Author(s): Steven Flanagan, MD, David Jevotovsky, MD, MBA
Originally published: November 10, 2011 Last updated: February 15, 2024
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Disease/Disorder

Definition

Aphasia is an acquired disturbance of any of the modalities of language: comprehension, expression, reading and/or writing caused by injury to cerebral areas that are specialized for this function.

Apraxia of speech is a disorder of carrying out or learning complex speech movements not accountable by disturbances in strength, coordination, sensation, comprehension or attention. Verbal apraxia is manifested by limited number of consonants and vowels, articulation errors and problems sequencing movements with increasing complexity.

Dysarthria is a group of speech disorders caused by muscle paralysis, weakness or incoordination manifested by impairments in articulation, rate of speech production, respiratory coordination and/or laryngeal control, rather than language content.

Dysphagia is a disorder of swallowing that impairs the speed and/or safe delivery of food materials from the point of entry into the mouth into the upper portion of the esophagus.

Etiology

  • Ischemia
  • Trauma
  • Hypoxia
  • Toxic/metabolic
  • Neoplasm
  • Congenital
  • Degenerative
  • Developmental

Epidemiology including risk factors and primary prevention

The overall prevalence of language impairment in the United States is between 6 and 8 million. Approximately 80,000-100,000 individuals acquire aphasia annually.1,2 Incidence of aphasia varies by etiology and is most commonly associated with stroke, affecting around 15% of patients with acute ischemic stroke.3 Dysphagia is highly prevalent in people with stroke, traumatic brain injury, Parkinson’s disease and community acquired pneumonia.  However, wide variations in reported prevalence exist in the literature due to methodological differences.4 

Patho-anatomy/physiology

Aphasia results from injury to specific areas of the dominant cerebral hemisphere with clinical manifestations dependent on location and extent of neural damage. Non-dominant hemisphere language dysfunction may manifest as impairments in prosody and higher-level cognition including unawareness of social cues, humor and body language, as well as inappropriate utterances.

Anatomical lesions vary in cases of speech apraxia, but frequently involve the left hemisphere insula.

Dysarthrias result from either upper or lower motor neuron injury, with clinical manifestations dependent on the location and extent of neural damage.

Dysphagia results from numerous causes, including lesions of the central and peripheral nervous system, trauma and structural abnormalities affecting the anatomical substrates involved in swallowing.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Disorders of language, speech and swallow resulting from stroke, trauma, and anoxia tend to improve over time. People with mild to moderate aphasia experience approximately 70% of maximal recovery based on validated measure within 3 months of stroke, noting recovery is most rapid during this time.5 Progression occurring from other conditions is variable and depends on disease state and progression as well as effects of treatment (e.g., radiation for neoplasms).

Essentials of Assessment

History

See Etiology, above.

Physical examination

Aphasia: Definitive classification of aphasia is achieved through formalized assessment tools. Bedside examinations focusing on fluency, comprehension, ability to repeat sentences, reading and writing can help delineate different aphasia subtypes.

  • Broca’s aphasia: Non-fluent, impaired repetition, intact comprehension;
  • Transcortical motor aphasia: Non-fluent, intact repetition, intact comprehension;
  • Global aphasia: Non-fluent, impaired repetition, impaired comprehension;
  • Wernicke’s aphasia: Fluent, impaired repetition, impaired comprehension;
  • Conduction aphasia: Fluent, impaired repetition, relatively intact comprehension;
  • Transcortical sensory aphasia: Fluent, intact repetition, impaired comprehension;
  • Pure word mutism: Impaired speech production with retained comprehension and ability to write;
  • Pure word deafness: Loss of auditory comprehension and repetition without abnormalities of naming, reading or writing;
  • Alexia without agraphia: Acquired inability to read, variable naming impairment with retained ability to write;
  • Anomic: Fluent, intact repetition, impaired naming.

Non-dominant hemisphere language disorders: Bedside examination

Dysarthria: Functional assessment of the larynx, respiration, vocal articulations and the pharynx.

  • Spastic: Hypertonic muscles with decreased range of motion, reduced speed of muscle excursion with strained-strangled vocal quality;
  • Hyperkinetic: Altered rhythm and rate of oromotor movements with involuntary muscle actions; variability in muscle tone with altered pitch and volume control, stress, rate, phoneme duration and sudden respiratory inhalations and exhalations;
  • Hypokinetic: Oromotor rigidity, decreased range of motion and force of movement with variable movement velocity manifested by decreased range of pitch and volume, reduced stress, festinating speech and a hoarse/breathy vocal quality;
  • Ataxic: Articulatory and prosodic impairments manifested by imprecise articulation of vowels and consonants, articulatory breakdowns, excessive and equal stress, prolongation of phonemes and inter-word intervals, decreased rate of speech, mono-pitch and mono-loudness, and harsh vocal quality;
  • Flaccid: Flaccid oromotor muscles and fasciculations. Detailed cranial nerve evaluation is essential; often manifested by breathiness, audible inspirations, hypernasal vocal quality, decreased phrase length, consonant imprecision, vocal harshness and reduced range of pitch and volume;
  • Mixed: Variable combination of above.

Apraxia of speech: Clinical features include effortful, groping or trial and error attempts at speech, dysprosody, inconsistent articulation errors and difficulty initiating speech.

Dysphagia: Bedside evaluation includes assessment of oral sensation, oral reflexes, postural abnormalities, motor assessment of face, lips, tongue, palate and larynx, level of arousal, ability to follow directions and management of saliva. Bedside screening tools useful to physicians include the 3-oz water swallow test or the Toronto Bedside Swallowing screening test (TOR-BSST).

Laboratory studies

Dysphagia:

  • Modified barium swallow (MBS) or video fluoroscopic swallowing study (VFSS): evaluates swallowing by radiographically visualizing swallow using various consistencies of barium. It provides real-time viewing of oral, pharyngeal and cervical esophageal phases of swallowing. 
  • Fiberoptic endoscopic evaluation of swallowing (FEES) directly visualizes laryngeal and pharyngeal structures involved in swallowing. It is portable, lacks radiation, lacks of radiation, visualizes secretions, and detects structural abnormalities of the pharynx and larynx.  It does not assess the oral stage of swallowing or the cervical esophagus.
  • Manometry determines the pressures and relative timing of pharyngeal contraction and relaxation of the upper esophageal sphincter during swallowing.

Supplemental assessment tools

Aphasia

  • Boston Diagnostic Examination of Aphasia assesses severity of language impairment and classifies aphasia into subtypes.  Five subtests assess conversation and expository abilities, auditory comprehension, oral expression, reading, and writing.
  • Western Aphasia Battery assesses the presence, degree and type of aphasia as well as both linguistic and non-linguistic skills.
  • Communications Activities of Daily Living assesses functional communication skills of adults.

Dysarthria

  • Assessment of Intelligibility of Dysarthric Speech is a standardized assessment of dysarthria severity that incorporates measures of speech intelligibility, overall rate of intelligible speech and a ratio of communication efficiency.
  • Frenchay Dysarthria Assessment is a standardized assessment of reflexive, respiratory, articulatory, resonatory and phonatory mechanisms of speech.
  • Fisher-Logemann Test of Articulation Competence is used primarily in pediatrics; testing generates an articulation profile that can be analyzed according to the nature of altered speech production within the context of developmental articulations and phonation errors.

Early predictions of outcomes

Severity of initial language impairment is predictive of neurological and functional recovery in certain central neurological disorders.  Other factors affecting recovery of language post stroke include the site and extent of neurological injury, age, sex, education level and various environmental factors.6 New research indicates that resting state fMRI may outperform traditional models in predicting language recovery in post-stroke aphasia treatment.7

Professional issues

Dysphagia: Placement of gastrostomy tubes provides a means to deliver nutrition, hydration and enteral medications to patients with dysphagia and may reduce the risk of aspiration. Gastrostomies are often recommended following acute neurological injuries and in most cases can be removed as recovery ensues. Patients with progressive disorders often require permanent placement and may be opposed by patients or their health-care proxies, resulting in ethical and legal issues regarding implantation and potential removal. The pros and cons of alternatives to gastrostomies, such as continued unsafe oral intake, intravenous supplementation, cuffed tracheostomy or surgery (e.g., laryngeal diversion) should be discussed with patients or their health-care proxies.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Aphasia: Speech-language therapy (SLT) to maximize communication skills through verbalizations or compensatory means (e.g., communication boards, augmentative communication) is standard practice. Utilization of melodic intonation may be useful. Review of literature tends to support effectiveness of SLT, noting more intensive therapy is possibly more effective than conventionally dosed treatment.8 Pharmacological interventions with catecholaminergic, dopaminergic, and acetylcholinergic agonists as well as piracetam and memantine may be effective although evidence is inconclusive.9

Dysarthria: Management focuses on maximizing strength and coordination of oromotor musculature. Behavioral approaches are used to optimize vocal cord adduction, improve posture, enhance breath support, improve strength and coordination of muscles involved in speech and improve prosody. Instrumental approaches used to improve speech include biofeedback and timers or pacers to control rate. Invasive procedures such as neurotoxins to treat spastic muscles, palatal lifts and injections to medialize paralyzed vocal cords can be used in selected cases. Augmentative communication devices are used when other strategies fail to improve intelligibility.

Dysphagia: Compensatory strategies include changing head and/or body position to reduce risk of aspiration (e.g., chin tuck, head tilt, head rotated); enhancing sensory input of food materials; exercises to improve swallowing (supraglottic, super-supraglottic, effortful, Mendelsohn exercises, tongue hold, double swallow); lingual exercises; head lifting exercises; changes in food consistencies (i.e., thickening liquids or changing size/consistency of solids); devices such as palatal lifts and vocal cord medialization in cases of vocal cord paralysis. Common position-based compensatory maneuvers are described in Table 1. The International Dysphagia Diet Standardization Initiative’s (IDDSI) developed a framework for classifying food textures and drink thicknesses which is commonly used to describe recommended changes in consistencies.10 Table 2 describes this framework in greater detail. Gastrostomy or jejunostomy are also options in cases where aspiration risk cannot be reduced and/or nutritional/hydration needs cannot otherwise be met. Effectiveness of neuromuscular electrical stimulation remains unproven.

Disorders-of-Language-Speech-and-Swallowing-Table-1
Disorders-of-Language-Speech-and-Swallowing-Table-2

Cutting Edge/Emerging and Unique Concepts and Practice

Cutting edge concepts and practice

Aphasia: Constraint Induced Aphasia Therapy (CIAT) combines massed practice over short periods and verbalizations with reduced attempts to use gestures or writing.  Multimodal Aphasia Therapy is an intensive treatment that uses multiple modalities to facilitate spoken output. Small neuromodulation studies examining stimulation by both direct electrical current (TES) and transcranial magnetic stimulation (TMS) have shown favorable results.8 Transcranial direct current stimulation uses a small electrical current typically induced between two electrodes placed on the scalp . Similarly, TMS utilizes magnetic fields to create electric currents in discrete brain areas. Combining traditional therapeutic modalities with transcranial stimulations have shown to improve word-finding, function, and activity outcomes. 

Dysarthria and dysphagia:  Respiratory muscle strength training (RMST) has demonstrated  efficacy in of the treatment of dysphagia and dysarthria.11,12,13,14 RMST is theorized to improve airway protection in people with neuromuscular impairments and resultant dysphagia or dysarthria.13 The majority of research has explored the effects of expiratory muscle training, but combined inspiratory-expiratory training has shown promising results as well.11,15 More investigation into RMST is warranted, as the duration of its impact is uncertain.15  Dysphagia: Studies on neuromuscular electrical stimulation (NMES) in persons with dysphagia has shown promising results in recent years.16,17 NMES involves the application of electrical current across the skin to excite nerve or muscle tissue during a functional task and is believed to support muscle performance and strength development.  NMES combined with swallowing rehabilitation training is effective in the treatment of swallowing dysfunction following stroke; however, conflicting evidence exists whether NMES effectively improves patients’ swallowing function and quality of life.17,18 NMES achieves maximal results when combined with other dysphagia treatment modalities.19

Gaps in the Evidence-Based Knowledge

Limited evidence supports the effectiveness of SLT for people with post-stroke aphasia, with more intensive therapy likely more effective than conventional approaches.7 There is a paucity of evidence supporting any one aphasia treatment technique over another. There is limited evidence supporting the effectiveness of specific SLT techniques for treatment of apraxia of speech in children20 and insufficient evidence supporting it following stroke.21 There is currently insufficient knowledge regarding the superiority of electrical stimulation on dysphagia over swallow therapy alone.22

References

  1. National Institutes of Health: National Institute on Deafness and Other Communication Disorders: Statistics on voice, speech, and language. Retrieved March 12, 2020 from http://www.nidcd.nih.gov/health/ statistics/statistics-voice-speech-and-language. Accessed March 12, 2020.
  2. Ellis C, Dismuke C, Edwards KK. Longitudinal trends in aphasia in the United States. NeuroRehabilitation 2010;27:327–33. doi:10.3233/nre-2010-0616.
  3. Wu C, Qin Y, Lin Z, Yi X, Wei X, Ruan Y, et al. Prevalence and impact of aphasia among patients admitted with acute ischemic stroke. Journal of Stroke and Cerebrovascular Diseases 2020;29:104764. doi:10.1016/j.jstrokecerebrovasdis.2020.104764.
  4. Takizawa C, Gemmell G, Kenworthy J, Speyer R. A systematic review of the prevalence of  dysphagia in stroke, Parkinson’s disease, Alzheimer’s disease, head injury, and pneumonia. Dysphagia 2016;31:434-41.
  5. Lazar RM, Minzer B, Antoniello D, Festa JR, Krakauer JW, Marshall RS. Improvement in aphasia scores after stroke is well predicted by initial severity. Stroke 2010;41:1485–8. doi:10.1161/strokeaha.109.577338.
  6. Lazar RM, Speizer AE, Festa JR, Krakauer JW, Marshall RS. Variability in language recovery after first-time stroke. Journal of Neurology, Neurosurgery & Psychiatry 2008;79:530–4. doi:10.1136/jnnp.2007.122457.
  7. Iorga M, Higgins J, Caplan D, Zinbarg R, Kiran S, Thompson CK, et al. Predicting language recovery in post-stroke aphasia using behavior and functional MRI. Scientific Reports 2021;11. doi:10.1038/s41598-021-88022-z.
  8. Brady MC, Kelly H, Godwin J, Enderby P, Campbell P. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews 2016;2016. doi:10.1002/14651858.cd000425.pub4.
  9. Saxena S, Hillis AE. An update on medications and noninvasive brain stimulation to augment language rehabilitation in post-stroke aphasia. Expert Review of Neurotherapeutics 2017;17:1091–107. doi:10.1080/14737175.2017.1373020.
  10. The IDDSI framework (2019) The International Dysphagia Diet Standardisation Initiative. Available at: https://iddsi.org/framework/ (Accessed: 02 January 2024).
  11. Liaw M-Y, Hsu C-H, Leong C-P, Liao C-Y, Wang L-Y, Lu C-H, et al. Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and Dysarthria – a prospective randomized trial. Medicine 2020;99. doi:10.1097/md.0000000000019337.
  12. Laciuga H, Rosenbek JC, Davenport PW, Sapienza CM. Functional outcomes associated with expiratory Muscle Strength Training: Narrative review. Journal of Rehabilitation Research and Development 2014;51:535–46. doi:10.1682/jrrd.2013.03.0076.
  13. Brooks M, McLaughlin E, Shields N. Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: A systematic review. International Journal of Speech-Language Pathology 2017;21:89–100. doi:10.1080/17549507.2017.1387285.
  14. PERIN C, MAZZUCCHELLI M, PISCITELLI D, BRAGHETTO G, MERONI R, CORNAGGIA CM, et al. Feasibility of a standardized protocol for respiratory training with intermitted positive pressure breathing ventilator application in dysphonia and dysarthria. European Journal of Physical and Rehabilitation Medicine 2022;58. doi:10.23736/s1973-9087.21.06946-x.
  15. Guillén-Solà A, Messagi Sartor M, Bofill Soler N, Duarte E, Barrera MC, Marco E. Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagic stroke patients: A randomized controlled trial. Clinical Rehabilitation 2016;31:761–71. doi:10.1177/0269215516652446.
  16. Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing. Archives of Otolaryngology–Head & Neck Surgery 2007;133:564. doi:10.1001/archotol.133.6.564.
  17. Wang Y, Xu L, Wang L, Jiang M, Zhao L. Effects of transcutaneous neuromuscular electrical stimulation on post-stroke Dysphagia: A systematic review and meta-analysis. Frontiers in Neurology 2023;14. doi:10.3389/fneur.2023.1163045.
  18. Bath PM, Lee HS, Everton LF. Swallowing therapy for dysphagia in acute and subacute stroke. Cochrane Database of Systematic Reviews 2018;2018. doi:10.1002/14651858.cd000323.pub3.
  19. Bengisu S, Demir N, Krespi Y. Effectiveness of conventional dysphagia therapy (CDT), Neuromuscular Electrical Stimulation (NMES), and transcranial direct current stimulation (tDCS) in acute post-stroke Dysphagia: A comparative evaluation. Dysphagia 2023. doi:10.1007/s00455-023-10595-w.
  20. Morgan AT, Murray E, Liégeois FJ. Interventions for childhood apraxia of speech. Cochrane Database Syst Rev. 2018 May 30;5:CD006278. doi: 10.1002/14651858.CD006278.pub3.
  21. West C, Hesketh A, Vail A, Bowen A. Interventions for apraxia of speech following stroke. Cochrane Database Syst Rev. 2005;19(4):CD004298. Accessed March 25, 2020.
  22. Chen YW, Chang KH, Chen HC, Liang WM, Wang YH, Lin YN. The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: a systemic review and meta-analysis. Clin Rehabil. 2016;30(1):24-35. doi: 10.1177/0269215515571681. Epub 2015 Feb 19.

Original Version of Topic

Steven Flanagan, MD. Disorders of Language, Speech and Swallowing.  11/10/2011.

Previous Revision(s) of the Topic

Steven Flanagan, MD. Disorders of Language, Speech and Swallowing. 9/18/2015. Steven Flanagan, MD, Yingrong Zhu, MD. Disorders of Language, Speech and Swallowing. 7/28/2020

Author Disclosures

Steven Flanagan, MD
Nothing to Disclose

David Jevotovsky, MD, MBA
Nothing to Disclose