Introduction

Overview of Gerstmann syndrome

Gerstmann syndrome is one of the rare nervous system disorders. It results from brain damage in specific areas which normally affects the left posterior parietal lobe in the angular gyrus. Some examples of brain damage that may result in this syndrome include ischemic stroke, tumours, or carotid artery aneurysm or stenosis.¹

There are four key symptoms of Gerstmann Syndrome:

• an inability to calculate (acalculia)
• an inability to identify their fingers (finger agnosia)
• an inability to distinguish left from right (left-right disorientation)
• an inability to write by using their hands (agraphia)

Importance of speech therapy in Gerstmann syndrome

How cognitive and language-related impairments affect communication

Patients with Gerstmann’s syndrome have difficulties performing various normal activities as left-right disorientation and an inability to write by hands exhibit the effect of cognitive functions. Moreover, there was a study showed that the inability to calculate is involved in trouble in understanding the meaning of words or naming people (semantic aphasia).^2,3 This further affects how patients communicate as patients have difficulties in understanding, speaking, or writing.

Role of speech therapy in managing related symptoms

Speech therapy plays a role in children's trouble with learning and develops Gerstmann’s syndrome. These children can improve after they are trained in speech practice.⁴

Speech and language issues in Gerstmann syndrome

Cognitive-linguistic challenges

Agraphia and its impact on writing and written communication

One of the most significant symptoms of Gerstmann syndrome is agraphia, which refers to the inability to write. This results from interrupting brain processes related to language and leads to an inability to perform the output of writing. To do a writing act, a letter or a group of letters to combine in writing is relevant to communicate information.⁵ Agraphia in Gerstmann syndrome shows difficulty forming letters and words, and difficult spelling and sentence structure. These can link to the effect on written communication or spoken language.⁵

Word-finding difficulties and challenges in language processing

Word-finding issues can also be present in patients with Gerstmann syndrome, particularly if their language processing is affected. Some patients with Gerstmann syndrome may encounter both writing and oral spelling. Some also found challenges in forming letters and repeating, adding to the communication difficulties already present due to agraphia.⁶

Potential speech impairments

Co-occurring language disorders

Gerstmann syndrome is associated with other language disorders, such as aphasia, or mental impairment, which normally combines with linguistic or cognitive defects. This results from brain damage in the area, involved in language comprehension and production, like Broca's or Wernicke's areas.⁶ For example, a patient experienced a sound substitution in a spoken word, which exhibited language disorders. These disorders complicate communication difficulties and require a multifaceted approach to speech therapy.

Impacts on verbal expression and comprehension

Beyond writing issues, verbal communication is affected. Patients may struggle with the correct pronunciation of words, or they may find it difficult to structure sentences verbally. These impairments make it essential for speech therapists to address both verbal and written forms of communication in their treatment plans. The therapy can help patients communicate effectively and also suggest other options for communicating such as aids and telling the patient’s family to understand the symptom.⁷

Role of speech therapy in Gerstmann syndrome

Addressing agraphia

Speech therapy techniques for improving writing skills

For patients with Gerstmann syndrome, speech and language therapy (SLT) and occupational therapy play key roles in treating agraphia. The therapy provides benefits for language impairment. There was a study supported that it could enhance the ability to write.⁸ These include guided practice in writing, exercises to strengthen fine motor skills, and the use of visual-spatial aids to help patients structure their writing.⁹

Strategies for enhancing written language comprehension and production

Apart from improving the mechanics of writing, therapy focuses on helping patients comprehend written language better. These include encouraging a patient to read and ask to enhance their ability to understand the context. For example, the therapist may ask about the consequences of the content that patients read.¹⁰

Supporting cognitive-linguistic skills

Exercises for improving memory, sequencing, and language processing

One symptom of Gerstmann syndrome is the inability to calculate. The first step of treatment is to identify and evaluate the calculation abilities. Starting from organising sets of geometric shapes, the step follows by matching with specific numbers. For quantity understanding, patients will be asked to categorise the same feature of objects, for example, dividing based on their shape or colour, then count the items. After that write the type and quantity of each set.¹¹ Moreover, therapists may use exercises such as story retelling, sequential picture descriptions, or numeric puzzles that challenge patients to process information in an organised manner.

Language-based activities to enhance cognitive functions affected by the syndrome

Patients with acalculia with a language defect receive language therapy in combination with calculation therapy. Language exercises, such as word retrieval tasks or sentence formation drills, are commonly used to enhance the patient's language processing abilities. These tasks help patients improve their ability to communicate ideas verbally and in writing.¹²

Communication strategies for other symptoms

Techniques for compensating for finger agnosia

Techniques to address agnosia include the use of intact sensory modalities. The techniques aim to focus on helping patients and others around them adapt to the condition. Some patients will be taught to identify. By providing a predictable environment and consistency in performing a task or labelling everything. Additionally, mnemonic devices (memory aids or visual aids) provide patients with clear, easy-to-reference instructions for tasks that require spatial understanding.¹³ This can also be helpful in orienting patients when reading or writing.

Using visual aids, mnemonic devices, and practical tools to support language skills

Visual aids, such as charts that display finger positioning or left-right markers, can be invaluable tools for patients struggling with finger agnosia or spatial disorientation. Mnemonics can also assist patients in recalling specific information about spatial and numerical concepts.¹³ Visual imagery shows that the memorising process will be created from visual figures that are imagined and related to the words. It functions when the words have a real representation, but it also can be used with abstract words.¹³

Speech therapy interventions and techniques

Individualised treatment plans

Speech therapy for Gerstmann syndrome should be personalised based on a thorough evaluation of the patient’s deficits. To give the overview pictures about treatment, each patient will receive two stages of behavioural intervention or phonological treatment and then receive interactive treatment.

Phonological treatment aims to improve sound-to-letter and letter-to-sound associated with an inability to write. The treatment focuses on helping patients improve their ability to match sounds with the letters (sound-to-letter) correctly for both consonants and vowels. It also aimed to retrain skills, the ability to break down a written word and use that information to sound out the word.

Second, interactive treatment guides patients to use phonological skills and current knowledge of word structures to come up with spellings. The treatment mainly focuses on spelling rather than reading, but the writing practices will also improve reading ability.¹⁴ However, therapy goals are set based on the patient's characterised symptoms. For instance, some patients may focus more on agraphia, while others may focus on verbal communication.

Common speech therapy approaches

Speech therapy is normally used in treating three main types of disorders including language, speech, and swallowing problems. There are various speech therapy techniques depending on each type of disorder. This treatment requires long-term series of treatment sessions with each lasting 30 to 60 minutes. The treatment approaches include.¹⁵

• Perception activities that help recognise and tell the different sounds and syllables
• Practice to produce specific sounds and improve speech fluency
• Exercises to strengthen breathing, swallowing, and voice control
• Communication assistant tools such as sign language, communication boards, and speech devices
• Guidance for people needing speech therapy, and their families
• Support to apply these strategies in daily life

Integration with multidisciplinary care

Integration with multidisciplinary care requires professionals and practitioners from different departments to work together to support the needs of people, their families, and their communities. Patients with Gerstmann syndrome require multidisciplinary care, including occupational therapists, assisting in improving motor skills, and physical therapists, helping with spatial orientation. Care coordination in Gerstmann’s syndrome should collaborate between a neurologist, psychiatrist, physiotherapist, and neurosurgeon to achieve a better outcome.¹ Additionally, family members are an essential part of therapy. Their involvement ensures continuity of care and reinforces the strategies introduced during therapy sessions.

Summary

Gerstmann syndrome poses unique challenges related to language and cognitive function, but with individualised speech therapy, patients can make significant strides in improving their communication abilities. By targeting agraphia, verbal expression, and cognitive-linguistic skills, speech therapy helps individuals with Gerstmann syndrome regain essential language functions and enhance their quality of life.