Clinical Implications of a Neuropsychological Approach to Aphasia Aura Kagan MA (Speech Pathology) (Witwatersrand),* Michael Saling PhD (Witwatersrand),t Margaret Marks Wahlhaus MA (Witwatersrand)* * Department of Speech Pathology and Audiology, University of the Witwatersrand, Johannesburg, t Department of Psychology, University of the Witwatersrand, Johannesburg. ABSTRACT This paper deals with the clinical implications arising out of a study designed to evaluate Luria's approach to the cerebral organi- sation of higher mental functions such as language. The research took the form of four in-depth case studies of aphasic patients and involved a comparison of neuropsychological predictions as to the site-of-lesion with radiological findings (cranial compute- rised tomographic scanning). Correspondence was felt to be good in most instances, indicating that Luria's theory provides a valid framework within which to relate clinical symptomatology andfocal brain damage. The fact that Luria places clinical practi- ce on a firm theoretical foundation is seen as being advantageous and is discussed in relation to assessment and therapy. OPSOMMING In hierdie studie word Luria se benadering tot die organisasie van hoer-verstandelike funksies soos onder andere, taal, evalueer. Die kliniese implikasies van die studie kom veral onder die soeklig. Die navorsing het uit vier gevalle studies van afatiese patiente bestaan. 'n Vergelyking is tussen die neuropsigologiese simptome as voorspelling van die lokus van die letsel, en radiologiese bewysings, getref. Die ooreenkoms tussen die neuropsigologiese voorspelling en die lokus van die letsel was in meeste gevalle goed. Dit dui dus aan dat Luria se teorie 'n geldige raamwerk verskaf waarbinne kliniese simptomatologie enfokale breinskade gekoppel kan word. Die kliniese praktyk wat Luria op so 'n vaste teoretiese grondslag bou, word met betrekking tot diagnose en behandeling bespreek. The speech clinician involved in the assessment and remedia- tion of aphasia is confronted by a bewildering array of ap- proaches to this complex disorder. This paper focuses on some clinical implications arising out of a study** designed to evaluate, within the context of speech pathology, the neuro- psychological approach developed by Luria, who has been described as "this century's leading Soviet figure in aphasiology".8 According to Hatfield,8 Luria is one of the few leading aphasiologists who has combined clinical practice with theory. This is seen as a major advantage, but it does imp- ly that an understanding of the general neuropsychological principles upon which Luria based his work is essential for the clinician who wishes to use this approach. A brief resume of theoretical aspects relevant to this paper follows. Luria viewed his work on the organisation of higher mental functions in the brain as incorporating the positive aspects of two opposed approaches to the subject. He felt that neither the mechanistic narrow view, given its major impetus by the work of Broca,1 nor the integral or noetic view, supported by authorities such as Goldstein,5 successfully accounted for the cerebral organisation of higher mental function. Both views in Luria's opinion contributed to misunderstandings of this com- plex subject. **This study formed part of the first author's MA dissertation entitled "A © SASHA 1983 In a re-examination of concepts such as function, localisation and symptom, Luria retained and integrated parts of both the extreme views mentioned above, while successfully avoiding the less desirable aspects, namely, the idea that complex men- tal processes can be located in a single focal area of the brain on the one hand, and that such activities involve the whole brain in an undifferentiated fashion on the other. According to Luria,12 13 one should conceptualise the higher mental functions as functional systems with an extremely complex composition. The performance of iany such mental activity necessarily involves the co-operation of many dif- ferent parts of the brain. Luria divides the brain into three main functional units. These units and their further subdivision into hierarchically arranged cortical zones, are described in detail in his works'2 13 and are represented schematically in Figure 1. Speech and language are thus viewed as complex functional systems to which many different cortical areas contribute (See Table 1). Luria13 refers to these cortical areas as "links" within the functional system. Damage to any one of these areas affects its ability to function optimally and it thus becomes a weak or broken link within the chain of the functional system. Although any damaged link :hological Approach to Assessment in Aphasia". The South African Journal of Communication Disorders, Vol. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Clinical Implications of a Neuropsychological Approach to Aphasia 57 UNITS I II III (Regulation of (Reception, analysis Programming, tone, waking and storage of regulation and mental information) and verifi- state) cation of activity ZONES 1. Primary: receives impulses from or sends them to the periphery 2. Secondary: processes incoming information or prepares programmes for action 3. Tertiary: responsible for the integrative participation of many areas Figure 1 Schematic view of Luria's division of the brain into units and zones. will affect the functional system, the effects will vary depen- ding upon the particular link involved. The interference with the normal function of a specified cortical area results in a primary or fundamental problem. The secondary or systemic effect of this primary problem is the breakdown in the func- tional systems to which the area normally contributes. Two points should be noted at this stage. First, what appears to be the same symptom complex, may actually be related to one of several primary problems. For example, the common aphasic symptom of word-finding difficulty may be caused by a breakdown in phonemic hearing, problems with simultaneous synthesis,' or difficulties at the articulatory level. Second, because the function of a specific cortical area may be a link in several functional systems, a focal lesion might result in a group of symptoms which are seemingly unrelated. However, appropriate neuropsychological analysis reveals that the symptom complex (consists of "externally heterogeneous but, in fact, internally' interconnected symptoms".13 For ex- ample, a lesion of the overlapping tertiary zone in Unit II results in a specific primary problem, namely, difficulty with simultaneous synthesis. However secondary or systemic effects include a problem with logical-grammatical relationships as well as acalculia. Rather than attempting to localise complex functional systems such as receptive or expressive language, an attempt should be made to identify the various focal areas of the brain which make a specific contribution to the system as a whole. The clinician who is able to localise the lesion and who understands how the resultant primary problem may af- fect the functional system under consideration, is then in a position to plan appropriate treatment. Thus within Luria's framework, a classifactory label attached to an aphasic patient is not merely descriptive but is rather an indication of the primary problem underlying the presenting symptom cluster (see Table 2). Luria14 himself recognised the need to evaluate his work in terms of some objective criterion and it was with this in mind that the present research evolved. The study was designed to assess Luria's views on the manner in which symptomatology relates to brain damage. More specifically, the aim was to compare the site-of-lesion in aphasic patients as ascertained by Luria's neuropsychological tests, with the results of radiological findings based on cranial computerised tomography (C.T.) scanning. The study itself will be described very briefly and will be followed by a discussion of clinical implications. METHOD This research took the form of four in-depth case-studies. SUBJECTS All subjects were diagnosed as aphasic by a speech therapist and a neurologist. Etiology was required to be a CVA resulting in a focal lesion that could be observed on a cranial CT scan. The upper age-limit was set at 55 years and hearing was re- quired to be within normal limits. A minimum period of three months had to have elapsed since the onset of the CVA to allow for spontaneous recovery in accordance with the, study by Demeurisse, Demol, Derouck, deBeuckelaer, Coekaerts and Capon.4 See Table 3 for a description of the subjects. PROCEDURE Subjects were scanned (cranial CT scanning) in order to establish the presence of a focal lesion. As this was a blind Table 1 An illustration of some aspects of the roles played by different cortical units and zones in the functional system of speech and language (with respect to left/dominant hemisphere function) UNIT I Maintains the optimal level of cortical tone necessary for the functioning of the systems of speech and language UNIT Π Auditory analyser Visual analyser Tactile-kinaesthe- tic analyser Zone 1 Receives auditory impulses Receives visual impulses Receives sensory impulses Zone 2 Recognition and processing of speech sounds or phonemes Visual gnostic functions Ibctile-kinaesthetic gnostic functions Zone 3 Integration of successive input UNIT ΠΙ Zone 1 Outlet channel for movement 1 Zone 2 Planning of movement Zone 3 Regulation and verification of complex behaviour D t e Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vbl. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Aura Kagan, Michael Saling and Margaret Marks Wahlhaus Table 2 Luria's classification of aphasia as related to primary problems and areas of cortical damage Type of aphasia Primary problem Cortical area Efferent motor Afferent motor Dynamic Sensory Acoustico-mnestic Semantic Skilled sequential movements Motor kinesthetic afferentation Speech drive Phonemic hearing Audio-verbal memory Simultaneous synthesis affecting quasi-spatial operations Pre-central Post-central Frontal lobes Superior, posterior temporal lobe Middle temporal lobe Posterior inferoparietal lobe (tertiary, overlapping zone) Table 3 Description of subjects Subjects Ο Ρ V D Age at time of testing 49 years 50 years 44 years 23 years Sex male male female male Time elapsed since onset 9 months 5 months 1} years almost 2 years Immediate effects of the CVA including progress in first 3 weeks Could not speak for first 3 days. Recovered slowly Could not speak for first 3 days. Recovered slowly. Paralysis of right upper limb - recovered completely Could not speak. Dense right hemiplegia. Coma for 2£ weeks. Right-sided hemiplegia. Speech therapy Immediately after stroke for 4 months - Immediately after stroke. Discontinued after 1 year Immediately after stroke until the present time Pre-morbid conditions Heart condition (3 previous heart attacks). High blood pressure. Diabetes diagnosed at age 35 years — Post-morbid complications in addition to aphasia Athetoid movements of right hand. Hemianopia — Severe hemiplegia Residual hemiplegia and hemiparesis. Jacksonian epilepsy Pre-morbid handedness Drags taken at the time of testing Right Right Right Left Pre-morbid handedness Drags taken at the time of testing Aldomet, Isoptin, Syndol Persanton, Librium Epinutin Epinutin, Persanton, Aspirin, Tegretol Home Language Afrikaans English Afrikaans English Pre-morbid occupation Lawyer Sheet-metal worker Secretary University student Present occupation - Same Housewife Stores issues clerk Pre-morbid educational level 1- I University degree Standard five Matriculation. Secretarial diploma University student study, the researcher did not have access to the scans at this stage, and thus had no knowledge of the extent or localisa- tion of the lesion. Luria's Neuropsychological Investigation (LNI)2·3 was then administered and analysed. The details of the neuropsychological process of analysis have been describ- ed in Kagan.» Once a neuropsychological decision as to the site-of-lesion for each subject had been reached, this was handed to a person uninvolved in the study. The cranial CT scans were then made available and were interpreted by a radiologist. A conclusion as to the correspondence between the neuropsychological and radiological findings was reached. RESULTS The results of the study are summarised in Table 4 which com- pares neuropsychological predictions as to the site-of-lesion with radiological findings (cranial CT scans). Bearing in mind normal individual variation in the cerebral organisation of higher mental functions, as well as subject characteristics en- countered in this study (for example, one left-handed subject and one with a premorbidly low level of intellectual function), the correspondence between the neuropsychological and radiological findings is felt to be good. However, mention must be made of instances of non-agreement. In certain cases, The South African Journal of Communication Disorders, l. 30 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Clinical Implications of a Neuropsychological Approach to Aphasia Table 4 Summary of results comparing neuropsychological and radiologi- cal findings for all four subjects Site-of-lesion SUBJECT Ο SUBJECT Ρ SUBJECT V SUBJECT D HEMISPHERE RIGHT 1 • · • · 0 1 1 LEFT • · • · 1 • · • · 1 • · • · 1 • · • · 1 CORTICAL AREAS Sensorimotor • · • · 0 • · • · 1 • · • · 1 • · • · 1 Tertiary parietal • · • · 1 • · • · 0 • · • · 1 • · • · 1 Prefrontal 1 • · • · 1 • · • · 1 • · • · 1 Superior, posterior temporal 1 1 0 0 Middle temporal • · • · 1 1 • · • · 1 0 Occipital • · • · 1 1 1 1 Radiological Confirmation of Neuropsychological Findings 1 Confirmed 0 Not confirmed done by Hardyck.7 However, it is more difficult to account for the same situation arising in Subject V, who is a right- hander. The fact that damage to Wernicke's area did not result in the expected symptomatology, despite good correspondence in other areas, leads one to consider the possibility of a premorbid bilateral representation of language in this subject. Despite the above instances of non-agreement the fact that the principles of Luria's neuropsychological analysis were useful in arriving at the site-of-lesion in most cases, indicates that his theory of functional localisation, in which the concept of the primary problem plays such a central role, is a valid means of relating observed symptomatology to focal brain damage. DISCUSSION This result has clinical implications for the speech clinician dealing with aphasia as Luria's views on diagnosis and therapy are logically related to his theory. First, as regards classifica- tion, Luria's approach12·13 differs from many traditional ap- proaches e g 16. Neuropsychological Findings • · · • · · Indication of damage Contra-indication of damage there was no evidence of structural damage to support clinical symptomatology. In this instance, it is possible that there is damage that has not been picked up on the scans. It should be borne in mind that the scanning techniques used here provide a static representation of extant neuropathology. It is our belief that neuroradiological procedures which can detect physiological or functional change such as blood-flow, for ex- ample, might correlate better with neuropsychological dysfunction, than the static structural damage observed on the scans used in this study. it is felt to be more important to account for the cases in which r e i s 3 definite indication of damage on the scan but no evidence of the clinical symptoms one would expect from such amage. In both subjects Κ and D, for example, there was little 0 r no clinical manifestation of observed damage to the ^Penor posterior temperal lobe (Wernicke's area). In subject 0 w a s premorbidly left-handed, there is a strong Possibility of bilateral representation in the premorbid erebral organisation of language, lending support to work D e Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vl. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 60 While accurate classification is stressed, this does not, as mentioned previously, merely involve the attaching of descrip- tive labels. Rather, classification gives an indication of the real (primary) problem or problems underlying the often confus- ing picture presented by the patient. As can be seen from Table 5, although the types of aphasia represented range from the highly specific, such as afferent motor aphasia, to those of a broader nature, such as dynamic and semantic aphasia, they all relate to underlying brain damage in the same fashion, namely, focal brain damage results in specific primary pro- blems which are manifested in the symptoms we observe. Aura Kagan, Michael Saling and Margaret Marks Wahlhaus One of the advantages of Luria's approach is that it enables one to be specific. For example, the commonly used term 'global aphasia' indicates that there are gross expressive and receptive language defects related to an extensive lesion probably in- volving both anterior and posterior parts of the brain.10·15 It might be for more useful clinically to have more detail about the exact extent of the lesion and the primary problems which need to be tackled. In other words, global aphasia should be viewed as a complex combination of several primary problems rather than as an undifferentiated whole. Similarly it would be more useful theoretically and clinically to classify complex Tbble 5 Classification of subjects according to the primary problem and types of aphasia Subject Primary Problem "type of aphasia in terms of Luria's classification Ο Visual agnosia for letters Spatial and quasi-spatial difficulties Mild audio-verbal memory difficulties Semantic aphasic Mild acoustico-mnestic aphasia Ρ Some quasi-spatial problems Mild semantic aphasia V Efferent and afferent organization of movement and speech Quasi-spatial difficulties Audio-verbal memory Regulation of movements and actions Efferent motor aphasia Semantic aphasia Acoustico-mnestic aphasia Possibility of dynamic aphasia Efferent and afferent organization of movement and speech Quasi-spatial difficulties Efferent aphasia Afferent aphasia Semantic aphasia "fable 6 Primary problems and effects relevant for therapy (Subject V) Primary problem Effects on speech and language Other major effects of relevance to the speech clinician Efferent and afferent organization of movement and speech Severe articulation problems Absence of narrative speech Hemiplegia Simultaneous synthesis (quasi-spatial problems) Quasi-spatial functions, for example, difficulty in understanding logical-gram- matical speech Note: Some difficulties, such as naming and comprehension Audio-verbal difficulties Difficulty with series of verbal stimuli Regulation of movements and actions Possibility of problems with internal speech Problems of,motivation, atten- tion, perseveration, attention to irrelevant stimuli, inhibition of actions, etc. diff.cu.ties may be due to a c o m b W o 7 S o m ^ ~ * * * P r o b l e m i n « * » * * « • Table 7 Primary problems and effects relevant for therapy (Subject O) Primary problem Simultaneous synthesis (quasi-spatial problems) Agnosia for letters Mild audio-verbal difficulties Visual field defect Effects on speech and language Word-finding difficulty Some difficulty with confrontation naming Mild problems with logical- grammatical structures Severe alexia Difficulty with the retention of series of auditory material in the absence of semantic cues / Other mqjor effects of relevance to the speech clinician Hemianopia The South African Journal of Communication Disorders, Vol. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Clinical Implications of a Neuropsychological Approach to Aphasia 61 cases of aphasia, such as Broca's, in terms of the primary pro- blems involved (see Table 5) instead of grouping them together in a broad symptomatological category often inac- curately related to an isolated focal area of the cortex. Second, in order to plan therapy appropriately, it is necessary to relate the primary problem to speech and language. Other effects of the primary problem while not directly related to speech and language, must also be taken into account. The following charts (see Tables 6 and 7) have been drawn up as an illustration of one way in which the speech clinician can relate the primary problem to the overall symptom complex. Subjects V and Ο have been chosen as examples because they represent different levels of severity and complexity. In the former case (V), brain-damage was extensive and the clinical picture highly complex, making it difficult to identify the underlying primary problems. In the latter case (O), the primary problems were relatively easy to identify. These therapy charts need to be individually tailored for each patient. Being able to isolate the primary problem does not mean that the entire symptom profile can be predicted, although symptoms should be able to be explained in terms of the primary problem. The neuropsychological examination, in addition to giving information about the site-of-lesion, enables the clinician to be fairly specific about the functional effects of this damage in the individual being examined. For example in subject V, there was evidence of both efferent and afferent motor aphasia. However, the latter predominated and would therefore require more attention initially. It was observed, that if this subject was able to circumvent kinaesthesis by compen- sating with her strong visual abilities or a combination of audio-visual stimulation for example, she was able to ar- ticulate reasonably well. This fact should be used in construct- ing an appropriately graded therapy programme. In addition, the major effects of prefrontal damage in the case of Subject V would definitely affect therapy adversely and would make for a far less favourable prognosis. Examples of the symptoms being referred to are problems of motivation, attention to ir- relevant stimuli, and inhibition of actions, among other things. The clinician must therefore be aware of which problems are of major importance and require most attention. It must be understood that 'important' in this case refers to the fact that the particular problem is having a major effect on the patient's ability to communicate. For example, in the case of Subject Ο (see Table 7), the mild audio-verbal difficulties noted did not affect communication significantly. CONCLUSION The implications of the findings of the study reported here have been discussed in relation to classification and therapy. Although these have been discussed separately, it is hoped that the logical and cohesive nature of Luria's neuropsychological othe7 ' S C V i d e n t i n t h e w a y i n w h i c h t h e s e topics relate to each The fact that Luria places clinical practice on a firm eoretical foundation is seen as being advantageous to the speech clinician, who, with her theoretical background and t j C C e s s t 0 c l i nical material, has in turn a significant contribu- °n to make to the neuropsychological study of aphasia. Fur- D e Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vl. 30, 1983 ther research in the field would be usefully augmented by clinical studies evaluating, in particular, Luria's approach to assessment and remediation in aphasia. Feedback from such studies could for example be used to remodel aspects of Luria's classification of aphasia which do not seem to tie in with clinical reality. On a more practical level, Luria's work should be made available in a format especially designed for use by the speech clinician involved in the field of aphasia. Although a considerable investment of time and energy is re- quired of the speech clinician interested in applying Luria's ap- proach, the effort is felt to be worthwhile "for practical- minded field speech pathologists, who are willing and flexible enough to try to understand the underlying philosophy".8 ACKNOWLEDGEMENTS Financial assistance from the Medical Research Council and the George Elkin Bequest is gratefully acknowledged as are a Senior Bursary and Freda Lawenski Scholarship Fund Grant administered by the University of the Witwatersrand, Johannesburg. REFERENCES 1. Broca, P. Remarques Sur le Siige de la Faculty du Langage Articuli, Suivies d'une Observation d'Aphimie (Perte de la Parole). Bulletins de la Societe Anatomique de Paris, 1861, 6, 330-357. 2. Christensen, A. L. 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