interventions for achieving speech movements final category of intervention approaches

Interventions for Achieving Speech

MovementsFinal Category of Intervention

Approaches

Interventions for Achieving Speech Movements

• Four interventions that primarily focus on helping children with SSD produce movements required to achieve appropriate speech production– Electropalatography– Ultrasound– Developmental Dysarthria– NSOMT

Levels of Evidence (LOE)

Level Description Approach

1a Well-designed meta-analysis of >1 randomized controlled trial

None

1b Well-designed randomized controlled study DD, NSOMT

2a Well-designed controlled study without randomization

US, NSOMT

2b Well-designed quasi-experimental study US, NSOMT

3 Well-designed nonexperimental studies, i.e., correlational and case studies

EPG, DD, NSOMT

4 Expert committee report, consensus conference, clinical experience of respected authorities

EPG, DD, NSOMT

3 Stages of Research

Stages of Research LOE Number of Studies

Exploratory Studies 3 7

Efficacy Studies 2b

2a

9

4

Effectiveness Studies 1b 4

Characteristics of InterventionsComparative Factors

Specifications

Age Older children and some adults

Population SSD of unknown etiology, particularly for children who have failed to respond to other interventions; also for children with medical diagnoses (e.g., hearing loss, MSD, DS, CP)

Intervention Agents SLP with parents/caregivers in supportive role

Key Components Augmented sensory feedback (EPG, US) or altered movement patterns to elicit improved movement (DD, NSOMT), followed by practice conducted under more typical speaking conditions

Characteristics of Interventions: con’t

Comparative Factors

Specifications

Broad Goals Improve speech production by helping children achieve speech movements

Target Selection Varied (nonlinear phonologic theory, strength, tongue-jaw differentiation, movement patterns)

Level of Focus Individual sounds (lingual targets, vowels, lingual consonants, movements of the oral muscalature outside of speech)

Session Type Individual (30-60 min 2x/wk)

Technology Electropalatography, ultrasound, bite blocks

ICF-CY Codes Primarily b320: Functions of productions of speech sounds

Electropalatography (EPG; Gibbon)

Developmental level Targeted stage of production

Targeted outcomes

Emerging

Developin

Elaborat

Key components

Tech and/or materials

Specific diagnoses

Plannin

Progra

Executio

Spch Prod

Spch Perc

Phono awareness

Other oral Language

Literacy

X Real time and static displays of tongue activity displayed through EPGPractice organized to take motor learning into account

EPG hardware and software; custom-made palatal plate

Including children with cleft palate

X X

ALICE LEE & FIONA E. GIBBON

Uses an artificial EPG plate moulded to fit against hard palate.

Embedded with 62 electrodes,for detecting characteristictongue-palate contact patternsfor lingual sounds.

Identifies abnormal patternsof articulation in assessment.

Can be used as a visual feedbackdevice for treatment.

VISUAL FEEDBACK: ELECTROPALATOGRAPHY (EPB)

Description of EPG• EPG is an instrumental approach that visually

shows the tongue’s contact with the palate• Provides visual feedback to client regarding

where their tongue is placed • Requires manufacture of special dental plate

that has 62 sensors arranged in 8 horizontal rows

• Individual wires come from each sensor into two bundles from back of plate

• The EPG plate connected to external processing unit, which is connected to computer

EPG frames• The EPG data are displayed as sequences of

two-dimensional representations of tongue-palate contact– Called palatograms or EPG frames

EPG: Review Questions

Ultrasound (Barnhardt et al.)


Targeted outcomes

Emerging

Developin

Elabora

Key components


Specific diagnoses

Plannin

Progra

Executio

Spch Prod

Spch Perc

Phono awareness

Other oral Language

Literacy

X Ultrasound to provide visual feedback on articulation combined with intervention strategiesGoal-setting based on nonlinear phonology

Ultrasound equipment; audio-visual recording equipment

Including children and adults with hearing impairment or other causes of vowel disorders

X X

Description of Ultrasound

• Use of ultrasound to provide articulatory visual feedback

• US can display static or dynamic images that approximate the tongue’s position and movement during speech production

• Transducer held beneath the chin while ultrasound waves are refracted from the air above the tongue

• Left to right tongue surface views are displayed

Ultrasound images for vowels

Unique features of vowel intervention using ultrasound

• Bernhardt’s nonlinear phonology studies of 1990s; Treated Cs and word structure: Vowels improved for free.....

• If, however, vowels need attention.....– Analyse vowel features singly and in combinations– Use pictures, especially moving ones (artic feedback)

iɪ

Review Questions

Developmental Dysarthria (Hodge)


Targeted outcomes

Emerging

Developin

Elaborat

Key components


Specific diagnoses

Planning

Program

Execution

Spch Prod

Spch Perc

Phono awareness

Other oral Language

Literacy

X X Bite block use followed by phonemic practice Two additional interventions described including intensive voice intervention and phonetic placement via electromyo-graphy

Bite block and associated materials for its safe use

Developmental dysarthria resulting from cerebral palsy, congenital conditions affecting the cranial nerves, and early onset muscular dystrophy

X X

Dysarthria

• Children with dysarthria have impairments that interfere with signals sent from their brains to muscle groups that produce the rapid, precise, and coordinated movements of speech– This results in weakness, slowness, and tone

abnormalities in the affected muscles and reduce the accuracy and coordination of their actions

– Different types of dysarthria (spastic, ataxic, flaccid, mixed)

– Results from conditions such as cerebral palsy, muscular dystrophy

Dysarthria Intervention

• Two-fold focus of intervention:

1. Education, support, and specific skills training for family/caregivers to facilitate child’s communication development

2. Direct intervention to maximize communication skills

Bite-Block and Phonemic Practice

• Children with DD have difficulty moving tongue independently of jaw for lingual sounds; and difficulty moving tip and body of tongue as separate units for speech

• A bite block can give the tongue the experience of moving independently of the jaw and improve child’s ability to control the tongue to achieve differentiated, precise placements for articulation of lingual-alveolar (/t,d,n,l/) and velar (/k,g,/) consonants.

Bite blocks

• Made from hard plastic or dental impression material

• Fit between upper and lower teech, between central incisors or the molars on one side of the mouth

• Child bites with sufficient force to keep block in place

• This holds jaw stable so lips and tongue can move independently from jaw

Review Questions

Nonspeech Oral Motor Intervention (Clark)


Targeted outcomes

Emerging

Developin

Elaborat

Key components


Specific diagnoses

Plannin

Progra

Executio

Spch Prod

Spch Perc

Phono awareness

Other oral Language

Literacy

X X Variable exercises depending on specific oral motor (OM) program, including bite-block and continuous positive airway pressure (CPAP)

Numerous materials are available but generally are unsupported by empirical evidence

Sensorimotor impairments, including children with Down syndrome, cerebral palsy, or tongue thrust

X X X

NSOMT

• OME often used to target muscle strength, range of motion (ROM), control, and sensory functions (e.g., somatosensory detection and perception)

• Children most likely to benefit from OME are those whose speech difficulties arise from sonsorimotor impairments

• IMPORTANT to distinguish NSOME vs OME + Speech

Unique features ofNon-speech Oral Motor Therapy

• Goals– To normalize underlying motor functions supporting

speech production – To provide kinesthetic and proprioceptive input that may

facilitate speech movements

• Targets– Strength, tone, control, somatosensation

• Key Issues– Identifying underlying impairments– Utilizing techniques based on sound neurophysiologic

principles– Incorporating integrated speech movements

What is the role of nonspeech oromotor exercises?

• Use them all we can. (We don’t know what else to do.)

• Don’t use them. There is no compelling evidence that they work.

• Use them selectively. There are some indications of efficacy, taking into account client characteristics and task requirements.

Nonspeech oral-motor trainingcounter arguments

• There is substantial evidence that motor learning is task-sensitive, which limits generalization or transfer from one task to another.

• Muscular forces in speech are on the order of 10-20% of maximum force capability, so that high levels of force are questionable goals in therapy.

Nonspeech oral-motor trainingcounter arguments

• Craniofacial muscles differ from limb and trunk muscles in their genetic, molecular, developmental, and functional properties; therefore, what works for the limbs and trunk may not work for the muscles used in speech and feeding.

• Etcetera…

Forrest (2002)

• “Based on currently available resources, oral-motor exercises cannot be considered to be a legitimate treatment protocol for children with PAD. First, empirical studies on the impact of oral-motor exercises on speech remediation do not provide support for the utility of these procedures. More generally, information on transfer of training during motor learning does not support the use of simple behaviors as a means to master a complex activity.”

Clinical Forum on NSOMT

LSHSS 2008 – Powell (2008) Epilogue:Series of articles in this clinical forum raise serious concerns about

the widespread clinical application of NSOMTs for treating developmental speech sound production disorders.

Such approaches were shown to have serious theoretical and empirical shortcomings.

The profession of speech-language pathology has taken pride in clinical practices that are theoretically sound and supported by a self-generated research base (Siegel & Ingham, 1987).

Today, however, unvalidated treatment methods are widely marketed under the guise of continuing education (Lof & Watson, 2008).

It is time for the profession to fulfill its ethical responsibility to speak out in favor of evidence-based treatments on behalf of those who cannot speak out for themselves.

INTERVENTION FOR MSD IN CHILDREN

Dilemmas and Clinical Decision-Making

Neuroplasticity

Ten Principles Identified through

Research in Neurophysiology

#1: Use it or lose it

• Inactivity of a neural substrate likely will lead to degradation of its function

• But increasing environmental input can alter or enhance cortical representation

#2: Use it and improve it

• Increased activity leads to enhanced function

• Underlies the concept of exercise-induced functional improvement

#3: Plasticity is Experience Specific

• Plasticity may be confined to a specific function that is being trained

• Related to the concept of task specificity

#4: Repetition matters

• Extensive and prolonged practice is needed to induce changes in the neural substrate of a function

• Corollary: changes may not appear in the early stages of a training process

#5: Intensity matters

• Continuous training over long periods is needed to change the neural substrate of behavior

• Question: What is the optimal dose of motor training therapy?

#6: Time matters

• Different forms of plasticity may occur at different times in recovery after an injury

• Hypothesis: plasticity is not always monolithic but may involve a sequence of phemenona

#7: Salience matters

• Salience of training influences rate and extent of changes in plasticity

• Corollary: Simple repetitive movements or strength training may not induce changes in neural substrate

• Think: What is the purpose of the skill being trained?

#8: Age matters

• In general, training and environmentally induced plasticity occur more readily in younger than older nervous systems

#9: Transference is possible

• Training on one area may enhance the learning of related behaviors

• The potential for transference indicates that training should be task-specific but not necessarily task-particular.

• Think: Species of tasks

#10: Interference can occur

• Some changes in plasticity may disrupt or limit certain behaviors or skills

Mental Imagery and Observational Learning

• A growing number of studies indicate that imagining a movement can facilitate the learning of that movement

• Similarly, studies show that observing another individual perform a movement helps in acquiring a motor skill

• Imagery and observation point to a mental representation of some kind

Principles of Motor Learning (Schmidt & Bjork, 1996)

• 1. Acquisition performance is not a good index of retention.

Suc

cess

Practice

Easy task

Hard task



Suc

cess

Practice Retention



• 2. Random practice is superior to blocked practice (drills)– E.g., avoid repetitive trials with a predictable time

pattern



• 2. Random practice is superior to blocked practice (drills)

• 3. Expanding interval retrieval practice is superior to massed practice– Vary the interval between trials


• 4. Variable practice is superior to constant practice

– Vary phonetic context for a sound target rather than use a fixed context

– Introduce prosodic variations in sound pattern to be practiced

– Use bite block to force reorganization of articulatory pattern

– Manipulate speaking rate for utterance


5. Faded or inconsistent feedback is superior to consistent feedback.

– Gradually eliminate feedback once a stability criterion is reached

– Provide feedback on reduced schedule, such as after every 5 trials

Blocked practice with constant feedback

Blocked practice with reduced feedback

Blocked variable practice with reduced feedback

Blocked variable practice with reduced feedback and expanded interval

Principles of Motor Learning...

• MORAL: make things difficult in early learning to maximize the learning result.

Cognitive-motor challenges appear to be the way to effective motor learning.

Next, a look at neural processes…

Simple Model of Speech Production

• Ideation (Cognitive)

• Language (Linguistic)– word retrieval, phonological mapping– Syntax & grammar

• Motor Planning/Programming (Motor)– Specification of ROM, strength, speed, direction,

• Motor Execution (Motor)– Respiration, phonation, resonance, articulation

However….

• Children with motor speech disorders frequently have coexisting cognitive and/or linguistic factors that influence our clinical decisions

• Clinical decisions have to be based on the relative contribution of deficits

This can lead to dilemmas….

Categories of Impairment

• For Example:

– Phonologic impairment

– Childhood apraxia of speech

– Dysarthria

However…

• Categories of impairment often occur together

• There is some lack of agreement on characteristics that put children into particular categories

This also leads to dilemmas….

and can lead to the temptation to use material labeled for “________”

Evidenced Based Practice

• Currently there is a great deal of discussion regarding evidence based practice – using the evidence from the literature to guide us in our clinical decisions.

• Unfortunately, the evidence for treatment efficacy in motor speech disorders in children is sparse.


• Dysarthria – • Search using Medline - only 93 articles came up

related to dysarthria treatment

• only 10 of those related to children

• All were descriptive or case studies


• Childhood apraxia of speech- studies of treatment efficacy/effects (last 10 years)– 2 studies focused on augmentative – 4 studies focused on speech production and only one

of those was a controlled single subject design– Earlier treatment literature is also sparse and typically

case studies

The literature

Models and theories of speech motor control

Severe

MSD

Clinical Decision Making

The Dilemma

• We have the challenge of treating children who are in the processes of acquiring language and speech skills in the context of one and usually more processing deficits

• There is some lack of consensus regarding how motor speech is controlled, especially during acquisition

• There is some lack of consensus regarding classification (especially for apraxia)

Clinical Decision Making

What Does That Mean???• What approach?

– Linguistic– Motor

• Integral stimulation• Tactile/gestural• rhythmic

Clinical Decisions

Precursors to Motor Learning

– Motivation – trust you – trust the process

– Focused attention to the feel of the movement

– Intent to improve movement

Clinical Decisions

Frequency of Sessions? -

Frequent

– Shorter but more frequent– Include two short (5 minute focused practice) at

home

Clinical Decisions

StimuliHow Many?

Use the Principle of Mass vs. Distributed Practice

Mass = better performance, poorer motor learning

Distributed = enhances motor learning

Dilemma – have to achieve accuracy – want generalization

Solution - it depends……..

Clinical Decisions

• Usually use severity as a guide– The more severe the apraxia, the smaller the set

size. – This gradually increases over time

Clinical DecisionsHow are Stimuli Presented?

– Listening/watch the clinician– Pictures– Objects

Go back to comments on Mental Imagery and Observational Learning– Observing another individual perform a movement

enhances learning the movement– How might pictures take away from motor

learning??– Given the attentional factors of small children, how

do we take advantage of this part of the knowledge base?

Clinical Decisions

– Pay attention to syllable shapes • Remember, the focus is improving movement

gestures• Often need to focus a great deal on vowel accuracy

– Encourage visual attention to your face (mental imagery and observational learning)• Avoid stimuli that take that attention away• Use reinforcers that facilitate attention to your face

Clinical Decisions

How much practice should be done?

• Go back to Neuroplasticity– Repetition Matters

• Go to motor learning literature – in order to learn motor skill you must practice the movement – in the context for which it will be used.

• Need to maximize practice trials per session

How is Practice Organized Within the Session?

– Blocked – better performance; inhibits motor learning

– Random – better motor learning

Remember:

Make things difficult in early learning to maximize the learning result.

Cognitive-motor challenges appear to be the way to effective motor learning.– But – these kids have impaired motor systems

– they have NEVER spoken– they have a great deal of difficulty with

achieving movement accuracy

Clinical Decisions

• Organizing Practice within the Session– Blocked – only early to get accuracy– Move toward more random as performance

improves (Yan, Thomas & Thomas, 1998)

• How Much Practice – a lot– Neuroplasticity – practice matters– Motor learning literature – have to practice the

movement – in the context for which it will be used (e.g.Schmidt, 1991)

– Intensive practice can be hard with little ones, or children with severe impairment, but

• use activities and reinforcers that are salient and quick

• be novel

• Switch activity and reinforcers frequently

Rate of Practice

No data on the effects of speaking rate adjustments in children with motor speech disorders

• Want to give the child more time for sensory motor feedback in order to maximize:– accuracy of movement– tactile feedback – proprioceptive processing

Clinical Decisions

• Speech movement rate during practice– Start slow enough to facilitate accurate movement– Gradually increase rate with repeated trials

• Prosody should also be varied– Practicing lexical and phrasal stress is important– Need to vary this as accuracy improves

How do we do this in practice while working toward speech naturalness??– Start as slow as necessary to get accurate

continuous movement gestures

– With repeated trials, as movement gets more accurate, slowly increase rate to normal.

Decisions re Feedback

When? How often?

Every trial; after ____ trials?

Timing and Frequency of Feedback:– immediate - use early in treatment and when

impairment is severe as this improves motor performance

– as child improves, use less immediate and less frequent to facilitate motor learning

Clinical Decisions

• Feedback

– Give knowledge of performance early, then fade to results

– Give less extrinsic feedback as child improves, in order to facilitate motor learning

– Give feedback frequently first, and without delay; gradually decrease frequency, and add delay

Feedback

• Intrinsic– Maximize proprioception– Make the “feel” of the movement salient

• Extrinsic– Use tactile/gesturing cueing

– Encourage visual attention to your face (remember –watching another individual perform a movement enhances learning the movement)

Decisions re Feedback

• Extrinsic feedback - – more important early and with more severe

impairment– later in treatment, give less extrinsic feedback (as too

much reliance on extrinsic may lead to decreased motor learning) (Schmidt & Bjork, 1996)

• Amount and precision of feedback should be great at first, then decreased as magnitude of errors decreases (to facilitate motor learning)

Clinical Decisions

• In general, for children with MSD

– Help them focus on the intent to improve movement

– Make the “feel” of the movement salient– Use smaller set size

Feedback

What Kind?• Knowledge of Performance augments accuracy;

inhibits motor learning

• Knowledge of Results better than performance for motor learning

Back to the same dilemma….

Feedback

Model Child’s Response KR interval

Clinicians feedback post KR interval next model and/or response

– No data regarding how long the KR delay should be in speech disordered children

– Our experience – keep it short at first, and when impairment is severe

– Gradually lengthen the interval and reduce frequency

Summary

The Solutions include

• Using the evidence (Evidence based practice)• Using the literature

– Models and theories of speech motor control– Speech science and speech pathology literature– Motor Learning Literature

• Careful Clinical Decision Making

interventions for achieving speech movements final category of intervention approaches

Documents

speech movements interventions

improved movement dd

palateprovides visual

lingual targets

lingual consonants

randomized controlled

visual feedbackdevice

artificial epg plate