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Acquired Apraxia of Speech (AOS)
Terms in this set (45)
adult apraxia of speech
-with CAS, more substitutions and omissions
-adults, many more distortions
-she has a lot of world experience
-she knows what it is like to not have aparaxia
-knows what normal speech and language feels like
-child: bottom-up, teaching child things they never had
-adult: has language, more functional therapy, use residual strengths
§ Explain methods of intervention for acquired apraxia of speech in adults.
§ Identify factors to consider when choosing an intervention method for individuals with apraxia of speech.
§ Differentiate therapy implications between acquired AOS from developmental AOS.
§ People with AOS have difficulty planning and programming specific movements of their articulators to produce speech sounds
§ Principles of motor learning are often invoked in treatment plans for AOS
-lesion higher in system
-not in motor execution
Defining AOS cont.
§ A neurological speech disorder that reflects an impaired capacity to plan or program sensorimotor commands necessary for directing movements that result in phonetically and prosodically normal speech.
§ Nearly always results from left cerebral hemisphere damage or subcortical lesions
§ Can exist without any impairment to speech subsystems— respiratory, phonatory, etc.
§ Can exist independent of impairments in auditory comprehension, reading comprehension, and writing
§ BUT often co-occur with aphasia and dysarthria (unilateral) which complicates treatment.
-assume they have language deficits
-phonemic paraphasia (Broca's) or motor speech level
-treat it, not about the cause
Motor Speech Programmer (MSP)
§ Hypothetical brain network that acts as an interface between language formulation and speech production
§ Involves widespread areas of the left frontal + parietal cortex that control sensorimotor planning and programming for speech.
-very focal strokes: may not cause a lot of aphasia but consistent with AOS
Motor Speech Programmer (MSP) Other Regions
• Basal ganglia control circuit
• Cerebellar control circuit
§ Some right hemisphere areas
MSP in AOS
§ MSP in mature speakers selects, sequences, activates, and controls preprogrammed movement sequences
§ It is hypothesized that individuals with AOS have difficulties with accessing or using preprogrammed routes
-phonological encoding, phonological processes
-network selects phonemes, sequences them in right order so that speech muscles can carry out motor commands
Nonspeech characteristics of those with AOS
§ Usually have damage to the left frontal or parietal lobe or left subcortical pathways and structures associated with the direct and indirect activation pathways.
§ Sometimes have varying degrees of right sided weakness and spasticity
§ Sometimes have limb apraxia or oral motor apraxia
-planning and sequencing non speech movements
Etiologies of AOS
§ Usually caused by stroke
§ Sometimes caused by tumor or trauma
§ Demyelinating disorders such as MS (more rare)
Apraxia versus aphasia
§ Phonological errors can occur with both aphasia and AOS
§ Phonetic distortions help classify an apraxic error versus an aphasic addition, substitution or prolongation that is not phonetically distorted
§ Ease of production and normal prosody appear to be major clues to distinguishing aphasic phonologic errors from phonetic-level errors attributable to AOS.
Author Attribution of Activity to Function
MEG: magnet on top of your head
-more orange or dark red = when activations are happening
-one person is saying word in one-second
-first visual processing, then head toward language selection
-semantics, phonology, motor function are red: they directly overlap in time
-no functional differences in your therapy if distortion you have arises from speech motor control and language
Patient perceptions and complaints
§ "I have the words I want to say, but they won't come out the right way."
§ "not as fluent as before"
§ "mispronounce words"
§ Complaints almost always center on articulation and rate and rarely on breathing, phonation, or resonance.
§ Those with isolated AOS do not complain of chewing, swallowing, or drooling difficulties.
-dysarthria: slurry, more effortful
-rarely will they say first point
-dysarthria = managing saliva, swallowing
Nonverbal Oral Apraxia Often Co-Occurs with AOS
§ Cough, blow, click the tongue (other OM tasks)
-can't sequence or initiate nonspeech movements
§ Sometimes vocalizations/verbalizations as part of (or in place of) target (i.e. may say "cough" instead of producing a cough)
§ The presence of NVOA is a sign of left hemisphere pathology, co-occurrence with AOS is high, but not a one-to-one correspondence
-nonspeech oral movements
Speech characteristics of patients with AOS (overlap with CAS)
§ Silent or audible groping
§ False starts
§ Reduced speech rate
-Extended intra- and inter-segment durations
-Long pauses as patients grope for sounds
§ Phoneme distortions/distorted substitutions, additions
§ Equal stress across adjacent syllables
§ Consonants often more affected than vowels
§ Fluency problems: self-correction, difficulty initiating, sound/syllable reps
§ Filled or silent pauses
-more distortions with adults, however not universal
§ Tasks placing demands on the production of motorically complex utterances are best able to elicit the salient and distinguishing features of AOS
§ Imitative tasks are helpful for two reasons
1. Helps to circumvent language barriers
2. Helps to elicit AOS errors by getting the client to produce more linguistically complex utterances.
§ Typically assess speech in a hierarchy from words to phrases to connected speech to identify what the patient can do and where breakdowns occur (Chapey monosyllabic, multisyllabic, sentence completion section 36.1-3)
-where are the errors?
Assessing AOS cont.
Conduct an inventory of sound production
§ Discern which sounds are easy vs. difficult for the patient
§ Obtain multiple exemplars of all sounds in different word positions and complexity levels
Elicit responses through various modes depending on patient's abilities:
§ Immediate repetition, delayed repetition, oral reading, sentence completion, confrontation naming, discourse
-how much prompts are you giving?
-immediate saying easier than discourse
-assessing where they are will lead you to therapy
Resources: MRC Psycholinguistic Database http://websites.psychology.uwa.edu.au/school/MRCDatabase/uwa_mrc.htm Chapey Appendices and 40,000 words by Blockcolsky, Frazer, and Frazer
Assessment of AOS-Apraxia Battery for Adults Second Edition (ABA-2)
§ Commercially published measure to diagnose presence and severity of AOS
§ Subtests surround speech and a few oral/limb apraxia
-informal more common
Assessment to Treatment of AOS
§ May also wish to assess speech rate
-if you have them talk slower = more time for planning and programming (more intelligibility and less errors)
-Talk faster: more errors, less time to plan/program
-How does rate affect their errors? How natural, how intelligible?
§ Summarize deficits in terms of sounds or class of sounds affected, word position, complexity level, and other error patterns
§ There is little data to guide the clinician in the selection of one treatment approach over another.
§ Some advocate using a period of trial therapy to assist in selecting a treatment approach.
-how is language affecting treatment?
Treatment of AOS: Family Considerations
§ Address common concerns and frustrations of family members
-Why does he work so hard to get the sounds out?
-When will she talk again?
-Why can he say a word at one time but not another?
-I know she can understand me, why won't she talk?
§ Educate family about what AOS is and after your assessment, areas of strength and weakness
§ Have family observe therapy and give them work to take home to practice
-you are a speech coach with the family
Treatment of AOS: Other Considerations
§ Attention—therapy requires a great deal of attention which may be compromised
§ Depression—often co-occurs with neurological impairments. Willingness to work hard is essential for successful treatment as it relies upon drill work/practice
§ Frustration—some patients may be very angry/upset by their deficits
-think about ICF
Defining Motor Learning
"a set of processes associated with practice or experience leading to relatively permanent changes in the capability of a movement (Schmidt and Lee, 2005)"
-want stable well learned motor actions (that is what speech is)
§ Involves skill acquisition & retention
§ Importantly distinct from cognitive learning to learning complex motor activities may require thousands of repetitions before adequate performance is achieved
§ Increased difficulty appears to enhance learners' retention (e.g. learners who had the most difficulty during learning ultimately did the best.)
-better learning later
-relearn well-learned motor movements that don't use exact same pathway
-it is all about repetition and intensity
-sometimes cognitive learning gets in way (trying harder)
Motor learning via Increased Difficulty
§ Performance during learning does not necessarily predict performance later.
§ Blocked conditions help during acquisition
§ Randomized conditions facilitate retention
-Randomized trials prevent learners from generating a stable "set"
-Must retrieve & organize slightly different movements for every trial
-have to consider how you set up therapy
Motor learning and Feedback
§ Performance during learning does not necessarily predict performance later.
§ Receiving feedback every trial facilitated acquisition of the task more rapidly
§ Summary feedback after every 15th trial facilitated retention
-don't forget these principles!
Treatment categories for AOS
§ Articulatory-Kinematic Treatments
§ Rate/Rhythm Treatments
§ Tactile/Gestural Methods
§ Alternative Augmentative Communication (AAC) approaches (more severe)
-how you do it will change with adults compared to children
Resources: Wambaugh et al., 2006a 2006b Guidelines for AOS
§ Therapy techniques are used to facilitate improved movement and/or positioning of the articulators
§ Repeated, motoric practice of speech targets
§ Most use modeling/repetition to elicit desired productions
§ Often "bottom up"
-lots of repetition!
-similar to CAS
Articulatory-Kinematic Treatments: Integral Stimulation
§ Focus on movement patterns of speech
§ Goal is to improve speech signal
§ Relies upon imitation
§ Emphasizes multiple input modes
-"Watch me and listen to me"
-reliance on what you are modeling so someone can match and mimic what you are doing
-you can gradually fade your support
-regular artic therapy
Articulatory- Kinematic Treatments: Integral Stimulation 8-Step Continuum by Rosenbek
1. Integral stimulation: patient imitates while watching and listening to the SLP's
2. Patient's response is delayed; SLP provides a model then mimes the response without sound during the patient's response
3. Integral stimulation followed by imitation
4. Integral stimulation with several successive productions
5. Client reads the target aloud with written stimuli
6. Written stimuli, with delayed production
7. A response is elicited by an appropriate question.
8. A response is elicited in an appropriate role-playing situation
-you want less and less feedback
-you want them repeating and imitating it
-question without reading
-just changing your scaffolding
-starts with maximal cueing
§ Selects a limited set of target utterances for the client (e.g. five functional target utterances, varying in length from one to seven words, individualized for each client, "My name is ______" "It's time to go.")
§ Target utterances are entered into a continuum one at a time, beginning at Step 1. Criterion for moving to the next step is 80% correct in 20 consecutive treatment trials.
-try to make less rigid
-very artificial for them, hard to stay motivated
Articulatory- Kinematic Treatments: Phonetic Placement Techniques
-Describe where (place) and how (manner, voice) that sounds are made
-Can be used with or without visual modeling
-May involve active manipulation of orofacial musculature
-Integral stimulation to elicit target word
-Provide articulatory placement cues
-Often build upon existing abilities to obtain improved productions
-Example if pt. can pop their lips, shape /p/, /b/
-or more mild aphasia (here is your tongue, etc)
SPT Sound Production Treatment by Julie Wambaugh https://www.youtube.com/watch?v=0Wuch-_oCnY
Rate/rhythm control treatments
§ Basic assumption is that AOS reflects an underlying disruption in the timing of speech production
§ Involves manipulations of rate and/or rhythm, which are often affected
§ Slowing of speech production, even in speakers who already have reduced rate, is thought to allow additional time for motor planning or programming and processing of feedback.
-more time for motor planning and programming
-however causes unnatural speech, use with caution
Rate/rhythm control treatments: Metronome Pacing
§ Speech is produced to metronome beats
§ Usually rate is 1 syllable or movement per beat
§ Initiation of practice may be set at extremely slow rates (15 or 30 beats per minute and gradually increased to 120 bpm)
§ Patient produces vowels, vowel sequences, SMRs, and multisyllabic word productions depending on treatment goals
-almost sounds like intense fluency tx
-gradually speeding them up over weeks/months
-slowing down = relearning motor pathways
-more efficient, more entrained
-however hard to stay motivated
Rate/rhythm control treatments: Contrastive Stress (See Table 12.3 Yorkston)
§ Uses prosodic cues & stress patterns to facilitate speech production & prosody
§ Most effective for those with mild-mod AOS
§ SLP produces an utterance with primary or emphatic stress on a particular word, client responds emphasizing different target word
§ Example: John loves Mary.
-Does Jim love Mary
-Does John hate Mary
-Does John love Jane?
-how do we do this to entrain speech motor control more effectively?
-varying stress changes linguistic meaning = speech motor control targets and linguistic aphasia
Rate/Rhythm Control Treatments: Melodic Intonation Therapy
§ Focuses on prosody--intonation or melodic pattern of a phrase is emphasized
§ Clinician models by intoning the phrase while tapping out the rhythm
§ Uses a structured sequence of tasks
-Client imitates tapping the rhythm
-Then progresses to imitating the phrase
§ Pitch and durational cues are exaggerated by the clinician in the model at first
-As the client improves, begin to fade the tapping and intonation cues
-hard to generalize in language gains (singing is not talking)
-caveat in conversation is hard
Tactile/Gestural Methods: Intersystemic Facilitation/Reorganization Treatments (for patients with limited capacity for speech)
§ Use of a relatively intact system/modality to promote functioning of an impaired system/modality.
§ Use of hand/limb gestures to facilitate movement for speech production
-Gestures are paired with verbal productions, such as words or sentences
-Both iconic (Amer-Ind gestural code) and nonmeaningful gestures (e.g. finger counting) have been used
-When only gestures are trained, no verbal changes have been reported (pair gesture with speech is speech is the goal)
-gestures for speech segments they are encoding
-trouble initiating = making gesture
Tactile/Gestural Methods: Vibrotactile Cueing
§ Vibratory stimulus applied to the finger used to signal each syllable
-small transducers on finger
§ May be used with integral stimulation
§ May be used in conjunction with rhythm/stress cueing
§ Evidence limited to case-studies
-having more feedback for when speech segment should start
Articulatory/Kinematic AND Tactile/Gestural Methods: PROMPT
§ Prompts for Restructuring Oral Musculature Phonetic Targets
§ Developed for treating CAS then applied to adults
§ Emphasizes tactile-kinesthetic cues to facilitate speech
§ Complex; requires clinicians to receive training to be certified providers
-lots of touching, more comfortable for child
Articulatory- Kinematic Treatments: PROMPTS (Prompts for Restructuring Oral and Muscular Phonetic Targets)
§ Formalized treatment for CAS
-Use tactile, auditory, and visual cues to facilitate speech movements
-Emphasizes pre-speech posturing, so maximizes physiologic support for speech
-Feedback is tactile/kinesthetic for most part
-Uses meaningful stimuli; bottom up approach
-Treatment is individualized, different prompts are used depending on the level of support required
-Clinician training is recommended for its correct administration
-setting articulators in right mode for speech sounds
Alternative Augmentative Communication: Speech Output Devices
§ Verbal communication is judged to be less than optimally effective and consequently, methods for either circumventing or supplementing speech are devised.
§ Not a treatment per se, but may facilitate functional communication
-language deficits may limit gains w/ AAC
-language deficits showing up in AAC
Sample Goals for Severe AOS
Patient will produce automatic speech tasks (days of the week, counting, months of the year) with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will produce words to complete carrier phrases with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will imitate/read/produce functional, monosyllabic words with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will imitate/read/produce 10/15/20 repetitions of target words with % accuracy and min/mod/max verbal/visual/tactile cues
Sample Goals for Moderate AOS
Using the Eight-Step Continuum (Integral Stimulation), patient will produce words/phrases/sentences with ___% accuracy
Using Sound Production Therapy, patient will produce target sounds in the context of words/phrases/sentences with ___% accuracy
Patient will produce 10/15/20 repetitions of target words/phrases/sentences with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will produce original short sentences when given a target word with % accuracy and min/mod/max verbal/visual/tactile cues
Sample Goals for Mild AOS
Patient will use appropriate speech prosody during imitated sentence production with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will use appropriate articulatory accuracy and speech rate when reading/speaking with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will complete contrastive stress drills with % accuracy and min/mod/max verbal/visual/tactile cues
Patient will produce select multisyllabic words with % accuracy and min/mod/max verbal/visual/tactile cues
Identify one way to assess for AOS.
Identify two Articulatory-Kinematic treatment techniques for AOS.
Metronome pacing is what type of treatment technique for AOS?
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