Recovery in Aphasia

Spontaneous Recovery

Recovery in aphasia patients that happens in most individuals regardless if they receive treatment

True or false - it is easy to determine if recovery is because of a treatment versus spontaneous recovery

False - it is difficult to discriminate between the two

What changes does recovery include?

Restoration (reactivation of dead brain areas), Reorganization (enabling other areas to take over for the injured parts) and Compensation (new ways to perform behaviour) at neural and behavioural levels

True or false - aphasia recovery/plasticity happens only at the macro level (i.e., behavioural changes
)

False - recovery can happen at the microlevel (i.e., neuronal changes) too

What is neuroplasticity at the microlevel called?

Neural plasticity

What is neuroplasticity as the macrolevel called?

Behavioural plasticity

What two things can cause plasticity?

Changes in the environment or changes in the organism itself

Describe the differences in the video of Gabby Giffords following her brain injury vs one year from injury

Initially, Gabby has major word finding difficulties, displays paraphasias, the bulk of her difficulties is at the expressive level, and she appears severely impaired at this point.
After 1 year, Gabby's speech is more fluent, but still somewhat effortful (a bit choppy), but there is a big difference from previous video

What is the typical course of recovery in aphasia?

Period of rapid recovery followed by steady improvement with a gradually decreasing rate

When is the biggest amount of recovery made for aphasia patients?

in the first year

What is the the frame of rapid recovery post stroke?

< 1 month

What are the likely causes of rapid recovery post stroke?

Resolution of edema and hypoprofusion (as you heal, blood flow improves so there is rapid improvement from this)

What is the likely cause of long-term improvement post stroke?

Functional compensation from intact brain regions

Where does functional compensation occur for aphasia?

Undamaged LH regions (especially perilesional areas next to language areas) and homologous RH regions (RH takes over some of the functions)

Why is RH compensation controversial?

It is a debate whether it is helping or hindering recovery. It may be absent, adaptive, or maladaptive (likely depends on person, task, strategy, timing, etc.)

What does sustained functional recovery depend more on?

likely depends more on restoration and reorganization of LH networks rather than RH compensation

How to measure recovery? (i.e., improvement in impairment test scores vs. function vs. QOL)

Recovery can go beyond testing scores, impairment is the easiest to measure and tends to be the focus since it is easy. QOL and function (especially communicative function) are more difficult to measure.

Is the right hemisphere involved in comprehension or production more?

Likely comprehension

What is the problem with repeated testing when measuring recovery?

Practice effects as people will become familiarized with the tests and questions - can make it look like there has been recovery when there hasn't been

How to calculate test change score?

Later score minus earlier score

True or false - the PICA is the main scale used to test cognitive functioning

False

True or false - aphasic individuals follow a very similar path to recovery

False - people vary widely in the amount of recovery

On average, when does the fastest rate of recovery occur?

During the first three months

When does recovery really start to taper off?

1 year

True or false - after one year function and quality of life typically does not change

False - real life improvement may occur for many years post-event even if test scores aren't changing

True or false - the end of recovery is marked when core language skills return to premorbid levels

False - core language skills often do not return to premorbid levels

When is end of recovery demonstrated?

When there is a plateau in test scores

Explain the "myth of the aphasia plateau"

Plateau does not mean that recovery stops, the brain will continue to change improve if worked on - progress is possible years after the stroke.

Briefly explain the Life Participation Approach to Aphasia (LPAA) as an alternative approach.

The LPAA places life concerns at the centre of all decisions, focuses on life participation and social relationships, it shifts the focus from deficits/remediation to inclusion and life participation.

What is the ultimate goal of LPAA?

Re-engagement into everyday society

What is the difference between impairment-based therapy and LPAA?

LPAA considers the whole person (it expands on ordinary impairment-based therapy) and how to connect therapy goals to task to participate in their everyday activities

Prognostic Variable Approach

Compare patient's biographical, medical, and behavioral characteristics against how these variables are believed to influence change in aphasia

What is something you must be wary of when using the prognostic variable approach to predict recovery?

Effects are based on group data and may not apply to all individuals and outcomes are measurement with impairment-based tests (not function or QOL)

Is being older or younger give you a better prognosis for recovery?

Younger

Does being female or male give you a better prognosis for recovery?

Female (because males only tend to use one side of their brain; evidence is rather weak for this)

Does being right handed or left handed give you a better prognosis for recovery?

Left handed (L-handed people tend to use both hemispheres and have less asymmetry)

True or false - having higher education/high premorbid intelligence does not impact recovery

False (less creative/adaptive people do not tend to recover as well)

What is one caveat of age being an indicator of recovery prognosis?

Sometimes if health effects are controlled for age it becomes less of an issue

True or false - the type of injury impacts recovery prognosis

True

True or false - Wernicke's aphasia and aphasia from a closed head TBI have worse recovery prognosis than aphasia from a stroke

False

True or false - subcortical aphasia has a better recovery prognosis than cortical

True

True or false - single lesions are harder to recovery from than multiple

False

True or false - lesions in the perisylvian areas are harder to recover from than those in marginal zones

True

True or false - hemorrhagic strokes have worse recovery than ischemic in terms of aphasia

False

True or false - smaller lesions have worse recovery prognosis than larger lesions (in terms of aphasia)

False

How do physical and psychological issues impact recovery prognosis?

Motor speech disorders, hemiplegia, depression, and anxiety can impact recovery, for instance, hemiplegia impacts QOL so it can decrease practice opportunities

What do the behavioural variables focus on?

The overall severity of aphasia

Why do auditory comprehension deficits impact recovery?

They have decreased insight into their disease and therefore have more difficulties with rehabilitation; it impacts them being able to take suggestions and be coaches impeding recovery

True or false - it is common for people to change from fluent to non-fluent types of aphasia and vice versa

False - people do not change from fluent to non-fluent in recovery

What type of stroke has the least severe initial deficits?

Anomic Aphasia

What type of stroke has the most severe initial deficits?

Global aphasia

For the aphasia quotient, anything above what value is considered 'normal'

94

True or false - Broca's and Wernicke's aphasia have been shown to have similar rates of recovery

True - although note that Broca's starts worse than Wernicke's on average

True or false - people can change from one type of aphasia to another

True - but recovery often stops at anomic aphasia (and can't go b/w non-fluent and fluent types)

Overall, which aphasia shows the most improved recovery (based on the aphasia quotient) over time?

TBI-related aphasia

Compared to Broca's and Wernicke's, how does the rate of recovery for conduction and transcortical aphasias compare?

Conduction and transcortical aphasias have less severe initial deficits

What are examples of behavioural variables that may impact recovery?

Awareness of deficit, personality & motivation, and social variables

How should recovery be predicted for individuals?

Because prognosis is multifactorial, clinicians need to investigate each factor and their interactions to see how likely it is that they will influence language recovery

True or false - Symptoms of aphasia can present the same across languages

False

Percentage of bilingual Canadians

About 20%

What is a parallel recovery pattern in bilingual aphasia?

When the languages improve in tandem, both languages recover at an equal rate in similar ways

What is a differential recovery pattern in bilingual aphasia?

Nonparallel; One language improves significantly more, most common nonparallel

What is a selective recovery pattern in bilingual aphasia?

Nonparallel; Only one language improves at all, 3rd most common non-parallel

What is a blended recovery pattern in bilingual aphasia?

Nonparallel; Code-mixing/switching becomes markedly abnormal, 2nd most common non-parallel

What is an antagonistic recovery pattern in bilingual aphasia?

Nonparallel; As one language improves the other deteriorates, least common

What portion of bilingual aphasia cases are parallel recovery patterns?

3/4

True or false - bilingual individuals with aphasia should be assessed and treated in their dominant language

False - because a single factor has not been identified to predict the status of one language relative to another, it is imperative that individuals are assessed in all languages

What are some factors influencing recovery in bilingual aphasia?

Age of language acquisition, premorbid proficiency of languages, frequency of use of language at time of stroke, linguistic demands, emotional attachment to language, and post-morbid frequency of use and linguistic environment