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324 MOTOR SPEECH DISORDERS: DIAGNOSIS AND TREATMENT
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children. It requires the patient to carefully watch the clinician’s
face while listening to him or her verbally produce a target word.
The combined presentation of a verbal and visual model can signicantly enhance an apraxic patient’s own attempts at a verbal
production. In the Eight-Step Continuum Treatment, often the clinician directly cues the patient to “Watch me and listen to me” before
presenting the stimulus.
Another key element of the Eight-Step Continuum Treatment
is careful selection of target sounds and words. The authors listed
ve principles that will facilitate the patient’s progression through
the treatment steps.
1. Begin with the easiest speech sounds and then move to the
more difcult ones. Vowels, nasals, and stops are the easier
sounds; fricatives, affricates, and consonant clusters are more
difcult.
2. As the patient begins to sequence sounds together, gradually
increase the distance between points of articulatory contact
in the target words. For example, the rst target words or
syllables might only contain bilabial consonants; the next
might have both bilabials and lingua-alveolar sounds; the
next could have bilabial and velar sounds.
3. Choose the initial phonemes of target words carefully. Words
that begin with vowels, nasals, or stops are more likely to
be produced correctly than words beginning with fricatives,
affricates, or consonant clusters.
4. Gradually increase the length of the target words. It is best
to start with short words that have repeating syllables, such
as B-B, so-so, and ta-ta. Once these are mastered, systemati-
cally begin using longer words that have more complex
syllable structure.
5. When choosing real words for treatment, start with words
that appear more often in day-to-day speech (i.e., high-
frequency words).
initial target syllables or words, the treatment sequence is ready to
begin. While guiding the patient through the eight treatment steps,
the clinician should keep in mind several general rules:
n Move through the steps at a pace that keeps the patient
successful.
n Repetitive drill will be necessary to help the patient relearn the
motor sequences needed to produce volitional speech.
Once these principles are incorporated into the selection of
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n Use functional, useful words in treatment as soon as possible.
n Encourage the patient to self-correct errors.
n Teach compensatory strategies to facilitate speech, such as
prolonging vowels, slowing rate, and pausing when needed.
The actual treatment steps in this program follow a logical
sequence that moves from maximal to minimal cueing by the clinician. The following list is a summary of what the clinician and
patient do in each of the eight steps. Not all patients need to start
on Step 1 or move through every step. Some will be able to skip
steps, depending on the severity of their decits.
1. The clinician tells the patient to “Watch me” and “Listen to
me” and says the target word. They then say the target word
in unison.
2. The clinician tells the patient to “Watch me” and “Listen
to me” and says the target word. Then, while the clinician
silently mouths the word, the patient says the word aloud.
3. The clinician tells the patient to “Watch me” and “Listen to
me” and says the target word. The patient then repeats the
word independently.
4. The clinician tells the patient to “Watch me” and “Listen to
me” and says the target word. The patient then repeats the
word several times independently.
5. The clinician presents the target word written on paper, and
the patient says the word while looking at it.
6. The clinician presents the target word written on paper,
removes it, and then the patient says the word.
7. The patient says the word in response to a question from the
clinician. For example, if the target word were the patient’s
name, the clinician would ask, “What is your name?” The
patient would then say his or her name.
8. Role playing with the clinician, family, or friends is used
to evoke the target word in an appropriate conversational
context.
Sound Production Treatment
Wambaugh and colleagues developed an apraxia treatment that
combined components of the Eight Step Continuum technique
with articulatory placement cueing, phonetic tasks, and extensive
modeling (Wambaugh et al., 1998). Like the Eight Step Continuum,
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Sound Production Treatment (SPT) is an articulatory kinematic procedure. It contains a four-step treatment hierarchy and is unique
in several ways. First of all, skipping steps in the treatment hierarchy is actually built into the treatment procedure. The clinician
can omit steps in the treatment sequence depending on how well
the patient produces the target sounds. For example, if the patient
produces a target word correctly in the rst step, that trial is complete, and the patient can move on to the next word. The benet
of this is that it allows the treatment to progress at a faster pace
than it would otherwise. A second unique feature of SPT is that it
combines phonetic treatment tasks with traditional motor sequencing activities. The phonetic tasks are included because some studies
have suggested that apraxia of speech is a phonetic-level disorder,
as well as a motor sequencing disorder. Because it incorporates
motor and phonetic tasks in the treatment hierarchy, SPT could
enhance a patient’s productions of target phonemes. The third
unique aspect is the amount of research that has been conducted
on this procedure: STP is the most well-researched treatment for
apraxia of speech (Wambaugh et al., 2006a, 2006b).
The SPT hierarchy presented here is Wambaugh and Nessler’s
(2004) modication of the original procedure. In contrast to the
original procedure, this version begins working immediately on
target sounds, and it requires the patient to repeat the target words
more frequently. In the following description of the SPT treatment
sequence, it is assumed that the patient is working on the phoneme
/m/ and that the clinician has prepared a list of ve target words
containing that target sound (mutt, me, mum, mow, and man).
Step 1 (Saying the Word)—The clinician says the rst word
(mutt) and asks the patient to repeat it. If mutt is repeated correctly,
the patient is asked to repeat the word ve more times independently. Once the ve repetitions are completed successfully, the
next word containing /m/ (me) is presented, and Step 1 is started
again.
If mutt is not repeated correctly, the clinician explains what
was wrong and says, “Let’s try a different word.” The clinician now
presents a word that is a minimal pair for mutt (e.g., but) and asks
the patient to repeat it. If the patient repeats but correctly, the clinician says, “Good, let’s go back to the other word” and moves to
Step 2 using mutt.
If the minimal pair word (but) is not repeated correctly, the
clinician says, “Watch me and listen to me and say the word with
me.” The clinician then says, but three times, while the patient
attempts to repeat the word in unison. Regardless of whether these
productions of but are correct or incorrect, the clinician moves on
to Step 2 with the original word (mutt).
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Step 2 (Show the Letter)—The clinician presents a card with
a large M (the target sound) written on it. The clinician then asks
the patient to repeat the word mutt. If the patient’s production is
correct, the clinician asks for ve independent repetitions of mutt
and then goes to Step 1 with next word on the list (me). If incorrect, the clinician moves to Step 3.
Step 3 (Watch Me and Listen to Me)—The clinician says,
“Watch me and listen to me and say the word with me,” and then
says mutt three times. The patient attempts to say the word in unison with the clinician. If correct, the clinician asks the patient to
repeat the word ve times independently and then goes to Step 1
with the next word on the list. If the patient cannot correctly produce mutt by looking and listening, the clinician moves to Step 4.
Step 4 (Articulatory Placement Cueing)—When the patient
cannot say the target word by looking and listening, the clinician
provides a combination of verbal, visual, or tactile cues on how to
produce the target sound. In the current example, the cues would
show or describe how the lips need to be together to produce /m/
and how the sound needs to travel through the nose, rather than
through the mouth. After giving the cue(s), the patient is asked
again to look and listen to the clinician and say the word (mutt)
three times in unison. If the productions in unison are correct, the
patient is asked to repeat the word ve times independently. If the
productions in unison are incorrect, the clinician and patient stop
working on mutt for the time being and go to Step 1 using the next
word on the list (me).
This written description of SPT might make the process seem
more complicated than it actually is. Beginning clinicians are
encouraged to thoroughly rehearse its treatment steps with a friend
or colleague before attempting it with a patient. With practice, SPT
sessions can progress at a comfortable pace, and the individual
steps have a logical hierarchy of cueing. Incidentally, when the
patient is independently repeating a stimulus word ve times during one of the SPT steps, Wambaugh recommended giving feedback on only about 60% of the patient’s attempts. The primary
reason for this is that too much feedback can interrupt the patient’s
concentration and inadvertently impose a delay between the separate attempts at saying the word, something that can make the task
more difcult for the patient. Furthermore, Wambaugh et al. (2017)
found that random presentation of stimulus words in SPT is moderately more effective than block presentation. For example, if a
patient were working on the phonemes /v/, /m/, and /t/, each with
10 target words as stimuli, block presentation would be working
on all the /v/ words rst, then all the /m/ words, and nally all the
/t/ words. Random presentation would be working on all 30 target
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words in random order. The study’s results showed that although
both methods increased speech accuracy for targeted phonemes,
there was a 12% greater improvement for random practice 2 weeks
after treatment and 8% at 10 weeks.
Darley, Aronson, and Brown’s Procedure
Darley et al. (1975) described another articulatory kinematic
approach to helping individuals with apraxia of speech relearn
the motor sequences for speech production. No controlled studies
show this technique’s effectiveness, but anecdotal clinical reports
indicate that it could be useful for patients with severe apraxia.
For instance, its rst steps are designed for a patient who is having difculty with voluntary phonations, tongue protrusions, and
other simple oral movements. Darley et al. called these beginning
procedures “initiating speech activities.”
1. Encourage the patient to prolong an “ah.” If this is not
possible, see whether the patient can cough voluntarily. If
so, then try to shape the cough into a prolonged exhalation
or sigh. If these are not successful, see whether the patient
can hum a familiar song or complete an automatic, openended phrase, such as “The sky is ______,” or “Open the
______.”
2. When a phonation is produced, the patient is asked to say
that sound repeatedly, using different durations and levels
of loudness. Then the patient should be encouraged to try
shaping the phonation into several vowel sounds, such as
“ee,” “oh,” “oo,” and so forth.
3. Once vowels are being produced, the patient is asked to
imitate the clinician’s model of /m/. Darley et al. (1975)
recommended using a mirror to facilitate the volitional
closing of mouth for the /m/. When this consonant is
produced, the patient is asked to begin forming syllables
with /m/ in the initial position, such as me, moe, and moo.
4. Slightly more complicated production of consonant–vowel
(CV) syllables can be encouraged by having the patient alternate between syllables with open and closed vowels, such as
moe-me, moe-me, moe-me. This also can be accomplished by
using syllables that have /w/ in the initial position.
ready for the next portion of this treatment program, which is
called “Using Automatic Responses.” For these tasks, it is assumed
Once these tasks are accomplished, the patient should be
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that the patient is able to produce some automatic phrases, such as
counting or other overlearned word sequences. Darley et al. (1975)
recommended that patients attempt to recite automatic responses
so that they can regain the experience of producing speech easily.
A list of recommended automatic responses is:
n Counting from 1 to 10.
n Reciting the days of the week or months of the year.
n Common expressions such as “hello,” “how are you?” “ne,”
“very well,” “thank you,” “I don’t know,” and so forth.
n Well-known materials including nursery rhymes, phrases from
television commercials, and opening lines from famous poems.
n Singing well-known songs.
The next step, called “Phonemic Drill,” is a return to working
on volitional speech production. It is hoped that by this stage the
patient is beginning to attempt some utterances spontaneously,
although they might be lled with apraxic errors. Darley et al.
(1975) recommended using the integral stimulation “watch and listen” method of presenting these phonemic drill tasks to the patient.
1. The rst step is to choose an easy phoneme such as /m/.
The patient is asked to hum the /m/ after the clinician
demonstrates what to do.
2. Then the patient adds a series of vowels to the /m/, such as
my, moe, maw, moo, may, and me. These words are prac-
ticed 10 to 20 times each.
3. These CV words are then doubled, so that me becomes
me-me and may becomes may-may. The patient again
practices saying these words 10 to 20 times each.
4. The next step is to add /m/ to the end of the CV words. For
example, mom, moom, and meem would be some of the
words created for this step.
5. The patient next begins saying actual words. Choose words
that begin with /m/ and have other easy phonemes in them.
Darley et al. (1975) suggested words such as more, man,
mine, moon, mare, mat, map, and mum. As with all of these
steps, the words are practiced at least 10 to 20 times each.
6. Producing two-word phrases is the next step. Both words in
the phrases should begin with /m/. Examples of words for
this step include my mom, my mail, miss me, much more,
and make me.
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7. Now the patient produces two-word phrases that end with
/m/, such as come home, name him, lame lamb, dumb bum,
and so forth.
8. This step has the patient say two-word phrases in which
/m/ is in the initial position of the rst word and in the nal
position of the second. Examples would include make him,
my home, must name, my name, meet them, and Mary’s room.
9. The nal step is having the patient produce longer phrases
that include multisyllabic words, such as moment by
moment, my morning meeting, made much money, Monday
morning, and among my memories.
From here, the patient moves to productions of other consonants in words, using the same sequence as with the /m/. Eventually, the patient will be asked to use the consonants he or she has
mastered in words that contain the same vowel, such as me, she,
we, tea, bee,
words into phrases and then into sentences.
fee, and key. Ultimately, the goal is to incorporate these
Melodic Intonation Therapy
MIT (Helm-Estabrooks et al., 1989) would be classied as a rateand-rhythm type of apraxia treatment. It is based on the observation that many individuals with aphasia or apraxia of speech can
sing the words of a song much better than they can say the same
words in conversation. Many clinicians have worked with patients
who could sing the words of a well-known song intelligibly, but
when asked to say the words, they could not. One theory for this
phenomenon is that singing is accessed through the undamaged
right hemisphere. It is thought that singing the words of a song
somehow allows the right hemisphere to facilitate the function of
the damaged left hemisphere, resulting in better verbalizations in
song than in conversation. MIT was designed to capitalize on this
by blending rhythm and melody into the volitional speech of individuals with aphasia or apraxia of speech. In the MIT program, the
rhythm and melody aspects of the program are emphasized primarily in the beginning steps of the program. The patient’s intonation
is then modied into a more natural prosody in the nal steps.
The authors identied the most successful treatment candidates for this program—those who (a) experienced a stroke,
(b) have nonuent aphasia or otherwise restricted verbal output,
(c) have good auditory comprehension, (d) demonstrate poor articu
lation and repetition abilities, and (e) are motivated and have an
-
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adequate attention span. Patients with large lesions in Wernicke’s
area or co-occurring right hemisphere damage are unlikely to benet from the MIT program.
The MIT program is divided into three levels, with each
level containing several individual steps. In the rst two levels,
the patient works on producing short, high-frequency words and
phrases. The third level concentrates on longer, more complex
utterances. The overall sequence of treatment is to rst incorporate
melodic intonation into the target utterances, then gradually shift
to saying the words with exaggerated prosody, and nally saying
the words with normal prosody. The following is a summary of the
MIT treatment sequence.
Elementary Level
1. First the clinician demonstrates the melody by humming and
singing the target word. The clinician taps the patient’s hand
on each syllable of the word or phrase. The patient does not
respond, but only listens carefully.
2. The clinician and patient sing the target word and tap out
the syllables together.
3. The clinician and patient begin by singing and tapping the
word together, but the clinician stops about halfway through.
The patient is required to complete the word alone.
4. The clinician sings and taps the target rst; the patient then
repeats it immediately.
5. When the patient repeats the word from Step 4, the clinician
immediately asks a question such as, “What did you say?”
The patient attempts to say the target word in response to
this question.
Intermediate Level. The four steps of this level follow the general
sequence found in the elementary level, except that delays of several seconds are inserted between the clinician’s presentation of the
target word and the patient’s response. The length and complexity
of the target words and phrases in this level are approximately the
same as in the elementary level.
Advanced Level. The ve steps in this portion of the program
also concentrate on the delayed repetition of target phrases, as was
done in the intermediate level. However, the melody used in the
patient’s utterances in the prior levels is now modied to match
more closely normal speech intonation through a procedure called
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speech-song. The authors described speech-song as being similar
to choral reading, in that the rhythm and stress of the target phrase
are exaggerated. The words are not actually sung in a melody. In
the nal step, the clinician asks a question, the patient waits about
6 s, and then answers with the correct target phrase using normal
intonation.
PROMPT
PROMPT, an acronym for Prompts for Restructuring Oral Muscular Targets, is an articulatory kinematic treatment approach. It
was developed originally as a treatment for childhood apraxia of
speech. The PROMPT program uses a combination of proprioceptive, pressure, and kinesthetic cues that show patients how
to sequence their oral movements for speech (Square-Storer &
Hayden, 1989). The clinician provides these cues by touching
the patient’s face and manually guiding the articulators to the
appropriate positions needed to produce the target sounds. These
“hands-on” cues are designed to provide the patients with sensory information regarding place of articulatory contact, extent
of jaw opening, voicing, relative timing of syllables, manner of
articulation, and coarticulation. The basic premise of PROMPT is
that clinicians are acting as external motor speech programmers
when they guide a patient’s articulators through the correct motor
sequence to produce a target sound. PROMPT identies numerous
contact points around the mouth, under the chin, and on the neck,
where clinicians place their ngers and hands to guide the articulators into the proper positions for speech production. The overall
sequence of a PROMPT treatment is to rst have the clinician say
the target syllable, word, or phrase. The patient then attempts to
say the word. If correct, the next word is presented. If incorrect, the
clinician nds the correct contact points for the phonemes of the
word and moves the patient’s articulators passively. The patient is
then asked to try saying the word again with the clinician simultaneously moving the articulators into the correct positions for the
word’s phonemes. Some of the cues are simple and can be understood by any clinician, such as those for bilabial sounds, voicing,
and jaw opening. Many, however, are complex and require special
instructions learned from a PROMPT workshop to understand fully.
For example, the more dynamic cues, such as those for coarticulation or phrases, can be quite intricate. Nevertheless, PROMPT has
been effective in helping some patients with co-occurring severe
Broca’s aphasia and apraxia of speech use a core vocabulary of a
few words and phrases (Bose et al., 2001; Freed et al., 1997; Square
et al., 1985; Square et al., 1986).
Summary of Apraxia of Speech
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n Apraxia of speech is a disorder of motor sequencing for
speech production, wherein the timing and accuracy of
movements is disturbed. It is not caused by muscle weakness, abnormal muscle tone, reduced range of movement, or
decreased muscle steadiness.
n Apraxia of speech is a subcategory of ideomotor apraxia,
which is dened as a disturbance in the performance needed
to complete an action. This contrasts with ideational apraxia,
which is a disturbance in the idea or purpose of a movement.
n The neural network thought to control the sequencing of
speech movements is called the motor speech programmer.
It is an indistinct cerebral structure that seems to be located
primarily in the perisylvian area of the brain.
n Apraxia of speech has numerous potential causes, including
stroke, degenerative diseases, trauma, and tumor.
n Apraxia of speech is primarily a disorder of articulation and
prosody.
n When diagnosing apraxia of speech, it is important to elimi-
nate conditions that can cause speech errors similar to those
in apraxia of speech. Brookshire (2015) listed four such conditions: muscle weakness, sensory loss, comprehension decit,
and incoordination.
n Many treatments for apraxia of speech have been developed.
The choice of which is best can depend on the severity of the
apraxia and the patient’s and clinician’s personal preferences.
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Study Questions
1. Dene apraxia of speech in your own words.
2. Describe how apraxia of speech is both similar to and
3. How are ideational apraxia and ideomotor apraxia different?
4. Limb apraxia, nonverbal oral apraxia, and apraxia of speech
5. What is the difference between nonverbal oral apraxia and
6. What is the motor speech programmer?
different from dysarthria.
are subcategories of which type of apraxia?
apraxia of speech?
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