Apraxia Flashcards
Define apraxia
Disordered planning and programming
What are the two main types of apraxia
- Ideational apraxia
- Ideomotor apraxia
What is ideational apraxia
uncommon impairment in knowledge of objects or gesture’s function/concept/purpose, resulting in inability to use object or gesture
Which type of apraxia is able to imitate?
Ideational apraxia will have difficulty with sequencing motor movements to complete the task, but will be able to imitate movements
Ideational apraxia results from?
Damage to left parietal lobe
Why is ideational apraxia difficult to detect/diagnose?
- because its very uncommon
- the symptoms can be masked by accompanying disorder (i.e., aphasia)
- symptoms are quickly resolved when caused by stroke
Give an example of someone with ideational apraxia
You are a Pt in the hospital. You are wanting to call the nurse over to your room, knowing you have to beckon her over (call her over), but not knowing how to gesture that with your hands so she understands you
What is ideomotor apraxia
intact knowledge of an objects or gesture’s function, but impaired ability (carry out motor plan) perform movements needed to use an object, make a gesture, or complete a sequence (2-step commands) of individual movements when commanded (know what they are being told, but do it wrong/backwards)
Ideomotor apraxia typically affects __ movements?
Voluntary movements
Can individuals with apraxia self correct?
Often those with ideomotor apraxia will demonstrate attempts made to revise and correct these out of sequence movements causing slow, halting, and awkward movements
Give an example of someone with ideomotor apraxia
Pt is asked to use a toothbrush. They may demonstrate the general pattern of movements required to brush their teeth (indicating they understand the toothbrush’s purpose), but the up and down motion to brush front teeth becomes the back-and-forth movement of brushing back teeth
What are the subtypes of ideomotor apraxia; briefly explain each
- apraxia of speech- impaired planning and programming specific to the movements needed to produce phonemes
- nonverbal oral apraxia- impaired ability to sequence nonverbal voluntary movements of oral structures
- limb apraxia- inability to sequence the movements of hands, arms, legs, or feet during a voluntary action
Characteristics of nonverbal oral apraxia
- Impaired ability to sequence nonverbal, voluntary movements of the tongue, lips, jaw, and other associated oral structures
_Often individual will grope for correct mouth position, delay performing the action, only partially complete the movement, or perform the action slowly/awkwardly - will have trouble protruding the tongue, whistling, biting the lower lip, puffing out cheeks, humming, smacking lip
Nonverbal oral apraxia is also known as
Buccofacial apraxia
Facial apraxia
Orofacial apraxia
Lingual apraxia
How can limb apraxia be assessed?
having individual pantomime a variety of well-known movements: hammering a nail, shaving, putting a key in a lock, combing hair
How can nonverbal oral apraxia be assessed?
Having pt puff out cheeks, hum, smack lips, whistle, protrude the tongue
Limb apraxia is a result of left hemisphere damage affecting…?
The right and left limbs, although hemiplegia may hide its effects on one side of the body
Define hemiplegia
paralysis of one side of the body
It is a severe or complete loss of strength or paralysis on one side of the body
What is hemiparesis
A mild or partial weakness or loss of strength on one side of the body
How is apraxia of speech assessed
-Repeat or read words of increasing complexity beginning with same CVC syllable
-Repeat words with simple CVC consisting of identical initial and final consonants
-Count from 1 to 20
-Count from 20 to 1
-Cookie theft spontaneous description
-Read the generated cookie theft description sentences (4 sentences) on demand
Definition of apraxia of speech
phonetic-motor disorder of speech with inefficiencies not attributed to abnormal muscle tone, abnormal reflexes, primary deficits in processing sensory information (auditory, tactile, kinesthetic, or proprioceptive), or language information.
Causing inefficiencies in the translation of phonologic frames (poor translation of neural-motor code into necessary movement patterns needed to accurately produce a sequence of phonemes in a word/sentence) into intended movement resulting in: inter and intraarticulator timing errors for sounds, syllables, and words; intra-articulator and interarticulator movement/spatial errors for sounds, syllables, and words; and prosody errors
Errors are relatively consistent
How are AOS errors relatively consistent
Distortions are relatively consistent in location within the utterance and error type (distortions, substitutions, omissions)
Intra-articulator and interarticulator timing/temporal errors for sounds, syllables and words causes…
extended durations between phones, syllables, words, and phrases
Intra-articulator and interarticulator movement/spatial errors for sounds, syllables, and words causes…
This causes distorted productions of vowels and consonants
But Distortions often sound like phoneme substitutions, but are actually distortions of the correct target sound OR real substitutions can occur
Prevalence of pure AOS?
Apraxia of speech in its pure form (occurring in isolation) is very rare
In it’s pure form it Will not be accompanied by disorders of basic motor physiology, perception, or language
AOS Often co-occurs with: another type of apraxia, Broca’s aphasia, or Unilateral UMN dysarthria
What is the motor speech programmer?
neural network in brain, near Perisylvian area of the left hemisphere, that sequences motor movements needed to produce speech by analyzing the sensory, linguistic, motor, and emotional information for accurate muscle contractions, intonation, stress, fluent speech
The motor speech programmer receives linguistic information from? What is linguistic information?
Linguistic information from the language centers of the brain (i.e., phonemes)
The motor speech programmer receives motor information from?
Basal ganglia & cerebellum
The motor speech programmer receives sensory information from?
Thalamus
The motor speech programmer receives emotional information from?
The limbic system and right hemisphere
AOS is primarily caused by damage to which brain areas?
Insula & basal ganglia
Causes of AOS most to least common
- Stroke (often affecting Perisylvian area of LH in frontal or parietal lobe; temporal lobe too)
- Degenerative disease (i.e., alzheimer’s, primary progressive aphasia, Creutzfeldt-Jakob disease, huntington’s, parkinsons)
- Trauma (i.e., surgical trauma: aneurysm repair, tumor removal, hemorrhage evacuation; TBI)
- Tumor
- Undetermined etiology
Which degrees of apraxis demonstrate the fewest characteristics
Mild and severe
Speech characteristics of AOS
–Disordered articulation (most common
–Frequently abnormal prosody
–Slow rate of speech- extended duration of consonants and vowels
–Labored (forceful) speech
–Halting speech- extended duration between sounds, syllables, and words
–Articulatory groping- trial and error attempts at finding the correct articulatory position for target, noticeable at the beginning of utterance or word
–Relatively consistent error location & error type demonstrated with repeated trials. Assessment and therapy should consist of multiple trials of target
Describe articulation errors in AOS
- Substitutions close to target phoneme
- Perseveration errors
- Distorted target phoneme
- Phoneme placement: More errors when producing fricatives and affricates than when producing stops, nasals, semivowels, or vowels
- Consonant context: more errors when producing clusters than singletons
- Phoneme position: more errors when producing initial phoneme than medial or final position
- Frequency: more errors when producing less frequent phonemes thaan frequently appearing phonemes
- Word type: more errors when producing nonsense words than real words
- Syllables: more errors when producing multisyllabic words than single-syllable words
- Artic contact: more errors when there is greater distance between points of articulatory contact (like in SMR) than when producing back and forth articulatory contact (like in AMR)
- Speech production task: more errors when producing voluntary speech on command (cookie theft) than when producing automatic speech (counting to 10) or reactive speech (swearing)
- Placement: more errors when producing phonemes with back placements than when producing front placements
Describe prosody errors in AOS
- Slower rate of speech
- Equal stress on all syllables in an utterance
- Silent pauses at initiation of word, between syllables, or between words
- Reduced variation of pitch
- Reduced variation of loudness
3 tasks to evaluate AOS
- Sequential Motor Rate Task (SMRs)- Sensitive assessment, especially when compared with alternating motion rate task (AMR)
- Conversational Speech and Reading Aloud- to Determine effects of prosody
- Repeating Words of Increasing Length- Will have more difficulty as the length increases (i.e., thick, thicker, thickening)
- Reading or Repeating Low-frequency, Multisyllabic Words in Isolation or Sentences
When is diagnosis of apraxia determined?
Can only be determined when a significant number of pt’s speech characteristics match those known to apraxia
In order to determine AOS, you should rule out other conditions that cause similar movement difficulties, such as:
- Muscle weakness, seen in dysarthria
- Sensory loss, seen in TBI
- Comprehension deficit, seen in wenicke’s aphasia
- Incoordination, seen in dysarthria
Wambaugh came up with Four Behavior Categories for Differential Diagnosis, what are the chategories?
A. Primary clinical characteristics
B. Nondiscriminative clinical characteristics
C. Clinical characteristics usually in other disorders
D. Clinical characteristics to rule out AOS
What are the 5 primary clinical characteristics
- Prosody abnormalities
- Slow rate of speech
- Consonant and vowel distortions
- Distorted phoneme substitutions
- Articulation errors during repeated utterances
What are the 6 nondiscriminative clinical characteristics?
- Short periods of error-free speech
- Automatic/spontaneous speech is better than propositional/commanded)speech
- Self-corrects errors; awareness of errors
- Difficulty initiating speech
- Perseveration errors (repeating same answer)
- Articulatory grouping (visual, audible, or both)
What are the 4 clinical characteristics usually in other disorders?
- Demonstrates a difference between expressive and receptive speech and language abilities
- Transpositional errors on phonemes or syllables (swaping phonemes in utterance)
- Anticipatory articulation errors (knowing theyre going to make an error prior to error)
- Limb apraxia or nonverbal oral apraxia (whistling, humming, blowing, tongue movements)
What are the 3 clinical charaacteristics to rule out AOS?
- Fast rate of speech
- Normal rate of speech
- Normal prosody
Someone with a high probability of having AOS would….?
Exhibit ALL 5 primary clinical characteristics
1. Prosody abnormalities
2. Slow rate of speech
3. Consonant & vowel distortions
4. Distorted phoneme substitutions
5. Articulation errors during repeated utterances
Someone with a moderate probability of AOS would…?
Exhibit mostly nondiscriminative clinical characteristics and some primary clinical characteristics
Someone with a low probability of having AOS would…?
Exhibit clinical characteristics usually in other disorders
- Demonstrates a difference between expressive and receptive speech and language abilities
- Transpositional errors on phonemes or syllables (swaping phonemes in utterance)
- Anticipatory articulation errors (knowing theyre going to make an error prior to error)
- Limb apraxia or nonverbal oral apraxia (whistling, humming, blowing, tongue movements)
Someone without the presence of AOS would…?
Exhibit 1+ clinical characteristics to rule out AOS
- Fast rate of speech
- Normal rate of speech
- Normal prosody
Differential diagnosis between AOS and which disorders can be challenging?
Fluent aphasia
Dysarthria
Phonological impairment
How is the lesion site different in AOS, dysarthria, and fluent aphasia?
AOS- anterior brain damage, near Broca’s area, left perisylvian area
Dysarthria- damage to upper motor neuron, lower motor neurons, cerebellum, and/or basal ganglia
Fluent aphasia- posterier brain damage
How is the co-occurrence of aphasia different in AOS, dysarthria, and fluent aphasia?
AOS- often co-occur with broca’s aphasia (nonfluent aphasia)
Dysarthria- typically no co-occurrence with aphasia
Fluent aphasia- type wenicke’s or conduction aphasia (no co-occurrence)
How is the respiration speech mechanism different in AOS, dysarthria, and fluent aphasia?
AOS- typically intact, but if impaired may experience breathy voice
Dysarthria- impaired respiration is common
Fluent aphasia- intact respiration
How is the phonation speech mechanism different in AOS, dysarthria, and fluent aphasia?
AOS- intact
Dysarthria- impaired phonation is common
Fluent aphasia- intact
How is the articulation speech mechanism different in AOS, dysarthria, and fluent aphasia?
AOS- impaired
Dyarthria- impaired articulation is common
Fluent aphasia-impaired
How is the resonance speech mechanism different in AOS, dysarthria, and fluent aphasia?
AOS- intact
Dysarthria- impaired resonance is common
Aphasia- intact
How is the prosody speech mechanism different in AOS, dysarthria, and fluent aphasia?
AOS- impaired
Dysarthria- impaired prosody is common
Aphasia- intact prosody
How are the salient features different in AOS vs dysarthria?
AOS- intact ROM, muscle tone, muscle strength, and coordination
Dysarthria- at least one is affected
How is initiation of speech different in AOS, dysarthria, and fluent aphasia?
AOS- difficulty with initiating speech, demonstrating articulatory groping
Dysarthria- less trouble initiating speech; unusual to have groping
Aphasia- may have word finding problem, but no trouble with initiating & no groping
How are articulation errors different in AOS, dysarthria, and fluent aphasia?
AOS- phoneme and syllable substitution close to target sound
Errors increase as complexity and length increase
Dysarthria- disortions present with inappropriate placement
Fairly consistent as complexity and length increases
Aphasia- substitution placement far off from target sound
How are phoneme distortions different in AOS, dysarthria, and fluent aphasia?
AOS- phoneme distortions present
Dysarthria- phoneme distortions present; vowel and consonant distortions if articulation is impaired
Aphasia- phoneme distortions are rare
How is self-repair different in AOS and fluent aphasia?
AOS- efforts to fix articulation errors often dont improve articulation
Aphasia- efforts to fix articulation errors improve articulation
How is translation time (phoneme duration) different in AOS, dysarthria, and fluent aphasia?
AOS- prolonged transitions- extended duration between phonemes and words. extended duration of vowels in multisyllabic words and sentences
Dysarthria- prolonged intervals between syllables or words if prosody is impaired
Aphasia- intact movement transition times
How does performance on speech tasks differ in AOS and dysarthria?
AOS- automatic speech and emotional speech are produced with few errors. More difficulty with propositional speech
Dysarthria- speech errors present regardless of if the utterance is overlearned or emotional in nature
How is speech rate different in AOS, dysarthria, and fluent aphasia?
AOS- slow rate of speech, even when words are produced accurately
Dysarthria- slowed rate due to inappropriate silences if articulation is impaired
Aphasia- WNL during error free-utterances
How does increased speech rate affect speech in AOS versus fluent aphasia?
AOS- phoneme production errors increase as speech rate increases
Aphasia- typically, accurate phoneme producition is maintained as speech rate increases
How are the language modalities different in AOS, dysarthria, and fluent aphasia?
AOS- impaired verbal expression (other 3 modalities intact)
Dysarthria- impaired verbal expression
Aphasia- some degree of impairment to all 4 modalities
Describe the treatment of AOS
mostly 1:1, intensive, behavior-based procedures
targeting correct selection and sequencing of speech sounds
Treatment goal for AOS therapy
Help pt relearn motor sequences to produce phonemes accurately
Darley’s 6 principles for treating AOS, explain each
- Not all patients are candidates of apraxia therapy
* AOS co-occurrence with aphasia may interfere with progress if apraxia is only targeted, therapy may be better spend on language therapy or nonverbal communication. Their language abilities must be sufficient to allow for improvement with speech production - Patients and families need to understand the nature of aphasia & the Tx process/rationale
* Counsel families/pt’s to ensure pt has adequate family support, family must understand what apraxia is and prognosis so they can know how to help them. They should also learn Tx techniques and why they work (evidence) so techniques are implemented at home - Repetitive and intensive drill
* Repetition, the most important part, helps relearning (principle of neuroplasticity) and rewiring brain to improve motor sequences of intelligible speech - Tx is sequenced to maintain success
* Targets should start with easier activities and progress to more difficult ones when accuracy is achieves - Patients should learn to self-monitor
* Teaching self-awareness allows for pt self-monitoring with knowledge of clinician feedback to start self-correcting errors - Concentrate on functional and useful words
* Tx targets should be relevant to pt’s life to make it meaningful; meaningful stimuli is easier than nonsense words
Specific types of AOS treatments
- Articulatory kinematic treatments
- Rate and rhythm procedures
- ALternative and augmentative communication
- Intersystemic facilitation and reorganization treatment
Describe articulatory kinematic treatments?
AKT treatments concentrate on improving timing and placement of articulatory movements through modeling, positioning of articulators, and repetition
Specific types of articulatory kinematic treatments
- Eight step continuum
- Sound production treatment
- Darley et al. articulatory kinematic approach
- Prompts for restructuring oral musculature targets
Explain the eight step continuum treatment
8 step sequence of structured activities that moves the pt from repeating target phonemes with clinician to independent productions in role-playing situations
What is integral stimulation
Pt carefully watches clinician’s face while listening to verbal production of target word “watch me and listen carefully” (giving them a verbal and visual model, them pt attempts to produce the target
Explain sound production treatment
eight step continuum + articulatory placement cues, phonetic tasks, and extensive modeling
Very well researched approach
Explain darley articulatory kinematic approach
three phase procedures to increase accuracy of phonemes in words: initiative speech activities, automatic responses, and phonetic drill
Explain prompts for resturcturing oral muscular targets
Uses a combination of proprioceptive, pressure, and kinesthetic cues to show pt how to sequence their oral movements for speech
- Hands on cues to provide sensory information regarding place of articulatory contact, jaw position, voicing, timing of syllables, manner of articulation, and co-articulation
Rate and rhythm treatment procedures assume….
They assume apraxia of speech primarily result in timing errors
Types of rate and rhythm procedure treatments
- metronome
- Melodic intonation therapy
Explain metronome therapy
Creating a pacemaker (computerized pace) for verbal productions
Explain melodic intonation therapy
MIT adds rhythms to speech while taping clients hand to train them on rate of speech. Therapy consists of tapping out sentence, humming, humming in unison, singing in unison, singing while fading out, singing in response to question
Explain alternative and augmentative communciation therapy
It is used for those with limited verbal communication to provide increased opportunity/ability to communicate
Modalities: pantomime, drawing, writing, comprehensive system (combined modalities)
Explain intersystemic facilitation and reorganization treatment
uses the patients communicative strengths to assist their verbal speech to improve ability to communicate
1. Combine two modalities- AAC + verbal treatment
2. Combined speech + Amer-Ind gestures
10 Principles of neuroplasticity
– Use it or lose it
– Use it and improve it
– Specificity (be specific in production of target)
– Salience matters (should be meaningful to you to increase motivation)
– Transference (one situation may transfer/generalize to another skill)
– Interference (practicing to improve one skill may interfere with improvement in another area)
– Timing matters (initiation of tx after injury is best 6mo)
– Age matter (younger people heal faster)
– Repetition matters (drill strengthens connections)
– Intensity matters (the number of times you do it, the better it will be)
It is often difficult to differentiate between Broca’s aphasia and AOS because…
–Little anatomical difference between site of lesion
–These two disorders often co-occur, causing the general descriptions of both disorders to be similar (nonfluent, effortful, halting, and disturbed prosody)
Is error consistency a characteristic of AOS
Errors are relatively consistent, but Error consistency is not a hallmark characteristic in AOS
What are literal paraphasias
the incorrect placement of one phoneme or more into a word, consisting of the transposition of phonemes or syllables in a word, the addition of extra phonemes to a syllable, or the substitution of phonemes or syllables
