1. effectiveness
2. efficient
3. naturally - don't think about your goals, thing about THEIR goals

1. restore
2. compensate / teach to use residual function
3. adjust/reduce the need for lost function

• reduce impairment (attempts)
• success influenced by etiology and course of disease; type & severity, as well
• **full restoration of speech is highly unlikely in most cases**

• knowing that restoration of normal speech will probably not occur should lead to effors to compensate for lost abilities
• alternative methods for communication - can take many forms
• modificiations of rate and prosody - use of prosthetic devices to amplify voice, etc.
• rate = best friend

• primary goal is to maximize speech and communication function so that the need to reorganize other life functiosn can be minimized
• psycho-social training
• want to reduce/minimize other life functions

1. medical diagnosis & prognosis
2. disability & handicap
3. environment and communication partner
4. motivation & needs
5. associated problems

factors influencing management decisions:

medical diagnosis/prognosis & disability/handicap

• medical diagnosis & prognosis
• nature and severity
• predicted course
• seldom (if ever) provide treatment before medical intervention
• disability and handicap
• impairment - any disturbance in function or structure
• disabiltiy - reflects the degree of inability to speak normally because of speech imaprimened; reduction in intelligence
• handicap/social limitation - effect of impairment or disability on the ability to accomplish a previously normal role

factors influencing management decisions:

enviornment & communication partners

motivation/needs

• enviornment & communication partners
• where is the individual discharged?
• who are the primary communication partners?
• motivation & needs
• need to communicate may be the most important determinant to a decision to provide treatment
• age, cognition/IQ, damage, vocation - job, co-existing deficit, family support, lifestyle, education, personality

factors influencing management decisions:

assoicated problems

focus of treatment

• associated problems
• most have accompanying neurologic deficits
• limb deficits
• cognitive deficits - motor speech disorder should nto receive direct treatment if attention, drive, or motvation to communication or result in non-functional communication
• Focus of treatment
• biggest bang the quickest
• treat the component of speech most functional to development, rapidly, and greatest support

• treatment should be provided for as long as it is nevessary to accomplish its goals but for as short a time as possible
• must justify existence thru documention as long as it is necessary and making progress
• no management program should begin without a plan about when it will end
• treatment should be terminated when goals are reached, when plateauing has occurred or when the patient does not wish to have further management
• follow up reassessments may be appropriate

1. medical management
• pharmacological management
• surgical management
2. prosthetic management
3. behavioral management
• speaker-oriented approach
• communication-oriented approach
4. alternattive & augmentative communication
5. couseling and support

• should always preced or be provided concurrently with other management approaches - unless referring
• the responsibilites of hte MEDICAL SLP is to carefully assess speech & establish:
• need for medical or surgical intervention
• likelihood that the patient will benefit from such intervetion
• the specific benefits to be derived
• need to post-procedure behavioral management and provision of such management - need to determine - talk to surgeon

1) medical management

pharmacologic management

&

surgical management

• pharmacological management
• almost always directed at relieving symptoms sometimes it effectively cures disorder
• approaches are directed to underlying process rather than designed to improve speech, per se
• surgical management
• may have direct or indirect effects on speech
• surgeries perofmred for the sole purpose of improving speech

• includes a number of mechanical and elctric devices
• palatal life prosthesis: promotes perceptual normalcy, facilitates velopharyngeal closure during speech, reduces hypernasality
• voice amplifiers - may increase vocal loudness - quick fix
• pacing boards, metronomes, DAF
• **look at whether we are modifying speech signal itself or way in which signal is produced
• vocal intensity monitoring device - provides auditory or verbal signal when speech loudness falls below the audible level

3) Behavioral management

• not medical or pharmacological - no surgery or prosthesis
• **primary goal is to maximize communcation**
• Goals are accomplished by:
• improving physiologic support for speech
• modifying speech through compensatory speaking strategies
• developing alternative and augementative means of communication
• controlling the environment and communicative interactions
• 2 types of intervention:
• speaker-oriented approach & communication - oriented approah

3) Behavioral management

Speaker-Oriented Approach

• focus on speech & altering the signal
• focus primarily on improving speech intelligibility and on improving the efficiency (increasing rate of communication without sacraficing intelligilibity), naturalness, and quality of communication
• goals are accomplished by reducing impairment or compensation
• can be direct (focus directly on modifying respiration, phonation, resonance, etc.) or indirect (independent of speech - compensation - strengthening exercies; modifying posture, change in respiration)

3) Behavioral management

Communication - oriented approaches

• may improve communcation when speech itself does not improve
• identifies most effective strategies for repairing breakdowns in communication
• repeating utterances
• rephrasing (different words)
• ask questions
• write out or spell out
• communication board - spell out few words
• alters speakers strategies; modify listener's reactions & how they act; alter environment

• part of behavioral management but also include prosthetic management because they often rely on the use of aids for hte transmission or receipt of messages
• tools of AAC are heterogenous
• ACC systems represent a wide variety of non-speech symbols, gestures, aids, strategies, and techniques that enhance communicaiton and are important temporary party or permannet part of management

• may need ot provide information about why certain aspects of speech are not normal and may not ever be normal, what can be done to remediate the underlying impairment or compensate for it
• important for the clinician to be sensitive and empathetic
• patients are living not just working with their problems
• the manner in which care is provided may be as important from the patient's persepctive as the actual outcome of efforts to improve their speech or communication
• Part of role of SLP
• Rreasonable expectations major part of services with degenerative disease, encourage to join support groups

1. improving speech requires speaking
2. drill is essential
3. instruction improves performance
4. self-learning is valuable
5. feedback is essential to motor learning (clinician provided & instrumental)
6. specificity training
7. consistent practice and variable practice
8. speed-accuracy trade off
9. increasing strength

Motor Learning Principles:

1. Improving speech requires speaking
2. drill is essential
3. instruction improves performance

1. Improving speech requires speaking -
• mental practice is more effective than no proactice, but is less effective than physical practice
2. Drill is essential
• immediate effects of bried periods of practice distributed over time may be better than length periods of massed practice
3. instruction improves performance
• give instructin what they are to do

Motor Learning Principles:

4. Self-learning is valuable

5. Feedback is essental to motor learning

4. Self-learning is valuable:

   - discovery learning, in which the individual determins how best to achieve goals, may lead to better generalization than learning that is highly prompted

             - explore what is being done to help them achieve the goal

5. Feedback is essential to motor learning:

     - Clinician provided - most appropriate when the immediate goal is intelligibility or some aspect of performance for which other feedback is not available            Knowledge of Results; Knowledge of Performance; Immediate                                Summary feedback

     - Instrumental/biofeedback - useful when a specific motor behavior or acoustic result is the focus of treatment

Motor Learning Principles:

6. Specificty Training

7. Consistent practice & variable practice

8. Speed-accuracy trade off

6. Specificity Training:

     - treatment should not begin with any skill below the most advanced skill that can be demonstrated during assessment (ex. don't start at sound level when patient can produce words)

7. Consistent practice and variable practice have value:

    - consistent practice refers to repeated practice on a single task

    - variable practice involves practice on a range of related task

8. Speed-accuracy trade off - rate = best friend; slow down - makes them more conscious, allows for more time; emphasizing speed tends to decrease accuracy, emphasizing accuracy reduces speed

           - can manipulate: articulation, stress, intelligibility when slowing down

Motor Learning Principle

9.  Increasing Strength

9.  Increasing strength:  somewhat controversial, general observation abotu strength training

   exercise may be isometric or isotonic

             isotonic - maintain same state of contraction - not variable

• frequency - suggest 2 session a day in early stages of treatment; watch because you cannot bil for 2 session, only bill for 1
• task ordering - sessions should be organized to move from easy to more difficult task & end with success
• error rate - should be kept low in aphasia therapy
• motor learning - challenges can slow rate of success - need repeated trials for skill acquisition
• fatigue - therapy is morst beneficial when client is not fatigued
• individual vs. group therapy - advantages and disadvantages of each are not known

Managing Dysarthria:

Speaker Oriented Treatment:

Respiration

Increasing Respiratory Support

Postural Adjustment

Prosthetic assistance

Behavioral compensation

• Increasing Respiratory Support
• taks that may improve respiratory support include producing consistent subglottal air pressure
• maximum vowel production
• controlled exhalation
• Postural Adjustment - important for maintaining adequate physiologc support for respiration
• Prosthetic assistance - provide postural support or help control respiration - usually OT
• Behavioral compensation - practice inhalling more deeply or using more force when exhaling

Managing Dysarthria:

Speaker Oriented Treatment:

Phonation

• medical
• surgeries - laryngosplasy, arytenoid adduction surgery, recurrent layngeal nerve resection
• pharmacologic - flat/teflon collagen injection, BoTox
• prosthetic
• amplification system
• artificial larynges
• neck braces
• vocal intensity
• behavioral - primary goal is to increase utterance length per breath group and to obtaon loudness lefvels that are sufficient for social contex; turning head; learning to initiate phonation at beg (easy onset) LSVT
  

Managing Dysarthria:

Speaker Oriented Treatment:

Resonance

• surgical management
• flap or injections to posterior pharyngeal wall
• prosthetic management
• preferred over surgical management, focus on palatal lift prostheses - WORKS BETTER WITH FLACCID
• behavioral management
• hard to do

Managing Dysarthria:

Speaker Oriented Treatment:

Articulation

• medical: surgical - neural anastomaosis (restore nerve function, use part of 12th cranial nerve) or botox (keep spasms down) & pharmacological - some may help, but don't truly know
• prosthetic management - limited : bite block - cannot use long term - when jaw control is disproportionately impaire relative to other articulators
• behavioral management
• strength - only when weakness has been established
• relaxation - reduce muscle tone - spacticity
• stretching - prevent joint & muscle contraction - modulate spasticity
• biofeedbck - modify hypertonicity
• traditional approaches - exaggerate consonants, minimal contrasts & drills (intelligibility)

Managing Dysarthria:

Speaker Oriented Treatment:

Rate

• pause time
• emphasis to allow to contemplate what is said - formulate thoughts - allows to re-group, can be used in group
• prosthetic management
• DAF - slows down
• Pacing device - reduce rate of syllable production - Parkinson's
• Alphabet board - supplement to slwo people down; point to 1st letter of word
• non-prosthetic management 
• visual feedback/osciolloscope
• rhythmic cuing - helps learn stress patter 
• backdoor appraoches - 

Managing Dysarthria:

Speaker Oriented Treatment:

Prosody & Naturalness

• natualness = perceptually derived
• working at levels at breath group - the prosodic pattern during a single exhalation - is important because the breath group is the basic unit of prosody
• contrastive stress taks - scripted responses in which segmental information does not vary, but stress patterns do
• referential task - patient read randomized phrases or sentences containing pre-specified stress targets that are unknown to a listener
• work across breath groups
• work on prosody may be beneficial effects on rate control

Speaker Oriented Treatment for Specific Types of Dysarthria:

Flaccid

• weakness
• increase strength or compensate for weakness
• treatments aimed at RESPIRATORY, laryngeal, resonatory, and articulatory compontents

Speaker Oriented Treatment for Specific Types of Dysarthria:

Spastic

• relaxation
• hyperadduction is generally a problem
• psuedorbulbar affect management - time out (neg. reinforcement shift/change to another task)

Speaker Oriented Treatment for Specific Types of Dysarthria:

Ataxia

• modify rate and prosody
• behavioral focus - with activities centered on improving or compensating for motor control and coordination
• MODIFYING RATE & PROSODY to improve intelligibility and naturalness:
• drills
• oral motor exercise
• intonation
• atriculation - directly

Speaker Oriented Treatment for Specific Types of Dysarthria:

Hypokinetic

• similar to flaccid
• surical brain stem stimulation
• medication improves - effects of medication can affect speech/fluccuate
• behavioral
• dysphonia
• LSVT - high levels of effort to increase loudness & adduction (phonation)

Speaker Oriented Treatment for Specific Types of Dysarthria:

Hyperkinetic

• surgical and pharmacologic
• abnormal movements that affects peech are not under voluntary control

Speaker Oriented Treatment for Specific Types of Dysarthria:

UUMND

• no formal treatment approaches
• disorder is usually mild
• behaviroal approaches focus on rate, prosody, and articulation

Speaker Oriented Treatment for Specific Types of Dysarthria:

Mixed Dysarthria

• behaviorally managed

Communication Oriented Treatment of Dysarthria:

what are the 3 aspects?

1. speaker strategies
2. listener strategies
3. interaction strategies

Communication Oriented Treatment of Dysarthria:

Speaker Strategies

• things to enhance comprehensibility & predictability of speech
• comprehensibility - degree to which utterance produced by a speaker is understoon in a natural communication setting
• prepare listneners with alterting signals - get attention
• convey how communication should take place - need instruction card for AAC
• Set the context and identify the topic - initial piece
• modify content, structure, and length
• gestures may help - may not be able to use with poor head or limb ctrl.
• monitor listening comprehension
• alphabet board for supplement

Communication Oriented Treatment of Dysarthria:

Listener Strategies

• maintain eye contact and direct face-to-face contact
• listen attentively and actively and work at comprehension
• modify the physical environment
• well lit, not noise, not a lot of distractions, limit the distance
• maximize listener hearing and visual activity
• wear glasses and/or hearing aid

Communication Oriented Treatment of Dysarthria:

Interaction Strategies

• time important - later in the day the dysarthrics will be tired
• set a conducive speaking environment
• maintain eye contact by listener and speaker
• identify breakdowns and establish methods of feedback
• listener feedback often is most effectively used if it is specific and immediate
• repair breakdowns
• establish what works best
• **goal is to improve communication (effectiveness) not focused on intelligibility**

Managing Apraxia of Speech

goals & Treatment

• goals:
• effectiveness, efficiency, naturalness
• Treatment for AOS -
• re-establish plans or programs
• imrpving ability to select of activate them
• improving ability to set the parameters (duration, force) for speech movements in a given context that will be executed by an "intact: neuromuscluar appartatus
• AOS = behaviorally managed (no medication or surgery) need to re-establish programs/reactivate them

Intervention of AOS:

Medical/Prosthetic

• medical/prosthetic
• no medical intervention for AOS treatment
• pharacologic intervention to treat underying etiology or prevent further impairment
• surgery may treat underlying neurologic disease, but cannot improve AOS directly
• some AOS may benefict from biofeedback
• pacing techniques

Intervention of AOS:

Behavior management of AOS - heart of it

• Communication-oriented approach
• those efforts at improving communicationi in the absence of changes in speech
• similar to dysarthrics
• Speaker-oriented approach
• seek to improve speech itself
• emphasize improved intelligibility, efficiency, and naturalness of communication
• **ARTICULATION OF PROSODY**
• **success is dependent of selection & ordering of stimuli** always stimulate next highest level

1. maintaining speech as long as possible
2. develop compensatory strategies for maintaining intelligibility or comprehensibility
3. address current or future needs for AAC

• measure of intelligibility and efficiency of communication
• establish presence & degree of associated deficits
• obtain an inventory of patient's communcation needs & goals
• determind patient's motivation level & perception of other's reaction to their problems
• determine spaking environment & communication partners
• determine difficult & easy speaking situations
• nature of articulation erros & accuracy
• factors that influence the adequacy
• accuracy of speech production

1. drill - systematic intensive & extensive drill is necessary to regain or learn lost speech skills
2. self-learning & instruction - going through and discovering & learn on their own; not depending on only therapy - Hw & drills
3. feedback - clinician provided or instrumental - give in terms of knowledge of movements vs. speech production
4. specificity of training - work at level where patient can have success - specific terms of what is being worked on hierarchial sense
5. consistent & variable practice - multiple trials and multiple drills druing acquisition the variable practice for retention
6. speed/accuracy trade-off - usually start slow & increase rate as patiet progresses

• share: emphasis on careful stimulus selection; orderly progression of treatment tasks; intensive & systematic drill
• imitatioin is integral parto of most treatment programs
• most include:
• intrasystemic - lower or high level of control
• emphasis on primitive or automatic function level
• make speech more volitional or conscious
• comination of phonetic placement & derication techniques
• intersystemic - non-speech activity
• use non-speech activities such as head/limb mvmt, finger or foot tapping, pacing board

1. 8 step continuum - "watch, listen, say with me"; present target - highly based on imitation
2. Sound production treatment - accuracy and timing focus; faciliate consonant production thru common strategies; minimal contrasts (shock vs sock)
3. PROMPTS - tactile cues to shape and stimulate artiulatory gestures; function communication = focus
4. Melodic Intonation Therapy (MIT) - have good auditory comprehension, but is not fluent
5. Biofeedback

1. automatic speech
2. carrier phrases ("I want___")
3. singing
4. push on abdomen - grunt/exhalation - phonatory control
5. artifical larynx
6. pairing a highly used symbolic gesture with its associted sound or word
7. MIPT - elicit any type of meaningful speech - severely aphasic patients - repetition abilites are stereotypic output --> pair with other words
8. VCIU - stimulate use of propositional pseech - rely on visual and verbal cues - shape output on spontaneous utterances