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Sunday, April 17, 2011

New Campaign Apr 17, 2011 at 8:50 AM


Motor Reconnect Apraxia Program – Principles
www.aphasiatoolbox.com 

While this newsletter is primarily intended for speech pathologists, it should also useful be for people with apraxia and their caregivers/coaches. If you missed the previous newsletter, you may review it by visiting our website at www.aphasiatoolbox.com and clicking on Resources then Archived Newsletters.  

SLP: If you would like to refer a client for online treatment or to consult with us in collaborative therapy, contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

 

PERSON WITH APHASIA or CAREGIVER: if you would like to set up an online consultation or for more information contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

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We communicate with hundreds of speech language pathologists (SLP) who treat clients with acquired speech and language problems. The difficulties encountered treating acquired apraxia that impacts speech are a major concern for many SLPs, especially when the apraxic impairment is severe. Likewise, numerous people with residual apraxia have shared their frustration concerning how their unresolved apraxia limits their speech, independence and social life.  The large number of people with apraxia who continue to suffer is unacceptable to us. We have developed the Motor Reconnect Apraxia Program (MRAP)
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 
  1. 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.
  2. 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.
  3. 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.
  4. 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 .
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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).
  10. Build in laryngeal pulsing; rhythm and flow (Wambaugh, 2006).  Establish presyllabic and preprosodic skills. Reestablish syllable structure use and knowledge early (Zeigler, 2010).
  11. 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.
  12. 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.
  13. 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.
  14. Move into production of syllables As Soon As Possible (ASAP).   Move syllables into words ASAP (e.g., pronouns) and words into canonical sentences ASAP.
  15. Thread into linguistic contexts when appropriate but make it as early as possible.
  16. 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.
  17. 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.
  18. We have found that most of these principles also apply to dysarthria, especially ataxic dysarthria.
  19. 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.
  20. 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
  21. 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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Monday, April 4, 2011

New Campaign Apr 4, 2011 at 3:56 PM

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Announcing - The Motor Reconnect Principles for Treating Acquired Apraxia 

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This is an exciting newsletter for the staff at www.aphasiatoolbox.com as we are introducing our new, innovative program for treating acquired apraxia that utilizes motor reconnect principles (MRP). These MRP take advantage of the powerful potential of brain plasticity. We are experiencing excellent success using these motor reconnect principles to help our clients speak and converse again, even those with severe speech impairments related to apraxia.

Traditionally, speech pathologists have used motor learning principles (MLP) in working with apraxia of speech due to stroke or brain injury.   We do know that these principles play a key role in the successful treatment of childhood apraxia of speech (CAS) in children who have not acquired the motor speech skill necessary for speaking ( McGlothlin, 2011, Strand, 2005.   While MLP provide valuable guidance and information, it may well, however, be a misguided interpretation to strictly apply MLP to clients with acquired apraxia.

 

It is important to remember that MLP have emerged from studies that involved, “…nonspeech motor tasks largely performed by individuals with intact motor systems.” ( Mass, et al, 2008). The literature on how motor learning principles apply to impaired motor systems is unsettled at this time. This raises a number of issues related to using motor learning principles to drive treatment for acquired apraxia:

 

  1. First it is unknown whether speech motor control is sensitive to the same principles as nonspeech motor control.  In other words, should we teach people to use rapid, rhythmic movements of the articulators in spoken syllables in the same manner as teaching them to juggle 3 balls? Do the same learning principles apply?
  2. Secondly, we have not defined clearly how the principles of motor learning affect speech versus nonspeech learning.   Is it safe to assume that MLP apply equally to speech and nonspeech treatment?
  3. Thirdly, if clients do already know how to talk, shouldn’t we be taking advantage of neuroplasticity by utilizing activities that facilitate reconnection of the established, albeit damaged, neural pathways?
  4. Since, “…motor control impairment of AOS extends beyond speech and is manifest in nonspeech movements of the oral structures.” (Ballard, 2000) and the vocal folds, separation of the neural controls for the larynx, jaw and tongue/lips is a necessity for successful acquired apraxia treatment.
  5. Nearly all people with acquired apraxia that limits their voice and speech control, also experience phonemic and linguistic and most probably cognitive (e.g., attention; working memory; mental resource allocation) problems (Ballard, 2000, Burns, 2011). This would not be true of non-impaired subjects used in MLP studies. 

 

It is clear that critical differences exist between learning a new motor skill and reacquiring or re-accessing previously mastered motor skills. For example, if a one takes a 5 year hiatus from golfing, he/she still knows how to golf; how to swing and grip a club, the rules of play, etc. He/she does not need to learn to golf; he/she just need to get reoriented and to reactivate motor memory of movement patterns.   He/she may want to take his/her golf swing apart and learn new skills but the basic motor pattern knowledge remains.  

 

Given this, we have developed the motor reconnect principles for acquired apraxia that affects speech and voice. We incorporate these into our Viking Program for Apraxia (VPA). VPA uses both those components MLP that apply to the expanded MRP. This program not only separates and truly treats acquired apraxia as a movement disorder, but also then effectively threads the phonological and language components into practice (Burns, 2011, Hicks, 2010). Carryover into conversation happens naturally as our clients simultaneously engage other clients in group activities such as the Aphasia Communication Cafe (http://www.aphasiatoolbox.com/?q=smallgroup ). 

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Table comparing and contrasting MLP with MRP

 

Motor Learning Principles for CAS                        Motor Reconnect Principles for acquired apraxia

GOAL: to help brain reorganize itself with new neural connections

GOAL: to help brain reorganize itself with renewed and new neural connections

A. Exploiting neuroplasticity: 1. Increase sensory input; 2. Provide many opportunities for specific input; 3. Modulate in lifelike contexts; 4. “Watch my face.”

A. Exploiting neuroplasticity: 1. Moderate/reduce sensory input; 2. Provide more opportunities for intrinsic focus; 3. Modulate in phrase and sentence contexts; 4. “feel- think”

B. Acquisition of performance is not a good index of retention

B. Reacquisition of performance is a good index of retention

C. Random practice is superior to blocked practice. Avoid repetitive trials with a predictable time pattern.

C. Blocked practice can play a bigger role. Utilize repeated rhythmic flows of a self-generated nature (not repetitious)

D. Intent to improve movement is critical.

D. Intent to improve movement is critical. Intent is thought.

E. Focus on individual phonemes should not be in the treatment plan.

E. Focus on individual vowel phonemes should be the treatment plan with early transition to syllable stimuli structure.

F. Focus on vowels a great deal.

F. Focus on vowels a great deal especially to reestablish jaw control.

G. Ongoing practice: blocked early for accuracy toward more random practice.

G. Ongoing practice: blocked early for accuracy toward more random practice.

H. Ongoing practice: lots and lots in context it will be used.

H. Ongoing practice: lots and lots combined with work on phonological, lexical and semantic as appropriate. (Hicks, 2010)

I. Make the ‘feel’ of the movement salient.

I. Make the ‘feel’ of the movement salient, salient, salient.

J. Utilize tactile and proprioceptive feedback.

J. Minimize tactile and maximize proprioceptive feedback.

K. Focus on function, core vocabulary.

K. Reconnect to vocabulary. (sub, pronouns, conjugate)

L. Segment syllables, not phonemes

L. Segment syllables, not phonemes (compounds, tripounds; increasing syllable words)

M. Fold in prosody early.

M. Fold in prosody early. (scatpraxia; OMC)

N. Focus on extrinsic feedback encourage visual and tactile feedback moving toward more intrinsic.

N. Minimize extrinsic feedback; focus on intrinsic feedback.

(adapted from McGlothlin, 2011, Strand, 2005)

 

 

 

Stay tuned : - ) . Our next newsletter will describe and discuss in more detail our treatment program for acquired apraxia.    

 

 

References:

Ballard, Kirrie, Granier, Jay and Robin, Donald, Understanding the nature of apraxia of speech: Theory, analysis, and treatment, APHASIOLOGY, 2000, VOL. 14, NO. 10

 

Burns, Martha, Apraxia of Speech in Children and Adolescents: Applications of Neuroscience to Differential Diagnosis and Intervention, Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders 21 15-32 April 2011

 

Hickok, GregoryThe role of mirror neurons in speech perception and action word semantics, Language and Cognitive Processes, 25: 6, 749 — 776, First published on: 29 March 2010 (iFirst)

 

Mass, Edwin, Robin, Donald, Austermann, Sharon, Wulf, Gabrile, Ballard, Kirie, Schmidt, Principles of Motor Learning in Treatment of Motor Speech Disorders, American Journal of Speech-Language Pathology • Vol. 17 • 277–298 • August 2008 • A American Speech-Language-Hearing Association

 

McGlothlin, Jenny, Utilizing Motor Learning Principles in Treatment of Childhood Apraxia of Speech, Advance Magazine Presentation, http://speech-language-pathology-audiology.advanceweb.com/ 2011

 

Strand, Edith, The Relationship of Practice and Repetition to Motor Learning for Speech in Children with Apraxia, http://www.apraxia-kids.org/site/apps/nl/content3.asp?c=chKMI0PIIsE&b=788447&ct=464503 , 2005

SLP: If you would like to refer a client for online treatment or to consult with us in collaborative therapy, contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

 

PERSON WITH APHASIA or CAREGIVER: if you would like to set up an online consutation or for more information contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

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© 2011 Aphasia Center of Innovative Treatment
This email was sent by Aphasia Center of Innovative Treatment, 800 Vinial Street, B408 , Pittsburgh, PA 15212, using Express Email Marketing. You subscribed to this permission-based list on 2/24/2011.
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