Treatment of Motor Speech Disorders

Transcription

2/13/2015
Speaker Disclosure
Treatment of Motor Speech Disorders
The Tools and How to Apply Them
Heather M Clark PhD CCC/SLP
[email protected]
• Financial:
• Senior Associate Consultant of Speech
Pathology and Associate Professor of
Speech Pathology, Mayo Clinic
• Honorarium from SHAA for this presentation
• Therasip resistance straws donated by
Neurorehab
• Nonfinancial:
• None
Speech & Hearing Association of Alabama
February 2015
©2014 MFMER | slide-1
Objectives
Overview
Participants will be able to:
• Guiding Frameworks
• ICF
• Neuromuscular Treatments
• Motor Learning Principles
• Select motor speech treatments targeting
underlying muscle function, communication
activity and participation
• Apply principles of neuromuscular treatment
and motor learning to motor speech treatment
• Treating Dysarthria
• Identify resources for evaluating the best
available evidence supporting motor speech
treatment for various patient groups
• Treating Participation and Quality of Life
• Treating AOS
• Case Studies & Discussion
Guiding Frameworks
International
Classification of
Function
EvidenceBased Practice
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
Guiding Frameworks
Motor Learning
Principles
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ICF
International Classification of Function (ICF)
Health
Condition
International
Classification of
Function
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
Body
Functions and
Structures
Contextual
Factors
(Personal and
Environmental)
Motor Learning
Principles
World Health Organization, 2001
Health Condition
• Goals
• Time course
• Relatively frequent during
establishment of skills or
strategies
• Relatively infrequent reevaluation with updated
recommendations
Underlying impairments of
or changes to anatomical
structures or physiologic
functions
Health
Condition
Informs
Treatment of motor speech
disorders associated with
neurodegenerative disease may
differ from acute or chronic disease
Body Functions and Structures
Disorder or disease
• Prognosis
• Predicted comorbidities
• Tolerance for specific
modalities
Activity and
Participation
Body
Functions and
Structures
Activity and
Participation
Contextual
Factors
(Personal and
Environmental)
In motor speech
disorders, impairments
are often described at the
level of muscle or nerve
impairment (e.g.,
weakness) or at the level
of subsystem (e.g.,
impairments of voice)
Health
Condition
Body
Functions and
Structures
Activity and
Participation
Contextual
Factors
(Personal and
Environmental)
Activity and Participation
Contextual Factors
Personal factors
Describes the impact
of health conditions,
impairments, and
contextual factors on
performance of and
participation in
functional activities
•
•
•
•
Health
Condition
Body
Functions and
Structures
Age
Life experiences
Personality
Co-morbidities
‒
Activity and
Participation
Speakers with dysarthria often
have concomitant impairments in
speech praxis, language,
cognition, and/or swallowing
functions
Health
Condition
Body
Functions and
Structures
Activity and
Participation
Environmental factors
•
•
•
•
•
•
Contextual
Factors
(Personal and
Environmental)
Technology
Geography
Support and relationships
Attitudes
Services
Systems and policies
Contextual
Factors
(Personal and
Environmental)
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Motor Speech Treatment (MST) Hierarchy
Speech Subsystems
International
Classification of
Function
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
Articulation
Resonation
Phonation
Respiration
Motor Learning
Principles
Prosody
Motor Speech Treatment
Hierarchy
Motor Speech Treatment
Hierarchy
• The speech subsystems do not act
independently
Third Order
Targets
• Adequate respiratory support and
velopharyngeal valving supports phonation
Second Order
Targets
• Articulatory precision is supported by
respiratory, resonatory, and phonatory
competence
First Order
Targets
Articulation
Prosody
Phonation
Respiration
Resonation
Dworkin, 1991
Dworkin, 1991
Neuromuscular Treatment (NMT) Principles
Neuromuscular Functions Thought to
Impact Motor Speech
International
Classification of
Function
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
• Strength
• Muscle tone
• Stability and coordination
• Motor planning and programming
Motor Learning
Principles
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Weakness
• Disrupted ability to produce or resist force
• Strength (1Rmax)
• Endurance/Fatigue
• Power
• Causes
• UMN lesion (UUMN and spastic dysarthria)
• LMN lesion (flaccid dysarthria)
• Disuse atrophy & deconditioning
Strength Training Principles
Strength Training
Overload & Progression
• Key issues
• Overload
• Progression
• Recovery
• Reversibility
• Specificity of Training
• Overload
• Taxing the muscles beyond typical
functioning
• Results in
• Hypertrophy of muscle tissue
• Increased motor unit recruitment
• Progression
• Systematic overload
• Implies need for regular reassessment of
maximum performance
Recovery
Recommended exercise intensity
• Strength training
• 60-80% 1Rmax
• 10 repetitions per set
• Possibly multiple sets
• Optimal interval between training sessions to allow
recovery yet avoid reversal
• In large muscle groups, optimal interval is > 24 hrs
• Tongue strengthening studies: 3-7 days/week
• Endurance training
• Respiratory muscle strengthening studies: 3-5
days/week
• 40-60% 1Rmax
• High number of repetitions (e.g., 60)
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Reversibility
Detraining in Lingual Musculature
• “Use it or lose it”
• Levels of strength must be used to be maintained
Detraining in the Respiratory Musculature
Specificity of Training
• The effects of strength training are highly
specific to the trained behaviors
• This is primarily related to motor unit
recruitment and motor learning
Motor units
Factors subject to specificity
• Vary
• Order of recruitment
• Speed of contraction
• Force of contraction
• Resistance to fatigue
• Force
• Contraction velocity
• Duration
• Dynamics
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Force
Contraction velocity
• Low force: Type I units (slow twitch)
• Velocity of exercise movements should match that
required for the desired outcome
• High force: Type II units (fast twitch)
If exercise is completed to the point of
fatigue, both Type I & II are trained
Dynamics
Integration
• Isometric (static): muscle changes tension while
maintaining constant length
• Stabilization
• Results of motor learning experiments suggest
that motor programs (specific patterns of motor
unit recruitment) are highly specific
• Isotonic (concentric): muscle shortens during
contraction
• Lifting
• Predicts that exercises that incorporate the entire
movement pattern (e.g., all articulators) will result
in greatest carryover
• Eccentric: muscle lengthens during contraction
• Controlled release
Examining Training Specificity of
Lingual Musculature – Competing Hypotheses
• Training Specificity
• Predicts that greatest gains in strength will be
observed for movements that match the exercise
• Muscular Hydrostat (ala Luschei, 1991)
• Tongue is a muscular hydrostat, with fibers
contracting against each other
• Exercise in any direction will recruit motor units
involving most lingual muscle groups
• Predicts that generalized increases in lingual
strength may be observed for untrained lingual
movements
Training Specificity Study
Direction of Exercise
• N = 39 (22 female, 17 male)
• Mean age = 37.8 years (18 – 67)
• No history of speech or swallowing
impairment
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Exercises
Training Methods
• Elevation: Push tongue up against the roof
of mouth as hard as possible
• Participants randomly assigned to sequential training
(n=29) or concurrent training (n=10)
• Sequential Training
• 1 exercise (elevation, protrusion, or lateralization)
• 3 sets of 10 maximum contractions (total: 30 reps)
• Once per day for 3 weeks
• Change exercise after 3 weeks, for a total of 9
weeks (order of exercise counterbalanced across
subjects)
• Concurrent Training
• All three exercises
• 1 set of 10 of each (total: 30 reps)
• Once per day for 9 weeks
• Protrusion
• Lateralization
Outcome Measures
Did Training Increase Lingual Strength?
• Pressures as measured by IOPI (examiners blinded to exercise
condition)
• Lingual elevation (standard IOPI procedures)
• Lingual protrusion (utilizing IOPI lateral
adaptor)
• Lingual lateralization (left & right)
• Cheek compression (left & right)
• Baseline and during each week of training, 2-4
weeks after training was discontinued
Was Specificity of Training Observed?
Sequential versus Concurrent Exercise
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Conclusions
• The findings support the hypothesis that general
training effects may be observed in the lingual
musculature
• The findings provide explanatory power for earlier
work demonstrating functional outcomes
(improved swallowing) from non-specific (lingual
elevation) training
• The findings do not suggest that any one lingual
exercise is more effective than another
• 5 subjects in each of 5 training conditions
• Strength
• Endurance
• Power
• Speed
• No exercise
• After 4 weeks of exercise, changes in strength,
endurance, power, and speed were assessed
Increased with Training
(> +1.0 z scores)
Strength
Endurance
Power
Speed
No
No
No
No
YES
No
No
No
No
YES
No
No
Power Training
No
No
YES
YES
Speed Training
No
No
No
No
Control
Strength
Training
Endurance
Training
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Exercise Protocol
Outcome Measures
• 40 healthy adult participants
• Lingual swallowing pressure
• 35 females / 5 males
• Mean age 23.7 years (range 18 to 59)
• Submental sEMG
• Negative pressure
• Obtained during
• Noneffortful dry swallow
• Effortful dry swallow
• Assigned to one of three training
conditions
• Tongue elevation + ES (N=15)
• Resistance straw training + ES (N=18)
• ES only (N=7)
• Tongue strength
• Daily exercise for 4 weeks
• 3 sets of 10 repetitions
Lingual Swallowing Pressure
Tongue + ES
60
Negative Pressure Generation
Straw + ES
ES Only
.0
-2.0
Training x Effort F(1, 37) = 15.2 p = .000
Noneffortful Training Effects t (39) = .703 p = .486
Effortful Training Effects t (39) = 4.73 p = .000
Oral Negative Pressure (kPa)
70
50
40
30
20
10
-4.0
-6.0
Tongue + ES
Straw + ES
ES Only
-8.0
-10.0
-12.0
-14.0
PreTraining
PostTraining
Noneffortful
PreTraining
PostTraining
-16.0
PreTraining PostTraining PreTraining PostTraining
Effortful
Noneffortful
Effortful
Training F(1, 37) = 9.66 p = .004 Effort F(1, 37) = 125.7 p = .000 Group F(2, 37) = 3.33 p = .047
Conclusions
Summary of Specificity Research
• Training effortful swallow (in isolation or with
preparatory contraction) improves only effortful
swallows
• Specificity of training observed for
• Strength, endurance and power (intensity of
contraction) and dynamics
(isometric/isotonic) for lingual elevation
• Functional orofacial movement patterns
• Effortful suck
• Intensity of effort for functional movement
patterns
• Effortful suck
• Effortful swallow
• Training with high resistance straws improves
only effortful sips.
• ES and/or tongue exercise did not improved
sipping strength
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Summary of Specificity Research
Contra-indications for strength training
• Specificity of training not observed for
• Speed of lingual elevation
• Direction of lingual movement
• Overall strength when trained within
functional movements
• Hypertonia
• This assumption has been strongly questioned in
recent years (e.g. Ashworth, Satkunam, & Deforge, 2004
Cochrane Review)
• Fatigue Susceptibility
• This assumption is also under scrutiny; a number of
studies are being published examining strength training
in ALS and MS (e.g., White & Dressendorfer, 2004)
• Reduced exercise intensity may be indicated
• Absence of Weakness
• This assumption is not under scrutiny(?)
Strength Training in Dysarthria (AJSLP, 2009)
Strength Training in Dysarthria
• Lower level evidence
• A small number of “low n” controlled studies and/or
case studies provide limited support
• Most authors caution against emphasizing strength
training over speech-directed treatment, but
acknowledge the potential benefit for specific
patients when appropriate principles are
incorporated (Dworkin, Linebaugh, Hageman, Duffy, Yorkston, Love, Murdoch)
• Sensory stimulation plus orofacial exercise improved
intelligibility of adults (Roy 2002) and children (Roy
2001). AMR rates were unchanged in both studies
• Some studies failed to report any results
Muscle Tone Defined
• Resistance of a resting muscle to passive
stretch
• Influenced by tissue elasticity and resting motor
unit activity
Disrupted Tone
Neuromuscular Principles
http://www.thespiraltree.com/userfiles/images/Spiral%20internal%20images/medpose1.jpg
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Muscle Tone Regulation
Stretch Reflex
• Receptor: Muscle
spindle
• Peripheral Reflexes
• Stretch (muscle spindles)
• Stimulus: Change in
muscle length
• Descending pathways
• Indirect upper motor neuron pathways
• Basal ganglia control circuit
• Cerebellar control circuit
• Effects
• Activates agonist
(stimulated muscle)
• Inhibits antagonist
Central Regulation
of the Muscle Tone
Central Regulation
of the Muscle Tone
• Indirect upper motor neuron
pathway
• Descending neural drive
has an overall inhibitory
effect on reflexes
• Removal of this influence
leads to hyperreflexia
(increased excitability of
gamma motor neurons)
• Basal Ganglia Control
Circuit
• Inhibitory effect on
the motor thalamus
• If damage leads to
reduced thalamic
inhibition, then
cortical excitation is
abnormally
heightened
Rubchinsky et al., 2003;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC283608/figure/fig1/
Central Regulation
of the Muscle Tone
Tone Impairments
• Hypotonia
• Flaccid: diminished signals in reflex arc
• Cerebellar: mechanism unknown
• Cerebellar Control Circuit
• Thought to affect tonicity,
such that damage leads to
hypotonia
• Most relevant in children
• Mechanism not understood
• Hypertonia
• Spastic: released inhibition from descending
indirect pathway onto gamma motor neurons
• Rigid: increased excitability of α motor neurons
• Variable Tone
http://sprojects.mmi.mcgill.ca/cns/histo/systems/cerebellum/images/cerebellum_efferents.gif
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Tone Impairments in
Neurologic Disease
• Developmental
Assessment of Muscle Tone: Clinical
• Acquired
• Cerebral Palsy
• Spastic: spastic
• Ataxic: hypotonia
• Hyperkinetic: variable
• Down Syndrome
• flaccid
• Moebius Syndrome
• flaccid
• Parkinson Disease: rigid
• Stroke
• Cerebral: spastic
• Brainstem: spastic and/or
flaccid
• Cerebellar: hypotonia
• MS: spastic
• ALS: spastic, flaccid
• Hyperkinesias: variable
tone
• Passive displacement of relaxed limb
• Modified Ashworth Scale (6-point scale)
• Position limb passively and release
• Observe if position is maintained
• Muscle palpation
• Feel for resistance to tissue deformation
• Pendulum swing
• Lift limb and release
• Observe free swinging of limb
Assessment of Muscle Tone: Instrumental
• Torque motor
• Resistance to rotation around a joint
Muscle Tone in Speech Musculature
• Assessment of orofacial muscle tone
• Unique anatomical and physiological features of
orofacial muscles
• Evidence of tone impairments underlying dysarthria
and dysphagia
• Measurement procedures
• Electromyography
• Muscle activity: agonist-antagonist
• Myotonometer
• Resistance to deformation
• Myoton
• Damped oscillation to tissue perturbation
• Therapeutic interventions: preliminary results
• Sensory: icing and vibration
• Motor: strengthening exercises
Muscle Spindle Action in
Speech/Swallowing Muscles
Muscle Spindle Action in
Speech/Swallowing Muscles
• Jaw closing muscles
• Tongue
• High density muscle spindles
• Strong stretch reflex
• Muscle spindle density similar to limbs
• Do not exhibit typical stretch reflexes
•
• Face & lips
(Neilson et al., 1979)
• Palate, Pharynx, Larynx
• Low density or lack of muscle spindles
• Do not exhibit stretch reflexes
• Presence of muscle spindles varies across muscles
• No studies to date have demonstrated stretch reflexes in the
human larynx (Ludlow, 2005) or pharynx
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Clinical Assessment of
Muscle Tone
Peripheral Muscle Groups
D-COME
• “Use gloved fingers of both
hands to pull down the
patient’s lower lip toward the
chin (at least three times) to
appraise muscle
tone/elasticity”
• “Hold gauze between the
thumb and index finger of both
hands and then grasp and
gently pull the tongue-tip in
various directions: forward,
right and left, and up and own,
at least three times in each
direction”
• Observation of resting position
• Facial droop
• Lip retraction
• Orofacial tone assessments
• Dworkin & Culatta (1996)
• Beckman (1988)
Proximal Muscle Groups
Instrumental Tools
Velum and pharynx
• Slow, symmetrical movements may indicate
hypertonia
• Droop, often asymmetrical, may indicate
hypotonia
• Measure tissue response to perturbation
• Resistance to passive stretch
• Resistance to tissue deformation/palpation
• Larynx
• Hypertonicity typically has bias for
hyperadduction (strained, strangled vocal
quality)
OroSTIFF
Myotonometer
• Measures deformation and force
• Calculates tissue compliance
Myotonometer (Neurogenic
Technologies, Missoula, MT)
(Chu, Barlow,
Kieweg, & Lee,
2010)
http://www.neurogenic.com
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Myoton
• Parameters
• Frequency of oscillation
• Damping coefficient
• Stiffness
(www.myoton.com;
Müomeetria, Estonia)
• Veldi et al. (2002)
• Application for sleep apnea
• Assess tone of tongue and velum
http://www.myoton.com/proddoc/Presentation.pdf
Evidence for Tone Impairments in
Dysarthria
Dysarthria
Hypothesized (Darley,
Aronson, Brown,
1969)
Data
Flaccid
Flaccid hypotonia
Flaccid: hypotonia
(Solomon & Clark,
2010)
Spastic
Spastic hypertonia
Management of Tone Impairments
• Pharmacologic
• Surgical
• Spasticity
Spastic: No hyperactive
stretch reflexes in the
tongue in spastic
dysarthria (Nielson et
al., 1979)
Ataxic
Normal
None
Hypokinetic
Rigid hypertonia
Hypokinetic: Increased
lip stiffness (Hunker,
Abbs, & Barlow, 1982;
Chu et al., 2010)
Hyperkinetic
Dystonic/variable
None
• Spasticity
• Muscle relaxants (e.g.,
Baclofen)
• Muscle paralytics (e.g.,
botulinum toxin)
• Tendon lengthening
• Rhizotomy
• Rigidity
• Rigidity
• Levodopa
Effects on speech tend to be less dramatic
than on postural and limb musculature
Behavioral Management of Tone Impairments
• Sensory
• Applied by clinician
• Target sensory endings or afferent pathways
of reflex loops
• Motor
• Performed by patient
• Target efferent pathways or muscle function
• Pallidotomy
• Deep brain stimulation
Slow Stretch
• Inhibits stretch reflex to
reduce tone and increase
ROM
• Applicable only for jaw
closing musculature
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Massage
Quick Stretch & Tapping
•
•
Intended to increase tone by stimulating the
stretch reflex
Would expect greatest effects in jaw-closing
musculature
• Targets superficial and
deep cutaneous
receptors
• Intended to decrease
tone and/or muscular
hyperfunction
Vibration
Cold
• Elicits tonic/tendon vibratory
reflex (TVR)
• Decreases tone by
decreasing nerve conduction
velocities
• Acts on the muscle spindle
• Increases tone of agonist
• Decreases tone of antagonist via
reciprocal inhibition
• Would be expected to only
influence jaw-closing muscles
• Decreases muscle
contraction speed and extent
• Evidence
• Improves head/neck alignment
(Canon et al 1987)
• Improves spasticity (Noma et al 2009)
Caution: Facial skin
prone to abrasion
• Evidence
• Numerous studies in PMR
literature addressing
various muscle groups
• Improved jaw opening in
children with spastic CP
(dos Santos & de Oliveira, 2004)
Sensory intervention on orofacial muscle tone:
Preliminary study
• Participants
•
•
Submental Compliance Before & After Sensory
Intervention
16.0
16 women
Neurologically normal
*
14.0
12.0
• Tissue compliance measures
•
•
10.0
Tested on 2 days
Before and after
Pre-Tx
Post-Tx
8.0
• Icing
• Vibration
6.0
4.0
2.0
.0
Vibration
Icing
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Muscle tone in the speech musculature:
Summary
Summary:
Submental compliance
• Perceptual assessment methods have not been
validated with instrumental measures
• Submental tissue compliance decreased
(stiffness increased) after icing but not
vibration
• Instrumental measures are under exploration but have
not yet met validity standards even in the research
setting
• Increased tissue stiffness after icing could
derive from
• Muscle tone in the orofacial muscles is regulated in
ways unique from the limb musculature
• Stiffening of non-muscular and muscle tissue
• Changes in blood flow
• Increased muscular activity
• Treatments described to address muscle tone in the
limbs unlikely to affect speech muscles other than jaw
closing muscles
• No evidence to demonstrate efficacy of tone altering
treatments for speech
Defining Motor Learning
Motor Learning Principles
Motor learning is a set of
processes associated with
practice or experience
leading to relatively
permanent changes in the
capability for movement
International
Classification of
Function
Guiding Frameworks
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
2011
Motor Learning
Principles
How is motor learning measured?
• Learning produces relatively permanent
changes in the capability for performance
• Separate from factors that temporarily change
performance (e.g., motivation, warm-up)
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Experimental conditions / Clinical parallel
• Measure performance on an identified task - baseline
• Institute a training program - treatment
• Measure performance periodically during the training
program – probe data collected separate from practice
• Discontinue the training program
• Measure performance shortly after training is discontinued –
immediate retention
• Measure performance some time after training is discontinued
– delayed retention
• Measure performance on related, but untrained tasks – carryover / transfer
Implications
• Performance during training is not a measure
of learning
• Factors that result in better performance
during rehearsal/training may not have the
same effect on permanent learning and/or
carryover
Select Principles of Motor Learning
Principles of Motor Learning
• Skill presentation techniques
• Forms of rehearsal (practice)
• Task sequencing
• Task sequencing
• Providing feedback
DTTC
Skill presentation techniques
A caution about verbal instructions
• Instructions
• The language system is a gas hog
• Attentional resources devoted to verbal
processing cannot be allocated to other
processes that may be more relevant for
movement
• Instructions should be brief, emphasizing
one or two major points
• Demonstration/modeling
• Guidance procedures
• This is particularly true for individuals with
neurologic injury
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Demonstration/modeling
• Requires attention
• External focus: attend to
environment and movement
outcomes
• Internal focus: attend to internal
cues (kinesthetics)
Demonstration/modeling
Current evidence
suggests that external
focus is more
effective in facilitating
permanent motor
learning
• Timing of models
• Model -> simultaneous production
• Model -> immediate imitation
• Model -> delayed imitation
• Visual cues
• Take advantage of mirror
neurons
Guidance Procedures
Disadvantages of Guided Practice
• Physically, verbally, or visually direct learners
through a task
• Guidance can modify the “feel” of the task
• Purpose is to reduce errors or dispel fear
• Reduces decision-making processes
• Reduces or eliminates experience of error
• Cannot make corrections
However…
• Guidance very early in training may be more
beneficial than extensive verbal instruction
• Guidance should be removed as soon as
possible to allow for maximum learning
• Target sequencing
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Slow motion vs Slow rate
Errorless versus Errorful Practice
• When “task speed” is reduced, various aspects
of the movement are not necessarily slowed
proportionately, and timing among movements
is not necessarily maintained
• What is the role of error in motor learning?
• Speech rate changes
• Slowed or prolonged movements can enhance
kinesthetic/proprioceptive feedback
Schema Theory
Movement Schema
• “we learn skills by learning rules about the
functioning of our bodies---forming relationships
between how our muscles are activated, what
they actually do, and how those actions feel”
Information incorporated
into movement schemata
• Initial conditions
• Response
specifications (Motor
program and
parameters)
• Outcome
• Sensory
consequences
Refining Schemata
• When the initial
conditions were **
• I selected ** movement
parameters
• Leading to ** outcome
• And it felt like **
Errors lead to
• Updated and refined motor programs that can
adapt to changes in initial conditions
• Improved ability to predict accuracy based on
sensory consequences
• Target sequencing
Take home message: Progression of complexity
can proceed before mastery of the simpler
movement patterns
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Target Sequencing
Target Sequencing
• Practicing different targets
• A
• Practicing different variations of the same target
• Practicing different
variations of the same
target
• B
• C
• D
Sequencing different targets
Effectiveness of blocked practice
• Blocked practice
• Same target is repeatedly rehearsed before
moving to next target
• Blocked practice enhances immediate
performance because learners are practicing in
a stable and predictable environment
• Random practice
• A number of targets are rehearsed in no
particular order, with minimal consecutive
repetitions of any one target
• The response specifications can be maintained
in working memory
• Carry-over is limited because most target
contexts do not involve unchanging repetitions
Effectiveness of Random Practice
• Elaboration hypothesis
• Learners appreciate distinctiveness of
different tasks
• Forgetting hypothesis
• Movement plan has to be regenerated for
each rehearsal
• Retrieval practice
Random Practice
Blocked Practice
Preceded by varied
conditions
Solution generated at
each attempt
Movements are not
successively repeated
One chance for
success
Preceded by stable
conditions
First solution
maintained throughout
Successive repetitions
Many chances for
success
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Implications
•
•
•
Target Sequencing
Practicing under stable conditions leads to
inappropriately high sense of
accomplishment
Blocked practice may be beneficial very early
in practice, when skill is being acquired
• A1
• Practicing different
variations of the same
target
• A2
• A3
• A4
A random schedule should be instituted as
soon as the learners “acquire a rough
approximation” of the target
• Be sensitive to frustration
Variations on the same target
• “Same targets” are assumed to use a single
GMP but with different parameter assignments
• Throw (soft, hard, fast)
• Jump (high, low, slow)
• Speech targets across contexts
• Constant practice
• Learner rehearses only one variation of
given class of movements
• Stable parameter assignment
• Varied practice
• Learner rehearses a number of variations of
the given class of movements
• Variable parameter assignment
Variable Practice
• Varied practice allows for richer schema
development
• Rate
• Richer schemas (resulting from varied practice)
enhance flexibility and/or adaptability of
movement production, ultimately resulting in
greater success in novel contexts
• Loudness
• Intonation
Do multiple exemplars of
the same “target” count as
different or same tasks?
21
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Combining random and varied practice
•
•
Random practice of the different variations of
the same skill
• A1, A4, A3, A1, A2, etc
Combining variations of the same target
among variations of different target (throwing,
catching)
• A1, B3, A4, B1, A2, B4
• Task sequencing
Feedback
Knowledge of results (KR)
• Types of feedback
•
• Purposes of feedback
Usually verbal information about the success in
achieving an environmental goal
•
KR is most important when learner cannot observe or
judge outcome
• Providing Feedback
Knowledge of Performance (KP)
Providing Feedback
•
Feedback regarding the quality of the
movement
• Should feedback be given?
•
Examples
• Good follow-through
• You didn’t step through the kick
• Your tongue was too far back
• What kind?
• How much information should be provided?
• How precise?
• How often?
• When?
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Forms of feedback
Descriptive vs Prescriptive
•
•
Verbal / Nonverbal
•
Biofeedback
•
•
•
•
•
Palatography
Ultrasound
EMG
Acoustic
Descriptive - describes the movement or the
outcome
Prescriptive
provides information about how to improve
the movement
• generally more effective
•
Reducing information overload
•
•
•
given after a series of attempts/trials
includes information about each attempt
slows acquisition, enhances learning
Reduced feedback frequency (50 -60% rather
than 80 – 100%)
•
•
Average feedback
•
•
•
How often should feedback be provided?
Summary feedback
•
•
•
feedback after a series of attempts
focuses on average performance - “the
gist”
Both summary and average feedback
allow the learner to attend to intrinsic
feedback to judge movement accuracy
When should feedback be provided?
• When feedback is provided, it should occur
within a time frame such that it is clear to which
movement the feedback pertains
Slows acquisition
Improves learning
•
Fading allows for reduction in relative
feedback frequency
•
Learners are forced to attend to intrinsic
feedback, self-evaluate, and self-correct
Evidence Supporting the Application of
Motor Learning Principles in Motor
Speech Disorders
• A short delay allows the learner time to process
intrinsic feedback for schema development
• That delay should remain empty
• Movement
• Verbal processing
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AJSLP 2013
But see Freedman et al
2007
Take-home Messages on Motor Learning
• Measuring Motor Learning
• Performance during the treatment session is
not a sensitive measure of learning
(retention/transfer)
• To best serve our patients and our
profession, we need to diligently report
progress/treatment success based on
outcomes obtained outside of rehearsal
(treatment sessions or at least targeted
practice)
• Many training factors that enhance learning
result in slower acquisition
• Random practice
• Varied practice
• Reduced feedback
• The more movement trials the better
• All evidence suggests that motor learning is
highly specific
• Underlying ability cannot be improved by
drills targeting speed or coordination
• Excessive verbal processing will direct
attentional resources away from motor control
processing
• Visual models
• Reduced verbal feedback
• Reducing feedback allows the learner to attend
to sensory consequences (more similar to the
target context)
The Treatment Process
International
Classification of
Function
Guiding Frameworks
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
Motor Learning
Principles
24
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Treatment Process
• Treatment planning
• Set functional goals
• Determine treatment format
Evidence-Based Practice
• Number, length, frequency of sessions
• Venue and format (e.g., individual/group)
• Identify treatment targets
• Plan treatment activities
International
Classification of
Function
Guiding Frameworks
• Treatment implementation
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
• Instruction, modeling, feedback
• Modify goals, targets, or methods as needed
• Outcome assessment
• Ongoing
• Immediately post-treatment
• Maintenance
Motor Learning
Principles
Evidence-Based Practice
Current Best Evidence
Applying and Integrating Frameworks
International
Classification of
Function
Clinical
Expertise
Client/
Patient/
Caregiver
Values
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
Motor Learning
Principles
Mixed Hyperkinetic-Ataxic Dysarthria:
Speech Features
Mixed Hyperkinetic-Ataxic Dysarthria
• Slow speaking rate
• Short phrases
• Vocal quality alternates between mild strain and breathiness
• Monopitch/Monoloudness with occasional unexpected and excessive
variations in pitch and loudness
• Consistent audible inhalation with intermittent inhalatory stridor
• Alternating hyper- and hyponasality
• Reduced loudness and increased breathiness at the end of phrase groups
• Speech interrupted by effortful swallows of saliva
• Speech AMRs equivocally slow and regular with the exception of /k/ which
she could produce at the frequency of the beating tremor
• Speech SMRs sequenced appropriately
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Mixed Hyperkinetic-Ataxic Dysarthria:
Non-Speech Features
• Unequivocal beating tremors (myoclonus) affecting her jaw, tongue, palate, pharynx,
and (to a lesser extent) lips
Application: ICF
Health Condition
• Alexander disease
• Reduced intelligibility
• Fewer conversational turns
• Sustained phonation characterized by beating tremor with consistent voice
interruptions
• Beating tremor with airflow interruption evident during sustained /s/ and /z/. Lips
retract and round with good range and strength.
Impairments
Contextual Factors
• Tongue protrudes at midline and moves laterally with good range and speed
• Muscle functions
• Speech pathology services
previously unavailable in country of
residence
• Concomitant impairments in
executive function
• Tech savvy
• Supportive family
– Involuntary movements
– Discoordinated movements
• Velum elevates appropriately upon phonation
• Gag reflex elicited bilaterally
• Speech functions
• Inhalatory stridor evident during a yawn, which had a beating tremor
• Performance on nonverbal oral praxis tasks uncoordinated but not frankly apraxic
• Difficulty coordinating phonation with respiration to produce a strong cough or glottal coup
• She performed blowing and whistling during inhalation
–
–
–
–
–
Loudness
Vocal quality
Resonance
Articulation
Prosody
Application: ICF
Medical team exploring
medical/surgical/
pharmacologic options
• Alexander disease
Impairments
– Involuntary movements
– Discoordinated movements
Speech functions
Loudness
Vocal quality
Resonance
Articulation
Prosody
Limitations
• Fewer conversational turns
Speech-level treatments may
improve coordination across
speech systems
• Speech pathology services
previously unavailable in
country of residence
• Concomitant impairments in
executive function
• Tech savvy
• Supportive family
Application: MST Hierarchy
Third Order Targets:
Overenunciation,
compensatory
articulatory placement
Second Order Targets:
Reducing phonatory
strain, coordinating onset
of phonation with top of
breath
First Order Targets:
Respiratory support
(diaphragmatic
breathing), resonance
(prosthetic?)
Strategies targeting
intelligibility and social
interaction may be limited by
executive dysfunction
Contextual Factors
Behavioral interventions will
not likely eliminate
involuntary movements
• Muscle functions
–
–
–
–
–
Application: ICF
Health Condition
•
Limitations
Articulation
Prosody
Phonation
Respiration
AAC may be introduced
using familiar platforms
(iPad)
Environmental factors may
be potential targets
Application: NMT
Prosody
targets
(incorporate
sooner than
later):
Phrasing of
breath
groups,
lexical
stress
Impairments
• Involuntary
movements
• Varying muscle
tone associated
with beat tremor
(palatopharyngeal
myoclonus)
• Discoordinated
movements
Resonation
Not typically amenable to
behavioral interventions
Orofacial muscle groups not
expected to respond to tonealtering treatments
Best managed at the task level
(see motor learning)
Weakness is not present,
strength should not be a target
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Application: Treatment Process
Application: Motor Learning
Plan to assess speech performance
outside of the practice context
Principles
• Learning versus
performance
• Treatment planning
During initial focus on skill
acquisition: practice (frequent, high
volume, constant, blocked) and
feedback (frequent, KP, and KR)
• Structuring practice
•
•
•
•
Amount
Distribution
Variability
Schedule
• KP versus KR
• Frequency
• Timing
Principles
Transition to learning focus as soon as
skills modestly consistent: practice
(frequent, high volume; variable:
respiratory tasks sitting and standing;
random: alternate diaphragm focus with
overenunciation) and feedback (less
frequent, focus on KR)
• General
• Number, length,
frequency of
sessions
• Venue and format
(e.g., individual/
group)
• Setting functional
goals
• Identifying treatment
targets
• Planning treatment
activities
School- and health-care-center-based
treatment (educational and social needs,
and complicated medical condition with
interventions that may impact
communication)
Functional goals (speech intelligible to
teachers and classmates in the context of
class discussions, successful participation
in conversation with peers in home and
community settings, and effective use of
conversation repair strategies)
Treatment targets (respiratory support,
velopharyngeal valving, coordination of
respiration and phonation, articulatory
precision, phrase length,
comprehensibility strategies, and AAC)
Application: Evidence-Based
Practice
Application: Treatment Process
Principles
• Treatment
implementation
• Instructing, modeling,
providing feedback
• Modifying goals,
targets, or methods as
needed
• Assessing outcomes
• Assessing
maintenance
• Best available evidence
Treatment implementation
(tech savvy, may be motivated
by apps that provide KP)
• Natural history of Alexander
disease
• Progressive motoric and
cognitive impairment
• Medical interventions
primarily symptomatic
• Interventions targeting
symptoms
Assessing outcomes
(patient has a degenerative
condition, success may be
judged by reduced rate of
decline)
• PT, OT, SLP
• Botox for palatal tremor,
laryngeal dystonia
• Respiratory-focused
treatments
• Intelligibility strategies
• Clinical expertise
• Background experience
• No experience with Alexander disease
• Extensive experience with dysarthria
and most dysarthria therapies
• Modest experience with Botox
• Issues
• Negative side effects of Botox injection
may outweigh benefits for speech
• Executive function impairments may
limit effectiveness of strategies
• Client’s values
• Typical teenage frustration
• No experience with the speech therapy
process
• Social aspects are a priority
Guiding Frameworks
• Inform decision making throughout the
treatment process
• Any one framework may be more or less
applicable for a given clinical decision
Dysarthria Treatment
Respiratory, Resonatory, Phonatory, Articulatory, and Prosody
Treatments
Intelligibility, Supplementation, and Comprehensibility
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Respiratory Impairments
Impairments
• Reduced inspiratory
capacity
• Reduced expiratory
pressure
Respiratory Treatments
• Reduced control
• Checking action
• Involuntary
movements
Associated Speech
Changes
• Reduced overall loudness
• Loudness decay
• Excessive loudness
variation
Supporting Respiratory Function
Inspiratory Muscle Training
• Postural adjustments
• Sitting upright or standing typically better
than lying supine
• Avoid excess flexion
• Trunk/abdomen
• Neck
• Diaphragm is primary target (belly breathing)
• Discourage excess use of accessory muscles
(shoulder breathing)
• Goal is to establish strong, quick inspiration
followed by slow, controlled exhalation
• Early training may incorporate slowed and controlled
inhalation and exhalation, discussed on next slide
• Strength training requires overload, which may be
best achieved with an inspiratory training device
• External supports
• Expiratory boards
Sapienza and Troche, 2012
Diaphragmatic Breathing
Controlled Expiration (Inspiratory
Checking)
• Promotes solid respiratory support
• Can be combined with diaphragmatic breathing
• May help inhibit excessive activation of
accessory inspiratory muscles and laryngeal
musculature
• Focus on quick, strong inhalation
• Followed by slow, steady exhalation
• Visual and tactile feedback (“belly breathing”)
often helpful
• Applications on handheld devices can support
independent practice
Netsell and Hixon, 1992
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Expiratory Muscle Strength Training
(EMST)
Expiratory Muscle Strength Training
(EMST)
• Pressure threshold trainer
• Training outcomes
• Increased expiratory pressures
• Reduced hypophonia
• Improved intelligibility
• Resistance set at 75% maximum expiratory
pressure
• Rule of 5s
• 5 repetitions
• 5 times per day
• 5 days per week
• Patient groups studied
• Parkinson’s disease
• Multiple sclerosis
• Ataxic disorders
• 4-8 weeks
Phrase Grouping
• Targets strategic pauses for inhalation
• Phrase length selected according to:
• Respiratory support
• Syntactic boundaries
Resonatory Treatments
Resonatory Impairments
Impairments
Associated Speech
Changes
• Velar weakness
• Hypernasality
• Slowness of velar
elevation
• Nasal emission
• Reduced control
• Incoordination
• Involuntary
movements
Velopharyngeal Exercise
• Weak articulatory contacts
• Hyponasality
• Non-speech exercise
• Examples
• Horn-blowing
• Straw-sucking
• No evidence for carryover to speech tasks
• Speech exercise
• Continuous positive airway pressure (CPAP)
• Overloads the velopharyngeal musculature
during speech tasks
• Alternating resonance
Cahill et al., 2004
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Speech-Based Resonatory Treatment
Prosthetic Management
• Emphasis of appropriate oral and/or nasal
resonance
• Palatal lift
• Assessment and implementation in
collaboration with prosthodontist
• Will be most helpful for speakers with
isolated hypernasality or nasality
disproportionate to other features
• Keeping in mind that adequate
velopharyngeal valving may support the
benefit of interventions targeting
phonation or articulation
• May incorporate augmented feedback
• Nasal mirror
• SeeScape
• Nasometry
• May incorporate progressive difficulty
•
•
•
•
Vowels
Liquids
Plosives and fricatives
Phonetic context
• Behavioral intervention usually still needed
Yorkston
et al., 2001
Prosthetic Management
Surgical Management
• Nose plugs
• Examples
• Pharyngeal flap
• Injection augmentation
• Nasal obturator
• Occlude the nares to prevent excess nasal
air escape
• Short-term solution while a palatal lift is
being fabricated
• Long-term option for patients who are not
candidates for palatal lift
• Candidacy issues
• Stable velopharyngeal impairment
• Patency of airway
• Behavioral intervention may still be needed
Hakel et al., 2009
Phonatory Impairments
Phonatory Treatments
Impairments
Associated Speech
Changes
• Hypo-adduction
• Strained voice
• Hyper-adduction
• Breathiness
• Reduced flexibility
• Reduced loudness
• Reduced stability
• Monopitch/monoloudness
• Tremor
• Flutter
Speyer, 2008
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Supporting Phonatory Function
Reducing Laryngeal Strain
• Hypo-adduction
• Head turn to facilitate approximation of vocal
cords
• Manual lateralization of the thyroid cartilage
• Surgical management
• Vocal cord injection augmentation
• Thyroplasty
• Direct speaker’s attention to somatosensory
aspects of excess muscle tension
• Hyper-adduction
• Relaxation
• Massage
• Some aspects of laryngeal tension/strain may
not respond completely to behavioral
approaches (e.g., dystonia in hyperkinetic
dysarthria; strain-strangled quality in spastic
dysarthria)
• Excess laryngeal tension may result from poor
respiratory support or poor coordination with
respiration (see Respiratory Treatments)
Laryngeal Exercise
Loudness Treatment
• Increasing medial compression (adduction)
• Push-pull
• Grunt
• Cough
• Lee Silverman Voice Treatment (LSVT)
• Systematic hierarchy of exercises, focusing
on a single goal “speak LOUD!”
• Targets respiratory, laryngeal, and
articulatory subsystems
• Incorporates high-intensity, high-frequency
practice
• Increasing pitch range and control
• Pitch glides and/or steps
• Pitch matching
• Nonstandardized loudness treatment
Smith and Ramig, 2014
Coordinating Respiration and
Phonation
• Potential targets
• Lung volume at onset of phonation
• Initiating phonation at the top of inhalation
• Phrase grouping (ceasing phonation before
respiratory support wanes)
• Rapid inhalation between phrases
Spencer
et al., 2006
Articulatory Treatments
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Articulatory Impairments
Supporting Articulatory Function
Impairments
Associated Speech
Changes
• Weakness and/or fatigue
• Articulatory imprecision
• Reduced range of motion
• Slow rate
• Velopharyngeal support (see Resonatory
Treatments)
• Jaw support (bite block)
• Sensory tricks (hyperkinetic dysarthria –
dystonia)
• Reduced speed
• Reduced coordination
• Stretching/massage
• Hyper-reflexia (spasticity) in jaw muscles
• Would not be expected to facilitate muscle
functions in lips, face, tongue
• Involuntary movements
Articulatory Exercise
Articulatory Treatments
• Tongue strengthening programs well studied for
dysphagia outcomes; speech evidence is less
compelling, even in dysarthria
• Exaggerated articulation (overarticulation)
• Alternative place/manner/voicing
• Coordination of complex phonetic sequencing
• Be mindful of task specificity
• Often targeted in concert with lexical stress
(see Prosody Treatments)
McCauley
et al., 2009
Prosody Targets
• Speaking rate
• Lexical stress
• Sentential stress
• Phrase groupings (see Respiratory Treatments)
Prosody Treatments
32
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Speaking Rate
Rate Reduction Strategies
• Even for patients with slow rate, increasing
overall speaking rate is almost never an
appropriate target
• Pacing board/hand tapping
• Metronome
• Reducing speaking rate, even for patients with
normal or slow rate, typically improves
intelligibility
• Speakers with hypokinetic dysarthria often have
rapid rate but may have difficulty intentionally
reducing rate
Yorkston et al., 2007
Rate Reduction Strategies
Lexical and Sentential Stress
• Delayed auditory feedback
• Visual cueing/feedback
• Hand gestures signaling change in loudness,
pitch, and/or duration
• Acoustic software
• Indirect strategies
• Increased loudness (see Phonatory
Treatments)
• “Clear” speech (see Intelligibility Treatments)
• Activities/stimuli
• Contrastive stress
• Metric pattern across various word lengths
• Verbal repair
Intelligibility Strategies
• Use any combination of speech behaviors to
improve intelligibility
• Often an appropriate first target, to establish
functional communication
Intelligibility, Supplementation, and
Comprehensibility
33
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Slow Rate by Separating Words
Slow Rate by Separating Words
• Speak slowly
• Video d19_red_rate.mp4
• Separate words, especially small words
• Don’t separate syllables
• Pause extra long before and after multisyllabic
words
• Maintain stress and intonation
Clear Speech
Speech Supplementation
• Speak as if talking to someone who is hard of
hearing or who has difficulty understanding the
language spoken
• Incorporated during spoken expression
• Instructions may focus on overarticulation
(hyperarticulation) but effects are broader
• Slow rate
• Wider loudness and pitch variation
• Strategies provide listeners with additional
information to help make sense of the spoken
message
• Typically involves “signal-independent”
information about the message
• Includes gestures
Smiljanić and Bradlow, 2009
Hanson et al., 2004
Alphabet Supplementation
Semantic/Topic Supplementation
• Point to initial letter of word as each word is
spoken
• Identifies the topic of discussion to help
listener’s word prediction and comprehension
• Also serves as a pacing strategy
• Topics can be identified through
•
•
•
•
• Identification of initial letter facilitates word
prediction by listener
A
E
I
O
U
B
F
J
P
V
C
G
K
Q
W
D
H
L
R
X
M
S
Y
Spoken expression
Written expression
Photographs/pictures
Other artifacts
• Calendars
• Souvenirs
• Newspapers
N
T
Z
Example of alphabet board with vowels aligned on left margin
34
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Comprehensibility Strategies
Comprehensibility Strategies: Speaker
• Facilitate successful exchange of ideas
• Reduce background noise
• Not limited to modifications to the speech signal
• Face the listener
• Include behaviors of both the speaker and the
listener
• Cue topic
• Signal change of topic
• Signal for a conversation turn
• Say listener’s name before beginning message
• Use predictable words and sentence types
Comprehensibility Strategies: Listener
Comprehensibility Strategies: Listener
• Reduce background noise
• Conversation repair
• Avoid the least-helpful question: “What?”
• Let the speaker know what parts of the
message were understood
• Ask follow-up questions for additional
clarification
• Face the speaker
• Look for turn-taking signals
• Identify the topic, watch for changes in topic
• Take advantage of all cues
Comprehensibility Strategies:
Speaker and Listener
Alphabet Supplementation & Glossing
• Glossing
• Listener repeats each word as soon as it is
heard
• Encourages speaker to separate words
while waiting for the listener’s response
• Speaker stops only when the listener repeats
incorrectly, then employs repair strategies
• Repeat
• Spell
• Works well in conjunction with alphabet
supplementation
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Amplification
AAC
• When efforts to increase loudness
• Induce dysphonia
• Cause undue fatigue
• Are insufficient to achieve audibility
• Augmentative and alternative communication
(AAC) is an appropriate option for speakers with
poor intelligibility
• Temporary as speech improves
• Introduced early in degenerative disease
• Issues
• Speakers may not like the sound of their
voice
• Social acceptability
• Portability
Principles of Treatment for Adult AOS
• Approach may vary depending on…
• Severity
• Nature of errors
• Progression
• Presence of concomitant aphasia and/or
dysarthria
Treatment of Adult AOS
• Principles of motor learning will apply
regardless
Management of Mild AOS
Management of Moderate AOS
• Typical features
• Sound distortions
• Mildly slowed rate
• Improved accuracy with slow rate
• Slowed rate and segmentation
• Distortions
• Improved (but not perfect) accuracy with
slowed rate
• Focus of treatment
• Slowed rate
• Targeted practice of functional multisyllabic
words and/or complex utterances
• Phoneme accuracy
• Lexical and sentential stress
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Management of Severe AOS
Treatment Programs
• Difficulty initiating speech
• Severe prosodic deficits
• Severe articulatory distortions
• Specific protocols with
treatment evidence
• Volitional phonation (may need to move from
reflexive to volitional laryngeal movements)
• Functional words and phrases
• AAC
AOS Treatment Programs
AOS Treatment
• Articulation Focused
• 8 Step Continuum
• DTTC
• PROMPT
• Sound Production Treatment
• Prosody Focused
• Utterance Focused
• Gestural / Aug Comm
• Prosody Focused
8 Step Continuum
Suggested Cue Hierarchy
• AKA Integral Stimulation
• (Tactile Cues)
• Designed to provide “threshold” level cueing so
the patient receives stimulation just adequate to
elicit a correct response without over-cueing
• Simultaneous Production
• Mimed Production
• (Immediate Repetition)
• Successive Repetition
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Dynamic Temporal and Tactile Cueing
Suggested Cue Hierarchy
(Strand et al, 2006; Baas et al, 2008)
• Delayed Repetition
• Variations of Integral Stimulation have been
incorporated into most articulation-focused
treatments for AOS
• For example, slowed productions
• Reading
• Reading with Delay
• Answering Questions
• Role Playing
38
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PROMPT
Prompts for Restructuring Oral Muscular
Phonetic Targets
• Tactile-kinesthetic approach
• Provides proprioceptive, pressure, and spatial
information through the use of oral-facial cues and
prompts
• Training is required
http://promptinstitute.com/uploads/CSHA%20SSD%20Powerpoint.pdf
©2014 MFMER
| slide-231
©2014 MFMER
| slide-232
Sound Production Treatment
• Emphasizes repeated practice of key sound
targets
• Uses hierarchical cues
• incorporates minimal contrast practice
• target sound paired with typical replacing
sound
• provides articulatory contrast
• provides pragmatic boost - avoidance of
homonymy
©2014 MFMER
| slide-233
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Selection of Treatment Targets
Selection of Exemplars of Targets
• Impact on intelligibility
• % in error
• homonymy
• frequency of occurrence in language
• 10 exemplars should be sufficient
• Real words when possible
• One word-position suggested
• Variety of vowels should be represented
• Level of success
• Minimal contrast word selected for each
exemplar
• Trial therapy - stimulability
•
•
•
•
Real word
Contains replacing sound or approximation
Key…tea
Cap…tap
Hierarchy of Cues (Word Level)
Treatment Sequence
Step 1 – Modeling/Imitation at Word Level
Step 4 – Articulatory Placement + Modeling
• Each Session (45 minutes to 1 hour)
• hierarchy applied to each word pair
• 10 words presented in random order = 1 trial
• attempt to complete at least 7 trials (70
words) per session
Step 5 – Production of target sound in isolation
• Three sessions per week recommended
Step 2 – Modeling + Written letter cue/Imitation
Step 3 – Integral Stimulation
Treating More than One Sound At a Time
with SPT
• Select minimal contrast words across the
sounds
Targeting Multiple Sounds
• Generally recommended only after single
phoneme targets are produced with relatively
high levels of accuracy (e.g., 40% +)
• “low” “mow” “know”
• Select the contrast word to reflect errors on all
sounds (may need more than one)
• “dough” “though”
• Number of trials is greatly reduced – probably would
be difficult to “establish” sounds
• Recall Motor Learning Principles
• Blocked trials - better for initial acquisition
• Randomized trials - better for learning / maintenance
40
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AOS Treatment
Metronome Training
• Focuses on rate reduction, not on accurate
phonetic productions
• Prosody Focused
• Metronome and Hand-tapping
• Melodic Intonation Therapy
• Multisyllabic targets
• Benefit
• Spaghetti
• Represent
↓ ___ ___
___ ↓ ___
___ ___ ↓
Metronome Training – Multisyllabic Words
Feedback
• Hierarchical levels vary the availability of a
model, speed of metronome, and nature of
rhythm
• Tapping accuracy
• # syllables
• Level 1: Clinician Model, Unison Production, Patient
Production
• Level 2: Faded Clinician Model
• Level 3: No Clinician Model
• Level 4: Increased Production Rate
• Level 5: Syncopated Rhythm
• Production to the beat (not about sound
production)
Why Might Rate Control/Pacing Facilitate
Articulation?
• Increased time to reach articulatory postures
Melodic Intonation Therapy
• MIT has been applied to the management of
AOS and nonfluent aphasia
• Improved functioning of central pattern
generators
• Emphasizes both melody and rhythm of
productions
• Decreased degrees of freedom in speech
production
• Increased allocation of resources
• Motoric “spillover”
• Increased afference
41
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Level 1
Level 2
• Step 1: Humming
• Clinical models melody and taps rhythm
• Next adds word to melody and rhythm
• Step 1: Clinician models target while tapping
(no patient response required)
• Step 2: Unison
• Step 3: Delayed repetition
• Step 3: Unison with clinician fading out
• Step 4: Response to probe question
• Step 2: Unison with fading
• Step 4: Immediate repetition
Level 3 (Speech Song)
AOS Treatment Programs
• Step 1: Delayed repetition
• Step 2: Introduce speech song
• Exaggerated rhythm and stress
• Prosody Focused
• Response Elaboration Training
• Voluntary Control of Involuntary Utterances
• Step 3: Speech song with fading
• Step 4: Delayed repetition of normal speech
prosody
Response Elaboration Training
Utterance Focused Treatments
Kearns and colleagues
• Emphasize effective volitional communication
regardless of phonetic accuracy
• Loose training procedure designed to increase
length and content of verbal productions
• Patient-initiated utterances
• guided by pictures
• NOT specified by therapist
• Modeling & forward chaining procedures
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RET Sequence
Modifications to RET
1. Present picture stimuli & elicit a response
• Provision of 2 phrase level models (NP & VP)
in the event of no response (initial response &
elaboration)
2. Repeat patient’s production & reinforce
3. Ask a question to elicit an elaboration of the
original response
4. Repeat & reinforce the new production;
model combined productions (1 + 3)
• Provision of integral stimulation upon incorrect
or no response (following previous models)
• Repeated practice of elaborated utterances
5. Model combined production and request a
repetition
• Use of a time delay prior to final repetition
6. Reinforce repetition and model again
Modified Version of RET
Modified Version Cont.
1. Present picture stimuli & elicit a response
4. Repeat & reinforce the new production; model
combined productions (1 + 3)
•
•
•
model 2 response options (e.g., “you could say NP
or VP”)
model a 1-word response - request repetition
use integral stimulation
2. Repeat patient’s production & reinforce
3. Ask a question to elicit an elaboration of the
original response
•
model as in step 1
5. Model combined production and request a
repetition
• if correct - 3 more productions
• if incorrect - use integral stimulation to elicit multiple
productions
6. Remove picture for 5 seconds - request
repetition of description
• Feedback as in step 5
RET Applied to Personal Recount
Summary of RET
• no picture stimuli
• Provides models and scaffolding to increase
length and informativeness of verbal
expression
• patient instructed to “Tell something about
anything that you would like to talk about.”
• treatment hierarchy applied as before
• at least 14 topic attempts elaborated upon per
session
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Voluntary Control of Involuntary Utterances
(VCIU)
• For patients with limited verbal expression
• Attempts to expand the communicative uses of
spontaneous productions
VCIU Sequence
• Clinician notes any spontaneous utterances and
writes them each on a card
• Patient reads card
• (spontaneous -> volitional)
• Utterances that can be produced volitionally are
targeted in other contexts
• Picture naming
• Sentence completion
• Discourse
VCIU Principles
• Target stimuli can be added continually
• Emphasis is on expanding use of spontaneous
utterances, not on correct productions (either
phonetic or semantic) during any given trial
Evidence-Based Practice Resources
EBP Resources
EBP Resources
www.ancds.org
44
2/13/2015
EBP Resources
EBP Resources
• Clinical Aphasiology Conference Proceedings
• www.clinicalaphasiology.org
• Conference on Motor Speech
• http://www.madonna.org/res_conferences
• Proceedings published in JMSLP
• ASHA
• Special Interest Division 2
www.speechbite.com
Case #1
• 70-year-old woman with 5-year history of changes in balance, speech, and
autonomic function
• Medical diagnosis of multiple system atrophy
• “Ms. X reports that she noticed a change in her speech 2–3 years ago. She
describes her speech as slurred and notes that there are some sounds that
are particularly hard to produce. Ms. X is a native Filipino speaker. Her
daughter indicates that because of this she has had difficulty producing
some English phonemes throughout her lifetime. Ms. X notes that her
speech is typically more impaired in the evening. She continues to use the
telephone, but only with her daughter because listeners have so much
difficulty understanding her when they cannot watch her face. In addition to
speaking more slowly, Ms. X reports that she tries to select words that are
easier to pronounce in order to make her speech clearer. She denies
change in emotional expression. She does endorse occasional swallowing
difficulties, which have been evaluated; she reports she is managing them
effectively. Ms. X was evaluated by a speech-language pathologist in June
2013. She had a brief course of therapy that targeted strengthening of the
articulators. Ms. X did not feel that her speech was markedly improved
following this therapy.”
Case Scenarios
Case #1
Case #1
• Speech features
• Reduced overall rate
• Reduced loudness
• Phonatory strain
• Monopitch and monoloudness
• Mild hypernasality
• Imprecise articulation, including irregular
articulatory breakdowns
• Speech-like features
• Sustained phonation
• 9 seconds (slightly below average)
• Vocal quality mildly strained
• Strain was exacerbated with attempts to
increase loudness
• Speech AMRs
• Slow and irregular
• Speech SMRs
• Slow but sequenced appropriately
45
2/13/2015
Case #1
Case #1
• Non-speech features
• Subtle jaw clonus
• Tongue, lips, jaw, and palate move with full
range and strength but equivocally reduced
speed
• Bilateral gag reflexes
• Bilateral suck, snout, and palmomental
reflexes
• Cough and laryngeal coup normally sharp
• Moderate difficulty rapidly adducting and
abducting the vocal cords (laryngeal AMRs)
• Differential diagnosis: Mixed spastic-ataxic
dysarthria
Case #1 Treatment Recommendations
Case #2
Recommendation
Rationale
All recommendations are
compensatory
MSA is progressive and is already advanced;
therapy not likely to affect change at the
impairment level
Intelligibility strategy: slow rate by
separating words
Word boundaries are particularly difficult to
detect when laryngeal spasticity causes
continuous phonation
Comprehensibility strategies,
including glossing
Conversation partners can take some
responsibility for communicative success
Personal amplification
Increasing loudness exacerbated phonatory
strain; amplification may allow her to be
audible without increased background effort
Introduce AAC
MSA is progressive
Electronic communication with
video and keyboarding options
(Skype)
She wants to use telephone communication,
takes advantage of facial cues and offers
repair modality
• 71-year-old
• Several-year history of dysphagia
• Speech change in the last few months
• “Slurred”
• “Double letters" are particularly difficult to
enunciate
• Medical diagnosis of probably myopathy
Case #2
Case #2
• Speech features
• Mild nonspecific hoarseness with occasional
fry
• Imprecise articulation, particularly of lingual
consonants
• Normal rate
• Articulatory precision decreased with
increased speaking rate, but she had no
difficulty increasing rate. With reduced
speaking rate and careful enunciation,
articulatory precision improved.
• 13 seconds (normal)
• Normal quality
• Speech AMRs - normal
• Speech SMRs - normal
46
2/13/2015
Case #2
Case #2
•
•
•
•
• Differential diagnosis: Flaccid dysarthria
primarily affecting CN XII, subtle CN VII deficits
Face grossly symmetric at rest
Jaw movement normal
Lip retraction was full, but lip rounding was mildly reduced
Tongue
• Asymmetric size R>L (subtle)
• Protruded at midline and moved laterally with equivocally reduced
range
• Mild-moderate weakness bilaterally
•
•
•
•
•
Velum ascended briskly at midline upon phonation
Gag reflex was normal bilaterally
No pathologic oral reflexes were elicited
Nonverbal oral praxis was normal
Cough and laryngeal coup were normal with respect to
sharpness
• No difficulty rapidly adducting and abducting the vocal cords
Case #3
Recommendation
Rationale
Reduce speaking rate
Articulatory precision improves with only slight
reduction in speaking rate
Clear speech/overenunciation
Deficits are limited to the articulatory system;
respiratory, phonatory, and resonatory
treatments are not needed
No strengthening
Medical workup suggests that inflammatory
myopathy is active; resistance exercise may
not be indicated
• 65-year-old woman with progressive cerebellar ataxia
with spasticity
• Progressive speech changes first noted 6 months ago
• Complains of soft voice with moments of unintended
excessive loudness that occasionally startles listeners
• Slurring, particularly with "hard" words
• Listeners have difficulty understanding her
• Speech does not significantly fluctuate
• Complains of dysphagia (swallow study normal)
• Mild word-finding difficulties, as she intentionally seeks
words that are easier to pronounce
Case #3
Case #3
• Speech features
• Speech features
• Variable prosodic variation
• During periods of slightly accelerated rate or during intentionally
slow rate, monopitch and monoloudness were evident
• When speaking rate was normal (neither rapid nor intentionally
slowed), prosodic variation improved
• Variable loudness
• Mostly reduced but interrupted by brief periods of
excessive loudness
• Variable speaking rate
• Articulatory imprecision
• Periods of increased speaking rate were accompanied by
reduced range of motion of the articulators
• Vocal quality
•
•
•
•
Tight breathiness
Subtle strain, most apparent during sustained phonation
Intermittent wet hoarseness
Equivocal and rare flutter
• Irregular articulatory breakdowns
• Mild imprecision associated with reduced range of motion of the
articulators
• Telescoping of syllables
• Segmentation evident during repetition of phonetically complex
sequences
• Intentional slowed rate and separated syllables to produce them
accurately
• With cuing, she was able to produce these sequences rapidly and
without segmentation, but with reduced articulatory precision
47
2/13/2015
Case #3
Case #3
• 12 seconds
• Breathy, improved with increased
loudness
• Speech AMRs
• Slow
• Irregular
• Speech SMRs
• Equivocally slow
• Subtle hypomimia
• Left-sided facial weakness resulting in asymmetric
lip movements, particularly during speech
• Lip volitional lip movements were symmetric but
mildly reduced in range
• Normal jaw movement
• Tongue
•
•
•
•
Protruded at midline
Range and speed were grossly normal
Strength equivocally reduced bilaterally
No atrophy or fasciculation
Case #3
Case #3
• Velum elevated briskly at midline upon
phonation
• Gag reflex elicited on the left
• Palmomental reflexes elicited bilaterally
• Cough normally sharp
• Laryngeal coup mildly reduced
• Mild difficulty rapidly adducting and
abducting the vocal cords; subtle phonatory
strain was noted during this task
• Differential diagnosis: Mixed ataxic-hypokineticspastic dysarthria
Case #4
Recommendation
Rationale
Increase loudness
• Respiratory coordination
• Loudness focused speech
therapy (LSVT)
• The habitual reduced loudness is a greater
detriment to intelligibility than the occasional
excessive loudness
• Vocal quality is improved with increased
loudness
• Preferred over amplification because of
benefits for vocal quality and potential
carryover to articulation and prosody
Slow rate
Increased rate is accompanied by reduced
range of the articulators, giving speech a
mumbled quality
Overenunciate
In combination with slow rate will maximize
potential for phonetic accuracy
Lexical stress
Segmentation that accompanies intentional
slow rate detracts from intelligibility and
naturalness
• 67-year-old woman with diagnosis of ALS
• First noted a change 5 months ago, does not feel it has
declined significantly
• Her description of her speech
•
•
•
•
Nasal
Slurred when her speech is at its worst
Some days her speech is quite completely normal
Speech is worse she is tired and the longer she talks; improves
if she rests
• If she speaks slowly her speech is easier to understand
• Unusual laughter
• No swallowing complaints (local swallow assessment
normal)
48
2/13/2015
Case #4
Case #4
• Speech features
• 10 seconds
• Mildly strained with brief and equivocal
flutter
• Speech AMRs
• Slow and regular
• Accompanied by voice/voiceless
substitutions and exaggerated jaw
movements during repetitions of /t, k/
• Speech SMRs
• Normal
• Intermittently and equivocally reduced speaking rate
• Mild phonatory strain
• Mild articulatory imprecision, including subtle
irregular articulatory breakdowns
• Moderate hypernasality with associated weak
consonants
• Hypernasality and articulatory imprecision became
more pronounced over the course of 60 seconds of
speaking and improved following 60 seconds of rest
Case #4
Case #4
• Differential diagnosis
• Mixed spastic-flaccid dysarthria, consistent
with ALS
• She further demonstrates rapid fatigue and
recovery with rest that is atypical in ALS
(remainder of neurologic workup showed no
evidence for myasthenia gravis)
• Face symmetric, no perioral fasciculations
• Jaw
• Opens with full range
• Mildly reduced in strength
• Lips
• Retract and round with mildly reduced range and strength
• Speed of alternating lip movements is also reduced
• Tongue
• Protrudes at midline and moves laterally with mildly reduced range, speed, and
strength
• Tongue elevation and protrusion have adequate range but reduced strength
• No lingual atrophy, but subtle lingual fasciculations are present
•
•
•
•
•
•
Velum moves sluggishly but improves with increased effort
Gag reflex elicited bilaterally
Bilateral suck, snout, and palmomental reflexes are observed
Cough is mildly weak, but laryngeal coup is normal
Mild difficulty rapidly adducting and abducting the vocal cords
Oral nonverbal praxis is normal
Case #5 Mrs. M
Recommendation
Rationale
• 80 yo
Energy conservation
She has already determined her speech declines
with use and improves with rest
Consider palatal lift
• Hypernasality is most prominent feature
• Seems to experiencing slow progression of
speech
• Gag reflex is not exaggerated
• Complaints
• hand tremor (present since age 20)
• leg cramps (began 5 years ago)
• gait changes (in the past year)
• speech changes (in the past year)
• vision changes
• hand clumsiness
• weepiness
Comprehensibility strategies
Intermittent follow-up with SLP
• Updated speech strategies
• Monitor swallowing function
• Introduce AAC
• PMH: noncontributory
49
2/13/2015
Case #5 Mrs. M
Case #5 Mrs. M
• Imaging
• FLAIR hypointensity in a laminar pattern
along the posterior aspect of the primary
motor cortex gyri bilaterally
• ENT
• The true vocal folds showed normal motion
with full abduction and complete adduction.
There is some mild tremor at times along the
larynx but no masses or lesions seen.
Videostroboscopy shows normal and
symmetric mucosal wave. Closure is
complete.
• Neurologic dx
• In light of the progressive nature, subtle
findings of cortical dysfunction, and obvious
eye movement abnormalities, the most likely
diagnosis would seem to be a tauopathy
such as progressive supranuclear palsy or
corticobasal syndrome. Amyotrophic lateral
sclerosis is much less likely.
Case #5 Mrs. M
Case #5 Observations
• Communication complaints
• Struggles to get words out
• Slow speech
• Frogginess in her voice, worse when she is
emotional
• No slurring or sound substitution
• No complaints re comprehension or
formulation
• Reduced speaking rate (-2,3) with consistent segmentation
• Previous speech therapy
• Breathing exercises which she found helpful
• She sustained phonation for seven, six, and six seconds over three trials. Vocal
quality during sustained phonation was mildly strained (1).
Case #5
• Mildly strained (1) vocal quality that became more obviously strained during
emotional expression
• Overall loudness was normal to equivocally increased.
• Monopitch/monoloudness (2)
• Occasional short phrases (1)
• Mild intermittent tremor was noted associated with head tremor
• Occasional anticipatory posturing/groping
• Equivocal articulatory imprecision
• Initial attempts at AMRs were mildly slow (-1) and irregular (1), primarily associated
with abbreviated breathing cycles. Subsequent attempts were quite normal.
Speech SMRs were sequenced appropriately.
• Differential Diagnosis: Spastic dysarthria and
AOS
• Has wide-eyed facial expression but no other
features of hypokinetic dysarthria
• Presence of AOS suggests CBS over PSP (PSP
usually includes hypokinetic features)
Recommendation
Rationale
Keep it up!
• Progressive neurologic condition
• Appropriate speaking rate
• Intelligible speech
Re-evaluation in 6 months
• Comprehensibility strategies and AAC can be
introduced as necessary
50
2/13/2015
Case #6
Case #6 – Nonspeech Oral Function
• 69 years old
• Hypomimia
• Outside diagnosis of Alzheimer disease “plus”
• Constant adventitious movements of her lower face
including jaw clenching, lip pursing, and less frequently
tongue protrusion
• Speech changes 4 yrs ago
• Began with difficulties with pronunciation
• Progressed to include changes in her voice
(higher pitch, whiny) and overall reduction in
spoken output)
• Reduced range and speed of jaw opening, lip retraction
and rounding are reduced
• Mildly reduced tongue strength
• Bilateral suck, snout, and palmomental reflexes
• Followed by changed in memory
• Mild nonverbal oral apraxia
• Followed by changes in motor control
• Normal cough and laryngeal coup
Case #6 – Speech Features
• Mild difficulty rapidly adducting and abducting the vocal
cords
Case # 6
• Limited overall output and short phrases
• Vocal quality is mildly tight and strained and has equivocally increased
pitch
• Reduced overall loudness; increasing loudness exacerbated phonatory
strain
• Monopitch/monoloudness
• Imprecise articulation
• Occasional distorted substitutions
• Rapid repetitions
• Additions of phonemes including intrusive schwa. Some of these intrusive
phonemes (e.g. /b/) were judged to be associated with involuntary
movements of the articulators.
• Vowel distortions
• Groping of the articulators
• Differential diagnosis
• Mixed hypokinetic-hyperkinetic-spastic
dysarthria
• Apraxia of speech
• Cognitive communicative impairment
• Medical diagnosis
• Corticobasal syndrome
Concluding Remarks
Recommendation
Rationale
Environmental modifications to
maximize signal to noise ratio
• Increasing loudness exacerbated phonatory
strain
Conversation partner strategies
• Cognitive deficits make it difficult for patient to
use intentional strategies
• Include strategies addressing reduced output
related to cognitive deficits
• Effective treatment of
motor speech disorders
requires active clinical
problem solving
• The guiding frameworks
presented here (as well
as others) inform the
questions asked and
the solutions proposed
International
Classification
of Function
Motor Speech
Treatment
Hierarchy
Treatment
Process
Neuromuscular
Treatment
Principles
Motor Learning
Principles
51
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Treatment of Motor Speech Disorders

Transcription

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