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Changes in speech production associated with alphabet supplementation

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Hustad and Lee (2008)

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12 speakers with dysarthria. Obtained speech samples while using alphabet board supplementation. 120 listeners transcribed

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Hustad and Lee (2008) Methods

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Higher intelligibility and greater pause frequency. Slower rate. Increase in vowel/word duration, and vowel space

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Hustad and Lee (2008) Results

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Allows a listener to distinguish between vowels. All not being pressed into schwa. Opens the mouth more

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Increasing vowel space

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Severity is more important than dysarthria type. Someone who can handle cognitive demands, can access letters, can be an active participant, have enough fine motor control to use board

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Candidate for alphabet board speech supplementation

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Decreasing rate

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An alphabet board is most effective for

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Useless and hard to implement. Easy for pt to ignore, need continuous cues

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Pacing board

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Possible but less likely. Active participator in communication when using this

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Can you ignore alphabet board?

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Data sheet, alphabet board, what to score, short term goal (in session), transfer goal (diff materials/setting), and retention goal (assessed at later date)

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Review tapes-Supplement strategies alphabet supplementation practice

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What pt brings to you that is clinically relevant to them that affects what you plan for therapy

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Internal evidence

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Impairment, level of disability, amount of previous therapy person has already had

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Identifying tx candidates-consider internal evidence

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1). Pt may not want to do what you suggest 2). Clinician may also say no more to therapy. Counsel pts out of therapy if they've tried everything and at their fx limit

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Challenge with internal evidence

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Substantial impairment before fx limitation becomes a disability

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Someone with minimal communication needs may experience

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With a career/lifestyle where they are required to speak a lot (ex. preacher)

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Mild impairment may be a concern for someone

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Make it known that normal performance can almost never be achieved. But say, "we are going to try and get you to be as fx as possible". Some compensatory strategies may move speech further than normal

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Setting tx goals

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Maximize or optimize effective communication in any way you can to become effective communicators. Comprehensibility framework

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Overall goal of therapy

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Any way at all to communicate. Alphabet board. Basic low tech communication book

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Most important immediate goal

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Find the 1 thing the client could do that would have the greatest impact on intelligibility. Always want to find this. Should be simple, basic, but effective

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What behavior to work on 1st?

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Influence of each component on speech production/intelligibility, degenerative vs chronic disease?, time available for intervention

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Considerations for choosing behaviors

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Stable (chronic) vs getting worse (degenerative)

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Main consideration

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If limited, the clinician will have to maximize intelligibility with compensatory strategies, rather than address individual components

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Time available for Ix

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Work at highest level the person is able to perform (optimal challenge) and you do not need to start every session with oral motor exercises

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Working on behaviors in Ix

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Initially they may focus on improving individual subsystems and as the person improves, can focus on speech as a whole

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Goals will evolve

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34 yr old male severe TBI in MVA. Decreasing words/min by half (60 wpm) of what pt normally does increased his intelligibility from 44% to 72%

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McHenry and Wilson (1994)

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Palatal lift, rate reduction, illustration of artic positions, phonetic transcriptions

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McHenry and Wilson (1994) intervention

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Highly structured, 1 sentence at a time, look for listener reaction, often required verbal/gestural cue to stop speaking after a single utterance

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McHenry and Wilson (1994) language intervention

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The patient abandoned the lift and left program after 8 months. However, it is possible to make a clinically significant difference in intelligibility with a combination of interventions (not just 1)

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McHenry and Wilson (1994) results and conclusion

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Whole body or system by system. Should focus more on whole body (for generally reduced intelligibility)

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Approaches to dysarthria treatment

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Changing 1 feature of speech has changes throughout physiological systems. Good for general reduced intelligibility

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Whole body approach

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Very simple cue for client. Always ideal to try to make biggest change with simplest intervention

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Advantage to whole body approach

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Manipulate vocal effort, reduce speaking rate, and clear speech

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Whole body approaches

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"Being loud", Maximizes motor unit recruitment across ALL physiological systems.

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Plausible physio rationale for increased vocal effort

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Respiration (take bigger breaths), Lx (increased VF adduction), VP (more complete closure), Articulatory (increased precision). All this happens with single cue "Talk loud"

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What happens across systems?

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All based on LSVT. Typically used for individuals with Parkinson's disease (hypokinetic dysarthria)

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Efficacy data to support increased vocal effort

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Exclusive voice focus, multiple repetitions of high effort productions, intensive tx, enhance sensory awareness of increased vocal loudness, quantification of behavior

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Key concepts of LSVT

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Increasing vocal effort improves articulatory precision. May increase stability

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Support for whole body effect

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5 speakers with PD, 2 groups of listeners. Read with loud speech and habitual speech. Listeners identification of loud was 8% higher than amplified and 11% higher than habitual sentences. Increased vocal effort increases intelligibility. Increased loudness does not impact artic precision

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Effect of increasing loud and amplification of speech on sentence and word intelligibility in PD

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Perceptual analysis of artic precision and intelligibility. Acoustic analysis of vowel formant space. Sig increased intelligibility at follow up in LSVT group. No sig difference between groups

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Changes to artic following LSVT and traditional dysarthria tx (2010)

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LSVT increased acoustic vowel space (F1/F2). Greater acoustic vowel space implies more tongue mx. Better distinction among the different vowels

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Impact of LSVT on vowel articulation in PD

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6 individuals with dysarthria produced phrases across habitual, loud, and slow conditions. Measured # of words perceived accurately. Loud conditions always perceived to be more intelligible.

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More support for impact of increased loudness on intelligibility

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Loud

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Are people more willing to be loud or slow?

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Those with mild and moderately reduced intelligibility. Will not work for someone with severely reduced intelligibility

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Who will being loud work for?

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Audibility is how well an utterance can be heard. Intelligibility is how much of an utterance is understood. An utterance can be heard without being understood

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What's the difference between intelligibility and audibility

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Isn't enough to make a difference in intelligibility

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Audibility with amplification

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Rigid (pacing board, alphabet board) or stretched vs breaks between words

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Rate control strategies

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Helps reach articulatory targets and increases processing time. Maybe use for flaccid dysarthria or someone with mild impairment

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Stretched control strategy

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Robotic sounding. Only used for severely reduced intelligibility.

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Breaks between words

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May use for someone who aren't literate or do not have motor control for pacing board

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Breaks between words-other considerations

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Gives articulators more time to reach targets, lets listener know breaks between words, gives listener more processing time

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Physiologic and linguistic justification for rate reduction strategies

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Severity, dysarthria type, and determining if supplementation is needed

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How to determine breaks vs stretched strategy?

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Stretching words. Intelligibility may be affected by muscle weakness causing imprecise articulation. This strategy may bring them to perfect intelligibility

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Someone with Flaccid dysarthria may benefit from which strategy?

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Supplementation

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If severely reduced intelligibility, what is necessary?

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People hate speaking slowly, would rather repeat. It's an unnatural interaction (alphabet board), requires external device. Naturalness vs intelligibility trade off

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Caveat to rate control strategies

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Say you are helping the listener, use "stretching" instead of speaking slowly, take data and show the client the results

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Ways to convince pt to use rate control strategies

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Increases articulatory precision (greater artic pressure and vowel space). Decreases rate by increasing vowel duration.

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Clear speech strategy

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Recorded in habitual speaking condition when instructed to "read as if they were speaking to a familiar person" and then "read as if they were talking to a listener with a hearing loss/non native speaker"

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Clear speech in older adults

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Individuals exaggerated articulation, slowed down, and spoke louder. # of pauses and their duration increased (almost 2x as much). Syllables/second decreased.

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Results of clear speech

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Individual differences in improvement due to pauses and speaking rate using clear speech. Intelligibility based on if they were slowing rate or putting pauses in speech

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Results of intelligibility in noise

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12 neuro typical participants. Sentences in different speaker conditions. Listeners judged with multi-talker babble. Instructions varied by "speak clearly" "speak if someone is hearing impaired" and "over enunciate each word"

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Clear speech strategies (2013) Study

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Over-enunciation condition led to greatest intelligibility

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Which condition of the (2013) study showed the most change?

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We want the patient to open their mouth more and slow rate down. No matter what instruction they need to do that, use it. As long as the behavior changes.

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Do instructions matter?

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Both clear and loud improved intelligibility across groups. No improvement with slow speech with stretching words (possible due to prosodic changes)

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Clear vs loud vs slow speech

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8 participants with non progressive dysarthria. Mild to severe dysarthria. All participants started out with 80-95% intelligibility

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Be clear (Park 2016)

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Follows motor learning framework. Uses functional phrases. Homework. Transfer tasks (phone calls)

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Be clear treatment

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Increased but all initially started with high intelligibility. To make the results more interesting, add noise to make it harder for the listener to see if the method really made a difference

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Be clear results

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Client/clinician problem solve. Ask client to produce speech as clearly as possible then use video to see which strategy was most effective. Watch video and decide together. Blend internal and external evidence to decide on strategy. Takes pt's preference into consideration

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Clear speech therapy example (2014)

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Intensive treatment, randomized practice (in therapy session), and home practice

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Treatment within motor learning framework of clear speech

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All topics salient and relevant to client. Include functional "service" questions, include functional phrases.

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Practice guidelines

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Ask other people/family to help create them

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Generating functional phrases

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Randomly in session mix: conversation, reading, functional service questions, and functional phrases

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Random practice

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Should be structured. All levels. Specify time/conversational partner. Client/partner time clarity. Transfer behavior outside of clinic.

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Home practice

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Probe all levels 1 week later. Same stimuli (retention), different stimuli (generalization). Do not use cues. Assess at beginning of session

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How to assess learning?

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Severity!!

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Remember judgment of strategy used will be based on

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Increasing vocal effort improves physiology across all systems (loud). Reducing rate with alphabet board can increase intelligibility by 25%. Over-enunciation improves intelligibility. The more severe the problem, the more signal independent (non speech) info is needed

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Conclusion for whole body strategies

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Probably don't need alphabet board supplementation, but need something. Try increasing loudness. This should work regardless of dysarthria type besides spastic.

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Strategies for: 50-75% intelligible

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Breaks

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For spastic dysarthria a strategy you may use

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Clear speech, cues (talk to me like I'm hearing impaired), talk to me from across the room. Find cue that makes them change behavior. Loudness could work too.

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Mildly reduced intelligibility

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Focus on individual subsystem (resp, lx, resonance, VP). Can be appropriate if the dysarthria is system specific

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System by system approach

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Individual with ONLY VP issue. Addressing VP port for hypernasality.

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System by system most appropriate for

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When challenging 1 system will make a difference in intelligibility. Typically used for mild/mod dysarthria. More severe usually require a more global approach.

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System specific strategies

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Rarely effective to treat in isolation (unless mild and isolated). What to do instead? Global strategy. Do not to oral motor exercises.

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Articulatory system

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Remember listener training for familiarization and focus on global strategy.

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Overall summary

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