Agraphia And Brain Injuries: Effects Of Traumatic Brain Injuries On Writing Abilities

Introduction

Traumatic brain injuries (TBIs) are injuries to the brain caused by trauma to the head, typically due to an accident such as a car crash or fall, or an assault or attack. The symptoms of a TBI depend on the location and severity of the injury. Symptoms can be physical, cognitive, emotional, and behavioural. Cognitive effects include an impaired ability to write, resulting in a condition known as agraphia.¹ This loss or impairment of writing ability can affect your daily life, making tasks such as writing down shopping lists far harder. Early diagnosis and treatment can improve the outcomes. Understanding the connection between TBIs and agraphia can help individuals and the healthcare professionals involved in their care to understand and tailor treatment. This article explains what agraphia is, how it can be caused by TBIs, and what can be done to diagnose and treat it.

Understanding agraphia

Agraphia is the sudden loss or impairment of the ability to write. This condition can present in various ways, including difficulty with spelling, having poor handwriting, and struggling to write down your thoughts on paper. There are a few different types of agraphia, which vary based on the underlying cause and the specific writing deficits, as writing involves a variety of cognitive processes such as language processing, spelling, visual perception, and motor control.²

Types of agraphia

Agraphia is separated into two main subtypes: central and peripheral.

Central agraphia

Central agraphia occurs when there are impairments in both spoken language and the numerous motor and visualisation skills involved in writing. The different subtypes of central agraphia are: 

• Lexical agraphia: difficulty with spelling and word retrieval³
• Phonological agraphia: difficulty converting sounds into written form
• Deep agraphia: severe impairment in both lexical and phonological aspects, often also affecting reading and speech^4,5

Peripheral agraphia

Peripheral agraphia occurs when only the motor skills required for writing are impaired. There are two main types: 

• Apraxic agraphia is associated with disruption or loss of the motor planning for the formation of letters, resulting in distorted, slow, effortful or imprecise writing⁶ 
• Visuospatial agraphia, where an individual will neglect portions of the writing page and write with an odd orientation or abnormal spacing between letters, syllables, and words.⁷

Individuals with both central and peripheral agraphia struggle with basic writing tasks, such as writing their names or forming coherent sentences. Handwriting may be illegible. and they may be unable to spell correctly or use correct grammar.

Traumatic brain injuries (TBI’s)

TBIs are caused by a sudden impact to the head, such as falls, car accidents, accidents at home or the workplace, or assaults. There are two broad types: penetrating (when an object pierces the skull and enters the brain tissue) and non-penetrating (caused by an external force strong enough to move the brain within the skull), although both can occur together. The damage can be specific to one area, known as a focal injury, or can be more widespread, known as a diffuse injury.⁸

The damage can range in severity, from mild concussions with temporary symptoms to bleeding in and around the brain, or diffuse axonal injury, which causes widespread damage and more severe, permanent symptoms. 

TBIs can result in a variety of cognitive issues such as memory loss and executive function impairments that encompass aspects of daily life such as attention, planning, and problem-solving. TBIs that affect the cortical areas responsible for language and communication, such as the frontal lobe, result in disorders such as aphasia (difficulty speaking or comprehending language), dysarthria (impaired speech due to a lack of muscle control), and agraphia.⁹

Links between TBIs and agraphia

Agraphia can be caused by many different factors, such as strokes, lesions, TBIs, or dementia, all involving damage to different regions of the brain. Twelve different regions of the brain are associated with handwriting,¹⁰ and the specific type of agraphia resulting from a TBI will depend on which region was damaged:

• Phonological agraphia is linked to damage in areas involved in phonological processing skills, or sounding out words, such as Broca’s area and Wernicke’s area, which are associated with language production and comprehension respectively⁴
• Lexical agraphia is associated with damage to the left angular gyrus and the posterior temporal cortex³
• Deep agraphia involves damage to the same brain regions, though the damage may be more extensive which causes more severe impairment⁵
• Apraxic agraphia is caused by damage to the superior parietal lobe, which is involved in the integration of sensorimotor information involved in movement, or the motor cortex, which is responsible for the planning and executive of motor actions, including writing⁶
• Visuospatial agraphia is linked to damage in the right frontal area of the brain, causing motor deficits, as well as damage to the posterior part of the brain’s right hemisphere, such as the parietal and occipital lobes, causing visual and spatial deficits^7,11

Diagnosis and treatment of agraphia post-TBI

Diagnosis 

The diagnosis of agraphia includes distinguishing it from other conditions, such as aphasia, dyslexia, and general motor disorders ranging from essential tremors to Parkinson’s disease. Different neuropsychological tests can be carried out to assess various cognitive functions, including writing. Specific writing and language exercises can be used to evaluate writing abilities, such as copying a section of text, writing spontaneously or on verbal instruction, or spelling words using anagrams. Brain imaging, such as MRI and CT scans, are also used to identify damage in key brain areas.

Treatment and recovery

There is no cure for agraphia. However, there are numerous interventions that can help individuals to regain some of their previous writing abilities. Speech and language therapy can be utilised to improve language processing and writing skills, whilst occupational therapy focuses on regaining the motor skills needed for writing.¹² Cognitive therapies may also improve general cognitive functioning if this was affected by the TBI. Early intervention can make a significant difference in recovery, with timely diagnosis and treatment essential in improving patient prognosis.

A variety of aids can be used to improve patient outcomes and overall quality of life. These include:

• Assistive writing devices such as adaptive pens
• Computer-based interventions such as text-to-speech software
• Predictive text and programs designed to improve writing abilities through regular practice and feedback¹³

Other strategies can also be carried out over the course of the disorder alongside therapy and the use of these aids, to help the individual manage in the long-term. For example, continuous monitoring or regular assessments of writing ability and motor function would be crucial in tracking the recovery progress as would support systems of family, friends or caregivers throughout the rehabilitation process.¹⁴

Frequently asked questions (FAQ’s)

What is the prognosis of agraphia after a TBI?

Depending on the severity and location of the brain injury as well as the effectiveness of therapy and rehabilitation attempts, agraphia can be either temporary or permanent. Some individuals may regain their full writing abilities over time with appropriate therapy, while others may show some improvement, regaining their ability to spell but still struggling with motor aspects such as letter and word formation. In some cases, individuals may experience more long-term and severe challenges. Early intervention and consistent therapy can result in significant improvements, so it is important to look out for signs as soon as possible after a TBI.

What are the early signs of agraphia after a TBI?

Early signs of agraphia may include new difficulty spelling common or ‘easy’ words, messy or illegible handwriting, problems structuring sentences, and a noticeable decline in general writing skills. 

Is agraphia related to other language disorders?

Yes, it is. Conditions such as aphasia (difficulty with speaking and understanding language) and alexia (difficulty reading) can co-occur with agraphia. Particularly after a TBI, and affect multiple aspects of communication due to damage to the communication centres of the brain.

Summary

Overall, traumatic brain injuries (TBI’s) can significantly impact different aspects of cognition, such as memory, planning skills, and writing ability, resulting in a condition called agraphia. Agraphia is the loss or impairment of writing skills, which can manifest as poor spelling, illegible handwriting and incoherent sentence structure. Understanding the different types of agraphia and their connection to specific brain regions damaged by TBIs is crucial for effective diagnosis and subsequent treatment. Whilst agraphia can be difficult to manage, early diagnosis and targeted therapies, such as speech and language therapy and those designed to improve motor skills can help individuals regain some of their writing abilities. Furthermore, technological aids and a strong support network can vastly improve the quality of life and prognosis for those affected.