The Neuroscience on the Web Series:
CMSD 642 Neuropathologies of Swallowing and Speech

CSU, Chico, Patrick McCaffrey, Ph.D


Chapter 10. Prognosis and Remediation of Apraxia


According to Wertz et al. (1984, as cited in Halperen, 1986), several factors affect the prognosis of an apraxic patient. These include:

Size of lesion

The smaller the lesion, the more favorable the prognosis.

Presence of concomitant disorders

If the patient has only minimal aphasia and does not display severe oral apraxia, the prognosis is better.

Health and attitude of the patient

The better the state of the patient's over-all health and the more motivated he/she is to practice drills and improve his/her speech, the better the prognosis.

Time post-onset

Patients who begin treatment within one month of the onset of apraxia have a better chance of recovery.

According to Wertz et al. (1984), patients with a better prognosis are those who: are less than one month post-onset; have a small lesion confined to Broca's area, have minimal coexisting aphasia, do not have significant oral apraxia, are in good health, and have the strength to endure intensive treatment.

Prognosis for functional recovery is poor without treatment; fair with treatment for the severe patient; and good with treatment for the moderate to mild patient.

Remediation/Therapy for Apraxia of Speech
(Halperen, 1981, pp. 425- 426)

Emphasis should be on the auditory and visual modalities, but especially the visual.

Using the phonetic placement method of describing the correct manner and place of articulation and the correct voice and voiceless components of phoneme production is useful.

Dabul and Bollier (1976 in Halperen, 1981) outlined the following sequential program:

Mastery of individual consonant phonemes.

Rapid repetition of each consonant plus the vowel /a/.

The buildup of sounds into syllables using CV CV combinations, such as /fa ta/, and CVC combinations such as /p a p/.

Once the patient has a solid base of articulatory positions, he can master words by breaking them down into individual phonemes, then blending them into syllables and words.

A visual technique (speech reading the clinician) and a placement technique (using oral directions and physical placements) are helpful. Words can be broken down into syllables using graphic materials, with part of the word covered.

Therapy can begin with vowel sounds, and then successive consonants, e.g. /m/, which is visible and manipulable. Once the /m/ can be produced in isolation, it can be combined in the initial position with the vowels that were learned (e.g. /mi, me, ma, mo/ etc.). Next /m/ is produced in the final position in one-syllable words (e.g. am, I'm, arm, etc.); two syllable words (mamam, memo, etc.); and then in word lists with /m/ in all positions (omen, madam, etc.). Then the therapist can build up from simple phrases (my man, my mama), to longer ones (e.g. miles from Montana) to sentences (e.g.The mailman will get the mail.) Further exercises might contrast words with /m/ in the initial position with a minimal pair (e.g. man- pan, mare-pear), and then /m/ in the final position (e.g. comb- coat, came-cape).

Melodic Intonation Therapy (Sparks and Holland, 1976) may be a useful therapy tool. This therapy, originally developed by Sparks and Holland for the treatment of severe non-fluent aphasia. Currently, however, it is most frequently used to treat apraxics. This technique involves teaching the patient to sing words or phrases set to simple melodies. It is hypothesized that this therapy is effective because the use of music helps involve the right hemisphere in the production of speech.

For severe apraxics, alternative or supplementary methods of communicating may be needed. A gestural system such as Amer-Ind can be taught to the patient and his family. Communication boards or computer programs may likewise be helpful.

The goal of therapy for apraxia is to help the patient regain conscious control over articulatory programming so that speech can be produced voluntarily.

Some, including Darley, recommend compensatory types of therapies for apraxia. Such therapies focus on helping the patient take full advantage of his remaining communication abilities. A number of people urge compensatory techniques. In contrast, the therapies for apraxia presented in this course are those that attempt to "re-train" the brain. Such techniques endeavor to stimulate another part of the cortex to take over the motor programming function previously served by Broca's area.

Sensory Modalities

According to most sources, apraxics must receive multimodality input or multisensory information, including visual, auditory, tactile and kinesthetic feedback, in order to benefit maximally from therapy. Virtually all research has found that visual input is the most important source of feedback for apraxics. This means that patients should be instructed to focus on how their speech sounds, on how it feels to produce speech targets and, most importantly, on how the articulators look during the production of speech targets. To encourage focus on the visual modality, patients should be told to watch as the therapist produces target sounds or words and then to observe their own production of these targets by using a mirror.

Repetition

When asking an apraxic patient to imitate your production of a target, allow him to make four or five attempts before repeating the stimulus. This groping, or trial and error articulatory process is believed to be essential in "re-training" the brain to do the motor programming necessary for voluntary speech.

Hierarchy of Speech Tasks

For an apraxic, the difficulty involved in producing a speech target depends on its length as well as on the types of speech sounds that it contains. Therefore, both these factors can be used to develop a hierarchy of speech drills for the apraxic patient. Of course, the hierarchical level at which therapy begins for any particular patient depends upon the extent of that individual's impairment. If a patient can produce CVC words, there is no need to start work at the single phoneme level.

Phonemic Categories

Below, classes of phonemes are listed in order from least to most difficult for an apraxic patient to produce. Note that this arrangement is the same as the order in which children acquire different categories of speech sounds. Also note that it is harder for apraxics to produce blends than single consonants. Consonant clusters are even more difficult to produce than blends.

    vowels, nasals, semivowels (w,u,dipthongs), plosives, fricatives, and affricatives

With therapy with a severely apraxic patient, it may be necessary to begin working on sound production by teaching the person to phonate voluntarily. To do this, hold the patient's hand against your larynx while you cough. Then ask them to hold their hand against their own larynx while they cough. Try to move from coughing to the production of /a/. (As first, the patient may have to start /a/with a cough.)

Once the patient can phonate voluntarily, work on the production of a few vowels. It is best to start with /u/, /i/ and / a / as these are the most visible. It may also be helpful for the patient to produce some diphthongs; moving back and forth between the two components.

When the patient has mastered some vowels, move on to the nasals. It is a good idea to begin with /m/ as the production of these sounds can be seen very easily. As therapy continues, sounds should be introduced in order from least to most difficult. So, after the nasals have been learned, the semivowels should be presented. These should be followed by the plosives, fricatives and affricates. Later, blends and clusters can be practiced.

Utterance Length

Remember, the shorter the utterance, the easier it is for an apraxic patient to produce it. For this reason, drills should be arranged based on utterance length as well as on phoneme type. As each new phoneme is incorporated into the drills, the length of targets including that sound should be increased gradually. Sounds might initially be produced in isolation and finally in phrases consisting of multi-syllabic words.

Here is an example of how drills involving the phoneme /m/ might gradually increase in length (Dabul and Bollier, 1976, in Halperen, 1981):

Work on /m/ in isolation. To facilitate production, tell the patient to hum. If that doesn't work, the patient might be instructed to use her fingers to put her lips together. (The clinician could use her fingers to do this if necessary.)

    Work on /m/ in the context of CV syllables like /mi/, /ma/, /mu/ and /mo/. (These four vowels are maximally contrasted.)

    Ask the patient to slowly shift from the production of one of these CV's to another. When he becomes proficient at doing this slowly, have him do the task more rapidly.

    Use double syllables. Have the client produce two successive repetitions of the CVs practiced in step #2. For example, the target might be /mi/ /mi/.

    As before, have the client shift from the production of one syllable to another (/mi/ /mi/ -- /mu/ /mu/).

    Use CVC forms. The initial and final consonants of these syllables should both be /m/. For example, the patient might be asked to produce the syllables /mim/, /mum/, and /mam/.

    Use words rather than nonsense syllables. Of course, the patient should begin with CV words like "my" and "me."

    Use CVC words like "more", "mayor", "mine", "map", and "mat."

    Use two-word segments like "more money," "my monkey"

    Use two-word segment in which the components end with /m/ instead of beginning with it. Some examples are:

      some dam

      same pram

      lame ram

      game time

    Use two-word segments in which one word begins with /m/ and the other word ends with /m/. Some examples are:

      money game

      Mary's lamb

      miserable Sam

    Repeat steps 7, 8 and 9 using multi-syllabic words.

Contrasting

It will be helpful for the apraxic patient to practice drills involving contrasting phonemes. At first, exercises should include maximally contrasting phonemes, or those that differ by the greatest number of distinctive features. For example, the patient might practice saying some words that begin with the labiodental /f/ and others that begin with the palatal sound /k/ (phil vs. kill). The degree of contrast between the phonemes paired in exercises should be gradually reduced until minimal pairs, or two phonemes that differ by only one distinctive feature, are used.

Exaggeration of Intonation and Stress

As apraxics often have abnormal prosody due to the dysfluent nature of their speech, it may be a good idea to have them practice using intonation and stress to change the meaning of utterances.

For example, a patient could practice contrasting phrases like "You must read that book" and "You must read that book."

Integral Stimulation

This simply means that the patient watches and listens to the therapist's productions and then attempts to imitate this model. According to Rosenbeck et al. (1973, in Halpern, 1981), this is the primary procedure to be used in the remediation of apraxia. It is an 8 step "listen and watch me" technique.

Phonetic Placement

The therapist may verbally instruct the patient on the correct placement of the articulators for the production of a particular sound. The therapist may also physically manipulate the patient's articulators. For example, the clinician might place the patient's lips together for the production of /m/ or use a tongue depressor to facilitate lingual movements.

Automatic Speech

One of the hallmarks of apraxia is the relative preservation of automatic or over learned speech sequences such as greetings, leave-takings and proverbs. Automatic speeches are used in therapy for two reasons; first, it gives the patient a break from the hard and frustrating work of drills and secondly, because it provides the brain with sensory feedback from fluent speech.

Types of automatic speech that may be used in therapy include:

Prayer

nursery rhymes

counting

recitation of the alphabet

familiar song

the pledge of allegianc

advertising jingle

proverbs

greetings (Hi, how are you)

leave-takings (Bye, see you later)

Of course, the clinician should find out what things will be most automatic for each individual patient.

Some Ideas from Duffy and Others on Remediation of AOS

Duffy, (1995) recommends the following treatment principles:

• make sure of a high level of success.

• use extensive and intensive drill.

• work on articulation as well as prosody.

• introduce meaningful and functional material as soon as possible.

• systematically manipulate variables which effect response accuracy:

Duffy feels that principles of motor learning are crucial to treatment of AOS. Furthermore he feels that drill is quite important. According to Darley, Aronson, and Brown; Wertz, LaPoint, and Rosenbeck and others apparently many apraxics have lost some of the pre-programmed sub routes for movement sequences that make normal speech so automatic. Accordingly, systematic and extensive drill is used to help the patient to gainor learn lost speech skill instructions.

Self learning and instruction is used by moderately involved patients as early as feasible in their treatment program. Patients are encouraged to monitor their speech, grope for correct targets, and self correct their errors.

Feedback, according to Wertz, LaPointe and Rosenbeck (1984), should be a general principle of AOS treatment. Rosenbaum (1991) and Singer (1980) feel that knowledge of results is crucial for patients. Patients should be encouraged to judge the accuracy of their responses reliably. When responses are inaccurate they should attempt to self-correct. Clinician feedback to the patient should be done from the beginning. Mirrors, or even video and audio-tapes may help. Some people have worked directly on deficiencies in oral sensation. However there are conflicting studies as to whether those approaches are helpful. Rubow (1982) has used vibrotactile stimulation for intersystemic reorganization to treat apraxia of speech. I'm quite familiar with vibrotactile research. My doctoral dissertation was in that area and I have published a number of articles on that topic. Others, Deutch (1981); Square and Weidner (1976), feel that work on oral sensation is unlikely to be of much help to apraxic patients.

Intersystemic reorganization used in the treatment of apraxia of speech has been discussed by Rosenbeck, Collins and Wertz (1976); and Rosenbeck (1978). Brookshire (1995) has quite a good description of this treatment in his text. Another type of reorganizational approach to apraxia remediation is gestural reorganization. It uses manual gestures paired with speech. Be aware too that speaking may not be a realistic goal for some severe apraxics. Augmentative communication may help as long as there is not another problem such as a severe aphasia that could preclude that. Duffy (1995, 2005) has a lot of additional material on remediation in his text.


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Other courses in the Neuroscience on the Web series:
CMSD 620 Neuroanatomy | CMSD 636, Neuropathologies of Language and Cognition

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