Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM

The ASHA Leader

April 26, 2011 Features

Acquired Apraxia of Speech: A Treatment
by Shannon C. Mauszycki & Julie Wambaugh

see also
ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and
Language Disorders


Acquired apraxia of speech (AOS) is a treatable neurologic, sensorimotor speech disorder.
The primary clinical characteristics considered necessary for the diagnosis of AOS include:
1) a slow rate of speech resulting in lengthened sound segments and intersegment durations,
2) speech-sound errors such as sound distortions and/or distorted sound substitutions, 3)
errors that are relatively consistent in type (i.e., distortion) and location (i.e., within a word),
and 4) disturbed prosody (McNeil et al., 2009). Other speech behaviors that frequently occur
with AOS include articulatory groping, perseverative errors, increased errors with increased
word length, and speech initiation difficulties (McNeil et al., 2009). These behaviors,
however, cannot be used to differentially diagnose AOS because they may also occur with
other communication disorders, such as phonemic paraphasia.

The severity of AOS varies from minor sound distortions to an inability to produce speech.
Stroke is the most frequent etiology resulting in AOS (Duffy, 2005). AOS is linked to
cortical and/or subcortical damage in the language-dominant hemisphere of the brain (McNeil
et al., 2009), but researchers are still uncertain about the specific brain regions involved in
AOS (Hillis et al., 2004; Ogar et al., 2006). Although AOS is most often associated with a
neurological event of sudden onset, progressive apraxia of speech has been reported in
individuals with a diagnosis of motor neuron disease (Duffy, 2006; Duffy et al., 2007).

There are limited data regarding the prevalence of the disorder, but Duffy (2005) reported Page 1 of 12

The World Health Organization's ICF offers a conceptual framework and uniform language for describing human functioning and disability. Wambaugh and Mauszycki (2010b) recently reviewed 74 investigations in the AOS treatment literature (15 additional treatment investigations were identified that had been conducted since the completion of the AOS guidelines). and Health (ICF. Since that initial investigation. when aphasia is the primary disorder..asha. including implications for developing and http://www. This review involved an extensive. These data reflect individuals evaluated at Mayo Clinic from 1987–1990 and 1993–2001 who were diagnosed with a neurological motor-speech disorder as the primary communication disorder when more than one disorder was present ( primary indicates the more severe disorder in terms of impairment). WHO. The AOS report concluded that the existing evidence base for AOS treatment indicates that individuals with AOS can benefit from treatment even when AOS is considered chronic (Wambaugh et al.e. AOS rarely occurs in its "pure" form (i.. The AOS treatment guidelines report evaluated the 59 studies and provided a detailed summary of each treatment study (see evidence table.... 2006b). The purpose of this review was to describe AOS treatment outcome measures using the context of the World Health Organization's International Classification of Functioning. 2) rate/rhythm control treatments. AOS co-occurs even more frequently with aphasia (i. and 4) alternative and augmentative communication (AAC) approaches. The committee found that the treatments evaluated in the report generally fell into one of four categories: 1) articulatory- kinematic treatments. 2006a. 3) intersystemic facilitation/reorganization treatments. Wambaugh et al.. objective evaluation of the existing English-language AOS treatment literature published through 2003. 1973).101cases. Published reports of treatment for AOS first appeared in 1973 with the influential treatment investigation conducted by Rosenbek and colleagues examining the effects of their eight-step task continuum (Rosenbek et al. As a secondary communication disorder. 2006b).e. Evidence Base for AOS Treatment A recent systematic review of the AOS treatment literature was conducted by the Apraxia of Speech Treatment Guidelines Committee of the Academy of Neurologic Communication Disorders and Sciences (ANCDS) for the purpose of developing AOS treatment guidelines (Wambaugh et al. 2001). 2005)..6% of 6.Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM that AOS was the primary communication disorder in 7.e. 2006b).htm Page 2 of 12 . there has been substantial growth in the literature documenting the benefits of AOS treatment. as the primary disorder in the absence of a secondary disorder). Disability. Duffy.

Typically.Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM measuring clinical treatments and outcomes (Eadies et al. 2005). modeling-repetition. and articulatory cueing. integral stimulation.asha. Articulatory-Kinematic Treatments More than half of the treatment investigations in the AOS treatment evidence base have used an articulatory-kinematic-based approach. Repeated practice is considered to be an important aspect of treatment and its use is supported by findings in limb motor-learning literature (Schmidt & Lee. Consequently. The rationale and the treatment techniques used in these investigations have focused on improving spatial and temporal aspects of speech production. these investigations have employed a combination of repeated. The investigators concluded that there is a need for development of functional communication outcome measures that are appropriate for persons with AOS. Systematic reviews have indicated that persons with AOS can benefit from treatment. motoric practice has been a primary component of most articulatory-kinematic treatment investigations. most outcomes reflected "articulation function" and/or "fluency and rhythm of speech function. 2006b). motoric practice.. Recent research has suggested that rate/rhythm treatments also may improve articulation in AOS and may provide additional benefits beyond articulatory/kinematic approaches (Brendel & Ziegler. 2006b) uncovered a limited number of treatment studies for each approach. Motoric Practice Repeated. The other two general treatment approaches—intersystemic facilitation/reorganization and alternative/augmentative communication—identified in the recent review of the AOS treatment literature (Wambaugh et al. but little is known about the impact of treatment on functional communication. 2008).. principles of experience-dependent neural plasticity involving rehabilitation following stroke or brain http://www." Only a limited number of studies included outcome measures that addressed other concepts included in the ICF's "Activity/Participation" category. 2006)..htm Page 3 of 12 . 2006a. The majority of objective evidence supporting treatment for AOS addresses articulatory-kinematic therapeutic approaches (Wambaugh et al. which recently have been applied to speech learning/ findings have been inconclusive in determining possible treatment effects for these approaches. Findings revealed that the majority of outcome measures reported in the AOS treatment literature corresponded to the ICF's level of "Body Function".

2007) have been used with speakers with AOS. Wertz et al..htm Page 4 of 12 . where (positioning or location).asha. but EPG and spectrographic analysis have become relatively accessible in terms of cost and usage. Integral stimulation aims to bring to conscious awareness the "look" and "sound" of the target movement in conjunction with simultaneous practice. 1999. A clinician using this technique provides instructions or models how to modify existing speech or non-speech movements to produce the intended target.. A variation is integral stimulation.. visual modeling. This technique increases awareness and actualization of articulatory postures and/or movements and may take the form of phonetic placement or phonetic derivation. 1999. Articulatory-kinematic treatments usually include a combination of techniques. Phonetic placement cues use descriptions of what (which articulators). Electromagnetic articulography (EMA. using descriptions from verbal explanations. 2001. Repeated practice with limited verbal feedback recently has been shown to result in improved articulation with persons with chronic AOS and aphasia without any other treatment (Wambaugh et al. 2010a). For example. Howard & Varley. and/or physical cueing by the clinician of the orofacial musculature (Square et al.. Sound Production Treatment (SPT. and spectrographic displays (Ballard et al. Wambaugh & Nessler.. 2007). 1998. and how ( Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM injury (Kleim & Jones.. 2008). 1998. McNeil et al. 2010a. Wambaugh et al.. 2000. 2007. These approaches require additional equipment and expertise that may limit their appeal to clinicians. Wambaugh et al. 1973. 1984).. in which the patient is instructed to "watch me. 1995).. drawings. and neural models of speech production in the early stages of speech development and acquiring speech sounds (Guenther. http://www. 1998. Wambaugh et al. 2010a). 2006). and say it with me" (Rosenbek et al. voicing) sounds are made. Articulatory Cueing A technique frequently incorporated into articulatory-kinematic treatments is articulatory cueing. 2010).. Instrumental approaches for providing supplemental feedback have received increasing attention as articulatory-kinematic treatments for AOS. The converging evidence from these different technologies suggests that instrumentally generated feedback may benefit speakers with AOS. listen to me. Phonetic derivation is a shaping technique that builds upon the articulatory or orofacial skills in the patient's repertoire (Knock et al. 1999. Modeling-Repetition Modeling-repetition is a component of many articulatory-kinematic treatments. electropalatography (EPG. Katz et al.

Little research has addressed the effects of different articulatory-kinematic techniques or components of treatment. Within the context of the patient's preference. 2006b p. Nine investigations have examined the effects of rate. 3) integral stimulation. The outcome measure for the majority of articulatory-kinematic investigations has been articulatory accuracy.. with steps applied only as needed. Perceptual evaluation via phonetic transcription. such as metronomic pacing and metrical 2006b.. which is considered to reflect "articulatory function" under the ICF framework.. Wambaugh & Mauszcyki. the effects of treatment were measured in probe sessions (measures of treated behaviors collected prior to administration of treatment or treatment session over the course of an investigation).lxii). the committee recommended that "articulatory kinematic approaches be utilized with individuals with moderate-to-severe AOS who demonstrate disrupted communication due to disturbances in the spatial and temporal aspects of speech production" (Wambaugh et al. Rate/Rhythm Control Treatment Rate. Although other articulatory-kinematic treatments (including those developed by clinicians) are likely to have positive effects. There is insufficient evidence to conclude that any one technique or combination of techniques is superior to another. rating scale. a substantial body of evidence supports the use of articulatory-kinematic treatments for AOS (Wambaugh et al. involve manipulation of rate and/or rhythm to improve speech production or reduce symptoms of AOS. the clinician must collect practice-based evidence to document patient outcomes with all AOS treatments. 2010b). As noted by the AOS Treatment Guidelines Committee. and/or descriptors of accuracy were most frequently used to assess speech production. A basic assumption of such approaches is that AOS involves a disruption in the timing of speech http://www.Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM 2004) uses a response-contingent hierarchy that includes the following steps: 1) verbal modeling/repetition. 2001) that have been studied repeatedly may have somewhat predictable outcomes. The hierarchy is applied to one target item at a time. 2) graphemic cue plus modeling/repetition. and 4) articulatory placement instruction. Treatments such as SPT or Prompts for Restructuring Oral and Muscular Phonetic Targets (PROMPT.htm Page 5 of 12 . Square et al.. Outcome Measures In most articulatory-kinematic investigations. 2006b).and rhythm-control treatments (for descriptions. see Wambaugh et al.and rhythm-control treatments.

. 1988) or away from speech production (Brendel et al. The use of a rhythmic source may re- establish internal oscillatory mechanisms suspected of being involved in speech production (Dworkin & Abkarian. choral speaking. 2000). This treatment also includes hand-tapping.. Wambaugh & Martinez.e. Typically. Brendel et However. In one treatment protocol (Wambaugh & Martinez. Wambaugh & Martinez. 2000). Rhythmic-control treatments usually have involved slowing the rate of speech production in speakers who already exhibit a reduced production rate. Metronomic Pacing In metronomic pacing. Treatment involves computer-generated pacing tones for each utterance that maintain the natural rhythm of the utterance regardless of rate of production.g. the beat has been set at a rate significantly slower than the speaker's habitual rate of speech (Dworkin et al. Hand-tapping— requiring speakers to tap along to the beat of the metronome—may be used in conjunction with metronomic pacing (Mauszycki & Wambaugh.Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM production. 2008. 1988. increased fluency) associated with this treatment approach are not well understood and remain speculative.htm Page 6 of 12 . 2000). 2000). improved articulation. the use of rate and rhythm controls may serve to focus the speaker's attention either on increasing the accuracy of speech production (Dworkin et al. the underlying mechanism or mechanisms responsible for the behavioral changes (i. tongue movements) to speech tasks of varying lengths (syllable to phrase-level productions). Metrical Pacing Metrical pacing is similar to metronomic pacing. but the natural rhythm or prosody of the target utterances is maintained (Brendel & Ziegler. productions of multisyllabic words were practiced to the beat of the metronome set to reduce http://www. The amount of clinical instruction and participation also varied among investigations from minimal clinician involvement to clinician modeling with gradual fading. Metronomic pacing and metrical pacing both entail repeated practice of target utterances in time to the pacing mechanism.. the speaker produces speech at the rate of one syllable or movement per beat of a metronome.asha. There are three proposed underlying mechanisms in which rate and rhythm control treatments are considered to influence AOS... 1996). Additionally. and varying levels of clinician participation. Behaviors targeted with this approach have varied from non-speech tasks (e. 2000).. The reduced rate is believed to allow additional time for speakers to reach their intended articulatory targets as well as to process sensorimotor feedback involved in speech production. 1996. 2008.

1994). In addition. clinical knowledge and experience. Outcome Measures As with articulatory-kinematic treatments. In terms of clinical application. The prediction of patient outcomes also is limited for most AOS treatment approaches. 1987). metrical pacing would be more labor-intensive than metronomic pacing.. or production of sound errors. pacing board practice (McHenry & Wilson. 1988)].. especially with respect to functional communication. 2008). however." Accuracy of articulation. Metronomic pacing and metrical pacing have resulted in improved articulation for speakers with AOS. With metrical pacing. Mauszycki & Wambaugh. and computerized pacing of oral reading (Southwood. Despite the advancements in understanding the effects of various treatment approaches for AOS.Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM the participant's rate of production by approximately 50% in comparison to his typical productions. 2008. Other methods for modifying rate/rhythm as treatment for AOS have received limited study. Dworkin et al. Other outcome measures have included measures of dysfluency (Brendel & Ziegler. and consideration of the patient's needs and treatment goals. http://www. theoretical rationale. 1978). Wambaugh & Martinez. Treatment resulted in positive changes in articulation despite no direct focus on articulation. and hand- tapping. various durational measures have been studied (Brendel & Ziegler. followed by participant production without assistance. As suggested by Wambaugh and colleagues (2006b).htm Page 7 of 12 . has been measured in several investigations (Brendel & Ziegler. but have not been directly compared experimentally. 1996. presence or absence of AOS symptoms in speech and non-speech behaviors that were treated (Dworkin & Abkarian. Such methods include finger-counting (Simmons. Clinician participation was faded across levels of treatment. A computer program also must be available for implementation of the templates at different rates. 2008. In addition. outcome measures have focused on "Body Function. The treatment included clinician modeling.e. 2008) and ratings of the acceptability of productions [i. Metrical pacing is theoretically appealing because the natural rhythm of the utterance is preserved. treatment for individuals with AOS should include integration of objective treatment evidence. unison production. 2000).asha. "metrical templates" must be developed for each target utterance based upon syllable-onset times derived from waveforms of the utterances. rate was gradually increased and syncopation was added to facilitate "naturalness" of productions. there are limits to the data available to help guide clinicians in selecting a specific treatment for a

C. June. Aphasiology. PhD.Acquired Apraxia of Speech: A Treatment Overview 5/17/11 3:42 PM Shannon C. PhD. interpret. J. (2011. Treating control of voicing in apraxia of speech with variable practice. CCC-SLP. Contact her at passbrat@aol.utah. ASHA Special Interest Group 2. D. K. CCC-SLP. published annually in April. She teaches and conducts research in the areas of aphasia and apraxia of speech. and December. cite as: Mauszycki. (2007). April 26). For more information and to join. Effectiveness of metrical pacing in the treatment of http://www. is a clinician at the VA Salt Lake City Health Care System and an instructor in the Department of Communication Sciences and Disorders at the University of Utah. She conducts research in the area of acquired neurogenic speech and language disorders. is a research career scientist at the VA Salt Lake City Health Care System and an associate professor in the Department of Communication Sciences and Disorders at the University of Utah.julie. Mauszycki.. Julie Wambaugh. Neurophysiology and Neurogenic Speech and Language Disorders SIG 2 strives to facilitate the highest level of professional practice provided to individuals with neurogenic communication disorders. The ASHA Leader. Brendel. References Ballard.asha.. S. & Robin. SIG 2 members have the opportunity to identify and network with others having an interest in neurogenic communication disorders through an affiliates-only e-mail list and affiliates-only online discussion forum. Maas. go to SIG 2's website. (2008).org/Publications/leader/2011/110426/Acquired-Apraxia-of-Speech--A-Treatment-Overview. Page 8 of 12 . Acquired Apraxia of Speech: A Treatment Overview. B. 1195–1217. Contact her at. and disseminate information relevant to neurogenic communication disorders and to serve as a conduit for the exchange of information and ideas among SIG affiliates. SIG affiliates also are eligible for a discount on select short courses at ASHA's annual convention. A. J. E. Its mission is to be the voice within ASHA that will promote. SIG 2 affiliates may earn CEUs for self-study of Perspectives. Affiliates receive Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders. 21(12). & Ziegler. the group's online-only publication.. & Wambaugh.

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