BROCA APHASIA: SYMPTOMS, TYPES, CAUSES, TREATMENT - NEUROPSYCHOLOGY - 2024

The Broca is impaired language due to brain injury. This type of aphasia was discovered in 1861 by Paul Broca, who observed a patient who only emitted one expression: “so”. However, he understood simple sentences perfectly as he responded to questions through gestures.

A few years later, he found 25 cases with similar alterations that presented lesions in the left hemisphere, occupying the third frontal gyrus. What he associated with this type of aphasia that today bears his name.

Drill area

Broca's aphasia is characterized by poor, difficult and slow speech. The problem is centered on the pronunciation of the words, the meaning of the message being perfectly preserved. It presents a series of characteristics:

• Alterations in the orofacial movements that make him speak with little fluency.
• Agrammatism.
• Impaired reading and writing.
• Difficulties in repeating phrases.
• The understanding of language is somewhat more conserved than its expression.

Signs and symptoms

The main symptoms of people with Broca's aphasia are:

Poor language

Broca's aphasia patients mostly utter single words and short phrases with great effort and slowness.

Errors in phoneme selection

It is common for phoneme selection errors (sounds of the language) to be commented, giving rise to substitutions or collations of phonemes. For example, instead of "guard" they could say "guadria". This is called phonological paraphasia.

Consonant omissions

Omissions and simplifications of consonants occur many times. For example, they may pronounce "da-do" instead of "dart."

Ungrammatical expression

Deficits in the use of adequate morphosyntactic constructs. This means that they are not able to establish an order of the words and link them to form correct sentences. Agrammatism can also appear alone, without problems for linguistic pronunciation. An example might be saying "garden dog" instead of "the dogs are in the garden."

Problems in the use of compound verb tenses

They do not tend to use compound verb tenses correctly. For example, a patient with this type of aphasia is normal to say "the child is hitting the ball" before a picture of a child who is hitting a ball on the head.

Altered sentence repetition

This is the main difference between this type of aphasia and transcortical motor aphasia, in which the repetition is preserved.

Anomie

Anomie is the difficulty in finding the right word. It is a common symptom of all aphasias but it is very noticeable in Broca's aphasia, since speech is very little fluent and patients show great effort in looking for the words that are seen in their facial expression and the emission of sustained sounds like "eeeh…"

Difficulty naming objects

The naming of objects, animals and people is bad, although it can improve if you help him by giving him clues such as saying the first syllable of the word.

Altered understanding

Passive reversible phrases such as "the girl was kissed by the boy" are not well captured. However, they have no problems with active phrases "the boy kissed the girl" or non-reversible active phrases "the boy fell to the ground."

Altered writing, with aphasic agraph

It means there are writing problems due to brain damage. His writing is clumsy, slow, abbreviated and grammatical. You can see paragraphies in anticipation (like "lelo" instead of "hair"), perseverations (like "pepo" instead of "hair") and omissions of letters or syllables ("libo" instead of "book"). These alterations are practically the same as those observed when the patient speaks.

Disease awareness

These patients, unlike Wernicke's aphasia, are aware of their limitations as they notice that their pronunciation is not correct and try to correct it.

Awareness of their problems results in patients feeling irritated and upset, and they often make gestures to indicate more clearly what they are trying to say. They may have symptoms of depression and anxiety.

Others

- Mainly hemiparesis or right motor paralysis, which can vary in severity that can range from weakness in the face to total hemiplegia.

- Apraxia such as ideomotor, which implies the lack of ability to use intact limbs voluntarily to perform the required actions.

- Like other types of aphasia, intellectual abilities that are not related to language are intact.

- Telegraphic language.

- Impaired reading, affecting even the understanding of what is read.

- Aprosodia.

- Sensory deficits as a result of the injury, although this is very rare.

Causes

The most common cause is stroke, especially those that lead to lesions in the left middle cerebral artery, which is the one that irrigates the language areas. However, it can also appear due to tumors, head injuries, infections or after brain surgery.

Multi-causality

Interestingly, it seems that the fact that Broca's aphasia appears is not enough with just an injury in Broca's area, as Paul Broca announced. In fact, if only this area is damaged, a “foreign accent” effect would be observed, that is, slight problems in the agility of language articulation and some deficits in finding the necessary words.

In addition, hemiparesis or apraxia would not appear, which do accompany Broca's aphasia described in this article many times.

Rather, what is truly known as Broca's aphasia today arises from lesions in Broca's area, the adjacent lateral cortex (Brodmann areas 6, 8, 9, 10, and 26), the insula, and the nearby white matter. The basal ganglia also have an important influence on articulation and grammar.

This produces the characteristic symptoms of this type of aphasia, since these brain structures are responsible for the correct use of prepositions, conjunctions, verbs, etc. Giving rise to problems both in production and in understanding as long as they are phrases whose meaning depends on prepositions and specific order of the words.

Causes of anomie and agrammatism

On the other hand, anomia and agrammatism seem to be caused by subcortical lesions or in the lower frontal lobe. These symptoms, together with the articulatory deficit, can be combined in different ways depending on the location of the brain damage and the recovery phase in which the patient is.

It seems that in Broca's aphasia there is a deficit in syntactic processing, leading to problems with the grammatical components of language. That is, there are many phrases in which its meaning depends on a single preposition, adverb or conjunction and if this is not processed well it will not be understood.

Types

Type I, minor or Broca's area aphasia

It is caused by brain damage that only covers Broca's area (whose symptoms we describe in the previous section).

Broca type II or extended aphasia

It occurs when the brain injury occupies the frontal operculum, the anterior insula, the precentral gyrus, and the white matter.

It is important not to confuse Broca's aphasia with dysarthria (injury to brain areas that control the muscles used for speech) or with apraxia of speech (inability to plan the sequence of movements of the orophonatory muscles necessary for language, due to injuries acquired brain)

What is its prevalence?

Broca's aphasia is the second most common type of aphasia after global aphasia (Vidović et al., 2011).

It is also known that it is more frequent in men than in women, the opposite happening with Wernicke's aphasia.

What is the prognosis?

The first weeks after the injury, severe and variable symptoms are always observed. However, it improves very quickly in parallel with brain recovery (which usually lasts between 1 and 6 months).

The aphasias that have the best prognosis are those caused by trauma because they usually occur in young people and the injury is not usually very extensive; while vascular ones have a worse evolution since, among other things, it normally affects older people with less brain plasticity and tends to occupy more parts of the brain.

It can be aggravated by the presence of dysarthria, which consists of difficulties in executing the movements of the mouth and tongue to produce speech.

How is it evaluated?

Boston Test for the Diagnosis of Aphasia (TBDA)

It is very useful when it is suspected that the patient has aphasia, to use the Boston Test for the Diagnosis of Aphasia (TBDA).

This helps detect what type of aphasia it is. This test examines all areas of language. Some of them are: comprehension, repetition, denomination, reading, writing…

Token Test

It is a group of 20 tiles with different shapes, sizes and colors. The patient must carry out the orders given by the examiner, for example "touch the blue chip".

This test is useful for understanding at easier levels and in the more complicated it can measure working memory or understanding of grammatical structures (which are affected in patients with Broca's aphasia).

That is, a patient with this problem would do the simpler levels well, but would have errors when the task goes up in difficulty including sentences like: "place the green circle between the red square and the yellow circle."

Boston Vocabulary Test

It consists of a group of pictures with pictures that the patient must name.

Verbal fluency tests like FAS

In this test the subject must say all the words that occur to him that begin with "f", with "a" and with "s" (which corresponds to phonological fluency) while in a second phase he must say all the names of animals that you remember (semantic fluency).

Initial interview

The level of agrammatism can only be seen with the initial interview.

Assessment of other cognitive functions

Assess other cognitive functions that may have been altered with brain damage such as:

- Attention and concentration

- Spatial, temporal and personal orientation

- Memory

- Perceptual skills

- Executive functions

- Intellectual capacity

- Processing speed

- Motor aspects

The diagnosis can also be confirmed through Magnetic Resonance tests.

Treatment

There is no specific and defined treatment for Broca's aphasia, rather it depends on the patient and their symptoms. The main objective of rehabilitation is to improve the quality of life of the person. To treat aphasia, it is necessary to intervene in:

- Language and communication

- Cognitive-behavioral adaptation of the patient to the environment

- Intervention with the family

- Social ambit

This can be achieved with a multidisciplinary team consisting of: neuropsychologists, speech therapists, doctors, nurses, occupational therapists and social workers.

-Considerations

It is important to bear in mind that in order to design an adequate rehabilitation program, it is necessary to focus on the person, that is, it must be created exclusively for that patient to better adapt to their strengths and weaknesses.

It is also essential not to forget the affective aspects. It is very common that after the brain injury or because of the awareness of their limitations, the person has anxiety or depression. Changes can also be observed in emotional expression that must be monitored and improved.

Awareness of the disease can help motivate the person to collaborate with treatment.

-Techniques and therapies

Maximize preserved language skills

Like the comprehension of oral and written language, increasing levels of difficulty, gesturing, drawing and simple arithmetic operations.

Rehabilitation of damaged areas

Rehabilitate deficits due to damaged areas, training:

• Orofacial apraxia, so that language articulation is improved.
• Begin by training the pronunciation of isolated words, then grammatical phrases and later phrases with simple grammatical structure.
• Writing, by copying and dictating words.
• Complete texts in which linking words are missing to improve agrammatism.
• To alleviate deficits with new technologies, such as promoting the use of computers or mobiles (it may be necessary here to train in parallel the motor deficits that can accompany aphasia).

Melodic intonation therapy

It has been observed that there are patients who, surprisingly, do not have language fluency problems when singing. It seems to use the preserved capacities of the right hemisphere (melodic and prosodic) and the rhythmic features and familiarity with the lyrics of the songs.

Wilson, Parsons & Reutens (2006) defend the benefits of this type of therapy, indicating that they facilitate speech, promoting the storage and access to representations of complete sentences.

However, one must be cautious, since in a study by Stahl et al. (2011) indicated that singing was not decisive in the production of speech in this type of aphasia, but what was important was the rhythm itself.

They also suggest that the good pronunciations of the lyrics of these patients may be due to long-term memory and the automation of the lyrics of the songs, whether they are sung or spoken.

Therapy of induced restriction aphasia

In this type of treatment, the patient is “forced” to speak without using compensatory strategies, unless they are absolutely necessary. Treatment is usually very intense, for several hours a day; and it is based on the enhancement of brain plasticity mechanisms to recover lost functions.

Imitation

In a study carried out by the University of South Carolina in 2013: it was stated that patients with this type of aphasia significantly improved their verbal production when they had to imitate people who appeared in videos pronouncing words and phrases.

References

1. Aphasic agraph. (2015, April 1). Obtained from Nisa Hospitals. Neurorehabilitation Service.
2. Aphasia. (sf). Retrieved on June 21, 2016, from the American Speech Language Hearing association.
3. Drill's Aphasia. (sf). Retrieved on June 21, 2016, from the National Aphasia Association.
4. Meinzer, M., Elbert, T., Djundja, D., Taub, E., & Rockstroh, B. (2007). Extending the Constraint-Induced Movement Therapy (CIMT) approach to cognitive functions: Constraint-Induced Aphasia Therapy (CIAT) of chronic aphasia. Neurorehabilitation, 22 (4), 311-318.
5. Sánchez López, MP, Román Lapuente, F. and Rabadán Pardo, MJ (2012). Chapter 9: Broca's aphasia. In M. Arnedo Montoro, J. Bembibre Serrano and M. Triviño Mosquera (Ed.), Neuropsychology. Through clinical cases. (pp. 111-125). Madrid: Editorial Médica Panamericana.
6. Stahl, B., Kotz, S., Henseler, I., Turner, R., & Geyer, S. (2011). Rhythm in disguise: why singing may not hold the key to recovery from aphasia. Brain, 13 4 (10): 3083-3093.
7. Vidović, M., Sinanović, O., Šabaškić, L., Hatičić, A., & Brkić, E. (2011). Incidence and types of speech disorders in stroke patients. Acta Clinica Croatica, 50 (4), 491-493.
8. Wilson, S., Parsons, K., & Reutens, D. (nd). Preserved singing in aphasia: A case study of the efficacy of melodic intonation therapy. Music Perception, 24 (1), 23-35.