Motor Speech Quiz 5

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Hustad and Lee (2008)
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Changes in speech production associated with alphabet supplementation
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Hustad and Lee (2008) Methods
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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) Results
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Higher intelligibility and greater pause frequency. Slower rate. Increase in vowel/word duration, and vowel space
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Increasing vowel space
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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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Candidate for alphabet board speech supplementation
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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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An alphabet board is most effective for
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Decreasing rate
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Pacing board
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Useless and hard to implement. Easy for pt to ignore, need continuous cues
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Can you ignore alphabet board?
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Possible but less likely. Active participator in communication when using this
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Review tapes-Supplement strategies alphabet supplementation practice
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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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Internal evidence
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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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Identifying tx candidates-consider internal evidence
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Impairment, level of disability, amount of previous therapy person has already had
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Challenge with 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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Someone with minimal communication needs may experience
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Substantial impairment before fx limitation becomes a disability
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Mild impairment may be a concern for someone
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With a career/lifestyle where they are required to speak a lot (ex. preacher)
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Setting tx goals
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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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Overall goal of therapy
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Maximize or optimize effective communication in any way you can to become effective communicators. Comprehensibility framework
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Most important immediate goal
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Any way at all to communicate. Alphabet board. Basic low tech communication book
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What behavior to work on 1st?
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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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Considerations for choosing behaviors
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Influence of each component on speech production/intelligibility, degenerative vs chronic disease?, time available for intervention
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Main consideration
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Stable (chronic) vs getting worse (degenerative)
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Time available for Ix
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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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Working on behaviors in 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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Goals will evolve
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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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McHenry and Wilson (1994)
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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) intervention
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Palatal lift, rate reduction, illustration of artic positions, phonetic transcriptions
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McHenry and Wilson (1994) language 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) results and conclusion
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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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Approaches to dysarthria treatment
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Whole body or system by system. Should focus more on whole body (for generally reduced intelligibility)
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Whole body approach
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Changing 1 feature of speech has changes throughout physiological systems. Good for general reduced intelligibility
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Advantage to 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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Whole body approaches
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Manipulate vocal effort, reduce speaking rate, and clear speech
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Plausible physio rationale for increased vocal effort
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“Being loud”, Maximizes motor unit recruitment across ALL physiological systems.
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What happens across systems?
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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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Efficacy data to support increased vocal effort
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All based on LSVT. Typically used for individuals with Parkinson’s disease (hypokinetic dysarthria)
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Key concepts of LSVT
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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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Support for whole body effect
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Increasing vocal effort improves articulatory precision. May increase stability
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Effect of increasing loud and amplification of speech on sentence and word intelligibility in PD
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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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Changes to artic following LSVT and traditional dysarthria tx (2010)
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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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Impact of LSVT on vowel articulation in PD
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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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More support for impact of increased loudness on intelligibility
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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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Are people more willing to be loud or slow?
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Loud
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Who will being loud work for?
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Those with mild and moderately reduced intelligibility. Will not work for someone with severely reduced intelligibility
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What’s the difference between intelligibility and audibility
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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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Audibility with amplification
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Isn’t enough to make a difference in intelligibility
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Rate control strategies
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Rigid (pacing board, alphabet board) or stretched vs breaks between words
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Stretched control strategy
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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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Breaks between words
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Robotic sounding. Only used for severely reduced intelligibility.
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Breaks between words-other considerations
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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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Physiologic and linguistic justification for rate reduction strategies
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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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How to determine breaks vs stretched strategy?
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Severity, dysarthria type, and determining if supplementation is needed
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Someone with Flaccid dysarthria may benefit from which 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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If severely reduced intelligibility, what is necessary?
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Supplementation
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Caveat to rate control strategies
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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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Ways to convince pt to use 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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Clear speech strategy
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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 in older adults
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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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Results of clear speech
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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 intelligibility in noise
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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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Clear speech strategies (2013) Study
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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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Which condition of the (2013) study showed the most change?
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Over-enunciation condition led to greatest intelligibility
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Do instructions matter?
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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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Clear vs loud vs slow speech
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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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Be clear (Park 2016)
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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 treatment
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Follows motor learning framework. Uses functional phrases. Homework. Transfer tasks (phone calls)
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Be clear results
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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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Clear speech therapy example (2014)
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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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Treatment within motor learning framework of clear speech
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Intensive treatment, randomized practice (in therapy session), and home practice
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Practice guidelines
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All topics salient and relevant to client. Include functional “service” questions, include functional phrases.
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Generating functional phrases
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Ask other people/family to help create them
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Random practice
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Randomly in session mix: conversation, reading, functional service questions, and functional phrases
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Home 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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How to assess learning?
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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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Remember judgment of strategy used will be based on
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Severity!!
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Conclusion for whole body strategies
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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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Strategies for: 50-75% intelligible
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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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For spastic dysarthria a strategy you may use
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Breaks
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Mildly reduced intelligibility
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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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System by system approach
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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 most appropriate for
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Individual with ONLY VP issue. Addressing VP port for hypernasality.
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System specific strategies
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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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Articulatory system
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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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Overall summary
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Remember listener training for familiarization and focus on global strategy.

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