Clark 2017 1

Clark 2017

Disclosures • Financial and non-financial conflicts of interest • Salary from Mayo Clinic

• Book royalties received from Pro-Ed (book topic unrelated to this talk) • Grant support Motor Speech • National Institute of Neurological Disorders and Stroke • National Institute on Deafness and Other Communication In Acute and Degenerative Conditions Disorders • National Institutes of Health Heather M Clark, Ph.D. CCC/SLP, BC-ANCDS

Iowa Conference on Communicative Disorders April 2017

Outline • Overview of Dysarthria • Motor Speech Treatment and AOS • Guiding frameworks • Clinical features • Consideration of • Neurologic substrates chronicity • Standardized treatment protocols • Motor Speech Overview of Motor Speech Disorders Assessment • Comprehensibility strategies •Overview of assessment • Consideration of chronicity

Dysarthria Neurologic speech disorder reflecting abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for respiratory, phonatory, resonatory, articulatory, or Dysarthria prosodic aspects of speech production

Duffy, 2013

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Flaccid Dysarthria Flaccid dysarthria • Features relate to muscle weakness Cranial Speech Features Nerve • Often asymmetric V Does not typically impact speech unless severe bilateral deficit • Specific features depend on LMNs involved and/or pathophysiology VII Unilateral: unlikely to significantly impact speech, perhaps • Consistent features vs rapid fatigue/recovery subtle with rest XPh Hypernasality

XSL Low pitch, monopitch

XRL Breathiness, diplophonia, short phrases

XII Imprecise articulation

Spastic dysarthria Ataxic dysarthria Subsystem/Domain Speech Features Subsystem/Dom Speech Features Respiration Short phrases ain Phonation Strained, strangled Respiration Excessive loudness variation Resonance Hypernasality Phonation May be harsh Articulation Imprecise Resonance Often normal, Prosody Slow rate otherwise may be Monopitch, monoloudness variable Articulation Irregular articulatory breakdowns Prosody Slow rate Scanning speech Excess and equal stress Other “drunken” quality

Hypokinetic dysarthria Hyperkinetic dysarthria Subsystem/Dom Speech Features Subsystem/Do Speech Features ain main Respiration Reduced loudness Respiration Interruptions Phonation Tight breathiness Excessive loudness variations Resonance Often normal Phonation Strain Articulation Imprecise, usually Tremor with reduced ROM Voice interruptions during speech movements Resonance Constant or variable Prosody Rapid rate Articulation Distortions Short rushes of Interruptions speech Prosody Often slow Monopitch, Other Visual features often monoloudness prominent Other Palilalia “Mumbling” quality

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UUMN dysarthria Mixed dysarthria Subsystem/Domain Speech Features Respiration Reduced loudness* • Any combination of the above Phonation Weak, strained, or hoarse Resonance Hypernasal* Articulation Imprecise Irregular breakdowns Prosody Slow (or normal) rate Reduced stress* Other *Particularly in the context of reduced background physiologic effort

Can be perceptually similar to flaccid, spastic, and/or ataxic dysarthria

Apraxia of Speech • AOS is a disturbance in the programming of movements for speech • muscles are capable of normal functioning (right-sided weakness secondary to UMN dysarthria may be seen) Apraxia of Speech • appropriate message has been formulated

Most agree that… Speech Characteristics (Duffy 2013) • AOS is distinct from dysarthria • Articulatory • Which involves impairments in speed, • Rate and Prosody strength, coordination, or muscle tone affecting all movements • Fluency • AOS is distinct from aphasia • Which involves impairments in manipulation (comprehension & expression) of linguistic symbols • AOS is distinct from nonverbal oral apraxia

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Articulatory Characteristics Rate and Prosodic Characteristics • Consonant and vowel distortions (imprecise • Slow overall rate, especially for longer articulation) utterances • Distorted substitutions • Prolonged but variable vowel duration and inter- • Perseverative word intervals • Anticipatory • Syllable segmentation • Distorted additions • Errors of stress assignment • Distorted sound prolongations • Reduced words per breath group relative to • Voicing errors MPT • Relatively consistent error type and location • Decreased phonetic accuracy with rate increases

Fluency Characteristics Influence of Task Variables • Attempts to self-correct articulatory errors • Syllabicity effects • False starts and restarts • Increased errors • Low frequency syllables • Visible and audible groping for articulatory postures • Syllables with more phonemes • Consonant clusters within syllables • Sound and syllable repetitions • Increased errors with more phonemes and/or more syllables (complexity) • Volitional/purposeful utterances have more errors than automatic/reactive utterances

Influence of Task Variables Severe AOS • Higher error rates in nonsense syllables • Limited repertoire of speech sounds • Higher error rates in consonant clusters • Limited variety of utterances • Initiation of utterances is particularly difficult • May be reflected by muteness • Imitation does not generally elicit more errors • Usually accompanied by severe aphasia and than are present in spontaneous speech of nonverbal oral apraxia equal complexity

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Differential diagnosis

“When do you give an aphasia battery? When you already know the patient has aphasia” Motor Speech Assessment - Joe Duffy

Motor Speech Assessment Medical History for Differential Diagnosis Information Key Indicators or Relevance for Communication Findings Current 1. Neurologic 1. Predict impairments and inform prognosis and • History diagnosis and 2. Pulmonary tx plan past medical 3. ENT 2. May account for respiratory impairments • Perceptual assessment of continuous speech history (PMH) affecting speech 3. May account for voice impairments affecting • Speech-like tasks speech Medications 1. Sedatives 1. Lethargy may influence communication • Examination of oral structure and function 2. Antihypertensives, function antihistamines, 2. May affect vocal quality diuretics 3. Timing of medication may influence 3. Carbidopa levadopa performance Imaging 1. Head CT or MRI 1. Site of lesion may predict impairments and differential diagnosis

Reports from 1. Nursing 1. Usually indicate level of alertness and ability to other disciplines 2. Physical medicine communicate basic needs 2. May indicate ability to participate in therapeutic intervention

Duffy, 2013 Duffy, 2013 Interview – Onset & Course Interview – Associated Deficits

Question Purpose Question Purpose Describe the changes in your Some descriptions occur more frequently in with specific speech motor speech disorders Other symptoms (beginning at the same time, “Company it keeps” may suggest etiology • “Mumbling” – hypokinetic prior to, or after development of speech • Slow and effortful – spastic dysarthria, AOS difficulties)? • Tongue is thick – flaccid • Cognitive/linguistic • Can’t pronounce words, “trip” over words – AOS • Swallowing/drooling • Sound drunk - ataxic • Gait/balance • Weakness/coordination

When did the problem start? Suggests possible etiologies Gradual or sudden? • Changes in emotional expression Flattened affect: hypokinetic dysarthria Pseudobulbar affect: spastic dysarthria Change since onset? Improving or worsening symptoms suggests possible etiologies

Improvement with therapy Responsiveness to intervention may suggest underlying impairment

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Speech Functions - Tasks • Connected speech • Reading • Picture description • Conversation Speech Functions • Repetition • Single words • Sentences • Automatic sequences

Speech-like tasks • Alternate motion rates (AMRs) • Sequential motion rates (SMRs) • Prolonged vowel (maximum phonation time/MPT) Speech-like Tasks

AMRs AMRs

Feature Relevance for Differential Diagnosis

Slow and regular Spastic

Irregular (slow or normal rate) Ataxic

Rapid/blurred Hypokinetic

Normal rate, imprecise Flaccid

Voicing errors Spastic

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SMRs Feature Relevance for Differential Diagnosis Better than AMRs Ataxic Worse than AMRs AOS

Nonspeech Tasks

Nonspeech Features Nonspeech Features Feature Relevance for Differential Diagnosis Feature Relevance for Differential Diagnosis Weakness Most apparent in LMN (flaccid) & UMN (UUMN/spastic) Reduced ROM During isolated movements: can reflect Subtle in hypokinetic weakness or spasticity 80 Unusual in ataxic Only during rapid alternating 70 movements: common in hypokinetic 60 Reduced speed Most apparent in spasticity 50 Possible but not typical in flaccid 40 Atrophy LMN 30 Fasciculations LMN

Pressure (kPa) 20 Pathologic or exaggerated UMN 10 reflexes 0 Hypomimia Hypokinetic Adventitious movements Hyperkinetic, functional

Assessment across the continuum of care • Timing/setting influences many aspects of assessment • Purpose • Time available • Patient and family insight Assessment • Nature of confounding factors Consideration of Chronicity

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Acute Care: Purpose • Differential diagnosis • Identification of reliable mode of communication • Discharge planning

Assessment in Acute Care

Acute Care: Time Available Acute Care: Patient and family insight • Patient available for assessment • Description of the problem by patient and family not necessarily particularly helpful at this point • Patient awake and alert for assessment • May have identified an effective mode of communication • Concern will be survival and (later) disability • This may be the first time the patient or family has ever heard of dysarthria or AOS

Acute Care: Confounding factors • Coma, delirium, encephalopathy, somnolence • Baseline cognitive impairments •Pain • Hemiplegia Assessment in Chronic Phase • Visuo-perceptual deficits • Hearing loss • Positioning • Presence of NG, endotracheal tubes, trachs

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Purpose Purpose • Confirm diagnosis • Develop a prognosis for improvement with therapy and/or • Obtain a thorough characterization of the motor speech disorder • Develop recommendations for maximizing communicative effectiveness • Probe for facilitating contexts

Purpose Chronic: Time Available • The task is usually to address communication • Often relatively extensive difficulties that • Have never been treated • Have been treated inappropriately Although probably never as much as is • Have been treated appropriately but may available in training settings benefit from a different approach • Have been treated optimally but patient and family have not effectively adapted to the “new normal”

Chronic: Patient and family insight Chronic: Patient and family insight • Description of the problem by patient and family • What have they been told the communication is invaluable at this point problem is called? • Impact on work, personal, and social • Question is usually whether additional therapy interactions could be helpful • Effective strategies • They may or may not have experience yet with • Challenging contexts ICF-guided therapy (more on this later)

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Chronic: Confounding factors Chronic: Confirm Diagnosis • Concomitant deficits • Thorough motor speech exam and evaluation •Pain for common co-occurring difficulties • Hemiplegia • If you are confident about previously • Visuo-perceptual deficits established diagnoses, it may be possible to screen for other deficits and then use most of • Hearing loss the time for comprehensive assessment of • Aphasia motor speech • Cognitive impairments • Consider the relative contribution of motor • Fatigue speech disorders to overall communicative effectiveness • Maladaptive patterns

Progressive: Purpose • Differential diagnosis • Characterization of concomitant communication disorders Assessment of Progressive Motor Speech Disorders

Progressive AOS: Characterization Progressive: Time Available

• Classifying Type of • Initial session for differential diagnosis Progressive AOS • Subsequent sessions likely needed for further • Articulatory characterization distortions predominate • Segmentation predominates • Distortions and segmentation are of equal severity

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Progressive: Progressive: Patient and family insight Patient and family insight Description of the problem by patient and family • What have they been told the communication is invaluable problem is called? • Nature • They will want to know if therapy can reverse • Complaints of change in voice, difficulty with the problem. pronunciation or enunciation, “tripping” over words, “can’t get words out” • With or without complaints of aphasia • Gradual onset and worsening over time • Impact on work, personal, and social interactions • Effective strategies • Challenging contexts

Progressive: Confounding factors • Concomitant aphasia and/or cognitive communicative deficits • Limb apraxia

Treatment of Motor Speech Disorders

General Considerations • Concomitant conditions • NVOA may be present but likely will not warrant treatment • Nonspeech oral motor activities not used at all except to shape towards speech in the Management of Motor Speech setting of muteness Disorders

• Severity Considering Chronicity • Guiding frameworks

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Acute Care Early rehabilitation • Goals • Goals • Identifying or establishing reliable mode of • Restoration of function communication • Optimizing activity, participation, quality of • Discharge planning life • For prolonged stays • Comprehensibility strategies • On-going assessment as medical status • Home and work modifications fluctuates • Conversation partner training • May be able to move forward with rehabilitative goals

Chronic Motor Speech Disorders Chronic Motor Speech Disorders • One task is to justify treatment • Goals • Involves identifying communication • Restoration of function difficulties that • Optimizing activity, participation, quality of life • Have never been treated • Comprehensibility strategies • Have been treated inappropriately • Home and work modifications • Have been treated appropriately but may benefit from a different approach • Conversation partner training • Have been treated optimally but patient and family have not effectively adapted to the “new normal” • Much of the highest quality evidence supporting treatment of dysarthria & AOS is the setting of chronic conditions

Progressive Motor Speech Disorders • Goals • Restoration (?), maintenance, and slowed decline, of function • Optimizing activity, participation, quality of life • Comprehensibility strategies • Home and work modifications Frameworks Guiding Decision Making • Conversation partner training

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International Classification of Function: ICF

Health Condition

Body Activity and Functions and Participation ICF Structures

Frameworks Guiding Decision Making Contextual Factors (Personal and Environmental)

Health Condition Body Functions and Structures

Disorder or disease Underlying impairments of Health or changes to anatomical Health Informs Condition Condition • Prognosis structures or physiologic • Predicted comorbidities functions • Tolerance for specific Body Body modalities Activity and Activity and Functions and Functions and Treatment of motor speech Participation In motor speech Participation disorders associated with Structures Structures neurodegenerative disease may disorders, impairments differ from acute or chronic disease are often described at the • Goals Contextual level of muscle or nerve Contextual • Time course Factors impairment (e.g., Factors • Relatively frequent during weakness) or at the level establishment of skills or (Personal and (Personal and strategies of subsystem (e.g., • Relatively infrequent re- Environmental) Environmental) evaluation with updated impairments of voice) recommendations

Activity and Participation Contextual Factors

Personal factors Describes the impact •Age Health Health of health conditions, • Life experiences Condition Condition impairments, and • Personality contextual factors on • Co-morbidities ‒ Speakers with dysarthria often performance of and Body have concomitant impairments in Body Activity and Activity and participation in Functions and speech praxis, language, Functions and Participation cognition, and/or swallowing Participation functional activities Structures functions Structures Environmental factors • Technology Contextual • Geography Contextual Factors • Support and relationships Factors (Personal and • Attitudes (Personal and Environmental) • Services Environmental) • Systems and policies

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Application: ICF Application: ICF • Differential diagnosis Recommendation Rationale • Mixed hypokinetic-hyperkinetic-spastic Environmental modifications to • Increasing loudness exacerbated phonatory dysarthria maximize signal to noise ratio strain • Cognitive deficits make it difficult for patient to • Apraxia of speech use intentional strategies Conversation partner strategies • Cognitive communicative impairment • Include strategies addressing reduced output related to cognitive deficits • Medical diagnosis • Corticobasal syndrome

Speech Subsystems

Resonation Articulation Phonation Motor Speech Treatment Hierarchy

Frameworks Guiding Decision Making Respiration

Prosody

Motor Speech Treatment Hierarchy Motor Speech Treatment Hierarchy

• The speech subsystems do not act Third Order independently Articulation Prosody Targets • Adequate respiratory support and velopharyngeal valving supports phonation Second Order • Articulatory precision is supported by Phonation respiratory, resonatory, and phonatory Targets competence

First Order Respiration Resonation Targets

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Application: Motor Speech Treatment Hierarchy

Prosody targets: Third Order Targets: Overenunciation Articulation Prosody Lexical stress

Loudness (e.g.,LSVT) Phonation Neuromuscular Treatment Principles

Frameworks Guiding Decision Making

Slow rate First Order Targets: Respiratory support Respiration Resonation (diaphragmatic breathing)

Strength Strength Training Principles • Weakness • Overload & Progression • Maximum force (strength;1Rmax) • Intensity • Sustained/repeated submaximal force (endurance) • Recovery • Power (near maximal forces at high speed) • Reversibility • Causes • Specificity of Training • UMN lesion (UUMN and spastic dysarthria) • LMN lesion (flaccid dysarthria) • Disuse atrophy & deconditioning (all dysarthrias)

Overload & Progression Intensity • Overload • Strength training

• Taxing the muscles beyond typical • 60-80% 1Rmax functioning • 10 repetitions per set • Results in •2-3 sets • Hypertrophy of muscle tissue • Endurance training • Increased motor unit recruitment • 40-60% 1R • Progression max • High number of repetitions (e.g., 60) • Systematic overload • Implies need for regular reassessment of maximum performance

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Recovery Reversibility

• Optimal interval between training sessions to allow • “Use it or lose it” recovery yet avoid reversal • Levels of • In large muscle groups, optimal interval is > 24 hrs strength must be used to be • Tongue strengthening studies: 3-7 days/week maintained • Respiratory muscle strengthening studies: 3-5 days/week

Specificity of Training Movement factors subject to specificity • The effects of strength training are highly •Force specific to the trained behaviors • Contraction velocity • Transference refers to the gains in function for • Duration tasks that do not perfectly match the exercise • Dynamics • Integration

Integration Contra-indications for strength training

• Results of motor learning experiments suggest • Hypertonia that motor programs (specific patterns of motor • Rationale: High resistance exercise presumed to unit recruitment) are highly specific increase spasticity, arose from principles of the Bobath approach • Predicts that exercises that incorporate the entire • Evidence has failed to support this presumption movement pattern (e.g., all articulators) will result • Stroke (Pak & Patten, 2008) in greatest carryover • Cerebral palsy (Dodd, Taylor & Damiano, 2002; Scholtes et al, 2012) •MS (in combination with anti-spasticity medications; Motl, Snook & Hinkle, 2007) •ALS (Ashworth, Satkunam, & Deforge, 2012 Cochrane Review)

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Contra-indications for strength training Contra-indications for strength training

• Fatigue Susceptibility • Inflammatory Myopathy • Neuromuscular junction deficits: the impairment does • Rationale: resistance exercise thought to exacerbate not reflect reduced motor unit recruitment nor inflammatory response peripheral muscle weakness. Resistance exercise • Evidence elicits the fatigue without inducing physiologic • Case study of lingual exercise in IBM: strength, P-A responses leading to increased muscle strength scores, bolus clearance did not decline over course • Progressive neuromuscular disease of 5 year progressive disease (Maladraki et al., 2012) • Rationale: resistance exercise induces fatigue • No clear evidence for harmful effects of exercise, without potential benefit of increased strength but insufficient evidence for benefit, either (Voet et al, • Evidence: Low to moderate intensity exercise may 2013; Cochrane Review) improve functional activity (Kjolhede, Vissing & Dalgas, 2012; White & Dressendorfer, 2004) • Absence of Weakness • This assumption is not under scrutiny(?)

Strength Training in Dysarthria (AJSLP, 2009) Strength Training in Dysarthria • Lower level evidence • A small number of “low n” controlled studies and/or case studies provide limited support • Most authors caution against emphasizing strength training over speech-directed treatment, but acknowledge the potential benefit for specific patients when appropriate principles are incorporated (Dworkin, Linebaugh, Hageman, Duffy, Yorkston, Love, Murdoch)

• Sensory stimulation plus orofacial exercise improved intelligibility of adults (Roy 2002) and children (Roy 2001). AMR rates were unchanged in both studies • Some studies failed to report any results

Flaccid dysarthria primarily affecting CN Flaccid dysarthria associated with XII, subtle CN VII & X deficits myasthenia gravis • Speech features • Speech features • Mild nonspecific hoarseness with occasional fry • Reduced loudness • Imprecise articulation, particularly of lingual • Hoarseness consonants • Hypernasality • Non-speech features • Articulatory imprecision • Lip retraction was full, but lip rounding was mildly • Short phrases reduced • Rapid fatigue • Tongue • Asymmetric size R>L (subtle) • Mild-moderate weakness bilaterally

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Strength training: Application • Are either of these speakers good candidates for strengthening? • Would strengthening be the only line of therapy? Disrupted Muscle Tone

Neuromuscular Principles

Skip Past Muscle Tone

Muscle Tone Defined Muscle tone versus muscle strength • Resistance of a resting muscle to passive • Muscle tone is a characteristic of muscle at rest stretch • Muscle strength is a characteristic of activated • Influenced by tissue elasticity and resting motor muscle unit activity

Muscle Tone Regulation Tone Impairments

• Hypotonia • Peripheral Reflexes • Flaccid: diminished signals in reflex arc • Stretch (muscle spindles) • Cerebellar: mechanism unknown • Descending pathways • Hypertonia • Indirect upper motor neuron pathways • Spastic: released inhibition from descending • Basal ganglia control circuit indirect pathway onto gamma motor neurons • Cerebellar control circuit • Rigid: increased excitability of α motor neurons • Variable Tone

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Muscle Spindle Action in Muscle Spindle Action in Speech/Swallowing Muscles Speech/Swallowing Muscles • Jaw closing muscles • Tongue • High density muscle spindles • Muscle spindle density similar to limbs • Strong stretch reflex • Do not exhibit typical stretch reflexes • (Neilson et al., 1979) • Face & lips • Low density or lack of muscle spindles • Palate, Pharynx, Larynx • Do not exhibit stretch reflexes • Presence of muscle spindles varies across muscles • No studies to date have demonstrated stretch reflexes in the human larynx (Ludlow, 2005) or pharynx

Clinical Assessment of Assessment of Muscle Tone: Clinical Muscle Tone: Speech musculature

• Passive displacement of relaxed limb • Observation of resting position • Modified Ashworth Scale (6-point scale) • Facial droop • Muscle palpation • Lip retraction • Feel for resistance to tissue deformation • Orofacial tone assessments • Dworkin & Culatta (1996) • Beckman (1988)

Evidence for Tone Impairments in Proximal Muscle Groups Dysarthria Dysarthria Hypothesized (Darley, Data Velum and pharynx Aronson, Brown, • Slow, symmetrical movements may indicate 1969) Flaccid Flaccid hypotonia Flaccid: hypotonia hypertonia (Solomon & Clark, • Droop, often asymmetrical, may indicate 2010) hypotonia Spastic Spastic hypertonia Spastic: No hyperactive stretch reflexes in the tongue in spastic • Larynx dysarthria (Nielson et • Hypertonicity typically has bias for al., 1979) hyperadduction (strained, strangled vocal Ataxic Normal None quality) Hypokinetic Rigid hypertonia Hypokinetic: Increased lip stiffness (Hunker, Abbs, & Barlow, 1982; Chu et al., 2010) Hyperkinetic Dystonic/variable None

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Management of Tone Impairments Behavioral Management of Tone Impairments • Target sensory endings or afferent pathways of reflex loops • Pharmacologic • Surgical • Spasticity • Spasticity • Examples • Muscle relaxants (e.g., • Tendon lengthening • Slow stretch – inhibit stretch reflex Baclofen) •Rhizotomy • Quick stretch/tapping – stimulate stretch • Muscle paralytics (e.g., • Rigidity reflex botulinum toxin) • Pallidotomy • Vibration – stimulate tonic vibratory reflex • Rigidity • Deep brain stimulation (stimulates agonist, inhibits antagonist) • Levodopa • Related modalities

Effects on speech tend to be less dramatic •Cold than on postural and limb musculature • Massage

Muscle tone in the speech musculature: Muscle tone in the speech musculature: Summary Summary • Perceptual assessment methods have not been • It is unclear how resting muscle tone affects speech validated with instrumental measures movements • Instrumental measures are under exploration but have • Treatments described to address muscle tone in the not yet met validity standards even in the research limbs unlikely to affect speech muscles other than jaw setting closing muscles • Muscle tone in the orofacial muscles is regulated in • No evidence to demonstrate efficacy of tone altering ways unique from the limb musculature treatments for speech

Motor learning

• Learning produces relatively permanent changes in the capability for performance • Separate from factors that temporarily change performance (e.g., motivation, warm-up) Motor Learning Principles • Implications • Performance during training is not a Frameworks for Guiding Decision Making measure of learning • Factors that result in better performance during rehearsal/training may not have the same effect on permanent learning and/or carryover

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Evidence Supporting the Application of Select Principles of Motor Learning Motor Learning Principles in Motor Speech Disorders • Skill presentation techniques • Task sequencing • Providing feedback

Schmidt & Lee, 2011

Take-home Messages on Motor Learning Take-home Messages on Motor Learning • Measuring Motor Learning • Many training factors that enhance learning • Performance during the treatment session is result in slower acquisition not a sensitive measure of learning • Random practice (retention/transfer) • Varied practice • To best serve our patients and our • Reduced feedback profession, we need to diligently report • The more movement trials the better progress/treatment success based on outcomes obtained outside of rehearsal • All evidence suggests that motor learning is (treatment sessions or at least targeted highly specific practice) • Underlying ability cannot be improved by drills targeting speed or coordination

Take-home Messages on Motor Learning Application: Motor learning • Excessive verbal processing will direct • Treatment targets • Skill presentation attentional resources away from motor control • Loudness • Direct and indirect modeling processing •Slow rate • “Loud” requires limited • Visual models • Over-enunciation verbal description • Reduced verbal feedback • Lexical stress •Practice • Random and variable • Reducing feedback allows the learner to attend (assuming the skill has to sensory consequences (more similar to the been acquired but not target context) generalized) • Nonverbal feedback (sound level meter) • Summary feedback

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Read the phrase •Go for it LOUD • Are you sure? • The cat’s out of the bag • Enormous hippopotamus SLOW Specific Dysarthria Treatments • I’m in! • Don’t count your chickens ENUNCIATE before they’re hatched • Coffee? CAREFUL STRESS

Respiratory Impairments Associated Speech Impairments Changes • Reduced inspiratory • Reduced overall loudness capacity • Loudness decay • Reduced expiratory pressure • Excessive loudness Respiratory Treatments variation • Reduced control • Checking action • Involuntary movements

Supporting Respiratory Function Inspiratory Muscle Training • Postural adjustments • Diaphragm is primary target (belly breathing) • Sitting upright or standing typically better • Discourage excess use of accessory muscles than lying supine (shoulder breathing) • Avoid excess flexion • Goal is to establish strong, quick inspiration • Trunk/abdomen followed by slow, controlled exhalation •Neck • Early training may incorporate slowed and controlled inhalation and exhalation, • External supports discussed on next slide • Expiratory boards • Strength training requires overload, which may be best achieved with an inspiratory training device

Sapienza, C. & Troche, M. (2012). Respiratory muscle strength training: Theory and practice. Plural Publishing.

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Controlled Expiration Diaphragmatic breathing (Inspiratory Checking) • Promotes solid respiratory support • Can be combined with diaphragmatic breathing • May help inhibit excessive activation of • Focus on quick, strong inhalation accessory inspiratory muscles and laryngeal • Followed by slow, steady exhalation musculature • Visual and tactile feedback (“belly breathing”) often helpful • Applications on hand-held devices can support independent practice

Expiratory Muscle Strength Training Expiratory Muscle Strength Training (EMST) (EMST) • Pressure threshold trainer • Training outcomes • Resistance set at 75% maximum • Increased expiratory pressures expiratory pressure • Reduced hypophonia • Rule of 5’s • Improved intelligibility • 5 repetitions • Patient groups studied • 5 times per day • Parkinson disease • 5 days per week • Multiple sclerosis • 4-8 weeks • Ataxic disorders

Phrase Grouping • Targets strategic pauses for inhalation • Phrase length selected according to • Respiratory support • Syntactic boundaries Resonatory Treatments

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Resonatory Impairments Velopharyngeal Exercise Associated Speech Impairments Changes • Nonspeech exercise • Examples • Velar weakness • Hypernasality • Horn-blowing • Slowness of velar • Nasal emission • Straw-sucking elevation • Weak articulatory contacts • No evidence for carry-over to speech tasks • Reduced control • Hyponasality • Incoordination • Speech exercise • Involuntary • Alternating resonance • Continuous positive airway pressure (CPAP) movements • Overloads the velopharyngeal musculature during speech tasks Cahill, L. M., Turner, A. B., Stabler, P. A., Addis, P. E., Theodoros, D. G., & Murdoch, B. E. (2004). An evaluation of continuous positive airway pressure (CPAP) therapy in the treatment of hypernasality following traumatic brain injury: a report of 3 cases. [Case Reports]. The Journal of head trauma rehabilitation, 19(3), 241-253. ©2016 MFMER | slide-139 ©2016 MFMER | slide-140

Speech-based Resonatory Treatment Prosthetic Management • Emphasis of appropriate oral and/or nasal • Palatal lift resonance • Assessment and implementation in • May incorporate augmented feedback collaboration with prosthodontist • Nasal mirror • Will be most helpful for speakers with • SeeScape isolated hypernasality or nasality • Nasometry disproportionate to other features • Keeping in mind that adequate • May incorporate progressive difficulty velopharyngeal valving may support the • Vowels benefit of interventions targeting • Liquids phonation or articulation • Plosives and fricatives • Behavioral intervention usually still needed • Phonetic context Yorkston, K. M., Spencer, K. A., Duffy, J. R., Beukelman, D.R., Golper, L. A., Miller, R. M., Strand, E. A., & Sullivan,M. (2001). Evidence-Based Practice Guidelines for Dysarthria: Management of Velopharyngeal Function. Journal of Medical Speech- ©2016 MFMER | slide-141 Language Pathology, 9(4), 257-273. ©2016 MFMER | slide-142

Prosthetic Management Surgical Management • Nose plugs • Examples • Nasal obturator • Pharyngeal flap • Occlude the nares to prevent excess nasal • Injection augmentation air escape • Candidacy issues • Short term solution while a palatal lift is being • Stable velopharyngeal impairment fabricated • Patency of airway • Long term option for patients who are not candidates for palatal lift • Behavioral intervention may still be needed

Hakel, Marshall, & McHenry (2009). Understanding palatal lifts and nasal obturators. Presented at the ASHA Convention (http://www.asha.org/events/convention/handout

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Phonatory Impairments Associated Speech Impairments Changes • Hypo-adduction • Strained voice • Hyper-adduction • Breathiness Phonatory treatments • Reduced flexibility • Reduced loudness • Reduced stability • Monopitch/monoloudness •Tremor • Flutter

Speyer, R. (2008). Effects of voice therapy: A systematic review. Journal of Voice, 22(5), 565- 580.

Supporting Phonatory Function Reducing Laryngeal Strain • Hypo-adduction • Direct speaker’s attention to somatosensory • Head turn to facilitate approximation of vocal aspects of excess muscle tension cords • Some aspects of laryngeal tension/strain may • Manual lateralization of the thyroid cartilage not respond completely to behavioral • Surgical management approaches • Vocal cord injection augmentation • dystonia in hyperkinetic dysarthria • Thyroplasty • strain-strangled quality in spastic dysarthria – but may overcorrect! • Hyper-adduction • Relaxation • Excess laryngeal tension may result from poor respiratory support or poor coordination with • Massage respiration (see Respiratory Treatments)

Laryngeal Exercise Loudness Treatment • Increasing medial compression (adduction) • Lee Silverman Voice Treatment (LSVT) • Push-pull • Systematic hierarchy of exercises, focusing • Grunt on a single goal “speak LOUD!” • Cough • Targets respiratory, laryngeal and articulatory subsystems • Increasing pitch range and control • Incorporates high intensity, high frequency • Pitch glides and/or steps practice • Pitch matching • SPEAK OUT with LOUD Crowd • Non-standardized loudness treatment

Smith, M. & Ramig, L. (2014). Neurologic disorders and the voice. In J.S. Rubin, G. Korovin & R. T. Sataloff (Eds.), Diagnosis and Treatment of Voice Disorders. Plural Publishing ©2016 MFMER | slide-149 ©2016 MFMER | slide-150

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Coordinating Respiration & Phonation • Potential targets • Lung volume at onset of phonation • Initiating phonation at the top of inhalation • Phrase grouping (ceasing phonation before respiratory support wanes) • Rapid inhalation between phrases Articulatory treatments

Spencer, K. A., Yorkston, K. M., & Duffy, J.R. (2006). Practice guidelines for dysarthria: evidence for the behavioral management of the respiratory/phonatory system. Academy of Neurologic Communication Disorders and

Articulatory Impairments Supporting Articulatory Function Associated Speech Impairments Changes • Velopharyngeal support (see Resonatory Treatments) • Weakness and/or fatigue • Articulatory imprecision • Jaw support (bite block) • Reduced range of motion •Slow rate • Sensory tricks (hyperkinetic dysarthria – • Reduced speed dystonia) • Reduced coordination • Stretching/massage • Involuntary movements • Hyper-reflexia (spasticity) in jaw muscles • Would not be expected to facilitate muscle functions in lips, face, tongue

Articulatory Exercise Articulatory Treatments • Candidates for exercise • Exaggerated articulation (over-articulation) • Detectable weakness is a primary contributor to articulatory imprecision • Alternative place/manner/voicing • Weakness may be detectable in spastic • Coordination of complex phonetic sequencing dysarthria, but slowness of movements • Be mindful of task specificity may be the greater detriment • No contra-indications for resistance exercise • Often targeted in concert with lexical stress (e.g., susceptibility to fatigue) (see Prosody treatment) • Tongue strengthening programs well studied for dysphagia outcomes; speech evidence is less compelling, even in dysarthria

McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009). Evidence-based systematic review: effects of nonspeech oral motor exercises on speech. American Journal of Speech-language

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Prosody Targets • Speaking rate • Lexical stress • Sentential stress • Phrase groupings (see respiratory treatments) PROSODY TREATMENTS

Speaking Rate Rate Reduction Strategies • Even for patients with slow rate, increasing • Pacing board/hand tapping overall speaking rate is almost never an • Metronome appropriate target • Reducing speaking rate, even for patients with normal or slow rate, typically improves intelligibility • Speakers with hypokinetic dysarthria often have rapid rate, but may have difficulty intentionally reducing rate

Yorkston, K. M., Hakel, M., Beukelman, D. R., & Fager, S. 2007). Evidence for effectiveness of treatment of loudness, rate or prosody in dysarthria: A systematic review. Journal of Medical Speech-Language Pathology, 15(2), ©2016 MFMER | slide-159 xi-xxxvi ©2016 MFMER | slide-160

Rate Reduction Strategies Lexical and Sentential Stress • Delayed auditory feedback • Visual cueing/feedback • Indirect strategies • Hand gestures signalling change in loudness, pitch, and/or duration • Increased loudness (see phonatory treatments) • Acoustic software • “Clear” speech (see intelligibility treatments) • Activities/stimuli • Contrastive stress • Metric pattern across various word lengths • Verbal repair

Yorkston, K. M., Hakel, M., Beukelman, D. R., & Fager, S. 2007). Evidence for effectiveness of treatment of loudness, rate or prosody in dysarthria: A systematic review. Journal of Medical Speech-Language Pathology, 15(2), xi-xxxvi ©2016 MFMER | slide-161 ©2016 MFMER | slide-162

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Treatment Programs

Standardized Treatments for AOS

AOS Treatment Programs AOS Treatment • Articulation Focused • Articulation Focused • Prosody Focused • 8 Step Continuum • DTTC • Utterance Focused •PROMPT • Gestural / Aug Comm • Sound Production Treatment • Utterance Focused • Prosody Focused • Gestural / Aug Comm

8 Step Continuum Suggested Cue Hierarchy • AKA Integral Stimulation • (Tactile Cues) • Designed to provide “threshold” level cueing so • Simultaneous Production the patient receives stimulation just adequate to • Mimed Production elicit a correct response without over-cueing • (Immediate Repetition) • Successive Repetition

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Suggested Cue Hierarchy Dynamic Temporal and Tactile Cueing • Delayed Repetition • Reading • Reading with Delay • Answering Questions • Role Playing

Dynamic Temporal and Tactile Cueing Dynamic Temporal and Tactile Cueing

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PROMPT Prompts for Restructuring Oral Muscular Phonetic Targets

• Tactile-kinesthetic approach • Provides proprioceptive, pressure, and spatial information through the use of oral-facial cues and prompts • Training is required

Sound Production Treatment Sound Production Treatment • Emphasizes repeated practice of key sound targets • Uses hierarchical cues • Incorporates minimal contrast practice • Target sound paired with typical replacing sound • Provides articulatory contrast • Provides pragmatic boost - avoidance of homonymy

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Selection of Treatment Targets Selection of Exemplars of Targets • Derived in the process of thorough • 10 exemplars should be sufficient characterization of speech sound accuracy • Real words when possible • Impact on intelligibility • One word-position suggested • % in error • Homonymy • Variety of vowels should be represented • Frequency of occurrence in language • Minimal contrast word selected for each exemplar • Level of success • Real word • Trial therapy - stimulability • Contains replacing sound or approximation • Key…tea • Cap…tap

Hierarchy of Cues (Word Level) Treatment Sequence Step 1 – Modeling/Imitation at Word Level • Each Session (45 minutes to 1 hour) Step 2 – Modeling + Written letter cue/Imitation • hierarchy applied to each word pair • 10 words presented in random order = 1 trial Step 3 – Integral Stimulation • attempt to complete at least 7 trials (70 Step 4 – Articulatory Placement + Modeling words) per session Step 5 – Production of target sound in isolation • Three sessions per week recommended

Treating More than One Sound At a Time with SPT Targeting Multiple Sounds • Select minimal contrast words across the • Generally recommended only after single sounds phoneme targets are produced with relatively • “low” “mow” “know” high levels of accuracy (e.g., 40% +) • Number of trials is greatly reduced – probably would • Select the contrast word to reflect errors on all be difficult to “establish” sounds sounds (may need more than one) • Recall Motor Learning Principles • “dough” “though” • Blocked trials - better for initial acquisition • Randomized trials - better for learning / maintenance

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AOS Treatment Metronome Training • Articulation Focused • Focuses on rate reduction, not on accurate phonetic productions • Prosody Focused • Metronome and Hand-tapping • Multisyllabic targets • Melodic Intonation Therapy • Benefit ↓ ______• Utterance Focused • Spaghetti ___ ↓ ___ • Gestural / Aug Comm • Represent ______↓

Metronome Training – Multisyllabic Words Feedback • Hierarchical levels vary the availability of a • Tapping accuracy model, speed of metronome, and nature of rhythm • # syllables • Level 1: Clinician Model, Unison Production, Patient • Production to the beat (not about sound Production • Level 2: Faded Clinician Model production) • Level 3: No Clinician Model • Level 4: Increased Production Rate • Level 5: Syncopated Rhythm

Why Might Rate Control/Pacing Facilitate Articulation? Melodic Intonation Therapy • Increased time to reach articulatory postures • MIT has been applied to the management of AOS and nonfluent aphasia • Improved functioning of central pattern generators • Emphasizes both melody and rhythm of productions • Decreased degrees of freedom in speech production • Increased allocation of resources • Motoric “spillover” • Increased afference

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Level 1 Level 2 • Step 1: Humming • Step 1: Clinician models target while tapping • Clinical models melody and taps rhythm (no patient response required) • Next adds word to melody and rhythm • Step 2: Unison with fading • Step 2: Unison • Step 3: Delayed repetition • Step 3: Unison with clinician fading out • Step 4: Response to probe question • Step 4: Immediate repetition • Step 5: Response to probe question

Level 3 (Speech Song) AOS Treatment Programs • Step 1: Delayed repetition • Articulation Focused • Step 2: Introduce speech song • Prosody Focused • Exaggerated rhythm and stress • Utterance Focused • Step 3: Speech song with fading • Response Elaboration Training • Step 4: Delayed repetition of normal speech • Voluntary Control of Involuntary Utterances prosody • Script Training • Step 5: Response to probe question • Gestural / Aug Comm

Response Elaboration Training Utterance Focused Treatments Kearns and colleagues • Emphasize effective volitional communication • Loose training procedure designed to increase regardless of phonetic accuracy length and content of verbal productions • Patient-initiated utterances • guided by pictures • NOT specified by therapist • Modeling & forward chaining procedures

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RET Sequence Modifications to RET 1. Present picture stimuli & elicit a response • Provision of 2 phrase level models (NP & VP) in the event of no response (initial response & 2. Repeat patient’s production & reinforce elaboration) 3. Ask a question to elicit an elaboration of the • Provision of integral stimulation upon incorrect original response or no response (following previous models) 4. Repeat & reinforce the new production; • Repeated practice of elaborated utterances model combined productions (1 + 3) • Use of a time delay prior to final repetition 5. Model combined production and request a repetition 6. Reinforce repetition and model again

Modified Version of RET Modified Version Cont. 1. Present picture stimuli & elicit a response 4. Repeat & reinforce the new production; model • model 2 response options (e.g., “you could say NP combined productions (1 + 3) or VP”) 5. Model combined production and request a • model a 1-word response - request repetition repetition • use integral stimulation • if correct - 3 more productions 2. Repeat patient’s production & reinforce • if incorrect - use integral stimulation to elicit multiple productions 3. Ask a question to elicit an elaboration of the original response 6. Remove picture for 5 seconds - request • model as in step 1 repetition of description • Feedback as in step 5

RET Applied to Personal Recount Summary of RET • no picture stimuli • Provides models and scaffolding to increase length and informativeness of verbal • patient instructed to “Tell something about expression anything that you would like to talk about.” • treatment hierarchy applied as before • at least 14 topic attempts elaborated upon per session

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Voluntary Control of Involuntary Utterances Script training (VCIU) • Goal is to produce • For patients with limited verbal expression islands of fluent • Attempts to expand the communicative uses of speech in spontaneous productions conversation • Isolated or sequenced phrases and sentences with specific conversational purposes are practiced extensively

VCIU Sequence VCIU Principles • Clinician notes any spontaneous utterances and • Target stimuli can be added continually writes them each on a card • Emphasis is on expanding use of spontaneous • Patient reads card utterances, not on correct productions (either • (spontaneous -> volitional) phonetic or semantic) during any given trial • Utterances that can be produced volitionally are targeted in other contexts • Picture naming • Sentence completion • Discourse

Operational Definitions

Intelligibility Comprehensibility The listener’s success in The listener’s success in understanding the acoustic understanding the signal produced by a message/meaning Management of Motor Speech speaker produced by a speaker Disorders

Comprehensibility Strategies & AAC • Both intelligibility and comprehensibility are influenced by the communication environment and the behaviors of the speaker and listener.

• Comprehensibility strategies include behaviors that improve intelligibility

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Comprehensibility Strategies Helpful resources • Seek to improve activity and participation Health • Include Condition • Optimization of environmental factors • Exploiting facilitating Body Activity and personal factors Functions and • Compensating for limiting Structures Participation personal factors

Contextual Factors Yorkston, K. M., Beukelman, D., Strand, E., & Hakel, M. (2010). (Personal and Management of motor speech disorders in children and adults (3 ed.). Austin, TX: Pro-Ed. Environmental)

Introducing Comprehensibility Strategies Comprehensibility Strategies • Initial visit Optimizing the environment • Providing recommendations • In order to obtain history Speaker behaviors

Listener behaviors

pixshark.com

Reducing background noise • Obvious, controllable sources • TV, radio, computer, etc

Optimizing the environment

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Reducing background noise Reducing background noise • Obvious, not-so-controllable sources • Not-so-obvious controllable sources • Crowd noise • Appliances • Open windows

• Move away • Turn ‘em off • Take advantage of barriers • Close ‘em • Move away

Reducing background noise Optimizing lighting • Not-so-obvious not-so-controllable sources • Avoid backlighting • Road/traffic noise • Avoid dim lighting

• May require other strategies

Optimizing the environment Optimizing the environment • Be in the same environment! • Reduce distractions

• Avoid communication over a distance • Auditory and visual distractions • Multi-tasking

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Optimizing the environment • Choose the time and place for communication

Speaker Behaviors Avoid important conversations when the speaking or listening will be difficult

Speaker behaviors Speaker behaviors: Speech-focused • Speech-focused • Speak slowly • Language-focused • Communication-focused

Clinician Pearls • Acknowledge this is challenging • Suggest “tricks” • Speak loudly • Speak clearly

Speaker behaviors: Speech-focused Speaker behaviors: Speech-focused • Speak very slowly* • Speak clearly • Pause briefly between each word • Imagine you’re speaking to someone who is • Pay attention to the small words hard of hearing or doesn’t understand your • Do not separate syllables within words language very well • Include every syllable • Over-enunciate • Speak carefully Instructions may focus on over- • Maintain intonation (may have to slow even articulation (hyper-articulation), but further) effects are broader Slow rate Wider loudness and pitch variation

Tjaden, K., Sussman, J. E., & Wilding, G. E. (2014). Impact of clear, loud, and slow speech on *when intelligibility is more dramatically impacted scaled intelligibility and speech severity in Parkinson's disease and multiple sclerosis. Journal of speech, language, and hearing research : JSLHR, 57(3), 779-792.

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Speaker behaviors: Speech-focused Speaker behaviors: Language-focused • Speak up! • Use complete, simple sentences • Not just for hypokinetic dysarthria • Use predictable wording • Great in the context of reduced background physiologic effort • Often improves articulatory precision • May reduce rate

Speaker behaviors: Speaker behaviors: Language-focused Communication-focused • When repeating • Get the listener’s attention • The first repetition, say it exactly as you said it the first time • Rephrase, but make sure the listener knows you’re rephrasing • Call his/her name • Wait until the listener is watching your face

Speaker behaviors: Speaker behaviors: Communication-focused Communication-focused • Help the listener predict what you’re going to • Use all modalities available say • Speak • Point •Gesture • Facial expression • Identify the general topic • Pictures (points or draw) • Take advantage of contextual cues (point to objects in the environment, •Write headlines, etc.) •Text • Signal topic changes •Type

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Speech Supplementation Alphabet Supplementation • Incorporated during spoken expression • Point to initial letter of word as each word is spoken • Strategies provide listeners with additional information to help make sense of the spoken • Also serves as a pacing strategy message • Identification of initial letter facilitates word • Typically involves “signal-independent” prediction by listener information about the message • Includes gestures ABCD EFGH IJKLMN Example of alphabet board OPQRST Hanson, E., Yorkston, K., & Beukelman, D. (2004). Speech with vowels aligned on left supplementation techniques for dysarthria: A systematic review. margin. UVWXYZ Journal of Medical Speech-Language Pathology, 12(2), ix-xxix. ©2016 MFMER | slide-235 ©2016 MFMER | slide-236

Speaker behaviors: Semantic/Topic Supplementation Communication-focused • Identifies the topic of discussion to help • Interact listener’s word prediction and comprehension • Topics can be identified through • Spoken expression • Use turn-taking signals • Written expression • Visible • Photographs/pictures • Audible • Other artifacts • Conspirator • Calendars • Souvenirs • Let listeners know “the rules” • Newspapers

Listener behaviors • Give your undivided attention

• Move close to the speaker • Watch the speaker Listener Behaviors

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Listener behaviors Listener behaviors • Know (ask for) the topic • Piece together the clues • Watch for topic-changing signals • Speech •Gestures • Facial expression • Pointing •Writing • Texting

Listener behaviors Listener behaviors • Signal to the speaker as soon as you don’t • Avoid the least helpful question in the English understand language

A nonverbal signal is often best so the speaker doesn’t feel interrupted

Listener behaviors Listener behaviors • Avoid the least helpful question in the English • Know the rules language

• How does the speaker signal a turn? • Repeat the part of the message • Should you “word predict”? you heard • What is the back-up plan? • Ask yes/no questions for clarification

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Speaker & Listener Behavior • Glossing • Listener repeats each word as the speaker says it Instruction in Comprehensibility • Speaker has to pause briefly between words so listener can repeat Strategies and • Correct breakdowns as they occur Developing Recommendations • Combine with alphabet supplementation

Presenting Comprehensibility Strategies Presenting Comprehensibility Strategies • Explain that the goal is successful exchange of • Allow speaker and family members to practice information, not word for word intelligibility and respond • Highlight the value of being understood the first • Troubleshoot obstacles time • Listeners who “can’t hear” • Emphasize that successful communication is • Listeners who only talk the responsibility of all participants • “Fast talkers” • “Good advice for all of us” philosophy • Give feedback and additional guidance

Evaluate success AAC • Some patients may be proficient after initial • Augmentative and alternative communication session (AAC) is an appropriate option for speakers with poor intelligibility • Some may need additional instruction • Temporary as speech improves • Follow-up consultation • Introduced early in degenerative disease • Component of on-going therapy • Value of individual strategies may vary across recovery, progression, and/or context

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EBP Resources

Evidence-Based Practice Resources

EBP Resources

EBP Resources EBP Resources • Clinical Aphasiology Conference Proceedings • www.clinicalaphasiology.org • Conference on Motor Speech • http://www.madonna.org/res_conferences • Proceedings published in JMSLP • ASHA • Special Interest Division 2 • UpToDate ®

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Mayo Clinic Locations

Questions & Discussion