impairment of the ability to perform preplanned volitional purposeful movements in absence of paralysis or weakness, sensory loss, comprehension deficit or ataxia
apraxia
misalignment on page, spatial disorientation is apart of which apraxia?
constructional apraxia
this apraxia is often found with right parietal lobe lesions
constructional apraxia
__________ is one of the biggest contributors to what we see in apraxia
stroke
Desired response may be absent; person may produce haphazard, unrelated movements to get from point a to point b
response
Appropriate movements of two or more gestures may be combined into one
response
Desired ___________ may be accurately completed after several groping gestures
response
Inability to perform visuospatial tasks such as drawing, assembling stick designs, and constructional three dimensional block arrangements
constructional apraxia
which apraxia affects writing?
constructional
Semiautomatic motor ability for dressing oneself is lost
dressing apraxia
Unable to organize the gestures necessary to establish the appropriate relationship between clothes and the body
dressing apraxia
which apraxia is related to visuospatial difficulties in the
right hemisphere
?
dressing apraxia
Inability to carry out facial movements to verbal command
-Commonly seen with left hemisphere/anterior region damage
oral apraxia
this apraxia is commonly seen with
left hemisphere/anterior region damage
oral apraxia
relationship of oral speech to apraxia is __________
unclear
Absence of spontaneous activity of the unimpaired side
unilateral limb apraxia
unilateral limb apraxia is also know as:
sympathetic apraxia
abnormal movements and impairment of activities that require coordination of both hands
unilateral limb apraxia
this apraxia is associated with right hemiplegia and motor aphasia
unilateral limb apraxia
Gestures performed by left arm and leg were severely impaired to command and imitation
unilateral limb apraxia
Apraxia of whole-body movements such as lying down, sitting, standing up or rolling over
whole body apraxia
gait disorder and preservation of whole body movement is seen in which apraxia?
whole body
Correctness of individual elements of a complex act without accomplishing the desired objective
ideational apraxia
the patient fails to apply the elements to a purpose/plan
ideational apraxia
Normal sequence of the overall act may be altered, resulting in inaccurate and sometimes bizarre performances (one action may be substituted for another, steps may be omitted, and preservation of one action into another is common)
ideational apraxia
Isolated gestures are impaired, but the overall purpose may be preserved
ideomotor apraxia
In ideomotor apraxia, the patient may be have difficulty performing volitional acts with the nonparalyzed hand, although performance of ____________________ with the same hand is not impaired
automatic movements
In ideomotor apraxia, disorder rarely presents itself during ________________ and is often detected by tests of ___________________________
-spontaneous activity
-verbal
command/imitation
this apraxia is associated with parietal and temporal lesions
ideomotor apraxia
n articulatory disorder resulting from impairment, due to brain damage of the capacity to program the positioning of speech musculature for the volitional production of phonemes and the sequencing of muscle movements for the production of word
apraxia of speech
a pathology in the left cerebral hemisphere results in which aparaxia?
apraxia of speech
individuals with _____________ apraxia experience:
-numerous phonemic errors, including substitutions, omissions, additions, repetitions, and distortions with a predominance of substitutions in the absence of significant weakness
-slowness or incoordinati
apraxia of speech
_________ errors are more common than manner, voicing or oral-nasal in apraxia of speech
place
which sounds are often correct in apraxia of speech?
alveolar and bilabial
marked prosodic disturbance without phonatory and resonators changes include:
-equal and even stress
-insert inappropriate inter syllabic pauses
-restriction and alteration of normal intonational contours
-normal durational relationships of vowels and consonants are distorted
-rate of production is slowed overall
apraxia battery for adults- dabul
-diadochokinetic rate
-increasing word length
-limb and oral apraxia
-latency and utterance time for polysyllabic words
-repeated trials
-inventory of articulation characteristics of AOS
basic goals of treatment for apraxia
-improve motor planning
-consider linguistic difficulties
-easy and simple articulatory positioning
-rassure patient that their musculature is all right because they are able to cough, laugh, etc.
generally, __________ planning is the primary impairment in apraxia, so use a _______ approach to therapy
motor
motor
the secondary impairment in apraxia is _______________ impairment, so use a _________________ approach
linguistic
Motor approaches are based on a _______________ of stimuli
-They require _____________ and __________
-Include methods such as: ____________. _________________, and _____________
-hierarchy
-repetitive practice and drill
-articulatory methods
-gestural methods
-prosodic methods
articulatory methods for motor approaches are a ________________ sequence and include __________, ________________, and ____________
-bottom up
-integral stimulation
-multiple phoneme therapy
-PROMPTS
what method is used with moderate to severe apraxia of speech?
-articulatory methods: integral stimulation
in this method, you tell the client to watch you and listen to you, then model the stimulus
articulatory methods: integral stimulation
clinician chooses set of utterances w/ client that are meaningful to client; begins at max or high cueing and slowly fade cueing as client improves
integral stimulaiton- eight step continuum
Checks for patient's ability to discriminate productions of phonemic error
phonetic placement Tx
use ___________________ with severe apraxia
multiple input phoneme therapy (MIPT)
a dynamic tactile-kinesthetic, oral-facial cueing system
PROMPT
Hierarchically structured program that is divided into 3 levels.
melodic intonation therapy
First 2 levels of MIT use
multisyllabic words/phrases that are musically intoned
3rd level of MIT uses:
1. longer or more phonologically complex sentences
2.first intoned
3. then produced with exaggerated speech prosody
4. then finally spoken normally
a good candidate for MIT has had a _____________ stroke near broca's area
unilateral, left-hemisphere
Based on the principle of intersystemic reorganization: the use of hand/limb gestures to facilitate movement for speech production
motor approaches: gestural methods
should you use gestural methods instead of speech production based treatment when prognosis for developing speech is good?
no
can you use gestural methods in conjunction with speech production focused therapy?
yes
AMERIND is a _________ method based on native american sign language
gestural
what is the primary goal of dysarthria speakers?
intelligibility
goal for mild apraxia is:
speech naturalness
goal for moderate apraxia is:
speech intelligibility
goal for severe apraxia is:
communication with AT/AAC
sustained /ah/ should not be louder than:
90dB SPL @ 30 cm
can you change LSVT functional phrases?
no
goal may not be normal speech production
goal- reduce impairment
Modify speech production to maximize use of remaining skills (may work on strengthening in LMN and relaxation in UMN)
-Can be behavioral or prosthetic
goal- compensation
Reorganization of environment so that functions which were lost are not required to interact
-Plan for the progressive loss of speech in degenerative disorders (AAC)
-Maximize communication so less adjustment is required
goal- adjust
Usually directed at relieving symptoms
-Know the drugs the client is taking and for what
-Begin other therapy when the effects are stable
-Be aware of the cycling of the effects
pharmacological management
-Palatal lift prosthesis
-Amplification system
-AAC
-Pacing board
-Delayed auditory feedback and biofeedback devices
prosthetic management
Focus on changing the speaker behavior (improve function or compensations)
speaker-oriented
(behavioral management)
Focus on changing the behavior or listeners or the environment
communication-oriented (behavioral management)
-Reduce the use of behaviors which are not improving communication
-May be strategies which the individual is using to try to compensate for current difficulties speaking
-May be strategies that worked at an earlier stage of the disorder, but now impede c
maladaptive behaviors
What are two clinical measures of intelligibility?
1. Assessment of Intelligibility of Dysarthric Speech (AIDS)
2. Frenchay Dysarthria Assessment (glorified oral mech)
-Connected speech
-Speech-like-tasks
-Tasks that involve only one or two components (sustained phonation)
-Tasks that focus on a single component (ratings of breath)
task and measurement appraoches
problems with perceptual measures
Same symptoms may be the result of very different underlying conditions.
if loudness is appropriate, then respiratory is like to be:
okay
What should we use for the assessment of respiratory/phonatory function?
voice evaluation
Respiratory Functions for Speech
-loudness
-breathing pattern
-voice quality
All of the words said on one breath
breath group
Want to look at structure, range of motion (look for dyskinesias), strength, rate, coordination, accuracy of movement, and muscle tone
oral mechanism examination
Should medical treatment start before speech therapy?
Yes, because the medical treatment may change the goals of therapy.
Should we do therapy due to the presence of an impairment?
Not always... we have to base this decision on the amount of activity and participation restriction; we also might not be the first concern
What is the goal of dysarthria management?
-reduce impairment
-compensate
-adjust
we want to look at communication as a whole, not just speech
What should the goals be set at?
60-80% success rate
at first, focus on __________, then slow __________ if necessary
accuracy
speed
in early treatment, use______________ sessions __________ times a day
frequent short sessions
2
How should we plan our sessions?
-begin with easy task
-proceed to harder task
-end with success
Allows for more individualized management, can complete more practice trials, can alter activity based on response more quickly.
individual therapy
Allows for carry-over and natural practice, give an opportunity for the client to see techniques being employed, lets the client see s/he is not alone, allows for peer feedback.
group therapy
What are the stages of dysarthria consideration?
Stage 1: No functional speech (AAC)
-Stage 2: Speech supplemented (intelligibility poor)
-Stage 3: Reduced intelligibility (look for compensatory strategies)
-Stage 4: Obvious dysarthria
-Stage 5: No speech disorder
the best treatment candidates are those whose disease is _____________ and who speech is ___________ by the treatment
treatable
improved
2 foundations of treatment
neuroplasticity (motor planning)
drill (motor memory)
bracing, slings, girdling (used with hyperkinetic movement disorders)
posture treatment
-Support head
-Jaw elevation
-Bite Block (inhibits hyperkinetic/tremor movement
posture for articulation treatment
-Progressive muscle relation
-Jaw shaking
-Chewing
muscle tone treatment
-Palatal Massage
-Visual Feedback
-Auditory feedback
Resonance Dysarthria Treatment
-Phonetic-
placement (voice, place, manner)
-Contrast drills
Articulation Dysarthria Treatment
-Postural Adjustments
-Prosthetic Assistance
-Speech Tasks -biofeedback/modifications of breathing patterns
respiratory management
Physical strategies to enhance adduction (effort closure techniques, posture adjustments, physical manipulations)
*LSVT Treatment
Hypoadduction Management (phonatory system)
-Nonspeech tasks
-Biofeedback
-Behavioral (volume levels/rotate head)
-Speech Tasks
-Relaxation strategies (spastic and hyperkinetic)
Hyperadduction Management (phonatory system)
botox injections are good for:
hyperadduction
what can you do to improve velopharyngeal impairment?
-prosthetics
-surgery
-exercise
Used most with TBI, cerebrovascular accident, and cerebral palsy
prosthetic management
-props up soft palate
-provides mechanical impedance to air attempting to enter the nasal cavity
palatal lift flaccid dysarthria
Used as a speech enhancing prosthesis by occluding the nares and decreasing nasal airflow for patients with VP insufficiency and VP incompetence
nasal obturator
Activity for inadequate breath support to speak long phrases in Flaccid dysarthria:
teach them to make phrases shorter
Activity for hypernasality in Spastic dysarthria:
have the patient open their mouth really wide when they speak
activity for uncoordinated speech movements in Ataxic dysarthria:
Work on articulation, starting with words and moving through phrases and sentences
Activity for short rushes of speech in Hypokinetic dysarthria
Teach the client to slow down their speech rate by chunking phrases to create natural pauses.
Activity for harsh voice in Hyperkinetic dysarthria
Symptoms are generally treated with medicine
Activity for inappropriate rate in Apraxia dysarthria
Teach the client to slow down their speech rate by chunking phrases to create natural pauses.
think loud for:
speech and improving loudness
think big for:
PT & OT- focus on bigger movements of body
should you use sign language if there are no individuals in the client's environment who will use it with them?
no
Uses prosodic cues and stress patterns to facilitate speech production and prosody
prosodic methods: contrastive stess
motor approaches: prosodic methods include
melodic intonation therapy
contrastive stress
you should only use prosodic methods if the individual has demonstrated _____________ skill for the ________________
articulatory
target phonetic string
in apraxia of speech, errors may be:
metathetic
error sounds in apraxia of speech are likely to vary from target by only:
1 phonetic dimension
consonant clusters are _____________
most difficult
are fricatives and affricates easy or hard?
hard
audible and visible groping movement of the articulators is key in:
apraxia of speech
T or F?: anticipatory errors are most common
true
as we increase word length, more __________ arise
problems
T/F?: you need both auditory and visual modalities to elicit most success
true
integral stimulation is where you sit side by side and look in mirror with client- a lot of imitation
...
MIPT is used to __________ down
slow rate of speech
Southwood treatment is used to __________ down
slow rate of speech
Square treatment uses:
PROMT
expectations for every patient should be ______________ in _________ sessions
-conversational speech
-16
speech no louder than
80-85dB SPL @ 30 cm
apraxia has numerous phonemic errors including: ___________ ___________ ______________ _________________ ________________
-substitutions
-omissions
-additions
-repetitions
-distortions
apraxia of speech has a _______________ of ________________ in the absence of ______________________, ________________, or _________________ of speech musculature
predominance
substitutions
weakness
slowness
incoordination
____________ movement of the articulators is common in apraxia of speech
groping
when the word length increases, what also increases?
number of phonemic errors
goal for LSVT
loud and good voice quality
aphasia is _____________ problems
word finding
can apraxia be aphasia?
yes
without aphasia, one does not have:
word finding problems
dysarthrics have trouble __________ while apraxics have trouble ___________
executing
planning
T/F?: strengthening artic and phonation muscles is the primary Tx for spastic dysarthria
false
T/F?: the primary treatment for hyperkinetic dysarthria is artic therapy
false
for sustained "ah" and high/low "ah", whats the best therapy to do ?
model, biofeedback, voice quality
a lady used a pencil the wrong way to write; which apraxia is this?
ideational
smiling is associated with which cranial nerve?
facial
daily tasks for LSVT
-maximum duration of sustained vowel phonation
-use loud voice in real life situations
apraxic speech is island free of speech error
true
Common positive outcomes of prosthetic management
-Improved articulation
-Improved speech intelligibility -Decreased hypernasality
-More efficient respiration for speech