In our last newsletter, we compared and contrasted the motor learning principles used routinely in treating childhood apraxia of speech with our proposed motor reconnect principles for treating people who have already learned how to talk but have an acquired impairment. In this edition, we will discuss in more detail the principles and techniques of this Motor Reconnect Apraxia Program. At a recent presentation, Nancy Helm-Estabrooks offered that, “The fact is that we are beyond using just linguistic therapy with people with aphasia.” (Helm-Estabrooks, 2011). Likewise, we are beyond just doing speech therapy with people with apraxia.Motor Reconnect Apraxia Program – Principles - Recognize that, “Apraxia is different for everybody.” Forget about using a cookie cutter or minimalistic treatment approach that stifles the opportunity for formative assessment and highly ‘responsive-to-change’ treatment.
- Be sure to consistently treat acquired apraxia truly as a movement disorder. Keep your focus on the clients’ knowledge of movements before, during and after execution. While placement cues may play a role treatment (Wambaugh, 2006), they are much less important than movement planning and implementation in MRAP.
- Ensure normal breath support. Have the client initiate each phonation or utterance with a ‘normal’ inhale as if he/she was going to say a few sentences. Keep this simple. Show the client how to ‘let the airflow turn on vocal your vocal folds” using normal body posture, action and inhalation. Minimize instructional details to compensate for the apraxia.
- Ensure metapraxia. This means that the client understands and knows what apraxia is. Help the client absolutely approach apraxia as a movement disorder. This is as much physical training as it is speech therapy http://www.armystudyguide.com/flashcards/flashcards.php?cat=19&qnum=14 .
- Get the patient to embrace his/her mistakes. Movement and sound errors are basically irrelevant as long as intrinsic knowledge of proprioceptive feedback is guiding and monitoring the client’s attempts and later corrections or verifications.
- Be sure to work on the cognitive underpinnings for speech, language and communication early, often, and continually. We know that improving cognition can result in improvements in aphasia. The cognitive skills especially important to improving motor control include: working memory; sustained, selective, alternating and focused attention; cognitive flexibility; and selective mental resource allocation.
- THIS PRINCIPLE IS IMPORTANT. Be sure to have the client working from his/her own memory using the normal self-generated neural pathways for movement patterns. If it is necessary to provide a model, make sure the client pauses and allows your voice to die down in his/her head before responding. Add a distracter stimuli between the presentation and the response to facilitate this intrinsic mental focus. Emphasize that the patient needs to generate a movement pattern as opposed to an imitation. Do not allow the client to struggle, to subvocally rehearse, or try to ‘get a running start’ after your model.
- Disassociate jaw and vocal fold neural controls. Most clients with apraxia seem to present with a concentrated, struggled neural control pattern. Maintain normal head/body posture having the client keep his/her eyes open while paying careful attention to sounds produced and the feel of the movements. Facilitate the client’s use of normal, self generated neural controls.
- The client focuses on finishing the proprioceptive feedback loop. “Your brain sends a message to move – you move – your jaw sends a message back –‘ I moved, here I am, what do I do next’?” - the brain tells then where to go next.” Focus on intrinsic, proprioceptive feedback is the key. Eliminate distracters that require the patient to externally focus (e.g., mirrors, tape recorders, photographs).
- Build in laryngeal pulsing; rhythm and flow (Wambaugh, 2006). Establish presyllabic and preprosodic skills. Reestablish syllable structure use and knowledge early (Zeigler, 2010).
- Introduce vowels as jaw positions with neutral controls separate from the laryngeal musculature. Pay less attention to lips and even less attention to tongue position at first but more as treatment progresses. Increasing accuracy of vowel production tends to come along as reconnection of controls and awareness improves.
- Minimize work on consonants early. If the phonatory apraxia (mental resource demands lessened) and ease in production of the vowels is facilitated (reconnected control), we have found that most consonants come along for free as the program progresses. Ignore cognate pair errors until later in treatment as these often improve as the other skills improve.
- Rely heavily on formative assessment and treatment adjustments. Minute-by-minute, day-by-day stay on top of the opportunities to grow the program and to make adjustments. Be prepared to revisit some activities that client progress would now make therapeutic. It is important to realize that there is no rigid sequencing of treatment activities in the motor reconnect apraxia program. The clinician, in concert with the clients, uses his/her clinical experience, knowledge and intuition in designing and constantly growing the treatment program. The client as an individual will require different activities at different stages of his/her treatment. This is the art of apraxia therapy.
- Move into production of syllables As Soon As Possible (ASAP). Move syllables into words ASAP (e.g., pronouns) and words into canonical sentences ASAP.
- Thread into linguistic contexts when appropriate but make it as early as possible.
- Challenge the client’s system; (e.g., scatpraxia group http://www.aphasiatoolbox.com/?q=smallgroup ). Set up apraxia treatment groups as clients gain much from observing peers. This is where subvocal rehearsing is facilitatory to reconnecting.
- Train like the Navy Seals: Have your client so prepared to move so that it’s not how to do it something (how to phonate; move jaw; speak), it’s what and when to do it (content and intent). He/she needs to be consistently able to phonate and articulate with minimal demands on mental resource allocation. Think automaticity.
- We have found that most of these principles also apply to dysarthria, especially ataxic dysarthria.
- It is our opinion that singing does not directly help the recovery of speech affected by apraxia. By all means, we do recommend that clients who enjoy singing do so for the enjoyment and to get the vocal folds active. In over 30 years of experience, however, including hundreds of hours attempting to utilize music/singing in treatment, we have seen little success in applying singing as a treatment technique.
- Simultaneously address any apraxia affecting arm/hand control. This allows us to: begin to address keyboarding and screen literacy skills, work on any asymbolia (impairment in understanding and using symbols), facilitate the client’s metapraxia, and help the client improve independent therapeutic efforts by recognizing shared elements of the effects of apraxia on various motor functions of the body
- Practice. Practice. Practice. On average, our clients practice about 2.5 hours per day outside of any treatment sessions. The importance of this dedication to practice cannot be overstated. This also means that the client practices both independently and with a practice coach. It is not difficult to train a caregiver to help the client practice. A few treatment sessions a week will not do the trick. Overcoming a moderate-severe apraxia is a daunting task that requires a tremendous amount of therapeutic time on task participating in smart activities.
Stay tuned : - ) . Our next newsletter will describe and discuss in more detail the actual activities involved in our treatment Motor Reconnect Apraxia Treatment program. References: Helm-Estabrooks, Nancy, Cognition and Aphasia: Clinical Implications, Pennsylvania Speech-Language-Hearing Association Convention, 4/7/2011, Pittsburgh, PA Wambaugh J., Duffy J., McNeil M, Robin D., and Rogers M., Treatment Guidelines for Acquired Apraxia of Speech: Treatment Desriptions and Recommendations, Journal of Medical Speech-Language Pathology, Vol. 14, Number 2, 2006 Ziegler, Wolfram, Aichert, Ingrid, and Staiger, Anja, Syllable- and Rhythm Based Approaches to Apraxia of Speech, Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20 59-66 October 2010 |
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