Motor Speech Disorders
Apraxia of speech and dysarthria
First
 The SLP does not fix or improve anyone
 People fix themselves (or not)
 Requires
 Willingness
 Ability
 Establishing these is as or more critical than all the other
diagnostic stuff we are usually taught
For example
 Hypernasality can be caused by weakness of soft palate
 Strain-strangle dysphonia can be caused by
hypertonicity
 Apraxic articulatory breakdown can be caused by
dyscoordination
Patient one
 So what do you hear?
 Strain-strangle dysphonia
Whitaker on CD
 Slow rate
 Hypernasality
 Consonant imprecision
 Trend toward equal and even
stress
Medical diagnosis
Progressive supranuclear palsy
(PSP)
Speech first abnormality in 35% of
cases
 Typical dysarthria
 Hypokinetic
 Ataxic
 Spastic
Note her hands appear normal as is
her gait
Often mistaken for Parkinson’s
disease
 This lady has spastic
 Tight dysphonia
 Slowness
 Hypernasality not so severe
 Often called pseudobulbar
Treatment
 The best treatment we have is skill treatment
 To increase differentiation of voiced and voiceless
 To improve rate
 To normalize stress
 Program will be featured at appropriate time
Example
Reported gradual onset
Speech difficulty
Which she called difficulty
pronouncing words
And once she called it stuttering
Denied any cognitive or linguistic
difficulties and mostly she is right
No postural, gait or upper
extremity deficits
Patient two
So what do you hear?
What does she have?
What would you do?
 Hear
 Slow
 Effortful
 Syllabification
 Mild articulatory errors
 Trend toward equal and even stress
 Dx
 Primary progressive apraxia of
speech
 Tx
 Skill training at sentence level
 Neuroprotection
Evolution
 Decline can occur over many years
 Nearly inevitably pts become mute
 Condition evolves into
Dementia
 PNFA
 Corticobasal degeneration
 Progressive supranuclear palsy
 Amyotrophic lateral sclerosis
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Leading to what some call progressive anarthria
Example
What do you hear?
What do you think the disease
might be
What would you do
Dyscoordination
What do you hear?
What do you think the condition
might be
What would you do about it
One type
What do you hear?
What might the medical condition
be
What do we do?
Treatment: other pathophysiology
 Some like depression and apathy usually require
 Meds
 Psychiatry/psychology
 like poor attention can be managed behaviorally
Functional
components
Lips
Jaw
Tongue tip and back
Soft palate
Larynx
For example
 Weakness in respiratory muscles
 Leads to inadequate loudness and often short phrases
 The treatment is respiratory muscle strengthening
 Who knows how to do that?
 Followed by skill training
So, question for you
 Which of the treatments you use (or have heard
about)results in making patient stronger
 Which increase background of effort
 Which increase skill
For example
 If a patient’s speech abnormality is not related to
weakness then it is a waste of time to use
strengthening treatments
 Also a waste if weakness is present but not severe
enough to influence speech (which is most of the time
by the way)
Regardless of technique or type of
deficit
 Motor speech therapy must be cognitive motor therapy to be
maximally effective
 MUST start here
 Lansford et al (2011). A cognitive-perceptual approach to
conceptualizing speech intelligibility and remediation practice in
hypokinetic dysarthria. Parkinsons Disease, doi 10:4061/2011/150962
 Six parts the way we do it-THIS IS HOW ALL TREATMENT STARTS
Why important ?
 Anyone here not heard a patient or family member say
“He talks really good when he remembers” ?
 Or, “He talks really good in therapy but not at home”?
 Learning what to do is usually relatively easy
 Remembering to do it is godawful hard
Thus
 We ought to spend more time in therapy helping a
patient remember
 Rather than-as we do now-teaching them what to do
1. Flip the switch
 Flipping the switch means engaging volitional-
purposive control
 Tx follows a rough shape
Teach, flip the switch
 Emphasis on planning every utterance prior to
production-extremely challenging
 Many pts hate this and acceptance requires counseling
 And promise that with luck they will not have to do it for
all time
 We tell them what we call it and they can use that or
some other name
 But pt MUST agree to flip
 Otherwise they are at mercy of phonetics and
spontaneous recovery
Procedure continued
 We try to be creative in helping pt 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 responses as opposed to imitation
whenever possible
2. Listen and evaluate flipping the
switch and response adequacy
 Must attend to evidence switch was flipped and
 Pt must come to be best judge of speech adequacy-
loudness, rate, precision, etc
 Pt and cl agree on a scale of adequacy
 Three points which pts usually immediately turn into 5
(1.5 2.5)
 Anchors : 1= the speech they came to you with and
3=the best possible speech
We drag out one of these
1
2
3
4
Old speech
5
Best possible
Best possible
Next
 Get as complete a view of what pt requires to assign the
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higher scores
May have to negotiate this if pt only accepts normal
If at all possible elicit a functional response from pt
First warning them that they will be responsible for
assigning a scale score
Then the pt followed by the clinician evaluate the response
Differences are resolved
Repeat
Continue resolving differences
A bit of slop in the scale is unavoidable
Scaling rate
 Here is an example done
by students-their first
time
 Thus there are multiple
ways to improve what
they did
 We will discuss those
 Go to the audio: ataxia
liver transplant
1 & 2. Flip and judge
 We use these with all patients
 At some time-usually as early as possible-in the
therapy
 These are among the critical conceptual or cognitive
parts of treatment
 They take time but it is time well spent in our opinion
 Then there are at least four more cognitive
manipulations in much of our treatment
3. Preparing patient to judge effort
 This is the 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)
 Can write effort reduction goal
Effort continued
 We try to move folks at least two effort points
 We have a rough notion that effort that stays in range
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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
We score effort only once per session usually
We have them score themselves outside clinic as well
4. Speak therapeutically
 Patients must be willing to speak therapeutically
 For us a major component of that is “keeping speech in
a box”
 That means doing all the planning and evaluating
 And avoiding long utterances without control
 Don’t tell me the whole story tell me one thing
The issue
 The best treatment for speaking is not speaking
 The best treatment for speaking is speaking
therapeutically
One critical component
 It seems important as well that there be a balance in
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expectations early on in tx
A balance between what the pt wants from therapy
What the clinician thinks is possible
If there is a gap then that gap must be resolved
Or treatment is likely to fail
Pt
wants
Cl
expect
TO AVOID FAILURE
 Need to work toward
Cl
expect
Pt
wants
or
Cl
expect
Pt
wants
5. Remember your brain is plastic
 We speak about “getting your brain to substitute for
the damaged nervous system part(s)”
 Example of ataxia secondary to cerebellar damage
 In other words we use plasticity language
 How worded depends, of course, on ability and
understanding of each patient
So what is this?
 Bit of treatment
Status post MVA without LOC
Post
 So what do you
conclude?
 One session of tx
 Three weeks or so later
she sounded as you hear
6. Adding cognitive-linguistic load
 We begin with as much cognitive-linguistic load as
person can manage
 And then add as much as we can as fast as we can
 Imitation is of limited usefulness although it may be
important for a few repetitions early in treatment
 Means
 Manipulating complexity of answers required by Q
 Having pt select what to practice
 Means introducing competition into the session
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Have person do an entirely different activity and then switch
back to the Q-A
LOAD
 Requiring longer responses
 And series of responses for example in the telling of a
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story
And requiring pt to evaluate several answers at one
time rather than evaluating after each
And bringing in other communication partners
And making it a group activity
And trying to duplicate this arrangement in the pt’s
environment
Admittedly
 This is a lot
 And we may not require all of this and in fact don’t in
the beginning
 May introduce rules 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
Putting it all together
 This is a program of my design using bits and pieces of
numerous “individual” programs
 A program that can be made to work with the most severe
to the mildest, regardless of speech diagnosis
 And the clinician can enter the program anywhere depending
 Begins (cause has to begin somewhere) with an emphasis
on articulatory competence
 In any motor speech disorder characterized by articulatory
errors including omissions, distortions, substitutions and
distorted substitutions
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All the dysarthrias and apraxia of speech
 But expands to treat all of speech
Putting it all together
 And can easily be shaped to work on all aspects of
prosody
 Including rate and abnormal pitch and stress
 Again without regard for speech diagnosis
 And respiratory mechanism, larynx and palate
 That has independent functional speech as its goal
 It is a false assumption that hard work under tightly
controlled clinical conditions produces treatments that
generalize
 Generalization steps MUST be built in
Heart is Sound Production Therapy
 SPT was originally developed for AoS using minimal pairs
 Data are strongest in apraxia
 “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
 Unfortunately no data for PPAoS
SPT
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Five step program, from less to more cueing
Depends on minimal contrast pairs in words
For example, p vs b (voicing)-where they started
One sound is (usually) the target-usually voiceless
Fifteen treatment sessions: and we and they
recognize the challenges here

Wambaugh et al (1998) Effects of treatment for sound
errors in apraxia of speech. JSLHR, 41, 725-743
Components
 Modeling
 Repetition
 Minimal pair contrasts
 Integral stimulation
 Articulatory placement cueing
 Feedback
To prepare for it
 Clinician needs to understand the articulatory errors
in each patient’s speech
 Lets listen to two patients with different speech
diagnoses
So here is patient
for us to treat
Listen to connected speech
very severe
and later
All you need to hear to be able to
begin fashioning treatment
What would you work on?
He tries to say “Madison”
And another
Can be adapted for a variety of other
neuropathologies
Starting with those having increased
tone usually called spasticity
A cardinal feature of such patients is
that they have difficulty turning the
larynx off
Same as in apraxia
Thus voice for voiceless substitutions
and common
The contrast then is between voiced
and voiceless sounds
To demonstrate will start with a
severe, obvious case
Which adds to the relevance of
discussing program basics first
Errors
 Total distortion
 Voicing is pervasive
 Plosion is also
Sound production treatment (SPT)
 The Pittsburgh group has structured a number of
traditional steps into a useful partial approach
 Stimulus selection is key to making it broadly useful
 Fricative vs plosive
 voice vs voiceless
 Program has been subjected to experimental scrutiny
in a series of single case studies with replication
 The first minimal pair they treated was /p/ and /b/
 But clinicians can use anything they want
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)
 Already seeing need for change, right?
 If not correct, step is repeated
 If still not, go to next step
Hardest step
 Is imitation
 Thus you can see this is a rigidly controlled program
 Allows patients no anonymity
 Attempts to keep error rates low
 The problem is that the brain learns more from errors
than from correct responses
Step two: modeling +
 Cl shows printed (known for generations that apraxic
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talkers especially are likely to profit from visual-in this
case reading-input) versions of the target
Say “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
Step three: Integral stimulation
 If only target is wrong earlier or if both are then only
target (or both) is subjected to integral stimulation
 Watch me, listen and say what I say
 Rbt Milisen from the 30s
 If correct try to get two to four more repetitions
 If correct go on to next pair
 If target (or other sound in my version) is incorrect go
to next step
Step four: modeling with juncture
 Cl produces the target using silent juncture after the
target and before the rest of word
P………….it
 If correct, go to next pair
 If not, go to next step
Step five: articulatory placement
 Cl provides verbal description of sound and produces
it in isolation
 To make a /p/ put lips together, build up a bit of air, then
puff the air out by quickly opening lips
 Correct or incorrect Cl go on to next pair
 Or as a permutation, simplify the context
 Although as designed the program used words
Stimuli
 Usually use 8 to 10 stimuli (for ex: pit-bit, par-bar, pan
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ban, pot-bought, etc
In substitutions use sound that most frequently
substitutes for the target
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
The data
 Trained and untrained items improved
 Generalization was limited
 As was maintenance or stability over time
 Subjects had aphasia and apraxia
 A PROBLEM IS OVERGENERALIZATION OF THE
SOUND TREATED
 So if treating /p/ it began to appear for /b/
Over generalization
 A huge problem
 But worse in AoS than in any other motor speech
disorder
 Possible answers:
 Treat more than one sound pair at a time
 Treat different manners such as fricatives and plosives
 Use at least quasi-random presentation of stimuli so pt
has to change set
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
Value of this report
 Can do the treatment based on it
 Some of our very best data
 And it is a spring board for further creative treatment
development
Problems
 In addition to overgeneralization of treated stimuli
 Have too little generalization across time-in other
words has less than satisfying maintenance of effects
 They have gone to work on the issue
 Wambaugh & Nessler (2004). Modifications of
SPT…Aphasiology, 18, 407-427
Revised SPT
 Wambaugh & Mauszycki (2010). Sound production treatment with
severe apraxia of speech. Aphasiology, 24 (6-8), 814-825
 This article on treatment of one severe pt contains a
revised form of the protocol in response to some issues
 Who by the way had a recurring utterance that was
pieces of the one phrase-I want water-that had
been her practice item in earlier therapy
Modified protocol
 Used “minimal pairs” and actually multiple stimuli
 Set 1 w vs b, s, l
 Set 2 w vs m, d, f
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So you can see that manner, voicing and place are all
manipulated
W was because that was sound that pt produced nearly
inevitably
 More contrasts absolutely critical
 Also less frequent feedback-also critical
 It worked in the clinic testing
However
 We have some apraxic persons (and some dysarthric)
so severe that they cannot work on words and
sometimes not even sounds
 BTW must guarantee that such patients are not more
severely aphasic than apraxic
 Thus lets extend the program at the bottom
So lets expand
SPT
For severe, single
sound and maybe even
nonverbal movements
If single sounds
 CATE would say that it is more efficient to choose difficult,
less stimulable-complxity account of therapeutic efficacy
 So /sh/ rather than /s/ for example
 Because one gets greater generalization
 Depends on the amount of co-existing difficulty
 The purer the apraxia, for example the more likely CATE is
to be a good idea
 But move the single sound into a word ASAP
 And only work on one if doing more is too hard
 Will demonstrate a pt in a moment
Oral nonverbal movements
 Students are taught they are critical to speaking-NO
 Neural circuitry controlling such movements are different
from speaking
 Maas and colleagues predict that generalization to speech
is unlikely
 Maas et al (2008). Principles of motor learning in treatment
of motor speech disorders. AJSLP, 17, 277-298
Rules on oral non-verbal
movements
 They should generally be a last resort tx target
 Those you choose should resemble real speech acts
 Clark (2003). Neuromuscular treatments for speech and swallowing: A
tutorial. AJ S-LP, 12, 400-415
 Generalization will not occur unless you structure
treatment to specifically cause generalization
Contrast
Too much
Just right
sometimes
 Clinician needs to be even more basic
 To prepare a person’s body to talk
So lets expand
SPT
Prostheses
single sounds/nonverbal
movements
Prostheses
 Palatal lift
 Nasal insert
 Bite block
 Maxillary reconfiguration
 Abdominal binder
Example
 Person with MS needing a belly binder
Another
 Person with stroke needing laryngeal manipulation
Another
 Person with stroke needing a palatal lift or other
palatal management
New device using Passey-Muir
valves
Here is an example
 Going to leave presentation so I can manipulate the
samples if need be
 Polke
Expand more
Prostheses
Posture
SPT with multiple stimuli (words) usin
Imitation
For severe single
Visual, written
Sound and maybe even
Phonetic placement
Nonverbal movements
Posture
 General
 Best is normal sitting
 Although prone is sometimes good if respiration
reduced
 Stabilized, especially in adventitious movements
 Head
 Level
 Jaw up (mouth closed)
 Stabilized, especially in adventitious movements
Example
 Person with multiple system atrophy (a form of
parkinsonism)
 Needing increased background of effort
Consider this pt
 KS DVD
 What is going on with her?
 What would you do?
SIMPLE
Get person is best upright posture
Provide instruction and respiratory
support
By pressing respiratory
muscles with hands
Have pt say low cognitive-linguistic
load utterance such as counting
Experiment with varying pressures
on inhalation and exhalation
Have pt provide the respiratory
support
Expand more
Prostheses
Posture
Compensations
SPT with multiple stimuli (words) usin
Imitation
For severe single
Visual, written
Sound and maybe even
Phonetic placement
Nonverbal movements
Compensations
 Sensory tricks in dystonia
 Amplifiers
 AAC
Here is a dramatic example
 What does he remind you of?
 What does his compensation do?
 Go to GS DVD
So lets expand
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
Program easy to expand
 Can create a kind of procedure drop down menu
 For now we will stay with single words as stimuli
 To demonstrate will assume using /p/ /b/ /s/ and /t/
 And have created a list: pie, by, sigh, tie; pick bic, sick,
tick; pack, back, sack, tack; poor, bore, sore, tore
The menu
 Lay out all in written form and tell pt to choose one say it
and I (clinician) will report what is heard
 Patient says a self-selected word from those worked on or
another word with the target (no visual stimuli) and asks
clinician to say it back
 I love these tasks
 Often speech is better here than in other tasks (even some
“easier” ones)
 Or use same stimulus and multiple different responses-give
me one of the words, now another, now another
 Or introduce competition-have pt make a gesture
between each utterance
 Turn on recorded noise during practice
More
 Clinician spells and has pt say what was spelled
 Clinician defines a word and patient says
 Clinician asks for a rhyming word
So
 That’s eight additional “steps”
 I am sure you could add others
 I have no idea if these can be rank ordered for difficulty
 Probably doesn’t matter
 What’s important is
 They use principles of skill building
 They provide variety which is badly needed in speech rehab
 They make treatment cognitive
 And some give pt more autonomy
Purpose of these
 All may enhance generalization
 They may slow acquisition
 So you have to decide what your goal is
 Good performance in clinic
 Good performance outside
 Techniques that give one seldom give the other
Pt has AoS
 Isaiah DVD tx
Working on words
Using CATE
/s/
/t/
/st/
Using visual cause it helps him as it
does most with AoS unless they
have too much aphasias
So lets expand
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
Sentences
Sentence stuff
 Use some of the previous words (if tx began with words)
 With apologies: I got pie on my tie and so on
 Or if patient is mild-moderate may be able to use almost
any sentences
 Which we do in our neuroprotective programs
 Can even use imitation-diagnostically- to be sure pt has the
motor ability under controlled conditions to handle what
you (or they) have created
Expanding sentences
 Can use many of the permutations already discussed for
words
 Tell me the sentence that tells me something about your tie
 Give me another sentence with the same key word; now give
me another sentence; another
 Say any sentence and I’ll tell you what I heard

This is actually an easier step with sentences than with single words
 BTW the best step here would be for the pt to create the
sentences
 Here now can realistically work on rate and other aspects of
prosody as well
 Say it faster
 Say it with stress on ________
An example
Pt has an apraxia plus he did not
receive any therapy for months
Using CATE-specifically /j/, the
hardest sound on average for
persons with apraxia of speech
Work on words (and risk
overgeneralization) cause I use
same sound for awhile
 Go to audio again so can
manipulate as time permits
 Begins with single words
written and my pointing to
them-no imitation unless
necessary
Then use the hardest contrast
Move around from word to
sentence and back
 First word is “yes”
So lets expand
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
Sentences
Here is an example
This lady has multiple medical
problems
And a complex dysarthria with
ataxic features dominating
This is an early session
I give her my standard set of
admonitions
Fricatives are difficult as is control
of all aspects of prosody
Thus goal will be to work on both
simultaneously
 Ataxia liver stroke
Contrastive stress drill
 Way to approximate communication
 Contrastive stress drill is a Q-A drill
 Could be used even with single words
 Idea is for cl to ask a variety of Qs about components
of sentences already worked on in other ways
For example
 Stimulus: I got pie on my tie
 Drill
 Cl: Did you get tooth paste on your tie?
 Pt: No, I got PIE on my tie
 Cl: Did you get pie on your shoe?
 Pt: No, I got pie on my TIE
 And so on
Cerebellar
degeneration
Contrastive stress drill
Goal is less on specific points of
articulation
More on prosody
Especially on rate and rhythm
Other forms of cognitive-linguistic
load
 As evidence that many methods are totally ignorant of
what we think they are good for
 Contrastive stress drill
 PACE: Promoting Aphasic Communicative Effectiveness
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Stimuli are put on cards and placed between cl and pt
Take turns selecting one and saying it without showing to
other person
 Scripts:
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Create two or more sentences to tell a more complex story
I will not embarrass all of us with an example
So lets expand
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
Sentences
GROUPS
Communication Partners
Groups
 Inserted at end in this presentation but can actually be
used from the beginning
 Limited data but consistent with expectations
Communication partners
 Developed for aphasia but can also work in dysarthria
 Hunter et al (1991). The use of strategies to increase
speech intelligibility in CP. BJDC, 26, 163-174
Communication Partners
 Bring other people into the clinic suite
 The principle is that a learned response is most likely
recovered in an environment that resembles the one in
which it was learned
 No wonder families say,” He talks so much better to
you than to me.”
Bit more on method
 No need to go far here as this is the birthplace of the
idea
 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
For example
 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
So what have we done?
 Taken the original five-step AoS program and made it
a menu
 Best of all perhaps is having added more functional
steps
 And these functional steps serve to move this from a
focal (articulation) therapy to a more general therapy
 That can be used to modify not only articulation but
also prosody including rate
So lets expand
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
Sentences
GROUPS
Communication Partners
Move to more functional
But what about apps and DAF
 They are not treatments
 They are adjuncts
 They can be fit into the framework
So lets expand
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
DAF
Amplifier
Etc
Sentences
GROUPS
Communication Partners
Move to more functional
Here is one ex
 What does it do to naturalness of speech
Data on rate
reduction from
Yorkston et al 1990
Intelligibility systematically
improved for both groups-ataxic
and hypokinetic
Greatest at 60% of habitual
Some subjects could not tolerate or
achieve the 60%
Finding the right percent of
habitual is worthwhile
Rate manipulation can be a
powerful tool for a general
approach to dysarthria treatment
Don’t neglect the simplest stuff
 Six or so studies of simple directions to encourage
some form of “try to speak more carefully” have been
published
 Yorkston (1996). JSHR, 39, 546-557
 Building improved speech from basic background of
effort
 And a bit of prosthetic bracing of respiratory system
can also be good starts
Transition
 Lets move from this discussion of skill training to methods
that seem to combine elements of skill and strengthening
 And can form a foundation upon which the skill training
can be imposed
 Thus may begin with the two types of therapy to be
described
 Maximum performance training
 Strengthening
So lets expand
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
DAF
Amplifier
Etc
Maximum performance
Strengthening
Sentences
GROUPS
Communication Partners
LSVT
 All permutations of this program require certification
 In the interest of fidelity to the protocols
 Thus I cannot teach it
 As probably all of you know the emphasis is on
maximum performance at least
initially
And it is most studied for effects
Maximum performance
training:our view
 May influence both skill (learning to use enhanced
effort) and endurance
 The idea is simple: have pt perform quality maximum
performance tasks
 And learn to transfer that effort to speaking
 An absolute minimum of 25 per day, five and
preferably six days per week
Steps
 Get pt in best posture-usually sitting upright
 Have pt increase background of effort-valsalva
 Have pt get to best size-appropriate inhalation
 Check or hold that inhalation so air does not escape in a
rush
 Then start maximum duration of vowel
 With attention to consistent airflow, loudness and quality
 Repeat enough so that you get a sense of duration person can
achieve with control
Steps, cont
 Cue pt to the sound and feel of this maximum




performance mode
Carefully monitor for laryngeal hyperfunction, pain,
dizziness, other discomfort
Have pt get a timer
URGE maximum, consistent performance
Work as hard as you need to to transfer the same
intensity and effort to speech using short sentences
heavy on plosives
Further steps
 Some of the steps or procedures listed in SPT can now
be introduced
 If the patient can identify appropriate loudness and if
effort is not 5, 6, 7 then adding to the cognitive
linguistic load is next
 Without these steps generalization is unlikely
Bonus
 It appears that LSVT and other maximum
performance training influences more than just the
larynx
 Even some evidence from LSVT that lingual strength
improves
 How is that possible?
Moving on
 More or less pure muscle strengthening
 But by self unlikely in majority of patients to have
functional consequences
So lets expand
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
DAF
Amplifier
Etc
Maximum performance
Strengthening
Sentences
GROUPS
Communication Partners
Strengthening
 Have some for respiration
 Emphasis here cause of data
 Although in swallowing
 For the tongue
 For the velopharynx
 And perhaps, depending on what you believe, for pharynx
Methods for respiration are
 Expiratory muscle strength trainers (EMST)
 With main effect on respiratory muscles other than
diaphragm
 Inspiratory muscle strength trainers (IMST)
 With main effect for diaphragm
 Warning: no data based guidelines on which to use
but will describe ours after description of methods
Candidacy
Those with respiratory system weakness or reduced endurance
 Can potentially be just about anyone with a neurodegenerative disease
 So long as they are not profoundly weak
 Those with respiratory system rigidity
 PD, MSA are prime examples
 Perhaps even those with hypertonicity
 Potentially any of the parkinson plus syndromes such as progressive
supranuclear palsy (PSP)
 Strengthening those with hypertonicity does not increase tone
Relevance
 Respiration provides critical air pressure and flow for
speech
 Reduced respiratory drive can influence all other components
of the speaking mechanism
 Respiration is coordinated with swallowing and respiratory
deficit can influence swallowing efficiency and safety
 Some superficially oropharyngeal abnormalities may be
secondary to inadequate apneic period as but one example
EMST
 Pt blows into a device




fitted with a one-way
spring-loaded, pressure
release valve
Amount of pressure can
be controlled
Increasing the pressure
to open valve can
increase respiratory drive
Training based on 70%80% of maximum
expiratory pressure
(MEP)
Or on clinical judgment
EMST
 This device calibrated
from approximately 5
to 140 cc of H2O
 So covers most of the
range of normal
pressures
 Cost 60.00 or so plus
shipping
 Can order from
www.aspireproducts.org
Another view
 This is a good diagram of
the device
 At left end (in this view)
is the cap that can be
tightened or loosened to
influence pressure
Training load
 Can measure maximum inspiratory and expiratory
pressures and train at 70-80% of max
 Using a spirometer
 Or can set clinically-judge the work or effort
 Remember the principle of overload
 Muscles to strengthen must work harder than they work
ordinarily
Basic treatment guideline
 EMST set at 75% of MEP (or clinically)
 Nose clip and cheek/lip press-CRITICAL
 25 trials per day in five groups of five
 I prefer more reps in two groups
 Five sessions per day is burdensome
 Five days per week
 I prefer 6
 Five weeks and I prefer 3 months or even longer
Cheek lip press
 Critical to maximize
flow thru mouth
 Minimize through nose
 Enhance lip seal
 Pt can do or caregiver
may have to
Reality of treatment
 Any pt with cognitive decline may have trouble
learning the steps
 Take deep inhalation
 Place device in mouth
 Press cheeks and lips
 Blow hard and quick
 Quit when you hear (or feel) that pressure valve has
opened

Distinguishing from flow around device takes practice
REMARKABLY HARD FOR BOTH CLINICIAN AND PATIENT TO LEARN
Especially early in clinician’s use and for patient with cognitive decline or multiple
system involvement
Thus
 Often need our whole bag of behavioral tricks
 We have been training MSA and PSP
 Nearly inevitably have to begin them with just blowing
and then blowing harder
 Then introduce the device but at no resistance
 Then hold cheeks for them (or get caregiver to)
 And then help mold their holding of device and of
their cheeks
Method continued
 Add just the smallest amount of resistance (approx 5





cc of water pressure equivalent)
And then repeat, repeat, repeat
Hone them in on the sound of quick airflow that
signals the valve has been broken
Educate caregiver as well
THE CHEEK/LIP SEAL IS CRITICAL
Sometimes takes several sessions merely to learn how
to use device
Aim
 Originally designed to improve strength of respiratory
mechanism
 With thought that stronger system would be able to
support sufficiently long apneic period
 And better, especially louder speech
 And perhaps produce a respiratory system better able to
support and coordinate with the other parts of swallow
and speech mechanisms
The literature
 Best article is Kim, Sapienza. (2005). JRRD, 42, 211-224
 Best book is Sapienza & Troche. (2012). Respiratory
Muscle Strength Training. Plural Publishing
 Strict schedule worked out
 25 repetitions per day in 5 groups of 5
 At 70%-75% of maximum expiratory pressure
 Home practice 5 out of every 7 days
 Weekly visits for 4 weeks (minimum) to reset device if
strength improving
 Can train for longer or shorter
 Will likely need to combine with other txs
Summary of uses
 So far used to treat speech and swallowing in PD, MSA,






stroke, Lance-Adams, some inherited ataxic disorders,
COPD, MS, Pompe, ALS, ventilator dependent (usually
inhalatory)
Results are tentative with all groups
Strongest with PD
Appears that hypophonia can be reduced-but not
without accompanying skill training
Intelligibility improved
Airway invasion reduced
Cough strengthened
 BUT NOT IN EVERYONE
Cough in PD
 Pitts et al (2009) Utilizing voluntary cough to predict
penetration and aspiration…Chest, 135, 1301-1308
 Two findings
 Voluntary cough predicts penetrating and aspirating PD
pts
 Voluntary cough competence is improved by EMST at
the previously discussed frequency and duration
Masked facies
 Data showing that computerized images of facial
expression reflect improvement in masked face
 In mild and moderate patients with PD
 With caregivers and patients reporting improved
communication
 IMST used
 Unpublished data by Bowers (2013)
Our program: once again
 75% of maximum expiratory effort
 25 reps divided among at least two sessions
 Six days per week
 For 4 to 12 weeks, OR LONGER, depending on
response
 Visit clinic once per week for adjustment and drill
Contraindications
 Untreated cardiac abnormalities
 Untreated HTN
 Till MD approves post surgery anywhere in body
 RECALL: this is real exercise
What is happening
 SLPs are hearing about this
 Trying it sometimes even unsuccessfully on themselves
 Are unsuccessful and reject the method
 Or try unguided with a patient, fail, and reject the
method
 Or they try it without transfer techniques and person
gets stronger but nothing else changes
IMST DEVICE
Order from:
WWW.RESPIRONICS.COM
This device is calibrated for 0 to 40 cm of H2o
So good for very weak
Use of IMT
 Notion is to get quick, smooth, deep inhalation
using diaphragm
 Followed by long controlled exhalation
 These two actions roughly parallel speech
breathing especially by some treated dysarthric
speakers
 Need to inhibit exaggerated shoulder raising and
other maladaptive responses
 Use nose plug
 Systematically increase resistance based on pt
performance
When to use
 IMST when diaphragm is focally or more weakened than
other respiratory muscles
 As can happen in phrenic nerve damage
 Not so likely in the neurodegenerative diseases
 May come to point when both are used
 And some are beginning to argue for the primacy of IMST
because of the importance of sufficient inhalation
The main idea for both I and E
 The treatment data in PD are positive
 The data and protocol can be used as a guide for
interventions with patients having similar control
abnormalities
 Rigidity or
 Weakness or
 Reduced neural drive generally
Recommendation
 EMST and IMST are not cure-alls
 Often will have to be joined by one or more skill treatments
 But are powerful new tools
 Including for reduced cough, a common sign in a variety of
neurodegenerative diseases
 Because of Neurology publication going to spread into
clinics rapidly
 Clinician training can be accomplished in one day
The program
Contrastive stress
PACE
SCRIPTS
Prostheses
Posture
Compensations
Sound
nonverbal
SPT
Single word with
refinements
DAF
Amplifier
Etc
Maximum performance
Strengthening
Sentences
GROUPS
Communication Partners
Summary
 Treatment must be cognitive
 I outlined the treatment options
 In hopes of giving us something to do for the full range
of persons from most to least severe
 Qs
Thank you very much