Apraxia

 

APRAXIA MANAGEMENT IN CHILDREN AND ADULTS

APRAXIA OF SPEECH –TREAMENT AND MANAGEMENT

Apraxia is a motor programming disorder  of neurogenic origin . The  primary etiology for the neurological damage leading to apraxia of speech (AOS) is a left hemisphere stroke in the frontal lobe although several other cases have also been identified .The onset of the disorder is sudden rather than progressive and it is most probably seen in adults  The severity of apraxia may range from mild to profound depending on the extent of the damage .this ofte manifests as varied speech characteristics from one client to another .

Since there is no widely used medical or surgical treatment for AOS ,the treatment for neuromotor disorder is mostly behavioural.

MANAGEMENT TERRITORY AND GOALS

The primary goal of managing AOS  is to maximize the effectiveness ,efficiency and naturalness of communication Management focuses on restoring or compensating for impaired functions ,as well as adjustment to the loss of normal speech or modifying  the need for it .AOS treatment focuses on

1.                 re-establishing plans or programs

2.                 improving the ability to select or activate them or set parameters (eg.duration ,force)  for speech movements in a given context  that will then be executed by an intact  neuromuscular apparatus.

FACTORS INFLUENCING MANAGEMENT DECISION

The influence of aphasia on decision of treatment for AOS deserves special attention. Aphasia is present in a high proportion of those with AOS by the virtue of the virtue of overlap of lesion sites that are associated with the two disorders,

Aphasia influences treatment in at least three important ways

1.     It affects language modalities in all modalities ,it can affect a patients ability t comprehend  spoken and written stimuli during treatment .

2.     Aphasia affects verbal expression ,it can be difficult to distinguish aphasic from apraxic errors. During AOS treatment activities.

3.     The decision to treat or not to treat the AOS ,the aphasia may be so severe that verbal communication may not be functional even though  even if motor speech ability was intact.

Treatment of AOS should not be undertaken or should be deferred until language or other cognitive abilities) is sufficient to generate adequate verbal messages.

The judgement can be difficult to make and must most often rely on careful assessment of verbal and reading comprehension ,writing or typing or other non verbal means of communication(pantomime or signing).

FOCUS DURATION AND TERMINATION OF TREATMENT

Treatment for AOS should focus on tasks that provide the greatest functional benefit most rapidly or one that provides the foundation  for improvement over the course of treatment .It is generally felt that people with progressive  AOS particulary those with no major cognitive problem  should begin treatment early and must be followed regularly to appropriately stage management eg: efforts to improve speech maintain comprehensibility ,establish AAC .The primary goal of such treatment is to enhance communication not to prevent decline or reverse .

APPROACHES TO MANAGEMENT

There are no medical intervention specifically designed to improve AOS for which there is a strong evidence for efficacy .Pharmacology treatment may be used for people to treat the underlying etiology or to prevent further impairment (eg:antibiotics for infection, anticoagulant to prevent strokes, anticonvulsant to prevent seizures . and may indirect

Ly prevent speech deteoiration.

A few studies have examined the use of dextroamphetamine  or the dopamine agonist ,bromocriptine in treatment  of aphasia including broca’s and non fluent aphasia  which are frequently accompanied with AOS.

The degree to which these drugs aid in have application for AOS is unknown byt examining the effect of various drugs that may influence speech initiation,planning  and programming appear warranted. There is no convincing data that establish the fact that certain features of AOS may be amenable with pharmacological treatment.

AOS may improve efollowing surgery to manage the neurological disease eg: aneurysm repair ,tumour resection but such surgeries are not designed for AOS per se.

No surgical procedure are aimed to specifically improve AOS.

PROSTHETHIC MANGEMENT AND ALTERNATIVE AND AUGMENTIVE COMMUNICATION (AAC)

The use of mechanical prosthesis is appropriate for  some people with AOS. There use is primarily  intended to stimulate improved speech without prosthesis.

Prosthesis that modify vocal tract events during speech eg: palatal lift or modify the acoustic signal after it is produced (eg: a voice amplifier is rarely appropriate  because AOS is characterized by  deviance in resonance or loudness that are consistent or pervasive enough to be aided by a relevant prosthesis. There are occasional  exceptions however  Marshall et al described a patient who was unable to phonate or articulate normally because of apraxia of phonation but who was able to articulate normally with an electrolarynx. This suggests that electrolarynx  may be worth a trial for persistently mute apraxic patient who are not responsive to traditional methods or for the occasional patient whose apraxia affects phonation to a much greater degree than articulation.

In conjunction with other behavioural management techniques some  apraxic patients may benefit from prosthesis that assist rate reduction or pacing of word production  but not always. Darley  et al suggested that external cues for pacing and setting the rate of speech might be less effective than self generated ones such as finger tapping and pacing board.

A pacing board may  help apraxic patients to slow rate and produce words and phrases  in a syllable by syllable fashion to facilitate articulatory accuracy .however stress and rhythm may require attention when using a pacing board because board use lead to stereotypic prosody.

AAC system is appropriate fro patients with AOS . The tools of behavioural intervention (eg: pictures ,letters, word boards ,electronic and computerized devices)can be used for some patients with AOS although the degree of accompanying aphasia may preclude or place limits on the sophistication of linguistic message that can be communicate dthrough them.AAC strategies eg:Amerind sign language ,blissymbols,handivoice for people with some carryover  of treatment effect to improved verbal communication. AAC is successful for some but it rejected if it is accompanied by significant degree of aphasia.

BEHAVIOURAL MANAGEMENT

Behavioural intervention is at the heart of managing AOS. It is unlikely that any pharmacological treatment or prosthetic management that might be appropriate would be beneficial  without the concomitant behavioural intervention alone is often used.

Like the management of dysarthria ,behavioural approach can be speaker oriented or communication oriented .Communication oriented approaches –those efforts at improving communication in the absence of changes in speech –are as applicable to AOS as in dysarthria .The strategies ,although individually determined and often influenced by accompanying aphasia are similar to those used in dysarthric patients.

Speaker oriented approaches –those that seek to improve speech itself –aim for improved intelligibility ,efficency and naturalness of communication. Their goals are achieved through efforts to improre the planning or programming of speech or to compensate for residual inadequacies I the planning or programming of speech. In most instances ,treatment focuses on speech itself .Sometime it is directed to non speech oromotor tasks to improve the ability to plan or program non speech oromotor movements as a necessary precursor to similar gains for speech .

Because AOS is predominantely a disorder of articulation and prosody .Focus on resonance is rarely appropriate or necessary and work on respiration and phonation is rarely taken for any other than the most severely impaired patients.

PRINCIPLES AND GUIDELINES FOR MANAGEMENT

Management should start early  It should be noted however that recommending treatment is not precluded by extended time after onset ,especially for patients who have not received any treatment or  those whose treatment has not focused on AOS.

Several single case studies or small group studies have shown treatment benefits in patients with AOS  who were in the chronic stage after stroke.

For patients with degenerative  disease ,treatment usually focuses on efforts to  maintain speech ,develop compensatory strategies for maintaining  intelligibility or comprehensibility and address current and future needs for AAC.

BASELINE DATA AND STIMULUS SELECTION AND ORDERING

Obtaining general measures of intelligibility and efficency of communication ,establishing the presence and degree of associated deficits and obtaining an inventory of the patients communication needs and goals,motivation ,speaking environment and communication partners ,difficult and easy communication situation and their perception of others reacton to their problem  are very important in planning.

Beyond this ,a careful inventory of the nature of articulatory errors and accurate  articulatory responses may be acquired as well as information on factors influencing the accuracy and adequacy of speech .this is because successful responses during treatment tasks are highly dependent on the selection and ordering of the treatment stimuli

In general it is important to establish the degree to which patients errors  correspond to the typical articulatory and prosodic characteristic of AOS  and the variables that effect error frequency .

PHYSIOLOGICAL SUPPORT

Treatment for AOS does not require efforts to improve posture or increase strength ,speed ,range and tone .that is it does not require effort to increase physiological support for speech ,nonetheless ,it is relevant  to speech if non speech oromotor movements should be targeted in treatment.?

Because there does not seem any consistent reliable relationship between speec and non speech  stimuli especially in people with AOS

,using speech stimuli as the target is usually more appropriate than non speech stimuli ,especially when the patient demonstrates some capacity  for speech. however when AOS  is so severe that sounds or sound segments cannot be produced ,work or non speech postures or movement sequence may be appropriate  because treatment should begin at some level at which success can occur..When used ,non speech oromotor practices should always involve movement targets or patterns  that closely approximate speech gestures(eg:lip rounding ,tongue elevation to the alveolar ridge,deep inhalation or prolonged exhalation.

These tasks are based on some unrelated assumption that  development of such controls will pave the way for improved programming of speech movements.

PRINCIPLES OF MOTOR LEARNING

These are highly relevant  for specific treatment approaches and relevant for  AOS  treatment.

Drill

Every specific behavioural treatment approach for AOS emphasize drill. The need for intensive and systematic drill  is consistent with general principles of motor learning and the possibility that ,for some patients ,their disorder represents more than inefficency in speech planning or programming. A substantial  number of apraxic speakers actually seem to have actually lost some of the” preprogrammed  subroutines ”. for movement sequences that make normal speech so automatic and effortless.Thus Darley ,Aronson and Brown ,observed that the apraxic speakers seems to have forgotten how to perform speech movements  and Wertz,La pointe and Rosenbeck indicated that the AOS is the structured relearning of skilled speech movements .As articulated by Rosenbek et al ,an essential principle of  treatment  for AOS is that systematic intensive and extensive drill  is necessary to regain or learn  lost speech skills. Drill becomes systematic when target responses are based on careful selection and ordering  of stimuli that ensure success at each step of the treatment programme. Drill is intensive and extensive when as many responses as possible occur during each of frequent treatment session.

Self learning and instruction

As early as possible in treatment ,patients should be urged to monitor their speech ,search for correct targets ,and self correct errors. Self learning is possible for many apraxic speakers especially if their impairment is not severe ,and what they learn on their own might not be improved  upon by clinician instructions. Clinicians can help by identifying the productive self cueing strategies used by patients and then helping them to use it consciously in various situations.

Apraxic speakers ,particularly those whose treatment must begin at the sound ,syllable and word level may need help in knowing how to produce speech movements. Sometimes this takes the form of simple watch    and listen imitation task in which the clinician shows what is to be done. Sometimes more explicit instructions or explaination is necessary. Techniques of phonetic placement and phonetic derivation are often essential for teaching  sound production,as are instructions and cues   for modifying  rate and stress. In addition ,instruction is a necessary component of some of the highly structed treatment programmes. In all instances instructions should be faded as soon as learning has occurred.

Feedback

Knowledge of results is considered a general principle of AOS treatment .Many apraxic patients can judge the accuracy of their  responses  reliabily and accurately ,and they should be encouraged   at the outset to do so ,with efforts self correction when they judge responses as inadequate. It may be especially important when working on non speech tasks , In speech tasks in which  targets  are non categorical (such as tasks emphasizing ,stress or rate ) ,or when intelligilbilty is the immediate goal.

Instrumental biofeedback and other forms of feedback may also be useful. The use of mirror may help some patients develop strong visual image of correct movement or targets ,although some patients develop a strong visual image of correct movements  or targets ,although some patients get confused or do not benefit or are confused by such feedback. The use of EMG and EPG biofeedback and vibrotactile stimulation for  some patients.

It is noteworthy that the retention and transfer (generalization ) of learning  are enhanced if feedback  is not constant (provided an approximation 30% to 60% of trials ). In addition ,studies  of limb motor learning suggests that feedback is more effective if it is provided 3 to 4 seconds after a response and if  a 3 to 4 seconds delay is present between feedback and the next stimulus. These delays although reducing the total number of responses obtainable in a given session ,provided uninterrupted time fro the speaker to retain the sensory aspects of the movement and self evaluated and understand adequate  versus inadequate responses.

Specificity of training

In general ,patients has fairly frequent success at the word or phrase level ,it is neither necessary nor appropriate  to focus on non speech ,sound level or syllable production tasks. Words and phrases are motivating ,and more meaningful and specific to the ultimate goal of treatment than are their precursors . however some patients cannot produce words  or sylaable ,sound or even non speech taks may be necessary ;in addition some patients may respond more adequately  on syllable level  tasks when syllable are  meaningless. The learning to plan program,execute, evaluate  and self correct non verbal oral movements,sounds in isolation and meaningless syllables may be necessary precursors to meaningful speech for some patients.

For mute apraxic patients,vegetative actions such as grunting ,coughing laughing and singing need to be reflexively elicted and then shaped towards volitional control as precursor to voluntary automatic speech production. The purpose of non speech tasks is  not to increase strength or other parameters of physiological support  for speech but to improve the planning or programming of volitional movements.

Consistent and variable practice

The use of consistent practice is part of many treatment approaches. For example ,clinical researchers often use multiple trials multiple repetitions of words ,phrases, nonsense syllables or non speech oromotor movements in treatment sometimes without intervening stimuli. These consistent practice efforts usually eventually give way to variable practice in which the patient is required to program more elements into responses ,with syllable to syllable or response to response  variability thus for example ,repetition of syllable “see” may merge into phonetic contrasts task in which variability of the response must be  produced either with minimal (sue-zoo) or intermediate(sue-moo) or greater contrast eg:tomato-tornado.

Consistent and variable stress may also include contrastive stress tasks in which stereotypic stress patterns  in sentences of identical length  and structure(john likes Mary ,Mary likes john). There are some evidence from a few patients with AOS that variable practice in which target sounds or words are presented randomly ,is more effect

Ive in facilitating retention and transfer of motor skills ,probably because it forces retrieval and organization of a response on every trial ,a challenge that is not present or is minimized in blocked practice. Although  blocked practice may be necessary in the early stage of patients with marked or severe AOS ,the principle and the finding suggest that variable practice should be used as soon as progress is demonstrated in response to it.

Speed accuracy trade off

The cy trade off applies to AOS treatment with reduced rate nearly always emphasized way to attempts to increase speed as accuracy increases. Rate reduction can take several forms .markedly impaired patients might have to be silent  responding in order to have their response in mind and for all but the automatic utterances ,a slow deliberate pattern of speech may be necessary to achieve accuracy. This may take the form of a syllable by syllable approach to production of a conscious prolongation of a vocalic nuclei.

For many apraxic patients who seem to have lost  or lost access to preprogrammed subroutines rate reduction  may facilitate feedback and the relearning of the sublearning of the submovements necessary for accurate speech..Once accurate articulation is achieved during treatment increased  rate shuld be pursued. This can be doen with AMR like tasks at the syllable ,word or phrase level ,within contrastive stress tasks at the phrase level  during sentence and paragraph reading tasks .

Although never formally assessed for efficacy ,divided attention tasks may be useful for mildly impaired  patients in order to assess and degree to which speech programming is approaching an automatic stage of learning.

BEHAVIOURAL MANAGEMENT APPROACHES

A number of  specific speaker oriented approaches for managing AOS has been developed. Many of these approaches are more similar than different from one another  and are distinguished preimarily by the nature of the stimuli used to elicit speech. They all share emphasis on careful stimulus selection ,an orderly progression of treatment tasks and the use of intensive and systematic drills.

Imitation is an integral part of most treatment programs ,especially during treatment early stages. There are several reasons for this. First imitation requires volitional responses to clearly established targets whose parameters can be carefully selected to ensure an appropriate level  of challenge and success. Second stimulus to be imitated provide a map for programming the response (eg:auditory and visual cues)that are facilitatory for many patients. Third it is efficient because it simplifies drills ,facilitates obtaining a maximum number of responses ,reduces demand for cognitive nad linguistic processing  and bypasses some of the language  deficits that affect comprehension and formulation in the many aphasics. Most programme also include steps that move beyond imitation to spontaneous speech ,they realize that imitation is less specific to the training goals than normal inter active communication and achieving neuromotor control  fro communication may not carry over to spontaneous speech.

Most speaker oriented behavioural treatment approaches employ the concept of  intersystematic and intrasystmetic reorganization .Both concepts recognise that the   behavioural treatment for AOS  require some kind of  reorganization of the way in which planning or organizing of the speech is accompalished.

Intrasystematic reorganization refers to attempts to improve  performance by emphasizing a more primitive or automatic level of function or a higher level of control. Making speech more volitional or conscious through imitation is an example of higher level of control. Eliciting automatic responses like counting ,singing or automatic social phrases are examples of more primitive  intrasystematic activities. Phonetic placement and phonetic derivation techniques used easily in imitation tasks  )probably combines both higher level and lower level functions .eg:using tongue protrusion  to help shape production of “th” uses a simple lower level  movement  in a highly volitional way to derive  correct placement of sound. Phonetic placement and derivation techniques may be beneficial for most patients but may be ineffective for those with a significant accompanying non verbal oral apraxia .

Intersystematic reorganization refers to the use of non speech activity to facilitate speech. Its use receives some support from studies of limb movement. For example “the magnet effect ‘refers to the tendency of the tempo of one movement to influence the tempo of another. It is a sustaining of  a mutual phase relationship simultaneous movements such as of the right and left arm or limb movement to influence the movement and speech)generally can be performed accurately as long as there is a harmonic relationship between them. Neurohysiologically ,the programming of a particular activity in the brain may spread out in the cerebral space and may affect the movements of other movements that  are being programmed. Interference occurs when simultaneous movements are not compatible.

Gestural reorganization is a prime example of using non speech movements to facilitate speech. It may include strategies such as hand or finger tapping ,foot  tapping head movements,or the use of pacing board to facilitate rate reduction and rhythm and stress patterns. In patients whose gestural control of such activities is better than speech ,the dominance of the gesture is used to organize the control of speech. The pairing of gestures with speech has been shown to facilitate sound production acquisition  and generalization to untrained exemplars within speech imitation tasks.

THE EIGHT STEP (INTEGRAL STIMULATION CONTINUM FOR TREATING APRAXIA OF SPEECH

Rosenbek et al described an 8 step continuum that they had found effective for teaching words or phrases  or sentences to 3 severely impaired patients. They emphasized on the importance of task continua to ensure high levels of success,the importance of intensive and extensive drill, the need to work on useful communication  as soon as possible and  the importance of self correction. They also recognized the importance of selecting and ordering stimuli on the basis of observed phonetic breakdown. They also stressed the importance of integral stimulation (watch ,listen ,say it with me)in the early steps of treatment with gradual fading of auditory and visual cues. The overall thme of the programme is one in which the stimulus prompts are initially maximal and gradually faded and response requirement  are gradually increased.

Each step may use stimuli at the syllable word or phrase level

Step 1:integral stimulation  in which the clinician presents targets stimulus that the patient then imitates while watching and listening to the clinician’s simultaneous production.

Step 2:Same as step 1  ,but the patients response is delayed and the clinician mimes the response(without sound) during the patients response  that is ,the simultaneous auditory cue is faded.

Step 3: integral stimulation followed by imitation without any simultaneous auditory cues from the clinician.

Step 4:Integral stimulation with several successive production without any intervening stimuli or without any simultaneous cues.

Step 5: written stimuli are presented without auditory or visual cues followed by patient production while looking at the written stimuli.

Step 6:written stimuli with  delayed production following removal of the written stimuli

Step 7:A response is elicited with an appropriate question .eg;”I like a cup of tea”,the patient is asked to respond with the phrase to the query “would you like anything”

Step 8: The response is elicited in an appropriate role playing situation .

The authors point out that not all patients need to go through steps that some steps need to be bypassed because they are particularly difficult.addition phonetic derivation  and placement techniques should be employed when integral stimulation fails. Subsequently modifications of the stimuli presentation programme steps and criteria  for progressing from one step to another has yielded improvements in speech .

SOUND PRODUCTION TREATMENT

This treatment is a relative recently developed and refined treatment the focus of improving accuracy of spatial targeting and timing of articulation at the segmental and syllable  level. Developed by Wambugh it deserves recognition for its programmes experimental documentation of the acquisition ,generalization and maintenance of its treatment effects. Efficacy data are more adequate for SPT than any other treatment for AOS.

SPT treatment relies on strategies common to  many AOS treatment including repetition ,integral stimulation ,modelling ,and phonetic placement cues and feedback to facilitate consonant production.It epahsizes on minimal contrast. The minimal contrast tasks used in SPF involve the production of words and phrases in which target contrasts are minimally different(conical –comical). It is believed that the use of minimum contrast pairs provide a context for practicing and refining the movement pattern necessary to distinguish  among minimally different sounds and that such practice is important when errora are due to a movement programming disorder..the stimulus are determined by the patients unique error patterns. The target of treat ment of sounds.

The steps described by  Wambaugh are:

Step 1:produce a target word or phrase in a minimal pair context or alone following a verbal mode.

Step 2 ;repeat step 1 but with a written cue so that a written letter representing the target sound.

Step 3: produce the target word only (i.e not phrases ) with integral stimulation (upto 3 attempts allowed).

Step 4:produc the target word only with placement cues and modelling from the clinician.

Step 5: produce a target sound in isolation with a model  from the clinician.

Step 6:next item

Verbal feedback is provided after each step

SPTcan be varied but its theme of orderly  progression minimal contrast ,integral stimulation ,models phonetic placemnt cues and feedback are constant.

It has been noted as partially effective treatment for apraxia.

PROMPTS FOR RESTRUCTURING ORAL MUSCULAR AND PHONETIC TARGETS

The approach to treatment was initially developed for children with AOS by Chumpleik but it has been subsequently been applied to adults. Its distinctive features is the use of tactile cues to produce touch pressure ,kinesthetic and proprioreceptive  cues to facilitate speech production.

In this case the clinician acts as an external programmer for speech providing intersystematic cues for  spatial and temporal aspects of speech production. The tactile and kinesthetic input used in PROMPT is typically prepared with auditory and visual stimulation.

PROMPTS  uses highly structured finger placement on the patient’s  face and neck to signal articulatory target positions and also cues about  other movement characteristics such as manner of articulation,degree of jaw movement and syllable and segment duration.eg:thumb placed at the sides of the nose signify nasality,another finger refers to the place of production such as bilabial contact.,the duration of the cues signal sound duration.By chaining together a number of PROMPT cues movement between phonemes may be facilitated. Square-Storer indicate that extensive training and practice  is required to actively is required to competently and efficiently conduct this form of treatment.

It is likely that patients with chroic ,severe AOS whose spontaneous verbal output is limited ,and fro whom traditional methods of treatment has failed are the most appropriate  patient for this approach.

The positive results associated with different investigations support the fact that PROMPT can be considered a partly established treatment for AOS.

MELODIC INTONATION THERAPY

This is a formal treatment  program  for patients with severe non fluent aphasia. The heart of the programme is the use musical intonation continuous voicing,to the rhythmic tapping to teach or re-establish verbal expression. This  program is systematic and it is hierarchically organized progressing form simple to more complex tasks.

Duffy indicate that adequate that adequate clients for this approach  are clients with good verbal comprehension ,preserved self criticism,a paucity of spontaneous verbal output and non fluent speech characteristics.  He further states that this approach  may be most appropriate for clients who do not respond t the more traditional programs such  as 8 step continuum.

GENERAL PROCEDURES

·                    high probability words with semantic value to the patient are selected for training .

·                    repetition forma the core of MIT.

·                    Working at levels that ensure a high degree of success

·                    The use of verbal and gestural cues  (but avoidance of pictures or written cues ,which are considered distracting).

·                    Frequent treatment sessions

·                    pictures or other environmental cues are used to evoke each target utterance.

·                    Each word ,phrase or sentence is intoned slowly and with constant voicing

·                    Normal speech pitch variation and stress variations are maintained.

·                    The client’s hand is tapped once for each intoned syllables.

·                    Signal is provided by the clinician prompting the client when to listen and when to intone

·                    Treatment is m0ved to the preceding step when the client fails a step.

Level 1

Humming: the clients is shown a picture hums the target item and taos the corresponding number of syllables on the client’s left hand. No response is required from the client.

Unison singing : the client is instructed to intone in unison with the clinician while the clinician taps the client’s left hand.

Unison with fading :the client is instructed to intone in unison with the clinician while the clinician taps the clients left hand. The clinician fades the model half way through the phrase.

Immediate repetition:the clinician  instructs the client to listen while he or she intones the phrase nad taps the corresponding number of syllables on the clients hand. The clinician then asks the client to imitate the target production..

Response to a probe question:following a correct immediate imitation the clinician intones a probe question(what did you say)

Level 2

Introduction of item:the clinician intones the target phrase twice and taps the corresponding number of syllables on the client’s hand.no response is required from the client.

Unison with fading:in unison with the clinician ,the client intones the utterance while the clinician taps the corresponding number of syllables on the clients hand. Te clinician fades half way through the phrase.

Delayed repetition:the clinician intones and taps and after 6 seconds of delay lets the client tap with assistance. The clinician then asks the client to intone without assistance.

Response to probe question;six seconds   after the clients response the clinician intones the probe question but does not tap the clients hand. The client is instructed to intone the phrase.

Level 3

Delayed repetition: the clinician tap the clients hand and intones the target phrase. Six seconds later the client is asked to intone the phrase. The clinician provides the tapping assistance.

Introducing speechgesang: the clinician presents the target phrase twice slowly without singing, but  with exaggerated rhythm and stress. The tapping is provided and no response required from the client .

Delayed spoken repetition:the clinician presents the phrase with normal prosody without hand tapping. After 6 seconds the client is asked to imitate the target production with normal prosody.

Response to a probe question ; the clinician asks a probe question with normal prosody. After a 6 second delay ,the client is asked to respond to the probe question with normal prosody.

GESTURAL REORGANIZATION

GESTURAL REORGANIZATION RFERS to a treatment approach that uses hand gestures to facilitate the correct verbal production in clients.(wertz,La pointe,1991). This method has helped clients in two ways

1.                                           to provide patients wh have sevee apraxia of speech with an alternative mode of communication

2.                                           facilitate or re-establish speech production.

Manual language such as ASLan other systematic manual systems have been used successfully in gestural reorganization.

When using gestural reorganization ,the clinician pairs target utterance with gestures that ma help facilitate their production.  The clinician begins by selecting words ,phrases or sentences for training and then selects gestures that mean the same thing as those target expressions. The symbolic gestures for those words and phrases or phrases can be selected from already established manual systems such as ASL ,or the clinician can invent gestures tat are appropriate for the expressions. The clinician then devotes the time needed to explain the meaning of the gestures and the premise of the treatment approach to the client.

The next step is o establish the use of gestures by the client. The client is to be asked to match the clinician’s gestures while modelling the target hand shape or movement . the clinician can also use pictures to evoke the use of a particular gesture. Shaping procedure and manual guidance are used as necessary .once the client can  shape the hand gestures to match the clinicians gestures or picture stimulus ,treatment progresses to facilitate te spontaneous use of  the target gestures.

The use of the trained gestures can be used as  a functional and alternative mode of communication for clients who are essentially mute. Or have vey limited verbal productions.

After the gestures has been well established ,the clinician pairs it with the target verbal expression. Therapy generally progresses from the simultaneous production of the gesture and the trget utterance to the separate use of each. This often requires the intensive training of several small steps. Eventually the gesture can be faded if appropriate ,while the verbal expressions continues to be practiced and reinforced.

Timing of gestures have also been used in the treatment of apraxia of speech .Rosenbek(1985) describes these as simple repetive gestures,such as hand tappin that can be made to accompany appropriate speech units.. clients can also be made to self prompt using their own timing  gestures to facilitate speech production.  These can be used with patients at all severity  level

The establishment of timing gestures should begib with frequently used and simple gestures such as tapping with the fingers ,drumming with one or more fingers,tapping the side of the leg with one or more fingers. The rationale of using such prompts should be clearly explained to the clinet. As the client learns to perform te timing gestures in a predictable manner ,they are paired  wth the production of target words ,phrases and sentences. Initially ,the client uses the established gestures while producing the utterance in unison with the clinician . once this is established ,the clinician provides a model of the gesture and the target utterance and ask the clients  to initiate both. Phrases and sentences systematically becomes longer and more complex. The clinician fades his or her tapping and then fades the verbal model as the therapy progresses to more spontaneous productions and conversational speech. The client gestures may be faded  if appropriate as he or she becomes verbally more proficient .Some client may also require the use of such gestures as a self prompting technique. A more subtle form of the gestures may need to be taught s o they are less obvious to the listener.

CONTRASTIVE STRESS DRILLS

Contrastive stress drills are a treatment method that can be used to promote articulatory proficiency and natural prosody especially the stress and rhythm of spoken language ,in clients with apraxia. In this approach different phrases and sentences are  used to train stress placement  on different words. In articulation training ,the clinician constructs phrase and sentences with a single target sound in them(eg;my name is Bob for “b”). the clinician asks a series of questions structured so that the client responds with the target phrase ,while placing extra stress on the target word or sound.eg:c:is her name Mary? P:no,her name is Terry.

The client is likely to stress the target word and thus improve the articulatory  proficiency  of the target sound. The client is reinforced for the precision of the  target sound. A similar procedure is used to teach appropriate stress and rhythm in words.

PROGRESSIVE ASSIMILATION

The clinician attempts to re-establish production of the target sounds from sounds that are not affected or from other non speech gestures. This method is similar to the successive approximation or shaping method.eg: the client may be asked to lightly bite his lower lip with his upper teeth. And then exhale which may yield/f/. the client may be asked to lightly pucker the lips and then say /e/ to derive the production of /u/. the voiceless palatal /s/ may be shaped from /s/ as the client is asked to protrude his or her lips while making/s/  . This  method is appropriate for  patients with severe apraxia of speech ,since they often must relearn to produce single sounds and syllables(Rosenbek,1985).

PHONETIC PLACEMENT

The use of these techniques have been extensively used with adults and children  with functional articulation disorders. Phonetic placement include giving the client detailed description of the position fo the articulators during the production of specific sounds and using diagram and pictures to supplement the clinician’s verbal  verbal descriptions. If necessary ,the clinician physically manipulates the clients articulators to evoke appropriate placement   for the production of the sound. The clinician can also provide tactile feedback through  the use of tongue blades and cotton swab sticks. Phonetic placement  cues are often needed with severe clients who may have difficulty producing sounds at the  isolation or syllable level.

ADDITIONAL APPROACHES AND TECHNIQUES

Techniques for the speechless apraxic patient

When AOS is characterized by extreme muteness or extremely limited or unreliable ability to vocalize –whether or not aphasia is present –there are some techniques that often get speech going. In general it is best to begin with techniques that elicit meaningful speech rather than focu son non verbal activities.

1.                                           automatic speech tasks such as counting or saying the days of the week may elicit speech when all other volitional attempts to speak fail. When this effective patients are also able to recite poems ,pledges,prayers  and rhymes.

2.                                           Apraxi patients without severe aphasia  may be able to complete predictable carrier phrase(eg: I’d like a cup of__________”. The americn flag is red ,white and _____________)”

3.                                           singing :some patients can sing familiar songs (Happy birthday),sometimes only the tune without intelligible words ,sometimes with reasonable approximation of the lyrics,even when they cannot vocalize under other conditions. Sometimes the ability to sing familiar tunes can be used as a mode of treatment to facilitate the production of communicative words and phrases.

4.                                           when phonation cannot be elicited with automatic speech tasks ,but the mouth is opened in an attempt to speak ,a quick push in the abdomen at the onset of exhalation may trigger vocal fold closure and phonation and provide a foundation for voluntary phonation. Similarly if a reflexive yawn or cough may be induced ,phonation may emerge with it or be shaped from it. Some patients can produce a vowel when the clinician’s hand is placed on the larynx and they are  asked to say “ah”.pressure or the thyroid cartilage sometimes facilitate phonation.

5.                                           the artificial larynx may facilitate articulation in some severe apraxic patients.

6.                                           pairing a highly used symbolic gesture with its associated sound or word may elicit vocalization or facilitate accuracy of word imitation in severely impaired patients who are otherwise not capable of speech. Eg: hi ,bye  with appropriate gestures. Other social questions that  may trigger automatic responses (how are you?leading to ok or fine).

Patients who remain mute or are unable to produce unintelligible syllables may need to work on non speech oromotor movements  with the same degree of drill and systematic progression that characterize speech tasks.

Techniques at the volitional sound,syllable and word level

For patients whose AOS has them working at the volitional sound ,syllable or single word level, phonetic placement  and derivation technique and gestural reorganization may be helpful. A number of useful general techniques can be employed at the stage to supplement integral stimulation and other treatment programmes .

Some clinician stress the  importance for some patients of working  at the sound or meaningless syllable level of production. Wertz ,La Pointe and Rosenbek note that some patients do better  if meaning is removed from treatment task and DAB recognizes the need for some patients to work  on isolated sounds ,which could then be shaped to syllables and words.

The key word technique is used by many clinicians. The technique uses words that are uttered accurately and automatically and requires the patient  to repeat  them frequently  in order to establish voluntary control. The patient may be also asked to answer questions  with the word,read the word, and so  on. Then the initial sound of the word ,for example is used to build new utterances, eg;patients who can utter fine in response to “how are you?”may be asked to repeat fine multiple times after the clinician and ten attempt the word”fire,five  ,fight”.

Cueing strategies;  are particularly relevant for sound syllable and word level activities ,with phonetic derivation and placement being especially useful cues. At the word level ,there seems to be a hierarchy of cues  that are effective, although  they usually need to be individually determined. In addition to biofeedback,cues that facilitate accurate responses at the word level may include word imitation(watch and listen),sentence completion, first sound  of the target sound ,the printed target word ,description of function and presentation of associated  words.

Some reponse parameters that can be used at the syllable an dword level (and beyond0 that may facilitate  or challenge response adequacy include prolongation of initial consonants, prolongations of vowels and syllables ,clinician-imposed or patient imposed  delays before responding ,rehearsal responding and immediate response.

Multiple input phoneme therapy

MIPT is a treatment approach that is designed for severely aphasics and apraxic patients whose repetition abilities are severely impaired and whose utterances are characterized by repetitive verbal stereotypes. Its main purpose is to shape from the persevertive verbal stereotypies a variety of   responses that may be eventually be used volitionally.

MIPT initially requires reducing the struggle to speak voluntary with resultant involuntary stereotypic responses . teb first step is to identify the most frequently occurring stereotypic utterance ,which becomes the initial target of treatment(a key word). The  patient then watches the clinician slowly produce the target 8-10 times ,emphasizing te initial phoneme,with the patient tapping simultaneously with the ipsilesional hand. The  patient tehn joins the clinician in several repetition of the utterance. Following this the clinician fades voice but continues to mouth the utterance and tap as the patient repeats the target. These steps a re repeated for a number of other stereotypic utterances. When joined new single syllable words are produced using the same initial phoneme of the stereotype. Targets are then broadened to other phonemes and then clusters ,multisyllabic words ,phrases and short sentences. Eventually repetition is faded and written and cues and picture naming and assisted phrase productions elicit response.

Voluntary control of involuntary utterances

The approach begins by identifying any real words that the patient has uttered in ay real context,even if it was inappropriate for that context. The words are then written on  a card  for oral reading . if a word is read correctly ,it is retained ,if it is replaced by another word when read eg:cat for dog,the original stimulus is discarded and the voluntary response is retained. These strategies is used to build a list of written words the patient can read voluntarily. The next step is for the patient to produce the words in confrontation  or responsive naming modes. Success at this level is followed by conversational activities that elicit target words.

Techniques at the multiple syllable utterance level

Phonetic contratst ,rate control,stress and prosody become important when patients begin to move from the single word level.

DEVELOPMENTAL APRAXIA OF SPEECH

Haynes (1985) indicates that information  regarding specific therapeutic techniques for the person with developmental apraxia  can be gleaned from not only direct reference to the disorder itself ,but also form the study of literature on acquired apraxia of speech  as well as the many  general principles included in articulation therapy. Thus some of the treatment approaches discussed under acquired apraxia  of speech can be modified to meet the needs of children with developmental apraxia of speech.

In general ,the treatment for DAS ,as for its adult counterpart tend to follow a sequential organization,progressing from simple to complex speech tasks. The vowels and consonants targeted for remedition  should be clearly outlined. Also the clinician should determine the linguistic level that is most appropriate starting point for therapy. For some children it may be the syllable level ,while other kids may be ready to start ta the word or sentence level.

Vollman emphasized that treatment at the isolation level does not correspond to the nature of the problem and does not address the underlying motor programming problems.

The following are the principles of speech production treatment programmes for children with developmental apraxia of speech.

1.                 the primary focus of treatment should be to control and organization of syllable structures within a variety of linguistic contexts.

2.                 treatment should facilitate the correct production of varying syllable shapes and the organization of these shapes into longer and more complex phonotactic patterns (combination of syllables).

3.                 a sound by sound approach emphasizing phoneme production in isolation before progressing to words and phrases does not address the hierarchical dynamic movement problem  associated with  development apraxia  of speech.

4.                 treatment should not focus on auditory discrimination training since that does not address the production problem.

5.                 treatment should be structured so that frequent short breaks are offered system fatigue may be prevented in this manner since that is typically a problem in developmental apraxia of speech.

6.                 treatment sessions should be divided into short parts

·                    imitation of body or oral  motor sequences(assuming those are a problem)

·                    syllable sequence drill activities (eg:g^d^b^)

·                    meaningful single word activities including core group of words that will help increase the child’s intelligibility.

·                    Short sentence activities starting with a key carrier phrase and changing one word eg: I like the…. Or I see the….”)the complexity and length are gradually increased.

Hegde (1996 b) an Haynes (1985) indicate that extensive speech drills may be used in which the sequencing of movements involved in speech production is emphasized. As with apraxia of speech in adults ,the clinician can use tactile ,visual and auditory cues  to facilitate correct production of target sounds,words and phrases. Children with DAS often benefit from  multimodality approach.especially when new sounds are introduced. Some children  with DAS  often benefit  from a multimodality  approach ,especially when new sounds  are introduced.

With children who have severe developmental  apraxia of speech ,non verbal communication system may be used to facilitate  functional communication. The child may be taught sign language  or an augmentative communication systems. The success of non verbal  communication system is highly dependant on the child’s intellectual abilities and receptive language skills.

Many of the treatment methods used in adult apraxia does overlap with childhood apraxia.

Among those include:

·                                                                    Treatment based on motor programming principles

·                                                                    Treatment based on motor programming

·                                                                    Treatment that incorporates touching touching or molding  of articulators.

·                                                                    Treatment that impose a supra segmental pattern on speech.

·                                                                    Treatment with a sensory motor focus

The first of this approach is te idea of starting every session with a kind of babbling practice,in which the child is encoureaged to produce strings of syllables containing phonemes ,that are already in their repertory. Tehse syllables are stringed with a variety of stress and intonation patterns,always with emphasis on accuracy of speech sound productions. The syllable may be CV or VC syllable  ,and they would be typically be nonsense syllable. McDonald’s goal appears to increase in the child’s ability to sequence the motor patterns of phonemes with normal timing and co articulation. It is precisely a deficit  in this ability appears to be the heart of DAS.

The second aspect of sensorimotor therapy  that is helpful  with DAS children is its emphasis on facilitating contexts.McDonalds emphasis on moving  from more facilitating contexts to less facilitating contexts is very useful concept  in th treatment of DVD.

Phonological treatment

Preschool children who have DVD may have the same kinds of difficulties in figuring out the phonological system of the ambient language that other children of similar age exhibit. In such cases their poor intelligibility  may stem from a general phonological disorder and from a specific difficulty in sequencing commands to produce speech

Aspects of phonological treatment that help the child to learn the patterns  of the language should be helpful to preschoolers nad early school ag e children with DAS. These include auditory bombardment ,simultaneous work on multiple exemplars = of the same phonological processes ,use of minimal pairs to demonstrate phonemic contrats  , and work with meaningful words and phrases as much as possible.

TREATMENT BASED ON BOTH MOTORIC AND LINGUISTIC CONSISDERATION

Crary (1993) have shown the importance of including a linguistic planning component in treatment programmes. By this they mean that not only does the child  practice sound in isolation ,words and phrases but also has an experience in slotting words into sentences and experience in formulating narrative using newly learned sounds and words. Crary regards a motor planning component an intrinsic part of linguistic aspect of communication.

The pressure point intervention (Smit 2000)is another approach ,in this method the stimuli is chosen so that when the child produces a sound in a word correctly ,the word will be completely intelligible to others and can be used immediately in communication. This has not been extended to further stages of intervention.

ORAL MOTOR EXCERCISES

Oral motor treatment includes all interventions intended to increase  STRENGTH AND AGILITY OF THE STRUCTURES FOR articulation and respiration. These exercises are not only presented as a way to increase strength and agility ,but also to promote normal orofacial tactile sensation ,increase functional differentiation of the head and the face from the rest of the body ,build muscle tone ,and heighten proprioreception.

Oromotor treatments have been promoted for both phonological disorders and for DAS. They have  a certain appeal because it seems obvious that the muscles must be strong enough to be used for the complexities of speech ,and the articulators must be agile enough to reach specified positions quickly. There are a number of assumption that follow from this intuitive position . one assumptionis that a complex behaviour can be broken down it’s parts and the practice of the parts will improve the whole pattern. Another assumption is that speech activities emerges from the structures used for vegetative functions such as swallowing ,consequently oro motor may improve the substrates or basis for speech.

Unfortunately there is very little evidence that oral motor exercises do improve speech production. There are further evidence which shows that they do not improve speech production. Forrest -2002 has shown that motor learning literature have shown that acquisition of complex behaviour ,namely training on constituent parts of such behaviour actually reduces the learning of these behaviours.

NON SPEECH ORAL MOTOR OR ORAL SENSORY SYMPTOMS

          stratgies for addressing non speech oral motor or oral sensory symptoms including the following:

consult an occupantional therapist .

 use tactile stimulation to increase oral awareness (if the child is hyoposensitive  and tolerance ,if the child is hypersensitive .

·                                                    In some cases ,tactile stimulation to the body may need to be introduced before the child will be able to accept stimulation to the face and mouth.

·                                                    Work from cheeks to jaws to lips.

·                                                    Use only firm ,slow pressures  for a child who is hypersensitive

·                                                    Use massage and light,quick strokes as well as firm touch for a child who is hyposensitive.

·                                                    Inside the mouth ,work from teeth /gums to inside cheeks ,tongue and hard palate.

·                                                    Tell the child before and as you do it

·                                                    Provide objects with a variety of textures for oral stimulation.

·                                                    Encourage the child’s own exploration of his or her mouth with clean hands to increase the child’s awareness of the articulators.

·                                                    Oral motor treatment

                                Imitation of production of specific gestures

                                Imitation and production of sequences should be the

                               Main focus

                            Feeding

                        Use tactile stimulation to increase oral awareness (hyposensitive) and to increase tolerance(hypersensitive ) immediately before introducing the food. Increase the child’s repertoire of food ,textures ,combination of textures taste and temperature.

PROCEDURES FOR TREATMENT OF DAS

All children

Principle

1.           schedule frequent short treatment sessions

2.                 target functional words and phrases as well as speech sounds

3.                 as much as possible work with meaningful utterance

4.                 vary target and material frequently within the treatment session

5.                 do warm ups at the beginning of each session

6.                 use multiple modalities in providing models ,cues and prompts.

7.                 let the severity of the DAS be the guide to the number of exemplar words used in the session

8.                 include phonological awareness activities in treatment

9.                 provide AAC for the child whose speech is not functional for conveying wants ,needs and thoughts.

SCHOOL AGE CHILDREN

Principles

1.           target as many different phonemes and oter phonological targets as the child can handle.

2.           target language forms along with phonetic forms

3.           provide large amount of practice

4.           vary the prosody and perhaps the rate of the desired response

5.           pay attention to facilitating and non facilitating phonetic contexts

PRE-SCHOOLERS

Principles

1.     use procedures developed for phonological disorders

2.     help the child get past difficulties with imitation

3.     the first goal of intervention should be to fill out the consonant and vowel inventory

4.     focus on consistent and fully correct production of words

5.     provide as much motor practice as possible

6.     reinforce in terms of success at communication.

EFFICACY

Almost all AOS treatment studies report positive outcomes and there seems to a general consensus that treatment of AOS especially when aphasia is not prominent or present is effective. Rosenbek estimated that about 90% of those patient with apraxia  more severe than their aphasia gained some functional communication and that the prognosis for recovery  of functional communication in such patients have significant aphasia language impairment.

A good deal more must be learned o the efficacy and effectiveness of treatment  for AOS. Inorder for treatment to be provided in the efficient and systematic way.

SUMMARY

·        Treatment of AOS and treatment of dysarthria are similar it os different in the their underlying nature .

·        The co occurrence of aphasia with AOS has a significant effect of treatment with AOS.

·        There are no pharmacological or surgical intervention will show efficacy

·        Communication oriented approaches to treatment are appropriate for people with AOS

·        Speaker oriented approach focuses mainly on articulation and prosody .

·        Extensive intensive and systematic drill is an essential component in all speaker oriented behavioural approaches to AOS.

·        Efficacy data and clinical impression suggest that various programs and techniques can be effective in managing AOS ,especially when aphasia is not present or prominent .

ARTICLES

Publication: Journal of Medical Speech - Language Pathology
Publication Date: 01-DEC-06

Author: Strand, Edythe A. ; Stoeckel, Ruth ; Baas, Becky

Article

Researchers and clinicians face innumerable challenges in the management of children with severe speech disorders, including demonstrating the efficacy of treatment provided. Pressure from third-party payers to establish the efficacy and effectiveness of treatments, as well as a need to engage in ethical clinical practice necessitates being accountable for treatment effects (Robey & Shultz, 1998). The important recent attention to evidence-based practice (Dollaghan, 2004; Robey, 2004; Ylvisaker et al., 2002) also calls for more treatment efficacy research. Such reports are rare, especially in the area of motor speech disorders in children and particularly in the area of childhood apraxia of speech (CAS).

CAS is a motor speech disorder caused by difficulty with planning and programming movement gestures for speech production (Caruso & Strand, 1999; Davis, Jakielski, & Marquardt, 1998). Although there are controversies regarding specific behavioral markers (Davis et al., 1998; Forrest, 2003; McCabe, Rosenthal, & McLeod, 1998), several characteristics are generally agreed to be discriminative for the disorder including difficulty with reaching and maintaining articulatory configurations, difficulty with smooth transitions from one configuration to another, vowel distortions, prosodic errors, and inconsistency of error patterns upon nonspeeded word repetition (Davis et al., 1998; Maassen, 2002; McNeil, 2002; Shriberg, Aram, & Kwiatkowski, 1997; Strand, 2002). There are numerous reports that children with CAS require intensive treatment (Davis & Velleman, 2000; Strand, 1995; Strand & Skinder, 1999), yet there is little empirical data regarding its outcome.

Parents of children who are essentially nonverbal due to severe apraxia of speech often ask about the prognosis for verbal communication. Currently there are no data to show whether intensive treatment, focused on improving motor skill for speech, may facilitate early speech acquisition in children who have not benefited from other more traditional forms of articulation treatment. This article reports data regarding the efficacy of intensive treatment for four young children with severe apraxia of speech, using dynamic temporal and tactile cueing (DTTC) for Speech Motor Learning. This treatment approach has been developed by the first author over a number of years. It has been described (Strand & Skinder, 1999) and examined for efficacy (Strand & Debertine, 2000), but has only recently been designated by the DTTC name. This is a treatment approach based on integral stimulation, which emphasizes the shaping of movement gestures for speech production and the continued practice of those gestures, in the context of speech. Shaping occurs initially through the use of simultaneous production. The utterances are practiced slowly and simultaneously at first to facilitate movement accuracy. The clinician helps the child achieve the correct jaw and lip positions for the initial articulatory configuration, has the child stay in that position for a few moments to maximize proprioceptive processing, and then simultaneously produces the utterance slowly with the child, utilizing tactile and gestural cues as needed. As the child produces the movement gesture with increased accuracy, the clinician slowly increases the rate of movement toward normal. The simultaneous production provides maximum support at first, allowing faster accuracy and success, which helps to keep the child motivated. Later, direct imitation and delayed imitation trials allow the child to develop more independent skill and eventually more automaticity in production.

ABSTARCT

This article reports data regarding the efficacy of treatment for four young children with severe childhood apraxia of speech (CAS). A single subject, multiple baseline design across behaviors was used for experimental control and replicated over the four children. Baseline, probe and maintenance data were continuously collected. A treatment approach based on integral stimulation, dynamic temporal and tactile cueing (DTTC), was used. The article includes a rationale for the treatment approach based on several principles of motor learning, a description of how treatment was implemented, and a summary of the data showing responses to treatment. Three of the four children exhibited rapid change following the implementation of treatment. The degree of performance change was greater than that for control probes, and improvement was maintained for all utterances, although performance was variable. This study shows that frequent treatment, incorporating the principles of motor learning, may facilitate the treatment of severe developmental speech disorders that are accompanied by motor impairment.

TREATEMENT OF SOUND ERRORS IN APHASIA AND APRAXIA :

EFFECT OF PHONOLOGICAL COMPLEXITY

AUTHORS:Maas.E,Barlow,J,Robin D and L Shapiro,Aphasiology 2002,16,609-622.

Recent research suggest that the complexity of treatment stimuli influences  the effectiveness of treatment. However no studies have examined the role of complexity on sound production impairment .

Aims ;this study examines effects of syllable complexity on treatment outcome on problems. in two patients with acquired sound product ,complexity is defined in syllable structure  :clusters are more complex than singletons.using a single subject multiple baseline design ,they addressed :Is treatment of complex syllables than treatment of simple syllables.

            Methods& procedure

            Two patients with aphasia and apraxia.  We found that treatment on simple syllables and treatment on complex syllables led to improved production of simple syllables. While treatment of complex syllables also led to improvement of some complex syllables for one of the two patients.

Conclusion

These results suggest that training complex items is more effective than training simple items, at least for some patients. 

References;

·        Motor speech disorders, differential diagnosis and management:Joseph.R.Duffy

·        Treating disordered speech motor control: for clinicians by clinicians-Vogel.D &Cannito,M

·        Neuromotor speech disorders:Nature assessment and management-Cannito & Michael.P.

·        Dysathria and apraxia of speech :perspectives on management;Moore,Christopher

·        Developmental dysarthria of speech –theory and clinical practice

·        Apraxia of speech in adults :disorders and management –Robert.T .Wertz

·        Childhood apraxia of speech a resource guide:-Shelley Vellman