language, pictures, tactile cues, visual prompts, and Augmentative and Alternative Communication (AAC) can be helpful.
Although these aspects of treatment are supported by much clinical documentation, they lack evidence from systematic research studies. In ASHA's position statement on DVD/CAS, ASHA states there is a critical need for collaborative, interdisciplinary, and programmatic research on the neural substrates, behavioral correlates, and treatment options for DVD/CAS.
In cases of acute AOS (stroke), spontaneous recovery may occur, in which previous speech abilities reappear on their own. All other cases of acquired AOS require a form of therapy; however the therapy varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). For severe forms of AOS, therapy may involve multiple sessions per week, which is reduced with speech improvement. Another main theme in AOS treatment is the use of repetition in order to achieve a large amount of target utterances, or desired speech usages.
There are various treatment techniques for AOS. One technique, called the Linguistic Approach, utilizes the rules for sounds and sequences. This approach focuses on the placement of the mouth in forming speech sounds. Another type of treatment is the Motor-Programming Approach, in which the motor movements necessary for speech are practiced. This technique utilizes a great amount of repetition in order to practice the sequences and transitions that are necessary in between production of sounds.
Research about the treatment of apraxia has revealed four main categories: articulatory-kinematic, rate/rhythm control, intersystemic facilitation/reorganization treatments, and alternative/augmentative communication.
- Articulatory-kinematic treatments almost always require verbal production in order to bring about improvement of speech. One common technique for this is modeling or repetition in order to establish the desired speech behavior. Articulatory-kinematic treatments are based on the importance of patients to improve spatial and temporal aspects of speech production.
- Rate and rhythm control treatments exist to improve errors in patients’ timing of speech, a common characteristic of Apraxia. These techniques often include an external source of control like metronomic pacing, for example, in repeated speech productions.
- Intersystemic reorganization/facilitation techniques often involve physical body or limb gestural approaches to improve speech. Gestures are usually combined with verbalization. It is thought that limb gestures may improve the organization of speech production.
- Finally, alternative and augmentative communication approaches to treatment of apraxia are highly individualized for each patient. However, they often involve a "comprehensive communication system" that may include "speech, a communication book aid, a spelling system, a drawing system, a gestural system, technologies, and informed speech partners".
One specific treatment method is referred to as PROMPT. This acronym stands for Prompts for Restructuring Oral Muscular Phonetic Targets, and takes a hands on multidimensional approach at treating speech production disorders. PROMPT therapists integrate physical-sensory, cognitive-linguistic, and social-emotional aspects of motor performance. The main focus is developing language interaction through this tactile-kinetic approach by using touch cues to facilitate the articulatory movements associated with individual phonemes, and eventually words.
One study describes the use of electropalatography (EPG) to treat a patient with severe acquired apraxia of speech. EPG is a computer-based tool for assessment and treatment of speech motor issues. The program allows patients to see the placement of articulators during speech production thus aiding them in attempting to correct errors. Originally after two years of speech therapy, the patient exhibited speech motor and production problems including problems with phonation, articulation, and resonance. This study showed that EPG therapy gave the patient valuable visual feedback to clarify speech movements that had been difficult for the patient to complete when given only auditory feedback.
While many studies are still exploring the various treatment methods, a few suggestions from ASHA for treating apraxia patients include the integration of objective treatment evidence, theoretical rationale, clinical knowledge and experience, and the needs and goals of the patient
Assessments for developmental coordination disorder typically require a developmental history, detailing ages at which significant developmental milestones, such as crawling and walking, occurred. Motor skills screening includes activities designed to indicate developmental coordination disorder, including balancing, physical sequencing, touch sensitivity, and variations on walking activities.
The American Psychiatric Association has four primary inclusive diagnostic criteria for determining if a child has developmental coordination disorder.
The criteria are as follows:
1. Motor Coordination will be greatly reduced, although the intelligence of the child is normal for the age.
2. The difficulties the child experiences with motor coordination or planning interfere with the child's daily life.
3. The difficulties with coordination are not due to any other medical condition
4. If the child does also experience comorbidities such as mental retardation; motor coordination is still disproportionally affected.
Screening tests which can be used to assess developmental coordination disorder include:-
- Movement Assessment Battery for Children (Movement-ABC – Movement-ABC 2)
- Peabody Developmental Motor Scales- Second Edition (PDMS-2)
- Bruininks-Oseretsky Test of Motor Proficiency (BOTMP-BOT-2)
- Motoriktest für vier- bis sechsjährige Kinder (MOT 4-6)
- Körperkoordinationtest für Kinder (KTK)
- Test of Gross Motor Development, Second Edition (TGMD-2)
- Maastrichtse Motoriek Test (MMT)
- Wechsler Adult Intelligence Scale (WAIS-IV)
- Wechsler Individual Achievement Test (WAIT-II)
- Test of Word Reading Efficiency (TOWRE-2)
- Developmental Coordination Disorder Questionnaire (DCD-Q)
- Children's Self-Perceptions of Adequacy in, and Predilection for Physical Activity (CSAPPA)
Currently there is no single gold standard assessment test.
A baseline motor assessment establishes the starting point for developmental intervention programs. Comparing children to normal rates of development may help to establish areas of significant difficulty.
However, research in the "British Journal of Special Education" has shown that knowledge is severely limited in many who should be trained to recognise and respond to various difficulties, including developmental coordination disorder, dyslexia and deficits in attention, motor control and perception (DAMP). The earlier that difficulties are noted and timely assessments occur, the quicker intervention can begin. A teacher or GP could miss a diagnosis if they are only applying a cursory knowledge.
"Teachers will not be able to recognise or accommodate the child with learning difficulties in class if their knowledge is limited. Similarly GPs will find it difficult to detect and appropriately refer children with learning difficulties."
Articulation problems resulting from dysarthria are treated by speech language pathologists, using a variety of techniques. Techniques used depend on the effect the dysarthria has on control of the articulators. Traditional treatments target the correction of deficits in rate (of articulation), prosody (appropriate emphasis and inflection, affected e.g. by apraxia of speech, right hemisphere brain damage, etc.), intensity (loudness of the voice, affected e.g. in hypokinetic dysarthrias such as in Parkinson's), resonance (ability to alter the vocal tract and resonating spaces for correct speech sounds) and phonation (control of the vocal folds for appropriate voice quality and valving of the airway). These treatments have usually involved exercises to increase strength and control over articulator muscles (which may be flaccid and weak, or overly tight and difficult to move), and using alternate speaking techniques to increase speaker intelligibility (how well someone's speech is understood by peers). With the speech language pathologist, there are several skills that are important to learn; safe chewing and swallowing techniques, avoiding conversations when feeling tired, repeat words and syllables over and over in order to learn the proper mouth movements, and techniques to deal with the frustration while speaking. Depending on the severity of the dysarthria, another possibility includes learning how to use a computer or flip cards in order to communicate more effectively.
More recent techniques based on the principles of motor learning (PML), such as LSVT (Lee Silverman voice treatment) speech therapy and specifically LSVT may improve voice and speech function in PD. For Parkinson's, aim to retrain speech skills through building new generalised motor programs, and attach great importance to regular practice, through peer/partner support and self-management. Regularity of practice, and when to practice, are the main issues in PML treatments, as they may determine the likelihood of generalization of new motor skills, and therefore how effective a treatment is.
Augmentative and alternative communication (AAC) devices that make coping with a dysarthria easier include speech synthesis and text-based telephones. These allow people who are unintelligible, or may be in the later stages of a progressive illness, to continue to be able to communicate without the need for fully intelligible speech.
Epidemiological surveys, in the US and Canada, estimated the prevalence of SLI in 5-year-olds at around 7 percent. However, neither study adopted the stringent 'discrepancy' criteria of the Diagnostic and Statistical Manual of Mental Disorders or ICD-10; SLI was diagnosed if the child scored below cut-off on standardized language tests, but had a nonverbal IQ of 90 or above and no other exclusionary criteria.
There is no curative treatment for this condition. Supportive management is helpful.
Currently, there is no standard treatment for expressive aphasia. Most aphasia treatment is individualized based on a patient's condition and needs as assessed by a speech language pathologist. Patients go through a period of spontaneous recovery following brain injury in which they regain a great deal of language function.
In the months following injury or stroke, most patients receive traditional treatment for a few hours per day. Among other exercises, patients practice the repetition of words and phrases. Mechanisms are also taught in traditional treatment to compensate for lost language function such as drawing and using phrases that are easier to pronounce.
Emphasis is placed on establishing a basis for communication with family and caregivers in everyday life. Treatment is individualized based on the patient's own priorities, along with the family's input.
A patient may have the option of individual or group treatment. Although less common, group treatment has been shown to have advantageous outcomes. Some types of group treatments include family counseling, maintenance groups, support groups and treatment groups.
Imaging studies have shown differing results which probably represents the heterogeneity of language problems than can occur in PNFA. However, classically atrophy of left perisylvian areas is seen.
Comprehensive meta-analyses on MRI and FDG-PET studies identified alterations in the whole left frontotemporal network for phonological and syntactical processing as the most consistent finding. Based on these imaging methods, progressive nonfluent aphasia can be regionally dissociated from the other subtypes of frontotemporal lobar degeneration, frontotemporal dementia and semantic dementia.
If a suspected brain injury has occurred, the patient undergoes a series of medical imaging, which could include MRI(magnetic resonance imaging) or CT (computed tomography) scan. After the diagnosis of a brain injury, a speech and language pathologist will perform a variety of tests to determine the classification of aphasia. Additionally, the Boston Assessment of Severe Aphasia (BASA) is a commonly used assessment for diagnosing aphasia. BASA is used to determine treatment plans after strokes lead to symptoms of aphasia and tests both gestural and verbal responses. Cognitive functions can be assessed using the Cognitive Test Battery for Global Aphasia (CoBaGa). The CoBaGa is an appropriate measure to assess a person with severe aphasia because it does not require verbal responses, rather manipulative answers. The CoBaGa assesses cognitive functions such as attention, executive functions, logical reasoning, memory, visual-auditory recognition, and visual-spatial ability. Van Mourik et al. conducted a study in which they assessed the cognitive abilities of people with global aphasia using the Global Aphasic Neuropsychological Battery. This test assesses attention/concentration, memory, intelligence, and visual and auditory nonverbal recognition. The results of this study helped the researchers determine there were varying levels of severity among individuals with global aphasia.
When addressing Wernicke’s aphasia, according to Bakheit et al. (2007), the lack of awareness of the language impairments, a common characteristic of Wernicke’s aphasia, may impact the rate and extent of therapy outcomes. Klebic et al. (2011) suggests that people benefit from continuing therapy upon discharge from the hospital to ensure generalization. Robey (1998) determined that at least 2 hours of treatment per week is recommended for making significant language gains. Spontaneous recovery may cause some language gains, but without speech-language therapy, the outcomes can be half as strong as those with therapy.
When addressing Broca’s aphasia, better outcomes occur when the person participates in therapy, and treatment is more effective than no treatment for people in the acute period. Two or more hours of therapy per week in acute and post-acute stages produced the greatest results. High intensity therapy was most effective, and low intensity therapy was almost equivalent to no therapy.
People with global aphasia are sometimes referred to as having irreversible aphasic syndrome, often making limited gains in auditory comprehension, and recovering no functional language modality with therapy. With this said, people with global aphasia may retain gestural communication skills that may enable success when communicating with conversational partners within familiar conditions. Process-oriented treatment options are limited, and people may not become competent language users as readers, listeners, writers, or speakers no matter how extensive therapy is. However, people’s daily routines and quality of life can be enhanced with reasonable and modest goals. After the first month, there is limited to no healing to language abilities of most people. There is a grim prognosis leaving 83% who were globally aphasic after the first month they will remain globally aphasic at the first year. Some people are so severely impaired that their existing process-oriented treatment approaches offer signs of progress, and therefore cannot justify the cost of therapy.
Perhaps due to the relative rareness of conduction aphasia, few studies have specifically studied the effectiveness of therapy for people with this type of aphasia. From the studies performed, results showed that therapy can help to improve specific language outcomes. One intervention that has had positive results is auditory repetition training. Kohn et al. (1990) reported that drilled auditory repetition training related to improvements in spontaneous speech, Francis et al. (2003) reported improvements in sentence comprehension, and Kalinyak-Fliszar et al. (2011) reported improvements in auditory-visual short-term memory.
Most acute cases of aphasia recover some or most skills by working with a speech-language pathologist. Recovery and improvement can continue for years after the stroke. After the onset of Aphasia, there is approximately a six-month period of spontaneous recovery; during this time, the brain is attempting to recover and repair the damaged neurons. Improvement varies widely, depending on the aphasia's cause, type, and severity. Recovery also depends on the person's age, health, motivation, handedness, and educational level.
There is no one treatment proven to be effective for all types of aphasias. The reason that there is no universal treatment for aphasia is because of the nature of the disorder and the various ways it is presented, as explained in the above sections. Aphasia is rarely exhibited identically, implying that treatment needs to be catered specifically to the individual. Studies have shown that, although there is no consistency on treatment methodology in literature, there is a strong indication that treatment in general has positive outcomes. Therapy for aphasia ranges from increasing functional communication to improving speech accuracy, depending on the person's severity, needs and support of family and friends. Group therapy allows individuals to work on their pragmatic and communication skills with other individuals with aphasia, which are skills that may not often be addressed in individual one-on-one therapy sessions. It can also help increase confidence and social skills in a comfortable setting.
Evidence dose not support the use of transcranial direct current stimulation (tDCS) for improving aphasia after stroke.
Specific treatment techniques include the following:
- Copy and Recall Therapy (CART) - repetition and recall of targeted words within therapy may strengthen orthographic representations and improve single word reading, writing, and naming
- Visual Communication Therapy (VIC) - the use of index cards with symbols to represent various components of speech
- Visual Action Therapy (VAT) - typically treats individuals with global aphasia to train the use of hand gestures for specific items
- Functional Communication Treatment (FCT) - focuses on improving activities specific to functional tasks, social interaction, and self-expression
- Promoting Aphasic's Communicative Effectiveness (PACE) - a means of encouraging normal interaction between people with aphasia and clinicians. In this kind of therapy the focus is on pragmatic communication rather than treatment itself. People are asked to communicate a given message to their therapists by means of drawing, making hand gestures or even pointing to an object
- Melodic Intonation Therapy (MIT) - aims to use the intact melodic/prosodic processing skills of the right hemisphere to help cue retrieval of words and expressive language
- Other - i.e. drawing as a way of communicating, trained conversation partners
Semantic feature analysis (SFA) -a type of aphasia treatment that targets word-finding deficits. It is based on the theory that neural connections can strengthened by using using related words and phrases that are similar to the target word, to eventually activate the target word in the brain. SFA can be implemented in multiple forms such as verbally, written, using picture cards, etc. The SLP provides prompting questions to the individual with aphasia in order for the person to name the picture provided. Studies show that SFA is an effective intervention for improving confrontational naming.
Melodic intonation therapy is used to treat non-fluent aphasia and has proved to be effective in some cases. However, there is still no evidence from randomized controlled trials confirming the efficacy of MIT in chronic aphasia. MIT is used to help people with aphasia vocalize themselves through speech song, which is then transferred as a spoken word. Good candidates for this therapy include people who have had left hemisphere strokes, non-fluent aphasias such as Broca's, good auditory comprehension, poor repetition and articulation, and good emotional stability and memory. An alternative explanation is that the efficacy of MIT depends on neural circuits involved in the processing of rhythmicity and formulaic expressions (examples taken from the MIT manual: “I am fine,” “how are you?” or “thank you”); while rhythmic features associated with melodic intonation may engage primarily left-hemisphere subcortical areas of the brain, the use of formulaic expressions is known to be supported by right-hemisphere cortical and bilateral subcortical neural networks.
According to the National Institute on Deafness and Other Communication Disorders (NIDCD), involving family with the treatment of an Aphasic loved one is ideal for all involved, because while it will no doubt assist in their recovery, it will also make it easier for members of the family to learn how best to communicate with them.
Speech and language therapy is typically the primary treatment for individuals with aphasia. The goal of speech and language therapy is to increase the person’s communication abilities to a level functional for daily life. Goals are chosen based on collaboration between speech language pathologists, patients, and their family/caregivers. Goals should be individualized based on the person’s aphasia symptoms and communicative needs. In 2016, Wallace et al. found the following outcomes were commonly prioritized in therapy: communication, life participation, physical and emotional well-being, normalcy, and health and support services. However, available research is inconclusive about which specific approach to speech and language therapy is most effective in treating global aphasia.
Therapy can be either group or individual. Group therapies that integrate the use of visual aids allow for enhanced social and communication-skill development. Group therapy sessions typically revolve around simple, preplanned activities or games, and aim to facilitate social communication.
One particular therapy designed specifically for treatment of aphasia is Visual Action Therapy (VAT). VAT is a non-verbal gestural output program with 3 phases and 30 total steps. The program teaches unilateral gestures as symbolic representations of real life objects. Research on the effectiveness of VAT is limited and inconclusive.
One important therapy technique includes teaching family members and caregivers strategies for more effectively communicating with their loved ones. Research offers such strategies including, simplifying sentences and using common words, gaining the person's attention before speaking, using pointing and visual cues, allowing for adequate response time, and creating a quiet environment free of distractions.
Another approach to speech and language treatment is constraint-induced language therapy (CILT). CILT involves teaching the patient to use speech in small segments but avoid using gestures and familiar words . The speech language pathologist provides positive feedback throughout and ignores any mistakes made by the patient. The intensity with which this treatment is provided has been debated in the literature. One study, performed in 2015, compared the outcomes of patients with aphasia who received CILT for either 30 hours total over 2 weeks or 30 hours distributed over 10 weeks. Results showed that both groups made significant speech and language improvements. Overall, CILT is an effective treatment at a variety of intensities.
Research supporting the efficacy of pharmacological treatments for aphasia is limited. To date, no large scale clinical trials have proven benefits of pharmacological treatment.
Agraphia cannot be directly treated, but individuals can be rehabilitated to regain some of their previous writing abilities.
For the management of phonological agraphia, individuals are trained to memorize key words, such as a familiar name or object, that can then help them form the grapheme for that phoneme. Management of allographic agraphia can be as simple as having alphabet cards so the individual can write legibly by copying the correct letter shapes. There are few rehabilitation methods for apraxic agraphia; if the individual has considerably better hand control and movement with typing than they do with handwriting, then they can use technological devices. Texting and typing do not require the same technical movements that handwriting does; for these technological methods, only spatial location of the fingers to type is required. If copying skills are preserved in an individual with apraxic agraphia, repeated copying may help shift from the highly intentional and monitored hand movements indicative of apraxic agraphia to a more automated control.
Micrographia is a condition that can occur with the development of other disorders, such as Parkinson's disease, and is when handwriting becomes illegible because of small writing. For some individuals, a simple command to write bigger eliminates the issue.
- Anagram and Copy Treatment (ACT) uses the arrangement of component letters of target words and then repeated copying of the target word. This is similar to the CART; the main difference is that the target words for ACT are specific to the individual. Target words that are important in the life of the individual are emphasized because people with deep or global agraphias do not typically have the same memory for the words as other people with agraphia may. Writing can be even more important to these people as it can cue spoken language. ACT helps in this by facilitating the relearning of a set of personally relevant written words for use in communication.
- Copy and Recall Treatment (CART) method helps to reestablish the ability to spell specific words that are learned through repeated copying and recall of target words. CART is more likely to be successful in treating lexical agraphia when a few words are trained to mastery than when a large group of unrelated words is trained. Words chosen can be individualized to the patient, which makes treatment more personalized.
- Graphemic buffer uses the training of specific words to improve spelling. Cueing hierarchies and copy and recall method of specific words are used, to work the words into the short-term memory loop, or graphemic buffer. The segmentation of longer words into shorter syllables helps bring words into short-term memory.
- Problem solving approach is used as a self-correcting method for phonological errors. The individual sounds out the word and attempts to spell it, typically using an electronic dictionary-type device that indicates correct spelling. This method takes advantage of the preserved sound-to-letter correspondences when they are intact. This approach may improve access to spelling memory, strengthen orthographic representations, or both.