Motor Speech Treatment Notes

Motor Speech Treatment

Learning Outcomes

  • Describe goals and approaches for motor speech disorders treatment.
  • Discuss communication-oriented treatment approaches.
  • List approaches for addressing speech subsystem deficits.

Goal of Motor Speech Treatment

  • Maximize effectiveness, efficiency, and/or naturalness of communication.

Treatment Approaches

  • Restoration: Direct attempts to reduce the degree of impairment (e.g., muscle strengthening, improving range of motion).
  • Compensation:
    • Behavioral compensation.
    • Social compensation.
  • Supplementation/Substitution: Adding to or replacing speech (e.g., letter board, AAC).

Approaches by Severity

  • Mild: Maximize communication efficiency and speech naturalness to maintain intelligibility.
  • Moderate: Maximize (compensated) intelligibility.
  • Severe: Establish functional means of communication (AAC).

Where to Start?

  1. Identify speech subsystem(s) impaired.
  2. Assess features that can be modified.
  3. Identify preserved function & existing compensatory strategies.
  4. Apply multiple approaches across speech subsystems.

Motor Speech Treatment Hierarchy

  • First Order Targets: Respiration, Resonation
  • Second Order Targets: Phonation
  • Third Order Targets: Articulation, Prosody

Respiratory Treatments

Direct
  • Inspiratory/Expiratory Muscle Strength Training:
    • Blow through force-sensitive device set to ~75% of maximum inspiratory/expiratory pressure.
    • Increase resistance as patient gets stronger.
    • Target = diaphragm (inspiratory) & abdominal muscles (expiratory).
    • Improvements are seen in respiratory pressures, but generalization to speech may be limited.
Compensation
  • Behavioral tasks:
    • Practice inhaling more deeply.
    • Diaphragmatic breathing.
    • Train optimal breath group.
    • Gradually increase # of syllables per breath.
    • Mark pauses for breath in text.
  • Postural adjustments:
    • Upright posture: gravity helps lower diaphragm on inhalation.

Resonatory Treatments

Direct
  • Medical/surgical management:
    • Pharyngeal flap.
    • Sphincter pharyngoplasty.
    • Injection pharyngoplasty.
Compensation
  • Prosthetics:
    • Palatal lift.
      • Increased intelligibility.
      • Decreased hypernasality.
      • Improved articulation.

Phonatory Treatments

Direct
  • Medical/surgical management (discussed in Unit 4):
    • Laryngeal framework surgery.
    • Vocal fold injection.
  • Behavioral approaches (discussed in Unit 4):
    • Gradually increase # of syllables per breath
    • Mark pauses for breath in text
  • Lee Silverman Voice Treatment (LSVT); Speak OUT!
    • Developed for individuals with Parkinson’s disease.
    • Goal: recalibrate the voice.
      • Speak louder.
      • Speak with intention.
      • Improve breath support.
      • Modify sensory processing related to voice/speech.
    • Intensive: 4-5 days/week for 4-5 weeks.
    • Maintenance programs required.
Compensation
  • Prosthetics:
    • SpeechVive.
      • Works on the Lombard effect: we reflexively increase vocal intensity in a noisy environment.
    • Portable voice amplification.

Articulatory Treatments

Direct
  • Minimal contrasts:
    • Purpose: make the distinction between contrasts as clear as possible.
    • Helpful to achieve control over consonants.
    • Work at word, phrase, sentence stimuli.
    • Examples: pay – may, pie – bye, chew – shoe, stop – top.
Compensation
  • Clear speech:
    • Over-articulation; exaggerated articulation.
      • Speak clearly.
      • Use big speech movements.
      • Slow down.
      • Overenunciate.
      • Exaggerate movements of your mouth.
      • Speak as if you were in a noisy room.
      • Speak with a big mouth.

Prosody Treatments

Prosody Targets
  • Rate
  • Stress
  • Phrase Groupings
Compensation
  • Speaking rate:
    • Decreasing rate typically improves intelligibility.
      • Facilitates articulatory compensation.
      • Allows time for full range of motion & coordination.
      • Improves phrasing.
      • Reduces variability of speech movements.
      • Gives listeners more time to process dysarthric speech.
    • Rate reduction = reduced articulatory rate + increased pause time.
  • Tools:
    • Pacing board.
    • Alphabet board.
    • Metronome.
    • Delayed auditory feedback.

Communication-Oriented Treatments

Goal
  • Maximize effectiveness, efficiency, and/or naturalness of communication.
  • Comprehensibility
Intelligibility vs. Comprehensibility
  • Intelligibility: Degree to which a listener understands the auditory signal produced by a speaker.
  • Comprehensibility: Degree to which a listener understands speech based on the auditory signal + all other information that may contribute to understanding.
Speaker Strategies
  • Get the listener’s attention.
    • Say listener’s name or “excuse me”.
    • Gesture, eye contact.
  • Instruct novel listeners on how best to communicate.
    • Disclose speech difficulties.
  • Identify topic/context.
  • Modify sentence content, structure, length.
    • Reduce complexity.
  • Monitor listener comprehension.
    • Acknowledge miscommunications.
  • Alphabet supplementation.
Listener Strategies
  • Maximize hearing & visual acuity.
  • Maintain eye contact.
  • Optimize physical environment.
  • Improve listening skills.
    • Familiarization with dysarthric speech.
Interaction Strategies
  • Schedule important interactions.
  • Select a conducive speaking/listening environment.
  • Identify breakdowns and establish methods for feedback.
  • Repair breakdowns.
  • Have a predetermined plan!

Speech Replacement/AAC

Goal
  • Facilitate effective communication for people with degenerative conditions (e.g., ALS) as the condition progresses past the point where they can use natural speech.
  • Typically use high-tech AAC.
  • Modality depends on remaining limb motor function.

Voice Banking & Message Banking

  • Individuals record personally meaningful sounds, words, phrases, sentences, stories, etc. using their natural voice.
    • No constraint on # of recordings.
  • Message Banking:
    • Use high-quality audio recordings of an individual’s speech to create a personalized synthesized voice.
    • Need to record 1600+ phrases.
  • Voice Banking:
    • Needs to be done early in disease progression!

Summary

  • Goals of speech treatment are to increase communication effectiveness, efficiency, and naturalness.
  • Can be direct, compensatory, or supplementation/substitution.
  • Address what is lacking and use what is preserved.
  • Intelligibility and comprehensibility are key.
  • Treatments typically address speech subsystems.
  • Important to involve communication partners.