Flashcards: Motor Speech Quiz LAST ONE BABY

•Goal: maximize effectiveness, efficiency, and naturalness of communication•Effectiveness: ability to communicate message•Efficiency: increasing rate of communication without sacrificing intelligibility•Naturalness: prosody (rate, rhythm, intonation, and stress) carries important syntactic information and increase redundancy in the speech signal

•Treatment usually involves some combination of:•restoration:• strengthening reduced physiologic support•compensation:• modifying aspects within the speaker or the environment that can influence ability to communicate message•adjusting:• reorganizing life functions to reduce need for/impact of lost functions

Medical diagnosis & prognosis, extent of impairment, activity limitations, and barriers to participation

• Likely to be acute or chronic?• Likely to improve, be stable, relapse/remit, or degenerate?• Is there a medical treatment for etiology that may result in speech improvement?

•Impairment = loss of function• Not necessarily the most influential factor in decision about whether to treat•Activity limitation = inability to speak normally because of speech impairment• Intelligibility and comprehensibility of speech•Barriers to participation = effect of impairment or activity limitation on ability to accomplish a previously normal role• May be internal and/or external barriers

• Individual’s communication needs• Individual’s perception of their ability to communicate• Attitudes of family, friends, employers, coworkers, society, etc. regarding individual’s ability to communicate

• Cognitive deficits:• Attention, memory, insight, planning, motivation• Language deficits:• Aphasia• Motor/sensory deficits

• Medical intervention• Pharmacologic management:• e.g., dopaminergic agents to treat Parkinson’s disease may or may not have beneficial effect on speech• e.g., botulinum toxin for spasmodic dysphonia may preclude the need for other speech intervention• Surgical management:• e.g., pharyngeal flaps, thyroplasty• Prosthetic management:• Prosthesis: device to augment/replace performance of a natural function• e.g., palatal lift, voice amplifier, DAF device, AAC

• Behavioral management:• Speaker-oriented approaches• Restore or compensate for impaired speech functions• Communication-oriented approaches• Modify environmental aspects (including communication partners) and teaching repair strategies• Counseling and support

• Treatment should begin with the component whose improvement will have the greatest effect on other components• Begin with functions that are readily modified with minimal instruction

• Start as “close” to discourse as you can:• Oral exercises (?)• Not much evidence that working on physiologic support outside of speech context has any effect on improving speech, except for one study that reported respiratory exercises done outside of speech context improved speech• Sound in isolation• Syllable• Word• Phrase• Sentence• Discourse

• Baselines of intelligibility, comprehensibility, or other measures of communicative effectiveness should be the standard for judging treatment effectiveness• Explain to patients and others how task-specific goals relate to these overall goals• Don’t underestimate how hard it is to monitor and change aspects of your own speech

• Neuroplasticity:• Changes in neural pathways & synapses caused by:• Experience: changes in behavior, environment, thinking, learning, emotions, etc.• Reorganization of brain after injury to reacquire or compensate for lost/impaired abilities:• Naturally• Through rehabilitation• The term “experience-dependent neuroplasticity” is increasingly used to explain the way that rehabilitation (structured experiences) changes the brain:• Studies that use neuroimaging tools are beginning to demonstrate the changes that occur with treatment

• Cortical area responsible for motor act gets bigger (more neurons are recruited):• Braille readers: area for reading finger gets bigger than for other fingers• Learning piano: cortical representation of hands get bigger• Synaptogenesis: neurons grow new processes which create new synapses

• are salient (motivating)• involve new learning

Voluntary use of the impaired body part leads to:• greater improvement• greater activation & reorganization of motor cortex• evidence from constraint-induced movement therapy

• Speech was previously effortless, but now requires constant monitoring, at least at first• Not easy shift to make• Requires a great deal of attention, using lots of cognitive resources: unexpectedly fatiguing:• We need to be aware of possibility of fatigue, but we also need to work our patients to that point, with some exceptions

• Traditionally, we have believed that the earlier intervention begins, the earlier improvement starts:• Typically start treatment when person is medically stable• Animal models suggest that there may be time periods during which intervention might not be as effective or might even be harmful:• Don’t know yet whether this is also true in humans• Work is starting to find biomarkers (in blood, etc.) that can tell us when these periods might occur during human recovery

• What we know is based on nonspeech motor tasks by individuals with intact motor systems• Motor learning – a set of processes associated with practice or experience leading to a relatively permanent change in movement capability:• Involves physical & cognitive effort• Acquisition is not the same thing as permanent learning:• Performance improvement may be temporary, especially at the beginning of treatment• Learning should be measured by retention or transfer• Retention (maintenance) – performance after completion of practice• Transfer (generalization) – practice on one movement affects related but untrained movements

• Motor programs are retrieved from memory and adapted to a particular situation:• Motor program – organized set of general motor commands that can be specified before motor initiation:• Generalized motor program (GMP): abstract movement pattern that specifies relative timing & force of m. contractions• Absolute timing & force are specified by parameters• In this way, the GMP can be adapted depending on current context (e.g., coarticulation, noise conditions, distance from listener)

• current conditions• general motor commands• sensory consequences of commands – prediction of consequences that will occur if movement goal is reached• Proprioception, tactile info, auditory info, etc.• actual outcomes of movement – compared to predicted consequences of correct movement• may be own judgment or external feedback• error in movement will cause a mismatch• used to update motor commands

• Deficit in activating &/or parametrizing GMP• Disturbance in processing somatosensory feedback• Impairment in predicting consequences• Muscle impairment/dyskinesias: motor specifications won’t produce intended movement outcomes:• Actual sensory consequences won’t match predicted outcomes

• Learning can only occur when the learner is challenged• Learning may be hampered if challenge is too great or not great enough:• Optimal challenge point for each learner depends on task difficulty & learner’s skill level

• Cognitive stage: understanding nature of problem, why change is necessary, and what needs to be done to effect the change• Associative stage: transition from conscious to more automatic control• May involve trial & error• Feedback usually helpful• Automatic stage: new skill can be performed quickly, with little conscious effort• Requires extended practice to achieve

• Motivation:• Understanding relevance of practice task for goal• Functionally relevant treatment targets• Include client in selection process• Salience• Set specific goals• Understanding task:• Avoid overinstruction; modeling may be better• Provide reference of correctness• Correct productions vs incorrect productions• Why incorrect productions are incorrect• Ensure adequate aud. perception abilities:• Otherwise client’s self-eval. will suffer

• Large no. of trials:• Provides more opportunities to estab. relationships among all types of info necessary for movement• Enhances stability• Requires many instances of retrieving GMP• May automatize GMP retrieval• However:• if exact same movement is practiced in same way, a large amt. of practice results in poorer retention &/or transfer than small amt.• for variable practice, large amt. of practice produces better retention &/or transfer than small amt.

• How the amt. of practice is distributed over time:• Massed practice – less time between trials or sessions• Distributed practice – more time between trials or sessions• Nonspeech literature suggests that distributed practice is better both for immediate performance and for maintenance• However, limited evidence from speech literature (LSVT-X) suggests that masses & distributed practice may be equivalent for speech• More research necessary

• Constant practice – practice on only one variant of a GMP• Variable practice – practice on more than one variant of a GMP:• e.g., varying phonemic environment• Evidence from AOS suggests:• constant practice may be beneficial early in tx or when AOS is severe• although variable practice may require a longer acquisition time (because more errors will be made during acquisition), it will result in better maintenance and generalization

• Random practice – different movements (different GMPs; e.g., different target sounds) are produced on successive trials & target for upcoming trial is not predictable to the learner• Blocked practice – learner practices a group of the same target movements before beginning practice on the next target• Random practice has resulted in better retention and transfer in MSDs, but more research is needed

• Goal: adequate loudness and breath patterning:• Cannot produce more than 1 word per breath group during speech• Cannot phonate because of reduced respiratory pressure• Cannot sustain movement of 1 cm of water for 5 sec. with breath• Generally, should do respiratory exercises using speech tasks:• Exception: if person cannot generate sufficient subglottal pressure to produce phonation• Remember that breath control for speech involves valving, so make sure the problem is not with valves before investing lots of time and effort on respiration

• Indirect treatment (doesn’t directly involve speech):• Sustain movement of 5 cm. H2O for 5 sec.; manometer, etc.• Evidence: Single subject design replicated across subjects

• Sustain vowel sounds (Expert Opinion)• Count progressively more numbers before taking breath (Expert Opinion)• Breath phrasing (respiratory/phonatory coordination) (Expert Opinion):• Consistent phonation in short utterances• Teach to break long utterances into natural-sounding shorter breath phrases- Use printed text at first and mark:Yesterday/ Bob and Joe came to see me/ and we played cards.• Let pt. mark text before reading- Pt. reads without marking- Structured conversation; tape and play back- “Real-time” self-monitoring• Postural changes: (Expert Opinion)• If muscles of expiration are affected, supine better-wheelchair/easy chair with adjustable back• If muscles of inspiration are affected (as in ALS), supine worse

• Prostheses (Expert Opinion):• Abdominal binder/corset for expiratory weakness• Get medical clearance first, involve respiratory therapy• Expiratory board/paddle:• Patient pushes this into abdomen when speaking• If poor arm strength and in wheelchair, can sometimes lean into lapboard when speaking; work with PT/OT to reduce danger of pushing lapboard off chair

• Problem - Aphonia: • Use any intact reflexive phonation to improve voluntary phonation (Expert Opinion)• Attempt to produce reflexive behavior on a repetitive basis• Artificial larynx (expert opinion)• Press the artificial larynx against their neck in the region of the vocal folds• Vibratory sensation will sometimes “trigger” voluntary phonation• If use of the artificial larynx does not trigger voluntary phonation by the person, then it can be used as a prosthetic device to serve as the sound source for speech

• Pushing exercises (SS design/non-randomized controlled study):• Get a the laryngeal exam first• Pushing hand/arm/head against resistance while attempting to phonate may induce reflexive glottal closure• Once consistent voluntary phonation is achieved, shape it: • Duration• Vowel sounds• Etc.

• Pushing (SS design/non-randomized controlled study)• “Think loud” (Randomized Controlled Trial):• Start with feedback from SL meter, tape recorder, Visi-pitch• Pt. needs to learn to judge adequacy of own productions; use tape recorder as necessary• Maintain adequate loudness during increasingly long periods of speech production

• Prosthetic management (Expert Opinion):• Portable amplification system• Surgical management (SS design/non-randomized controlled study):• Injections into vocal fold- Botox injections for spasmodic dysphonia- collagen, autologous fat injections, for paralysis of one vocal fold in paramedian or abducted position

• Improve respiratory-laryngeal timing: • Adequate inhalation first• Prompt initiation of phonation at beginning of exhalation• Adjusting pitch to achieve better quality• Postural adjustments:• Head turn to stretch v.f.• Shape so that pt. can achieve good quality with face at midline• Laryngeal compression:• Gently grasp thyroid cartilage between thumb and forefinger and squeeze gently• Thought to decrease distance between vocal folds

• Behavioral approaches: only likely to help in mild cases:• Pushing: “overflow” of contractive effort into other muscles• Increasing loudness• Reducing rate• Exaggerated articulation• Prosthetic methods:• Palatal lift• Work with prosthedontist• Constructed in stages to get best shape for patient• May need to desensitize gag reflex• Problem with patients who are edentulous, but has been done• Surgical interventions:• Not terribly successful• Pharyngeal flaps• Injections to PPW

• Techniques for which no evidence is currently available:• Non-speech strengthening (blowing & sucking)• Control/modification of airstream (blowing)• Inhibition techniques like icing, brushing, desensitization

• Reducing tone (spastic dysarthria):• Biofeedback: surface electrodes, usually on lips, machine creates a sound that gets louder as muscle tone increases, softer as it decreases• Patient concentrates on lowering audible sound during speech tasks• Traditional artic tasks:• Integral stimulation: watch, listen, say it with me• Phonetic placement• Phonetic derivation: use intact nonspeechgesture to establish target sound

• Exaggerated consonant production• Minimal pair drills• Compensatory strategies:• Increase loudness• Slow rate-pacing• Prosthetic management:• Alphabet board supplementation: Point to first letter on alphabet board as each word is spoken• Orthodontic prosthesis to “lower” hard palate so tongue can reach it• Bite block to maintain constant jaw position during speech

• Use if reduction in speaking rate results in improved intelligibility• Speaking rate = articulation time & pause time:• Pauses easiest to manipulate• Intra-utterance: around clauses• Inter-utterance: between sentences• Typical speaking rate: • 160-170 wpm for par. reading• 150-250 wpm for conversation

• Rigid approaches:• Max. control over rate, but neg. impact on prosody• Pacing boards• Finger tapping• Alphabet board supplementation• Metronome• Rhythmic approaches:• Attempt to preserve naturalness while controlling rate• Visi-Pitch (Computerized Speech Lab): use intensity trace in stationary mode, set time display based on desired target rate• Delayed Auditory Feedback• Indirect Approaches:• Increase loudness• Exaggerate articulatory contacts

•Drill on intonation contours for various sentence types•Contrastive stress drills: patient must answer questions by stressing appropriate word in sentence• “Bob hit Joe.”• “Who hit Joe?” or “Did Tom hit Joe?”• “Did Bob bite Joe?”• “Did Bob hit Tom?”

• Best documented txfor dysarthria in PD• Ramigand colleagues are continuing to investigate effects and explore outcomes• Must be certified to provide treatment• Intensive treatment focused on increasing vocal loudness• Good candidates: patients with idiopathic Parkinson’s disease and relatively good cognition

• Focus on voice: “Think Loud”• High effort• Intensive treatment: 4 days/wk. X 4 wks. = 16 individual 50-60 minute sessions in 1 month• Calibration: patient knows and accepts amount of effort needed to use vocal loudness level WNL• Quantification: objective measures• Daily homework (habituation)• Daily caregiver exercises (habituation)• Each session consists of Daily Variables & Hierarchical Speech Loudness Drills

• max. duration sustained vowel:• at least 10 times• use sound level meter, increase 5-25 dB from baselines, sustain for as long as possible• max. fundamental frequency range:• highest pitch and lowest pitch• glides or stair-step• sustain extremes 2-3 sec.• at least 10 times• visipitch, pitch pipe, etc. to measure• max. functional speech loudness:• 10 functional phrases loudly, 3 to 5 times each• sound level meter to monitor loudness

audiotape and playback for SLP and self-critique; use sound level meter• Week 1: single words/phrases• Week 2: sentences• Week 3: paragraph reading• Week 4: conversation

• Teach strategies to compensate for residual impairment:• Provide context, especially when switching topics• Increase redundancy• Supplement with alphabet board or writing• Modify physical environment:• Avoid noisy settings• Reduce noise when possible• Face-to-face interactions• Reduce visual distractions so listener focuses on speaker’s face• Phone conversations can be very difficult:• Encourage to text/video chat when possible• If they must use standard phone call, use relay service

• For people with degenerative disorders who will ultimately lose the ability to use speech, but who will retain language and other cognitive abilities that allow them to use sophisticated AAC –like people with ALS• Voice Banking –recording a large inventory of speech that is then used to create a synthetic voice that sounds like the speaker’s natural voice:• This allows people to create unique messages and then “speak” them through a synthesizer that sounds like their natural voice by typing what they want to say• Message Banking–digitally recording and storing words, phrases, sentences, personally meaningful sounds (like a laugh), and stories using a person’s natural voice, intonation, and inflections:• This allows a person to retrieve messages, but does not allow the creation of new messages.• If individual words have been recorded, they can be combined and spoken in new sentences, but the intonation will be “off” when they are combined

•Staging: sequencing natural speech & AAC interventions so:• Current problems are addressed• Future problems are anticipated•Based on natural course of disease, levels of disability, and severity of speech disorder

1. No detectable speech disordersDxof illness made, but not discernible speech disorders yet2. Obvious speech disorder with intelligible speechSpeaker can still interact effectively with natural speech, although disorder is apparent to both listeners & speaker3. Reduction in speech intelligibilityCommunicative effectiveness is compromised in adverse or demanding listening situations4. Natural speech supplemented by AAC• Natural speech no longer functional in most situations5. No functional speech• Natural speech carries little of communicative load in almost all situations, with reliance on AAC

• No detectable speech disorder:• Physiologic level: Preventive exercises for highly demanding communication situations• Warm-up vocalization/speech exercises for public speaking• Participation level: educate the individual about speech symptoms that are likely to occur and the sequence of interventions that are available• Discuss frequent occurrence of poor self-assessment in PD speakers, and suggest seeking feedback from someone they trust• Obvious speech disorder with intelligible speech:• LSVT• Physiologic intervention: improve respiratory/phonatory support for speech• Activity intervention: • increase loudness of natural speech during common speech activities• Maintain diary of difficult speaking situations, script communication strategies for them, practice strategies

• LSVT• Physiologic intervention: continue to improve respiratory/phonatorysupport for speech• Activity level: • Continue loudness training• Tasks to control speaking rate in common speaking situations• Participation level:• Encourage client to pretend they are doing public speaking even in 1:1 conversations• Reduces rate, increases loudness, increases prosody

• Little-to-no benefit from physiologic intervention• Activity level:• Alphabet supplementation• DAF

• Only happens in very small percentage of PD speakers• Activity level:• AAC strategies: alphabet/word boards, electronic systems permitting letter-by-letter spelling• Participation level:• Partners must take most of responsibility for clarifying topic, resolving breakdowns, etc.

• No detectable speech disorder:• Physiologic interventions: none• Participation level• Education about accessing speech & AAC intervention at appropriate time• Voice and Message Banking• Obvious speech disorder with intelligible speech• Physiologic interventions:• Instruction in respiratory techniques for energy conservation• Prevention of maladaptive breathing patterns for speech• Palatal lift• Activity level:• Rate reduction in common speaking situations• Participation level:• Communication oriented approaches• AAC: amplification in groups• Voice and Message Banking

• Physiologic intervention not common because of need to avoid fatiguing exercises• Activity level:• Exaggerated articulation• Reduced speaking rate• Exaggerated prosody• Participation level:• Partners encouraged to:• identify topic/context to verify• Reduce adverse environmental factors• Serve as “translators” to resolve breakdowns• Support in use of AAC/Voice & Message Banking

• Natural speech supplemented with AAC:• No physiologic intervention• Activity level:• Alphabet supplementation• No useful speech:• Participation level• AAC devices

1.Integral stimulation (“watch me, listen to me, say it with me”) : unison2.Integral stimulation: client imitates while clinician mimes3.Integral stimulation: imitation 4.Integral stimulation: client produces mult. reps.5.Written stimuli: client reads6.Written stimuli: remove written word, client says word7.Question stimuli: client produces response8.Role playing

• Hierarchical task difficulty:• Manner & place of artic• Speech sound position• Difficulty of initial sp. sounds• Distance between successive sp. sounds within words• Word length• Systematic intensive drill• Knowledge of performance and results• Devel. of strong vis. memory for correct artic postures

• Response-contingent hierarchy: subsequent steps of hierarchy only used when response is incorrect1. Clinician provides verbal model of target [sound/word/phrase/minimal pair], requests repetition• Correct response: pos. verbal feedback, request for another rep., present next stim.2. Incorrect response: provide appropriate feedback, present written letter corresponding to target sound, repeat step1 3. Incorrect response: provide feedback and use integral stimulationup to 5 times4. Incorrect response: provide articulatory placement cues (verbal, visual, tactile) specific to sound error5. Incorrect response: model in simplified context (drop back to word, isolation, etc.)6. Incorrect response: go to next target

• Evidence: single-subject designs systematically replicated across participants, conditions, etc.• Improvement on targets, no generalization to untrained sounds• Treating more than 1 sound at a time minimizes overgeneralization• Adding sentence completion as a treatment context resulted in improved generalization• One study reported positive outcomes for a participant with severe AOS & nonfluent aphasia for generalization to treated sounds in untreated words, but not to other sounds• Compared traditional (1 hr/day, 3 days/wk) vs intense (3hrs/day, 3 days/wk):• Improved production with both txschedules• Superior maintenance of improvement for untreated items at 8 wkspost txwith traditional schedule

• Metronomic pacing (Dworkin et al.):• Synchronize speech prod. to metronome mvt.• Withdraw metronome and use emphatic stress in sentences as facilitator• Improvement on targets, no generalization• Metronomic pacing plus hand tapping (Wambaughet al.):• Produce 1 syll. of 3 syll. words per beat while tapping hand in unison • Tapping: Intersystemicreorganization (Luria)• Feedback only about no. & timing of tappings• Increased sound production accuracy for trained & untrained words • Metrical Pacing Therapy (MPT) (Brendel & Ziegler, 2008):• Compared computer-controlled metrical pacing to phonetic placement treatment.• MPT superior to control txfor rate and fluency• For segmental accuracy, both treatments equal

• Prompts For Restructuring Oral Muscular Phonetic Targets• Both artic/kinematic and rhythmic/rate control• www.promptinstitute.org–requires extensive training• Finger placement on face and neck to signal targets for articulators as well as cues for: • voicing• degree of jaw movement• duration, etc.• Original studies (4 case studies) not well controlled• Freed et al. (1997) used PROMPT in a controlled single-subject design:• Improved production of core vocabulary• No generalization

• Identify any real word uttered in any context, • Write it on index card• Pt. reads word• Add other words, or try emotion-laden words like “love”, “die”, “damn”, or high-frequency words like “no”, “bye”, etc.• Ask question that has word as answer, pt. reads word• Improvement & generalization for 5 pts.

• Electromagnetic articulography(EMA):• (Katz et al., 1999, 2007)• Sensors are attached to pt.’s tongue with medical adhesive• Thin wires run from sensors out corner of mouth to computer• Computer generates image of tongue placement & movement, which serves as biofeedback to pt.• Single-subject design/non-randomized controlled study evidence, improvement on targeted single phonemes and targeted words, no generalization

• Pt. fitted with artificial palate• Lingual surface of art. pal. contains electrodes that transmit data to computer to track timing & location of lingual-palatal contacts• Converted to provide visual image of contacts to pt.• Single-subject designs/non-randomized controlled study evidence, • Early studies reported minimal improvement on targeted phonemes, no generalization• Mauszyckiet al. reported improvement of target sounds in treated and untreated phrases

• Following stroke, the cerebral hemisphere on the side of the stroke reduces activity and the other hemisphere becomes overactive• Repetitive transcranialmagnetic stimulation (rTMS):• low-frequency rTMSdiminishes excitability of (inhibits) unaffected hemisphere• high-frequency rTMSexcites affected hemisphere • either method can restore balance and promote functional reorganization in affected hemisphere• Enhances motor performance with rehabilitation• Dysphagia• Transcranial direct current stimulation (tDCS) provides a longer and more sustained method of driving plasticity within the cortex:• Improves hand motor function in patients with chronic motor impairments when combined with rehabilitation

• 3 participants with AOS and mild aphasia (SS design)• 3 functional scripts were constructed collaboratively with each participant based on their choices of topics• Tx:• Individual 60-min sessions 2 or 3 times/wk• Easession = at least three 10-min episodes of concentrated script practice interspersed with open conversation• HW = recorded script conversations at least twice daily for 15 min

• All participants mastered all scripts and improved percent of script words produced accurately after treatment.• Improvements on scripts maintained up to 6 mosafter txstopped• Speech sound accuracy did not change• Speech naturalness and comprehensibility of speech improved

• Clinician modeling• Clinician & client in unison• Unison with clinician fading• Independent client production with written cue cards• Independent production, no cues• Feedback on artic placement/sound production provided after independent production• When 3 phrases mastered independently with 90% accuracy, randomized practice of phrases initiated and additional phrases added as they were mastered

• Treatment is desired by pt.• Sufficient insight, motivation, & capacity for learning & carryover• Functional communication is present or possible• Clear recognition that txwill not reverse progression but my help maintain or enhance communication• Significant others are motivated & involved:• To enhance awareness of successful strategies & to practice with pt. when appropriate•Efficacy data VERY limited

• Tx may be unnecessary/inappropriate at a point in time but:• Prescheduled or as-needed reassessment at regular intervals to update recommendations & provide brief interval of txmay be appropriate• Changes during staging often anticipate increasing needs for compensation & adoption of AAC:• Adaptations should be in place & used with skill before they are actually needed• Consider influence of aphasia and limb motor & visual problems

• Could justify articulatory-kinematic or rate/rhythm approaches for some individuals• Some evidence for:• Daily reading aloud with primary focus on accurate (intelligible) speech• e.g., 5-minute periods, 3-4 times daily• Script training with primary focus on accurate (intelligible) speech

(predominance of prosodic abnormalities, including segmentation of words and syllables)• Speech Lab Real-Time Pitch Module:• SCED• Match pre-recorded utterance that modeled appropriate pitch and intensity• Targeted 5-syllable words and functional sentences• Sessions: 1x/wkin person or via telepractic, with home practice between sessions• Outcomes:• Improved syllable sequencing• Improved pitch and intensity

• Info about disorder:• What it is and what it is not• Prognosis• What can be done to help• Emotional support• Troubleshooting

•NOTE: neither expert considers counseling to be telling someone what they should do!•Counseling is interspersed throughout the assessment and treatment process:• “counseling moments”• You may schedule a separate session for counseling if it seems necessary, but most often it is woven into everything that we do

• Grieve what has been lost:• Stages of grief: denial, anger, bargaining, depression, acceptance (Elisabeth Kubler-Ross)• Understand what has happened as fully as possible• Develop coping strategies and increase resilience:• Resilience –the quality that enables a person to thrive despite adversity• Make peace with the disorder• Capitalize on strengths in order to minimize weaknesses• Live as fully as possible, despite impairments

• We must recognize the limits of our skills• We are not:• Marriage counselors• Clinical psychologists• Psychiatrists• Social workers• So, we must know when to refer to others with the necessary skills

Solid professional knowledge base• Disorder• Resources –community and internet

• Good listener; can “hear” both:• Surface message• Underlying content• Active constructive responder:• Responses focused on client, not on ourselves or similar things that happened to us unless we are absolutely sure we are sharing for the client’s benefit and not for our own• Good communicator:• Reach clients/families on their terms, at their level of understanding• Communicating with body language

• Listen comfortably to people who have trouble talking:• Never fake understanding• If you don’t understand, try taking the responsibility for the breakdown• “I’m sorry. I’m having a hard time listening today. Can you say that again?”• Listen to emotions:• For crying, sadness, use helpful and authentic responses• Gently take/touch a hand, offer a tissue, encourage verbal expression behind the tears• For anger, realize that it’s not really about you, although it may be aimed at you at the moment

• Listen to and accept ideas that conflict with your values:• Can you take another’s perspective?• Sensitive to cultural differences:• http://www.asha.org/practice/multicultural• Optimistic and positive:• Realistic optimism, not unrealistic optimism or overly cheerful attitudes• Actively seek the positive• These qualities can be learned and improved, and they are essential to YOU to avoid burnout• Good sense of humor:• See the light/funny side of things

• Know and like yourself:• Self-respect, self-esteem, self-knowledge• Ongoing, lifelong, essential process• Like challenges:• Energized by challenges rather than threatened by them• Share authority appropriately:• SLP has expertise about disorder and techniques for its management• Client/family has expertise on what it’s like to live with the disorder every day

• Active listening and understanding:• Signaled by posture, eye contact, head-nodding, avoiding interruptions and overlaps• Empathizing:• Compassion, not sympathy• Feeling like you’re walking in someone else’s shoes, but NOT TRULY walking in them• Be careful of saying “I know just how you feel.” YOU DON”T.

• Clarifying and reflecting:• Clarifying -Making sure you understand what is being said• Questioning and restating• “I think I’m hearing you say....”• “Let me see if I understand...”• “Help me to understand.”• Reflecting –reflect/restate underlying message that you think you’ve heard• Disclosing:• Sharing a bit of yourself when its relevant and helpful

• Affirming:• Recognizing and celebrating client’s/family’s strengths• Know when to say nothing:• Judicious pausing encourages contemplation, consideration, and reflection

•Provide information about the problem and accompanying problems•Goals change over time

• What is a stroke?• What is AOS/dysarthria?• Where can we get more info about disorder?• What is the best that we can expect?• What can we do?• What resources are available as we leave the hospital?• Provide in spoken and written form

• What is the purpose of testing?• What is the purpose of treatment?• Can we watch/participate in treatment?• How can we improve interactions?• How can we help?• What other things should we be aware of?• Is there someone we can talk to who has gone through this?

• What alternative therapies or activities are available?• Whom can we call when we have questions?• What else can help at home?• Where can we get travel information?• Is job training available?• What support services are available?• What resources are available for long-range planning?

• Loss that remains unclear, indeterminate, and unresolved for some period of time, with a lingering lack of closure and clarity• “Goodbye without leaving”:• People are still alive but can’t communicate in their usual style• Provide AAC strategies/devices to prevent “goodbye without leaving” for as long as possible

•Augmentative/Alternative communication:•Means of communication other than oral speech•Augmentative = used to ASSIST speech•Alternative = used to REPLACE speech•Covers a host of systems:•Low-tech•High-tech

•Be sure to read Beukelman & Mirenda re:• Members of team• Phases of assessment• Identifying participant patterns & communication needs• Identifying barriers• Assessing potential to use/increase natural speech• Assessing potential to use AAC system/devices• Assessing capabilities

•Consider vocabulary needs:• Greetings• Small talk: used for initiating and maintaining social interactions• Storytelling (narrative discourse)• Procedural discourse• Specific content• Wrap-up remarks and farewells

• Age• Environments• Gender• Literacy• Core vocabulary: words & messages commonly used by variety of individuals, occur frequently• Fringe vocabulary: words & messages specific to individual

•Memory-based:• Rote memorization• Mnemonic strategy•Chart based:• Codes linked to messages on chart• Sender &/or receiver use chart to encode or decode• No memorization•1= I have pain•2= I’m hungry•3= I’m thirsty•4= Call my husband

•Dynamic; options change based on message:• Single letter prediction• Word level prediction• Word pattern prediction• Linguistic prediction• Phrase/sentence level prediction•Sometimes prediction programs take more time to use than direct selection

Did you know that your computer can read text aloud?•Find “Settings” and explore

•We only need to ACKNOWLEDGE and VALIDATE feelings:• Don’t judge• Can judge behavior, not feelings• Be careful of expecting them to respond as you would respond• Must give them permission to feel what they’re feeling • It is not our job to (and, indeed, we can’t) “make everything better”

• Message Banking by Proxy –someone else records for the person, usually because of fatigue, progression of disease beyond point where speech is intelligible, etc.

• Recognize that there is no “right” way to cope with uncertainty• Reinforce behaviors that encourage physical activity and interaction with others• Encourage families to use respite care as necessary and to attend to own health• Use humor as a coping mechanism• Make the physical environment work• Know that communication involves more than words• Value the abilities that remain

•Provide options and encourage exploration of them•There are neither right nor wrong decisions. There are only decisions one can live with.•Decisions should reflect the values of the client/family, not the counselor's

•Client/family dealing with feelings

• 8-10 exemplars (e.g., words, phrases) containing target sound used for tx• Tx session = 45-60 min.• Sounds selected for tx are specific to individual client:• More than 1 sound at a time• Sounds or error patterns that will have greatest impact on intelligibility when corrected• Select sounds first that are only moderately or infrequently misarticulated• Trial therapy may reveal which sounds have best potential for correction

Salient: weakness, reduced tone, reduced/absent reflexes, atrophy, fasciculations, occasionally progressive weakness with recovery.

- Restorative: VF exercises; target rate & increase strength-Compensatory/Behavioral: Respiration -- posture adjustment, deep inhalationPhonation -- head turn, VFE, RVT, voice amplification Resonance -- reduce rate, increase loudness Artic -- intelligibility drills, stretching, over artic-exaggerated consonants, Rate -- hand/finger tapping, vowel prolongation Prosody -- contrastive stress drills Medialization of paralyzed VF, VF Reinnervation, Thyroplasty Prosthetic: Palatal lift Laryngeal injection Pharyngeal flap

Salient: drooling & increased tone

- Artic: exaggerated consonants/overartic

- Resonance: visual feedback, increased loudness to reduced hyper-nasality

- Prosody: contrastive stress drills, combining utterances to breath at natural syntactic boundaries, pitch range/glides,

- Comm strategies + Environmental modification: Pharyngeal flap, palatal lift

Salient features: Unsteady/ interruption movements rapid or slow (dykinesia), Impairment is typically mild and may resolve, Intermittent breaths (and other symptoms), Reduced refluxes, Varied tone

- Behavioral--SLP, PT, counseling

- Pharmacological intervention: Dopamine-Tetrbenazine, Anti-psychotics and antidepressants, serotonin, reuptake inhibitors

Salient features: Rushes speech, increased tone, reduced force, reduced ROM (rigidity), hypertone

LSVT-boost levels of physical effort, resp, and phon. effort, improve artic resonance and prosody

Salient Features:movement errs, force, speed range, direction, timing. Variable ROM, hypotone, lack of coordination, normal oral mech. (slurred "drunken" speech and gait)

Behavioral modifications: finger tapping, chunking phrases, over artic, slowed rate, contrastive stress drills, manual placing board, increase of self monitoring, increase breath control, slow controlled resp. speak immediately on exhale, stop phonation early, increase volume control, intelligibility drills, pitch range exercises focus on artic and prosody

Salient: timing and coordination, poor coordination is increased with increased complexity, groping, (motor planning and programming), frequently occurs with aphasia. Greater difficulty on volitional than automatic speech tasksGreater difficulty on SMRs and multisyllabic words than AMRs and single syllable tasks

Goal is max effectiveness, efficiency, & naturalness - build automatic speech drill intensive & automatic

- Behavioral Management: imitation to help planning

- speaker oriented: artic & prosody impairment- build on client's strengths short bursts melodic intonation therapy minimal contrastive pairs/drills therapy

Salient: lateral, central, facial and tongue weakness, imprecise artic, reduced loudness, change in vocal quality

Respiratory work and positioningstretch and relax muscles before speakingExaggerated consonantsEmotional Support

("LOSS")►Linguistic competence - Receptive and expressive language skills of one's native language

- Linguistic code unique to AAC system (what do the icons/buttons look like?)►Operational competence - Technical skills required to operate AAC system accurately and efficiently

- Immediate need to develop this skill as quickly as possible (teach competencies as early as possible to habituate them)►Social competence - Skills of social interaction: initiating, maintaining, developing, and terminating communication interactions

- Requires knowledge of sociolinguistic and sociorelational aspects of communication

►Strategic competence - Compensatory strategies used by people who rely on AAC to deal with functional limitations associated with AAC

- Unfamiliar listeners, resolving/repairing communication breakdowns, compensating for slow speaking rate

1. Identify participation patterns and communication needs

- Obtain information specific to the person who will potentially use AAC

2. Identify participation barriers 

– opportunity barriers: These types of barriers are those which are imposed on the person using AAC by outside sources such as policies and practices that are set in place, the attitudes of family, friends, therapists and other communication partners, and therapist and communication partner knowledge and skill

– access barriers: These types of barriers include those which are internal to the person using AAC such as attitude, capabilities and constraints (e.g. motor, literacy, cognitive-linguistic, and sensory-perceptual skills)

3. Plan and implement interventions

the AAC team will collaborate to:

Determine the tools required to meet the needs of the environment, tasks, and abilities of the person using AAC.

4. Evaluate intervention effectiveness: Once the initial evaluation has been completed and intervention strategies have been implemented, continual follow up assessments should be conducted to assess if the interventions have been effective.

Speech rate and intelligibility in early phase. AAC assessment recommended when speaking rate reaches 125 words per minutePeople with Bulbar ALS experiences dysarthria early in the disease process. For a limited number of individuals, dysarthria of such severity that it reduces speech intelligibility occurs prior to significant rate reduction; AAC assessment recommended when sentence intelligibility drops below 90%, regardless of speaking rate.Speech slurring, difficulties with swallowing, and/or hoarseness are early symptoms.

- What kind of AAC? (gestures, pen/paper, yes/no chart, alphabet board)

- The AAC team monitors and reviews the use of the communication equipment allowing the AAC team to make changes to the system based on feedback from the client and family or as the client improves during their hospital stay. Family and clients also provide input on the vocabulary content of their communication system allowing the AAC team to customize accordingly.