THERAPEUTIC
APPROACHES
TO APRAXIA
Barbara Dabul Veterans Administration Outpatient Clinic, Los Angeles, California
Betty Bollier Los Angeles Unified School District, California
Although identifying descriptions of apraxia are nnmerous in recent literature, few articles present guidelines for apraxia therapy. In this paper, several therapeutic techniques for apraxia are introduced and discussed. Sequencing of speech sounds is recognized as the apraxic patient's most characteristic problem. Rapid repetition of consonant plus /a/, build-up of speech sounds into syllables, and word attack by phone and syllable are all recommended for the purpose of improving sequencing. Facilitation techniques are discussed for the acquisition of articulatory postures. Case laistol'ies are presented to illustrate the therapy approach.
Descriptions of apraxia and its characteristics are rampant in recent literature (DeRenzi, Pieczuro, and Vignolo, 1966; Ettlinger, 1969; Dabul, 1971; Rosenbek and Wertz, 1972; Rosenbek et al., 1974; Yoss and Darley, 1974). Apraxia is generally defined as impaired ability to perform vohmtarily appropriate motor movements (especially for speech). As such, it is not considered a symbolic problem but rather as a difficulty in transmission of the speech product. However, apraxia occurs frequently in combination with aphasia, and from this has emerged the erroneous treatment of apraxia with a language rehabilitation emphasis. This paper presents several therapeutic techniques which have been found valuable in work with adult apraxic patients at the Veterans Administration Outpatient Clinic, Los Angeles. There is relatively meager literature expounding practical treatment procedures for this population (Dabul, 1971; Rosenbek et al., 1974; Skelly et al., 1974; Yoss and Darley, 1974). T h e methods we are recommending were designed for the specific problem of apraxia. Other attendant communication problems must be treated with different therapies. S E Q U E N C I N G OF S P E E C H S O U N D S
One of the apraxic patient's major difficulties is the proper sequencing of 268
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DABUL, BOLLIER:TherapeuticApproachesto Apraxia 269 speech sounds for a syllable, word, or sentence. According to the literature (Johns and Darley, 1970; Deal and Darley, 1972) as well as our own clinical observations, apraxic patients typically make the following types of errors: 1. Anticipation The patient anticipates a sound which will occur later in the word or sentence, for example /glin gl~es/ for /grin gl0es/. 2. Transposition The patient confuses the order of sounds in a word or sentence, for example /~erifk~/ for/~efrik~/. 3. Addition The patient adds sounds which do not belong to the original production, for example/r for/~ts/.
These errors are made both orally and in the patient's graphic efforts. Because of the nature of these errors, we have found it extremely difficult to accurately predict which consonant or class of consonants is most likely to be misarticulated in r u n n i n g speech. Therapeutic attention must be paid to the process of sequencing speech sounds rather than to the product which, being highly inconsistent, is not easily predictable. Several techniques to improve sequencing of speech sounds in the apraxic patient will now be described.
Mastery of Individual Phones T h e apraxic patient's errors in speech sound sequencing stem partly from his inability to stabilize a correct articulatory posture for the individual phone. T h e first approach advocated, therefore, is a presentation and mastery of individual consonant phones, much as one would learn an alphabet of letters before attempting to read or write a language. Mastery at this unitary level is a logical precursor to appropriate phone sequencing. However, different consonants will be mastered at different rates by different patients. As soon as a particular phone is learned to criterion (18 correct positionings out of 20 attempts) the following sequential steps are taken: (1) rapid repetition of each consonant with the vowel / a / , (2) build-up of phones into syllables, and (3) word-attack by phones and syllables.
Rapid Repetition of Consonant + /a/ This syllable production step increases the patient's ability to leave the correct articulatory posture and return to it efficiently and accurately. This ability is crucial to the rapid articulatory adjustments of spontaneous conversation. T h e /a] vowel is used for practice because it requires the greatest downward excursion of the mandible, thus requiring the patient to relocate the desired articulatory posture from a mouth-open position. A criterion of 60 repetitions per 15-second trial is met before proceeding to other steps in the therapy. T i m e trials are made for each consonant indicating which postures present the most difficulty for the individual patient.
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JOURNAL OF SPEECH AND HEARING DISORDERS
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1976
Build-up of Sounds into Syllables This step increases the patient's ability to make the transition from one articulatory posture to another and to achieve the appropriate production of the phone within varying phonetic environments. In this stage of therapy, CV CV combinations, such as / f a t a / , and CVC combinations, such as /pap[, are employed. Criterion is set at 20 two-syllable repetitions per 15-second trial. In these drills, the use of nonmeaningful syllable combinations is deliberate and has been established for several reasons. First, we want the patient to concentrate solely on the necessary phone sequencing. Second, if the patient were successful at repeating a meaningful syllable combination rapidly, it would be difficult to determine whether the movements were voluntary or automatic. As volitional control is what the apraxic patient lacks, automatic repetition of a familiar, meaningful syllable or word is not generalizable. In contrast, mastery of volitional control over nonmeaningful syllable combinations leads, we have found, to improved articulation of meaningful words. Word Attack by
Phone and Syllable
This step has been made possible by the patient's acquisition of a solid basic "vocabulary" of articulatory positions. When he encounters a word which he is unable to articulate, he can attack it by saying each phone in isolation and then blending these separate productions into syllables and words. We have found that this word attack approach works especially well, although extra sounds frequently intrude, particularly the schwa. These intrusive sounds are often difficult to eliminate. Rosenbek et al. (1974) suggest the deliberate introduction of the schwa between consonant clusters, to simplify their production. The decision to eliminate or to utilize the schwa depends most probably on the severity of the patient's deficit. F A C I L I T A T I O N T E C H N I Q U E S IN THE A C Q U I S I T I O N OF CORRECT A R T I C U L A T O R Y POSTURES
The above-mentioned procedures for improving speech sound sequencing must sometimes be supplemented by techniques to help the patient produce the sound that is to be sequenced. To be successful the clinician must depart from traditional articulation therapy techniques. When performing articulation therapy, the clinician often assumes the role of auditory model. She instructs the patient to listen, says the word, and requests the patient to repeat the word. The patient's task is to match his production of the word to her auditory model. While he may well perceive accurately the clinician's auditory model (although this point is open to question, according to Lemme, Rosenbek, and Wertz, 1974) a significant part of the apraxic patient's difficulty is his inability to match his oral production to the clinician's auditory stimulus. As he does
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DABUL, BOLLIER:Therapeutic Approachesto Apraxia 271 not make optimal use of auditory models, traditional auditory stimulation is frequently ineffective. Instead, we have utilized two alternative methods of structuring the patient's oral productions: a visual technique and a placement technique.
Visual Technique The apraxic patient, aside from exhibiting poor ability to match auditory models, may actually be experiencing increased auditory noise which proves disruptive to his speech production. Therefore, it is often helpful to eliminate the auditory stimulus entirely and to present the patient with an exclusively visual (no phonation) presentation of the speech stimulus. Patients can often profit from seeing how a word is articulated when hearing the word has not helped. See Dabul (1971) for an example of this method. In this technique, the patient is essentially speechreading the clinician. Obviously, highly visible syllables are mo~t successfully utilized with this technique. It may be speculated that elimination of the auditory stimulus deemphasizes the semantic component of the word and allows the patient to concentrate on the word as a set of movements to be mastered.
Placement Technique A combination of oral directions to the patient such as "Put your tongue between your teeth" and physical manipulation to achieve correct articulatory placement is designated the placement technique. A patient who cannot profit from either auditory or visual models will often respond effectively when the clinician tells him, in simple terms, where to put his articulators for correct production of a sound. This type of patient seems unable to profit from an external model in locating articulatory positions; however, he can, when given a "road map" of verbal cues, locate the position on his own. FACILITATION
OF SPEECH S O U N D S E Q U E N C I N G
THROUGH
GRAPHIC CUES
Literate adults and older children often show improved articulation of a polysyllabic word when the graphic form is available. Graphic materials may be used in the breakdown of words into syllables by covering those parts of the word not being immediately produced and allowing the patient to see only that part of the word which he is attempting to say. For example, in attempting the word policeman, the patient may first be shown po/poo/, then li [li/, then lice /lis/, then police /poolis/, then man /m~en/, then policeman. This technique improves the patient's monitoring abilities, increases the correspondence of oral production to written stimuli, and reduces errors such as omission, addition, or transposition of phones or syllables. Writing the word or syllable phonetically rather than orthographically also helps the patient to focus on the desired articulatory movements.
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Another technique for encouraging accurate syllable representation in a polysyllabic word is to cut a word card into syllable cards and have the patient place each card on the table as he says the syllable. Leftover or insufficient cards will cue the patient as to the numerical adequacy of his syllable production. CASE HISTORIES ILLUSTRATING SPEECH SOUND SEQUENCING TECHNIQUES Patient S
Mr. S was 50 years old at initiation of the described therapy in August 1973. He was 16 years postonset of left CVA related to surgery for a tumor in the left temporal lobe. During these 16 years, Mr. S had received a total of one year of aphasia therapy. In November 1973, he was scoring at the 75%ile overall on the Porch Index of Communicative Ability (PICA) (Porch, 1972), with a gestural score at the 81%ile, verbal at 59%ile, and graphic at 77%ile. All errors on the PICA were integrally related to his oral and graphic deficits of apraxia. These PICA scores had been stable through six months of aphasia therapy at our clinic. Reading aloud was extremely laborious for him, although his silent reading was of adequate speed and comprehension was only mildly impaired as measured by the Sklar Aphasia Scale (Sklar, 1966) and the Science Research Associates (SRA, 1968) Reading Index. When presented a set of Language Master word cards, Mr. S was unable to pronounce 55 words, a majority of which were polysyllabic words with difficult phone sequences, such as handkerchief and billfold. His production attempts at these words indicated that he knew the word but was unable to handle accurately the complex speech sound sequences involved. These word cards were set aside as a test list to measure the results of speech sound sequencing therapy. In August 1973, Mr. S was presented with a list of consonant + ]o/ combinations and given time trials on each of the syllables. His scores for a 15-second trial ranged from 38 to 51 repetitions (average 43). In one month, his scores for these syllables ranged from 60 to 80 repetitions (average 69), making an average gain of 26 repetitions per 15-second trial. This part of the syllable drills was then discontinued. A few CV CV combinations were also introduced in August 1973. From the beginning, certain combinations were consistently much more difficult than others. He performed poorly on voiced-voiceless combinations such as ]pobo] as initiation of phonation was not under voluntary control. He also reported difficulty discriminating auditorily between voiced and voiceless consonants. Table 1 shows Mr. S's initial scores in September 1973 compared with scores obtained a year later. T h e higher scores in 1974 reflect somewhat more rapid movements of the articulators; even more, however, they reflect a greater consistency in leaving and finding articulatory positions. This increased skill
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DABUL, BOLLIER: Therapeutic Approaches to Apraxia 273 TABLE 1. Scores o f P a t i e n t S o n
CV CV Combinations
i
CV CV
Training Initiated
fata la ta ma ta ba va ka ta la ga pa ga fa va ma ba ba ga fa tha ba ma pa ba fa da data ta la ka ga
September 1973 September September September September September October November December December December January 1974 February Fcbruary March June July
Number o] Repetitions per 15-Second Trial Initial Posttest (September 1974)
13 11 12 3 (unable to repeat) (unable to repeat) 2 2 7 9 16 4 2 7 4 4 5
19 17 16 14 27 15 16 12 9 10 16 10 8 8 2 10 10
saved much valuable conversation time which was formerly wasted in articulatory searching. A story which formerly took Mr. S 60 minutes to read aloud was now read by him in 20 minutes. W h e n retested on the 55 Language Master cards, he was able to pronounce 34 of the words accurately on the first try. After repeated attempts he was able to pronounce seven more words correctly b u t he continued to misarticulate 14 words. T h i s result represented a 74% increase in articulation accuracy after one year of speech sound sequencing therapy. By February 1975, his scores on the P I C A had increased to the 86%ile overall (gestural, 95%ile; verbal, 75%ile; graphic, 85%ile) with significant reduction in articulation errors on the verbal subtests and reduction of word order and spelling errors in sentence writing. His residual errors on the PICA are still entirely related to apraxic difficulties. Patient J
Mr. J was 57 years old at initiation of apraxia therapy. He was nine years postonset of left CVA (embolism). Mr. J had received i n t e r m i t t e n t aphasia therapy d u r i n g the nine years poststroke. In November 1973, he scored in the 70%ile overall on the P I C A (gestural, 68%ile; verbal, 52%ile; graphic, 80%ile). These PICA scores had been stable since his entrance to our clinic in February 1973. In contrast to Mr. S, many of Mr. J's errors were attributable to aphasic (symbolic) difficulties. However, because his oral apraxia threatened to impede further recovery, it was decided to focus t h e r a p y on the apraxic features of Mr. J's language. W h e n presented a set of Language Master word cards,
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Mr. J was able to produce all words accurately, after some searching behavior. His articulatory accuracy deteriorated in sentences. W o r d order was extremely j u m b l e d in both oral and written sentence construction. In November 1973, Mr. j was presented a list of consonant + / a / combinations and time trials were begun. His initial scores (50-124 repetitions per 15-second trial, average 87) were so high that trials on these syllables were discontinued. W o r k was begun on C V C V combinations. Like Mr. S, Mr. J h a d great difficulty with voiced-voiceless consonants. However, Mr. J's greatest difficulty was in retaining a consistent production of the vowel ] a / . W i t h i n any 15-second period, production of this vowel tended to drift i n t o / u / o r / o / or even / i / without Mr. J being auditorily or kinesthetically aware of the change. His productions tended also to become hypernasal. These vowel productions and hypernasality difficulties have remained with Mr. J to date, and although his scores on the drills after one year (see T a b l e 2) are more rapid
TABLE 2.
Scores of Patient J on c v c v Combinations i
CV CV
Training Initiated
ma ba fa da ta la ma ga da ka fa ba ta ka pa ba la ta la ga fa tha fa va ba va ka ga da ta ba pa ga ka ba ka pa ga
November 1973 November November November November November December January 1974 January January January February February February February September September September September
Number o] Repetitions per 15-Second Trial Initial Posttest (November 1974)
13 13 13 12 11 17 15 13 14 18 14 14 13 15 13 13 12 15 13
15 30 34 15 23 17 15 15 25 23 27 18 21 13 16 15 15 20 18
than those of Mr. S, they are less accurate and he has been less able to transfer his gains into spontaneous conversation. A P I C A administered in October 1974, revealed an overall score in the 80%ile (gestural, 75%ile; verbal, 57%ile; graphic, 88%ile). T h e gains in all three areas indicated a lessening of apraxic difficulties. In the gestural area, a large gain was made on Subtests II and III in executing meaningful gestural sequences. On the verbal subtests, the gain resulted from improved articulatory accuracy rather than increased n a m i n g ability. In the graphic area, spelling and word order improved significantly.
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DABUL, BOLLIER: Therapeutic Approaches to Apraxia
275
APPLICATION It is our view that i m p a i r e d s e q u e n c i n g i n the a p r a x i c p a t i e n t can encompass oral s e q u e n c i n g errors (speech misarticulations), gestural s e q u e n c i n g errors (facial a n d l i m b apraxia), a n d g r a p h i c s e q u e n c i n g errors (letter a n d w o r d o r d e r transpositions). O u r two patients e x h i b i t e d these errors on the P I C A a n d showed i m p r o v e m e n t following speech s o u n d s e q u e n c i n g therapy, w h e r e they h a d shown no i m p r o v e m e n t w i t h a n a p h a s i a t h e r a p y regime. Because we h a d n o c o m p a r i s o n subjects, o u r only control consisted of P I C A records pre- a n d p o s t i n i t i a t i o n of the speech s o u n d s e q u e n c i n g therapy. T h e b r o a d g e n e r a l i z a t i o n of i m p r o v e d response suggests to us a general s e q u e n c i n g i m p a i r m e n t i n the a p r a x i c p a t i e n t w h i c h was successfully r e m e d i a t e d by use of the t r e a t m e n t o u t l i n e d above. As these were c h r o n i c patients whose i m p r o v e m e n t occurred only after an entire year of relatively intensive t r e a t m e n t (two to three hours per week), we h o p e that this a p p r o a c h will be a t t e m p t e d w i t h recent a p r a x i c patients to d e t e r m i n e w h e t h e r s i m i l a r results can be o b t a i n e d more rapidly. Also, a p o p u l a t i o n of two is always subject to idiosyncratic responses. A p p l i c a t i o n of o u r a p p r o a c h to larger n u m b e r s of a p r a x i c patients could serve to support or r e f u t e our p r e l i m i n a r y b u t p r o m i s i n g results.
ACKNOWLEDGMENT At the time of this study Betty Bollier was affiliated with the Veterans Administration Outpatient Clinic in Los Angeles, California. Requests for reprints should be addressed to Barbara Dabul, Audiology and Speech Pathology Service, MDP 126, Veterans Administration Outpatient Clinic, 425 South Hill Street, Los Angeles, California 90013.
REFERENCES DABUL, B. L., Lingual incoordination--Language delay: A case of lazy tongue? Calif. ].
Commun. Dis., 2, 30-33 (1971). DEAL, J. L., and DARLEY, F. L., The influence of linguistic and situational variables on phonemic accuracy in apraxia of speech. J. Speech Hearing Res., 15, 639-653 (1979). DE RENZI, E., PIFczuRo, A., and VIGNOLO,L. A., Oral apraxia and aphasia. Cortex, 2, 50-73 (1966). ETTLINGER, G., Apraxia considered as a disorder of movements that are language dependent: Evidence from cases of brain bi-section. Cortex, 5, 285-289 (1969). JOHNS, D. F., and DARLEY,F. L., Phonemic variability in apraxia of speech. J. Speech Hearing Res., 13, 556-583 (1970). LEMM~, M. L., ROSENBEK,j. c., and WERTZ,R. T., The effects of stimulus modality on verbal output in brain-injured adults. Paper presented at the Annual Convention of the American Speech and Hearing Association, Las Vegas (1974). PORCH, B. E., Multidimensional scoring in aphasia testing. J. Speech Hearing Res., 14, 776-792 (1972). ROSWNBEK,J. C., HANSEN,R., BAUGHMAN,C., and LEMME, M. L., Treatment of developmental apraxia of speech: A case study. Lang., Speech Hearing Serv. Schools, 5, 13-22 (1974). ROSENBEK,J. c., LVMME, M. L., AHERN,M. B., HARRIS,E. H., and WERTZ,R. T., A treatment for apraxia of speech in adults. J. Speech Hearing Dis., 38, 462--472 (1973). ROSENBEK,J. C., and W~Ra'z, R. T., A review of 50 cases of developmental apraxia of speech. Lang., Speech Hearing Serv. Schools, 3, 23-33 (1972).
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SCIENCE RESEARCH ASSOCIATES,INC., SRA Reading Index. Chicago: Science Research Associates (1968). SI~ELLY, M., SCnlNSKY, L., S~n'iJ, R., and FusT, R. S., American Indian sign (Amerind) as a facilitator of verbalization for the oral verbal apraxic. J. Speech Hearing Dis., 39, 445-456 (1974). SkLA~, M., Sklar Aphasia Scale. Los Angeles: Western Psychological Services (1966). Yoss, K. A., and DARLEY, F. L., Developmental apraxia of speech in children with defective articulation. J. Speech Hearing Res., 17, 399-416 (1974). Received July 11, 1975. Accepted October 4, 1975.
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APPROACHES
TO APRAXIA
Barbara Dabul Veterans Administration Outpatient Clinic, Los Angeles, California
Betty Bollier Los Angeles Unified School District, California
Although identifying descriptions of apraxia are nnmerous in recent literature, few articles present guidelines for apraxia therapy. In this paper, several therapeutic techniques for apraxia are introduced and discussed. Sequencing of speech sounds is recognized as the apraxic patient's most characteristic problem. Rapid repetition of consonant plus /a/, build-up of speech sounds into syllables, and word attack by phone and syllable are all recommended for the purpose of improving sequencing. Facilitation techniques are discussed for the acquisition of articulatory postures. Case laistol'ies are presented to illustrate the therapy approach.
Descriptions of apraxia and its characteristics are rampant in recent literature (DeRenzi, Pieczuro, and Vignolo, 1966; Ettlinger, 1969; Dabul, 1971; Rosenbek and Wertz, 1972; Rosenbek et al., 1974; Yoss and Darley, 1974). Apraxia is generally defined as impaired ability to perform vohmtarily appropriate motor movements (especially for speech). As such, it is not considered a symbolic problem but rather as a difficulty in transmission of the speech product. However, apraxia occurs frequently in combination with aphasia, and from this has emerged the erroneous treatment of apraxia with a language rehabilitation emphasis. This paper presents several therapeutic techniques which have been found valuable in work with adult apraxic patients at the Veterans Administration Outpatient Clinic, Los Angeles. There is relatively meager literature expounding practical treatment procedures for this population (Dabul, 1971; Rosenbek et al., 1974; Skelly et al., 1974; Yoss and Darley, 1974). T h e methods we are recommending were designed for the specific problem of apraxia. Other attendant communication problems must be treated with different therapies. S E Q U E N C I N G OF S P E E C H S O U N D S
One of the apraxic patient's major difficulties is the proper sequencing of 268
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DABUL, BOLLIER:TherapeuticApproachesto Apraxia 269 speech sounds for a syllable, word, or sentence. According to the literature (Johns and Darley, 1970; Deal and Darley, 1972) as well as our own clinical observations, apraxic patients typically make the following types of errors: 1. Anticipation The patient anticipates a sound which will occur later in the word or sentence, for example /glin gl~es/ for /grin gl0es/. 2. Transposition The patient confuses the order of sounds in a word or sentence, for example /~erifk~/ for/~efrik~/. 3. Addition The patient adds sounds which do not belong to the original production, for example/r for/~ts/.
These errors are made both orally and in the patient's graphic efforts. Because of the nature of these errors, we have found it extremely difficult to accurately predict which consonant or class of consonants is most likely to be misarticulated in r u n n i n g speech. Therapeutic attention must be paid to the process of sequencing speech sounds rather than to the product which, being highly inconsistent, is not easily predictable. Several techniques to improve sequencing of speech sounds in the apraxic patient will now be described.
Mastery of Individual Phones T h e apraxic patient's errors in speech sound sequencing stem partly from his inability to stabilize a correct articulatory posture for the individual phone. T h e first approach advocated, therefore, is a presentation and mastery of individual consonant phones, much as one would learn an alphabet of letters before attempting to read or write a language. Mastery at this unitary level is a logical precursor to appropriate phone sequencing. However, different consonants will be mastered at different rates by different patients. As soon as a particular phone is learned to criterion (18 correct positionings out of 20 attempts) the following sequential steps are taken: (1) rapid repetition of each consonant with the vowel / a / , (2) build-up of phones into syllables, and (3) word-attack by phones and syllables.
Rapid Repetition of Consonant + /a/ This syllable production step increases the patient's ability to leave the correct articulatory posture and return to it efficiently and accurately. This ability is crucial to the rapid articulatory adjustments of spontaneous conversation. T h e /a] vowel is used for practice because it requires the greatest downward excursion of the mandible, thus requiring the patient to relocate the desired articulatory posture from a mouth-open position. A criterion of 60 repetitions per 15-second trial is met before proceeding to other steps in the therapy. T i m e trials are made for each consonant indicating which postures present the most difficulty for the individual patient.
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JOURNAL OF SPEECH AND HEARING DISORDERS
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1976
Build-up of Sounds into Syllables This step increases the patient's ability to make the transition from one articulatory posture to another and to achieve the appropriate production of the phone within varying phonetic environments. In this stage of therapy, CV CV combinations, such as / f a t a / , and CVC combinations, such as /pap[, are employed. Criterion is set at 20 two-syllable repetitions per 15-second trial. In these drills, the use of nonmeaningful syllable combinations is deliberate and has been established for several reasons. First, we want the patient to concentrate solely on the necessary phone sequencing. Second, if the patient were successful at repeating a meaningful syllable combination rapidly, it would be difficult to determine whether the movements were voluntary or automatic. As volitional control is what the apraxic patient lacks, automatic repetition of a familiar, meaningful syllable or word is not generalizable. In contrast, mastery of volitional control over nonmeaningful syllable combinations leads, we have found, to improved articulation of meaningful words. Word Attack by
Phone and Syllable
This step has been made possible by the patient's acquisition of a solid basic "vocabulary" of articulatory positions. When he encounters a word which he is unable to articulate, he can attack it by saying each phone in isolation and then blending these separate productions into syllables and words. We have found that this word attack approach works especially well, although extra sounds frequently intrude, particularly the schwa. These intrusive sounds are often difficult to eliminate. Rosenbek et al. (1974) suggest the deliberate introduction of the schwa between consonant clusters, to simplify their production. The decision to eliminate or to utilize the schwa depends most probably on the severity of the patient's deficit. F A C I L I T A T I O N T E C H N I Q U E S IN THE A C Q U I S I T I O N OF CORRECT A R T I C U L A T O R Y POSTURES
The above-mentioned procedures for improving speech sound sequencing must sometimes be supplemented by techniques to help the patient produce the sound that is to be sequenced. To be successful the clinician must depart from traditional articulation therapy techniques. When performing articulation therapy, the clinician often assumes the role of auditory model. She instructs the patient to listen, says the word, and requests the patient to repeat the word. The patient's task is to match his production of the word to her auditory model. While he may well perceive accurately the clinician's auditory model (although this point is open to question, according to Lemme, Rosenbek, and Wertz, 1974) a significant part of the apraxic patient's difficulty is his inability to match his oral production to the clinician's auditory stimulus. As he does
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DABUL, BOLLIER:Therapeutic Approachesto Apraxia 271 not make optimal use of auditory models, traditional auditory stimulation is frequently ineffective. Instead, we have utilized two alternative methods of structuring the patient's oral productions: a visual technique and a placement technique.
Visual Technique The apraxic patient, aside from exhibiting poor ability to match auditory models, may actually be experiencing increased auditory noise which proves disruptive to his speech production. Therefore, it is often helpful to eliminate the auditory stimulus entirely and to present the patient with an exclusively visual (no phonation) presentation of the speech stimulus. Patients can often profit from seeing how a word is articulated when hearing the word has not helped. See Dabul (1971) for an example of this method. In this technique, the patient is essentially speechreading the clinician. Obviously, highly visible syllables are mo~t successfully utilized with this technique. It may be speculated that elimination of the auditory stimulus deemphasizes the semantic component of the word and allows the patient to concentrate on the word as a set of movements to be mastered.
Placement Technique A combination of oral directions to the patient such as "Put your tongue between your teeth" and physical manipulation to achieve correct articulatory placement is designated the placement technique. A patient who cannot profit from either auditory or visual models will often respond effectively when the clinician tells him, in simple terms, where to put his articulators for correct production of a sound. This type of patient seems unable to profit from an external model in locating articulatory positions; however, he can, when given a "road map" of verbal cues, locate the position on his own. FACILITATION
OF SPEECH S O U N D S E Q U E N C I N G
THROUGH
GRAPHIC CUES
Literate adults and older children often show improved articulation of a polysyllabic word when the graphic form is available. Graphic materials may be used in the breakdown of words into syllables by covering those parts of the word not being immediately produced and allowing the patient to see only that part of the word which he is attempting to say. For example, in attempting the word policeman, the patient may first be shown po/poo/, then li [li/, then lice /lis/, then police /poolis/, then man /m~en/, then policeman. This technique improves the patient's monitoring abilities, increases the correspondence of oral production to written stimuli, and reduces errors such as omission, addition, or transposition of phones or syllables. Writing the word or syllable phonetically rather than orthographically also helps the patient to focus on the desired articulatory movements.
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Another technique for encouraging accurate syllable representation in a polysyllabic word is to cut a word card into syllable cards and have the patient place each card on the table as he says the syllable. Leftover or insufficient cards will cue the patient as to the numerical adequacy of his syllable production. CASE HISTORIES ILLUSTRATING SPEECH SOUND SEQUENCING TECHNIQUES Patient S
Mr. S was 50 years old at initiation of the described therapy in August 1973. He was 16 years postonset of left CVA related to surgery for a tumor in the left temporal lobe. During these 16 years, Mr. S had received a total of one year of aphasia therapy. In November 1973, he was scoring at the 75%ile overall on the Porch Index of Communicative Ability (PICA) (Porch, 1972), with a gestural score at the 81%ile, verbal at 59%ile, and graphic at 77%ile. All errors on the PICA were integrally related to his oral and graphic deficits of apraxia. These PICA scores had been stable through six months of aphasia therapy at our clinic. Reading aloud was extremely laborious for him, although his silent reading was of adequate speed and comprehension was only mildly impaired as measured by the Sklar Aphasia Scale (Sklar, 1966) and the Science Research Associates (SRA, 1968) Reading Index. When presented a set of Language Master word cards, Mr. S was unable to pronounce 55 words, a majority of which were polysyllabic words with difficult phone sequences, such as handkerchief and billfold. His production attempts at these words indicated that he knew the word but was unable to handle accurately the complex speech sound sequences involved. These word cards were set aside as a test list to measure the results of speech sound sequencing therapy. In August 1973, Mr. S was presented with a list of consonant + ]o/ combinations and given time trials on each of the syllables. His scores for a 15-second trial ranged from 38 to 51 repetitions (average 43). In one month, his scores for these syllables ranged from 60 to 80 repetitions (average 69), making an average gain of 26 repetitions per 15-second trial. This part of the syllable drills was then discontinued. A few CV CV combinations were also introduced in August 1973. From the beginning, certain combinations were consistently much more difficult than others. He performed poorly on voiced-voiceless combinations such as ]pobo] as initiation of phonation was not under voluntary control. He also reported difficulty discriminating auditorily between voiced and voiceless consonants. Table 1 shows Mr. S's initial scores in September 1973 compared with scores obtained a year later. T h e higher scores in 1974 reflect somewhat more rapid movements of the articulators; even more, however, they reflect a greater consistency in leaving and finding articulatory positions. This increased skill
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DABUL, BOLLIER: Therapeutic Approaches to Apraxia 273 TABLE 1. Scores o f P a t i e n t S o n
CV CV Combinations
i
CV CV
Training Initiated
fata la ta ma ta ba va ka ta la ga pa ga fa va ma ba ba ga fa tha ba ma pa ba fa da data ta la ka ga
September 1973 September September September September September October November December December December January 1974 February Fcbruary March June July
Number o] Repetitions per 15-Second Trial Initial Posttest (September 1974)
13 11 12 3 (unable to repeat) (unable to repeat) 2 2 7 9 16 4 2 7 4 4 5
19 17 16 14 27 15 16 12 9 10 16 10 8 8 2 10 10
saved much valuable conversation time which was formerly wasted in articulatory searching. A story which formerly took Mr. S 60 minutes to read aloud was now read by him in 20 minutes. W h e n retested on the 55 Language Master cards, he was able to pronounce 34 of the words accurately on the first try. After repeated attempts he was able to pronounce seven more words correctly b u t he continued to misarticulate 14 words. T h i s result represented a 74% increase in articulation accuracy after one year of speech sound sequencing therapy. By February 1975, his scores on the P I C A had increased to the 86%ile overall (gestural, 95%ile; verbal, 75%ile; graphic, 85%ile) with significant reduction in articulation errors on the verbal subtests and reduction of word order and spelling errors in sentence writing. His residual errors on the PICA are still entirely related to apraxic difficulties. Patient J
Mr. J was 57 years old at initiation of apraxia therapy. He was nine years postonset of left CVA (embolism). Mr. J had received i n t e r m i t t e n t aphasia therapy d u r i n g the nine years poststroke. In November 1973, he scored in the 70%ile overall on the P I C A (gestural, 68%ile; verbal, 52%ile; graphic, 80%ile). These PICA scores had been stable since his entrance to our clinic in February 1973. In contrast to Mr. S, many of Mr. J's errors were attributable to aphasic (symbolic) difficulties. However, because his oral apraxia threatened to impede further recovery, it was decided to focus t h e r a p y on the apraxic features of Mr. J's language. W h e n presented a set of Language Master word cards,
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Mr. J was able to produce all words accurately, after some searching behavior. His articulatory accuracy deteriorated in sentences. W o r d order was extremely j u m b l e d in both oral and written sentence construction. In November 1973, Mr. j was presented a list of consonant + / a / combinations and time trials were begun. His initial scores (50-124 repetitions per 15-second trial, average 87) were so high that trials on these syllables were discontinued. W o r k was begun on C V C V combinations. Like Mr. S, Mr. J h a d great difficulty with voiced-voiceless consonants. However, Mr. J's greatest difficulty was in retaining a consistent production of the vowel ] a / . W i t h i n any 15-second period, production of this vowel tended to drift i n t o / u / o r / o / or even / i / without Mr. J being auditorily or kinesthetically aware of the change. His productions tended also to become hypernasal. These vowel productions and hypernasality difficulties have remained with Mr. J to date, and although his scores on the drills after one year (see T a b l e 2) are more rapid
TABLE 2.
Scores of Patient J on c v c v Combinations i
CV CV
Training Initiated
ma ba fa da ta la ma ga da ka fa ba ta ka pa ba la ta la ga fa tha fa va ba va ka ga da ta ba pa ga ka ba ka pa ga
November 1973 November November November November November December January 1974 January January January February February February February September September September September
Number o] Repetitions per 15-Second Trial Initial Posttest (November 1974)
13 13 13 12 11 17 15 13 14 18 14 14 13 15 13 13 12 15 13
15 30 34 15 23 17 15 15 25 23 27 18 21 13 16 15 15 20 18
than those of Mr. S, they are less accurate and he has been less able to transfer his gains into spontaneous conversation. A P I C A administered in October 1974, revealed an overall score in the 80%ile (gestural, 75%ile; verbal, 57%ile; graphic, 88%ile). T h e gains in all three areas indicated a lessening of apraxic difficulties. In the gestural area, a large gain was made on Subtests II and III in executing meaningful gestural sequences. On the verbal subtests, the gain resulted from improved articulatory accuracy rather than increased n a m i n g ability. In the graphic area, spelling and word order improved significantly.
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275
APPLICATION It is our view that i m p a i r e d s e q u e n c i n g i n the a p r a x i c p a t i e n t can encompass oral s e q u e n c i n g errors (speech misarticulations), gestural s e q u e n c i n g errors (facial a n d l i m b apraxia), a n d g r a p h i c s e q u e n c i n g errors (letter a n d w o r d o r d e r transpositions). O u r two patients e x h i b i t e d these errors on the P I C A a n d showed i m p r o v e m e n t following speech s o u n d s e q u e n c i n g therapy, w h e r e they h a d shown no i m p r o v e m e n t w i t h a n a p h a s i a t h e r a p y regime. Because we h a d n o c o m p a r i s o n subjects, o u r only control consisted of P I C A records pre- a n d p o s t i n i t i a t i o n of the speech s o u n d s e q u e n c i n g therapy. T h e b r o a d g e n e r a l i z a t i o n of i m p r o v e d response suggests to us a general s e q u e n c i n g i m p a i r m e n t i n the a p r a x i c p a t i e n t w h i c h was successfully r e m e d i a t e d by use of the t r e a t m e n t o u t l i n e d above. As these were c h r o n i c patients whose i m p r o v e m e n t occurred only after an entire year of relatively intensive t r e a t m e n t (two to three hours per week), we h o p e that this a p p r o a c h will be a t t e m p t e d w i t h recent a p r a x i c patients to d e t e r m i n e w h e t h e r s i m i l a r results can be o b t a i n e d more rapidly. Also, a p o p u l a t i o n of two is always subject to idiosyncratic responses. A p p l i c a t i o n of o u r a p p r o a c h to larger n u m b e r s of a p r a x i c patients could serve to support or r e f u t e our p r e l i m i n a r y b u t p r o m i s i n g results.
ACKNOWLEDGMENT At the time of this study Betty Bollier was affiliated with the Veterans Administration Outpatient Clinic in Los Angeles, California. Requests for reprints should be addressed to Barbara Dabul, Audiology and Speech Pathology Service, MDP 126, Veterans Administration Outpatient Clinic, 425 South Hill Street, Los Angeles, California 90013.
REFERENCES DABUL, B. L., Lingual incoordination--Language delay: A case of lazy tongue? Calif. ].
Commun. Dis., 2, 30-33 (1971). DEAL, J. L., and DARLEY, F. L., The influence of linguistic and situational variables on phonemic accuracy in apraxia of speech. J. Speech Hearing Res., 15, 639-653 (1979). DE RENZI, E., PIFczuRo, A., and VIGNOLO,L. A., Oral apraxia and aphasia. Cortex, 2, 50-73 (1966). ETTLINGER, G., Apraxia considered as a disorder of movements that are language dependent: Evidence from cases of brain bi-section. Cortex, 5, 285-289 (1969). JOHNS, D. F., and DARLEY,F. L., Phonemic variability in apraxia of speech. J. Speech Hearing Res., 13, 556-583 (1970). LEMM~, M. L., ROSENBEK,j. c., and WERTZ,R. T., The effects of stimulus modality on verbal output in brain-injured adults. Paper presented at the Annual Convention of the American Speech and Hearing Association, Las Vegas (1974). PORCH, B. E., Multidimensional scoring in aphasia testing. J. Speech Hearing Res., 14, 776-792 (1972). ROSWNBEK,J. C., HANSEN,R., BAUGHMAN,C., and LEMME, M. L., Treatment of developmental apraxia of speech: A case study. Lang., Speech Hearing Serv. Schools, 5, 13-22 (1974). ROSENBEK,J. c., LVMME, M. L., AHERN,M. B., HARRIS,E. H., and WERTZ,R. T., A treatment for apraxia of speech in adults. J. Speech Hearing Dis., 38, 462--472 (1973). ROSENBEK,J. C., and W~Ra'z, R. T., A review of 50 cases of developmental apraxia of speech. Lang., Speech Hearing Serv. Schools, 3, 23-33 (1972).
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SCIENCE RESEARCH ASSOCIATES,INC., SRA Reading Index. Chicago: Science Research Associates (1968). SI~ELLY, M., SCnlNSKY, L., S~n'iJ, R., and FusT, R. S., American Indian sign (Amerind) as a facilitator of verbalization for the oral verbal apraxic. J. Speech Hearing Dis., 39, 445-456 (1974). SkLA~, M., Sklar Aphasia Scale. Los Angeles: Western Psychological Services (1966). Yoss, K. A., and DARLEY, F. L., Developmental apraxia of speech in children with defective articulation. J. Speech Hearing Res., 17, 399-416 (1974). Received July 11, 1975. Accepted October 4, 1975.
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