Acquired disorders of speech and language constitute a breach of verbal communication. They are secondary to the appearance of an organic cerebral lesion and are observed in numerous pathologies both acute (e.g., stroke) that progressive (e.g., Alzheimer’s disease).
They differ both disturbances of language acquisition process appearing at an early age, as developmental dyslexia, or perinatal suffering after-effects, and communication disorders associated with psychiatric disorders.
The practitioner’s approach is to recognize the existence of communication disorders, and to characterize the class prerequisites for the etiological and therapeutic decisions. The essence of the approach is clinical. Only the etiological investigation requires the use of additional tests, mainly brain imaging (CT or MRI).
We recognize three main problems:
– Speech disorders: joint disorders (realization motive) of language;
– Aphasic disorders: disorders affecting the structure of the language;
– Supralinguistiques disorders: disorders and disturbances secondary to impaired speech and other cognitive functions.
Local examination should identify disorders characteristics that identify the level of achievement of communication.There are four main registers of signs:
– Anomie: Failing the words;
– Distortion of the language (or language deviations);
– Syntax disturbance;
– Abnormality of influence.
The patient has difficulty, or inability, to give the name of an object or a concept, assumed known. The deficit occurs orally or in writing. In the patient’s spontaneous speech, the deficit is manifested by the lack of the word, a phenomenon that may be the cause of the patient’s complaints.
Anomie indicates an aphasic disorder when the patient manifests a loss of representation of the word form (lexical disorder), or a loss of connection between the word and what it designates (semantic disorder).
In the case of a lexical disorder, the patient shows with circumlocutions or gestures knowledge of the concept that fails to styling. The contribution of the first sound of the word ( “a pa …”) or the provision of a meaningful context ( “when it rains it opens its …”) facilitate the production of the word (here “umbrella”).
– In the case of a semantic disorder, the patient behaves as if the meaning of the concept and even escaped him. Aid ABOVE cited are usually ineffective.
Aphasic anomies are most often associated with other signs of an aphasic syndrome, including paraphasias and disorders of syntax, such as Broca’s aphasia they are one of the major signs. Anomie can be long isolated in degenerative diseases like Alzheimer’s.
However, any lack of the word is not necessarily aphasic. Anomie may also reflect a non aphasic mechanism, as in amnesia or agnosia (default recognition). In the latter case, the patient may, for example, make visual approximations.
Linguistic deviations are distortions introduced in the production of oral or written language. They may occasionally occur in normal subjects, but they are most often observed in the pathology of language. We distinguish the deformations of language:
– Oral: paraphasia;
– Wrote paragraphie.
These distortions may be present singly or in combination.
The paraphasia concerns the deformation of oral language. many types of deformations can be associated can be observed:
– Paraphasias phonetic: abnormal production phonemes (not belonging to the register of the language) or phoneme substitution by relatives phonemes ( “ba” with “pa”, “seu” with “Shi”, etc.). They usually result from a joint disorder (motor development) speech;
– Paraphasias p honémiques: transformation of words by elision ( “breaks” instead of “class”), addition ( “claspe” instead of “class”) or movement ( “tchélocosvaquie”) of their constituent phonemes;
– Verbal paraphasias: replacing a word with another word of the language, without obvious sense ratio ( “door” for “magnifying glass”);
– Semantic paraphasias: replacing a word with another word of the language with a more or less close sense of kinship ( “brush” instead of “pen”);
– Neologisms: production of a word “sounds” like the words of the language, but no sense (a “poisâtre” to a gum);
– J argon: the level of excessive deformation to restore the meaning of the statements of the patient.
The paragraphie regards distortion of written language. Abnormal written productions are classified according to the same logic:
– Paragraphies graphics: secondary to handwriting disorders;
– Paragraphies graphemic: revises letters representing phonemes ( “lene” instead of “wool”);
– Semantic or verbal paragraphies: defined as their oral equivalent;
– Jargonagraphie: production of a written jargon.
It differs according to the level of disruption agrammatism and dyssyntaxie. In some patients, there may be an absence or reduction of grammatical indicators (such as conjugations, articles, etc.) in oral productions and / or written. The term agrammatism is reserved for the most severe deficits when the patient can not produce a “telegraphic” style devoid of any grammatical marker, a situation which is very typical of non fluent aphasia (see above). In milder cases, we talk about dyssyntaxie.
Language disorders often have a change of language production rate.
This criterion establishes the classic opposition between fluent aphasia or not fluent:
– Fluent aphasia not: decrease speech rate and / or the average number of words transmitted consecutively in a sentence. At most, one can observe a silence;
– Fluent aphasia: primarily qualitative achievement of language with preservation or even exaggeration, flow, while achieving a logorrhée as in typical forms of Wernicke’s aphasia.
the review’s objectives are to assess the patient’s level of residual communication, describe and classify presented disorders.
Ideally, this examination should be performed by a speech therapist, who uses a battery of standardized tests aphasiologique essential for accurate quantification prior to a rehabilitation treatment. However, it is perfectly possible to get guidance in minutes, without special equipment at the bedside or in consultation.
The examination of language reflects the general parameters as handedness, level of education, the degree of familiarity with the language tested and practice of written language, the defects of vision or hearing, level of alertness and fatigue, the presence of depressive or anxiety disorders.
Review of the word:
We must first analyze the functioning of the phonatory muscles, state of tone of the veil, the presence of the gag reflex.Orofacial apraxia is sought by asking the patient, on verbal command then imitation, performing simple gestures (such as tongue, cheeks inflate, whistle, etc.).
The study of spontaneous speech can evaluate the presence and nature of arthriques or prosodic disorders (voice modulations). This search can be sensitized by asking the patient to repeat several times difficult sequences ( “weeping baby”, “exceptional performance”).
Examination of language:
Even brief, the review should evaluate various modes of language (spontaneous and forced), different levels of achievement (oral, written, Production comprehension) and complexity. This assessment allows for a quantitative and qualitative profile of unrest and nosological orientation.
Review of spontaneous language:
Any review starts with a production phase “free” patient: response to open questions about the history of his disease, history, etc. This phase provides valuable insights:
– Patient Communication Skills: adapting answers to inform the level of understanding, the ability to transmit relevant information (despite any deformation), provides information on the informativeness of the patient;
– Fluence: it allows the distinction between fluent patients not fluent;
– Frequency and type of deformation, the level of persistence of syntax;
– Degree of recognition of its troubles by the patient: the existence of anosognosia is attached to certain types of aphasia.
Review of language constrained:
In a second phase, we evaluate the different axes and language complexity.
We explore by symmetrical tests of spoken language and written language.
Axis transmission / reception / transcoding:
The language in oral and written procedures has two poles:
– Language production (with the intention of others);
– Reception of language (the productions made by others).
A simple way to test production is naming objects, pictures or body parts. The reception is evaluated by the designation of the same stimuli and performing simple commands.
But also to evaluate the transcoding, the passage that is to say from one modality to another. Repetition tests the transposition of oral to oral; dictation tests the transposition oral / written; the reading aloud the transposition written / oral; copy the written transposition / writing.
Levels of complexity:
Within each domain, consider at least two levels of complexity, some patients with disorders for the most elaborate levels. Exploration of elementary language addresses the most simple language levels as naming objects, their appointment, the matching capabilities heard words and writings, etc.
The review assesses sophisticated capabilities more complex levels as the production or comprehension of difficult phrases, definitions, tests, stories, text synthesis.
It is important not to attribute falsely to language impairment which amounts to another cognitive impairment. A patient who made gross errors in naming image may suffer from visual agnosia. A memory deficit may explain repeat errors occurring for long words or especially for phrases.
Speech impairment and aphasic disorder:
Their distinction is the first stage of reasoning.
Pragmatically, an isolated speech impairment does not affect the written language, does not lead to change in the syntax.
The deformations observed are limited to phonetic paraphasias excluding other deformations.
The two varieties of the most common disorders are dysarthrias and dysprosodies.
The dysarthrias have in common is an alteration in the articulation of speech in at least one of its components: strength, speed, tone, consistency, coordination, accuracy and range of motion of the phonatory muscles. This defective motor realization led to phonetic distortions without other types of paraphasias (verbal, semantic, etc.) or written language disorders.
The engine system underlying speech production is very complex (motor cortex, motor descending pathways, several cranial nerves, sensory feedback, basal ganglia, cerebellum, etc.). Reaching every part of this system gives a different type of dysarthria, according to own functional role of each structure.
Neurological examination distinguishes different forms of dysarthria whose brain imaging (magnetic resonance imaging [MRI]) specifies the etiology:
– Dysarthrias paralytic: observed in myopathies, myasthenia gravis, central facial paralysis or peripheral motor neuron diseases (amyotrophic lateral sclerosis [ALS]), diffuse lesions in the white matter (stroke [stroke] gaps, multiple plate [SEP]);
– Cerebellar dysarthria (or ataxic) observed in the achievement of motor coordination and control of the amplitude of articulations. They are common in MS and rarely caused by cerebellar ischemic pathologies, degenerative or paraneoplastic;
– Dysarthrias dystonia, dyskinetic or hypokinetic: observed in diseases of the basal ganglia accompanied by extrapyramidal syndrome (Parkinson’s disease, Huntington’s disease, progressive supranuclear palsy, side effects of neuroleptics, etc.).
Disorders of prosody:
Prosody is the set of vocal modulations that allow a subject to express pragmatic intentions (denote interrogation, exclamation, etc.) or emotional (happy, sad, etc.). The terms dysprosody and aprosodia denote partial alteration and the total disappearance of prosodic modulations. prosody disorders are still observed with dysarthria.
Unlike speech disorders, aphasia are manifested by impaired to varying degrees of expression and / or comprehension in oral and / or written terms.
Their semiotic importance is to sign an altered function of the dominant hemisphere for language, that is to say, the left in 96% of right-handed and 70% left (known as cross aphasia in other cases ).
Aphasia by major syndromes cortical lesions:
Their classification recognizes a plethora of aphasic syndromes, sometimes defined by clinicopathological criteria, sometimes by linguistic mechanisms supposed. The contemporary approach is critical vis-à-vis these classifications due to the inconsistency of clinical efficacy (15 to 40% of aphasia are “unclassifiable”) and the variability of their anatomical and clinical relevance. At present, it seems more important to accurately describe the performance of a patient rather than the label “Broca” or “Wernicke”.
These varieties of aphasia are primarily the result of ischemic strokes, regularity signs of combinations corresponding to the consequences of the distribution of arterial territories (Fig. 1).
The aphasic disorder is often associated with neurological deficits (hemiplegia, sensory deficits, visual field defects, etc.) and other cognitive deficits (apraxia, achievement of executive functions, etc.). The severity of the damage associated complicates the prognosis of aphasic disorder.
When the lesions are small or broken (as in head injuries) or when degenerative diseases, disorders can be much more discreet, limited to a variety of defi cit. We can thus observe disorders limited to written language (alexia or agraphia) or isolated anomie.
This type of disorder refers to an elderly incipient degenerative disease, including Alzheimer’s disease or frontotemporal dementia (FTD).
Lesions exclusively subcortical (white matter or basal ganglia) can cause aphasia, close enough to the classical and atypical forms.
Etiology of aphasia:
The etiologic orientation is guided by the evolving fashion disorders:
– Transient aphasia: a period of several minutes to several hours, they must be suspected primarily transient ischemic attack and to achieve an appropriate balance.
More rarely it reveals a focal epilepsy (EEG abnormalities [EEG]) or “accompanied” migraine (headache and aphasia succession, typical of a known migraine, is suggestive);
– Sustainable aphasia acute or subacute installation: the numerous possible causes are stroke, head trauma, infectious processes (viral encephalitis) (Fig. 1). Cerebral MRI is the test of choice for etiological research;
– Sustainable aphasia gradual onset: they must first seek out a tumor pathology by MRI (without and with contrast medium injection) (Fig. 2).
However, the most common cause (especially after age 65) is a degenerative disease.
Uninsulated fluent aphasia suggests a progressive aphasia. A non-fluent aphasia associated with behavioral disorders inaugural fact seek frontotemporal dementia.
Finally the combination of multiple cognitive deficits (including memory) evokes the diagnosis of Alzheimer’s disease.
These situations require a complex exploration (MRI, comprehensive neuropsychological assessment, possibly analysis of biomarkers in cerebrospinal fluid [CSF] and brain scans) performed best in an expert center.
Supralinguistiques disorders of speech:
Some reversible pathological situations (psychiatric disorders, use of psychotropic drugs, mental confusion) or irreversible (frontal syndrome, amnestic disorders, etc.) may cause a malfunction of the language, without the linguistic unit is
Supralinguistiques these disorders differ from aphasia by:
– Predominant involvement of the speech, which is more or less incoherent because of multiple fractures or digression;
– The preservation of the most basic linguistic operations;
– The scarcity of paraphasias (especially semantic).
The practitioner must ensure treatment of the causal disease, in some cases facilitating the recovery of communication disorders.
Persistent communication disability require rehabilitative care, implemented by a specialized pathologist.
The rehabilitative strategies are decided after a thorough evaluation to determine the level and severity of language alterations, residual performance levels, associated deficits (neurological and cognitive), the level of awareness of the disorders, the existence of associated depression . Age is not a limiting factor, as opposed to fitness.
The initiation of therapy should be early, as soon as the patient’s participation allows. The frequency of therapy sessions can be daily (or twice daily) in the initial stage.
The usual rhythm in the recovery phase (after a stroke) is about three times a week. The duration of rehabilitation is conditioned by the speed of progression, one year is not unusual.