Treating Apraxia of Speech as
a Result of Postencephalitic
Parkinsonism Using Discourse
Meghan C. Savage, Ph.D., Amanda L. Stead, Ph.D., and
Paul R. Hoffman, Ph.D.
Louisiana State University, Department of Communication Sciences and Disorders,
Baton Rouge, Louisiana
Keywords: apraxia, apraxia of speech, Postencephalitic parkinsonism, apraxia therapy,
phoneme production
Background: The purpose of this single-subject study was to investigate if phonologic
placement treatment seated in spontaneous discourse would improve phonetic accuracy
and increase intelligibility in an individual with postencephalitic parkinsonism resulting
in apraxia of speech.
Methods: The participant was a 60-year-old male with postencephalitic parkinsonism,
oral and speech apraxia, and dysarthria. A single-subject ABAB design using pre- and
posttesting and repeated measurement of phonemes during baseline and treatment was
used. Phonological and visual supports were embedded within conversational discourse
related to current events. Data were analyzed using visual inspection and effect sizes.
Results: Results showed a treatment effect for all targeted phonemes as well as posttest
measures of overall intelligibility. Assessment of Intelligibility of Dysarthric Speech scores
rose from 0% to 24% intelligible at the single word level. Large effect sizes were found for
all target phonemes, /b/ (d = 2.89), /m/ (d = 4.76), /r/ (d = 1.18) and /n/ (d = 1.94).
Conclusions: A phonologically based treatment embedded in discourse was effective in
facilitating basic verbal communication in a previously nonverbal individual.
INTRODUCTION
Apraxia of speech (AOS) is a neurogenic speech disorder caused by unilateral damage to the left cerebral
hemisphere, which results in impaired positioning
and movement of articulators during volitional production of speech. It can occur without significant
weakness or neuromuscular slowness and in the
absence of disturbances of conscious thought or language (Duffy, 2005). Clinical manifestations of AOS
include problems of speech initiation; articulatory
groping; reduced rate of speech; perseverations; slow
transitions between sounds, syllables, and words;
and disordered prosody (Wambaugh, Duffy, McNeil,
Robin, & Rogers, 2006a).
The majority of AOS treatments have been impairment oriented. Impairment-based approaches
seek to remediate the underlying linguistic impairment using models of normal language and
cognitive processing to structure units and levels
of language organization for practice (Martin,
Thompson, & Worrall, 2008). The basic tenet of this
approach is that the primary access to language
units is damaged. Therapy uses static noninteractive tasks that target the linguistic forms of language (Sarno, 2004). Speech tasks are presented
in clinician-directed stimulus–response–feedback
activities targeting an increased ability to access
various sized language units. However, there is
a need for more functional approaches to AOS
Journal of Medical Speech-Language Pathology
Volume 20, Number 2, pp. 35–42
Copyright © 2012 Delmar Cengage Learning
26537_ch04_ptg01_035-043.indd 35
8/2/12 2:01:57 PM
36
JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 20, NO. 2
treatments. Functional approaches, also termed
social, participation, or psychosocial, address the
consequences the disorder has on the person’s
life. Intervention targets the use of speech and
language to accomplish social needs in authentic,
relevant, and natural contexts such as conversations (Simmons-Mackie, 2008b). The interventionist acts as a collaborator seeking to facilitate the
person’s participation in the social context.
Current AOS treatments, including articulatory
kinematic, rate or rhythm, intersystemic facilitation
or reorganization, and alternative or augmentative
communication (Wambaugh, Duffy, McNeil, Robin,
& Rogers, 2006b) are primarily impairment based
and rooted in principles of motor learning. Motor
learning typically involves intensive practice in
repetition of movement patterns that are organized
in hierarchies from simple to more complex
(Austermann Hula, 2007; Maas et al., 2008; McNeil,
Doyle, & Wambaugh, 2000).
Articulatory-kinematic approaches currently
demonstrate the highest levels of evidence
( Wambaugh, 2010). Articulatory-kinematic
approaches involve practice in production of:
individual phonemes and syllables (Knock, Ballard,
Robin, & Schmidt, 2000; Raymer, Haley, & Kendall,
2002), single words (Knock, et al., 2000; LaPointe,
1984; Wertz, 1998), nonwords (Katz, Bharadwaj, &
Carstens, 1999; Maas, Barlow, Robin, & Shapiro,
2002), phrases, and sentences. The clinician provides visual and auditory stimulation before each
patient response. Articulation placement cues have
been presented in drawings (Raymer et al., 2002),
verbal instructions (Wambaugh, Kalinyak-Fliszar,
West, & Doyle, 1998; Wambaugh, Martinez,
McNeil, & Rogers, 1999; Wambaugh, West, &
Doyle, 1998), video-taped models (Aten, 1986),
Prompts for Restructuring Oral and Muscular Phonetic Targets (PROMPT) (Bose, Square, Schlosser,
& van Lieshout. 2001; Square, Martin & Bose,
2001), and visual modeling (Wambaugh et al.,
1998; Wambaugh et al., 1999; Wambaugh, West, &
Doyle, 1998). Models of syllables and words have
been presented in contrastive consonant vowel
(CV) pairs (Wertz, LaPointe, & Rosenbek, 1984),
blocked presentation of repeated syllables or
words, or randomly.
Other treatments such as Sound Production
T r e a t m e n t ( S P T ) ( Wa m b a u g h , 2 0 1 0 ) a n d
Phonomotor Treatment (Kendall, Rodriguez,
Rosenbek, Conway, & Gonzalez Rothi, 2006) have
been shown to be effective. In SPT, eight to 10
vowel or consonant sounds are selected based on
individual performance. Each sound is targeted one
at time. Stimuli increase in complexity from monosyllabic and multisyllabic words to phrases and sentences. Treatment for each sound is continued until
the criterion is met. Sound production is facilitated
using modeling, repetition, minimal pair contrast,
integral stimulation, articulatory placement cueing,
and verbal feedback in a response contingent hierarchy (Wambaugh, 2010). Data indicate that SPT
improves articulation accuracy in trained and untrained words (Wambaugh et al., 1998; Wambaugh
et al., 1999; Wambaugh, 2004; Wambaugh, 2006a,
2006b). Some generalization has been found for
sounds similar in place and manner to the targeted
sounds. For targets that reached a high level of accuracy during treatment, maintenance effects were
found 1 to 2 months after treatment.
Kendall et al. (2006) conducted a single-subject
design to examine a phonomotor treatment for
an individual with apraxia and aphasia. Pictures
of mouths depicting articulatory placement were
used to cue individual sound production. The
study also used auditory discrimination, verbal
production, mental practice, and tactile and
kinesthetic modalities to target sound production.
After 104 hours of therapy, the individual was able
to produce individual sounds, but targets did not
generalize to multisyllabic words and discourse.
Although targets did not generalize, discourse
production became less effortful, and the patient
reported increased ease of communication and
community integration (Kendall et al., 2006).
Functional interventions are based in the
holistic nature of learning. Life experiences
are considered to be interactive contexts for
learning, motivation, and participation. Learning is best when learners take responsibility for
defining what they want to learn, know why they
have to learn something before they undertake
it, and are internally motivated to learn things
that will help them cope effectively with real-life
situations (Kimbarow, 2007). The present study
investigates an intervention incorporating the
use of visual cues to speech sound production
and modeling to aid in accessing phonological
units, a common strategy of impairment-based
interventions, within a conversational discourse structure, a common practice of functional approaches. It is a test of the hypothesis
that speech production practice in meaningful
contexts is a potentially efficacious strategy
that should be compared with the traditional
hierarchical strategy.
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 36
8/2/12 2:01:57 PM
TREATING APRAXIA OF SPEECH USING DISCOURSE
METHODS
Participant
37
and BNT from audio and video recordings. The
Apraxia Battery for Adults-Second Edition (ABA-2;
Dabul, 2000), which measures the presence and severity of apraxia, was used to assess the presence of
oral, speech, and limb apraxia. The presence of oral
apraxia was characterized as moderate. No limb
apraxia was found. RH was rated severe on diadochokinetic rate, utterance time, increasing word
length, and repeated trials, leading to a rating of
severe for speech apraxia.
The participant, RH, was a 60-year-old African
American man who presented with postencephalitic parkinsonism, oral apraxia, apraxia of speech,
dysphagia, and hypokinetic dysarthria. Premorbidly, RH had been a resident physician at a local charity hospital. He contracted encephalitis
in 1972 while administering vaccinations. Initial
magnetic resonance imaging results showed lesions
in the substantia nigra region, consistent with the
diagnosis of parkinsonism. He did not develop any
cognitive impairments or language disorders as a
result of the encephalitis. Immediately after contracting encephalitis, RH maintained the ability to
use speech, but as the disease ran its course, he lost
the ability to volitionally control his speech mechanism and has been primarily mute for 20 years. RH
has been receiving therapy for several years to address concerns with dysphagia. At the time of the
intervention, RH’s primary mode of communication
was through the use of an Alternative Augmentative Communication (AAC) device, a DynaWrite.
Because he did not have any cognitive impairment,
his typed output consists of complete intelligible
sentences. He participates in higher level intelligent
conversations by typing his responses. His vocal
output consisted of a high-pitched /e/ vowel produced when excited. When asked to imitate a single
word, RH exhibited groping behaviors, inconsistent
productions, and delayed initiation of phonation for
5 seconds or longer. At the time of the study, he was
taking the following medications: Drovan, Nexium,
Flomax, Levoxyl, Sinemet, Baclofen, and Zetia.
Phonemic targets were based on a variety of factors
including errors recorded on the BNT, a phonemic
inventory, frequency of occurrence in the English
language, order of acquisition, and necessity. In
addition, literature on motor learning theory and
the underlying pathophysiology was taken into account, resulting in six target sounds, including /r,
b, t, m, n, d/. These target sounds were probed in
single-word naming of picture cards for three sessions before the initiation of treatment. Five photographic noun picture cards for each phoneme
were randomly presented to RH. He was asked to
name each picture and was given adequate time to
respond. If he self-corrected or produced numerous
productions, the last correct response was scored.
A response was considered accurate if he correctly
produced the initial phoneme of the target picture.
No prompts were given at any time. Based on
performance on baseline probes, /t/ and /d/ were
omitted from the training because of zero baseline performance. Upon completion of baseline
probing, treatment was initiated. All sessions were
conducted at the patient’s place of residence.
Assessments
Experimental Design
RH’s speech production was measured by administration of The Assessment of Intelligibility of
Dysarthric Speech (AIDS; Yorkston, Beukelman,
& Traynor, 1984). Because RH had such limited
output, only the Single Word Intelligibility subtest
of the AIDS was administered. Single-word intelligibility was 12% when judged using multiple choices
and 0% when scored by transcription. The Boston
Naming Test (BNT) (Goodglass & Kaplan, 2001),
a 60-item picture-naming test, was administered
to assess his phonetic inventory of initial sounds.
RH was 27% accurate on initial phonemes on the
BNT. An unfamiliar judge blind to the time (pretest
or posttest) of the speech samples scored the AIDS
The study was an ABAB design. The first phase
(A1) consisted of the three sessions to collect baseline data on probe items. In the treatment phase B1,
seven sessions were conducted until RH reached
80% accuracy on target phonemes. Following in
phase A2, the treatment was withheld for three sessions, and again three baseline probes were taken.
In phase B2, three additional treatment sessions
were provided for a total of 10 treatments.
Before the initiation of treatment, the participant expressed to the researchers that he enjoyed
discussing current events. Therefore, to ensure the
treatment was personally relevant and highly motivating for the participant, target phonemes were
Procedure
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 37
8/2/12 2:01:57 PM
38
JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 20, NO. 2
addressed in conversational discourse discussing
current events. RH participated in the conversational discourse by typing his utterances using the
DynaWrite. When he typed a response that contained a target phoneme, phonological support was
provided to produce the sound. Phonological support
for the target phonemes included the use of Phonic
Faces (letters superimposed on drawings of faces to
cue an aspect of phoneme production) (Norris, 2001),
photographs of mouths depicting articulatory
placement taken of the investigators, tactile cues
specific to the phoneme being targeted, and auditory input of the phoneme (see Appendix). The interaction between the investigator and participant
continued in a conversational discourse structure
for approximately 30 minutes or until each target
had been elicited between 40 and 50 times. The
investigator facilitated the production of the target
phoneme during the course of the conversation
using direct elicitation. An example interaction is
exhibited below.
Topic: Proposed federal bailout of Wall Street
Target phoneme: /f/
Setup: Investigator will begin by introducing the
topic and reading a short related article.
Investigator: “What did you think about
this article?”
RH: types “fine”
Investigator: (points to phonic face card)
“See how she is biting her lip, ffffffffff.
Now you try.”
RH: “-ine”
Investigator: (Model correct placement
and give tactile cue of /f/) “Feel the airflow.” “Try biting your lip and blowing.”
RH: “Fine” (Repeated numerous productions)
RH: “The Fed is wrong.” (produced with
an appropriate [f] sound; this response
was typed by RH, and only the target
phoneme word was phonated)
Investigator: “The Fed is wrong; they
need to come up with a better plan.”
RESULTS
A treatment effect in this design would be demonstrated by an increase from A1 to B1 when the intervention is first applied, a decline from B1 to A2
when the intervention is removed, and a second
increase from A2 to B2. This pattern was clearly
shown for production of the labials /b/ and /m/ and
less clearly for linguals /r/ and /n/ (see Table 1 for
data on all phonemes). Percent correct production
of both /b/ and /m/ during every session during B1
was higher than every session in A1. Percent correct productions in all of the sessions of A2 were below all of the sessions in B1. Finally, the averages
in all of the sessions of B2 were higher than all of
the sessions of A2 (Figure 1). Correct production
of the lingual sounds /r/ and /n/ both show a delay
in treatment effect (Figure 2). A1 scores for /r/ fall
from 100% to 40% followed by similarly variable
responses in the first two sessions of B1. However,
the final five sessions of B1 were higher than the
final sessions of A1. In similar fashion, /n/ production stayed stable during the first two sessions
of B 1 and then rose in the final sessions of B1.
Both /r/ and /n/ declined as expected when the
treatment was removed in A2 and then rose again
in B2. Although the baseline phases do not demonstrate stable behaviors, which is a weakness of the
study, the levels achieved during treatment were
higher than the baseline and withdrawal phases.
TABLE 1. Individual Target Data for Intervention
r (%)
b (%)
m (%)
n (%)
Baseline 1
100
40
20
60
Baseline 2
Baseline 3
40
40
0
20
20
40
40
60
Tx 1
86
71
86
60
Tx 2
36
57
50
27
Tx 3
88
64
100
72
Tx 4
100
53
45
68
Tx 5
89
71
88
70
Tx 6
Tx 7
69
100
75
100
73
81
83
83
Withdrawal 1
25
33
13
25
Withdrawal 2
Withdrawal 3
29
45
38
42
33
29
40
43
Tx 8
46
83
63
73
Tx 9
Tx 10
83
92
89
83
75
71
71
100
1.18
27.27
2.89
16.18
4.76
9.95
1.94
13.44
Effect size d
SD A
SD, standard deviation; Tx, treatment.
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 38
8/2/12 2:01:58 PM
39
TREATING APRAXIA OF SPEECH USING DISCOURSE
120
100
80
60
40
20
9
10
Tx
Tx
Tx
W
7
ith
dr
aw
W
l
ith
dr
aw
W
l
ith
dr
aw
l
Tx
8
6
5
Tx
Tx
3
4
Tx
Tx
1
2
Tx
3
Tx
e
2
in
e
in
se
l
Ba
se
l
Ba
Ba
se
l
in
e
1
0
m
b
Figure 1. Probe data and treatment (Tx) data for /b/ and /m/.
120
100
80
60
40
20
r
10
Tx
9
Tx
dr
aw
W
l
ith
dr
aw
W
l
ith
dr
aw
l
Tx
8
7
W
ith
Tx
6
Tx
5
Tx
4
Tx
3
Tx
1
2
Tx
Tx
3
e
lin
e
2
se
Ba
lin
se
Ba
Ba
se
lin
e
1
0
n
Figure 2. Probe data and treatment (Tx) data for /r/ and /n/.
Effect sizes were calculated for each of the
treatment sounds by comparing the scores in the
A phases with the scores in the B phases. Large
effect sizes were found for all target phonemes /b/
(d 2.89), /m/ (d 4.76), /r/ (d 1.18), and /n/ (d
1.94) (see Table 1). The effect size calculation
for single-subject design was taken from Robey,
Schultz, Crawford, and Sinner (1999) as follows:
ES XBXA
SA
X with the bar over it is the mean and S is the
standard deviation. The subscript z should be subscript A.
Before treatment, the patient was 0% intelligible
at the single-word level as measured by the AIDS.
After treatment, the patient was 24% intelligible
at the single-word level. This intelligibility was
judged by an unfamiliar listener and included
words that contained nontargeted sounds. In a
1-month follow-up, RH and his family reported
a marked increase in spontaneous word productions at home. He reportedly used spontaneous
single words to request, greet, and comment on
his surroundings. Many of the words he used during the 1-month follow-up contained word initial
sounds that were not trained during the intervention, such as “hello,” “goodnight,” and “thanks.”
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 39
8/2/12 3:40:08 PM
40
JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 20, NO. 2
DISCUSSION
The current study sought to combine the theories
of adult learning and articulatory-kinematic
approaches into a treatment for a person with
postencephalitic parkinsonism resulting in severe
apraxia of speech. This treatment incorporated
the use of visual cues embedded in spontaneous discourse for a client-centered approach. RH
demonstrated the core speech features of AOS,
including inconsistency, groping, and increased
durations. Before the intervention, RH had nonfunctional speech output and difficulty initiating
single phonemes. Pretesting indicated that RH’s
speech was severely compromised by the presence
of oral and speech apraxia and dysarthria. Without the support of external cues, RH was unable
to produce any spontaneous intelligible speech.
Initial consonants were deemed as an appropriate
target for intervention because of RH’s difficulty
with initiation. It was believed that by targeting
frequently occurring word initial phonemes during
conversational discourse, RH would be able to use
some words to communicate verbally. Consistent
with AOS treatment literature, multiple phoneme
targets were chosen based on their maximum impact in spoken language. Because of the severely
impaired nature of RH’s output, four sounds were
chosen for intervention: /b, n, r, m/.
Although one of the clinical features of AOS
is its inconsistency from day to day and even
word-to-word, the treatment used in this study
increased consistent accurate productions for all
target sounds. RH demonstrated positive treatment effects and large effect sizes on each target
phoneme. The individual sound treatment also
increased the patient’s overall intelligibility by
24%. In addition to increased target sound productions and single-word speech intelligibility,
RH’s family members and caregivers reported
that he demonstrated a marked number of spontaneous words or utterances. This anecdotal report led the investigators to be encouraged about
the treatment’s generalization given the fact that
RH had been essentially nonverbal for nearly
20 years.
This study demonstrated that a top-down approach to apraxia treatment could improve overall communication. Although Kendall et al. (2006)
and Wambaugh (2010) demonstrated that improved articulation can be achieved by targeting
sounds and words, this study extends the previous research by illustrating that seating target
phonemes within personally relevant discourse
production can increase articulatory production
of target sounds. Both previous research and the
current study achieved minimal carryover onto
untrained targets and increased social communication success, but unlike previous research,
the current study achieved rapid communication
gain (10 hours) in a person who was previously
nonverbal. It is possible that these results were
achieved because the intervention was functionalparticipation based.
Although traditional research focuses on
individuals with single disorders, the individual
who participated in this study presented with
multiple confounding speech disorders. Because
AOS can often co-occur with other speech and language impairments, it is necessary to investigate
if our current treatments extend to those
individuals with multiple impairments. This can
provide for better clinical service to the neurogenic population.
One of the limitations of this study was that the
probe data should have been collected throughout
the baseline and treatment phases. However, this
study does demonstrate a consistent difference
in producing phonemes in a supported conversational context (during intervention) as opposed to
confrontational naming (during baselines).
This is a phase 1 study whose aim was to determine whether a treatment effect could be demonstrated. Therefore, although the study’s findings
cannot be generalized, they do provide preliminary evidence that would lead to further research
for this treatment. Future investigations into AOS
should further examine the effects of various linguistic contexts on increasing accurate speech
productions. It is also necessary for future investigations to assess maintenance effects. Given that
the level of AOS treatment research is preliminary,
it is necessary to engage in systematic replication
and clinical trials.
Acknowledgments We would like to thank RH
for giving us his time and trust to participate in this
treatment study. We would also like to thank Dr. Hugh
Buckingham and Dr. Neila Donovan for providing
guidance on this manuscript.
Address Correspondence to Meghan C. Savage, Ph.D.,
Louisiana State University, Department of Communication
Sciences and Disorders, 63 Hatch Hall, Rm 71, Baton
Rouge, LA, PHONE: (225) 620-5807
e-mail: meg.collins.e@gmail.com
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 40
8/2/12 2:02:01 PM
TREATING APRAXIA OF SPEECH USING DISCOURSE
REFERENCES
Aten, J. (1986). Aphasia and severe apraxia of speech:
Charting the treatment course. In R. Marshall (Ed.),
Case studies in aphasia rehabilitation (pp. 119–132).
Austin, TX: Pro-Ed.
Austermann Hula, S. (2007). Current directions in
treatment for apraxia of speech: Principles of motor
learning. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorder, 17(3), 3–6.
Bose, A., Square, P., Schlosser, R., & van Lieshout, P.
(2001). Effects of PROMPT therapy on speech motor function in a person with aphasia. Aphasiology,
15(8), 767–785.
Dabul, B. (2000). Apraxia Battery for Adults (2nd ed.).
Austin, TX: Pro-Ed.
Duffy, J. (2005). Motor speech disorders: Substrates, differential diagnosis, and management (2nd ed.). St.
Louis: Elsevier.
Goodglass, H., & Kaplan, E. (2001). Boston Naming Test
(2nd ed.). Baltimore: Lippincott, Williams & Wilkins.
Katz, W. F., Bharadwaj, S. V., & Carstens, B. (1999).
Electromagnetic articulatory treatment for an adult
with Broca’s aphasia and apraxia of speech. Journal
of Speech, Language and Hearing Research, 42(6),
1355–1366.
Kendall, D., Rodriguez, A., Rosenbek, J., Conway, T., &
Gonzalez Rothi, L. (2006). Influence of intensive phonomotor rehabilitation on apraxia of speech. Journal
of Rehabilitation Research and Development, 43(3),
409–418.
Kimbarow, M. (2007). Integrating life participation approaches to aphasia treatment with adult learning
theory: A synergistic approach. Topics in Language
Disorders, 27(4), 318–323.
Knock, T., Ballard, K., Robin, D., & Schmidt, R.
(2000). Influence of order of stimulus presentation
on speech motor learning: A principled approach
to treatment for apraxia of speech. Aphasiology,
14(5/6), 653–668.
LaPointe, L. (1984). Sequential treatment of split lists: A
case report. In J. Rosenbek, M. McNeil & A. Aronson
(Eds.), Apraxia of speech: Physiology, acoustics, linguistics, management (pp. 141–153). San Diego:
College-Hill Press.
Maas, E., Barlow, J., Robin, D., & Shapiro, L. (2002).
Treatment of sound errors in aphasia and apraxia of
speech: Effects of phonological complexity. Aphasiology,
16(4/5/6), 609–622.
Maas, E., Robin, D., Austermann Hula, S., Freedman,
S., Wulf, G., Ballard, K., et al. (2008). Principles
of motor learning in treatment of motor speech
disorders. American Journal of Speech-Language
Pathology, 17(3), 277–298.
Martin, N., Thompson, C., & Worrall, L. (2007). Aphasia
rehabilitation: The impairment and its consequences.
San Diego: Plural Publishing.
41
McNeil, M., Doyle, P. J., & Wambaugh, J. (2000). Apraxia
of speech: A treatable disorder of motor planning
and programming. In S. Nadeau, L. Gonzalez Rothi,
& B. Crosson (Eds.), Aphasia and language: Theory
to practice (pp. 221–266). New York: The Guilford
Press.
Norris, J. (2001). Phonic faces. Baton Rouge, LA: Elementory.com.
Raymer, A., Haley, K., & Kendall, D. (2002). Overgeneralization in treatment for severe apraxia of speech:
A case study. Journal of Medical Speech-Language
Pathology, 10(4), 313–317.
Robey, R., Schultz, M., Crawford, A., & Sinner, C.
(1999). Single-Subject clinical-outcome research: Designs, data, effect sizes, and analyses. Aphasiology,
13(6), 445–473.
Sarno, M. T. (2004). Aphasia therapy: Historical perspectives and moral imperatives. In J. Duchan
& S. Byng (Eds.), Challenging aphasia therapies: Broadening the discourse and extending the
boundaries (pp. 19–32). New York: Psychology
Press.
Simmons-Mackie, N. (2008a). Intervention for a case of
severe apraxia of speech and aphasia: A functionalsocial perspective. In N. Martin, C. Thompson
& L. Worrall (Eds.), Aphasia rehabilitation: The
impairment and its consequences. San Diego:
Plural.
Simmons-Mackie, N. (2008b). Social approaches to
aphasia intervention. In R. Chapey (Ed.), Language
intervention strategies in aphasia and related neurogenic communication disorders (5 ed., pp. 290–318).
Baltimore: Lippincott, Williams & Wilkins.
Square, P., Martin, N., & Bose, A. (2001). The nature
and treatment of neuromotor speech disorders in
aphasia. In R. Chapey (Ed.), Language intervention
strategies in aphasia and related neurogenic communication disorders (pp. 847–884). Baltimore: Lippincott, Williams, & Wilkins.
Wambaugh, J. (2004). Stimulus generalization effects
of sound production treatment for apraxia of speech.
Journal of Medical Speech-Language Pathology,
12(2), 77–97.
Wambaugh, J. (2010). Sound production treatment for
acquired apraxia of speech. Perspectives on Neurophysiology and Neurogenic Speech and Language
Disorders, 20(3), 67–72.
Wambaugh, J., Duffy, J., McNeil, M., Robin, D., &
Rogers, M. (2006a). Treatment guidelines for acquired
apraxia of speech: A synthesis and evaluation of
the evidence. Journal of Medical Speech-Language
Pathology, 14(2), xv–xxxiii.
Wambaugh, J., Duffy, J., McNeil, M., Robin, D., &
Rogers, M. (2006b). Treatment guidelines for
acquired apraxia of speech: Treatment descriptions
and recommendations. Journal of Medical SpeechLanguage Pathology, 14(2), xxxv–lxvii.
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 41
8/2/12 2:02:01 PM
42
JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 20, NO. 2
Wambaugh, J., Kalinyak-Fliszar, M., West, J., & Doyle,
P. J. (1998). Effects of treatment for sound errors in
apraxia of speech and aphasia. Journal of SpeechLanguage, and Hearing Research, 41, 425–743.
Wambaugh, J., Martinez, A., McNeil, M., & Rogers, M.
(1999). Sound production treatment for apraxia of
speech: Overgeneralization and maintenance effects.
Aphasiology, 13(9-11), 821–837.
Wambaugh, J., West, J., & Doyle, P. J. (1998). Treatment for apraxia of speech: Effects of targeting sound
groups. Aphasiology, 12(7/8), 731–743.
Wertz, R. (1998). A case of aphasia, apraxia of speech,
and apraxia of phonation. In N. Helm-Estabrooks &
A. Holland (Eds.), Approaches to the treatment of aphasia (pp. 11–36). San Diego: Singular Publishing Group.
Wertz, R., LaPointe, L., & Rosenbek, J. (1984). Apraxia
of speech in adults: The disorder and its management. Orlando, FL: Grune & Stratton.
Yorkston, K., Beukelman, D., & Traynor, C. (1984).
Assessment of Intelligibility of Dysarthric Speech.
Austin: Pro-Ed.
Submit a manuscript online – www.cengage.com/community/JMSLP
26537_ch04_ptg01_035-043.indd 42
8/2/12 2:02:01 PM
Appendix: Examples of Phonological
Support Visual Cues
c
a
n
d
y
Phonic Faces (Norris, 2001)
Photographs of mouths depicting articulatory placement taken of the
investigators
Journal of Medical Speech-Language Pathology
Volume 20, Number 2, p. 43
Copyright © 2012 Delmar Cengage Learning
26537_ch04_ptg01_035-043.indd 43
8/2/12 5:29:46 PM