L19: Apraxia Treatment

Question 1

in AOS, the primary focus of treatment is on…. rather than…

how does this compare to dysarthria treatment?

Answer 1

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.

Question 2

what are the 2 things AOS treatment focuses on?

Answer 2

(1) reestablishing plans or programs for speech sounds

(2) improving the ability to select or activate these plans/programs.

Question 3

AOS treatment primarily involves _____ procedures, little if any ______ procedures

Answer 3

behavioural

medical or prosthetic

Question 4

primary focus is on ____ - rarely involves a focus on resonance, resp, or phonation

Answer 4

articulation

Question 5

focus is often on _____ and _____ positioning of the _____, achieving….

Answer 5

accurate and consistent

articulators

Achieving spatial targets a major focus of many treatments

Question 6

may also include a focus on _____ coordination and ….

Answer 6

interarticulatory coordination and timing during the production of specific speech segments (ie. laryngeal ‑ upper articulatory timing for voiced/voiceless contrasts).

Question 7

most treatments emphasize extensive and …..

Answer 7

systematic drills of target speech sounds. Burning in the motor program for a sound (Shewan, 1980). As many responses as possible during tx sessions.

Question 8

treatment planning often involves the careful.. following…

Answer 8

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

Question 9

what types of hierarchies are followed? how are they developed?

Answer 9

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.

Question 10

______ words are easier than nonsense words

Answer 10

meaningful

Question 11

_____frequency words are easier than ______frequency words

Answer 11

high

low

Question 12

Increased speech rate tends to

Answer 12

increase sound error frequency

Question 13

Syllables with fewer phonemes are

Answer 13

easier than syllables with more phonemes

Question 14

____________ are easier than clusters

Answer 14

Consonant singletons

Question 15

Production of stressed syllables/words is

Answer 15

easier than production of unstressed syllables/words

Question 16

Automatic/reactive speech is easier than

Answer 16

volitional, purposive speech

Question 17

Oral/nasal distinctions are easier than

Answer 17

voicing distinctions, which are easier than manner distinctions, which are easier than place distinctions

Question 18

Combined visual and auditory stimulation (watch and listen) often leads to

Answer 18

more accurate responses than auditory or visual stimulation alone

Question 19

Most speaker-oriented behavioral treatment approaches employ concepts of …..

Answer 19

intersystemic or intrasystemic reorganization. Both recognize that improvement may require some neural reorganization of the way in which speech planning or programming is accomplished

Question 20

intrasystemic reorganiztion…

Answer 20

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

Question 21

intersystemic reorganization…

Answer 21

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.

Question 22

3 main treatment categories for AOS

Answer 22

articulatory kinematic approaches

rate and/or rhythm approaches

additional approaches and techniques

Question 23

what are the two main articulatory kinematic approaches?

Answer 23

sound production treatment

PROMPT: Prompts for restructuring oral muscular phonetic targets

Question 24

describe the focus of articulatory kinematic approaches

Answer 24

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.

Question 25

what does sound production treatment focus on

Answer 25

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.

Question 26

what techniques does sound production treatment rely on?

Answer 26

relies on techniques used by many AOS treatments, including repetition, integral stimulation, modeling, orthographic cuing, phonetic placement cues, and feedback.

Question 27

what is a unique feature of sound production treatment?

Answer 27

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.

Question 28

how are treatment stimuli determined for sound production treatment

Answer 28

by a given patient’s unique error patterns. The targets of treatment are sounds, but stimuli typically are words, phrases, or sentences.

Question 29

what are the 5 steps of the sound production treatment hierarchy?

Answer 29

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.

Question 30

in sound production treatment the hierarchy is...

Answer 30

is response-contingent (steps are only used as needed) and does not reverse directions. **Will not be used with sentence level stimuli.

Question 31

What is the distinctive feature of PROMPT?

Answer 31

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.

Question 32

PROMPT uses highly structured finger placements on the patient’s...

Answer 32

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.

Question 33

Improvements in speech in response to PROMPT have been reported...

Answer 33

for a small number of patients.

Question 34

PROMPT can be considered a ________ treatment for AOS

Answer 34

partly established

Question 35

how does PROMPT work?

Answer 35

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

Question 36

what are the 3 rate and/or rhythm approaches?

Answer 36

pacing techniques melodic intonation therapy vibrotactile stimulation

Question 37

describe the reasoning behind rate and/or rhythm approaches

Answer 37

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.

Question 38

how do pacing techniques work?

Answer 38

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

Question 39

Rate/rhythm techniques are ____systemtic and may allow for...

Answer 39

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.

Question 40

bc these gestural pacing techniques usually slow the rate of speech it is difficult to determine...

Answer 40

the relative impact of gesture effects versus rate reduction effects. Likely a combination of these effects

Question 41

limitations/considerations of rate/rhythm techniques?

Answer 41

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

Question 42

describe melodic intonation therapy

Answer 42

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.

Question 43

what do the melodies employ for melodic intonation therapy?

Answer 43

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.

Question 44

limitations to melodic intonation therapy?

Answer 44

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

Question 45

Describe vibrotactile stimulation... results?

Answer 45

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

Question 46

what are three additional approaches for severe AOS?

Answer 46

key word derivation phonetic derivation phonetic placement

Question 47

describe key word derivation

Answer 47

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)

Question 48

describe phonetic derivation (progressive approx)

Answer 48

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

Question 49

describe phonetic placements

Answer 49

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

Question 50

what are the 3 visual (kinematic) feedback procedures that may be used w AOS?

Answer 50

electromagnetometer (EMA) Electropalatography (EPG) Ultrasound

Question 51

electromagnetometer (EMA)

Answer 51

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.

Question 52

electropalatography (EPG)

Answer 52

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.

Question 53

what considerations need to be made w visual feedback procedures

Answer 53

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).