According to Wertz et al. (1984, as
cited in Halperen, 1986), several factors affect the
prognosis of an apraxic patient. These include:
smaller the lesion, the more favorable the prognosis.
patient has only minimal aphasia and does not display severe
oral apraxia, the prognosis is better.
Health and attitude
of the patient
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.
Patients who begin treatment within
one month of the onset of apraxia have a better chance of
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.
functional recovery is poor without treatment; fair with
treatment for the severe patient; and good with treatment
for the moderate to mild patient.
for Apraxia of Speech
(Halperen, 1981, pp. 425- 426)
Emphasis should be on the auditory
and visual modalities, but especially the visual.
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
Mastery of individual consonant
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).
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.
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
The goal of
therapy for apraxia is to help the patient regain conscious
control over articulatory programming so that speech can be
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
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
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
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.
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.
semivowels (w,u,dipthongs), plosives, fricatives, and
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.
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,
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
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.
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
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."
segments like "more money," "my monkey"
segment in which the components end with /m/ instead of
beginning with it. Some examples are:
segments in which one word begins with /m/ and the other
word ends with /m/. Some examples are:
Repeat steps 7,
8 and 9 using multi-syllabic words.
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.
Intonation and Stress
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
For example, a patient could practice contrasting phrases
like "You must read that book" and "You must read that
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
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
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:
recitation of the
the pledge of
greetings (Hi, how
(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.
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.
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.