Sound Production Treatments - Case Study Example

Therapy methods Apraxia of speech (AOS) can be considered as an impairment of linguistic phonological processing, motor control or both (Ballardi, Granier, Robin, 2000). Various modalities of treatment have been tried. One strategy focuses on the articulatory kinematic aspects of sound production to produce specific sounds with the use of techniques like articulatory placement cues, phonetic derivation, and practice of phonemic contrasts (Wambaugh et al., 1998). Another technique uses the manipulation of temporal or prosodic variables via metronomic pacing, vibro-tactile stimulation, contrastive stress drill, prompts for restructuring oral muscular phonetic targets (PROMPT), and melodic intonation therapy (Wambaugh et al., 1998). Word prompt programs are computer software programs used in addition to basic word processing (Wood, Rankin, Beukelman, 1997). Sound production treatments have also been tried (Wambaugh et al., 1999). The Kaufman Speech Praxis Treatment Kit has been used for treating children with apraxia of speech (Kaufman Children’s center, n.d). Wambaugh & Doyle, 1994, made a review of 28 treatment reports over the past 20 years. Positive results were noted with the following treatments: flexible treatment hierarchy combined with home programs; combination of sound placement, sound drill and graphic stimulation; metronome pacing accompanying drill of all behaviors; package modeling, integral stimulation, phonetic placement, multiple repetitions; PROMPT system and integral stimulation; and PROMPT motokinesthetic stimulation with some rate control. The majority of subjects were chronic apraxic speakers, with 62% being 6 months post onset. Currently, although most treatments have reported good results, most current AOS treatments have limited data to support their use, and there is a lack of replication of treatment findings (Wambaugh, 2002). Another limitation is the lack of measurement of generalization and maintenance effects of treatment (Wambaugh et al., 1998). PROMPT for AoS Chumpelik is credited for developing the PROMPT (Prompts for Restructuring Oral and Muscular Phonetic Targets) system in 1984. This is a tactile–kinesthetic based treatment method, originally developed for the treatment of children with developmental motor speech disorders; later, it was modified for use in adults with motor speech disorders (Bose et al., 2001) Prompts are applied to the mylohyoid muscle, facial musculature and through mandibular manipulation. Some or all of the following parameters receive input from PROMPTs: spatial targeting for place and sometimes manner of production, degree of mandibular excursion, protrusion or retraction of facial muscles, the number of speech muscles required to contract and relative segment and syllable durations (Square-Storer& Hayden, 2000). PROMPTs are used to cue or prompt speech segments at the level of a phoneme, word, or phrase. It may also be used only to facilitate certain parameters of movement like jaw opening, or the temporal flow of multi-syllabic utterances (Bose et al., 2001) In a PROMPT treatment session, the clinician first engages the patient in a sitting position. To obtain head control, the clinician may stabilize the patient’s head using one hand behind the head and using the other hand to control and provide cues; the patient is then instructed to allow the clinician to program in the target phoneme, word or phrase (Square-Storer & Hayden, 2000). Integral stimulation (‘listen to me,’ ‘watch me, ‘do what I do’) is also used for multimodality input (Strand, 2006) Four places of contact are prompted; these traverse the mylohyoid muscle from just behind the mandible, to just above and behind the larynx. By manipulating these placements digitally, the tongue may be prompted to articulate with the palate at the most anterior lingua-alveolar position to the most posterior linguavelar position. The place of contact is also signaled on the facial muscles. It is also important to obtain a proper balance of tongue-jaw action, which is phased with the coordinated facial muscle contraction. Recent theories of initiation and control of movement specifies 3 processes in the rationale of PROMPT: planning, programming, and execution. Motor plan involves devising an action strategy, specification of ‘where’, ‘when’ and ‘how to act’ and putting ‘together the package of motor actions’ (Square-Storer & Hayden, 2000). Programming involves assembling simple single sequences, which specifies the agonists, antagonists, synergists and postural fixators activities. Motor execution involves starting the sequence of movements, running necessary programs, controlling the course of movement, and stopping the action (Square-Storer & Hayden, 2000.) PROMPT: Critical review of the evidence Three studies (Freed, Marshall, & Frazier, 1997; Square, Chumpelik, Adams, 1985; Square, Chumpelik, Morningstar, Adams, 1986), which evaluated the treatment efficacy of the PROMPT system in adults with chronic apraxia and aphasia, have shown encouraging results. Freed, Marshall, Frazier, 1997, examined the acquisition and long-term maintenance of a functional core vocabulary by a 24-year old, severely apractic-apahasic male, who suffered a left-hemisphere CVA. Before treatment he could only verbally produce 5 words (‘yes’, ‘no’, ‘hi’, ‘thanks’, and ‘hey’). He was also able to repeat single-syllable words that had visible initial phonemes (like/b/, /p/, /m/ etc) on 15% of attempts. A core vocabulary of 30 functional words and phrases were taught via PROMPT treatment. The treatment sessions consisted of verbal presentation of a target word from a treatment set, and an attempt by the patient to repeat it. If correct, the next trial on that word was presented. If incorrect, the PROMPT cues that focused on the errors, were presented by the clinician. Approximately 20 trials for each of the 5 target words were completed in each session. The maintenance of any treatment gains were monitored over 41-weeks. The results indicated that the 30 target words and phrases were produced accurately during the treatment phases and even after treatment was discontinued. Square, Chumpelik, Adams, 1985, used PROMPT therapy on one adult patient with severe chronic apraxia of speech and moderate Broca’s aphasia. Multiple baseline data over 21 treatment sessions were obtained for the production of 8 phrases and 13 pairs of minimally-contrasting words. For the first 3 days, all the stimuli were probed 30 times each using repetition. In addition, during each subsequent session, except for the PROMPT–trained phrases, all the rest were probed 30 times each using repetition plus integral stimulation. The results indicated that a 90-100% accuracy of segment productions was achieved by the patient for all segments within a phrase within approximately 4 training sessions. However, the accuracy of production of phrases, which were elicited using integral stimulation was 0%. Similar results were obtained for PROMPT trained and untrained, but integrally-stimulated, minimally-contrastive word pairs. This study showed the efficacy of PROMPT for teaching both motor plans as well as motor programs in patients with a combination of apraxia of speech with aphasia. Square, Chumpelik, Morningstar, & Adams, 1986, used the PROMPT system on 3 patients. The treatment involved production of 24 pairs of minimally contrastive phonemes given 3 times (total of 9 productions for each pair and 222 total productions), 10 bisyllabic words given 10 times each (total 90 productions of each word) and 9 functional phrases (total of 90- productions of each phrase). For each patient, 4 pairs of minimally contrasting phonemes were selected. For 2 subjects, 4 polysyllabic words were randomly selected. For the third subject, 6 polysyllabic words were selected. For 2 subjects, functional phrases were trained. For the other one subject, one phrase was trained and a second was not. The results indicated that PROMPT therapy was highly efficacious in all 3 subjects. Some minimal, yet variable improvement was demonstrated for several words in untrained phrases. Bose et al., 2001 aimed to determine whether PROMPT therapy is effective for improving the speech motor control abilities in individuals with aphasia, and whether the acquisition of movement precision is affected by sentence structure. The subject was a female speaker with Broca’s aphasia and AOS. She could formulate the sentence types used as stimuli (imperatives, active declaratives, and interrogatives), but did not have the motor facility to support these productions. Three linguistically different forms of sentences including imperatives, active declaratives and interrogatives were examined for treatment effects and generalization. The results indicated that in case of relatively simple sentence structures like imperatives and active declaratives, PROMPT therapy was able to improve the precision and automaticity. A positive but more variable effect was observed for generalization items. However, there was no appreciable change or improvement for the interrogatives even after the treatment phase. This study, therefore, demonstrated that in this subject, the ability of motor speech acquisition was compromised by linguistic task of higher complexity, which indicates the interactive nature of the linguistic and motor processes. This study also supports the fact that the nature of expressive deficits associated with Broca’s aphasia is both linguistic and motoric. A critical review of the above studies shows some methodological flaws. The study by Freed et al. (1997) used PROMPT treatment but did not follow the PROMPT motor speech treatment hierarchy. The treatment also extended over a number of sessions for motorically heterogeneous words and phrases. Some patients might also negatively react to the frequent manipulation of their articulators by the clinician, or may not have the patience for the repetition of the target words. Less intrusive cues might be more beneficial. Square, Chumpelik, & Adams, 1985, used 2 simultaneous treatments, which could have altered the results. An alternating treatment design should have been used, since the integral stimulation probably facilitated the results that were obtained. Square, Chumpelik, Morningstar, & Adams, 1986, used a limited number of phoneme contrasts, target words, and phrases. Bose et al, 2001, demonstrated that the ability of motor speech acquisition was compromised by higher linguistic task complexity, indicating the interactive nature of the linguistic and motor processes. However, the findings of this study have to be viewed in the context of the subject’s reaction. She was extremely motivated, willing, welcomed the PROMPT cues, and showed no aversion reactions to the PROMPT cues. It is not known if the findings can be reproduced in subjects who are less motivated or have difficulty tolerating the PROMPT cues. Therefore, the findings cannot be generalized. From the various studies, it is clear that PROMPT therapy works but the studies do have some methodological flaws and the results cannot be generalized. Further research in a large number of subjects is required. Traditionally, speech treatment for apraxia is frequently administered separately from that for aphasia, rather than being integrated simultaneously to facilitate both the motoric and the linguistic components of verbal expression. Therefore, therapies that focus only on improving linguistic formulation to enhance verbal expression (e.g., The Helm-Estabrooks Language Program for Syntax Stimulation- HELPSS) may not be enough for the patient to improve verbal production abilities (Fink et al, 1995). A simultaneous motor treatment or support to the motor speech system integrated with strategies of language formulation may be optimally beneficial in the production of verbal expression (Bose et al, 2001). Bose et al., 2001 have shown that PROMPT therapy was most effective and beneficial when the linguistic formulation demands on the individual are reduced to the level of the individual’s verbal production abilities. The exact neurophysiologic mechanisms of PROMPT is not elucidated but it is believed that the somatosensory information from muscles, joints, and skin act directly on the intermediate cerebellum and motor cortex and also programs motor events via input to the association cortex. For the PROMPT system to succeed, the patient must have breath support, phonation ability for an open vowel, ability to cooperate, and minimal/basic comprehension skills; the PROMPT system cannot elicit speech where there is an extremely severe impairment in neuroinnervation (dysarthria) (Square-Storer, & Hayden, 2000). It can be said that by providing tactile and kinesthetic (closed-loop) feedback, the PROMPT system controls the articulators, while at the same time guiding the structures toward sequential feed-forward (open-loop) programming (Hayden, n.d). Ultimately, this reduces inappropriate feedback and corrects the sequence of movements for proper articulation (Hayden, n.d). In an ideal world where there is no lack of money and there is access to many patients, I would try to investigate the application of alternating treatment designs using repetition, rhythmic timing, phonetic placement and PROMPTS. This would help to determine the specific reason for the efficacy of PROMPT therapy. I would also consider the use of environmental probes to determine whether the phrases acquired in PROMPT are generalized and used optimally by all patients. By methodically varying either the dependent or independent variables, I would be able to allow individualization of the treatment program. I would also consider a careful measurement of generalization and maintenance effects of treatment References Bose, A, Square, P.A, Schlosser, R, van Lieshout, P. “Effects of PROMPT therapy on speech motor function in a person with aphasia and apraxia of speech.” Aphasiology. 15 (8) (2001): 767–785. Ballardi, K.J, Granier, J.P, Robin, D.A. “Understanding the nature of apraxia of speech: Theory, analysis, and treatment.” Aphasiology. 14 (8) (2000): 969-995. Freed, D.B, Marshall, R.C, Frazier, K.E . “Long term effectiveness of PROMPT treatment in severely apractic-aphasic speaker.” Aphasiology, 11(1997): 365–372. Fink, R.B, Schwartz, M.F, Rochon, E, Myers, J.L, Socolof, G.S. “Syntax Stimulation Revisited.” American Journal of Speech-Language Pathology, 4 (1995): 99-104. Hayden. “Childhood Motor Speech Disorders and the PROMPT System.” April 10, 2007< https://www.kintera.org/site/apps/nl/content2.asp?c=chKMI0PIIsE&b=701773&ct=464155> Kaufman Children’s center. “Kaufman Speech Praxis Materials.” April 10, 2007 Square, PA, Chumpelik, D, Adams, S. “Efficacy of the PROMPT system of therapy for the treatment of acquired apraxia of speech.” In R. Brookshire (Ed.), Clinical Aphasiology Conference Proceedings (1985):319–320. Square, P.A, Chumpelik, D, Morningstar, D, Adams, S. “Efficacy of the PROMPT system of therapy for the treatment of acquired apraxia of speech: A follow up investigation.” In R. Brookshire (Ed.), Clinical Aphasiology Conference Proceedings (1986):221–226. Square-Storer, P & Hayden, D. “PROMPT treatment.” Brain Damage, Behaviour and Cognition-Developments in Clinical Neuropsychology. Ed. Square-Storer, P. Lawrence Erlbaum Associates, Publishers, 2000. 191-193. Strand, E. “Integral Stimulation Method.” April 15, 2007 Wambaugh, J.L, Kalinyak-Fliszar, M.M, West, J.E, Doyle, P.J. “Effects of Treatment for Sound Errors in Apraxia of Speech and Aphasia.” JSLHR, 41(1998): 725–743. Wambaugh, J.L, Doyle, P.J. “Treatment for acquired Apraxia of speech: A review of efficacy reports.” Clinical Aphasiology, 22 (1994): 231-243. Wambaugh, J.L, Martinez, A.L, McNeil, M.R, Rogers, M.A. “Sound production treatment for apraxia of speech: overgeneralization and maintenance effects.” Aphasiology. 13 (9-11) (1999): 821-837. Wambaugh, J.L. “A Summary of Treatments for Apraxia of Speech and Review of Replicated Approaches.” Semin Speech Lang. 23 (2002): 293-308. Wood, L.A, Rankin, J.L, Beukelman, D.R. “Word Prompt Programs: Current Uses and Future Possibilities.” American Journal of Speech-Language Pathology, 6 (1997). Read More