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Aphasia overview失语症指南(下)

(2011-04-09 23:58:44)











分类: 资料共享



[quote]Aphasia overview
翻译   李琳1  审核  叶祥明1
For many years, aphasia therapies were based on early neuroanatomic concepts developed in the 19th century.
“This part of the brain does that,” in other words.
Our understanding of the brain and of language has led to a less structure-driven approach.
Both hemispheres of the brain do contribute to language function. Although the left-hemisphere seems to be the primary regulator of language, researchers now recognize that the right-hemisphere also contributes to language production.
The brains of some patients have demonstrated surprising plasticity in language recovery after strokes (which is the good news) but seem to involve a variety of neural mechanisms which have yet to be clearly identified (which is the bad news.) 35 Reorganization of the speech networks may possibly occur for more than one year after the stroke. 36
However, “…results stress the inferior role of the right hemisphere language-related network for recovery from post-stroke aphasia; i.e., it contributes to improvement to some extent, if the more important left hemispheric areas are destroyed….” 37
We are still learning about the brain mechanisms for human language, considered the most complex of human cognitive functions. Language uses a large amount of the cerebral cortex, but does not map directly to regions in a straightforward fashion.
Brain imaging now points to three neural correlates of language: widely distributed; regional; and highly localized.38
Thus we know that language is not confined to one or two discrete areas but aren’t yet able to capitalize on this knowledge.
As imaging techniques continue to improve, the diagnostic and treatment value of brain imaging will certainly increase the chances of reasonable recovery of language after strokes. At the moment, however, it is not clear exactly what we need to know from imaging studies that would improve the outcome of speech and language, or even pharmacotherapeutic interventions.
An additional challenge is the question of how available brain imaging would be for the average patient. Until there is a clear connection demonstrated for how the results of brain imaging could enhance aphasia therapy, it is unlikely that insurance companies or Medicare would reimburse for functional MRI’s or other scans.
Summary of current treatment approaches for aphasia目前失语症治疗方法概述
“Until World War I, the majority of techniques used in aphasia rehabilitation were ‘borrowed’ from the field of childhood education. The years following World War I witnessed an increase in aphasia treatment studies because of the large numbers of patients with penetration cranial injuries returning from the war.” 39
Research in the past fifteen years has largely focused on resolving the question of whether therapy can produce measurable gains over that observed in spontaneous language recovery.
“Although different aphasia therapies are usually considered to be either effective or ineffective in particular settings, they have not generally been thought of as having the potential for harm. Thus, it is perfectly reasonable to try one approach, and if it doesn’t work, to try another, without ever facing a risk of detriment to the patient (other than prolonging recovery.) This may not be correct. If aphasia treatments have the potential to change the brain, then they have the potential to change it both for better or for worse.” 40
Stimulus-response approach (most common)刺激---反应法
“First the aphasic deficit is identified and, then, repetitive drill through several modalities (e.g., reading or repetition) is encouraged. An endless array of sophisticated modifications of this traditional approach has been developed.” 41
A promising modification of the stimulus-response model is Melodic Intonation Therapy. “Based on the assumption that the stress, intonation, and melodic patterns of language output are controlled by the right hemisphere and, thus, are available for use in the individual with left hemisphere damage.” 42
一个很有前景的刺激反应模型衍生的治疗方法是旋律吟诵法。 “因为人们认为重音,语调和旋律由右半球控制,所以,左脑损伤的患者功能不受影响。”
MIT “is a hierarchically structured program that is divided into three levels….multisyllabic works and short, high-probability phrases are musically intoned….then, longer more phonologically complex sentences are intoned…and finally spoken normally.” 43
Not all patients are suitable candidates for MIT.
The drill basis for speech therapy is widely used. Doubtless, even with newer therapies, it will be found that repetition of some kind will continue to be important component of therapy.
Psycholinguistic approach精神语言疗法
Combining both the psychologist’s and linguist’s approaches to the study of language as it is learned and used by people, psycholinguistics has proven more helpful with anomia and agrammaticism than aphasia. Psycholinguists “ask questions about what information is in the ‘mental dictionary’ and how it is organized so it can be accessed in ‘real time’ (i.e., while we are listening or speaking), and used to assemble multi-word phrases and sentence structure into coherent discourse.” 44
“The premise underlying this approach is that a specific aphasic sign of symptom may be the surface clinical manifestation of different underlying deficits in within the cognitive structure of language. Only by uncovering the precise underlying psycholinguistic deficit can therapy be properly targeted.” 45
Cognitive neurorehabilitation认知神经康复
Treating neurobehavioral deficits such as inattention and memory loss is at the core of cognitive neurorehabilitation. Some researchers are finding that treating perseveration or attentional dysfunctions can help improve language function. 46
The neuropsychological exam can uncover many problems with cognition: such as level of self-awareness; attention/concentration difficulties; visual and perceptual abilities; memory and learning abilities; planning and organizing abilities; and perseveration.47
Each of these deficits may require a different set of tasks or exercises, which cognitive neuroscientists are developing.
Brain imaging studies support the involvement of “subcortical and prefrontal areas associated with various aspects of arousal, attention, and sequenced planning of response seem particularly important in language and speech.” 48
Computer aided therapy电脑辅助治疗
“Technology has also entered the scenario of aphasia therapy, with computers and mechanical devices that can potentially help aphasic persons to communicate more efficiently. The development of various programs for computerized language training opened new expectation on aphasia treatment. These programs were considered either as a way for improving cost effectiveness in aphasia treatment, or as a potential tool for developing new therapeutic approaches.
Despite the initial enthusiasm, most programs consist of repetitive drills with lack of flexibility and proved to be no good substitutes for a trained speech pathologist…Hopes for the future lay on
an increasingly thoughtful use of technology.” 49
The use of computers for some patients with severe aphasia can be almost life-saving. Icons, pictures and even simple words are represented on a screen and patients learn to point or manipulate them in order to express basic concepts. 50
Treating the whole patient患者的全面治疗
Dr. Martha T. Sarno was one of the early pioneers in recognizing the loss of language had vast implications on the individual and his or her community. One of the methods for dealing with the
various social and community issues, as well as individual and family difficulties, was to encourage the formation of aphasia support groups.
Group treatment for patients with aphasia has a great deal of support. There are community based groups. Major research centers for aphasia have support groups associated with them, as do many out-patient clinics. Most universities with speech and language pathology graduate programs also have communication disorder clinics associated with them which may include aphasia support groups.
The idea is to help aphasics recover functional communication using all available techniques in a comprehensive manner.
As with other groups recovering from major illness or disability, groups can form a powerful social support network as well as opportunity to practice skills and share knowledge.
The Dalhousie School of Human Communication Disorders in Halifax, Nova Scotia has an intensive residential rehabilitation effort. This service, which is unique in Canada, is based on two main principles: research in aphasia has indicated that improved communication skills can be best facilitated through intensive treatment; and, communication does not occur in isolation, therefore partners must be actively involved in any communication intervention program.
Halifax Dalhousie人类交流障碍学院的Nova Scotia努力建立了完善的住院康复系统。这项服务,在加拿大是唯一的,有两个主要原则:失语症研究显示强化治疗可以最有效地提高沟通技巧;沟通不会单独存在,因此,任何交流干预计划都必须有拍档的积极参与。
The National Aphasia Association founded in 1987 is the first national association in the United States to focus on the person with aphasia and his or her family.
Aphasia support groups are now found in almost state in the US. 51 The NAA lists the groups on its web site and points out: that the list “represents a wide variety of group types and structures. Some consist only of persons with aphasia and their significant others and some are more inclusive. Some are free and some are not.”
The use of drugs in stroke has been largely limited either to stroke preventative measures or acute poststroke therapies administered to reduce damage.
Using adjunct drug therapies to improve communication has a sound theoretical basis, but the experimental evidence of real benefit remains unconvincing to some researchers.
“Pharmacotherapy has not yet fulfilled its promise, despite many decades of effort.” 52
The drugs are utilized in conjunction with speech therapy and some promising work is being done in Germany with piracetam to facilitate rehabilitation of post-stroke aphasic patients. 53 Other drugs that have been tried include bromocriptine 54, 55 which was found helpful in high doses. Vasopressin used in Russia resulted in improvement in speech in 79% of cases.56 Other promising work has been done using amphetamines 57 and agents that influence specific neurotransmitter systems. 58
“Selected linguistic capacities, including verbal fluency and verbal memory, appear to be influenced by specific neurotransmitter systems…At this moment, we are aware of no neurochemical agent that has yet been rigorously proven to ameliorate specific language signs or symptoms…The purpose of pharmacotherapy would not be to replace traditional language therapy.” 59
Future directions of therapy未来言语治疗的方向
•  “Further development of mechanisms to promote neural plasticity in adult humans;” and further development of behavioral techniques that optimize the re-laying of new neural networks within a more plastic cerebrum. 60
•  “Information gained from functional neuroimaging, in combination with behavioral assessment, could direct the therapist to target relatively left or right hemisphere language processes for treatment in a particular individual.” 61
•  “Refinement of cognitive processing models so that they more closely approximate real brain
mechanisms… envision candidate treatment approaches specified for a patient might be tested in simulation.” 62
•  “Use novel biological therapies, including stem cell infusion, neuronal transplantation, and pharmacotherapy to make the brain more amenable to dramatic change in function… This will put new responsibilities on therapists, requiring a shift from‘effective therapy’ (by comparison with no therapy) to ‘beneficial therapies’ to achieve certain particular biological and behavioral goals.”  63
•  Increased understanding of role of specific neurotransmitters; defining optimal amount of drug treatment and timing effects on the recovery process…based on the increasing body of literature exploring the use of pharmacotherapy in aphasia therapy. 64
About dysarthria 构音障碍
The dysarthrias are a group of diverse, chronic motor speech disorders in which patients are unable to speak with normal muscular speed, strength, precision, or timing. Dysarthria is a frequent symptom found in conditions such as Parkinson’s disease, cerebral palsy, amyotrophic lateral sclerosis, as well as being a complication of stroke.
The location of the lesion or damage corresponds to a specific pattern of abnormal speech. The Mayo Clinic developed a classification system for six groups of dysarthria.
依据特定异常言语模式所对应的病变或损伤部位。Mayo Clinic将构音障碍分为6种类型。
The type of dysarthria determines the treatment.
“Speech scientists have argued that the instrumental assessment of speech physiology provides more accurate and comprehensive information in neurological cases than do clinical speech tests…..(researchers have described) a sophisticated instrumental model for assessment of the dysarthric speaker. However, such a well-equipped speech laboratory is not available to many speech pathologists in the field….it appears that a combination of perceptual measures, nonspeech maneuvers, and instrumental measures provides the most reliable and valid assessment of dysarthria.” 65
“语言学家讨论过,语言生理学器械评定所提供的病例信息比临床语言测试更准确、更全面... ..(研究人员描述过)一个更高级的构音障碍器械评估模型。不过,这样装备精良的语音实验室对于该领域的许多言语治疗师来说都不现实...。看来,知觉测试,非言语演练和器械评估相结合是构音障碍评估是最可靠、最有效的评估方法。
In the treatment of dysarthrias,“the roles played by speech-language pathologists include participation in differential diagnosis, provision of speech treatment, staging of treatment, and timely education so that clients and families can make informed decisions about communication alternatives.” 66
Clinical guidelines for treatment of aphasia失语症治疗临床指南
United States美国
Current United States clinical guidelines 67 for post-stroke speech and language therapy recommend:
“Patients with aphasia should be offered treatment targeted at the identified language retrieval or comprehension deficits and aimed at improving functional communication.”
This recommendation was a“consensus” recommendation, which means that 75 to 89 % of the reviewers agreed with it. (Strong consensus means that 90 % of the reviewers agree.)
The research evidence was “C” which means that the recommendation was supported by a single, nonrandomized controlled trial by studies using historical controls or studies using quasi-experimental designs such as pre- and post- treatment comparisons.
Further comments:
“Treatment for aphasia can be integrated with treatments for sensorimotor or cognitive deficits or can be provided separately. Treatment should involve family and caregivers so that effective communication can be reestablished….”
“Evidence from controlled trials on the effectiveness of treatment for aphasia is not conclusive….Some studies indicate benefit…while other studies fail to document sustained benefits….Treatment by trained volunteers appears to be equally effective as that by speech and language professionals, and results appear to be unaffected by delaying treatment.”
In addition, the guidelines have the following recommendations:
•  identify characteristics of patients most likely to benefit from rehabilitative interventions
•  determine optimal type of rehabilitation program for different types of patient
•  identify factors that affect optimal timing, intensity, and duration of rehabilitation
• determining effectiveness of specific treatments or combinations thereof, in reducing impairments
•  develop and validate standardized tests for monitoring post-stroke rehabilitation.
Scottish guidelines 68 state explicitly:
“All patients with a communication problem resulting from a stroke should be referred to a speech and language therapist for assessment and treatment.”
Further, the guidelines state:
“Family therapy involving aphasic patients and other family members improves handicap of the aphasic handicap and reduces depression and emotional isolation in patients.”
“The efficacy of treatment for dysarthria has rarely been addressed, but benefits of early intervention are indicated.”
United Kingdom英国
Guidelines issued in the United Kingdom 69 state:
“Stroke can affect communication in different ways. The patient may have impaired motor speech production (dysarthria) resulting in unnatural or unintelligible speech; they may have impaired language skills (aphasia or dysphasia); or they may have impaired planning and execution of motor speech (articulatory dyspraxia). The patient may have subtle communication problems due to higher level language impairment associated with non-dominant hemisphere stroke. Untrained clinicians may misdiagnose the cause of abnormal communication. Accurate diagnosis is essential to guide and inform the team and the family. A speech and language therapist is the most competent person to assess a patient with abnormal communication.
•  Every patient with a dominant hemisphere stroke should be assessed for dysphasia using a reliable and valid method
•  Every patient with difficulties in communication should be assessed fully by a speech and language therapist (SLT)
•  If the patient has communication difficulties, the staff and relatives should be informed by the SLT of communication techniques appropriate to the impairment
•  Where achievable goals can be identified, and continuing progress demonstrated, patients with communication difficulties should be offered appropriate treatment, with monitoring of progress
•  Patients with specific communication difficulties should be assessed by a SLT as to their suitability for intensive speech and language therapy treatment which the trials suggest should be for a 4–8 week period
•  For patients with long-term language difficulties, especially with reading, a period of reading retraining should be considered
•  Any patient with severe communication disability but reasonable cognition and language should be assessed for and provided with appropriate alternative or augmentative communication aids.”
Tables of evidence supporting the recommendations appear for the guidelines. The criteria for recommendations are modeled on those used by the United States.
Glossary of terms词表
This information is derived from the National Aphasia Association website. 70
Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia can be so severe as to make communication with the patient almost impossible, or it can be very mild. It may affect mainly a single aspect of language use, such as the ability to retrieve the names of objects, or the ability to put words together into sentences, or the ability to read. More commonly, however, multiple aspects of communication are impaired, while some channels remain accessible for a limited exchange of information.
Global aphasia is the most severe form of aphasia, and is applied to patients who can produce few recognizable words and understand little or no spoken language. Global aphasics can neither read nor write. Global aphasia may often be seen immediately after the patient has suffered a stroke and it may rapidly improve if the damage has not been too extensive. However, with greater brain damage, severe and lasting disability may result.
Broca’s aphasia is a form of aphasia in which speech output is severely reduced and is limited mainly to short utterances, of less than four words. Vocabulary access is limited in persons with Broca’s aphasia, and their formation of sounds is often laborious and clumsy. The person may understand speech relatively well and be able to read, but be limited in writing. Broca’s aphasia is often referred to as a ‘non fluent aphasia’ because of the halting and effortful quality of speech. Broca’s失语,语言输出被严重削弱,仅能说少于4个字的短句。患者选词障碍,发音艰涩、笨拙。患者听理解相对完好,可以阅读,但书写障碍。由于言语常出现停顿且说话费力,Broca’s失语常被称为非流利性失语。
Mixed non-fluent aphasia is applied to patients who have sparse and effortful speech, resembling severe Broca’s aphasia. However, unlike persons with Broca’s aphasia, they remain limited in their comprehension of speech and do not read or write beyond an elementary level.
In Wernicke’s aphasia the ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected. Therefore Wernicke’s aphasia is referred to as a ‘fluent aphasia.’ However, speech is far from normal. Sentences do not hang together and irrelevant words intrude-sometimes to the point of jargon, in severe cases. Reading and writing are often severely impaired.
Anomic aphasia is applied to persons who are left with a persistent inability to supply the words for the very things they want to talk about-particularly the significant nouns and verbs. As a result their speech, while fluent in grammatical form and output is full of vague circumlocutions and expressions of frustration. They understand speech well, and in most cases, read adequately.
Difficulty finding words is as evident in writing as in speech.
Perseveration is susceptibility to interference from previous stimuli. In some cases this shows up as being unable to shift to a new category or activity. Behavior may also be continue inappropriately, for example, drawing extra loops when copying a multi-loop design. It may result from difficulty in disengaging attention from a stimuli.
In addition to the foregoing syndromes that are seen repeatedly by speech clinicians, there are many other possible combinations of deficits that do not exactly fit into these categories. Some of the components of a complex aphasia syndrome may also occur in isolation.
This may be the case for disorders of reading (alexia) or disorders affecting both reading and writing (alexia and agraphia), following a stroke. Severe impairments of calculation often accompany aphasia, yet in some instances patients retain excellent calculation in spite of the loss of language.
There are a variety of disorders of communication that may be due to paralysis, weakness, or incoordination of the speech musculature or to cognitive impairment. Such impairment may accompany aphasia or occur independently and be confused with aphasia. It is important to distinguish these disorders from aphasia because the treatment(s) and prognosis of each disorder are different.
Apraxia is a collective term used to describe impairment in carrying out purposeful movements. People with severe aphasia are usually extremely limited in explaining themselves by pantomime or gesture, except for expressions of emotion. Commonly they will show you something in their wallet, or lead you to show you something, but this is the extent of their non-verbal communication. Specific examination usually shows that they are unable to perform common expressive gestures on request, such as waving goodbye, beckoning, or saluting, or to pantomime drinking, brushing teeth, etc. (limb apraxia). Apraxia may also primarily affect oral, non-speech movements, like pretending to cough or blow out a candle (facial apraxia). This disorder may even extend to the inability to manipulate real objects. More often, however, apraxia is not very apparent unless one asks the patient to perform or imitate a pretended action. For this reason it is almost never presented as a complaint by the patient or the family. Nevertheless it may underlie the very limited ability of people with aphasia to compensate for the speech impairment by using informative gestures.
Apraxia of speech is a term frequently used by speech pathologists to designate an impairment in the voluntary production of articulation and prosody (the rhythm and timing) of speech. It is characterized by highly inconsistent errors.
Dysarthria refers to a group of speech disorders resulting from weakness, slowness, or incoordination of the speech mechanism due to damage to any of a variety of points in the nervous system. Dysarthria may involve disorders to some or all of the basic speech processes: respiration, phonation, resonance, articulation, and prosody. Dysarthria is a disorder of speech production not
language (e.g., use of vocabulary and/or grammar). Unlike apraxia of speech, the speech errors that occur in dysarthria are highly consistent from one occasion to the next.
Dementia is a condition of impairment of memory, intellect, personality, and insight resulting from brain injury or disease. Some forms of dementia are progressive, such as Alzheimer’s disease, Picks disease, or some forms of Parkinson’s disease. Language impairments are more or less prominent in different forms of dementia, but these are usually overshadowed by more widespread intellectual loss. Since dementia is so often a progressive disorder, the prognosis is quite different
from aphasia.

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