Treatment for Acquired Apraxia of Speech: A Systematic Review of Intervention Research Between 2004 and 2012

Verbal and oral apraxia in patients with acute stroke: Frequency, relationship, and some risk factors

Verbal and oral apraxia are two possible consequences of stroke. It seems that there are not sufficient studies regarding the frequency of these disorders. This study aimed to evaluate the frequency of Verbal and oral apraxia. In addition, the relationship between apraxia and some variables such as age, gender, and education, as well as the relationship between types of apraxia with each other, and damaged areas of the brain in apraxia of the oral system in Persian-speaking patients with stroke were studied. In this descriptive-analytical study, 42 patients participated using the convenient sampling method. Verbal and oral apraxia were assessed using the oral and verbal apraxia tasks for adults test. Data were analyzed using independent t-test, Chi-square, and Fisher's exact test. The frequency of patients with oral apraxia was 35.7%, those with verbal apraxia was 2.3%, and the combination of both verbal and oral apraxia was 4.7%. People with apraxia were significantly older than those without apraxia. There was not any significant relationship between apraxia and gender, apraxia and education, and oral apraxia with verbal apraxia (p < 0.05). The present study's findings showed the high frequency of post-stroke apraxia and the high rate of its incidence with age.

A Comparison of Sound Production Treatment and Metrical Pacing Therapy for Apraxia of Speech: A Single-Case Experimental Design

PURPOSE

The purpose of this investigation was to compare the effects of two specific treatment protocols for acquired apraxia of speech (AOS): Sound Production Treatment (SPT) and Metrical Pacing Therapy (MPT), and to examine changes in communicative participation.

METHOD

Four speakers with chronic AOS and aphasia were each administered SPT and MPT in a replicated crossover design (ABACA/ACABA) with nonconcurrent multiple baselines across participants and behaviors. Treatment outcomes were compared with respect to whole word correctness (WWC) for treated and untreated multisyllabic word targets. Speech intelligibility was assessed using the Chapel Hill Multilingual Intelligibility Test, and communicative participation was measured using the Communicative Participation Item Bank at baseline, washout, and follow-up phases.

RESULTS

Three of the four participants experienced statistically significant improvements in WWC with SPT, and three of the four participants with MPT. Based on a priori criteria, three participants demonstrated relatively greater benefit from SPT and one participant demonstrated relatively greater benefit from MPT. There were measurable improvements in intelligibility following SPT for three of the four participants. Only one participant in this investigation reported a significant change in communicative participation, and only following MPT.

CONCLUSIONS

This study demonstrated that individuals in the chronic stages of AOS can benefit from both SPT and MPT, corroborating prior research on articulatory kinematic and rate and/or rhythm control treatment approaches. It contributes a comparison of two protocols for AOS with respect to whole word targets, intelligibility, and individual self-report of communicative participation changes. More participants showed a relative advantage of SPT over MPT. One individual reported communicative participation improvement after MPT.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23971929.

The Impact of Telehealth on the Efficacy of Sound Production Treatment

PURPOSE

This investigation was designed to systematically examine the acquisition, maintenance, and response generalization effects of Sound Production Treatment (SPT) delivered via telehealth in comparison to existing in-person outcomes for SPT.

METHOD

A multiple-baseline design across behaviors and participants was used with two individuals with chronic apraxia of speech (AOS) and aphasia. Accuracy of target speech sounds in treated and untreated words within phrases served as the dependent variable.

RESULTS

Both participants demonstrated positive gains for treatment and generalization items. Participant 1 demonstrated gains for both sets of treatment items with the application of treatment, but production accuracy at 2 and 6 weeks posttreatment was inconsistent. Participant 2 demonstrated large gains for both sets of treatment items with good maintenance at 2 and 6 weeks posttreatment. Effect sizes for both participants were similar to the traditional (in-person) SPT effect size benchmarks.

CONCLUSIONS

The positive outcomes from this study indicate that individuals with AOS can benefit from SPT delivered via telehealth. These findings warrant further research examining the effects of SPT through telehealth and should include individuals with AOS with varying severity. This investigation serves as the first telehealth study to systematically examine treatment outcomes for SPT.

Normative Values for Word Syllable Duration With Interpretation in a Large Sample of Stroke Survivors With Aphasia

PURPOSE

Slow speech rate and abnormal temporal prosody are primary diagnostic criteria for differentiating between people with aphasia who do and do not have apraxia of speech. We sought to identify appropriate cutoff values for abnormal word syllable duration (WSD) in a word repetition task, interpret them relative to a data set of people with chronic aphasia, and evaluate the extent to which manually derived measures could be approximated through an automated process that relied on commercial speech recognition technology.

METHOD

Fifty neurotypical participants produced 49 multisyllabic words during a repetition task. Audio recordings were submitted to an automated speech recognition (ASR) service (IBM Watson) to measure word duration and generate an orthographic transcription. The transcribed words were compared to a lexical database, and the number of syllables was identified. Automatic and manual measures were compared for 50% of the sample. Results were interpreted relative to WSD scores from an existing data set of 195 people with mostly chronic aphasia.

RESULTS

ASR correctly identified 83% of target words and 98% of target syllable counts. Automated word duration calculations were longer than manual measures due to imprecise cursor placement. Upon applying regression coefficients to the automated measures and examining the frequency distributions for both manual and estimated measures, a WSD of 303-316 ms was found to indicate longer-than-normal performance (corresponding to the 95th percentile). With this cutoff, 40%-45% of participants with aphasia in our comparison sample had an abnormally long WSD.

CONCLUSIONS

We recommend using a rounded WSD cutoff score between 303 and 316 ms for manual measures. Future research will focus on customizing automated WSD methods to speech samples from people with aphasia, identifying target words that maximize production and measurement reliability, and developing WSD standard scores based on a large participant sample with and without aphasia.

Behavioral Treatment for Speech and Language in Primary Progressive Aphasia and Primary Progressive Apraxia of Speech: A Systematic Review

Primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS) are neurodegenerative syndromes characterized by progressive decline in language or speech. There is a growing number of studies investigating speech-language interventions for PPA/PPAOS. An updated systematic evaluation of the treatment evidence is warranted to inform best clinical practice and guide future treatment research. We systematically reviewed the evidence for behavioral treatment for speech and language in this population. Reviewed articles were published in peer-reviewed journals through 31 May 2021. We evaluated level of evidence, reporting quality, and risk of bias using a modified version of the American Speech-Language Hearing Association (ASHA) Levels of Evidence, an appraisal point system, additional reporting quality and internal/external validity items, and, as appropriate, the Single Case Experimental Design Scale or the Physiotherapy Evidence Database - PsycBITE Rating Scale for Randomized and Non-Randomized Controlled Trials. Results were synthesized using quantitative summaries and narrative review. A total of 103 studies reported treatment outcomes for 626 individuals with PPA; no studies used the diagnostic label PPAOS. Most studies evaluated interventions for word retrieval. The highest-quality evidence was provided by 45 experimental and quasi-experimental studies (16 controlled group studies, 29 single-subject designs). All (k = 45/45) reported improvement on a primary outcome measure; most reported generalization (k = 34/43), maintenance (k = 34/39), or social validity (k = 17/19) of treatment for at least one participant. The available evidence supports speech-language intervention for persons with PPA; however, treatment for PPAOS awaits systematic investigation. Implications and limitations of the evidence and the review are discussed.

Three-Dimensional Speech Profiles in Stroke Aphasia and Apraxia of Speech

PURPOSE

Behaviorally, acquired apraxia of speech (AOS) is a multidimensional syndrome that the experienced clinician recognizes based on impaired articulation and abnormal temporal prosody. We conducted this study to determine the extent to which three core features of AOS-when defined quantitatively-distinguish categorically among aphasia with no or minimal speech sound involvement, aphasia with AOS, and aphasia with phonemic paraphasia (APP).

METHOD

The study involved retrospective analysis of 195 participants with stroke-induced aphasia. We used three quantitative measures (phonemic error frequency, distortion error frequency, and word syllable duration [WSD]) to divide the sample into four participant groups according to the most likely speech diagnosis: aphasia with minimal speech sound errors, AOS, APP, and a borderline group with mixed profiles. We then conducted nonparametric comparisons across groups for which the measures were not defined and visualized all three measures in a three-dimensional graph.

RESULTS

The measures distributed as multidimensional spectra rather than discrete diagnostic entities, and there was considerable behavioral overlap among participant groups. Thirty percent of participants presented with aphasia with minimal sound production difficulties, and they were statistically indistinguishable from the APP group on distortion frequency and WSD. Distortion frequency and WSD were in a borderline region between AOS and APP for 29% of participants. Compared to all other groups, participants with AOS produced significantly more errors that affected listeners' phonemic perception.

CONCLUSIONS

The results suggest that the current AOS-APP dichotomy has limited validity. We conclude that a continuous multidimensional view of speech variation would be a constructive perspective from which to understand how the left cerebral hemisphere produces speech and that quantitative and normed speech measures should be used to inform differential diagnosis in clinical settings.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21807609.

Apraxia of Speech in the Spontaneous Speech of Nonfluent/Agrammatic Primary Progressive Aphasia

Background

Apraxia of speech (AOS) is a core feature of nonfluent/agrammatic primary progressive aphasia (naPPA), but its precise characteristics and the prevalence of AOS features in spontaneous speech are debated.

Objective

To assess the frequency of features of AOS in the spontaneous, connected speech of individuals with naPPA and to evaluate whether these features are associated with an underlying motor disorder such as corticobasal syndrome or progressive supranuclear palsy.

Methods

We examined features of AOS in 30 patients with naPPA using a picture description task. We compared these patients to 22 individuals with behavioral variant frontotemporal dementia and 30 healthy controls. Each speech sample was evaluated perceptually for lengthened speech segments and quantitatively for speech sound distortions, pauses between and within words, and articulatory groping. We compared subgroups of naPPA with and without at least two features of AOS to assess the possible contribution of a motor impairment to speech production deficits.

Results

naPPA patients produced both speech sound distortions and other speech sound errors. Speech segmentation was found in 27/30 (90%) of individuals. Distortions were identified in 8/30 (27%) of individuals, and other speech sound errors occurred in 18/30 (60%) of individuals. Frequent articulatory groping was observed in 6/30 (20%) of individuals. Lengthened segments were observed rarely. There were no differences in the frequencies of AOS features among naPPA subgroups as a function of extrapyramidal disease.

Conclusion

Features of AOS occur with varying frequency in the spontaneous speech of individuals with naPPA, independently of an underlying motor disorder.

Speech Motor Profiles in Primary Progressive Aphasia

PURPOSE

Previous research on motor speech disorders (MSDs) in primary progressive aphasia (PPA) has largely focused on patients with the nonfluent/agrammatic variant of PPA (nfvPPA), with few systematic descriptions of MSDs in variants other than nfvPPA. There has also been an emphasis on studying apraxia of speech, whereas less is known about dysarthria or other forms of MSDs. This study aimed to examine the qualitative and quantitative characteristics of MSDs in a prospective sample of individuals with PPA independent of subtype.

METHOD

We included 38 participants with a root diagnosis of PPA according to current consensus criteria, including one case with primary progressive apraxia of speech. Speech tasks comprised various speech modalities and levels of complexity. Expert raters used a novel protocol for auditory speech analyses covering all major dimensions of speech.

RESULTS

Of the participants, 47.4% presented with some form of MSD. Individual speech motor profiles varied widely with respect to the different speech dimensions. Besides apraxia of speech, we observed different dysarthria syndromes, special forms of MSDs (e.g., neurogenic stuttering), and mixed forms. Degrees of severity ranged from mild to severe. We also observed MSDs in patients whose speech and language profiles were incompatible with nfvPPA.

CONCLUSIONS

The results confirm that MSDs are common in PPA and can manifest in different syndromes. The findings emphasize that future studies of MSDs in PPA should be extended to all clinical variants and should take into account the qualitative characteristics of motor speech dysfunction across speech dimensions.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22555534.

Speech Therapy Interventions for Acquired Apraxia of Speech: An Updated Systematic Review

PURPOSE

This systematic review aims to summarize and evaluate the available literature on speech and language therapy interventions for acquired apraxia of speech since 2012.

METHOD

A systematic search in six electronic databases was performed from 2013 to 2020. The following primary outcomes were summarized: (a) improvement in targeted behaviors, (b) generalization, and (c) maintenance of outcomes. Moreover, studies were evaluated for the level of evidence and the clinical phase.

RESULTS

Of the 3,070 records identified, 27 studies were included in this review. The majority of the studies (n = 22) used articulatory kinematic approaches followed by intersystemic facilitation/reorganization treatments (n = 4) and other approaches (n = 1). According to the classes defined in Clinical Practice Guideline Process Manual (Gronseth et al., 2017), one was Class II, 10 were Class III, 10 were Class III-b (fulfill Class III criteria except for independence of assessors' criterion), and five were Class IV. In terms of clinical phase, one study classified as Phase III, 10 as Phase II, and 15 as Phase I.

CONCLUSIONS

Among the interventions for apraxia of speech, articulatory kinematic treatments have become prominent over the last 8 years. Focusing on self-administrated therapies, use of technology for therapy administration and development of treatments that focus on apraxia of speech and aphasia simultaneously were identified as new advancements in the apraxia of speech literature. The methodological quality, clinical phase, and level of evidence of the studies have improved within the past 8 years. Large-scale randomized controlled trials for articulatory kinematic approaches and future studies on other treatment approaches are warranted.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22223785.

The impact of visual and motor skills on ideational apraxia and transcortical sensory aphasia

BACKGROUND

Patients with extensive left hemisphere damage frequently have ideational apraxia (IA) and transcortical sensory aphasia (TSA). Difficulty with action coordination, phonological processing, and complex motor planning may not be indicative of higher-order motor programming or higher-order complex formation. We report on the effects of IA and TSA on the visual and motor skill of stroke patients.

PURPOSE

The study aims to address the question of whether IA and TSA in bilingual individuals are the results of an error of motor function alone or due to a combined motor plus and cognitive dysfunction effect.

METHOD

Twelve bilingual patients (seven males, and five females) were diagnosed with IA and TSA, and are divided into two groups of six patients. Then, 12 healthy bilingual controls were evaluated for comparing with both groups. Bilingual aphasia testing (BAT) and appropriate behavioral evaluation were used to assess motor skills, including coordination, visual-motor testing, and phonological processing.

RESULTS

Findings (pointing skills) show that the performance of the L1 and L2 languages are consistently significant (p < 0.001) in healthy individuals compared to the IA and TSA groups. Command skills for L1 and L2 languages were significantly higher in healthy individuals compared to IA and TSA controls (p < 0.001). Further, the orthographic skills of IA and TSA vs controls in both groups were significantly reduced (p < 0.01). Visual skills in the L1 language were significantly improved (p < 0.05) in IA and TSA patients compared to healthy controls after 2 months. Unlike orthographic skills which were improved in IA and TSA patients, languages in bilingual patients did not simultaneously improve.

CONCLUSION

Dyspraxia is a condition that affects both motor and visual cognitive functions, and patients who have it often have less referred motor skills. The current dataset shows that accurate visual cognition requires both cognitive-linguistic and sensory-motor processes. Motor issues should be highlighted, and skills and functionality should be reinforced along with the significance of treatment between IA and TSA corresponding to age and education. This can be a good indicator for treating semantic disorders.

Do People With Apraxia of Speech and Aphasia Improve or Worsen Across Repeated Sequential Word Trials?

PURPOSE

During motor speech examinations for suspected apraxia of speech (AOS), clients are routinely asked to repeat words several times sequentially. The purpose of this study was to understand the task in terms of the relationship among consecutive attempts. We asked to what extent phonemic accuracy changes across trials and whether the change is predicted by AOS diagnosis and sound production severity.

METHOD

One hundred thirty-three participants were assigned to four diagnostic groups based on quantitative metrics (aphasia plus AOS, aphasia-only, and aphasia with two borderline speech profiles). Each participant produced four multisyllabic words 5 times consecutively. These productions were audio-recorded and transcribed phonetically and then summarized as the proportion of target phonemes that was produced accurately. Nonparametric statistics were used to analyze percent change in accuracy from the first to the last production based on diagnostic group and a broad measure of speech sound accuracy.

RESULTS

Accuracy on the repeated words deteriorated across trials for all groups, showing reduced accuracy from the first to the last repetition for 62% of participants. Although diagnostic groups differed on the broad measure of speech sound accuracy, severity classification based on this measure did not determine degree of deterioration on the repeated words task.

DISCUSSION

Responding to a request to say multisyllabic words 5 times sequentially is challenging for people with aphasia with and without AOS, and as such, performance is prone to errors even with mild impairment. For most, the task does not encourage self-correction. Instead, it promotes errors, regardless of diagnosis, and is, therefore, useful for screening purposes.

The Apraxia of Speech Rating Scale: Reliability, Validity, and Utility

PURPOSE

The purpose of this study was to examine the interrater reliability and validity of the Apraxia of Speech Rating Scale (ASRS-3.5) as an index of the presence and severity of apraxia of speech (AOS) and the prominence of several of its important features.

METHOD

Interrater reliability was assessed for 27 participants. Validity was examined in a cohort of 308 participants (120 with and 188 without progressive AOS) through item analysis; item-Total score correlations; correlations among ASRS Total score and component subscores and independent clinical ratings of AOS, dysarthria and aphasia severity, intelligibility, and articulatory errors, as well as years postonset and age; and regression models assessing item and Total score prediction of AOS presence.

RESULTS

Interrater reliability was good or excellent for most items and excellent for the Total score. Item and Total score analyses revealed good separation of participants with versus without AOS. Inter-item and item-Total score correlations were generally moderately high as were correlations between the ASRS Total score and independent ratings of AOS severity, intelligibility, and articulatory errors. The Total score was not meaningfully correlated with ratings of aphasia and dysarthria severity, years postonset, or age. Total scores below 7 and above 10 revealed excellent diagnostic sensitivity and specificity for AOS. The presence of eight or more abnormal features was also highly predictive of AOS presence.

CONCLUSIONS

The ASRS-3.5 is a reliable and valid scale for identifying the presence and severity of AOS and its predominant features. It has excellent sensitivity to AOS presence and excellent specificity relative to aphasia and dysarthria in patients with neurodegenerative disease.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21817584.

The effect of responsiveness to speech-generating device input on spoken language in children with autism spectrum disorder who are minimally verbal†

The use of speech-generating devices (SGD) in early interventions for children with autism spectrum disorder (ASD) can improve communication and spoken language outcomes. The purpose of this study was to describe children's responsiveness to SGD input modeled by a social partner during adult-child play interactions over a 24-week intervention trial and explore the effect of that responsiveness on spoken language growth. This secondary analysis consisted of 31 children with less than 20 functional words at study entry who received a blended behavioral intervention (JASPER + EMT) as part of a randomized controlled trial. Significant improvements were seen in rate of responsiveness to both adult SGD models and adult natural speech models; only rate of responsiveness to SGD models at entry was a significant predictor of frequency of commenting and was a more robust predictor of number of different words post-intervention. Lastly, at entry, children with more joint attention and language responded to SGD models at significantly higher rates. Attention and responsiveness to SGD output may be important mechanisms of language growth and children who have more joint attention skills may particularly benefit from use of an SGD.

The Cerebellar Mutism Syndrome: Risk Assessment, Prevention and Treatment

Cerebellar mutism syndrome (CMS) has received increasing attention over the last decades as a complication of posterior fossa tumour surgery in children. Risk factors, aetiological aspects, and treatment measures of the syndrome have been investigated, yet the incidence of CMS remains unchanged. Overall, we are currently able to identify patients at risk, but we are unable to prevent it from occurring.Once CMS sets in, several symptomatic pharmacological treatments have been suggested, but only in smaller case series and not in randomized controlled trials, and it is not clear whether the treatment or time itself had a helpful effect.Within weeks to months, most patients regain their ability to speak after a phase with mutism or severely reduced speech; however, many patients continue to have speech and language deficits. At this point, anti-cancer treatment with chemotherapy and radiotherapy may be of focus more than the prognosis of CMS; however, many patients continue to have speech and language problems for months and years to come, and they are at high risk of other neurocognitive sequelae as well.Without reliable measures to prevent or treat the syndrome, we may look towards improving the prognosis of speech and neurocognitive functioning in these patients. As speech and language impairment is the cardinal symptom and late effect of CMS, the effect of intense and early-onset speech and language therapy as a standard of care in these patients should be investigated in relation to its effect on regaining speech capacity.

Management of communication disability in the first 90 days after stroke: a scoping review

INTRODUCTION

People with communication disability after stroke need interventions to optimise healthcare communication and rehabilitation outcomes. Current evidence syntheses do not adequately inform the management of communication disability during the first 90 days post-stroke.

PURPOSE

To explore the scope of literature for the management of communication disability in the first 90 days after stroke.

MATERIALS AND METHODS

A scoping review was conducted using a systematic keyword search of six databases. A descriptive synthesis was generated using communication-related domains related to the biopsychosocial framework of the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

A total of 129 studies met eligibility criteria. Aphasia was the most frequently addressed communication disability after stroke (76/129 studies) with a paucity of evidence investigating other acquired neurogenic communication impairments. Management predominantly focused on communication-related: body functions and structures (62 studies) (e.g., linguistic-behavioural therapies), followed by environmental factors (39 studies) (e.g., communication partner training/support); activities and participation (15 studies) (e.g., augmentative and alternative communication); and personal factors (13 studies) (e.g., assessment of depression after aphasia).

CONCLUSION

A coordinated, integrated approach to developing and testing acute and subacute interventions for all communication disabilities across all communication-related domains is required.IMPLICATIONS FOR REHABILITATIONInterdisciplinary stroke clinicians need to manage communication disabilities in the first 90 days after stroke to optimise healthcare communication and rehabilitation outcomes.There is some evidence to guide clinicians in aphasia management but less in other disabilities of speech and cognitive functioning.Most interventions to inform clinical practice address communication-related body functions and structures (e.g., linguistic and speech therapies). Clinicians need to address all domains and more evidence is needed to address environmental factors (e.g., communication support); activities and participation (e.g., person-centred goal setting); and personal factors (e.g., psychological care).

Barcelona scale for buccophonatory apraxia: Quantitative assessment tool

INTRODUCTION

Currently there is no tool to quantify buccophonatory apraxia to stratify, compare and monitor patients longitudinally in an objective manner. Our aim in this study is to create a quantitative scale for buccophonatory apraxia and evaluate it in patients with the non-fluent/grammatical variant of primary progressive aphasia (nfvPPA) and other neurodegenerative diseases that occur with speech and/or language problems.

METHODS

The scale was designed based on useful elements in the assessment of buccophonatory apraxia and the total was quantified in seconds. The scale was administered to 64 participants with diagnoses of: nfvPPA, semantic variant of primary progressive aphasia (svPPA), logopenic variant of primary progressive aphasia (lvPPA), Huntington's disease, Parkinson's disease, as well as a group of healthy controls.

RESULTS

Patients showed a significantly higher score compared to controls. The nfvPPA group had the highest mean score on the scale (429 seconds ± 278). The scale was useful to differentiate vnfPPA from svPPA and Parkinson's disease (area under curve [AUC] of 0.956 and 0.989, respectively), but less to differentiate it from Huntington's disease (AUC = 0.67) and lvPPA. There was a statistically significant relationship between total score and disease severity in nfvPPA (P < .029).

CONCLUSIONS

The Barcelona scale for buccophonatory apraxia could be useful to quantitatively evaluate buccophonatory apraxia in different neurodegenerative diseases, and compare patients, especially in nfvPPA.

Left Frontal White Matter Links to Rhythm Processing Relevant to Speech Production in Apraxia of Speech

Recent mechanistic models argue for a key role of rhythm processing in both speech production and speech perception. Patients with the non-fluent variant (NFV) of primary progressive aphasia (PPA) with apraxia of speech (AOS) represent a specific study population in which this link can be examined. Previously, we observed impaired rhythm processing in NFV with AOS. We hypothesized that a shared neurocomputational mechanism structures auditory input (sound and speech) and output (speech production) in time, a "temporal scaffolding" mechanism. Since considerable white matter damage is observed in NFV, we test here whether white matter changes are related to impaired rhythm processing. Forty-seven participants performed a psychoacoustic test battery: 12 patients with NFV and AOS, 11 patients with the semantic variant of PPA, and 24 cognitively intact age- and education-matched controls. Deformation-based morphometry was used to test whether white matter volume correlated to rhythmic abilities. In 34 participants, we also obtained tract-based metrics of the left Aslant tract, which is typically damaged in patients with NFV. Nine out of 12 patients with NFV displayed impaired rhythmic processing. Left frontal white matter atrophy adjacent to the supplementary motor area (SMA) correlated with poorer rhythmic abilities. The structural integrity of the left Aslant tract also correlated with rhythmic abilities. A colocalized and perhaps shared white matter substrate adjacent to the SMA is associated with impaired rhythmic processing and motor speech impairment. Our results support the existence of a temporal scaffolding mechanism structuring perceptual input and speech output.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Case study: use of sentence completion with a person with aphasia and apraxia of speech

Several interventions for acquired apraxia of speech (AOS) involve models, imitation, or repetition to elicit production of words. Early researchers wrote about anecdotal experiences, in which sentence completion facilitated speech production for individuals with AOS. The use of sentence completion to elicit production of words during intervention has not been systematically researched. The purpose of this research was to evaluate the effectiveness of sentence completion to elicit correct productions of words, as part of an intervention for one individual with aphasia and AOS. Training occurred three times a week for six weeks. In each session, the participant answered 20 simple questions, for which the answer was one of 20 target words. Ten of these 20 words were used for training, while the other set of 10 words remained untrained. During training, the participant produced words, as the final word of a sentence. The participant improved production of the trained target words. By the end of training, the participant produced more words, as the final word in a sentence and as the answer to a simple question. For this case study, an individual with severe Broca's aphasia and severe AOS increased the number of personally-relevant words produced following training using sentence completion to elicit production.

Types of motor speech impairments associated with neurologic diseases

Speech disturbances are common consequences of acquired brain injury or neurodegenerative impairment. Although sudden difficulties with speech may signal acute pathologic conditions such as cerebrovascular accidents, determining the etiology of insidious disruptions in communication can be less straightforward. The identification of motor speech impairment, independent of difficulties with language, can be useful for diagnosis since there are subtle, albeit distinct, patterns of speech production impairments associated with different neurologic conditions. Furthermore, the identification of impairments specific to speech production can help elucidate the suspected pathologic mechanisms or even the neuroanatomic structures compromised. During a routine clinical evaluation, early warning signs of motor speech impairment may go undetected if a clinician is unaccustomed to examining motor speech or is unaware of its manifestations. Accordingly, this chapter provides clinicians with a concise yet thorough guide for the practical assessment and differential diagnosis of motor speech disorders (MSDs)-apraxia of speech and dysarthrias. This chapter is divided into neurologic conditions associated with disorders of speech planning/programming, execution, and articulatory control. The underlying mechanisms associated with these impairments are presented both from a clinical perspective as well as through a scientific discussion of recent research in the field on MSDs.

Behavioral interventions for poststroke aphasia

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

Substrates of speech treatment-induced neuroplasticity in adults and children with motor speech disorders: A systematic scoping review of neuroimaging evidence

Purpose: Neuroimaging may provide clinical evidence for speech treatment-induced neuroplasticity. This review aimed to report the current scope of evidence relating to brain changes identified using neuroimaging techniques, following effective speech intervention in adults and children with motor speech disorders (MSD).Method: Studies were retrieved from five electronic databases (PubMed, CINAHL, EMBASE (Medline), SCOPUS, and Web of Science) and a general internet search.Result: Seven studies met the inclusion criteria. Using structural or functional neuroimaging techniques, five studies reported on the effects of the Lee Silverman Voice Treatment for dysarthria in adults and children, one study on the outcome of rhythmic-melodic voice training in adults with apraxia of speech, and one study on the effects of Prompts for Restructuring Oral Muscular Phonetic Targets therapy in children with idiopathic apraxia of speech. Identified brain changes included: enhanced white matter tract integrity; normalisation of baseline cortical activity; right-hemisphere shifts in re-organisation; perilesional activations; and cortical thinning.Conclusion: The current review identified preliminary evidence for treatment-dependent brain changes in adults and children with MSD. Although important to interpret within the context of Phase I research, the identification of therapeutic effects across seven heterogeneous studies suggests that treatment-induced improvements in speech performance are underpinned by demonstrable alterations in brain structure and/or function. Future research is required to better define these mechanisms of neuronal re-organisation in individuals receiving treatment for MSD, including their prognostic potential.

Word Fluency Test Performance in Primary Progressive Aphasia and Primary Progressive Apraxia of Speech

Purpose This study compared performance on three-word fluency measures among individuals with primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS), and examined the relationship between word fluency and other measures of language and speech. Method This study included 106 adults with PPA and 30 adults with PPAOS. PPA participants were divided into three clinical subgroups: semantic (svPPA), logopenic (lvPPA), and nonfluent/agrammatic with or without apraxia of speech (nfPPA). Category fluency, letter fluency, and action/verb fluency tasks were administered to all participants. Results The four clinical groups performed abnormally on the word fluency measures, although not to a degree that represented high sensitivity to their PPA or PPAOS diagnosis. All PPA subgroups produced fewer words compared to individuals with PPAOS on all word fluency measures. Moderate correlations were found between word fluency and aphasia severity and naming performance in some of the clinical groups. Conclusions Word fluency measures are often challenging for individuals with PPA and PPAOS, but they are not of equal difficulty, with letter fluency being the most difficult. Differences among word fluency tests also vary to some degree as a function of the clinical group in question, with least impairment in PPAOS. However, the findings of this study do not support statistically significant differences in word fluency task performance among the PPA subgroups. Correlations suggest that word fluency performance in PPA is at least partly related to aphasia severity.

Improvements in Speech of Children with Apraxia: The Efficacy of Treatment for Establishing Motor Program Organization (TEMPOSM)

Purpose: This study investigated the efficacy of Treatment for Establishing Motor Program Organization (TEMPO^SM) in childhood apraxia of speech (CAS).Method: A mixed between- and within-participant design with multiple baselines across participants and behaviors was used to examine acquisition, generalization, and maintenance of skills. TEMPO^SM was administered in four one-hour sessions a week over a four-week period for eleven participants (ages 5 to 8), allocated to either an immediate treatment group or a wait-list control group. Acoustic and perceptual variables were measured at baseline, immediate post-treatment, and one-month post-treatment.Results: Children demonstrated significant improvements in specific acoustic measures of segmentation and lexical stress, as well as perceptual measures of fluency, lexical stress, and speech-sound accuracy. Treatment and generalization effects were maintained one-month post-treatment with generalization to untreated stimuli.Conclusion: TEMPO^SM was efficacious in improving segmental and suprasegmental impairments in the speech of children with CAS.

Critically Appraising Systematic Reviews in the Field of Speech-Language Pathology: A How-to Guide for Clinician Readers

Purpose This tutorial will provide speech-language pathologists with foundational knowledge about systematic reviews and their importance in everyday practice. It will also assist clinicians in developing critical appraisal skills so that current research can be translated judiciously to clinical environments for patient care. Systematic reviews are often regarded as the highest level of research evidence for implementing best evidence-based practice, because they synthesize research findings from multiple high-quality research studies, identify methodological weaknesses and biases from the studies included, and assist in illuminating areas for future research work based on current gaps in the literature. While systematic reviews can provide comprehensive knowledge to inform clinical practice, few speech-language pathologists receive training on appraising and applying the findings from systematic reviews appropriately within clinical settings. Conclusion Clinicians within the field of speech-language pathology can use the framework provided in this tutorial to evaluate systematic reviews as a preliminary step for determining appropriate assessment and treatment methods for implementing evidence-based practice within clinical settings.

Vagus Nerve Stimulation as a Potential Adjuvant to Rehabilitation for Post-stroke Motor Speech Disorders

Stroke often leaves lasting impairments affecting orofacial function. While speech therapy is able to enhance function after stroke, many patients see only modest improvements after treatment. This partial restoration of function after rehabilitation suggests that there is a need for further intervention. Rehabilitative strategies that augment the effects of traditional speech therapy hold promise to yield greater efficacy and reduce disability associated with motor speech disorders. Recent studies demonstrate that brief bursts of vagus nerve stimulation (VNS) can facilitate the benefits of rehabilitative interventions. VNS paired with upper limb rehabilitation enhances recovery of upper limb function in patients with chronic stroke. Animal studies reveal that these improvements are driven by VNS-dependent synaptic plasticity in motor networks. Moreover, preclinical evidence demonstrates that a similar strategy of pairing VNS can promote synaptic reorganization in orofacial networks. Building on these findings, we postulate that VNS-directed orofacial plasticity could target post-stroke motor speech disorders. Here, we outline the rationale for pairing VNS with traditional speech therapy to enhance recovery in the context of stroke of speech motor function. We also explore similar treatments that aim to enhance synaptic plasticity during speech therapy, and how VNS differs from these existing therapeutic strategies. Based on this evidence, we posit that VNS-paired speech therapy shows promise as a means of enhancing recovery after post-stroke motor speech disorders. Continued development is necessary to comprehensively establish and optimize this approach, which has the potential to increase quality of life for the many individuals suffering with these common impairments.

Stability of Speech Intelligibility Measures Over Repeated Sampling Times in Speakers With Acquired Apraxia of Speech

Purpose The purpose of this investigation was to measure the test-retest stability of single-word intelligibility in a group of 28 speakers with chronic apraxia of speech and aphasia. Method The Assessment of Intelligibility of Dysarthric Speech was administered twice to each participant, with samples separated by 1 week. Scoring of recorded samples was completed independently by three expert listeners using transcription and multiple-choice scoring formats. Results Percent intelligible words was very similar for the group over the two sampling times for both scoring formats (i.e., within 1.5%), with no statistically significant differences found between times. Statistically significant, very strong, positive correlations were found between sampling times for intelligibility scores. Transcription and multiple-choice scores were strongly, positively correlated, with multiple-choice scores being statistically higher. There was a statistically significant difference between mean transcription and multiple-choice scores for the group at Time 1 and Time 2. Individual performance was similar to group performance for the majority of participants. Conclusions These findings indicate that single-word intelligibility measures are stable over repeated sampling occasions. Stability was evident for transcription and multiple-choice scoring methods. Supplemental Material https://doi.org/10.23641/asha.14226737.

Outcomes of semantic feature analysis treatment for aphasia with and without apraxia of speech

BACKGROUND

To date, studies have not explored whether a dual diagnosis of aphasia plus apraxia of speech (AOS) versus aphasia alone (APH) affects the response to language-based naming treatments.

AIMS

To compare the effects of semantic feature analysis (SFA) treatment for individuals with APH versus aphasia plus AOS, and to test if the presence of AOS impacted the effects of treatment.

METHODS AND PROCEDURES

A non-randomized experimental group study was conducted to explore the treatment, generalization and maintenance effects between the AOS and APH groups. Participants included nine individuals with aphasia and 11 with concomitant aphasia and AOS. Dependent measures included lexical accuracy, number of sound-level distortions, and lexical stress and syllable segmentation errors.

OUTCOMES AND RESULTS

Both groups showed significantly improved naming accuracy of trained items for up to 2 months post-treatment. Improvement on naming accuracy of untrained items post-treatment, both semantically related and unrelated to trained items, was lower in magnitude. That this may have been due to effects of repeated probing (which included target repetition) or regression to the mean cannot be excluded. There was a tendency for the AOS group to respond slightly better to treatment than the APH group overall, which was not correlated with aphasia severity. Also, measures of phonetic accuracy and fluency improved for both groups, with no main effect of group. Treatment effects did not generalize to formal measures of (untrained) picture naming or expression of correct information units in discourse in a story retelling task.

CONCLUSIONS AND IMPLICATIONS

Findings indicate that individuals with aphasia plus AOS can gain equivalent benefits in word retrieval and production from the language-based SFA treatment as individuals with aphasia alone. This may be, in part, due to the tendency for SFA to incorporate principles of practice that are known to support motor learning in AOS, such as high intensity, random stimulus presentation and variable practice. Findings provide further support for high-intensity practice and use of self-generated features to facilitate maintenance of effects. What this paper adds What is already known on the subject SFA treatment is the most common intervention for word-finding difficulties for individuals with aphasia. AOS is a common concomitant disorder to aphasia. However, it is not clear whether the effects of language-based SFA treatment are mitigated by the presence of AOS, which tends to respond well to treatments focused on articulatory-kinematic aspects of speech movement. What this paper adds to the existing knowledge This study compares the effects of SFA in a group of individuals with aphasia alone and a group with similar severity of aphasia but with concomitant AOS, ranging from mild to moderate-severe. Overall, AOS did not have a negative effect on response to the treatment. What are the potential or actual clinical implications of this work? Individuals with aphasia plus AOS can be expected to benefit to a similar degree from SFA as people with aphasia alone. It is likely that the use of practice principles of high intensity, random stimulus presentation and varied practice are important components of the protocol.

Sound Production Treatment for Acquired Apraxia of Speech: An Examination of Dosage in Relation to Probe Performance

Purpose This study was designed to examine the association of dosage and effects of Sound Production Treatment (SPT) for acquired apraxia of speech. Method Treatment logs and probe data from 20 speakers with apraxia of speech and aphasia were submitted to a retrospective analysis. The number of treatment sessions and teaching episodes was examined relative to (a) change in articulation accuracy above baseline performance, (b) mastery of production, and (c) maintenance. The impact of practice schedule (SPT-Blocked vs. SPT-Random) was also examined. Results The average number of treatment sessions conducted prior to change was 5.4 for SPT-Blocked and 3.9 for SPT-Random. The mean number of teaching episodes preceding change was 334 for SPT-Blocked and 179 for SPT-Random. Mastery occurred within an average of 13.7 sessions (1,252 teaching episodes) and 12.4 sessions (1,082 teaching episodes) for SPT-Blocked and SPT-Random, respectively. Comparisons of dosage metric values across practice schedules did not reveal substantial differences. Significant negative correlations were found between follow-up probe performance and the dosage metrics. Conclusions Only a few treatment sessions were needed to achieve initial positive changes in articulation, with mastery occurring within 12-14 sessions for the majority of participants. Earlier occurrence of change or mastery was associated with better follow-up performance. Supplemental Material https://doi.org/10.23641/asha.12592190.

Examining speech motor planning difficulties in apraxia of speech and aphasia via the sequential production of phonetically similar words

This study investigated the underlying nature of apraxia of speech (AOS) by testing two competing hypotheses. The Reduced Buffer Capacity Hypothesis argues that people with AOS can plan speech only one syllable at a time Rogers and Storkel [1999. Planning speech one syllable at a time: The reduced buffer capacity hypothesis in apraxia of speech. Aphasiology, 13(9-11), 793-805. https://doi.org/10.1080/026870399401885]. The Program Retrieval Deficit Hypothesis states that selecting a motor programme is difficult in face of competition from other simultaneously activated programmes Mailend and Maas [2013. Speech motor programming in apraxia of speech: Evidence from a delayed picture-word interference task. American Journal of Speech-Language Pathology, 22(2), S380-S396. https://doi.org/10.1044/1058-0360(2013/12-0101)]. Speakers with AOS and aphasia, aphasia without AOS, and unimpaired controls were asked to prepare and hold a two-word utterance until a go-signal prompted a spoken response. Phonetic similarity between target words was manipulated. Speakers with AOS had longer reaction times in conditions with two similar words compared to two identical words. The Control and the Aphasia group did not show this effect. These results suggest that speakers with AOS need additional processing time to retrieve target words when multiple motor programmes are simultaneously activated.

A Phonomotor Approach to Apraxia of Speech Treatment

Purpose This study continued Phase I investigation of a modified Phonomotor Treatment (PMT) Program on motor planning in two individuals with apraxia of speech (AOS) and aphasia and, with support from prior work, refined Phase I methodology for treatment intensity and duration, a measure of communicative participation, and the use of effect size benchmarks specific to AOS. Method A single-case experimental design with multiple baselines across behaviors and participants was used to examine acquisition, generalization, and maintenance of treatment effects 8-10 weeks posttreatment. Treatment was distributed 3 days a week, and duration of treatment was specific to each participant (criterion based). Experimental stimuli consisted of target sounds or clusters embedded nonwords and real words, specific to each participants' deficit. Results Findings show improved repetition accuracy for targets in trained nonwords, generalization to targets in untrained nonwords and real words, and maintenance of treatment effects at 10 weeks posttreatment for one participant and more variable outcomes for the other participant. Conclusions Results indicate that a modified version of PMT can promote generalization and maintenance of treatment gains for trained speech targets via a multimodal approach emphasizing repeated exposure and practice. While these results are promising, the frequent co-occurrence of AOS and aphasia warrants a treatment that addresses both motor planning and linguistic deficits. Thus, the application of traditional PMT with participant-specific modifications for AOS embedded into the treatment program may be a more effective approach. Future work will continue to examine and maximize improvements in motor planning, while also treating anomia in aphasia.

Behavioral and neurological effects of tDCS on speech motor recovery: A single-subject intervention study

This paper reports a feasibility study designed to evaluate the behavioral and neurological effects of using transcranial direct current stimulation (tDCS) in conjunction with speech motor learning treatment for individuals with acquired speech impairment subsequent to stroke. Most of the research using tDCS to enhance treatment outcomes in stroke recovery has focused on either limb motor control or aphasia treatment. Using a multiple-baseline multiple-probe crossover design, we compared both behavioral and brain connectivity-based outcomes following speech motor learning treatment with both Active tDCS and Sham tDCS. We observed that both treatment phases led to improvement in short-term maintenance, but that Active tDCS was associated with greater long-term maintenance improvement. Active tDCS was also associated with an increase in functional connectivity in the left hemisphere and interhemispherically in an ROI-based network analysis examining correlations among areas associated with speech production and acquired speech impairment. This report supports the possibility that tDCS may enhance both behavioral and neurological outcomes and indicates the importance of additional work in this area, although replication is required to confirm the extent and consistency of tDCS benefits on speech motor learning treatment outcomes.

Mobile Apps for Speech-Language Therapy in Adults With Communication Disorders: Review of Content and Quality

Background

Worldwide, more than 75% of people with acquired brain injury (ABI) experience communication disorders. Communication disorders are impairments in the ability to communicate effectively, that is, sending, receiving, processing, and comprehending verbal and nonverbal concepts and symbols. Such disorders may have enduring impacts on employment, social participation, and quality of life. Technology-enabled interventions such as mobile apps have the potential to increase the reach of speech-language therapy to treat communication disorders. However, ensuring that apps are evidence-based and of high quality is critical for facilitating safe and effective treatment for adults with communication disorders.

Objective

The aim of this review is to identify mobile apps that are currently widely available to adults with communication disorders for speech-language therapy and to assess their content and quality using the validated Mobile App Rating Scale (MARS).

Methods

Google Play Store, Apple App Store, and webpages were searched to identify mobile apps for speech-language therapy. Apps were included in the review if they were designed for the treatment of adult communication disorders after ABI, were in English, and were either free or for purchase. Certified speech-language pathologists used the MARS to assess the quality of the apps.

Results

From a total of 2680 apps identified from Google Play Store, Apple App Store, and web searches, 2.61% (70/2680) apps met the eligibility criteria for inclusion. Overall, 61% (43/70) were available for download on the iPhone Operating System (iOS) platform, 20% (14/70) on the Android platform, and 19% (13/70) on both iOS and Android platforms. A content analysis of the apps revealed 43 apps for language, 17 apps for speech, 8 apps for cognitive communication, 6 apps for voice, and 5 apps for oromotor function or numeracy. The overall MARS mean score was 3.7 out of 5, SD 0.6, ranging between 2.1 and 4.5, with functionality being the highest-scored subscale (4.3, SD 0.6), followed by aesthetics (3.8, SD 0.8), information (3.4, SD 0.6), and engagement (3.3, SD 0.6). The top 5 apps were Naming Therapy (4.6/5), Speech Flipbook Standard (4.6/5), Number Therapy (4.5/5), Answering Therapy, and Constant Therapy (4.4/5).

Conclusions

To our knowledge, this is the first study to systematically identify and evaluate a broad range of mobile apps for speech-language therapy for adults with communication disorders after sustaining ABI. We found a lack of interactive and engaging elements in the apps, a critical factor in sustaining self-managed speech-language therapy. More evidence-based apps with a focus on human factors, user experience, and a patient-led design approach are required to enhance effectiveness and long-term use.

Primary Progressive Apraxia of Speech: From Recognition to Diagnosis and Care

BACKGROUND

Apraxia of speech (AOS) can be caused by neurodegenerative disease and sometimes is its presenting sign (i.e., primary progressive apraxia of speech, PPAOS). During the last several decades our understanding of PPAOS has evolved from clinical recognition to a fuller understanding of its core and associated clinical features, its distinction from but relationship with primary progressive aphasia, its temporal course and eventual progression to include other neurological deficits, and its neuroimaging correlates and underlying pathology.

AIMS

This paper provides a comprehensive summary of the literature that has built the current knowledge base about PPAOS and progressive AOS as it co-occurs with progressive aphasia. It reviews the history of its emergence as a recognized syndrome; its relationship with the agrammatic/nonfluent variant of primary progressive aphasia; its salient perceptual features and subtypes; the acoustic and structural/physiological imaging measures that index its presence, severity, and distinction from aphasia; and principles and available data regarding its management and care.

MAIN CONTRIBUTION

A broad summary of what is known about AOS as a manifestation of neurodegenerative disease.

CONCLUSIONS

Primary progressive apraxia of speech is a recognizable syndrome that can be distinguished from other neurodegenerative conditions that affect speech and language.

Formulaic Language Resources May Help Overcome Difficulties in Speech-Motor Planning after Stroke

Purpose

Decades of research have explored communication in cerebrovascular diseases by focusing on formulaic expressions (e.g., “Thank you”—“You’re welcome”). This category of utterances is known for engaging primarily right-hemisphere frontotemporal and bilateral subcortical neural networks, explaining why left-hemisphere stroke patients with speech-motor planning disorders often produce formulaic expressions comparatively well. The present proof-of-concept study aims to confirm that using verbal cues derived from formulaic expressions can alleviate word-onset difficulties, one major symptom in apraxia of speech.

Methods

In a cross-sectional repeated-measures design, 20 individuals with chronic post-stroke apraxia of speech were asked to produce (i) verbal cues (e.g., /guː/) and (ii) subsequent German target words (e.g., “Tanz”) with critical onsets (e.g., /t/). Cues differed, most notably, in aspects of formulaicity (e.g., stereotyped prompt: /guː/, based on formulaic phrase “Guten Morgen”; unstereotyped prompt: /muː/, based on non-formulaic control word “Mutig”). Apart from systematic variation in stereotypy and communicative-pragmatic embeddedness possibly associated with holistic language processing, cues were matched for consonant-vowel structure, syllable-transition frequency, noun-verb classification, meter, and articulatory tempo.

Results

Statistical analyses revealed significant increases in correctly produced word onsets after verbal cues with distinct features of formulaicity (e.g., stereotyped versus unstereotyped prompts: p < 0.001), as reflected in large effect sizes (Cohen’s d_z ≤ 2.2).

Conclusions

The current results indicate that using preserved formulaic language skills can relieve word-onset difficulties in apraxia of speech. This finding is consistent with a dynamic interplay of left perilesional and right intact language networks in post-stroke rehabilitation and may inspire new treatment strategies for individuals with apraxia of speech.

Acquired Apraxia of Speech: Comparison of Electropalatography Treatment and Sound Production Treatment

Purpose This investigation compared 2 treatment approaches for acquired apraxia of speech. The effects of a treatment that uses an articulatory-kinematic approach in conjunction with visual biofeedback (VBFB) via electropalatography (EPG) were compared to Sound Production Treatment (SPT), an established behavioral treatment that is also an articulatory-kinematic approach. Method A multiple baseline design across behaviors and participants was used with 2 participants with chronic apraxia of speech and aphasia. Accuracy of target speech sounds in treated and untreated words or phrases in probe sessions served as the dependent variable. The effects of 2 treatments based on an articulatory-kinematic approach were compared: (a) VBFB via EPG and (b) SPT. The order of treatments was counterbalanced across participants. Results Positive changes in articulatory accuracy were observed for SPT and VBFB treatment via EPG. Generalization to untreated stimulus items composed of treated speech sounds was also positive for both treatments. However, participants achieved greater articulatory accuracy with SPT during treatment and better long-term maintenance. Discussion Both treatment approaches resulted in improved speech production accuracy, but gains were greater for SPT. However, further research with additional participants is needed due to the small sample size included in this investigation.

Repeated word production is inconsistent in both aphasia and apraxia of speech

PURPOSE

There is persistent uncertainty about whether sound error consistency is a valid criterion for differentiating between apraxia of speech (AOS) and aphasia with phonemic paraphasia. The purpose of this study was to determine whether speakers with a profile of aphasia and AOS differ in error consistency from speakers with aphasia who do not have AOS. By accounting for differences in overall severity and using a sample size well over three times that of the largest study on the topic to date, our ambition was to resolve the existing controversy.

METHOD

We analyzed speech samples from 171 speakers with aphasia and completed error consistency analysis for 137 of them. The experimental task was to repeat four multisyllabic words five times successively. Phonetic transcriptions were coded for four consistency indices (two at the sound-level and two at the word-level). We then used quantitative metrics to assign participants to four diagnostic groups (one aphasia plus AOS group, one aphasia only group, and two groups with intermediate speech profiles). Potential consistency differences were examined with ANCOVA, with error frequency as a continuous covariate.

RESULTS

Error frequency was a strong predictor for three of the four consistency metrics. The magnitude of consistency for participants with AOS was either similar or lower compared to that of participants with aphasia only. Despite excellent transcription reliability and moderate to excellent coding reliability, three of the four consistency indices showed limited measurement reliability.

DISCUSSION

People with AOS and people with aphasia often produce inconsistent variants of errors when they are asked to repeat challenging words several times sequentially. The finding that error consistency is similar or lower in aphasia with AOS than in aphasia without AOS is incompatible with recommendations that high error consistency be used as a diagnostic criterion for AOS. At the same time, group differences in the opposite direction are not sufficiently systematic to warrant use for differential diagnosis between aphasia with AOS and aphasia with phonemic paraphasia. Greater attention should be given to error propagation when estimating reliability of derived measurements.

Use of diverse diagnostic criteria for acquired apraxia of speech: a scoping review

BACKGROUND

There is a growing body of evidence that speech and language therapy (SLT) intervention is effective in improving communication ability for individuals with non-progressive acquired apraxia of speech (AOS). However, there is no universally agreed diagnostic standard for AOS, and diverging opinions on its diagnostic features. This has led to claims that diverse diagnostic criteria may be used to select participants for AOS research studies. These claims raise concerns for evidence-based practice in AOS but have yet to be systematically investigated.

AIMS

To determine the presence, nature and extent of diversity in the diagnostic criteria for non-progressive AOS used in both published studies and clinical practice internationally.

METHODS & PROCEDURES

The study used a scoping review methodology that followed the 2005 framework of Arksey and O'Malley and included a consultation exercise in the form of an online survey of international SLTs. The scoping review included 157 studies involving participants with acquired AOS, published between 1997 and 2017. There were 264 respondents to the online survey of SLTs, with a completion rate of 72%. Respondents came from 15 countries and had varying levels of clinical experience.

MAIN CONTRIBUTION

This study found that no common set of diagnostic criteria for AOS was used universally across research and practice. Although the diagnostic criteria used to select participants with AOS were reported explicitly in most studies, they varied from study to study. Some studies used directly conflicting criteria. Use of specific diagnostic criteria in studies was influenced by year of publication but not by location. There was a trend towards increasing consistency in diagnostic criteria in recent years. Compared with the research, the survey revealed relatively greater consistency among SLTs on the speech features considered indicative of AOS, although the SLTs who responded to the survey showed variation in how diagnostic criteria were combined into sets. Use of specific diagnostic criteria was not associated with SLTs' location or experience. There were differences between the diagnostic criteria for AOS used most commonly in research studies and those selected most commonly by SLTs in the survey. These findings have implications for the generalizability of AOS research to clinical practice, as well as implications for effective research synthesis.

CONCLUSIONS & IMPLICATIONS

The claim that research and practice in the field of AOS is characterized by the use of diverse diagnostic criteria is supported by this scoping review. The findings support the need to develop a universal consensus standard for AOS diagnosis to ensure consistency across research and clinical practice.

An N-of-1 Randomized Controlled Trial of Interventions for Children With Inconsistent Speech Sound Errors

Purpose The aim of this study was to test the hypothesis that children with inconsistent speech errors would respond differentially to 1 of 3 specific interventions depending on their primary underlying impairment: Children with deficient motor planning were expected to respond best to an auditory-motor integration (AMI) intervention, and children with deficient phonological planning were expected to respond best to a phonological memory and planning (PMP) intervention. Method Twelve participants were diagnosed with a motor planning (n = 7) or phonological planning (n = 5) deficit based on a comprehensive assessment, which included the Syllable Repetition Task as an important source of diagnostic evidence. An N-of-1 randomized controlled trial was used. Each child experienced all 3 interventions: AMI, PMP, and control (CTL); however, these interventions were randomly allocated to sessions within weeks (3 sessions per week × 6 weeks for 18 sessions). The AMI intervention procedures targeted knowledge of the acoustic-phonetic target and integration of auditory and somatosensory feedback during speech practice. The PMP intervention procedures targeted segmenting and recompiling the phonological plan for each word. The CTL intervention was standard drill practice. The child was taught 5 pseudowords in a meaningful context in each intervention condition. Results Same-day (SD) probes assessed transfer from taught pseudowords to untaught real words, and next-day (ND) probes assessed retention of that learning. Nonparametric resampling tests with pooling of p values across children with the same diagnosis were used to assess the results. Pooled p values indicated a significant benefit of AMI over PMP for the group with a motor planning deficit (p = 2.01E-04 for SD probes and 2.97E-03 for ND probes) and a significant benefit of PMP over AMI for the group with a phonological planning deficit (p = 1.22E-02 for SD probes and 1.32E-02 for ND probes). Response to the CTL intervention was variable within groups. Conclusion In this study, the child's underlying psycholinguistic deficit helped to predict response to intervention.

Feasibility of Automatic Speech Recognition for Providing Feedback During Tablet-Based Treatment for Apraxia of Speech Plus Aphasia

Purpose Individuals with neurogenic speech disorders require ongoing therapeutic support to achieve functional communication goals. Alternative methods for service delivery, such as tablet-based speech therapy applications, may help bridge the gap and bring therapeutic interventions to the patient in an engaging way. The purpose of this study was to evaluate an iPad-based speech therapy app that uses automatic speech recognition (ASR) software to provide feedback on speech accuracy to determine the ASR's accuracy against human judgment and whether participants' speech improved with this ASR-based feedback. Method Five participants with apraxia of speech plus aphasia secondary to stroke completed an intensive 4-week at-home therapy program using a novel word training app with built-in ASR. Multiple baselines across participants and behaviors designs were employed, with weekly probes and follow-up at 1 month posttreatment. Four sessions a week of 100 practice trials each were prescribed, with 1 being clinician-run and the remainder done independently. Dependent variables of interest were ASR-human agreement on accuracy during practice trials and human-judged word production accuracy over time in probes. Also, user experience surveys were completed immediately posttreatment. Results ASR-human agreement on accuracy averaged ~80%, which is a common threshold applied for interrater agreement. All participants demonstrated improved word production accuracy over time with the ASR-based feedback and maintenance of gains after 1 month. All participants reported enjoying using the app with support of a speech pathologist. Conclusion For these participants with apraxia of speech plus aphasia due to stroke, satisfactory gains were made in word production accuracy with an app-based therapy program providing ASR-based feedback on accuracy. Findings support further testing of this ASR-based approach as a supplement to clinician-run sessions to assist clients with similar profiles in achieving higher amount and intensity of practice as well as empowering them to manage their own therapy program. Supplemental Material https://doi.org/10.23641/asha.8206628.

Speech motor planning in the context of phonetically similar words: Evidence from apraxia of speech and aphasia

The purpose of this study was to test two competing hypotheses about the nature of the impairment in apraxia of speech (AOS). The Reduced Buffer Capacity Hypothesis argues that people with AOS can hold only one syllable at a time in the speech motor planning buffer. The Program Retrieval Deficit Hypothesis, states that people with AOS have difficulty accessing the intended motor program in the context where several motor programs are activated simultaneously. The participants included eight speakers with AOS, most of whom also had aphasia, nine speakers with aphasia without AOS, and 25 age-matched control speakers. The experimental paradigm prompted single word production following three types of primes. In most trials, prime and target were the same (e.g., bill-bill). On some trials, the initial consonant differed in one phonetic feature (e.g., bill-dill; Similar) or in all phonetic features (fill-bill; Different). The dependent measures were accuracy and reaction time. The results revealed a switch cost - longer reaction times in trials where the prime and target differed compared to trials where they were the same words - in all groups; however, the switch cost was significantly larger in the AOS group compared to the other two groups. These findings are in line with the prediction of the Program Retrieval Deficit Hypothesis and suggest that speakers with AOS have difficulty with selecting one program over another when several programs compete for selection.

Sound Distortion Errors in Aphasia With Apraxia of Speech

Purpose Loosely defined diagnostic criteria for acquired apraxia of speech (AOS) limit clinicians' ability to diagnose the disorder validly and reliably. The purpose of this study was to contribute to the development of more precise diagnostic guidelines by characterizing the frequency and quality of sound distortion errors in speakers with clinically diagnosed AOS. Method Audio-recorded motor speech evaluations from 24 speakers with AOS and aphasia were analyzed by trained listeners using a narrow phonetic transcription protocol that included 12 distortion categories. We calculated percentage of segments transcribed with phonemic error, distortion error, and a combination of phonemic and distortion error. Results Distortion frequency varied substantially across participants, distributing on a continuum from 5% to 22% of segments. The frequency of phonemic errors was significantly greater than the frequency of distortion errors, which, in turn, was greater than the frequency of distorted substitution errors. The most common distortion qualities were voicing ambiguity and segment lengthening, but over 40% of distortion errors were distributed across an assortment of tongue modifications. Conclusions The results replicated observations from previous studies of speakers with quantitatively defined AOS in a new sample of participants with clinically diagnosed AOS. Similar distortion qualities were observed across studies, offering focus for diagnosticians and guidance for operationalizing future measures. The broad performance continua we observed help explain why binary classification of the presence/absence of AOS can be challenging and indicate a need to develop quantitative norms.

Sub-classification of apraxia of speech in patients with cerebrovascular and neurodegenerative diseases

Some studies have hypothesized that primary progressive apraxia of speech (ppAOS) consists of heterogeneous symptoms that can be sub-classified; however, no study has classified stroke-induced AOS (sAOS) and ppAOS according to common criteria. The purpose of this study was to elucidate the symptoms and relevant brain regions associated with sAOS and ppAOS for sub-classification. Participants included 8 patients with sAOS following lesions in the left precentral gyrus and/or underlying white matter, and 3 patients with ppAOS. All patients with sAOS could be classified into three subtypes: type I, with prominent distorted articulation; type II, with prominent prosodic abnormalities or type III, with similarly distorted articulation and prosodic abnormalities. This sub-classification was consistent with the subtypes of ppAOS proposed in previous reports. All patients with ppAOS were classified as type III, and exhibited three characteristics distinguishable from those of sAOS. First, they showed prominent lengthened syllables compared with the segmentation of syllables. Second, they could not always complete the production of multi-syllabic single words in one breath. Finally, they showed dysfunctional lesions in the bilateral supplementary motor area. We conclude that sAOS and ppAOS can be sub-classified and are universal symptoms that are common between the English and Japanese populations.

Word-level prosodic measures and the differential diagnosis of apraxia of speech

Impaired production of prosody is considered a primary diagnostic criterion for apraxia of speech. In this study, we examined diagnostic relevance for five word-level prosody measures. Seven speakers with AOS, nine with aphasia and no AOS, and 19 age-matched neurotypical controls produced nine words consisting of three or four syllables. Lexical stress indices were computed based on relative values for duration, fundamental frequency, and intensity across pairs of unstressed-stressed syllables with varying intrinsic vowel duration contrast patterns. A simple average syllable duration measure was also obtained. AOS speakers differed from the other two groups on three metrics that were solely or primarily derived from duration measures. The degree of diagnostic overlap was smallest for the syllable duration metric, which also showed the strongest inter-observer reliability and most complete overlap between neurotypical speakers and speakers with aphasia and no AOS. Vowel intrinsic durational properties affected lexical stress metrics significantly, indicating a need to select word targets purposefully. Based on these results, it appears that the average syllable duration metric is a more stable and informative alternative for differential diagnostic purposes. The results will, however, need to be replicated in a larger sample.

An Investigation of Compensation and Adaptation to Auditory Perturbations in Individuals With Acquired Apraxia of Speech

Two auditory perturbation experiments were used to investigate the integrity of neural circuits responsible for speech sensorimotor adaptation in acquired apraxia of speech (AOS). This has implications for understanding the nature of AOS as well as normal speech motor control. Two experiments were conducted. In Experiment 1, compensatory responses to unpredictable fundamental frequency (F0) perturbations during vocalization were investigated in healthy older adults and adults with acquired AOS plus aphasia. F0 perturbation involved upward and downward 100-cent shifts versus no shift, in equal proportion, during 2 s vocalizations of the vowel /a/. In Experiment 2, adaptive responses to sustained first formant (F1) perturbations during speech were investigated in healthy older adults, adults with AOS and adults with aphasia only (APH). The F1 protocol involved production of the vowel /ε/ in four consonant-vowel words of Australian English (pear, bear, care, dare), and one control word with a different vowel (paw). An unperturbed Baseline phase was followed by a gradual Ramp to a 30% upward F1 shift stimulating a compensatory response, a Hold phase where the perturbation was repeatedly presented with alternating blocks of masking trials to probe adaptation, and an End phase with masking trials only to measure persistence of any adaptation. AOS participants showed normal compensation to unexpected F0 perturbations, indicating that auditory feedback control of low-level, non-segmental parameters is intact. Furthermore, individuals with AOS displayed an adaptive response to sustained F1 perturbations, but age-matched controls and APH participants did not. These findings suggest that older healthy adults may have less plastic motor programs that resist modification based on sensory feedback, whereas individuals with AOS have less well-established and more malleable motor programs due to damage from stroke.

Clinical Progression in Four Cases of Primary Progressive Apraxia of Speech

PURPOSE

This case series details the clinical progression of patients with primary progressive apraxia of speech (PPAOS) to illustrate, using several methods and supplemental material examples, the changes that occur in speech and language functioning in this patient population.

METHOD

Four patients who presented with PPAOS were followed between 5 and 6 years. Two patients had predominant articulatory abnormalities (termed phonetic PPAOS), 1 had predominant prosodic abnormalities (prosodic PPAOS), and 1 had relatively equal articulatory and prosodic abnormalities (mixed PPAOS). Detailed speech (including acoustics), language, neurologic, and neuropsychological data were collected.

RESULTS

At initial exam, the patients ranged from 60 to 77 years old, with presenting disease duration of 1.5-10 years. Although all patients presented with an isolated apraxia of speech, all developed varying degrees of aphasia and dysarthria. Patients with phonetic PPAOS developed relatively more severe aphasia than the other 2 patients. All patients eventually had severe functional communication limitations and required alternative or augmentative means of communication, although at varying times postonset of their initial speech problem. Two patients developed dysphagia, 3 showed mild-moderate Parkinsonism, and 2 developed depression. For all patients, simple temporal acoustic measurements documented slowed speech rate over time.

CONCLUSIONS

This case series demonstrates that patients who initially present with PPAOS may develop aphasia and dysarthria, cognitive and behavioral changes, and other neurologic signs. Whether these changes can be predicted by the perceptual characteristics of the apraxia of speech is yet to be determined. The detailed longitudinal profiles provide valuable clinical insight into the progression of disease in people with PPAOS.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.7051616.