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MSD Final Exam Study Guide
Terms in this set (43)
Describe the similarities/differences between adult AOS and CAS in regard to treatment.
-variety of cueing
-what therapy functionally looks (adults = use strengths to advantages)
-more distortions with adults, however not universal
-adults have a lot of world experience, where as someone with CAS does not
-adults know what it is like to not have apraxia
-less touching with adult
Provide the 3 components of a clinical examination for MSDs.
1. History of the Speech Condition
2. Physical Examination (Oral-Mechanism Assessment)
3. Motor Speech Examination
-what will you have them say and do so you have information you need
Provide strategies for promoting generalization of therapy skills outside of the clinic room.
Make sure to target different tasks to ensure speaker is adapting across speech tasks:
§ Short vs. long utterances
§ Stressed vs. unstressed words
§ Conversational speech vs. reading
§ Speaking to one listener vs. a group
§ Speaking in quiet vs. in noise
-speaking situation is important
-intermittent feedback, self learning, self evaluation, random practice, incorporating real world situation
Describe how phonatory or velopharyngeal dysfunction might manifest as problem(s) at the level of articulation.
-velopharyngeal: non-nasals with sound nasility
-velar sounds can be affected
-not enough oral-pressure for plosives
-or unable to sustain pressure for fricatives
-difficult to distinguish nasals/nonnasals
-voiced versus voiceless
-aspirated vs nonaspirated sounds
How might you define/describe dysarthria or AOS to a parent or spouse of a person or child with these diagnoses?
Acquired Apraxia of Speech (AOS) is a motor speech impairment caused by damage to the parts of the brain that are responsible for planning and programming movements for speech. The messages coming from the brain to the mouth are disrupted, and the individual has difficulty finding the correct muscle placement (e.g., lips, tongue) to say sounds correctly and in coordination with one another.
Dysarthria is a motor speech impairment caused by damage to the areas of the nervous system that execute motor movements for speech. These movements may be slowed down, happen imprecisely, weak, or may not occur at all.
What are the benefits to reducing speech rate in clients with AOS or dysarthria?
§ May also wish to assess speech rate
-if you have them talk slower = more time for planning and programming (more intelligibility and less errors)
§ 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
§ Allow for improved precision in articulation
-Reduce articulation undershoot
-more precision, less blurred lines between phonemes
§ Improve coordination between speech subsystems
§ Helps speaker produce more appropriate breath groups and pause at syntactically appropriate boundaries
§ Slowed rate may help the listener by
-Providing extra processing time to process the dysarthric speech
-Identify word boundaries more easily with clear pauses
What are informal techniques to use to estimate the effects of improved velopharyngeal function for someone with resonance problems?
§ Occluding the nares to eliminate escape of air through the nasal cavity
-judge with and without occlusion
§ Positional changes upright vs supine
§ Dental mirror to elevate soft palate for flaccid dysarthria
• Assess change in vowel quality
§ Instruct client to speak at a variety of rates to determine impact of speaking rate on VP function
-how is resonance affected across slower or faster rate
-if you find something that counteracts resonance issue, you don't really have to treat the resonance issue
Be able to provide examples of appropriate goals for working with clients with mild, moderate, or severe AOS.
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
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 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
Discuss characteristics that would (and would not) make a client a candidate for a palatal lift.
§ For progressive conditions, better candidates are those with slow progression
-ALS: how fast are they progressing?
§ Other speech systems are relatively Intact.
§ Predominant flaccid do better than spastic
§ No significant spasticity of velum and hyperactive gag reflex
§ High motivation levels
§ Able to insert/remove without assistance
-need to remove regularly for hygiene
§ Does not have significant saliva management issues
§ Dysphagia: will throw off their swallow
-may need new swallow eval at that point
-have you tried less invasive therapy?
-you need ENT and prosthodontist
Be able to discuss the tradeoffs between naturalness and intelligibility.
-To make speech more intelligible, rate reduction often works; however, this makes speech less natural
-when speech is made more natural, intelligibility may decrease
§ BUT clinicians should do everything possible to avoid negatively affecting naturalness while targeting other treatment goals
-make someone's speech as natural as you can while improving intelligibility as much as you can
-don't sacrifice intelligibility for complete naturalness and vice versa
natural versus intelligibility cont.
§ What are consequences of slowing the rate?
§ Consider: Intelligibility & Naturalness
§ Rate control is typically addressed only for those who are not completely intelligible or whose excessive rate makes listening & comprehending very difficult
§ Compromise increase in intelligibility and decrease in naturalness
§ Be sure to consider the patient's feelings about this trade-off
-if person is mild (intelligible speech), having them slow their speech sacrifices a lot of naturalness
Selecting an Optimum Speaking Rate
§ Intelligible speech at normal rates is rarely attainable for speakers with moderate to severe dysarthria
§ If there is a choice between intelligibility & naturalness - intelligibility must be the deciding variable
-it is a trade-off
-not a panacea
-if mild, you will lose more naturalness than you will gain in intelligibility
Identify strategies that speakers with dysarthria can use to enhance a listener's comprehension of their message
§ Preparing your partner (e.g. say his/her name)
§ Setting the topic (saying it, writing it, AAC, or raising a finger to signal a topic change)
§ Using grammar to enhance the message (use complete sentences, indicate part of speech on an AAC device)
§ Using gestures
§ Using turn-taking/turn-maintenance signals (holding up hand to signal not completed yet)
§ Timing of important communication exchanges (scheduling in the morning or after rest)
-fatigue plays a big role, even in mild
§ Selecting a conducive environment
-shutting off TV
-first letter on alphabet board
-predictable words or sentences
Co-managing communication breakdowns
§ Speaker should encourage listener to indicate right away if they do not understand
-so they can say it again
-when listener realizes they lost thread: they should engage
§ Begin by repeating the message
-If after 2-3 attempts, attempt new strategy (synonym, circumlocution)
-having multiple strategies ready
§ Speaker pauses and checks in to see if understood
-with a question, etc.
-also helps speech more intelligible
§ Listener repeats what was understood to determine where breakdown occurred
-then individual can let them know
§ "Shadowing" - repeating each word, phrase to confirm comprehension and determine location of breakdown
-can be cognitively taxing
Co-managing communication breakdowns cont.
§ Establishing interaction "rules" or strategies with most familiar partners.
§ May vary across communication partners
-shouldn't assume all people with dysarthria want the same ground rules
-do this as prep
Identify strategies that listeners can use to facilitate communication with someone who has reduced speech intelligibility.
§ Maintain topic identity: periodically check in with speaker to ensure on same topic
§ Pay attention to the speaker
-Focus! Attention matters
-Piece together clues
• Be a facilitator, but don't take control away from the speaker (it is an exchange)
-"Wait, this is at the blah blah blah, right"
-verify topic hasn't changed, helps ensure that conversation partner has same semantic knowledge
-not multitasking while they talk
-use information you have, like visual cues, pragmatics
I will give you a few examples of patients with different neurological diagnoses or speech symptoms. Be able to provide the type of dysarthria (flaccid, spastic, ataxic, hypokinetic, hyperkinetic), which division of the motor system is the impairment located (UMN, LMN, cerebellar, basal ganglia...) and general approaches to treating dysarthria for each type.
1. The final common pathway (LMN)
2. The direct activation pathway
-Unilateral Upper Motor Neuron Dysarthria
3. The indirect activation pathway
-Unilateral Upper Motor Neuron Dysarthria
4. The control circuits (cerebellar and basal ganglia)
-Basal Ganglia: Hypokinetic and Hyperkninetic
-Cranial and Spinal Nerves (LMN)
-Cerebral Cortex Motor Areas (bilaterally)
-UMN damage bilaterally
6. Unilateral Upper Motor Neuron
-Cerebral Cortex Motor Areas
Dysarthria Subtypes and conditions
-MG, LMN lesion, muscular dystrophies, chiari malformation
-UMN lesions bilateral, CP, primary lateral scherolis, strokes
-Parkinsons, Lewy Body Disease, exposure to toxins
7. Mixed Spastic-Flaccid
8. Mixed Spastic Ataxic
9. Hypokinetic Spastic Ataxic
Know general differences when designing treatment approaches for severe, moderate, or mild MSDs (for example, what is overall goal for someone who is severe with little speech vs someone who is mild and mostly intelligible?)
Goals of Treatment: Mild Impairment
§ Maximizing communication efficiency and speech naturalness to allow full participation in activities important to the person.
-how do I make their speech more natural sounding so they are less negatively impacted
-intelligible yet not completely natural sounding
-still can be severely affected and require lots of therapy so they can deal with negative impact
-however severity is mild
Goals of Treatment: Moderate Impairment
§ Maximizing intelligibility - "compensated intelligibility"
-do this in many ways
§ E.g. effort to control speaking rate for individuals with coordination problems, palatal lift for individuals with little velopharyngeal movement.
-chip away at making speech more intelligible
Goals of Treatment: Severe Impairment
§ Establishing functional means of communication with any means possible (often w AAC)
-even if short-term
§ Educating family/significant others about ways to increase communicative efficiency
§ If degenerative impairment → may select AAC to prepare for increasing level of impairment
-hard conversation to have
-we want you to learn this so you can communicate with loved ones when you need it
What are some general strategies for treating prosodic deficits?
§ Modifying stress patterns
§ Durational adjustments
§ Generalization to spontaneous speech
-generalize as fast as you can, mix things up
Contrastive Stress in Production
Characterized by a falling and then rising pattern of pitch change (examples)
§ Patient: Sam likes fat cats.
§ SLP: Sam likes skinny cats?
§ Patient: No Sam likes fat cats.
§ SLP: Sam likes fat dogs?
§ Patient: No Sam likes fat cats.
§ Ask speaker what word they tried to make most important (compare their intention with your perception)
-If they are wrong, prompt them to place emphasis on alternate word
-change as a function of what prosody is through reflective questioning
Provide a strategy that you could use to promote speech naturalness.
Explain when you might use a rigid rate control strategy with a client. What are benefits/drawbacks to these approaches? Finally, be able to provide an example of a rigid rate technique.
§ More rigid techniques tend to result in less natural sounding speech
§ Impose a "one word at a time" production style
§ Usually reserved for those with the most severe involvements
§ Often entail a type of external pacing
-often for individuals who are much more severe
-hard to work on pacing board with Parkinson's w/ limited range of motion
Rigid Rate Control Techniques Advantages
§ Often effective when other techniques are not
§ Speech intelligibility often improves
§ Alphabet board helps to provide info to listeners (not just aid to speakers)
§ Not technical or expensive
§ Require little user training
-simple to teach basics
§ Allow for continual practice of slowed rate
Provide an example of a contrastive stress task. Why might you implement this with a client?
I went to the store yesterday.
You went to the store today?
No, i went to the store yesterday.
Sam went to the store yesterday?
No, I went to the store yesterday.
Catherine plays soccer.
Catherine plays golf?
No, Catherine plays soccer.
Sarah plays soccer?
No, Catherine plays soccer.
§ Assess ability to adjust prosody to signal emotional speech, emphatic stress & syntactic junctures
-help prosody and naturalness
-for those with monotony in their voice
-aware of prosody
Briefly describe how to develop voluntary phonation with a severe client.
Evaluating reflexive phonation
§ Inventory of nonspeech reflexive vocalizations
§ Note positioning setting/situation
§ Diary of phonation
-journaling is helpful for therapy gains
-how to involve family
Once they start reflexive phonation more, build off for developing voluntary phonation
§ Attempt reflexive behaviors repetitively
§ Ask the person to produce phonation voluntarily
-structuring someone for more natural levels of phonation
§ Add on oral cavity shaping to produce vowel sounds
-making speech sounds!
Be able to list the different categories of approaches for AOS treatment and be able to provide an example for each category.
§ Articulatory-Kinematic Treatments
-SPT, 8-step continuum, integral stim
§ Rate/Rhythm Treatments
-metronome pacing, contrastive stress, MIT
§ 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
Be able to match a treatment approach with a general definition.
When speech is degraded, as is often the case in people with dysarthria, listeners rely on contextual information. Provide several examples of contextual information.
§ Supplement natural speech with remnant books and photo albums
§ Speaker uses them to introduce topics/ideas
§ Photos can help sequence events or explain how to do something
§ These tools help improve comprehensibility and take demands off the speaker
What are neurologic and genetic conditions associated with childhood dysarthria?
-May accompany neurological conditions § Examples: Cerebral palsy, pediatric CVA, tumors, FAS
-has an origin
-May accompany genetic conditions diagnosis
§ Examples: Prader Willi syndrome, Down syndrome, Fragile X, Moebius syndrome
-More commonly however, we see "soft neurological signs" in the absence of a clear diagnosis
-multiple subsystems affected
-kids have a lot going on!
-speech may not be a primary concern
Discuss the concept of 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"
-Watch me, listen to me, do as I do
-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
Know the general principles of motor learning that we have discussed that are often applied to the treatment of MSDs.
When conducting an initial evaluation, what is a good way to begin the session (after introducing yourself)?
-Their perspective of the problem
-Quality of life
-Ask patient: why are you here? what difficulty are you having with your speech?
-Explain purpose of your visit/assessment
-Do you have any difficulty with your speech?
-When did the problem begin?
-Do you have any other difficulties associated with your speech problem?
-Has the speech problem changed (better/worse)?
-Is there anything that seems to affect your speech (medications, fatigue, stress, contexts)?
-we naturally compensate, so reinforce any compensations they are making
Discuss how treating other subsystems (e.g., respiratory, laryngeal/phonatory) often results in improvements in overall intelligibility.
-lower level systems
-look in notes
Treating respiratory = intelligibility
-treating breath pauses:
§ Listeners use breath pauses to parse running speech into syntactic units
§ Taking breath pauses at syntactic locations makes speech more comprehensible
§ Can impact intelligibility
§ Optimizing respiratory performance is an important aspect of speech intervention for many speakers with dysarthria, because other speech subsystems are strongly influenced by patterns of respiratory support for speech.
-power for speech
-airflow stays constant, constant subglottal pressure
-inhalation for speech: regulate air with muscles and vocal tract so that that flow of air stays extremely constant when volume of lungs change
-stabilizing respiratory pattern
Treating laryngeal = intelligibility
-larger inhalations to translate to ecologically valid speech
-really hard to make gains in daily life situations
-respiration is first order processes: focusing on loudness will help other processes
-will naturally make someone's articulation less severe, improve VPI, etc.
-foundational speech science, will naturally help other speech systems
-feedback is helpful in learning this
-helps create needed pressure
coordination of the phonatory system with other aspects of articulation
-high level of motor control needed
-subtle differences between voice and voiceless consonants
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