January^j?^ P H Y S I O T H E R A P Y Page Three

TH E  A P H A S I C  P A T I E N T
by THELMA STOHR, M.A. (Log.), (Rand.).

Head o f the Speech Therapy Department, Johannesburg Hospital.

F O L L O W IN G  dam age to certain areas o f the brain, 
J  some individuals may develop aphasia. This is the 
. airment o r loss o f the ability to use or com prehend 
l a n g u a g e  after it has been acquired.

Types of Aphasias:
There are two main types o f this problem. (1) The 

sensory or receptive type, which is characterized by an 
inability to understand the written or spoken word.
(2) The m otor o r expressive type which results in the loss 
of power to speak write o r draw . It is rare indeed to find 
an individual suffering from  pure m otor or sensory aphasia. 
Usually there is a com bination o f the two, with a greater 
predominance o f the m otor disability.

Generally speaking, aphasia is caused by two main 
types o f lesion. (1) Those resulting from external causes. 
These are usually o f traumatic origin such as gunshot 
w o u n d s  and accidents. This type usually responds well 
to speech therapy especially when treatment is begun as 
soon as possible. (2) Aphasias o f vascular origin are the 
commonest type found in the Speech Therapy Department. 
Apart from the severely deteriorated speech condition, 
most of these cases show a great loss o f learned material. 
An educational estimate usually reveals a loss o f even the 
rudiments o f reading, writing and arithmetic. These cases 
also tend to show an intellectual deterioration as well as an 
inability to maintain adequate emotional control.
Incidence of Aphasia:

While traumatic' aphasics are comparatively rare in a 
peace time speech clinic, the incidence o f vascular aphasia 
is quite high. There also appears to be a greater number 
of males as compared with females. Our files reveal that 
approximately 66% o f patients referred for speech therapy 
are males. With regard to the rate o f recovery however, 
there does not appear to be any appreciable sex difference.

In a recent survey among non-European patients it 
was found that the greatest number o f cases referred for 
speech therapy were aphasics o f vascular and traumatic 
origin. The incidence o f traumatic aphasias was higher 
than that in the European group. It is not possible to 
compare the rate o f recovery between the two racial 
groups as yet.
Cerebral Dominance:

The importance o f the left cerebral hemisphere for 
speech and allied functions in right handed persons is an 
acredited fact, what ever may be its correct explanation. 
In the same way it has commonly been assumed that in the 
case of left handed persons the same importance is attached 
to the right hemisphere. Thus unequivocal handedness 
whether right or left has been thought to imply a corres­
ponding dominance o f the hemisphere contralateral to the 
preferred hand.

Evidence concerning aphasia and left sided hemiplegia 
in left handed individuals is available in the literature. 
However it is interesting to note that few if any lefthanded 
hemiplegics suffering from aphasia, have been found in 
the Speech Therapy Department. Most o f the cases referred 
for speech re-education have invariably shown a greater 
or lesser degree o f right sided hemiplegia.

In retraining, the speech therapist usually encourages 
the use o f the unaffected hand, if the hemiplegia shows little 
sign o f improvement. This may or may not be in conflict 
with the various theories on speech therapy for aphasics. 
The fact remains that a comparatively few patients ever

regain the full use o f the preferred hand again, and it is 
important that the patient learns to write as soon as possible, 
since this ability is tied up with speech and language.

Speech Therapy:
Treatment for each patient is varied to meet the indi­

vidual’s needs. These cover the major categories o f com­
prehension, speaking, reading, writing and arithmetic. 
Before beginning therapy, several factors have to be taken 
into consideration. These include the length o f time which 
has elapsed between the onset o f the problem and the 
beginning o f therapy. The longer the period, the poorer 
the prognosis. The premorbid educational, cultural and 
intellectual level must also be considered, since the treat­
ment should be based on the patient’s background. Finally 
a careful assessment o f the loss o f the language modalities 
must be made. This gives a pointer to prognosis and treat­
ment.

Whether the patient is predominantly a motor or sensory 
type, a most important aspect must be borne in mind, 
namely, regardless o f the extent or localisation o f the injury, 
new association pathways must be established. Every 
avenue o f approach is utilized in presenting material for 
relearning. The visual stimulus is frequently the most 
important. The patient sees the object, the written word, 
watches its formation on the therapist’s lips, and then his 
own attempts in the mirror. The auditory stimulus is 
given at the same time. Listening to the therapist saying 
the word or sound, and then comparing it with his own 
is another important step. Emphasis is also placed upon 
the kineasthetic pattern, and the patient is made conscious 
o f the “feel” o f the sound or word.

Some o f the severely amnesic cases who cannot recall 
long enough to say even a short word are the most difficult 
o f all patients. Their training must consist o f constant 
repetition o f the bare rudiments o f the alphabet and simple 
words that can be used every day. The less difficult sounds 
are learned first and then combined into easy words. All 
preliminary drills are written in a notebook as they are 
required so that there is a record o f what has been learned.
As facility is acquired, the exercises are divided into units 
so that there are some words at the patient’s command to 
meet the needs o f simple situations. For example a 
unit may be built around parts o f the body, and includes 
such words as “thumb”, “mouth”, “arm”, and so on. 
Whenever possible they are used in short sentences.

During the therapy period the problem o f persever­
ation must be dealt with. Re-iteration o f earlier taught 
words tend to crop up when new words are being learnt. 
Fatigue also affects the therapy session. Even if allowances 
for brief rest periods between speech attempts are made, 
patients often reach a point beyond which no adequate 
response can be elicited. As the treatment progresses this 
condition tends to improve to a certain extent.

Aphasia is a serious condition, and the patient is 
given every opportunity for speech re-education even if 
prognosis is poor. It is o f great importance that the indi­
vidual suffering from aphasia be able to express his wishes 
even though the words are meagre and incorrectly used. 
He is often in a state o f emotional turmoil and even a poor 
ability to express himself affords an outlet.

Speech therapy is not necessarily the sole solution to 
the problem o f aphasia. Teamwork between the physic- 
therapist the occupational therapist and the social worker 
often produces more beneficial and lasting results.

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