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3/30/2018
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New (and some not so new) Responsibilities and Opportunities in
Motor Speech Disorders 2018 SAC Conference
Jay Rosenbek, PhD
COI
• Financial
– Receiving an honorarium for this presentation
– Royalties from Plural Publishing, Cengage and Northern Speech Services
• Non-financial
– None
Learning Outcomes
• Write a rationale for expanding motor speech therapy to cognitive-motor speech therapy
• List the components of a cognitive motor therapy
• Describe specific techniques appropriate to these component
• Describe approaches targeting activity and participation
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But before we go there
• Two reminders
– What are the motor speech disorders
• Three slides
• What is the health of our data base?
Motor speech disorders
– The dysarthrias
– The apraxias of speech
• Acquired
• Progressive, neurodegenerative
Progressive, neurodegenerative Called primary progressive apraxia of speech Josephs & Duffy (2008). Curr Opin Neurol, 21, 688-92 Duffy & Josephs (2012). The diagnosis and understanding of Apraxia of speech. Why including neurodegenerative etiologies may be important. JSLHR, 55, S1518-S1522 May be more frequent these days than that caused by stroke May evolve into a Broca’s-like aphasia Or into something resembling corticobasal degeneration Or even into an ALS variant One of best responsibilities and opportunities
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And our data?
• As Netsell said years ago, “Almost everything we do with dysarthric speakers makes them better.” – If they have the relatively simple conditions identified
by Darley Aronson and Brown sixty years ago • Second half of today spent in part on documenting that
those old days are long gone from the modern clinic
• Same is true in AoS, depending on presence and amount of co-existing aphasia
Netsell supported by data
• Speak more clearly, louder, slower all change speech – Tjaden et al (2014). Impact of clear, loud and slow speech …JSLHR, 57,
779-92
– Tjaden et al (2004). Rate and loudness manipulations in dysarthria…JSLHR, 47, 766-83
– McAuliffe et al (2014). Cognitive-perceptual examination of remediation approaches …JSLHR, 57, 1268-83
• Especially those with hypokinetic and ataxic dysarthria, especially if mild to moderately severe
More data
• Yorkston et al (2007). Evidence for effectiveness of treatment of loudness, rate, or prosody in dysarthria: a systematic review. JMSLP, 15, xi-xxxvi
• 51 articles total
• 21 on loudness
– No surprise: LSVT best documented
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Best candidates
• Best treatment candidates:
• 1. reduced loudness,
• 2. decreased respiratory support,
• 3. good stimulability, and
• 4. high level of motivation
Typical rate data
Yorkston et al, 1990
Rate change influenced intelligibility in hypokinetic and ataxic dysarthria
Most therapeutic change was 60% of habitual
Some, of course, could not tolerate or change rate
At very least rate manipulation can show whether or not a patient can change
And if so the impact on intelligibility
Need a review of rate?
• Blanchet & Snyder (2010). Speech rate treatments for individuals with dysarthria. Per Motor Skills, 110, 965-982
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Data even for the simplest stuff
• Six or so studies of simple directions to encourage some form of “try to speak more carefully” had been published
– Yorkston (1996). JSHR, 39, 546-557
– This too can help
• And for dementia
– “Talk loud”
Almost as simple
• Netsell and Hixon. ASHA 34:152, 1992 • Pt instructed to: take a deep breath and let it out
slowly as you talk • Results
– 3 Of 6 chronic, severe TBI patients got immediate improvements in intelligibility
– With training gains appearing to be maintained
– Patients were still dysarthric but intelligible
Other sample data
• Yorkston et al (2003). Behavioral management of respiratory/phonatory dysfunction from dysarthria: A systematic review of the evidence. JMS-LP, 11, xiii-xxxviii
• Leading to a flow chart for clinical decision making
– Spencer et al (2003). JMS-LP, 11, xxxix-lxi
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One more
• Yorkston et al (2001). Evidence-based practice guidelines for dysarthria: management of velopharyngeal functions. JMS-LP, 9, 257-74
• Palatal life is effective
• Best candidates: – Flaccid soft palate
– Pharyngeal wall movement
– Good orofacial movement otherwise
– Good respiratory drive
APRAXIA OF SPEECH
• A substantial data base
• But the tyranny of the RCT leads to – “Impossible for conclusions to be drawn” about
treatment effects for developmental form • Morgan & Vogel (2009). A Cochrane review of
treatment for childhood apraxia of speech. Eur J Phys Rehab Med, 45, 103-110
– No trials hence no evidence in acquired, adult AoS • West et al (2005). Interventions for apraxia of speech
following stroke. Cochrane Database Syst Rev, 19, CD004298
CONSIDER ENTIRE DATABASE
• “individuals with apraxia of speech can be expected to make improvements in speech production a a result of treatment, even when apraxia of speech is chronic”
– Wambaugh et al (2006a). Treatment guidelines….JMS-
LP, 14, xv-xxxiii
• See also: Wambaugh et al (2006b). Treatment guidelines for acquired apraxia of speech. JMS-LP, 14, xxxv-Lxvii
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FOUR CLASSES OF TX FOR AOS
• Articulatory kinematic: most well-studied
– Includes Sound Production Therapy (SPT)
• Wambaugh & Mauszycki (2010). Sound production treatment with severe apraxia of speech. Aphasiology, 24 (6-8), 814-825
A neat package
• The Pittsburgh group has structured a number of traditional steps into a useful program
• Name has come to be Sound Production Treatment (SPT)
• This program can be used with a variety of severities by simply selecting appropriate stimuli
• It is conceptually sound • And the developers have done the hard work
of research
Overview
• Wambaugh et al JSHR, 41, 1998 (20 years old)
• Five step program, from less to more cueing
• Built on minimal contrast pairs in words
• For example, p vs b (pad vs bad)
• In one experiment one sound was the target – Logical because of frequent AoS error pattern of :
Place, voicing, and plosion for frication errors
• Data based on only fifteen treatment sessions
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Components
• Modeling
• Repetition
• Minimal pair contrasts
• Integral stimulation
• Articulatory placement cueing
• Feedback – All sounds pretty familiar and it should
– We’ve known about txing speech problems for decades
Step one: modeling/imitation
• Clinician produces both in pair and pt says both
• If error, then each one of pair presented and produced separately
• If both correct, repeat and on to next pair
• Provide knowledge of results (good, okay, etc)
• If not, step is repeated
• If still not, went to next step
Step two: modeling +
• Cl showed printed versions of the target
• Says this is the sound you are working on
• Then repeat step one
• If BOTH okay go on to next pair
• If not, go to next step
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Step three: integral stimulation
• If only target was wrong earlier or if both were then only target was subjected to integral stimulation
• Watch me, listen and say what I say
• If correct try to get two to four more repetitions
• If correct go on to next pair
• If target is incorrect go to next step
Step four: modeling with juncture
• Cl produced the target using silent juncture after the target and before the rest of word
• If correct, went to next pair
• If not, went to next step
Step five: articulatory placement
• Cl provided verbal description of sound and produced it in isolation
• Correct or incorrect Cl then went on to next pair
• Or in another version, simplify the context
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Stimuli
• Usually use 8 to 10 stimuli
• In substitutions use sound that most frequently substitutes for the target (one of several emerging rules)
• Try to work at word or phrase level
• Try to use all stimuli in each session
• Try to get through all at least 4 to 8 times per session
Data
• Trained and untrained items improved
• Generalization was limited
• As was maintenance
• Subjects had aphasia and apraxia
• Another problem was overgeneralization of the sound treated
– Started showing up where it was not appropriate
Commentary
• This program uses all the traditional approaches
• It is the time honored task continuum
• The study itself is controlled in the traditional ways with generalization probes, baseline line and maintenance probes
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Value of this report
• Can do the treatment based on it
– So excellent for students and new clinicians
• Some of our very first convincing data
Second major type
• Rate-rhythm control • Gesture
• Metronome
• Metrical in which timing is derived from normal speech
• Vibrotactile stimulation
• Nearly identical to what is popular in dysarthria
Other two
• Intersystemic reorganization pairing (usually) meaningful gesture
– Interesting article on melody and gesture in tx
• Zumbausen et al (2014). Melodic intonation therapy: Back to basics for future research. Front Neurol, 5, 7
• AAC
– Either profound AoS or substantial co-existing language and/or cognitive
deficit
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What these studies tell us
• External stimulation and cueing, using apps or other external devices such as DAF, and prostheses, and instructions for maximum performance, clear speech, phonetically based drill and other suggestions are biologically active in dysarthria and AoS
What the data re-enforce
• The notion that clinical practice is primarily selecting and applying a few simple procedures
• This notion is not entirely helpful
More useful to understand
• Clinicians do not delay, slow, or reverse signs and symptoms, activity limitations or participation restrictions; men and women with motor speech disorders do those things themselves using the clinician’s support, guidance, and the right kind of processes and procedures, procedures that go well beyond external stimulation
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To reach goals
• Of providing support, guidance, and the right
kind of processes and procedures to promote the greatest good (meaning speech, and activity, and participation), for the greatest number of patients, with the greatest efficiency
• Therapies depending on clinician controlled stimulation and focused solely on body structure/function (impairment such as speech sound imprecision) are not enough
Brief aside: Activity and participation?
World Health Organization
These goals contain clinical responsibilities
• 1. Treatment that is less clinician controlled and more patient-centered and cognitive – In this presentation will emphasize the cognitive piece
• 2. Management approaches expanded to include not only impairment (body/structure function) but also activity/participation
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Patient-centered, cognitive-motor therapy for motor speech disorders
When someone mentions cognitive
• Many immediately think, of course, cognitive deficits
often accompany motor speech deficits • True but the point is that treatment can profitably be
cognitive even when and perhaps especially when) patient’s cognition is normal
• Thus – Cognitive approaches to management critical to learning
and generalization in those with cognitive integrity – And some overlapping and some unique approaches for
those with both motor and cognitive deficits
Lets consider an unfortunately common case
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Commentary
• He has learned an active maximum performance task (motor)
• No generalization to his functional speaking
• This is danger of purely
mechanical or motor oriented treatments
And the problem is exacerbated by cognitive deficit
So you are advocating we do even more in treatment?
• Nope
• Emphasis everywhere on productivity, time is a precious commodity
• Cognitive-motor therapy need not take more time – It does require a different orientation to
treatment for some
Not more but some different
• Time to delete or shorten some traditional activities, substitute others
• How many prolongations of /a/ do you need
• Or puh tuh kuh
• Or “Make me a Hong Kong cookie”
• Some are critical if your primary job is differential dx
• Fewer can be sufficient if your primary job is treatment – And I understand the interaction of of eval and tx
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Don’t misunderstand
• A physical exam is one vital organ of clinical speech-pathology
– Select items on everyone allows comparison across patients
– And can improve understanding of why speech sounds as it does
However
• Treatment planning and prognostication involves more than simply sifting the results of the physical examination
• Part of the clinical art is determining – How much physical exam is enough
– What other observations/measures will be helpful to treatment planning
Changing anything may be irrelevant
• If you have never had a patient say, “I talk okay when I
remember to do what you tell me to do.”
– Or a patient’s spouse say some form of “He sure talks better (tries harder) with you than he does at home.”
– Or “She doesn’t really practice as much as she says she does”
– Or “I feel like I’m hounding him about his homework all the time.”
– Or “S/he gets mad when I remind h(er/im) what to do.”
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Or
• If your goal is only acquisition in the clinic-not generalization
• Or if your goal is limited to changing body structure/function and not activity and participation – Most of us know that changes in body structure/function
usually do not transfer magically to activity/participation
– And sometimes that some changes in body structure/function do not even generalize to other body structure/function abnormalities
If
• You have heard some of
those comments
• Of if you want generalization outside the clinic
• And to influence who a patient is and what s/he does outside the clinic
Then
• Cognitive-motor treatment makes some sense
• Or-perhaps more appropriately for experienced clinicians-making treatment even more cognitive makes sense
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Begins with shifting the emphasis
• The emphasis is less on manipulating patient’s speech (which in many if not most instances is pretty easy to do)
• More on teaching patient to manipulate speech independent of clinician, or
• More on enhancing value of and memory to perform those manipulations away from clinic and clinician (which in many instances is harder)
Said another way
• Emphasis is less on what to do and more on remembering to do it
A more cognitive treatment includes
• Step one: Determining patient’s willingness to undergo the rigors of treatment
• And to influence if willingness is in short supply
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Measuring willingness
• Not in our usual bag of evaluative tricks
• Can be measured at least roughly
• Improving /creating willingness is possible
• Doing so places us firmly inside cognitive activities as part of cognitive-motor therapy
Willingness
• Has a peculiar place in traditional SLP
• Clinicians-if narrowly taught-assume patients are excited about improvement
• Education/experience confirm not always the case
Scaling stage of willingness
• Stage one: Precontemplation: person has lack of knowledge that change is necessary or lacks motivation to change
• Stage two: Contemplation: considering change but not committed
• Stage three: Preparation: committed to change in near future
• Stage four: Action • Stage five: Maintenance
– DiClemente & Prochaska (1982). Self-change and theorizing change…Addict Behav, 7, 133-42
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Mistake to assume
• That all persons are at Stage 4 even if they come to or seek out treatment
• Or that enthusiasm, an evaluation and explanation of treatment will move them there
• Beginning a motor treatment if person at earlier stage is wasteful
Some would say
• Reduced willingness explains at least a portion of why only 5% or so of men and women with Parkinson’s disease-the second most common neurodegenerative disease-are in or have been in treatment – Referral another reason of course
• Reduced willingness also contributes to non-compliance for some already enrolled in treatment
Insight into stage
• URICA-VOICE questionnaire
– Teixeira et al (2013). The use of the URICAS-VOICE…Codas, 25, 8-15
• 35 items, Rated 1-5 with
– 1=strongly disagree
– 3=neutral
– 5=strongly agree
• Sample item: voice treatment is a waste of time for me because my voice does not bother me
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Stage one is frequent
• Some (usually dysarthric) do not recognize the presence or severity of deficits
• Especially with basal ganglia deficits – Structures importance in monitoring and evaluating
self-generated cues (such as vocal loudness)
• Can be a problem even in those with final common pathway lesions – Joseph Heller (author of Catch-22) wrote with Speed
Vogel a book on his struggles with Guillain Barre – He did not know how unintelligible his flaccid
dysarthria was
Treatment implications
• External cueing fine for
demonstrating to the clinician and patient’s satisfaction that speech can be modified
• To showing at least limited biological activity
• And to begin the training in monitoring and identifying speech adequacy
A data base is growing
• For example: – Kopf et al (2015). Video influences behavior
change measures for voice and speech in individuals with Parkinson’s disease. Proc Wirel Health, doi: 10.1145/2811780.2811932 • Video from internet used to influence stage and self-
efficacy
• Included videos describing disease effects on speech and effects of treatment
• Results: readiness to change was enhanced
• 5 of 8 subjects moved along the stages
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Step two: evaluating and treating self-efficacy
• Reduced willingness and getting stuck at stage 2 or 3 may in some be related to
– Lack of self-efficacy
Self-efficacy
• Defined as an estimate of a person’s confidence in abilities to change – Interacts with motivation/willingness
• Measures of self-efficacy – See: Williams & Rhodes (2014). Confounded self-
efficacy construct…on line 10:1080/17437199.2014.941998
– Lee et al (2008). Interplay of negative emotion and health self-efficacy…Commun Res, 35, 358-81
Treatment suggestions
• Motivational interviewing
• See: (www.motivationalinterviewing.org), for a set of attitudes and methods for helping people consider change; and therapeutic manipulation
– Lopes, L. W., Vilela, E. G. (2016). Self-assessment and readiness for change in dysphonic patients. Codas, July 4:0:0. doi: 10.1590/2317-1782/20152013088
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Motivational interviewing
• Week-long workshops on topic so just a mention here
• If you are looking for ways to freshen your practice this may be one
• Principles include – Client centered and emphasizing pt autonomy
• Approach person as equal-clinician not holder of the answers
• Lets look for evidence you have changed something in past
Another tool
• Communicative effectiveness survey – Eight items
– Scored 1=not at all able to 7=very effective
– So maximum score is 56
• Items – Speaking to family in quiet place
– To stranger in quiet place
– Familiar person on phone
– Stranger on phone
Neila Donovan
Others
• Speaking when angry or upset
• Having conversation in car
• Having conversation in noisy environment
• Having conversation with someone at a distance
• We get both pt and caregiver to complete
– And here arises specific treatment material
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Other values of measure
• Easy
• Quick
• Functional
• Can also be used as outcome measure and folded into a functional goal
• In public domain
• Does not cost a cent
• And it leads directly to treatment
Difference between pt and spouse
• These can be explored with both persons
• For example, pt gives higher scores than spouse – Okay lets explore this in a non-judgmental way – This is tough stuff – But can write a functional goal: more or less equal
estimates from pt and spouse for example
Step three: reconciling expectations
• Differences in patient and clinician expectations – May affect willingness
• For your consideration (or reassurance if you have been doing this since time immemorial) is the need as an early evaluation/treatment task to compare expectations
• And why they differ if they do
• Another cognitive task
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Expectations
• Needs balance in expectations early on in tx
• A balance between what the pt wants from therapy
• What the clinician thinks is possible
• Any gap must be resolved
• Or treatment is likely to fail
Cl expect
Pt wants
And in one of the worst cases
Patient expects nothing
And clinician thinks sky is the limit
TO AVOID FAILURE
• Need to work toward
Cl expect
Pt wants
or
Cl expect
Pt wants
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One portion of getting balance
• Agreeing on goals
• Clinicians traditionally identify
– Improved precision, reduced hypernasality, faster speech, other impairment oriented goal
– Increased intelligibility
– Sometimes increased naturalness
• Patients may have completely different vocabulary
Procedure which grows from this
• Discussion with pt about what specific speech characteristic(s) patient is labeling and reacting to
• And then listening to speech samples together to identify
• This is slow, frustrating stuff often
Other steps
• Step four: Cooperative planning
• Step five: Use plasticity language, appropriate to patient
• Step six: Flip the switch-don’t speak; speak therapeutically
• Step seven: Keep speech in a box
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Fourth, cooperative planning
• Put first but for some may be delayed till they gain increased confidence, awareness and sense of efficacy
• This is common sense stuff
– Discussion of agreeing on goals fits here, for example
– As does selecting at least some stimuli
– And discussing pt preference for autonomy
– As does scheduling and amount and type of work outside clinic
Fifth: plasticity language
• We speak about “getting your brain to substitute for the
damaged nervous system part(s)” – With reminder that this substitution occurs most predictably
with careful, control
• One emphasis here is on self-efficacy-on ability to change
• And on making it a brain-based thing • How worded depends, of course, on ability and
understanding of each patient
Plasticity
• Cells are looking for something to do
• Cells that fire together wire together
– Hebb
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Sixth: Flip the switch
• Or engaging volitional-purposive control
• The best treatment for speech is NOT speaking; its THERAPEUTIC speaking
• Tx follows a rough shape
That shape
• Emphasis on planning prior to production – Many pts hate this and acceptance requires
counseling
– And clinician promise that its not forever, unless it is
• We tell them to call this step whatever
• MUST agree to flip, regardless of name
• Otherwise at mercy of phonetics and spontaneous recovery
That shape
• identify a cue to prompt the planning (flipping) – Such as a slight shift in posture
– Or quick inhalation
– Or gesture
• Then practice, practice, practice – On patient generated-or at least selected-
responses as opposed to imitation whenever possible
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Seventh: speech in a box
• Next is “keeping speech in a box” • Means avoiding long utterances
– Keep it short – Tell me one thing – Or use one word – Or one short answer – Try to use meaningful stuff from the first – Remember the simplest direction of all: speak as
clearly as you can • Remarkable how often that works when blended with the
rest
In a box
• This is another of the cognitive components that requires work
• Drill, drill, drill
• Functional, important to patient speech are most challenging stimuli
• Must avoid allowing person to merely talk or functional practice becomes ineffective practice – NOT talking but talking Therapeutically
Only a few words
• Pt must judge speech adequacy-loudness, rate, precision, etc-whatever has been agreed upon
• First cl and pt agree on what speech characteristic(s) will be emphasis
• Next, cl and pt agree on a scale of adequacy • Usually three points which pts usually
immediately turn into 5 (1.5 2.5) • The anchors are 1=the speech they came to you
with and 3=the best possible speech (not normal usually)
Step eight: Listen and evaluate response adequacy
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We drag out one of these
1 2 3 4 5
Old speech
Best possible
Best possible
A brief story Pt with multiple medical problems
Mixed but primarily ataxic dysarthria
Typical articulatory and prosodic breakdowns plus some pretty predictable sound (fricative mostly) distortions
The characteristic she wanted to change” “I don’t want to sound dumb”
“What about speech do you worry makes you sound dumb?”
“Its so slow”
The conundrum: getting the brain to assume the cerebellum’s role requires thousands of repetitions of careful and carefully monitored speech
• Get complete view of what pt requires to assign the higher scores
• May have to negotiate this if pt only accepts normal
• Use most functional possible responses
• First warning them that they will be responsible for assigning a scale score
Other components
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Other continued
• Then the pt followed by the clinician evaluate the response – Gives insight into what pt really values as target
• Differences are resolved
• Repeat
• Continue resolving differences
• Slop in the scale is unavoidable
Step nine: judging effort
• Effort the pt feels is being invested in talking therapeutically
• Cl and pt work out a 3, 5 or 7 point scale of effort
• Pts reject treatments even ones that improve intelligibility and naturalness if they perceive them as requiring too much effort (5,6,7)
• We write an effort reduction goal into our plans of care
Effort continued
• Try to move at least two effort points
• Effort that stays in range of 5-7 is harmful to carry over
• Effort in the 1-3 range is better
• Effort seems to be mostly concentration for our folks
• Score effort only once per session usually
• Score themselves outside clinic
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Step ten: Add cognitive-linguistic load
• Part of art and science of rehab is stimulus selection
• Many now arguing that all stimuli should be functional – Before tx ends for sure
– But in beginning too much load may require more resources than patient can muster
Sometimes a surprising notion
• Load in the form of hard, rare, nonstimulable items may actually speed generalization
Begin as data do in language
• Looked at typical and atypical exemplars as part of semantic feature training in naming therapy
• Atypical as in gibbon rather than chimpanzee
• Training on atypical produced more generalization to untrained items
• Kiran, Thompson. 2003. JSLHR, 46, 773-787
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More on generalization
• Training of linguistically more complex sentence forms generalizes more than treatment of simpler
– Thompson et al. 2003. JSLHR, 46, 591-607
• Lead her to formulate a complexity account of treatment efficacy (CATE)
• CATE is also shown to be powerful in phonology
Selected data in AoS
• Comparison of cluster training vs singleton training, N=2
• One got generalization from cluster training to singletons and two sound clusters but no generalization from singleton training
• The other pt got generalization to singletons in both conditions – Maas et al (2002). Aphasiology, 16, 609-622
Other data in AoS
• Trained N=3 individuals with syllable sequences varying in complexity
• POPOPO vs PO PI PA
• Training in complex generalized to real word production but training in simple did not – Schneider & Frens (2005). Aphasiology, 19, 451-471
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Admittedly
• Ten cognitive items are a lot
• And we may not require all of this and in fact don’t in the beginning
• May introduce as treatment moves along
• HOWEVER if a patient is not finally able to do all these things improvement will be
– Limited and contingent mostly on environmental cueing
Who are these steps easiest for?
• Those with more peripheral disease – Muscle disease – Final common pathway – ALS, except for 5 or more % with co-existing higher
cortical dysfunction
• The further up the neuroaxis the more the challenges – Progressive supranuclear palsy, Parkinson plus
syndromes
Txing activity and participation
• “If the goal of intervention is to improve communicative participation, intervention may need to extend beyond traditional speech-language pathology boundaries to include other health symptoms as well as personal, social and physical environments” (p.143)
• Baylor et al (2010). Variables associated with communication participation in people with multiple sclerosis: a regression analysis. AmJS-LP, 19, 143-153
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How to do that?
• Get insight into the activity/participation restrictions pt experiences
– Eadie et al (2006). Measuring communicative participation: a review of self-report instrumentation…Am J S-LP, 15, 307-320
• No measure does the complete job necessary but some do some things
• Consider: ASHA Quality of Communicative Life. Paul et al (2004). Manual. ASHA publication
Next
• Write one or more goals addressing one or more of these restrictions
• Then the touch part----create therapy to reach that (and other goals, of course) that or those goals
• Our typical impairment work will not do it
What might help: 1
• Involving family and friends in treatment from the outset
• A learner is most likely to recover learned material in environments that resemble those in which the material was originally learned
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What might help: 2
• Group therapy
• Not much data here in dysarthria but some intriguing work
What might help: 3
• Life Participation Approach to Communication Disorders
• You recognize this as Life Participation Approaches to Aphasia
Communication partners
• Heart of method is – Pairing speaker with dysarthria with a partner
• Need not be-and some would say-should not be a family member
• Person comes into treatment and learns goals and cueing – Hunter et al (1991). The use of strategies to increase speech
intelligibility in CP. BJDC, 26, 163-174
• Then cl, cp and patient work out participation activities
• Complete
• Come back to clinic and describe what went well and what did not
• What did not becomes focus of next tx
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Bit more on method
• No need to go farther here as this is the idea’s birthplace
• But to be clear
• This is not bringing others in for education in a traditional sense
• This is a method for making others skilled, facilitating communicators
Some interesting and complicating data
• Partner training – Hunter et al (1991). BJDC, 26, 163-174
– Excellent modern version of this is by • Borrie et al (2012). Perceptual learning of dysarthric
speech: a review of experimental studies. JSLHR, 55, 290-305
• The data based lessons – Listeners can be taught to understand and this is a critical part
of treatment
– Clinicians learn as well and that may contaminate their view of how much better the pt is
What might help: 4
• We would do well to expand our view of rehabilitation
• From an impairment model that emphasizes speech goals
• To include an enablement model that emphasizes speaker goals
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In summary
• After 46 years of practice I am still dissatisfied with most of my treatment effects in motor speech disorders
• Like all of you I continued to ask myself: what could I do better?
• At this moment the answer that satisfies most is: make treatment cognitive
• Leave acquisition for the insurance companies and administrators
• And emphasize not only body structure/function but also activity/praticipation
Thanks
