Using Motor Learning Principles to Train Speech ...

Using Motor Learning Principles to Train Speech: Motor Learning Guided Approach Adrienne B. Hancock, Ph.D. Ilana B. Friedman, B.A The George Washington University Today’s handout available on www.AdrienneHancock.com in “Research” tab

Learner Objectives  List

the basic principles of motor learning theory.

Describe

why and how motor learning theory can be applied in treatment of apraxia of speech.  Motor

Learning Guided Approach Script Training List

considerations and appropriate modifications when using any principles of motor learning in treatment.

Principles of Motor Learning Used to promote retention, accuracy, and consistency of learned motor skills  Contribute to ability to perform the same movements many times with little or no cognitive effort  Commonly used in sports specific training  Recently being applied to rehabilitation (PT, OT) 

Principles of Motor Learning (Duffy, 1995)

Drill is essential  Initial instruction and cueing matters  Self-learning is valuable  Specificity of training  Practice schedule  Type of feedback  Goal: Automaticity! 

Principles of Motor Learning: Specificity 

Exercises more similar to actual activity  More

likely to generalize to other contexts

(Rutherford & Jones, 1986)



Speech exercises:  Incorporate

complete desired movement  Equals greater functional gain than targeting isolated muscle groups (Clark, 2003)

Principles of Motor Learning: Practice Schedules 

Blocked practice 



Faster acquisition

Random practice 

more consistent productions and less variability (Schmidt, 1991,Knock, Ballard, Robin & Schmidt, 2000)



Leads to retention and transfer

Principles of Motor Learning: Feedback Type 

Knowledge of performance (KP)  



“Your tongue was too forward, try to bring it back more” Reliance on extrinsic feedback

Knowledge of results (KR) feedback indicates accuracy of response  

“You got a score of 10 or higher on three of the four productions.” promotes self-monitoring and self-correction (Kilduski and Rice, 2003)

Current Research in motor learning Rehabilitation of non-speech motor tasks following stroke or TBI:  task-specific, repetitive, motor learning approach was more beneficial in gait rehabilitation than more traditional approaches (Hesse, 2001)  motor relearning treatment lead to   

shorter hospital stays, more improvement in motor function and Improved ADLs than traditional physiotherapy treatment (Langhammer & Stanhelle, 2000)

Current Research applying motor learning to speech  Younger 

adults

more consistent and faster in movement times than older adults following learning of a novel motor skill (Schulz, Stein, & Micallef, 2001)

 Parkinson’s 

ML not implicated for speech tx

 Cerebellar 

Disease

Pathology

ML intact, could use ML

Current Research applying motor learning to speech 

Persons who stutter 

less automaticity

(Smits-Bandstra et al., 2006,DeNil and

Bosshardt 2001)



Apraxia of speech 

Practice effects  

(Knock, Ballard, Robin & Schmidt, 2000)

Limb similar to oral AOS similar to NBD

Apraxia (Wertz et al. 1984) A neurogenic phonologic disorder resulting from sensorimotor impairment of the capacity to select, program, and/or execute in coordinated and normally timed sequences, the positioning of the speech musculature for the volitional production of speech.

Apraxia Why is motor learning treatment a good fit? Facilitates improvements in    

coordination, consistency, accuracy and automaticity

of muscle movements leading to improved speech initiation and production

Application #1:

Motor Learning Guided (Stierwalt, Hageman & LaPointe)

Overview: Motor Learning Guided (MLG) 

Purpose: 



Client-centered, Functional approach 



To develop automatic words/phrases

Client selects personally relevant phrases

Clinician guides Client to use Motor Learning Principles   

Increasing client’s independence during tx Frequent practice- block and random elements Increasing client’s automatic speech productions

MLG Procedure  With  

patient/family, select 5 -10 stimuli

Functional (daily, emergency) Word or phrase length appropriate for abilities

Write

stimuli on index cards

Record

on audiotape

MLG Procedure (with additions) Step 1: Say together, then a. Client repeats once immediately, waits 4 sec b-d. Client repeats 3 times, with 4 second pauses between Clinician says it, waits 4 seconds, provides # correct out of 4 attempts. Step 2: (random order) Clinician will verbally read card, wait 4 seconds, give client card to read a. Client repeats once immediately, waits 4 sec b-d. Client repeats 3 times, with 4 second pauses between Clinician says it, waits 4 seconds, provides # correct out of 4 attempts. Step 3: (random order) Client will read card aloud (Clinician prompts him if wrong) a. Client repeats once immediately, waits 4 sec b-d. Client repeats 3 times, with 4 second pauses between Clinician says it, waits 4 seconds, provides # correct out of 4 attempts. * Client will say it again without looking at card. * Client will say it in response to a questions.

MLG Procedure continued Step 4: Repeat steps 1-3 with a different set of 5 stimulus cards Step 5: Using both sets of cards (10 stimuli total) in random order, client will read written card aloud, a. Client repeats once, immediately, waits 4 sec b-d. Client repeats 3 times, with 4 second pauses between Clinician says it, waits 4 seconds, provides # correct out of 4 attempts.

Multi-dimensional scoring 11 Accurate and immediate (minimal distortion ok) 10 Delayed less than 2 seconds 9 Delay with groping/posturing 8 7

Not readily accurate (you have to consider for intelligibility), but acceptable approximation Not readily accurate, but acceptable, AND delayed more than 2 seconds

6 5

Needs stimuli repeated Self-corrects

4

Incomplete. Similar characteristics (e.g., # syllables) but not the target Error Error AND 2+ second delay Perseveration (produces previous response) No response

3 2 1 0

Tell me about __

Sponge Bob Square Pants

Barbie Dolls

Wizard of Oz

Freaky Friday

a. b. c. d.

a. b. c. d.

a. b. c. d.

Step 1: In unison a. b. c. d.

a. b. c. d.

Step 2: clinician, 4 seconds, then client a. b. c. d.

a. b. c. d.

a. b. c. d.

a. b. c. d.

a. b. c. d.

a. b. c. d. no card:

a. b. c. d. no card:

a. b. c. d. no card:

a.

a.

Step 3: client read card a. b. c. d. no card:

a. b. c. d. no card:

In response to question a.

a.

a.

Crucial client instructions 

You will not say right/wrong after each production.



During the 4 second “wait”, client is to “think about” how it sounded and what to modify for the next production (if necessary).



Daily practice at home!!

Motor Learning Principles involved: 

Stimuli similar to target



Several repetitions- with delays



Random practice, with blocks



Increasing reliance on internal feedback, KR emphasis

Questions about MLG? Fountain, Lasker, & Stierwalt. (2007). Improving speech production in profound apraxia using MLG and AAC. A poster session presented at the ASHA Annual Convention, Boston, MA. Gildersleeve-Neumann, C. (2007). Treatment for childhood apraxia of speech: A description of integral and stimulation and motor learning. The ASHA Leader, 12(15), 10-13, 30. Lasker, J., Stierwalt, J.A.G., Gealy, F., & Revolinski, T.(2005). Enhancing Conversation Skills in Aphasia/Apraxia Using a Multimodal Approach. A technical session presented at the ASHA Annual Convention, San Diego, CA. Seo, I., Kim, I., Hageman, C.F., Stierwalt, J.A.G., LaPointe, L.L. (2005, November) Treating AOS Using the MLG Approach: A Cross Cultural Examination. A poster session presented at the ASHA Annual Convention, San Diego, CA. Stierwalt, Hageman & LaPointe. (2004). The motor learning guided approach to apraxia of speech. Symposium conducted at the meeting of the World Congress of the International Association of Logopedics and Phoniatrics, Brisbane, Australia. Stierwalt, J.A.G. (2002). Principles of motor learning: Application to motor speech disorders. Staff Appreciation Symposium, Florida State University Speech and Hearing Clinic.

Try it with a partner! Select functional stimuli Step 1: In unison Step 2: Clinician model Step 3: Client read card *no card *response to question a. Client repeats once immediately, waits 4 sec b-d. Client repeats 3 times, with 4 second pauses between Clinician says it, waits 4 seconds, provides # correct out of 4 attempts.

Video of MLG Left-handed 51 year-old male  Three CVAs in May, 2000  Broca’s Aphasia, anomia, oral apraxia, and weakness of the right upper and lower extremities  Former computer analyst  The client plays the bass guitar, and occasionally plays with a local band.  WAB AQ: 61  Mod-Severe Apraxia (ABA score) 

Participant 29 year-old male, 3 years post TBI (GSW) 

ABA-2: 





articulatory groping, sound distortions, substitutions, additions and exchanges, poor transitions between syllables and words, reduced rate of speech, difficulty with sequencing of syllables and phonemes, and difficulty initiating speech even when the linguistic message is known Patient exhibits a profile of moderate to severe apraxia of speech

BTHI:  

Severe deficit in linguistic organization Moderate deficits in:      

memory reading comprehension orientation/attention following commands Naming visual-spatial skills

Number of Phrases (out of 5) with a Score of Nine or Higher Baseline

Treatment

Baseline

Treatment Baseline

Number with score 9 or higher

Phrases in Response to a Question

5 4

Set A

3

Set B

2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Session Number Session

Appropriateness/ Limitations Daily practice  Generalization  Scoring reliability 

Pop Quiz! 

When might it be appropriate to use MLG?



Distinguish the 3 steps.



Why have 4 seconds between each production?



What modifications may be necessary?



How would you record results?

Stretch Break?

Application #2:

Script Training

Overview of Script Training Purpose: To re-inject islands of automatic speech into impaired, non-automatic speech

Previously applied to individuals with Non-Fluent Aphasia (Youmans, Holland, Munoz & Bourgeois, 2005) Functional approach to therapy, Client-centered  

Client selects personally relevant scripts Performed in natural, conversational context

Follows the Instance Theory of Automatization  

Scripts practiced as whole phrases, not phonemes or syllables Scripts practiced in multiple contexts for generalization (Logan 1988)

Script Training modified for AOS Follows tenants of Motor Learning Theory (Schmidt & Lee, 1999)  Acquisition Phase:  Block practice of phrases  To promote rapid acquisition – initial success, decreased frustration 

Maintenance & Generalization Phase:  Random practice  To promote long term retention and generalization

Script Training Procedure 1. 2. 3. 4. 5.

6. 7.

Client-generated, relevant topics Client and clinician write short scripts Scripts divided into short phrases for training 45-minute sessions, 2 times per week Practice with tape recording at home 2 times per day, for at least 15 minutes per practice session Script phrases were trained using a cuing hierarchy 3 Scripts were practiced in a cumulative fashion

Example Script WB: Excuse me, I need help Dr. H: What can I do for you? WB: Can you look up a magazine? Dr. H: no problem, what is it? WB: I like things about guitar, history, and computers. Dr. H: We have a new book about World War II WB: Please show me where to go. Dr. H: Ok, here it is.

Cuing Hierarchy for Acquisition: Block practice 1. 2. 3. 4. 5. 6.

Clinician modeled word/phrase Client produced phrase in unison with clinician many times Clinician gradually faded participation Client independently produced phrase with cue card in place, 5-10 times. Client produced phrase independently without cue card 5-10 times Conversation breaks were taken throughout session

After Stable Production: Random Practice 

Initiated when practice reached