Aphasia management: the role of clinicians and speech therapists

Hollywood star Bruce Willis’ sudden retirement from acting after being diagnosed with aphasia has shed light on a communication disorder, which experts say often goes untreated.

An estimated 140,000 Australians suffer from aphasia – a number that is expected to grow as the population ages, said Professor David Copeland, speech pathologist and director of the Queensland Center for Aphasia Research.

What is aphasia?

Professor Copeland explained that aphasia is a heterogeneous communication disorder.

“It can be caused by any neurological condition that affects the language networks in the brain,” he said.

The most common cause is stroke, with aphasia affecting one in three stroke patients. There is also a primary, progressive form of the condition, resulting from frontotemporal dementia or Alzheimer’s disease, which is more difficult to diagnose because the onset of symptoms can be subtle, Professor Copeland said.

Aphasia can also be caused by a brain tumor, brain surgery, epilepsy, trauma, and, in rare cases, viral infection.

Professor Copeland said aphasia can manifest as problems with language comprehension or language production.

“It can affect speaking, reading, writing, or understanding spoken language,” he said.

Some patients have problems at the single word level, which affects their ability to restore the phonetic representation of words or their meanings.

“Other patients have problems constructing grammatical sentences or getting the correct word out at the right time.”

Can aphasia be treated?

Treatment and prognosis options vary, depending on the type of aphasia.

Professor Miranda Rose, speech pathologist and director of the National Health and Medical Research Council-funded Center for Research Excellence in Aphasia and Rehabilitation at La Trobe University explained:

“Primary progressive aphasia is very different from post-stroke aphasia because we’re talking about a different neural mechanism that underpins the problem,” she said.

“Post-stroke aphasia is caused by sudden damage to the neural processing networks, and if you survive the stroke, the brain first initiates its own healing processes and then experience-dependent neuroplasticity can occur,” she said.

“So for most stroke survivors with aphasia where language processing networks remain adequate, if you get good treatment you will recover well.”

Unfortunately, the same cannot be said for patients with primary progressive aphasia, although experts agree that there are a number of vital interventions for these patients (more on that below).

Post-stroke aphasia treatment

A Cochrane review found that high-intensity, high-dose, or over a longer period of time speech and language therapy may be beneficial for post-stroke aphasia.

Professor Rose and Professor Copeland co-authored a major study published this month in the Journal of Journal of Neurology, Neurosurgery and Psychiatry which found that intensive speech therapy for post-stroke aphasia was effective in the chronic phase of the condition—at least 6 months after the stroke. Intensive face-to-face interventions were performed in small groups for 3 hours, 5 days per week for 2 weeks.

The multi-site randomized controlled trial of 216 patients found that global aphasia severity (the primary end point) was not significantly different between treatment and post-intervention control groups. However, patients in the intensive treatment arms showed improvements in measures of functional connectivity, quality of life, and word retrieval (secondary end points), compared with no improvements in the usual care group.

Professor Copeland said the findings challenge the concept that there is a limited ‘early window’ when recovery from aphasia is possible after a stroke.

“If there is adequate treatment, and the right type of treatment, patients can still show benefits after 6 months,” he said.

However, Professor Copeland and Professor Rose said most Australian patients with post-stroke aphasia did not get enough speech therapy to improve outcomes.

Professor Rose said: “The lack of treatment for post-stroke aphasia patients is really sad for speech pathologists as a profession.”

While there was more research to be done on the ideal duration and severity of speech therapy for post-stroke aphasia, Professor Rose said the typical length of hospital stay after a stroke was often 3 weeks or less, with limited opportunity for interventions.

“Patients are often sent home too early with a complete disability in communication and sometimes no community rehabilitation or follow-up,” she said. “They fall through the gaps in a major way.”

Professor Rose said GPs have had a critical role in helping patients and their families living with aphasia access speech pathology services in the months and years following a stroke.

“Because communication is central to nearly everything we do in life, aphasia can have significant negative effects on employment, relationships, mental health, and identity,” she said. “All of these areas may need to get into [GP] management plan.”

There are also high hopes that the technology might fill some of the gaps in services.

Professor Copeland and Professor Rose are studying how to implement high-dose treatments with the help of software and applications that allow patients to access treatment independently once they are discharged from the hospital.

Professor Rose recommended the aphasiasoftwarefinder.org website, which lists different software tools available to treat different types of aphasia, sorting them according to levels of evidence and expense.

“Patients should be referred to a speech pathologist to develop a personalized self-care program using both intensive face-to-face therapy and software tools,” she said.

Helping patients with primary progressive aphasia

For primary progressive aphasia, there is little evidence for direct behavioral therapies such as speech therapy.

“It’s really difficult because the condition is only going to get worse over time,” Professor Copeland said. “Methods tend to focus on compensatory approaches, such as using an iPad to aid communication, as well as on training communication partners to help the person get their message across.”

Prof Rose said the goal with these patients was to maintain treatment networks for as long as possible and to create tools and techniques to keep a person connected.

“For example, if a person cannot remember the names of family members, a speech therapist may help them set up a foldable page on their iPhone containing the photos and names of their family members,” she said.

Professor Rose said she wishes more people with PPA would receive speech pathology.

“It should become a gold standard care,” she said.

“Unfortunately, the biomedical perspective is often, ‘It can’t be fixed, so don’t send them in for an intervention,'” she added.

“But if you think of it as a biological, psychosocial problem, with implications for family, psychological well-being and identity, of course you’d refer that person so you can manage it while they still have the ability to learn and adapt.”

For more information and aphasia resources, visit the La Trobe Center for Research Excellence and the Australian Aphasia Society.

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