Articulatory Kinematic Approaches to Treat Apraxia of Speech
Apraxia of Speech (AOS) is a motor speech disorder that reflects a disturbance in the planning or programming level of speech production. Although AOS often co-occurs with a dysarthria or aphasia, it has distinct characteristics that categorize it as a unique speech disorder. AOS almost always results from neurologic impairment in the left cerebral hemisphere. It reflects impairment in planning or programming the sensorimotor commands that are necessary for the phonetic and prosodic components of speech. In other words, AOS affects organization of motor plans, although message formulation and muscle strength are unaffected.
The primary goal of managing AOS is to maximize the effectiveness, efficiency, and naturalness of communication (Duffy, 2005). Treatment may be centered on relearning the plans or programs or improving the patient’s ability to organize and implement them. Specific kinematic approaches directly improve the spatial (place and manner of articulation) and temporal (timing) features of speech sounds in order to improve overall intelligibility.directly improve the spatial (place and manner of articulation) and temporal (timing) features of speech sounds in order to improve overall intelligibility.
Eight-Step Integral Stimulation Continuum
The first kinematic approach we will discuss is the Integral Stimulation Continuum (“watch, listen, say it with me”). This eight-step approach uses intensive drill, meaningful communication, and self-correction to improve word, phrase, or sentence production.
Step 1 – Integral stimulation in which the clinician presents a target stimulus that the patient then imitates while watching and listening to the clinician’s simultaneous
Step 2- The patient’s response is delayed and the clinician mimes the response
Step 3 – Integral stimulation followed by imitation without cues from the clinician
Step 4 – Integral stimulation with several successive productions without any cues
Step 5 – Written stimuli are presented without any auditory or visual cues, followed by patient production while looking at the written stimuli
Step 6 – Written stimuli with delayed production following removal of the written stimuli
Step 7 – A response is elicited with the appropriate question
Step 8 – A response is elicited with an appropriate role-playing situation
Sound Production Treatment
The next kinematic approach is Sound Production Treatment (SPT). It is sometimes referred to as minimal contrast treatment due to its emphasis on minimal contrasts. SPT focuses on improving articulation at the segmental and syllable level and combines repetition, integral stimulation, modeling, cues, and feedback. Unlike the eight-step continuum that uses maximum assistance, SPT only provides minimal assistance and
subsequent steps only when an error occurs. The steps are as follows:
Step 1 – Clinician produces a target item containing the target sound following a verbal model
Step 2 – Clinician shows a printed letter representing the target sound, says the target word, and requests repetition on the target word
Step 3 – Clinician uses integral stimulation to elicit target word
Step 4 – Clinician provides articulatory placement cues, then requests production after providing integral stimulation
Prompt therapy, also referred to as tactile cueing, consists of specific cueing techniques used on the face and neck of a patient with AOS. The goal of Prompt Therapy is to kick start speech production by providing external forces upon important target positions used in typical speech patterns. The use of this technique can also signal accurate movement and articulation manner along with syllable and segment duration times. Visual and auditory stimulations are often used in union with prompting. Speech-Language Pathologists may administer this treatment approach after receiving specialized training. However, the use of Prompt Therapy is deemed a “partly established” (Wambaugh, 2002) treatment for AOS. Research studies of its use show improvements in only a modest amount of patients, therefore not making Prompt Therapy a widely used treatment approach.
Biofeedback includes a wide range of useful instruments used to elicit precise speech from a patient with AOS. These tools are often used in addition to auditory and visual cueing. One form of biofeedback is an Electromyogram (EMG), which measures muscle action potentials using electrodes placed upon the skin of the desired area of measurement. Another is Electromagnetic Articulography (EMA), which specifically focuses on the tongue’s activity in AOS. Small receiver coils are placed inside and outside of the mouth, which in turn, send signals to a visual display, which detail articulator movements during speech. Electropalatography (EPG) uses a retainer-like device containing electrodes that is placed on the palate, recording and visualizing how the tongue interacts with the palate during speech.
Aside from the methods mentioned above, there are numerous other approaches in the treatment and management of AOS. Presently, there is no data available that suggests one particular method being the gold standard above others, though the use of evidence-based practice is important within this patient population. In rare instances, spontaneous recovery, or random resolution of AOS, can occur. A Speech-Language Pathologist may have to use trial and error in order to find what therapeutic approach works best with each patient. Sometimes, a combination of a few different techniques may prove to be the best fit in managing and treating AOS.
Acquired Apraxia of Speech: Treatment. (2017). Retrieved October 19, 2017, from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942115§ion=Treatment
Duffy, J. R. (2013). motor speech disorders: Substrates, differential diagnosis, and management . St. Louis, MO: Elsevier.
Ferguson, G. P. (n.d.). Biofeedback and the Treatment of Motor Speech Disorders. Retrieved October 19, 2017, from http://www.appstate.edu/~clarkhm/neuropages/biofeedback.html
Rosenbek, John & L. Lemme, Margaret & B. Ahern, Margery & H. Harris, Elizabeth & T. Wertz, Robert. (1973). A Treatment for Apraxia of Speech in Adults. The Journal of speech and hearing disorders. 38. 462-72.
Wambaugh JL: A summary of treatments for apraxia of speech and review of replicated approaches, Semin Speech Lang 23:293, 2002.