Speech Therapy Techniques and Strategies

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Questions and Answers

What is one primary use of a pacing board in speech therapy?

To break up syllables and slow down sentence utterances.

How does the use of an alphabet board assist in communication for individuals with speech disorders?

It decreases the rate of speech and provides visual cues for listeners.

List two goals of prosody in speech therapy.

To improve emotive stress and produce a natural speech melody.

What tip can help patients improve listener comprehension during conversations?

Say one word or phrase before starting to talk in sentences. Signup and view all the answers

What is a suggested strategy for children struggling with speech clarity when tired?

They should try not to talk a lot when they are tired. Signup and view all the answers

What are the key pre-practice considerations that should be discussed prior to treatment?

Memory, attention, motivation, and goal setting. Signup and view all the answers

What is one method to establish respiratory support during treatment?

Making postural adjustments. Signup and view all the answers

How can the inhalation/exhalation relationship be improved?

By increasing the duration of air intake and modifying exhalation. Signup and view all the answers

What are some approaches to improving voice quality in treatment?

Utilizing postural adjustments and relaxation therapy. Signup and view all the answers

Name one type of feedback that can enhance articulation during speech therapy.

Articulatory placement cues. Signup and view all the answers

What are the three factors involved in prosody that should be manipulated during treatment?

Loudness, pitch, and duration. Signup and view all the answers

What do rate and rhythm control approaches focus on improving in individuals with AOS?

Intonation patterns like melody, rhythm, and stress. Signup and view all the answers

What is a common method for diagnosing Apraxia of Speech?

Asking the patient to repeat particular words or a list of increasing length. Signup and view all the answers

What is the general outcome for children with cerebral palsy when treatment is initiated early?

Children usually have a better chance of overcoming developmental disabilities or learning new ways to accomplish tasks. Signup and view all the answers

Name three disciplines involved in the management of cerebral palsy.

Pediatricians, occupational therapists, and physiotherapists. Signup and view all the answers

How do surgeons contribute to the treatment of cerebral palsy?

Surgeons perform surgeries to correct anatomical abnormalities or release tight muscles. Signup and view all the answers

What role do clinical psychologists play in the management of cerebral palsy?

They provide emotional wellbeing support and conduct cognitive evaluations for school placement. Signup and view all the answers

Explain the importance of parent counseling in the treatment of CP.

Parent counseling is vital as parents are pivotal in managing their child's care and development. Signup and view all the answers

Can cerebral palsy lead to profound disabilities in all cases?

No, the severity of CP varies; some children may only experience slight awkwardness. Signup and view all the answers

What types of skills can supportive treatments and medications improve in individuals with CP?

They can improve motor skills and the ability to communicate. Signup and view all the answers

What sensory capabilities remain intact in limbs affected by cerebral palsy?

Limbs affected by CP can feel pain, heat, cold, and pressure. Signup and view all the answers

What characterizes cerebral palsy as a disorder?

Cerebral palsy is characterized by persistent but not unchanging disorders of movement, tone, and posture due to a non-progressive defect of the immature brain. Signup and view all the answers

What are the common associations of cerebral palsy with developmental disabilities?

Cerebral palsy is commonly associated with mental retardation (60%), epilepsy (33%), and visual, hearing, and speech defects. Signup and view all the answers

Describe the classification of hemiplegia in cerebral palsy.

Hemiplegia is classified as an upper motor neuron lesion affecting one side of the body, with one arm and one leg typically being involved. Signup and view all the answers

List the functional classifications of cerebral palsy and their activity limitations.

The functional classifications are Class 1 (no limitation), Class 2 (slight limitation), Class 3 (moderate limitation), and Class 4 (no useful physical activity). Signup and view all the answers

What are early signs of cerebral palsy related to birth history?

Early signs include prematurity, seizures, and intracranial hemorrhage. Signup and view all the answers

Explain the significance of delayed milestones in diagnosing cerebral palsy.

Delayed milestones suggest abnormal development and can indicate possible cerebral palsy as the child may not meet typical developmental criteria. Signup and view all the answers

What role does abnormal motor performance play in identifying cerebral palsy?

Abnormal motor performance, such as unusual crawling patterns and toe walking, can be significant indicators of cerebral palsy and prompt further evaluation. Signup and view all the answers

Identify two early markers of cerebral palsy and their implications.

Two early markers are slow head growth and poor head control, which can indicate abnormal brain development. Signup and view all the answers

What is one common characteristic of apraxia of speech?

Articulation errors are a common characteristic of apraxia of speech. Signup and view all the answers

How do speech-language pathologists typically approach the treatment of apraxia of speech?

They use intensive, one-on-one therapy sessions that focus on repetitive drills. Signup and view all the answers

What role do visual cues play in therapy for apraxia of speech?

Visual cues, such as practicing speech in front of a mirror, help individuals learn how to move their mouths correctly. Signup and view all the answers

What is the goal of speech therapy for individuals with apraxia of speech?

The goal is to achieve functional speech abilities. Signup and view all the answers

What might individuals with severe apraxia of speech use for communication if they struggle with speech?

They may use formal or informal sign language, picture boards, or electronic communication devices. Signup and view all the answers

Name one specific program used in the treatment of severe apraxia of speech.

Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) is one specific program used. Signup and view all the answers

What is one potential outcome for individuals with acquired apraxia of speech?

Some individuals may experience spontaneous recovery of their speech abilities. Signup and view all the answers

How does severe apraxia of speech differ from more mild cases in terms of therapy?

Severe apraxia may require more intensive and specialized therapies, such as the Melodic Intonation Therapy (MIT). Signup and view all the answers

What is the primary goal of establishing diaphragmatic breathing in patients?

To promote proper respiratory patterns and enhance breath control during speech. Signup and view all the answers

What are two strategies used to practice sustained phonation?

Maintaining intensity and varying intensity levels while phonating. Signup and view all the answers

How does Lee Silverman Voice Therapy (LSVT) help patients with neurological disorders?

It focuses on increasing vocal loudness and improving intelligibility through intensive practice. Signup and view all the answers

What is meant by the term 'focus on high effort' in LSVT?

It refers to pushing patients to use greater vocal effort to combat rigidity and hypokinesia. Signup and view all the answers

Describe the role of calibration in the LSVT methodology?

Calibration involves establishing the right level of vocal effort and providing patient feedback. Signup and view all the answers

What is one goal related to resonance in voice therapy?

To improve velopharyngeal closure for optimal speech production. Signup and view all the answers

What techniques can be used to improve intra-oral pressure during speech practice?

Blowing into straws, balloons, or using facial air pressure exercises can help. Signup and view all the answers

How often should LSVT sessions typically occur for effective voice therapy?

Sessions should occur at least 3-4 times per week. Signup and view all the answers

Study Notes

Cerebral Palsy

Chronic central nervous system disorder
Characterized by aberrant posture and movement control
Appears early in life
Not a progressive neurological disease

Definition of Cerebral Palsy

Persistent but not unchanging motor disorder
Affecting movement tone and posture
Caused by a non-progressive defect/lesion
Affecting the immature brain (fetal life, infancy, childhood)
Frequently associated with developmental disabilities
Mental retardation (60%)
Epilepsy (33%)
Visual, hearing (deafness - 10%), and speech defects
Strabismus (abnormal eye alignment - 50%)
Cognitive dysfunction
Sensory problems
Emotional and behavioral problems

Excluding/Including

EXCLUDING: Progressive pathology and lesions of the spinal cord
INCLUDING: Non-progressive genetic or congenital malformation

Classifications

Monoplegia: One limb affected (most often an arm)
Hemiplegia: Upper motor neuron lesion on one side of the body
Double Hemiplegia: Bilateral upper motor neuron lesion
Diplegia: Upper motor neuron lesion of all four limbs, but legs more affected than arms
Quadriplegia: Equal involvement of arms and legs
Paraplegia: Lower parts of the body, including toes, feet, legs (and potentially the abdomen) affected

Functional Classifications

CLASS 1: No limitation of activity
CLASS 2: Slight limitation
CLASS 3: Moderate limitation
CLASS 4: No useful physical activity

Gross Motor Function Classification System (GMFCS)

Level	Description
I	Walks without restrictions; limitations in more advanced gross motor skills
II	Walks without assistive devices; limitations in walking outdoors and in the community
III	Walks with handheld assistive mobility devices; limitations in walking outdoors and in the community
IV	Self-mobility with limitations; children are transported or use power mobility outdoors and in the community
V	Self-mobility is severely limited even with the use of assistive technology

Early Signs of Cerebral Palsy

1. Birth History:*
Prematurity
Seizures
Intracranial hemorrhage (bleeding within the skull)
Periventricular leukomalacia (white-matter brain injury)
2. Delayed Milestones*
3. Abnormal Motor Performance:*
Handedness
Abnormal crawling (Reptilian crawl)
Toe walking (spastic diplegia)
4. Altered Tone*
5. Persistence of primitive reflexes* (Asymmetrical tonic reflex)
6. Abnormal posturing*

Early Markers of CP

Slow head growth
Poor head control
Eye - roving eyes, poor hand regard, persistent squint
Ear - lack of auditory response
Irritability, seizures, poor suck, poor quality of sleep
Extreme sensitivity to light
Cortical thumb beyond 8 weeks in babies
Handedness
Lack of limb movements
Scissoring of lower limbs
Toe walking
Abnormal tone
Stereotypic abnormal movements
Lack of alertness

Body Stiffens Like a Board (Clinical Observations of CP)

Normal posture described & visualized
Floppy posture described & visualized
Stiff posture described & visualized
Issues with limbs as the child tries to stand described & visualized

Typical Athetoid arm and hand movements

Test for Ataxia

Balance problems during walking described
Test demonstrated for ataxia

Incidence of Cerebral Palsy

High in low-birth-weight babies
Increased incidence in babies weighing 2.5-4kg
Higher prevalence in boys (58%)
More common in lower socioeconomic groups
Maternal age

Types of Cerebral Palsy

Spastic CP: More than 70%, Increased muscle tone, stiff, tight muscles
Athetoid CP: 10-20%, Uncontrollable movements
Ataxic CP: 5-10%, Difficulties with balance & coordination
Mixed CP: 10%, Symptoms of more than one type are present

Motor Types of Cerebral Palsy

Spastic: 70-80% most common form
Dyskinetic: 6%, involuntary movements
Mixed: combination damage
Ataxic: 6%, shaky movements affecting balance & spatial awareness

Terms Commonly Used to Describe Involuntary Movements

Athetosis: Slow writhing movements, especially in hands & face
Ataxia: Unsteady walking, balance problems (resulting from cerebellum damage).
Chorea: Jerky movements of head, arms, or legs
Dystonia: Twisting movements & postures of trunk or limbs

Assessment of Cognition and Behavior

Mental retardation is a common problem in children with CP
Standard intelligence tests may not be accurate due to motor & communication issues
Use age-appropriate non-verbal intelligence tests instead

Assessment of Vision and Hearing

Hearing impairments often associated with microcephaly and congenital heart disease
Sensorineural hearing loss is common in iodine-deficient areas

Assessment of Speech and Language

Hearing impairment, cognitive/oromotor dysfunction may cause speech/language problems
Communication difficulties (language/gestures) may exacerbate behavioral problems

Comprehensive Assessment

Neuro-developmental pediatrician (team leader)
Physiotherapist
Occupational therapist
Clinical psychologist
Speech pathologist
Orthopedic surgeon
ENT
Teacher
Play therapist
Social worker
Preferably under one roof

Treatment of Cerebral Palsy

CP cannot be cured
Intervention improves capabilities & quality of life
Many children with CP live near-normal adult lives with proper management
Earlier treatment = better chance at overcoming developmental disabilities & acquiring new skills

Treatment of Cerebral Palsy (Continued)

CP affects multiple areas of function, requiring coordinated multidisciplinary management
Various disciplines involved in CP management include
Pediatricians – Child development and care
Surgeons – Surgeries for abnormalitites & tight muscles
Occupational therapists – Fine motor activities, daily life skills
Physiotherapists – Gross motor skills
Speech therapists – Speech improvement, treatment & counseling
Clinical Psychologists – Emotional well-being, cognitive evaluation, school placement
Special educators – Education for children with cognitive impairments
Parent counseling is critical, requires ongoing support throughout the child's development

Prognosis of Cerebral Palsy

CP does not always cause significant disabilities
Some children need extensive, lifelong care while others require minimal assistance

Conclusion Concerning Cerebral Palsy

Limbs affected by CP can still feel sensations (pain, heat, cold, pressure)
Individuals with CP may not be able to speak, but they may still have thoughts & feelings that are important

Question: Does Cerebral Palsy Get Worse Over Time?

No, CP is not a progressive disorder.
Brain damage occurs at birth and does not worsen over time.
Symptoms can sometimes be reduced with effective therapy & treatment.

Question: Does CP Affect Everyone the Same Way

No, CP affects unique individuals differently.
Multiple causes of CP result in various forms and expressions in each individual.
Classification is based on movement disorder type and number of affected limbs.

MSD Treatment

Focused on (re)-learning speech motor aspects
Acquisition: Temporary improvements during treatment
Retention: Lasting performance enhancements
Generalization: Improvements in either related untrained behaviors or targeted behaviors in varied contexts

Treatment Targets

Nonspeech tasks in assessment don't always translate to treatment
Few studies support the use of oral motor activities for articulator improvement
Focusing on more complex targets improves learning over simpler targets

Treatment Strategies

Primary Strategies: Improve the impaired system in speech tasks (e.g., improve respiratory support for speech)
Compensatory Strategies: Support for the affected individual, the environment, or the communication partners

Treatment Contexts

Generalization (transferring improvements to other tasks) is a key indicator of effectiveness
Speech production in varied tasks and with different conversational partners should be assessed

The Treatment Plan

Pre-practice considerations (memory, attention, motivation, goal setting) are important
A reference of correctness/standard of comparison (baseline) needs to be established prior to treatment

Treatment of Respiratory System

Establish respiratory support (e.g., postural adjustments)
Modify inhalation (e.g., increase duration)
Modify exhalation (e.g., vowel prolongation)
Improve inhalation/exhalation relationship
Increase respiratory flexibility

Treatment of Phonatory System

Improve voice quality (e.g., postural adjustments, relaxation therapy)
Control vocal folds to enhance naturalness of speech
Improve velopharyngeal port strength & control (e.g., nasal vs. oral)
Palatal lifts (may be needed for severe cases)

Treatment of Articulatory System

Focus attention on accuracy, range, and direction of movement during speech
Clinician feedback may include articulatory placement cues

Treatment of Prosody and Rate Control

Prosody involves manipulation of loudness, pitch, and duration
Approaches to reducing rate include rigid and non-rigid control techniques

Rate and Rhythm Control Approaches

Use of intonation patterns (melody, rhythm, and stress) to improve speech production
Can also improve articulation in individuals with AOS
Clinician guides patient through utterances gradually

Apraxia Treatment

Methods for diagnosing Apraxia of Speech (AOS) include formal testing involving repeating words successively.
- Repeating a list of words, increasing in length (love / loving / lovingly )

How is Apraxia of Speech Diagnosed

Informally assessing acquired and childhood AOS, Speech-Language Pathologists might ask the patient to repeat a word numerous times ( love, loving, lovingly) or repeat a list of progressively more complex words.

Treatment for Apraxia of Speech

Repeat words or phrases repeatedly.
Practice specific syllables and words to improve moving from one sound to another.
Observe how the therapist moves their mouth when saying words or phrases.
Practice speech in front of a mirror

Apraxia Speech Characteristics

Articulation errors
Inconsistent errors
Substitution errors of placement are most common
Anticipatory errors
Perseverative errors
Metathetic (transposition) errors
Longer sound sequences cause more articulation errors
Voluntary speech more difficult than automatic
Prosody errors
Slow rate of speech
Equal stress
Monotone pitch

How is Apraxia of Speech Treated

Spontaneous recovery is possible in some cases.
Different approaches are used, with no single approach confirmed most effective.
Frequent, intensive, one-on-one therapy is recommended for both children and adults.
Repetitive exercises and individual attention are crucial, as group therapy may not be effective.
Intensive therapy may last for years for severe cases

In severe cases (AOS)

Alternative ways to communicate might be beneficial (e.g., sign language, notebooks)
Electronic communication devices, such as smartphones, tablets, or laptops
These devices can help individuals write or produce speech.

Treatment (General Procedures) for AOS

Progress is slow
Extensive, repetitive drills are often required
Sequencing phonemes meticulously
Achieving functional speech is the ultimate goal

Specific Programs for AOS

Restructuring Oral Muscular Phonetic Targets (PROMPT), Melodic Intonation Therapy (MIT) are used for more severe AOS.
Rosenberg Hierarchy of Apraxia Drills (8-step continuum) is used for milder cases.

Therapy for AOS

Typically follows a sequential organization.
progresses from simple to complex speech tasks
Examples of Sequential organization:
- CV, VC, CVC, CCVC syllable shapes, words, phrases, sentences, conversational speech

General Principles of Treatment for CAS

Some children with Childhood Apraxia of Speech (CAS) may have experienced prior failures with speech
Ensure initial success during therapy
May start with correcting dominant errors, such as vowel errors
Auditory discrimination is not a primary focus in initial phases
Address stimulable, early-developing, and visible sounds

Additional Techniques for CAS Treatment

Start practicing sounds in word-initial positions.
Include frequent, short breaks during therapy sessions.
Conduct repeated trials of the same movement to help program muscle memory.
Practice target words and phrases multiple times before moving on.
Select core words with practical meanings for early treatment (examples include words like “eat”, “drink”, “play”)

Specific Treatment Approaches (CAS)

Multimodal approaches are essential throughout treatment
Sign language or augmentative/alternative communication (AAC) might be necessary for many severe cases

Phonetic Placement Techniques

Detailed descriptions and visuals can be used to guide sound production.
Tools like tongue depressors, cotton swabs, mirrors, and diagrams are vital during treatment.

Shaping/Progressive Assimilation

Using non-speech gestures/sounds help in producing speech sounds.
This is useful when the child struggles with affected sounds.

Contrastive Stress Drills

Effective in teaching stress and rhythm of spoken language.
Helps enhance articulation skills (e.g., stress and rhythm)

Remember Concerning AOS Therapy

Therapy for AOS typically takes years.
It is critical to reinforce learned (mastered) skills to prevent regressors or regression.

Rosenbek's Eight-Step Continuum

1. Clinician/client produce target utterances in unison
1. Clinician presents stimuli with visual only cues while the client produces the target aloud
1. Clinician presents stimuli.
1. Repeat step 3 several times without additional model
1. Clinician presents written stimuli, which the client reads aloud
1. Clinician presents stimuli, removes stimuli, client produces target
1. Clinician presents questions designed to elicit target utterance, client responds
1. Clinician engages in role-play situations to elicit target utterance

AOS Treatment (General Procedures)

Treatment for AOS typically involves progressive complexity, from simple CV to complex utterances, aiming to enhance functional speech.
Techniques that facilitate increasingly automatic speech (many reps), and supportive cues like visual and tactile aids (visual cues to facilitate desired movements).
Decreasing rate of speech (slower pace) may also prove helpful.

Treatment for Dysarthria

Treatment strategies depend on the specific type of dysarthria
May include slowing down speech, using more breath to speak, strengthening mouth muscles, improving clarity in words and sentences

Indications for Dysarthria

slurred/mumbled speech that is hard to understand
Slow speech rate
Rapid speech rate
Soft or quiet tone.
Struggles with movements of the tongue, lips and jaw.
Robotic or choppy sound quality
Vocal changes (e.g., hoarse, breathy, sounds that come from the nose)

Important Issues concerning Dysarthria

SLPs should work alongside family and friends to help them implement techniques for communication

Treatment of Dysarthria (Focus)

Therapy focus is determined by the affected subsystems (i.e., components of speech production) and the specific type of dysarthria (type of neurological damage).

Treatment Goals (Dysarthria)

General Goals: Includes improving speech accuracy and communication effectiveness, as well as enhancing the ability for independent communication.
Specific Goals vary based on the subsystems affected, such as increasing or decreasing tone, increasing or decreasing muscle strength, and improving speech control.

Respiration (Goals)

Correct breathing pattern establishment
Increasing vital capacity
Managing inhalation/exhalation control
Enhancing respiratory muscle strength & coordination,

Respiration (Strategies)

Modifying posture (optimal sitting position, etc.)
Determining best breathing technique based on individual needs. (e.g., diaphragmatic breathing for overweight patients).
Practicing slow and deep breaths.
Sustained phonation practice
Monitoring breath patterns during continuous speech

Phonetic Placement

Phonetic placement helps guide sound production by visualizing and describing oral movements.

Prosody (Goals)

Improving emotive and linguistic stress
Producing natural speech melody (inflection, pitch, loudness )

Prosody (Approaches)

Pitch control
Loudness control
Stress patterns imitation
Production of specified stress patterns
Terminal declination
Question inflection
Intra-word stress influencing meaning

Tips for Patients

Saying one word or phrase before starting to talk in sentences to help listeners understanding the topic. E.g., “Dinner” before discussing what one wants to eat.
Checking with listeners to ensure comprehension
Speaking slowly and loudly
Avoiding excessive talking sessions when tired
Utilizing alternative communication methods like pointing, writing , or drawing

Articulation (Goals)

Improving speech power, speed, and tone
Enhancing articulation accuracy and speech coordination
Increasing articulatory precision

Articulation (Therapy Approaches)

Strengthening techniques
- Tongue exercises (contractions in various directions & locations)
- Lips/face exercises (ex. contractions, resistance movements)
Tone reduction techniques
- Massage or stretching of the tongue, lip, and face muscles
- Reduction or modification in articulation rate

Intelligibility and Comprehensibility (Goals)

Intelligibility enhancement in specific contexts
- Clinic
- Interactions with the spouse
- Interactions with strangers
- Noisey environments
- Phone conversations
Includes self-monitoring and clarification strategies

Intelligibility and Comprehensibility (Approaches)

Utilization of pacing boards
Over articulation (e.g., repeating sounds several times)
Increasing speech effort
Modification of the environment (e.g., reducing background noise)
Training listeners to understand
Utilizing non-verbal communication strategies
Implementing augmentative communication devices

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This quiz covers various techniques and strategies used in speech therapy to assist individuals with speech disorders. Topics include the use of pacing boards, feedback methods for articulation, and enhancing prosody. Test your knowledge of effective communication tools and treatment goals in speech therapy.