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    PROMPT

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    20 views15 pages

    Prompt Treatment

    Uploaded by

    Constanza Miranda Arriola
    PROMPT

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 15
    PROMPT Treatment + and Del Square-St (Ch The PROMPT System (Prompts for Restructuring Oral Muscular Phonetic Targets) is a dynamic tactile method of treatment for speech disorders which capitalizes upon touch pressure, kinesth proprioceptive cues. The method was developed by Chuny (Hayden) (1984) ori ren. Subsequent! expression among adults with apraxia of specch and Broca’s aphasia (Square, Chumpelik (Hayden), and Adams, 1985; Square ct al, 1986). fon the nature of the speech disorder or nd some proximal articulators through 1 ulation provides for the patient, a framework for sps otor speech programming. Prov Je, facial musculature, and throu ulation of the ing on the nature and degree of severity of th 1 oF retraction 's required to c purpose of this chapter nts of the PROMPT Syst hod by providing pre of producti of facial results of single-case research. Rationale proc 190 ' i 1 | i PROMPT « veatment specification of ‘where..., when.. ogether the f motor action other hand, was described as includ igle sequences specifying the activity of agonists, antagonists, synergists and postural Gxators' plus ‘assembly of subroutines and complex sequences of the program’ (p. 522). Motor was said to enta ting of beginning the movement 1B Necessary programs, ... controlling the course of , and terminating ot ccasing action’ (p. 552). To our way of inking, motor planning is roughly analogous to the generation of the phonological matrix which, according to the motor theory of speech production (Liberman etal, 1967), is an abstract representation of pattcrns of neural activity for scts of distinctive features; for example, lency may have one representation of neural activity while retro- flexion, another. As such, this level of control of specch may be thought of as the generation of higher order linguistic phonological rules or the planning of phonemic templates. Itis a this level that disruptions result phonemic paraphasias marked by phoneme substitutions andjor phoneme sequencing disorders. Remediating such impairments may ‘entail using transcoding between phonemes and graphemes (Wiegl and Bierwisch, 1970), sinee \guistic units. Program thought to be the disrupted control mechanism in the apraxias. It is at this level of motor control that ‘motor pretuning’ (Kelso and Tuller, 1981), and ‘phasing’ (Kent and Rosenbek, 1983) of rupted resulting in temporospatial »n of movements (sce Chapter 2). Finally, itis usually the level of motor exe in the dysarthrias in that neural activation of the muscles of the speech system is disrupted; precludes the efficient running of programs and control of the course of Although the exact neurophysiologie mechanisms cannot be fully specified, it is known that somatosensory information from muscles, ly influences execution via direct routes to the m1 and motor cortex, but also the programming of notor events via input to the association cortex. According to Brooks 1979) the basal ganglia and cerebellar hemisphere communicate with associatis jing volitional movements. Marsden (1982) state ermedia (of the cerebellum) updates the ded movement, based upon the motor command originally issued nil somatosensory description of ... position and velocity on which the is to be superimposed’ (p. 522); and, ‘to execute a motor fan, one has to move trom point to point of a sequence, the signal of it Acquired Apravi Speech in Aphasic A. arrival at cach required to p. 535). Teis upon this model that we predicate the efficacy of PROMPT treatment. The skilled and experienced PROMPT clinician provides for the patient an enhanced and, initially, clinician-controlled somatosen- sory description of the postural fixators or articulatory end-points, velocities, and trajectories of movements, and the ‘phasing’ or temporal assembly of motor subroutines. The clinician acts as an ‘external programmer’ and, once having mapped in the program, ensures that the patient remains motorically but not sensorily passive. Immediately after, the paticnt is allowed motoric control while the clinician con- tinues to provide somatosensory support for the constraints and patterns of movement. Eventually, the patient appears to internalize the program for cach target and, especially among children, begins to generate related programs (Chumpclik (Hayden), 1984) in that prin- int being the trigger to delivery of the motor progeim if to the next point ina sequence (Marsden, 1982, PROMPTS used for treatment be discussed. Our readers must be aware that PROMPT treatment is multifaceted treatment and that many principles beyond those reported here compri System is a dyn required in order to c: treatment, Av ng and practice are stor this form of When init engages the pat maintenance of head control. For example, the cli patient using one hand behind hisfher head, wh id provide cues to the or ian complete control thro ician, thus, has full liberty to program in the is encouraged not to watch the clinician further but rather to ‘feel’ the 192 i | PROMPT Treatment ected to the ‘sequenced’ aspects of the production. That is, cues for the temporal aspects of speech movements are stressed. The PROMPT System cannot clicit speech where there is an extremely severe neuroinnervation irment (dysarthria). The patient must have, minimally, breath support, phonation ability for an open vowel, some ability to cooperate, and minimal/basic comprchen- sion skills, The System can guide the articulators to specific postures and actions sequentially, and, thus, stimulate motor speech program- ming. If the clinician is skilled, the PROMPT System can help the patient to approximate phonemes successfully and independently pro- duce programmed words/phrases, ic, depending upon tl preserved abilities and extent of disability with regard to language and motor speech processes, spontaneous generalization is more oF less probable but seems to occur to a much lesser degree, in aphasic~aprac~ are: place of 1d phonatic to one another; manner of production; and coarticulation. Each will be discussed below. Place of contact of contact is traditionally seen as the end point of a target indblom, 1963; Stevens and How treatment identifies arcas of orofacial structures, i.c., upper/lower lips, alveolar ridge, hard palate, and soft palate, as ‘places’ where various ¢ production of /t/ the tongue yyoid muscle from just bi (point A), to just above and behind the larynx (point D). Through manipulation of these placements the tongue may be prompted nost posterior linguavclar place. For example, an A position is {forall tongue tip/blade productions (le). fll Jl sf, fa). and D For 1 productions (Jk, fg). fn). Poi prodections (Fel. If ‘or three fingers to sti 193 praxia of Speech in Aphasic Adults PLACE OF CONTACT FOR TARGET POSITIONS MYLOHYOID PLACEMENTS Mylohyoid ——— finger placements 8, tongue tip 40. apex 14, blade front 12, dorsum of production and amount of lingual (depth of movement as signaled es into the placement pos lar patter gual musculature required for 194 PROMPT ment Place of contact is also signaled on the facial muscles. These prompted positions are most often bilateral using two digits, usually the thumb tion to the facial muscles for the postures of spreading and rounding, or for degree of mandibular excursion. On the face, all prompts are worked from terally to stimulate ical action, an importa ng. This is especially desirable for those: patients with various ervation dysfunction or unilateral facial paresis. As with d hyoid prompts, pressure is provided as a cuc that deeper muscles or muscle groups which cannot be dircctly timing of activity. 1 Figure 8.2, pl nts 1 and 2 are used to stimulate labial rounding as for fo/ or /u), or retraction as for /s/; placements 3 and 4, the upper for /i/ and the lower for /@/; placement 5 for /f] or /v/ (labial i placement 6 and 7 for /f/ and one component of /t{/ 8 for indicating velar lowering to signal ‘asality (cue only); placement 9 indicating phonation for voicing (cue nt 10 for jaw excursion. The latter three ‘place’ cues icate major speech idicate move nents towards spat jount of jaw opening needed for nce of tongue-jaw action phased” facial muscles to achieve actions 0 critical for coarticulation. libular excursion is a crucial component of mm although, in the management of some able (Rosenbek and ular kinesthesia nts may complicate the primary motor speech programming rent (Rosenbek, Wertz and Darley, 1973). Thus, place of contact, nay be correct, but segmental production may be distorted duc to exaggerated or restricted mandibular action. The PROMPT System provides kinesthetic manipulation for the degree of opening required for cach target, segment, or syllable as well as mandibular changes during transitions between segments. four positions shown in Figure 8.3 are used by the signal different degrees of mandibular excursion. Depending on the 195 Acq Figure 82 ‘on he lowe marin pot of contact for Haas cy beyond ip comers {lees of Buechatorm, ond zygomate mal) of contact for nasal prompt of contact fr vleed promt Jaw poston movement a0 frm Chupa, 0. PROMP1 — catment JAW POSITIONS FOR VOWEL PRODUCTION Jaw Positions for Vowel Production FRONT, ‘CENTRAL BACK High (9)_sbove I) oat (A) ha (oboe a het Pig 83 vow! production (Adapted by permission tram Canoes, D. Vo 5, No. 2, Thieme Medien! Pusshars, Now mn 1 include the fi. Ju). Ip/. If; at 2, |, and fef; and at 4, /k/, /g/, [ee/, and 4 position to encourage the movement of the the soft palate (place of contact). ly exaggerated tactile and 197 ing will facilitate the Figure 8.2. The thumb provides tactile stimulation to the side of the nose and this prompt is incorporated with a mylohyoid ager prompt for place of production of [nf oF /nf, of Inj. The nasality cuc is always provided for the cl consistency of production. As stated above, the degece of mandibular excursion is also provided as needed, ¢.g.. pt apractic patients, devoicing/voicing and nasality/orality ions often occur (Itoh and Sasanuma, 1984). With the PROMPT lity, andfor voicin ipulation of A devoiced airstream res 00 a voicinghdevoici ened sc percepts ee of pressure appl parameters. Also the deeper t the higher the al anel frei vowels as [u]. Further, cles to the periphery, PROMPT > — ment delivered to the face, as there are more layers of tissue to work through before cués for contraction of the varying lingual muscles become salient to the patient. For example, different degrees of tension and thus prompted pressure, exist for fa/, fe] and [3°|. For fal, when trained iso jaw is at a full open 4 position and there is ro specific pressure applied to the tongue via the mylohyoid. For /e], the Jaw is at an open 3 position and thee is tension in the blade area of the This pressure provide igual muscles which should contract, as well as the duration of muscle contraction. For [2°], the jaw is looscly opened at a 1 position and consistent, firm pressure is placed on the ion C using three Gngers. This Grm consistent pressure signals the activation of deep lingual muscles of the blade and dorsum. Facial prompts at the 1 and 2 position also increase the overall mn. AS noted above in ‘tension’, the prompt may be k or held longer to . When there is a not normally signal features require that fow muscle groups be contracted. For example, little a longer relative duration may signal features such as influence the relative as the timing of speakers are often deviant (sce Square-Storer, need of timing control. The PROMPT critical 'yoid), degree of mandibular excur- sion (of jaw opening), orality nasality, duration, and pressure cues. That 199 sic Adults Acqu— Apravia of Speech in Ap is, airstream management in this treatment approach is always depend- adequate prompting of other articulatory actions. For Jc. ifa patient is producing a stop consonant, [tf for the fricative, Js], duration is a critical factor as well as the facial prompts for placements 1 and 2. For each manner class, different prompts may be emphasized. For example, for bilabial stop plosion, the lips need to be coccludea lightly and quickly released after appropriate imploding of the airstream. Thus, PROMPTS for position, pressure, and timing are titical. For production of frication, the tongue or the cutting edge of isors is involved. Depending on the effectors required for cach mphasized. For /ff, placement of tongue involvement (three fingers at a C position) as well ind 7, for labial protrusion anteriorly and buccal fering amounts of input by in will be needed. Inherent to all of the above, is imparting to the knowledge of what muscle groups must contract under specific constraints in order to achieve the appropriate action. Equal important is cucing for the coarticulation of muscle groups in a tightly “pha temporal prompting for the integration of the articulatory subfeatures of phonemes and parameters of coarticula~ tion between the articulatory features is necessary. f approa treatment level with occasional steps back to the At this level at the phras phonetic environment. Coarticulation infuences may be noted in that, 200 PROMPT Treatment consonant features are easily distorted and/or determined by the preceding or following vowel. For example, in ‘coat’ rounded while the /k/ and /t/ are produced. When needed, the clin can provide anticipatory and regressive assimilation cues, influences. The clinician, thus, focuses on these ‘order to achieve coordinated coarticulated muscle a n which results in appropriately perceived speech. If specific target production continues to be. in need of prompting, the clinician may isolate the phoneme, prompt it alone and then return to the word of phrase. In adult aphasic-apractic patients, phrases are usually the preferred stimuli for treatment as they can be ‘programmed in’ as casily as a single word. With phrases, however, the li prompts all targets dynamically. This skill demands a complete understanding of the normal dynamics of spcech production as well as experience with PROMPT treatment. Excellent clinical results, however, are achieved. In the next section, we present our pilot research regarding PROMPT treatment for adults with acquired apraxia of speech with cocxisting aphasia and, possible, coexisting mild dysarthria. Evidence of the Efficacy of PROMPT Treatment Subjects The subjects of this investigation were three patients, two males, PW RY, aged 58 and 59, and one female, SS, aged 38, Each demonstrated at least ten symptoms of apraxia of specch as discerned from admin- istration of both the Apraxia of Specch Battery for Adults (Dabul, 1979) and the Mayo Clinic Screening Battery for Apraxia of Spech. The latter is similar to the battery described by Wertz, LaPointe and Rosenbek (1984). The characteristics of apraxia of specch demonstrated by each are summarized in Table 8.1. All subjects were classified as Broca’s aphasic subjects on the Western Aphasia Battery (WAB) (Kertesz, 1982). Their aphasia quotients (AQ) were 23.2 (PW), 45.5, (Ry), and 52.8 (SS). Informal testing revealed that one subject, (SS), was severely agrammatic; the other two subjects demonstrated agram- matism to a lesser degree. Each had suffered a single left-hemisphere thromboembolic accident. There was confirmation that PW's lesion was a deep one extending into the internal capsule. It was suspected that SS's lesion was also a decp one, based upon her dense hemiplegia and pervasive yet mild hypernasality. R's neuropsychologic profile was oat n discharged from formal al verbal expression, and wvidence of progress. nguage treatment due to s, twenty-four pairs of © 8.2 were repeated three overall total of 216 pr on of twenty polysy for cach subject. Te le imperatives, th cof each oF, 300 tokens per were scored as correct oF itor who had not obser Tate 8.2: Mwmot Pas. Tasted ee ist ono ‘st ww OF vo ™ st va Pa P pt P 2 Ma v ons M3 Ma ° i) Ps M tr og. ve v ve p> v bp ok vB ° be v8 Mo. M dz om 8 Vio ™ ne V10 Pi P fp a Miz fooy wig p ba Mia ™ wo Baa v v ae va P v Sa P16 vir P vn Mia u Mie vig u v 19 P20 P ob P 20, M2 v Poo mat M22 ~ oP oma P23 P rd PR via v i v 24 Bisyaves Poses Fricaives for the invest contrasting phonemes were ». For cach patient, four pairs of mit lected; none had ever been pr Two pairs were randomly nd two pairs acted as controls 203 ed Apraxia of Speech in Aphasic Adults Table 84° Functional Praces Tested ig imitation. For two subjects (PW and R), four labic words were ra cted, two for trait rd subject (SS), six d chree for ing. For two subjects, functional phrases were trained. For one subject (PW), two phrases were trained and two were probed. For the ther subject (R), Ja second was not ‘Training of phrases for the third subject (SS) was not undertaken due to her severe age Instead the subject’s performances on le was decided a priori to score and analyze the dat first was to use a bit of correet-incorrect. The second scoring system graded imal pair production oF cach polysyl- labic word response using a 2, 1, 0 categorical system in which ‘2° represented a response which was spatially and temporally correct, ‘was defined as a response in w ant) was correct with regard to place mn and in which there were no gross distortions, additions, nor omissions of segments nor any initial gropes. ‘Temporal cor- rectness’ denoted several parameters including the perception of correct onset and termination of voicing, correct ‘phasing’ of all articulatory atures, correct relative segment durations, and, in the case of polysyl- labic words and phrases, no intersyllabic or word pauses. A slow rate of specch was acceptable. AI” denoted a response which was marked by a spatial or temporal error, while a ‘0’ was given for a response which was spatially and temporally incorrect or characterized by more one spatial or temporal error. For phrases only, cach word produced two ways. 204 PROMPT Treatment correctly both spatially and temporally received one point; that is, the graded scoring system was not used. Point-to-point, inter-rater reliability using the graded scoring system was found to be acceptable n that it ranged from B1.4 per cent to 70.1 per cent. Point-to-point, nter-rater f \correct system was found to range from 89.3 per cent to 91.1 per cent. Mean reliability was 91.09 per cent. The PROMPT training procedure was as follows. First, the patient ed with an auditory model of a minimal pair, word, or functional phrase. No prompts were given, The patient attempted to the target according to a model and a score of 0 given. Ifa score of '2° was received, the next item was presented for a total of twenty tokens. If however, a score of ‘I" or ‘0° was received, the clinician prompted as follows: the subject was instructed not to respond as the clinician ‘mapped in’ the correct motor pattern for the sequence of phonemes to be produced using the PROMPT System. The ian then instructed the subject to attempt the target phoneme, word, or phrase as the cli pattern again. The response was scored as a token in cach train of ew and the same procedure was followed based upon the subject's ability to imitate the token after the first presentation. Untrained series of items were presented auditorily only and the subject's ability to repeat those items was scored using the same scoring methods. wltaneously prompted the motor The next 1’ or Results The results are reported for each patient according to accuracy of production of each type of stimulus item, ic., minimal pairs, polysyl- labic words, and phrases, during the course of treatment. Minimal pairs ‘As graphically depicted in Figure 8.4, using the plus-niinus scoring system, PW demonstrated accelerated learning curves for the phonemes which were trained using PROMPT. These are observed at the top of the figure and are indicated by the solid line. Results for those phoneme contrasts which were not prompted are shown in the lower part of Figure 8.4. No acquisition of the nontrained pairs occurred when accuracy of production was scored using the correct-incorrect method. Results using the graded 0, 1, 2 scoring system were essentially the same 205 pati scone geersacanee TRAINED gageeagaree Pram 8A Mom 26 geereavaase UNTRAMED erases eretw geeessgaree ms PW) PROMPY ~ cea as indicated by the dotted lines on all graphs. A P hely improved erformance for the trained pair, tf, was discerned when partial credit ¢ seen for production of the untrained

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