treatment of dysarthria, 7390 - asha · 2009-10-20 · 4 treatment of dysarthria: evidence-based...

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Treatment of Dysarthria: Evidence-Based Practice

Contents

Treatment of Dysarthria: Support by Evidence-Based Research and Expert Opinion .........................................3

Evidence for the Treatment of Respiratory/Phonatory Dysfunction From Dysarthria .................................................. 5

Managing Speaking Rate in Dysarthria ....................................................................................................................... 19

Nonspeech Oral Motor Treatment Approaches for Dysarthria: Perspectives on a Controversial Clinical Practice ... 25

Augmentative and Alternative Communication Intervention in Neurogenic Disorders With Acquired Dysarthria ..... 33

Please note: ASHA CEUs may not be earned more than once for the same program. If you completed thisproduct when it was initially published in the Division newsletter, you are not eligible to take it again. Call the

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Note: Edythe A. Strand was issue editor for Division 2 at the time the content of this self-study was first published inNeurophysiology and Neurogenic Speech and Language Disorders. For current information on ASHA’s special interest divisions, visitthe division pages on the ASHA Web site (http://www.asha.org/about/membership-certification/divs/) or call the ASHAAction Center at 1-800-498-2071.

Edythe A. Strand, Issue Editor

Treatment of Dysarthria: Support by Evidence-Based Research andExpert Opinion

Kristie Spencer leads off with an overview ofintervention approaches in the area of respiratory/phonatory function. Her article comes from the largerbody of work by the committee to establish PracticeGuidelines for the management of dysarthric speakers.She summarizes the research evidence, as well as expertopinion available, regarding intervention of therespiratory/phonatory deficits that typically occur withdysarthria of different types. She reviews 35intervention articles covering four general categories oftreatment and summarizes expert opinion regardingthese types of intervention. The combination of researchevidence and expert opinion is organized by general“treatment paths” which focus intervention towardimproving respiratory support, respiratory/phonatorycoordination, and/or phonatory function. Kristie’sarticle concludes by noting that evidence-based supportdoes exist for at least two treatment approaches in eachof the three main treatment paths. Her comprehensivediscussion provides the clinician guidance in clinicaldecision making about the management of therespiratory/phonatory deficits in dysarthricindividuals.

The second article by Vicki Hammen focuses onstrategies for rate control. Vicki reviews the differenttypes of rate control discussed in the literature, factorsconsidered in the selection of a specific rate controlmethod, and the impact of rate control on speechproduction. She differentiates the impact of rigid versusrhythmic rate control strategies and provides support

The term dysarthria refers to a group of motorspeech disorders that vary in speech and voicecharacteristics, depending on the neurologicsubsystems involved. Consequently, there are numerousapproaches to the treatment of dysarthria, and these arealso varied and can be organized in a number ofdifferent ways. Some textbooks organize treatment bydysarthria type (McNeill, 1997). Others suggest thinkingin terms of speech subsystem involvement (e.g.,respiratory, articulatory) and staging of disease severity(Yorkston, Beukelman, Strand, & Bell, 1999). Dysarthriatreatment approaches are sometimes organizedaccording to the treatment goal (e.g., rate control orincreased loudness), or by specific method (e.g., AAC,biofeedback).

A comprehensive overview of evidence-basedtreatment in dysarthria is not possible within the formatof the newsletter. Rather, we have chosen specificapproaches from among these different organizationalschemes: (a) treatment of respiratory/phonatory deficits,(b) treatment of rate control, (c) nonspeech oral motortraining, and (d) augmentative and alternativecommunication. The four areas of intervention werechosen because they are frequently the focus oftreatment in dysarthria. We have gathered a number ofexperienced clinician-researchers to discuss theseintervention approaches. They were asked to provide anupdate on the treatment strategies suggested for eachapproach, and summarize the research evidencesupporting the use of each.

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from the research literature for their use. The researchsupport for indirect effects on rate reduction is alsoaddressed. Finally, Vicki utilizes expert opinion todiscuss criteria for selecting a rate control approach.

Megan Hodge offers a comprehensive overview ofthe research support for nonspeech oral motor treatmentapproaches for dysarthria. She begins with a definitionand description of the range of activities (bothnonspeech and speech-like) that are typicallyconsidered to be “oral motor treatment.” Her discussionis especially helpful given that the term oral-motor isused so pervasively and in different ways in the clinicalliterature. Megan discusses reasons for the opposingviews about the effectiveness of these nonspeech oralmotor approaches to the treatment of dysarthria. Shethen provides a comprehensive review of the literatureexamining the effectiveness of these techniques,pointing out that few controlled experimental studieshave been published that examine the application ofthese techniques to either children or adults withdysarthria. Megan also provides a perspective from theoccupational and physical therapy literature, notingthat there has been a shift away from more traditionalneurophysiological therapy approaches to ones basedon task-oriented models. Her article concludes with asuggested list of questions to assist the clinician inclinical decision making regarding the use of nonspeechoral-motor treatment approaches.

The final article, by Pamela Mathy, provides areview of the use of alternative and augmentative (AAC)intervention for individuals with acquired dysarthria.Pamela describes a model for clinical decision-makingthat is based on stages of functioning or diseaseprogression. The model is multidimensional in thatplanning for AAC intervention requires consideration ofspeech, language, cognitive, physical, and visualfunctioning. Low and high technology devices, as wellas those strategies for which no external device isneeded, are reviewed in this article, with examples oftheir use from the literature. Pamela points out,however, that most of the support for the use of AAC forindividuals with dysarthria comes from case studiesand anecdotal clinical evidence. She concludes herarticle by pointing out the need for controlled studiesexamining the efficacy of AAC interventions forindividuals with acquired dysarthria.

One of the goals of this volume of Perspectives hasbeen to bridge current research with clinical practice byproviding articles related to evidence-basedintervention. Providing clinicians with a summary ofsupport for particular treatment approaches as well ascalling for prudence in others may help speechpathologists in clinical decision-making. The group ofarticles in this issue illustrates that, although speech-language pathology is moving in the direction of

evidence-based practice, we still have a way to go. Thereis still limited treatment efficacy evidence for manytreatment approaches commonly used in treatingdysarthric individuals.

The Academy of Neurologic CommunicationDisorders and Sciences (ANCDS) is moving forward inthe development and publication of evidence-basedpractice guidelines for the management ofneurologically based communication disorders. Thiswork began consequent to the 1997 Joint LeadershipConference, which was co-sponsored by Division 2 andANCDS. The initial focus was to establish practiceguidelines for the management of speakers withdysarthria. Please refer to publications completed todate (Golper et al., 2001; Yorkston et al., 2001), as well asthe ANCDS Web site (www.ancds. duq.edu) for updatedtechnical reports.

Edythe Strand is a consultant in the Division of SpeechPathology, Department of Neurology at the Mayo Clinic inRochester, MN. She is also an associate professor in the MayoMedical School.

ReferencesGolper, L. A., Katz, R., Myers, P., Wertz, R., Yorkston, K.,

Beeson, P., Wambaugh, J., Bayles, K., Ken-nedy, M., &Frattali, C. (2001). ANCDS practice guidelines coordinat-ing committee report. Journal of Medical Speech-LanguagePathology, 9 (4), ix-x.

McNeil, M. R. (Ed.). (1997). Clinical management of sensorimotorspeech disorders. New York: Thieme.

Robey, R. R. (2001). Treatment effectiveness, treatment effi-cacy, and clinical trials. ASHA Special Interest Division 2,Neurophysiology and Neurogenic Communication DisordersNewsletter, 11 (1), 6-9.

Yorkston, K. M., Spencer, K. A., Duffy, J. R., Beukelman, D.,Golper, L., Miller, R., Strand, E., & Sullivan, M. (2001).Evidence-based practice guidelines for dysarthria: Man-agement of velopharyngeal function. Journal of MedicalSpeech-Language Pathology, 9 (4), 257-274.

Yorkston, K. M., Beukelman, D., Strand, E., & Bell, K. (1999).Clinical management of motor speech disorders. Boston: Little,Brown & Co.

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Evidence for the Treatment of Respiratory/Phonatory DysfunctionFrom Dysarthria

Kristie A. Spencer and Kathryn M. YorkstonUniversity of Washington, Seattle

Respiratory and phonatory subsystem disruptionis a common manifestation of dysarthria, and canhave a formidable impact on speech production.Treatment of respiratory and phonatory subsystems isoften given priority, because improvements at thislevel are believed to generate improvements in otheraspects of speech as well (Hayden & Square, 1994;Netsell & Daniel, 1979; Ramig, 1992; Rosenbek &LaPointe, 1985; Yorkston, Beukelman, Strand, & Bell,1999). The management of respiratory/phonatorydysfunction, therefore, is often a fundamental elementof the therapeutic process when providing services tospeakers with dysarthria.

The clinical decision-making required whentreating speakers with respiratory/phonatory deficitscan be quite complex, particularly given the oftenconcomitant involvement of the other speechsubsystems and the heterogeneity of speakers withrespiratory/phonatory dysfunction from dysarthria.Guidance for management decisions can be provided,in part, from knowledge of the support available forvarious treatment options. The support for aparticular management technique may come fromresearch evidence or from expert opinion. Evidence-based support from the research literature impliesthat positive outcomes have been reported for aminimum of one intervention study for at least oneperson with dysarthria. Conversely, support fromexpert opinion suggests that while data-basedevidence was not available for that particulartechnique, support was derived from the training orexperience of an expert. These techniques areacknowledged in textbooks or review articles byexperts in the field of speech-language pathology.

The delineation of the types of support forspecific management strategies is not intended todictate or limit the management decisions made byclinicians. Rather, this information is intended tooffer guidance for clinicians and researchers alikewho are interested in the existence and nature ofsupport for management options.

This article emerged from a larger effort by anAcademy of Neurologic Communication Disordersand Sciences committee to establish evidence-basedpractice guidelines for the management of speakerswith dysarthria. It is meant to highlight the researchevidence and expert opinion available for the

behavioral management of respiratory/phonatorydysfunction from dysarthria and is by no means aconclusive set of guidelines for practice. Readers mayrefer to the technical report (http://www.ancds.duq.edu/guidelines.html) or pertinentarticles (Spencer, Yorkston, & Duffy, submitted;Yorkston, Spencer, & Duffy, submitted) for moredetailed and comprehensive information.

Research EvidenceSearches of electronic databases (PsycINFO,

MEDLINE, and CINAHL) and books in the field ofdysarthria and voice disorders yielded 35 studies ofbehavioral intervention for respiratory/phonatorydysfunction in at least one person with dysarthria.Although this intervention research began in 1979,the majority of studies were conducted in the lastdecade. Tables 1 through 5 (on pages 13-16) providegeneral information on each study, including theexperimental design, psychometric adequacy, level ofexperimental control, and types of outcomesmeasured. The psychometric adequacy of each studywas assessed by indicating whether information wasprovided regarding reliability and stability of themeasurement of the outcomes (e.g., inter- or intra-raterreliability). Evidence for experimental control alsowas noted—that is, evidence that the interventionrather than other factors was responsible for thechange. Additionally, the outcome measures of eachstudy were grouped according to levels ofdisablement, specifically, whether the outcomes weremeasured at the level of impairment, activity, orparticipation restrictions (World HealthOrganization, 2001).

Four general categories of treatment focusemerged from the 35 intervention studies. Variousforms of biofeedback were utilized as a primary formof treatment in 10 of the 35 studies. Six studiesreported the use of devices to address respiratory/phonatory impairment (two of these were included inthe biofeedback category as these particular studiesexamined more than one treatment approach). Therewere 16 studies of the Lee Silverman Voice Treatment.Finally, three studies examined the efficacy of grouptherapy (i.e., the use of the same treatment strategieswith two or more clients concurrently) forrespiratory/phonatory impairment. Two studies did

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not conform to these general categories: the Murryand Woodson (1995) investigation of voice treatmentafter Botox injections and the Cerny, Panzarella, andStathopoulos (1997) study of expiratory resistivebreathing. For each treatment category, we will reviewthe primary clinical populations studied, theexperimental designs used, the level ofmethodological rigor, and the dispersion of outcomemeasures based on the World Health Organization’slevels of disablement.

Biofeedback techniques were used in therespiratory/phonatory intervention studies toprovide participants with feedback on the physiologicvariables of intraoral air pressure, chest wallmovements, lung volume, and pitch. Treatments wereimplemented in speakers with flaccid and mixeddysarthrias from traumatic brain injury (TBI; n=4speakers), hypokinetic dysarthria from Parkinson’sdisease (n=39), and spastic, flaccid or mixeddysarthrias from stroke (n=3). Case studies and singlesubject designs were most common (8/10 studies).These designs are consistent with the need to tailorbiofeedback to the physiologic variables that areappropriate for individual speakers. Thepsychometric adequacy was satisfactory for 7/10biofeedback studies, and experimental control wasevident in 9 of 10 studies. Thus, the reported resultsfrom this category can be accepted with a fairly highlevel of confidence. In Figure 1 (on page 6), outcomesfrom biofeedback studies typically were measured atthe level of impairment. Measures of activity andparticipation were less common. Frequently, therelationship between changes at the level of theimpairment and changes in activity/participationwas unclear. In one case, physiologic measureschanged in the desired way, but perceptualassessment suggested unremarkable progress inspeech production (Murdoch, Pitt,Theodoros, & Ward, 1999). Inother cases, measures of activityor participation were notsystematically obtained, so acomparison between changes inimpairment and changes inactivity/participation could notbe made.

Six studies focused on thetherapeutic benefit of devicessuch as delayed auditoryfeedback (DAF), voice amplifiers,and masking devices. Treatmentswere implemented primarily inspeakers with dysarthria fromParkinson’s disease (n=15), aswell as one speaker with

progressive supranuclear palsy and one speaker withbasilar artery stroke. All of these studies were casereports or single subject designs. Psychometricadequacy was established in 5/6 studies. All studiesdemonstrated adequate experimental control bycomparing performance with and without use of thedevice. As shown in Figure 1, outcomes werefrequently measured at the level of impairment, oftenin conjunction with measures at the level of activity,such as speaking rate and speech intelligibility.Communication participation was not studiedsystematically.

The Lee Silverman Voice Treatment (LSVT) wasthe most extensively studied form of respiratory/phonatory intervention. Treatments wereimplemented primarily with speakers withParkinson’s disease (total subjects equal 90+), butalso have been applied to speakers with Parkinson’sPlus syndromes (n=3), multiple sclerosis (n=2), andtraumatic brain injury (n=1). Studies were eithergroup designs (n=9) or case reports (n=7). Outcomemeasures were psychometrically sound in 13/16studies, and experimental control was satisfactory inall studies. It should be noted that among thesestudies, those published later improved upon earliermethodological limitations, such as reporting onlypre- and post-treatment measures without controlgroups. Outcome measures of impairment included abroad range of acoustic variables along withaerodynamic and kinematic measures in somestudies. As shown in Figure 1, outcome evaluationfrequently included activity/participation variables,using both formal measures (e.g., the Sickness ImpactProfile, described by Bergner, Bobitt, Carter, & Gilson,1981) and informal measures (e.g., patient reports ofconfidence during social situations).

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Figure 1. The dispersion of outcome measures based on the World HealthOrganization’s (2001) levels of disablement.

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Three studies addressed group therapy forrespiratory/phonatory dysfunction in dysarthria,and each focused on speakers with Parkin-son’sdisease (n = 38). Interventions included one caseseries, one group design with control participants,and one group design without control participants.The psychometric adequacy and experimental controlof the studies were generally lacking, suggesting amore cautious acceptance of findings from thisresearch category. For the few studies available,outcome measures were fairly evenly distributedbetween measures of impairment and activity/participation.

Combining Evidence-Based ResearchWith Expert Opinion

Our knowledge of treatment for respiratory/phonatory dysfunction from dysarthria stems frommore than research evidence. A wealth of informationalso exists in the opinions of experts in the field ofspeech-language pathology. It is the combination ofresearch evidence and expert opinion that forms thefoundation of our knowledge of treatment forspeakers with respiratory/phonatory dysfunction.One way to conceptualize this corpus of informationis by general treatments paths, specifically, treatmentsto improve (1) respiratory support, (2) respiratory/phonatory coordination and control, and (3)phonatory function. If respiratory/phonatoryfunctioning is impaired, it is apt to stem at least inpart from one (or more) of these three areas. Despitethe natural coupling of the respiratory and phonatorysystems, this theoretical separation encouragesclinicians to approach treatment methodically. Foreach treatment path, information will be summarizedregarding (a) general candidacy issues, (b) theevidence-based support for a particular approach,and (c) expert opinion regarding that treatmentapproach. Techniques lacking support from eitherexperts or the research literature also will be noted.

Improving Respiratory SupportThe term decreased respiratory support is broadly

defined as insufficient breath support for speech.Lack of appropriate breath support would likelymanifest as reduced loudness, short phrases, andreduced pitch and loudness variability. Thisconstellation of signs from weakened respiratorydrive is most often found in persons with flacciddysarthria, but can result from other forms andcombinations of dysarthria. Depending on theabilities, needs, and stimulability of an individualpatient, clinicians may opt to use one or more of thefollowing treatment approaches to address reduced

respiratory support: (a) nonspeech tasks, (b) posturaladjustments, (c) prosthetic assistance, and (d) speechtasks.

Nonspeech Tasks

Generally, intervention focusing on nonspeechactivities is limited to speakers unable to generateadequate subglottal air pressure to supportphonation. Nonspeech tasks are typicallyinappropriate for patients who can perform speechexercises to accomplish the treatment goal (Duffy,1995). The following techniques have evidence-basedsupport from the dysarthria intervention literature forimproving respiratory support:

• Breathing against resistance through a simplewater manometer or blow bottle (Daniel-Whitney, 1989; Hixon, Hawley, & Wilson, 1982;Netsell & Daniel, 1979; Workinger & Netsell,1992), or a resistive mask (Cerny, Panzarella, &Sta-thopoulos, 1997)

• Pushing and pulling techniques (Workinger &Net-sell, 1992)

• Biofeedback of chest wall movement, to helpincrease abdominal movement and overall lungvolume (Thompson-Ward, Murdoch, & Stokes,1997)

There are several nonspeech tasks that are notsubstantiated by dysarthria intervention research, butare instead supported by expert opinion. Some ofthese techniques arise from a similar physiologicrationale for improving respiratory support as theabove methods, and include:

• Maximum inhalation and exhalation tasks(Ramig & Dromey, 1996; Ramig, Pawlas, & Coun-tryman, 1995)

• Controlled exhalation tasks (Brookshire, 1992;Murry & Woodson, 1995; Ramig & Dromey,1996; Ramig, Pawlas, et al., 1995)

• Breathing against resistance through pursedlips (Solo-mon & Charron, 1998)

• Using an air pressure transducer with feedbackfrom an oscilloscope or computer screen

• Sustaining phonation with feedback fromVisipitch or the VU meter on a tape recorder

Techniques lacking empirical or expert supportinclude blowing with items such as balloons, bubbles,feathers; applying pressure or vibration to variousbody parts such as the diaphragm or ribs; applyingice to the diaphragm; and electrical stimulation.

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Postural Adjustments

The nature of the postural adjustments willdepend on many factors, including the degree of thepatient’s inspiratory versus expiratory difficulty, thelevel of the patient’s voluntary motor control, and hisor her concomitant medical/physical difficulties. Atpresent, the efficacy of using postural adjustments tomanage respiratory/phonatory dysfunction is largelyunknown. Postural manipulations have been used asa relatively inconsequential part of larger treatmentprograms with unknown influences on the outcomemeasures (e.g., Murdoch et al., 1999). Generally,guidance for intervention in this area stems primarilyfrom expert opinion only. In sum, patients withsignificant inspiratory problems may perform best inthe upright position, because gravity can assist inlowering the diaphragm into the abdomen uponinspiration (Duffy, 1995). Conversely, individualswith expiratory difficulties may benefit from thesupine position, because gravity and abdominalcontents help to push the diaphragm into the thoraciccavity to assist expiration (Netsell & Rosenbek, 1985).Appropriate positioning for adequate physiologicsupport can be accomplished using adjustable bedsand wheelchairs and chairs with adjustable backs(Yorkston et al., 1999). Limitations of this approachare discussed by Hoit (1995) and Yorkston andcolleagues (1999). The long history of positionmodifications has been motivated, in part, by aneurodevelopmental treatment (NDT) framework(Redstone, 1991). However, reviews of the literature(e.g., Solomon & Charron, 1998) suggest that efficacyof NDT for breathing or speech has not beenestablished.

Prosthetic Assistance

In rare cases, prosthetic devices may be necessaryto supplement expiratory forces during speech.Abdominal trussing, or the process of fixing theabdomen inward relative to rest position, hasgarnered some empirical support for patients withsevere dysarthria (Simpson, Till, & Goff, 1988) andspinal cord injury (Watson & Hixon, 2001). The use ofexpiratory boards or paddles, however, is supportedby expert opinion only (Rosenbek, 1984) and is notsubstantiated by dysarthria intervention research.

Speech Tasks

Improvements in respiratory support are ideallytargeted during actual speech production.

Numerous research studies have reportedimprovement of various aspects of respiratorysupport from biofeedback treatment (McNamara,1983; Murdoch, Pitt, Theodoros, & Ward, 1999; Ramig& Dromey, 1996; Simpson, Till, & Goff, 1988;

Thompson-Ward, Murdoch, & Theodoros, 1997).Various forms of biofeedback can be used to allowpatients to gauge both respiratory force and ability tomaintain consistent subglottal air pressure whilespeaking. Speech stimuli can progress from speech-like tasks, such as repetition of syllables, to utterancesof increasing length. Manipulations of breathingpatterns during speech production also can improverespiratory support, although the suggested methodsare supported by expert opinion only. These methodsinclude practice inhaling more deeply or using moreforce when exhaling during speech (Hammen &Yorkston, 1994; Ramig, 1986; Ramig, Pawlas, et al.,1995), inspiratory checking (Netsell, 1992; Netsell,1995), and abdominal or diaphragmatic breathing(Thompson-Ward et al., 1997).

Respiratory/Phonatory Coordination/Control

The term decreased coordination and control impliesthat the individual has adequate respiratory support,but difficulty with the synchronization of breathingand speaking. Speech signs might include excessloudness variations, inappropriate silences, a harshvoice quality, inappropriate breath patterning,transient breathiness, and voice stoppages. Deviantspeech signs of this nature most often stem from theabnormal, involuntary movements associated withthe hyperkinetic dysarthrias or from the inaccuratetiming and range of movement associated with ataxicdysarthria. It is also quite possible for clients withdiffuse or multifocal brain injury to evidence bothinadequate respiratory support and decreasedcoordination/control. Techniques in this treatmentpath are designed to stabilize respiratory/phonatorypatterns during speech and can be divided intononspeech and speech tasks.

Nonspeech Tasks

The caveat regarding non-speech tasks outlinedin the previous section applies here as well, that is,nonspeech tasks are often inappropriate for patientswho can perform speech exercises. Only one researchstudy exists which supports the use of nonspeechtasks to increase control of respiration: Murdoch andcolleagues (1999) implemented nonspeech tasks aspart of the respiratory treatment for a child withpersistent dysarthria following severe TBI. Supportfrom expert opinion, however, is available for severalnonspeech techniques, which mainly derive from thetreatment of children with cerebral palsy. Theseinclude

1. Practicing an effective breathing pattern (quickinspirations and slow, controlled exhalations),

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2. Using inspiratory checking without speech if it isproblematic for the patient to speak on controlledexhalations (Net-sell, 1992),

3. Facilitating inspiratory coordination/speedthrough sniffing or exhalatory coordinationthrough blowing, and

4. Practice switching between inspiration and expira-tion.

These techniques are not restricted to patientswith dysarthria from cerebral palsy; similar strategieshave been suggested for use with other patientpopulations, such as individuals with spasticdysarthria (Thompson, Murdoch, & Theodoros, 1997)and mixed dysarthria (Murdoch et al., 1999).

Speech Tasks

With the exception of a study by Thompson-Ward and colleagues (1997), the use of speech tasks toimprove respiratory/phonatory coordination andcontrol is supported by expert opinion, rather thanresearch evidence. Thompson-Ward and colleaguesprovided feedback on chest wall movement andphonation to train a speaker with spastic dysarthriato learn to phonate throughout the breath stream.

In general, patients who experience difficultywith respiratory/phonatory coordination or controlmay benefit from improved awareness of the speech-breathing pattern—that is, quick inspiration followedby prolonged exhalation during speech production.Patients may need to modify how much air is inhaledprior to speaking and may need to learn how tocontrol air use during speaking. Instrumentalfeedback from Respitrace and magnetometers, forexample, can be particularly useful for demonstratingthe desired breathing pattern. Speakers also can beinstructed to use “optimal breath groups”(Linebaugh, 1983)—that is, the number of syllablesthat can be produced comfortably on one breath. Oncea baseline is established, the targeted length ofphrases and sentences uttered in a single breathgroup can be gradually increased to encouragerespiratory control. Additionally, inspiratorychecking may prove useful for speakers who releaseexcessive airflow through the larynx when they speak(Netsell, 1995). Finally, Yorkston and colleagues(1999) provided suggestions regarding the training ofrespiratory flexibility, which include practice readingcued and uncued conversational scripts with andwithout a conversational partner.

Reduced Phonatory FunctionReduced phonatory function refers to

hypoadduction or hyper-adduction of the vocal folds.

Hypoadduction often results in breathiness,hoarseness, and reduced loudness and is most oftenassociated with flaccid and hypokinetic dysarthrias.Hyper-adduction typically manifests as harsh/strained vocal quality, slow rate of speech, and lowpitch and is typical of persons with spastic andhyperkinetic dysarthrias. Reduced phonatoryfunction can, and often will, overlap with decreasedrespiratory support or decreased coordination/control. Hyperadduction also may occur as acompensatory mechanism for managing weakness atthe laryngeal or velopharyngeal level. Behavioraltechniques to improve hypoadduction generallyinclude (a) physical strategies to enhance adductionor (b) loudness training via the Lee Silverman VoiceTreatment.

Enhancing AdductionVarious physical strategies can be implemented

to address phonatory impairment from vocal foldhypoadduction. These strategies fall under the broadcategories of effort closure techniques, posturaladjustments, and physical manipulations. As awhole, these treatment strategies are supported byexpert opinion only. Research evidence does exist,however, for intervention using effort closuretechniques for respiratory/phonatory dysfunctionfrom dysarthria (DeAngelis, Mourao, Ferraz, Behlau,Pontes, & Andrade, 1997; Workinger & Netsell, 1992).

Effort closure techniques are exercises thatincrease the adductory forces of the vocal folds bymodifying background of effort. Examples includeclasping hands and squeezing palms together as hardas possible (Aronson, 1990; Dworkin & Meleca, 1997;Yamaguchi et al., 1993) or pushing against a lapboard on a wheelchair (Rosenbek, 1984). Somelimitations associated with these techniques havebeen discussed by Solomon and Charron (1998) andYamaguchi and colleagues (1993).

Postural adjustments also have been cited as abehavioral strategy for treating speakers withhypoadduction (Aronson, 1990; Duffy, 1995; Ramig,1995; Yorkston et al., 1999). The primary strategysuggested for speakers with vocal fold weakness is toturn their head to the left or right during phonation.This postural change may increase the tension of theparetic/paralyzed fold (Ramig, 1995). However, headturning can be considered a pragmaticallyundesirable solution to the hypoadduction and maynot lead to any true improvement in vocal foldadduction (Rosenbek & LaPointe, 1985).

Physical manipulations of the thyroid cartilageoccasionally are used to improve vocal quality andloudness in speakers with hypo-adduction. This

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technique requires the speech-language pathologist togently push on the larynx while the speakerphonates. It has been used to successfully elicitvoicing from two speakers with whispered phonationfollowing TBI (Sapir & Aronson, 1985). However,positive results from laryngeal compression inchronic conditions should prompt consideration ofsurgical treatment options, such as vocal foldrepositioning or medialization (Dworkin & Meleca,1997).

Loudness TrainingThe Lee Silverman Voice Treatment program is an

intensive behavioral treatment developed by Ramig,Pawlas, and Countryman (1995) to improve the oralcommunication of speakers with hypokineticdysarthria. Ramig and colleagues have conducted aseries of studies to demonstrate the efficacy of LSVT,and continue to investigate its use in patients withidiopathic Parkinson’s disease and other neurologicdisorders. The effectiveness of LSVT is well-established in speakers with dysarthria from mild tomoderate Parkinson’s disease. At present, there is lessevidence to support the long-term efficacy of LSVT forspeakers with severe Parkinson’s disease or otherdisorders associated with basal gangliapathophysiology. Research on the use of LSVT withother neurologic disorders, such as multiple sclerosis,TBI, and stroke is promising, but it is premature todraw conclusions regarding efficacy in these clinicalpopulations.

Behavioral techniques to addresshyperadduction of the vocal folds in persons withdysarthria can be grouped as nonspeech techniquesand speech tasks. Behavioral treatment of voicequality often is not undertaken for hyperadduction inspeakers with dysarthria, because it is quite difficultto modify and may result in a negligible improvementof intelligibility (Duffy, 1995). If the dysphonia is feltto contribute to the speaker’s overall disability,traditional voice techniques designed to reducelaryngeal hyperadduction and increase airflowthrough the glottis may be appropriate (Pann-backer,1998).

Nonspeech techniques for improvinghyperadduction generally include relaxationstrategies and biofeedback. To date, no studiesdemonstrating the efficacy of muscle relaxation ormassage are available. Relaxation strategies, such asthe “rag doll” technique (Dworkin & Meleca, 1997) orprogressive whole body relaxation (McClosky, 1977),report inconsistent success for improvinghyperadduction from dysarthria. Several types ofbiofeedback on airflow or laryngeal muscles may be

used to address dysphonia from hyperadduction.Dworkin and Meleca (1997) suggested using VisiPitchto provide biofeedback of nonvocal airflow control.Ramig (1995) suggested electromyographic andvideoendoscopic feedback to provide speakers withinformation on the level of laryngeal muscle tension.There is no research available to support nonspeechbiofeedback treatments for hyperadduction due todysarthria.

Speech tasks for addressing hyperadduction tendto focus on traditional tension-reducing strategiesand biofeedback-enhanced relaxation. Traditionalapproaches to reducing laryngeal tension duringspeech include strategies for easy onset of phonation,such as the “yawn-sigh” or “chanting” techniques(Darley, Aronson, & Brown, 1975; Dworkin & Meleca,1997). Murry and Woodson (1995) conducted effort-reducing voice treatment with a group of speakerswith extrinsic muscle hyperfunction and airflowabnormalities following Botox injection for spasmodicdysphonia. The investigators found that speakerswho received both Botox treatment and behavioraltreatment demonstrated improved phonation in termsof increased airflow rate and acoustic measures.Biofeedback during speech may help speakersmonitor levels of extrinsic laryngeal muscle tension.This feedback can be electromyographic, videoen-doscopic, or aerodynamic. Visual biofeedback of vocalfold vibrations would allow the speaker to practicemodifying phonatory behaviors during vowelexercises. A progressive hierarchy can beimplemented from vowels to syllables, words, andsentences. No studies are available to document theeffectiveness of biofeedback in reducing hyperad-duction due to dysarthria.

ConclusionsClinical management decisions can be guided by

an understanding of the support available for varioustreatments aimed at respiratory/phonatorydysfunction. Evidence-based support exists for atleast two approaches in each of the three maintreatment paths: (a) improving respiratory support,(b) increasing respiratory/phonatory coordinationand control, and (c) improving phonatory function.The most studied treatment approach is the LSVT,which has demonstrated efficacy for persons withmild-moderate dysarthria associated with idiopathicParkinson’s disease. If candidacy requirements for atreatment with evidentiary support are met, cliniciansmay be directed to that particular treatment for an

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individual patient. In addition to the evidence, expertopinion is available for many management options.While these techniques do not have the desiredsupport of the research literature, they serve to offertherapeutic guidance to clinicians with the caveatthat supportive evidence is lacking. It is hoped thatthe delineation of management strategies and thecorresponding levels of support will prompttreatment efficacy research in the areas that lackstrong evidence-based support.

AcknowledgmentsThe authors wish to acknowledge the members of

the ANCDS writing committee for Practice Guidelinesin Dysarthria Management, particularly Joseph R.Duffy. This work was supported by a personneltraining grant T32-DC00033 from the NationalInstitute on Deafness and Other CommunicationDisorders, National Institutes of Health, to theUniversity of Washington.

Ms. Kristie Spencer is a doctoral candidate in theDepartment of Speech and Hearing Sciences at theUniversity of Washington in Seattle. She will be joiningthe UW faculty as an assistant professor in September2003. Dr. Kathryn Yorkston is a professor and head of theDivision of Speech Pathology, in the Department ofRehabilitation Medicine at the University of Washington.Dr. Yorkston is chair of the ANCDS Dysarthria PracticeGuidelines Committee.

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14


Table 1. Summary of evidence-based studies using biofeedback

ReferenceType of Study Treatment

Number of

SubjectsType of

DysarthriaMedical

Diagnosis

Evidence for experimental

control

Psycho-metric

Adequacy

Outcome Measures of Impairment

Outcome Measures of Activity or

Participation

Netsell & Daniel (1979)

casePressure

biofeedback program

1 flaccid TBI limited present Yes Yes

McNamara (1983) caseHypertonic exercises;

biofeedback1 flaccid CVA absent absent Yes No

Scott and Caird (1983)

group with

controls

Prosodic exercises with and without

visual feedback

26 not specified PD present present No Yes

Rubow and Swift (1985)

single subject design

Portable biofeedback

device1 not

specified PD present present Yes No

Simpson, Till, and Goff (1988) case

Abdominal binder,

biofeedback, voice amplifier

1 not specified

Basilar artery stroke present present Yes Yes

Daniel-Whitney (1989) case

Biofeedback of intraoral air pressure

1spastic-ataxic TBI present present Yes No

Johnson and Pring (1990)

group with

controls

"Less intensive" treatment

targeting pitch and volume with visual feedback

12 not specified PD present absent Yes No

Workinger and Netsell (1992) case

Respiratory support and coordination

exercises

1 not specified TBI limited absent Yes No

Thompson-Ward, Murdoch, and Stokes (1997)

single case

design

Two types of biofeedback of

respiratory kinematics

1 spastic CVA present present Yes Yes

Murdoch, Pitt, Theodoros, and

Ward (1999)

single case

design

Traditional therapy versus physiological biofeedback

1 spastic-ataxic-flaccid

TBI present present Yes Yes

15


Table 2. Summary of evidence-based studies using devices

ReferenceType of Study Treatment

Number of

SubjectsType of

DysarthriaMedical

Diagnosis

Evidence for Experimental

Control

Psycho-metric

Adequacy

Outcome Measures of Impairment

Outcome Measures of Activity or

Participation

Hanson and Metter (1980)

case Delayed auditory feedback

1 hypokinetic PSP present present Yes Yes

Hanson and Metter (1983)

case series

Delayed auditory feedback 2 hypokinetic PD present present Yes Yes

Rubow and Swift (1985)*

single subject design

Portable biofeedback

device1 not

specified PD present present Yes Yes

Simpson, Till, and Goff (1988)* case Voice amplifier 1

not specified

Basilar artery stroke present present Yes Yes

Adams and Lang (1992)

case series

Masking noise to increase voice

intensity10 not

specified PD present present Yes Yes

Cariski and Rosenbek (1999)

case series

Speech Enhancer with

and without behavioral treatment

2 hypokineticPD; multiple

strokes present absent No Yes

*Also included in summary of biofeedback studies; overall treatment included both approaches.

16


T a b l e 3 . S u m m a r y o f e v i d e n c e - b a s e d s t u d ie s u s in g t h e L e e S i lv e r m a n V o i c e T r e a t m e n t P r o g r a m

R e f e r e n c eT y p e o f

S t u d y T r e a t m e n t

N u m b e r o f

S u b j e c t sT y p e o f

D y s a r t h r i aM e d i c a l

D i a g n o s i s

E v id e n c e fo r E x p e r i m e n t a l

C o n t r o l

P s y c h o m e tr ic

A d e q u a c y

O u t c o m e M e a s u r e s o f I m p a i r m e n t

O u tc o m e M e a s u r e s o f

A c t i v i t y o r P a r t i c i p a t i o n

C o u n t r y m a n a n d R a m i g ( 1 9 9 3 ) c a s e

L e e S i l v e r m a n V o i c e T r e a t m e n t p ro g r a m ( L S V T )

1m ix e d

h y p o k in e t i c -s p a s t i c

P D ( w i t h b i l a t e r a l

t h a l a m o t o m y )l im i t e d p r e s e n t Y e s Y e s

C o u n t r y m a n , R a m i g , a n d P a w l a s ( 1 9 9 4 )

c a s e s e r i e s L S V T 3 n o t

s p e c i f i e d

P a r k in s o n i a n P l u s

S y n d r o m el im i t e d p r e s e n t Y e s Y e s

R a m i g , B o n i t a t i , L e m k e , a n d H o r i i ( 1 9 9 4 )

g r o u p L S V T 4 0n o t

s p e c i f i e d P D l im i t e d p r e s e n t Y e s Y e s

D r o m e y , R a m ig , a n d J o h n s o n ( 1 9 9 5 ) c a s e L S V T 1 n o t

s p e c i f i e d P D p r e s e n t p r e s e n t Y e s N o

R a m i g , C o u n t r y m a n , T h o m p s o n , a n d H o r i i ( 1 9 9 5 )

g r o u p w i t h

c o n t r o l s

L S V T v e r s u s r e s p i r a t o r y - o n l y

t h e r a p y4 5 n o t

s p e c i f i e d P D p r e s e n t p r e s e n t Y e s Y e s

S m i th , R a m ig , D r o m e y , P e re z , a n d S a m a n d a r i ( 1 9 9 5 )

g r o u p w i t h

c o n t r o l s




R a m i g a n d D r o m e y ( 1 9 9 6 )

g r o u p w i t h

c o n t r o l s



s p e c i f i e dP D p r e s e n t p r e s e n t Y e s N o

R a m i g , C o u n t r y m a n , O 'B r i e n , H o e h n a n d T h o m p s o n ( 1 9 9 6 )

g r o u p w i t h

c o n t r o l s


t h e ra p y ; l o n g -t e r m t r e a t m e n t

e f fe c t s

3 5 n o t s p e c i f i e d P D p r e s e n t p r e s e n t Y e s Y e s

C o u n t r y m a n , H i c k s , R a m i g a n d S m i t h ( 1 9 9 7 )

c a s e L S V T 1 n o t s p e c i f i e d

P D w i t h s u p r a g lo t t i c

h y p e r -a d d u c t i o n

p r e s e n t p r e s e n t Y e s Y e s

T h e o d o r o s , T h o m p s o n - W a r d , M u rd o c h , L e t h le a n a n d S i l b u r n ( 1 9 9 9 )

c a s e L S V T 1 h y p o k in e t i c

P D w i t h t h a la m o t o m y

a n d p a l l i d o t o m y

p r e s e n t a b s e n t Y e s Y e s

W a r d , T h e o d o r o s , M u rd o c h , a n d S i l b u r n (2 0 0 0 )

g r o u p w i t h

c o n t r o l sL S V T 3 0 n o t

s p e c i f i e d

P D w i t h o r w i t h o u t

p a l l i d o t o m y a n d / o r

t h a la m o t o m y

p r e s e n t a b s e n t Y e s Y e s

R a m i g , S a p i r , F o x , a n d C o u n t r y m a n ( 2 0 0 1 )

g r o u p w i t h

c o n t r o l sL S V T 1 4 n o t

s p e c i f i e d P D p r e s e n t a b s e n t Y e s N o

S a p i r , P a w l a s , R a m i g , S e e l e y , F o x , a n d C o r b o y (2 0 0 1 )

c a s e s e r i e s L S V T 2

n o t s p e c i f i e d M S p r e s e n t p r e s e n t Y e s Y e s

S o lo m o n , M c K e e , a n d G a r c ia - B a r r y ( 2 0 0 1 )

c a s e

L S V T a lo n e v e r s u s L S V T

c o m b i n e d w i t h r e s p i ra t i o n

t r e a t m e n t a n d p h y s i c a l t h e ra p y

1m ix e d

h y p o k in e t i c -s p a s t i c

T B I p r e s e n t p r e s e n t Y e s Y e s

R a m i g , S a p i r , C o u n t r y m a n , P a w l a s , O ' B r i e n , H o e h n , a n d T h o m p s o n ( 2 0 0 1 )

g r o u p w i t h

c o n t r o l s


t h e r a p y3 3

n o t s p e c i f i e d P D p r e s e n t p r e s e n t Y e s N o

B a u m g a r t n e r , S a p i r , a n d R a m i g ( 2 0 0 1 )

g r o u p w i t h

c o n t r o l s




17


T a b le 4 . S u m m a ry o f e v id e n c e - b a s e d s tu d ie s u s in g g r o u p th e ra p y

R e f e re n c eT y p e o f

S t u d y T re a t m e n t

N u m b e r o f

S u b je c t sT y p e o f

D y s ar t h r iaM e d ic a l

D ia g n o s is

E v id e n c e fo r E x p e r im e n t a l

C o n tr o l


A d e q u a c y

O u t c o m e M e a s u r e s o f Im p a i r m e n t

O u tc o m e M e a s u re s o f

A c t iv i t y o r P a rt ic ip a tio n

R o be r t s o n a n d T h o m s o n (1 9 8 4 )

g r o u p w ith

c o n t ro ls

G ro u p the r a p y to im p ro v e

c a p a c i ty /c o n t ro l o f re s p ir a ti o n ,

a n d c o o rd in a t io n /c o n t

ro l o f v o ic e p r o d u c t io n

1 2 n o t s p e c if ie d P D p r e s e n t a bs e n t N o Y e s

S u lliv a n , B r u n e , a n d B e u k e l m a n

( 1 9 96 )

c a s e s e r ie s

G ro u p the r a p y to i nc r e a s e b r e a th

s u p p o rt a n d v o ic e p r o je c t io n

6 h y p o k in e t ic P D lim ite d p r e s e n t Y e s Y e s

D e An g e lis , M o ur a o , F e r r a z, B e h la u ,

P on te s , a n d A n d r a d e ( 1 9 9 7 )

g r o u pG ro u p the r a p y to

in c re a s e v o c a l in te n s ity

2 0n o t

s p e c if ie d P D lim ite d a bs e n t Y e s Y e s

T a b le 5 . M is c e lla n e o u s e v id e n c e - b a s e d s t u d ie s

R e f e re n c eT y p e o f

S t u d y T re a t m e n t

N u m b e r o f

S u b je c t sT y p e o f

D y s ar t h r iaM e d ic a l

D ia g n o s is

E v id e n c e fo r E x p e r im e n t a l

C o n tr o l


A d e q u a c y

O u t c o m e M e a s u r e s o f Im p ai r m e n t

O u tc o m e M e a s u re s o f

A c t iv i t y o r P a rt ic ip a tio n

M u r r y a n d W o o d s o n (1 9 9 5 )

g r o u p w ith

c o n tro ls

V o ic e th e ra p y a f te r B o to x t r e a tm e n t

(c o m p a re d to B o to x o n l y )

1 7 h y p e r k in e t icA d du c to r

s p a s m o d ic d y s p h o n i a

p r e s e n t a bs e n t Y e s N o

C e rn y , P a n za r e lla , a n d S ta th o p o u lo s

( 1 9 97 )g r o u p

E x p ir a to ry r e s is t iv e

b r e a th in g1 0 n o t

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Managing Speaking Rate in DysarthriaVicki L. HammenArnett ClinicLafayette, IN

The manipulation of speaking rate is often usedas a strategy to improve speech intelligibility inpersons with dysarthria. This is likely because it isthe approach used by neurologically intact personswhen we experience a breakdown in intelligibility orwhen we want our message to be understood clearly.Persons without dysarthria will tend to self-regulatespeaking rate, depending on the situation. Indysarthria, however, this self-regulation is oftenimpaired. Thus, the clinician must provide the personwith dysarthria with a systematic approach toreducing his or her speaking rate. This article willaddress the factors used in the selection of a ratecontrol method, the types of rate control approachesavailable, and the impact of rate control on speechproduction. The article includes both evidence fromthe research literature and the opinions of experts inthe field.

Rationale For many persons with dysarthria, reducing

speaking rate results in a substantial improvement inspeech intelligibility. Yorkston, Hammen, Beukelman,and Traynor (1990) showed an average improvementin intelligibility of 26% for 4 persons with ataxic and4 persons with hypokinetic dysarthria. Otherresearchers, however, have found a less clear-cutrelationship between rate and intelligibility. Turner,Tjaden, and Weismer (1995) found that only abouthalf of the persons with Amyotrophic LateralSclerosis in their study showed an increase in speechintelligibility with a reduction in speaking rate. Whilethere is compelling evidence that rate control is aneffective approach to improving intelligibility in somepatients, each clinician must determine if it is anappropriate intervention strategy for his or herparticular client.

Speaking Rate CharacteristicsOverall speaking rate is comprised of two factors,

speech (or articulation) time and pause time. Pausescan be intra-utterance (such as a pauses around aclause) or inter-utterance (such as those that occurbetween sentences). Typical speaking rates forneurologically normal speakers during paragraphreading tasks are approximately 160-170 words perminute (wpm; Fairbanks, 1960). Yorkston andBeukelman (1981) reported rates of around 190 wpm

for speakers completing a sentence reading task.Conversational speaking rates ranged from 150 wpmto 250 wpm for a set of speakers studied by Goldman-Eisler (1968). Of the two components related to overallspeaking time, pause time is the most changeablewhen rate control methods are employed.

Speaking rate differs as a function of thespeaking task. Reading tasks have natural boundarymarkers, such as commas and periods that cue aspeaker to pause. In conversational speech it is thecognitive flow of the individual and conversationalturn taking that most often determine the location andduration of pauses.

Common ApproachesClinicians may divide the types of rate control

into two categories: rigid and rhythmic approaches.Rigid approaches, such as pacing boards andalphabet supplementation (discussed below), aredesigned to have maximum control over the speaker’srate. However, they also have a negative impact onprosody and, in turn, naturalness. Most rigidapproaches to rate control affect the number andduration of pauses. This can serve to better markword and syntactic boundaries as well as allow foradditional listener processing time. The prosodic cuesthat provide important information regardingsentence structure and meaning may be lost, however,due to the word-by-word production style theseapproaches induce.

Yorkston, Beukelman, Strand, and Bell (1999)used the concept of “preserving prosody” to describethe rhythmic approaches (discussed below). Theseapproaches, such as rhythmic cueing, typically havea lesser impact on prosody, and therefore,naturalness, but are not as effective at controllingspeaking rate to a specified target. Creating a balancebetween the control of speaking rate and naturalnessis the challenge of rate manipulation intervention.

Rigid Techniques

One of the earliest reports on the use of ratecontrol in dysarthria was Helm’s (1979) descriptionof the use of a pacing board to reduce palilalia in aperson with Parkin-son’s disease. This individualwould rapidly repeat phrases multiple times. Thepacing board devised by Helm was a narrow,

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rectangular board with a set of colored squaresseparated by a ridge or divider. The person tapped hisor her finger on a square for each word. Alternatively,the person could slide his or her hand along theboard, then lift it over the ridge to the next square inorder to say the next word. This movement providedan external method of pacing speech and yielded aword-by-word production style.

Another rigid method of rate control is fingertapping. In this approach the person taps his fingerwhile saying a word. He or she may tap his finger onthe table, or tap his thumb to each finger insuccession in a metered fashion. The key element isthat the patient taps his finger as he begins toproduce each individual word in an utterance. Theadvantage of this technique over the pacing board isthat no external device is needed. This approach ismore unobtrusive than the pacing board, but requiresmore diligence on the part of the speaker. It isincumbent upon the individual to tap for each word.For some patients, finger tapping becomes easier andmore automatic, causing them to either tapindependently of their speech production, or speedup the finger tapping to match the rapid rate ofspeech. Should this occur, it may be necessary tochoose a different strategy.

A third rigid method of controlling speaking rateis alphabet board supplementation (Beukelman &Yorkston, 1977; Crow & Enderby, 1989). The boardcontains the letters of the alphabet arranged in rows.Boards can be arranged to suit the patient; forexample, the letters may be arranged with the vowelsat the start of each row. Control phrases, such as“Start again” or “End of sentence” can be included toprovide the speaker with additional cues to give hisor her communication partner. The individual withdysarthria is instructed to point to the first letter ofthe word she is saying, as they begin to say it. Thisprovides a rigid method of controlling speaking ratebecause the motor act of pointing to the letter prior toproducing the word automatically reduces rate. Abenefit of this method is that the communicationpartner is provided with a phonemic cue for the wordbeing produced. Finally, should the communicationpartner be unable to decode the intended word, theboard can be used by the speaker to spell out theword. When using this technique with persons withsevere dysarthria, it may be helpful to have thecommunication partner repeat each word after thespeaker says it. This allows the speaker to knowwhen communication breakdown has occurred andmake a repair before the message is lost.

Pilon, McIntosh, and Thaut (1998) employed ametronome to control speaking rate. Threeindividuals with dysarthria following a traumatic

brain injury were participants in this study, whichused a single-case design with baseline reversal, inwhich treatment was followed by a no-treatmentperiod of baseline data collection. Consistent withwhat has been documented for other forms of rigidrate control, these authors found that metronomepacing resulted in the greatest synchrony between themetronome rate and actual speech rate as comparedto singing and board pacing. That is, it was the mosteffective in controlling speaking rate. In addition, thistechnique was associated with the greatest change inspeech intelligibility for the two out of three personswho showed a change in intelligibility with ratereduction.

Rhythmic Techniques

In contrast to the rigid rate control techniques,the rhythmic techniques attempt to preservenaturalness, while providing some control over theperson’s speaking rate. Computerized, rhythmicpacing can be accomplished by the use of the Pacer/Tally program (Beukelman, Yorkston, & Tice, 1997).With this program, user-created text is analyzed forthe number of syllables per word and presence ofpunctuation (for pausing). The clinician can addadditional pause markers at specific locations. Aduration is assigned to each syllable and pausemarker. The target syllable per minute rate is specifiedby the clinician, and multisyllabic words areallocated more time than single-syllable words. Thepassage appears on the computer screen and is pacedby the use of underlining, bolding, or highlighting.The speaker is directed to follow the pacing signalthrough the passage by saying the word when it ismarked. He or she is encouraged not to get ahead or tolag behind and to slow down articulation for thelonger words. While it may require many practicesessions to train the speaker to produce a slower rate,many persons with dysarthria readily internalize thisrate and no longer require the computerized pacingsystem to maintain their new speaking rate.

Berry and Goshorn (1983) described a method ofrhythmic pacing that uses an oscilloscope. Theypresented a case study in which an individual withsevere ataxic dysarthria was given a time-by-intensitydisplay on the oscilloscope as feedback for rate andintensity. The researchers determined a set length ofspeech time for the oscilloscopic display, and theclient was instructed to “fill up the screen.” Usingthis form of feedback, the client was successful inreducing his speaking rate and improving hisintelligibility. Clinicians with access to a Visi-pitch(Kay Elemetrics) can use this strategy for reducingspeaking rate. The intensity trace in the stationarymode is used, and the clinician can set the time

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displayed based on the intended target rate. With thesplit screen option, a model can be provided for theclient to match if necessary.

Delayed auditory feedback (DAF) is anotherrhythmic rate control method that is primarily used inthe treatment of stuttering but may have a positiveimpact on dysarthric speech as well. In the early1980s, Hanson and Metter (1980, 1983) reported theuse of DAF with two persons with hypokineticdysarthria. These speakers slowed their speakingrates by 62-116 wpm and improved their intelligibilityby up to three scale points on a 7-point, equal-appearing interval scale. Adams (1994) used DAF toslow the speaking rate of a person with suspectedsupranuclear palsy who presented with hypokineticdysarthria and rapid, accelerating speech. Throughthe use of DAF this individual was able to slow hisspeaking rate from 350-400 wpm to 150-200 wpm. Hisspeech intelligibility increased from 55% pre-DAF to95% post-DAF. It is important to note, however, thatDAF has not been found to be effective with allpersons with hypokinetic dysarthria (Yorkston et al.,1999), nor has it been employed with other types ofdysarthria.

The final method that is considered a rhythmicapproach to rate control is direct magnitudeproduction (DMP; Castor, 1995). In this paradigm, theindividual speaks at her comfortable or habitual rate.She may then be asked to speak at “twice that rate” or“half that rate.” Habitual rate is often given a number(e.g., 10) with multiples of that number being given forthe “twice habitual rate” and “half habitual rate.”This strategy differs from the others discussed thusfar in that there is no external device needed forimplementation.

Various types of instructions are used to elicit achange in speaking rate during a DMP task. Forexample, Castor (1995) used both Pacer and DMP tocontrol speaking rate, while examining whetherspeakers with and without Parkinson’s disease couldgeneralize reduced speaking rates to novel material.For the DMP task the author assigned the number 10to each speaker’s habitual rate. Speakers weresubsequently asked to reduce their rate to a 5 and a2.5. No further instructions were provided. Castorfound that when asked to reduce rate to a 5, speakersactually reduced their rate to about 75% of theirhabitual rate. This provided evidence that directmagnitude production was effective in reducingspeech rate in persons with and without neurologicdisease, though not with the same degree of accuracyas found in other methods, such as Pacer.

Recently, Logan, Roberts, Pretto, and Morey(2002) investigated the effects of several self-guided

approaches to rate reduction neurologically normalspeakers. One of the approaches, termed the self-devised method, instructed participants to reduce theirspeaking rates by about 25%. They were furtherinstructed to reduce their rate any way they preferred(e.g., pausing more often or stretching out words). Thesyllable per second rate dropped from an average of4.35 sec during the control phase to 4.29 sec using theDMP approach, a statistically significant decrease.

A number of researchers have used the DMPmethod to control speaking rate while examining avariety of physiologic and acoustic variables (Adams,Weismer, & Kent, 1993; Kleinow, Smith, & Ramig,2001; Shaiman, Adams, & Kimel-man, 1997; Tjaden,2000). Tjaden (2000) found that when speaking ratewas reduced in persons with and withoutParkinson’s disease, coarticulation (as measured bythe ratio of F2 onset frequency/target frequency)decreased. Velocity profiles for lip and tonguemovements were investigated by Adams andcolleagues (1993) and Shaiman and colleagues (1997).Adams and colleagues interpreted their finding ofchanges in the topology of velocity profiles assuggesting that changes in speaking rate affect motorcontrol strategies. In support of this impression,Shaiman and colleagues (1997) found greaterasymmetry, irregularity, and changes in the shape oflip velocity profiles when speaking rates werereduced from the speaker’s habitual rate.

Recently, some interesting questions have beenraised from the work of Kleinow and colleagues(2001). In their work with individuals withParkinson’s disease, Kleinow and colleagues reportedthat the index of spatial and temporal stability in theorofacial system showed that slower speech ratesresulted in the greatest amount of motor variability.One would have predicted that if rate controlimproves speech intelligibility then motor variabilitywould be reduced, not increased. The relationshipbetween the effects of rate control, variability in themotor system, and speech intelligibility needs to beexamined.

Indirect EffectsFinally, there are a number of treatment

approaches that have an indirect effect of ratereduction. Yorkston and colleagues (1999) refer tothese as “backdoor approaches to rate control” (p.426). These approaches do not specifically focus onrate manipulations, but usually rate reduction is a byproduct of successful implementation of the treatmentparadigm. One backdoor approach to rate reductionis improving prosodic characteristics of speech. Anearly example of this phenomenon was described by

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Simmons (1983), who found that by focusingtreatment for an individual with severe ataxicdysarthria on improving pitch and loudnesscharacteristics, changes occurred in the rate ofspeech. The client lengthened syllables and insertedadditional pauses. It was hypothesized that the clientneeded additional time to produce the intended pitchand loudness variations. The author concluded thattarget behaviors in the treatment of dysarthria are notindependent; that is, working on one aspect, such asloudness or pitch variation, can cause alterations inother aspects of speech, such as rate.

The concept of improving rate by improvingloudness has support from Ramig, Pawlas, andCountryman (1995), who suggested that instructingan individual with Parkinson’s disease to “ThinkLoud” as part of the Lee Silverman Voice Treatment(LSVT) program results in a reduction of speakingrate. Since it has been shown that increased drive tothe orofacial muscles occurs with increased loudness(Wohlert & Hammen, 2000), it is reasonable tohypothesize that this may result in increasedarticulatory excursions. When the distance anarticulatory structure travels is increased, there willlikely be a concomitant increase in articulation orspeech time.

Selecting StrategiesYorkston and colleagues (1999) identified three

criteria for selecting a rate control approach for anindividual client: effectiveness, training requirements,and consequences. Effectiveness refers to whether thestrategy used actually reduces speaking rate in anindividual and whether maintenance of the reducedrate over time is possible. An additional component ofeffectiveness is how the rate reduction isaccomplished. As discussed previously, somestrategies have a greater impact on pausing andpause structure, while others can affect speech time. Itis necessary for the clinician to determine whetheralteration of speech time or the duration anddistribution of pauses will have the most beneficialeffect on speech intelligibility. The amount of trainingrequired for implementation of a rate control strategyis an important factor to consider in today’schallenging health care environment. The rigidmethods of rate control, such as alphabet boardsupplementation or a pacing board, require minimaltraining and can be effective almost immediately. Asthey have the most negative impact on naturalness,however, they may not be the preferred method in thelong-term. Backdoor approaches such as LSVT requireseveral weeks of intensive therapy to achieve thedesired outcome, but may be associated with a moredesirable outcome than rigid control techniques.

While on the surface, self-determined approachessuch as DMP may seem like they would requireminimal training, This may not be the case, as theyhave less control over the actual rate produced, andextensive training may be necessary to effectivelydecrease speaking rate.

It may be possible to use both rigid and rhythmicapproaches when working on improving speechintelligibility through rate reduction. Use of analphabet board or finger tapping can substantiallyimprove intelligibility and the ability of the personwith dysarthria to communicate effectively within oneor two therapy sessions. This can be motivating to theindividual and demonstrate the benefits of ratereduction. Simultaneously, training with a rhythmicmethod, such as DMP, can be initiated. Once theindividuals can reliably produce an effective ratechange with a self-regulated method, the rigid methodis phased out.

The last selection criterion for a rate controlstrategy discussed by Yorkston and colleagues (1999)is consequences. The main consequence for the use ofrate control strategies is the reduction in speechnaturalness. Yorkston and colleagues (1990) foundthat rigid rate control methods had a more negativeimpact on naturalness than did rhythmic methods.Logan and colleagues (2002) investigated the effect ofrate reduction on naturalness in a group of femalecollege students without speech impairments. Theyused four different, self-devised rate control methods.In three of the four conditions, the participants wereasked to alter speech time, turn-taking pauses, or thenumber and duration of intra- and inter-sentencepauses. The fourth condition was the self-devisedmethod, in which speakers were instructed to reducetheir speaking rates by 25% using any strategy theychose. The results showed that, with the exception ofaltering turn-taking pauses, there was a significant,negative impact on naturalness when rate reductionstrategies were employed. On a positive note, theyfound that the self-determined or DMP-type methodhad the least negative effect on naturalness.

ConclusionsRate control is an effective strategy to improve the

speech intelligibility of persons with dysarthria.While it would seem that selection and use of a ratecontrol strategy is a simple endeavor, in fact, thedecision-making process must take into account anumber of factors. There are no specific guidelines toindicate which method is most effective for anindividual with dysarthria. Selection of the target ratewill vary from person to person. The clinician mustconsider not only improvement in intelligibility, but

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also maintenance of speech naturalness. Theavailable knowledge of the impact of certain types ofrate control on speech characteristics can be helpfulto the clinician in providing effective treatment. Weknow from the available research that rate controloften improves the speech intelligibility of personswith dysarthria. We have just begun to understandwhy that improvement occurs. It is important thatclinical researchers continue to provide researchevidence to guide our clinical decisions regardingrate control strategies.

Dr. Vicki L. Hammen is the speech-language pathologist inthe Department of Speech Pathology at the Arnett Clinic inLafayette, IN.

ReferencesAdams, S. G. (1994). Accelerating speech in a case of

hypokinetic dysarthria: Descriptions and treatment. InJ. A. Till, K. M. Yorkston, & D. R. Beukelman (Eds.),Motor speech disorders: Advances in assessment and treat-ment (pp. 213-228). Baltimore: Brookes.

Adams, S. G., Weismer, G., & Kent, R. D. (1993). Speaking rateand speech movement velocity profiles. Journal of Speechand Hearing Research, 36, 41-54.

Berry, W., & Goshorn, E. (1983). Immediate visual feedbackin the treatment of ataxic dysarthria: A case study. InW. Berry (Ed.), Clinical dysarthria (pp. 253-266). Austin,TX: PRO-ED.

Beukelman, D. R., & Yorkston, K. M. (1977). A communica-tion system for the severely dysarthric speaker with anintact language system. Journal of Speech and HearingDisorders, 42, 265-270.

Beukelman, D. R., Yorkston, K. M., & Tice, R. (1997). Pacer/tally rate measurement software. Lincoln, NE: Tice Tech-nology Services.

Castor, K. M. (1995). Generalization of speaking rate in Parkinsondisease. Unpublished master’s thesis, Purdue Univer-sity, West Lafayette, IN.

Crow, E., & Enderby, P. (1989). The effects of an alphabetchart on the speaking rate and intelligibility or speak-ers with dysarthria. In K. M. Yorkston, & D. R.Beukelman (Eds.), Recent advances in clinical dysarthria(pp. 99-108). Boston: College-Hill Publications.

Fairbanks, G (1960). Voice and articulation drillbook. New York:Harper & Brothers.

Goldman-Eisler, F. (1968). Psycholin-guistics: Experiments inspontaneous speech. New York: Academic Press.

Hanson, W., & Metter, E. J. (1983). DAF speech rate modifi-cation in Parkinson’s disease: A report of two cases. InW. Berry (Ed.), Clinical dysarthria (pp. 231-254). Austin,TX: Pro-Ed.

Hanson, W., & Metter, E. J. (1980). DAF as instrumentaltreatment for dysarthria in progressive supranuclearpalsy: A case report. Journal of Speech and HearingDisorders, 45, 268-276.

Helm, N. (1979). Management of palilalia with a pacingboard. Journal of Speech and Hearing Disorders, 44, 350-353.

Kleinow, J., Smith, A., & Ramig, L. (2001). Speech motorstability in IDP: Effects of rate and loudness manipula-tions. Journal of Speech, Language, and Hearing Research,44, 1041-1051.

Logan, K. J., Roberts, R. R., Pretto, A. P., & Morey, M. J. (2002).Speaking slowly: Effects of four self-guided approacheson adults’ speech rate and naturalness. American Jour-nal of Speech-Language Pathology, 11, 163-174.

Pilon, M. A., McIntosh, K. W., & Thaut, M. H. (1998). Auditoryvs visual speech timing cues as external rate control toenhance verbal intelligibility in mixed spastic-ataxicdysarthric speakers: A pilot study. Brain Injury, 12, 793-803.

Ramig, L. O., Pawlas, A. A., & Countryman, S. (1995). The LeeSilverman Voice Treatment: A practical guide to treatingthe voice and speech disorders in Parkinson disease. IowaCity: National Center for Voice and Speech.

Shaiman, S., Adams, S. G., & Kimelman, M. D. (1997). Velocityprofiles of lip protrusion across changes in speakingrate. Journal of Speech, Language, and Hearing Research,40, 144-158.

Simmons, N. (1983). Acoustic analysis of ataxic dysarthria:An approach to monitoring treatment. In W. Berry(Ed.), Clinical dysarthria (pp. 283-294). Austin, TX: Pro-Ed.

Tjaden, K. (2000). A preliminary study or factors influencingperception of articulatory rate in Parkinson disease.Journal of Speech, Language, and Hearing Research, 43,997-1010.

Turner, G. S., Tjaden, K., & Weismer, G. (1995). The influence ofspeaking rate on vowel space and speech intelligibility forindividuals with amyotrophic lateral sclerosis. Journal ofSpeech, Language, and Hearing Research, 38, 1001-1013.

Wohlert, A. B., & Hammen, V. L. (2000). Lip muscle activityrelated to speech rate and loudness. Journal of Speech,Language, and Hearing Research, 43, 129-1239.

Yorkston, K. M., & Beukelman, D. R. (1981). Communicationefficiency of dysarthric speakers as measured by sentenceintelligibility and speaking rate. Journal of Speech andHearing Disorders, 46, 296-301.

Yorkston, K. M., Beukelman, D. R., Strand, E. A., & Bell, K. R.(1999). Management of motor speech disorders. Austin, TX:PRO-ED.

Yorkston, K. M., Hammen, V. L., Beukelman, D. R., & Traynor,C. (1990). The effect of rate control on the intelligibilityand naturalness of dysarthric speech. Journal of Speech andHearing Disorders, 55, 550-561.

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Nonspeech Oral Motor Treatment Approaches for Dysarthria:Perspectives on a Controversial Clinical Practice

Megan M. HodgeUniversity of AlbertaEdmonton, Alberta, Canada

This article addresses non-speech oral motortreatments and reports the results of a search forevidence of their effectiveness in improving thespeech of persons with dysarthria. The term oral motortreatment refers to a range of nonspeech and speech-like activities used to achieve a variety of goals thatinvolve actions of the lips, jaw, and tongue. Interestedreaders should refer to the comprehensive review byChapman Bahr (2001) for further information on thistopic. Typically, these treatments are limited tobehavioral techniques applied by professionals (e.g.,oromyo-functional therapists, occupationaltherapists, speech-language pathologists) who aremembers of health service delivery teams, but theymay be conducted in conjunction with surgical,orthodontic or pharmacological treatments in anattempt to maximize the functional benefits of thesemedical procedures (ASHA, 1993; Dworkin, 1991).

Nonspeech oral motor treatment activitiesdescribed in the literature fall under three broadcategories. These include: (a) isotonic and isometricstrengthening exercises, (b) relaxation exercises, and(c) neurophysiological or neuro-therapeuticapproaches (Gordon, 1987). The goal of strengtheningexercises is to promote appropriate lip, jaw, andtongue postures at rest and to increase the stability,strength, range, speed, and control of lip, jaw, andtongue movements (Duffy, 1995; Hanson & Barrett,1988). In strengthening exercises, a personvoluntarily activates target muscle groups to performisometric or isotonic exercises, with or withoutresistance. These exercises are based on generalprinciples of muscle conditioning. Increases instrength occur when muscle mass (number and/orsize of muscle fibers) or recruitment and rate of firingof motor units increases (Duffy, 1995). If available,instrumentation can be used with these exercises toprovide feedback to the person about strength orforces achieved.

The goal of relaxation exercises is to reduceabnormally high muscle tone in the lip, jaw, andtongue muscles. The goals of neurophysiological orneurotherapeutic approaches are to reduce muscletone, inhibit abnormal oral reflexes and postures atrest and during functional tasks like talking andeating, and promote sensorimotor integration forlearning skilled actions of the lips, tongue, and jawfor speech and the oral phase of eating (Chapman

Bahr, 2001; Dworkin, 1991; Mysak, 1983; Robertson &Thompson, 1986). These approaches, which includethe application of sensory stimuli to facilitate muscleactivity, are based on techniques of Rood (1956) andproprioceptive neuromuscular facilitation (Knott &Voss, 1968), as well as techniques that focus onnormalizing abnormal muscle tone and posturalcontrol and inhibiting reflexes and abnormalmovement patterns. The latter techniques are based,in turn, on neurodevelopmental treatment (NDT; e.g.,Bobath & Bobath, 1984).

Neurotherapeutic approaches are based on reflexor hierarchical models of motor control andtraditional motor developmental and learningtheories. They use a neurophysiological rationale toexplain normal motor behavior and share the sameassumptions about how the central nervous system(CNS) is organized and what happens when CNSdamage occurs (Gordon, 1987; Mathiowetz &Haugen, 1994).

Some authors (e.g., Boshart, 1998; Chapman Bahr,2001) include techniques that are components oftraditional articulation therapy in “oral motor”treatment. These techniques use sensory stimulationin the form of physical prompts, spoken instructions,and visual, auditory, and tactile cues to help childrenand adults learn or relearn how to position and movethe lips, jaw, and tongue to produce target consonantand vowel sounds. They resemble Duffy’s (1995)description of traditional methods of articulationtherapy for dysarthric speakers, which includeintegral stimulation (watch and listen imitationtasks); phonetic placement (hands-on assistance inattaining targets and movements, with picture orother cues for articulatory place and manner); andphonetic derivation (using an intact nonspeechgesture to establish a sound target such as blowing tofacilitate production of /u/). The use of traditionalarticulation therapy placement techniques will not bereviewed here. Instead, the paper focuses onnonspeech oral motor treatment techniques.

Perspectives on Nonspeech OralMotor Treatment

Nonspeech oral motor techniques are mentionedunder behavioral treatments for the articulatorysubsystem in many publications on intervention for

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persons with congenital and acquired dysarthria (e.g.,Chapman Bahr, 2001; Duffy, 1995; Dworkin, 1991;Hodge & Wellman, 1999; Love, 2000; Theodoros &Thompson-Ward, 1998; Mysak, 1983; Solomon &Stierwalt, 1995; Ton-kovich, Boettcher, & Rambow,2001; Yorkston, Beukelman, Strand & Bell, 1999). Theauthors vary, however, in their views on theappropriateness and effectiveness of these techniques.

Advocates state that nonspeech techniquesreduce neuromuscular impairments such asweakness, muscle tone abnormalities (abnormallyincreased or reduced), and reduced control in the lips,jaw, and tongue. The underlying hypothesis is that ifthe neuromuscular impairment in these musclegroups is reduced, the articulatory movements of theperson with dysarthria will “normalize,” resulting inimproved speech function such as increasedarticulatory accuracy and speech intelligibility.Proponents claim that these techniques improvemuscle function and motor control for speech by oneor more of the following:

1. Increasing muscle strength and endurance,

2. Normalizing abnormal muscle tone,

3. Increasing sensory awareness and sensorimotorintegration, and

4. Eliminating abnormal reflex behaviors that inter-fere with voluntary speech movements.

The predicted results are increased stability,speed, range, strength, and accuracy of movement oforal muscle groups (lips, jaw, tongue) in speecharticulation.

Several authors who promote the inclusion ofnonspeech oral motor techniques in treatment ofdysarthria (e.g., Chapman Bahr, 2001; Dworkin, 1991;Mysak, 1983) provide step-by-step, sequentiallyordered behavioral exercises for treating variousspeech subsystem disturbances, including deficits inarticulation. These include exercises to treat lip,tongue, and jaw weakness or hypertonia andtypically precede activities that involve phoneticstimulation of speech sounds. For example, ChapmanBahr (2001) described a typical 45-minute oral motortreatment session as having four segments, in thefollowing order:

1. Gross motor activity to improve postural tone andstability necessary for improved eating, drinking,and speaking;

2. Oral massage that may improve precision of oralmovements needed to improve drinking and eatingskills as well as speech production;

3. Specific nonspeech oral motor activites and exer-cises to improve oral strength, mobility, and coor-dination for eating, drinking or speaking; and

4. Specific speech and language activities.

The gross motor, oral massage, and oral exercisesoccur in the first 15 to 20 minutes, leaving 20 to 25minutes for more traditional speech and languagetreatment.

In contrast, several authors who are consideredexperts in the assessment and management ofdysarthria (Duffy, 1995; Love, 2000; Theodoros &Thompson-Ward, 1998; Yorkston, Beukelman, Strand& Bell, 1999) expressed guarded opinions about theeffectiveness of nonspeech oral motor techniques inimproving speech performance and noted that the useof these techniques is controversial. For example,Duffy stated that patients who require a focus onarticulation typically receive traditional articulationtreatments, while other techniques like strengthtraining, relaxation, stretching, and biofeedback areless universally appropriate. He advised that, ingeneral, strengthening exercises should be used onlyafter establishing that weakness of the oralarticulators is clearly related to the dysarthria. Hecommented that patients whose physiologic supportfor speech is severely compromised might benefit fromefforts to increase strength. Duffy also observed that ifincreasing the strength of a muscle group (in this casethe lips, jaw, or tongue) is a treatment goal, thenprocedures need to adhere rigorously to principles forstandard muscle strengthening exercises. Forexample, one would have to do five sets of 10repetitions each, three to five times per session, with 5to 10 exercise periods per day. The exercises shouldoverload the muscle in some way, such as with highrepetition-low resistance exercises or low repetition-high resistance exercises.

Theodoros and Thompson-Ward (1998) observedthat the effectiveness of nonspeech techniques to altermuscle tone and strengthen oral muscles is difficult toquantify and has yet to be determined for thepopulation of persons with dysarthria. Yorkston andcolleagues (1999) stated that there is little evidence tosupport any generalization of nonspeech oral motorinterventions to improved speech function in personswith spastic, hyperkinetic, hypokinetic, or ataxicdysarthria and advocated that intervention focus onspeech or speech-like movements. Specific to children,Yorkston and colleagues were of the opinion thatsome nonspeech activities may be useful on occasionfor children with dysarthria, who may benefit fromimproving strength or range of motion. They alsostated that oral motor techniques they have foundhelpful are those that lead directly to phoneticplacement and derivation. They concluded by stating

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that, “although nonspeech activities may be usedduring the first few minutes of a session to increaseattention to the face, increase awareness of movementand so on, spending much of the session onnonspeech movement is probably not the best use oftreatment time” (Yorkston et al., 1999, p. 563).

Love (2000) noted that there are conflictingresearch findings concerning the effects of muscleweakness and other types of oral motor impairmenton speech performance. He suggested that carefulanalysis of muscle strength and movement rates in agiven child with dysarthria is probably the onlyreliable guide for recommending oral exercises toincrease strength or movement. He observed thatcurrent management programs for childhooddysarthria are likely to use a broad spectrum oftechniques and that oral exercises are generally givenlimited prominence in current interventionapproaches. Tonkovich and colleagues (2001) statedthat while many clinicians advocate the use ofnonspeech repetitive exercises in the clinicalmanagement of dysarthric speech, there is little if anyevidence to support the efficacy of such exercises.These authors stated that they did not includerepetitive nonspeech movement exercises in theirclinical program manual, Dysarthria Rehabilitation,because they believe that repetitive nonspeechmovements do not generalize to speech intelligibility.They stated that clients might be misled by implicit orexplicit claims that the practice of nonspeechmovements will result in restored speechperformance.

There appear to be many reasons for opposingviews about the effectiveness of nonspeech oraltreatment techniques for dysarthria. As descriptionsof the specifics of these treatments vary from source tosource, they are not delivered in a standardizedmanner. Also, dysarthria is a low incidence disorderand persons with dysarthria are a heterogeneouspopulation. Children with dysarthria are undergoinggrowth and maturation, and are changing over time.They also differ in how they respond to theconstraints imposed by their nervous systemimpairment as they attempt to function in theirenvironments. It would appear, however, that themajor reason for continued controversy is that there isnot sufficient or compelling information available toresolve it. The arguments put forward by those whoadvocate nonspeech oral treatment techniques are notconvincing those who oppose these techniques tochange their views. Arguments put forward by thosewho oppose these techniques are not convincingthose who do support their use to change theirpractice.

Data-Based Studies of theEffectiveness

Electronic health databases, books, andnewsletters addressing treatment for dysarthriawritten by authorities in the field and two recenttherapy manuals that include nonspeech oral motortechniques were reviewed. The purpose was to obtaindata-based information addressing the effectivenessof non-speech oral motor treatment techniques foradults and children with dysarthria.

Literature searches of health research databases.Medline, PsychInfo, and CINHAL were searched forcitations from January 1960 to July 2002 that includedthe combined terms “oral motor” or “oromotor” and“dysarthria.” Only one article was identified thatreported the results of behavioral oral motorintervention. Harris and Murry (1984) reported thecase of a 44-year-old man with flaccid dysarthria andaphagia resulting from a gunshot wound. Seven yearsafter his injury, he received speech therapy. Initially,therapy focused on glottic closure, velopharyngealclosure, and tongue strength and mobility. After 9weeks of intensive practice, gains were noted instrength and movement of the tongue, velum, andlarynx, and in speech and swallowing function. Theliterature search did not identify any published,controlled, experimental studies (either group orsingle subject design) of the application of nonspeechoral motor behavioral techniques to children or adultswith dysarthria.

Together, Duffy (1995) and Theodoros andThompson-Ward (1998) identified 12 publishedstudies of cases with dysarthria that reported resultsof the application of EMG biofeedback therapy to altermuscle tone and strength by decreasing andincreasing muscle activity in the lips and jaw. In afew of these (e.g., Nemec & Cohen, 1984; Netsell &Daniel, 1979), improvements noted in jaw closureand/or lip strength were reported to result in anincrease in speech intelligibility, which wasmaintained following discontinuation of thebiofeedback.

Published anecdotal reports. Chapman Bahr (2001)and Dworkin (1991) were judged to be mostcomprehensive in their descriptions of the specificapplication of non-speech oral motor techniques.Dworkin described the case of a 52-year-old womanwith flaccid dysarthria resulting from a unilateral leftacoustic neuroma. Strengthening exercises for thetongue, then lips, and then jaw were followed bytraining to improve the fine force control of each ofthese muscle groups. This was followed in turn byphonetic stimulation for consonants. Performance onthese exercises was reported for each session. Ratings

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of the woman’s speech improved from a pre-treatmentarticulation subsystem baseline rating of 3.5 on a 7-point scale, indicating mild to moderate articulatoryimprecision, to a post-treatment score of 2.0. The effectof this change in rating on speech intelligibility wasnot reported. Chapman Bahr presented casedescriptions to consider for practice in treatmentplanning, but did not report any data fromindividuals with dysarthria.

In a previous ASHA Division 2 newsletter,Solomon and Stierwalt (1995) described two patientswith dysarthria who underwent tongue-strengthening training. The first was a 17-year-oldwoman who had sustained a traumatic brain injuryas a result of a motor vehicle accident 30 months priorto the authors’ evaluation. A program to increasetongue strength was implemented. After 18 months,tongue strength increased from 9 kPa to high 40s tolow 50s kPa and the woman was able to produce 10 to15 functional phrases. Speech progress wasconfounded by velopharyngeal incompetence. Theprogress with speech indicated that a palatal lift wasan option to further enhance speech intelligibility.

The second case involved a 72-year-old man withParkinson’s disease who demonstrated reduced andvariable measures of tongue strength following aunilateral pallidotomy. Use of tongue strengtheningexercises was one of several approaches used toincrease his speech intelligibility. While his overalltongue strength improved, his performance remainedvariable and conversational speech remained largelyunintelligible. Tongue strength training wasterminated and treatment approaches with morepromise were identified. Solomon and Stierwaltcommented that strengthening exercises might nothave been the best approach to remediating thispatient’s speech, even though he had reduced tonguestrength. These authors suggested that tasksaddressing the underlying motor problems of controland consistency of productions probably would havegreater impact on speech.

In summary, the use of strengthening exercisesfor treatment of acquired dysarthria in adults wasdescribed in a few case studies. No studies ofchildren were located. Reports of improvement inspeech were limited to individuals with flacciddysarthria and/or severely compromised function ofthe lips, jaw, and tongue for speech. There also are afew single case studies in which adults withdysarthria were reported to successfully alter muscletone using biofeedback, with positive effects observedon speech. It would appear that there is insufficientempirical evidence to evaluate the effectiveness ofthese approaches for persons with dysarthria.

Occupational and Physical TherapyIn the occupational and physical therapy

literature, several authors (e.g., Gordon, 1987; Math-iowetz & Haugen, 1994) have contrasted traditionalneurophysiological approaches with morecontemporary task-based approaches. As notedearlier, the former approaches are based on olderreflex and hierarchical theories of motor developmentand motor responses to CNS damage. The latterapproaches are based on systems models of motordevelopment and control and are influenced bycontemporary developmental and motor learningtheories. Treatment approaches based on a task-oriented model of therapy focus on accomplishingfunctional goals rather than normalizing movementpatterns. They involve more problem-solving by theclient and less “hands-on” facilitating by theclinician. The emphasis is on specific skill acquisitionversus enhancing quality of movement. Task-basedapproaches have emerged because of the limitationsof neurophysiological approaches. As Gordon (1987)stated, “essentially the facilitating[neurophysiological] approaches promised more thanthey could deliver. The hope was that we couldreinstate normal movement patterns. The reality wasthat even when we succeed in accomplishing this, wefind that patients use movements different from theones we teach them when confronted with functionaltasks in meaningful environments” (p. 11). Gordon’schapter is relevant across the rehabilitationdisciplines. It is recommended for clinicians lookingfor a very interesting, thoughtful, and reader-friendlydiscussion of the relationship between changes inscientific attitudes and new scientific knowledge andthe development of new therapeutic models.

Another relevant contribution from the physicaltherapy literature is the American Academy forCerebral Palsy and Developmental Medicine(AACPDM) evidence report on the effects of NDT(Butler & Darrah, 2000). In the report summary, theauthors stated that the preponderance of resultspresented in the evidence table did not confer anyadvantage to NDT over the alternatives to which itwas compared, other than immediate improvement indynamic range of motion. There was no consistentevidence that NDT changed abnormal motorresponses or facilitated more normal motordevelopment or more functional motor activities.Based on the evidence reported, the authors noted theneed for concerted efforts to investigate other therapyapproaches that may prove more clearly beneficial.They suggested that these new approaches mightgrow out of more contemporary theories of motordevelopment and motor learning and skill acquisition

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and may include task-oriented approaches based ondynamic systems concepts.

Treatment principles that are derived fromcontemporary motor learning theories have also beenproposed to guide speech therapy practice. Sampleprinciples based on Schmidt and Bjork (1996) andStrand (1995) include the following:

1. Training tasks are goal-directed and build on pre-viously learned behaviors;

2. Learning is context-specific, and training activi-ties should simulate real-world tasks (in this case,speech); and

3. The learner has the necessary prerequisite behav-iors (motivation, attention, effort/focus, trust), isactively involved as a problem solver, has multipleopportunities to practice attaining the goal, andhas knowledge of the results.

ConclusionsThe use of nonspeech oral motor treatment

approaches for persons with dysarthria iscontroversial. Acknowledged experts in assessmentand treatment of dysarthria are guarded in theiropinions about the use of these techniques to improvefunction. There is very little published data on the useof nonspeech oral motor treatments for treating speechfunction in persons with dysarthria. The informationthat does exist is limited to adults and primarilyaddresses the use of strengthening exercises. A few casestudies reported beneficial effects of strengtheningexercises for adults with acquired flaccid dysarthriaand/or severely compromised physiologic support forspeech. Similarly, a small number of adult case studiesreported positive changes in speech when biofeedbackwas used to decrease or increase abnormal muscle tone.In regard to children with dysarthria, no empiricalstudies were located in any of three major healthdatabases for either oral motor strengthening exercisesor neurotherapeutic approaches. Although severalcurrent therapy manuals advocate such techniques forchildren, none include efficacy data or even anecdotaldescriptions of treatment results. The search yielded noevidence to support the use of passive facilitativetechniques (like brushing, icing, application ofstretching or massage to inhibit reflexes, normalizeincreased muscle tone, or promote sensorimotorintegration) to improve speech function in children oradults with dysarthria.

Contemporary reviews of the use of traditionalneurophysiological treatment approaches by physicaland occupational therapists suggest that theseapproaches are not effective in improving functionalmotor behaviors. A recent AACPDM evidence report on

the effects of NDT, which has strongly influenced thedevelopment of nonspeech oral motor neurothera-peutictechniques, did not find consistent evidence that NDTchanged abnormal motor responses or facilitated morenormal motor development or functional motoractivities in children with cerebral palsy. There is a shiftin the occupational and physical therapy literatureaway from these more traditional neurophysiologicaltherapy approaches to ones based on more task-orientedmodels.

The AACDPM reports list levels of evidence based onwhether evidence is empirical or not and, if so, the rigorof the experimental design. The highest level of evidenceis Level I, which is group or single subject randomizedcontrolled trials. The lowest is Level V, which rangesfrom descriptive case studies, anecdotes, expert opinion,and theories based on physiology, to “common sense/first principles.” The little “evidence” that wasidentified for the effects of nonspeech oral motortreatment for persons with dysarthria falls at this lowestlevel. Clearly, if these treatments are used with theexpectation that they will improve speech function, theireffects need to be documented and reported. Studies ofthe relative effects of these treatments compared to otherapproaches, such as those based on more recenttheoretical models of motor development and control,are also required. There are alternative treatmentapproaches for dysarthria that have evidence to supporttheir effectiveness, while evidence to support theeffectiveness of nonspeech oral-motor treatmentapproaches for dysarthria is lacking. Until thisinformation is available, the clinician may want toconsider a set of guiding questions to assist in clinicaldecision-making. These are based on the literature andthe author’s “common sense” and may be helpful whenconsidering the use of nonspeech treatment approachesfor persons with dysarthria.

• What is the overarching goal of treatment?

Is speech the highest priority for the individual’scommunication needs and goals?If speech is a priority, remember that in dysarthria,the impairment may extend to structures beyondthe oral arti-culators. The articulatory disorderneeds to be considered in relation to function of therespiratory, laryngeal, and velo-pharyngeal sys-tems. Will effective treatment of articulatory dis-turbances need a broader treatment approachrather than a focus on just articulatory training?

• Will the selected exercises result in improved per-formance on the target behaviors?

• Is there a better technique available to accomplishthe goal? As an ethical practitioner, one mustalways consider the principles of beneficence (dogood) and non-maleficence (do no harm). Use of an

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ineffective or unnecessary technique has the po-tential to do harm because it is wasting client timeand resources that could be spent on more efficient(better outcome in less time) treatment approachesto achieve functional speech goals.

• Are there contraindications to using therapeuticnon-speech oral motor exercises?

• Are there structural constraints (e.g., trismus, largetonsils, complete lip paralysis) on oral function?

• Is there a potential for harm (e.g., temporoman-dibular joint vulnerability)?

• Is the client motivated to participate in a therapeu-tic exercise program? Attention, motivation, andeffort are needed for learning.

• If strengthening exercises are used, can the client,family, and clinician invest the time needed for theoral motor exercises to make a difference? Theclient must “overload” muscle to change itsstrength so multiple repetitions and sets are neededseveral times a day over several weeks.

• How will the individual know that he or she hasaccomplished the task successfully (i.e., achievedthe goal)?

• How will you know when the goal of the exerciseshas been met?

• What will the individual have learned when thegoal of the exercises has been met?

• How will you tell if treatment is working?

• How will you document and report the results ofthe treatment?

Dr. Megan M. Hodge is an associate professor in theDepartment of Speech Pathology and Audiology at theUniversity of Alberta in Edmonton, Alberta, Canada.

ReferencesASHA (1993). Orofacial myofunctional disorders: Knowledge

and skills. Asha, 35 (Suppl. 10), 21-23.

Bobath, K., & Bobath, B. (1984). The neuro-developmentaltreatment. In D. Scrutton (Ed.), Management of the motordisorders of children with cerebral palsy (pp. 6-18). Philadel-phia: J. B. Lippincott.

Boshart, C. (1998). Oral motor analysis and remediation tech-niques. Temecula, FL: Speech Dynamics.

Butler, C., & Darrah, J. (2001). Effects of neurodevelopmentaltreatment (NDT) for cerebral palsy: An AACPDM evi-dence report. Developmental Medicine and Child Neurology,43, 778-790.

Chapman Bahr, D. (2001). Oral motor assessment and treatment:Ages and stages. Boston: Allyn & Bacon.

Duffy, J. (1995). Motor speech disorders: Substrates, differentialdiagnosis and management. St. Louis: Mosby.

Dworkin, J. (1991). Motor speech disorders: A treatment guide. St.Louis: Mosby Year Book.

Gordon, J. (1987). Assumptions underlying physical therapyintervention: Theoretical and historical perspectives. InJ. Carr & R. Shepherd (Eds.), Movement science: Founda-tions for physical therapy in rehabilitation (pp. 1-30). Rockville,MD: Aspen Publishers.

Hanson, M., & Barrett, R. (1988). Fundamentals of orofacial myo-logy. Springfield: Charles C. Thomas.

Harris B., & Murry T. (1984). Dysarthria and aphagia: A casestudy of neuromuscular treatment. Archives of PhysicalMedicine and Rehabilitation, 56, 408-412.

Hodge, M. M,. & Wellman, L. (1999). Management of childrenwith dysarthria. In A. Caruso & E. Strand (Eds.), Clinicalmanagement of motor speech disorders in children (pp. 209-280). New York: Thieme Medical Publishers.

Knott, M., & Voss, D. (1968). Proprioceptive neuromuscular facili-tation (2nd ed.). New York: Harper & Row.

Love, R. (2000). Childhood motor speech disability (2nd ed.). Bos-ton: Allyn and Bacon.

Mathiowetz, V., & Haugen, J. (1994). Motor behavior research:Implications for therapeutic approaches to CNS dysfunc-tion. American Journal of Occupational Therapy, 48, 733-745.

Mysak, E. (1983). Treatment of deviant phonological systems:Cerebral palsy. In W. H. Perkins (Ed.), Dysarthria andapraxia: Current therapy of communication disorders (pp. 3-23). New York: Thieme-Stratton.

Nemec, R., & Cohen, K. (1984). EMG feedback in the modifica-tion of hypertonia in spastic dysarthria: A case report.Archives of Physical Medicine and Rehabilitation, 65, 103-104.

Netsell, R., & Daniel, B. (1979). Dysarthria in adults: Physiologi-cal approach to rehabilitation. Archives of Physical Medi-cine and Rehabilitation, 60, 502-508.

Robertson, S., & Thompson, F. (1986). Working with dysarthricclients: A practical guide to therapy for dysarthria. Tucson:Communication Skill Builders.

Rood, M. (1956). Neurophysiological mechanisms utilized inthe treatment of neuromuscular function. American Jour-nal of Occupational Therapy, 10, 220-225.

Schmidt, R., & Bjork, R. (1996). New con-ceptualizations ofpractice. In D. Robin, K. Yorkston, & D. Beukel-man(Eds.), Disorders of motor speech: Assessment, treatment andclinical characterization (pp. 3-23). Baltimore, MD: Paul H.Brooks.

Solomon, N., & Stierwalt, J. (1995). Strength and endurancetraining for dysarthria. ASHA Division 2, Neurophysiologyand Neurogenic Speech and Language Disorders Newsletter,5 (4), 13-16.

Strand, E. (1995). Treatment of motor speech disorders inchildren. Seminars in Speech and Language, 16, 126-139.

Theodoros, D., & Thompson-Ward, E. (1998). Treatment ofdysarthria. In B. E. Murdoch (Ed.), Dysarthria: A physiologi-cal approach to assessment and treatment (pp. 130-175).Cheltenham, UK: Stanley Thornes.

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Tonkovich, J., Boettcher, T., & Rambow, M. (2001). Dysarthriarehabilitation (2nd ed.). Austin, TX: Pro-ed.

Yorkston, K., Beukelman, D., Strand, E., & Bell, K. (1999).Management of motor speech disorders in children and adults(2nd ed.). Austin, TX: PRO-ED.

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Augmentative and Alternative Communication Intervention inNeurogenic Disorders With Acquired Dysarthria

Pamela MathyArizona State UniversityTempe, AZ

A diverse group of individuals with acquiredneurogenic disorders and severe dysarthria maybenefit from augmentative and alternativecommunication (AAC). These include persons withtraumatic brain injury (TBI), stroke, and those withdegenerative neurological diseases such asamyotrophic lateral sclerosis (ALS), Parkinson’sdisease (PD), Huntington’s disease (HD) and multiplesclerosis (MS; Doyle, Kennedy, Jausalaitis, & Phillips,2000; Klasner & Yorkston, 2000; Mathy, Yorkston, &Gutmann, 2000; Yorkston, 1996). The etiology,incidence, and characteristics of these disorders aredescribed elsewhere (e.g., Doyle et al., 2000; Klasner &Yorkston, 2000; Mathy, Yorkston, & Gutmann, 2000;Yorkston, Miller, & Strand, 1995).

January 1, 2001, the United States’ nationalpublic health care system, Medicare, responded to thegrowing body of evidence documenting the efficacy ofAAC interventions for individuals with dysarthriaand other severe expressive communication disorders(aphasia, apraxia, aphonia) by reversing thelongstanding policy of non-reimbursement of AACdevices (AAC/RERC Web site). This policy changewas a major step in the journey to bring AACintervention into standard speech/languagepathology practice for persons whose speechfunctioning is so impaired that they are unable tomeet their communicative needs in activities of dailyliving. For the first time, AAC intervention, includingassessment, treatment and prescription of high techAAC devices (referred to as Speech GeneratingDevices, SGD, by Medicare) has national Health CareFinancing Administration Common ProcedureCoding System (HCPCS) billing codes. Moreover,since the Medicare policy took effect, privateinsurance carriers have begun to modify theircoverage policies for AAC devices and services (L.Golinker, 2002, personal communication). Therefore,the goal of this article is to provide an update on AACintervention focusing on individuals with severeacquired dysarthria. The article includes a multi-dimensional clinical decision-making model for AACintervention in dysarthria, an overview of thecomponents of AAC intervention, and a summary ofrecent research in evidence-based practice in AACwith individuals who have dysarthria.

Clinical Decision-Making ModelThe process of clinical decision-making involves

determining the stage of functioning or progression ofa disorder and providing evidence-based treatmentsat each level. This practice is well established in themedical profession and is becoming more common inspeech language pathology. For example, Yorkstonand Beukelman (1999, 2000) described a treatmentstaging strategy for individuals with progressivedysarthria. They described five stages, beginning withStage 1—“no detectible speech disorders” andculminating with Stage 5—“no functional speech.”Proposed treatments ranged from providinginformation for planning for the future loss of speechin Stage 1, to the use of low technology and hightechnology AAC strategies in Stage 5. An example ofthis model was provided by Mathy, Yorkston, andGuttman (2000) who presented an overview of AACintervention in ALS. They included a detaileddescription of the staging of AAC intervention, basedon stages of speech and physical functioningtypically observed during the progression of thedisease.

An AAC treatment staging strategy thatencompasses the range of disorders associated withacquired dysarthria requires a multidimensionalperspective. This approach addresses speech,language, cognitive, physical, and visual functioningas well as progression (static or progressive), andprognosis for regaining functional speech withtreatment. At the end of this paper is a list of thestages of functioning in speech, language (literacy),cognitive, visual, and physical domains relevant forAAC intervention planning, in disorders associatedwith acquired dysarthria (“Functional Staging forAAC Intervention”).

Speech Staging

The planning and implementation of AACintervention differs based on the etiology of thedysarthria. In degenerative diseases, for example,speech decline into stage 2 and beyond may be apresenting or early symptom, such as with bulbaronset ALS and HD (Klasner & Yorkston, 2000; Mathyet al., 2000; Yorkston, Miller, & Strand, 1995). Incontrast, dysarthria may not appear until late in thecourse of the disease in PD and MS (Armstrong, Jans,

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& MacDonald, 2000; Klasner & Yorkston, 2000;Porter, 1989; Yorkston et al., 1995). As well asevidencing persistent changes over time, speechperformance in people with degenerative dysarthriamay show fluctuation during the course of a day dueto the effects of fatigue or medication. In some cases(e.g., MS), speech also may oscillate betweenfunctional stages due to exacerbations and remissionsof the disease. These factors may influence AAC useand must be taken into consideration in interventionplanning.

In all of the studies reviewed for this paper, theauthors stressed that an essential component ofsuccessful intervention was the provision of regularfollow up to assess speech functioning and assistindividuals with degenerative diseases and theirfamilies to plan for the future. (Armstrong et al., 2000;Ball, Willis, Beukelman, & Pattee, 2001; Doyle &Phillips, 2001; Klasner & Yorkston, 2000, 2001; Porter,1989). For example, Ball and colleagues (2001)stressed the importance of monitoring speechfunctioning over time, using objective measures ofspeech intelligibility, speaking rate, voice, andresonance. Their longitudinal monitoring of speech inpersons with ALS showed that rapid (within 2 to 4months) decline in speech functioning into Stage 3and below consistently followed a reduction inspeaking rate to half of that predicted for non-impaired speakers. The implications of these resultsare that once speaking rate has declined to this point,the decision to begin the assessment for a hightechnology AAC device should occur immediately, toallow time for the funding process and for theindividual to learn to use the AAC device beforeneeding to rely on it.

In contrast to degenerative dysarthria, peoplewith TBI may show a recovering pattern of speechfunctioning. Based on their review of speech recoveryin TBI, Doyle, Kennedy, Jasualaitis, and Phillips(2000) concluded that the majority of persons withTBI recover speech functioning to the point wherethey do not need to rely on AAC or require it only inchallenging speaking situations (e.g., noise,unfamiliar communication partners). Doyle andcolleagues also found a relationship between speechand cognitive recovery in adults with TBI. Whenspeech recovered, it typically occurred by the middlestage of cognitive recovery. This corresponds toStages V and VI in the Levels of CognitiveFunctioning (LOCF; Hagen, 1984). Those who did notrecover speech by this stage were likely to havepermanent speech impairment. The rate of recovery ofspeech in the studies reviewed by Doyle andcolleagues (2000) ranged from 3 to 48 months post-injury. An example of a protracted period of recovery

was given by Light, Beesley, and Collier (1988), whodocumented improvement of speech in an adolescentgirl across a 44-month period. During that time, shebegan augmenting her communication using lowtechnology AAC strategies and then moved tomicrocomputer-based devices. Finally, she regainedthe ability to rely primarily on natural speech to meether communication needs.

Cognitive Staging

Concurrent cognitive processing deficits are seenin both degenerative and acquired motor speechdisorders (Armstrong et al., 2000; Doyle et al., 2000;Klasner & Yorkston, 2000, 2001; Mathy et al., 2000;Yorkston et al., 1995). Therefore, the intervention teamshould be prepared to examine functional cognitiveskills as part of AAC intervention. This includes useof information from formal cognitive assessments andscales (e.g., LOCF; Hagen, 1984) and observation ofthe person’s ability to learn to communicate withtargeted AAC strategies and devices. In addition,AAC interventions for persons with both degenerativeand acquired disorders must accommodate changing(i.e., declining or improving) cognitive status overtime.

The five stages of cognitive functioning describedin “Functional Staging for AAC Intervention”highlight important skills related to the selection anduse of AAC strategies and devices. For example, withindividuals who have cognitive impairmentsaffecting attention, memory and learning (Stage 3 orbelow), published reports have documented greatersuccess with AAC devices and strategies thatcapitalize on well-learned skills (Armstrong et al.,2000; Doyle et al., 2000; Klasner & Yorkston, 2000,2001; Mathy et al., 2000). For example, Doyle andcolleagues (2000) found that persons unfamiliar withthe QWERTY layout did better with an alphabeticletter arrangement on a low technology or hightechnology AAC device.

Language (Literacy) Staging

As part of the AAC assessment process, it isimportant to determine the person’s ability toconstruct messages using spelling. Most adults withthe neurogenic disorders discussed in this paperretain the ability to spell, but cognitive processingdeficits may impede their ability to use spellingindependently to communicate (Doyle et al., 2000). Toconstruct messages through spelling, thecommunicator must formulate the message and keepit in mind long enough to deliver it through a processof searching for and selecting each letter to spell themessage. Motor impairments and languageimpairments, such as word retrieval deficits, also may

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increase the cognitive load of message construction(Doyle et al., 2000).

Visual Staging

Many individuals with acquired dysarthria haveconcomitant visual processing deficits that affect theirability to use and benefit from features available onAAC devices. Although formal assessment of visualprocessing may be helpful, as was suggested inrelation to cognitive functioning, determination of theeffects of visual functioning may best be determinedby observing performance with target AACtechnologies during the assessment process. Forexample, word prediction, a common feature on hightechnology devices, requires the user to look awayfrom the keyboard to the screen to determine if theprogram has predicted the target word. Individualswith visual tracking deficits (functioning in Stage 2 orbelow) may have difficulty using word prediction orother features that require rapid shifts of gaze.

Upper and Lower Extremity Staging

The staging of upper and lower extremityphysical functioning also influences the selection ofhigh technology and low technology AAC aids. Forexample, an individual who is at Stage 1 in upperextremity physical functioning, but at Stage 5 inspeech functioning, may benefit from a high techdevice with a full-sized keyboard to allow for a typingrate (communication rate) that is as rapid as possible.Before an individual enters the final phase of AACdevice selection, however, he and his caregivers andservice providers should consider the stage of lowerextremity physical functioning. Individualsfunctioning at Stage 3 or above in ambulation usuallywant a device that is small enough to be carried byhand or in a purse or “fanny pack,” whereas thoseusing a wheelchair may require a wheelchairmounting system to transport the device. A teamevaluation that includes an occupational andphysical therapist is recommended for the assessmentof upper and lower extremity functioning and todetermine the best options for the person to accessand transport AAC devices.

Intervention StrategiesThe next section is a review of AAC intervention

strategies ranging from those designed to supplementnatural speech to interventions for individuals whosespeech is no longer functional. In each section, resultsfrom published studies of the use of AACinterventions by people with acquired dysarthria willbe presented when available.

Speech Supplementation

Even when their speech is moderately to severelyunintelligible, most individuals with dysarthriacontinue to rely on it as their primary mode ofcommunication. In such instances, speechsupplementation strategies, also referred to as signal-independent strategies (Yorkston, Beukelmen, Strand,& Bell, 1999), should be evaluated. These strategiesare designed to provide listeners with contextualinformation external to the speech signal, to increasethe comprehensibility of the message. Such strategiesinclude gestures, alphabet supplementation, topicsupplementation, and managing the environment(e.g., reducing background noise).

When using alphabet supplementation, thespeaker points to the first letter of each word on analphabet display as the word is spoken, therebyproviding the listener with the orthographic-phoneticcontext to support speech production and increasingthe listener’s ability to understand the message(Yorkston et al., 1999). For topic supplementation, theuser indicates the topic of the message prior tospeaking it, to provide the listener with a frame ofreference in hopes of increasing the accuracy ofunderstanding (Yorkston et al., 1999). Each of thesemethods can be used alone or in combination withlow technology or high technology communicationdisplays. The user can point manually, if possible, oruse a head stick or head-mounted optical pointer.

Hustad and Beukelman (2000) reviewed theresults of published experimental studies examiningthe effects of speech supplementation strategies,including alphabetic cues and topic cues, on sentenceand discourse intelligibility. They found thatlisteners’ ability to transcribe sentences and discourseproduced by dysarthric speakers was better withalphabetic and topic cues when compared to no cues.Results varied based on the type of cue. Alphabeticcues were more beneficial than topic cues, andcombined cues (alphabetic and topic) had the greatesteffect on improving intelligibility. In addition, theseverity of dysarthric speech also affected results. Ingeneral, speech supplementation produced thegreatest improvement in intelligibility for individualswith moderate and severe dysarthria compared tothose with profound dysarthria.

Although a number of studies have examined thepotential of speech supplementation to improvespeech intelligibility of dysarthric speakers, Hustadand Beukelman (2000) found few studies thatexamined its use in daily communication. Other areasfor future research include examination of patterns ofuse of speech supplementation strategies byindividuals who have access to them, partner

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attitudes and acceptance of speech supplementation,and cognitive/linguistic skills required to use speechsupplementation strategies successfully. Research onlistener attitudes toward speech supplementation is acurrent focus of the Research Engineering ResearchCenter (RERC) on AAC (http://www.aac-rerc.com).As part of this project, Hustad (2001) examinedlistener attitudes toward three speechsupplementation strategies: topic cues, alphabet cues,and combined cues. Listeners indicated a higherdegree of communicative effectiveness andwillingness to interact with the dysarthric speakerwhen combined cues (topic and alphabet) were used.

When Speech Is Not Functional

When speech is no longer functional,intervention becomes focused on AAC methods thatwill maintain the person’s communicativefunctioning in activities of daily living. Researchexamining the outcomes of AAC intervention forpeople with ALS (Doyle & Phillips, 2001; Mathy et al.,2000) indicates that these individuals use differentAAC methods, depending on factors such as theircommunication goal and their communicationpartner. For example, Mathy and colleagues (2000)found low technology methods were preferred tocommunicate a simple request such as for somethingto drink, whereas high technology methods were usedto communicate detailed directives, talk on the phone,and tell stories. These results emphasize theimportance of providing a continuum of AACmethods that can be employed, depending on the userneeds and communicative circumstances.

Unaided AAC Methods

Unaided AAC methods are those that do notrequire any external device or chart, such as facialexpressions, responses to yes-or-no questions,gestures, and partner-assisted auditory scanning.With partner-assisted auditory scanning, thecommunication partner verbally lists the alphabet ora predetermined list of options until the userindicates that the desired element has been reached,and then the process is repeated until the message iscomplete. When this method is used to spellmessages, the alphabet may be segmented in half orinto quarters to speed up the message constructionprocess (e.g., A-M, M-Z). The user can indicate a letterthrough any means established by the user and thelistener (e.g., gesture, vocalization, buzzer switch).For example, the author worked with a patient withALS who used a buzzer switch (e.g., one buzz for“yes,” two buzzes for “no”) with partner-assisted-auditory scanning. At a clinic visit, he and his wifeshared how they used this method to communicate inbed at night. When she helped him into bed, his wife

clipped his buzzer switch to his pillow. When heneeded something, he moved his head to access thebuzzer to wake his wife. Once awake, his wife beganthe process of assisting him to construct his messageusing partner-dependent auditory scanning.

As unaided AAC methods require minimalphysical movement, they are appropriate forindividuals functioning across the range of physicalstages described in “Functional Staging for AACIntervention.” They can also be used in situationswhere the partner cannot look at or see the listener(e.g., in the dark, riding in a car) or when the AACuser has reduced visual acuity and/or visualprocessing deficits. In addition, partner-assistedauditory scanning can be adjusted to accommodatefor a range of cognitive and language (literacy)functioning. For example, individuals who have agood attention span and unimpaired spelling abilitycan use partner-dependent auditory scanning to spellmessages. Those with reduced attention span andspelling skills may benefit from a hierarchy of yes andno questions, asked in a consistent order to narrowdown the message as illustrated in “Example of aYes/No Question Heirarchy” at the end of this article.

Research on the use of unaided AAC methods islacking. There are, however, a few published reportson their use by individuals with acquired neurogeniccommunication disorders. Mathy and colleagues(2000) reported on AAC use patterns by people withALS. A total of 24 subjects were included, 12 withspinal onset and 12 with bulbar onset of the disease.At the time of the study, all subjects functioned atStage 5 on the speech scale. All subjects reportedusing facial expression and responses to yes-or-noquestions. Five of the 12 patients with spinal onsetALS reported using partner-dependent auditoryscanning, but none of the patients with bulbar onsetALS used this method. The latter group functioned atStage 1 or 2 in upper extremity functioning and atStage 3 or above in lower extremity functioning and,therefore, had less need to rely on partner-dependentcommunication methods than did the patients withspinal presentation, who all functioned at Stage 5 inboth upper and lower extremity staging at the time ofthe study.

In their long-term case studies of AACintervention for four people with ALS, Doyle andPhillips (2001) found that although the participantshad access to high technology AAC devices, theyprimarily relied on unaided approaches during thelate stage of the disease. This stage correspondedwith reduced motor abilities and a narrowing ofcommunication partners and topics. During the finalstage of the disease, subjects spent most of their timein bed cared for by family members and

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communicated primarily to indicate basic needs. In asimilar vein, Porter (1989) presented a case study ofAAC intervention for a man during late stage MS. Dueto motor and visual deficits, he relied primarily onauditory scanning (both partner-assisted andautomatic scanning). Finally, Soderholm, Meinander,and Alaranta (2001) reported on the use of AAC by 17patients with locked-in syndrome. The initialcommunication methods used by all of theseindividuals included eye movements to indicateresponses to yes-or-no questions and respond whenthe alphabet was “read-out” by the communicationpartner.

Teaching unaided AAC strategies, particularlyestablishing a means to answer yes-or-no questions,is often the first step in the AAC intervention process.Moreover, research examining the use of thesestrategies with individuals with acquired dysarthriaindicates that the strategies continue to be used aspart of the individual’s communication repertoire,even when the user has access to high technologyAAC devices. This is particularly true for individualswith reduced upper extremity functioning.

Low Technology AAC

Low technology AAC methods include alphabetboards or picture symbol communication displays,accessed using either manual direct selection, opticaldirect selection, or partner-assisted manual scanning.Partner-assisted manual scanning requires thecommunication partner to point sequentially to letterson the alphabet board, written message lists, orpicture symbol displays until the user indicates thatthe desired element has been reached. The process isrepeated until the message is completed. It is usefulfor the partner to write down the elements of amessage during the message construction process sothat both partners can keep track of the message as itis created.

As with unaided AAC methods, an advantage oflow technology AAC methods is their cost and theflexibility to be adjusted by the communicationpartner to meet the physical, cognitive, and linguisticabilities of the AAC user. Low technology AACstrategies also allow for immediate improvement ofcommunicative functioning and provide a means topractice skills necessary to be successful with hightechnology AAC methods. For example, individualsin Stage 5 in upper extremity functioning may needpractice to become proficient in accessing a switch fora high technology AAC device that uses row-columnscanning. Practice can be accomplished with partner-assisted manual scanning by having the user access abell or buzzer placed in the most physicallyaccessible location to indicate when the partner has

reached the desired message element on the manualscanning display. Partner demands for timing andaccuracy can gradually be increased to simulate thedemands of scanning on a high technology AACdevice.

A few recent studies have examined lowtechnology AAC use by individuals with acquireddysarthria, including those with ALS (Doyle &Phillips 2001; Mathy et al., 2000), HD (Klasner &Yorkston 2001), and PD (Armstrong et al., 2000). Intheir report of AAC usage patterns in ALS, Mathy andcolleagues (2000) found that the majority of thesubjects with spinal onset (9/12) and all of thesubjects with bulbar onset (12/12) used lowtechnology AAC techniques; however, the techniquesdiffered based on physical abilities. All of the bulbaronset subjects had adequate upper extremityfunctioning at the time of the study and thereforeused handwriting as their primary low technologymethod. The spinal onset group relied on alphabetboards accessed with partner-dependent visualscanning or optical pointing. The four subjects withALS studied by Doyle & Phillips (2001) included twowith bulbar onset and two with spinal onset ALS.Both of the subjects with bulbar onset usedhandwriting in the early and middle stages of thedisease when it was still physically possible. One ofthe subjects with spinal onset used an Eye-Gazeboard, and no low technology strategies weredescribed for the other subject with spinal onset ALS.

Klasner and Yorkston (2001) described the use oflow technology AAC strategies termed “cognitive andlinguistic supplementation” for WD, a 44-year-oldman diagnosed with HD in 1993. They used an in-depth, guided interview process with WD and hiswife to identify the communicative activities that weremost important to him and that he wished to haveassistance to maintain. These included involvementin running the household and family decision-making and talking to his wife and friends about hisdaily life. Intervention for conversation with his wifeinvolved the use of linguistic-cognitivesupplementation with scripts. For example, WDwanted to be able to talk to his wife about what he didat home during the day while she was at work. Tosupport this activity, a notebook with shortdescriptions of the activities in which WD typicallyengaged during the day was developed. Duringtherapy, WD learned to trigger his scripts of variousactivities using key words and his wife learnedstrategies to facilitate effective conversation with WD,such as beginning with similar questions each day.

Armstrong and colleagues (2000) surveyedspeech language pathologists in Scotland regardingtheir experiences implementing AAC with

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individuals diagnosed with PD. Of the 32 therapistsinitially contacted, 23 responded. When queriedabout their application of low technology AACdevices, respondents indicated most frequent use ofamplifiers, alphabet boards, picture charts, andpacing boards. Nearly half of those surveyedindicated a low rating of success with low technologywith PD clients. Among the primary reasons given forthis rating included cognitive/memory problems,preference for speech, and lack of motivation.

As is the case with unaided strategies, lowtechnology AAC strategies are inexpensive andhighly adaptable to needs of the user. Continuedresearch on low technology AAC strategies is neededto support evidence-based AAC practice withindividuals who have acquired dysarthria.

High Technology AAC

Traditionally, high technology AAC devices areplaced in two categories: dedicated devices andintegrated/multipurpose devices. Dedicated devicesare designed and manufactured specifically for thepurpose of augmentative communication. Theyprovide a means to select message elements on thedevice (e.g., a keyboard, switch scanning, orcombinations of input methods), a means to formulatemessages (e.g., iconic codes, orthography, orcombinations of message construction elements), anda mode of output (e.g., synthesized speech ordigitized speech). Multipurpose/integrated AACdevices consist of standard microcomputer platformsand special software and hardware. The specialsoftware instructs the operating system (e.g.,Windows, Windows CE, Macintosh OS) to work witha speech synthesizer, and provides access to thecomputer through a variety of methods including amodified keyboard, joystick, or mouse, and optical orswitch scanning.

As indicated above, the means to access the AACdevice is an essential component. Access technologiesare designed to accommodate the user’s physicalabilities to make selections. These technologies rangefrom simple micro-switches to brain-computerinterface technologies in which the user moves thecursor on the computer screen by learning to controlthe amplitude of mu and beta rhythms inelectroencepha-lographic recordings from thesensorimotor cortex (Wolpaw, Bir-baumer, Heetderks,McFarland, Peckham, Schalk, Donchin, Qua-trano,Robinson, & Vaughan 2000).

In their studies of AAC technology usagepatterns with people with ALS, Doyle and Phillips(2001) and Mathy and colleagues (2000) reported thatall subjects used high technology devices. People with

bulbar onset were more likely to use small, keyboard-based devices such as the LinkTM and theLightWRITERTM. These devices were accessed usingmanual direct selection in the early to middle stagesof the disease process (Doyle & Phillips, 2001), andadapted to be used with a keyguard (LinkTM) andscanning (LightWRITERTM) as upper extremityfunctioning declined in the late stage of the diseaseprocess. These results underscore the need to plan forupper and lower extremity functioning decline, whenselecting high technology devices for people withdegenerative diseases.

All of the individuals with spinal-onset ALSstudied by Doyle and Phillips (2001) and Mathy andcolleagues (2000) used multipurpose devices, such asEZ KeysTM, accessed using single-switch scanning ortwo-switch Morse Code. This multipurpose AACdevice includes the EZ KeysTM software implementedon a notebook computer (the package is sold as theFreedom 2000TM). In addition to providing a means forspeech communication, this program also allows theuser to apply his or her physical access method (e.g.,single switch scanning, Morse Code, Joystick) for fullcomputer access. Mathy and colleagues found thatsubjects with spinal onset ALS used their hightechnology AAC devices extensively for computeractivities, such as written communication and email,as well as for speech augmentation.

In their survey of AAC use by individuals withPD, Armstrong and colleagues (2000) found that theLightWRITERTM was the most frequently used devicewith this group. The respondents in the studyreported a generally higher level of success with hightechnology AAC than with low technology strategies.In their conclusions from this preliminary study, theauthors stressed the need to provide early and regularspeech/language intervention for people with PD toenable timely introduction of AAC intervention asneeded. They also stressed the need for controlledresearch examining the efficacy of AAC interventionin PD.

Medicare groups all dedicated AAC devicesunder four codes based on the followingcharacteristics: type of speech output (synthesized ordigitized), message type (pre-recorded messages orformulated “spelled” messages), recording time (fordigitized devices only—shorter than 8 minutes orlonger than 8 minutes), and access method optionsavailable (direct physical contact only or multipleaccess methods). AAC software programs forintegrated devices have a separate Medicare code.There are additional codes for device accessories andwheelchair mounting systems. Further informationregarding Medicare guidelines for AAC assessment

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and funding can be found on the Medicareinformation Web site (AAC/RERC Web site).

Future Research NeedsAs indicated in the beginning of this article, the

documentation of positive outcomes of AACintervention for individuals with severe expressivecommunication disorders was essential to bringabout the change in Medicare reimbursement policyfor AAC intervention. For continued optimalintervention for individuals with AAC needs, the fieldmust continue to provide evidence. As illustrated bythe publications reviewed in this paper, most of theinformation currently available to support evidence-based practice in AAC for people with acquireddysarthria comes from clinical experience and casestudies. Although this information is useful toillustrate the effects of AAC intervention withindividuals with various disorders, there is also aneed for controlled studies examining the efficacy ofAAC interventions for individuals with acquireddysarthria across the etiological groups. A suggestedlist of questions for future research includes thefollowing:

• What are the most effective service deliverymodels for assuring the timely provision of AACintervention across the etiological groups?

• What features of AAC devices and accessoriesdo individuals prefer across the etiologicalgroups?

• Which AAC devices are the most effective forindividuals from different etiological groups withdifferences in cognitive, literacy, visual, and physi-cal functioning?

• Which cognitive skills and deficits have the great-est impact on the success of AAC intervention?

• Which features of AAC devices and accessories dofamily members and friends of AAC users prefer?

The field of AAC is diverse and challenging, butthere are numerous resources (e.g., books, workshops,World Wide Web sites) available for speech languagepathologists and other professionals to assist them inassessment, funding, and treatment planning in AACintervention. In addition to the AAC-RERC Web site,which contains information on Medicare anddescriptions of research in AAC currently in process,the site hosted by The Hattie B. Munroe and the BarkelyMemorial Augmentative Communication Centers isanother valuable resource (http://aac.unl. edu/). Thematerials provided on this site include links to all of thevendors and manufacturers of AAC devices, AACdevice tutorials, treatment resources, and more.Moreover, with the lifting of barriers to funding AAC

devices and services by Medicare and private insurancecarriers, there has never been a more rewarding time toprovide AAC intervention for individuals with acquiredneurogenic disorders.

Dr. Pamela Mathy is Director of Clinical Services in theDepartment of Speech and Hearing Science at Arizona StateUniversity in Tempe.

ReferencesAAC-RERC Web site. http://www.aac-rerc.com—Medicare

Funding of AAC Technology. Information obtained on10/16/2002. Supported in part by the National Instituteon Disability and Rehabilitation Research (NIDRR).

Armstrong, L., Jans, D., & MacDonald, A. (2000). Parkinson’sdisease and aided AAC: Some evidence from practice.International Journal of Communication Disorders, 35 (3),377-389.

Ball, L. J., Willis, A., Beukelman, D. R., & Pattee, G. L. (2001). Aprotocol for identification of early bulbar signs in amyo-trophic lateral sclerosis. Journal of Neurological Sciences,191, 43 – 53.

Doyle, M., Kennedy, M., Jausalatis, G., & Phillips, B. (2000). AACand traumatic brain injury: Influence of cognition onsystem design and use. In D. Beukelman, K. M. York-ston,& J. Reichle (Eds.), Augmentative and alternative communi-cation for adults with acquired neurologic disorders (pp. 271-304). Baltimore: Paul H. Brookes.

Doyle, M., & Phillips, B. (2001). Trends in augmentative andalternative communication use by individuals with Amyo-trophic Lateral Sclerosis. AAC Augmentative and Alterna-tive Communication, 17, 167-178.

Hagen, C. (1984). Language disorders in head trauma. In A.Holland (Ed.), Language disorders in adults (pp. 257–258).Austin, TX: PRO-ED.

Hustad, K. C. (2001). Unfamiliar listeners’ evaluation of speechsupplementation strategies for improving the effective-ness of severely dysarthric speech. AAC Augmentative andAlternative Communication, 17, 213 – 220.

Hustad, K. C., & Beukelman D. R. (2000). Integrating AACstrategies with natural speech in adults. In D. Beukelman,K. M. Yorkston, & J. Reichle (Eds.), Augmentative andalternative communication for adults with acquired neurologicdisorders (pp. 83-106). Baltimore: Paul H. Brookes.

Klasner, E. R.,& Yorkston, K. M. (2000). AAC for HD andParkinson’s Disease: Planning for change. In D. Beulkman,K. M., Yorkston, & J. Reichle (Eds.), Augmentative andalternative communication for adults with acquired neurologicdisorders (pp. 233-271). Baltimore: Paul H. Brookes.

Klasner, E. R., & Yorkston, K. M. (2001). Linguistic and cognitivesupplementation strategies as augmentative and alterna-tive communication techniques in Huntington disease:Case report. AAC Augmentative and Alternative Communi-cation, 17, 154-160.

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Light, J., Beesley, M., & Collier, B. (1988). Transition throughmultiple augmentative and alternative communica-tion systems: A three year case study of a head injuredadolescent. AAC Augmentative and Alternative Commu-nication, 4, 2-14.

Mathy, P., Yorkston, K. M., & Gutmann, M. (2000). Augmenta-tive communication for individuals with AmyotrophicLateral Sclerosis. In D. Beukelman, K. M. Yorkston, & J.Reichle (Eds.), Augmentative and alternative communicationfor adults with acquired neurologic disorders (pp. 183-232).Baltimore: Paul H. Brookes.

Porter, P. B. (1989). Intervention in end stage of MultipleSclerosis: A case study. AAC Augmentative and AlternativeCommunication, 5, 125-127.

Soderholm, S., Meinander, M., & Alaranta, H. (2001). Augmen-tative and alternative communication methods in Locked-In Syndrome. Journal of Rehabilitation Medicine, 33, 235-239.

Wolpaw, J. R., Birbaumer, N., Heetderks, W. J., McFarland, D.J., Peckham, P. H., Schalk, G., Donchin, E., Quatrano, L. A.,Robinson, C. J., & Vaughan T. M. (2000). Brain-computerinterface technology: A review of the first internationalmeeting. IEEE Transactions on Rehabilitation Engineering,8 (2), 164-173.

Yorkston, K. M. (1996). Treatment efficacy: Dysarthria. Jour-nal of Speech and Hearing Research, 39, S46-S57.

Yorkston, K. M., & Beukelman, D. R. (2000). Decision makingin AAC intervention. In D. Beukelman, K. M. Yorkston,& J. Reichle (Eds.), Augmentative and alternative communi-cation for adults with acquired neurologic disorders (pp. 55-82). Baltimore: Paul H. Brookes.

Yorkston, K., & Beukelman, D. (1999). Staging interventions inprogressive dysarthria. ASHA Division 2, Neurophysiologyand Neurogenic Speech and Language Disorders Newsletter,9 (4), 7-11.

Yorkston, K. M, Beukelman, D., Strand, E., & Bell, K. R. (1999).Management of motor speech disorders in children and adults(pp. 403-434). Austin, TX: PRO-ED.

Yorkston, K. M., Miller, R. M., & Strand, E. (1995). Managementof speech and swallowing in degenerative diseases. Tuc-son, AZ: Communication Skills Builders.

Functional Staging for AACIntervention (based on Yorkston &

Beukelman; 1999, 2000).

Speech Staging

1. No reduction in speech functioning.

2. Detectable speech disorder but speech remains intel-ligible.

3. Speech intelligibility reduced especially in challeng-ing speaking situations (e.g., noise groups).

4. Natural speech requires supplementation by aug-mentative communication aids and strategies in mostsituations.

5. No functional speech. Augmentative communica-tion aids or strategies needed to maintain functionalcommunication.

Cognitive Staging

1. Cognitive functioning not affected.

2. Cognitive functioning mildly affected in the areas ofattention, memory and new learning but aware ofdeficits and able to compensate independently.

3. Cognitive functioning moderately affected in the areaof attention, memory, new learning, self monitoring.Performs best with previously learned tools

4. Cognitive functioning severely affected in all areas.Needs context (e.g., scripts) and partner support toengage in communication.

5. Cognitive functioning profoundly affected may notbe aware of communication partner.

Literacy Skills Staging

1. Spelling communicator. Has functional literacy skillsfor written communication and has no difficultyusing spelling to communicate on an AAC device.

2. Supported spelling communicator. Reading is func-tional for reading the newspaper but relies on spell-ing supports such as word prediction to maintainindependent communication.

3. Graphic symbol/sight word communicator. Recog-nizes basic sight word vocabulary, is not able to usespelling to maintain independent communicationeven with support, however, may be able to identifyfirst letters of words.

4. Graphic symbol communicator. Not able to read orspell. Relies on graphic symbols to construct/repre-sent messages.

5. Non-symbolic communicator.

Visual staging:

1. Visual processing not affected.

2. Visual processing mildly affected. May have ocularmotor deficits that affect tracking, and/or field cutsthat cause visual neglect, but is aware of deficits andable to use compensatory strategies effectively.

3. Visual processing moderately affected. Unable toindependently compensate for deficits in tracking,neglect, etc. Performs best when materials are placedin optimal areas for viewing.

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4. Visual processing severely affected. Requires audi-tory and/or tactile information to augment visualinput for optimal performance.

Upper Extremity Staging

1. Accelerated rate AAC communicator. Has full use ofboth upper extremities, may already have developedgood keyboarding skills or is capable of learningkeyboarding. Handwriting not affected.

2. Moderate rate AAC communicator. Has adequateuse of one or both upper extremities, but demon-strates some fine motor impairment that affects mes-sage construction rate. Able to handwrite but legibil-ity may be affected.

3. Supported manual use communicator. Has suffi-cient use of one or both upper extremities for access-ing AAC device but requires supports (e.g., key guard)to maintain accuracy. Unable to handwrite.

4. Alternate access direct selection communicator. Up-per extremities not functional for access but hassufficient control head or other body part to useoptical pointer (e.g., head mouse).

5. Alternate access switch user. Must use micro switchwith scanning, etc. to access an AAC device.

Lower extremity staging:

1. Ambulation not affected.

2. Gait affected but independent ambulation.

3. Supported ambulation (must use crutches, cane orwalker to prevent falling, may use wheelchair forlong distance mobility).

4. Independent supported mobility (uses manual orpower wheelchair to maintain independent mobil-ity).

5. Dependent supported mobility (requires assistantto move wheelchair).

Example of a Yes/No QuestionHierarchyDirections

1. Determine the method that the individual uses toindicate “yes” and “no.”

2. Ask the questions in the same order each time.

3. Continue through the series of questions until themessage has been determined.

Questions to Narrow Down the MessageCategory

• Do you need to tell me something? [If “yes,” ask thenext question]

• Is it an emergency? [If “yes,” go to Emergency Ques-tions sub list]

• Are you in pain? [If “yes,” go to the Pain Questionssub list]

• Do you want to do something? [If “yes” go to theThings to do Questions sub list]

• Do you want to ask about someone in your family?[If “yes,” go to the Family Questions sub list]

Question Lists by Category

EmergencyDo you need the doctor?Do you need your medication?Do you need to lay down?

Pain

Where is the pain; is it your head, eyes, ears, nose,back, stomach?

Things to doWatch T.V.Listen to music.ReadBookMagazine

FamilyHusbandChildrenDaughterSon

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