Acquired Apraxia of Speech

See the Treatment section of the Apraxia of Speech (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Consistent with the WHO's ICF framework (WHO, 2001), the goal of intervention is to help the individual achieve the highest level of independent function for participation in daily living. Intervention is designed to

  • capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication;
  • facilitate the individual's activities and participation toward the acquisition of new skills and strategies; and
  • modify contextual factors that serve as barriers and enhance those that facilitate successful communication and participation, including development and use of appropriate accommodations.

For individuals with AOS, treatment goals focus on facilitating the efficiency, effectiveness, and naturalness of communication by

  • improving speech production and intelligibility and, when indicated,
  • using augmentative and alternative forms of communication (AAC), such as gestures, manual signs, electronic speech output devices, and context-specific communication boards.

Barriers to successful communication and participation can be minimized for individuals with AOS by

  • modifying the environment (e.g., reducing background noise, maintaining eye contact, and decreasing the distance between speaker and listener);
  • informing listeners about the individual's communication needs and his or her preferred method of communication; and
  • encouraging the speaker to use strategies for repairing breakdowns in communication (e.g., repeating, rephrasing, using gestures, writing).

See Person-Centered Focus on Function: Acquired Apraxia of Speech [PDF] for an example of functional goals consistent with ICF.

Family-Centered Practice

The goal of family-centered practice for individuals with AOS is to create a partnership so that family members fully participate in all aspects of the individual's care. The range of services offered to families includes counseling; providing resources and information; coordinating services; advocating for practices that incorporate family preferences and address family priorities; and teaching specific skills to family members and other significant communication partners. See family-centered practice.

Treatment Considerations

When designing a treatment program for an individual with AOS, consider the following factors:

Target selection

  • Stimulability is often used to determine initial therapy targets; however, more difficult targets may promote better generalization (Ballard, 2001; Maas et al., 2008; Odell, 2002).
  • Words and phrases are motivating and functional; whenever possible, treatment begins with meaningful and self-selected speech stimuli.

Task hierarchy

  • Consistent with the principles of motor learning, practice is hierarchical, and selection of stimulus targets promotes success at each step (Guadagnoli & Lee, 2004).
  • Tasks typically begin at the syllable level—the basic unit of speech programming (Duffy, 2013; Schoor, Aichert, & Ziegler, 2012; Ziegler, Aichert, & Staiger, 2010)—unless the individual has some success at the word or phrase level.
  • Single sounds (phonemes) or nonspeech oral-motor movement patterns that approximate speech gestures (e.g., lip rounding and tongue elevation) might be targeted initially if the individual is not yet capable of meaningful speech (Duffy, 2013), especially when oral apraxia is absent.
Examples of Stimulus and Task Variables That Affect Responses
Easier More difficult
Oral/nasal distinctions Voiced distinctions
Bilabial and lingual/alveolar place of articulation Other places of articulation
Consonant clusters that cross syllables Consonant clusters within syllables
Shorter syllables Longer syllables
High frequency syllables and words Low frequency syllables and words
Stressed syllables and words Unstressed syllables and words
Automatic/reactive speech Volitional/propositional speech
Imitation of a model Self-generation of response (especially in those with co-existing aphasia)
(Duffy, 2013)
  • For individuals who are nonverbal, reflexive actions (e.g., cough, laugh) may be initially elicited as reflexes and then shaped to volitional control and ultimately to voluntary speech production (Simpson & Clark, 1989).

Feedback

  • Learning may be enhanced when feedback is intermittent rather than constant (e.g., 60 % of the time) or when there is a delay (e.g., 5 seconds) between response and feedback (Austermann Hula, Robin, Maas, Ballard, & Schmidt, 2008).
  • Self-monitoring and self-correction can facilitate learning and maintenance of skills (Rosenbek, Lemme, Ahern, Harris, & Wertz, 1973).

Treatment Approaches

Treatment can be restorative (i.e., aimed at improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for deficits not amenable to retraining).

Approaches aimed at improving speech production and intelligibility focus on re-establishing motor plans/programs and improving the ability to select and activate them and set program parameters (e.g., speed) in specific situations (Knock, Ballard, Robin, & Schmidt, 2000). These treatment approaches include articulatory–kinematic approaches, sensory cueing, rate and/or rhythm control, and various combinations thereof.

Augmentative and alternative communication (AAC) approaches are used to provide functional communication options, while at the same time, supporting, enhancing, and potentially improving speech production (Lasker, Stierwalt, Hageman, & LaPointe, 2008; Yorkston, Beukelman, Strand, & Hakel, 2010).

From the perspective of the WHO's ICF framework (WHO, 2001), approaches aimed at improving speech production and intelligibility focus on "body functions/structures" within the ICF framework, whereas AAC approaches are directed at "activities/participation."

Treatment Options

Below are brief descriptions of treatment options for addressing AOS, grouped by approach. This list is not exhaustive, and the inclusion of any specific treatment does not imply endorsement from ASHA. See Ballard et al. (2015) and Wambaugh, Duffy, McNeil, Robin, and Rogers (2006) for systematic reviews of AOS interventions.

Treatment selection depends on a number of factors, including severity of the disorder, communication needs of the individual, and presence and severity of co-occurring conditions (e.g., aphasia and associated language and cognitive deficits, dysarthria, or progressive neurological diseases).

Apraxia in other systems may play a role in treatment. For example, the presence of limb apraxia may preclude using manual signs to support functional communication. The presence of oral apraxia may support the need for more aggressive or alternative approaches to the use of phonetic placement cues in speech treatment.

Articulatory–Kinematic Approaches

Articulatory–kinematic approaches are based on principles of motor programming/planning. They

  • provide frequent and intensive practice of speech targets;
  • focus on accurate speech movement;
  • include external sensory input for speech production (e.g., auditory, visual, tactile, cognitive cues);
  • consider practice schedules, such as random versus blocked practice (see, e.g., Wambaugh, Nessler, Wright, & Mauszycki, 2014; Wambaugh, Nessler, Wright, Mauszycki, & DeLong, in press); and
  • provide appropriate types and schedules of feedback regarding performance.

See Bislick, Weir, Spencer, Kendall, and Yorkston, 2012 and Maas et al. (2008) for discussions of motor learning principles as they apply to the treatment of motor speech disorders.

Multiple Input Phoneme Therapy (MIPT)

MIPT is appropriate for individuals with severe apraxia of speech. The program proceeds through a hierarchy of steps that stress phoneme generalization using multiple input stimuli. The individual's stereotypic utterances are used as initial stimuli; the clinician models these utterances while simultaneously providing a gestural/prosodic cue (e.g., tapping the individual's arm). The clinician then fades the voice and mimes the movement while the individual continues to produce the target. New words use the initial phoneme of a stereotypic utterance (e.g., "one" to "win"). The number of targets and the length and phoneme complexity progressively increase. The individual initially repeats the stereotypic utterance in a nonvolitional manner and eventually regains volitional control and the ability to spontaneously express words and phrases (Stevens, 1989; Stevens & Glaser, 1983).

Script Training

Script training is a functional approach to treating neurogenic communication disorders (Holland, Milman, Munoz, & Bays, 2002). It is used to facilitate verbal communication on specific topics selected by the individual. Script training helps the individual who wants to speak relatively normally on a few personally relevant topics. A number of phrases are practiced so that they become automatic and can be inserted into conversation relatively fluently (Youmans, Youmans, & Hancock, 2011).

Sound Production Treatment (SPT)

SPT is used to improve production of consonants that are problematic for a particular speaker. It uses a treatment hierarchy that incorporates modeling and repetition of minimal-contrast word pairs. Auditory, visual and tactile cues are used, along with articulatory placement cueing and graphemic cues (Wambaugh, Kalinyak-Fliszar, West, & Doyle, 1998; Wambaugh & Mauszycki, 2010).

Speech Motor Learning (SML) Approach

The SML treatment approach addresses the underlying inability to plan and program the production of speech motor targets (SMTs) in varying phonetic contexts and in utterances longer than single words or nonwords. Nonwords, constructed from a corpus of target consonants and vowels, are used as treatment stimuli. Treatment proceeds in steps, taking the individual from imitated blocked practice of each nonword to self-initiated production of a series of nonwords. Eventually, real words and phrases containing these words are identified and rehearsed until the criterion is met (Van der Merwe, 2011).

Sensory Cueing Approaches

Many treatments for AOS incorporate sensory input (e.g., visual, auditory, proprioceptive, and tactile cues) to teach the movement sequences for speech. Sensory cues can be used separately or in combination (i.e., multisensory approach). Feedback is an important aspect of motor learning. These external cues may facilitate speech production by providing additional feedback to the individual if he or she cannot benefit from, or does not receive, sufficient intrinsic sensory feedback.

Integral Stimulation (IS)

IS is part of many treatment approaches. It is a method for practicing movement gestures for speech production that involves imitation and emphasizes multiple sensory models (e.g., auditory, visual, tactile). Treatment follows a "listen to me, watch me, do what I do" sequence, in which the individual hears and sees how the clinician produces a targeted sound sequence or word/phrase and then imitates (Rosenbek et al., 1973).

Tactile Cueing

Tactile cueing methods of speech facilitation are those that provide direct tactile input for correct speech production. Using these methods, the SLP applies pressure or otherwise touches the individual's face, neck, and head to provide a tactile cue for correct production or speech movement gesture.

Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT)

PROMPT is a tactile method of treatment based on touch pressure, kinesthetic, and proprioceptive cues (Bose, Square, Schlosser, & van Lieshout, 2001; Chumpelik, 1984; Freed, Marshall, & Frazier, 1997). Using this approach, the clinician uses finger placements on the individual's face and neck to cue various aspects of speech production (e.g., place and manner of articulation) and help the individual limit unnecessary movements. PROMPT requires specialized training.

Visual Cueing

Visual cueing methods provide visual "cues" as to the shape, placement, or movement of the articulators. Visual cues can be provided via "low-tech" methods (e.g., simple hand signs or visual feedback via a mirror) or more technologically advanced methods that utilize computer software and screen, ultrasound images, and other forms of biofeedback, such as acoustic/spectrographic feedback displays.

Electropalatography (EPG)

EPG utilizes a palatal device with electrodes to record and visualize contact of the tongue on the palate while an individual makes different speech sounds (Howard & Varley, 1995). EPG provides real-time visual feedback as well as a split-screen option so that the SLP can model the correct tongue placement while the patient observes.

Electromagnetic Articulography (EMA)

EMA uses miniature receiver coils placed on and in the mouth (e.g., tongue dorsum, corners of mouth, or velar margin) to record and provide a visual display of tongue, mouth, palate, and jaw movements during treatment. AOS treatment research involving EMA has focused on tongue placement (see, e.g., Katz, Bharadwaj, & Carstens, 1999; Katz, McNeil, & Garst, 2010).

Rate and Rhythm Control Approaches

Rate and rhythm control approaches (also called prosodic facilitation approaches) use intonation patterns (melody, rhythm, and stress) to improve speech production. Although these approaches are aimed at improving prosody, they have also resulted in improved articulation for individuals with AOS (Mauszycki & Wambaugh, 2011). Using these patterns, the clinician guides the individual through a gradual progression of steps that increase the length of utterances, decrease dependence on the clinician, and decrease reliance on intonation (Martin, Kubitz, & Maher, 2001).

Contrastive Stress

Contrastive stress is used when speaking to highlight a particular word in a phrase or sentence; varying the stressed word also changes the meaning of the sentence. In treating AOS, contrastive stress can be used in target phrases or sentences to improve the individual's ability to produce speech with varying intonation contours (Wertz, LaPointe, & Rosenbek, 1984).

Melodic Intonation Therapy (MIT)

MIT is a prosodic facilitation approach that uses melody, rhythm, and stress to facilitate speech production. The clinician provides models of intoned utterances of varying lengths; reliance on intonation is gradually decreased over time. MIT was first designed for individuals with nonfluent aphasia, many of whom have co-occurring apraxia of speech (Sparks, Helm, & Albert, 1974; Sparks & Holland, 1976; Zumbansen, Peretz, & Hébert, 2014).

Metrical Pacing Treatment (MPT)

MPT is a type of pacing technique that uses rhythmical sequences of tones that provide metrical templates to guide production of target utterances. Individuals are asked to produce the target utterances in synchrony with the pacing signals. The synchronization pulse is generated by a computer and can be varied by rate (corresponding to speech rate) and metrical structure (syllable number and stress pattern) to simulate the natural stress patterns of speech (Brendel & Ziegler, 2008).

Rhythmic Pacing

Rhythmic pacing strategies use various rate control techniques to provide temporal cues that help pace speech production. Techniques include hand or finger tapping and use of a pacing board or metronome (Dworkin, Abkarian, & Johns, 1988; Mauszycki & Wambaugh, 2008).

Transcranial Direct Current Stimulation (tDCS)

tDCS is an experimental procedure in which transcranial direct current is delivered to the left inferior frontal gyrus (IFG) to modulate cortical activity. It has been used in conjunction with articulatory–kinematic treatment to improve the speech of individuals with AOS secondary to stroke. Speech targets consist of syllables and words that are presented auditorily and are repeated by the individual (Marangolo et al., 2011).

Augmentative and Alternative Communication (AAC)

AAC involves supplementing or replacing natural speech or writing with aided symbols (e.g., picture communication, line drawings, speech-generating devices, and tangible objects) or unaided symbols (e.g., manual signs, gestures, and finger spelling). Whereas aided symbols require some type of transmission device, the production of unaided symbols requires only body movements. When selecting AAC systems or devices, it is important to determine the individual's willingness to use them. See Lasker and Bedrosian (2001) for a discussion on promoting acceptance of AAC by adults with acquired communication disorders.  See ASHA's Practice Portal page on Augmentative and Alternative Communication for additional information.

Treatment Considerations: Factors Influencing Treatment Decisions

Not all individuals with AOS are candidates for treatment. For example, the language impairments associated with aphasia can affect both comprehension and expression so severely that functional communication (verbal or alternative/augmentative) is not possible. In such cases, clinicians might first focus on improving basic language and cognitive abilities to support functional communication. If language and cognitive abilities do not improve sufficiently, AOS treatment would not be appropriate (Freed, 2012).

Treatment for individuals with AOS resulting from degenerative disease is often appropriate, particularly for those with no significant language or cognitive impairments. The goal of treatment is to maximize communication at each stage of the disease, not to reverse decline (Duffy, 2013). Goals in the early stages might begin with efforts to improve speech and maintain comprehensibility, followed by establishing the use of compensatory strategies, including AAC (Duffy & McNeil, 2008; Jung, Duffy, & Josephs, 2013).

Treatment Considerations: Adults With Previously Or Newly Diagnosed Childhood Apraxia Of Speech (CAS)

Some adults were diagnosed with CAS as children, but, despite having had treatment, their speech difficulties persist. Others have had long-standing speech difficulties that are only now being diagnosed as apraxia. Adults with previously or newly diagnosed CAS often seek services because their speech difficulties are having an impact on communication in school, work, or social settings. The treatment principles and at least some of the options described above may be appropriate for these individuals. Goals focus on the individual's specific communication needs (e.g., in the classroom, at work, or in social situations). See childhood apraxia of speech for more detailed information about CAS.

Service Delivery

In addition to determining the optimal speech and language treatment for an individual with AOS, the clinician considers other service delivery variables that may have an impact on treatment outcomes, such as format, provider, dosage, timing, and setting.

Format

Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal at a particular point in the treatment process. For example, initial treatment may involve intensive drills to improve speech production and/or practice in using AAC aids. However, once the individual has made progress on these goals, group treatment may be incorporated to provide opportunities for practice.

Provider

Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver). SLPs treat the speech-motor and communication aspects of AOS and train individuals in the use of AAC. It is important to involve family members, caregivers, and other communication partners in the treatment process to help them understand the individual's communication needs and learn strategies to facilitate communication. Other professionals (e.g., physical therapist or occupational therapist) may be involved in treatment of co-morbid deficits. It is important for SLPs to collaborate with other professionals regarding treatment and to take advantage of opportunities for co-treatment.

Dosage

Dosage refers to the frequency, intensity, and duration of service. Treatment dosage for AOS should be consistent with principles of motor learning (Maas et al., 2008; Rosenbek et al., 1973; Wambaugh et al., 2014). Given the need for repetitive production practice in motor speech disorders like AOS, intensive and individualized treatment is often stressed. See Ballard et al., 2015, for a discussion of average dosage.

Timing

Timing refers to the timing of intervention relative to diagnosis. Generally speaking, treatment begins as early as possible post onset. Treatment can also be appropriate when an extended amount of time has elapsed since onset, particularly if an individual has not received any treatment for AOS during that time. Treatment can be effective for individuals in the chronic phase of AOS, based on data from AOS treatment studies and supporting data from stroke literature suggesting that recovery of stroke-related deficits can occur during this phase (Wheaton, 2015).

Setting

Setting refers to the location of treatment (e.g., home, community-based). A naturalistic treatment environment that incorporates a variety of communication partners may facilitate generalization and carryover of skills.

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