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XXXApraxia of Speech

XXX Apraxia of Speech Final Exam

What is Apraxia of Speech (AOS) AOS is a motor speech disorder resulting from impairment in programming of sensorimotor commands for speech
What are sensorimotor commands for speech? the motor commands needed to position and move the muscles for volitional speech production.
Can AOS occur without weakness or slowness? AOS can occur without significant weakness or neuromuscular slowness.
Can AOS occur without Aphasia Yes. Whether or not AOS occurs with or without Aphasia depends on the lesion site.
There are two kinds of AOS Apraxia and Dyspraxia
What is the difference between Apraxia and Dyspraxia? Apraxia means without action and Dyspraxia means disordered action
In Ideomotor apraxia there is disturbance in what? the performance of individual movements or performance of movements
With Ideomotor apraxia response is easier when manipulating a real object or responding to a gestural command.
Ideomotor apraxias include limb apraxia nonverbal oral apraxia (which can co-exist with verbal apraxia) Verbal Apraxia (which is apraxia of speech)
Neurological Basis for AOS damage to left frontal lobe especially when near Broca’s area (that is why it often occurs with Broca’s Aphasia)
AOS often occurs with Broca’s Aphasia damage to left frontal lobe and with a UUMN dysarthria
Motor planning / programming relates to the compiling of motor commands for the production of phonetic segments and syllables at particular rates and with particular patterns of stress and prosody based on acoustic goals and feedback – Duffy
What is the neurological ‘mechanism’ thought to control the programming and planning for speech the Motor Speech Programmer
What is the Motor Speech Programmer? a concept of what must be in the brain in order to analyze the linguistic motor sensory and emotional information through neural connections with appropriate brain areas
What does the Motor Speech Programmer do turns information into neural code that represents muscular contractions necessary for speech
Where might the Motor Speech Programmer be? near the perisylvian area of the left hemisphere where it would have close associations with language and motor centers
The existence of the Motor Speech Programmer is inferred because humans can rapidly sequence speech movements and damage to this area disrupts the ability to carry out the tasks necessary for speech
What are the etiologies for AOS? any event that damages the ‘motor speech programmer’ such as injury to the perisylvian area of the Left hemisphere and also from injuries to two other areas: The Insula and the Basal Ganglia
Etiologies for AOS percentage based Vascular 58% (single Left hemisphere stroke 48%) followed by Degenerative 16% and TBI 15%
Key Evaluative Tasks for AOS: compare SMR to AMR! Conversational speech and reading. Repetition of complex multisyllabic words and sentences. But diff with severe cases…
Key Evaluative Tasks for AOS for Severe Cases compare SMR to AMR! Counting! Imitating simple CVC syllables! Singing!
Speech Characteristics of AOS: ARTICULATION AND PROSODY; inconsistent speech errors
Confirmatory Signs for AOS groping difficulty starting speech
In severe cases of AOS patients may be mute or able to only produce a few stereotypic phrases.
AOS Articulation Errors substitutions are more common than distortions/omissions/additions but PLACEMENT ERRORS ARE MOST COMMON
With AOS Articulation Errors Fricatives and Affricates are more error prone than other sound classes and Clusters and Multisyllabics are error ridden.
With AOS automatic speech is better than novel utterances and speakers are often aware of errors.
How does AOS affect Prosody??? Not clear how it affects it… but the rate of connected speech is slow there is equalized stress across syllables there are silent pauses and there is reduced pitch and loudness variations
What are some other speech components of AOS? voluntary respiration might be disrupted but reflexive is intact No significant resonance problems Phonation varies
How does Phonation vary with AOS? Mild-mod = no isolated phonation deficits but with SEVERE AOS voluntary phonation can be impaired…
Does AOS have neuromuscular alterations? NO. There are no neuromuscular alterations with AOS.
AOS is predominantly what? AOS is predominantly an Articulation and Prosody disorder…
With Dysarthria damage could be at ANY ANATOMICAL LEVEL…
With Dysarthria deviant speech characteristics are due to what kind of alterations? Neuromuscular Alterations
With Dysarthria what components of speech can be altered? With Dysarthria ALL COMPONENTS OF SPEECH MAY BE AFFECTED.
AOS is often associated with Aphasia
AOS has variable errors that can include modality automaticity and linguistic
With AOS there may be GROPING
What kind of oral mech exam do you find with AOS? A NORMAL Oral Mech Exam with AOS
With Dysarthria there isn’t usually a co-occurrence of aphasia
Dysarthria is consistent with regard to speech characteristics across modality
Dyarthria does NOT have groping
Spastic Dysarthria may present with dysphagia drooling pseudobulbar affect and hyperactive reflexes
AOS does not have random uncontrolled movements like Hyperkinetic Dysarthria
AOS has regular ______ and ABNORMAL... AOS has regular AMRs and Abnormal SMRs. There is a mismatch between automatic speech and propositional speech and there is GROPING / attempts to correct.
Ataxic Dysarthria has IRREGULAR ________ and NORMAL ________: Ataxic Dysarthria has IRREGULAR AMRs but Normal SMRs. No groping no corrections.
A person can have a PURE apraxia or a pure aphasia and can have a COMBO of BOTH (which would no longer be pure)
In pure apraxia the pt.’s reading writing and A/C should be intact but aphasia will affect multiple language modalities.
Apraxia Errors: Anterior Brain Damage co-occurs with Broca’s Aphasia difficulty initiating speech results in disturbed prosody substitutions in phonemes and syllables are close but not quite right
Literal Paraphrasias: POSTERIOR brain damage co-exists with Wernicke’s Aphasia Normal prosody little difficulty initiating words substitutions far from intended sounds
Not all individuals with AOS are appropriate candidates for TX
Patients need to understand the rational of Tx
Tx with AOS repetitive and intensive drill work sequenced carefully to maintain a high success rate
Patient in AOS treatment should learn to monitor their own treatment
Treatment with AOS should focus on functional and useful words as soon as possible
Absent or mild aphasia: Meaningful stimuli can be used
Moderate aphasia: Treatment needs to improve both language and movement
Severe aphasia: Emphasis should be on language and communication
Severe AOS: Usually requires building speech up from basic units of sound and syllables using phonetic placement and derivation as well as imitation of carefully selected stimuli
Moderate and mild AOS: Will allow for typical treatment paradigms of imitation contrastive stress drill and systematic expansions of client control over planning and execution
Therapy for the severe apraxic If imitation is not possible try phonetic placement If not possible go to phonetic derivation beginning with whatever verbal or nonverbal movements the speaker can make
Brown Initiating Phonation cough shape into sigh or exhalation try humming or completing an automatic phrase upon phonation go to loudness and shape into vowels add m open/closed variations
DAB Automatic Responses 1-10 days of week months of year prayers nursery rhymes commercials common expressions
DAB Phonemic Drill: m hum cv with vowels 20x each double the cvs cvc with same consonant real words same initial change final consonant two words begin with m two words end in m 2 words begin and end with m (Make them)
Severe Apraxia: Take inventory of spontaneous utterances and the conditions underwhich they are produced Try to get forceful and repetitive imitation of these utterances eliciting the longest meaningful stimulus possible
Moderate to Mod Severe AOS Contrastive stress drills Rosenbek’s 8-step continuum MIT cuing to pt cuing move away from imitation to narratives
8 Step Continuum: watch me/listen to me say in unison imitate after model imitate after silent model repeat independently read while looking read after visual prompt state in response to question state in role playing
Melodic Intonation Therapy singing accesses undamaged right hemisphere thus more intact melody rhythm with volitional speech sing words than work towards more natural prosody.
Three levels in MIT Elem singing and tapping together immediate repetition produce response to question Intermediate = delayed repetition Advanced = delayed repetition more like normal speech with 6 second delay. ‘
ORLA Oral Reading for Language in Aphasia ORLA Cherney graphemes to phonemes sentences and paras read aloud in unision then with clinician then independently pointing to words occurs
PROMPT Prompts for Restructuring Oral Muscular Phonetic Targets proprioceptive pressure and kinesthetic cues to sequence oral movements clinician acts as motor speech programmer
AOS most commonly suggested principles pair auditory and visual focus on transitional movement not individual phonemes use repetitive practice carefully consider hierarchy of stimuli use decreased rate gradually progress to normal rate
Combine these three for apraxia bottom up approach tactile gestural approach prompt tactile cueing prosodic approaches (MIT and Contrastive Stress)
Motor Learning is acquiring the ability for producing skilled action through experience and practice multifactor influences
Some things that affect Motor Learning motivation focused attention repetitive practice mass practice instead of distributed frequent sessions number and content of stimuli random versus blocked practice variability of practice feedback
Conditions that help with AOS therapy amount of practice mass versus distributed practice variability of practice and feedback these help with motor speech disorders!
Random is better than blocked
Feedback helps with generalization



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