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Dysarthria Associated with PD
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
52 Dysarthria Associated with Parkinson’s Disease
Jessica E. Huber
52.1 Introduction
People with Parkinson’s disease (PD) often present with significant speech and voice changes, called hypokinetic dysarthria.
Speech characteristics most commonly associated with PD
include reduced loudness, weak voice, breathiness, hoarseness,
fast rate of speech, and imprecise articulation.
self-monitoring
to perceive changes in their speech and alter their production
in everyday communication environments. This is a case of an
individual with fairly advanced PD and significant dysarthria as
a result. Lack of previous treatment response was a complicating factor in devising a treatment plan.
4
and cognitive resources,5reducing their ability
3
PD also impacts
1,2
52.2 Clinical History and
Description
DG was a 73-year-old woman diagnosed with idiopathic PD
approximately 12 to 14 years ago. She lived at home with her
husband. Her pr imary concern was decreased vocal intensity,
which varied with dopaminergic medication. Although she did
not complain of voice fatigue, she frequently lost her voice by
the time her husband returned from work in the evening. DG
was a retired nurse and her husband was often the only communication partner that she had all day. She had occasional visitors, but was otherwise mostly homebound. DG stated that she
generally avoided communicative situations due to her difficulty speaking. Her voice was typically better when she had
some vocal use during the day; she reported that her voice
improved in the evening on days she had visitors. Three years
ago, an evaluation by an otolaryngologist revealed unremarkable vocal folds. She underwent the Lee Silverman Voice Treatment program (LSVT LOUD)
LSVT LOUD is an intensive behavioral treatment program to
increase loudness, clarit y, and self-monitoring. She and her husband reported no significant improvement after the program.
She scored in the normal range on the Montreal Assessment of
Cognition (MoCA).
7
6
at two facilities in the past 2 years.
52.3 Clinical Testing
Perceptual characteristics: Perceptually, her speech consisted
of moderate-to-severe hypophonia, slightly decreased speech
rate, and occasional articulation errors. Her vocal quality was
moderately severely breathy and moderately hoarse. She was
mostly intelligible (75%) in conversation with careful listening.
Her husband assisted with communication repair.
Oral mechanism examination:DGdemonstratedaslight
right lip droop, but adequate protrusion, retraction, and
labial seal. Eye and mandibular dystonia were observed.
Tongue lateralization and st rength were moderately reduced,
and tongue tremor was observed as well as a weak volitional
cough. Alternating and sequent ial motion rates were slow
but rhythmic.
Respiratory function: Inspiratory and expiratory muscle
strength were assessed by measuring maximal inspiratory and
expiratory pressures. Pressures were much lower than expected
(see ▶ Table 52.1).
Voice evaluation:DG’s sound pressure level was 66.3 dB on
average during conversation (using a 6-cm mouth-to-microphone distance), signif icantly lower than published norms
(about 80 dB).
determine whether she was stimulable for increased vocal
intensity in noise. The SpeechVive device is a small wearable
device that elicits increased sound pressure level by playing
noise in one ear, eliciting the Lombard effect. DG increased
sound pressure level to 69.3 dB on average with the SpeechVive
device in place during conversation. However, increased intensity varied across conversation. Intensity tended to be lower at
the ends of sentences and for short (one- to two-word) utterances. The Communication Participation Item Bank (CPIB)
administered; she scored 3/30 and reported her condition
interfered very much with communication. Her husband scored
2/30, indicating agreement with significant difficulties in communication participation.
Swallowing evaluation: DG and her husband indicated some
coughing during most meals, particularly when ingesting thin
liquids. DG reported that occasionally she has difficulty starting
to swallow chewed solids, but that pureed foods did not cause
any difficulty. DG was referred for a Videofluoroscopic Swallow
Study (VFSS) at a local medical facility.
8
The SpeechVive device9was implemented to
10
was
52.4 Questions and Answers for
the Reader
1. What muscle(s) is/are likely weak, as reflected by reduced
maximum expirator y pressure?
a) Diaphragm.
b) Scalene muscles.
c) External intercostals.
d) Abdominal muscles including the rectus abdominis, inter-
nal and external oblique muscles, and transverse abdominis muscle.
e) Posterior and lateral cricoarytenoid muscles.
Table 52.1 Maximum inspiratory and expiratory pressure results
13
Measurement Client’s pressures: evaluation
Maximum expiratory pressure 52 102 121
Maximum inspiratory pressure 24 44 56
(cm H
O)
2
Client’s pressures: after 6 weeks
of therapy (cm H2O)
Expected pressures
(cm H2O)
199
Dysarthria Associated with PD
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Answer: d is correct. The abdominal muscles act to increase
alveolar pressure and cause expiration.
aisincorrect. The diaphragm is the main muscle of inspiration.
b is incorrect. The scalene muscles are small, relatively weak
muscles that elevate the first rib.
c is incorrect. The external intercostals are mostly muscles
associated with inspiration.
e is incorrect. The posterior and lateral cricoarytenoid
muscles are associated with arytenoid movement, resulting in
true vocal fold movement.
2. Given her physiological presentation, which of the following
issues are you most concerned with assessing, in addition to
her speech production?
a) Walking.
b) Balance.
c) Feeding and swallowing.
d) Cognitive function.
e) Language skills.
Answer: c is correct. Given her voice quality and oral mechanism exam results, it is likely that she experiences both oral
and pharyngeal swallowing issues and is at risk for aspiration.
a and b are incorrect. They are not in the scope of practice
for speech-language pathologists.
d is incorrect. She and her husband report no change in cognition. Her primary complaint is speech-related. She scored
normally on the MoCA screening. She seems able to adequately
judge her communication and report her condition.
e is incorrect. Generally, language changes in PD are related
to cognitive change. Given that any changes in cognition are
subtle, language is likely acceptable.
3. Which treatment might you try with DG to improve her
communication?
a) LSVT LOUD.
b) SpeechVive alone.
c) SpeechVive with vocal warm-ups and behavioral therapy
to improve voicing and communication repair strategies.
d) Pacing therapy to increase speech rate.
e) Oral motor exercises to increase lip and tongue strength.
Answer: c is correct. The SpeechVive was effective in cueing
increased vocal intensity. However, the effects were variable,
suggesting the need for behavioral therapy in addition to daily
use of the SpeechVive device.
a is incorrect. She has had two courses of LSVT LOUD in the
last 2 years without improvement. However, effortful voice production training may assist her.
b is incorrect. Due to the variable effects of the SpeechVive
device, additional behavioral therapy is indicated to improve
speech and communication. Her reports of better voice with
use suggest that vocal warm-ups would be of benefit to her.
d is incorrect. We would not want to increase her speech
rate, even though it is slow. Her slower speech rate likely contributes to intelligibility.
e is incorrect. Oral motor exercises have not been shown to
have clinical efficacy for speech.
4. If you were to attempt treatment to increase respiratory
muscle strength, which would you choose?
a) Inspiratory muscle strength training with the PowerBreathe.
b) Expiratory muscle strength training with the EMST 150.
c) Both inspiratory and expiratory muscle strength training
with the breather.
d) Both inspiratory and expiratory muscle strength training
with an incentive spirometer.
e) Both inspiratory and expiratory muscle strength training
with the PowerBreathe and EMST 150.
Answer: b is correct. Since she is experiencing significant
issues with vocal intensity, strengthening the respiratory system is critically important. There are excellent data demonstrating that expiratory strength can be improved in people
with PD as a result of expiratory training.
ment with the EMST 150 has been shown to improve hyolaryngeal elevation, which may mitigate issues with aspiration,
depending on the findings of a swallowing evaluation.
it is possible for treatment of expiratory muscle strength to
increase maximum inspiratory pressure by improving abdominal support for the diaphragm and rib cage during breathing.
a and e are incorrect. There are less efficacy data regarding
the use of inspiratory strength in people with PD. Also, it is
often difficult for patients to keep up with both treatments at
once. This would require 60minutes per day of respiratory
exercise, at least 5 days per week.
c and d are incorrect. Neither of those devices provide
enough overload to result in increased strength.
11
Additionally, treat-
11
Finally,
52.5 Description of Disorder and
Recommended Treatment
DG presented with moderate-to-severe dysarthria as a result of
PD. Major impair ments were associated with respiratory weakness and laryngeal valving. Treatment was recommended twice
a week for 6 weeks. Treatment focused on improving vocal
quality, speech breathing patterns, and clear speech,
with communication repair strategies including augmentative
low-tech systems. Expiratory muscle strength training using
the EMST 150 was initiated, five sets of five breaths five times
per day for at least 5 days. Vocal warm-up exercises were taught
and she was asked to perform them twice daily, once in the
morning and again in the afternoon before her husband comes
home. Treatment with the SpeechVive device was also initiated.
She wore the device daily for at least 3 to 8 hours and read
aloud with the device for 30 minutes per day. She was also
encouraged to engage in more social communicative situations
during the week. Safety and efficiency of swallow was also
assessed via VFSS. The evaluation indicated that DG had (1)
intermittently reduced oral transit with chewed solids, (2)
delayed initiation of the swallow, (3) moderately reduced laryngeal elevation, (4) moderate aspiration of thin liquids during
the swallow, and (5) moderate pharyngeal residue for solids
leading to inconsistent aspiration after the swallow.
12
along
52.6 Outcome
DG improved her voice quality and vocal intensity within 6
weeks of therapy. Her speech was clearer and she used a textto-speech system well for communication repair. However, she
was unable to maintain increased vocal intensity without the
200
Dysarthria Associated with PD
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
SpeechVive device. It was recommended she continue to use
the device daily during communicative situations. Her inspiratory and expiratory muscle strength increased, but she
remained below norms (see ▶ Table 52.1). It was recommended
that she continue expiratory muscle strength training. Treatment for swallowing was conducted during speech therapy sessions since much of the speech work could be practiced outside
of the therapy room with the SpeechVive.
52.7 Key Points
●
It is important to consider respiratory muscle strength, particularly expiratory strength, in individuals with PD.
●
The lack of success with LSVT LOUD suggests the need for
modified or alternative therapies.
●
Oral motor exercises are not acceptable approaches to
improve speech, even in the context of oral motor weakness.
●
Technological treatments such as the SpeechVive can be used
in combination with other speech and swallowing treatment
approaches.
Suggested Readings
[1] Sapienza CM. Respiratory muscle strength training applications. Curr Opin
Otolaryngol Head Neck Surg. 2008; 16(3):216–220
[2] Fox CM, Morrison CE, Ramig LO, Sapir S. Current perspectives on the Lee Sil-
verman Voice Treatment (LSVT) for individuals with idiopathic Parkinson disease. Am J Speech Lang Pathol. 2002; 11:111–123
[3] Stathopoulos ET, Huber JE, Richardson K, et al. Increased vocal intensity due
to the Lombard effect in speakers with Parkinson’s disease: simultaneous laryngeal and respiratory strategies. J Commun Disord. 2014; 48:1–17
References
[1] Logemann JA, Fisher HB, Boshes B, Blonsky ER. Frequency and cooccurrence
of vocal tract dysfunctions in the speech of a large sample of Parkinson patients. J Speech Hear Disord. 1978; 43(1):47–57
[2] Ho AK, Iansek R, Marigliani C, Bradshaw JL, Gates S. Speech impairment in a
large sample of patients with Parkinson’s disease. Behav Neurol. 1999; 11(3):
131–137
[3] Darley FL, Aronson AE, Brown JR. Differential diagnostic patterns of dysarth-
ria. J Speech Hear Res. 1969; 12(2):246–269
[4] Ho AK, Bradshaw JL, Iansek T. Volume perception in parkinsonian speech.
Mov Disord. 2000; 15(6):1125–1131
[5] Zgaljardic DJ, Borod JC, Foldi NS, et al. An examination of executive dysfunc-
tion associated with frontostriatal circuitry in Parkinson’s disease. J Clin Exp
Neuropsychol. 2006; 28(7):1127–1144
[6] Fox CM, Morrison CE, Ramig LO, Sapir S. Current perspectives on the Lee Sil-
verman Voice Treatment (LSVT) for individuals with idiopathic Parkinson disease. Am J Speech Lang Pathol. 2002; 11:111–123
[7] Armstrong MJ, Duff-Canning S, Psych C, Kowgier M, Marras C. Independent
application of montreal cognitive assessment/mini-mental state examination
conversion. Mov Disord. 2015; 30(12):1710–1711
[8] Huber JE. Effects of utterance length and vocal loudness on speech breathing
in older adults. Respir Physiol Neurobiol. 2008; 164(3):323–330
[9] Stathopoulos ET, Huber JE, Richardson K, et al. Increased vocal intensity due
to the Lombard effect in speakers with Parkinson’s disease: simultaneous laryngeal and respiratory strategies. J Commun Disord. 2014; 48:1–17
[10] Baylor C, Yorkston K, Eadie T, Kim J, Chung H, Amtmann D. The Communicative
Participation Item Bank (CPIB): item bank calibration and development of a disorder-generic short form. J Speech Lang HearRes.2013; 56(4):1190–1208
[11] Troche MS, Okun MS, Rosenbek JC, et al. Aspiration and swallowing in Parkin-
son disease and rehabilitation with EMST: a randomized trial. Neurology.
2010; 75(21):1912–1919
[12] Lam J, Tjaden K. Clear speech variants: an acoustic study in Parkinson’s dis-
ease. J Speech Lang Hear Res. 2016; 59(4):631–646
[13] Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE, Cardiovascular
Health Study Research Group. Respiratory muscle strength in the elderly. Correlates and reference values. Am J Respir Crit Care Med. 1994; 149(2, Pt 1):430–438
201
Stroke-Induced, Moderate, Acquired AoS and Nonfluent Aphasia
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
53 Stroke-Induced, Moderate, Acquired Apraxia of Speech
and Nonf luent Aphasia
Lisa D. Bunker and Julie L. Wambaugh
53.1 Introduction
Apraxia of speech (AOS) is an acquired neurogenic communication disorder resulting from disrupted planning/programming
of motor speech production. Although, historically, there has
been some disagreement regarding the characteristic features
of AOS, most experts in the field agree that the following features are characteristic of AOS: sound errors (i.e., distortions,
often perceived as sound substitutions), increased segment
and/or intersegment durations, and slowed speech rate with a
tendency to segregate syllables and equalize stress across sylla-
1,2
Other common features that may be present, but are not
bles.
unique to AOS include articulatory groping (silent or audible),
increased errors with increased length and/or complexity of
utterances, motor perseveration, difficulty initiating speech,
self-awareness of errors, improved automatic speech production, and periods of errorless speech (e.g., social conventions).
Differentiating AOS from other neurogenic speech and language
disorders (e.g., aphasia with phonemic paraphasia) has also
been an area of concern for researchers and clinicians alike. This
case will present the history and assessment tasks necessary to
adequately differentiate and diagnose AOS with subsequent intervention as indicated.
53.2 Clinical History and
Description
BB was a 64-year-old Caucasian man who was referred for a
speech and language evaluation and subsequent treatment due
to complaints of difficulty “[saying] the right words, but [knowing] what [he wants] to say,” and poor intelligibility. BB’s wife
reported that his speech/language symptoms began 6 months
ago following a stroke. A review of the neurologist’s computed
tomography scan report confirmed an ischemic cerebrovascular
accident in the left middle cerebral artery. Residual symptoms
included a mild-negligible right lower extremity weakness, a
mild-to-moderate right upper extremity weakness, and speech/
language impairment.
and polysyllabic words incorporating a thorough inventory of
consonants in various word positions. He was also asked to
repeat words with similar phonemic structure, but with
increasing length (e.g., “car,”“carpet,”“carpenter,” and “carpet-
bagger”), and repeated productions of polysyllabic words (e.g.,
“octopus” repeated three times). Sentence repetition was completed as well (approximately five to seven words in length;
“The boy is raking leaves”). Diadochokinetic tasks, including
alternating and sequential motion rates, were elicited and
audiorecorded to verify the calculation of syllables per second.
Several automatic language tasks were given, including counting, reciting days of the week, and singing a familiar tune (i.e.,
“Mary had a little lamb”). Lastly, BB was engaged in brief conversational, narrative, and reading tasks to determine the
impact of any deficits on connected speech. The preceding
speech samples were audiorecorded.
After completing these screening tasks, the presence of
apraxic symptoms was rated using the Apraxia of Speech Rating Scale (ASRS),
tures associated with AOS (both differential and nondifferential, such as sound distortions or ar ticulator y groping) on a
5-point scale. Single-word speech intelligibility was assessed
using the computerized Chapel Hill Multilingual Intelligibility T est (CHMIT),
labic words. Responses were recorded and then scored by
three unfamiliar listeners.
The Western Aphasia Battery-Revised (WAB-R)
istered to assess presence, type, and severity of aphasia. Tasks
include spontaneous speech (conversation and picture description), auditory verbal comprehension (question comprehension, word recognition, and following directions), repetition,
and naming/word-finding (object naming, fluency, sentence
completion, and short-answer questions). To assess functional
communication, BB completed the general short form (10 questions) of the Communicative Participation Item Bank (CPIB),
which included questions such as “Does your condition interfere with giving someone detailed information?” All assessment
results are reported in ▶ Table 53.1.
4
which rates the presence/severity of 16 fea-
5
which involved BB repeating 50 monosyl-
6
was admin-
7
53.3 Clinical Testing
After collecting BB’s case history, an oral-mechanism examination was administered to identify possible characteristics associated with dysarthria and nonverbal oral apraxia.
tasks were requested to determine the presence of limb apraxia
(e.g., making a “thumbs up,” clapping, or snapping fingers).
BB was then given a series of AOS screening tasks,
included repetition of sounds, syllables, monosyllabic words,
3
Additional
3
which
53.4 Questions and Answers for
the Reader
1. Which of the following characteristics must be present for a
diagnosis of AOS?
a) Articulatory groping.
b) Sound distortions.
c) Increased errors with increased ut terance length.
d) Islands of error-free speech.
202
Stroke-Induced, Moderate, Acquired AoS and Nonfluent Aphasia
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Table 53.1 Speech and language assessment results for BB
Assessment task BB’s performance/response
Oral mechanism exam (and limb apraxia)
Sound, syllable, and monosyllabic word repetition
Repetition of words of increasing length
Polysyllabic word repetition
Repeated productions (3 ×)
Sentence repetition
Conversation, narrative, and reading tasks
DDK rates
●
AMRs
●
SMRs
Automatic language tasks
Prosody
CHMIT
Other
ASRS score
WAB-R
CPIB
AMRs, alternating motion rates; ASRS, Apraxia of Speech Rating Scale; CHMIT, Chapel Hill Multilingual Intelligibility Test; CPIB, Communicative
Participation Item Bank; DDK, diadochokinetic; SMRs, sequential motion rates; WAB-R, Western Aphasia Battery-Revised.
●
No characteristics of dysarthria (e.g., weakness, hypo-/hypertonicity, unilateral deviations)
●
Symptoms of nonverbal oral apraxia were absent
●
No apparent limb apraxia; some difficulty with bilateral tasks due to his right upper extremity
paresis
●
Slight slowed rate on some monosyllabic words
●
Occasional consonant errors on monosyllabic words (about 10%)
●
Slow rate, slower on longer words
●
Consonant errors = 40%; voicing, fronting/backing, and other distortion errors; errors were
predominantly on stops, affricates, and clusters
●
Vowel errors = 10%; errors were generally on diphthongs
●
Slow rate on most productions (prolonged and segmented syllables)
●
60% consonant errors, 15%–20% vowel errors, on words 3 + syllables in length
●
Errors predominantly on stops, affricates, clusters, and diphthongs
●
Moderate difficult y initiating, particularly words beginning with affricates/clusters
●
Articulatory groping, increased on longer utterances
●
Slow rate, false starts/self-corrections
●
56% consonant errors; 10% vowel errors
●
Error type/place was generally consistent
●
Stop errors in medial and final syllable positions
●
Affricates/cluster errors in all positions
●
Vowel errors in longer utterances
●
Slow rate on most productions (prolonged and segmented syllables)
●
Overall slow rate (prolonged and segmented syllables)
●
Similar frequency and pattern of consonant and vowel errors as word and sentence repetition
tasks
●
5.2, 4.8, and 4.3 syllables/second for /p/, /t/, and /k/, respectively
●
Mild difficulty after several repetitions
●
Unable without integral stimulation (i.e., “ watch me, listen to me, say it with me”)
●
Slightly slow, but within functional limits
●
Overall monotone quality with occasional inappropriately stressed syllables
●
Intelligibility was rated, on average, at 63%
●
Perseveration (during speech repetition tasks) and periods of fluent speech were infrequent
●
Scored 2 or 3 on most items (i.e., frequent or pervasive but not significantly impacting
intelligibility)
●
Overall score of 38/64 (cutoff of 8 for diagnosis of AOS)
●
BB’s aphasia quotient (AQ) was 65, and was categorized as Broca’s aphasia
●
Language production characterized as moderately agrammatic, anomic, and perseverative, but
with relatively good comprehension
●
BB scored 18/30 (higher scores indicate less par ticipation interference).
Answer: b is correct. A diagnosis of AOS can be made if key
features, including sound distortions, are present.
a is incorrect. Although persons with AOS often demonstrate
articulatory groping, this symptom is also present in some individuals with aphasia without AOS. Thus, it cannot be reliably
attributed to only AOS.
c is incorrect. Increased errors with increased syllable length
is a common feature of apraxic speech production, but it is also
associated with aphasia. Thus, its presence—in the absence of
the compulsory features of AOS—should not be used to make a
diagnosis.
observed for some types of aphasia and cannot be used to differentiate AOS from aphasia.
2. AOS usually co-occurs with aphasia. AOS symptoms overlap
somewhat with symptoms often considered diagnostic of
nonfluent aphasia. Which symptoms are characteristic of
both Broca’s aphasia and AOS?
a) Word-retrieval difficulties.
b) Significantly reduced comprehension of spoken language
in comparison to production of verbal language.
c) Difficulty with reading comprehension.
d) Effortful speech and language production.
d is incorrect. Brief periods of error-free speech may be noted
for an individual with AOS, especially for very automated or
stereotypic responses. However, this characteristic may be
Answer: d is correct. Effortful speech production is considered
characteristic of both Broca’s aphasia and AOS.
203
Stroke-Induced, Moderate, Acquired AoS and Nonfluent Aphasia
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
a is incorrect. Impaired word retrieval is a symptom of
aphasia (i.e., it is a language disorder and not a motor speech
disorder).
b is incorrect. Language comprehension problems may be
evident in Broca’s aphasia, but tend to be less severe than language production problems. Impairment of language is not a
symptom of AOS, which is a motor speech disorder.
c is incorrect. As with a and b, language problems, such as difficulty with reading, are not symptoms of motor speech disorders, but may be found with many types of aphasia.
3. In seeking reimbursement, which of the following assess-
ment results would be most important to include in any
report given to insurance justifying a need for skilled
speech-language pathologist (SLP) services (i.e., document-
ing a risk that warrants treatment by an SLP)?
a) Communicative Participation Item Bank (CPIB).
b) Apraxia of Speech Rating Scale (ASRS).
c) Western Aphasia Battery-Revised (WAB-R).
d) Apraxia screening tasks.
Answer: a is correct. Any inability to communicate wants/needs
or participate in functional communication settings presents a
risk to the individual/patient. The CPIB is the best choice to provide an assessment of functional communication, as it reports
on the individual’s ability to participate in various, and often
critical, contexts.
b is incorrect. The ASRS assists a clinician in making a differential diagnosis of AOS (vs. dysarthria or aphasia with phonemic paraphasia) and quantify the severity of symptoms. This
rating can be useful in description, treatment planning, and
measuring progress/outcomes, but it does not specifically
report any medical risks associated with decreased communication skills. This assessment would not be necessary for justifying the need for treatment.
c is incorrect. Just as with the ASRS, the WAB-R quantifies
the type and severity of a communication disorder—aphasia—
but in and of itself does not directly describe the impact of
aphasia on various communication contexts. It may be used for
descriptive purposes, treatment planning, and measuring progress/outcomes, but would not be necessary for justifying the
need for treatment.
d is incorrect. Apraxia screening tasks are used for assessment
and diagnosis and provide no quantifiable score related to safety
risks secondary to decreased functional communication skills.
53.5 Description of Disorder and
Recommended Treatment
BB presented with moderately severe AOS and Broca’s-type
aphasia. An accurate diagnosis of AOS may be difficult to make,
particularly with co-occurring aphasia, but BB demonstrated all
required characteristics for an AOS diagnosis (i.e., sound distortions, slow rate, and prosodic abnormalities) as well as several
commonly associated characteristics (e.g., articulatory groping).
A “moderate” severity rating was based on his ASRS score,
speech intelligibility, and type and percentage of sound errors.
BB’s language and speech impairments negatively impacted his
communicative abilities and participation in desired activities.
Due to the need to improve both verbal language and speech
skills, BB’s clinician felt that he would be an excellent candidate
for Combined Aphasia and Apraxia of Speech Treatment
(CAAST).
10
aphasia (M-RET),
impairments in the same session. SPT is the most extensively
researched treatment for AOS, and has been shown to be effective in improving targeted sounds for both trained and
untrained stimuli.
get sound—typically embedded in a one- to two-word context—
after clinician model, with a response-contingent hierarchy.
That is, that subsequent steps—which include practicing minimal contrasts, graphemic cues, integral stimulation, and isolated practice with placement cues—are completed depending
on the response of the previous step. M-RET involves presenting a picture of an action/scene and eliciting a descriptive response. The clinician then prompts an elaboration by asking a
question and modeling, if needed, to encourage the client to
add additional content (e.g., BB said “She drive” to describe a
picture of a woman driving. The clinician asked, “What is she
driving?” BB responded “car,” and was encouraged to repeat the
new, longer response, “She drive car”). CAAST combines both
treatments by applying SPT to any sound errors produced during the M-RET portion of treatment (i.e., in response to a picture stimulus).
weeks. Using the Life Interests and Values (LIV) cards,
clinician was able to select 16 personally relevant pictures of
actions/activities (e.g., hobbies, interests, occupation, etc.) to
use during treatment. The 16 pictures were divided into two
sets of eight with 3 to 4 weeks of treatment for each set (targeting too many pictures at a time would have lengthened the session unnecessarily and restricted the amount of time spent on
SPT). SPT typically targets preselected sounds, but with CAAST,
it was applied as needed for each picture stimulus. An example
of the protocol and BB’s response (for a single stimulus item) is
shown in ▶ Table 53.2.
8,9
CAAST combines Sound Production Treatment (SPT)
for AOS with Modified-Response Elaboration Training for
BB was scheduled for three 1-hour sessions per week for 8
11
which allowed the clinician to target both
12
SPT consists of a repeated practice of a tar-
13
BB’s
53.6 Outcome
BB enjoyed and participated well in treatment. After 8 weeks,
he was administered the CHMIT, WA B-R, and CPIB again. Clinically significant increases in speech intelligibility were
observed, and modest improvements were noted in his WAB-R
AQ and CPIB scores. Both BB and his wife report improved intelligibility, particularly for face-to-face conversations, although
telephone conversations remain difficult. They also reported an
increase in sentence length and use (i.e., using a sentence where
he had typically used single words or short phrases before),
with a greater variety of words. BB’s clinician documented that
although his speaking rate and prosody did not improve perceptually, he was able to produce a greater amount of content,
with improved grammatical productions, as well as increased
articulatory accuracy. These changes, combined, contributed to
a “significant” improvement in functional communication. BB
and his wife were educated regarding resources and home
exercises
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Table 53.2 Example of CAAST treatment for a single picture stimulus for BB
Clinician instruction/feedback BB’s response
(After explaining the sentence frame and components of a sentence, the
clinician presented a picture of a man talking on the phone.) “BB, can you tell
me what is happening in this picture, or anything it reminds you of?”
Great! “A man talks on the phone.” (Response was written onto the sentence
frame.) Who might he be talking to?
“‘Friend’ works well.”“A man talks on the phone with a friend.” (Clinician
added the new content to sentence frame.) Let’s practice that longer
sentence now. Can you say the whole thing for me? “A man talks on the
phone with a friend.” (Clinician pointed to each word as BB repeated the
sentence.)
“Nice job! There were a few sounds that weren’t quite right—these
sounds
here” (Clinician underlined /t, s, ծ, fr, and nd/.) Think about those sounds
and try it again. “A man talks on the phone with a friend.”
“Good try! A couple of those were still a little off. Let’s practice each of
those words and then we will do the whole sentence again. Let’s start
with ‘talks,’ you had trouble with both the first sound ‘t’ and the last
sound ‘s.’ Can you try that word for me, ‘talks’.”
“That ‘ t’ was closer, but it still sounds a little like a ‘d.’ The ‘s’ on the end
sounds almost like an ‘sh.’ Let’s try it together, watch me, listen to me,
and then say it with me. ‘Talks, talks, talks …” (integral stimulation up to
3×.)
“Excellent! Let’s
try the next word and work on this (pointed to /ծ/)
sound.” (Clinician proceeded in a similar manner to apply SPT to each errored
consonant in a single word context … BB’s responses are not all reported here,
but were similar to his response on “talks”.) “Okay, now that we’ve
practiced each of those sounds, let’s try the whole sentence together
again. ‘A man talks on the phone with a friend’.” (Clinician pointed to each
word on the sentence frame as BB responded.)
“Very nice! You hung on to most of those sounds! I’m going to move the
picture and sentence; let’s wait just a sec.” (Clinician waited 5 seconds and
then replaced the picture.) “Okay, can you describe this picture for me
again?”
“Great job BB! Okay, let’s move on to our next picture.” (Clinician presented
the next item and the treatment protocol was repeated. Cueing and feedback
were gradually faded as treatment progressed across sessions. After all
pictures were presented, if time permitted, additional SPT was applied to any
previously produced responses.)
“A woman, no … a man … talk (pronounced /dak/) on … um … te- te- …
um … phone.”
“Um … um … a fff- … ff- (Oh! That is hard for me) … friend (pronounced
/f: εn/). Not right … close (/kos/).”
“A man … talks (/dakʃ/) on … a- … the (/θə/) phone … uh … with a f- ff- …
(Oh man!) a … friend (/f: εn/).”
“A man talk s (/dakʃ/) … on … the phone … with a f-…a…friend (/f: εn/).”
“/dakʃ/.”
(Joined in with clinician) “… /takʃ/, /taks/, /taks/.”
“A man talks (/daks/) on the te- … phone … with his f- ff- … friend (/frεnd/
with slight distortion on /r/).”
“A…a man talks…on the…f- phone phone…with his…with his f-… friend
(/frεnd/ with slight distortion on /r/).”
53.7 Key Points
●
BB received a diagnosis of AOS because he demonstrated
slowed rate, prosodic abnormalities, and a predominance of
sound distortion errors. Additional features were present, but
not necessary for his diagnosis.
●
BB’s AOS and aphasia were relatively equal in severity and it
was difficult to determine which disorder had a greater
impact on his communication. Thus, BB’s clinician selected a
treatment (i.e., CAAST), which effectively addresses both
disorders in the same protocol.
Suggested Readings
[1] McNeil MR, Duffy JR, Ballard KJ, Wambaugh J. Apraxia of speech, theory, as-
sessment, differential diagnosis, and treatment: past, present, and future. In:
van Lieshout P, Massan B, Terband H, Eds. Speech Motor Control in Normal
and Disordered Speech: Future Developments in Theory and Methodology.
Rockville, MD: ASHA; 2016:195–221
[2] Miller N, Wambaugh JL. Apraxia of speech. In: Papathanasiou I, Coppens P,
Eds. Aphasia and Related Neurogenic Communication Disorders. 2nd ed.
Burlington, MA: Jones & Bartlett Learning; 2016:493–526
References
[1] Ballard KJ, Wambaugh JL, Duffy JR, et al. Treatment for Acquired Apraxia of
Speech: A Systematic Review of Intervention Research Between 2004 and
2012. Am J Speech Lang Pathol. 2015; 24:316–337
[2] McNeil MR, Robin DA, Schmidt RA. Apraxia of speech: definition and differ-
ential diagnosis. In: McNeil MR, Ed. Clinical Management of Sensorimotor
Speech Disorders. New York, NY: Thieme; 2009:249–268
[3] Duffy JR. Motor Speech Disorders: Substrates, Differential Diagnosis, and Ma-
nagement. 3rd ed. St. Louis, MO: Elsevier; 2013
[4] Strand EA, Duffy JR, Clark HM, Josephs K. The Apraxia of Speech Rating Scale:
a tool for diagnosis and description of apraxia of speech. J Commun Disord.
2014; 51:43–50
[5] Haley KL, Roth H, Grindstaff E, Jacks A. Computer-mediated assessment of in-
telligibility in aphasia and apraxia of speech. Aphasiology. 2011; 25(12):
1600–1620
[6] Kertesz A. The Western Aphasia Battery-Revised. San Antonio, TX: Pearson;
2007
[7] Baylor C, Yorkston K, Eadie T, Kim J, Chung H, Amt mann D. The Communica-
tive Participation Item Bank (CPIB): item bank calibration and development
of a disorder-generic short form. J Speech Lang Hear Res. 2013; 56(4):1190–
1208
[8] Wambaugh JL, Wright S, Nessler C, Mauszycki SC. Combined Aphasia and
Apraxia of Speech Treatment (CAAST): effects of a novel therapy. J Speech
Lang Hear Res. 2014; 57(6):2191–2207
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copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
[9] Wambaugh JL, Wright S, Mauszycki SC, Nessler C, Bailey D. Combined Aphasia
and Apraxia of Speech Treatment (CAAST): Systematic replications in the development of a novel treatment. Intern J Speech Lang Pathol. 2018; 20(2):
247–261
[10] Wambaugh JL, Kalinyak-Fliszar MM, West JE, Doyle PJ. Effects of treatment
for sound errors in apraxia of speech and aphasia. J Speech L ang Hear Res.
1998; 41(4):725–743
[11] Wambaugh JL, Martinez AL. Effects of modified response elaboration training
with apraxic and aphasic speakers. Aphasiology. 2000; 14(5-6):603–617
[12] Bailey DJ, Eatchel K, Wambaugh J. Sound production treatment: synthesis
and quantification of outcomes. Am J Speech Lang Pathol. 2015; 24(4):S798–
S814
[13] Haley KL, Womack J, Helm-Estabrooks N, Caignon D, McCulloch K. Life Inter-
ests and Values Cards. Chapel Hill, NC: Department of Allied Health Sciences,
University of North Carolina at Chapel Hill; 2010. Available at: https://www.
med.unc.edu/ahs/sphs/card/resources/livcards
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copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
54 Compensatory and Restorative Application of AAC in
Chronic, Severe Aphasia
Kimberly A. Eichhorn
54.1 Introduction
Alternative and augmentative communication (AAC) strategies in persons with aphasia (PWA) require careful consideration. Cognitive and linguistic strengths and limitations
directly influence device and field complexity as well as language content and layout. Without a general understanding
of the PWA’s phonological, semantic, syntactic, and input/
output span abilities, the effectiveness of AAC for PWA can be
significantly limited.
54.2 Clinical History and
Description
GA was a 68-year-old left-handed man status post multiple,
remote, cerebrovascular accidents (CVAs), the most recent of
which was 10 years ago. His medical history and the course
surrounding the CVAs were limited as his care was at a different facility. However, a head computed tomograp hy was
available for review, which showed a large wedge-shap ed
area of infarction in the left hemisphere in the area of the
middle cerebral ar tery (MCA) dist ribut ion extending from
the frontal to the parietal lobe. Per report, he received
speech-language therapy immediately following one of his
strokes, but he had not received ser vices within the past
5years.
GA earned an associate’s degree, served in the army for 2
years, and worked for a local gas company for 20 years. His
brothers and sisters were his primary caregivers; he never
married. At the time of evaluation, GA was completely dependent for care, including all activities of daily living. Verbal output was limited to several automatic, overlearned phrases
(such as “Idon’tknow” or “here we go”)withislandsofappro-
priate single word content. Additi onal past medical history
was significant for chronic myeloid leukemia, peripheral vascular disease, diabetes mellitus, visual field deficit, prostate
cancer, chronic obstructive pulmonary disease, benign hypertension, deep vein thrombosis, and right above the knee
amputation.
54.3 Clinical Testing
54.3.1 Clinical Interview
Some key information obtained during interviews of GA’s family included the following: GA received “some speech therapy”
following a CVA 16 years ago, GA typically used gestures to
communicate at home and was relatively effective expressing
his needs, and GA’s family expressed a desire for him to have
more input in his daily activities, such as meal selection.
54.3.2 Oral Motor Examination/Motor
Speech Evaluation
Completion of a full oral motor examination was limited by
GA’s inability to complete many of the tasks requested, even
with a model. Of note, mild right-sided weakness of the upper
and lower face was observed. Facial sensation was intact bilaterally. Jaw strength was intact bilaterally. Significantly reduced
range of motion was observed during labial retraction. GA was
unable to complete alternating nonspeech motion tasks. Speech
tasks were slow, but articulatory precision was grossly intact
for bilabial plosives and lingual-alveolar stops. Vocal quality
was mildly harsh and wet at baseline. Maximum phonation
time was not assessed due to poor coordination of respiration/
phonation. GA presented with lower dentition only.
54.3.3 Cognitive Linguistic Quick Test
The Cognitive Linguistic Quick Test (CLQT) is a brief measure of
five cognitive domains in adults with known or suspected cognitive dysfunction. Criterion-referenced severity ratings for the
five cognitive domains and overall severity rating and a clock
drawing severity rating are provided for two age range categories. GA presented with severely impaired attention, memory,
executive functions, language, and visuospatial skills. These
results were interpreted with caution given his known aphasia
and observed low frustration tolerance with testing.
54.3.4 Comprehensive Aphasia Test
The Comprehensive Aphasia Test (CAT) contains both a cognitive screening and complete language battery. The design of this
assessment tool permits the clinician to determine patterns of
errors, such as complexity and phonological versus semantic
errors. Consistent with previous evaluations, low frustration
tolerance and task abandonment were occasionally observed.
Behavioral observations led to concern for mild right neglect.
In addition, GA was unable to gesture object use or complete
word fluency tasks. On a semantic memory task, he recalled
items previously seen, but the errors he made were consistently
related to semantic distrac tions. Comprehension of spoken simple sentences was a relative strength, with significant impairment noted with comprehension of single words and complex
language structures. Comprehension of written language was
consistent with spoken language; a relative strength was seen
with simple written sentences. Again, errors in comprehension
were most consistently related to semantic relationships. Relative strengths were seen in the ability to repeat simple/short
words with notable breakdown in polysyllabic structures. Repetition of digit strings was also impaired, with maximum repetition of two information units following multiple practice trials.
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No items were named to confrontation. First syllable cueing
paired with visual model increased appropriate verbal productions in naming tasks. GA was unable to read any words aloud.
He did, however, write his name and copy letters. He was
unable to write picture names or write to dictation. He was
unable to provide any information for a picture description
task, verbally or in writing.
54.4 Informal Assessment
As part of the evaluation, several communication pages were trialed in a grid layout of both four and six options. Given observations regarding GA’s semantic deficits, content was organized
with icons and text of semantically distinct targets as well as
semanticallysimilar targets (▶ Fig. 54.1). Performance for identification of targets(auditory comprehension) was accuratefor fields
of four semantically different items. Breakdown occurred in
larger fields and with semantically related items. Additionally, for
semantically distinct items, he was able to choose correct items
from a field of four when presented with more abstract questioning (i.e., which one would you pick if you werehungry?).
54.5 Questions and Answers for
the Reader
1. A 55-year-old woman post left temporoparietal CVA
presents to your clinic with her tablet device requesting
applications to assist with her communication deficits. What
is your first course of action?
a) Complete a thorough case history, interview, and evalua-
tion of cognitive-language skills.
b) Recommend applications as requested by the patient.
Answer: a is correct. The first course of action in this case
would be to evaluate the patient. Discuss previous therapies
and goals. Determine the type of device she has and which
applications might be appropriate based on your impressions
from the evaluation.
b is incorrect. Unless you already have testing results from
another source, it is important to establish a baseline that
should drive your recommendations. Input from the patient
regarding goals and expectations will also direct your treatment/recommendations.
2. An 80-year-old PWA presents with his family who are
requesting a “communication device.” Family reports that
since the stroke, their father has been able to communicate
in a very limited fashion. Although they have developed a
form of gesture communication, they are convinced that
some form of technology will increase the effectiveness of
their interactions with their father. Throughout the course of
the interview and evaluation, the patient rarely makes eye
contact with you, does not engage in any type of device trial
you attempt, and only periodically uses gesture or a single
word to communicate with you. What are your primary concerns regarding the use of technology for this patient?
a) Family/caregiver support.
b) Visual acuity/perception.
Fig. 54.1 Sample pages from GoTalkNow designed with semantically
distinct and similar nouns.
c) Fine motor skills.
d) Motivation to use technology.
Answer: d is correct. This patient’s seemingly limited interest
in device trials within the session should raise a concern.
Although the family is very motivated for use of a device, the
patient must also be on board. It is possible that given his age,
he has limited exposure to technology. It would be wise to
spend some time alone with the patient to ascertain his personal goals regarding communication. A thorough evaluation of
his language/communication skills should be undertaken as
well as his candidacy/desire for traditional, restorative therapy
based on his language deficits. Consideration of low/no technology supports (such as boards or pict ure books) as well as family
education may be the appropriate place to start.
a is incorrect. This patient clearly has a supportive family
who are attempting to advocate for him. This is paramount for
successful use of AAC. However, without patient “buy-in,” AAC
will not be an effective tool.
b is incorrect. Although a thoughtful consideration, visual
acuity/perception should not be the immediate concern in this
case.
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