Aphasia is a brain impairment that creates an inability to comprehend or formulate language properly. It is distinct from motor or sensory impairments that may effect speech, even though both may be caused by brain injury. Aphasia, however, is a phenomena rooted purely in processing—the ability of the brain to translate thought into language expression.
Because of this, it is one of the most frustrating conditions that speech language pathologists will ever have to treat. Those who specialize in treating aphasia patients require a healthy dose of patience as well as incredible therapeutic skills and training.
Despite the frustration that can sometimes come with working with aphasia patients, the prognosis for many is good. Almost all aphasics show at least some improvement, and for some types a majority of function can be restored. This is a great specialty for SLPs who enjoy happy endings and want to go home knowing they made a difference in the lives of their patients.
Causes and Types of Speech Aphasias
Aphasia is always caused by damage to the brain, whether traumatic or disease-related. The most common cause of aphasia today are cerebrovascular accidents, or strokes—incidents where blood flow is either restricted (ischemic strokes) or hemorrhages (hemorrhagic strokes) in areas of the brain responsible for language processing.
This means that most aphasia patients are older, matching the population among whom strokes are most likely, but aphasia can also result from:
- Traumatic brain injury
- Brain tumors
- Other diseases affecting the brain
This means that aphasia can strike anyone of any age and SLPs have to be prepared to treat aphasia among any patient population. According to the National Aphasia Association, around 1 million Americans currently suffer from aphasia, and around 180,000 more acquire it each year.
Because the mechanism of the disorder comes from brain damage, it is often co-morbid with other damage or disorders, including dysarthria and apraxia, as well as those unrelated to speech and language production. These factors often complicate treatment plans for SLPs working with aphasia patients, who have to work around other difficulties in the course of providing therapy.
The two major categories of aphasia are fluent and nonfluent, each requiring different treatments…
Fluent aphasia leaves the patient able to produce the sounds and words of their language, while being unable to combine them in ways that make complete sense. In the most extreme cases, this results in nonsense sentences that are pronounced perfectly, but have absolutely no meaning. Patients may not be aware they are using the wrong words and become frustrated when their listeners appear to be ignoring them. Conversely, they may themselves be unable to understand the normal speech of others.
Less severe cases may result in only certain words being lost, a condition known as anomic aphasia.
Nonfluent aphasia results in the complete inability to speak, or to speak certain words. Broca’s aphasia (named after the area of the brain that seems to cause this type of aphasia when damaged) leaves patients with the ability to understand speech, but to lose all or some of their own ability to speak. In milder forms, small words such as “is,” “and,” and “the” may be omitted from otherwise normal sentences. In other cases, the patient may be able to speak, but only with great effort.
The Challenges and Rewards of Treating Aphasia
There is a lot of good news for aphasic patients, starting with the fact that recovery often occurs naturally and begins almost immediately after the trauma. Brain plasticity allows for an enormous level of flexibility when it comes to remapping functions from damaged parts of the brain to areas that were unaffected. In fact, this is so commonly the case in aphasia that it has been used as a mechanism for studying brain plasticity itself.
Recovery for aphasic patients can continue over the course of years, so SLPs have a great deal of work to do whether the injury is fresh or from the past. Because the disorder affects the language centers of the brain, it can prevent an SLP from using many of the most common speech augmentation systems they might typically turn to in the course of speech therapy. For example, aphasics who are already deaf and use ASL (American Sign Language) find that they lose the ability to sign just as they do speech.
On the other hand, multilingual patients sometimes find that their ability to converse in one of their languages remains, even if others are impaired. This offers an avenue for communication that can be used as a lever to work on other language skills.
Some approaches actively discourage the use of alternative communication mechanisms, though, essentially attempting to force the patient’s brain to relearn the lost language skills. Like physical therapy, which restrains patients from using a healthy limb to compensate for deficiencies in another as a way to ensure the unhealthy appendage recovers faster and more fully, SLPs use a method know as Constraint-Induced Language Therapy (CILT).
Repetition and encouraging the patient to participate in normal conversations are also often used as a routine part of aphasia therapy. This is an element of the approach known as the “Life Participation Approach to Aphasia,” or LPAA. It seeks to manage aphasia over the long term by helping patients reengage with life through regular daily activities. Sometimes, therapies as basic as simply reading aloud from books can be helpful.
There are also more unusual techniques that have been found to be effective for some aphasia patients. Melodic Intonation Therapy, which uses the musical elements of speech, is one surprising approach that often works. The left hemisphere of the brain is the part that has been damaged in aphasia patients, as it controls language and other skills of logic. But singing, a creative function, is driven by the right hemisphere. In cases where that hemisphere remains undamaged, it can offer a way to leverage the healthy part of the brain for communication.
Research Into New Therapies May Unlock Secrets of The Brain
Aphasia has often proven fertile ground for research into brain function, and that research in turn has helped SLPs develop new evidence-based therapies for aphasics. The discovery of brain plasticity, for example, rose in part from research into the natural recovery of language skills in aphasic patients, but the understanding of how it was happening has helped SLPs make better use of the phenomena.
Therapies like Gestural Facilitation of Naming (GES) and Response Elaboration Training (RET) use repetitive cognitive training models to encourage the development of new neural pathways to provide language abilities.
Researchers are also looking into drug therapies, to see if drugs that effect the chemical neurotransmitters in the brain can help repair language functions.
Another, even stranger, approach that is being looked at involves using transcranial magnetic stimulation (TMS) to jump start brain activity in the damaged areas. Using magnetic fields to directly stimulate nerve cells in the affected regions is being combined with more traditional therapies in hopes of accelerating recovery.
Specializing in Aphasia Treatment as an SLP
Developments in the field are likely to continue as our understanding and appreciation for how the brain works improve. SLPs specializing in working with aphasia will have no shortage of new approaches to try in the coming years and it remains an exciting part of the field to be involved with.
Because aphasia is a common condition and extends across age groups, most SLPs will likely end up working with aphasic patients at some point in their careers. Those working with older populations will likely encounter more cases due to the prevalence of stroke as a cause of aphasia.
Although there are no industry certifications specific to working with aphasia, it can be helpful to obtain a board certification from the Academy of Neurologic Communication Disorders and Sciences (ANCDS). This credential is available to CCC-SLP holders with a minimum of 5 years of full-time equivalent experience working with neurologic communication disorders. You have to produce three letters of recommendation from health care professionals with first hand knowledge of your skills, at least one of whom must also be a speech language pathologist.
That’s just the first step, however. The rigorous qualifications require you to review two case studies provided by ANCDS, providing written commentary, followed by delivering a presentation and undergoing an oral examination on the cases. Only when evaluators have decided you meet their exacting standards will you become certified.
The ANCDS board certification is not restricted to aphasia and may be more in-depth than you might need for that practice area. However, it indicates a degree of expertise that will certainly make you valuable to employers with large aphasia populations in need of treatment.