What is Aphasia?

Aphasia refers to lesions in brain tissues related to language functions, such as stroke, brain trauma, brain tumors, and inflammation in the brain, which impairs the patient's understanding and expression of communicative symbol systems in humans, especially speech and vocabulary. , Grammar and other components, language structure and language content and meaning understanding and expression barriers, as well as the decline of language cognitive processes and impairment of functions as the basis of language. Aphasia does not include language symptoms caused by impaired consciousness and general mental decline, nor does it include speech, reading, and writing impairments caused by hearing, vision, writing, pronunciation and other sensory and motor organ damage.

Sun Shiyou	(Chief physician)	Department of Clinic, Beijing Huilongguan Hospital
Gan Mingyuan	(Attending physician)	Department of Clinic, Beijing Huilongguan Hospital

Western Medicine Name: aphasia

Affiliated Department: Internal Medicine-
Contagious: Non-contagious

Aphasia disease profile

It refers to the lesions of brain tissues related to language functions, such as stroke, brain trauma, brain tumors, and inflammation in the brain, which impairs the patient's understanding and expression ability of human communication symbol system, especially speech, vocabulary, and grammar. Other components, language structure and language content and meaning understanding and expression barriers, as well as the decline and functional impairment of language cognitive processes as the basis of language. This damage is manifested as varying degrees of dysfunction in listening, speaking, reading and writing. Because aphasia is a barrier to understanding and expressing symbolic speech, it also includes other systemic barriers related to the symbolic system, such as the ability to apply gestures. And patients with aphasia will also have intelligent changes, such as changes in memory, logical thinking, calculations, and attention.

Aphasia does not include language symptoms caused by impaired consciousness and general mental decline, nor does it include speech, reading, and writing impairments caused by hearing, vision, writing, pronunciation and other sensory and motor organ damage. Language difficulties caused by congenital or juvenile diseases are not aphasia.

Causes of Aphasia

Stroke (most common), occupying lesions (such as tumors), neurodegenerative diseases (primary progressive aphasia)

Right-handed and most left-handed, the left hemisphere is the language superiority hemisphere accounts for 95%

Aphasia etiology and pathology

Speech function is dominated by one hemisphere, called the dominant hemisphere. With the exception of a few, the dominant hemisphere of most people is in the left cerebral cortex and its connecting fibers. Aphasia occurs often when the dominant hemisphere is damaged. Different specific parts of the dominant hemisphere are damaged, and different types of aphasia can occur: the third part of the frontal gyrus is the center of spoken language, and when it is damaged, it loses its ability to express speech, that is, motor aphasia; the first part of the horizontal transverse gyrus is the hearing The speech center is incomprehensible to other people's language when it is damaged, that is, sensory aphasia; the third frontal gyrus is the writing center; when it is diseased, it cannot be expressed by writing, which is aphasia; the corner gyrus is the reading center. The pronunciation of the text when it is damaged and the meaning is unknown. It is dyslexia; the area between the first temporal gyrus and the angular gyrus is the naming center of the object. When the disease is damaged, the name of the character you cannot see is named aphasia. disease. Cerebrovascular disease is the most common cause of aphasia, followed by brain inflammation, trauma, and degeneration.

Clinical manifestations of aphasia

Aphasia as a language disorder ^[1]

Aphasia hearing impairment

It is generally believed that the process of speech listening comprehension is the reception of acoustic speech signals, linguistically meaningful sound units, that is, the perception of phonemes, tokens of phoneme sequences with specific meanings, such as vocabulary and semantic understanding, and semantics that produce multiple levels of meaning The complex interaction of units, that is, the understanding of syntax.

Aphasia hearing impairment can be manifested in one or more of the above-mentioned obstacles, thus showing different hearing impairments.

1. Pure word deafness: Wernicke believes that the posterior superior temporal gyrus (Wernicke area) is a storehouse of auditory vocabulary images, and its damage often causes perceptual difficulties in auditory language, that is, full or partial deafness. Patients with pure-word deafness understand or repeat the speech stimuli presented in the auditory way, while reading, reading, writing, and spontaneous speech are relatively normal. They can hear and understand nonverbal stimuli such as car horns, rain, dog barks and other environmental sounds. True pure-word deafness is rare, and most patients show other characteristics of mild aphasia, such as occasional phonemic aphasia, and mild naming difficulties.

2. Selective impairment of semantic categories: Some patients show better listening comprehension of certain semantic category vocabularies, but poorer comprehension of other category vocabulary, such as letters, numbers, colors, and names of body parts. . It is usually a localized lesion around the lateral fissure of the base hemisphere.

3 Semantic connection and partial retention of semantic knowledge. Although clinically, patients cannot accurately understand the meaning of a word, but can classify the word into a certain category, and there is a semantic connection.

4 Short-term memory impairment: Understanding of vocabulary and sentences requires short-term storage of the received speech sequences in memory. Patients do not have much difficulty in understanding simple sentences with only one meaning link, but they encounter difficulties in understanding the information or complex grammatical structure composed of several meaning links. Due to the destruction of short-term memory, mutual interference occurs between several meanings of information, which inhibits patients from remembering one center of meaning (block of information) well, but cannot reproduce other centers of meaning.

5. Impairment of syntactic understanding: Some aphasia patients can understand the meaning of words, especially nouns, and there is no difficulty in understanding single words and similar meanings. They can also understand simple sentences but cannot understand complex grammatical structures.

Aphasia Speech Disorder

1. Speech apraxia: refers to the inability to convert the formed and filled speech frames into a purposeful speech movement plan due to brain damage. Speech movement plan is to specify the movement target of the vocal organs (such as round lips, raised tongue tip). The basic unit of the exercise plan is the phoneme, and each phoneme series has its space and time assigned.

2. Grammar deficiency: In the non-fluent aphasia patients' self-speech, they can often see that their verbal expressions are mostly sense words, but lack grammatical functions, relatively few verbs, and speech cannot be expanded, that is, "telegram" speech.

3 Paraphrasing difficulties: The simplest form of expressive speech is paraphrasing speech. Simple recitations of phonemes, syllables, and words require precise hearing and analysis of the phonemes. Finally, a memory-synthetic representation of the paraphrasing material becomes another paraphrase. The condition is to have a fairly accurate pronunciation system, and the conversion from one pronunciation unit to another pronunciation unit or one word to another.

4 Naming errors: Patients with various types of aphasia can see naming errors when naming. Common name errors include circuitous words, semantic errors, phonemic errors, irrelevant words, new words, negative reactions, and so on.

Aphasia classification

In the 1960s, Geschwind proposed that aphasia can be described as "fluent" and "non-fluent". Fluent aphasia refers to fluent pronunciation, effortlessness, long sentences, normal grammar, and normal rhythm. Non-fluent aphasia refers to laborious, slow, unclear, or clumsy pronunciation. The classification of aphasia can also be divided into two categories of cortical aphasia and subcortical aphasia according to the anatomy. The common classification is as follows ^[2] .

Aphasia motor aphasia

The main manifestation is that the expression disorder is more obvious than the mental disorder, and the prognosis is good.

1. Damage localization: the posterior part of the dorsal frontal gyrus of the dominant hemisphere (cortex from the prefrontal frontal to the frontal parietal region, including the island leaf and the surrounding sylvian cortex).

2. symptom

(1) Broca aphasia (mainly motor aphasia): understandable speech, not fluent disorder. Reduced or missing connectives, pronouns, etc. (telegram style).

1. Impaired features: fluency, naming, recitation and writing.

2. Intact functions: spoken and written understanding.

Late manifestations of stroke generally

(2) Dysphonia: obstacles to coordination of motor organs involved in dysphonia, such as breathing (dysphonia), intelligibility (dysphagia), emotional intonation (aphasia), and subsequent aphasia.

(3) Silence: no language, good understanding, relatively reserved writing, and more common hemiplegia. Common in the acute phase of stroke.

Aphasia sensory aphasia

Cannot understand the meaning of words, which is characterized by fluent speech, but can not understand the words of others, hearing is normal. The prognosis is poor.

1. Damage localization: posterior superior temporal gyrus (temporal lobe, posterior parietal lobe, lateral side of occipital lobe)

2. symptom

(1) Wernick aphasia (mainly sensory aphasia): fluent and absurd language, dialogue (talking, "language salad"). The form of speaking and writing (grammar) is relatively reserved, and the content and meaning (semantic) are wrong.

1) Impaired functions: naming, paraphrasing, speaking and writing comprehension

2) Intact function: fluent

3) Aphasia: A large number of aphasia and new words are mixed together, which are called jumble and strange words. There are also obvious obstacles to naming and finding words. The language is fluent, but lacks the core content of expression, and the comments are empty. Such as phonetic errors (wrong word concepts, such as "time" confusing "sub-table")

(2) Pure character deafness: impaired auditory comprehension, while speaking and reading comprehension are relatively reserved. More common in cerebrovascular accidents, brain tumors and infections, the lesions involve unilateral or bilateral temporal lobe.

(3) Dyslexia and dyslexia: Reading comprehension and writing are impaired, while spoken language is less affected, and the prognosis is better.

Aphasia conductive aphasia

In terms of expression, self-speech is fluent, but it is characterized by multi-phoneme aphasia. , Retelling and self-speech naming, reading words are all wrong. Good understanding of text and sound. Generally good prognosis

1. Injury site: left temporal lobe or upper parietal lobe (possibly anterior and posterior linguistic area of the connecting fiber is damaged).

2. Symptoms: Obstacles to recitation are obvious, and language and understanding are relatively reserved to varying degrees ^[3] .

Aphasia complete aphasia (also known as global aphasia)

1. Injury site: Multiple injuries to the left hemisphere in a large injury

2. Symptoms: Language function is severely impaired in all aspects, without any language and loss of understanding.

Aphasia named aphasia

The outstanding feature is the obvious difficulty in finding words in self-speaking and visual object naming, but the speech is relatively fluent.

1. Injury site: Common lesions are located in the medial temporal gyrus and angular gyrus, localized damage such as Alzheimer's disease.

2. Symptoms: Difficulty in naming objects, literal or semantic errors.

Aphasia thalamus

The patient spoke fluently, with a low tone and low volume, but the tone was clear.

1. Injury site: The hypothalamus nucleus, which is connected to the language area, is common in cerebral hemorrhage and brain tumors.

2. Symptoms: Generally simple answers to questions and a history. Retelling normal or mild obstacles, there are obvious naming obstacles, more semantic misspellings, better color naming, nouns, verbs, phrases to understand well, and poor oral instructions. The prognosis is good.

Aphasia mixed aphasia

1. Injury site: Marie's quadrilateral region is damaged due to the interruption of communication pathways due to extensive lesions in the dominant hemisphere motor and sensory regions or subcortical lesions.

2. Symptoms: sensory aphasia and motor aphasia coexist. Reading and writing are completely impossible at this time. You can neither understand nor express yourself in words. Those who are light often give the illusion of insanity.

Evaluation of Aphasia Language Function

Speech function assessment uses a complete evaluation of aphasia individuals, usually a measure of severity, which can be used to classify aphasia in individuals. Such standardized aphasia evaluations include: Boston diagnostic aphasia test, Minnesota aphasia differential diagnosis test. Western aphasia test set, aphasia screening test, Frenchay aphasia screening test, etc. There is also a common Chinese aphasia test

1. Boston Diagnostic Aphasia Test (BDAE). Standard aphasia test currently used in English-speaking countries. It consists of 27 sub-tests divided into 5 major items. 1) Conversation and self-speaking speech; 2) listening comprehension; 3) oral expression; 4) comprehension of written language; 5) writing.

3 The Western Aphasia Test (NAB), which evolved from the BDAE, can be used to differentially diagnose aphasia and classify its severity.

4. Chinese Standard Aphasia Examination: In 1997, the Chinese Rehabilitation Research Center compiled a set of 30 sub-tests divided into 9 major items. Only suitable for adults with aphasia.

5. Grand Chinese Aphasia Test: Prepared by the Department of Neuropsychology, the First Hospital of Beijing Medical University. Began for treatment in 1986.

Evaluation of functional communication ability in aphasia

In the process of person-to-person communication, both verbal and non-verbal communication content plays a large role. Functional evaluation focuses on understanding whether the subject can communicate normally, not his flaws.

Common are:

1. Check of daily activities (CADL)

2. Functional Evaluation of American Speech and Hearing Society's Communication Ability (ASHA-FACS)

3 Functional Communication Test (FCP)

Aphasia Severity Classification

Aphasia Severity Rating-Boston Aphasia Diagnostic Test (BDAE):

Level 0: Lack of meaningful speech or listening comprehension.

Level 1: There are discontinuous verbal expressions in verbal communication, but most require the listener to guess, ask, and guess; the range of information that can be communicated is limited, and the listener has difficulty in verbal communication.

Level 2: With the help of the listener, it is possible to communicate with familiar topics, but often they cannot express their thoughts on unfamiliar topics, which makes patients and assessors feel that it is difficult to communicate with each other.

Level 3: With little or no help, patients can discuss almost every day-to-day problem, but some conversations are difficult or unlikely due to weakened speech or understanding.

Level 4: Fluent in speech, but observable obstacles and no obvious restrictions on thought and speech expression.

Level 5: There are very few distinguishable speech disorders, and the patient may feel somewhat subjective, but the listener may not be able to notice it.

Goals of Aphasia Rehabilitation

The overall goal of rehabilitation is to maximize the ability of the patient to communicate with the family or society through speech therapy.

Aphasia aims to improve language function

1. Block removal method: According to Weigl's theory, patients with aphasia basically retain language ability, but there are obstacles to the use of language. Through training, patients can regain their ability to use language.

2. Schuell's Stimulation Method: Stimulation training is a method explored in years of aphasia training. It was the application of stimulation method to cognitive psychology research in the 1970s. And produced a new theory.

3 Program introduction method: The stimulation sequence is divided into several stages, and the strengthening of stimulation methods and responses is strictly limited to make it reproducible and quantitatively measure the positive response rate.

4 De-inhibition method: Use the functions that the patient may retain, such as singing, to release the inhibition of the function.

5. Functional reorganization: through the training of inhibited pathways and other pathways to achieve functional recombination and development, to achieve the purpose of language use.

Aphasia aims to improve daily communication skills

1. Communication Effect Promotion Act

2. Functional communicative therapy

3 Group therapy and communication board application

4 Family training and adjustment of language environment promote the improvement of patients' language ability.

Aphasia rehabilitation treatment of aphasia

Indications for aphasia treatment

All aphasia are indications in principle, but patients with significant disturbances of consciousness, abnormal emotional behavior, and mental illness are not suitable for training

Aphasia medication for aphasia

There are 4 types of drugs that can be used for aphasia treatment: 1) increase norepinephrine in the brain, such as amphetamine, can increase patient alertness; 2) increase acetylcholine content in the brain, improve naming and language understanding; 3) increase in the brain Dopamine content such as bromocriptine improves speech output; 4) Promotes the release of choline and excitatory amino acids, improves learning and memory functions, such as brain rehabilitation.

Aphasia treatment principles

1. Be targeted: According to whether the patient has aphasia, type, degree, in order to determine the treatment direction.

2. Comprehensive training, focusing on spoken language. If listening, speaking, reading, writing, and writing language are damaged in many ways, comprehensive training should be carried out, but the focus and goal of treatment should be on oral rehabilitation training.

3, due to the person's casting, step by step, to suit the patient's cultural level and interest, easy to difficult, from shallow to deep, from little to more, and gradually increase the amount of stimulation.

4, flexible and diverse with psychological treatment. When treatment progresses, patients should be encouraged in time to strengthen their confidence. When the patient is full, the difficulty can be appropriately increased.

5. Family guidance and language environment adjustment. It is necessary to give necessary guidance to the patient's family members to make it more effective with treatment.

6. For patients with certain language disorders, we should distinguish between priorities and treat them separately.

Prognosis of rehabilitation for aphasia

Generally, the prognosis of aphasia is consistent with the prognosis of the primary disease. As the pace of aging in China accelerates, aphasia tends to become severe and complicated. Coupled with the decline in brain function caused by aging, symptoms may sometimes worsen. Aphasia may also worsen if the stroke is recurrent or based on progressive disease. The prognosis of aphasia is related to the following factors:

1. The sooner language training begins, the better.

2. The younger the patient, the better.

3 Aphasia: Mild is better.

4 Primary symptoms: The scope of brain injury is small, the first stroke has a good prognosis, and the brain trauma is better than the stroke.

5. Comorbidities: Those without comorbidities are better than those with comorbidities.

6. Broca aphasia, cortical motor aphasia, guided aphasia, and named aphasia have a better prognosis than other types of aphasia.

7. Aphasia caused by cerebral hemorrhage has a better prognosis than that caused by cerebral infarction.

8. It is better to strengthen training for a long time.

9. Sharp hand: Left sharp hand or both hands have better prognosis than right sharp hand.

10 Type of aphasia: The prognosis is better for those with predominance of expression than predominance of comprehension.

11. Intelligence level: The patient's IQ college entrance examination is better than the lower one.

12. Self-training ability: Those with self-training ability and awareness are good.

13. Personality: Extroverts are good.

14. Desire for recovery: Patients and family members have a high desire for recovery training.