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Mr. Jones

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Katie Manson

on 29 July 2015

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Transcript of Mr. Jones

Acquired Apraxia of Speech
Mr. Jones
Age: 66

Reasons for referral:
Mr. Jones had a left hemisphere stroke causing expressive aphasia, apraxia, dysphagia, ambulia, hypersomnolence, and right hemiparesis.
Mrs. Jones says her husband knows what he wants to say, but that he "cannot get it out."

The client was referred to the MU clinic by the SLP previously treating him at a rehabilitation center. It was noted that Mr. Jones is motivated to overcome his communication deficits.



Long-Term Goals
1. Client will improve motor planning of articulatory movements.

2. Client will increase fluency in connected speech.
Procedures
LTG: Client will improve motor planning of articulatory movements.
Objectives
LTG: Client will improve motor planning of articulatory movements.
Lexi Mok, Kristin White, Katie Lorenz, and Katie Nielson
Client will accurately produce fricatives /s, z, , ð, f/ in multi-word, polysyllabic utterances in all word positions given clinician modeling in 80% of opportunities.
Client will accurately produce plosives (i.e., /p, b, k, g, t, d/) in the word initial position of multisyllabic words given clinician’s model in 80% of opportunities.
LTG: Client will increase fluency in connected speech.
Objectives:
Client will respond in 4 seconds or less given clinician prompting in 80% of opportunities.

Client will intelligibly produce five target functional phrases with 80 % accuracy as judged by three unfamiliar listeners.
Client will accurately produce fricatives /s, z, ɵ, ð, f/ in multi-word, polysyllabic utterances in all word positions given clinician modeling in 80% of opportunities.

Clinician will facilitate an increase of voluntary motor control of fricatives using a structured, clinician-directed 10-step phonemic drill approach. Five frequently used fricatives will be targeted in therapy (i.e., /s, z, ,ð, f/). Initially, the client will produce and hold one phoneme in isolation when given clinician modeling (e.g., /ssssss/) and gradually move to produce the target fricative in all word positions of multiword utterances containing monosyllabic, disyllabic, and polysyllabic words (e.g., Sally sleeps on Saturdays).

Upon mastery of the first target, the client will move to the next phoneme and begin the process again. Verbal praise and short, specific feedback will be given intermittently (i.e., 60% of productions) to ensure generalization of learning and plenty of opportunities for drill. If the client fails to produce a target accurately, the clinician will use integral stimulation (“watch me, listen to me, say it with me”) to support correct productions of the target. If the client is still unable to produce the target, further supports will be used to facilitate accurate production (e.g., tactile cues, usage of a mirror).

Throughout therapy, the clinician will prompt the client to anticipate phonemes and plan the appropriate articulatory positions upon producing the targets. Upon mastery of the targets, task complexity will increase by introducing minimal word pairs to foster the transition of phonemes across words (e.g., fun-sun). The clinician will also encourage natural discourse upon mastery of targets by increasing the speed of speech and incorporating prosodic components into drill therapy. Rest breaks will be given if needed.
Client will accurately produce plosives (i.e., /p, b, k, g, t, d/) in the word initial position of multisyllabic words given clinician’s model in 80% of opportunities.
A sound production treatment approach will be used to target accurate articulation of plosives (i.e., /p, b, k, g, t, d/) in the initial position of multisyllabic words. Treatment will begin with a clinician model of the individual phonemes in minimal pairs (e.g., /p/ and /b/), followed by multiple productions by the client. Upon mastery, target will increase to CV monosyllabic sounds (e.g., /ba/ and /pa/) with plosives in initial position. Clinician will model sounds in minimal pairs and request multiple imitated responses from the client.

Upon mastery, targets will increase to monosyllabic words with plosives in the initial position and then to multisyllabic words following the same minimal pair procedure. Specific feedback will be given after each trial. If target is incorrect, clinician will integrally stimulate target sound or word through a ‘watch me, listen to me, and say it with me’ method. If still incorrect, client will model the target sound or word in segments and have the client imitate. If client is still unable to articulate the sound or word correctly, client will provide verbal cues for correct articulatory placement (e.g., start with your lips closed for the /p/). Positive verbal reinforcement will be given for accurate productions. Rest breaks will be given if necessary.
Procedures
LTG: Client will increase fluency in connected speech.
Client will respond in 4 seconds or less given clinician prompting in 80% of opportunities.
A structured, clinician-directed approach will be used to decrease latency time in automatic speech. Automatic speech in word pairs will be addressed first through the use of Wetz, LaPointe, and Rosenbek’s 8 step program. The clinician will give Mr. Jones a word pair requiring a single word answer (e.g., salt and …) and transition from step 1 of the clinician and client saying it together, all the way to step 8 where the client can use it spontaneously in a role-play situation.

After Mr. Jones has mastered all 8 phases of a word pair, then he will transition to phrases (e.g., An apple a day …) and then sentences (e.g., Twinkle, twinkle little star …). Word pairs, phrases, and sentences will be taken from common expressions, poems, and songs. Throughout the 8 steps verbal and visual cues will be given along with verbal praise and specific feedback. Rest breaks will be given if needed.


Client will intelligibly produce five target functional phrases with 80 % accuracy as judged by three unfamiliar listeners.

A structured clinician directed integral stimulation motoric approach will be used to target the client's ability to volitionally produce functional meaningful phrases.

Initially the clinician will target 5 short phrases chosen by the client and his wife as having functional meaning (e.g. "I'm tired." "I'm hungry" "I love you."). These phrases will be practiced using a drill-based approach. Simultaneous input in multiple modalities (especially auditory and visual) will be used. Once the client says the phrase correctly, he will be asked to repeat it over and over, to embed it in his motoric memory.

A flexible cueing hierarchy will be used, including tactile cues, simultaneous production, mimed production, immediate repetition, successive repetition, and delayed repetition. Adding and fading of cues will be done as each utterance is produced and will be varied in order to elicit a large number of accurate responses from the client. Massed and distributed practice will be balanced in order to ensure both success and generalization. Feedback will be specific but short, so that the client will have time to produce a large number of phrases in each session. Reinforcement will include verbal praise and the naturalistic reinforcement of the ability to be understood. Rest breaks will be included as necessary.

Once the client has shown the ability to produce the target phrases with relative ease and accuracy, other functional meaningful phrases will be targeted, using the same cueing hierarchy.
References
Yorkston, K. M., Beukelman, D. R., Strand, E. A., Bell, K. R. (1999). Management of motor speech disorders in children and adults, 2nd edition. Pro-Ed.
Roth, F. P., Worthington, C. K. (2016). Treatment resource manual for speech-language pathology, 5th edition. Clifton Park, NY: Delmar, Cengage Learning.
Lawrence, L. (2015). Motor speech disorders: Intervention [PowerPoint slides].
Apraxic Concerns
Oral-motor planning difficulties contributing to severely unintelligible connected speech.
Imprecise articulation
Substitution of /b/, /s/, and the blend /sp/ for several phonemes
Inconsistent phonemic errors
10-second latency time when responding to others
Groping postures
ɵ
ð
ɵ
ɵ
Objective:
Objective:
Objective:
Objective:
Duff J. R. (2013). Motor speech disorders: Substrates, differential diagnosis, and management, 3rd edition. St. Louis, MO: Elsevier.
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