Jo Field

Issue Report

2014

Aphasia

Aphasia is a neurological condition which can lead to severe

problems using language correctly, often occurring after a stroke.
How eff ective is the use of Transcranial Direct Current Stimulation
for the treatment of aphasia?

What is aphasia?
Aphasia is a neurological disorder caused by damage to the portions of the brain
that are responsible for language. Key signs of the disorder include difficulty in
the patient expressing themself when speaking, trouble understanding speech,
and difficulty with reading and writing (1). Aphasia is most often caused by
stroke, but can also be caused by brain haemorrhage, head injury or tumours (2).
There are two main types of aphasia; non-fluent (Brocas aphasia) and fluent
(Wernickes aphasia) (5).
In Brocas aphasia, the condition is presented through suppression of speech
output. Production of speech is effortful, and often produced
with strenuous articulation (4). Patients often have a bank
of well-practised words which can be produced with perfectly
normal articulation, such as conversational stereotypes like
I do not understand.

Figure 1: Areas of the

brain affected by
Brocas and Wernickes
aphasia, in the left
temporal lobe of the
brain.

Anatomy: Involves a lesion encompassing the cortical Brocas

area (Pars Opercularis and Pars Triangularis of the left frontal
lobe) (4), as shown in figure 1 showing the left temporal lobe.
In Wernickes aphasia, the speech output of the patient is
easy with perfect articulation, but sentence structure tends to
be filled with poor word choice, or in severe cases, can only

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Issue Report

2014

contain nonsense jargon (4). The rate of speech can often be excessively rapid,
and the patient may be unaware of their speech output errors.
Anatomy: Involves a lesion that covers entire posterior
portion of the first temporal gyrus, known as Wernickes area
(4) as shown in figure 1, near Brocas area.

The problem
Aphasia affects an estimated 250,000 people in the UK, with 20,000 new cases
occurring each year (3). For these people, understanding words or sentences
they heard or read becomes challenging, as well as communicating through
speech to others, sometimes using the wrong sounds or words, or putting
sentences together (3). As communication is at the core of daily activities,
aphasia affects a persons ability to carry out everyday tasks, making patient
often feel isolated, anxious and depressed as they struggle to communicate with
others.

One potential solution: Transcranial Direct Current

Stimulation
Current speech and language therapy (SLT) strategies have only limited
effectiveness in improving aphasia (Baker et al, 2010). A possible adjunct to SLT
for improving speech outcomes might be non-invasive brain stimulation by
transcranial direct current stimulation (tDCS) to modulate cortical excitability and
hence to improve aphasia.

Figure 2: Salinesoaked sponges

attached to the
electrodes are
placed on the
affected areas of
the scalp in order
to improve

Transcranial Direct Current Stimulation (tDCS) is a non-invasive

brain stimulation treatment which uses direct electrical currents
at a constantly low intensity, in order to stimulate specific areas
of the brain (6). Two electrodes are placed on the scalp, one a
negatively charged cathode and one a positively charged
anode, as demonstrated in figure 2 by the placement of
sponges attached to the cathode and anode on the scalp. An
electric current is passed through the anodes by a stimulator in
order to increase cortical excitability of the brain (7). Side
effects most commonly associated with tDCS include mild
headaches, nausea, difficulty concentrating, visual phosphenes
and vertigo (6). A phosphene is a brief flash of light that can
occur if an electrode is placed near the eye (15).

Research data
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876210/

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Issue Report

2014

In this study, carried out by Baker et al, 2010 (19), 10 patients with chronic
aphasia underwent two separate weeks (five days per week) of Anodal-tDCS (1
mA, 20-min) and Sham-tDCS (20-min) while performing a computerized anomia
treatment. During both types of tDCS, the active electrode was placed on the
scalp overlying the left frontal cortex. Ten patients, five females and five males
with chronic, stroke-induced aphasia aged 45- to 81-years (Mean = 65.50;
Standard Deviation = 11.44) participated in the study, which was approved by
the University of South Carolinas Institutional Review Board. An aphasia
assessment before treatment showed that six (P2, P4, P5, P7, P9, and P10) of the
ten patients were classified with fluent aphasia, while the remaining four patients
(P1, P3, P6, and P8) were classified with non-fluent aphasia (13). As seen in
figure 3 below, all of the ten patients differed greatly in education, post-stroke
onset, and lesion location and size. Because of these uncontrollable variables, it

Figure 3: Biographical information and lesion description of all ten patients involved in the Baker at al, 2010
study. This table shows how the age, sex and education background of all the patients differ, and how the
post-stroke onset, lesion location and size are unique in each case. This may affect the end results of the
study, as mentioned in the text.

may be hard to tell from the results of the study as to whether or not tDCS helps
all types of aphasia.
The stimulation and treatment task lasted for 20-min each session, a time
chosen based on previous tDCS research which demonstrated that tDCS
administration is safe up to 20-min (12). To assess cardiovascular arousal, blood
pressure and heart rate were measured before and after each session.
Additionally, discomfort ratings were recorded following the end of each session
using the Wong-Baker FACES Pain Rating Scale, a visual description scale
designed for patients with limited verbal skills (14). tDCS (1 mA) was delivered
for 20-min per session via saline-soaked sponge electrodes (5 5 cm) and a
constant current stimulator that was placed out of the patients sight.

The self-administered anomia treatment consisted of a picture-word matching

task. To determine whether the patients ability to name the treated items
improved over the course of each treatment phase (A-TDCS vs. S-tDCS), a
computerized naming test consisting of the 25 treated nouns for each phase was
administered at baseline, immediately following the final session of each
treatment phase (T1), and one-week following the final session of each treatment
phase (T2) to examine performance maintenance.

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Issue Report

2014

Figure 4: This table shows the results of the treatments carried out in the Baker et al. study
(2010). The table shows the change in the number of correctly named treated and untreated
items between post-treatment testing and baseline testing following anodal tDCS (A-tDCS) and
sham tDCS (S-tDCS).

During the A-tDCS phase, of this treatment, the mean number of correctly named
treated items was 14.2/25 (SD = 8.69) at baseline, 17.8/25 (SD = 9.44) at T1
(immediately after treatment termination), and 17.7/25 (SD = 9.07) at T2 (oneweek following treatment termination) (19). As shown in figure 4 above, the total
increase in correct naming responses following A-tDCS treatment for the entire
group was 36 treated items at T1 and 35 treated items at T2. Compared to the
placebo (S-tDCS), these results show that anodal-tDCS is effective for the
treatment of post-stroke aphasia, as it improves the patients ability of naming.
These results show that tDCS has a positive effect on the treatment of poststroke aphasia, as when the treatment was applied, the number of correctly
named items increased, compared to the control group (sham-tDCS), where the
number still remained low.

Validity of results
Although the Baker et al 2010 study showed a significant enhancement for AtDCS, individual patients showed a wide range of treatment outcomes. This may
be due to the fact that, as figure 3 shows, all of the patients had a wide range
between the lesion size and location on the brain, making each individual case of
aphasia different in the study. This may affect the validity of the results as there
is a larger margin of error, as indicated by the greater standard deviation, which
is over half of the mean values.
Also, the small sample size (10 patients) does not provide a representative
sample of people with stroke-induced aphasia. This means that the results
cannot be fully relied on that tDCS improves aphasia and that it is impossible to
make strong conclusions. However, Baker et al. (17) mention in the study that

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2014

they believe that these are important considerations for the development of
future studies.
Another factor that may affect the validity of the results is how the patients were
selected to be a part of the study. In the Baker et al. article, it does not mention
how the participants of the study were selected, and so it is unknown as to
whether or not the selection process was biased or not. This may affect the
validity of the studys results as the individual results for each of the patients
may be biased, making them less reliable and valid.

Appropriateness and effectiveness of tDCS

From the Baker et al 2010 study, it can be seen that transcranial direct current
stimulation is appropriate to the treatment of aphasia, as it has shown to
improve the naming of pictures in stroke-induced aphasia patients by the results
provided in figure 4. These results show how when tDCS was applied, the results
of the anomia treatment was significantly enhanced than when tDCS was not
applied, and so the appropriateness of tDCS for the treatment of aphasia can be
proven by these results.
The method used in the Baker et al study also allowed the appropriateness of
TDCS to also be proven as the method was kept consistent, with the voltage and
time spent exposed to the current being kept the same throughout the study, as
well as the position of the electrodes. This ensured that the results provided were
reliable and so these results can be used to prove the appropriateness of tDCS
for the treatment of post-stroke aphasia.
The effectiveness of tDCS for aphasia has been proven by the Baker et al 2010
study that showed anodal-tDCS was between 2-3 times more effective in name
and picture matching than the control group (sham-tDCS) where no active
treatment was applied.

Implications of using tDCS

Economic:
Compared to other treatments for post-stroke aphasia, Transcranial Direct
Current Stimulation is the cheapest and most cost-effective treatment (9), as it
does not rely on the use of pharmaceuticals and only requires basic technology
with a low intensity electrical current. A study carried out showed that the
average cost of one hour long session of tDCS was $167.72 (101.69) (9),
compared to the average cost of one session of Speech and Language Therapy
(SLT) on the NHS, which is roughly 147 (10).

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Issue Report

2014

Social:
As seen in some cases of tDCS, some patients dislike the treatment of tDCS as
some experience a tingling sensation on the scalp from the electrodes. Because
of this side effect of tDCS, some patients who are offered this treatment are put
off tDCS and are scared of feeling this sensation. Also, some people who do
initially start of with the treatment of tDCS drop out as they do not like the
sensation.

Benefits of using tDCS in the treatment of aphasia

One benefit that Transcranial Direct Current Stimulation has over other
treatments for post-stroke aphasia is that the treatment involves non-invasive
techniques, unlike drug treatments. This means that often more patients are
willing to undergo this method of treatment over others. One other benefit of
using tDCS is that it is much cheaper and cost effective than other treatments,
such as speech and language therapy or drug treatments with L-Dopa and
Bromocriptine, as seen by the difference in costs of different treatments for
aphasia (explained in the economic implication).
One main benefit of using tDCS is that repeated stimulation sessions can not
only increase neurone excitability within the brain to help improve post-stroke
aphasia. This treatment can also be used in order to treat other mental factors
such as depression, pain relief, Parkinson's disease, tinnitus, fibromyalgia, and
also the improvement of carrying out cognitive tasks (11).

Risks/disadvantages of using tDCS

One disadvantage of using tDCS as a treatment for aphasia is that the wide
spacing of electrodes on the scalp means that the current doesnt focus on one
specific area of the brain, and alternatively covers a substantially large area (15).
This could mean that the treatment is less effective as the electrical current isnt
focused over the damaged section, for example Brocas area, and so there is a
lower intensity of the current affected that section, making the treatment less
effective.
Another disadvantage of using tDCS is that although there have been several
tests as to whether the use of transcranial direct current stimulation helps in the
treatment of aphasia, there is not enough evidence as to whether it does or not.
This may be due to the fact that there havent been a huge number of studies
carried out to test its effectiveness, and also the fact that the studies that have
been carried out only use small sample numbers, and so this evidence cannot be
reliable as it isnt a representative sample of the population of people with
stroke-induced aphasia.
Another disadvantage of tDCS is that some patients experience unwanted side
effects, such as headaches, tingling sensation on the scalp, nausea, difficulty
concentrating, visual phosphenes and vertigo (6). These unwanted side effects
can cause people to drop out during the treatment process, or prevent patients

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2014

from wanting the treatment of tDCS for aphasia altogether. This means that the
number of patients who would be treated with tDCS is lower than the actual
number, and this means that tDCS isnt the most common form of treatment for
stroke-induced aphasia.

Another solution: Speech and Language Therapy

Speech and language therapy (SLT) has been used for hundreds of years in order
to help people with speech and language deficits such as the improvement of
articulation, fluency, resonance and specific language disorders, such as aphasia.
SLT is also used to help people suffering with a hearing impairment, weak
muscles around the mouth, cleft lip or palate, vocal nodules, autism and
swallowing disorders.
For people with aphasia, speech and language therapy aims to help patients
communicate to the best of their ability, helps restore as much of their speech
and language as possible, and helps to find alternative ways of communicating
(3). Evidence suggests that speech and language therapy is more effective if it is
started as soon as possible, as most people who make a recovery do so within
six months. However, it is important to remember there can be improvements
even after many years. How the therapy is carried out depends on the patients
circumstances. If appropriate, an intensive course of speech and language
therapy may be used as this can be more effective. This involves longer
individual sessions spread out over a shorter period of time. However, speech
and language therapy can be exhausting and an intensive course of treatment
isnt suitable for everyone (3).

Alternative solutions
Drug treatment:
Drugs that have been used to treat aphasia include meprobamate which has
tranquillising and muscle relaxing effects, and L-Dopa, a dopaminergic agent,
which is used to reduce the symptoms of Parkinson's disease. Bromocriptine,
also a dopamine agonist, has also been administered to aphasic patients with
some evidence of success, shown from a small group before-and-after study (8).
There is, therefore, some reason to suppose that dopamine has a positive effect
on language, the hormone in the brain responsible for emotions. These drugs can
be used to aid the treatment of aphasia as they increase the release of
dopamine, which increases the brains activity, and so excites areas of the brain
responsible for language, aiding the recovery process of aphasia.
However, there are some side effects that follow the use of these drugs. In LDopa, these include hypotension, arrhythmias, nausea, gastrointestinal bleeding,
hair loss, and disorientation (7). The most frequent side effects following the use
of Bromocriptine are nausea, hypotension, headaches, and vomiting, liver
problems, and pulmonary fibrosis has also been reported when bromocriptine

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Issue Report

2014

was used in high doses for the treatment of Parkinson's disease (8). In
meprobamate, symptoms can include drowsiness, unresponsiveness, loss of
muscle control, severe impairment of breathing, or shock.

Repetitive transcranial magnetic stimulation (rTMS)

Repetitive transcranial magnetic stimulation has been reported to
improve naming in chronic stroke patients with non-fluent aphasia
since 2005 (16). TMS is a non-invasive treatment which uses a
magnet instead of an electrical current to activate the brain. As
shown in figure 5 opposite, an electromagnetic coil is held against
the forehead and short electromagnetic pulses are administered
through the coil. The magnetic pulse easily passes through the skull,
and causes small electrical currents that stimulate nerve cells in the
Figure 5: The method
of rTMS used, showing targeted brain region. Because this type of pulse generally does not
how an electromagnet reach further than two inches into the brain, scientists can select
is held against the
head to pass electrical which parts of the brain will be affected and which will not be. rTMS
currents through the
has been tested as a treatment for various disorders including
skull to a targeted
migraine, stroke, Parkinson's disease, tinnitus and depression (11).
area of the brain.

rTMS can be used for the treatment of aphasia as it stimulates

neurones in the brain, similar to tDCS, as this can lead to increases
or decreases in excitability of the affected cortex. This change in
excitability in patients with post-stroke aphasia has been seen to
improve their performance in naming tests, and hence improve
aphasia (16).

Bibliography
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Available at: http://www.aphasia.com/about-aphasia/types-of-aphasia [web source]
Date accessed: 6.3.14
Figure 2: Somatic Treatments for Mood Disorders, 2014
Moacyr A. and Lisanby S.
American College of Neuropsychopharmacology
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Date accessed: 9.3.14
Figure 3: Biographical information and lesion description
Baker et al. Stroke. 2010; 41(6): 12291236.
Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876210/pdf/nihms182627.pdf [journal source]
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Figure 4: Change in the number of correctly named treated and untreated items between post-treatment
testing and baseline testing following anodal tDCS and sham tDCS
Baker et al. Stroke. 2010; 41(6): 12291236.
Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876210/pdf/nihms182627.pdf [journal source]
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(2) About aphasia Connect - the communication disability network, 2010

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Available at: http://www.ukconnect.org/about-aphasia.aspx [web source]

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(6) Is tDCS Safe? Giulio Ruffini 2012
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(7) The two faces of L-DOPA: benefits and adverse side effects NIH Pub no. 177-81, 2004
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(12) Safety and cognitive effect of frontal DC brain polarization in healthy individuals
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(13) Transcranial direct current stimulation (tDCS).
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(15) "Transcranial direct current stimulation: State of the art 2008".
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Jo Field

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2014

Reliability of sources
One way I had to ensure my data was both reliable and valid was through the
actual source itself. I carefully selected my sources and information from websites
that were reliable. For example, I used the NHS website as, as an official and
recognised health organisation, and they are clearly going to have precise and
up-to-date information. I used the NHS Choices website in order to provide facts
about aphasia which would be reliable and valid pieces of data as the statistics I
used in The problem section of my report would have been collected from large
databases with evidence collected from lots of scientific journals and reports,
making them valid and reliable pieces of data.
Another way I ensured the sources I used were reliable was by checking where
the information had been sourced from. For example, I used the NCBI website for
a lot of my information throughout my report, as not only is the website made up
of journals written by credited scientists and researchers, but it also contains
references within the journals which link to other scientists research and
information. In my opinion, this makes this source reliable as it is made up of a
strong chain of many scientists research, which has all been peer reviewed and
credited, making each reference reliable.
Finally, I used the book Understanding aphasia by Harold Goodglass as one of
my sources as he holds a doctorate in clinical psychology, and is a wellestablished psychologist who has spent most of his career focus on research into
aphasia. His work is credited by so many researchers and scientists that after his
death in 2002, an aphasia research centre was opened at Boston University
School of Medicine in his name. By using his book as one of my sources, it
ensured that the information I used was reliable as it was credited by so many
other scientists in his field, and so I can be sure that this data is valid as well as
reliable.
Overall, I believe that all of the sources I used were reliable, as I used credited
journals from scientists sourced from official websites such as NCBI in order to
gather reliable information, and ensured that the journals used were reviewed to
date. I also believe that the sources used were reliable as multiple sources
suggested similar outcomes or theories. This means that the sources are reliable
as they are consistent with each other in terms of the information provided.