Motor Speech – Final UNT

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Overall goals for selection & sequence of dysarthria treatments
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* improving speech motor control. * improving speech intelligibility.
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Treatment objectives for dysarthria
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* oral motor development. * adequate body/ orofacial postures. * integration of primitive/ higher-level orofacial reflexes. * reductions or increases in orofacial muscle tone. * increases in orofacial muscle strength
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Inhibition techniques for dysarthria
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* increased tone and any associated weakness and paresis. * hyperactive reflexes. * hyperkinesias. * hypersensitivity.
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Facilitation techniques for dysarthria
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* decreased tone and any associated weakness and paresis. * hypoactive reflexes. * hyposensitivity.
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Overall goal: selection & sequence of apraxia treatments
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* promoting adaptive response to produce more productive, advanced, organized, and flexible behavior
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Treatment objectives for apraxia
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* teaching a slow-deliberate speaking rate. * pairing motor gestures/ external temporal pacing stimuli with speech attempts. * evoking automatic-reactive speech. * using melodic intonation techniques to stimulate speech output causing the right hemisphere to compensate. * focusing on articulation imprecision. * beginning phonetic training with short, reduplicating utterances.
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A general hierarchy for subsystem treatments
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(RRPAP) * resonation and respiration. * phonation. * articulation and prosody.
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General practices for treatment
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* treating one subsystem at a time in moderate or severe cases; treating 2 subsystems concurrently in mild cases. * considering augmentation and non-oral communication systems.
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Criteria for treatment advancement
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* 75% improvement over the baseline score or 100% whichever is less. * on a 7-point scale, at least 3 scale values better than baseline score, or 1 i.e. normal, if baseline was rated a 3 or 4. * continued until reaching a plateau.
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Criteria for discontinuing treatment
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no improvement shown after 30 consecutive trials
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Do this to verify Maintenance of Retained behavior
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track maintenance by checking carry-over ever 5 sessions
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Types of Medical intervention
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* pharmacological intervention which can have side-effects such as what is seen with L-dopa in Parkinson’s disease. * surgical intervention
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Surgical intervention techniques
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*Treating Parkinsons Disease* * brain ablation techniques – this is not reversible. * pallidotomy: rigidity and dyskinesia. * thalamotomy: Tremor. Deep brain stimulation – used for rigidity or tremor. * globus pallidus. * subthalamic nuclei. Fetal cell transplants – research has not shown a permanent benefit.
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Prosthetic management – overview of types available
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* mechanical and electronic prosthetic devices. * oral prosthesis. * voice amplification devices. * biofeedback devices. * pacing devices. * AAC device
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Behavioral management primary goal
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* to maximize communication with whatever means will produce the most rapid, effective, and natural results; the principal is to get the results in the shortest time possible
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The four principles of neural plasticity and motor learning
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* intensity or treatment frequency is the primary way to see results. * complexity need to be high & task spontaneous. * saliency determined with family input. * use it or lose it / use it and improve it
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Intensity for motor learning
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* frequency of at least 4 times a week. * force & resistance to the point of fatigue. * repetitions SLP to model then require mass drills. * effort needs to be high. * accuracy needs to be high. * fatigue should set in before stopping the activity
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Complexity for motor learning
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* targeting multiple motor tasks with complex & spontaneous tasks. * raising demands by varying communicative contexts – i.e. adding dual cognitive / motor tasks, increasing durations and difficulty of speaking tasks.
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Saliency for motor learning
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* tasks specificity refers to practicing tasks that target the movement goal, would include real speech tasks. * salient tasks are chosen by the client because they are relevant or emotionally rewarding, activate the brain, i.e. basal ganglia and may increase motivation. * saliency is incorporated in therapy by using positive feedback, providing homework to be completed in social interactions, and selecting familiar movements for speech
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Use it or lose it / use it and improve it for motor learning
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* incorporate target behavior during everyday activities, which provides the opportunity for continuous practice
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Principles of motor learning and skill acquisition
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* acquisition of behavior in the practice context; reflected in improvements seen at the end of treatment, i.e. block design of mass practice. * retention of behaviors in untrained context, i.e. during a quick assessment on a follow-up visit. * use of block design in therapy for acquisition but distributed practice for retention and generalization.
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Paradigm shifts for motor speech therapy / a new evidence-based approach
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* model for the client to change behavior and do not give unnecessary reinforcement. * minimize clinical explanations. * push the patient, even to the level of discomfort. * each treatment activity or therapy session is exercise
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Teach patients how to do the exercise for oral motor therapy
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* model it; show don’t tell. * shape it; increase desirable behavior with correct stimulus. * effort; drive muscle activation. * stabilize; using repetitions and reinforce. * calibrate; retain sensory perceptions i.e. ask what did your family say when they noticed this? Or; use an external by having them leave you a voicemail that you can listen to together.
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Controversial practices / oral motor therapies
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* oral motor therapy are considered pseudoscience, which claims to be based on the scientific method but it is not * not only is there no empiral evidence to support the use of nonverbal oral motor exercises/ therapies, but clinicians may also lack the foundational information needed to judge the theoretical soundness of unstudied treatment strategies
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Respiration prosthetic assistance ideas
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* abdominal binders or corsets. * expiratory board or paddle. * Posture may also be an issue, i.e. a person in a wheelchair given support could have a board strapped across their chest they can lean on for more airflow.
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Types of Behavioral management for respiration
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* relaxation and postural support * increasing respiratory support * behavioral compensation
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Behavioral management for respiration / Relaxation and postural support
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* myofascial release – swallowing, speech, and voice- release tension through deep massage; relax the neck. * stretching the muscles around the neck to loosen them can also offer benefit
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Behavioral management for respiration / Increasing respiratory support
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* water glass manometer. * TriFlo; this looks like 3 ping pong balls in tubes. * See-Scape. * controlled exhalation tasks: To increase respiratory capacity and control of exhalation. * deep and forceful inhalation * inspiratory checking * Doing this with controlled exhalation leads to:* * maximum vowel prolongation * optimal breath group * longer phrases and sentences * respiratory muscle strengthening
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Behavioral management for respiration / Behavioral compensation
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* glossopharyngeal breathing *called frog breathing;* involves a series of six to ten gulps, using the lips, tongue, pharynx, and larynx to pull air into the lungs when the normal inspiratory muscles are not functioning. * they inhale with nose and exhale with mouth. * if a ventilator stops, they can do this. * neck breathing – uses sternocleidomastoid, scalene, and trapezius muscles of the neck to bring to-and-fro displacement of the rib cage for inspiration
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Phonation: medical intervention
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* medialization laryngoplasty; AKA laryngeal framework surgery. * thyroplasty type 1: a reversible surgical procedure, during which a wedge-shaped block of Silicone is inserted into the parathyroid pocket to medialize the paralyzed Vocal Folds. *used when 1 VF is paralyzed; you make it more medial.* * may also help with swallowing. * arytenoid adduction: a reversible procedure for correcting a large posterior glottal gap; the tip of arytenoid’s muscular process is pulled forward and, in turn, rotate vocal process posteriorly as well as pull vocal ligament medially; sutured up for a smaller opening.
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Vocal fold injections
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* Teflon injection- irreversible procedure, makes weaker Vocal Folds bigger but this has been stopped as Teflon was a poor choice and not removable. * Rediesse injection- mineral constituent of bone and teeth, highly biocompatible and of potential for long-term (1-year) and even permanent VF augmentation
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Neuromuscular pedicle reinnervation
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* to re-innervate adductors / tensors of the Vocal Folds; feasible only for people whose voices must not be satisfactory but as close to perfect as possible; the only technique that restores pitch control ability as well as medializes paralyzed Vocal Folds; for weak vocal folds, not paralyzed.
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Recurrent laryngeal nerve resection
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* to induce a unilateral Vocal Fold paralysis in patients with spasmodic dysphonia; initial success rate of 100% only 10-36% of patients maintain improvement. * one side of the recurrent laryngeal nerve is cut; over time it will often regenerate.
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Botulinum toxin injection
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* to temporarily weakens laryngeal muscles in patients with Spasmodic Dysphonia; high success rates; effective up to 4 months. *Adductor SD in thyroarytenoid muscle* *Abductor SD in posterior cricoarytenoid muscle*
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Prosthetic assistance for phonation
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* amplifier. * vocal intensity controller for volume; good for Parkinson’s. * artificial larynx used when larynx is removed by placing firmly against throat; sounds like a robot voice. * neck braces and cervical collar can be used to push against the paralyzed vocal fold.
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Behavioral management for phonation – hypoadductory larynx
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* effort closure techniques, i.e. pushing palms together or pushing up from a chair. * initiating phonation in beginning of exhalation; a SeaScope can be used to show when to initiate. * digital manipulation using fingers to press thyroid. * head-turning and chin tuck-in posture by turning head to paralyzed side and looking down to medialize the vocal fold. * hard glottal attack using a cough of glottal coup.
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Behavioral management for phonation – hyperadductory larynx
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* relaxation. * yawn-sigh; i.e. letting out a sigh. * vowel prolongation. * soft voice onset
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Behavioral management for phonation – Ataxic dysphonia
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*They will have tremor, onset, and offset irregularities.* * laryngeal timing and coordination exercises
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Resonance: medical intervention
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* pharyngeal flap surgery creates a fillet for hypernasality / typically for cleft palate; this closes the velopharyngeal wall but not all the way. * sphincter pharyngoplasty is not used for a stroke, but only a cleft.
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Resonance: Prosthetic assistance
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* palatal lift looks like a retainer attached to teeth with an extension at the back. used for a paralyzed soft palate. * nasal obturator; which is a nasal filter plugged with putty.
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Resonance: Behavioral management facilitation techniques
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* pressure. * icing; usually with a Q-tip. * brushing and stroking. * electrical stimulation. *expert opinion is these don’t work.*
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Resonance: Inhibition techniques for spastic dysarthria
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* prolonged icing. * pressure to muscle insertion points. * slow and irregular stroking and brushing. * relaxation and desensitization works well and is often necessary. For cerebral palsy use pressure so over time the gag reflex is reduced.
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Resonance: Controlling nasality and nasal emission
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* See-scape. * nasometry is a game to teach a child to control nasality. * listening device such as a long straw from the nose to the ear.
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Articulation: medical intervention
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* neural anastomosis is where the nerve is cut and grafted back and may be used for Bell’s Palsy. * Botox injection for management of spasms, torticollis, Meig’s syndrome, oral-mandibular dystonia
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Articulation: Prosthetic assistance
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* mechanical and electronic prosthetic devices which may be used for slurred speech. * speech enhancer dot com is one company.
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Articulation: Behavioral management
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* stabilization; bite block for hyperkinetic dysarthria; can be a rubber block of bite bar. * strengthening. * stretching; myofascial release for spastic conditions. * biofeedback. EMG. Linguagraphia; a retainer-like device made from dental mold that measures where the tongue touches so the patient can visually see it. * Articulation therapy for strokes or dementia * traditional * multi-sensory sitmulation
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Articulation: Rate very slow or fast; prosthetic assistance
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* delayed auditory feedback for fluency to slow speech. * pacing devices, i.e. a metronome; good for apraxia but make sure to fade. a pacing board for Parkinson’s. * interactive metronome for ADHD to improve timing and give motor practice. it measures the ability to keep pace. * alphabet board supplementation
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Articulation: Behavioral management for rate
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* hand and finger tapping. * visual feedback. * rhythmic cueing. * increasing loudness will slow the speaker down.
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Prosody and naturalness behavioral management for rate
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breath group. * respiratory and phonatory control. * proper phrasing. Across breath group. Contractive stress tasks. Modifying loudness, pitch, and duration
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Lee Silverman Voice Treatment clinical applications
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* Parkinson’s disease and other neurological conditions. * Over 20 years of EBP.
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Purposes of LSVT
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* to improve vocal fold adduction and overall speech. * to increase vocal effort to improve loudness, which then improve respiratory drive, vocal fold adduction, laryngeal muscle activity and coordination, laryngeal and supralaryngeal articulatory movements and vocal tract configurations
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LSVT: Therapy procedures
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* total of 16 therapy sessions, one hour each, over 4 week period. * first 30 minutes in each session focuses on drill exercises: increasing sustained vowel phonation, increasing pitch range, increasing functional loudness. * last 30 min focuses on speech of increased complexity. Week 1 – words and phrases. Week 2 – sentences and short reading tasks. week 3 – longer reading material and short conversations. week 4 – conversations.
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LSVT: more Therapy procedures
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* homework assignment every day. * after therapy is over, daily speech exercises are maintained with practice forever. * typically 15 minutes at home each morning.
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LSVT: Five essential concepts
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* voice is soft, more volume is needed. * high effort targeting complex motor movements and multiple muscles. * intensive treatment that can vary to 8 weeks but protocol is followed. * calibration is feedback from the clinician. * quantification because everything is measured and documented. * also useful for cerebral palsy, TBI, tremor.*
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See-scape purpose
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* to detect and provide instant visual feedback on the nasal emission of air during speech. * to be used as a visual biofeedback tool when treating resonance and respiratory support problems. *for visual feedback of nasal emission and data collection.*
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See-scape clinical applications
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* velopharyngeal incompetence. * respiratory inefficiency. * respiratory-phonatory coordination
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Therapy techniques with See-scape
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* relaxation and postural support. * pressure generating exercises. * prolonged inhalation exercises. * quick breathing exercises. * inhale / Exhale sync. exercises. * isolated sound production exercises. * connected speech breathing exercises. * measure subglottal air pressure and nasal airflow.
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Metronome clinical applications
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* fluency: stuttering * prolongation
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Metronome can be used with
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* speaking rate control: Parkinson’s disease, ataxic dysarthria * automatic oromoter control: apraxia of speech
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Purposes of metronome
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* to pace all speech and oromotor control tasks such as timing, rate, and rhythm.
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Procedures of the metronome
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* planning * familiarization * establishment * stabilization * transfer * maintenance
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Bite-block clinical applications
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* hyperkinetic dysarthria * spastic dysarthria * flaccid dysarthria * oro-neuromoter immaturity, interruptive jaw activity
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Purposes of bite block
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* jaw stabilization * reduction of jaw hypertonicity * jaw, tongue, lip strengthening and stretching
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Therapy techniques of bite block
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* dental putty, acrylic bite-blocks, resistance block, crossbar apparatus. * always immediately follow-up with speech tasks; oral motor exercise without speech is useless.
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Therapy techniques of bite block; dental putty
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* jaw hypertonicity exercise. * tongue force physiology exercise. * lip force physiology exercise. * lip strengthening exercise.
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Therapy techniques of bite block; resistance block
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* tongue strengthening exercise. * lip strengthening exercise.
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Therapy techniques of bite block; crossbar apparatus
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* tongue strengthening exercise. * lip strengthening exercise. * jaw strengthening exercise.
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Speech enhancer
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* automated speech processing system for electronic speech clarification and functional voice volume. * Dispensed by a company trained SLP. * cleans up speech formants.
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Clinical applications of the speech enhancer
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* moderate to severe dysarthria * aphonia, dysphonia, * ventilator dependence, tracheotomy * laryngectomy * deafness
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Purposes of speech enhancer
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* to help clarify and enhance the speech sound signal to aid in restoring volume and increasing the accuracy of speech recognition.
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Procedures of the speech enhancer
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* the system functions by using the person’s own speech and analyzes & modifies the articulation, resonation, and phonation.
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Speech enhancer cost
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* approximately $6,000. * insurance may cover if it is “medically necessary”.
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AAC
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* symbols, aids, strategies, techniques used by individuals to improve successful communciation
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Clinical application of AAC
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* congential disorders, i.e. Cerebral Palsy, Autism Spectrum Disorder, Down syndrome, ID. * acquired disorders, i.e. TBI, Stroke. ventilator dependency. * progressive disorders, i.e. ALS, Parkinsons, MD, MS, Huntington’s, Alzheimer’s.
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Purposes of AAC
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* to augment speech. * to improve intelligibility. * to improve successful communication exchange in different speaking situations. * to provide alternate communciation.
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Prerequisites for successful AAC use
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* purposeful response to environment. * adequate cognitive states, i.e. alert, initiating intentional communication. * generally oriented. * adequate language skills to support symbolic communication. * motor response. * sensory/ perceptual skills, i.e. vision. * cognitive and language skills.
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Types of AAC
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* unaided. * low-tech. * high-tech.
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Unaided AAC
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* gestures. * facial expressions. * sign language.
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Low-tech AAC
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* writing. * word or picture or alphabet board. * eye gaze board.
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High-tech AACs
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* computer software. * technology interface.
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AAC evaluation considerations
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* candidacy, i.e. acute or chronic. * access, i.e. direct or scan. * cognitive skills & memory. * language skills & literacy. * user maintenance support. * resources; such as cost or available funding.

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