ETSU 2017 Comps everything

polyps

Unilateral If bilateral, asymmetrical Contralateral reactive lesion More VASCULAR Possibly translucent (floppy) Fluid filled Intact BMZ Superficial LP Midpoint Junction 1/3 anterior 2/3 posterior

transcortical sensory area of involvement

Watershed injury Lesion in border area Posterior and inferior to Wernicke's area Occlusion to anterior cerebral artery

parkinsons- voice symptoms and characteristics

Weak voice, mono-loudness, mono-pitch Starts rapid Disrupted articulation Slow and imprecise voice onset and offset

webs

Webs (tissue connecting the V; fundamental frequency will rise because the web shortens the folds so that they can vibrate faster) can be congenital or acquired

cysts

" Small spheres on TVF margin Unilateral Contralateral reactive lesion Similar to nodules Definitive Dx with biopsy Fluid filled sacs in SLP

childhood apraxia of speech

"inability to plan and/or program the spatiotemporal parameters of movement sequences" (apraxia= inability to plan volitional movement); separate from phonology; lack of research (hard to identify and definitely diagnose); 3-5% of speech impaired preschoolers; 75% misdiagnosed

late 8

"sh", voiceless "th", voiced "th" , s, z, 3

purpose of intervention

1-change or eliminate underlying problem 2- change the disorder 3-teach compensatory strategies 4?? influence environment and context

abductor SD- symptoms and characteristics

Produces a normal voice during sustained phonation of vowels, falsetto singing and during vegetative laryngeal activities such as coughing and laughing

browns stage 4

Regular past (He jumped) Irregular past (she fell) Regular 3rd person singular (He jumps) Articles (the dog, a book) Contractible copula be (He's eating)

Screening indicators suggesting need for evaluation

Rejection of food Gagging on multiple feeding attempts Open-mouth posture / breathing

conduction aphasia characteristics

Relatively uncommon Spontaneous speech is fluent Considerable word finding difficulty Preserved auditory comprehension Significant difficulty with repetition Literal paraphasia Self-correction Numerous pauses Filled pauses Reading deficit-variable Writing deficit-variable

things to consider when planning intervention

The goal Chronological or developmental age The dosage The procedure Child characteristics, such as: attention, motivation, memory, motor skills, reproduction Materials available and usable by intervention agent

polyps- causative factors

Unclear Thought to be Impact Stress Single distinct event or few Exogenous irritants (smoke) Vessel dilators (alcohol)

contraindication for speaking valve

Unconscious and/or comatose patients Inflated tracheostomy tube cuff Foam-filled cuffed tracheostomy tube Severe airway obstruction Unmanageable, thick secretions- can help clear in most cases because can cough Severe risk for aspiration Severely reduced lung elasticity Do not use during sleep- or in person who cant stay awake

ICF

body structure and functions activities and participation contextual factors- environmental and personal

Preparation (Pops homeland pride)

bring all materials- penlight, food, stethoscope etc. chart review check for allergies, cultural diet restrictions, aversions

aphasia types with retained auditory comprehension skills

brocas conduction anomic transcortical motor

TBI neuropsychological deficits

cognitive abilities, personality, and behavioral and emotional problems relating to disability adjustment, self-awareness, and coping difficulties.

norms for emerging language stage

communicative acts- Rapid increase in rate: 2/min at 18 mos to 5/min at 24 mos. Syntax At 24 mos. MLU 1.5 - 2.4 with approximately equal numbers of 1- and 2-word utterances Vocabulary (lots of variability 18 to 30 mos) Rapid increase in expressive vocabulary: 1st word at 12 mos, 110 wds at 18 mos, 168 wds at 20 mos, 312 at 24 mos, and 546 at 30 mos

diet changes

compensatory Four Food Levels -pureed, homogeneous, cohesive, pudding-like -mechanical altered, cohesive, moist, semisolid -advanced soft-solid, easy to cut -solid Four liquid levels -thin -nectar -honey -spoon thick

tx for pharyngeal disorders- Unilateral pharyngeal paralysis or scarred pharyngeal wall

compensatory turn head toward affected side, maybe also tilt head toward strong side supraglottic swallow; alternate liquids/semisolids

Chin up

compensatory strategy- postural change Uses gravity to drain food from the oral cavity

tx for pharyngeal disorders- pseudoepiglottis post partial laryngectomee

compensatory- posture changes or thinner food consistencies

compensatory vs facilitative

compensatory- Circumvents the disorder Techniques may result in swallow restoration facilitative- to change disorder physiology

lying down

compensatory- postural change Gravity holds bolus on pharyngeal walls rather than letting residual food drop down in the airway

head rotation

compensatory- postural change towards damaged side Improves adduction by pushing damages side toward the midline, allows food to flow down normal side

head tilt

compensatory- postural change towards strong side Uses gravity to drain food down the stronger side where there is better control

super supraglottic swallow

compensatory/facilitative swallow maneuver designed to close airway at vestibule inhale and hold your breath bear down tightly keep holding and pushing as you swallow cough

supraglottic swallow

compensatory/facilitative swallow maneuver designed to close airway at vfs take deep breath and hold it (keep holding and lightly cover trach tube) keep holding breath while you swallow immediately cough

effortful swallow

compensatory/facilitative swallow maneuver designed to increase posterior tongue movement and bolus passing over valleculae as you swallow, squeeze hard with all your muscles

supraglottic swallow w no tongue

compensatory/facilitative swallow maneuver hold breath dump whole bolus in head back multiple swallows

mendelsohn m

compensatory/facilitative swallow maneuver to increase laryngeal elevation and cricopharyngeal opening swallow saliva and pay attention to your neck and feel as it lifts and lowers now when you swallow and it lifts, hold it up and don't let it drop

CILT

constraint induced language treatment the employment of forced use and constraint whereby participants are required to produce and respond to verbal communication and alternative communicative modalities such as gesture are constrained. Shaping is also a component of treatment requiring increasingly more challenging linguistic goals.

granuloma

contact ulcer Granulated surface of VOCAL PROCESS or smooth BALL appearance Unilateral—contralateral concavity or ulceration Bilateral Resistant/Recurring Vocal processes of the arytenoid cartilage

vocal fold layers- body cover model

cover-mucosa transition-vocal ligament body- muscle

risks with thick liquids

dehydration constipation -lack of appeal -failure to satisfy thirst

Langmore 7 predictors PNA

dependent for feeding dependent for oral care number of decayed teeth tube feeding more than one medical diagnosis number of medications smoking

why complete a basic speech assessment

determine eligibility ID predominant error patterns find order in disorder to make differential diagnosis to evaluate severity and intelligibility to determine if addiitional in depth probing is needed to establish intervention goals to design appropriate intervention to evaluate treatment outcomes and measure progress

empty set

developing execution Speech production Unintelligible speech, gaps in inventory Contrastive word pairs (unknown-unknown) Preschool age with moderate-severe SSD R~d row vs doe

auditory perceptual

deviation in vocal parameters GRBAS CAPE-V

differential diagnosis

differentiate skills/learners: perception testing- SAILS stimulability testing- GDAP or probe differentiate MSD: Motor speech exam- OM, MPT< cueing levels

homonymy approaches

directly confront child's rule by contrasting his/her error with the new target sound(s) to be learned. - Minimal Pairs and Multiple Oppositions

despite variation what are some common trends with 2yr olds

final inventory never greater than initial tendency for stops, nasals, glides before fricative, liquids and affricates front consonants appear before back consonants

informed consent elements

disclosure of information understanding- must make sure they fully understand risks and benefits voluntary decision making- free of coercion authorization

sulcus

distributed lesion "Sulcus Vocalis" (only one type of sulcus) Loss of viscoelastic properties of the lamina propria Longitudinal furrow Parallel to free margin of VF

child centered approaches

hanen responsivity education indirect language stimulation

consonantal sounds

have marked constriction along the midline region of the vocal tract

ICF- body structure

includes: CNS, sensory, oral mech assessment: Hearing, vision, oral motor tx: Aids, devices, medical intervention

tx for oral transit- disorganized tongue movements

increase awareness and use effortful swallow movement

traditional approaches focus on

individual sound learning emphasis on placement and sound production accuracy

brown stage 2

ing (Me playing.) in (cookie in) plural (that books)

communication based aphasia therapy

intended to enhance communication by any means and encourage support from caregivers. These therapies often consist of more natural interactions involving real life communicative challenges. PACE SCA group therapy

shimmer

intensity instability, may indicate mucosal abnormality or neuromuscular abnormality

physiologic index

intrinsic laryngeal muscle strength and function mucosal function PTP Airflow

dynamic assessment

measure of learning, see If different cues change results, can go back on standardized and try ones missed with cueing to gain info Used to establish goals Measure progress

main ethical considerations

medical indications- prognosis, tx options patient preferences- expressed preferences, QOL, advanced directives quality of life- external assessment of pros and cons contextual features- money, insurance, support

broad based approaches- phonological awarenes and literacy

metaphonological approach psycholinguistic approach

contrastive approaches- homonymy

minimal pairs multiple oppositions

integrated approaches- language and phonology

morphosyntax approach naturalistic speech intelligibility training Dynamic systems (whole language) Non-linear phonological approach

maximum flow decimation rate

primarily used in research increase produces richer spectrum

infrahyoid

pulls hyoid down-laryngeal depression (TOSS) • Thyrohyoid • Sternothyroid • Sternohyoid • Omohyoid

4 interventions used for late talkers

stimulability approach EMT- phonological basis PACT- parent and children together cycles

intrinsic muscles- tensor

stretches • Cricothyroid (CT) • TA (only when con-contracted with CT)- bulk of vocal fold

Physiologic index- PTP

the minimum amount of subglottal pressure required to initiate vocal fold oscillation • Measuring Instruments: • Manometry • Tracheal puncture • Inferenced by esophageal pressure Inferenced by oral pressure using a U-tube manometer or translabial pressure transducer (we use this Rationale/description dryness, stiffness, inter-vocal process distance ~ Phonation Threshold Pressure (PTP)

Emerging language- following directions

use # of salient items vs # of steps Get the red cow (2 salient items)

puberphonia treatment

Behavioral Move the position of the larynx downward to hear the change in pitch

polyps- case example

HOARSE Loss of high notes Fatigue Difficulty being heard in loud situations Case example: 1.68-69 years old 2.Hoarse voice 3.Soreness in throat (right side of the neck) 4.Occasional loss of voice with voice use 5.Started about 2 months ago 7.Progressed gradually, getting worse 8.Hoarseness increases with convos over the telephone 9.Preacher once a month 10.Soreness in glands around the neck 11.Increased effort during preaching, people have problems hearing him a. Moderate dysphonia b. Moderate roughness c. Breathiness d. Mild/mod strain decreased glottal closure increase airflow decrease subglottic pressure pitch and range are within normal limits

polyps- symptoms and characteristics

HOARSE Loss of high notes Fatigue Difficulty being heard in loud situations Fundamental freq: Increased? Pitch range: Reduced Dynamic range: Reduced Intensity: Decreased NHR: Reduced Subglottal pressure: Airflow:

cysts- symptoms and characteristics

HOARSE Gradual worsening Upper pitch range lost Vocal fatigue Pitch range: Reduced Dynamic range: Reduced Intensity: NHR: Reduced Subglottal pressure: Increased Airflow: Min- Increased Avg - higher end of norm During phonation: decreased

reinkes edema symptoms and characteristics

HOARSENESS Lower pitch Increased effort Vocal fatigue Airway issues (occasional) Decreased pitch Increased subglottic pressure Decreased average airflow

granuloma- symptoms and characteristics

HOARSENESS Throat pain-localized Throat tickle Lump in throat Voice BREAKS Fundamental freq: Lower Pitch range: Reduced Dynamic range: Intensity: NHR: Subglottal pressure: Equal to or higher than normal? Airflow:

ways to increase sensory input

Increase downward pressure of the spoon against the tongue when presenting food Presenting a sour bolus Presenting a cold bolus Presenting a bolus requiring chewing Presenting a larger bolus Thermal-tactile stimulation

structural pathologies associated with contact stress

granuloma

contrastive approaches- complexity

maximal oppositions empty set

intrinsic muscles- abductors

open vocal folds Posterior Cricoarytenoid (PCA)

sulcus- causative factors

unknown congenital? ruptured cyst?

ASHA ICFCY activities and participation

(FOCUSf , Child and Caregiver Interviews) • Johnny has difficulty making friends and being included in other children's games. • Johnny has difficulty telling adults about past events • Johnny has difficulty joining in conversation with his peers. • Johnny has difficulty communicating independently with unfamiliar adults. • Johnny enjoys having family members read to him.

ICF case example- body structure and functions

(Formal/Informal Assessments) Cognitive functioning • Normal Speech (DEAPa) • English PCCb = 78, PVCc = 82 • Difficulty producing Spanish and English consonant clusters and fricatives Language (English) • Normal receptive language • Mild expressive difficulty Oromusculature, swallowing • Normal structure + function Voice/resonance, fluency, hearing • Normal; history of otitis media Early literacy • Poor phonological awareness and letter knowledge

ASHA ICF structure and functions

(Formal/Informal Assessments) Cognitive functioning • Normal (KBIT2a); poor working memory (AWMAb) Language (CELF-P2c ) Language (CELF-P2c ) • Normal single-word receptive vocabulary (PPVT-4d) • Severe morphosyntax (CELF-P2) and narrative deficits (language sample) Speech • Mild speech sound disorder Oromusculature, swallowing • Normal structure + function Voice/Resonance, Hearing • Normal Early literacy • Poor print concepts (PALSe )

vascular dementia

(multi-infarct or post stroke dementia) • Loss of cholinergic neurons; common risk factors with AD • Clear temporal relationship between occurrence of a vascular event (e.g., a stroke) and the subsequent onset of cognitive deficits • Standardized assessment for VaD; differential diagnosis from AD

Steps of screening

) interview of patient and/or caregiver 2) observation of signs and symptoms of oropharyngeal swallowing dysfunction 3) observation of routine feeding situation if indicated 4) interpretation of results: Is the patient dysphagic? 5) formulation of recommendations - including need for swallowing assessment 6) communicate results/recommendation to patient care team

Dementia with Lewy bodies and Parkinsons with dementia

- Neurodegenerative disorders characterized by a combination of cognitive impairments and extrapyramidal signs and symptoms.

four questions that need to be answered during assessment

- What is the extent of the problem? - Where does the communicative behavior break down? - What helps the communicative behavior? - What are the underlying mechanisms for the communicative behavior?

suprahyoid

- pulls hyoid upward-laryngeal elevation (DGMS) • Digastric • Mylohyoid • Geniohyoid • Stylohyoid

schuells patient factors influencing task performance

-alertness/fatigue -overall state of health -effects of meds on processing -patient processing style (slow rise, fading out, intermittent aud. imperceptions) -mental health -motivation/ownership in therapy -neurological soft signs (perseveration, distractability, etc) -anosognosia, neglect, visual field cuts, etc. -Pt learning style

schuells clinician factors influencing task performance

-knowledge base and therapeutic technique -Clinician's attitude -nature and promptness of Pt feedback -clinician's pacing of therapy (too fast may lead to response perseveration)

schuells response variables influencing task performance

-response modality -Time and repetition requirements of response mode *immediate response *repetitive response *delayed response *generative/spontaneous reponse

3 types of vocal sulci

1)physiologic sulcus—superficial tissue—Surgically removed or treatment or not at all 2)Sulcus Vergeture: Furrow extends to Ligament 3)Sulcus Vocalis: Mucosal bridge—extends deep into muscle

Schuells 3 practical applications

1-knowledge about stimulus manipulation may maximize performance can be used to ensure patient is working at a level where failure is minimized 2-knowledge about stimulus manipulations can be applied in opposite way to challenge mildly impaired patients those who respond without difficulty to tasks 3-many of the factors are important to discuss with people in the patient's environment about how to best communicate with the patient

Prioritizing goals based on baseline achievement

1. 10-50% accuracy 2. 1-10% accuracy 3. 50-90% accuracy

4 approaches to reading literature in depth

1. Determine the relevance of the literature • Categorize literature into levels of relevance with respect to the research topic: A = highly relevant; B = less relevant, but still important; C = articles that you feel that you should have read; X = irrelevant 2. Reading the work of prominent authors E.g. letters to the editor & forums where their work has been debated 3. Categorizing a conceptual literature review • Begin by reading highly relevant articles and write notes on the front page of each • Create a concept map 4. Critiquing individual articles • One should aim for key articles from international peer-reviewed journals

6 steps for using research in practice

1. Develop a well built question 2.Select and search sources of evidence 3.Examine, critique and synthesize the research 4.Apply the evidence 5. Evaluate the application of evidence 6. Disseminate findings

7 step plan for EBP

1. Generate a PICO (patient, intervention, comparison, outcome) clinical question. 2. Find external evidence that pertains to the question. 3. Critically evaluate the external evidence. 4. Evaluate the internal evidence from clinical practice. 5. Evaluate the internal evidence with respect to client factors, values and preferences. 6. Integrate the three sources of evidence to generate a clinical decision. 7. Evaluate the outcome of the decision.

5 purposes of swallowing assessment

1. IDENTIFY cause of swallow impairment 2. ASSESS ability to protect airway 3. IDENTIFY effective treatment strategies 4. DETERMINE need for referral 5. ESTABLISH baseline data

An Evidence-Based Systematic Review on Cognitive Interventions for Individuals With Dementia (Hopper, et al., 2013)

1. Individuals with dementia and mild and mild-moderate to moderate cognitive decline may be able to learn and relearn facts and procedures using specific cognitive intervention strategies; evidence was limited for individuals with moderate-severe and severe dementia. 2. SR training (in various forms) is a promising technique to facilitate recall of facts and procedures; other techniques were promising as well, including EL, VC, and specific instructions/cueing, although more research to support the use of these techniques is required. 3. Intervention tasks should be functional and include ecologically valid facts and procedures. 4. Improvement on training items may be expected, but generalization and long-term maintenance of facts and procedures may be limited without additional intervention. 5. Improvement in overall cognitive functioning should generally not be expected from cognitive intervention on specific tasks and information. 6. Because little is known about personal and environmental factors that influence learning by individuals with dementia, clinicians should consider ethnic, cultural, linguistic, and educational factors when making prognostic statements about learning outcomes.

primary cortical areas for speech

1. Primary Auditory Cortex 2. Primary Visual Cortex 3. Wernicke's Area 4. Broca's Area 5. Primary Motor Cortex

steps for summarizing articles

1. Reference: author(s), year, title, journal (book), volume, pages 2. Hypothesis (es) 3. Subjects/Participants 4. IV or IVs 5. DV or DVs 6. Procedures and measures of the DV(s) 7. Statistics used, including significance level 8. Summary of results 9. Conclusions

pediatrics ideas for hypersensitive

Increase flexion Soft music/ singing Slow, firm touch Consider joint compressions and massage Warm surfaces In order to learn, keep calm, alert state

granuloma- case example

45-year-old male presents with complaint of a raspy voice. Auditory perceptual evaluation reveals a low-pitched deep voice and increased roughness. Videostroboscopic evaluation reveals a bilateral bump on the vocal process

reinkes edema- case example

43-year-old female with complaints of intermittent dysphonia, an effort to produce her voice, shortness of breath during exertion. Constantly asked by other people, "What is wrong with your voice?" On the telephone, people mistake her for a male. She revealed constant throat clearing and wakes up hoarse every morning, used to smoke half a pack for 20 years

CATE (critical appraisal of treatment evidence)

1. Was there a plausible rationale for the study? 2. Was the evidence from an experimental study? 3. Was there a control group or condition? 4. Was randomization used to create contrasting conditions? 5. Were methods and participants specified prospectively? 6. Were patients representative and/or recognizable, at beginning and end? 7. Was treatment described clearly and implemented as intended? 8. Was the measure valid and reliable, in principle and as employed? 9. Was the outcome (at a minimum) evaluated with blinding? 10. What nuisance variable(s) could have seriously distorted the findings? 11. Was the finding statistically significant? 12. If the finding was not statistically significant, was statistical power adequate? 13. Was the finding important (ES, social validity, maintenance)? 14. Was the finding precise? 15. Was there a substantial cost-benefit advantage?

Schuells variables that may impact performance

1. Volume and noise 2. Visual perceptual clarity 3. Size and form 4. Method of delivery of auditory stimulation 5. Discriminability 6. Combining sensory modalities 7. Repetition 8. Rate and pause 9. Length and redundancy 10. Cues, prompts and prestimulation 11. Frequency and meaningfulness 12. Grammar and syntax 13. Context 14. Stress 15. Order of difficulty 16. Resource allocation 17. Response considerations 18. Feedback

abductor SD- case example

42-yearold with complaints that her voice gives out on certain sounds like, /f/,/s/,/p/, etc. and sounds like there are just airflow spasms rather than sound. She reports normal ability to sing and whistle

Schuells organization of treatment session

1. each session begins with informal chat to orient patient and wamr-up processing circuitry 2. Treatment exercises to address motor speech/swallowing deficits 3. Treatment exercises to address each modality in turn (alternating stronger and weaker modalities) 4. Conclude Treatment with pragmatic/functional carryover activity especially if prior exercises have been drill. Prepare client for activities next session.

leukoplakia- case example

1.Band director; needs to use a loud voice on the field (uses amplification but has probs with feedback) 2.Increased vocal effort 3.Significant Vocal Fatigue 4.Soreness and tightness in neck with voice use 5.No swallowing difficulty 6.Sound/feel of voice bothers him 7.Acid Reflux- Takes tums 8.Constant need to clear throat 9.Constant Globus sensation 10.Seasonal Allergies affect voice Fundamental Frequency: Normal (because not on free edge) iii. Intensity: Normal to almost normally (because he does have okay subglottal closure) iv. Glottal Closure: Increased (because of complaint of fatigue) v. Average Airflow: Lower end of normal vi. Because of increased subglottal pressure

PVFM case example

14-year-old with hoarse voice. Her mother reports she has asthma. Contributes the voice problem, to asthma and points to the inspiratory wheezing as a sign of asthma. Further probing indicates that the inspiratory stridor worsens with physical exertion and mom reports that medication has minimal effect on her symptoms

puberphonia- case example

17-year-old male with complaints of high pitched voice. Indicates that he is perceived as a female on the phone and that his voice never changed after puberty

how many communicative acts per min before words

2

MG- case example

26-year-old in acute care hospital. Her voice is weak, but articulation appears grossly normal in brief conversation. After vocal tests, the most remarkable finding is extremely rapid reductions in laryngeal diadokinetic rates over 7-second trials (i.e. striking slowing and weakening repeated glottal stops over time) with rapid recovery of rate after a brief rest

MTD case example

28-year-old female Symptoms Weak raspy voice quality, losses voice at the end of the day, voice rest restores vocal quality, high pitched strained voice, pain or discomfort in neck with voice use, vocal effort/fatigue, occasional pain and soreness with swallowing, difficulty breathing at night, constant need to clear throat, no complaint of acid reflux but recently put on proton pro inhibiter by doctor High Pitch because vocal folds are staying tight and stiff, her voice is strained Increased airflow because there was no closure during phonation Aphonic Airflow Increased Subglottal Pressure Increased because there is no closure and she is using effort to create her voice

LPR case example 1 w/o compensation

32-year-old with extreme vocal fatigue at the end of the day. Globus sensation constant need to clear her throat soreness in the throat and vocal effort with voice use. Denies acid reflux. On evaluation you see diffuse edema on the true vocal folds, thick mucus, erythema and edema of the arytenoids and pachydermia of the post cricoid area, decreased mucosal wave, but adequate vocal fold closure, decreased glottal amplitude and no Supraglottic compression

sulcus- case example

35-year-old male with high pitched weak voce and significant vocal fatigue. He indicates his voice never changed during puberty. You observe a furrow that is parallel to the free edges of the left vocal fold, you see glottal closure issues

Enhanced milieu teaching: effects of parent-implemented (Hemmeter & Kaiser, 1994)

4 parents with preschool aged kids with developmental delay, positive effects for 3 of 4 kids EMT

acoustic index-dysphonia severity index

4 voice characteristics based on multivariate analysis of 387 subjects MPT- sec Highest frequency (Fo-high, Hz) Lowest intensity (l-low, dB(A)) Jitter- %

ICF-CY environmental and personal factors

4 years old and attends Head Start preschool • Lives with his mother, who has a learning disability, and his grandmother, who has a hearing impairment • Is the younger of two children and is shy • Is healthy, with an easygoing temperament • Enjoys attending preschool, where he is more comfortable with teachers than with peers • Lives in a low socioeconomic neighborhood • He was born in the U.S., and only English is spoken at home

presbyphonia case 1

50-year-old male with weak voice and inability to project. Videostroboscopic exam reveals bilateral atrophy of the vocal folds, a significant glottal gap and no Supraglottic compression. Fo decreased (because of less mass which leads to a loss of bulk) Decreased intensity because of the large subglottal gap Decreased subglottic pressure because of the glottal gap

subglottic pressure

6.1 hectopascals (hPa) in control subjects to initiate and maintain phonation pressure below vocal folds too much can cause phonotrauma

nodules- case example 1

65 yo female Hoarse vocal quality; constant need to clear throat; sudden onset; no voice in the morning, needs to clear throat to get going, quality decreases, volume/pitch and decrease, vocal effort, vocal fatigue, coughing spells, shortness of breath and dry throat when singing, symptoms get better with hydration; difficulty swallowing, Acid Reflux, does not get better with rest Strain, Roughness (due to aperiodicity of vocal fold movement), No breathiness, aphonia, perception of lower voice (decreased loudness/pitch because of irregular vibration) Minimum Airflow: increased Average Airflow: higher end of normal During phonation the airflow would be decreased because of the roughness of her vocal quality (roughness creates irregular vibration of the vocal folds which would decrease airflow) Subglottal Pressure Increased

Parent-implemented enhanced milieu teaching with preschool children who have intellectual disabilities (Kaiser & Roberts, 2012)

77 preschool aged kids with ID-autism and downs, children with EMT gained more language

description of TBI

: a blow (or jolt) to the head or a penetrating head injury that disrupts brain function. o Primary causes of TBI: motor vehicle accidents, falls, and sports-related injuries in nonmilitary, civilian incidents.

characteristics of CAS

; high incidence vowel errors; inconsistent articulation errors**; lengthened and disrupter co-articulatory transitions**; inappropriate prosody**; altered suprasegmental characteristics; limited consonant and vowel inventory, frequent omission errors, increased errors on longer units of speech, significant difficulty imitating words/phrases; use of simple syllable shapes.

Decision making guide at bedside

<2 predictors of aspiration oral feeding and reassess with change 2 or more predictors- perform VFSS no aspiration on VFSS continue/ advance diet aspiration on VFSS, diet recs, initiate tx

speaking valve

A "closed" system Restore positive subglottic air pressure Promotes restoration of physiologic Positive End Expiratory Pressure (PEEP) Facilitates oxygenation Stronger cough Ability to perform valsalva maneuver (bowels, swallowing)

SYSTEMATIC REVIEW OF THE TREATMENT OF FUNCTIONAL DYSPHONIA AND PREVENTION OF VOICE DISORDERS (Ruotsalainen, Sellman, Lic, Lehto, Verbeek, 2008)

A combination of a direct and an indirect voice therapy should be considered the best available intervention for treating functional dysphonia. Screening and subsequently treating teachers and student teachers are feasible and yield positive results. The speech and language therapist must always assess the patient, and then choose the aims and the specific techniques of voice therapy accordingly. We have not found high-quality evidence to support the current practice of giving training to at-risk populations to prevent development of voice disorders.

tracheostomy

A tracheostomy is an opening surgically created through the neck (just above the sternal notch) into the trachea ("windpipe") to allow direct access to the airway and lungs. A tube is usually placed through this opening to provide a stable airway and to remove secretions from the lungs. Changes with trach Airflow bypasses the upper airway Warming and humidification of air Filtering of air Vocalization Smell & Taste Sensory stimulation to pharynx, oral, and nasal passaged Loss of "closed" respiratory system and positive subglottic air pressure Pressure generation for cough, bowels, swallowing Possible "anchoring" of the larynx

arcuate fasciculus

A white matter tract that connects Broca's Area and Wernicke's Area through the Temporal, Parietal and Frontal Lobes. Allows for coordinated, comprehensible speech.

strident

AKA sibilant-fricative with intense noise energy also called a sibilant, s and sh, z and zh sounds that are produced by forcing the airstream through a small, constricted opening

tips for successful intervention

Active engagement Feedback about accuracy Reinforcement to increase rate or likelihood Repetition to provide meaningful opportunities Specificity of the target Control complexity within the ZPD Minimize errors through cuing and scaffolding Work within schemas: new forms - old functions; new function - old forms

FEES advantages and limitations

Advantages • Can be done at the bedside - Mobile • Real food and liquids • Length of time for the study unlimited o Fatigue • Portable • Family, caregivers, nurses, physicians can see a clear picture of the problem • No restrictions on positioning • No radiation exposure • Direct view of the anatomy • REAL LIFE Limitations • Invasive • Cannot see during the swallow • Comfort level • Gagging/vomiting • Risks/side effects • Use of dye • Limited to same view during entire exam • Technically more difficult to learn for SLP • Patients may find it uncomfortable • Confused/agitated patients may not allow scope to be passed

MBS advantages and limitations

Advantages • Views of the oral, pharyngeal and esophageal structures and phases of swallowing. • Can assess the duration of each of the oral, pharyngeal and esophageal stages of swallowing. • Information about the safety of different food and fluid textures/viscosities and ability to use compensatory techniques or therapeutic maneuvers • Can be recorded Limitations • The procedure involves the use of ionizing radiation - frequent test • repetition is inappropriate. • The procedure uses modified foods and fluids. The barium may affect • the taste and/or the texture of the foods/fluids • The MBS provides a 'test' or artificial situation. Due to time limitations of the procedure (because of radiation safety considerations), the time required for some patients to eat may be underestimated and fatigue might also be less obvious. • Focuses on motor function; unable to directly analyze the sensory • function of the oropharyngeal system. • Accessibility and availability • Cost • Patient size

obstruent

Affricates, fricatives, and stops; sounds made with notable amount of air obstruction in the vocal tract; narrow constriction or complete closure of oral cavity opposite of sonorant

ASHA ICF environment and personal factors

Age: 37 • Occupation: elementary school teacher • Vocal use: approximately 7 hours per day • Constant background noise during afternoon classes • Use of caffeinated beverages to hydrate herself throughout the day • Self-described as "talkative" and "outgoing"

Mechanisms of airway protection

Airway closure- True and false vocal folds adduct, laryngeal aditus narrows Laryngeal elevation- Larynx raises and tilts under the base of tongue Tongue base retraction- Posterior tongue action causes tongue base to deflect bolus away from the airway Epiglottic invertion- Rising larynx and thyroepiglottic ligament contraction allow the epiglottis to fold over the laryngeal aditus Vallecular spaces- Bolus is divided and channeled around the airway

therapy tips non-fluent aphasia

Allow your family member or patient to fail. By this, I mean don't be in such a hurry to finish every phrase the person starts. Give hints if you need to (like in a cueing hierarchy), but overall try and allow them space to find the word(s) they are looking for. Provide opportunities to work on language and turn off the TV. This can be done by having the person describe their surroundings, talk together about items you see in a newspaper or magazine ("Tell me about the _________ on this page."), talk about a picture album with them (familiar content!), or take turns describing a picture scene where only the person describing the picture can see it. Create or use activities that have multiple modes of language active simultaneously. For example, if naming an object/picture is hard, then pair it with the object name in written format. If that is really easy then give multiple words to choose from with one object/picture in a naming task. Scaffolding. This is a term a lot of teachers will be used to hearing, and a man by the name of Lev Vygotsky was responsible for creating this idea. In short, it just means that you find where the person's strengths and weaknesses are and you provide just enough help to get them over the hump with whatever task you are doing. Sometimes that means that you take a task that someone gives up on and you modify it. If a task is within that zone where someone can do it, then provide the scaffolding needed to allow them to succeed. Then, of course, as they get better at the task, you take away some or all of the scaffolding that was needed to allow them to succeed. Automatic speech drills are often good to improve correct fluency or allow more voluntary control by tapping into long-term procedural memory. Examples include: counting 1-20, naming the days of the week, naming the months of the year, the pledge of allegiance, and some highly familiar nursery rhymes. Music Therapy. Often overlooked, this therapy can allow a patient to participate in song in ways that they cannot with typical speech production. If the person is too shy to participate in choral style singing exercises (all highly familiar songs at first please!), then encourage singing in privacy. Improvements in fluency, strength of voice, and reduced stress are all outcomes that can be realized through this method. [I almost always use Christmas carols, church hymns, or other basic nursery rhymes/songs].

difference btwn an articulation and a phonological disorder

An articulation disorder is the child's difficulty at a phonetic/motoric level. They have trouble making the individual speech sounds. A phonological disorder is a child's difficulty at their phonemic level (in their brain). This "phonemic level" is sometimes referred to as "the linguistic level" or "a cognitive level". A phonological process disorder involves patterns of sound errors.

transcortical motor area of involvement

Areas surrounding Brocas Similarities to motor Aphasia But with intact repetition Lesion in border area Superior or anterior to Broca's area

multiple oppositions basis

Assumes learning is facilitated by the size and nature of linguistic "chunks" presented to the child (learning of the whole is greater than the sum of its parts) Assumes learning is a dynamic interaction between child's unique sound system and intervention Predicts learning will be generalized across a rule set (i.e., learning will generalize to obstruents and clusters collapsed to [g] in the 1:17 phoneme collapse) and result in systemwide restructuring

what is key to voice assessment

Auditory and self-perceptual measures

RLN damage- case example 2 (no compensation)

Auditory perceptual analysis reveals breathy, weak voice and significant strain to produce voice. The voice problem started following a heart surgery 2 months ago. Low subglottal pressure and a large minimum and average airflow

laryngitis- causative factors

Bacterial or viral, particularly if acute Exposure to irritants: Smoke, LPR, allergies

EMT

Behavioral approach to language Social interactionist approach Emphasis on parents as language teachers Incidental teaching • environmental arrangement, responsive interaction and milieu procedures to prompt language • natural setting, play based, model, mand design activities to encourage language • components are taught to parents sequentially: 1. environmental arrangement- activities of interest to kid, natural situations (sabotage, creative stupidity), child initiates 2. responsive interaction strategies-follow child's lead, respond to attempts to communicate, provide meaningful feedback, expand utterances 3. milieu therapy strategies- time delay, mand, model • When the child responds correctly: 1. Acknowledge 2. Expand and extend 3. Provide the natural consequence/material • When the child responds incorrectly: 1. Repeat the prompt 2. Model the correct response 3. Provide the natural consequence/material Hybrid Hemmeter and Kaiser- multiple baseline, 4 parents with preschool aged kids with developmental delay, positive effects for 3 of 4 kids Kaiser and Roberts 2013- 77 preschool aged kids with ID-autism and downs, children with EMT gained more language • promotion of functional use of productive language • goals based on functional needs and developmental level • can target specific forms • morphemes • child and parent goals • parents don't move to new skill until previous one is mastered • Parents trained by SLP, 20-36 sessions for parents, training in homes, clinics, or schools • 45mins-1hour, first 15 minutes' review progress, 15-20mins parent with child, 15 minutes to reflect on session

Wetherby and Prizant communicative acts

Behavioral regulation- request and protest (protoimperatives) Social interaction- attract or maintain on self (mix of protoimperative and protodeclarative) • Call or greet • Request comfort • Request a social routine • Show off • Request permission Joint attention (protodeclaratives) • Attract attention to any object, event or topic • Comment on action or object • Request info

functional dysphonia treatment

Best-documented tx—often with excellent results—is aggressive laryngeal massage fairly traditional voice therapy (relaxation, breathing, e.g.) + "Cognitive-Behavioral Therapy" around voice (identify antecedent events, cognitive and emotional reactions thereto)

Hinckley 2011 Model for selecting therapy based on cognitive abilities

Better cognition- communication based intervention PACE, conversational coaching, Script training, SFA, assistive device, direct attention training, external memory aids Worse cognition- Impairments context focused training, errorless learning, SRT, SCA

cysts- causative factors

Blockage of glandular duct to surface (retention of fluid) Impact stress

RLN damage- case 3 with secondary MTD

Breathing difficulty and voice difficulty, weak voice, cannot project, high pitched squeaky voice, tightness in voice along with pain in use, effort to produce voice, vocal fatigue with voice use, people have difficulty hearing her in social situations, swallowing difficulties, occasional acid reflux, body dryness, history of laryngitis Post cervical disc fusion

Nonfluent aphasia types

Broca's, transcortical motor, global, mixed transcortical (mixed nonfluent)

leukoplakia- causative factors

CHRONIC irritation Smoke Alcohol Environmental/chemical irritants

Essential tremor syndrome

CNS disorder may involve head, limbs, tongue, palate, and larynx tends to start in hands, then goes to arms, head, neck, face, etc. Typically absent at rest: Most apparent during postural maintenance, reduced during movement, increased at end of movement May be associated with aging

aphasia types with impaired ability to repeat

CONDUCTION brocas wernickes global

Medications (pops hoMeland pride)

Can impact alertness, ie: Ativan with CNS depression. Medication that may have involvement with esophageal injury, ie: aspirin. Medication impacting oral cavity dryness, ie: certain ACE inhibitors for hypertension. Monitor for certain topical anesthesia, ie: xylocaine and a numbing impact on the airway.

Esophagus (pops homeland pridE)

Determine if there are pre-existing esophageal based conditions, ie: stricture, diverticulum. Assess for possible GERD symptoms, ie: belching. Determine if patient is being medicated for reflux, ie: Pepcid.

webs- case example

Case example: 47-year-old male experiencing problem after a cold 1 year ago. The patient's voice never recovered. Physical exam shows the left vocal fold does not come to midline on adduction and moves sluggishly when it moves at all. Exam reveals moderate sized tissue bridge across the vocal folds at the anterior commissure. Patient states his voice was never entirely normal even from childhood

Parts of an assessment

Case history Aphasia testing (formal and informal) Cognitive testing Quality of life

LPR

Caused by dietary triggers GERD Spicy foods Acidic foods Dairyproducts Alcohol Caffeine Distributed in the larynx Diffuse laryngeal edema Erythema and edema Pachydermia- Post cricoid area

pediatrics- signs suggesting disorganization

Change in muscle tone Sighing Gaze aversion - horizontal nystagmus Mottling Rapid respiratory rate Elevated tongue posture Anterior spilling Increased WOB/ chin tugging --SHUT DOWN-

presbyphonia case 2

Changes in quality since mid November Significant cough, unable to sing in church, vocal effort, vocal fatigue, vocal quality worsens with voice use, experiences some difficulty swallowing, vocal quality clear in the morning but gets worse with voice use, high pitch makes his voice better, needs to clear throat, acid reflux, experienced the symptoms but they got better over time

ASsessment components

Chart review Case history observatons oral mech feeding trials

what is goal of phonological intervention

Child learns the new RULE • Production of new contrast becomes AUTOMATIC - Density of responses - Bridging activities to program for generalization

SPACS- characteristics

Child's ENTIRE system is examined as a unique, independent system ("own language") • Views child as ACTIVE and CREATIVE learner of the sound system • Compares SYSTEM to SYSTEM (child:adult) • Maps child:adult system in terms of phoneme collapses (one-to-many correspondence) • Child-based rather than adult-based

Recommendation (pops homeland pRide)

Clear and concise verbal and written communication to staff and family. Should address aspiration risk and dysphagia. Should address referral to other disciplines, ie: ENT. Should address: nutrition, hydration, and medication delivery needs. Should address need for instrumental assessment, ie: MBS and potential therapy follow up. Should include: patient positioning and delivery rate of bolus volumes.

pharyngeal expectoration

Clearing post swallow residue Hocking a loogie

clinician directed intervention pros and cons

Clinician controls all aspects of the treatment Rapidly elicits accurate task-specific productions Must build in generalization tasks Valuable for increasing exposure to rarely occurring forms Useful for early- and later-developing forms

hybrid interventions pros and cons

Clinician controls choice of activities and materials Child controls play and conversational topics Strong generalization Valuable for increasing exposure to rarely occurring forms Useful for early- and later-developing forms

clinician-client exchange in stimulation approach

Clinician: delivers carefully chosen, sufficiently strong language stimulus to which patient will have success Client: responds to stimulus Clinician: provides instructive feedback and restimulates

adductor spasmodic dysphonia- symptoms and characteristics

Common to produce a normal voice during sustained phonation of vowels, falsetto singing and during vegetative laryngeal activities Intermittent adductory action of folds during speech

laryngectomy- immediately after surgery

Communication board; picture-based, alphabet, word-based Encourage pt to utilize voiceless phonemes Primary TEP voice prosthesis insertion, able to test the voice soon after surgery.

Chin down

Compensatory strategies- postural changes Pushes anterior pharyngeal wall back, pushes tongue base and epiglottis closer to the posterior pharyngeal wall, narrows airway, widens vallecular space

standardized tests and scoring

Con: decontextualized Norms- adequate size, representative of target population Normal is usually standard score of 85-115 (1 SD from mean) bell curve Percentiles: 15-85?? 1-1.5 SD below- mild to moderate 1.5-2 SD below- moderate Below 2SD severe

RHD linguistic deficits

Confrontational naming Body part naming Auditory comprehension of complex material Word fluency Writing Oral sentence reading

browns stage 5

Contractible aux be (they're playing) Uncontractible aux be (Is she swimming? She is) Uncontractible copula be (Is he here? He is) Irregular 3rd person singular (She has)

Therapy inconsistent speech errors

Core vocabulary nuffield center dyspraxia programme

Aspiration (pops homelAnd pride)

Cough, wet gurgly voice Cough- pre- premature spilage, gottal closure deficit Peri Post- residuals, ph Clinical symptoms of aspiration risk: cough, choke, wet voice, throat clearing, eye tearing, increased work of breathing, congestive changes with oral intake, drop in O2 saturation level

high challenge targets

Could frustration discourage the child? • YET with rich supports and supportive contexts, child can get RAPID change • child is positively engaged • Series of studies by Nelson & colleagues reported that higher challenges were picked up quicker

low challenge targets

Could run risks: • hold child below optimal learning rates • child less interested • child's ability is greater than their assessment performance

laryngeal cancer- role of SLP

Counseling and education most important Permanency of tracheostomy Difference of breathing from the larynx vs. stoma Changes in olfactory and taste Impact on the oropharyngeal swallow Loss of vocal folds but preservation of articulation and resonance They should also see a support group

acoustic index- fundamental frequency

Count from 1-5 obtain F0 on "3;" compare to norms (mostly within or not within normal range) Jitter-F0 instability, may indicate mucosal abnormality Range often compromised with lx pathology Procedures Sitting, glide from a low note to a high note Decreased range indicates presence of stiffness, mass or neuromuscular abnormality (SLN)

steps towards cultural competence (5)

Cultural awareness: self-examination, exploration own culture Cultural Knowledge: seeking & obtaining educational foundation re diverse cultural and ethnic groups Cultural skill: collecting relevant data and performing culturally sensitive and appropriate assessment, intervention Cultural encounters: engage cross-cultural interactions to refine, modify existing beliefs Cultural desire: motivation to WANT to rather than have to engage in the process of becoming culturally aware, knowledgeable,skilled and familiar with cultural encounters

conduction aphasia area of involvement

Damage to arcuate fasciculus-a deep white matter tract connecting the Wernicke's area to the Broca's area

alexia

Damage to the mature reading system resulting in impaired comprehension of written language Peripheral alexias do not have to co-occur with aphasia. Central alexias tend to co-occur with aphasia.

acoustic index- intensity

Decreased intensity can reflect pathology increased intensity might reflect etiology for pathology (e.g. high impact stress), though data indicate it rarely does (people with mass lesions tend to have poor output for given Ps) Shimmer- intensity instability, may indicate mucosal abnormality or neuromuscular abnormality

parkinsons

Degeneration of path between substantia nigra and BG Rest tremor Increase in muscle tone (rigidity) Difficulty with initiating movement and reduction in spontaneous movements (akinesia) Slow movement execution (bradykinesia): characteristic shuffling gait Reduced range of motion (hypokinesia), possibly due to rigidity, possibly contributing to flat-appearing affect

Bolus modifications for particular impairments

Delayed pharyngeal swallow reflex- Larger bolus Weak pharyngeal swallow- Smaller bolus

components of case hx

Demographic information Occupation Patient complaints Onset and course Medical history Voice history Vocal hygiene

Swallow screen

Determine presence / absence of dysphagia but no etiology Indicate need for swallow examination Look for signs and symptoms of dysphagia which could lead to airway compromise or inadequate nutrition/ hydration Needs to be completed by medical professional and available 24/7 All children under 3 years of age should be evaluated and not screened!

Primary goals of assessment

Determine presence of communication impairment, severity and type of impairment, determine individuals strengths and weaknesses Identification of exacerbating factors such as: vision and hearing deficits, agnosias (ability to recognize), deficits in proprioception or praxis, mood disorders or effects of medications Identify intervention goals.

maximal oppositions

Developing Execution Speech production Unintelligible speech, gaps in inventory Contrastive word pairs(known-unknown) Preschool age with moderate-severe SSD M~d moo vs do

nuffield center dyspraxia program

Developing Planning, programming, execution Speech production, phono awareness Build speech processing skills from bottom up through est motor programs for single sounds in isolation & increasing phonotactic complexity *Auditory discrim and specific NSOM skills within repetitive practice Childhood apraxia age 3-7

multiple oppositions

Developing execution Speech production Unintelligible speech, extensive homonymy from phoneme collapse Contrastive word pairs (error-targets), uses collapse Preschool age with moderate-severe SSD d,f,ch,st collapse to g then: Goo-dew, foo, chew, stew

cycles

Developing execution Speech production, phono awareness, literacy Unintelligible speech Ordering of phonological patterns within cycles, auditory bombardment Young children w limited sound inventory Target patterns, ie- final k within a pattern (velars) is targeted for 60mins for one week then patterns are recycled until generalized Children under 3 includes a focused auditory input cycle, parallel play, not required to say anything just hears sound a lot

minimal pairs

Developing, elaborating Execution Speech production Unintelligible speech/homonymy Contrastive word pairs (error-target) Preschool age with mild-moderate SSD (common phonological errors) G~d goo vs do

morphosyntax approach

Developing, elaborating Execution Speech production, other oral language Phonological and morphological difficulties Cycles that target speech sounds and grammatical morphemes Preschool mild-mod SSD w morphological errors Indirect focus on speech by targeting morphemes such as past tense, kicked-word final clusters Adapted stories and scripts to elicit production Often 1 morpheme per week, or alternate speech intervention every other week

core vocabulary intervention

Developing, elaborating Planning, execution Speech production Inconsistent sound errors not apraxia Children 2+ including bilingual and those w cognitive disabilities Focus on specific vocab of 50 functionally powerful words Children try to produce best production of 10 new words per week

dynamic systems

Developing, elaborating Planning, execution Speech production, other oral language, literacy Phonological and language impairments Addresses discourse structure, semantic, syntactic, morphological and letter-sound knowledge Preschool w concomitant speech and language disorder Adult and child explore topic, play, snack etc. increase refinement through constellation processors, macrostructure, connotative, denotative, referential, canonical, categorical and perceptual

non-linear phonological approach

Developing, elaborating Planning, execution Speech production, speech perception, phono awareness Phonological impairment Addresses speech within syllable and phrase level Preschool w mild-mod SSD Phonological awareness, prosodic and new individual element goals, new word structures, focus on non-linear hierarchal form of phonology from prosodic to individual feature

psycholinguistic approach

Developing, elaborating Planning, programming, executing Speech production, phono awareness, literacy Speech and literacy difficulties Processing models-input-representation-output Preschool and school aged, mod-severe SSD and literacy difficulties Spoken and written language strengths identified and built upon

metaphonological approach

Developing, elaborating executing Speech production, phono awareness Speech and phonological processing difficulties Phonological awareness activities in addition to production activities Preschool aged, mod-severe SSD w/ phonological awareness difficulties Sound matching, mispronunciation id, categorization from internal representation, rhyming, syllable clapping

developmental dysarthria interventions

Developing, elaborating execution Speech production 3 approaches to intervention: 1. Designed to get child to produce sounds and words that are within physiological capabilities- min pairs, nonlinear phono approaches 2. Develop child's capability to control and coordinate articulators- phonetic placement techniques, bite blocks, instrumental feedback etc. 3. Develop compensatory movements and strategies to produce sounds that otherwise can't produce, i.e.- lingua-dental contacts for child w/ lip paralysis, production of derhoticized r and dentalized sibilants

NSOMT

Developing, elaborating execution Speech production, speech perception Children with cerebral palsy, down syndrome, children with oral myofunctional disorders Oral motor exercises- non speech Exercises to target muscle strength, range of motion, control and sensory function

intervention for elaborating stage

Developmental dysarthria Core vocab Electropalatography Ultrasound PROMPT NSOMT Non-linear phono approach Dynamic systems Morphosyntax Psycholinguistic Metaphonological Minimal pairs

intervention for developing stage

Developmental dysarthria Nuffield Dysarthria Core vocab PROMPT NSOMT Non-linear phonological approach Dynamic systems NSIT morphosyntax CYCLES PACT Psycholinguistic Metaphonological Maximal oppositions/empty set Multiple oppositions Minimal pairs

EMT-PE

Emerging execution Speech production, other oral language Limited sound system Increasing vocab and sound production using phonological recasting Young kids (18mos-3yo) w limited sound inventory, cleft palate Same processes as EMT but with phonological focus, recasting, responsive interaction and environmental arrangement

physiologic index- mucosal function

Diadochokinesis (DDK) Procedures and scoring Adductory L-DDK rapid glottal stops over 7 sec calculate # stops/sec rate strength rate rhythmic consistency compare to norms with z-score (5-7/sec) Interpretation Poor performance may indicate neuromuscular abnormality rate/strength decrements may be PNS additional rhythmic inconsistency may be CNS Voice changes may arise from several abnormalities in mucosal function Failed glottal closure Stiff, dry and elongated mucosa Irregular mucosal oscillation

LPR treatment-

Diet modifications Vocal Hygiene Sleep slightly elevated Medications (Inhibitors/Blockers)

pyramidal system

Direct Activation Pathway. o All of the motor impulses that originate at the cortical level travel through this tract. o This pathway supplies the voluntary muscles of the head, neck, and limbs. o Neurons of this tract originate in the post-central gyrus or primary motor cortex and descends to the spinal cord (the corticospinal tract) passes through the pyramids of the medulla

RHD non linguistic deficits

Disorientation to time and direction o Topological disorientation Left Side Neglect o Fail to recognize one side of body o Deficit in directed attention o Severity of neglect is usually indication of size of lesion and overall severity of condition Anosognosia o Failure to recognize the symptoms of one's own illness Visuospatial Deficits o Figure ground problems o Recall of visual forms o Mental rotation Prosopagnosia o Inability to recognize familiar faces

reinkes edema

Distributed edema along margins of VFs Some sections with greater edema Translucent Floppy folds Enlarged fluid bags or balloons

parkinsons- treatment

Drug and surgical tx critical for control of many Sx (but usually don't help voice/speech) Behavioral tx

COPD and swallowing

During swallow we don't breathe. The longer food is in the pharynx, the longer the period of apnea, in people with respiratory issues like COPD they can not hold their breath that long and if they have to breathe in during swallow it will likely result in aspiration

Diagnosis (pops homelanD pride)

Dysphagia from structural etiology, ie: head and neck cancer, from neurological etiology: CVA, from chronic conditions, ie: COPD, will each require specific interventions. Patients with more comorbidities are often the more complex dysphagia patients, ie: neurological and structural deficit

intervention possibilites for overall devt delay or autism in developing language phase

EMT, dialogic reading

ASHA ICF structures and functions

ENT diagnosis of vocal nodules • No history of neurological or respiratory conditions • Rough, breathy, strained vocal quality • Vocal quality that worsens with use and fatigue • Increased muscle tension (neck/strap muscles)

SOVT

Efficient voicing Minimally touching vocal folds Heightened interaction between glottis and supraglottal tract Laryngeal lowering Widening of hypopahrynx Decreased PTP- less vocal fold adduction MFDR is maximized Lip trills Tongue trills Kazoo Straw exercises Without phonation With phonation Pitch glides Humming a tune Laryngeal hyperfunction- lesions Glottal insufficiency Singers

NSIT

Emerging, developing execution Speech production Phonological and language impairments Recasts of child productions during natural play Preschool w mild SSD and language, also Downs and ASD Natural play and recasting, NOT imitative prompting and drill

PACT

Emerging, developing execution Speech production Unintelligible speech Parent-family training, metalinguistic training, contrastive intervention Preschool age w mod-severe SSD Parent education, metalinguistic training, phonetic production training (stimulability techniques), multiple exemplar training, homework

PROMPT

Emerging, developing, elaborating Planning, programming, executing Other oral language, literacy Children 2+ with speech production, sensory and motor impairments Tactually grounded, sensory motor model Use of physical cues and visual symbols

irritable larynx- symptoms

Episodic laryngospasms Airway distress Dysphonia Weak voice Globus sensation ? Chronic cough? Specific chemical triggers symptoms LPR

disorders by phase- esophageal

Esophageal to pharyngeal backflow Laryngopharyngeal reflux -LPR- can lead to aspiration pneumonia- can lead to recurrent • Prandial aspiration-during swallow • Non-prandial- not during swallowing(reflux) Tracheoesophageal (TE) fistula- hole in tissues, in common wall of trachea and esophagus- can allow food to leak into trachea, requires surgical intervention Zenker's diverticulum GERD

therapy tips for working with fluent aphasia

Establish a sign that lets the person with fluent aphasia know that they need to be quiet and listen. (Do this quickly or therapy will be out of control). If reading skills are intact (or partially intact) make sure and use this to your advantage. Many times the patient will have auditory processing problems, but will be able to read text fairly well. Pair listening exercises (1,2, or 3 step directions; Basic and Complex Yes and No questions; Item identification or picture identification) with text to help with scaffolding. Item identification drills involve placing between 2 and 6 or more objects within the field of view of the person with aphasia. Then, you name the item you want the person to find (e.g.- "Show me the __________"). To make this same drill harder, you can add prepositions into the mix (e.g.-"Before you point to _________, point to ____________"; "Put the ____________ on top of the ______________"; "Place the ___________ under the ____________ then point to the ___________________"; etc.). Automatic speech drills are often good to improve correct fluency or allow more voluntary control by tapping into long-term procedural memory. Examples include: counting 1-20, naming the days of the week, naming the months of the year, the pledge of allegiance, and some highly familiar nursery rhymes. Group aphasia therapy may also prove helpful, as it can reinforce listening, turn-taking, and non-verbal communication skills. Communication Boards may also be of benefit. These are usually very patient specific and you will likely need the help of an SLP to set this up initially and train you on the best use of it.

Dollahan, 2007 CATE critical appraisal of treatment

Evidence source: Foreground question addressed by the evidence: For ___________________ (Patient/problem) Is ___________________ (Treatment/condition) associated with ___________________ (Outcome) as compared with ____________________ (Contrasting treatment/condition) Appraisal points 1. Was there a plausible rationale for the study? 2. Was the evidence from an experimental study? 3. Was there a control group or condition? 4. Was randomization used to create contrasting conditions? 5. Were methods and participants specified prospectively? 6. Were patients representative and/or recognizable, at beginning and end? 7. Was treatment described clearly and implemented as intended? 8. Was the measure valid and reliable, in principle and as employed? 9. Was the outcome (at a minimum) evaluated with blinding? 10. What nuisance variable(s) could have seriously distorted the findings? 11. Was the finding statistically significant? 12. If the finding was not statistically significant, was statistical power adequate? 13. Was the finding important (ES, social validity, maintenance)? 14. Was the finding precise? 15. Was there a substantial cost-benefit advantage? Validity: Compelling _____ Suggestive _____ Equivocal _____ Importance: Compelling _____ Suggestive _____ Equivocal ____ Clinical bottom line: The Handbook for Evidence-Based Practice in Communication Disorders, by Christine A. Dollaghan, Ph.D., CCC-SLP. Copyright © 2007 Paul H. Brookes Publishing Co., Inc.

pediatrics positioning

Feet on stable surface Head/neck/trunk alignment Decrease elevated shoulders Hands toward midline Slight chin tuck Chair, lap, bean bag, tumbleform, sidelying If GER, remain at 35-45degrees after feeding

irritable larynx- treatment

Find what triggers the laryngospasms Respiratory retraining Avoidance of environmental triggers

language disorder as part of a larger devt delay- characteristics and deficits

Example diagnosis: intellectual disability, fragile x, Williams syndrome, cerebral palsy, developmental delay Intellectual disability Low IQ, low adaptive ability (p102) Language- • Form slower development, less complex sentences, fewer elaborations and relative clauses • Content- vocabulary size less effected than syntax • Use- slow to develop intentional communication, good at turn taking and topic maintenance, issues with coherent narratives, • Literacy- slower to progress, same link btwn phonological awareness and literacy as typical developing Downs syndrome- • global delay in fine and gross motor, intellectual ability • Expressive more severely impaired than receptive language • Form-Low speech intelligibility • More pronounced grammatical deficits than others with similar IQ • content-first words significantly delayed and expressive vocab growth slow • receptive vocab more in line with cognitive ability • use- an area of strength relative to other areas • literacy- extremely variable Developmental delay not specified • Motor difficulties • Lower IQ

general intervention techniques

Expansion- response to child's utterance that adds semantic content Extension- repeat back what was said and add more information Recast- maintains child's central meaning, can be corrective (fixes grammar, inserts missing words) or non-corrective (alternate form) Mands (commands)- require direct response from child o Questions o Mands for imitation Wait time

example treatment targets for nonfluent aphasia

Extending length of coarticulated speech Improving auditory comprehension Work on oral expression tasks Understanding written language (reading) Improve writing

MG- symptoms and characteristics

Extremely rapid fatigue Pronounced fluctuation of performance Restoration of performance after rest

high functioning autism characteristics and deficits

Extremely variable Diagnostic criteria- A) deficits in social communication all 3 of following: 1.Deficits in social-emotional reciprocity (lack of initiation of interaction, no turn taking, lack of emotion and affect) 2.Deficits in nonverbal communication- eye contact, body language, facial expression 3.Deficits in developing and maintaining relationships- B) Restricted, repetitive patterns of behavior- 2 of the following: 1. echolalia 2. excessive adherence to routines or patterns 3. highly fixated restricted interests 4. hyper or hypo reactive to sensory input 50-70% also have ID Form: • articulation relatively unimpaired • Phonological processing difficulties • Grammar issues and morphosyntax deficits Content- • Qualitative difference in vocab vs typical developing Use • abnormal rather than immature • Significant deficit in conversational skills • Poor inferencing skills Literacy- Links are less strong btwn phonological awareness difficulties and reading difficulties than other groups

jitter

F0 instability, may indicate mucosal abnormality

dialogic reading

Facilitates language and literacy Connectionist model of development Practical • Adults are taught specific strategies to model language while engaging kids with books • Uses models, mands, recasts and expansions • Crowd questions: • Completion statements • Recall questions • Open-ended questions • Wh-questions • Distancing prompts-questions ties story to real life Child centered Crain-thoresn and Dale (1999)- trained parents and educators to use dialogic reading and then looked at language development, SLI and broader delay, they found increase in language across the group • Form, content and use General goals with parents, more specific forms with slp and then home can help generalize • Many contexts, by parents, clinician and teachers, clinic, home and school

how can intervention change language

Facilitation- accelerate rate of growth or learning Maintenance- preserve a behavior that would otherwise disappear Induction- teaching a new skill, determined endpoint

Complex sentence level approaches

Fast ForWord Dialogic reading Conversational recast Direct instruction Drill play Story Grammar

Story level approaches

Fast ForWord Dialogic reading Conversational recast Direct instruction Drill play Story Grammar

anomic aphasia area of involvement

Focal damage to left temporal and parietal lobes

assessment of language delay/ disorder in the developing language stage (SLI or part of larger devt delay)

Focus on assessing language and eliminating other potential causes or delays Hx (ages and stages questionaire) Nonverbal IQ (Leiter-3) language test (CELF, OWLS) Language/play sample (SALT) artic/phonology assessment if needed (GFTA)

MG- treatment

Focus on compensatory and coping strategies ***Not on muscle strengthening or resistance training

flow phonation

Focus on the flow; airflow management With flow: co-ordination of respiratory and phonatory systems Smooth, consistent airflow Easy voice: VFs less impact stress (although no evidence) Release breath holding/medial compression Airflow release Breathy phonation Flow phonation Articulatory precision Key: AIRFLOW Sigh Negative practice Articulated airflow (ooh, wa..wa..; poo,loo); phrases Breathy phonation Flow phonation (add voice, but still maintain flow) Articulatory precision BIOFEEDBACK : Tissue, ease of phonation Breath-holding Hyperfunction Lesions, MTD

Simple sentence level approaches

Focused stimulation EMT Fast ForWord Dialogic reading Conversational recast Direct instruction Drill play

acoustic index

Fundamental frequency (F0) Intensity

prelinguistic- communicative act

Gaze, gesture or vocalization Was it directed? Did it have communicative function

developing language- assessment

General measure of language ◦ TOLD-P:3; CELF-P, PLS5 Measure of morphology Language samples: TTR-type token ration, number of different words/number of total words MLU-mean length of utterance, average number of morphemes in utterance Analyze presence of morphemes Rice/Wexler Test of Grammatical Impairment Exclusionary History (sensory deficits; neurological impairment) Nonverbal/Performance IQ; Leiter, Kaufman; WPPSI-R, TONI-3

approximants

Glides and liquids; degree of contact is approximate, not nearly as firm or closed as it is for fricatives, affricates, and stops.

LPR- voice symptoms and characteristics

Globus sensation Hoarse in the morning Heartburn sensation Dysphonia Dysphagia Vocal Fatigue

Fey's multidimensional model

Goals: Basic-long term Child will increase frequency of functional communication acts, i.e. gestures, vocalizations and eye gaze Intermediate (semester goals) Increase frequency and spontaneity of vocalizations Increase frequency and spontaneity of eye gaze Use two or more modes of communication together Specific (session goals) Child will increase CV vocalizations in response to clinician modeling Child will use pointing to request more snack Context: clinic, daycare, home, natural play, structured play etc. Agents: parents, SLP, teacher Dosage: 2 types: frequency and length of sessions, time assigned to each goal Goal Attack strategy: horizontal, vertical, cyclical Activities:

nodules- symptoms and characteristics

Gradual voice issues Voice symptoms based on SIZE and glottal configuration Vocal fatigue Upper pitch range affected Fundamental freq: Decreased Pitch range: Reduced Dynamic range: Reduced Intensity: NHR: Subglottal pressure: Increased Airflow: Min- Increased Avg - higher end of norm During phonation: decreased

guidance vs terminal feedback

Guidance is poorer than terminal feedback Application to voice and speech training Wait till the patient is finished with an utterance before jumping in with great ideas on how to improve/change voice

electrolarynx

HOW: The mechanical sound produced by the battery-powered artificial larynx is transmitted through the tissues of the neck or delivered intra-orally by presenting a plastic tube into the oral cavity for speech production. PROCESS: 1. Determine is neck tissue is conducive to placement. If not, intraoral tubing. 2. Neck placement: determine the sweet spot, overarticulation, utilize voiceless phonemes, improve pt awareness to sound quality and teach pt how to make adjustments. 3. Intraoral Tubing: Determine sweet spot overarticulation, utilize voiceless phonemes, improve pt awareness to sound quality and teach pt how to make adjustments.

tracheoesophageal puncture (TEP)

HOW: The tracheoesophageal puncture (TEP) shunts air from the lungs to the esophagus and the residual tissue at the PE segment and thus becomes a vibratory source for speech in the laryngectomized pt. PROCESS: Surgical opening/fistula created at the time of the total laryngectomy, called a primary TEP, or as a separate surgery later on, called a secondary TEP. A surgically created fistula within the common wall involving the posterior wall of the trachea and the anterior wall of the esophagus.

esophageal speech

HOW: injection of air from an area of greater pressure (oral cavity) will allow for flow of air into an area of lower pressure (esophagus). PROCESS: 1. Open the mouth wide 2. Close the lips with little or no elevation of the mandible 3. Pucker the lips 4. Bring the teeth together. * When executed correctly, air has not escaped through the labial or velar seals, is forced into the esophagus and is available to produce an esophageal tone.

1st word tx approaches

Hanen Milieu tx Focused stimulation Enhanced mileu tx (EMT)

ICF and aphasia

Helps individuals communicate and engage in daily life activities Promotes the role of communication partners Considers aphasia within the context of real-life situations Encourages full life participation Focuses on quality of life with aphasia

puberphonia

High-pitched voice after puberty in males Say its from psychological issues Mechanical Hypothesis-too rapid of growth, did not learn to acquire new neuromuscular patters

laryngitis- symptoms and characteristics

Hoarseness Throat pain Pitch breaks? Aphonia (extreme)

phonetic approaches

Inconsistent speech errors: Core vocab*** also phonemic Motor planning: Dynamic tactile and temporal cueing PROMPT Nuefield Resonance: EMT-PE Continuous positive air pressure (CPAP) Articulation: Traditional electropalatography Ultrasound

thick liquids/purees- indications and contraindications

INDICATIONS oral tongue dysfunction delayed reflex reduced laryngeal closure CONTRAINDICATIONS reduced oral/tongue function reduced cricophar opening e.g. restricted laryngeal movement reduced pharyngeal wall movement reduced posterior tongue tongue ramping

thin liquids- indications and contraindications

INDICATIONS oral tongue dysfunction reduced tongue base retraction reduced pharyngeal wall contraction reduced laryngeal elevation reduced cricopharyngeal opening CONTRAINDICATIONS delayed reflex reduced airway closure

nodules- causative factors

Impact stress Dehydration Genetic history (fibroblasts, fibronectin) Personality

functional/self perceptual measures

Importance of voice (0 - 10) Feelings about voice therapy Vocal handicap index Vocal effort (DME) Fatigue/ Endurance Quality of life measure

RHD extralinguistic deficits

Inability to integrate information Inadequate use of context in interpretation of linguistic and nonlinguistic messages Difficulty distinguishing significant from unimportant information Literal Interpretations Inability to interpret body language and facial expressions Flat affect Inability to follow conversational rules Impulsivity Confabulation

ASHA ICF activities and participation

Inability to teach for longer than 10 minutes without significant vocal fatigue • Limited ability to engage in recreational acting roles • Reduced ability to talk in social situations at the end of the day

Pharynx (pops homeland Pride)

Include exam of larynx and pharynx. Determine: can patient produce saliva swallow at baseline, if there is swallow weakness and/or delay, if patient is showing wet voice which may reflect laryngeal penetration, if there are quality changes during PO trials, if there is vocal cord dysfunction (increasing hoarseness, increasing breathiness, diplophonia).

ICF- Contextual factors

Includes: Attitudes, products and technology, environment, support Assessment :Caregiver interview, questionnaires, policies and procedures tx: Collaborative intervention, modify caregiver's communication, environmental accommodations

ICF- activities and participation

Includes: Communication, social interactions, relationships, learning Assessment: Direct observation in different contexts, interview Tx: Functional communication, education to others

ICF- body function

Includes: Speech, language, literacy ASsessment: Standardized assessment Tx: Modes and modalities

wernickes characteristics

Increased verbal content Para-grammatism speech running Phrase length generally greater than five words Grammatical sentences (close to normal) Paraphasic errors (literal or verbal) Literal- sound substitution with errors (winging for ringing) Semantic- word substitutions (sister for mother) Neologisms- made up words Logorrhea-inability to stop speaking Severely impaired auditory comprehension

stages of phonation

Initiation • Adductors- lateral cricothyroid, inner arytenoid, thyroarytenoid, Ps Maintenance • Ps, medial compression, Bernoulli effect Termination • Abductors- PCA

reinkes edema- causative factors

Irritants—alcohol, smoke Inflammatory agents (LPR)

tx for parkinsons or ataxia

LSVT, respiratory retraining

emerging language- semantic functions 1 word utterance

Labeling: that; car; mommy; uhoh; fall Answering: uhhuh; no; car Requesting Action: swing; open; car Requesting Answer: whazzat?; car? Calling: mommy; hey; car Greeting: hey; hi; bye Protesting: no; stop; car Imitating: A: That's a car. C: car. Practicing: car, car, car, car

phonological delay

Larger inventories Greater syllable diversity More complex syllable structure Higher pcc Lower variability Typical errors Fast rate of resolution

Environment (pops homEland pride)

Level of medical intensity/acuity will shape the approach to the CBSE and recommendations. Hospitals and skilled nursing facilities will have different needs and requirements. Level of supervision for patient based on what is possible in the setting.

granuloma- goals of treatment

Limit mechanical trauma to vocal processes 1)raise pitch 2)abduct VFs slightly Limit chemical trauma:

phonological deviance

Limited inventories Limited syllable diversity Simple syllable structure Lower pcc Greater variability Atypical errors Slower rate of resolution

laryngeal cancer

Lobulated appearance, often w/ Feeding vessels Epithelial TVFs Squamous cell Anywhere in larynx

ASHA ICF functional goals

Long-Term Goal Johnny will use age-appropriate grammar, pre-literacy, and social skills in everyday activities with family, peers, and unfamiliar adults 80% of the time in home and preschool settings by the end of the preschool year after receiving a block of language therapy and teacher-trained supports. Short-Term Goals • By the end of the preschool term, Johnny will use past tense correctly 90% of the time when he is telling news during group time with his classmates. • By the end of the preschool term, Johnny will correctly identify rhyming words during bookreading activities with his mother, grandmother, and teacher 90% of the time. • Johnny will take turns, make requests, and initiate conversations with his peers during snack time during a 10-minute period over 5 days.

ICF case example functional goals

Long-Term Goal Raúl will be understood (intelligible) when talking with friends and teachers in academic and social contexts and will demonstrate age-appropriate letter knowledge skills in at least 50% of communicative interactions with familiar and unfamiliar listeners by the end of the academic school year. Short-Term Goals • By the end of the school term, Raúl will produce consonant clusters correctly (i.e., reduce cluster reduction) 90% of the time with his sister on the playground (e.g., swing, slide, grass, friends, play). • By the end of the semester, Raúl will use the correct number of syllables when naming dinosaurs (90% of the time) while playing with a friend. • By the end of the school term, Raúl will correctly identify the sounds and letters in the names of his sisters, friends, and pet animals (90% of the time) with his teacher.

ASHA ICF- functional long term goal

Long-Term Goal: Mr. J will safely consume modified diet in the community and at home to maintain full hydration and satisfy nutritional needs.

ASHA ICF functional goal examples

Long-Term Goal: Mr. L will use functional communication skills for social interactions (e.g., greetings, social etiquette, and short questions/simple sentences) with both familiar and unfamiliar partners with 90% success. Short-Term Goals: • Mr. L will formulate 3-word utterances to communicate daily needs in response to pictures with 75% accuracy with minimal cues. • Mr. L will increase the use of strategies for effective repair of misunderstandings during conversations 80% of the time with minimal cues. • Mr. L will demonstrate reading comprehension of 5-sentence paragraphs with 80% accuracy with minimal cues. • Mrs. L's skill in supporting conversation with her husband with aphasia will improve as rated on the MSC (Measure of Skill in Supported Conversation, Kagan et al., 2004).

assessments for dementia

MMSE-2, MoCA, Arizona Battery for Communication Disorders of Dementia (ABCD), Dementia Rating Scale (DRS-2), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), SLUMS, Minimum Data Set (MDS)

assessment of CAS

MPT (maximal performance tasks), DEMSS (Dynamic Evaluation of Motor Speech Skill), Kaufman Speech Praxis Test for Children,

hybrid tx examples

MT conversational recast focused stimulation vertical structuring script based dialogic reading

irritable larynx- causative factors

MTD (1o/ 2o) Globus sensation Dysphagia Cough PVFMD Frequent throat clearing Exposure to environmental toxins Laryngeal hypersensitivity LPR

global aphasia- area of involvement

Massive brain damage Fronto-temporo-parietal lesion Complete occlusion of MCA

Informal assessment of reading

Match pictures, letters, forms Match printed words to pictures Read aloud: numbers, letters, words, phrases Answer written questions Silent reading/comprehension

granuloma- causative factors

Mechanical: Intubation trauma Phonatory trauma: Low pitch may involve "resonant frequency" of arytenoids Tight posterior approximation Chronic cough Throat clearing

PVFM tx

Medical intervention addresses any physical and/or psychological factors. Behavioral intervention with an SLP includes vocal exercises, relaxation techniques, and proper breath support for speech. The goal of intervention is to make the individual aware of what triggers PVFM so they can avoid those situations. The person is also taught how to handle an episode when it occurs.

reinkes edema- case example w/ secondary MTD

Mid-40's Smokes up to 2 packs per day (1/2 pack per day normally) Loss of voice since 2015 No precipitating factor; around her cousin who was sick with laryngitis Voice quality decreases as day progresses High pitched voice Vocal Effort to produce voice Vocal Fatigue Unable to project voice/cannot be heard Swallowing difficulty Chokes on certain foods; started 2 months ago

screeners for dementia

Mini-Mental State Examination, Clock Drawing Test, Short Portable Mental Status Questionnaire, Montreal Cognitive Assessment, Saint Louis University Mental Status Exam

direct speech production interventions

Minimal pair intervention Multiple oppositions Complexity approaches Core vocab Cycles approach Stimulability intervention Nuffield center dyspraxia programme

nodules- goals of tx

Minimize impact stress Hydrate Prevent Treat/prevent reflux

vocal registers

Modification of mode of vocal fold vibration 3 primary registers Glottal fry (Pulse) • LF popping sound- Initiating motor boat • Irregular VF vibration • Minimal average flow Modal (Chest)- most common • Midrange • Our daily voice/ brilliant voice • Good average airflow Falsetto (loft) • High frequency • VF stretched • Greater average airflow- slightly abducted VFs

descriptive analysis

More current method of assessing speech disorders • Examines child's system as unique, selfcontained sound system • Includes the following: - PPK - SPACS - OT

RLN damage- case example 1 (no compensation)

Occurred after disc fusion surgery Hoarseness and weak voice, inconsistent vocal quality, effort to produce voice, weak voice, vocal fatigue, pain with voice use, voice is gurgly after swallowing, Fibromyalgia, thyroid conditions

browns stage 3

On doggy on car Possessive Mommy's shoe

ASHA ICF functional goals

Ms. S will demonstrate healthy vocal quality in the context of her daily work and social activities during continuous voice use for at least 15-minute monologues. Short-Term Goals: Ms. S will: • identify baseline behaviors that impact vocal hygiene by charting frequency of instances of unhealthy vocal behaviors (loud talking, throat clearing) as they occur throughout the day in natural settings x 1 week; • reduce laryngeal hyperfunction by demonstrating use of appropriate resonant voice focus on 18/20 phrases produced with the clinician in the therapy room; • use portable microphone for at least 3 hours of teaching per day; • explore options for reducing background noise in teaching environment and implement three strategies over the course of 1 month, reporting results back to the clinician.

Irritable larynx syndrome

Mucosal and/or sensory afferent abnormality of larynx due to chemical exposure

Hypoglossal- XII

NOT SENSORY, MOTOR ONLY Motor- Intrinsic and extrinsic muscles of the tongue (not palatoglossus) Infrahyoid muscles How to test- look for Wasting or fasciculation of tongue Protrude tongue Tongue movement

child centered intervention pros and cons

Naturalistic, daily interactions Involves caregivers Particularly helpful for children who : Are responsive but with their own agendas Rarely initiate Strong generalization Valuable during initial stages of language development

residual errors

Need to predict which children with one or more residual errors will correct them without intervention and which ones will not • Research suggests that children 5-6 years old who are not stimulable for an accurate production will need intervention; those who are stimulable may self-correct. • Therefore, may want to do short-term intervention with first graders who are not stimulable in order to make them stimulable and then monitor for change - "jump-start" the process and prevent later intervention

discourse sampling and analyses

Need to thoroughly examine connected speech or discourse at the activity and participation level of the ICF model Assessment of certain language skills (e.g., turn-taking) that pertain to discourse Sensitive and thus useful for quantifying more modest treatment-related improvements

RLN damage- treatment options

Nerve regeneration Behavioral Improve hydration Release the compensation to relieve tension Medialization Thyroplasty Surgery to move the right cord to the midline to help the left make contact This is irreversible; you must work on unloading before the surgery so that you maintain airway protection for the patient

transcortical motor characteristics

Non-fluent Limited speech output Auditory comprehension good Reading comprehension-good Syntax not as bad as in Broca's

abductor SD- treatment

Non-response to behavioral intervention trials increases confidence in the diagnosis Regular botox injections into PCA muscles may help

adductor SD- treatment options

Non-response to behavioral intervention trials increases confidence in the diagnosis Regular botox injections into TA muscles may help

muscle tension dysphonia

Now used to describe a wide range of conditions of presumed hyperfunction! Pathological posterior glottic gap, with or without nodules Type I, I, III: Pathological posterior glottal gap (PGG)(Type I); + false VF compression (Type II); + anteroposterior

ICF case example- activities and participation

Obtained through: ICSd, FOCUSe, Child and Caregiver Interviews • Raúl is intelligible to family members but is often unintelligible to peers, teachers, and unfamiliar adults. • Raúl experiences frustration and social isolation (e.g., isn't invited to children's birthday parties, plays alone on the playground). • Raúl has difficulty making friends. • Raúl enjoys playing with dinosaurs and his pets.

ASHA ICF- body function and structures

Oral swallow • Reduced range of motion in tongue, lips, and jaw • Reduced labial closure with poor management of secretions • Poor tongue lateralization with food pocketed in left buccal cavity Pharyngeal swallow • Poor pharyngeal constriction Cognitive function • Reduced insight and safety judgment • Impulsivity

Intake status (pops homeland prIde)

Oral vs. non-oral, if oral then which food and liquid consistencies are best tolerated. Determine need for nutrition dept. follow up, calorie counting, and PEG weaning (when applicable).

Orders (pOps homeland pride)

Orders Facility guidelines Insurance guidelines Vital stim- probably should check with the DR Types MBS modified barium swallow FEES- fibrooptic endoscopic evaluation of swallowing (ST) sensory ttreatment Diet restrictions Aspiration precautions Clinical bedside swallow eval (CBSE) NMES- neuromuscular electrical stimulation Speaking valve (passy-muir) Maybe to deflate cuff?

PICO question

P: problem, patient or population I: intervention C: comparison O: outcome/observation e.g. Are patients with aphasia who received SLP services shortly after their stroke more or less likely to achieve functional communication abilities than stroke patients who received such treatments later?

EPB treatment approaches for targeting multiple modalities of language

PACE • Task-specific training • Communication Partner Training • Spaced retrieval

laryngeal cancer- symptoms and characteristics

Persistent Sore throat or cough Shortness of breath Change in the voice Hoarse Vocal Quality Globus Sensation Otalgia (Ear Pain) Dysphagia/Odyonophagia (Painful swallowing) Bad Breath (Halotosis) Weight Loss Chest Infection

ICF case example assessment of contextual factors

Personal and environmental factors Obtained though interview and/or assessment like CCRSA (Communication confidence rating scale) Examples: • Age: 64 • Comorbid chronic health conditions: right hemiparesis, hypertension • High level of motivation • Desire for greater independence in social interactions • Reduced confidence in communication with familiar and unfamiliar speakers • Supportive family & friends

phoRTE

Phonation resistance training exercise Exercise Physiology Progressive resistance training for limb skeletal muscle atrophy Motor control and learning High intensity exercises and progressive resistance training overload respiratory and laryngeal muscles in order to increase muscle strength and endurance Increases muscle activity- improving Ps, airflow and VF vibration Hold a continuous vowel /a/- strong voice Glide from low to high /a/ and high to low /a/ on the pitch range with a strong voice Call out functional phrases- high voice (over the fence) and a low (authoritative) voice Currently for hypofunction- Specifically Atrophy

phonation threshold pressure (PTP)

Phonation threshold pressure (PTP) : minimum pressure required to initiate VF oscillation • Dehydration can make vocal folds sticky increasing PTP

traditional method target selection

Phonetic Characteristics of sounds Early sounds, most stimulable, most knowledge Motoric basis of sound learning, ease and sequence of acquisition SODA n/a but generally unmarked

nonverbal tx-PECS

Picture Exchange Communication System o Picture cards that child can give to communication partner o Starts with mands "I want..." o Helps teach functionality of communication o Designed for autistic kids Theoretical Basis: Pragmatics and kids needing something to use to communicate basic wants and needs Visual rather than auditory Communication units are constant Empirical Basis: Charlop (02) results indicated all 3 in study increased verbal speech, and small gains in social behaviors and decrease in problem behaviors

MBS procedure

Placement of patient in radiology suite • lateral view typically first • if time anterior-posterior (a-p) view • Place patient as vertical as possible • focus from lips to UES • place arms low so shoulder out of way • explain to patient what you are about to do • if possible let patient self-feed • encourage patient to cough or spit out if necessary • take all radiation precautions

examples of stimulation approach tasks

Point-to Task: which is simply asking the patient to point to a specific object Yes-No Questions: asking questions like, "is Stephen Harper Prime Minister of Canada?" Reading Tasks: matching a word or sentence to a picture

Neurological status (pops homelaNd pride)

Pons stroke- cant swallow and slow hard progress Alertness Obtundation- barely able to respond Lethargy- can rouse but drift back Acute (encephalopathy, CVA) vs. chronic (Dementia) conditions, patient's ability to follow directions, patients orientation awareness. Deficits can impact dysphagia training and instruction to the dysphagia patient. Determine the neurological impact for patient's wakefulness and alertness for safe oral feeding

acoustic index-range

Poor range may indicate presence of mass, stiffness, or neuromuscular abnormality Spectral composition-spectogram frequency over time

brain arteries

Posterior cerebral arteries Cerebellar arteries External carotid artery Internal carotid artery Middle cerebral artery Anterior cerebral artery

Oral mech exam

Posture Face Jaw Lips Tongue Velopharynx Check at rest, with sustained movement, and with consecutive movements

Predictors of aspiration/penetration at bedside

Predictors: 1. Dysphonia 2. Dysarthria 3. Abnormal volitional cough 4. Abnormal gag reflex 5. Cough after swallow 6. Voice change after swallow

Development stages

Prelinguistic (0 - 1 year) o reflexive vocalizations o cooing o vocal play o babbling o variegated babbling First words (1-1.6) o Whole-word strategy o Unanalyzed "wholes" o Progressive idioms Phonemic development o Rule-governed strategy o 50 word vocabulary Stabilization o Acquisition of later sounds

Prelinguistic tx approaches

Prelinguistic milieu tx (PMT) Hanen Milieu Tx

stages of language devt

Prelinguistic: development of gestures, making adequate eye contact, sound repartee between infant and caregiver, cooing, babbling and crying Emerging Language: 1st words Developing language criteria: o More than 50 words o Beginning to combine words into sentences o They haven't acquired all basic sentence structures of the language

laryngectomy- preop assessment

Preop assessment Oral mech exam Cognitive screen V-QOL Scale Evaluate current communication ◦ Articulation ◦ Resonance ◦ Writing ability ◦ Current voice characteristics; may or may not present with an overt dysphonia ◦ Presence of a tracheostomy

anomic aphasia characteristics

Primary deficit word finding and naming Speech output is fluent with numerous pauses Pauses may be filled with circumlocutions Auditory comprehension is intact Reading and writing intact Least localized of all aphasias

what is primary goal in wernickes aphasia

Primary goal is to improve comprehension and the ability to self-monitor

Dialogic reading PEER

Prompts the child to say something about the book, Evaluates the child's response, Expands the child's response by rephrasing and adding information to it, and Repeats the prompt to make sure the child has learned from the expansion.

words to avoid when working on 1st words

Pronouns - hard teach because deictic Colors - not broadly useful, but they do have social benefit only if the the child is already matching colors accurately Numbers - not broadly useful, but they do have social benefit; some children use "two" to mean "more" Opposites - children only use one "pole" first Internal states - conceptually difficult; teach action words that represent states ("kiss, ouch")

Yoder and Warren categories of communicative acts

Protoimperatives (commands) vs protodeclarative (comments)

nodules

Protuberances on margins of TVFs Possible edema Bilateral Symmetrical Accumulated fibronectin in SLP Disruption anchoring fibers BMZ Superficial LP Midpoint Junction 1/3 anterior 2/3 posterior

Dysphagia (pops homeland priDe)

Provide PO trials, document dysphagia behaviors, and determine dysphagia severity and location, ie: oral/pharyngeal or both.

speech interventions in broader context

Psycholinguistic intervention Metaphonological Computer based intervention Speech perception Nonlinear phonological Dynamic systems morphosyntax Naturalistic intervention Parents and children together (PACT) Enhanced milieu with phonological emphasis PROMPT

Heat and Moisture exchange system (HME)

Purpose: Pulmonary rehabilitation Function: Water vapor condenses during exhalation and re-humidifies during inhalation. Pulmonary heat is retained and exchanged. Consistent maintenance of heat and humidity. Provides a barrier to obvious airborne matter.

tx for oral transit- reduced tongue strength

ROM exercises

tx methods for glottal incompetence

RVT, VFE, PhoRTE (particularly atrophy), SOVT, respiratory retraining

tx methods for functional disorders

RVT, VFE, respiratory retraining, CLM

laryngeal cancer- treatment

Radiation Does not just kill the cancer; it will leave a burn and the skin will be fibrous and tough Surgical Removal Will normally need chemotherapy after to ensure all of the cancer is gone

global aphasia characteristics

Rarely without hemiplegia Severe impairment in all modalities Speaking, listening, reading and writing Severely impaired auditory comprehension Very limited speech output Only few understandable utterances Some areas of spared speech function

CAPE-V

Rating scale intended to help with consistency in rating voice Vocal Attributes Overall severity Roughness Breathiness Strain Pitch Loudness Resonance Other (e.g., tremor, diplophonia, fry, aphonia, falsetto, etc) Rating VAS (100mm) Consistent/ intermittent

physiologic index- airflow

Rationale/description Poorly closing mucosa, due to postural neuromuscular or membranous deficits, increases minimum and average flow • Interpretation • High min and average flow indicates poorly closing mucosa, due to postural or membranous deficits • S:Z ratio > 1.35 generally indicates poor membranous VF closure due to postural or mucosal deficits

MTD tx

Reduce hyperfunction (laryngeal massage) Increase efficiency (RVT, flow phonation)

Disorders by phase- oral prep

Reduced lip closure- respiratory problems • Food or liquid falling from the mouth Reduced tongue shaping/coordination Pt. Unable to hold bolus • Premature loss of bolus over the tongue base which may result in aspiration Reduced range of tongue motion or coordination • Pt. Cannot form bolus • Food will be spread throughout oral cavity Reduced labial tension/tone • Pt. Has food lodged in anterior sulcus Reduced buccal tension/tone • Pt. Has food lodged in lateral sulcus Reduced tongue control/tongue thrust • Pt. Holds bolus against front teeth

hierarchy of cues for word retrieval

Repetition Delay Phonemic Sentence completion Semantic association Printed word Description Rhyming word Situational context Spelled word Functional description Superordinate Generalization

intervention for prelinguistic

Responsivity education/ prelinguistic milieu therapy Imitating and reflecting motor, vocalizations and encouraging communication o Imitation o Interrupting script to encourage communication o Last stage requires child to use two modes together o Responsivity Education- discussion and training for parents to be optimal communicator, encouraging responsive communication Theoretical basis: based on the transactional model of communication, non-verbal communicative acts are building blocks for future language Empirical Basis- Fey 2006 study showed highly functional impact on children's communication levels Yoder and Warren 98- Showed an increase in generalized intentional communication but it did vary based on caregiver responsivity Target population- children not consistently using nonverbal communicative acts

description of RHD

Right hemisphere plays secondary role in language processing in most people frequently have communicative and cognitive deficits RHD share similarities with head injury

Differential diagnosis btwn SLI, larger devt delay or autism

SLI-• More likely to have speech production difficulties than ASD • Immature pragmatic skills but not abnormal like with autism • Less severe pragmatic issues than autism • Normal range nonverbal IQ • No hearing impairment, no neuro impairment, no frank sensory issue, no socioemotional disorder • All milestones met • No motor issues LArger devt delay • lower nonverbal IQ • Difficulties in other areas, motor etc • Did not achieve other milestones Autism Abnormal not just delayed pragmatics More likely to have deviant language features that are not typical at any age: • Repetitive use of stereotyped phrases • Unusual and exaggerated intonation • Pronoun reversal • Idiosyncratic words • Echolalia • Failure to respond to others speech

laryngectomy- after 1-3 days postop

SLP can initiate Electrolarynx training with intraoral tubing, Esophageal speech training, etc.

tx methods for lesions

SOVT, RVT, VFE, flow phonation

polyps- goals of treatment

SURGICAL Minimize Impact stress Hydrate minimize Smoking alcohol use Med review

leukoplakia- treatment goals

SURGICAL Removal of irritants (smoke, alcohol) Hygiene

cysts- goals of treatment

SURGICAL lesion Tx before surgery (minimize inflammation) Minimize impact stress

WErnickes therapy approaches

Schuells PACE SCA

phonological approach and inconsistency

Select sounds that are consistent in their errors, rationale: Rationale: Consistent errors reflect category representations, which will result in appropriate category shift to correspond to the target representation as a result of treatment

phonological approach to stimulability

Select sounds that are not stimulable, rationale: stimulable sounds will emerge w/out direct intervention Non-stimulable sounds represent less phonological knowledge than stimulable sounds. Selecting sounds that represent less phonological knowledge results in greater change across the sound system (

Oral motor (pops hOmeland pride)

Sensory testing- face Face movement Teeth- dental status Look in mouth palate moves

Facial (VII)

Sensory- Anterior 2/3 of tongue Motor- Sublingual and submandibular glands Buccinators, posterior belly of digastric Stylohyoid muscle Saliva and tears production How to test-Raise eyebrows Screw up eyes smile and show teeth Blow out cheeks Pucker and retract lips

Glossopharyngeal (IX)

Sensory-Mucus membranes, tonsils, faucial pillars, posterior 1/3 of tongue taste Motor- Parotid gland Stylopharyngeus muscle How to Test- Cough soft palate movement Gag reflex Sustained /ah/ Glottal attack

factors related to compliance

Severity of condition Vocal demands Realistic expectations of voice therapy Readiness to change Self efficacy Clinician-patient interaction

PVFM symptoms

Shortness of breath Throat tightness, chest tightness Wheezing or noisy breathing when inhaling (breathing in) Chronic coughing or throat clearing Mild hoarseness (weak, scratchy or breathy voice)

Paul definition of language disorder

Significant deficit in learning to talk, understand or use any aspect of language appropriately relative to both environmental and norm-referenced expectations for children of similar devt level

transcortical sensory characteristics

Similarities to wernickes aphasia but with intact repetition Deficits in all language modalities Fluent aphasia Echolalia They can repeat but cannot understand it Much difficulty communicating Syntax not as bad as in Broca's aphasia

laryngeal cancer- causative factors

Smoking Alcohol Environmental and Chemical irritants Tobacco (5-35x), alcohol 92-6x), combo of both (40x) HPV Radiation Exposure Environmental Exposure Betel Nut Race Age

reinkes edema- treament

Sometimes surgical Removal of irritants Adapt to "new voice"

continuant sounds

Sound that are produced with an incomplete point of constriction; airflow is not entirely stopped at any time and sounds may be produced continuously until the person runs out of breath. Fricatives and approximants

Hinckley, 2013 Factors to use to select treatment approach

Specific language processes Cognitive abilities patient's functional/personal goals NOT by aphasia type

prelinguistic stages

Stage 1 (0-2mos) reflexive: crying, fussing, grunts, sighs, vowel like sounds Stage 2 (2-4 mos) cooing: back sounds and vowel, isolated vowels, nasal pleasure sounds Stage 3 (4-6 mos) vocal exploration: laugh, squals, growls, more vowels, CV, front sounds-stops, lip smacks, raspberries, pitch play, reciprocal play Stage 4(6-10 mo)- babbling: nasals, stops, glides, reduplicated, early variegated (gabuba). Exclamations, first word possible Stage 5 (10-12 mos) jargon babble: true variegated, add sentence-like prosody, protowords, word approximations, actual words

conduction aphasia therapy considerations

Start where the patient is successful and increase therapy in small steps Reduce visual and verbal cues gradually Extend treatment from concrete to abstract stimuli Work on auditory-verbal memory enhancement Provide immediate feedback and encouragement (easily frustrated)

cysts- case example

Started 2 months ago, no specific factor, occasional hoarseness, onset with pitch breaks during singing and progressively gotten worse, inconsistent voice quality, significant vocal effort to produce voice, constant vocal fatigue, constant need to clear throat Fundamental freq: Increased? Pitch range: Reduced Dynamic range: Reduced Intensity: NHR: Reduced Subglottal pressure: Increased Airflow: Min- Increased Avg - higher end of norm During phonation: decreased Case example: Case example: Minimum: Increased because of incomplete glottal closure Average: Same or slight increase due to overcompensation Subglottal Pressure Decrease due to Glottal Closure Incomplete; Hourglass shaped

Intervention for emerging stage

Stimulability EMT-PE NSIT PROMPT

impact stress

Stress: pressure per unit area Impact stress: stress perpendicular to the free margins of the VFs Subglottic pressure (Ps)- high VF adduction- more and harder VF elongation- subglottic pressure is increased, until a certain point once your are in falsetto vocal folds aren't touching Phonation threshold pressure (PTP) : minimum pressure required to initiate VF oscillation • Dehydration can make vocal folds sticky increasing PTP

ICF case example assessment of structure and function

Structures and function: results and scores of formal and informal assessment measures

choosing first lexicon

Substantive words (people, objects, places) Relational words (verbs, prepositions, adjectives, negatives) Social words (greetings, answer words, polite) Select words that are within the child's phonological inventory

anterior cerebral artery

Supplies middle portion of parietal and frontal o Also supplies corpus callosum and basal ganglia o Joins with PCA in back of brain o Can cause cognitive deficits such as impaired judgment, concentration, paralysis of feet and legs

laryngitis

Swelling and inflammation of laryngeal tissue Distributed throughout lx tissue

pediatrics- ideas for hyposensitive

Swinging, jumping, topsy-turvy Consider joint compressions Brisk, firm touch Icing Vibration Electrical Stimulation Vital Stimulation

Laryngeal depressors

TOSS thyrohyoid omohyoid sternohyoid sternothyroid

developing language- how to know when to target next level

Target first words when children produce 2 communicative acts / min Target early morphemes and simple sentences when children are combining 3 words Target complex sentences when simple sentences are mostly grammatically correct 20% of children's sentences should be complex before kindergarten entry Target stories when children use complete simple sentences and begin to string them together Children should be telling personal event and retell stories that are mostly understandable before kindergarten entry Retell and stories will still often end-at-the-high point.

4 parts of a goal

Target- behavior you want to change Mode- manner in which you want child to demonstrate behavior Criterion- level of success- accuracy or frequency Context- environment or activity in which response takes place

close jaw

TeMMP temporalis masseter medial pterygoid

PMSV and swallowing

The swallow mechanism functions based on mechanical and pneumatic forces Oropharyngeal musculature: deflation of the trach cuff may alleviate an anchoring effect that the inflated cuff may have on laryngeal elevation Positive(+)/Negative(-) pressures: (+) pressure is maintained in the airway with PMSV in place, with (-) pressure in the esophagus—air pressure aids to "pull" the bolus into the esophagus MBS should be completed with and without PMSV in place Observe motion of swallowing structures before, during, and after both oral and pharyngeal phases ROM and Timing Observe bolus transit Bolus flow by viscosity Entry into laryngeal vestibule Identify mechanisms of dysfunction Assess efficacy of compensatory strategies

paradoxical vocal fold movement (PVFM)

The vocal folds (cords) behave in a normal fashion almost all of the time, but, when an episode occurs, the vocal cords close when they should open, such as when breathing. be mistaken for asthma as it leads to wheezing and difficulty breathing

Dialogic reading-CROWD

There are five types of prompts that are used in dialogic reading to begin PEER sequences. You can remember these prompts with the word CROWD. Completion prompts You leave a blank at the end of a sentence and get the child to fill it in. These are typically used in books with rhyme or books with repetitive phases. For example, you might say, "I think I'd be a glossy cat. A little plump but not too ____," letting the child fill in the blank with the word fat. Completion prompts provide children with information about the structure of language that is critical to later reading. Recall prompts These are questions about what happened in a book a child has already read. Recall prompts work for nearly everything except alphabet books. For example, you might say, "Can you tell me what happened to the little blue engine in this story?" Recall prompts help children in understanding story plot and in describing sequences of events. Recall prompts can be used not only at the end of a book, but also at the beginning of a book when a child has been read that book before. Open-ended prompts These prompts focus on the pictures in books. They work best for books that have rich, detailed illustrations. For example, while looking at a page in a book that the child is familiar with, you might say, "Tell me what's happening in this picture." Open-ended prompts help children increase their expressive fluency and attend to detail. Wh- prompts These prompts usually begin with what, where, when, why, and how questions. Like open-ended prompts, wh- prompts focus on the pictures in books. For example, you might say, "What's the name of this?" while pointing to an object in the book. Wh- questions teach children new vocabulary. Distancing prompts These ask children to relate the pictures or words in the book they are reading to experiences outside the book. For example, while looking at a book with a picture of animals on a farm, you might say something like, "Remember when we went to the animal park last week. Which of these animals did we see there?" Distancing prompts help children form a bridge between books and the real world, as well as helping with verbal fluency, conversational abilities, and narrative skills.

parent teaching prereqs

They are interested in participating It is a priority that they are committed to Support, time, and energy are available Their children are developmentally likely to benefit Their children's communication needs can be met through parent intervention

sulcus- symptoms and characteristics

Thin weak voice Minimal to worse Vocal Fatigue Vocal fold closure issues

3 cartilages

Thyroid Cricoid Arytenoid (paired)

confidential voice therapy

To produce an easy, quiet, breathy voice With easy, quiet, breathy voice VFs vibrate with small amplitude Less impact stress Less chances of injury Produce an easy, quiet, breathy voice To imitate speaking confidentially to someone at closer range NOT a whisper Wh sounds/ words Look for quiet and easy voice Negative practice Fade away to strong, safe way of talking, when transitioning: Why? Voice conservation Post-surgery VF injury (phonotrauma)

error analysis

Traditional method of assessing speech disorders • Only examines child's errors • Includes the following assessments: - SODA - Phonological Process Analysis - Place-Voice-Manner Analysis

basis of schuells approach

Treatment is focused on only the auditory system rather than on each system separately because it is believed that improvements there will spread to the other channels since they are all connected. The approach uses a very controlled repetition of auditory stimuli.

Schuells where should tx begin

Treatment should begin where language breaks down and should proceed through gradually increasing levels of difficulty

essential tremor- treatment

Tremor hard to overcome behaviorally In some cases increased vocal effort (loudness) may help to mask, e.g. in singing Sometimes decreased vocal effort (quiet, breathy, easy onset, smooth tone) may help to reduce

cranial nerves for speech or swallowing

Trigeminal (V) Facial (VII) Glossopharyngeal (IX) Vagus (X) Accessory (XI) Hypoglossal (XII)

stages of swallow- esophageal phase

UES --> LES 8 to 20 seconds Bolus pushed down esophagus by peristaltic wave

leukoplakia

White, plaque-like PRE-cancerous Epithelial ANYWHERE along VFs

critical age hypothesis

Unintelligible speech during early school years may affect literacy development. Given that many children do not come to SLP for treatment until age 4 (Castrogiovanni, 1999), there is a significant need for efficient and effective therapies to remediate the speech disorder within a short time period (e.g., 18 months

setting goals

Use assessment data (ZPD) Consider how much impact will have on childs ability to communicate effectively Some morphemes don't impact undersanding as much Choose one new thing at a time (use idioms in a topic ASD client already knows) Choose targets within child's phonological ability

6 strategies for aiding comprehension in aphasia

Use gestures when you speak. Gestures can represent objects or actions while you're talking. This helps the person pair the auditory (when you say the word aloud) with a meaningful clue. Write down key words while speaking. Using more than one method of communication is crucial to helping someone with aphasia understand. Talk about things that are relevant to "right now". You'll find that "do you want a drink?" when you're at the dining table is understood better than "how are you getting to the doctor?" with no immediate context. Don't shout if the person isn't hard-of-hearing. Raising your voice doesn't make someone understand you better. Slow your speech a little when talking. Pause frequently for them to "catch up". Most people with aphasia cannot process spoken language at the same rate that they used to, so slow your rate a speech a bit. This does not mean use a tone or phrasing you would use with a child, it means pause between sentences and don't use complex language sequences. Be close enough to maintain eye contact. Don't talk to them from across the room or from the other room where they can't see you. People with aphasia need context and clues to assist with their comprehension.

PACE Promoting Aphasics' Communication Effectiveness

Uses compensatory strategies to communicate a message Provide a stimuli picture face down between patient and clinician and the patient must look at it and use any available means to communicate the message; SLP guesses and provides feedback

functional dysphonia

Usually extreme dysphonia mixed with aphonia, without evident organic basis, and strikingly resistant to traditional voice therapy Assumed psychogenic Basically, (unknown) cause Hyperfunction is implicated in most cases Co-contraction of AB and AD-ductory muscles (hyperadducted hypofunction) Kaufman thinks there is a role of LPR in some cases Too much ap compression, supraglottal compression

functional aphonia treatment

Usually treated symptomatically as first-line approach; usually successful almost immediately (in first or second session) Fixation of aphonia?- usually no! There is some likelihood of recurrence in such cases, but not necessarily Extremely resistant-psychotherapy

Trigeminal (V)

V Sensory-Tongue, teeth, lips, palate and chin Motor- Muscles of mastication, tensor veli palatini How to test: Palpate temporalis Palpate masseter Open jaw Move jaw from side to side

leukoplakia- symptoms and characteristics

VARIABLE

tx methods for hyperfunction

VFE, CLM, flow phonation, SOVT, respiratory retraining

tx for singers

VFE, SOVT, respiratory retraining

vocal fold oscillation

VFs come together prior to phonation onset • Ps (Subglottal pressure) builds below folds • When Ps > Rg (glottal resistance), folds are open Once folds are open, two factors bring them back to midline • Elastic recoil of tissue • "Bernoulli effect"

stages of swallow- pharyngeal phase basics

Velum elevates and retracts Hyoid and larynx elevate and move anteriorly Larynx closes all three valves (Aryepiglottic folds, Ventricular folds, True vocal folds) Cricopharyngeal sphincter opens Tongue base ramps, then retracts Pharyngeal wall contracts and makes contact with tongue base Pharyngeal constrictors activate from top to bottom

interventions for improving speech movements

Visual feedback (EPG) Vowel intervention (ultrasound) Developmental dysarthria interventions Nonspeech oral motor intervention (NSOMT)

presbyphonia- treatment

Vocal Function Exercise (using forte /ah/ really loud higher in pitch and lower in pitch to improve the functioning of your vocal folds) Medical Injections to increase bulk of the vocal fold

VFE

Vocal function exercises To work with laryngeal muscles as in PT To increase bulk, strength and coordinated interaction of laryngeal muscles. Coordination of 3 systems: respiratory, phonatory and articulatory Maximal prolongations: Strengthen and coordinate laryngeal muscles ? Coordination between laryngeal and respiratory muscles Pitch glides: Cricothyroid and vocal fold muscles are strengthened? 4 exercises- go as high as can wout pitch breaks and hold Maximal vowel prolongations (/i/) - warm-up Pitch glides (high to low and low to high- on knoll) Sustain musical notes (Knoll: minus Kn) Resonant voice (m) ? Transfer ? Hyperfunction (Lesions, MTD), Hypofunction & functional disorders, singers

presbyphonia- symptoms and characteristics

Vocal quality changes Thin vocal quality Inconsistent vocal quality Breathiness Weak Voice Vocal Fatigue Aspiration of thin liquids Spindle Closure

laryngitis treatment

Voice Rest Tissue Mobilization (elongation, large-amplitude low impact oscillations Removal of inflammatory influences

sulcus- treatment

Voice therapy? Surgery: mixed results

wernickes area of involvement

Wernicke's Area Brodmann's 22 The auditory comprehension of spoken speech takes place in the posterior end of the superior temporal gyrus Wernicke's area MCA territory stroke-left superior temporal lobe

ICF questions to ask when planning treatment and goals

What impairments most affect function in this setting, based on clinician assessment and individual/family report? What activities are most important to the individual in the current setting? What environmental/ personal characteristics help or hinder participation in activities or situations in the current setting?

EVIDENCE-BASED PRACTICE: A MATRIX FOR PREDICTING PHONOLOGICAL GENERALIZATION (Gierut & Hulse, May 2009)

When later developing sounds are treated, the scope of learning encompasses the treated sound, within-class generalization, and across-class generalization. Across-class generalization is not seen when earlier developing sounds are treated. The late-8 sounds /θ ð s z ∫ ʒ l r are seen as more efficacious treatment targets. • · Treatment of non-stimulable sounds are preferred in the matrix over treatment of stimulable sounds because the data shows tx of these sounds results in generalization of both the non-stimulable and stimulable sounds compared to just stimulable sounds when they are all that is treated

phonemic approaches

Young (2-4) w limited sound inventory: Stimulability treatment(STIM) Parents and children together (PACT) Cycles homonymy: Minimal pairs Multiple oppositions Non homonymy: Maximal oppositions Empty set Phonological awareness/ literacy: Metaphonological approach Psycholinguistic intervention integrated language: Morphonological approach Naturalistic speech intelligibility training (NSIT) Dynamic systems Nonlinear phonological approach inconsistent speech errors: Core vocabulary** also phonetic

articulation disorder

a speech sound disorder that affects the PHONETIC level. The child has difficulty saying particular consonants and vowels. The reason for this may be unknown (e.g., children with functional speech disorders who do NOT have serious problems with muscle function); or the reason may be known (e.g., children with dysarthria who DO have serious problems with muscle function).

phonological disorder

a speech sound disorder that affects the PHONOLOGICAL (phonemic) level. The child has difficulty organizing their speech sounds into a system of sound patterns (phonemic patterns).

Secondary goals of assessment

a. Determine prognosis b. Monitor change c. Assess maintenance of function d. Define factors that facilitate comprehension, production and use of language

3 phases of cough

a. Inspiratory- large suck in of breath b. Compression- vocal folds adduct to build pressure c. Expiratory- rapid opening of vocal folds and burst of air made greater by bronchi

LPR case example 2 w MTD

a. Pain on the left side of the neck after falsetto singing that started one-month prior, difficulty with speaking voice, tightness on the left side, symptoms improve with rest but do not return to baseline, burning or raw sensation in the throat with voice use, globus sensation, constant throat clear, cough, vocal fatigue, effort to produce vice, cannot reach high notes, hurts to sing falsetto, symptoms aggravate with anxiety and voice use, Acid Reflux

resonant voice (RVT)

achieve strongest, cleanest voice with the least effort and impact between VFs & to minimize injury With RV: VF's are barely ad/abducted Best posture for strongest, clearest voice o/p Least amount of impact stress Least amount of lung pressure Basic resonant voice training gesture- humming ("m") Other sounds: "n", "ng", "z", "v" Transition to: words, functional phrases Loudness: m.......M Conversation Hypo/ hyper VF's during phonation, lesions, glottal incompetence, functional disorders

Single word test steps

administer test perform analysis if phonemic then PVM or SPACS if phonetic then SODA

Enhanced milieu therapy (EMT)

agents: preschool or older kids with early language development, SLI, retardation or other disabilities verbally imitative mlu btwn 1-3.5 at least 10 productive words components: environmental arrangement, responsive interaction and milieu procedures to prompt language natural setting, play based, model, mand design activities to encourage language agents: clinicians nature of goals: promotion of functional use of productive language

impairment based aphasia therapy

aimed at improving language functions and consist of procedures in which the clinician directly stimulates specific listening, speaking, reading and writing skills. CILT MIT SFA

bernoulli effect

air flows faster through the folds causing a pressure drop and hence a force pulling the folds together.

aphasia types with ability to repeat

all types of transcortical anomic

general pattern of development- 36 months

approximately 1000 words 75% intelligible by strangers MLU of 3.1

general pattern of development- 24 mos

approximately 300 words 50% intellgible by strangers

steps of assessment

assessment meaures analysis procedures intervention planning progress monitoring

agrammatism

associated with non-fluent aphasia telegraphic speech omission of grammatical markers e.g. instead of "May I have some water now?" they say " water now"

presbyphonia

atrophy Disordered or consequence of normal aging Loss of bulk of vocal folds Reduced joint mobility Typically 65 and older

average flow and minimum flow

average flow-100-200ml or cc/ sec increases with glottal incompetence minimum flow- 10-20ml/sec used clinically

technical vs awareness instruction

awareness is better e.g. resonant voice technical- relax your throat and your tongue awareness- do you feel vibrations behind your teeth? does your voice feel easy?

stages of swallow- oral prep basics

before it starts must recognize food Labial seal and nasal breathing mastication

stages of swallow- oral phase basics

begins when tongue moves bolus back 1-1.5 seconds

significant deficit (KPW criteria)

below 10th percentile 1.25 standard deviations below the mean standard score of 80

Research ethic principles

beneficence non-malfeasance individual rights privacy justice/equity

parts of EBP

best research evidence clinical expertise patient values and preferences

Group designs

between subjects- bivalent, multivalent or parametric-several groups receiving different treatments compared to control

8 point aspiration scale

can be used during MBS to judge penetration/asp 1- no penetration or aspiration Material does not enter airway PENETRATION 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway. 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway. 4 Material enters the airway, contacts the vocal folds, and is ejected from the airway. 5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway. ASPIRATION 6. Material enters the ariway, passes below the vocal folds, and is ejected into the larynx or out of the airway. 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort. 8. Material enters the airway, passes below the vocal folds, and no effort is made to eject.

Intraoral prosthetics

cancer velopharyngeal weakness palatal lift, obturator, augmentation or shaping

steps of assessment

case history general index acoustic index physiologic index diagnosis

History (pops Homeland pride)

check chart TBI, CVA, congenital, hypertension Precautions

Pulmonary (poPs homeland pride)

chest xray O2 sat respiration rate respiratory acidosis

continuum of naturalness

child centered, hybrid, clinician directed Who selects the focus? Who directs the topic? Who chooses the activity? e.g. clinician directed-drill, hybrid-games, child centered-typical daily activities

1 step of intervention

choose purpose of intervention

irritable larynx- case example

client was admitted following a laryngospasm where she passed out and could not breathe. She experienced 3-4 such episodes in the past that is triggered by chemical odors where she has difficulty catching her breath and has tried to take asthma medication to relieve the symptoms with minimal relief. Her main complaints with swallowing include a feeling of something stuck on her throat and she cannot seem to get it down

beneficence

duty to do more good than harm must address important questions whose answers will benefit people

malfeasance

duty to not do harm must not cause undue risk to participants results of research must be used for good

metacognitive strategy instruction

effective for training a variety of functional activities or skill sets and for obtaining changes in process-specific impairment outcomes.

3 e's of treatment

efficacy-does it work in clinical trials? effectiveness-does it work in clinical practice? efficiency- does it contribute to more efficient use of resources?

ultrasound- vowel intervention

elaborating Execution Speech production Children with hearing loss, persistent speech impairment Often used w/ Vowel intervention, Provides visual feedback to pair with sounds

Electropalatography- visual feedback

elaborating execution Speech production Children who haven't responded to other intervention, any disorder Visual feedback- tongue palate contact Shows children link between sounds they hear and their tongue position etc.

4 motor based approaches

electropalatography ultrasound PROMPT NSOMT

stimulability approach

emerging Execution Speech production, phono awareness Limited sound system Increase inventory by making sound stimulable Young children (2-4) w limited sound inventory Sounds are paired with characters and body movements, vocal practice through play

vocal fold layers- 5 level schema

epithelium lamina propria 1. superficial layer 2. intermediate layer 3. deep layer muscle

Important thing to remember in assessment

establish baseline functioning before starting could they read before the stroke?

what is difference btwn experimental and quasi experimental

experimental- randomized and control group quasi- non randomized but has control group or multiple measures

electical stimulation

facilitative Place surface electrode along neckline or inferior jaw Stimulates skin, muscles below it to contract Controversial research Note: caution with CAD, pacemaker, head and neck cancer, check with other types of cancer Can be used after cancer removed and may help because of scar tissue

enhanced sensory motor exercises

facilitative considered therapeutic as well as will improve physiology of swallow with repeated swallows for some the arm/hand action of self-feeding is a critical component of automatic sensory motor experience of swallowing thermal-tactile stim followed by small amount of colored ice, ginger ale or saliva if NPO may be necessary to do this over a period of months

DPNS

facilitative Deep pharyngeal neuromuscular stimulation SLP stimulates certain areas of oral cavity with frozen lemon swab to trigger reflexes In theory, increases muscle strength, endurance, and range of motion Limited research support over thermal gustatory stimulation

EMST

facilitative Expiration against set resistance levels Rationale based on literature is to improve cough effort for airway protection Low tech option: blow a balloon

tx for oral prep- reduced lateral tongue mvmts

facilitative ROM exercises compensatory mash tongue against roof, use mobile side of tongue, head tilt

laryngeal closure exercises

facilitative airway closure pushing/bearing down rapid glottal attack on vowels push and phonate practice breath holds followed by cough - prepares for swallow maneuvers slide up pitch scale to falsetto - simulate laryngeal elevation

bolus control exercises

facilitative gauze pad or licorice or lifesaver with string or juice-soaked cloth tape manipulate using eating movements bolus control - using 1/3 tsp paste consistency and later liquid - spit it out

bolus propulsion

facilitative gauze soaked in juice - push up and back to squeeze the liquid

chin tuck against resistance

facilitative put something under chin and press down and hold, modified shaker for pple who cant do that

Shaker

facilitative to improve laryngeal elevation and UES opening lie on back and raise head off bed

ROM exercises

facilitative tongue front/back imitate movements that are components of swallowing process push against resistance tongue base push tongue back and hold it pretend to gargle pull tongue back during yawn -all three improved tongue retraction -gargle was significantly better

surface EMG

facilitative used as biofeedback procedure during normal swallowing activities can assist in improving swallow functions

tx for pharyngeal disorders- reduced laryngeal closure at airway

facilitative supersupraglottic swallow - works like a ROM exercise as well may be difficult to manage for a whole meal compensatory supersupraglottic swallow

tx for oral prep- reduced ROM of mandible

facilitative- ROM exercises compensatory- tongue mashing of food

tx for oral prep- reduced buccal tension

facilitative- Rom exercises for lips/face compensatory- pressure against face to close the sulcus; place food on strong side, head tilt

tx for pharyngeal disorders- reduced laryngeal closure at vocal folds

facilitative- exercises for laryngeal adduction compensatory- supraglottic swallow; forward, chin down posture (need to have an epiglottis); rotate toward weak side

tx for oral transit- tongue thrust

facilitative- exercises to move tongue from alv ridge and backwards compensatory- position food posteriorly, tilt head backward or recline chair backward

tx for pharyngeal disorders- cervical osteophytes

facilitative- possibly medical intervention compensatory- posture changes or thinner food consistencies

tx for oral transit- reduced tongue anterior-posterior mvmt

facilitative- rom exercises Compensatory- position food posteriorly, tilt head backward or recline chair backward

tx for oral prep- reduced vertical tongue mvmt

facilitative- rom exercises compensatory- palatal reshaping device (optimum shape for both speech and swallow)

tx for oral transit- reduced tongue elevation

facilitative- rom exercises compensatory- position food posteriorly; syringe liquid posteriorly into mouth if confident reflex will trigger; suck with straw positioned posteriorly in oral cavity; head back posture possibly with breath-holding maneuver

tx for pharyngeal disorders- reduced laryngeal elevation

facilitative- rom exercises with falsetto pitch compensatory- Mendelsohn maneuver; supraglottic swallow; immediate throat-clearing

tx for oral prep- reduced tongue mvmt to form or hold bolus

facilitative- rom exercises; exercises with paste bolus held in place compensatory- head tilt forward and then backward when ready; avoid manipulating the bolus and just hold it

tx for oral transit- decreased/absent swallow trigger

facilitative- thermal stim, suck/swallow, increase sensory input compensatory- head tilt down; small volume bolus

tx for pharyngeal disorders- bilateral reduced pharyngeal constriction

facilitative- tongue holding/swallowing maneuver - stresses posterior wall compensatory- alternate liquid and semisolids; limit diet to thin paste and liquids; use consecutive dry swallows; supraglottic swallow

justice/equity

fair, equitable treatment for all all potential eligible participants should have access to participate irrespective of race, SES etc

clinician directed approaches

fast forWord Drill/ drill play didactic instruction

basic speech assessment

first step usually a single word test e.g. GFTA although they elicit a sample of all consonants they are limited in size of sample they give comparison to norm sample but dont give info about systematic nature of errors

intervention possibilities for SLI in developing language stage

focused stimulation, dialogic reading, Conversational recast

SPPA Sentence Production Program for Aphasia

for non-fluent aphasia Goal is to reduce agrammatism and to improve the ability to communicate with more syntactically complex sentences (more function words, grammatical morphemes, and content) Contains 8 sentence types ranging from simple to complex that are all functional (type a: imitation, type b: spontaneous) Picture representations of 3 different families Very structured program

aphasia types with impaired auditory comprehension

global wernickes transcortical sensory

factors to identify in ongoing assessment with aphasia

have sufficient stamina and stability to begin regular treatment sessions; are continuing to respond positively to treatment; are reaching a plateau, suggesting a need to change treatment procedures or to discharge from treatment; are maintaining treatment-related gains beyond discharge from treatment.

collateral factors that can affect communication

hearing, Oral motor abnormalities, Nonverbal cognition and Social functioning (pragmatics, shy)

tx for oral transit- swallowing apraxia

heighten sensory input and reflex will trigger normally

Masako

hold tongue between teeth and swallow Appears that tongue-holds take time for effect, but may increase pharyngeal pressures May work against laryngeal elevation/anterior movements, therefore, use in conjunction with Shaker exercises to improve anterior laryngeal movements Be careful, if used during swallowing, may place at risk for aspiration

alzheimers disease

is characterized by a loss of neurons and synapses in the cerebral cortex and select subcortical regions; beta-amyloid plaques and neurofibrillary tangles visible on microscopic examination. o Plaques and tangles significant decline in semantics, with a relative sparing of phonological and syntactic components.

APHASIA ASSESSMENT AND FUNCTIONAL OUTCOME PREDICTION IN PATIENTS WITH APHASIA AFTER STROKE (Gialanella & Bernardo, 2011)

language comprehension is an important predicting factor for cognitive functional independence measure but not motor FIM Spontaneous speech production seems to be a predictive factor for motor functional independence measure The purpose of the study was to determine if language examinations predict functional and motor outcomes in pt's with aphasia who are in rehab · Early, accurate predictions of progress is necessary for appropriate discharge planning, placement post-discharge, and f/u for pt's who've suffered a CVA

Labs (pops homeLand pride)

look for trends Lab values to check: White blood cell (WBC) elevation may represent infection. Pre-albumin is another lab to check. When pre-albumin levels are lower than normal (less than 18 mg/dL), it may be a sign of malnutrition.

early 8

m, b, j, n, w, d, p, h

visual perceptual

movement and vibratory characteristics Laryngeal structure, function Voice and vegetative functions Vibratory Symmetry: Look at arytenoids (brisk and symmetric) Amplitude (black spot between VFs) Glottal closure (complete/incomplete; shape of closure) Periodicity (flutter in VFs) Mucosal wave (shiny layer/ soft wave over the top of VF) Phase symmetry (closing versus opening of VFs in relation to each other) Supraglottic hyperfunction

tx for pharyngeal disorders-cricopharygeal dysfunction

myotomy - cut to relax the muscle - only after a number of months show no recovery if poor lifting of larynx - try Mendelsohn maneuver- can help open UES Shaker maneuver Chin tuck against resistance- put something under chin and press down and hold, modified shaker for pple who cant do that

Myasthenia gravis (MG)

neuro disorder Autoimmune neuromuscular disease Muscle weakness and fatigue Affects the vocal folds bilaterally

Unilateral RLN paralysis

neuro disorder Impaired Vocal fold mobility Median position: at midline Paralysis in the median position Dyspnea may occur with exertion or during voice use due to reduced airway opening Voice may sound near normal Tonicity of the VFs play a role Paramedian position: Slightly off the midline position (1-2 mm) Halfway between open and closed and do not move either way Lateralized position: An abducted position with large glottal gap (3-4mm) Far away from the midline position Paralysis in the paramedian or lateralized: position Breathy dysphonia Reduced loudness Reduced pitch and loudness ranges Loss of voice during shouting Complaints of vocal fatigue Loss of air requiring frequent breaths during speech

abductor SD

neuro disorder Intermittent breathy breaks following voiceless sounds in connected speech, consistent with visual evidence of intermittent vocal fold adduction

adductor spasmodic dysphonia

neuro disorder Perceived intermittent voice stoppages during voiced speech sounds in connected speech consistent with visual evidence of hyperadduction

functional aphonia

no organic cause Complete lack of voice, without apparent organic basis Onset often sudden May persist following known organic cause of aphonia or dysphonia, e.g. laryngitis; in such cases a "learning" hypothesis may be entertained May recur over the lifespan Patients often demonstrate remarkably little concern ("la belle indifference" Usually assumed psychologic, or "learning" based • Hyperfunctional • Hypofunctional (more typical) CANNOT get acoustic data because no voice Vegetative functions are key to diagnosis

structural pathologies associated with vibratory stress

nodules cyst polyp

REsponse elaboration training (RET)

non-fluent aphasia Uses loose training with patient-initiated responses Uses simple line drawn picture stimuli requiring personal interpretation The clinician expands upon the patient's utterance to make it slightly more complex

mixed transcortical

nonfluent o Patients falling in this category have sparse output of Broca's aphasia but auditory comprehension is too impaired for them to be assigned to Broca's category o Patients falling into this category include partially recovered global aphasics who have recovered a degree of auditory comprehension and some ability to produce a few words and phrases

extrapyramidal system

o Basal ganglia o Thalamus o Cerebellum o Form complex circuits composing extrapyramidal system o Connected to direct motor pathway of pyramidal tract

circle of willis

o Base of brain, joining of 2 vertebral and 2 carotid arteries o Cerebral arteries branch off from here o Protective mechanism- limits damage if artery issue is below it

middle cerebral artery

o Biggest branch of internal carotid o Supplies entire lateral surface of cortex o Damage may result in aphasia, reading and writing deficits, contralateral hemiplegia, impaired sensation

Example aphasia tests for specific functions

o Boston Naming Test (BNT)- anomia o Northwestern Assessment of Verb and Sentences- comprehension and production of action verbs, production of verb argument structure in sentence contexts, and comprehension and production of canonical and non-canonical sentences o Psycholinguistic Assessments of Language Processing in Aphasia (PALPA)-assess language processing skills in people with aphasia

brocas area of involvement

o Brodmans 44 o Motor area for spoken speech which is situated in the posterior part of left inferior frontal gyrus o MCA territory stroke of Left frontal lobe

prelinguistic assessment protocol

o Case History • CSBS-Communication and Symbolic Behavior Scales- Wetherby and Prizant- looks at eye gaze, gestures and vocalizations, social interaction (8-24mos up to 72 mos if delay)- behavioral sample, parent questionnaire, norm referenced • Rosetti Infant-Toddler Language Scale- criterion referenced, birth-4, preverbal and verbal language • McArthur Bates- communication devt inventories, standardized parent report, 8-30 mos. Vocab comp, production, gestures • Play Sample- analyzed using clinical judgment

Traits of nonverbal

o Communicative intent o Symbolic communication o Decent to typical receptive skills o No verbalization

coup and countercoup

o Coup: Focal injury at the site of the lesion o Countercoup: at a site, distant to the lesion

Descriptive developmental model

o Detailed description of current level of functioning: Semantics, syntax, morphology, phonology and pragmatics, comprehension and expression o Research in normal language development guides intervention o Direct connection btwn assessment intervention o Creation of a profile and strengths and weaknesses

basic research

o Development of knowledge base o Constructing new theories o Modifying existing theories e.g. What causes autism?

3 stages

o Emerging: late talkers (Whole-Word Stage) o Developing: preschoolers (Phonemic Stage) o Elaborating: school-age (Stabilization Stage)

emerging language- semantic relations 2 word utterance

o Existence: that car; this ball o Nonexistence/Disappearance: all gone car o Rejection: no car; don't push. o Denial: no car; not ball o Recurrence: more car; ball again o Attribution: fast car; heavy ball o Possession: my car; mommy ball o Locative-Action: sit down; push high; in go o Locative-Entity: car out; in box; baby swing o Agent-Action: mommy push, baby swing o Action-Object: push swing; ball throw o Agent-Object: baby swing; mommy throw

Posterior cerebral arteries

o Formed from basilar artery o Supple lateral and lower portion of temporal lobe o Supply lateral and middle of occipital lobe

pediatrics signs of reflux

o Frothy spit o Head turn o Coughing/gasping after burp o Re-swallows after feedings o Excessive saliva rush o Arching & irritability with/after feeding

TBI assessment

o Galveston Orientation and Amnesia Test (GOAT), Westmead PTA Scale (WPTAS). o Intelligence (current and premorbid). o Judgment, reasoning, problem solving, executive functioning, decision making, organization, speed and efficiency of information processing. o Attention, memory, learning, and recall capacity for verbal and nonverbal information.

external carotid artery

o Goes towards face o Small branches supply different parts of the face Internal carotid artery

Trial swallows order of presentation

o Ice Chips or lemon ice o Thin liquid (water then move to juice) o Nectar thickened liquid (tomato juice) o Honey thickened liquid o Pureed (applesauce, pudding) o Mechanical soft texture (soft fruit, noodles, soft veggies) o Regular texture: apple, graham cracker, meat o Meats: pureed, ground, chopped o High risk textures: cornbread (particulates), rice, lettuce-liquid in it, mixed consistencies (fruit cup and cereal with milk), popcorn • Straw - diameter matters • Cup • Spoon

phonological dysgraphia

o Impaired nonword spellings • Resulting from the inability to match the grapheme with the phoneme or the inability to segment auditory stimulus into phonemes, phoneme discrimination deficit, or reduced phonological short-term memory. o Can spell regular and irregular known words. o Influenced by imageability, grammatical class, & frequency o Misspellings are usually implausible but visually similar. Often reported in patients with damage to the perisylvian cortical regions

Nonverbal assessment protocol

o Language sample- analyzed for communication acts o Fine Motor, vision and hearing o Functional Communication Profile- 3 and up, looks at many categories, receptive and expressive, sensory-motor, pragmatics, non-oral communication o Communication Complexity Scale- kids to adults, looks at symbolic and non-symbolic communication skills, verbal and non-verbal acts o Peabody Vocabulary Test-2.6+, standardized, looks at receptive vocab, use of symbols o Differential Ability Scales- non-verbal intelligence, child friendly, looks at cognitive ability and processing o Assessment of communication partners- questionnaire used in planning for AAC o TASP- test of aided communication symbol performance-child must be able to point at symbols- benchmark progress in aided communication

Definition of aphasia

o Language-level problem o Affects input and output modes o Multimodal in nature o Caused by a CNS dysfunction

internal carotid artery

o Major supplier to brain o Branches into parts that supply different parts of brain o Includes middle cerebral and anterior cerebral

nonverbal associated diagnoses

o Motor Impairments o Cerebral palsy o Facial anomalies o Autism o Brain Injuries Some can also be prelinguistic with these diagnoses depends on particular childs skills)

hypoglossal

o NOT sensory o Motor- intrinsic and extrinsic tongue muscles except palatoglossus, infrahyoid muscles, geniohyoid

Prognostic factors

o Neurologic factors: o etiology of injury o size and site of lesion o severity and type of aphasia

acute phase of TBI and treatment

o Periods of confusion resulting from fatigue and increased task demands; categorization and decision-making problems as well as problems in social cognition and pragmatics. o Treatment focus on environmental arrangement

targeted stages of production

o Planning: linguistic/conceptual o Programming: motor/sequencing o Execution: production

cerebellum- role and damage

o Primary role - Synergy of muscles o Cooperative action of the muscles by providing feedback to other structures in the CNS motor system o In the case of gross motor movements, it helps maintain proper posture and balance in walking and execution of sequential motor movements such as eating, dressing and writing. o In the case of speech, it guides the production of rapid, alternating, repetitive movements. o Damage to the cerebellum or its tracts results in Asynergy o Lack of coordination of agonistic and antagonistic muscles (ex, biceps and triceps) o Deficits resulting in disorders in fine movement, equilibrium, posture, and motor learning.

facial (VII)

o Sensory- anterior 2/3 of tongue o Motor- sublingual and submandibular glands, buccinators, posterior belly of digastric, stylohyoid

vagus (X)

o Sensory- mucosa or pharynx, epiglottis, larynx and esophagus o Motor- palatoglossus, muscles of palate NOT tensor veli palatini, muscles of pharynx NOT stylopharyngeus, intrinsic muscles of larynx

glossopharyngeal (IX)

o Sensory- mucus membranes, tonsils, faucial pillars, posterior 1/3 of tongue o Motor- parotid gland, stylopharyngeus Vagus (X)

oral phase detailed steps

o Slight elevation of palate, hyoid and velum o Tongue tip elevates and begins pushing bolus back towards palate o Tongue base ramps to help move bolus back towards pharynx o Rolling and stripping action of the tongue, central groove acts as a chute to help contain bolus

cerebellar arteries

o Stem from basilar o Anterior, posterior, superior and inferior o Supply inner ear, cerebellum and pons External carotid artery

accessory (XI)

o Supplemental role- stabilization and movement of shoulders etc

brocas characteristics

o Telegraphic speech o Reduced verbal content o Phrase length generally less than four words o Agrammatical sentence (or frequent errors) o Mostly content words (nouns and verbs) o Absence of functional words (prepositions/conjunctions)

dementia- methods for cognitive communication therapy

o Treatment capitalizing on spared cognitive abilities and reducing demands on impaired ones o Treatment including stimuli that evoke positive emotion, action, and fact memory. Individualized specific treatment stimuli and activities to ensure meaningfulness o Treatment focusing on strengthening knowledge and processes that have the potential to improve o Reminiscence therapy (RT) is discussion of the past that is meant to stimulate recall; topics illustrated using pictures, clothing, props, and are associated with meaningful life themes. o Written and graphic cues are the basis for memory books and wallets. They contain information that is personally relevant, important, and likely to be used regularly by the individual with dementia o Compensation strategies for cognitive impairments through linguistic modifications

Universalist Linguistic theory of development

o Unfolding of abilities (linear progression) o passive learner o universal order of acq (all children develop in same way)

applied research

o Used to solve problem o Understanding nature of disorders o Understanding clinical processes e.g. does conversational recast improve the grammar of school aged children

SPACS

o Using phoneme collapses that represent compensatory strategies developed to accommodate a limited phonetic inventory, we can use a distance metric to select those targets that will result in the greatest amount of change in the least amount of time o The distance metric represents a different perspective to target selection that doesn't rely on the dichotomous characterization of targets as early ~ late; stimulable ~ non-stimulable; known ~ unknown, etc. o RATHER, it is based on the function a particular sound has within a given child's system

pharyngeal phase detailed steps

o Velum elevates completely to seal off nasopharynx o Hyoid moves anteriorly o Larynx elevates o Tongue base moves back o Arytenoids come in contact with base of tongue to close laryngeal vestibule o Larynx closes arieppiglottic folds, true vocal folds and ventricular folds o Epiglottis goes down to cover laryngeal vestibule o Cricopharyngeal sphincter opens o Tongue base retracts o Pharyngeal wall contracts and makes contact with tongue base o Pharyngeal constrictors activate from top to bottom

Aphasia batteries

o Western Aphasia Battery—Revised (WAB-R) o Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN) o Boston Diagnostic Aphasia Examination-3 (BDAE-3) o Aachen Aphasia Test

criterion referenced

o Zone of proximal development- difference btwn baseline and target, influence of max cue and moderate cue, should shrink through intervention o Used to analyze language samples- SALT

Personal/individual factors that affect prognosis

o age o education o handedness o psychological issues o emotional issues o Hemorrhagic stroke better recovery than infarction o Lesion size may not necessarily predict recovery o Lesion site and aphasia type may be more effective predictor o Nonfluent aphasia better prognosis than fluent aphasias o Younger patients usually better prognosis than older due to better health o Females better than males o One study seems contradicted by another o Multi-factorial and complicated process

General patterns of development

o at 24 mo, generally have expressive vocab of ~ 300 words o ~ 50% of what they say is understood by strangers o by 3 yrs, 75% intelligibile with vocal of ~ 1000 wds and MLU of 3.1

frontal lobe- functions and important parts

o cognitive functioning, motoric functioning, and in speech and language. o Area 4 corresponds to the precentral gyrus or primary motor area (or cortex). o Area 6 is the premotor or secondary motor area (or cortex). o Area 8 is anterior of the premotor cortex. It facilitates eye movements and is involved in visual reflexes as well as pupil dilation and constriction. o Areas 9, 10, and 11 are anterior to area 8. They are involved in cognitive processes like reasoning and judgment which may be collectively called biological intelligence. o Area 44 is Broca's area. o Inferior frontal gyrus - has the Broca's area - Important for speech production. o Is in front of the area of the Primary motor cortex that controls jaw, lip, tongue, and vocal fold movements. o Damage to this area results in "motor aphasia," in which patients can understand language but cannot produce meaningful or appropriate sounds.

relational analysis

o compares child's pronunciation of word with adult form and identifies what is correct/ incorrect in relation to adult target o PCC o error patterns (phonological processes)

difficulties of TBI can be due to

o direct result of the injury o secondary effect of other injury-related complications and their pharmacological outcomes.

What areas of language to assess

o fluency o output o Auditory comprehension o Repetition o Naming o Written output o Reading comprehension o Drawing o Gesture o Facial expression o Awareness of deficit

independent analysis

o focuses on the sound types and syllable structures produced by the child independent of the adult target phonetic inventory (by WI/WF positions) syllable structure

temporal lobe- function and parts

o involved in the processing of auditory information and semantics, as well as the appreciation of smell. o Area 41 is the primary auditory area or cortex or Heschl's gyrus . o Also a part of the primary auditory cortex, Area 42 immediately inferior to area 41 and is also involved in the detection and recognition of speech. More detailed processing and analysis is done in this area. o Areas 21 and 22 are the auditory association areas. o Area 22 is also known as Wernicke's area or association language cortex

cognitive theory of development

o non-linear development o active learner o individual differences

red flags for atypical devt

o numerous vowel errors o frequent initial consonant deletion o substitution of glottal stop of [h] for various consonants o deletion of final consonants at 3 years

Trigeminal (V)

o sensory- tongue, teeth, lips, palate and chin o motor- muscles of mastication, tensor veli palatine, mylohyoid, anterior belly of digastric

parietal lobe- function and parts

o somatosensory processing. o Areas 3, 2, and 1 are located on the primary sensory strip, with area 3 being superior to the other two. These are the primary somatosensory areas or cortex for touch and kinesthesia. o Areas 5, 7, 39 and 40 are found posterior to the primary sensory strip and correspond to the presensory or secondary or somatosensory association areas. o Area 39 is the angular gyrus. o it is involved in a number of processes related to language and cognition & is believed to be responsible for understanding metaphors.

ICF case example assessment of activities and participation

obtained using a tool such as Assessment of Living with Aphasia and/or interview Examples: Reduced participation in activities outside of the home (e.g., viewing or participating in sports) • Difficulty engaging in preferred reading activities (e.g., reading novels or newspapers) • Increased withdrawal from social interaction • Wife reports difficulty understanding his attempts to communicate needs at home

ORLA

oral reading for language in aphasia repeated practice reading aloud sentences with a clinician Level 1. Simple 3-5 word sentences at a first-grade reading level; Level 2. 8-12 words that may be single sentences or two short sentences, at a third-grade reading level; Level 3. 15-30 words, divided into 2-3 sentences, at a sixth-grade reading level; Level 4. 50-100 words comprising a 4-6 sentence simple paragraph, also at a sixth-grade reading level.

OUTCOME ASSESSMENT IN APHASIA: A SURVEY (Simmons-Mackie, Threats, & Kagan, 2005)

outcome assessment targeting the individual client might measure specific aspects of language such as word finding or sentence formulation (clinically derived outcome), functional changes in the ability to perform activities of daily living (functional outcomes), return to work or engagement in recreational activities (social participation outcomes), improvements in the perceived quality of life (client-defined), or the "cost" or amount of therapy associated with a specific improvement (financial)

Innervation- SLN

paired branch of vagus Motor (External branch)- cricothyroid (CT) Sensory (Internal branch)- Intrinsic larynx

Innervation-RLN

paired branch of vagus motor Intrinsic Larynx all but CT Other 4: PCA, LCA, interarytenoids, thyroartenoid

phonological complexity target selection

phonemic Characteristics of sounds Later developing sounds, non-stimulable, least knowledge Learnability enhanced, max change in least amt of time PVM analysis Marked High frequency, low density words

distance metric target selection

phonemic Function of sounds Maximal classification- different manner, voicing, place and linguistic units maximal distinction-far from error sound in PVM Learnability enhanced, max change in least amt of time SPACS analysis Marked or unmarked

Epilogue: Perspectives on Assessment of a Child's Speech (Williams, 2002)

phonological approach: Select sounds that are not stimulable, rationale: stimulable sounds will emerge w/out direct intervention Non-stimulable sounds represent less phonological knowledge than stimulable sounds. Selecting sounds that represent less phonological knowledge results in greater change across the sound system Select sounds that are consistent in their errors, rationale: Rationale: Consistent errors reflect category representations, which will result in appropriate category shift to correspond to the target representation as a result of treatment general approach to phonological assessment that: 1. Identified patterns of error and their generality across a child's sound system; 2. Attempted to find the "order" in the "disorder" and examined consistencies of errors; 3. Utilized their assessment framework for recommendations for target selection and/or intervention planning. • it will lead us to conceptualize phonological disorders from a broader-based and multidimensional perspective, which in turn will direct us in our pursuit of the order within the disorder.

intervention planning

phonological impairment- phonological approach- contrastive approaches articulation impairment- phonetic placement approach motor speech disorder- motor approach

teachability

pick things easier to teach to improve efficiency 1.easily demonstrated 2. taught through stimulus materials that are accessible 3. things used frequently in child's life

Hanen program

population: late talkers and preschool w develop or cognitive delay components: parent training in natural context-facilitate communication development small group parent training sessions, individual video feedback sessions assessment: video play sessions, and rosetti or bates agents: parents and SLP nature of goals: parents use of interaction strategies

Focused stimulation

population: late talking toddlers, children w SLI or mental retardation toddler thru early elementary age components: target morpheme or words repeat and recast during play exposure to multiple exemplars of target form, content etc. in natural setting individual supplemented by parent at home assessments: test, parent report and language sample, dynamic assessment for changing targets agents: slp or parents goals: improvement of vocab or early grammar

tx for oral prep- reduced oral sensitivity

position food on more sensitive side increase sensory input with temp and flavor

POPS HOMELAND PRIDE

preparation orders pulmonary sensory history oral motor medications environment labs aspiration neurological diagnosis pharynx recommendations intake status dysphagia esophagus

what is descriptive research

quantitative • Classification of subjects • Application of measurement procedures to find differences between groups, trends etc non experimental no randomization, no control or multiple measures

3 principles of quantitative research

randomization, control, manipulation

tx for oral prep- reduced labial closure

range of motion, strength, and duration exercises lips repeat multiple times per day

3 points of disturbance in repetition

recognition articulation selective dissociation

Dr. G definition voice disorder

refers to a condition in which voice functioning is unacceptable to the user in social, professional, or other contexts, and for which the SLP or other practitioner generally finds some corroborative evidence

cognitive rehab

remediation and compensation for impaired posterior functions and networks • errorless learning. • Method of vanishing cues (MVC). Awareness of deficits Generalization Spaced retrieval therapy o Capitalizes on preserved implicit memory processes through errorless learning and intense practice. o Direct attention training APT o Categorization training Categorization program (CP): basic levels of categorization progressing to higher processes (e.g., abstract thought) Pragmatic therapy

Schuells repetition task

repetition of 10 stimuli words words are common items slow speech rate on delivery with a pause btwn 2 words example goal: J will repeat 10 stimulus words immediately following their auditory presentation with 80% accuracy.

individual rights

respect of individual's right to her or his own person and ability to make own informed choices participants must be informed of all benefits and risks they must be free to withdraw consent at any time

vocal hemmorhage

result of a forceful impact (shouting, yelling and screaming) during which the vocal cords slam against each. This trauma causes the blood vessels within the layers of the vocal cords to bleed and bruise similar to what happens under your nail when you slam your finger in the door.

Using the picture exchange communication system (PECS) with children with autism: assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior. (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002)

results indicated all 3 in study increased verbal speech, and small gains in social behaviors and decrease in problem behaviors

selecting therapy based on type of aphasia

selecting a treatment on the basis of a syndrome diagnosis is likely to overlook crucial individual differences. Rather, finer-grained decisions need to be made, for instance about the person's priorities for therapy and the processing impairments that contribute to their problems. In an ideal world, this level of assessment should enable the clinician to turn to evidence-based treatment approaches that address their client's particular symptoms

Vagus (X)

sensory- Mucosa of pharynx, epiglottis, larynx and esophagus motor- Palatoglossus Muscles of palate (not tensor veli palatine) Muscles of pharynx (not stylopharyngeus) Muscles of larynx How to test- Cough soft palate movement Gag reflex Sustained /ah/ Glottal attack

treatment of CAS

sequential organization from simple to complex speech tasks; integral stimulation, tactile-kinesthetic facilitation (touch-cue method, PROMPT, DTTC), rhythmic and melodic facilitation, and gestural cueing

connected speech sample analysis

severity- PCC intelligibility- scaling judgments prosody-rate stress and fluency

Sensory (popS homeland pride)

signs of impairment: Gurgling after trial- w/o response Anterior spillage- w/o response Gag-hyper or hypo sensitive Irrational behavior responses Residue and not trying to clear

profile of a typical 2 year old

simple structure- CV, CVC, CVCV, CVCVC few or no clusters (only WF) word initial inventory- 9-10 sounds, nasals, stops, fricatives and glides word final inventory- 5-6 sounds, stops with some nasals, fricatives or liquids about 70% accuracy

sonorants

sounds produced with a narrowing of vocal tract but no pressure buildup behind opening, vowels, glides and nasals

ICF factors to consider when setting goals

structure and functions: What impairments most affect function in the current setting or at discharge, based on clinician assessment & the individual's self-report? activities and participation :What activities are most important to the individual in the current or discharge setting? contextual factors: What personal/environmental characteristics help or hinder participation in activities or situations in the current or discharge setting?

resource allocation models (schuells)

suggest that humans have a limited amount of cognitive resources for conducting mental or cognitive operations. If elements of treatment tasks are simplified, demands of the resource pool will be decreased, thus improving the aphasic individual's performance. The primary manner in which clinicians can manipulate the processing load is through manipulation of the task stimuli

medical/surgical interventions

suture larynx closed myotomy- cut LES botox

phonological approaches focus on

system wide change emphasis on generalization and system shifting

levels of evidence from top to bottom

systematic reviews or meta analysis randomized control trial other controlled clinical trials observational studies (cohort and case controlled) case studies, anecdote (can generate hypotheses)

middle 8

t, k, g, ng, f, v, "ch", "dj" in jump

paragramatism

tangled grammatical organization associated with fluent aphasia substitution of incorrect grammatical markers rather than omission like agrammatism e.g. Target: The man is painting the woman. Paragrammatic Response: Painting the picture.

phonological awareness intervention

target population: 3-4 yo, children with specific speech or language impairments Components: Phonological awareness activities Activities that target syllable awareness-segmenting two syllable words sound awareness- e.g.- sort animals by their beginning sound Phonological awareness continuum- 1. Aware that words have syllables, 2. Aware that a syllable has an onset and a rime, 3. Awareness that words are formed by individual phonemes (phoneme awareness) SLPs working with other caregivers or teachers Individual and small groups Nature of goals: Prevention of written language and reading difficulties in children who are at increased risk because of language Impairment

assent

term used to express willingness to participate in research by persons who are by definition too young to give informed consent but who are old enough to understand the proposed research in general

Supported conversation for adults with aphasia (SCA)

treatment method Focuses on communication partner Acknowledging competence Verifying message Use communication techniques when breakdowns occur. Start with gesture and then gradually add more techniques, as needed

Thematic language stimulation

treatment method o Establish a core vocabulary theme o Predictable systematic linguistic tasks o Hierarchy of tasks- 12 exercises- target all modalities

conversational scripting

treatment method repeated practice of relevant phrases and sentences that, when mastered, can potentially be used in other communicative situations.

semantic feature analysis

treatment method for anomia therapy technique that focuses on the meaning-based properties of nouns. People with aphasia describe each feature of a word in a systematic way by answering a set of question e.g. location, function, action, properties,

vocal hemmorhage symptoms

typically associated with sudden onset of painless hoarseness of the speaking and/or singing voice.

quantitative research

used to quantify the problem by way of generating numerical data or data that can be transformed into usable statistics. It is used to quantify attitudes, opinions, behaviors, and other defined variables - and generalize results from a larger sample population. Quantitative Research uses measurable data to formulate facts and uncover patterns in research. experimental, quasi-experimental, pre-experimental descriptive

mixed methods

uses both quantitative and qualitative methods can be: o Sequential o Concurrent • research that involves collecting, analysing and integrating quantitative (e.g., experiments, surveys) and qualitative (e.g., focus groups, interviews) research.

melodic intonation therapy

uses the musical elements of speech (melody & rhythm) to improve expressive language by capitalizing on preserved function (singing) and engaging language-capable regions in the undamaged right hemisphere Each level consists of 20 high-probability words (e.g., "Water") or social phrases (e.g., "I love you.") presented with visual cues. Phrases are intoned on just 2 pitches, "melodies" are determined by the phrases' natural prosody (e.g., stressed syllables are sung on the higher of the 2 pitches, unaccented syllables on the lower pitch (Fig.2)), and the patient's left hand is tapped 1x/syllable

requirements of ethical clinical research

value validity fair subject selection favorable risk/benefit ratio independent review informed consent respect for enrolled participants

essential tremor- voice symptoms and characteristics

vocal tremor btwn 3-7Hz

timbre

voice quality; ~ Spectrum

tx post surgery or vocal hemmorage

voice rest Confidential voice, respiratory retraining

fluent aphasia types

wernickes, transcortical sensory, conduction, anomia

Intrinsic muscles- adductors

work together to close vocal folds • Lateral Cricoarytenoid (LCA) • Interarytenoids (IA)- adductor, relaxer, even tensor when works with CT • Thyroarytenoid (TA)- makes up most of vocal folds (vocalis muscle)

pitch

~ Fo Fundamental frequency Low F0 implies added mass high F0 implies stiffness Low-high continuum Pitch range Correlate of pitch- frequency Variations in speech- intonation Influenced by voice quality (e.g., hoarse voice- lower) SLN->CT Increase in pitch- Ps increases

loudness

~ Intensity Soft- loud continuum Dynamic range Correlate- Intensity • Subglottal pressure • VF adduction • VT adjustments- tuning- resonance

Oral Care and the elderly (Ashford & Skelley, 2008)

• Aspiration of certain oral pathogens into the lower respiratory tract has been associated with the development of pneumonia leading to illness complications and death in some elderly or sick persons • Oral care using brushes and oral rinses have been shown to significantly reduce pneumonia development and fever in the sick and elderly populations • An important new role of speech-language pathologists is to assert themselves as practitioners and advocates of better oral health with these populations.

Conversational coaching: Treatment outcomes and future directions (Hopper, Holland & Rewega, 2002)

• 2 couples • During treatment sessions, the same procedure was used, but the clinician intervened and coached both participants in the use of selected verbal and non-verbal strategies to improve the quality of the conversation First, the percentage of main concepts successfully communicated was significantly greater during post-treatment probes than during pre-treatment probes for both dyads. • Second, Mr Y demonstrated significant improvement in his total CADL-2 scores following treatment. • Third, individuals who judged the quality of pre- and post-treatment conversations understood more of the conversation between both couples during post-treatment probe conversations than during pre-treatment ones

Training volunteers as conversation partners using "Supported Conversation for Adults With Aphasia" (SCA): A controlled trial (Kagan, Black, Duchan & Simmons-Mackie, 2001)

• 20 volunteers received the training and 20 served as control • Comparisons between the groups' scores on a Measure of Supported Conversation for Adults with Aphasia provide support for the efficacy of SCA • trained volunteers scored significantly higher than untrained volunteers on ratings of acknowledging competence and revealing competence The training also produced a positive change in ratings of social and message exchange skills for the people with aphasia

Schuells basic priniciples

• : Intensive auditory stimulation should be used • B: The stimulus must be adequate—it must get into the brain. Therefore, it needs to be controlled along a number of dimensions • C: Repetitive sensory stimulation should be used • D: Each stimulus should elicit a response • E: Responses should be elicited, not forced or corrected • F: A maximum number of responses should be elicited • G: Feedback about response accuracy should be provided • H: The clinician should work systematically and intensively • I: Sessions should begin with relatively easy, familiar tasks • J: Abundant and varied materials that are simple and relevant to the patient's deficits should be used • K: New materials and procedures should be extensions of familiar materials and procedures

ASSESSMENT OF PEDIATRIC DYSPHAGIA AND FEEDING DISORDERS: CLINICAL AND INSTRUMENTAL APPROACHES (Arvedson, 2008)

• A holistic approach to evaluation is stressed with a primary goal for every child to receive adequate nutrition and hydration without health complications and with no stress to child or to caregiver. • Successful oral feeding must be measured in quality of meal time experiences with best possible oral sensorimotor skills and safe swallowing while not jeopardizing a child's functional health status or the parent-child relationship

Voice Training and Therapy With a Semi-Occluded Vocal Tract: Rationale and Scientific Underpinnings (Titze, 2006)

• A semi-occlusion in the front of the vocal tract (at the lips) heightens source-tract interaction by raising the mean supraglottal and intraglottal pressures. • Impedance matching by vocal fold adduction and epilarynx tube narrowing can then make the voice more efficient and more economic (in terms of tissue collision). •

central alexias

• Affects later stages of reading • Impairments in lexical or sublexical processing • Deep, surface, phonological

OUTCOME OF RESONANT VOICE THERAPY FOR FEMALE TEACHERS WITH VOICE DISORDERS: PERCEPTUAL, PHYSIOLOGICAL, ACOUSTIC, AERODYNAMIC, AND FUNCTIONAL MEASUREMENTS (Chen, Hsiao, Hsiao, Chung, & Chiang, 2007)

• After therapy the severity of roughness, strain, monotone, resonance, hard attack, and glottal fry in auditory perceptual judgments, the severity of vocal fold pathology, mucosal wave, amplitude, and vocal fold closure in videostroboscopic examinations, phonation threshold pressure, and the score of physical scale in the Voice Handicap Index were significantly reduced • The speaking Fo, maximum range of speaking Fo, and maximum range of speaking intensity were significantly increased after therapy • No significant change was found in perturbation and breathiness measurements after therapy • Resonant voice therapy is effective for school teachers and is suggested as one of the therapy approaches in clinics for this population

MBS description

• Aka. Videoradiography, videofluorography, modified barium swallow study (MBSS), oropharyngeal motility study (OPMS) • Dynamic radiography utilizing continuous x-rays • Most frequently used • Requires minimal radiation

Consensus Auditory-Perceptual Evaluation of Voice: Development of a standardized clinical protocol (Kempster, Gerratt, Abbott, Barkmeier-Kraemer, & Hillman, 2009)

• Although there is no known ideal method for obtaining reliable and valid judgments of auditory-perceptual features, the CAPE-V derives its protocol and measurement scales from a state-of-the-art understanding of the multidimensional factors that underlie psychophysical measurement and human perception.

description of dementia

• An acquired and persistent impairment of multiple cognitive domains that is severe enough to limit competence in activities of daily living, occupation, and social interaction. • Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson's disease (PD), frontotemporal lobar degeneration (FTLD), and mixed dementia types.

Informal assessment of auditory comprehension

• Answer closed-open questions • Point to objects/pictures • Follow spoken directions • Answer questions in discourse

Types of recovery

• Any and all behavioral change • Restoration • Reorganization • Compensation • Habituation • Restitution • Substitution • New learning

Screening Tests for Aphasia in Patients With Stroke: A Systematic Review (Hachioui, 2016)

• Any aphasia screening test: o designed to assess the presence and/or severity of aphasia o has quick administration (i.e., 15 minutes or less) • Eight aphasia screening tests were identified and evaluated across 11 studies • Of the four studies with an intermediate or low risk of bias, the [Language Screening Test (LAST)] and the ScreeLing seem to have the best diagnostic properties

Disorders by phase- oral transit

• Apraxia of swallow/reduced oral sensation- unaware of residue or location of bolus • Tongue thrust • Reduced labial tension/tone • Reduced buccal tension/tone • Reduced tongue shaping/ poor tongue seal • Tongue scarring- surgery etc • Lingual weakness • Lingual discoordination • Reduced tongue elevation/strength • Tongue pumping • Piecemeal deglutition- break bolus into small bits and multiple swallows

ASSESSMENT, TARGET SELECTION, AND INTERVENTION: DYNAMIC INTERACTIONS WITHIN A SYSTEMIC PERSPECTIVE (Williams, 2005)

• Assessment: SPACS maps the child's sound system onto the adult's sound system in terms of phoneme collapses; 245 single word elicitation; all english phonemes a minimum of 5 times in all word positions; uses phoneme collapses. • Target Selection: Distance Metric- utilizes maximal classification (vertical parameter that that selects targets from a phoneme collapse) and maximal distinction (horizontal parameter that selects a target that is maximally distinct from the child's error). • "By selecting targets that are more distinct from the child's error and are representative of the sound classes collapsed across a phoneme collapse, the targets sounds contrasted to the child's error can be made more salient and are therefore predicted to be more learnable." • Select targets based on function rather than characteristics (stimulability, difficulty, etc) • Intervention- Multiple Oppositions- larger tx sets are integrated to address several errored sounds simultaneously within one rule set in prediction of generalization • Systematic approach aims to find the "order" in the "disorder"

assessment of breathing patterns during bedside

• At rest and with po • Monitor apneic period (should be <1 sec.) • Monitor resp rate immediately after swallow • after successive swallows • over course of meal

A systematic perspective for assessment and intervention: A case study (Williams, 2006)

• Based on the organizational principles suggested by the phoneme collapses, targets were identified for intervention using the distance metric approach, which is based on the function of sounds within a given system rather than the characteristics of a given sound, and assumes that targets will interact dynamically with the child's unique sound system • Finally, a multiple oppositions treatment approach intended to facilitate learning across phoneme collapses and lead to system-wide phonological restructuring was described. • With the multiple oppositions approach, each target word is presented in contrast with the comparison word. For the goal of [b]*/f, sp/ wordinitially, the clinician would model bat * fat and the child would repeat both words of the contrastive word pair. Then the clinician would model bat *spat for the child to imitate. Then the next set of contrastive word pairs would be addressed until all five sets of contrasts were completed for a total of 10 responses

Systematic review dialogic reading (U.S. Department of Education, Institute of Education Sciences, What Works Clearinghouse, 2010)

• Based on the two studies, the [What Works Clearinghouse] found potentially positive effects of dialogic reading on communication and language competencies for children with disabilities

assement of dysgraphia

• Before assessing deficits of visual acuity, visual neglect, motor apraxia, and ect. must be ruled out • Goal is to describe deficits and identify the underlying mechanism o Linguistic and motor components must be assessed • No formalized assessment though some assessments do have a writing portion. o These should be used as a screener. • A comprehensive assessment must include o Spontaneous writing sample and writing at the single-word level.

frontotemporal lobe degeneration

• Behavioral variant • Semantic variant of PPA • Progressive nonfluent aphasia • Logopenic variant

visual alexia

• Better "butter" Prince "price"

Constraint-induced therapy of chronic aphasia after stroke. (Pulvermuller, et al., 2001)

• CILT was performed through a game activity in small groups of 2-3 pts and therapist who had to perform all communication through spoken words. No gestures were allowed. • CILT aphasia therapy led to significant and pronounced improvements on several standard clinical tests, on self-ratings, and on blinded-observer ratings of the patients' communicative effectiveness in everyday life. Patients who received the control intervention failed to achieve comparable improvements

Perspectives on Treatment for Communication Deficits Associated With Right Hemisphere Brain Damage (Blake, 2007)

• Controlled treatment studies for communication deficits specifically for adults with right hemisphere brain damage are limited to aprosodia. • For other communication deficits, clinicians may select treatments based on current theories of right hemisphere function and right hemisphere deficits, and/or treatments developed for other etiologies for which deficits are similar to those associated with right hemisphere damage

Informal assessment of writing

• Copy letters, numbers, shapes, words • Write to dictation-letters, numbers, words, sentences • Write a paragraph/written narrative

ASHA ICF- activities and participation

• Coughs when drinking thin liquids • Cannot safely chew and swallow preferred solid food items • Cannot locate food and liquid on the left side of the table

lexical (surface) dysgraphia

• Damage to the orthographic output lexicon, associated with posterior temporal lesions. • Junction of the posterior angular gyrus and left parietal lobe • Orthographic representations or words are missing/ diminished • Difficulty spelling irregular words, relative intact spelling for regular words • Misspellings are generally phonologically plausible. • Individuals must rely on the preserved non-lexical route.

graphemic buffer impairment dysgraphia

• Defective short-term storage of graphemic information • Difficulties in grapheme identification and order in all spelling task regardless of word status. • Difficulties in lexical access and phoneme-grapheme conversion during writing process • Retain the ability to write well-formed graphemes, although the substitution, omission, addition or transposition of letters within words may be observed • Effects all written output modalities • Word length plays a role in accuracy.

central dysgraphias

• Deficit is in the central spelling routes • Lexical, phonological, deep, semantic, and graphemic buffer dysgraphias

disorders by phase- pharyngeal

• Delayed pharyngeal swallow reflex • Reduced velopharyngeal closure- velum closing off nasopharynx • Cervical osteophytes • Reduced posterior movement of tongue base • Scar tissue or pharyngeal pouch (very rare) • Reduced laryngeal elevation • Reduced laryngeal closure • Reduced anterior laryngeal motion; cricopharyngeal dysfunction; stricture • Unilateral pharyngeal wall weakness • Bilateral pharyngeal wall weakness

non homonymy approaches

• Non-homonymous approaches indirectly address child's rule with assumption that greater contrastive distinction of word pairs facilitates learning. maximal oppositions and empty set

SLI or Primary language disorder- characteristics and deficits

• Diagnostic criteria: • 1 or more SD from mean • Difficulty with grammar particularly tense • Poor non-word repetition, poor sentence imitation, poor ability to define words • language impairment is most salient presenting challenge • Biological cause not known • No other diagnostic label is appropriate Form • deficits in grammar are hallmark • Most common finding- omit morphosyntactic markers of grammatical tense • Not always lack of knowledge but inconsistent implication • Phonological deficits Content • low vocab • Slow to learn new words • Difficulty retaining new word labels • Older kids- don't realize word can have more than one meaning • Some research shows particular difficulty with verbs Form-pragmatics • Issues with turn taking, matching communication style, requesting and protesting

peripheral dysgraphias

• Difficulties in the selection and/or production of letters in hand writing. • Allographic, apraxic, motor nonapraxic, and special (afferent) dysgraphias.

neglect alexia

• Difficulty correctly identifying initial or final letters of the word • Only in orthographic forms not the same as visual neglect. • Spatially consistent errors

open jaw during mastication

• Digastric • Lateral pterygoid DoLloP

laryngeal elevators

• Digastric • Mylohyoid • Geniohyoid • Stylohyoid o Hyoglossus o Genioglossus Dig GemS Higher Ground

Vocal tract and glottal function during and after vocal exercising with resonance tube and straw. (Guzman, et al., 2013)

• During and after phonation into the tube or straw, the velum closed the nasal passage better, the larynx position lowered, and hypopharynx area widened • the ratio between the inlet of the lower pharynx and the outlet of the epilaryngeal tube became larger during and after tube/straw phonation • Acoustic results revealed a stronger spectral prominence in the singer/speaker's formant cluster region after exercising • Listening test demonstrated better voice quality after straw/tube than before • Vocal tract and glottal modifications were more prominent during and after straw exercising compared with tube phonation.

Predictors of Aspiration Pneumonia: How Important Is Dysphagia?* (Langmore, et al., 1998)

• Dysphagia is a risk for aspiration pneumonia but not alone a cause for aspiration pneumonia without other risk factors • Dominant risk factor: dependency on others for feeding (increased amount of material) • Aspiration pneumonia calls for 13%-48% of all infection at nursing homes 7 predictors

Oropharyngeal dysphagia after stroke: Incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit (Falsetti, et al., 2009)

• Dysphagia was not influenced by type of stroke • Patients with dysphagia had significantly lower functional independence measurement (FIM) and level of cognitive functioning on admission and lower FIM on discharge, longer hospital stay, and more frequent malnutrition, and they were more frequently aphasic and dysarthric • Clinical assessment demonstrates good correlation with VFS

Effect of a tongue holding maneuver on posterior pharyngeal wall movement during deglutition. (Fujiu & Logemann, 1996)

• Effects of a tongue-holding maneuver (masako) on anterior bulging of the posterior pharyngeal wall (PPW) during swallowing were investigated in 10 young adult normal subjects • A significant increase in PPW bulging was seen with the maneuver at both pharyngeal levels • These findings indicate potential for developing new treatment techniques to facilitate compensatory anterior movement of the PPW, which has not been a target for direct treatment in the past • At present, the tongue-holding maneuver can be employed clinically as an easy method for testing the compliance of the PPW videofluorographically

FEES procedure

• Endoscope is passed transnasally to the hypopharynx to view the patient's larynx and pharynx • Nasendoscope is inserted through the nose o Passed over the soft palate (velum) through the velopharyngeal port o Turned downward and progressed into the pharyngeal cavity o Stopped above the level of the laryngeal vestibule and vocal cords (hypopharynx)

vocal fold layers

• Epithelium • Superficial lamina propria- most injury here, phonotrauma • Intermediate lamina propria- vocal ligament • Deep lamina propria • Muscle/ vocalis- bulk of vocal folds • Thyroarytenoid • Thyrovocalis- medial • Thyromuscularis- lateral

Treatment Effects for Dysphagia in Parkinson's Disease: A Systematic Review (van Hooren, Baijens, Voskuilen, Oosterloo, & Kremer, 2014)

• Expiratory Muscle Strength Training (EMST) and Video-Assisted Swallowing Therapy (VAST) may be effective dysphagia treatments solely or in addition to dopaminergic therapy for PD • While further research is needed to investigate the efficacy of dysphagia treatments for individuals with Parkinson's disease, a number of swallowing interventions (e.g., oral-motor treatments, electrical stimulation, thermal stimulation, positioning strategies, video-assisted swallowing therapy) show promising results.

FEES description

• Fiberoptic Endoscopic Evaluation of Swallowing o Method to evaluate swallowing using an endoscope placed nasally and inserted to the level of the hypopharynx

Treatment of laryngeal hyperfunction with flow phonation: A pilot study (McCullough, et al., 2012)

• Flow phonation Participants received five treatment sessions and were evaluated prior to treatment and after each session using a Phonatory Aerodynamic System to measure airflow during voicing tasks. Noise-to-harmonic ratio and perceptual voice measures were also obtained, as was self-perception of voice handicap • All increased airflow and decreased laryngeal airway resistance over five sessions

Interactive Focused Stimulation for Toddlers With Expressive Vocabulary Delays (Girolametto, Pierce, & Weitzman, 1996)

• Following treatment, mothers' language input was slower, less complex, and more focused than mothers in the control group. • children used more target words in naturalistic probes, used more words in free-play interaction, and were reported to have larger vocabularies overall as measured by parent report • children in the experimental group used more multiword combinations and early morphemes than children in the control group

procedural memory and dementia

• Nondeclarative memory- procedural memory, how to make a pb&j • Procedural memory is retained longer- can be used to help patients function more independently

IMPROVING THE SOCIAL-CONVERSATIONAL SKILLS OF DEVELOPMENTALLY DELAYED CHILDREN: AN INTERVENTION STUDY. (Girolametto, 1988)

• Following treatment, the mothers in the experimental group were more responsive to and less controlling of their children's behavior than the mothers in the comparison group • The children initiated more topics, were more responsive to their mother's preceding turns, and used more verbal turns and a more diverse vocabulary than the control group children

oral prep detailed steps

• Food is placed into mouth • Lips are sealed • Buccinators are activated to keep food from lodging in lateral sulci • Bolus is kept on anterior of tongue • Soft palate and tongue come together • Hyoid is stabilized for chewing • Mastication if necessary by mandible moving up and down and side to side • During mastication breathing continues through the nose • Bolus is recollected onto tongue • Tongue tip elevates to move bolus back which is start of next phase

mgmt of respiratory control

• For feeding-dependent individuals - caregiver should be cognizant of timing of respiratory phase, allow time to swallow and regain respiration, smaller boluses (Morton el al., 2002) • Benefit of goals in dysphagia therapy to address respiratory support

language modalities

• Form: syntax, morphology and phonology • Content: semantics • Use: pragmatics

Multiple Oppositions: Case Studies of Variables in Phonological Intervention (Williams, 2000)

• Frequently, however, children with moderate-to-severe phonological disorders collapse several adult phonemes to a single sound. Therefore, the contrastive function of many adult sounds is absent, which significantly reduces the child's speech intelligibility • A treatment approach that directs intervention across the multiple collapses of adult contrasts is the multiple opposition approach • This approach contrasts several target sounds simultaneously to the child's errored sound, thereby using multiple homonymous treatment contrasts • In this study, the intervention approach of multiple oppositions was used with all the children; minimal pairs was used with 6 of the 10 children; and NSI was used with 5 of the 10 children • These children represented the ranges of severity of moderate, severe, and profound • May not be good for children with mild phonological impairments • Conversely, in this study, minimal pairs and NSI training were only incorporated in later phases of treatment and therefore appeared to be better matched with less severe degrees of impairment. • This approach to target selection is based on three premises: (1) knowledge of the child's unique phonologic organization relative to the adult sound system, (2) selection of targets that will focus the new information to the restructuring of the child's original organization, and (3) selection of specific targets based on saliency (maximal distinction and maximal classification).

LANGUAGE INTERVENTION WITH CHILDREN WHO HAVE DEVELOPMENTAL DELAYS: EFFECTS OF AN INTERACTIVE APPROACH. (Tannock, Girolametto, & Siegel, 1992)

• HANEN Consistent with the interactive model, mothers in the treatment group became more responsive, less directive, and provided clearer linguistic models • these changes were maintained for at least 4 months after intervention, and involvement in the parent-centered intervention program did not increase maternal stress. • these changes were accompanied by concomitant increases in children's use of vocal turns • an interactive model may afford a useful adjunct to other intervention approaches by instructing parents on how to promote children's use of existing abilities, but an interactive model may have no effect on language acquisition of at least some children with developmental delays.

systematic review

• Highest level of evidence answers a defined research question by collecting and summarising all empirical evidence that fits pre-specified eligibility criteria • meta-analysis- the use of statistical methods to summarise the results of systematic reviews

airflow and voice characteristics

• Hoarseness- combination of breathiness and roughness • Breathiness- unmodulated airflow • Roughness- irregularly modulated airflow

assessment of dementia

• Identification of individuals who are at risk for developing dementia or who have cognitive communication disorders suggestive of dementia. • Assessment of cognitive communication disorders of dementia, using formal and informal evaluation tools.

deep alexias

• Impaired pseudo word reading in conjunction with the production of semantic and visual errors in oral reading. • Hallmark characteristics • Impaired pseudo word reading • Semantic errors in oral reading • Visual errors in oral reading • Morphological errors in oral reading • An imageability effect in word reading

phonological alexia

• Impaired pseudo word reading in the absence of semantic reading errors • Some overlap with deep alexia

surface alexia

• Impaired reading of irregularly spelled words with relatively intact reading of regularly spelled words • Irregular words yacht, sword, doubt, choir, island

ASHA ICF- functional short term goals

• In 90% of trials—with moderate verbal cues during 30-minute meals, Mr. J will check and clear pocketed material. • With minimal cues, Mr. J will use customized scanning strategies to locate and consume food and drink during a meal. • In 90% of trials of a home exercise program, Mr. J will use mobile technology to increase range and strength of lips, tongue, and jaw so that he can drink from a straw and eat without oral spillage. • With minimal cues, Mr. J will self-monitor his rate of drinking and use compensatory strategies to eliminate coughing.

conversational recast expanded

• Incidental teaching- • Milieu teaching • Rare event and conversational recast • Transactional model of communication • Children's productions are responded to using recasts (language models that are somewhat more complex than original) 1.Child initiation, 2. Adult response, 3. Goal that is developmentally appropriate • Interactive context- playing with a toy, reading a story Hybrid Camarata et al 1994- 21 kids with SLI, compared to discrete trial intervention, took less than half the number of recasts compared to imitation, supported use of recast to target grammar • Acquisition of forms • Words, suffixes, phonological forms and syntax • Acquisition of a set of words, use of grammatical morphemes, auxiliaries etc. • Dosage example- 2x week for 30 mins for 6 or more months • Many contexts, by parents, clinician and teachers

attentional alexia

• Incorrect productions of letters due to interference with other letters in the word • River bank "biver bank" bare rare

EFFECTIVENESS OF SPEECH INTERVENTION FOR PHONOLOGICAL DISORDERS: A RANDOMIZED CONTROLLED TRIAL ((Almost & Rosenbaum, 1998)

• Initially, minimal pairs were used to teach the child phonological contrasts • Once the child was easily able to produce the error pattern and contrast it with the correct production the emphasis was then placed upon production of the patterns in a traditional articulation therapy hierarchy, i.e. word, phrase, sentence, and conversational levels • 8-month assessment point the measures for conversational speech intelligibility continued to be significantly different, with group 1 scores higher than those of group 2.

expected assessment results with language delay as part of devt delay

• Intake and Ages and Stages- issues with other areas, motor issues, didn't meet milestones • Oral mech- may have weakness • Leiter- lower nonverbal IQ • May have artic issues depending on cause of delay • Vocab may be a relative strength compared to syntax • Grammar issues • Expressive lower than receptive • Pragmatics relative strength

expected assessment results with high functioning autism

• Intake and ages and stages- issues with pragmatics, behavioral problems • Leiter- possibly lower nonverbal IQ, variable in autism • Play sample and peanut butter protocol- pragmatic deficits, abnormal not just delayed • Grammar issues • Lower quality vocab

A COMPARISON OF THREE THERAPY METHODS FOR CHILDREN WITH DIFFERENT TYPES OF DEVELOPMENTAL PHONOLOGICAL DISORDER (Dodd & Bradford, 2009)

• Intervention that focused on teaching a rule about the contrastive use of phonemes was most successful for a child who consistently made non-developmental errors • Children making inconsistent errors received most benefit from the core vocabulary approach that markedly enhanced consistency of production • findings suggest that different parts of a child's phonological and phonetic system may respond to various types of treatment approaches that target different aspects of speech

ASHA ICF- environment and personal factors

• Is 72 years old • Has comorbid chronic health conditions— diabetes and hypertension • Receives limited family support for compliance with diet modification • Has limited access to rehabilitation services • Was previously independent with the aid of technology • Has sufficient financial resources to pay for personal care

deep dysgraphia

• Large left hemisphere lesions • Similar to phonological dysgraphia • Differentiated by prominent semantic errors

expected assessment results with SLI

• Leiter- IQ in normal range but may be on lower end • Morphology deficits • Low vocab • Possibly delayed pragmatics but not atypical • No other developmental issues, non-language milestones met • Oral mech and hearing normal • No obvious cause of language issues

pure alexia

• Letter by letter reading extremely slow • May have right homonymous hemianopia • Anomic aphasia may be present

velopharyngeal closure

• Levator veli palatine • Superior pharyngeal constrictor • Palatopharyngeus

paraphasias

• Literal/phonemic: shooshbruss/toothbrush; tevilision/television- transposition or extraneous phonemes, at least half word is intact • Verbal/semantic: table for chair, cranberry for teapot- sub entire word, often related but not necessarily • Neologism: chantlast/refrigerator- non-word or transposition or extraneous phonemes with less than half word intact • Perseverative: comb, fork/toothbrush, comb/key- stuck on a word, produce a word that they have heard before (need to distract to reboot system)

traits of prelinguistic

• Little to no functional communication • Lack of symbolic representation • Little to no receptive language understanding • lack building blocks for language • Need 2 communicative acts per minute to progress to words

experimental research

• Manipulation of independent variable and its effect on dependent

A SYSTEMATIC PERSPECTIVE FOR ASSESSMENT AND INTERVENTION: A CASE STUDY (Williams, 2009)

• Mapping the child-to-adult sound systems through phoneme collapses revealed a logical and symmetrical system that maintained systematicity • Based on the organizational principles suggested by the phoneme collapses, targets were identified for intervention using the distance metric approach • based on the function of sounds within a given system rather than the characteristics of a given sound • a multiple oppositions treatment approach intended to facilitate learning across phoneme collapses and lead to system-wide phonological restructuring was described. • By utilizing an assessment framework that views a sound system as dynamic, logical, and symmetrical, we can commence with the task of phonological analysis as a ''detective'' in search of the order within the disorder • a systemic perspective assumes that there is a dynamic interaction between a child's unique phonological profile and the teaching input of the targets selected and the intervention • hypothesized that the greatest system-wide change will result from the integrated intervention of multiple oppositions that provides distributed, focused treatment across a rule set

Treatment approaces specifically for Nonfluent aphasia

• Melodic Intonation Therapy

mild cognitive impairment

• Mild cognitive impairment (MCI): subtle cognitive deficits that may exist up to 9 years prior to a diagnosis of dementia. • Core clinical criteria for MCI: - Concern regarding a change in cognition, impairment in one or more cognitive domains, preservation of independence in functional abilities, and no dementia

treatment strategies for dementia

• Modify environment • Simplify tasks • Establish structure and routine • Concrete tasks via repetition and practice • Task specific training using hands on techniques • Effective cueing and communication

alexia treatment- text level approaches

• Multiple Oral Rereading (MOR; Moyer, 1979)

EBP and cultural competence

• Need to respond to diversity • Different cultures have different beliefs, customs, perspectives re health care • Includes multilingualism • ASHA ( 2011) SLPs need to develop cultural competence to provide appropriate EBP assessments and interventions • Knowledge, understanding and appreciation for linguistic and cultural factors that may influence service delivery

characteristics of pseudoscience

• Not empirically based, but appear to be • Collection of beliefs- nonscientific evidence • Treatment benefits untestable; lack of controlled, repeated experiments • Use of questionable sources • Lack of public sharing • Citing ancient truths • Finding small effects • Making extraordinary claims • Complaining about observation effects • Inappropriate credentials of the proponents • Use of rhetoric and propaganda • Mysterious lexicon

A Need for Improved Training Interventions for the Remediation of Impairments in Social Functioning Following Brain Injury (Driscoll, Dal Monte, & Grafman, 2011)

• One of these approaches (facial affect recognition [FAR]) was intended to enhance the recognition of emotions from facial features (e.g., the eyes or mouth), • the second approach (stories of emotional inference [SEI]) trained participants to infer emotions from a series of short stories. • The authors reported that participants who received the SEI training showed improvement in making emotional inferences, while the FAR training was associated with gains in recognizing facial emotions, in making emotional inferences, and in caregiver ratings of socioemotional behavior.

An Evaluation of the Effects of Two Treatment Approaches for Teachers With Voice Disorders (Roy, et al., 2001)

• Only the group who adhered to the VFE regimen reported a significant reduction in mean VHI scores • when compared to the VH group, the exercise group reported more overall voice improvement (p<.05) and greater ease (p<.02) and clarity (p<.01) in their speaking and singing voice after treatment • These findings suggest that the VFE should be considered as a useful alternative or adjunct to vocal hygiene programs in the treatment of voice problems in teachers

EGG electroglottogram

• Open phase until peak • Decrease-closing • Bottom closed phase • Average air flow 100-200ml or cc/ sec • Min air flow 10-20ml/sec Average flow- Used clinically; increases w/ glottal incompetence, mostly due to min flow Minimum flow- Used clinically; Maximum flow decimation rate- Used more in research; Increase produces richer spectrum

The effects of stretch-and-flow voice therapy on measures of vocal function and handicap (Watts, et al., 2014)

• Outcome variables consisted of two physiologic measures (s/z ratio and maximum phonation time), an acoustic measure (cepstral peak prominence [CPP]), and a measure of vocal handicap (voice handicap index [VHI]) • The s/z ratio, maximum phonation time, sentence CPP, and VHI showed statistically significant (P < 0.05) improvement through therapy. • This study provides supporting evidence for preliminary efficacy of stretch-and-flow voice therapy in a small sample of patients. Treatment effect was moderate to large

(Williams, 2005). Assessment, target selection, and intervention: dynamic interactions within a systemic perspective.

• PEEPS provides two word lists: Basic and expanded • The primary goal of assessment at 2 years old is to provide info about a range of domains (sound domains, word and syllable shapes, stress patterns, types of errors) rather than solely accuracy • PEEPS uses age of acquisition of words from the MacArthur-Bates Communicative Developmental Inventories (CDI) • PEEPS can be used with young children with typically developing vocabulary or late talkers

tongue base retraction

• Palatoglossus • Styloglossus • Hyoglossus • Transversus • Upper pharyngeal constrictor

Enhancing linguistic performance: Parents and teachers as book reading partners for children with language delays (Crain-Thoreson & Dale, 1999)

• Parents and staff showed changes in their shared book reading style consistent with the instruction they had received • children in all three groups spoke more, made longer utterances, produced more different words, and participated more in shared book reading • The magnitude of change in the children's linguistic performance from pre- to posttest was positively correlated with the magnitude of change in adult behavior • no statistically significant changes in children's vocabulary test scores • findings as consistent with a Vygotskian model in which children's linguistic performance can be enhanced by a supportive social context

example long term goals

• Patient will tolerate least restrictive diet without overt signs or symptoms of aspiration. • Patient will safely consume _____ diet with _____ liquids without complications such as aspiration pneumonia. • Patient will be able to complete a meal in fewer than _____ minutes. . Patient's quality of life will be enhanced through eating and drinking small amounts of food and liquid.

example short term goals

• Patient will use head rotation to R/L with/without cues on ___ of ___ trials • Patient will increase laryngeal elevation via SEMG biofeedback on ___ of ___ trials. • Patient will use Mendelsohn maneuver for ___ consistencies with/without cues on ___ of ___ trials. • Patient will demonstrate Valsalva maneuver (breath hold) on ___ of ___ trials. • Patient will achieve lip closure against resistance provided by clinician placing fingers on upper and lower lips on ___ of ___ trials.

EFFECTS OF HEAD ROTATION ON PHARYNGEAL FUNCTION DURING NORMAL SWALLOW (Ohmae, Ogura, Karaho, Kitahara, & Inouye, 1998)

• Pharyngeal manometric study indicated that the pharyngeal peak pressures toward the side of head rotation were significantly increased, whereas the pharyngeal pressures opposite the side of head rotation were not affected. • Head rotation swallow produced a significant fall in upper esophageal sphincter (UES) resting pressure and a delay in UES closing • head rotation swallow in normal subjects not only alters the bolus pathway, but also has a useful effect on both pharyngeal clearance and UES dynamics

Robey 2004 A FIVE-PHASE MODEL FOR CLINICAL-OUTCOME RESEARCH

• Phase I research-The therapeutic effect is the manifestation of altered physiology (through the application of treatment) as beneficial change. and describe the many ways in which benefit can be assessed -- Phase II research is exploring the dimensions of the therapeutic effect and making the necessary preparations for conducting a clinical trial. Phase III research conduct a clinical trial to test efficacy. This step is critical, clinical trials are characterized by large sample sizes and conservative tolerance for Type I error. --Phase IV research is mostly field research. The fundamental task is to assess the degree to which the therapeutic effect is realized in day to day clinical practice Phase V research is to determine who benefits from the treatment protocol and at what cost.

WHAT FACTORS PLACE CHILDREN WITH SPEECH SOUND DISORDERS AT RISK FOR READING PROBLEMS? ((Anthony, et al., 2011)

• weaknesses in representation-related phonological processing may underlie the difficulties in phonological awareness and reading that are demonstrated by children with SSDs.

INTERVENTION FOR CHILDREN WITH SEVERE SPEECH DISORDER: A COMPARISON OF TWO APPROACHES (Crosbie, Holm, & Dodd, 2005)

• Phonological contrast approaches: Reorganize a child's linguistic system. Intervention, aims to develop meaningful contrasts of words. The clinician shows the child that phonemes contrast a difference in meaning (key-tea, shoe-two) and that these contrasts need to be made to avoid misunderstanding. • Core vocabulary: therapy does not target surface error patterns or specific sound features; it targets whole word production. Learning to say a set of high frequency, functional words consistently, targets the underlying deficit in phonological planning. Providing detailed specific information about a limited number of words and drilling the use of that information with continued systematic practise improves the ability to create a phonological plan on-line. • All the children increased their consonant accuracy during intervention. However, core vocabulary therapy resulted in greater change in children with inconsistent speech disorder (increased PCC & Consistency) and phonological contrast therapy resulted in greater change (increased PCC) in children with consistent speech. • The results provide evidence that treatment targeting the speech processing deficit underlying the child's speech disorder will result in generalization. A phonological planning deficit (inconsistent PD) can be targeted effectively using a whole word approach. A cognitive-linguistic deficit (Consistent PD) responds best to a phonological contrast approach

Multiple Oppositions: Theoretical Foundations for an Alternative Contrastive Intervention Approach (Williams, 2000)

• Phonological descriptions identify phoneme collapses, which are viewed as phonologic strategies developed by the child to accommodate a limited sound system relative to the full adult system of the ambient language • Intervention is then directed systemically across the child's entire rule, or collapse, by using larger treatment sets of multiple oppositions rather than by one contrast at a time. • The theoretical perspective of singular contrastive approaches, such as minimal pairs, focuses on the level of the sound for both the description and intervention of phonological disorders. • The linguistic construct of oppositions, whether they involve minimal or maximal distinctions, is the focus of systemic phonologic learning and change. • the larger treatment sets of multiple oppositions are explicitly directed at inducing change across an entire rule rather than by one contrast at a time • This theoretical perspective assumes that the greatest amount of change will occur in the shortest amount of time with the least amount of effort when intervention is focused on disruption of the original phonological pattern • restructuring a child's system is more efficient when the original phonological structure is directly addressed in intervention.

Evidenced based therapy approaches for targeting oral expression

• Phonological/semantic cueing • Task-specific training (phonological/semantic cueing) • PACE • Verb Network Strengthening Treatment • Response Elaboration Training • Constraint-induced aphasia tx • Melodic Intonation Training • Semantic Feature Analysis • Script training

Speech and swallowing rehabilitation in head and neck cancer patients (Logemann, Pauloski, Rademaker, & Colangello, 1997)

• Pilot data support the use of range of motion (ROM) exercises for the jaw, tongue, lips, and larynx in the first 3 months after oral or oropharyngeal ablative surgical procedures • patients who perform ROM exercises on a regular basis exhibit significantly greater improvement in global measures of both speech and swallowing, as compared with patients who do not do these exercises

apraxic dysgraphia

• Poor letter formation that cannot be attributed to poor letter shape knowledge, sensorimotor, extrapyramidal, or cerebellar dysfunction of the writing limb. • Damage to the systems that translate these programs into accurate movement planning • Oral spelling, typing, anagram spelling, and letter imagery are all unaffected. • Errors include spatial distortions, stroke insertions, and deletions • Often unintelligible hand writing. • Alteration in planning and generation of the motor sequences required to write letters

The behavioral voice-lift: Learn how SLPs can help restore the youthful voice of an aging population (Zieglar & Hapner, 2013)

• Preliminary data indicate that the use of PhoRTE for the treatment of presbyphonia demonstrates improved vocal outcomes and improved voice-related quality of life • However, the PhoRTE group demonstrated an increased reduction in vocal effort and increased treatment satisfaction with the process and the outcome of therapy. • Although the PhoRTE voice therapy program aims to decrease the phonatory glottal gap, the vocal folds approximate one another but not past the point of a barely adducted/abducted vocal fold configuration • This configuration maximizes vocal economy by minimizing impact stress and thus, the risk of phonotrauma, while at the same time increasing vocal loudness

alexia assessments

• Psycholinguistic Assessment of Language Processing in Aphasia (PALPA), Reading Comprehension Battery for Aphasia 2nd ed. (RCBA), Gray Oral Reading Test - 4, Gates- MacGinitie Reading Test (GMRT), Woodcock-Johnson III Diagnostic Reading Battery (WJ-III DBR)

Peripheral alexia

• Pure, neglect, attentional, visual • Affects early stages of reading • Difficulty perceiving the written word

Alexia treatment- word level approaches

• Rapid presentation treatment (Rothi & Moss, 1992) • Tactile-kinesthetic treatment (Lott & Friedman, 1999)

ICF case example- environmental and personal factors

• Raúl is 5 years old. • He is in kindergarten, with access to speech services. • Raúl's older sisters attend the same school and act as interpreters for him on the playground. • Raúl has two friends, but others at school tease him about his speech. • Raúl becomes easily upset when others don't understand him. • Raúl speaks Spanish and English at home and school. • Raúl's father and grandfather have a history of speech sound disorder.

Informal assessment of speech

• Recitation • Object/picture naming • Phrase or sentence completion • Phrase or sentence repetition • Produce single sentences-longer utterances

THE IMPACT OF MUSIC THERAPY ON LANGUAGE FUNCTIONING IN DEMENTIA (Brotons & Koger, 2000)

• Results from 20 participants revealed that music therapy significantly improved performance on both speech content and fluency dimensions of the spontaneous speech subscale

Semantic feature analysis treatment for anomia in two fluent aphasia syndromes (Boyle, 2004)

• Results indicated that confrontation naming of treated nouns improved and generalized to untreated nouns for both participants • Both participants demonstrated improvement in some aspects of discourse production associated with the confrontation naming SFA treatment

Differential Learning of Phonological Oppositions (Gierut, 1990)

• Results indicated that treatment of maximal oppositions led to greater improvement in the children's production of treated sounds, more additions of untreated sounds to the posttreatment inventory, and fewer changes in known sounds than treatment of minimal oppositions

Evidence-based clinical voice assessment: A systematic review (Roy, et al., 2013)

• Results provide evidence for selected acoustic, laryngeal imaging-based, auditory-perceptual, functional, and aerodynamic measures to be used as effective components in a clinical voice evaluation

William's distance metric target selection

• Select up to 4 different target sounds from one rule set based on two parameters: - Maximal Distinction: select targets that are maximally different from child's error in terms of PVM - Maximal Classification: select targets from each of the following: (a) different manner classes (b) different places of production (c) different voicing

Functional Outcomes Associated With Expiratory Muscle Strength Training: Narrative Review (Laciuga, Rosenbek, Devenport, & Sapienza, 2014)

• Several studies demonstrated promising outcomes of EMST as a non-task-specific training for airway protection in persons with dysphagia secondary to neuromuscular impairments • Expiratory muscle strength training appeared to improve airway protection in individuals with dysphagia secondary to neuromuscular disorders.

Maternal Responsivity Predicts the Prelinguistic Communication Intervention That Facilitates Generalized Intentional Communication (Yoder & Warren, 1998)

• Showed an increase in generalized intentional communication but it did vary based on caregiver responsivity • In families with mothers who responded to a high percentage of the children's communication acts at the pretreatment period, the children in the PMT group used more frequent intentional communication in post-treatment generalization sessions • PMT facilitates intentional communication in children whose parents are relatively responsive.

Randomized Comparison of Augmented and Nonaugmented Language Interventions for Toddlers With Developmental Delays and Their Parents (Romski, et al., 2010)

• Sixty-eight toddlers with fewer than 10 spoken words • assigned to augmented communication input (AC-I), augmented communication output (AC-O), or spoken communication (SC) interventions • ll children in the AC-O and AC-I intervention groups used augmented and spoken words for the target vocabulary items, whereas children in the SC intervention produced a very small number of spoken words • Vocabulary size was substantially larger for AC-O and AC-I than for SC groups • Clinical implications suggest that augmented communication does not hinder, and actually aids, speech production abilities in young children with developmental delays.

Communication donts when working with people with dementia

• Speak down to a person • Use infantile communication • Overly complex commands or explanations • Having a stern or agitated voice • Speaking too quickly or not allow for information processing • Rushing through activity • Effective communication style one of most effective tools

SMART goals

• Specific - Based on strengths and weaknesses; what sort of supports? • Measurable - When will the goal be met? • Attainable - Can lead to frustration/burnout • Relevant - Does it work toward the patients' end goals? • Timely - Want to see progression

Howe, 2009 THE ICF CONTEXTUAL FACTORS RELATED TO SPEECH-LANGUAGE PATHOLOGY

• Speech-language pathologists need to address contextual factors routinely, in order to provide a holistic approach to intervention for their clients • The ICF conceptualizes functioning and disability as a dynamic interaction between a person's health condition and their Contextual Factors • Reasons to address contextual factors as SLP's: 1. speech-language therapy's goal is to generalization. This will not happen without considering the client's everyday environment. 2. Communication requires a communicative partner. This is an environmental factor. The SLP must address who the partners are and what they require. 3. "The speech-language pathologist is uniquely qualified to analyse the communication requirements of activities, identify potential communication adaptations, and collaborate with involved parties to enhance participation''. 4. The ICF provides the ability to document and be reimbursed for things that happened but weren't reimbursed for in the past. 5. The ICF provides standardized terminology to be used in the discipline, across other disciplines, and throughout other countries. 6. The availability of an Environmental Factor classification system makes it easier to identify the specific barriers that need to be considered and to advocate for positive environmental factors. 7. Systematic consideration of the Personal Factors for each client is important because it demonstrates a client-centredness approach and respect for clients

How should dysphagia care of older adults differ? Establishing optimal practice patterns. (Barczi, Sullivan, & Robbins, 2000)

• Standard outcome measures of pneumonia, malnutrition, and mortality must be blended with other quality of life indices • Advanced directives are essential in caring for elderly patients with dysphagia irrespective of their health acuity or care setting • Ultimately, patient and family preferences should dictate the swallowing and feeding interventions offered

laryngeal excursion

• Superior pharyngeal constrictor • Palatopharyngeus

pharyngeal contraction

• Superior, middle and inferior pharyngeal constrictors • Palatopharyngeus

qualitative research

• Systematic and interpretative to seek answers to questions that stress how social experiences are created and sustained • Ethnography • Narrative • Case study • Focus group

intrinsic muscles- relaxer

• TA (shortens VF)

Intensive voice treatment (LSVT) for patients with Parkinson's disease: a 2 year follow up (Ramig, et al., 2001)

• The LSVT® was significantly more effective than the RET in improving (increasing) SPL and STSD immediately post-treatment and maintaining those improvements at 2 year follow up • The findings provide evidence for the efficacy of the LSVT® as well as the long term maintenance of these effects in the treatment of voice and speech disorders in patients with idiopathic Parkinson's disease.

THE RELATIVE EFFECTIVENESS OF VOCAL HYGIENE TRAINING AND VOCAL FUNCTION EXERCISES IN PREVENTING VOICE DISORDERS IN PRIMARY SCHOOL TEACHERS (Pasa & Oates, 2006)

• The VH and VFE participants reported improved vocal characteristics and voice knowledge after training while the control group showed deterioration on most variables • The VH participants showed greater improvements than the VFE participants

Assessing the Amount of Spontaneous Real-World Spoken Language in Aphasia: Validation of Two Methods (Haddad, et al., 2017)

• The Verbal Activity Log (VAL; Johnson et al., 2014) has participants, aided by caregivers, indicate current amount and quality of real-world spoken language compared with before stroke • The Communicative Effectiveness Index (Lomas et al., 1989), a previously validated measure of functional communication, was used as a comparison measure • These results present preliminary evidence for the reliability and validity of the VAL and spoken language recording for assessment of the amount of real-world spoken language in aphasia

Swallowing function after stroke: Prognosis and prognostic factors at 6 months (Mann, Hankey, & Cameron, 1999)

• The assessment of swallowing function should be both clinical and videofluoroscopic • important predictors of subsequent swallowing abnormalities and complications are videofluoroscopic evidence of delayed oral transit, a delayed or absent swallow reflex, and penetration. • The single independent predictor of failure to return to normal diet was delayed oral transit (detected by videofluoroscopy)

Effects of two lexical retrieval cueing treatments on action naming in aphasia (Wambaugh, Doyle & Martinez, 2002)

• The effects of two cueing treatments, Phonological Cueing Treatment (PCT) and Semantic Cueing Treatment (SCT) • These findings indicate that PCT and SCT may have utility in facilitating action naming for some speakers with aphasia but that the effects of these treatments may vary across grammatical form classes (e.g., nouns versus verbs)

EFFICACY OF VOCAL FUNCTION EXERCISES AS A METHOD OF IMPROVING VOICE PRODUCTION (Stemple, Lee, Amico, & Pickup, 1994)

• The experimental group engaged in vocal function exercises • Objective measures taken after 4 weeks of exercise demonstrated significant changes in phonation volume, flow rate, maximum phonation time, and frequency range for the experimental group

Measurement of hyolaryngeal muscle activation using surface electromyography for comparison of two rehabilitative dysphagia exercises (Watts, 2013)

• The isometric CtC exercise resulted in greater activation of the hyolaryngeal muscles compared with an isometric head-lift exercise. • ll participants performed an isometric jaw-opening exercise against resistance (CtC) and an isometric head-lift exercise (Shaker), both targeting activation in the hyolaryngeal (suprahyoid) muscles

Effects of mendelsohn maneuver on measures of swallowing duration post-stroke (McCullough, Kamarunas, Mann, Schmidley, Robbins, & Crary, 2012)

• The purpose of this pilot study was to determine whether intensive use of the Mendelsohn maneuver in patients post stroke could alter swallow physiology when used as a rehabilitative exercise. • Significant changes occurred for measures of the duration of superior and anterior hyoid movement after 2 weeks of treatment • Improvements were observed for duration of opening of the upper esophageal sphincter (UES), but results were not statistically significant. • Measures of penetration/aspiration, residue, and dysphagia severity improved throughout the study, but no differences were observed between treatment and no-treatment weeks • Intensive use of the Mendselsohn maneuver in isolation altered duration of hyoid movement and UES opening in this exploratory study

Respiratory retraining therapy in long-term treatment of paradoxical vocal fold dysfunction (Nacci et al., 2010)

• The results show that long-term respiratory retraining is particularly efficacious if the cycles of treatment are repeated, no matter what clinical conditions are present. • In fact, when only one cycle of retraining treatment is given a year, there is initial improvement that slowly disappears throughout the year until the next treatment • .Long-term respiratory rehabilitation is effective, especially if the treatment is given at least once every 3 months

LARYNGOPHARYNGEAL REFLUX: POSITION STATEMENT OF THE COMMITTEE ON SPEECH, VOICE, AND SWALLOWING DISORDERS OF THE AMERICAN ACADEMY OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY (Koufman, Aviv, Casiano, & Shaw, 2002)

• The symptoms of LPR are protean; however, the most common are hoarseness, globus pharyngeus, dysphagia, cough, chronic throat clearing, and sore throat • Symptoms are often intermittent or chronic intermittent • The most common manifestation of LPR is re- flux laryngitis with or without granulation or granuloma formation

The treatment of muscle tension dysphonia: A comparison of two treatment techniques by means of an objective multiparameter approach (Van Lierde, De Bodt, Dhaseleer, Wuyts, & Claeys, 2010)

• The vocal quality before and after the two treatment techniques was measured by means of the dysphonia severity index (DSI), which is designed to establish an objective and quantitative correlate of the perceived vocal quality. • The DSI is based on the weighted combination of the following set of voice measurements: maximum phonation time (MPT), highest frequency, lowest intensity, and jitter. • This study showed evidence that MCT is an effective treatment technique for patients with elevated laryngeal position, increased laryngeal muscle tension, and MTD CLM=MCT

Retraining Writing for Functional Purposes: A Review of the Writing Therapy Literature (Thiel, et al., 2015)

• There is substantial evidence on the use of impairment-based therapies (lexical and phonological) for improving the writing of treated sentences and words, and some evidence to support improvement in spelling untreated words • Both impairment-based therapies and assistive technologies (e.g., predictive writing software, voice recognition), when they encourage transfer to functional writing, can improve functional writing activities like letter writing or note-taking

A RANDOMIZED STUDY COMPARING THE SHAKER EXERCISE WITH TRADITIONAL THERAPY: A PRELIMINARY STUDY (Logemann, et al., 2009)

• There was significantly less aspiration post-therapy in patients in the Shaker group • Residue in the various oral and pharyngeal locations did not differ between the groups • With traditional therapy, there were several significant increases from pre- to post-therapy, including superior laryngeal movement and superior hyoid movement on 3-ml pudding swallows and anterior laryngeal movement on 3-ml liquid boluses, indicating significant improvement in swallowing physiology • After both types of therapy there is a significant increase in UES opening width on 3-ml paste swallows

TACTILE THERMAL ORAL STIMULATION INCREASES THE CORTICAL REPRESENTATION OF SWALLOWING (Teismann, et al., 2009)

• Thermal tactile oral stimulation (TTOS) is an established method to treat patients with neurogenic dysphagia especially if caused by sensory deficits • Compared to the normal swallowing task a significantly increased bilateral cortical activation was seen after oropharyngeal stimulation • functional cortical changes elicited by oral sensory stimulation could be demonstrated. • these results reflect short-term cortical plasticity of sensory swallowing areas • Analysis of the chronological changes during swallowing suggests facilitation of both the oral and the pharyngeal phase of deglutition

Submental sEMG and hyoid movement during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training (Wheeler-Hegland, Rosenbek, & Sapienza, 2008)

• This indicates that the hyoid bone was achieving a larger vertical movement with the experimental tasks relative to the normal swallows • Discussion about motor strength building- With the Mendelsohn maneuver and effortful swallow, the load imposed was volitional. That is, the submental muscle activity found to increase on sEMG resulted from the intention of the participant to "squeeze" those muscles, or to "swallow hard." Conversely, the load imposed by EMST results from an externally imposed threshold that must be overcome in order to break the spring-loaded valve and allow air to flow through the device.

The effectiveness of a voice treatment approach for teachers with self-reported voice problems (Gillivan-Murphy, Drinnan, O'Dwyer, Ridha, & Carding, 2006)

• This study suggests that a voice treatment approach of VFEs and VH education improved self-reported voice symptoms and voice care knowledge in a group of teachers

Effect of surface electrical stimulation of suprahyoid muscles on hyolaryngeal movement (Kim & Han, 2009)

• Trajectories of the hyoid and larynx during electrical stimulation were smaller than but similar to those that occurred during liquid swallowing • This study suggests that surface electrical stimulation of suprahyoid muscles causes the elevation and anterior excursion of hyolaryngeal structures, as is observed during normal physiologic swallowing, although the movements involved were smaller

Systematic review of the literature on the treatment of children with late language emergence (Cable & Domsch, 2010)

• Treatment for children with late language emergence improved performance on formal measures of language, mean length of utterance, and target word use as indicated by medium to large effect sizes in these good-quality studies • focused stimulation and modelling of single words can lead to improvements in the language of children with late language emergence.

treatment of dysgraphia

• Treatment of impaired semantics • Lexical spelling treatment • Therapy for graphemic buffer impairment • Therapy for peripheral dysgraphias • CART, ACT- or combo ACRT

Evaluation and management of oropharyngeal dysphagia in different types of dementia: A systematic review (Alagiakrishnan, Bhanji, & Kurian, 2013)

• Use of Percutaneous Endoscopic Gastrostomy (PEG) tubes in advanced dementia, did not show benefit with regards to survival, improvement in QOL, or reduction in aspiration pneumonia

Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient (Lazarus, Logemann, & Gibbons, 1993)

• Use of the Mendelsohn maneuver improved coordination and timing of pharyngeal swallow events, including timing of posterior movement of the tongue base to the pharyngeal wall in relation to airway closure and cricopharyngeal opening, with elimination of aspiration • The Mendelsohn maneuver compensated for anatomic and physiologic changes in the oropharyngeal swallow and enabled reinstatement of safe oral intake in this surgically treated head and neck cancer patient who was previously unable to take nutrition orally.

Chin down posture effects on aspiration in dysphagic patients. (Shanahan, Logemann, Rademeker, Pauloski, & Kahrillas, 1993)

• Use of the chin-down posture during swallowing has been reported to reduce the occurrence of aspiration in some dysphagic patients. This study measured four pharyngeal dimensions in 30 neurologically impaired patients who aspirated before the swallow because of a delay in triggering the pharyngeal swallow • 15 for whom the posture eliminated aspiration and 15 who aspirated despite the chin-down position • Patients who did not benefit from the posture were significantly younger and aspirated material from the pyriform sinus rather than the valleculae when the pharyngeal swallow was triggered • Indicates a need to visualize effect of compensatory strategies such as chin down posture during a visual study (MBS) to see if it is effective for particular patient

USING STANDARDIZED TESTS TO INVENTORY CONSONANT AND VOWEL PRODUCTION: A COMPARISON OF 11 TESTS OF ARTICULATION AND PHONOLOGY. ((Eisenberg & Hitchcock, 2010)

• Use of the data from a single standardized test of articulation or phonology would not be sufficient for completely inventorying a child's consonant and vowel production and selecting targets for therapy • It is recommended that clinicians supplement test data by probing production in additional phonetically controlled words.

Preliminary data on two voice therapy interventions in the treatment of presbyphonia (Ziegler, Verdolini, Johns, Klein, & Hapner, 2014)

• VFE registered slightly greater adherence to home practice recommendations than did PhoRTE, but PhoRTE perceived greater treatment satisfaction than VFE • Findings provide new evidence regarding the efficacy of voice therapy exercises in the treatment of age-related dysphonia and suggest PhoRTE therapy as another treatment method for improved voice-related quality of life and reduced perceived vocal effort in this population.

aerodynamics

• VFs close, lungs compress, molecules build up below folds • VFs open, region of dense molecules rushes past folds • VFs close, region of dense molecules "travels" into vocal tract; region of rarefied molecules is right above folds • Flow-induced oscillation (voice is about regulated/modulated airflow)

Parental Recasts and Production of Copulas and Articles by Children With Specific Language Impairment and Typical Language (Proctor-Williams, Fey, Loeb, 2001)

• We examined target-specific copula and article recast usage by 10 parents of children with SLI and 10 parents of younger language-matched children with TL, and we examined their children's productions of these same forms at three points across an 8-month period. • conclude that children with SLI can benefit substantially from the grammar-facilitating properties of recasts, but only when the recasts are presented at rates that are much greater than those available in typical conversations with young children. • Sentence recasts are adult responses to child utterances that repeat some of the child's words and correct or otherwise modify the morphologic or syntactic form of the child's sentence while maintaining the central meaning of the child's production

Case history questions to ask

• When did swallowing problem begin? • How long has the problem existed? • How is your appetite? • Immediate or gradual onset? • Pain with swallowing (Odynophagia)? • Feeling of a lump or fullness in throat (Globus)? • How long does it take to eat a meal? • Modified diet, change in food types? • Change in voice? • Change is ability to taste food? • Is the person aware there is a problem? • Advanced directives and Code status? • Any changes in medication types or dosage?

End of life

• Withdrawal from life-sustaining activities—eating and drinking is most obvious. • Loss of appetite, physical strain of chewing/swallowing—PO intake can be distressing to the patient • Hunger and Thirst reduced as they move naturally toward coma and death (medications for symptom relief may also contribute) • The gut and digestion begin to slow; presence of undigested material in the gut, and excess fluids can cause additional harm and discomfort. (vomiting, diarrhea, increased pulmonary secretions, peripheral edema, painful urine output->catheterization, cerebral edema)

description of dysgraphia

• also, known as agraphia • It is the partial or total inability to produce written language following neurological damage • Result of language impairment or of praxis and visuospatial dysfunction

A Systematic Review of Resonant Voice Therapy (Yiu, Lo, & Barrett, 2017)

• available data showed that resonant voice therapy has a moderate level of evidence to support its use in clinical practice • Consistently found positive results in perceptual voice quality and efficiency of voice production.

An Evidence-Based Systematic Review on Communication Treatments for Individuals With Right Hemisphere Brain Damage (Blake, Frymark & Venedictov, 2013)

• evidence pertaining to right hemisphere communication treatments is at a very preliminary stage, some positive findings were identified to assist speech-language pathologists who are working with individuals with right hemisphere brain damage • speech-language pathologists should look to the current RHBD literature as well as the literature from other neurological populations and recommendations from professional organizations and experts. • Due to shortage in research specific to RHD, clinicians may need to look at treatments used in other disorders, particularly TBI recommendations for treating cognitive and pragmatic deficits

INTENSITY IN PHONOLOGICAL INTERVENTION: IS THERE A PRESCRIBED AMOUNT? (Williams, 2012)

• findings indicated that greater intensity yields greater treatment outcomes. • quantitative and qualitative changes in intensity occur as intervention progresses, and there were differences in intensity based on severity of the SSD • A minimum dose of more than 50 trials and duration of at least 30 sessions is required for a phonological intervention to be effective. A dose below 50 trials in a 30 minute session and fewer than 30 sessions appears to have limited effectiveness. • For children with a more severe SSD, greater intensity is required to effect change. For these children, the suggested dose is 70 trials per session for ∼ 40 sessions.

semantic dysgraphia

• inability to attribute meaning to written words o Often observed with left hemisphere lesions o Difficulties in spontaneous writing or written naming. Writing under dictation is spared, in the absence of word meaning

Schuells stimulation approach

• intensive, controlled auditory stimulation • should begin where language breaks down and should proceed through gradually increasing levels of difficulty

phonemic factors target selection

• markedness (choose marked sounds) • PPK (choose "least PPK") • distinctive features (choose major class features) • saliency (choose maximally distinct)

Treatment outcomes research

• measures results of various treatments and/or interventions in patient populations • identifying, measuring and evaluating effects of care provided to patients

INTERVENTION FOR EXECUTIVE FUNCTIONS AFTER TRAUMATIC BRAIN INJURY: A SYSTEMATIC REVIEW, META-ANALYSIS AND CLINICAL RECOMMENDATIONS (Kennedy, et al., 2008)

• metacognitive strategy instruction (MSI) and outcomes were evaluated in a meta-analysis These results, along with positive outcomes from the other group, single-subject design and single case studies, provided sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal

extrinsic muscles

• move larynx up and down • Should NOT be involved in phonation unless something is wrong (pathology) • Main structure: Hyoid

Embedding language therapy in dialogic reading to teach morphologic structures to children with language disorders (Maul & Ambler, 2014)

• participants were read to using principles of DR intended to evoke their production of specific bound morphemes • multiple-baselines-across-subjects research design was employed • all three participants improved production of their respective target morphemes, although to varying degrees, and exhibited some generalization to unfamiliar stimuli and in conversation

Clinical observations

• respiratory status - pulmonary functions and pneumonia o tracheostomy tube/ mechanical ventilation/intubation • intubation - no swallowing appropriate until respiratory status changes to trach • tracheostomy tube status o if possible, with medical permission, cuff needs to be in deflated position during assessment • Nutritional Status: o Oral (PO) or Nonoral (NPO-nil por os) o ND tube= Nasal Duodenum Tube o NG = Nasal Gastric Tube o G tube = gastrostomy tube o J-tube=jujenostomy (1st segment of small intestine) o PEG = percutaneous endoscopic gastrostomy-into stomach put into stomach with camera, make a fistula, gastric part of tummy o TPN = Total parenteral nutrition = intravenous Medications Cognitive status

Three treatments for teachers with voice disorders: A randomized clinical trial (Roy, et al., 2003)

• results from a posttreatment questionnaire regarding the perceived benefits of treatment showed that compared to RT and RMT, teachers in the VA group reported significantly more overall voice improvement, greater vocal clarity, and greater ease of speaking and singing voice following treatment • These findings replicate previous results from an earlier clinical trial confirming the efficacy of VA and provide new evidence to support RT as an effective treatment alternative for voice problems in teachers

Implementing the Free Water Protocol Does Not Result in Aspiration Pneumonia in Carefully Selected Patients With Dysphagia: A Systematic Review (Gillman, Winkler, & Taylor, 2016)

• review has found that when the protocol is closely adhered to and patients are carefully selected using strict exclusion criteria, including an evaluation of their cognition and mobility, adult rehabilitation inpatients with dysphagia to thin fluids can be offered the choice of implementing the Free Water Protocol • Was shown to improve QOL

Horner & Minifie, 2011 Research Ethics III: Publication Practices and Authorship, Conflicts of Interest, and Research Misconduct

• scientists are both entrusted and obligated to use the highest standards possible when proposing, performing, reviewing, and reporting research or when educating and mentoring new investigators • All who are involved in the research enterprise—at all levels—should be aware of and adhere to publication guidelines and conflict of interest policies and regulations, and to avoid practices that falsify, fabricate, or plagiarize, or otherwise violate the expectations of the scientific community as articulated by the requirements of academic institutions, professional/scientific societies, or journal publication boards

PVFM causative factors

• shouting or coughing • physical exercise • acid reflux • breathing cold air • irritants such as smoke or pollen • psychosocial issues • neurological issues

phonetic factors target selection

• stimulability (choose non-stimulable sounds) • phonetically complex • developmental norms (choose later developing sounds)

Medical Treatment and Speech Therapy for Spasmodic Dysphonia: A Literature Review (Fabron, Marino, Nobile, Sebastiao, & Onofri, 2013)

• studies that looked at speech therapy speech therapy showed positive results from this treatment when combined with [botulinum toxin] injection

PECS Systematic review (Sulzer-Azaroff, Hoffman, Horton, Bondy & Frost, 2009)

• supports the conclusion that PECS is an especially promising system for enabling nonspeaking individuals to communicate functionally across a wide audience of 'listeners' • Several investigators provided evidence that learning to use PECS was associated with some of their participants increasing their speaking and social approaching esults indicated all 3 in study increased verbal speech, and small gains in social behaviors and decrease in problem behaviors

Early Effects of Responsivity Education/Prelinguistic Milieu Teaching for Children With Developmental Delays and Their Parents (Fey et al., 2006)

• the RE/PMT group exhibited superior gains in communication compared with the no-treatment group. • RE/PMT may be applied clinically with the expectation of medium-size effects on the child's rate of intentional communication acts after 6 months of intervention

Dysphagia in the elderly: Management and nutritional considerations (Sura, Madhavan, Carnaby, & Crary, 2012)

• the best advice for clinicians is to verify the impact of swallow maneuvers is to use swallowing imaging studies before introducing any of them as compensatory strategies. • low acceptability and resulting poor adherence with modified foods/liquids can contribute to increased risk of inadequate nutrition in elderly patients with dysphagia • in general, exercise-based swallowing interventions have been shown to improve functional swallowing, minimize or prevent dysphagia-related morbidities, and improve impaired swallowing physiology

Investigation of the immediate effects of two semi-ocluded vocal tract exercises (Sampaio, Oliveira, & Behlau, 2008)

• the finger kazoo and phonation with straw exercises produced positive and similar reports in the vocal self-assessment, and similar reports in the acoustic analysis, whereas the auditory-perceptive evaluation indicated positive effects only in the phonation with straw.

ACCESS FOR PERSONS WITH NEUROGENIC COMMUNICATION DISORDERS: INFLUENCES OF PERSONAL AND ENVIRONMENTAL FACTORS OF THE ICF (Threats, 2011)

• the following should be studied in terms of their effects as either facilitators or barriers to improved access to persons with aphasia: conversational partners; written materials for persons with aphasia; systems and policy decisions and implementation; products and technology; general public knowledge concerning aphasia; and attitudes of health professionals towards persons with aphasia

children with specific language impairment (Camarata, Nelson, & Camarata, 1994)

• the results indicated that although both kinds of treatments were effective in triggering acquisition of most targets, consistently fewer presentations to first spontaneous use were required in the conversational procedure • In addition, the transition from elicited production to generalized spontaneous production was more rapid under conversation-interactive treatment • although imitation treatment was more effective in generating elicited production, a significantly greater number of spontaneous productions occurred under the conversational training procedures

Systematic review conversational recasting (Cleave, Becker, Curran, Owen Van Horne & Fey, 2015)

• vast majority of studies provided support for the use of recasts • A conversational recast is a response to a child's utterance in which the adult repeats some or all of the child's words and adds new information while maintaining the basic meaning expressed by the child

Discourse Analyses: Characterizing Cognitive-Communication Disorders Following TBI (Le, Mozeiko & Coelho, 2011)

• • Impaired discourse is the hallmark of post-TBI cognitive-communication disorder • impaired discourse abilities contribute to the participation restrictions that underlie the social isolation commonly experienced among individuals living with TBI. • extent of discourse impairments in individuals with TBI influences the diagnostic process, formulation of prognoses, and development of effective interventions for social reintegration suggest that intervention for discourse deficits may be more effective when directed toward the improvement of cognitive abilities rather than discourse alone

A Treatment Sequence for Phonological Alexia/Agraphia (Beeson, Rising, Kim, & Rapcsak, 2010)

• • The first phase of phonological treatment was implemented using a cuing hierarchy to retrain the relations between graphemes and phonemes for 20 consonants and 12 vowels. • Interactive treatment focused on training a problem-solving approach to spelling. Participants were trained to implement the following strategy when spelling difficulties were encountered: o Generate plausible spelling by relying on phonological skills. o Evaluate spelling on the basis of residual orthographic knowledge (lexical check). o Use electronic device sensitive to phonologically plausible renderings (Franklin Language Master) to check and correct spelling errors. Both participants improved phonological processing abilities and reading/spelling via the sublexical route. They also improved spelling of real words and were able to detect and correct most residual errors using an electronic spelling aid.

(Elman & Bernstein-Ellis, 1999) The efficacy of group communication treatment in adults with chronic aphasia

• • The focus of treatment included increasing initiation of conversation and exchanging information using whatever communicative means possible. Results revealed that participants receiving group communication treatment had significantly higher scores on communicative and linguistic measures than participants not receiving treatment. • In addition, significant increases were revealed after 2 months of treatment and after 4 months of treatment.

CART Copy and recall therapy

•dysgraphia re-training of specific orthographic representations for a given set of words • Present picture to participant (for example, 'dog') • Present a handwritten model of the word • Cover up all written examples of the word. Show the picture, and prompt recall of the spelling three times.

ACT Anagram and Copy therapy

•dysgraphia clients are required to write the target word using letters presented in an array which may or may not include distractors (i.e. letters that are not required to spell the target word). • Client is presented with a picture. Clinician provides a spoken prompt to elicit writing (e.g. 'Can you write money'?). • If client can successfully write the target, then clinician should provide reinforcing feedback and move onto the next target • If client is unable to successfully write the target, then the clinic should present the component letters in a random order

Effects of two breath-holding maneuvers on oropharyngeal swallow (Ohmae, Logemann, Kaiser, Hanson, & Kahrillas, 1996)

•supraglottic and super supraglottic swallow Using the maneuvers, subjects produced earlier cricopharyngeal opening, prolonged pharyngeal swallowing, some degree of laryngeal valving before swallowing, and change of the extent of vertical laryngeal position before swallow • The changes are more successful and maintained longer with these 2 maneuvers • The authors concluded that breath-holding maneuvers altered airway conditions before the swallow, and the temporal and biomechanical events during the oropharyngeal swallow

SEMANTIC FEATURE ANALYSIS AS A TREATMENT FOR APHASIC DYSNOMIA: A REPLICATION (Coehlo, McHugh, & Boyle, 2000)

•• SFA was applied to an individual with a moderate fluent aphasia secondary to a closed head injury • Gains in confrontation naming of both trained and untrained stimulus pictures were noted as well as measures of connected speech findings provide additional support that training a relatively small number of exemplars may be sufficient to achieve generalization to untrained stimuli

Age related changes

◦ Infant: structures are high and forward; they just suck, swallow, breathe Older adults (over 65) ◦ Older individuals tend to show "dipper" style ◦ Oral stage is slightly longer ◦ "normal" delay in triggering of pharyngeal swallow ◦ Reduction in laryngeal elevation ◦ Increased frequency and extent of oral and pharyngeal residue ◦ Increased penetration, but not aspiration ◦ Taste and smell are reduced (after 40)