Doi:10.1016/j.mehy.2005.10.035 Situational therapy for Wernicke’s aphasia Eric Lewin Altschuler a,b,*, Alicia Multari c, William Hirstein b,d,V.S. Ramachandran b a Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry ofNew Jersey, 30 Bergen Street, ADMC 1, Suite 101, Newark, NJ 07101, USAb Brain and Perception Laboratory, University of California, San Diego, 9500 Gilman Drive, La Jolla,CA 92093-0109, USAc Department of Speech and Language Therapy, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst,NY 11373, USAd Department of Philosophy, Elmhurst College, 190 Prospect Avenue, Elmhurst, IL 60126, USA Received 3 October 2005; accepted 6 October 2005 Patients with Wernicke’s or expressive aphasia are able to produce fluent speech, however, this speech may be complete gibberish sounds and totally incomprehensible, or even when comprehensible to a degree is oftenlaced with severe errors and abnormalities such as verbal and phonemic paraphasias and neologisms. Furthermore,patient’s with Wernicke’s aphasia have poor to no understanding of speech or language. There is no proven method forrehabilitation of Wernicke’s aphasia, or even much guidance for physicians or speech therapists to treat Wernicke’saphasia patients. In contrast to their poor to non-existent communication skills using speech or other forms oflanguage, it has long been appreciated informally and formally that Wernicke’s aphasia patients are able tocommunicate well, even normally, using non-verbal means such as actions, movements, props, gestures, facialsexpressions, and affect. Furthermore, in non-language domains Wernicke’s aphasia patients can show normal memoryand learning abilities. Thus, we here suggest that the non-language communication channels of Wernicke’s aphasiapatients be channeled and utilized in their functional rehabilitation: Specifically, we suggest that therapy forWernicke’s aphasia patients should consist of placing patients in real or simulated important functional situations –e.g., buying food, taking transport – and let the patients train and learn to use and hone their non-languagecommunication means and skills for improved practical functioning.
c 2006 Elsevier Ltd. All rights reserved.
Aphasia – acquired difficulty with language – is a ber of different forms of aphasia: In 1861 Paul not uncommon and often extremely severe sequel Broca was the first to give a definitive descrip- of stroke or other brain lesion There are a num- tion of a type of aphasia – now known eponymously(or as expressive aphasia) – complete with ana-tomical localization. (There is an extensive prehis- * Corresponding author. Tel.: +1 973 972 4394; fax: +1 973 972 tory of sophisticated and accurate descriptions of expressive and other forms of aphasia dating back at least as far as the Biblical Book of c 2006 Elsevier Ltd. All rights reserved.
Psalms (137: p. 5–6).) In Broca’s aphasia left fron- in which patients have relatively preserved under- tal cortical lesions cause the patient to have diffi- standing and speech but grossly impaired ability culty expressing thoughts using verbal or written to repeat phrases. But most clinical problems in language (including sign language while under- aphasia derive from difficulty with expression (pure standing of language is largely intact. In 1874 Carl Broca’s aphasia), understanding (pure Wernicke’s Wernicke described a different kind of aphasia aphasia) or some combination of expressive and due to damage of the left posterior temporal cor- receptive language difficulties, for example severe tex. In this remarkable description, Wernicke cata- globally aphasic patients who have grave difficul- loged the cardinal signs of a form of aphasia now ties in both expression and understanding of lan- also known eponymously, or as receptive aphasia: (1) patients have poor to no understanding of lan- Wernicke’s aphasia should benefit not only patients guage in any modality – spoken or written. (2) Pa- with pure receptive language difficulties, but also tients have no trouble producing speech but it is those whose clinical syndrome includes a signifi- often completely lacking in meaning and includes cant component of receptive deficits.
all sorts of errors such as verbal paraphasias (e.g., ‘‘knife’’ for ‘‘fork’’), phonemic paraphasias continues to be a significant challenge. Expressive (‘‘bife’’ for ‘‘knife’’) or neologisms (new words, (Broca’s) aphasic patients would seem to be the such as ‘‘bort’’ for ‘‘fork’’). (3) Curiously, these easiest to rehabilitate as these patients can under- patients are oblivious and unperturbed by their stand the method used in a given rehabilitation problems, and often seem not to notice that others technique, or at least the directions to utilize the cannot understand their speech. It is important to technique. However, there has been scant success note another feature of Wernicke’s aphasia – no in rehabilitation trials in expressive aphasia. A doubt long recognized informally by physicians, large trial 20 years ago, which has not been super- speech therapists, other medical personnel, and seded, highlights the problem: nearly 200 patients patients’ families and friends, as well as formally who lived to be discharged after a stroke with – which we think may be able to be harnessed expressive aphasia were randomized to receive to achieve functional rehabilitation in these pa- speech therapy with whatever method the speech tients: Wernicke’s patients’ ability to communi- therapist felt was best twice a week or no therapy significantly better, sometimes approaching nor- both groups, but the therapy produced no signifi- mal, using non-verbal means such as actions, cant benefit over no treatment. In another sort of movements, props, gestures, facials expressions, approach, two trials using the stimulant bromocrip- and affect, than verbally. For example, when tine, a dopamine agonist, failed to produce posi- standing in a cafeteria line with choices of fish or tive results For Wernicke’s aphasia, upon pasta, a Wernicke’s patient will shake his head checking the literature (e.g., Medline) or books ‘‘no’’, when the cafeteria staff tries to put fish on his tray – though not answer coherently with words when asked if he wanted the fish – and then there are no proven rehabilitation methods for point to the pasta. Similarly, we have seen Wer- receptive aphasia, and very little guidance for the nicke’s patients upon egress from a clinic appoint- ment, walk correctly to the elevator, press Unlike treatment methods for aphasia, methods correctly the up or down button, get out of the to assess the degree and specific type of deficit in a way of people exiting, the elevator, exchange nor- given patient’s aphasia have been well-validated mal non-verbal pleasantries with other elevator But after assessment, what should come next users, and press the button correctly for the floor for a patient found to have typical Wernicke’s to which they want to go. When another person aphasia or a strong component of expressive apha- waiting for the elevator would try to speak with sia in their assessment? Often we see a basis for the patient, there was no effective, or even coher- therapy taken from the observation that a given ent conversation. We here suggest that standard patient may have more preserved receptive lan- speech therapy per se not be used for Wernicke’s guage when reading than when listening to spoken patients, but instead place Wernicke’s patients in speech, or vice versa. But we have not seen this to real or simulated situations important to them be of practical utility. And, theoretically, we would and have them work on using non-verbal means to not expect it to be particularly useful because, while there may be some differential ability of There are other kinds of aphasias besides understanding written vs. spoken language, this Broca’s and Wernicke’s, e.g., conduction aphasia difference is usually not large enough to be clini- Situational therapy for Wernicke’s aphasia cally significant. Similarly, while there may be a mine what real life problems are important for slight difference in the overall language level in that patient to work on, much as patients with understanding, this difference often does not man- hemiplegia or simply geriatric patients with deficits ifest as the ability to recognize specific words reli- from ‘‘normal’’ aging in vision, sensation and ably from session to session, or in successive real movement do to make sure the house is safe. Or world encounters. Drilling on specific words or one can give Wernicke’s patients a clock or calen- phrases, a common approach in therapy of Broca’s dar to have them demonstrate when they need to aphasia, is not and should not be useful in Wer- be places. If a Wernicke’s aphasia patient needs nicke’s aphasia patients, as receptive aphasia pa- to buy various items at a store, have the therapist tients cannot understand the directions of the go with him or her to the store, or simulate the drills, and even when a gain is made, it is not store and let the patient use all in communication means, not just spoken language to communicate.
In stark contrast, we have found Wernicke’s Also, while their words are poor and not consistent aphasia patients’ non-spoken/written language from day to day, their thoughts are largely clear communication to be robust, practically useful and consistent, and patients if trained in a situa- and amenable to training: for example, nurses tion may be able to learn to muster some words know that Wernicke’s aphasia patients are able to like ‘‘sasta’’ for ‘‘pasta’’. or ‘‘setti’’ [‘‘spa- indicate by gesticulation and facial expression if ghetti’’], rather than trying to work on a single they are given another patient’s medication, or reliably present their arm for a blood pressurecheck. Such abilities of Wernicke’s aphasia pa-tients are not merely ‘‘overlearned’’: Patients typ- ically know when it is time for medications to betaken by mouth, or to pull up their shirt for a sub- We suggest the following method for therapy of pa- cutanenous injection of heparin – a medication not tients with Wernicke’s aphasia: (1) make a thor- taken at home. The presence of these abilities may ough assessment of the patient’s language ability.
indicate that the patient’s system of concepts is (2) Until a particular method to improve speech largely intact, but he or she has merely lost the or language itself in Wernicke’s aphasia is proven verbal tags and grammatical structure to communi- in a good quality trial, no time during the speech cate his or her thoughts with. Furthermore, learn- therapy session should be spent specifically on lan- ing in Wernicke’s aphasia patients is not only guage therapy. (3) A home visit should be made by procedural as in patients with severe hippocampal a speech therapist and/or a social worker to deter- lesions and anterograde amnesia. For example, mine the patient’s need for things at home, work even in crowded hospital hallway Wernicke’s apha- and leisure activities. (4) Therapy sessions should sia patients have often stopped us, smiling broadly be focused on using non-verbal means to work on with a look of recognition and offered their hand to those areas: e.g., if a patient needs to be able to shake as a greeting, while making comments such shop go to a store with the patient and assist them as ‘‘the san, the san [‘‘man’’]’’, or ‘‘she and train them. As interactions with the therapist [‘‘he’’]’’. Thus, Wernicke’s aphasia patients are involve language, patients get exposure to this able not only to learn to recognize individuals they did not know before becoming aphasic, but can usetheir all in skills to communicate a warm greeting,even with extremely poor spoken language ability.
These all in communication abilities which Wer-nicke’s aphasia patients are thus spontaneously Assemble a large group Wernicke’s patients and effectively deploying need to be nurtured and har- have one set of testers assess their language skills.
nessed. Wernicke’s aphasia patients are also able Have another set of investigators do a home visit to to understand and communicate subtle concepts: assess which areas or skills the Wernicke’s aphasia When playing chess or checkers with Wernicke’s patients need work on. Then randomize the pa- aphasia patients, if the examiner makes an illegal tients to standard speech therapy to use traditional (‘‘cheating’’) move, the patients invariably give a spoken and written language based therapy ses- look of disbelief or anger to the examiner or waive sions to improve patients in their needed domains their hands in objection, though they do not pos- (control group), or to a group using the same num- sess sufficient language to complain verbally.
ber and length of sessions as in the control group Some of the following approaches might be help- but in which patients are placed in situations ful: aphasia patients need a home visit to deter- important to them and trained and encouraged to use any communication means possible, e.g., [4] Benton AL. A biblical description of motor aphasia and right pointing to a picture of a food item on a menu to hemiplegia. J Hist Med Allied Sci 1971;26:442–4.
[5] Hickok G, Bellugi U, Klima ES. The neurobiology of sign order, using a clock or calendar to make or set language and its implications for the neural basis of appointments, facial expressions, residual words, language. Nature 1996;381:699–702.
etc. to achieve their goal (intervention group). At [6] Wernicke C. Das aphasische symptomenkomplex. Breslau: the end of the therapy sessions assess the patients’ ability to perform their needed task, and compare [7] Boller F, Green E. Comprehension in severe aphasics.
[8] Lincoln NB, McGuirk E, Mulley GP, Lendrem W, Jones AC, We believe that the training procedure and spirit Mitchell JR. Effectiveness of speech therapy for aphasic we have put forth may be of greater overall benefit stroke patients. A randomised controlled trial. Lancet to patients than current methods, and we hope our hypothesis stimulates more interest in developing [9] Gupta SR, Mlcoch AG, Scolaro C, Moritz T. Bromocriptine treatment of non-fluent aphasia. Neurology 1995;45: and testing methods for rehabilitation of Wer- nicke’s and other forms of aphasia.
[10] Sabe L, Salvarezza F, Garcia Cuerva A, Leiguarda R, Starkstein S. A randomized, double-blind, placebo-con-trolled study of bromocriptine in non-fluent aphasia.
[11] Rogers MA, Alarcon NB, Olswang LB. Aphasia management considered in the context of the World Health Organization [1] Benson DF. Aphasia: a clinical perspective. Oxford: Oxford model of disablements. Phys Med Rehabil Clin N Am [2] Broca P. Perte de la parole, ramollissement chronique et [12] Bogey RA, Geis CC, Bryant PR, Moroz A, O’neill BJ. Stroke and neurodegenerative disorders 3. Stroke: rehabilitation management. Arch Phys Med Rehabil 2004;85(Suppl. 1): [3] Finger S. The origins of neuroscience: a history of explo- rations into brain function. New York: Oxford University [13] Helm-Estabooks N, Albert ML. Manual of aphasia therapy.


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