Research supported by VA Rehab. R&D Riverside … 18 Wambaugh handout.pdf · Riverside Community Hospital October 18, ... compensation for this presentation ... what? when? where?

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Research supported by VA Rehab. R&D

Riverside Community Hospital

October 18, 2014

DISCLOSURE STATEMENT: Dr. Wambaugh is receiving financial

compensation for this presentation

◦ Review characteristics of AOS

◦ Discuss differential diagnosis

◦ Describe assessment for treatment planning

◦ Summarize the existing AOS Practice Guidelines

◦ Describe on-going guidelines work – update in progress

◦ Highlight important new developments in AOS treatment

◦ Discuss clinical application of existing treatments

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Disruption of motor planning/programming ◦ sound selection and ordering assumed to be intact

◦ neuromuscular system for realizing articulatory command assumed to be intact

Problem with the translation of correctly selected sounds to previously learned articulatory-kinematic parameters ◦ what? when? where? how long? how fast? with how

much force?

Slowed rate of speech production ◦ Increased interval time between words and syllables

◦ Increased time to produce individual sound segments and to transition between sounds

Sound Errors ◦ distortions (predominant type), perceived

substitutions, omissions, additions (intrusive schwa)

◦ relatively consistent across repeated productions - location and type*

Prosodic Abnormalities ◦ Related to slow rate

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Articulatory groping

Increasing errors with increasing word length or complexity

Perseverative errors

Speech initiation difficulties

Awareness of errors (e.g., self-corrections)

Automatic speech better than propositional speech

Islands of error free speech

Have been used in the past

May co-occur

More likely to be attributable to other disorders

◦ anticipatory errors (pillow lillow)

◦ transposition errors (spaghetti psghetti)

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Mild-moderate AOS; samples from Duffy protocol (2005)

Moderate PURE AOS ◦ http://heart.utah.gov/hearthighway/time.html

Butterfly Octopus Volcano Animal

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F, mild AOS, minimal aphasia ◦ Mono-multisyllabic words

M, mild-mod. AOS, mod.-severe aphasia ◦ Monosyllabic

◦ Mono-, multisyllabic

M, moderate AOS, mod. Aphasia ◦ ABA words of increasing length

◦ Naming

◦ 3X repetition

◦ Picture description

Prosody/Rate ◦ Slow rate in “on-target” and “off-target” phrases

and sentences

◦ Inability to increase rate while maintaining sound integrity

◦ Prolonged movement transitions

◦ Prolonged interword intervals

◦ Abnormally long vowels

◦ Increased movement durations

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Sound Errors: ◦ sound distortions

◦ distorted substitutions, perseverations, anticipatory, exchange, and cluster errors (primarily prolonged phonemes and devoiced sounds)

◦ location of errors is relatively consistent from trial to trial

◦ types of errors are consistent (NOT VARIABLE) from trial to trial

◦ schwa insertions common

M, mod-severe PP, moderate Conduction aphasia ◦ Monosyllabic words

◦ Conversation

M, moderate PP, moderate Conduction aphasia ◦ Words

◦ conversation

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Dronkers (Nature, 1996) – insula (superior, precentral gyrus of insula), double-dissociation ◦ 25 AOS, 19 non AOS

◦ Ogar et al., 2006 – additional S’s

◦ AOS subject selection problematic: catastrophe: “/patastrophe/, /t/, /katasrifrobee/, /k/, /kata/, /sh/….I don’t know”

◦ Hillis (2004) suggests insula is particularly vulnerable to MCA occlusion

Hillis (2004) – different approach: probability of insular lesion causing AOS - no assoc. between AOS & insula ◦ Pts. studied patients at stroke onset with Diffusion

Weighted MRI (DWI; to identify areas of infarct) and Perfusion Weighted MRI (PWI; to identify areas of reduced blood flow or hypoperfusion)

◦ 80 left MCA stroke – 40 with and 40 without insular damage

◦ ½ pts. with AOS had insular damage ◦ 2/3 pts. without AOS had insular damage ◦ 84% of pts with AOS had hypoperfusion to Broca’s area; 9%

w/o AOS had hypoperfusion to Broca’s area left, inf. frontal gyrus assoc. with AOS

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McNeil et al. (1990) – 2/4 S’s with relatively pure AOS had insular damage

Robin and colleagues (2008) – post hoc ◦ 7 pts. with relatively pure AOS ◦ Structural MRI ◦ Only region of overlap was BA 6 in 6/7 pts. ◦ 1 subcortical only – basal ganglia & insula ◦ All had lesions beyond BA 6 (especially BA 44 &

BA45)

Left posterior inferior frontal gyrus (BA 44 &45)

Supplementary motor areas (BA 6)

Insula

Parietal lobe

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ABA-2 (Dabul, 2000) ◦ DDK Rate

◦ Increasing Word Length

◦ Limb Apraxia and Oral Apraxia

◦ Latency Time and Utterance Time for Polysyllabic Words

◦ Repeated Trials

◦ Inventory of Articulation Characteristics of Apraxia

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Exhibits phonemic anticipatory errors (e.g., gleen glass for green glass) ◦ Not an AOS symptom (level of phonology)

Exhibits phonemic perseverative errors (e.g., pep for pet) ◦ Not an AOS symptom (level of phonology)

Exhibits phonemic transposition errors (e.g., Arifca for Africa) ◦ Not an AOS symptom (level of phonology)

Exhibits phonemic voicing errors (ben for pen) ◦ Could be AOS or PP (phonologic or motoric)

Exibits phonemic vowel errors (moan for man) ◦ Could be AOS or PP (phonologic or motoric)

Exhibits visible/audible searching ◦ Could be AOS or PP

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Exhibits numerous and varied off-target attempts at the word o Numerous attempts = consistent with AOS o Numerous, varied, off-target = PP

Errors are highly inconsistent o NOT AN AOS SYMPTOM

Errors increase as phonemic sequence increases o Consistent with AOS & PP

Exhibits fewer errors in automatic speech than in volitional speech ◦ Consistent with AOS & PP

Exhibits marked difficulty initiating speech ◦ Consistent with AOS & PP

Intrudes a schwa sound between syllables or in consonant clusters ◦ Consistent with AOS

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Exhibits abnormal prosodic features ◦ Consistent with AOS

Exhibits awareness of errors and inability to correct them ◦ Consistent with AOS & PP

Exhibits a receptive-expressive gap ◦ Consistent with AOS & PP

Duffy, J.R. (2005). Motor speech disorders. Substrates, differential diagnosis, and management (2nd ed.). St. Louis, MO: Elsevier Mosby.

AOS screening tool

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Sound repetition

Monosyllabic words – inventory of consonants in (i) and (f) positions: fife, pipe

Polysyllabic words

Increasing length

Repeated productions

Sentence repetition

AMRs & SMRs

Counting

Days of the week

Singing familiar tunes

Conversational & narrative speech

Reading aloud

Slowed rate of speech production ◦ Increased interval time between word and syllables

◦ Increased time to produce individual sound segments and to transition between sounds

Sound Errors ◦ distortions (predominant type), perceived

substitutions, omissions, additions (intrusive schwa)

◦ relatively consistent across repeated productions - location and type

Prosodic Abnormalities

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Articulatory groping

Increasing errors with increasing word length or complexity

Perseverative errors

Speech initiation difficulties

Awareness of errors (e.g., self-corrections)

Automatic speech better than propositional speech

Islands of error free speech

Sound Errors

◦ Percentage of errors

◦ Level of breakdown

Intelligibility

Rate/ durational measures

◦ Segments

◦ Syllabic/word durations

◦ ISIs

Measures of prosody

Ratings of naturalness

Functional measures

Non discriminatory behaviors

Etc.

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AOS

Sound error analysis Intelligibility assessment Durational analysis Quantification of accompanying behaviors OTHER

Aphasia Oral, nonverbal apraxia Dysarthria Cognition

Sounds in isolation * Single monosyllabic words/syllables (all word

positions) Multisyllabic words Words of increasing length Phrases Sentences Discourse

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Repetition

Oral reading

Sentence completion

Self generation

Patterns

Generative analysis

% of errors

Level of breakdown - context & elicitation

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May use assessments designed for dysarthria

Should not use primary clinician as “listener”

◦ Use another clinician

◦ Use a student

◦ Use a significant other Be consistent in use of listener

False starts Silent or audible groping Starters Fillers Overall communication efficiency

◦ (e.g., CIU’s/time) Perceived effort # of verbal initiations

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Content measure in discourse

Narrative & procedural discourse elicited systematically

Measures ◦ Total # words

◦ Total # CIUs

◦ Efficiency measure

Normative data

4 single pictures (cookie thief, picnic scene, cat up tree, dog & birthday cake)

2 sequences of pictures

2 response to requests for personal information Do on Sundays?

Where live? Describe.

2 procedural descriptions Doing dishes

Write & send a letter

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TREE: Ah how say that…cat cat da ah dog ahm

man bird girl ah bike bike ahm how say that two men ahm how say that hm ah gi gi truck truck trunk

Words: 22

CIUs: 9

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Nicholas, L.E., & Brookshire, R.H. (1993). A system for quantifying the informativeness and efficiency of the connected speech of adults with aphasia. JSHR, 36, 338-350.

Most applicable if working on rate control or prosody

Syllables or words per second

Efficiency measure (e.g., CIUs per minute)

Segmental measures – acoustic analyses

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Sound error analysis

Intelligibility assessment

Durational analysis

Accompanying behaviors quantification

Paucity of functional outcome measures

◦Majority of measures reflect WHO body function

◦WHO activity and participation levels have received limited attention

◦Wambaugh & Mauszycki (2010)

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Functional Assessment of Communication Skills for Adults (ASHA FACS; Fratalli et al., 1995)

Communication Effectiveness Index (CETI; Lomas et al., 1989) & CETI-M (Ball et al., 2004)

Quality of Communication Life Scale (ASHA QCL; Paul et al., 2004)

Dysarthria Impact Profile (DIP; Walsh, Peach, & Miller, 2009).

Communicative Participation Item Bank (Baylor et al., 2010)

Walshe, M., Peach, R.K., & Miller, N. (2009). Dysarthria impact profile: development of a scale to measure psychosocial effects. Int. Journal of Language and Communication Disorders, 44(50), 893-715.

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Effect of dysarthria (AOS – speech difficulty) on me as a person

Accepting my dysarthria (AOS)

How I feel others react to my speech

How dysarthria (AOS) affects my communication with others

10-14 questions per section

Negatively and positively worded

I am as confident now as I was before I had a speech problem.

I am not happy with my speech as it is now

I don’t care what people think of my speech

The difficulties I have with my speech restrict my social life

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Sponsored by Academy of Neurologic Communication Disorders and Sciences (also supported by ASHA’s SIG 2)

J. Wambaugh, J. Duffy, M. McNeil, D. Robin, M. Rogers

www.ancds.org

Wambaugh, J.L., Duffy, J.R., McNeil, M.R., Robin, D.A., & Rogers, M.(2006). Treatment guidelines for acquired apraxia of speech: A synthesis and evaluation of the evidence. Journal of Medical Speech Language Pathology, 14(2), xv-xxxiii. Wambaugh, J.L., Duffy, J.R., McNeil, M.R., Robin, D.A., & Rogers, M.(2006). Treatment guidelines for acquired apraxia of speech: Treatment descriptions and recommendations. Journal of Medical Speech Language Pathology, 14(2), xxxv-ixvii. Wambaugh, J.L. (2006). Treatment guidelines for apraxia of speech: Lessons for future research. Journal of Medical Speech-Language Pathology, 14(4), 317-321.

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English language reports published through 2003

59 published reports ◦ there was measurement of effects of treatment on the

impact of acquired apraxia of speech (AOS) at any or all levels of functioning

◦ authors must have indicated their intention 1) to treat AOS; 2) to measure the impact of a treatment on AOS; or 3) to impact the sequelae of AOS

◦ report must have provided some form of data pertinent to the effects of treatment with at least one person with AOS

“n” = 146

Etiology: 93% CVA, 5% TBI, 2% other

Gender: 78% male, 22% female

Age: mean = 54 yrs, min-max = 21-82

TPO: mean = 31 months; median = 14

months; min-max: 2 weeks – 192 months

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Highest Confidence Limited Confidence

Little to No Confidence

0

10

20

30

40

50

60

70

80

1 2 3

% o

f S

tud

ies

65 % Class IV - uncontrolled studies, case series, case reports, or expert opinion

33% Class III - controlled trials (including well-defined natural history control subjects or patients serving as own control subjects) in a representative population where outcome assessment is independent of patient treatment

2% Class II - prospective matched group cohort study in a representative population with masked outcome assessment

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Relatively small “n” overall and in individual studies

Few attempts to replicate findings

Only a few systematic lines of research

Synthesis of findings of studies with generally similar foci (e.g., AAC, rate/rhythm control)

Consequently, treatment guidelines are more general than specific

General approaches summarized ◦ rationales

◦ treatment techniques

◦ treatment targets

◦ outcomes

◦ participants

◦ candidacy issues

◦ quality of the evidence

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Articulatory-Kinematic – use of techniques to improve articulatory accuracy

Rate/Rhythm control – use of techniques to reduce rate, impose timing or rhythm

Intersystemic reorganization – use of relatively intact systems to facilitate speech production

AAC – use of alternative or augmentative means of communication

Other

Therapies that “concentrate on the disordered articulation…(and) emphasize the regaining of adequate points of articulation and the sequencing of articulatory gestures” (Rosenbek et al., p. 463).

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Repeated practice

Modeling

Integral stimulation

Articulatory placement cues

Shaping

Minimal contrast practice – practice of contrasts

Visual biofeedback

Verbal feedback

PROMPT

Nonspeech movement practice (e.g., tongue tip movements)

Txs. that imposed control over rhythm/timing/rate

Rationale for use: ◦ Increased time to reach articulatory postures ◦ Improved functioning of central pattern generators ◦ Decreased degrees of freedom in speech production ◦ Increased allocation of resources ◦ Motoric “spillover” ◦ Increased afference

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Metronomic pacing

Finger tapping – finger counting

Instructional feedback

Computerized pacing – oral reading

Pacing board

Indirect control (MIT, PROMPT)

Use of a relatively intact system to facilitate functioning of another system

Iconic Gestures – Amerind most frequently used to facilitate and/or supplement speech

Rhythmic Gestures – tapping, fingercounting

Vibrotactile Stimulation – externally applied rhythmic stimulation

Singing – choral singing, sentence completion, phrase production

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Gestures – Amerind most frequently used

Communication boards/notebooks

Spoken computer output

Multiple communication systems – writing,

drawing, notebooks, gestures

Electrolarynx

Alternative strategies for unproductive

behaviors

Conversational practice

Training significant others (e.g., interviewing

skills)

Head movement training

Biofeedback for tension reduction

Silent rehearsal

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Case/

Series

S-S

Design

Group

Non-

exp.

Group

Exp.

Internal

Validity

Artic-Kinem. 14 14 1 1 13

Rate/Rhythm 4 3 0 0 3

Intersyst. 4 4 0 0 3

AAC 7 1 0 0 1

Other 4 1 0 0 0

articulatory kinematic approaches - “probably

effective”

rate/rhythm control approaches - “possibly

effective”

intersystemic approaches - “possibly effective”

AAC approaches - could not be rated in terms

of likelihood of benefit

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Designations which “communicates the guideline developers’ (and the sponsoring organizations’) assessment of the importance of adherence to a particular recommendation” (Marcuse et al., 2004)

“guidelines are never intended to overrule professional judgment; rather they may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance”

Strong recommendation – none

Recommendation - articulatory kinematic approaches be utilized with individuals with moderate to severe AOS who demonstrate disrupted communication due to disturbances in the spatial and temporal aspects of speech production

Options – rate/rhythm, intersystemic, AAC

In 2006 there was no evidence concerning superiority of one technique over another

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Treatment for AOS can be expected to result in improvements in speech production, particularly when treatment has an articulatory-kinematic focus

More than half of the evidence base is derived from A-K treatments

Across all studies, all participants had AOS plus aphasia

Evidence base is modest in terms of “n” and experimental control, but is improving

New Guidelines Committee ◦ Kirrie Ballard – chair

◦ Joe Duffy

◦ Mick McNeil

◦ Julie Wambaugh

◦ Edwin Maas

◦ Shannon Mauszycki

In process – initial report provided at ASHA 2013 convention, published update expected soon

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~32 studies identified beyond the 2006 ANCDS guidelines report

◦ 23 - articulatory kinematic tx.

◦ 2 - rate/rhythm control tx.

◦ 1 - implicit phoneme manipulation tx.

◦ 1 - visual speech perception

◦ 2- script training (1 w/ A-K; 1 w/ sp. percep.)

◦ 2 – multimodality stimulation

◦ 1 – tDCS (+ modeling/repetition/slowed rate)

Feedback ◦ Frequency

◦ Timing

◦ Biofeedback

Repeated Practice

Stimuli

Instructional Method

Intensity of Treatment

Plus tDCS

Feedback

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Frequency of Feedback : “n” = 4 ◦ High Frequency Feedback (HFF) = 100%

◦ Low Frequency Feedback (LFF) = 60%

◦ Performance enhanced with LFF for 2/4

Timing of Feedback: “n” = 2 ◦ Immediate Feedback = no delay

◦ Delayed Feedback =5 second delay

◦ Performance enhanced with DF for 1/2

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Sensors placed on articulators of interest (lips, teeth, tongue)

Display provided to participant - target zone for the desired sound/word

Series of treatment investigations by Katz and McNeil et al. ◦ Improvements in articulation reported for

participants with chronic AOS

Cost may be prohibitive

Targeted control of voicing (“n” = 2)

Used spectrographic feedback + phonetic placement cues

Participants consistently produced voiced fricatives and stops as voiceless prior to treatment

Improvements seen for treated and untreated sounds (of same manner)

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No new studies published recently

Mauszycki et al. – in progress with 3 AOS speakers

Biofeedback of tongue position relative to palate

Cost may not be prohibitive for clinical practice

May be desirable for persons with AOS who have issues with proprioceptive feedback

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◦ Timing

◦ Biofeedback

Repeated Practice

Stimuli



Plus tDCS

Repeated Practice

10 participants

Chronic AOS + non fluent aphasia

Repeated practice tx. only until plateau

Metronomic pacing + hand-tapping added

after plateau

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8/10 improved from repeated practice alone

Addition of metronome resulted in slight

improvement for a few participants

2/10 did not improve with any treatment

At least a few sound errors remained after tx.

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43


◦ Timing

◦ Biofeedback

Repeated Practice

Stimuli



Plus tDCS

Stimuli

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Scheider & Frens (2005) trained complex and less complex non words – “n” = 3 (e.g., Level 4: natigbo, Level 1: bobobobo) ◦ Complex generalized to less complex (1 of 4 tx.

opportunities)

◦ Less complex generalized to more complex (1 of 4 opportunities)

Equivocal findings

Differs from findings from Aichert & Ziegler (2008)

Aichert & Ziegler (2008) – “n” = 4 ◦ Production of words with complex syllables (e.g.,

CCVCC) improved following practice of less complex

◦ Less complex were derived from the more complex

◦ Phonetically similar syllables may share motor program units at subsyllabic levels

Schoor, Aichert, & Ziegler (2012) found generalization occurred only when practiced and unpracticed syllables overlapped in the POSITION of shared syllabic constituents (i.e., same initial consonant and vowel)

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◦ Timing

◦ Biofeedback

Repeated Practice

Stimuli



Plus tDCS


Treatment involved provision of information concerning manner & place of articulation ◦ Verbal

◦ Gestural (cued articulation)

◦ Combined verbal + gestural

No clinically relevant difference among delivery modes

Suggested that type of information provided (artic. Instruction contrasting target & error) more important than delivery method

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◦ Timing

◦ Biofeedback

Repeated Practice

Stimuli



Plus tDCS


Principles of experience-dependent neural plasticity (Kleim & Jones, 2008): “intensity matters” - increased intensity is likely to be associated with improved outcomes

But…distributed practice vs. massed practice or treatment trials: distributed practice over a longer period of time may produce superior results (Janiszewki et al., 2003; Schmidt & Lee, 2005)

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Blocked Practice: More rapid acquisition effects during treatment

Randomized Practice: Better maintenance effects

Schmidt & Lee, 2005

Multiple Baseline Design ◦ Across Participants

◦ Across Behaviors

4 replications of treatment

Intensive – Blocked

Intensive – Randomized

Traditional – Blocked

Traditional – Randomized

Wambaugh et al. (2013). AJSLP

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Intense

4 hours per days / 4 days per week

32 hours of tx. over 2 weeks

Traditional

1 hour per day / 3 days per week

32 hours of tx. over 11 weeks

Blocked: all items for a given sound target practiced in a block, then all items for the other target practiced in a block

Randomized: items for each sound target were practiced in alternating manner

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Positive changes in articulation occurred for all treatment variations for all participants

For the INTENSE application, performance was similar for Blocked and Random for all Participants

For the TRADITIONAL applications, P2 and P3 had poorer performance upon conclusion of the Random treatment, but differences were not apparent at follow-up


◦ Timing

◦ Biofeedback

Repeated Practice

Stimuli



Plus tDCS

Plus tDCS

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Anodic tDCS – used to increase cortical

excitability.

Compared to a sham treatment

Both paired with A-K therapy with “n” = 3

Improvements found with both conditions

BUT…greater increases with tDCS condition for

all participants – maintained at 2 months post

tx.

3 new investigations (Brendel & Ziegler, 2008; Mauszycki & Wambaugh, 2008, Wambaugh et al., 2012)

Reinforces previous findings that practice in the context of rate/rhythm control results in improved articulation – without direct articulation instruction

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pacing tones reflect the natural, relative

distances of syllables (taken from waveforms)

compared to non-pacing, control tx. – variety

of artic.-kinem. techniques

10 speakers with AOS

both txs. reduced # errors

MPT reduced dysfluencies

Mauszycki & Wambaugh (2008) ◦ Participant with mild AOS

◦ 4-5 syllable words & sentences

◦ Reduced rate, then increased rate

◦ Positive findings

Wambaugh et al. (2012) ◦ Modest improvements in sound production accuracy

with addition of R/R tx. for some, but not all participants

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Use of AAC device as a means for improving speech production; as opposed to replacing and/or supplementing speech

Lasker et al. (2008; 2010) ◦ Speech generating device

◦ Motor Learning Guided Treatment

◦ Face-to-face plus home practice with AAC device

◦ Also…employed Skype (2010)

Interest in capitalizing on theorized actions of mirror neurons (automatic process that

links/matches observed actions with performance – shared motor representations for observation and execution – controversial)

◦ Fridricksson et al. (2012) – “speech entrainment” (integral stimulation)

Computerized therapy ◦ Whiteside et al. (2012)

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Principles of Motor Learning ◦ Trend toward increased interest / use ◦ Maas et al., (2008) AJSLP

Combining AOS and aphasia therapy ◦ Youmans et al. (2011) – SCRIPT + artic. Instruction ◦ Wambaugh et al. (in prep) – Combined Aphasia and

Apraxia of Speech Treatment (CAAST)

Modified Response Elaboration Training (M-RET) plus Sound Production Treatment

Designed to improve… ◦ Production of content (Correct Information Units)

◦ Length of utterance

◦ Sound production

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CIUs (Correct Information Units; Nicholas & Brookshire, 1993) ◦ With experimental stimuli (trained & untrained

pictures) ◦ With N & B stimuli

Percent Consonants Correct – sentence repetition ◦ With printed sentences ◦ Without printed sentences

Word Intelligibility

Participant 1

0 5 10 15 20 25 30

SE

T 1

: #

CIU

s

0

20

40

60

80

100

120

140

160

180Baselilne Treatment

0 5 10 15 20 25 30

SE

T 3

: # C

IUs

0

20

40

60

80

100

120

140

160

180

Probe Sessions

0 5 10 15 20 25 30

SE

T 2

: #

CIU

s

0

20

40

60

80

100

120

140

160

180

Follow Up2 & 6 weeks

adjusted trend line

adjusted mean line

d=8.89

d=6.9

d=4.12

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Participant 2

0 5 10 15 20 25 30 35

SE

T 3

: #

CIU

s

0

10

20

30

40

50


0 5 10 15 20 25 30 35

SE

T 1

: #

CIU

s

0

10

20

30

40

50

60

Probe Sessions

0 5 10 15 20 25 30 35

SE

T 2

: #

CIU

s

0

10

20

30

40

50

60

Maintenance Follow Up2 & 6 weeks

adjusted trend line

adjusted mean line

d=5.41

d=6.11

d=3.8

Participant 3

0 5 10 15 20 25 30 35 40

SE

T 1

: #

CIU

s

0

20

40

60

80

100

120

140

160

180

200

220


0 5 10 15 20 25 30 35 40

SE

T 3

: # C

IUs

0

20

40

60

80

100

120

140

160

180

200

220

240

Probe Sessions

0 5 10 15 20 25 30 35 40

SE

T 2

: #

CIU

s

0

20

40

60

80

100

120

140

160

180

200

220

240

Maintenance Follow Up 2 & 6 weeks

adjusted trend line

adjusted mean line

d=15.52

21.63

d=5.72

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Participant 4

0 5 10 15 20 25 30 35

SE

T 2

: #

CIU

s0

10

20

30

40

50


0 5 10 15 20 25 30 35

SE

T 3

: #

CIU

s

0

10

20

30

40

50

60

Probe Sessions

0 5 10 15 20 25 30 35

SE

T 1

: #

CIU

s

0

10

20

30

40

50

60

Maintenance Follow Up 2 & 6 weeks

adjusted trend line

adjusted mean line

d=13.64

d=16.01

d=5.79

All participants CIU production with experimental stimuli ◦ Trained pictures

◦ Untrained pictures

2/4 participants CIU productions in Nicholas & Brookshire task

2/4 participants PCC in sentence repetition – larger increases with written stimuli

1/4 participants intelligibility

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AOS Guidelines update indicates a trend toward use of PML ◦ Treatments based specifically on PML

e.g., Motor Learning Guided (MLG) Lasker et al. (2008)

◦ Many treatments have incorporated some PML – including SPT

Few direct tests of PML applied to AoS tx.

Systematic review by Bislick et al. (2012) ◦ Limited evidence with some promising findings

◦ More research needed

Blocked practice – all trials for a given behavior are grouped together in a practice session

Random practice – across the practice session different behaviors are practiced in non predictable order

Robust effects in motor learning literature ◦ More rapid improvements during practice with

Blocked practice

◦ Better retention and generalization with Random practice

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Knock, Ballard, Robin, & Schmidt (2000) ◦ 1 of 2 participants had advantage for random

practice (probe performance)

Wambaugh, Nessler, Cameron, & Mauszycki (2013) ◦ Pilot investigation with 4 participants

◦ Treatment intensity & practice schedule

◦ No differences observed for random and blocked practice schedules

Maas & Farinella (2012)

Dynamic Temporal and Tactile Cueing treatment (Strand et al., 2006)

Findings ◦ 2 participants - advantage for Blocked

◦ 1 participant – advantage for Random

◦ 1 participant – no response with either

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To examine the effects of Sound ProductionTreatment (SPT) administered with BLOCKED stimulus presentation and with RANDOM stimulus presentation on accuracy of production of target sounds

NOT designed as a pure test of blocked vs. random practice

◦ Maintain the basic SPT protocol ◦ Focus on optimizing clinical application

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n: 6

Gender: 5 men, 1 woman

Etiology: stroke

◦ L hemisphere, ischemic, MCA

MPO: 28 to 87 months

Age: 46 - 71 yrs

Yrs. Ed: 11-20

Handedness: right

Hemiparesis: RUE & RLE

Consistently slow rate

Sound errors ◦ often perceived as distortions

◦ relatively predictable – location and type of error

◦ some sounds consistently in error

Disrupted prosody

after McNeil et al., 2009

62

P1 P2 P3 P4 P5 P6

AIDS 56% 28% 24% 6% 74% 48%

monosyllabic 67% 27% 33% 15% 55% 68%

bisyllabic 45% 14% 19% 3% 51% 36%

trisyllabic 0% 0% 5% 0% 20% 15%

4-syllable 0% 0% 5% cnt 5% 10%

5-syllable 0% 0% 0% cnt cnt 0%

sentences 0% 0% 0% cnt 27% 0%

Estimated Severity

MOD MOD-SEV

MOD-SEV

SEV MOD MOD

WAB – Type of Aphasia Broca’s

WAB AQ 28.7 – 68.9

PICA Overall Percentile 41st – 63rd

63

Single subject multiple baseline design across behaviors & subjects ◦ Minimum of 5 baseline probes

Treatment applied sequentially to 2 sets of words

2 week no-treatment interval after 1st treatment phase ◦ Maintenance probe with 1st treated set at 2 weeks

◦ Extended pre treatment probing with 2nd set

Follow-up probes at 2, 6, and 10 weeks following end of all treatment

2 sets of 30 items each ◦ 20 treatment & 10 generalization items

◦ 15 exemplars for each of 2 sound targets

10 tx & 5 generalization items for each target

Individualized for each participant ◦ Monosyllabic words – 3 syllable words w/ carrier

phrase

64

P2: Set 1 – T1 stab, start

T2 rose, news

Set 2 – T1 glass,globe

T2 knife, leaf

P6: Set 1 – T1 threading, throughout

T2 glossary glamorous

Set 2 – T1 snapdragon, snowmobile

T2 quietly, quotation

Step 1: Modeling-repetition ◦ minimal contrast practice on error (monosyllabic)

Step 2: Orthographic cue + modeling/rep

Step 3: Integral stimulation

Step 4: Articulatory production instruction

Next Item

Blocked & Random Phases counterbalanced

65

20 sessions per phase

3X per week

Treatment time = 50-60 minutes

# trials determined by session length ◦ Fewer trials in initial sessions

Probes conducted prior to treatment ◦ Excluded from session length determination

ASHA certified SLPs

Accurate production of sound target in words produced in probes

30 words for each set presented one at a time by examiner and repetition requested

Scored online with audio recordings used for verification

Target required to be produced… ◦ Without distortion

◦ In correct location of word

◦ Number of correct syllables required

66

Conducted following every 2 treatment sessions

Completed at start of session, preceding treatment ◦ Short term maintenance

◦ Differs from “acquisition” as used in motor learning literature – NOT performance during practice

Participant 1

0 5 10 15 20 25 30 35 40 45 50 55

Set

1 %

Corr

ect

Blo

cked T

reatm

ent

0

10

20

30

40

50

60

70

80

90

100

Probe Sessions

0 5 10 15 20 25 30 35 40 45 50 55

Set

2 %

Corr

ect

Random

Tre

atm

ent

0

10

20

30

40

50

60

70

80

90

100

Baseline Treatment Maintenance Follow-up2, 6, & 10 wks.

2 wk.no tx interval

Treated

Untreated

&

&

adjusted trend line

adjusted mean line

67

Participant 2

0 5 10 15 20 25 30 35 40 45 50 55 60 65

Set

1 %

co

rrect

Rando

m T

rea

tmen

t

0

10

20

30

40

50

60

70

80

90

100

Probe Sessions

0 5 10 15 20 25 30 35 40 45 50 55 60 65

Set

2 %

Corr

ect

Blo

cked T

rea

tmen

t

0

10

20

30

40

50

60

70

80

90

100

Baseline Treatment Maintenance2 wk.

no tx interval

Follow-up2,6,&10 wks.

Treated

Untreated

&

&

adjusted trend line

adjusted mean line

Participant 3

0 5 10 15 20 25 30 35 40 45 50 55 60

Se

t 1

% C

orr

ect

Ra

nd

om

Tre

atm

en

t

0

10

20

30

40

50

60

70

80

90

100

Probe Sessions

0 5 10 15 20 25 30 35 40 45 50 55 60

Se

t 2

% C

orr

ect

Blo

cke

d T

rea

tme

nt

0

10

20

30

40

50

60

70

80

90

100

Baseline Treatment 2 wk.no tx interval

MaintenanceFollow-up

2, 6, & 10 wks.

Treated

Untreated

&

&

adjusted trend line

adjusted mean line

68

Participant 4

0 5 10 15 20 25 30 35 40 45 50 55 60

Set

1 %

Corr

ect

Blo

cked T

reatm

ent

0

10

20

30

40

50

60

70

80

90

100

Probe Sessions

0 5 10 15 20 25 30 35 40 45 50 55 60

Set

2 %

Corr

ect

Random

Tre

atm

ent

0

10

20

30

40

50

60

70

80

90

100

Baseline Treatment2 wk.

no tx interval Maintenance Follow-up2,6, & 10 wks.

Treated

Untreated

&

&

adjusted trend line

adjusted mean line

Participant 5

0 5 10 15 20 25 30 35 40 45 50 55 60

Set

1 %

Corr

ect

Blo

cked T

rea

tmen

t

0

10

20

30

40

50

60

70

80

90

100

110

Probe Sessions

0 5 10 15 20 25 30 35 40 45 50 55 60

Set

2 %

Corr

ect

Rando

m T

rea

tmen

t

0

10

20

30

40

50

60

70

80

90

100

Baseline Treatment

2 wk. no tx interval Maintenance Follow-up

2, 6, & 10 wks.

Treated

Untreated

&

&

adjusted trend line

adjusted mean line

69

Participant 6

0 5 10 15 20 25 30 35 40 45 50 55 60

Set

1 %

Corr

ect

Blo

cked T

reatm

ent

0

10

20

30

40

50

60

70

80

90

100

Probe Sessions

0 5 10 15 20 25 30 35 40 45 50 55 60

Set

2 %

Corr

ect

Random

Tre

atm

ent

0

10

20

30

40

50

60

70

80

90

100

Baseline Treatment Maintenance Follow-up2, 6, & 10 wks.

2 wk. no tx interval

Treated

Untreated&

&

adjusted trend line

adjusted mean line

70

See Wambaugh (2010) in Perspectives for Summary

Articulatory - kinematic approach ◦ “is a nonlinguistic sensorimotor disorder of

articulation.....Therefore, therapy should concentrate on the disordered articulation...(and) emphasize the regaining of adequate points of articulation and the sequencing of articulatory gestures” (Rosenbek et al., 1973)

Derived from Rosenbek et al.’s (1983) “8-step continuum”

Techniques ◦ Verbal and visual modeling ◦ Repeated practice ◦ Integral stimulation ◦ Minimal contrast practice

target sound paired with typical replacing sound provides articulatory contrast

71

Identify problematic sounds

Determine appropriate level/complexity of production

Prioritize sounds to be treated

Group sounds to be treated

Elicit production of all sounds in desired word positions

Productions should include several exemplars of each sound with varied phonetic context

Randomized presentation likely to be more difficult than blocked

72

Suggest selecting 1-3 sounds to be treated

at one time 8-10 items needed for each sound (if only

one word position) ◦ “items” = monosyllabic words, multisyllabic words,

words in phrases/sentences ◦ Real words preferred

matching minimal contrast words for each ◦ may need to approximate error

vary phonetic contexts!!! (variety of vowels) ◦ vary syllable shape if appropriate

/r/ = 30% accuracy ◦ ray → way

◦ rip → wip

/sh/ = 0% accuracy ◦ shy → sigh

◦ she → see

/k/ = 10% accuracy ◦ key → dee

◦ car → dar

73

Level of success

Impact on intelligibility ◦ % in error

◦ homonymy

◦ frequency of occurrence in language

Trial therapy - stimulability

ray…way (CV…eɪ) rip…whip (CVC…ɪ) rock…wok (CVC…ɑ) rue…woo (CV…u) right…white (CVC…aɪ) reed…weed (CVC…i) row…woe (CV…o) rut…what (CVC…ʌ)

74

shave…save (CVC…e) ship…sip (CVC…ɪ) shock…sock (CVC…ɑ) shoe…Sue (CV…u) shy…sigh (CV…aɪ) she…see (CV…i) show…sew (CV…o) shun…sun (CVC…ʌ)

Kay…day (CV…e) kill…dill (CVC…ɪ) cot…dot (CVC…ɑ) coo…do (CV…u) cab…dab (CVC…æ) keep…deep (CVC…i) comb…dome (CVC…o)

Ken…den (CVC…ɛ)

75

Distortions errors

More than one replacing sound

Cluster errors

Perseveration

pie….die (CV…aɪ) pot….dot (CVC…ɑ)

ping….ding (CVC…ɪ)

pea….thee (CV... i ) pay…they (CV…eɪ) pope…dope (CVC…o) pen…then (CVC…ɛ)

pert…dirt (CVC)…ɝ)

76

lie…thy (CV…aɪ) low…though (CV…o) lip…dip (CVC…ɪ) late…date (CVC…eɪ) lamb…dam (CVC…æ) lark…dark (CVCC…ɑr) luck…duck (CVC…ʌ) loose…deuce (CVC…u)

star…tar stop…top sty…tie stew…two store…tore stack…tack Stan…tan stow…toe

77

Step 1 – Modeling/Imitation

Step 2 – Modeling + Written letter cue/Imitation

Step 3 – Integral Stimulation

Step 4 – Modeling with silent juncture

Step 5 – Artic. Placement instructions & production of sound in isolation

All steps ◦ 5 additional repetitions attempted upon correct

response Step 1

◦ target only attempted initially ◦ Minimal pair introduced only upon incorrect

response Step 3

◦ Integral stimulation attempted up to 3X Step 4

◦ eliminated Step 5

◦ Integral stimulation integrated with articulatory placement cues

Blocked and random practice incorporated into trials

78

1. Say word and request repetition ◦ if correct, request additional repetitions (5 times*)

and go to next item. ◦ if incorrect, give feedback and say: “Now, let’s try

a different word” and present minimal pair word.

if correct, give feedback and say: “Now, let’s go back to the other word” & go to step 2 with the target word

if incorrect, give feedback, attempt with integral stimulation up to 3 times and go to 2 with target word

2. Show letter representing the target sound, say word, and request repetition

◦ if correct, request additional repetitions (5 times*) and go to the next item

◦ if incorrect, go to 3

79

3. Integral stimulation – “watch me, listen to me, and say it with me” up to 3 times ◦ If correct, request additional repetitions (5

times*) and go to next item ◦ If incorrect, go to 4

4. give Articulatory Placement Cues, attempt word again after cueing using integral stimulation ◦ if correct, request additional repetitions (5

times*) ◦ if incorrect, go to next item

5. go to the next item

Moderate AOS

Severe AOS /s/

/l/

/b/

80

hierarchy applied to each target word ◦ response contingent

◦ not reversed

8-10 words presented in random order = 1 trial

attempt to complete at least 6- 7 trials per session

session – 45 min to 1 hour

research application – 3X/week

1st trial: blocked presentation ◦ if target sounds are correct in <6/8 words (for any of

the sounds), next trial is blocked ◦ if target sounds are correct in 6/8+ words for all 3

sounds, next trial is randomized

if 6/8 criteria is met (on 1st or any subsequent trials), alternate between blocked and randomized for the rest of the session

but, continue with blocked until criteria is met

81

Blocked

pie, pot, ping, pea, pay, pope, pen, pert

say, sis, seal, sigh, sue, sock, sank, soap

loose, luck, lamb, lark, lie, low, lip, late

Randomized

sis, pope, ping, low, late, sigh, pert, loose, soap, say, pen, luck, pot, sock, lamb….etc.

Probe vs. treatment data

Acquisition measure: is the person learning what he/she has been working on in therapy?

Can the target behaviors be produced when not in the context of therapy? (under similar conditions, but without treatment occurring)

82

Response Generalization Measure – to untrained exemplars of trained behaviors

Production of items that are very similar to the trained items ◦ same target sound

◦ same syllable structure

◦ same elicitation procedure

Response Generalization Measure – to untrained behaviors

production of behaviors that are related to, but not the same as, the trained behaviors ◦ different, but related sound ◦ voiced cognate ◦ similar in manner or place ◦ behavior that MIGHT respond to the treatment of the

trained behavior

83

Stimulus Generalization Measures – to untrained contexts

production of the behavior in contexts that vary from the training context ◦ complexity ◦ phonetic environment ◦ method of elicitation

how where who

Acquisition: 24 trained items produced in response to examiner model prior to treatment session; no feedback; no treatment

Response Generalization (untrained exemplars): 4-5 untrained items of trained sounds ◦ pack, pole, pop, paw

◦ seed, sign, saw, soup

◦ leak, limb, load, lay

84

Response Generalization – untrained, related sounds ◦ /p/ by, bee, bed, bit, bay ◦ /s/ zoo, zip, Zane, zeal, zing ◦ /l/ ??

Stimulus Generalization ◦ different word position ◦ phrases ◦ bisyllabic words ◦ different elicitation mode (e.g., story completion) ◦ etc.

Pt: 55 yr old male, 24 mpo, severe AOS with verbal perseveration, mod-severe Broca’s aphasia

results of sound testing: all sounds except /w/ and /n/ produced incorrectly

perseveration: “water” or variant (i.e., replacing sound = /w/)

85

Develop 8 treatment items and 5 response generalization items (untrained exemplars of trained) for /b/, /s/, /l/ ◦ use CV and CVC syllable shapes

Develop 8 treatment items and 5 response generalization items for /m/ , /f/, /d/ ◦ CV and CVC

Develop response generalization stimuli for sounds of interest ◦ untrained exemplars of untrained, related sounds

◦ suggest 5 exemplars for each

86

Develop at least 2 stimulus generalization tasks to assess treatment effects

3 participants ◦ Moderate to severe, chronic AOS

◦ Significant Broca’s aphasia

SPT applied to one sound at a time

Multiple baseline design across sounds and participants

87

Speaker 1

0 5 10 15 20 25 30 35 40

/z/ (i)

0

20

40

60

80

100

0 5 10 15 20 25 30 35 40

/sh/ (

f)

0

20

40

60

80

100

Sessions

0 5 10 15 20 25 30 35 40

/"j"/

(i)

0

20

40

60

80

100

Baseline Treatment Maintenance 6 wk.

Tx. 1 (z) 1.59 44% increase

Tx. 2 (sh) 1.1 36% increase

Tx. 3 (“j”) 3.6 >50% increase

88

Speaker 2

0 5 10 15 20 25

/sh/ (i

)

0

20

40

60

80

100

0 5 10 15 20 25

/r/ (i)

0

20

40

60

80

100

Sessions

0 5 10 15 20 25

/sw/ (i

)

0

20

40

60

80

100

Baseline Treatment Maintenance 6-wk

Measured to target words embedded in phrases

Speaker 1 – slight change (40% increase) for 1 sound

Speaker 2 – increase to 80% accuracy for all 3 sounds

Speaker 3 – no sustained changes for any sound

89

Wambaugh & Martinez, 2000

Mauszycki & Wambaugh, 2008

Schematic and tapping review

↓ ___ ___ Metronome set at reduced rate (increase

word durations about 50%) ◦ CM – one production ◦ Patient taps along while clinician models (4-5X) ◦ Unison production and tapping (3X) ◦ Patient production (1X)

Feedback = about tapping accuracy, # syllables, production to the beat (not about sound production)

Target items presented in random order (n=20; ?X)

90

Benefit

↓ ___ ___ Spaghetti

___ ↓ ___

Represent

___ ___ ↓

Schematic & tapping review Reduced metronome setting ◦ Clinician model (1X) ◦ PPT (3X)

If errors (tapping to beat or # syllables) then CM (1X) + unison production and tapping

If correct – next word

Feedback – same Scoring: +/- for 1st production of PPT

91

Schematic & tapping review

Metronome set to reduced rate ◦ Clinician produces word with normal rate &

prosody (not to the beat and with no tapping)

◦ PPT (3X) If errors (tapping to beat or # syllables) then CM (1X) +

PPT (3X)

If errors remain, then CM (1X) + UPT (3X)


Feedback – same

Scoring: +/- for 1st production of PPT

Schematic & tapping review

Metronome setting increased from previous levels ◦ Clinician produces word with normal rate &

prosody (not to the beat and with no tapping)

◦ PPT (3X) If errors (tapping to beat or # syllables) then CM (1X) +

PPT (3X)

If errors remain, then CM (1X) + UPT (3X)


Feedback – same

Scoring: +/- for 1st production of PPT

92

Clinician explains concept of syncopation ◦ Target word produced in 2 beats

◦ 1st syllable on first beat

◦ 2nd syllable & 3rd syllable on second beat

Schematic, tapping review

Metronome set at Level 4 rate

Apply syncopation to Levels 1-4

ignorant management crocodile therapy cranium dangerous rosary industry replica generate camisole moccasin

treasury dignity badminton restaurant habitat Winchester celibate satisfy wonderful saxophone fabulous

93

Dangerous Regular Moccasin* Chivalry* Casual* Cranium* Restaurant Calcium* Generate Recipe Beautiful* Fabulous Management* Casserole * = UNTRAINED,

GENERALIZATION ITEMS

Rosary* Wonderful Hospital* Antelope Sensitive* Therapy Badminton Benefit Winchester* Celibate Replica* Dignity* Treasury* Galaxy

Target Pre-Post

% words

Pre-Post

%Cs

Group 1 – Tx. (1st syllable) 9 - 72 64 – 94

Group 1 – Untx. 5 - 60 75 – 85

Group 3 – Tx. (3rd syllable) 20 - 90 67 – 91

Group 2 – Untx. (2nd syllable) 29 - 48 79 – 95

Group 4 – Untx. (4 syllables) 16 - 35 70 – 86

Group 5 – Untx. (blends) 28 - 60 81 - 90

94

Few significant durational changes in probes

Increased duration of 1st syllable

Increased ratio of 1st syllable to total word

Consider combining with a-k

Select rate for practice

Select tx. items

Select generalization items

95

Hand-tapping – hand/location

Amount of therapist instruction/modeling – fading of participation

Type of metronome control – Visible? Audible?

Criteria for changing timing

Type/amount/timing of feedback

Outcome measures

Research supported by VA Rehab. R&D Riverside … 18 Wambaugh handout.pdf · Riverside Community Hospital October 18, ... compensation for this presentation ... what? when? where?

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