How should we treat apraxia of speech?

Rosemary Varley

Language & Communication, UCL

Speech learning/intervention• How much is our philosophy of therapy influenced by general culture

of education (and language teaching in particular)?

• Teacher/therapist instructs by sharing declarative/conscious/explicit knowledge of [X] with learner.

• Therapists knows about articulatory phonetics; this knowledge shared with patient; patient acquires knowledge & relearns speech control.• Microstructural (also articulatory-kinematic or sound production therapy).

• Therapy rebuilds segmental plans & provides practice in combining gestures to form cohesive syllables:

• Typically, ‘easy’ sounds combined with set of maximally different vowels.

Evidence-Base for Microstructural Therapy

• Wambaugh, et al. (2006). J. Medical Speech-Language Pathology. Treatment Guidelines for Acquired Apraxia of Speech: A Synthesis and Evaluation of the Evidence• Majority of research on microstructural/articulatory therapies• Outcomes: Learning of targeted gesture/syllable but poor

generalisation of learning• If therapy uses nonsense syllables, therapy might lead to little

functional gain in speech.

• Cochrane Review (2009): “No evidence was found for the treatment of AOS.”

• Therapists view as hard-to-treat condition.

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Concerns about being explicit

• Speakers have explicit knowledge about some aspects of language (e.g. vocabulary), but in other areas knowledge is procedural & implicit (syntax, speech control), Ullman (2001).

• Articulatory therapy based on premise that declarative knowledge converted to procedural knowledge.

• Internal focus of attention (e.g. directing attention to position of muscles) leads to less automaticity in complex motor skill learning that an external focus (Wulf, et al., 2001. Quart. J. Expt. Psych.).

• Ballard et al. (2011). Motor Control. Poorer retention of novel speech movement in healthy learners with kinematic feedback on location of tongue (EPG), than those without feedback.

Microstructural Therapy

Whole wordTherapy

Sub-components of movements

Whole words/utterances

Isolated motor processinge.g. non-speech gestures;

nonsense syllables

Connectivity: sensory-perceptual; linguistic

Declarative/conscious knowledge

Procedural knowledge

Errorful learning Errorless learning

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Therapy Dose• Ample evidence that low-dose therapy ineffective in achieving

significant behavioural gains (e.g., Pulvermüller, et al. 2001; Bhogal, et al.,2003; Bowen et al., 2012; Leff & Howard, 2012).

• Challenge of achieving high-dose intervention in cost-effective way.

• Use of computer self-managed therapy model.

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Example Interfaces

Intervention Study

• 51 participants with chronic AOS+

(min. 5 months post-onset).

• Loaned laptop. Advised to use intervention regularly for short periods (‘little and often’). Supported by visiting T in early stages. Program records user interactions.

• 6-week intervention period

• Study design: Cross-over• Participants complete two ‘interventions’: active (speech) vs. sham (visual)• 4-week rest phase between interventions• Randomised to two groups: speech-first vs. sham-first

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Tx 2 (6 weeks)

Tx 1 (6 weeks)

Baselines (x2) &

Randomisation

Speech

Sham

Sham

Speech

Re-test

Maintenance (8 weeks)

N = 51

N = 44

Visual Sham Intervention

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Outcome Measures

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• Speech Production repetition & naming single words; plus spontaneous speech samples at baseline & maintenance

• 3 word sets (35 words each)

• Untreated behaviours• Written word-picture matching (PALPA 48, Kay et al., 1992)• Spoken sentence-picture matching (CAT, Swinburn et al., 2004).

• Cost-effectiveness assessment

Treated Phonetically-matched Untreated

Non-matchedUntreated

Dog Door Game

Generalisation to Un-Tx Words

Tx: ‘Dog’ P-match ‘Door’ U-tx.‘Game’Significant

improvementz -3.825 p<.0001

Significant improvement

z -2.884 p<.004

No change

Whiteside et al (2012) Neuropsychological Rehabilitation 12

B1

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Compliance with ‘little and often recommendation’

•Program use (hours:mins in 42 day period)• Speech program: 3:32 – 50:29; M=16:48• Sham program: 0:41 – 50:09; M=14:54•No significant difference between

sham/speech-first groups in level of use of either program

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Summary & Conclusions

• Intervention study with large sample of patients, administered single treatment protocol.

• Self-administered, IT-based therapy may represent cost-effective way of resolving dosage problem.

• Word-level therapy for AOS was effective.

• Effects most evident on treated word forms.

• Gains on treated words maintained.

• Evidence of generalisation to phonetically-similar untreated words (although no wholescale generalisation).

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CollaboratorsSandra Whiteside & Patricia Cowell

(University of Sheffield)

Research team

Lucy Dyson; Lesley Inglis; Abigail Roper: Tracey Young

Additional collaborators

SLTs across South Yorkshire, & in particular Rotherham NHS

Funders

The Health Foundation; BUPA Foundation: University of Sheffield/HEIF4 knowledge transfer grants

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Conflict of Interest Statement

Sword Software

• Software program is commercially available

• ‘Inventors’ Varley, Whiteside & Cookmartin receive share of royalties from sales

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Thank youVarley, R. A. & Whiteside, S. P. 2001. What is the underlying impairment in acquired apraxia of speech? Aphasiology, 15, 39-49.

Varley, R. 2011. Rethinking aphasia therapy: a neuroscience perspective. International Journal of Speech-Language Pathology, 13, 1, 11-20.

Whiteside, S.P., Inglis, A.L., Dyson, L., Roper, A., Harbottle, A., Ryder, J., Cowell, P.E., & Varley, R.A. 2012. Error reduction therapy in reducing struggle and grope behaviours in apraxia of speech. Neuropsychological Rehabilitation, 22, 267-294.

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Input 1• Computer models errorless spoken word-picture matching

Input 2• Computer models errorless spoken-written word matching

Input 3• Interactive: Participant performs spoken word-picture matching task

Input 4• Interactive: Participant performs spoken-written word matching task

Input 5• Computer models errorless spoken lexical decision task

Input 6• Interactive: Participant performs spoken lexical decision task

http://www.propeller.net/sword.htm

Output 1• Observe video of speaker saying target word

Output 2• Imagined production of words

Output 3• Immediate repetition of words

Output 4• Delayed repetition

Output 5• Repetition with audio-recording & playback

Output 6• Practice of target words in sentences

Output 7• Production of word in isolation, with cue support if needed