Apraxia- MSD Test 2

feedback

"watch and listen" imitation tasks in which the clinician demonstrates what is to be done OR *explicit instructions* are needed for specific phonetic placement for teaching sound production plus cues for modifying rate and stress

melodic intonation therapy

(MIT) Utilizing the right hemisphere to help with rhythmic use and melody to assist patients with programming. MIT does not target sound accuracy.

motor speech programmer

(MSP) the motor planning/ programming component that involves the interactive, parallel, and sequential participation of all components of the sensorimotor speech system. It transforms abstract phonemes into a neural code that is compatible with operations of the motor system

supplementary motor area

(SMA) involved in the actual initiation and control of speech production; it is also tied to cognitive and emotional processes that drive or motivate action

linguistic

*left* hemisphere MSP functions tied strongly to _______________ attributes of speech (phonological, semantic, grammatic/ syntactic, and prosody) than to its emotional (limbic system in R hemisphere)

etiologies of AOS

- *degenerative diseases* (PPAOS, PPA, PSPS, CBS) - stroke--> embolism - tumor - trauma - anoxia

major clues

- ease of production and normal prosody are major clues for clinicians. Phonologic errors that are fluent, easily produced, and prosodically normal rate probably are aphasia errors. AOS errors are effortful and labored

additional AOS characteristics

- effortful trial and error grouping of articulatory movements and attempts to self correct - articulatory inconsistency on repeated production of the same utterance - dysprosody by extended periods of normal rhythm or stress - difficulties initiating utterances

differentiating apraxia and aphasia

- phonological errors are most common in pt with wernicke's and conduction aphasia - pt with AOS tend to have *articulation* and *prosody* disturbances - wernicke's aphasics should be fluent without pervasive prosodic deficits (normal rate and prosody while speaking) - AOS can occur independently of aphasia - no comprehension, verbal, or AC problems noted in purely AOS - linguistic aspects of writing should be normal - aphasia is multimodality disorder therefore some problems should be present in all modalities - nonverbal oral apraxia is probably more common when AOS is present - AOS is more commonly associated with UUMN - AOS is strongly associated with frontal and insular lesions than temporal or parietal lesions - substitutions in AOS produced in the context of articulatory hesitance, struggles, and grouping - distortions may lead to the perception of non-English phonemes - aphasia phonologic errors not perceived as distorted and no groups or articulatory hesitancy - AOS attempts to self correct and often recognize errors - phonologic errors tend to go unnoticed - AOS approximate the target whereas phonologic errors may not - AOS errors more frequent in the initial position - phonologic errors are more frequent in the final position - there is a strong association between broca's aphasia and AOS - brocas aphasia exhibit syntactic errors, naming, comprehension, reading, and writing - speech deficits in broca's aphasia probably reflect AOS rather than aphasia phonologic deficits - Artic complexity influences error frequency in AOS - artic complexity does not influence aphasia phonologic errors - tx facilitating aphasic language production not effective for AOS - distinguishing paraphasias from AOS is very difficult

practice schedule

- repetitive drill - massed vs. distributed practice - blocked (consistent) vs. random practice

tx goal

- reproduction of stimuli-- acquisition of behavior - reorganization of the person-- maintenance and generalization, retention and transfer

salient characteristics necessary for dx

- slow rate of speech production-- increased interval time - sound errors (distortions, substitutions, intrusive schwa) - prosodic abnormalities-- slow rate

rate and prosody errors

- they could represent fundamental features - they could be a by-production of a fundamental problem with articulation - they could reflect efforts at compensation for a fundamental deficit in articulation - we just don't know the full scope yet

dysarthria and apraxia

29% CNs involved

prevalence

4% of all MSD out of 92 patients. - its highly associated with aphasia, so then the prevalence is much higher 7% - RARELY will you sure pure apraxia

aphasia and apraxia

72% left hemisphere and motor cortex in the frontal lobe

absence

AOS can occur in the ______________ of physiologic disturbances associated with dysarthria and ______________ of any disturbances in any component of language

aphasic

AOS frequently occurs simultaneously with aphasia, all people with suspected AOS should be considered ______________ until comprehensive language assessments proves otherwise

behavioral

AOS is a _________________ syndrome; a collection of errors

left

AOS is distinctive from other MSD bc it almost always results from abnormalities in the ____________ hemisphere

articulation and prosody

AOS is predominantly an ________________ and ________________ impairment, treatment typically focused on these two speech components

coexists

AOS often ______________ with dysarthria and/ or aphasia, but can be identified as its own unique disorder

Focus and duration of apraxia treatment

AOS treatment should focus on tasks that provide the greatest benefit most rapidly or that provide the best foundation for lasting gains

self learning

As early as possible pt should be urged to monitor their speech, search for correct targets, and self-correct errors ______ _____________ is possible for pt if their impairment is not severe and what they learn on their own might not be improved upon by clinician instruction

broca's area

Controls language expression - an area of the frontal lobe, usually in the left hemisphere, that directs the muscle movements involved in speech. Directs the articulatory code for speech movements based on connections to the SMA in the motor cortex

primary progressive AOS

PPASO- when AOS is the prominent manifestation of neurodegenerative disease they get this dx.

stimulus items for AOS

SIMPLE TO COMPLEX - meaningful words are easier than nonsense words - high frequency words are easier than low-frequency words - increased speech rates tends to increase sound error frequency - high frequency syllables are easier than low-frequency syllables - syllables with fewer phonemes are easier than syllables with more phonemes - stressed words are easier than production of unstressed syllables - automatic speech is easier than volitional speech - bilabial and lingual places of articulation are easier than other places of articulation - consonant singletons are easier than clusters - combined visual and auditory stimulation often leads to more accurate responses than auditory or visual alone

General treatment strategies for AOS

Treatment strategies: - intensive and systematic *drill* - drill assists in relearning skilled speech movements - careful selection and ordering of stimuli is necessary to ensure a high level of success - combined visual and auditory stimulation (listen and watch me) lead to more accurate responses

without

Unlike dysarthria, AOS can exist __________ clinically apparent impairments in the speech muscles for non-speech tasks

articulatory kinematic approaches

Works primarily to improve the spatial and temporal aspects of movement in order to improve articulatory accuracy of speech sounds and sequences of sounds

apraxia

___________ is just articulation and prosody problems. Dysarthria affects most speech systems

disruption

____________ of the motor planning or programming causes sound selection and ordering assumed to be intact. Neuromuscular system (brain) for realizing articulatory commands assumed to be intact

nonverbal oral apraxia

a disorder of nonverbal movement involving the oral muscles. The tongue won't stick out when you ask them, lips don't come together, you'll see movement during OM exam but not accurate movements

how much to practice

a high number of trials is associated with acquisition and retention. Too many trials in a blocked condition can actually slow both acquisition and retention. Pt with AOS generally like to practice. Outside practice is beneficial if someone helps them

clinical features of AOS

a message has been correctly formulated but its physical expression was inefficiently or improperly planned or programmed, although this is not due to motor abnormalities of the speech muscles

motivation

a need or desire that energizes and directs behavior. - What is the goal and does the pt know what, when, why, and how many times? - specific instructions - modeling: side by side in a mirror - understanding the practice setting and the "who" is giving instructions

Apraxia

a neurologic speech disorder that reflects an impaired capacity to *plan* or *program* sensorimotor commands necessary for directing movements that result in phonetically (*articulation*) and *prosodically* normal speech

motor learning

a set of processes associated with practice or experience leading to relatively permanent gains in the capability for skilled performance - must have motivation, focused attention, and pre-practice

limb apraxia

ability to move limbs, but not for some or many skilled movements. Might see hemiparesis, hyperreactive stretch reflexes

blocked

all trials of a task are bunched together in a session. Very fast acquisition, may increase perseveration, may endanger retention

consistent practice

also known as blocked practice is using repeated trials of multiple repetitions of sounds, words, phrases, nonsense syllables, or nonspeech oromotor movements in tx this is often necessary in early stages of treatment for severe AOS

script therapy

an apraxia approach where patients learn the scripts and practice the script using individualized sentences. The entire script is rehearsed through turn-taking with the SLP

motor learning guided treatment

an apraxia treatment that shares features with the articulatory- kinematic approach build on motor learning principles. Practice of randomly organized relevant meaningful words and phrases in varying contexts. Clinician provides delayed feedback after every 3rd production. The organization of this therapy is intended to increase/ improve self awareness of errors and promote the development of strategies to decrease these errors

Apraxia and phonemic paraphasias

aphasia (the programming and motor ARE intact) - if a person with aphasia has no distortions, no slowed speech, no abnormal prosody, what you are seeing/ hearing "should be" paraphasias - a pt "should not" and "can not" have BOTH apraxia and phonemic paraphasias - there is no checklist to distinguish between the two -- clinical judgement

always

apraxia ________ occurs with a left hemisphere cerebral lesion

weakended

apraxia is NOT a disturbance that is attributed to some kind of _________ or misdirected action of specific muscle groups (dysarthria and coarticualtion)

loss

apraxia is NOT the ________ of phonological rules or impairment of the native language (this is not aphasia aka paraphasias)

Sound Production Treatment

apraxia treatment that focuses on improving spatial targeting (where is my tongue in space) and timing of articulation (planning and programming) at the segmental and syllable level. Utilizing repetition, integral stimulation, modeling, orthographic cueing, phonetic placement cues, and feedback. 10-15 sessions per target. Use acquisition of trained sounds, maintenance of trained sounds, response generalization, and stimulus generalization.

rate reduction strategies

apraxia treatment that utilizes simple instructions to reduce rate. Syllable to syllable approach to production. Increase pause time and prolong speech. Use rate to increase speech production

prosthetics

artificial devices that modify vocal tract events during speech (ex palatal life) or modify the acoustic signal after it is produced (voice amplifier) are rarely appropriate for AOS BC AOS is *NOT* characterized by deviations in resonance or loudness

Differential DX

ask these questions to figure out - is the apraxia a separate entity? - is the aphasia involved? - is the apraxia a type of phonetic/phonemic paraphasia? - is there disrupted articulation? - is the apraxia treatable? - Is AOS synonymous with Broca's aphasia? NO - are all sound level errors by aphasic pt manifestations of AOS? NO - are there different subtypes of AOS? we don't know

pre therapy

be diligent about _______________ data, data collection and post-therapy data. Focus on tasks that provide the greatest functional benefit most rapidly or that provide the best foundation for improvement over the course of tx

aphasia

behavioral therapy approaches (comm-oriented or speaker-oriented) are used to target AOS but the disorder is often accompanied by _____________ which can impact how much they truly understand and express in addition to the speech difficulties

knowledge of performance

can be a verbal or kinematic feedback where we tell them exactly where their tongue is while they are moving articulators. Kinematic only critical if they have no other access to the right movements

reinforcing and encouraging

clinician-provided feedback can be __________ and ______________ especially important for non-speech tasks, in noncategorical speech tasks (emphasizing stress or rate) or when intelligibility is the immediate target

imitation

copying the behavior of another person - volitional responses to clearly established targets with carefully selected parameters - this facilitates obtaining the max number of responses by reducing cognitive and linguistic efforts (watch and listen) - this provides a "map" for programming the correct response - this is efficient because it *simplifies* DRILL

repetitive drill

drilling pt with AOS with many repetitions within a practice setting for motor learning to take place AND for it to become habitual these steps will make speech more automatic with less processing and less planning. Can use gaming theory to motivate and push them

apraxia treatment

focuses on reestablishing plans or programs OR improving the ability to select or activate them, or set the parameters (duration, force) for speech movements in a given context, which will then be executed

apraxia treatment

focuses on restoring or compensating for impaired functions and adjusting to the loss of normal speech

behavior management of apraxia

focusing on either speaker-oriented therapy or communication oriented therapy the overall goal is to improve intelligibility, efficiency, and naturalness of communication

primary goal

for managing apraxia is to maximize the effectiveness, efficiency, and naturalness of communication (reestablish the programs or ability to program speech movements). As well as restoring or compensating for impaired functions as well as the adjustment to the loss of normal speech/ modify the need for normal speech

knowledge of results

how did that feel? How well the pt did. *external feedback on total performance after completing a movement* this is what most clinicians are used to-- giving feedback after ever each word. If pt can comprehend and process well this is great.

communication oriented treatment

improving communication in the absence of speech target

speaker oriented treatment

improving speech itself by improving intelligibility, efficiency, and naturalness

distract

in between responses, have the PT count or copy a letter or make a gesture or answer an unrelated questions to ___________ them and see if they can do the stimulus this makes more enduring response once acquired

full evaluation

in order to tx apraxia we must know their *language abilities* - must establish precisely the amount of co-existing language and cognitive impairment

construction apraxia

inability to draw, construct, or copy geometric figures.

dressing apraxia

inability to plan and perform the motor acts necessary to dress oneself. OTs will build dressing songs with rhythm and music

competition

introduce _________ into drill as early as possible because it motivates the patient to work hard

distributed practice

involves the same duration of practice across more sessions. This takes longer, but achieves better motor learning and generalize it better

difficult

it is very ____________ to differentiate between apraxia and aphasia bc: - there are no significant differences between the 2 disorders in their neurophysiological, anatomic, and/or vascular characteristics - aphasia frequently occurs in the absence of AOS; AOS is a common co-occurrence with aphasia - aphasia pt make sound errors (distortions are most common) that can be linguistic (phonologic paraphasias) and apraxia pt errors can be planning/ programming

severe apraxia

limited repertoire of speech sounds - speech may be limited to a few meaningful utterances - imitation of isolated sounds may be in error - speech sound errors may be limited in variety and highly predictable - automatic speech may not be better than volitional speech - articulatory errors on imitation tasks may approximate target usually if they have severe apraxia they usually have severe aphasia too

slow

more severe AOS pt who have lost their "pre-programmed" ability to speak NEED to __________ their rate so their articulation can become more accurate and precise. But need to increase it again once "pre-programmed" words, phrases, and sentences can be used

training

more severe or less skilled patients may need self-feedback __________ training to improve error recognition, although a relationship between errors recognition and speech production accuracy has not been clearly established

random

multiple tasks introduced in random order. Stimuli vary- plosives, fricatives, nasals. Stimulus mode varies: imitation, question/ answer, oral reading. Rate of response varies. Length of response varies. this prevent pt from developing a single set. Requires greater attention. Focuses retrieval of different responses each time. Increases active processing. More closely resembles natural communication.

Key to tx

need: - the right method - the right stimuli - the right structure - the right amount of practice - the right type and schedule of feedback --> we have to figure out what they need. It can interfere with their attention if we give them too much feedback after every word

articulatory characteristics

new information has led us to believe that there are vowel errors in ppl with AOS. The *rate* and *prosody* characteristics are probably more important than the articulatory errors in *distinguishing* AOS from phonemic paraphasias

management approaches

no medical, not pharmacological, maybe some electrolarynx, maybe AAC. There are no specific tx

non-speech characteristics of apraxia

non-verbal oral apraxia (NVOA), limb apraxia, dressing apraxia, construction apraxia

fatigue

people with apraxia say that they often have extreme ____________.

apraxia

persons with __________ - most articulatory errors are distortions, substitutions, repetitions, and prolongations - may have islands of error free speech - errors may vary across repetitions of identical utterances

dysarthria

persons with _____________ - rarely groupe for correct articulatory placement - rarely try and attempt to self correct their errors - their errors are mostly distortions - there is no difference in automatic and propositional speech - consistency is the key to determining this kind of speech

function of MSP

plays a role in establishing the plans and programs for achieving the cognitive and linguistic goals of spoken messages. It has a specification of the details of articulatory movements before they are executed. - the code MUST abide by language rules - it mostly "pre-programs"

nonverbal oral mech exam

probably won't see reflex problems, UUMN dysarthria could be present, bc of corticobulbar damage they may exhibit some central facial weakness and slight tongue weakness. SMRs worse than AMRs, articulation and prosody worse than other speech systems

8 step continuum

program for effectively improving word, phrase, or sentence production and regaining use of volitional speech patterns in pt with severe AOS. Can bypass the steps you don't need. Now we only use 5 steps

Prompts

prompts for restructuring oral muscular phonetic targets using tactile cues- touch pressure, kinesthetic, proprioceptive provides cues for spatial and temporal aspects of speech production. Highly structured finger placement on the patient's face and neck to signal articulatory target positions. Need extensive *training and practice* to administer this

Kent intelligibility test

pure articulation test that is not published. Doesn't test phrases or sentences. Just looks for what sounds are intact or disordered. *It only gives an inventory of sounds*

rate control strategies

the use of techniques to reduce rate, impose timing or rhythm. What rate control strategies are available. Don't always have to slow them down, using a metronome to pace to speed them up and make them flow better

NOT

returning to normal is _________ the goal

speech accuracy trade off

severely impaired patients may need to be silent before responding in order first to have their response "in mind"/ planned *oppositely* some pt do better when speaking rapidly, without making conscious efforts to "think"/plan about how they are producing speech and using pre-programmed words

functional

therapy must always be __________ they won't be able to lay it down neuroplasticity wise

aphasia

similar to ____________ research working on less stimulable (more difficult) targets may promote better generalization even if the initial acquisition is more difficult

planning

speech requires ____________ the pt has to know what they want to say, (what is the plan and the programming for what they want to say)

ordering stimuli

success during treatment of AOS is highly dependent on selection and ordering of treatment stimuli

no

there are ______ medical interventions now for AOS

abstract phonemes

syllables, words, or phrases that get transformed into a neural code that is compatible with the operations of the motor system

8 step focuses on

task continua to ensure high levels of success, intensive and extensive drill, meaningful communication as soon as possible, and self-correction. *Integral stimulation* ("Watch, listen and say it with me") but no evidence to support this

other apraxia treatments

techniques used at the volitional sound, syllable, and word level - key word technique: familiar words - cueing strategies: phonetic placement together - phonetic contrasts - contrastive stress drills-- with or without accompanying gestural cues

acquiring speech

the *faster* a response; the less likely it will be retained the *slower* the aquisiting, the better the retention the more complex the stimulus-- the better retention

left

the MSP relies heavily on the ________ hemisphere's specialized capacity to prepare for speaking and drive the acquisition and execution of learned motor speech programs

AOS problem

the _____ _____________ is with the translation of correctly selected sounds to previously learned articulatory-kinematic parameters (where do I want my articulators to move?)

OM

the ________ exam clarifies dysarthric symptoms secondary to neuromuscular variations

hallmark

the ___________ of AOS tx is planning a response. Thinking=planning

script acquisition

the client's productions continue to contain minor errors during maintenance phase. Self monitoring was much improved. The client has difficulty initiating the lines of the script but once initiated, the script was fluently do it. The client's prosody continues to have limited inflection

apraxia and ataxic dysarthria

the most difficult type of dysarthria to differentiate from apraxia

non speech

the purpose of ____-__________ tasks is not to increase strength or other parameters of physiologic support for speech, but rather to improve the planning and programming of volitional oral movements

lack of data

there are few studies that demonstrate "pure" tx efficacy, efficiency, or generalization

NOT dx apraxia

these characteristics can NOT be used to diagnosis apraxia - anticipatory errors - transposition errors - non-speech oral apraxia

reinforcement

this is praise or feedback, but should not take up too much time OR make noise during speech. Don't interrupt them in the middle of practice. Choose functional activities that provide, facilitiatie, invite and repeat opportunities for the production of target behavior

mirror

this is useful to help patients develop a strong visual image of correct movements of targets

behavioral treatment

this type of treatment focuses on articulation and prosody, not on respiration or phonation - must collect baseline data to measure intelligibility changes - establish *presence* and *degree* of associated deficits - obtain an inventory of the patient's communication needs and goals

apraxia treatment

treatment focuses on 1) reestablishing plans and programs 2) improving the ability to select or activate them or set parameters (duration, force) for speech movements in a given context which will then be executed by an "intact" motor execution apparatus

apraxia treatment

treatment principles include: - obtaining an inventory of *nature* of articulatory errors - obtaining an inventory of *accurate* articulatory responses that can be acquired - get information on factors *influencing* articulatory accuracy and adequacy

variable practice

treatment type in which random stimuli are used in practice in which multiple sounds are targeted or the patient is required to program more elements in responses with syllable-to-syllable or response-to-response variability

retention and transfer

two primary goals of AOS therapy and these are improved when feedback is not constant feedback is more effective if provided 3-4 seconds after a response

massed practice

tx that involves fewer but longer sessions. This promotes quick development of skills, but poor generalization. Not retaining the information outside of tx

independently

unlike aphasia, in which there are nearly always multimodality impairments of language, AOS can exist _________________ of problems with verbal comprehension, reading comp., writing, and of spoken errors unrelated to articulation and prosody

think

use the word "__________" before they initiate. Make them pause, they have far more control over the plan, than the programming if they don't have aphasia or cognition

automatic

we cannot let a person with AOS use _______________ speech. This is because we need them to plan, not just spit out pre-planned speech. It has to be their original planning and programming

lesion sites for AOS

we don't know - Primary: Insula - left inferior frontal gyrus - left posterior inferior frontal gyrus - supplementary motor area (SMA) - parietal lobe (where our body "tongue" is in space)

execution

when overt (planned) speech is the goal, once the phonological representation of a message has been assembled, the MSP must be engaged to organize and activate the plan for _____________ which exports the abstract phonemes

tx complete

when the pt has failure to generalize across stimuli. Failure to generalize across environment. A red flag in all areas- language, physical, and AOS.

patient complaints

±"I know what I want to say, I just can't get it out" ±"I'm not as fluent as I used to be" ±"I mispronounce a lot of words" ±"I have to speak quite slow to be able to say things" ±Slow, effortful, careful, stressful, stutter

Motor speech programmer network

±Left cerebral hemisphere ±Posterior Parietal Cortex ±Primary motor cortex ±Broca's area ±Supplementary motor area (anterior to motor cortex) ±Basal Ganglia ±Control circuitry: cerebellum ±Limbic system ±Insula part of the limbic system