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Article

Language Diversity and Bi/Multilingualism in Aphasia Research

by
Monike Egia-Zabala
1,† and
Amaia Munarriz-Ibarrola
2,*,†
1
Euskaltzaindia, 48005 Bilbao, Spain
2
Department of Linguistics and Basque Studies and ELEBILAB research group, University of the Basque Country UPV/EHU, 01006 Vitoria/Gasteiz, Spain
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Languages 2024, 9(10), 325; https://doi.org/10.3390/languages9100325
Submission received: 31 March 2024 / Revised: 31 August 2024 / Accepted: 27 September 2024 / Published: 9 October 2024
(This article belongs to the Special Issue Challenging the Paradigm of Bi/Multilingual Research)
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Abstract

:
Previous research on aphasia has recognised the need for cross-linguistic studies and studies on bi/multilingual aphasia. However, a study by Beveridge and Bak revealed that papers published between 2000 and 2009 were restricted to a few languages, with a clear predominance of English. The aim of this study is to present a follow-up to that study with more recent literature from the next decade (2010–2019) and to compare it with the previous one. We analysed 307 articles published between 2010 and 2019 following a similar procedure to the one used by Beveridge and Bak. The results revealed that there still is a pronounced bias towards studies on English speakers (60.29%), that the distribution of language families is similar across the two decades, with the exception of the increment in non-Indo-European languages, and that there has been an increase in studies reporting bi/multilinguals’ performance in more than one language. Still, the literature on aphasia between 2010 and 2019 seems not to reflect the reality of the world’s languages. We discuss some possible explanations for these findings related to challenges for clinical practice as well as insights for future research.

1. Introduction

Aphasia is an acquired language disorder, usually affecting both language comprehension and production, which is caused by brain injury, though it can also be caused by a tumour, infection or degenerative disease (Caplan 1992; Hillis 2007). Despite the heterogeneity of symptoms and the degrees of impairment across individuals, cross-linguistic studies on aphasia have shown that aphasia manifestations differ from language to language and that not all languages might be affected to the same extent in bi/multilingual individuals. Therefore, it is essential (a) to analyse how this language disorder is manifested in individuals with aphasia (IWAs) who speak different languages (Menn and Obler 1990a; Paradis 2001b) and (b) to assess all the languages of bi/multilingual IWAs (Paradis 2001a, 2004). Another relevant factor to consider in bi/multilinguals is language competence in each language before the brain injury, given that the disorder and the recovery can be different in each language (Kuzmina et al. 2019; Peñaloza and Kiran 2019; Verreyt et al. 2013).
However, empirical studies on aphasia do not always reflect linguistic diversity and bi/multilingualism. Beveridge and Bak (2011) analysed articles published on aphasia in the first decade of the 21st century (2000–2009). They focused on linguistic diversity and bi/multilingualism and concluded that those studies were not representative of the linguistic diversity of the world.
The purpose of this study is to analyse how linguistic diversity and bi/multilingualism are reflected in more recent studies on aphasia (between 2010 and 2019) as a follow-up to Beveridge and Bak’s (2011) work. This study will allow us to see if there is any change in time during the first two decades of the 21st century. To that aim, we followed a similar procedure to the one by Beveridge and Bak (2011): a search of articles on aphasia assessment between 2010 and 2019 was carried out in the Scopus database and restricted to the following four journals: Aphasiology; Brain and Language; Journal of Neurolinguistics; and Language, Cognition and Neuroscience. The sample obtained was 307 articles in total.
This paper is organised as follows: In the remaining part of this introduction, we will refer to the manifestations of aphasia across different languages (Section 1.1), to the studies on bi/multilingual IWAs (Section 1.2) and to the main aim and predictions of our study (Section 1.3). After that, in Section 2, we will present the methodology regarding the sample (Section 2.1) and the coding and the analyses (Section 2.2). Next, Section 3 deals with the results. Finally, the discussion of the results and the main conclusions, together with some directions for future research, are presented in Section 4 and Section 5, respectively.

1.1. Cross-Linguistic Aphasia

Manifestations of aphasia are very heterogeneous across IWAs; although they depend on the severity and the region affected, there is no one-to-one correspondence between lesion and symptoms (Dronkers et al. 2017). Moreover, studies on aphasia have concluded that the manifestations of symptoms can be related to the formal characteristics of the languages, as aphasia syndromes can manifest very differently depending on the typological characteristics of the languages (Bates et al. 1991; Menn and Obler 1990b; Paradis 2001b). Therefore, it is necessary to analyse how language difficulties are revealed in different types of languages to obtain better knowledge of the underlying language deficit.
One such example is the Special Issue edited by Paradis (2001b), which included papers on aphasia in 14 languages that had not been previously reported, with most of them non-hegemonic languages such as Afroamerican English, Afrikaans, Catalan, Czech, Farsi, Finish, Friulian, Greek, Hebrew, Hungarian, Polish, Spanish, Swedish and Basque.
Cross-linguistic studies on agrammatism have revealed that symptoms do not surface similarly depending on the structural characteristics of the languages. One of the landmarks of agrammatism is the omission and/or substitution of functional or grammatical words/morphemes in production (Menn and Obler 1990a). As such, depending on the morphosyntactic characteristics of the languages, the symptoms might vary. For instance, the deletion of pronouns might not surface similarly in non-pro-drop or pro-drop languages where the production of the pronoun is not necessary; thus, phrases without subject pronouns cannot be considered symptoms of agrammatism. Moreover, differences have also been reported regarding the percentage of substitution and omission errors depending on the morphological characteristics of the languages, with the first being more common in richly inflected languages, like Italian or German, in comparison to English (Bates and Wulfeck 1989). Thus, it is essential to report on the performance of IWAs from different languages, with a variety of typological characteristics, in order to better characterise aphasic syndromes.
However, the literature on aphasia is still far from representing the linguistic diversity of the world. Beveridge and Bak (2011) offered a systematic study of articles on aphasia published between 2000 and 2009 in order to analyse the representation of different languages in the aphasia literature in the first decade of the 21st century. This study revealed a clear predominance of English and Indo-European languages, while other languages were underrepresented. In fact, 91.87% of the articles were reports on IWAs from Indo-European languages and only 8.13% reported on non-Indo-European languages. Among the studies on Indo-European languages, there was a strong bias towards Germanic languages (74.27%), mainly because English-speaking IWAs were reported to represent 61.48% of the sample.
A recent study by Kidd and Garcia (2022) revealed a similar predominance of English and Indo-European languages in their study on language diversity in language acquisition research. They reported that in the last 45 years of research published in the four main child language acquisition journals, there is at least one paper published on a total of 103 languages, which represents only 1.5% of the world’s language diversity, assuming there are 7000 natural languages. Among these papers, the majority were on English (54%) and other Indo-European languages (30%).
The limited number of aphasia language tests in languages other than English, especially in minority languages (Hassan et al. 2024; Villanueva-Sánchez et al. 2021), may play a vital role in the reduced linguistic variability in the literature, given that the scarcity of assessment tools poses a great challenge not only to clinical practice but also to research (Ivanova and Hallowell 2013; Martínez-Ferreiro et al. 2024).

1.2. Studies on Bi/Multilingual IWAs

Today, half or more of the world’s population is bi/multilingual (Faroqi-Shah et al. 2010) and the world’s population over 60 years old is increasing. This suggests that there will be an increase in the number of multilingual people with stroke and, consequently, aphasia (Centeno et al. 2020; Norvik et al. 2022). Thus, bi/multilingual aphasia studies appear nowadays as an important goal in both theories on aphasia and on language processing.
Research on bi/multilingual aphasia has thoroughly demonstrated that patterns of language impairment are varied and that aphasia in bi/multilinguals does not always affect all languages to the same extent (Paradis 2004). In some cases, all languages are relatively equally affected (parallel impairment), but in other cases, one of the languages is more severely impaired than the other(s) (differential impairment). The same can be observed regarding recovery, since the effects of treatment can lead to parallel recovery or differential recovery, in which recovery in one of the languages is more pronounced compared to the other(s) (Peñaloza and Kiran 2019; Verreyt et al. 2013).
Numerous studies have attempted to explain the factors that lead to specific impairment and recovery patterns and to determine which language will be better preserved and more quickly/better recovered. Ribot (1882) proposed that the first language of a bilingual IWA would be the less damaged and better recovered one. However, according to Pitres (1895), the language that is first and better recovered would be the one most widely used before the brain injury. Despite empirical evidence for so-called Ribot’s law and Pitre’s law, a recent literature review by Kuzmina et al. (2019) demonstrated that bilingual IWAs had either parallel recovery or better recovery in the first language (L1) than in the second language (L2). These authors also found that the age of acquisition of L2 was one of the key factors to explain the type of impairment. In general, those bilinguals who acquired their L2 before the age of 7 showed similar recovery, whereas those bilinguals who learnt their L2 after 7 revealed better recovery in their L1.
Two important themes emerge from the studies discussed so far in order to guarantee a reliable assessment in bi/multilingual IWAs. First, considering that different impairment and recovery patterns can be attested, it is essential to assess all languages of bi/multilinguals. Otherwise, impairments in the unassessed language might go unnoticed (Kuzmina et al. 2019; Paradis 2004). Second, several factors can affect the language better preserved/recovered in aphasia (L1, the age of acquisition of L2, proficiency in each language before the injury, etc.). Therefore, the literature on aphasia suggests that it is crucial to be aware of the linguistic profile and language history of the bi/multilingual IWAs (Kuzmina et al. 2019; Lerman et al. 2020), as proposed in studies on bilinguals without brain damage (Surrain and Luk 2019).
Nevertheless, empirical studies on aphasia do not yet meet these needs, as revealed by a study by Beveridge and Bak (2011). Among the sample of 1184 articles published from 2000 to 2009 that they analysed, those studies on bilingual IWAs reporting on all languages were only 3.97%. Note that they found an increase during this decade: between 2000 and 2004, the percentage of articles on bilinguals was 3%, and in the next five-year period (2005–2009), it was 5%.
This gap between the theory and the current research has a clear impact not only on clinical practice but also on research, especially for bi/multilingual IWAs with non-hegemonic languages. Recent evidence has established that speakers from minority languages with speech and language disorders are at special risk of being misdiagnosed because they are frequently evaluated (and then treated) in their other (the majority) language (Beauchamp et al. 2022; Villanueva-Sánchez et al. 2021). Thus far, it has been argued that due to both language and cultural barriers, IWAs from diverse cultures and who speak diverse languages, especially racial–ethnic minority groups, are at risk of disadvantage in their access to comprehensive aphasia assessment and intervention (Mellahn et al. 2023; Penn and Armstrong 2017; Scimeca et al. 2022).

1.3. Aims and Predictions

The main objective of this study is to analyse how language diversity and bi/multilingualism are reflected in the literature on aphasia by reviewing studies on aphasia assessment between 2010 and 2019 as a follow-up to the study by Beveridge and Bak (2011). These authors investigated the literature published during the years 2000–2009, so the present article will compare the updated literature with that of the previous one and examine the trends over those two decades. To that aim, we have analysed a number of factors related to the assessment of language disorders, which include language diversity, bi/multilingualism and assessment tools. The following are the research questions and our main predictions:
  • RQ1. How is the world’s linguistic diversity reflected in the literature on aphasia?
Beveridge and Bak (2011) found that in the literature about aphasia from 2000 to 2009, there was a clear dominance of English and Indo-European languages. Therefore, we predict that between 2010 and 2019, the representation of linguistic diversity will continue with the same predominance of English and Indo-European languages, although language diversity might have increased in the most recent literature.
  • RQ2. How is bi/multilingualism reflected in the literature on aphasia?
Although more than half of the world’s population is bi/multilingual, this was not reflected in the empirical studies from the first decade of the 21st century (Beveridge and Bak 2011). In line with this, our hypothesis is that studies on bi/multilinguals reporting on all their languages will still be a minority within empirical studies, although we predict an increase in the second decade in line with the increase observed by Beveridge and Bak (2011) in the second five-year period analysed.
  • RQ3. Are there any changes observed between 2000 and 2019?
This study will provide us with a 20-year period that will allow us to observe some development in the literature regarding language diversity and studies on bi/multilingualism. The recent literature has claimed the importance of assessing and comparing languages of different typologies and minority groups (Paradis 2001b; Scimeca et al. 2022), and recently, new tools have been developed for language assessment (Ballard et al. 2019; Fyndanis et al. 2017). Thus, previously unreported new languages can be expected in the literature, leading to an increase in the language diversity observed in empirical studies on aphasia.
In the same vein, considering that (1) the need for the assessment and treatment of all languages of bi/multilinguals has been thoroughly acknowledged in recent years (Ansaldo and Saidi 2014; Kuzmina et al. 2019; Paradis 2008) and that (2) Beveridge and Bak (2011) found a slight increase in papers where all the languages of bi/multilinguals were assessed in the second half of the decade they analysed, we predict that this increase will continue in empirical studies during the decade 2010–2019 in this globalised world where monolinguals are becoming the exception rather than the norm.

2. Methods

2.1. Sample

For the sample selection, we followed Beveridge and Bak (2011); that is, we used the Scopus database, and we selected articles on aphasia published between the years 2010 and 2019 in the following 4 journals: Aphasiology; Brain and Language; Journal of Neurolinguistics; and Language, Cognition and Neuroscience. In the process of sample selection, we searched for the keywords aphasi* and assess* by limiting the search to the journals and years mentioned above. Note that we conducted the search by including the keywords aphasi* and assess* in order to restrict the articles to those reporting on IWA assessments. After the first screening, the results obtained were 307 articles (see Figure 1).
The inclusion criterion was empirical studies reporting on new data on IWA language assessment. Some of the articles automatically searched did not meet the inclusion criteria, as they did not evaluate people with aphasia or they were reviews of the literature (cf. Beveridge and Bak 2011); thus, 84 articles were not included in our sample. Among these 84 articles, 33 were literature reviews, 16 were professional’s opinions, 9 articles used data based on previous research, 7 others summarised another work, 5 were introductions, 4 were not from IWAs but rather a control group, 5 did not assess IWAs, 2 articles were a description of an assessment tool, 1 was a hypothesis, 1 was on didactics and, finally, 1 article was repeated in two different years. Thus, the final sample constituted 223 articles (Figure 1). A list of the articles included in the sample is provided in Supplementary Materials.

2.2. Analysis

Once the sample was selected, we encoded the following data using Excel (Microsoft Office Professional Plus 2016): the language(s) evaluated in people with aphasia1; whether patients were monolingual or bi/multilingual and, in the case of bi/multilinguals; whether all their languages were evaluated; whether information about their language history was reported and, if so, how these data were obtained (through questionnaires, otherwise); and finally, what assessment tool(s) was used. See Table 1 for an example of the coding and supplementary material available in the OSF project (https://osf.io/xjm4r/?view_only=3fff599e783946c797ea6e2fb49b3b1d, (accessed on 31 August 2024)). Next, we performed descriptive statistics.

3. Results

We will present the results based on two aspects: on the one hand, those related to linguistic diversity (Section 3.1), and on the other hand, those related to the study of bi/multilinguals (Section 3.2).

3.1. Language Diversity

A total of 35 different languages were identified in the articles, so taking into account that there are about 7164 languages in the world (Ethnologue 2024), 0.49% of the world’s languages were reported. In addition, as observed in Table 2, these languages appeared in the articles in a very heterogeneous way: English was present in 60.29% of the articles, and besides Spanish (3.68%), German (3.68%) and French (3.68%), the rest of the languages were present in less than 3% of the articles.
As far as the language families are concerned, 86.76% of the articles belonged to languages from the Indo-European family, while 13.24% belonged to non-Indo-Europeans (Figure 2). Within the Indo-European languages, 71.32% were Germanic languages, with a clear predominance of English (n = 164, 60.29%). Apart from English, other Germanic languages (11.03%) were German (n = 10), Dutch (n = 7), Swedish (n = 6), Norwegian (n = 4), Afrikaans (n = 2) and Danish (n = 1). The second most frequent branch within the Indo-European family was the one with Romance languages (10.29%), with French (n = 10), Spanish (n = 10), Italian (n = 4), Catalan (n = 2) and Portuguese (n = 2). The remainder of the Indo-European languages reported were Indo-Iranian languages, such as Persian (n = 2), Bengali (n = 1) and Hindi (n = 1), and isolate Greek (n = 4). The non-Indo-European languages analysed were Mandarin (n = 5), Cantonese (n = 1), Turkish (n = 3), Finnish (n = 3), Malaysian (n = 2), Hungarian (n = 1), Sotho (n = 1), Tswana (n = 1), Zulu (n = 1), Xhosa (n = 1), Hebrew (n = 1), Japanese (n = 1) and Arabic (n = 1) (see Table 2).
It should be noted that in some of these articles (n = 36, 16.14%), the language in which people with aphasia spoke was not explicitly mentioned, though, in the examples reported, we found that they were English speakers. This might also be regarded as evidence of English predominance.
Moreover, we examined whether this trend is constant or variable year after year, studying the annual diversity of main languages or language groups. As observed in Figure 3, as far as English is concerned, this language predominates year over year, with a great difference from the other languages. In addition, no other remarkable result is observed apart from the slight increase in Romance languages in 2012 and the one in other Germanic languages in 2015. Overall, the trends remained similar between 2010 and 2019.
The predominance of English is also reflected in the assessment tools used for assessing aphasia. In most articles (94.2%), a standardised tool was used for the assessment of IWAs. A total of 96 different instruments were mentioned, of which 9 were used more than 10 times (Table 3): Western Aphasia Battery (WAB, WAB-R, n = 84), Boston Diagnostic Aphasia Examination (BDAE, BDAE-3, n = 40), Boston Naming Test (BNT, BNT-2, n = 34), Comprehensive Aphasia Test (CAT, n = 32), Psycholinguistic Assessments of Language Processing in Aphasia (PALPA, n = 24), Pyramids and Palm Trees Test (PPTT, n = 18), Aachen Aphasia Test (AAT, n = 15), Bilingual Aphasia Test (BAT, n = 12) and Token Test (TT, n = 10). These nine instruments account for 66.34% of the total number of instruments used. The remaining 33.66% were constituted of 87 instruments. Among the assessment tools used, most of them (71.88%) were available in English, and those instruments that were not used in English were mostly designed in English and adapted into another language. Apart from the BAT (used in 13 languages in the papers included in this study), the assessment tool available in the highest number of languages was the WAB (11 languages).

3.2. Studies on Bi/Multilinguals

Of the articles investigated, only 28.25% (n = 63) made explicit whether the IWAs they reported on were bi/multilingual or monolingual, and 18.83% of the total sample was explicitly categorised as bilinguals or multilinguals. Of these, 7.62% studied more than one language of bilinguals or multilinguals (40.48% of those categorised as bi/multilinguals); in the rest, only one language was studied. Figure 4 illustrates the percentage of bi/multilingual IWAs reported in more than one language year by year. These data reveal no clear patterns, and there seems to be no change with time.
In addition, in those articles where bi/multilinguals were investigated, half of them reported on the language history of the IWAs (54.76%). Among those who specified the language history questionnaire used, the most common questionnaire used (n = 21) was the Bilingual Aphasia Test’s Part A (Paradis and Libben 1987).

4. Discussion

The main purpose of this study was to analyse how linguistic diversity and bi/multilingualism are reflected in the literature on aphasia during the decade 2010–2019, as a follow-up to the paper by Beveridge and Bak (2011).
The results on linguistic diversity are consistent with both predictions and the previous literature. In fact, when comparing our results with those by Beveridge and Bak (2011), we observe almost the same pattern: during 2000–2009, 61.48% of the articles reported on English-speaking IWAs, and in the following decade analysed in this paper, the number was very similar: 60.29% (no statistical difference was found between the two decades). During the decade 2010–2019, only 0.49% of the world’s languages were reported, indicating that several languages remain still understudied in the most recent literature.
Another result that reinforces English hegemony in the literature on aphasia is the fact that English is the language spoken by IWAs in 13.14% of the articles in which the language was not explicitly mentioned. Such results confirm the predominance of English in more recent literature on aphasia despite the claims of the need to study diverse languages (Paradis 2001b).
As far as language families are concerned, even though the predominance of Indo-European languages continues (86.76% during 2010–2019), the results have revealed a slight change in the most recent literature: the number of non-Indo-European languages has significantly increased from 8.13% in 2000–2009 to 13.24% in 2010–2019 (χ2 = 33.83, p < 0.0001), as we predicted. However, it is crucial to note that the non-Indo-European languages have only been assessed in two of the four journals analysed: Aphasiology (58.82%) and Journal of Neurolinguistics (41.17%). This limitation highlights the narrow scope of linguistic diversity in the current literature. The concentration of studies on non-Indo-European languages in just these two journals suggests that the other two journals prioritise research on Indo-European languages. This imbalance raises several critical concerns, such as the Eurocentric bias of this field, which underrepresents research on languages spoken by a substantial portion of the global population and, therefore, does not consider important findings related to those languages.
Indeed, one reason for the low language diversity could be the lack of standardised assessment tools in non-English languages and the lack of professional training on the assessment of bi/multilinguals with aphasia (Centeno 2015; Ivanova and Hallowell 2013; Kuzmina et al. 2019; Norvik et al. 2022). In a recent study by Villanueva-Sánchez et al. (2021) in the Basque Country, 98.5% of professionals working with IWAs expressed the need for more tools in Basque to evaluate people with aphasia. In the case of the Norwegian language, for example, a study carried out by Norvik et al. (2022) emphasised the fact that professionals saw a great shortage of instruments for languages other than Norwegian. Regarding the lack of training, in Norway, 80% of professionals had never received training on working with bilinguals (Norvik et al. 2022). In the same vein, a study by Centeno (2015) also revealed similar concerns: 77.6% of local professionals admitted that they had not been trained to evaluate bilingual patients. Remarkably, this drawback is not restricted to small languages; for example, among the papers in the ten-year period analysed here, Jalil et al. (2011) remarked that there are no language assessment tools designed for the 200 million Malay-speaking people in Southeast Asia, so professionals use translations or informal tests.
Thus, in the coming years, advancements in assessment tools can be expected since there have recently been numerous efforts in the literature to improve the assessment and treatment practices of multilinguals with aphasia. An example of this is that Ballard et al. (2019), based on the Boston Naming Test (BNT) they provided guidelines for the creation of Naming Tests for languages in which a test is not available (i.e., minority languages). Another example is the Comprehensive Aphasia Test (CAT), which is in the process of being adapted to 14 languages (Fyndanis et al. 2017; Martínez-Ferreiro et al. 2024). Abou El-Ella et al. (2013) already performed an adaptation of CAT to Arabic so that it was socio-culturally suitable for the Egyptian population and showed that the modification was useful among their speakers.
Note that in order to evaluate the real use of language, those adaptations might consider dialectal and transcultural aspects of language (Peña-Casanova et al. 2022). Hence, we believe that the development of tools in other languages will provide the opportunity to conduct reliable assessments in languages other than English, and consequently, the number of studies in other languages can be enhanced, especially those in minority groups (Cruz-Flores et al. 2011; Scimeca et al. 2022). Thus, we expect the slight change observed in this decade to continue in the next decade. The availability of assessment tools in new languages may facilitate healthcare by improving the quality of cognitive–linguistic evaluation and also the participation of these minority groups in clinical research.
On the other hand, regarding our second research question on studies on bi/multilinguals, our prediction was partially confirmed, as there seems to be some slight increase in the more recent literature on studies reporting bi/multilinguals’ performance in more than one language, although they remain scarce. In fact, according to the work of Beveridge and Bak (2011), 3.46% of the papers between 2000 and 2009 assessed bi/multilinguals in all their languages, and the percentage was significantly higher (7.62%) in the next decade, as reported in this study (χ2 = 7.2, p < 0.01). Note, however, that the increase does not seem to be an expression of a sustained trend: between 2000 and 2004, all bi/multilingual languages were analysed for 3% of the sample, and that percentage increased to 5% during 2005–2009 (Beveridge and Bak 2011). In the next decade, the percentage from 2010 to 2014 was 11% (Egia 2023), though in the second half (2015–2019), it was lower (4.4%) (Mendia 2022). Overall, from 2000 to 2019, the average number of studies on bi/multilinguals with aphasia was 7.62%, a low number considering that more than half of society is bi/multilingual (Faroqi-Shah et al. 2010). In fact, language assessment with bi/multilingual adults with aphasia can be challenging for clinicians due to the complexity surrounding both aphasia and bi/multilingualism. And, therefore, there are few investigations focusing on the assessment of bi/multilingual speakers with aphasia (Jodache et al. 2015).
Another important result concerns the low reports on the language history of bi/multilingual IWAs (54.76%), which calls into question the awareness of the relevance of reporting on the language history of bi/multilingual IWAs (for example, for identifying the pattern of impairment). As Lerman et al. (2020) claim, collecting information about pre-stroke language proficiency, exposure and use is vital in order to interpret post-stroke language abilities in multilingual IWAs and specifically to “disentangle the effects of the brain lesion, spontaneous recovery and direct treatment effects from other post-stroke factors such as exposure and use of each language, as well as pre-stroke factors including proficiency, exposure and use” (Lerman et al. 2020).
In sum, this study surfaces, again, the gap between the theory and the real clinical practice, as revealed by the recent literature on aphasia. Although ample evidence has confirmed that bi/multilingual IWAs might exhibit different patterns of language impairment across their languages, reinforcing the calls for assessing all languages of IWAs (Kuzmina et al. 2019), the most recent empirical studies on IWAs are not yet facing this demand. Investigations on bi/multilinguals with aphasia will not only improve patient assessment and treatment practice but will also advance our understanding of theoretical questions about the patterns of impairment in IWAs and their implications for typical language processing (Goral and Hejazi 2021).

5. Conclusions

Research on aphasia conducted in 2010–2019 has shown that the current literature on aphasia is not representative of the world’s language diversity. The extreme tendency towards English and other Western European languages limits the applicability of aphasia therapy around the world. Following the trends of the study carried out by Beveridge and Bak (2011) in the first decade of the 21st century, similar results have been observed during the next decade, as five languages have accounted for three-quarters of all research: English, French, German, Spanish and Mandarin (74%). Therefore, there is still a strong tendency to consider only hegemonic languages in studies on aphasia. However, considering that symptomatology may be different from one language to another, in the future, further emphasis should be placed on describing and analysing languages that are typologically different, as previously claimed by other scholars (Beveridge and Bak 2011; Paradis 2001b).
The poor results associated with studies of bi/multilinguals and the low and non-steady increase over the past two decades might be related to the lack of professional training with bi/multilinguals and/or the need for more standardised assessment tools in languages other than English (Centeno 2015; Norvik et al. 2022; Villanueva-Sánchez et al. 2021). This is a serious drawback, as noted above, because bilingualism influences the study of aphasia, so it is necessary to study all bi/multilinguals’ languages (Kuzmina et al. 2019; Paradis 2004).
To sum up, efforts should be made to introduce changes among those who study aphasia in the coming years. These include an extension of research to more underrepresented languages, including non-Indo-European ones, and an increase in the number of empirical studies on bi/multilinguals. In order to achieve this objective, it would be necessary to develop new assessment tools for the assessment of aphasia or to adapt them to more languages. Developing a more linguistically pluralistic view of aphasia should be one of the priorities in future research in this more and more globalised world.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/languages9100325/s1, List of the sample analysed.

Author Contributions

Conceptualization, A.M.-I.; methodology, A.M.-I.; formal analysis, M.E.-Z. and A.M.-I.; writing—original draft preparation, M.E.-Z. and A.M.-I.; writing—review and editing, M.E.-Z. and A.M.-I.; supervision, A.M.-I.; funding acquisition, A.M.-I. All authors have read and agreed to the published version of the manuscript. The authors thank Itziar Mendia for her help in the coding and analysis of the 2015-2019 period.

Funding

This research was funded by the Basque Government (IT1627-22) and the Ministerio de Ciencia, Innovación y Universidades (PID2023-148030NB-I00).

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data supporting reported results can be found in the following OSF project: https://osf.io/xjm4r/?view_only=3fff599e783946c797ea6e2fb49b3b1d (accessed on 30 March 2024).

Conflicts of Interest

The authors declare no conflicts of interest.

Note

1
For the number of languages reported, we counted every language as one, irrespective of being part of the same article. That is in studies on bilinguals two languages were counted.

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Languages 09 00325 g001
Figure 1. A flow chart describing the procedure involved in searching and filtering the papers for the sample of this study.
Figure 1. A flow chart describing the procedure involved in searching and filtering the papers for the sample of this study.
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Figure 2. The language families reported in the articles.
Figure 2. The language families reported in the articles.
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Figure 3. Language groups reported in the articles by year.
Figure 3. Language groups reported in the articles by year.
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Figure 4. Percentage of bi/multilingual IWAs reported in more than one language by year.
Figure 4. Percentage of bi/multilingual IWAs reported in more than one language by year.
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Table 1. Example of codification.
Table 1. Example of codification.
AuthorTitle and YearLanguage(s)Mono/Bilingual SpecifiedIs It Bilingual?All L. EvaluatedL. HistoryQuestionnaireAssessment Tool
(Wilshire et al. 2014)The sentence production test for aphasia2014EnglishNo -NoNoBDAE, BNT
(Mccann and Doleman 2011)Verb retrieval in nonfluent aphasia: A replication of Edwards and Tucker, 20062011EnglishNo-NoNoCAT, OANB, VAST, PALPA
Table 2. Number of articles where each language is reported.
Table 2. Number of articles where each language is reported.
LanguageN%Language Family
English164(60.29%)Indo-European > Germanic
German10(3.68%)Indo-European > Germanic
French10(3.68%)Indo-European > Romance
Spanish10(3.68%)Indo-European > Romance
Mandarin8(2.94%)Sino-Tibetan
Dutch7(2.57%)Indo-European > Germanic
Swedish6(2.21%)Indo-European > Germanic
Russian5(1.84%)Indo-European > Slavonic
Hebrew4(1.47%)Afro-Asiatic > Semitic
Turkish4(1.47%)Altaic > Turkic
Norvegian4(1.47%)Indo-European > Germanic
Greek4(1.47%)Indo-European > Isolate
Italian4(1.47%)Indo-European > Romance
Finnish4(1.47%)Uralic > Finno-Ugric
Japanese2(0.74%)Altaic > Isolate
Korean2(0.74%)Altaic > Isolate
Malay2(0.74%)Austronesian
Afrikaans2(0.74%)Indo-European > Germanic
Persian2(0.74%)Indo-European > Indo-Iranian
Catalan2(0.74%)Indo-European > Romance
Portuguese2(0.74%)Indo-European > Romance
Arabic1(0.37%)Afro-Asiatic > Semitic
Indonesian1(0.37%)Austronesian
Samoan1(0.37%)Austronesian
Tamil1(0.37%)Dravidian
Danish1(0.37%)Indo-European > Germanic
Bengali1(0.37%)Indo-European > Indo-Iranian
Hindi1(0.37%)Indo-European > Indo-Iranian
Czech 1(0.37%)Indo-European > Slavonic
Sotho1(0.37%)Niger–Congo > Bantu
Tswana1(0.37%)Niger–Congo > Bantu
Xhosa1(0.37%)Niger–Congo > Bantu
Zulu1(0.37%)Niger–Congo > Bantu
Cantonese1(0.37%)Sino-Tibetan
Hungarian1(0.37%)Uralic > Finno-Ugric
Total272(100%)
Table 3. Distribution of assessment tools used more than 10 times and languages in which these tools were administered in the papers analysed in this study.
Table 3. Distribution of assessment tools used more than 10 times and languages in which these tools were administered in the papers analysed in this study.
LanguageN%Languages
Western Aphasia Battery (WAB, WEAB-R)8437.50Bengali, Mandarin, Korean, Hebrew, Spanish, English, Tamil, Portuguese, Hungarian, Afrikaans, Hindi
Boston Diagnostic Aphasia Examination (BDAE. BDAE3)4017.86Spanish, English, Finnish, Swedish, Mandarin, Portuguese, German, French
Boston Naming Test3415.18English, Dutch, Hungarian, French, Spanish
Comprehensive Aphasia Test (CAT)3214.73English, Dutch, Malay, Arabic
Psycholinguistic Assessment of Language Processing in Aphasia (PALPA)2411.16English, Dutch, Spanish, Norvegian
Pyramids and Palm Trees test (PPTT)188.48English, German, French, Spanish
Aachen Aphasia Test (AAT)156.70Italian, Indonesian, English, Dutch, German, Portuguese
Bilingual Aphasia Test125.36English, Italian, Hindi, Mandarin, Spanish, Catalan, Greek, Czech, Persian, Turkish, Norvegian, German, Japanese
Token Test (TT)104.91Dutch, English, French, German, Arabic, Portuguese
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Egia-Zabala, M.; Munarriz-Ibarrola, A. Language Diversity and Bi/Multilingualism in Aphasia Research. Languages 2024, 9, 325. https://doi.org/10.3390/languages9100325

AMA Style

Egia-Zabala M, Munarriz-Ibarrola A. Language Diversity and Bi/Multilingualism in Aphasia Research. Languages. 2024; 9(10):325. https://doi.org/10.3390/languages9100325

Chicago/Turabian Style

Egia-Zabala, Monike, and Amaia Munarriz-Ibarrola. 2024. "Language Diversity and Bi/Multilingualism in Aphasia Research" Languages 9, no. 10: 325. https://doi.org/10.3390/languages9100325

APA Style

Egia-Zabala, M., & Munarriz-Ibarrola, A. (2024). Language Diversity and Bi/Multilingualism in Aphasia Research. Languages, 9(10), 325. https://doi.org/10.3390/languages9100325

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