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International Journal of Clinical and Health Psychology (2014) 14, 240---245

International Journal
of Clinical and Health Psychology
www.elsevier.es/ijchp

CLINICAL CASES

Transcranial Direct Current Stimulation improves word

production in Conduction Aphasia:
Electroencephalographic and behavioral evidences
Alberto Dominguez a, , Rosario Socas a , Hipolito Marrero a , Nieves Leon a,b ,
Jesus LLabres c , Enrique Enriquez b,c

a
Facultad de Psicologa, Universidad de La Laguna, Spain
b
Hospital Universitario de Canarias, Spain
c
Clnica INSTRAL, Santa Cruz de Tenerife, Spain

Received 8 October 2013; accepted 7 February 2014

Available online 10 May 2014

KEYWORDS Abstract A Conduction Aphasic patient, RH, with many difculties at the level of phonological
TDCS Therapy; output, was subjected to Transcranial Direct Current Stimulation (tDCS) therapy six months after
Conduction aphasia; suffering a stroke. Fifteen daily sessions were administered (ve days per week). The treatment
Production language; led to a better intra-hemispheric electrical coherence and inter-hemispheric balance, as shown
Single case by the quantitative EEG analysis. Transcranial Direct Current Stimulation therapy was shown to
experiment be effective in inhibiting irregular activation of the right hemisphere, offering the healthy areas
of the left hemisphere the possibility of reassuming their linguistic processing abilities. Also,
the number of errors in picture naming and repetition of words and pseudowords dropped con-
siderably following treatment. The recovery was greater for long stimuli and was not affected
by semantic or lexical variables such as familiarity. These results suggest that the Phonolog-
ical Output Buffer, a mechanism dedicated to the maintenance, ordering and production of
phoneme strings, was the processing stage modied by the treatment.
2013 Asociacin Espanola de Psicologa Conductual. Published by Elsevier Espaa, S.L. All
rights reserved.

PALABRAS CLAVE La Estimulacin de Corriente Directa Transcraneal mejora la produccin de palabras

Terapia TDCS; en la afasa: evidencias electroencefalogrcas y conductuales
Afasia de conduccin;
Produccin del Resumen Una paciente con Afasia de Conduccin, RH, con dicultades en el nivel de produc-
lenguaje; cin fonolgica, fue sometida a la Terapia de Estimulacin de Corriente Directa Transcraneal
Experimento de caso (tDCS), 6 meses despus de haber sufrido un ictus, durante 15 sesiones diarias. El tratamiento
nico produjo mayor coherencia elctrica y equilibrio entre los hemisferios, evidenciado por el anlisis

Corresponding author at:. Facultad de Psicologa. Campus de Guajara. 38004, La Laguna, Santa Cruz de Tenerife, Spain.
E-mail address: [email protected] (A. Dominguez).
http://dx.doi.org/10.1016/j.ijchp.2014.02.001
1697-2600/ 2013 Asociacin Espanola de Psicologa Conductual. Published by Elsevier Espaa, S.L. All rights reserved.
Document downloaded from http://zl.elsevier.es, day 04/11/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

Transcranial Direct Current Stimulation improves word production in Conduction Aphasia 241

de EEG. La Terapia tDCS demostr ser un procedimiento efectivo para inhibir la activacin
irregular del hemisferio derecho, y posibilitar a las reas sanas del hemisferio izquierdo el
reasumir sus habilidades de procesamiento lingstico. Asimismo, el nmero de errores en nom-
brado de dibujos y repeticin de palabras y pseudopalabras se redujo signicativamente despus
del tratamiento. La recuperacin fue mayor en los estmulos largos, y no se vio inuenciada por
variables lxicas o semnticas como la familiaridad. Estos resultados sugieren que el Buffer de
Salida Fonolgico, un mecanismo dedicado al mantenimiento, secuenciacin y produccin de
fonemas, fue el estadio de procesamiento modicado por el tratamiento.
2013 Asociacin Espanola de Psicologa Conductual. Publicado por Elsevier Espaa, S.L. Todos
los derechos reservados.

Conduction Aphasia is a linguistic disorder characterized a

by errors of reduplication, substitution, addition, trans-
position or omission of phonemes or groups of phonemes
in picture naming, repetition, writing and reading tasks
(Shallice, Rumiati, & Zadini, 2000). The locus of the damage
is situated at the level of the Phonological Output Buffer
(POB), a mechanism entailing processes of working mem-
ory, phonological identication and phonological assembling
previous to the articulation of the word. If a pure damage
in a phonological buffer is assumed in a patient, decits in
the patient performance will be observed in all the linguis-
tic tasks using the output mechanism (Annoni, Lemay, de
Mattos-Pimenta, & Lecours, 1998; Caramazza, Miceli, Villa,
& Romani, 1987; Mondini, Arcara, & Semenza, 2012). This
was observed in our patient-case.

Identication and history of the case

b
RH is a 60-year-old, right-handed, married female with a FP1-LE

FP2-LE
degree in Obstetrics & Gynaecology. On February 2011, she
F3-LE
suffered a brain stroke (see Figure 1a) with acute ischemia F4-LE
affecting the temporal and parietal lobes of the left hemi- C3-LE

sphere. She presented motor dysphasia and problems of C4-LE

naming and repetition that constituted Conduction Aphasia. P3-LE

An improvement of spontaneous speech was soon P4-LE

01-LE
observed, with the patient producing more uent verbal-
02-LE
ization and emission of complete sentences. However, the F7-LE

naming decits persisted. Reading was preserved, but she F8-LE

syllabied words. No other neurological or functional disor- T3-LE

ders were diagnosed. She was referred to the Rehabilitation T4-LE

Department of the Hospital Universitario de Canarias for T5-LE

T6-LE
a neuropsychological evaluation (Jurado & Pueyo, 2012; Fz-LE
Rodrguez Prez, Gonzlez Castro, lvarez, lvarez, & Cz-LE

Fernndez-Cueli, 2012) and to determine her suitability for Pz-LE

rehabilitation treatments. 00:02 00:03 00:04 00:05 00:06 00:07

Figure 1 RH CT brain scan (a) and Monopolar EEG fragment

Behavioral analysis (b).

In order to assess verbal capacities in comprehension

and production, the patient was given the Beta Battery be efcient. However, decits were found when task per-
(Cuetos & Gonzlez-Nosti, 2009). This evaluation showed formance required cognitive mechanisms at the level of
that phoneme identication and auditory word recogni- phonological output. She made many mistakes in naming
tion were normal. Semantic processing was also found to and repetition, especially on the long words. Also, she had
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242 A. Dominguez et al.

a 50% error rate when writing pseudowords. The absence a 6 Hz 7 Hz 8 Hz

of problems in reading contrasted with the high number of
errors made in naming and repetition. Some other difcul-
ties were related to the level of sentence comprehension.
The errors in sentence-picture matching supported a verbal
memory span decit at the moment of processing complex
and highly demanding syntactic structures.

3 2 1 0 1 2 3 3 2 1 0 1 2 3 3 2 1 0 1 2 3

Selection and treatment goal

b 6 Hz 7 Hz 8 Hz
Two months after her stroke the patient started speech ther-
apy, which she followed three days a week for four months
without any apparent improvement of her linguistic produc-
tion abilities (see percentage of errors at Figure 4 before
the electrical stimulation). The patient was then subjected
to Transcranial Direct Current Stimulation (tDCS) therapy
while the speech therapy continued. Studies of the com-
bination of electrical stimulation with speech training have
3 2 1 0 1 2 3 3 2 1 0 1 2 3 3 2 1 0 1 2 3
shown improvement in verbal uency in healthy subjects
(Fertorani, Rosini, Cotelli, Rossini, & Miniussi, 2010) and
patient samples (Baker, Rorden, & Fridriksson, 2010). In c 6 Hz 7 Hz 8 Hz

accordance with these ndings, the goal of the tDCS treat-

ment was to improve RHs linguistic production abilities.
Our research case (Buela-Casal & Sierra, 2002; Montero &
Len, 2007) is aimed at broadening the ambit of effective-
ness for such combined treatment by examining behavioral
(language task) and electrophysiological evidence of brain
changes after electrical stimulation. We also compare per-
formance in language tasks as a function of words length and 0.00 0.03 0.06 0.00 0.03 0.06 0.00 0.03 0.06

familiarity in order to test the hypothesis that is the Phono- Figure 2 Power electroencephalographic measures. Z scores
logical Output Buffer the processing stage modied by the before tDCS (a); after tDCS (b); and p values for before and
treatment. after tDCS differences (c): White represents no statistically sig-
nicant differences, red indicates p < .001 and green and blue
p < .05.
Application of the treatment

Electrical current of 1 mA of anodal stimulation was applied Evaluation of the effectiveness of treatment
to the left frontal area. The cathodal electrode was placed
over the homologous right contra-lateral area. To approach Power and coherence measures were calculated on the
Brocas area, the electrode was placed 2 cm behind the F7 EEG recording before and after tDCS stimulation. A t-
site in accordance with the International 10-20 EEG sys- ted electrode-cap with leads placed at the International
tem. Fifteen daily sessions lasting 20 minutes each (5 days 10/20 System was applied to achieve a standardized 19-
per week) were administered via 7 5 cm saline-soaked channel EEG recording. References were linked to combined
sponge electrodes. The Eldith DC-stimulator of Neuroconn mastoids. Impedances were kept under 5 KOhms prior to
was used as a micro-processor-controlled constant current recording. The recording was taken with eyes closed (relax-
source. Many studies have demonstrated that anodal stimu- ation) and eyes open (relaxation). Sampling frequency was
lation has excitatory effects on the underlying left cortex, 200 Hz. Digitized data were submitted to an automatic arti-
whereas cathodal stimulation produces inhibitory effects on fact detection routine and visual review. Waves were ltered
the right hemisphere (Liebetanz, Nitsche, Tergau, & Paulus, at delta (0-4 Hz), theta (4-8 Hz), alpha (8-13 Hz) and beta
2002). It was expected that the assembly described above (13-30 Hz) bands. The EEG data were analyzed for frequency
would reduce activation of the habitually over-stimulated content using discrete Fourier Transformation (FFT) and
right hemisphere, forcing the areas around the damaged Analysis of Variance following the Neuroguide package of
cortex of the left hemisphere to reassume their linguis- Applied Neuroscience Inc.
tic processing abilities (Monti et al., 2013), thus enabling As can be seen in Figure 1b, abnormal electrophysiolog-
the improvement of language production (Gmez-Palacio ical activity at T3 (record in line 13) and F7 (record in line
Schjetnan, Faraji, Metz, Tatsuno, & Luczak, 2013). During 11) was shown in agreement with the localization of the left
electrical stimulation the patient did not perform linguistic temporal lesion.
tasks, due to we were interested in evaluating long-lasting As can be seen in Figure 2a, before tDCS the cartography
effects of electrical stimulation, but not in evaluating online shows the medium-temporal power in left delta (T3) and
effects. theta diffuse. The Alpha 1 is fronto-temporal. Only the left
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Transcranial Direct Current Stimulation improves word production in Conduction Aphasia 243

a Delta (1.0 - 4.0 Hz) Theta (4.0 - 8.0 Hz) Alpha (8.0 - 12.0 Hz)

+ +
Z-Score 1.96 Z-Score 2.58

b Delta (1.0 - 4.0 Hz) Theta (4.0 - 8.0 Hz) Alpha (8.0 - 12.0 Hz)

+ +
Z-Score 1.96 Z-Score 2.58

c Delta (1.0 - 4.0 Hz) Theta (4.0 - 8.0 Hz) Alpha (8.0 - 12.0 Hz)

+ +
P-Value 0.050 P-Value 0.025

Figure 3 Coherence electroencephalographic measures. Z scores before tDCS (a); after tDCS (b); and p values for before and
after tDCS differences (c): Red indicates more coherent values between electrodes and blue less coherent electrodes. Thicker lines
indicate higher statistical t-test values.

temporal delta focus could be related to the peri-lesional p-values of coherence comparing both conditions
area. The remaining power areas in the map represent non- (Figure 3c), are more informative.
adaptive changes after ischemia. Prior to tDCS (Figure 3a) we observe a reduced coher-
Figure 2b shows the cartography after tDCS and Figure 2c ence in the left hemisphere and, as a consequence, there is
shows the p-value FFT absolute power in band differences a signicant compensatory increase of coherence in the right
before and after tDCS. The only signicant difference was hemisphere. After tDCS, however, we observe an increase of
located in the right frontal area with an increase in the coherence in the frontal left hemisphere in delta and theta
power of the alpha band. The coherence measures taken bands, as evidenced in z-scores (Figure 3b) and paired t-
before (Figure 3a) and after (Figure 3b) tDCS, and the tests (Figure 3c). More importantly, a positive coherence
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244 A. Dominguez et al.

ratio affects the entire left hemisphere at the 8 Hz band 100 92

(alpha). 90
89
83
In the light of these results, tDCS therapy would appear 80 71 86
Picture
to be an effective treatment to inhibit irregular activation of 70
61 naming
64
the right hemisphere, and thus to assist the healthy areas of 60 53
58 Word
the left hemisphere to reassume their linguistic processing 50
50 44 repetition
abilities. 40
30 Pseudowor
20 d repetition
Monitoring the effectiveness of treatment 10

PRE 1M 2M 1Y
Three tasks were employed to evaluate the phonolog-
ical output level: picture naming, word repetition and Figure 4 Percentage of correct responses in picture naming,
pseudoword repetition. These tasks were run before the word repetition and pseudoword repetition along the pretreat-
stimulation with tDCS as well as one month, two months ment phase and the three subsequent to tDCS phases: 1 month,
and one year later. The stimuli were taken from the picture 2 months and one year later.
database of Snodgrass and Vanderwart (1980). Two lists of
36 pictures were constructed to alternate their presentation
and so avoid stimulus repetition in the same session. The
stimuli were ordered by two factors: familiarity (Alameda the difference of errors between long and short words in the
and Cuetos, 1995) and length (short words of 4-5 letters and repetition task at the pretreatment stage (N = 10 vs. N = 16)
long words of 6-8 letters). The two factors were crossed was about 32%, which was reduced to 11% (N = 15 vs. N = 17)
orthogonally to obtain four categories of nine stimuli per one year after treatment. The difference was even more
list. Pseudowords were formed by changing one letter on dramatic for pseudowords, where a drop from 87% (N = 1 vs.
the lists of words. N = 17) to 5% (N = 11 vs. N = 12) was observed. In contrast,
Figure 4 shows an improvement in verbal production tasks familiarity was not differentially affected by treatment: the
of over 10%, which was consolidated one year later. The difference of errors produced on frequent and infrequent
improvement mainly affected the long stimuli (see Figure 5); words was similar before and after treatment.

100
100 100
94 94
88 88 89 89
90 90
83 78 83
80 80
72 72
70 70
56
60 60

50 50
44
40 40
33 33
30 30

20 20

10 10

PRE 1M 2M 1Y PRE 1M 2M 1Y

Short words Long words High familiarity Low familiarity

100 100 100

93 100
90 90 89
81 83 83
80 80 78
66 66
70 70
61 61 63
60 60
50
50 50

40 40
27
30 30

20 20

10 6 10

PRE 1M 2M 1Y PRE 1M 2M 1Y

Short pseudowords Long pseudowords High familiarity Low familiarity

Figure 5 Percentage of correct responses for long and short stimuli in repetition task (left panels) and for familiar and unfamiliar
words (right) in picture naming (upper right panel) and repetition (lower right panel).
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Transcranial Direct Current Stimulation improves word production in Conduction Aphasia 245

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uacin de los trastornos afsicos. Madrid: EOS.
Fertorani, A., Rosini, S., Cotelli, M., Rossini, P. M., & Miniussi,
tDCS therapy would appear to produce a signicant increase
C. (2010). Naming facilitation induced by transcranial
of activation of the peri-lesional areas in RHs left hemi-
direct current stimulation. Behavioral Brain Research, 208,
sphere, as a consequence of the inhibitory electrical current 311---318.
applied on the right hemisphere (see Figures 2 and 3). Gmez-Palacio Schjetnan, A., Faraji, J., Metz, G. A., Tatsuno, M.,
The electrical therapy develops the patients ability to & Luczak, A. (2013). Transcranial Direct Current Stimulation in
produce words in the three tasks employed, even one year Stroke Rehabilitation: A Review of Recent Advancements. Stroke
after treatment. Also, the different impact received by Research and Treatment, 13, 1---14.
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semantic or lexical memory but to a more peripheral stage and Health Pychology, 12, 123---141.
Liebetanz, D., Nitsche, M. A., Tergau, F., & Paulus, W. (2002).
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Pharmacological approach to the mechanisms of transcranial
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