CHAPTER I

ISSUE

A. Definition of Aphasia

Aphasia is a disorder that results from damage to portions of the brain that
are responsible for language. For most people, these are areas on the left side
(hemisphere) of the brain. Aphasia usually occurs suddenly, often as the result of a
stroke or head injury, but it may also develop slowly, as in the case of a brain tumor, an
infection, or dementia. The disorder impairs the expression and understanding of
language as well as reading and writing. Aphasia may co-occur with speech disorders
such as dysarthria or apraxia of speech, which also result from brain damage.
Anyone can acquire aphasia, including children, but most people who have
aphasia are middle-aged or older. Men and women are equally affected. According to
the National Aphasia Association, approximately 80,000 individuals acquire aphasia
each year from strokes. About one million people in the United States currently have
aphasia.
Aphasia is caused by damage to one or more of the language areas of the
brain. Many times, the cause of the brain injury is a stroke. A stroke occurs when blood
is unable to reach a part of the brain. Brain cells die when they do not receive their
normal supply of blood, which carries oxygen and important nutrients. Other causes of
brain injury are severe blows to the head, brain tumors, brain infections, and other
conditions that affect the brain.

B. Types of Aphasia
There are two broad categories of aphasia: fluent and non-fluent.
1. Fluent Aphasia
Damage to the temporal lobe (the side portion) of the brain may result in a
fluent aphasia called Wernicke’s aphasia (see figure). In most people, the damage
occurs in the left temporal lobe, although it can result from damage to the right lobe as
well. People with Wernicke’s aphasia may speak in long sentences that have no
meaning, add unnecessary words, and even create made-up words. For example,
someone with Wernicke’s aphasia may say, “You know that smoodle pinkered and that
I want to get him round and take care of him like you want before.” As a result, it is
often difficult to follow what the person is trying to say. People with Wernicke’s
aphasia usually have great difficulty understanding speech, and they are often unaware
of their mistakes. These individuals usually have no body weakness because their brain
injury is not near the parts of the brain that control movement.
2. Non-Fluent Aphasia
A type of non-fluent aphasia is Broca’s aphasia. People with Broca’s
aphasia have damage to the frontal lobe of the brain. They frequently speak in short
phrases that make sense but are produced with great effort. They often omit small words
such as “is,” “and,” and “the.” For example, a person with Broca’s aphasia may say,
“Walk dog,” meaning, “I will take the dog for a walk,” or “book book two table,” for
“There are two books on the table.” People with Broca’s aphasia typically understand
the speech of others fairly well. Because of this, they are often aware of their difficulties
and can become easily frustrated. People with Broca’s aphasia often have right-sided
weakness or paralysis of the arm and leg because the frontal lobe is also important for
motor movements.
Another type of non-fluent aphasia, global aphasia, results from damage to
extensive portions of the language areas of the brain. Individuals with global aphasia
have severe communication difficulties and may be extremely limited in their ability to
speak or comprehend language.
There are other types of aphasia, each of which results from damage to
different language areas in the brain. Some people may have difficulty repeating words
and sentences even though they can speak and they understand the meaning of the word
or sentence. Others may have difficulty naming objects even though they know what the
object is and what it may be used for.
C. How is Aphasia Diagnosed and Treated
Aphasia is usually first recognized by the physician who treats the person
for his or her brain injury. Frequently this is a neurologist. The physician typically
performs tests that require the person to follow commands, answer questions, name
objects, and carry on a conversation. If the physician suspects aphasia, the patient is
often referred to a speech-language pathologist, who performs a comprehensive
examination of the person’s communication abilities. The examination includes the
person’s ability to speak, express ideas, converse socially, understand language, read,
and write, as well as the ability to swallow and to use alternative and augmentative
communication.
In some cases, a person will completely recover from aphasia without
treatment. This type of spontaneous recovery usually occurs following a type of stroke
in which blood flow to the brain is temporarily interrupted but quickly restored, called a
transient ischemic attack. In these circumstances, language abilities may return in a few
hours or a few days.
For most cases, however, language recovery is not as quick or as complete.
While many people with aphasia experience partial spontaneous recovery, in which
some language abilities return a few days to a month after the brain injury, some amount
of aphasia typically remains. In these instances, speech-language therapy is often
helpful. Recovery usually continues over a two-year period. Many health professionals
believe that the most effective treatment begins early in the recovery process. Some of
the factors that influence the amount of improvement include the cause of the brain
damage, the area of the brain that was damaged, the extent of the brain injury, and the
age and health of the individual. Additional factors include motivation, handedness, and
educational level.
Aphasia therapy aims to improve a person’s ability to communicate by
helping him or her to use remaining language abilities, restore language abilities as
much as possible, compensate for language problems, and learn other methods of
communicating. Individual therapy focuses on the specific needs of the person, while
group therapy offers the opportunity to use new communication skills in a small-group
setting.
 CHAPTER II
ARGUMENT
1. Recovery
Several of Research has shown that most aphasic people make some
recovery from acute stages, but most studies have used operational definitions of what
recovery is, based on a group’s performance on a standardized test battery (Basso, 1992;
Code, 2001). Such operational definitions, like change in a total score on a
psychometric battery, are used widely, but tell us little about the cognitive and
neurological processes underlying recovery. One hypothesis is that recovery is best seen
as neural sparing and distinguishes between “losses” which simply cannot be recovered,
and behavioral deficits which are the result of attempts to shift control to undamaged
neural systems. Real recovery requires the sparing of the underlying neural tissue.
Behavioral deficits – the symptoms or features by which we recognize aphasia, for
instance – are compensatory. Recovery for an individual therefore may occur through a
combination of restitution of lost cognitive functions or compensation for lost functions.
A range of prognostic factors have been identified, and significant
relationships are often found between demographic variables and outcome, but there is
disagreement on the importance of many of them (Basso, 1992; Code, 2001). Such
factors as severity of aphasia, aphasia type, site and extent of lesion, presence of
dysarthria and bilateral damage, are clearly interrelated and probably interdependent
(Code, 1987). There is considerable controversy as to whether some are useful
theoretical constructs at all (e.g., type of aphasia, as discussed above). For some, like
age, sex, and handedness, there is considerable disagreement between studies regarding
their prognostic value (Basso, 1992; de Rieztal and Werts 2004)
One approach involves classification into aphasia type, as described above,
with each type having a particular prognosis (e.g., Kertesz, 1979). However, between 30
and 70 percent of aphasic speakers are not classifiable (Basso et al., 1985). Many
change type with recovery (Kertesz, 1979), and many do not recover in predictable
ways. Fundamentally, milder types (conduction, transcortical, anomia) have the best
prognosis, and severe types (global, Broca’s, Wernicke’s) have the least hopeful.
However, aphasia type correlates highly with severity, and the argument has been made
that it is initial severity that is the crucial variable (Schuell, 1965).
 A small number of studies have used statistical approaches to prediction,
entailing detailed analysis of test scores. Porch et al. (1980) used multiple regression
with scores on the Porch Index of Communicative Abilities (the PICA) (Porch, 1967),
and demonstrated that PICA scores at 1 month post-onset could predict an overall PICA
score at 3, 6, and 12 months post-onset with correlations ranging from 0.74 to 0.94.
Code, Rowley, and Kertesz (1994) trained neural networks to predict recovery for 90
aphasic participants tested at 1 and 12 months post-onset on the WAB (Kertesz, 1979).
This study found that it was possible to predict recovery at 12 months to within 4–5
percent from scores at 1 month. However neither clinicians nor people with aphasia are
just interested in this kind of “psychometric” recovery, but mainly in the ability to cope,
to function, and to adjust, which is what really matters to the person with aphasia and
their family: recovery of these aspects of communication disability have hardly been
researched at all, although preliminary studies suggest a complex relationship between
the severity of aphasia, its recovery and psychological or emotional status (Hemsley &
Code, 1996; Kuroda & Kuroda, 2005), and scores on a range of standard aphasia
measures fail to predict communication distress in aphasic people (Doyle et al., 2006).

2. Treatment
There is clear agreement in the field that treatment aimed at aphasic
impairments can result in significant improvement for many aphasic people. At its best,
therapy for impairments is tailor-made for the individual and guided by their pattern of
impairment, but treatments aimed at shared impairment patterns can also be effective,
and intense and extended treatment is most effective. It was thought that treatment had
to be delivered during acute stages to be effective, but it is becoming recognized more
recently that people with chronic aphasia can also show significant improvements (for
review see Bhogal, Teasell, & Speechley, 2003; Davis, 2000; Robey, 1998; Robey et
al., 1999; Wertz, 1995).
Bhogal et al. (2003) took the changes in mean scores from the large clinical
trials that have been conducted over the years to investigate the outcomes of aphasia
therapy after stroke. They also recorded the intensity of therapy in terms of the hours of
therapy provided each week and the total hours of therapy. They found that those
studies demonstrating a significant treatment effect had provided 8.8 hours of therapy
per week for 11.2 weeks, compared to studies that did not find a significant effect of
treatment providing only 2 hours per week for 22.9 weeks. Studies with a positive
outcome had provided an average total of 98.4 hours of therapy and ineffective studies
provided 43.6 hours of therapy. The total number of hours of therapy provided in a
week was significantly correlated with greater improvement. The study concluded that
intense therapy over a short amount of time can significantly improve outcomes of
speech and language.
Treatment for aphasia is generally targeted at language impairments and/or
communication disabilities – how the impairments impact on using communication in
the aphasic person’s everyday interactions with people in their community. Treatment
aims either at restoration (or restitution or reestablishment) of lost functions or
compensation (or substitution) for lost functions (Code, 2001). Therapists may employ
specific reorganizational methods in an attempt to restore or compensate. Therapy
utilizes aspects of education, learning theory, counseling, linguistics, neuro-and
cognitive psychology. Following Howard and Hatfield (1987), we can classify most
approaches into several main approaches, although in practice many clinicians adopt a
fairly eclectic approach. Didactic methods aim to re-teach language using traditional
and intuitive educational methods from child and foreign-language teaching. Behavioral
methods such as repetition, imitation, modeling, prompting and cuing are routinely
used. These are often utilized in hierarchically organized therapy approaches for
apraxia of speech and contemporary computer-based methods using systematic
behavioral methods (see chapters in Code & Muller, 1989, 1995; and Helm-Estabrooks
& Albert, 1991).
Research in cognitive neuropsychology has strongly influenced the
development of an hypothesis-driven single-case testing process based on information
processing models. The claim is that standardized assessment batteries provide
inadequate information on the specific deficits underlying individual impairment, but
hypotheses developed by the clinician concerning impairments must be tested using
psycholinguistically controlled tests, and such resources have been developed (Kay,
Lesser, & Coltheart, 1992). An alternative view is that standardized and reliable tests
should provide a baseline against which to measure change (Howard, Swinburn, &
Porter, in press; Shallice, 1979). Aphasia test batteries may be best seen as standardized
and reliable screening tests providing a basic profile, and can identify areas for more
detailed investigation. Howard and Patterson (1990) suggest three strategies for
impairment-based therapy inspired by the cognitive neuropsychological model: (1) re-
teaching of the missing information, missing rules or procedures based on detailed
testing; (2) teaching a different way to do the same task; (3) facilitating the use of
impaired access routes. Research suggests that person-and deficit-specific treatment can
improve performance in speakers that cannot be accounted for in terms of spontaneous
recovery or non-specific effects (Howard & Hatfield, 1987).
 CHAPTER III
CONCLUSION
Aphasia is a disorder that results from damage to portions of the brain that
are responsible for language, anyone can acquire aphasia, including children, but most
people who have aphasia are middle-aged or older. Men and women are equally
affected aphasia can be caused by damage to one or more of the language areas of the
brain. Many times, the cause of the brain injury is a stroke. While there are two broad
categories of aphasia namely fluent and non-fluent aphasia.