Greece

CROSSROADS Motor Speech DisordersApraxia of speech and dysarthriaFirstThe SLP does not fix or improve anyone

People fix themselves (or not)

RequiresWillingnessAbilityEstablishing these is as or more critical than all the other diagnostic stuff we are usually taughtOther orientation to treatmentEasy to get overwhelmed but it is actually pretty easyTwo critical components in treatment planningKnowing or at least having an hypothesis about why the patient speaks dysarthrically or apraxicallyThis means having an idea about the pathophysiologyKnowing the active ingredients of our treatment approaches

PathophysiologyDysarthria in all conditions caused by one or combination of WeaknessReduced endurance or easy fatiguabilityHypotonicityHypertonicityAbnormal rateDyscoordinationAdventitious movements such as tremorApraxia caused by breakdown in skilled movement

For exampleHypernasality can be caused by weakness of soft palate

Strain-strangle dysphonia can be caused by hypertonicity

Apraxic articulatory breakdown can be caused by dyscoordination

Other characteristics that influence response to treatmentDepressionApathyCognitive impairment, especiallyReduced memoryReduced attentionReduced intentionImpaired ability to judge accuracyImpaired ability to respond to internal cuesInability to plan

Patient oneWhitaker on CDSo what do you hear?

Strain-strangle dysphoniaSlow rateHypernasalityConsonant imprecisionTrend toward equal and even stressMedical diagnosisProgressive supranuclear palsy (PSP)

Speech first abnormality in 35% of cases

Note her hands appear normal as is her gait

Often mistaken for Parkinsons disease

Typical dysarthriaHypokineticAtaxicSpastic

This lady has spasticTight dysphoniaSlownessHypernasality not so severeOften called pseudobulbar

TreatmentThe best treatment we have is skill treatment

To increase differentiation of voiced and voiceless

To improve rate

To normalize stressProgram will be featured at appropriate timeExampleReported gradual onset

Speech difficulty

Which she called difficulty pronouncing words

And once she called it stuttering

Denied any cognitive or linguistic difficulties and mostly she is right

No postural, gait or upper extremity deficits

Patient twoSo what do you hear?

What does she have?

What would you do?HearSlowEffortfulSyllabificationMild articulatory errorsTrend toward equal and even stressDxPrimary progressive apraxia of speechTxSkill training at sentence levelNeuroprotectionEvolutionDecline can occur over many years

Nearly inevitably pts become mute

Condition evolves intoPNFA Corticobasal degenerationProgressive supranuclear palsyAmyotrophic lateral sclerosisLeading to what some call progressive anarthria

DementiaPathophysiologyDysarthria in all conditions caused by one or combination of WeaknessReduced endurance or easy fatiguabilityHypotonicityHypertonicityAbnormal rateDyscoordinationAdventitious movements such as tremorApraxiaAphasia

Treatment: weaknessStrengthening txs at relatively high resistances and relatively low frequencies per session but multiple sessions per week for weeks to monthsUsually with some maintenance dose when active treatment endsEndurance building txs which can be same as strengthening but lower resistance and more reps

Treatment: abnormal toneSkill training appears to be the most appropriate tx for hypertonicity

Begin with increased background of effort for hypotonicityAs can be accomplished with Lee Silverman Voice Therapy and any other maximum performance treatmentPlus skill training

Treatment: rateWhether too fast, too slow or too variable

Skill building treatments would seem to be the best

Skill training is target practice or any attempt to improve the accuracy and adequacy of motor performanceExampleWhat do you hear?

What do you think the disease might be

What would you do

DyscoordinationDisruption of the timing of movements of the various structures critical to speech

Most likely in Basal Ganglia and cerebellar diseases and in AoS after cortical lesion

Skill building is best treatment approachDyscoordinationWhat do you hear?

What do you think the condition might be

What would you do about it

Adventitious movementsIn this case refers to regular or erratic movements of the speaking structures caused byChorea as in HuntingtonsDystonia as in Meige syndromeMyoclonus (as in palatal myoclonus)Tics as in TouretteTremor as in PDDyskinesia as in Tardive Dyskinesia

One typeWhat do you hear?

What might the medical condition be

What do we do?

Treatment: adventitious movementsCompensations most likely

No evidence we can change adventitious movements with behavioral txs

But some rehab techniques are emerging and will be discussed at end of dayApraxiaTreatment is skill training such as an expanded program of Sound Production TherapyTo be completely describedTreatment: other pathophysiologySome like depression and apathy usually require

MedsPsychiatry/psychology

like poor attention can be managed behaviorallyNext stepSelect the tx approach(es) that fit the underlying pathophysiology you know or suspect

And the locus of these abnormalities across the speech structures

And their posited influence on speech

Functional componentsLips

Jaw

Tongue tip and back

Soft palate

Larynx

For exampleWeakness in respiratory musclesLeads to inadequate loudness and often short phrasesThe treatment is respiratory muscle strengtheningWho knows how to do that?Followed by skill training

So, question for youWhich of the treatments you use (or have heard about)results in making patient stronger

Which increase background of effort

Which increase skill

This is a discussion of active ingredientsInterestingly little discussion of this in the speech literatureMore or less traditionally assume that methods are forStrengthening And perhaps endurance trainingAnd for improving skill (target practice)And the other category is compensation

Why care?Whyte (2006. J Head Trauma Rehab) says clinicians should pay careful attention to determining a txs active ingredientsOne benefit is that knowing it (or them) would allow the clinician to Better match tx and patientSelect the best outcomesImprove prediction of duration of tx and durability of changesFor exampleIf a patients speech abnormality is not related to weakness then it is a waste of time to use strengthening treatments

Also a waste if weakness is present but not severe enough to influence speech (which is most of the time by the way)So how to classify our treatments for motor speech disorders?As noted, treatments can be divided into Compensation and rehabilitationRehabilitative ones changeSTRENGTH/ENDURANCE

SKILL

COMBINATIONAppropriateness of compensationsWhen rehab is impossibleWhen it will be protractedWhen patient requestsThe newest compensations-nasal olives-will be discussed at length in next sectionOther compensations: Posture and stabilizationSlow speech

Regardless of technique or type of deficitMotor speech therapy must be cognitive motor therapy to be maximally effectiveMUST start here

Lansford et al (2011). A cognitive-perceptual approach to conceptualizing speech intelligibility and remediation practice in hypokinetic dysarthria. Parkinsons Disease, doi 10:4061/2011/150962

Six parts the way we do it-THIS IS HOW ALL TREATMENT STARTSWhy important ?Anyone here not heard a patient or family member say He talks really good when he remembers ?Or, He talks really good in therapy but not at home?

Learning what to do is usually relatively easy

Remembering to do it is godawful hardThusWe ought to spend more time in therapy helping a patient remember

Rather than-as we do now-teaching them what to do

1. Flip the switchFlipping the switch means engaging volitional-purposive control

Tx follows a rough shape

Teach, flip the switchEmphasis on planning every utterance prior to production-extremely challengingMany pts hate this and acceptance requires counselingAnd promise that with luck they will not have to do it for all timeWe tell them what we call it and they can use that or some other nameBut pt MUST agree to flipOtherwise they are at mercy of phonetics and spontaneous recovery

Procedure continuedWe try to be creative in helping pt identify a cue to prompt the planning (flipping)Such as a slight shift in postureOr quick inhalationOr gestureThen practice, practice, practiceOn patient generated responses as opposed to imitation whenever possible

2. Listen and evaluate flipping the switch and response adequacyMust attend to evidence switch was flipped and Pt must come to be best judge of speech adequacy-loudness, rate, precision, etcPt and cl agree on a scale of adequacyThree points which pts usually immediately turn into 5 (1.5 2.5)Anchors : 1= the speech they came to you with and 3=the best possible speech

We drag out one of these1 2 3 4 5Old speechBest possibleBest possibleNextGet as complete a view of what pt requires to assign the higher scoresMay have to negotiate this if pt only accepts normalIf at all possible elicit a functional response from ptFirst warning them that they will be responsible for assigning a scale scoreThen the pt followed by the clinician evaluate the responseDifferences are resolvedRepeatContinue resolving differencesA bit of slop in the scale is unavoidable

Scaling rateHere is an example done by students-their first time

Thus there are multiple ways to improve what they did

We will discuss thoseGo to the audio: ataxia liver transplant1 & 2. Flip and judgeWe use these with all patientsAt some time-usually as early as possible-in the therapyThese are among the critical conceptual or cognitive parts of treatmentThey take time but it is time well spent in our opinionThen there are at least four more cognitive manipulations in much of our treatment3. Preparing patient to judge effortThis is the effort the pt feels is being invested in talking therapeuticallyCl and pt work out a 3, 5 or 7 point scale of effortPts reject treatments even ones that improve intelligibility and naturalness if they perceive them as requiring too much effort (5,6,7)Can write effort reduction goal

Effort continuedWe try to move folks at least two effort pointsWe have a rough notion that effort that stays in range of 5-7 is harmful to carry overEffort in the 1-3 range is betterEffort seems to be mostly concentration for our folksWe score effort only once per session usuallyWe have them score themselves outside clinic as well4. Speak therapeuticallyPatients must be willing to speak therapeuticallyFor us a major component of that is keeping speech in a boxThat means doing all the planning and evaluatingAnd avoiding long utterances without controlDont tell me the whole story tell me one thing

The issueThe best treatment for speaking is not speaking

The best treatment for speaking is speaking therapeuticallyOne critical componentIt seems important as well that there be a balance in expectations early on in txA balance between what the pt wants from therapyWhat the clinician thinks is possibleIf there is a gap then that gap must be resolvedOr treatment is likely to failClexpectPtwantsTO AVOID FAILURENeed to work towardClexpectPt wantsorClexpectPt wants5. Remember your brain is plasticWe speak about getting your brain to substitute for the damaged nervous system part(s)Example of ataxia secondary to cerebellar damage

In other words we use plasticity language

How worded depends, of course, on ability and understanding of each patientSo what is this?

Bit of treatmentStatus post MVA without LOC

Post

So what do you conclude?

One session of tx

Three weeks or so later she sounded as you hear6. Adding cognitive-linguistic loadWe begin with as much cognitive-linguistic load as person can manageAnd then add as much as we can as fast as we canImitation is of limited usefulness although it may be important for a few repetitions early in treatmentMeans Manipulating complexity of answers required by QHaving pt select what to practiceMeans introducing competition into the sessionHave person do an entirely different activity and then switch back to the Q-ALOADRequiring longer responsesAnd series of responses for example in the telling of a storyAnd requiring pt to evaluate several answers at one time rather than evaluating after eachAnd bringing in other communication partnersAnd making it a group activityAnd trying to duplicate this arrangement in the pts environmentAdmittedlyThis is a lotAnd we may not require all of this and in fact dont in the beginningMay introduce rules as treatment moves alongHOWEVER if a patient is not finally able to do all these things improvement will beLimited andContingent mostly on environmental cueingPutting it all togetherThis is a program of my design using bits and pieces of numerous individual programsA program that can be made to work with the most severe to the mildest, regardless of speech diagnosisAnd the clinician can enter the program anywhere dependingBegins (cause has to begin somewhere) with an emphasis on articulatory competenceIn any motor speech disorder characterized by articulatory errors including omissions, distortions, substitutions and distorted substitutionsAll the dysarthrias and apraxia of speechBut expands to treat all of speech

Putting it all togetherAnd can easily be shaped to work on all aspects of prosodyIncluding rate and abnormal pitch and stressAgain without regard for speech diagnosisAnd respiratory mechanism, larynx and palate

That has independent functional speech as its goalIt is a false assumption that hard work under tightly controlled clinical conditions produces treatments that generalizeGeneralization steps MUST be built in

Heart is Sound Production TherapySPT was originally developed for AoS using minimal pairsData are strongest in apraxiaindividuals with apraxia of speech can be expected to make improvements in speech production a a result of treatment, even when apraxia of speech is chronicWambaugh et al (2006a). Treatment guidelines.JMS-LP, 14, xv-xxxiiiSee also: Wambaugh et al (2006b). Treatment guidelines for acquired apraxia of speech. JMS-LP, 14, xxxv-Lxvii Unfortunately no data for PPAoS

SPTFive step program, from less to more cueingDepends on minimal contrast pairs in wordsFor example, p vs b (voicing)-where they startedOne sound is (usually) the target-usually voicelessFifteen treatment sessions: and we and they recognize the challenges here

Wambaugh et al (1998) Effects of treatment for sound errors in apraxia of speech. JSLHR, 41, 725-743

60ComponentsModeling RepetitionMinimal pair contrastsIntegral stimulationArticulatory placement cueingFeedbackTo prepare for itClinician needs to understand the articulatory errors in each patients speech

Lets listen to two patients with different speech diagnosesSo here is patient for us to treatListen to connected speechvery severeand later

All you need to hear to be able to begin fashioning treatment

What would you work on?

He tries to say MadisonAnd anotherCan be adapted for a variety of other neuropathologies

Starting with those having increased tone usually called spasticity

A cardinal feature of such patients is that they have difficulty turning the larynx offSame as in apraxia

Thus voice for voiceless substitutions and common

The contrast then is between voiced and voiceless sounds

To demonstrate will start with a severe, obvious case

Which adds to the relevance of discussing program basics first

ErrorsTotal distortion

Voicing is pervasive

Plosion is alsoSound production treatment (SPT)The Pittsburgh group has structured a number of traditional steps into a useful partial approachStimulus selection is key to making it broadly useful Fricative vs plosive voice vs voicelessProgram has been subjected to experimental scrutiny in a series of single case studies with replicationThe first minimal pair they treated was /p/ and /b/But clinicians can use anything they want

Step one: modeling imitationClinician produces both in pair and pt says bothIf error, then each one of pair presented and produced separatelyIf both correct, repeat and on to next pairProvide knowledge of results (good, okay, etc)Already seeing need for change, right?If not correct, step is repeatedIf still not, go to next step67Hardest stepIs imitation

Thus you can see this is a rigidly controlled program

Allows patients no anonymity

Attempts to keep error rates lowThe problem is that the brain learns more from errors than from correct responsesStep two: modeling +Cl shows printed (known for generations that apraxic talkers especially are likely to profit from visual-in this case reading-input) versions of the targetSay this is the sound you are working onThen repeat step oneIf BOTH okay go on to next pairIf not, go to next step69Step three: Integral stimulationIf only target is wrong earlier or if both are then only target (or both) is subjected to integral stimulationWatch me, listen and say what I sayRbt Milisen from the 30sIf correct try to get two to four more repetitionsIf correct go on to next pairIf target (or other sound in my version) is incorrect go to next step70Step four: modeling with junctureCl produces the target using silent juncture after the target and before the rest of word

If correct, go to next pair

If not, go to next stepP.it71Step five: articulatory placementCl provides verbal description of sound and produces it in isolationTo make a /p/ put lips together, build up a bit of air, then puff the air out by quickly opening lips

Correct or incorrect Cl go on to next pair

Or as a permutation, simplify the contextAlthough as designed the program used words72StimuliUsually use 8 to 10 stimuli (for ex: pit-bit, par-bar, pan-ban, pot-bought, etcIn substitutions use sound that most frequently substitutes for the targetTry to work at word or phrase levelTry to use all stimuli in each sessionTry to get through all at least 4 to 8 times per sessionThe dataTrained and untrained items improvedGeneralization was limitedAs was maintenance or stability over timeSubjects had aphasia and apraxiaA PROBLEM IS OVERGENERALIZATION OF THE SOUND TREATEDSo if treating /p/ it began to appear for /b/Over generalizationA huge problemBut worse in AoS than in any other motor speech disorderPossible answers:Treat more than one sound pair at a timeTreat different manners such as fricatives and plosivesUse at least quasi-random presentation of stimuli so pt has to change set

CommentaryThis program uses all the traditional approaches

It is the time honored task continuum

The study itself is controlled in the traditional ways with generalization probes, baseline line and maintenance probes76Value of this reportCan do the treatment based on it

Some of our very best data

And it is a spring board for further creative treatment development ProblemsIn addition to overgeneralization of treated stimuliHave too little generalization across time-in other words has less than satisfying maintenance of effectsThey have gone to work on the issueWambaugh & Nessler (2004). Modifications of SPTAphasiology, 18, 407-42778Revised SPTWambaugh & Mauszycki (2010). Sound production treatment with severe apraxia of speech. Aphasiology, 24 (6-8), 814-825This article on treatment of one severe pt contains a revised form of the protocol in response to some issuesWho by the way had a recurring utterance that was pieces of the one phrase-I want water-that had been her practice item in earlier therapyModified protocolUsed minimal pairs and actually multiple stimuliSet 1 w vs b, s, lSet 2 w vs m, d, fSo you can see that manner, voicing and place are all manipulatedW was because that was sound that pt produced nearly inevitablyMore contrasts absolutely criticalAlso less frequent feedback-also criticalIt worked in the clinic testingHoweverWe have some apraxic persons (and some dysarthric) so severe that they cannot work on words and sometimes not even soundsBTW must guarantee that such patients are not more severely aphasic than apraxicThus lets extend the program at the bottomSPT So lets expandFor severe, single sound and maybe evennonverbal movementsIf single soundsCATE would say that it is more efficient to choose difficult, less stimulable-complxity account of therapeutic efficacySo /sh/ rather than /s/ for exampleBecause one gets greater generalizationDepends on the amount of co-existing difficultyThe purer the apraxia, for example the more likely CATE is to be a good ideaBut move the single sound into a word ASAPAnd only work on one if doing more is too hardWill demonstrate a pt in a momentOral nonverbal movementsStudents are taught they are critical to speaking-NO

Neural circuitry controlling such movements are different from speaking

Maas and colleagues predict that generalization to speech is unlikelyMaas et al (2008). Principles of motor learning in treatment of motor speech disorders. AJSLP, 17, 277-298

Rules on oral non-verbal movementsThey should generally be a last resort tx targetThose you choose should resemble real speech actsClark (2003). Neuromuscular treatments for speech and swallowing: A tutorial. AJ S-LP, 12, 400-415

Generalization will not occur unless you structure treatment to specifically cause generalizationContrastToo muchJust right

sometimesClinician needs to be even more basic

To prepare a persons body to talkSPTSo lets expandsingle sounds/nonverbal movementsProsthesesProsthesesPalatal liftNasal insertBite blockMaxillary reconfigurationAbdominal binder

ExamplePerson with MS needing a belly binder

AnotherPerson with stroke needing laryngeal manipulation

AnotherPerson with stroke needing a palatal lift or other palatal management

New device using Passey-Muir valves

Here is an exampleGoing to leave presentation so I can manipulate the samples if need be

PolkeSPT with multiple stimuli (words) usingImitationVisual, writtenPhonetic placementExpand moreFor severe single Sound and maybe evenNonverbal movementsProsthesesPosturePostureGeneralBest is normal sittingAlthough prone is sometimes good if respiration reducedStabilized, especially in adventitious movementsHeadLevelJaw up (mouth closed)Stabilized, especially in adventitious movements

ExamplePerson with multiple system atrophy (a form of parkinsonism)Needing increased background of effort

Consider this ptKS DVD

What is going on with her?

What would you do?SIMPLEGet person is best upright posture

Provide instruction and respiratory support

By pressing respiratory muscles with hands

Have pt say low cognitive-linguistic load utterance such as counting

Experiment with varying pressures on inhalation and exhalation

Have pt provide the respiratory support

SPT with multiple stimuli (words) usingImitationVisual, writtenPhonetic placementExpand moreFor severe single Sound and maybe evenNonverbal movementsProsthesesPostureCompensationsCompensationsSensory tricks in dystonia

Amplifiers

AAC

Here is a dramatic exampleWhat does he remind you of?

What does his compensation do?

Go to GS DVDSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsProgram easy to expandCan create a kind of procedure drop down menuFor now we will stay with single words as stimuliTo demonstrate will assume using /p/ /b/ /s/ and /t/And have created a list: pie, by, sigh, tie; pick bic, sick, tick; pack, back, sack, tack; poor, bore, sore, toreThe menuLay out all in written form and tell pt to choose one say it and I (clinician) will report what is heardPatient says a self-selected word from those worked on or another word with the target (no visual stimuli) and asks clinician to say it backI love these tasksOften speech is better here than in other tasks (even some easier ones)Or use same stimulus and multiple different responses-give me one of the words, now another, now anotherOr introduce competition-have pt make a gesture between each utteranceTurn on recorded noise during practice MoreClinician spells and has pt say what was spelled

Clinician defines a word and patient says

Clinician asks for a rhyming word

SoThats eight additional stepsI am sure you could add others

I have no idea if these can be rank ordered for difficulty

Probably doesnt matter

Whats important isThey use principles of skill buildingThey provide variety which is badly needed in speech rehabThey make treatment cognitiveAnd some give pt more autonomyPurpose of theseAll may enhance generalization

They may slow acquisition

So you have to decide what your goal isGood performance in clinicGood performance outsideTechniques that give one seldom give the otherPt has AoSWorking on words

Using CATE

/s//t//st/

Using visual cause it helps him as it does most with AoS unless they have too much aphasiasIsaiah DVD txSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesSentence stuffUse some of the previous words (if tx began with words)

With apologies: I got pie on my tie and so on

Or if patient is mild-moderate may be able to use almost any sentencesWhich we do in our neuroprotective programs

Can even use imitation-diagnostically- to be sure pt has the motor ability under controlled conditions to handle what you (or they) have createdExpanding sentencesCan use many of the permutations already discussed for wordsTell me the sentence that tells me something about your tieGive me another sentence with the same key word; now give me another sentence; anotherSay any sentence and Ill tell you what I heardThis is actually an easier step with sentences than with single wordsBTW the best step here would be for the pt to create the sentencesHere now can realistically work on rate and other aspects of prosody as wellSay it fasterSay it with stress on ________An examplePt has an apraxia plus he did not receive any therapy for months

Using CATE-specifically /j/, the hardest sound on average for persons with apraxia of speech

Work on words (and risk overgeneralization) cause I use same sound for awhile

Then use the hardest contrast

Move around from word to sentence and backGo to audio again so can manipulate as time permits

Begins with single words written and my pointing to them-no imitation unless necessary

First word is yesSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSHere is an exampleThis lady has multiple medical problems

And a complex dysarthria with ataxic features dominating

This is an early session

I give her my standard set of admonitions

Fricatives are difficult as is control of all aspects of prosody

Thus goal will be to work on both simultaneouslyAtaxia liver strokeContrastive stress drillWay to approximate communication

Contrastive stress drill is a Q-A drill

Could be used even with single words

Idea is for cl to ask a variety of Qs about components of sentences already worked on in other ways

For exampleStimulus: I got pie on my tie

Drill Cl: Did you get tooth paste on your tie?Pt: No, I got PIE on my tieCl: Did you get pie on your shoe?Pt: No, I got pie on my TIEAnd so onCerebellar degenerationContrastive stress drill

Goal is less on specific points of articulation

More on prosody

Especially on rate and rhythm

Other forms of cognitive-linguistic loadAs evidence that many methods are totally ignorant of what we think they are good forContrastive stress drillPACE: Promoting Aphasic Communicative EffectivenessStimuli are put on cards and placed between cl and ptTake turns selecting one and saying it without showing to other personScripts:Create two or more sentences to tell a more complex storyI will not embarrass all of us with an example

SPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSGROUPS

Communication PartnersGroupsInserted at end in this presentation but can actually be used from the beginning

Limited data but consistent with expectationsChanging the environment: groupsSullivan et al. Brookes, 1996.Used all traditional methods such as rate and stress manipulationBut all practice in groups of 6 P.D. pts and spousesEight sessions in one monthAll practicing done in functional context122Results of Sullivan et alFive of six changed speech perceptually

Gains maintained at 10 months

Hardest to maintain was rate adjustmentWhich means-at a minimum-many more repetitions

For survey of rate manipulations seeBlanchet & Snyder. (2010). Speech rate treatments: A tutorial. Percep Motor Skills, 110 (3), 965-982123Communication partnersDeveloped for aphasia but can also work in dysarthria

Hunter et al (1991). The use of strategies to increase speech intelligibility in CP. BJDC, 26, 163-174Communication PartnersBring other people into the clinic suite

The principle is that a learned response is most likely recovered in an environment that resembles the one in which it was learned

No wonder families say, He talks so much better to you than to me.

Bit more on methodNo need to go far here as this is the birthplace of the ideaBut to be clearThis is not bringing others in for education in a traditional senseThis is a method for making others skilled, facilitating communicatorsFor examplePartner trainingHunter et al (1991). BJDC, 26, 163-174Excellent modern version of this is byBorrie et al (2012). Perceptual learning of dysarthric speech: a review of experimental studies. JSLHR, 55, 290-305The data based lessonsListeners can be taught to understand and this is a critical part of treatmentClinicians learn as well and that may contaminate their view of how much better the pt isSo what have we done?Taken the original five-step AoS program and made it a menuBest of all perhaps is having added more functional stepsAnd these functional steps serve to move this from a focal (articulation) therapy to a more general therapyThat can be used to modify not only articulation but also prosody including rateSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSGROUPS

Communication PartnersMove to more functionalBut what about apps and DAFThey are not treatments

They are adjuncts

They can be fit into the frameworkSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSGROUPS

Communication PartnersMove to more functionalDAFAmplifierEtcHere is one exWhat does it do to naturalness of speech

Data on rate reduction from Yorkston et al 1990

Intelligibility systematically improved for both groups-ataxic and hypokinetic

Greatest at 60% of habitual

Some subjects could not tolerate or achieve the 60%

Finding the right percent of habitual is worthwhile

Rate manipulation can be a powerful tool for a general approach to dysarthria treatment

Dont neglect the simplest stuffSix or so studies of simple directions to encourage some form of try to speak more carefully have been publishedYorkston (1996). JSHR, 39, 546-557Building improved speech from basic background of effortAnd a bit of prosthetic bracing of respiratory system can also be good startsTransitionLets move from this discussion of skill training to methods that seem to combine elements of skill and strengthening

And can form a foundation upon which the skill training can be imposed

Thus may begin with the two types of therapy to be describedMaximum performance trainingStrengtheningSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSGROUPS

Communication PartnersDAFAmplifierEtcMaximum performanceStrengthening

LSVTAll permutations of this program require certificationIn the interest of fidelity to the protocolsThus I cannot teach itAs probably all of you know the emphasis is on maximum performance at least initiallyAnd it is most studied for effects

Maximum performance training:our view

May influence both skill (learning to use enhanced effort) and endurance

The idea is simple: have pt perform quality maximum performance tasks

And learn to transfer that effort to speaking

An absolute minimum of 25 per day, five and preferably six days per week StepsGet pt in best posture-usually sitting uprightHave pt increase background of effort-valsalvaHave pt get to best size-appropriate inhalationCheck or hold that inhalation so air does not escape in a rushThen start maximum duration of vowelWith attention to consistent airflow, loudness and qualityRepeat enough so that you get a sense of duration person can achieve with control

Steps, contCue pt to the sound and feel of this maximum performance modeCarefully monitor for laryngeal hyperfunction, pain, dizziness, other discomfortHave pt get a timerURGE maximum, consistent performanceWork as hard as you need to to transfer the same intensity and effort to speech using short sentences heavy on plosives

Further stepsSome of the steps or procedures listed in SPT can now be introducedIf the patient can identify appropriate loudness and if effort is not 5, 6, 7 then adding to the cognitive linguistic load is nextWithout these steps generalization is unlikely BonusIt appears that LSVT and other maximum performance training influences more than just the larynx

Even some evidence from LSVT that lingual strength improvesHow is that possible?

Moving onMore or less pure muscle strengthening

But by self unlikely in majority of patients to have functional consequencesSPTSo lets expandSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSGROUPS

Communication PartnersDAFAmplifierEtcMaximum performanceStrengtheningStrengtheningHave some for respirationEmphasis here cause of dataAlthough in swallowing

For the tongue

For the velopharynx

And perhaps, depending on what you believe, for pharynx

Methods for respiration areExpiratory muscle strength trainers (EMST)With main effect on respiratory muscles other than diaphragmInspiratory muscle strength trainers (IMST)With main effect for diaphragm Warning: no data based guidelines on which to use but will describe ours after description of methods

CandidacyThose with respiratory system weakness or reduced enduranceCan potentially be just about anyone with a neurodegenerative diseaseSo long as they are not profoundly weak

Those with respiratory system rigidityPD, MSA are prime examples

Perhaps even those with hypertonicityPotentially any of the parkinson plus syndromes such as progressive supranuclear palsy (PSP)Strengthening those with hypertonicity does not increase tone

RelevanceRespiration provides critical air pressure and flow for speechReduced respiratory drive can influence all other components of the speaking mechanismRespiration is coordinated with swallowing and respiratory deficit can influence swallowing efficiency and safetySome superficially oropharyngeal abnormalities may be secondary to inadequate apneic period as but one example

EMSTPt blows into a device fitted with a one-way spring-loaded, pressure release valveAmount of pressure can be controlled Increasing the pressure to open valve can increase respiratory drive Training based on 70%-80% of maximum expiratory pressure (MEP)Or on clinical judgment

EMSTThis device calibrated from approximately 5 to 140 cc of H2OSo covers most of the range of normal pressuresCost 60.00 or so plus shippingCan order fromwww.aspireproducts.org

Another view

This is a good diagram of the device

At left end (in this view) is the cap that can be tightened or loosened to influence pressureTraining loadCan measure maximum inspiratory and expiratory pressures and train at 70-80% of maxUsing a spirometerOr can set clinically-judge the work or effortRemember the principle of overloadMuscles to strengthen must work harder than they work ordinarily

Basic treatment guidelineEMST set at 75% of MEP (or clinically)Nose clip and cheek/lip press-CRITICAL25 trials per day in five groups of fiveI prefer more reps in two groupsFive sessions per day is burdensomeFive days per weekI prefer 6Five weeks and I prefer 3 months or even longer

Cheek lip press

Critical to maximize flow thru mouthMinimize through noseEnhance lip sealPt can do or caregiver may have to

Reality of treatmentAny pt with cognitive decline may have trouble learning the stepsTake deep inhalationPlace device in mouthPress cheeks and lipsBlow hard and quickQuit when you hear (or feel) that pressure valve has openedDistinguishing from flow around device takes practiceREMARKABLY HARD FOR BOTH CLINICIAN AND PATIENT TO LEARN

Especially early in clinicians use and for patient with cognitive decline or multiplesystem involvementThusOften need our whole bag of behavioral tricksWe have been training MSA and PSPNearly inevitably have to begin them with just blowing and then blowing harderThen introduce the device but at no resistanceThen hold cheeks for them (or get caregiver to)And then help mold their holding of device and of their cheeksMethod continuedAdd just the smallest amount of resistance (approx 5 cc of water pressure equivalent)And then repeat, repeat, repeat Hone them in on the sound of quick airflow that signals the valve has been brokenEducate caregiver as wellTHE CHEEK/LIP SEAL IS CRITICALSometimes takes several sessions merely to learn how to use device

AimOriginally designed to improve strength of respiratory mechanismWith thought that stronger system would be able to support sufficiently long apneic periodAnd better, especially louder speech

And perhaps produce a respiratory system better able to support and coordinate with the other parts of swallow and speech mechanisms

The literatureBest article is Kim, Sapienza. (2005). JRRD, 42, 211-224Best book is Sapienza & Troche. (2012). Respiratory Muscle Strength Training. Plural PublishingStrict schedule worked out25 repetitions per day in 5 groups of 5At 70%-75% of maximum expiratory pressureHome practice 5 out of every 7 daysWeekly visits for 4 weeks (minimum) to reset device if strength improvingCan train for longer or shorterWill likely need to combine with other txs

Summary of usesSo far used to treat speech and swallowing in PD, MSA, stroke, Lance-Adams, some inherited ataxic disorders, COPD, MS, Pompe, ALS, ventilator dependent (usually inhalatory)Results are tentative with all groupsStrongest with PDAppears that hypophonia can be reduced-but not without accompanying skill trainingIntelligibility improvedAirway invasion reducedCough strengthenedBUT NOT IN EVERYONECough in PDPitts et al (2009) Utilizing voluntary cough to predict penetration and aspirationChest, 135, 1301-1308Two findings Voluntary cough predicts penetrating and aspirating PD ptsVoluntary cough competence is improved by EMST at the previously discussed frequency and duration

Masked faciesData showing that computerized images of facial expression reflect improvement in masked faceIn mild and moderate patients with PDWith caregivers and patients reporting improved communicationIMST usedUnpublished data by Bowers (2013)

Our program: once again75% of maximum expiratory effort25 reps divided among at least two sessionsSix days per weekFor 4 to 12 weeks, OR LONGER, depending on responseVisit clinic once per week for adjustment and drillContraindicationsUntreated cardiac abnormalities

Untreated HTN

Till MD approves post surgery anywhere in body

RECALL: this is real exerciseWhat is happeningSLPs are hearing about thisTrying it sometimes even unsuccessfully on themselvesAre unsuccessful and reject the methodOr try unguided with a patient, fail, and reject the methodOr they try it without transfer techniques and person gets stronger but nothing else changes

IMST DEVICEThis device is calibrated for 0 to 40 cm of H2oSo good for very weakOrder from:WWW.RESPIRONICS.COMUse of IMTNotion is to get quick, smooth, deep inhalation using diaphragmFollowed by long controlled exhalationThese two actions roughly parallel speech breathing especially by some treated dysarthric speakersNeed to inhibit exaggerated shoulder raising and other maladaptive responsesUse nose plugSystematically increase resistance based on pt performanceUse of IMTNotion is to get quick strong, inhalation using diaphragmFollowed by long controlled exhalationThese two actions roughly parallel speech breathing especially by some treated dysarthric speakersNeed to inhibit exaggerated shoulder raising and other maladaptive responsesUse nose plugSystematically increase resistance based on pt performance or maximum inspiratory pressure measurement or clinicallyWhen to useIMST when diaphragm is focally or more weakened than other respiratory muscles

As can happen in phrenic nerve damageNot so likely in the neurodegenerative diseases

May come to point when both are used

And some are beginning to argue for the primacy of IMST because of the importance of sufficient inhalationThe main idea for both I and EThe treatment data in PD are positive

The data and protocol can be used as a guide for interventions with patients having similar control abnormalitiesRigidity orWeakness orReduced neural drive generally

RecommendationEMST and IMST are not cure-allsOften will have to be joined by one or more skill treatments

But are powerful new tools

Including for reduced cough, a common sign in a variety of neurodegenerative diseases

Because of Neurology publication going to spread into clinics rapidly

Clinician training can be accomplished in one daySPTThe programSound nonverbalSingle word with refinementsProsthesesPostureCompensationsSentencesContrastive stressPACESCRIPTSGROUPS

Communication PartnersDAFAmplifierEtcMaximum performanceStrengtheningSummaryTreatment must be cognitive

I outlined the treatment options

In hopes of giving us something to do for the full range of persons from most to least severe

Qs

Thank you very much