L19: Apraxia Treatment Flashcards
in AOS, the primary focus of treatment is on…. rather than…
how does this compare to dysarthria treatment?
Primary focus on speech sound production rather than on physiological support for speech.
Dysarthria treatment often has a focus on improving/compensating for loss of physiological support.
what are the 2 things AOS treatment focuses on?
(1) reestablishing plans or programs for speech sounds
(2) improving the ability to select or activate these plans/programs.
AOS treatment primarily involves _____ procedures, little if any ______ procedures
behavioural
medical or prosthetic
primary focus is on ____ - rarely involves a focus on resonance, resp, or phonation
articulation
focus is often on _____ and _____ positioning of the _____, achieving….
accurate and consistent
articulators
Achieving spatial targets a major focus of many treatments
may also include a focus on _____ coordination and ….
interarticulatory coordination and timing during the production of specific speech segments (ie. laryngeal ‑ upper articulatory timing for voiced/voiceless contrasts).
most treatments emphasize extensive and …..
systematic drills of target speech sounds. Burning in the motor program for a sound (Shewan, 1980). As many responses as possible during tx sessions.
treatment planning often involves the careful.. following…
selection and ordering of the speech stimuli based on the patient’s articulatory errors and factors that appear to influence accuracy or errors.
following hierarchies
what types of hierarchies are followed? how are they developed?
Hierarchies of sound complexity, place and manner of articulation, length of utterance, frequency of occurrence, visibility of sound, meaningfulness, context, rate of speech, input modalities, etc.
Hierarchies developed from an assessment of the individual patient’s error patterns and more general knowledge about characteristics of apraxia, speech complexity and speech development.
______ words are easier than nonsense words
meaningful
_____frequency words are easier than ______frequency words
high
low
Increased speech rate tends to
increase sound error frequency
Syllables with fewer phonemes are
easier than syllables with more phonemes
____________ are easier than clusters
Consonant singletons
Production of stressed syllables/words is
easier than production of unstressed syllables/words
Automatic/reactive speech is easier than
volitional, purposive speech
Oral/nasal distinctions are easier than
voicing distinctions, which are easier than manner distinctions, which are easier than place distinctions
Combined visual and auditory stimulation (watch and listen) often leads to
more accurate responses than auditory or visual stimulation alone
Most speaker-oriented behavioral treatment approaches employ concepts of …..
intersystemic or intrasystemic reorganization. Both recognize that improvement may require some neural reorganization of the way in which speech planning or programming is accomplished
intrasystemic reorganiztion…
attempts to improve performance by emphasizing a more primitive or automatic level of function or control. For example, speech entrainment (say it with me) or imitation more primitive than cued or spontaneous speech. Counting or automatic social phrases more primitive than spontaneous. Nonspeech movements (i.e. place lips together versus bilabial speech sound) may be more primitive than similar movements for speech sounds
intersystemic reorganization…
attempts to improve performance by combining a different (nonspeech activity) with speech. Gestural reorganization is an example. Combine a rhythmic limb movement (syllabic hand tapping) with speech syllables. The limb gesture control may help organize the control of speech. Intersystemic reorganization is also considered to be involved in procedures that combine singing or melody or rhythm with speech.
3 main treatment categories for AOS
articulatory kinematic approaches
rate and/or rhythm approaches
additional approaches and techniques
what are the two main articulatory kinematic approaches?
sound production treatment
PROMPT: Prompts for restructuring oral muscular phonetic targets
describe the focus of articulatory kinematic approaches
focus on the spatial and temporal aspects of movements to improve sound and sound sequence accuracy. They have received more treatment research attention, so they have the strongest evidence of effectiveness.
what does sound production treatment focus on
improving spatial targeting and timing of articulation at the segmental and syllable level.
Efficacy data are better for SPT than for any other treatment for AOS.
what techniques does sound production treatment rely on?
relies on techniques used by many AOS treatments, including repetition, integral stimulation, modeling, orthographic cuing, phonetic placement cues, and feedback.
what is a unique feature of sound production treatment?
A unique feature is its frequent, although not exclusive emphasis on minimal contrasts; minimal contrast tasks require production of words in which target contrasts are minimally different (e.g., shock-sock, conical-comical). Such tasks provide practice at refining movement patterns that distinguish among minimally different sounds, an important skill when errors are due to a movement programming disorder.
how are treatment stimuli determined for sound production treatment
by a given patient’s unique error patterns. The targets of treatment are sounds, but stimuli typically are words, phrases, or sentences.
what are the 5 steps of the sound production treatment hierarchy?
1- The therapist says the target and requests a rep (e.g., “say sun”). (correct = repeat x5 go to step 5, incorrect =feedback)
2- The therapist shows the printed letter representing the target, says the target word, and requests a rep (e.g., “let’s focus on this sound on the card…say sun”).(correct = x5 + next step, incorrect = step 3)
3 - The therapist uses integral stimulation to elicit the target word – “watch me, listen to me, and say it with me” up to 3 times. (correct = x5 next step, incorrect = step 4)
4- The therapist gives articulatory placement cues, and requests production of the target word again after cueing using integral stimulation (note: cues are dependent upon the errors produced by the client). (correct = x5, incorrect = step 5)
5-Go to the next item.
in sound production treatment the hierarchy is…
is response-contingent (steps are only used as needed) and does not reverse directions.
**Will not be used with sentence level stimuli.
What is the distinctive feature of PROMPT?
its use of tactile cues to provide touch pressure, kinesthetic, and proprioceptive cues to facilitate speech production. In this sense, the clinician acts as an “external programmer” for speech, providing intersystemic cues for spatial and temporal aspects of speech production.
The tactile-kinesthetic input used in PROMPT is typically paired with auditory and visual stimulation.
PROMPT uses highly structured finger placements on the patient’s…
face and neck to signal articulatory target positions as well as cues about other movement characteristics, such as manner of articulation, degree of jaw movement, and syllable and segment duration.
Improvements in speech in response to PROMPT have been reported…
for a small number of patients.
PROMPT can be considered a ________ treatment for AOS
partly established
how does PROMPT work?
moderate-severe AOS
the clinician touches points on the patients face and throat to provide tactile/kinesthetic cues for specific phonetic features
first work on establishing associations between prompts and speech features/sounds
then work on consistency and accuracy of sounds
eventually work on sequences of sounds in words and phrases
fade prompts
what are the 3 rate and/or rhythm approaches?
pacing techniques
melodic intonation therapy
vibrotactile stimulation
describe the reasoning behind rate and/or rhythm approaches
Some approaches place primary emphasis on modifying rate and/or rhythm. They recognize that rate, rhythm, and stress can have powerful faciliatory effects on articulation. These approaches can be combined with gestural procedures to further enhance intersystemic reorganization processes.
how do pacing techniques work?
Use of a pacing board, hand/finger/foot tapping or other gestures (squeeze fist) that can be produced consistently. Pair imitated tapping patterns with imitated speech. Progress through hierarchies of complexity and then begin to fade imitation and shape towards use in spontaneous speech and eventually fade the gestures
Rate/rhythm techniques are ____systemtic and may allow for…
inter
may allow for the use of the intact mechanisms involved in the control of limb gestures to facilitate control of disordered speech movements. They may also provide a temporal basis for organizing sequences of speech movements.
bc these gestural pacing techniques usually slow the rate of speech it is difficult to determine…
the relative impact of gesture effects versus rate reduction effects. Likely a combination of these effects
limitations/considerations of rate/rhythm techniques?
no comparisons across these gestural pacing or rate reduction methods
some rate reduction techniques (i.e., metronome pacing and DAF) have been reported not to be effective in AOS
prolongation of vowels using visual feedback of the acoustic signal has been reported to slow and improve apraxia of speech in some patients
describe melodic intonation therapy
a formal treatment program originally intended for people with severe nonfluent aphasia. It has been used by some clinicians to treat AOS.
MIT begins with the gradual teaching of preselected hand-tapping rhythms, eventually with simultaneous humming, in unison with the clinician, with gradual fading of the clinician’s model. When these basics are acquired, meaningful language is added. Clinician cues and patient hand tapping are eventually faded, and imitation gives way to the patient answering questions.
what do the melodies employ for melodic intonation therapy?
The melodies employed avoid the use of familiar tunes but emphasize exaggerated pitch, tempo, and rhythm, with tempo lengthened and pitch varied to create a lyrical melodic pattern, as well as rhythm and stress exaggerated for the purpose of emphasis. When this singing style can be used for the accurate repetition of verbal materials, it is modified to “sprechgesang,” or “spoken song,” a prosodic pattern lying between singing and speech.
limitations to melodic intonation therapy?
Multiple factors involved in MIT so it is hard to determine which factors have important effects. Factors include: slower rate; emphasis of stress pattern; consistent but exaggerated tones; gestures combined with speech; and rhythmic tactile kinesthetic stimuli
Describe vibrotactile stimulation… results?
moderate AOS
vibration (50Hz) applied to the surface of the index finger
greater intensity and duration of tactile stimulation for stressed syllables in polysyllabic words
clinician says words and simultaneously provides patient with matching tactile stimulation
then pt tries to imitate word and stress pattern while receiving second tactile stimulation
Rubow et al., 1982 found imitation + vibrotactile stimulation had a greater effect than imitation alone in the treatment of one moderate AOS patient
what are three additional approaches for severe AOS?
key word derivation
phonetic derivation
phonetic placement
describe key word derivation
used with severe AOS and for apraxic place/manner/voice segment errors
the idea is that the patient learns to transfer control of a sound that can be produced automatically in a key word to similar sounds in other more difficult words
1st search for a few key words that the patient can say consistently and automatically (i.e., spouse’s name ‘Sue’)
practice producing the key word consistently in a variety of less automatic contexts to expand the volitional control of the key word
next the patient focuses on the feel of selected target sounds (/s/) in the key word
then other words beginning with target /s/ are then practiced in combination with the key word (i.e., soap, sun, sit, etc)
describe phonetic derivation (progressive approx)
severe AOS and used for apraxic positioning errors
· may be a problem for patients with oral nonverbal apraxia
· (Can patient consistently produce nonspeech oral postures?)
· shaping of speech sounds from nonspeech postures and sounds
examples:
deriving /f/: bite lower lip + unvoiced airstream
deriving /th/: tongue protrusion + airstream
deriving /p/: shape a popping sound with lips or puffed cheeks
describe phonetic placements
severe AOS and used for apraxic place & manner errors
may not be suitable for patients with oral sensory deficits
extensive use of
1- verbal descriptions of how sounds are produced
2- drawings and models of the vocal tract
3- methods to enhance sensory awareness of vocal tract locations
4- manipulation of the patient’s articulators
ex. /p/: clinician uses hands to compress lips together while patient blows
what are the 3 visual (kinematic) feedback procedures that may be used w AOS?
electromagnetometer (EMA)
Electropalatography (EPG)
Ultrasound
electromagnetometer (EMA)
has been used to provide visual feedback about articulatory movements during treatment to a small number of patients with AOS (Katz et al., 1999; 2009). Kinematic and auditory perceptual data have revealed improvements in accuracy and generalization of effects for at least some speakers and some treated sounds.
electropalatography (EPG)
which provides visual feedback about lingual to hard palate contact patterns during treatment has been used in a small number of patients with chronic AOS and aphasia.
what considerations need to be made w visual feedback procedures
Further study of more patients is required to determine the effectiveness of these instrumental kinematic feedback approaches relative to other A-K approaches such as SPT. Also, need to determine if they can be used as adjunctive AOS treatment (i.e. SPT + EPG tx).
