TBI Challenge! (Vol. 3, No. 5, 1999) Aphasia: When Speech is Lost Richard C. Senelick, MD

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1 TBI Challenge! (Vol. 3, No. 5, 1999) Aphasia: When Speech is Lost Richard C. Senelick, MD Frank made his living working at the cattle auction. Cows, sheep and goats all paraded past him, as he called out in a peculiar language familiar to all the local ranchers. Living in the Hill Country was a way of life, as were the two packs of cigarettes each day, gravy-smothered chicken fried steak and more than an occasional beer. He was a huge man, seemingly invulnerable. That was until that hot August day when he was getting ready for a large cattle sale. He felt his right arm and face go numb. As he opened his mouth to speak all that came out was - I, I, but, but Then it got worse his leg gave out and he fell to the ground. Again he tried to call for help, but this time no sound came out. When his friends found him, he was paralyzed on the right side of his body and unable to speak. Frank had experienced a large stroke on the left side of his brain. The cattle auction was canceled and Frank was taken to the hospital. How We Speak We take it all for granted looking at a word on a page and reading it aloud or to ourselves, singing in the choir at church or having a conversation with our spouse after the children have gone to bed at night. The truth is that this seemingly simple process is actually a complicated, yet perfectly engineered system. For most of us the power of speech is housed in the left side of the brain. About 95% of right handed people and 60% of left handed people use the left side of their brain to understand what is said to them and articulate their thoughts. When I look at the word cat on a piece of paper and then read it aloud, in less than a second a detailed train of events takes place in my brain. First, each eye looks at cat and sends the message to the left and right side of my brain. Since each side of the brain sees only half of the word, the information from the right side of the brain must be transferred to the left. Once the back part of the brain (the occipital lobes) sees the word, it must send the message forward to the parietal lobe where it will search to see if it is recognized. Much like the spell check program on a computer, the brain looks to see if it can find and recognize the word cat. In an instant, the brain comprehends the word as a small, furry animal with four legs, sharp claws and a strong meow. The parietal lobe then sends this information

2 forward to the frontal lobes where the brain engages the mechanisms for speech: controlling breathing, rolling the tongue or shaping lips into the necessary shape of the word. In less than a second, our own personal computer works flawlessly. Aphasia The loss of one s ability to communicate after brain injury is called aphasia. Although the ability to express oneself is most prominently affected, so is the ability to understand speech, read or write. A brain injury or stroke may impair the ability to communicate thoughts and understand what is being said. There are two major types of aphasia non-fluent and fluent. Non-fluent aphasias are characterized by halting speech with few words. The individual may speak in slow single words or utterances. In response to How do you feel? he/she might say, But...I...I...I good! These individuals may learn to use gestures in place of words. Davis wanted to tell his therapist his hair was a mess and that he wanted to look better when his daughter brought the grandchildren to visit. But, he could not get the words out. Instead, he pointed to his hair and frowned, a clear signal that a shampoo and combing were in order. Fluent aphasia is characterized by many words at a normal or increased rate of speed that may make no sense at all. It has been called word salad where nothing makes sense, but the person always has an answer to a question. When asked to describe her day, Julia responded that, It canged and framhated till her chrisan was brotten! Julia had no recognition that what she was saying did not make sense, since the part of her brain that interpreted and understood her own speech also was injured. At other times, the speech abnormalities are subtler. There may be word substitutions, or paraphasias. Harry might say spoof for spoon or fore for fork. Individuals may make up new words called neologisms. Leeann may ask her husband to please turn on the croffitt before he leaves for work. Many individuals with aphasia may be able to find and use those automatic phrases of everyday life. When asked, How are you? they may automatically answer, Just, fine thank you. Phrases such as Yes, no, hi and bye all may be used at the right time in a casual conversation. But ask them to repeat the phrase and there is silence or a struggle to get out a few

3 words here and there. Unfortunately for some, expletives or swear words are preserved while little else can be said. For these individuals, the frustration of not being able to speak filters in. Asked to tell you his name, Mark furrows his eyebrows, gets red in the face with exasperation and blurts out, But, but.. sh**, da**, da**! The Secretary and the Typewriter An easy way to remember the two different types of aphasia is to think of a secretary and a typewriter. Assume for a moment that both start the day working fine the secretary awake and competent, the typewriter in perfect working order. Out of the typewriter come reams of perfectly typed documents. Then someone takes a hammer and hits the typewriter on the side. Now, the secretary still understands what he/she needs to type, but the means of expressing it (i.e., the typewriter) has been damaged. Maybe the typewriter is so severely injured that nothing comes out, or maybe some of the keys can still function and a few sporadic words appear here and there. This is very similar to non-fluent aphasia. So what happens if it is the secretary who has injured his/her brain? The mechanism for producing the words (the typewriter) is intact, but the input mechanism (the secretary) is damaged. He/she now types a stream of nonsense into the machine and out comes the word salad of a fluent aphasia. When I try to dictate a letter, he/she can no longer appropriately understand what I am saying and continues to type out nonsense. What did they say? A brain injury or stroke may affect not only the ability to produce language and written words, but also the ability to read or understand spoken words. After a stroke or injury that affects the parietal lobe, a person still may understand the words that are spoken to him/her. He/she is not deaf and there is nothing wrong with his/her hearing. It is the brain that cannot interpret the sounds and language. This is called an auditory comprehension deficit. Individuals living with impairments brought on by stroke also can have difficulty with reading comprehension, the ability to understand what is seen in print. Again, there may be nothing wrong with their eyes, as the signal is making its way back to the occipital lobes. Once there, however, the rest of the brain cannot make sense of the message. The ability to communicate also involves the written word and most people with aphasia also will have difficulty with written expression. That is why they just cannot compensate by scribbling their thoughts on a magic slate or

4 Big Chief pad. Although they may be able to write short phrases, many individuals will not be able to compose paragraphs or properly use grammar. There is help Rehabilitation with a speech and language pathologist is the key. These highly trained and skilled professionals evaluate and treat disabilities that pertain to using, understanding, reading and writing language. They are experts in teaching people how to compensate for their disabilities. When the muscles that produce speech are affected, an individual may have difficulty articulating and producing words, a condition known as dysarthria. To those unfamiliar with this condition, dysarthria may cause slurred speech in an individual, often making him/her sound intoxicated. Weakness of the throat muscles also can make it difficult to swallow. Again, these areas and concerns are under the domain of the speech therapist. Rehabilitation is very much like going back to school and relearning skills that were once second nature. Therapists will work on exercises to strengthen the individual s mouth and throat muscles. Repetition and speech exercises will help the brain relearn how to speak and re-access the information stored in the brain. A big part of the rehabilitation process is developing methods to compensate for skills that have been lost. Augmentative communication devices such as storyboards, cue cards and hand signals all can be useful in getting an idea across. They might be as simple as a sheet of paper with pictures on it or a high tech computer that speaks for the person. The American Speech/Language and Hearing Association (ASHA) has produced a consumer guide about these devices that can be obtained by calling (800) The potential use of medications to help the individual with aphasia makes for exciting prospects. Many medical facilities utilize a number of these medications for individuals with brain injury to try and improve attention and concentration. Several studies have been performed looking at the use of dopamine and amphetamines in persons with aphasia. Some of the same medicines given to individuals with Parkinson s disease were given to persons with acquired language disorders. So far, the results are mixed; some investigators noted marked improvement in speech production, while others noted no changes. The same is true for the use of amphetamines. Because of these mixed results, each case should be viewed individually. Persons interested in utilizing medications to treat aphasia should confer with their treating physician.

5 Dos and Don ts The National Aphasia Association (800) has produced a list of dos and don ts for dealing with people with aphasia. This list has been adapted below: Make certain that the person is paying attention to you before you start to speak. Allow the person enough time to respond. Remember that his/her brain is processing information at a much slower rate. Use gestures whenever possible to emphasize what you are trying to communicate. You do not need to shout. In most cases hearing is not impaired. Treat the person with respect and do not revert to baby talk. His/her IQ hasn t changed, just his/her ability to speak or comprehend. Attention and concentration may also be affected by a stroke, so eliminate other distractions such as televisions or radios when you are trying to communicate. Speak in short simple phrases. Direct, rather than open-ended questions are best. Construct questions that require only a yes/no response. Do not avoid communication -- encourage it. Set realistic goals and expectations. If we ask someone to do something that is too difficult, he/she will become frustrated and do worse. We may not be able to prevent or cure aphasia, but there is much that can be done to help individuals who live with it. Dr. Senelick is a neurologist who specializes in neurorehabilitation. He is the medical director of HealthSouth Rehabilitation Institute of San Antonio (RIOSA) where he also serves as director of the Brain Injury Program. He is also the author of Living with Brain Injury: A Guide for Families.