medical treatment EVALUATION OF THE LANGUAGE COMMUNICATIONAL SKILLS OF PERSONS WITH BROCA’S APHASIA AS A CONCOMITANCE FROM CEREBROVASCULAR INSULT

ПРОЦЕНА НА КОМУНИКАЦИСКИТЕ ЈАЗИ Ч НИ СПОСОБНОСТИ КАЈ ЛИЦА СО БРОКИНА АФАЗИЈА КАКО ПОСЛЕДИЦА ОД ЦЕРЕБРОВАСКУЛАРЕН ИНСУЛТ Илија ТОДОРОВ 1 Владимир ТРАЈКОВСКИ 2 Одделение за физикална медицина и рехабилитација, ЈЗУ Здравствен дом „Скопје“ – Скопје 1 Филозофски факултет Институт за дефектологија 2 EVALUATION OF THE LANGUAGE COMMUNICATIONAL SKILLS OF PERSONS WITH BROCA’S APHASIA AS A CONCOMITANCE FROM CEREBROVASCULAR INSULT Ilija TODOROV ¹ Vladimir TRAJKOVSKI ² Department of Physical Medicine and Rehabilitation, PHF Health center “Skopje” – Skopje¹ Faculty of Philosophy, Institute of Special Education and Rehabilitation² Примено: 01.12.2010 Прифатено: 11.01.2011 UDK: 616.89-008.434:159.946.3 Received: 01.12.2010 Accepted: 11.01.2011 Original article Резиме Abstract Лицата со Брокина афазија побрзо се соци­ја­ли­зираат во општеството, поради раниот реха­билитациски третман со примената на логопедска терапија. Во почетокот на болес­та, говорната продукција е напорна, а гово­рот е со променета просодија, болниот се изразува исклучително со именки и работни гла­голи, а се користи и со мимика и гестови. Основната цел на ова истражување е про­цен­ката на комуникациските јазични спо­собности кај лицата болни со Брокина афа­зија, уште во акутната фаза на болеста, да се испитаат и утврдат мислењата на лицата со Брокина афазија, членовите на семејствата и медицинскиот персонал околу примената на раниот рехабилитациски третман со говорна терапија. Основните задачи на ова истражување се да се утврди дали кај лицата со Брокина афа­зи­ја нару­шувањaтa на вербалната продукција че­с­то пати се проследени со говорна апрак­си­ја и аграматизам. Во истражувањето се вклу­­че­ни две групи на испитаници. ­Истражувањето беше изведено во Скопје, во пе­риод од три месеци, а пода­то­ците кои што се добиени од истра­жу­вањето се групирани, та­белирани, обра­ботени и графички при­ка­жа­ни со употреба на програмата Microsoft Office Excel 2003, а разликите во податоците на испитаниците се анализирани со  χ 2 тестот со ниво на зна­чајност од  р<0.05 . Од анализата и интер­пре­та­цијата на резул­та­тите можеме да за­бе­лежиме дека кај лицата со Брокина афа­зи­ја, иако речениците им се нецелосни, тие се со­др­жински и инфор­ма­тивни за сого­вор­ни­кот, а аудитивното разбирање е помалку ош­те­­тено од експре­сив­ната функција на го­во­рот. За­клучуваме дека со раниот рехаби­ли­та­циски трет­ман, преку примената на говор­ната те­ра­пи­ја, лицата со Брокина афазијa по­брзо и по­доб­ро се оспособуваат за говорно-јази­чната ко­муникациска способност. Persons with Broca’s aphasia socialize in society much faster, because of the early rehabilitation treatment using the speech therapy. In the beginning of the illness, the voice production is arduous and the speech is with variable prosody. The patient expresses himself exceptionally with nouns and working verbs, also using mimics and gestures. The main purpose of the research is the evaluation of the communicational language skills of persons with Broca’s aphasia, even in the acuteness of the illness. The goal is also to examine and establish the opinion of persons with Broca’s aphasia, their family members and medical staff regarding the use of early rehabilitation treatment with speech therapy. The basic tasks of this research are to determine whether the disturbance of verbal interaction is often followed with speech apraxia and agrammatism among the persons suffering from Broca’s aphasia. Two types of examinees are included in the research. The survey was conducted in Skopje and in a period of three months. The data gained from the research are grouped, tabulated, processed and graphically shownusing the program Microsoft Office Excel 2003. The  differecnces in the data of the examinees is analyzed with Chi squaretest with level of sig­ni­ficance р<0.05. From the analyzis and inter­pre­tation of the results we can see that persons with Broca’s aphasia, although produce in­com­ple­te sentences, they verbalise sentences with content which are informative for their in­ter­lo­cu­tor and the auditory understending is less de­ma­­ged than the expressive funcion of the speech. In conclusion, the study found that early rehabilitation treatment using speech therapy for persons with Broca’s aphasia resulted in faster improvements and better capabilities for speech-language communicational skills. Клучни зборови: комуникациска процена, цере ­ ­ броваскуларен инсулт, Брокина афазија, го ­ ворно-јазични способности, логопедски трет ­ ман. Key words: communication assessment, cerebrovacular insult, Broca’s aphasia, speech-language skills, speech therapy treatment. Адреса за коресподенција: Илија ТОДОРОВ бул. Видое Смилевски Бато бр. 39 – 67 1000 Скопје, Р. Македонија e-mail:  ilija.todorov@yahoo.com Address for correspondence: Ilija TODOROV bul. Video Smilevski Bato n.39 – 67 1000 Skopje, R. of Macedonia e-mail:  ilija.todorov@yahoo.com

Persons with Broca's aphasia socialize in society much faster, because of the early rehabilitation treatment using the speech therapy.In the beginning of the illness, the voice production is arduous and the speech is with variable prosody.The patient expresses himself exceptionally with nouns and working verbs, also using mimics and gestures.The main purpose of the research is the evaluation of the communicational language skills of persons with Broca's aphasia, even in the acuteness of the illness.The goal is also to examine and establish the opinion of persons with Broca's aphasia, their family members and medical staff regarding the use of early rehabilitation treatment with speech therapy.The basic tasks of this research are to determine whether the disturbance of verbal interaction is often followed with speech apraxia and agrammatism among the persons suffering from Broca's aphasia.Two types of examinees are included in the research.The survey was conducted in Skopje and in a period of three months.
through the damaged blood vessel (4).The vascular diseases of the brain, according to the etiology and the clinical picture, are divided into two large groups; haemorrhagic which based on the localization of the change can be: subarachnoidal hemorrhage, intracerebral hemorrhage, intraventricular hemorrhage; and ischemical that can be: transient ischemic attack, heart-attack, embolism (5,6).The Broca's aphasia in the literature is described under the term of motor and expressive aphasia.The term is derived from the name of the French doctor, Broca.However, it is interesting that the patient whom Broca described did not manifest the clinical picture of the aphasia syndrome that now carries his name.Broca's patient actually had aphemia (7).The basic features of the Broca's aphasia are: influent, non-spontaneous voice, which is characterized with incomplete, syntactically simplified and agrammatical sentences, reduced length of the phrase (the length of the phrase in those cases is around 4 words), with changed prosody and difficult "unfit" articulation (8).The disorder of verbal production is often followed by speech apraxia and agrammatism, although those are not invariant characteristics of the Borca's aphasia (9).Agrammatism, although not always present, is a central symptom of the Broca's aphasia.It characterizes with discharge or with misuse of functional words, so-called free morphemes (conjunctions, articles, prepositions, auxiliary verbs) and dependent morphemes (prefix and suffix).Because of a lack of articles, conjunctions, auxiliary verbs and flexible endings, the speech of these patients sounds "telegraphic."With other spoken words, the patients produce a short series of words, which mainly consist of nouns and verbs, "Although the sentences are incomplete, they have content and are informative for the interlocutor."The auditory comprehension is less damaged than the expressive function of the speech.often is enough for everyday communication, so that during the normal conversation the deficit of decoding is not noticeable.The disorders are detected by means of formal and informal tests and the deficits are manifested as deficits in understanding of complex syntactical structures (complex orders) and deficits in understanding the discourses (the stories).The rehearsal of the speech tasks (words and sentences) usually is very severely damaged.The nominative function of the speech is also damaged, and the deficit of naming concepts mainly manifests in accordance with the type of expressive anomie (inability to correct production of a certain concept).Reading out loud is also damaged and the mistakes manifest with difficult articulation of the words as a whole, with phonetic paraphrases and reduced reading speed.Understanding what they read is a deficiency in that extent how is a deficiency and auditory comprehension.Manifest lack of understanding and perception of long text.The disorder in writing goes with full disgraphia to disgraphical forms of milder degree.The mistakes in writing are qualitatively similar to the mistakes in the verbal production.The written discourse is significantly reduced, the letters are damaged, the sentences are syntactically ruined and agrammatical (7,8,10).The Broca's aphasia varies according to the clinical picture as well as the duration of recovery and localization of the brain damages.According to the localization of the lesions and during the recovery, can be distinguished 4 forms of Broca's aphasia.

Прв облик
First form Characteristically, the speech and language function result with fast and complete recovery and the motor deficits of the muscles completely disappear.
An almost identical picture of aphasia gives the lesion of the lower part of the motor cortex and the direct sub cortical white matter.This disorder in the acute phase has milder degree and quickly results with complete withdrawal of the language deficits among patients.
However it can sometimes be present for a longer period in the form of a disorder of the articulation and prosody of the speech.
Typically the patients suffering of the first two forms of Broca's aphasia generally do not develop agrammatism, although in the acute phase there are many limited syntactical abilities (phrase is consist of 1 -2 words).
This form of Broca's aphasia occurs with patients with heart-attack in the level of frontal operculum, on the lower motor cortex, lateral striatum and the subcortical white matter.The recovery of the speech and language abilities lasts for months.The basic symptoms are agrammatism, deficit in finding words and dysarthria.
The fourth form is the chronic Broca's aphasia that usually derives from the global aphasia.
The lesion usually appears in the dorsolateral frontal area, operculum, the anterolateral part of the parietal cortex, the lateral striatum and the periventricular white matter.This recovery of the speech and language process is a long process and very often remains permanent deficits on some language functions (10,11).
Trying to explain the mechanism for the occurrence and origin of the symptoms which form the essence of the clinical picture of Broca's aphasia, aphasialogists often relied on the results from agrammatism research, which is one of the central signs in this kind of aphasiac syndrome.
The interpretation of the mechanism about the occurrence on the language disorders resulted with two relatively independent assumptions: nonlinguistic and linguistic view.The nonlinguistic hypothesis highlights the meaning of the nonlinguistic factors, such as damage processing, memory and individual compensatory strategy in language production.The first nonlinguistic explanation about agrammatism was given by Pick.He presented the hypothesis which explains that discharge of low informative lexical units in the agrammatical speech occurs as a result of the patient attempts to avoid the effort in the speech production.This assumption is from an intuitive nature and implies the position that, agrammatism represents a compensatory strategy at the patient detour the difficulties, such as the difficult, arduous, hesitant and impractical speech.The linguistic hypothesis of agrammatism was defined by Jacobsen, who was the first to present the linguistic description about aphasiac disorders.He used the term paradigmatic to mark selections of the verbal symbols and syntagmatic to mark the process of sequentially combining the linguistic elements to express the grammatical relations.Using this linguistic dichotomy about the problem finding words, Jacobsen thought that as a disorder of the similarity, the paradigmatic aspect of the language includes word selection with multiple lexical possibilities which have strong meaning (8,12).
The evaluation of the communicative abilities and determination of the quality and degree of expressiveness with the disorder is based on the clinical picture during the observatory and testing.The clinical observatory is effectuated in the acute phase of the illness in order to begin with the rehabilitation treatment as soon as possible The testing is effectuated by using the standard test batteries for aphasia and tests for evaluation of the specific language abilities.From the standard battery tests the most commonly used is the Boston test and The West battery.By using the Boston test the profile of the speech characteristics which is typical for most of the patients with Broca's aphasia can be established.The patients with most severe form of the Broca's aphasia have complete absence of intonation contours (the melody of pronouncing the sentence) and are able to produce only certain words.Other standard battery that is designed for classification of the patients is the west battery test for aphasia.With the use of this battery, the patients with Broca's aphasia and other forms of influent aphasia receive assessment for fluency from 0 to 4. Contrary to this, the assessment for fluency between 5 and10 denotes a patient with fluent aphasia.The performances of the tasks about understanding at patients with Broca's aphasia are from 4 to 10, which indicate relative preservation of the auditory understanding (13,14).examinees belonging to the medical staff from the medical institutions where these patients are hospitalized.The examinees are selected by random sampling.The research was carried out in Skopje.The data gathering was performed in home conditions, medical institutions where the patients are hospitalized and geriatric centre where they are nurtured; PHC "Institute of physical and medical rehabilitation" -Skopje; PHC "Medical rehabilitation Katlanovo spa" -Skopje; PHC "Neurological clinic" -Skopje; PHC geriatric centre "Meri Terzieva" -Skopje; PHC centre for care of elderly "Sveta Nadezh" -Skopje.The research was conducted between June and August 2010.Methods: Causal method, Method of descriptive analysis Method of comparative analysis.Techniques: Polling, Observation, Analysis of the medical documentation.Instruments: A questionnaire sheet for the examinees with Broca's aphasia specially prepared for the research was used to collect the data relevant for confirmation of the hypothesis.The questionnaire was composed of 28 questions from closed type with selection.Another questionnaire sheet was used for the family members of the examinees which are situated in home conditions and the medical staff from the medical institutions where the patients are hospitalized.This poll was composed of 14 questions from closed type with selection.The data obtained from the research are grouped, tabulated, processed and graphically shown by the use of the Microsoft Office Excel 2003 program.By use of descriptive statistics, the structure and the differences in the data between the first and the second category of examinees analyzed with the χ² test with level of significance of p<0.05 are represented.In table 1, it is shown that speech intelligibility of persons with Broca's aphasia is partially good, which can be seen from the answers of the two surveyed groups.In the first group of examinees the following results are obtained: 15% showed positive results of good intelligibility of their speech, 51% have partially intelligible speech and 34% of the examinees had bad intelligibility.From the second group of examinees the following results were obtained: 22% of the examined participants responded positively using "good" as descriptive expression and 22% of the examinees responded negatively using "not good" as descriptive expression.Through the achieved results we can conclude that there are no statistically significant differences.From the question "Is the meaning of the speech shown with gestures?" the following results were obtained: from the total persons with Broca's aphasia, most of them (49%) responded positively, 31% responded that occasionally help their vocabulary expression with gestures and 20 % responded negatively, never show the speech with gesture.We can determine that 49% of the examined persons with Broca's aphasia, most often assist their speech with gesture, which can give the conclusion that their communication is improving by using the alternative form.(Figure 2)
Table 2 shows the comparison of answers of the first and second group of examinees to the question whether patients use alternative forms to improve the communication such as mimics, gestures, eye indication, drawing etc.The following results are collected from the first group examinees; 34% of respondents are using alternative forms, at highest 51% of respondents are occasionally using and 15% of the examinees are not using alternative forms.The second group of examinees gave the following answers: 22% of the examinees responded yes, 56% responded to use alternative forms occasionally and the rest, 22%, responded negatively.We concluded that there are no statistically significant differences (p>0.05) between the two groups of examinees.In Figure 3 the answers to the question: "Does he understands the orders?"The examinees gave the following answers are illustrated: 67% of the respondents answered that they understand, 26% of the respondents partially understand and 7 % of the examinees do not understand the orders.In terms of the number of the persons with Broca's aphasia who were questioned, it can be concluded that 67% of them don't have a disorder in understanding orders.This indicates that the auditory comprehension is much less damaged than the expressive function of the speech.Table 3 shows the answers given by the examinees to the question: "Are there present language problems in the patient?"Forty-nine percent of the first group examinees have language problems, 36% partially have problems and only 15% of the examinees do not have language problems.The second group of respondents gave these answers: significant number or 78% responded to have language problems, 11% think that they partially have problems and 11% of the examinees responded that they don't have language problems.From the obtained result we conclude that there is a statistically significant difference between the two groups of examinees in their answers.examinees answered that the patients use partially short sentences and only 10% of the examinees responded negatively.To the question: "Can he tell short stories?", the examinees gave the following answers: 20% responded that patients can say short stories, 62% of the examinees responded that they partially can and 18% responded that patient cannot tell short stories.In composition of longer stories, the deficit of expressive function is apparent.Analyzing the question whether grammatical irregularities exist in the speech of persons with Broca's aphasia, it was found that the majority of examinees in both groups responded similarly to this question.Forty-nine percent answered that grammatical irregularities are present in people who have Broca's aphasia, while up to 67% of the examined family members and medical staff responded that that grammatical irregularities are present in the patients suffering from Broca's aphasia.When compared, from the separate answers to this question can be concluded that there is no significant statistical difference (p>0.05).This confirms the hypothesis that agrammatism, although not always present, is the central symptom of Broca's aphasia.

Table 1 .
Speech understanding

Table 2 .
Using alternative forms for improving the communication

Table 3 .
Results from the language problems with the patient