Session 2 9

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning
Gabrielle Zimmer, M.S., CCC-SLP, CBIS

Caryn Graboski, M.S., CCC-SLP CBIS
2015 NJSHA Convention
April 30, 2015
Learner Outcomes
1. Summarize five complex and unique case studies in adult rehabilitation.
2. Identify and define speech and language deficits in individuals with diagnoses ranging in severity related to acquired speech
and language disorders.
3. Advance ability to facilitate meaningful treatment objectives in order to optimize functional independence and community
reintegration of individuals with acquired communication disorders and co-morbid diagnoses.
4. Incorporate evidence-based practice during treatment planning for adult rehabilitation.
Overview
• Treating concomitant deficits
• Four case studies
• Overview of diagnosis and deficits
• Video samples of assessment
• Goal writing
• Video samples of treatment
• Treatment planning
• Materials
• Summary/Questions
 Concomitant Deficits
 Identify and prioritize deficits
 Differential Diagnosis
 Strong clinical decision making
 Review of PMH
• Maximize independence: Pre-morbid level of Functioning
• Identify patient goals: Functional
• Create clinician goals
• Objective and Quantifiable
• Review funding and insurance guidelines
Case Studies
• Aphasia
 Mixed receptive/expressive
 Fluent
 Non-Fluent
• Apraxia of speech
• Dysarthria
• Primary Progressive Aphasia
Assessment
• Boston Diagnostic Aphasia Evaluation (BDAE-4)
• Boston Naming Test (BNT)
• Western Aphasia Battery (WAB)
• Expressive One Word Picture Vocabulary Test (EOWPVT-4)
• Apraxia Battery for Adults (ABA-2)
• Reading Comprehension Battery for Adults (RCBA-2)
• Receptive One Word Picture Vocabulary Test (ROWPVT-4)
• Ross Information Processing Assessment (RIPA-2)
• Behavioural Assessment of the Dysexecutive Syndrome (BADS)
• Measure of Cognitive Linguistic Abilities (MCLA)
• Frenchay Dysarthria Assessment (FDA-2)
There are no financial or non‐financial relationships to disclose for this presentation.
April 30, 2015
Case Study #1- AF

• 47-year-old male
• Employed as parole counselor
• Collapsed when boxing
• Occlusion of the left carotid artery resulting in a left MCA infarct
• Malignant edema s/p left hemicraniectomy
• Resultant right hemiplegia and global aphasia
• Dysphagia status post PEG tube placement
• Course complicated by aspiration pneumonia
• PMH of hypertension and obesity
• Hospitalized at the acute stage for 3 weeks
• Transferred to a rehabilitation setting and received inpatient therapy for 2.5 months
• Discharged to home with close supervision
• Home Care Services:
 2-3 days/week for 4 weeks
 Upgraded to regular solid diet with all liquids
Case Study #1- Assessment BDAE- Cookie Theft

Case Study #1- Assessment BNT-Short Form
Case Study #1- Characteristics

• Expressive Language
 Severe non-fluent aphasia
 Telegraphic utterances
 Stereotypical Utterances/Overlearned Phrases
 Word Retrieval Deficits
 Poor syntax & grammar
 Paraphasias- semantic & literal
 Perseveration
 Stimulable for phonemic and semantic cues
 Expressive < Receptive
• Receptive Language
 Preserved self-monitoring
 Auditory comprehension of basic information
 Poor body part identification
 Basic y/n reliability
 1-Step Commands
• Reading Comprehension: Basic phrase-sentence level
• Written Expression: Basic Functional Level
Case Study #1- Long-Term Goals

• LTG #1: The patient will demonstrate basic functional expressive language skills at the sentence level 90% of the time given
minimal cues for home, community, medical and safety needs.
• LTG #2:The patient will demonstrate receptive language skills at the moderately complex conversation level with 90% accuracy
given minimal cues for home, community, medical and safety needs.
• LTG #3:The patient will demonstrate reading comprehension skills at the moderately complex multi-paragraph level with 90%
accuracy given minimal cues for home, community, medical and safety needs.
• LTG #4:The patient will demonstrate written expression skills at the basic sentence level with 90% accuracy given minimal cues
for home, community, medical and safety needs.
Case Study #1- Short-Term Goals
April 30, 2015
• STG #1: The patient will complete a variety of basic word retrieval tasks (e.g. phrase completions, concrete divergent naming,
naming synonyms/antonyms, naming objects, etc.) with 75% accuracy given maximal visual, verbal, tactile cues.
• STG #2: The patient will complete basic phrase-sentence level production tasks (e.g. SVO picture description, conversational
exchanges, etc.) with 75% accuracy given maximal visual, verbal, tactile cues.
• STG #3:The patient will complete basic-moderately complex y/n reliability questions with 90% accuracy given minimal cues.
• STG #4: The patient will follow basic 2-step auditory directions with 90% accuracy given moderate cues (e.g. Body part
identification, object manipulation, etc.)
• STG #5: The patient will complete basic single word level written expression tasks (e.g. basic phonics and irregulars at the
monosyllabic word level) with 90% accuracy given minimal cues.
• STG #6: The patient will complete basic sentence level reading comprehension tasks (e.g. sentence/picture matching, following
written directions, etc.) with 90% accuracy given minimal cues.
• STG #7: The patient will implement 1 word retrieval strategy during basic structured word retrieval tasks (e.g. circumlocution,
SFA, written expression, gesture, etc.) with 90% accuracy given minimal cues.
Case Study #1- Treatment: Picture Description “What’s Wrong”

Case Study #1- Treatment: Feature Identification
Case Study #1- Treatment: Anagram and Copy
Case Study #1- Evidence Based Practice
“Using CART with two clinical sessions per week and daily homework, an individual with severe Broca’s aphasia relearned written
spelling for 46 words over 3 months.” (Beeson et al, 2002)
“Writing should be considered an alternative modality for individuals who are unable to recover spoken language.” (Beeson et al,
2003)
“More people with aphasia gestured as compared to typical controls, and that for many people with aphasia, the gestures produced were
iconic.” (Sekine & Rose, 2013)
“Importantly, aphasia type appeared to have an impact on the types of gesture the people with aphasia produced. Whereas concrete deictic
gestures and emblems were used by individuals with all types of aphasia, significantly higher proportions of individuals with Broca’s and
Wernicke’s aphasia produced concrete deictic gestures; significantly higher proportions of individuals with Broca’s and conduction aphasia
produced iconic CVPT gestures; and, consistent with the second hypothesis, a significantly higher proportion of individuals with Broca’s
aphasia produced pantomime and number gestures.” (Sekine & Rose, 2013)
“Results of this study show that improvements in gesture and naming can be achieved (a) by people with severe and chronic aphasia and (b)
in response to a limited therapy dose.” (Marshall et al, 2012)
“Multimodality therapies take advantage of other mechanisms to support verbal production and provide multimodality communication skills
for social interaction when word production fails. Taken together, it seems that multimodality treatments are a valid option for rehabilitation
of individuals with chronic aphasia, and that constraining participant responses to the verbal modality is not strongly supported by current
evidence.” (Rose, 2013)
“When utilized as early stroke intervention in patients with non-fluent aphasia, MMIT demonstrates significant positive results in patients’
overall ability to verbally respond following one session and continued improved verbal output after twenty-four hours.” (Conklyn et al,
2012)
“Results from this study suggest that a copy and recall methodology can be effective for training single-word spelling using the texting
function on a cell phone in a manner similar to that with pen and paper. The time required to train words and the accuracy immediately after
treatment were comparable for both modalities, but for this participant, long-term retention was stronger for words trained with pencil and
paper compared with those trained with the cell phone.” (Beeson et al, 2013)
“Script training intervention is effective in improving dialogic discourse on a chosen topic for people with aphasia. The result of
generalization probes indicates that people with aphasia are able to use learned scripts in similar functional situations. Furthermore,
April 30, 2015
this study highlighted how people with aphasia focus on different aspects of script training, relative to their impairments and goals.
Strong self-cuing abilities appear to facilitate script learning. This study also suggests that videoconferencing may be a useful avenue
for script training, as a supplement to in-person interaction with a clinician.” (Goldberg et al, 2012)
“Results indicated that participants evinced some improvement for naming accuracy for treated words but not untrained words, and
produced more target words from trained lists on the discourse tasks from the initial testing session to the post-treatment and
maintenance sessions.” (Rider et al, 2008)
Case Study #1- Treatment Planning

• Script training: Initiating basic conversational turn-taking
• Training AAC (e.g. picture boards-speech generating application)
• Naming tasks (responsive/convergent/divergent)
• Object/picture naming & description
• Body part identification
• Moderately complex y/n reliability
• Inclusion of language applications for HEP
• E.g. TherAppy, Lingraphica, etc.
• Multimodal training- gestural, written expression, etc.
• Incorporating writing & reading across all tasks
• Functional Tasks- Restaurant simulation/MD appointments
Case Study #2- RM

• 52 year old female
• Full time sales associate in retail
• Found to have slurred speech and right facial droop and right-sided weakness
• MRI revealed left MCA territory infarct with hemorrhagic transformation
• Intraparenchymal hemorrhage
• Left frontoparietal lobe
Case Study #2-RM

• Slight midline shift from left to right
• Dysphagia and initially NPO but upgraded to regular diet with thin liquids
• Course complicated by malignant hypertension
• Past Medical History
• Dyslipidemia
• Hypertension
Case Study #2- RM

• Acute Hospitalization for 6 days
• Inpatient Rehabilitation for 3 weeks
• Discharged to home with close supervision
• Immediately transitioned to outpatient rehabilitation
Case Study #2 Assessment: Diadochokinesis

Case Study #2 Assessment: Repetition (ABA-2)
Case Study #2-Assessment: BDAE-4 Cookie Theft
Case Study #2-Assessment: BNT-Short Form

• Severe non-fluent aphasia
• Severe apraxia of speech
• Poor initiation
April 30, 2015
• Consonant and vowel distortions

• Unsuccessful attempts to self-correct
• High error rate for volitional/purposeful utterances vs. automatic/reactive utterances
• Limited to a few meaningful or unintelligible utterances
• Sequential Motion Rate<Alternating Motion Rate
• Oral apraxia
• Limb apraxia
• Mild dysarthria
• Receptive language is WFL
• Reading comprehension at 2 sentence level
• Written expression at the basic functional level
• Suspected concomitant cognitive deficits
• Highly aware of errors with frustration
• Stimulable for visual, verbal, tactile cues
Case Study #2- Long Term Goals

• LTG #1: The patient will demonstrate the ability to express functional wants and needs at the basic conversation level via
multiple modalities (i.e. verbal, AAC, and gestural) with 70% accuracy given moderate cues.
• LTG #2: The patient will demonstrate reading comprehension at the multi-paragraph level with 90% accuracy given moderate
cues.
• LTG #3: The patient will demonstrate written expression at the basic phrase level with 90% accuracy given moderate cues.
Case Study #2- Short Term Goals

• STG #1: The patient will complete repetition tasks at the monosyllabic word level (e.g. Voiced/Voiceless Cognates) with 90%
acc. given maximal visual, verbal, and tactile cues.
• STG #2: The patient will state basic functional personally relevant information (e.g. first and last name) with 90% acc. given
maximal visual, verbal, and tactile cues.
• STG #3: The patient will complete a variety of automatized sequences (e.g. Counting, DOW, MOY, etc.) with 90% accuracy
given maximal visual, verbal, and tactile cues.
• STG #4: The patient will complete a variety of oral reading tasks at the single word level (e.g. words of increasing length) with
90% acc. given maximal visual, verbal, and tactile cues.
• STG #5: The patient will identify items on page with use of augmentative and alternative communication to express basic
wants/needs with 80% success given moderate cues.
• STG#6: The patient will request basic objects via gesture demonstrating function (e.g. cup) with 80% success given moderate
cues.
• STG #7: The patient will complete basic paragraph level (2-3 sentences) reading comprehension tasks with 80% success given
moderate cues.
• STG #8: The patient will complete a variety of written expression tasks at the single word level (e.g. monosyllabic with 1-2
graphemes missing) with 80% success given moderate cues.
Case Study #2-Treatment: Sequences

Case Study #2- Treatment: Spelling & Oral Reading
“Repeated practice treatment was applied to 32 different lists of experimental stimuli across the 10 participants. Increases in
production accuracy were evident for eight speakers for all lists. Given that repeated practice is a ubiquitous component of almost all
AOS treatments, it was expected that positive changes in sound production would be found. However, it was not expected that
maximal changes would be achieved with repeated practice treatment alone, as was the case with several of the participants.”
(Wambaugh et al, 2012)
April 30, 2015
“The degree of improvement achieved with repeated practice alone (with limited feedback concerning accuracy) was not anticipated
but highlights the importance of this treatment technique.” (Wambaugh et al, 2012)
“The results of this investigation do not support current diagnostic guidelines concerning the use of error variability to help differentiate
between AOS and aphasia with phonemic paraphasia in clinical samples of stroke and traumatic brain injury survivors. Four main findings
indicate that low error variability is an ineffective diagnostic criterion for this population. First, the magnitude of error variability and
consistency varied depending on its operational definition. Second, there were no differences in error variability across diagnostic groups
formed on the basis of other quantified diagnostic criteria for AOS versus aphasia with phonemic paraphasia. Third, the variability displayed
by individuals with salient profiles of AOS was similar to that of individuals with salient profiles of aphasia with phonemic paraphasia or
showed differences in the direction opposite to the guidelines. Finally, differences in error variability were mediated by differences in overall
error frequency.” (Haley et al, 2013)
“Patients with a (postlexical) phonological impairment—such as, for instance, in patients with conduction aphasia—differ from speakers with
apraxia in that they lack any obvious motor problems. Their speech is well-articulated and largely fluent, without visible groping, and—more
or less—is prosodically unremarkable. Their core symptom is that they produce phonemic errors—that is, substitutions, omissions, and
additions of phonemes.” (Ziegler et al, 2012)

• Automatic Sequences
• Melodic Intonation
• PROMPTs for Re-structuring Oral Muscular Phonetic Targets
• Oral Reading (Increasing Syllable Length)
• Repetition Tasks
• Naming Tasks (e.g. Sentence Completions)
• Contrasting CV combinations
• Producing Varied Stress
• Functional reading comprehension: signs, scanning, etc.
• Functional writing (e.g. personally relevant information/single word level)
• Use of iPad applications for HEP
• AAC Trial- Picture Boards, Applications, Dynavox, Tobii, etc.
Case Study #3- TW

• 69 year old male
• Full-time Cardiologist
• Severe TBI due to bicycle accident
• CT scan showed left-sided subarachnoid hemorrhage with midline shift
• Left temporal lobe contusion
• Craniotomy with evacuation of the bleed
• Partial left temporal lobectomy
Case Study #3- TW

• Past Medial History
• Hypertension
• Hyperlipidemia
• Coronary artery disease
• Myocardial infarction in 2006
• Transferred to acute inpatient rehabilitation
• Initially transferred to Kessler in a vegetative-minimally conscious state
Case Study #3- TW

• Hospitalized for approximately 2 months
• Discharged to home with supervision
• Participated in approximately 2 months of home speech therapy 2-3x/week
April 30, 2015
• Discontinued services and did not transition to outpatient rehabilitation

• Poor compliance due to poor insight/awareness
Case Study #3- Assessment: BDAE-4 Cookie Theft

Case Study #3- Assessment: BNT-Short Form
Case Study #3- Assessment: BDAE Repetition
Case Study #3- Assessment: WAB Object Identification

• Severe Fluent aphasia
• Moderately-severely impaired auditory comprehension
• Jargon
• Neologisms
• Empty/run on speech
• Semantic/literal paraphasias
• Perseveration
• Not stimulable for phonemic/semantic cues
• Repetition at basic monosyllabic word level
• Word retrieval deficits
• Poor oral reading

• Severely reduced auditory comprehension
• Unable to follow 1-step commands
• Poor comprehension of basic task instructions
• Poor y/n reliability
• Poor single word comprehension (e.g. object I.D.)
• Poor awareness of errors/poor self-monitoring
• Reading Comprehension
• Basic functional level (e.g. family names, etc.)
• Written Expression
• Basic functional-single word level
Case Study #3- Long Term Goals

• LTG #1: The patient will demonstrate accurate word retrieval abilities at moderately complex conversation level 80% of the time
given moderate cues for home, community, medical and safety needs.
• LTG #2:The patient will demonstrate receptive language skills at the moderately complex conversation level with 80% accuracy
given moderate cues for home, community, medical and safety needs.
• LTG #3:The patient will demonstrate reading comprehension skills at the basic 2-3 sentence level with 90% accuracy given
minimal cues for home, community, medical and safety needs.
• LTG #4: The patient will demonstrate written expression skills at the basic sentence level with 90% accuracy given minimal cues
for home, community, medical and safety needs.
Case Study #3- Short Term Goals

• STG #1: The patient will complete basic functional word retrieval tasks (e.g. naming family members, automatized sequences,
naming objects, etc.) with 90% accuracy given maximal cues.
• STG #2: The patient will generate a basic subject/verb/object sentence shown a picture with 70% accuracy given maximal cues.
• STG #3: The patient will identify absurdities in basic statements with 90% success and maximal cues to improve functional
auditory comprehension skills.
April 30, 2015
• STG #4: The patient will increase basic auditory comprehension via accurately answering basic yes/no questions (e.g. pertaining
to pictures) with 90% accuracy given moderate cues.
• STG #5: The patient will follow basic 1-step directions with 80% accuracy given maximal cues.
• STG #6: The patient will complete basic functional written expression tasks at the single word level (e.g. via picture naming) with
90% acc. given moderate cues.
• STG #7: The patient will complete single word level reading comprehension tasks (e.g. picture/word matching) with 90% acc.
given moderate cues.
Case Study #3- Treatment: Oral Reading

Case Study #3- Treatment: Family Names
“Results of this experiment demonstrated that SFA treatment improved the ability of both participants to name treated and untreated
items, as predicted. Using many exemplars did not enhance generalization to untrained items, contrary to predictions. Both
participants demonstrated improvement on some, but not all, discourse measures as a result of SFA treatment, but the measures that
improved differed for each participant.” (Boyle, 2004)
“It is worth reiterating that ST’s acquisition of a functional written vocabulary resulted in significant changes in his ability to
communicate. ST ultimately began to write several words in combination (with no formal syntax) to convey a thought or event. This
chaining of ideas paired with gesture, drawing and prosodic information conveyed by his stereotyped utterances moved ST to a new
level of communicative competence. His success prompted the treatment of other individuals with severe aphasia who also showed the
capacity to re-establish written communication while their spoken language was severely limited. The fact that written words can be
constructed one letter at a time, with ample time to examine, reject, and revise, provides a flexibility that is unavailable for speech
production. This difference may be a critical element allowing individuals with multiple processing deficits to re-establish written
communication when spoken communication fails.” (Beeson, 1999)
“The current findings provide support for a semantically based treatment, focused on the featural detail of category items, for training naming
in patients with fluent aphasia. The strong generalization effects observed in the present study also indicate that the items selected for
treatment within categories are important to consider, in that training atypical items within semantic categories results in generalization to
untrained items, whereas training typical items does not. These data suggest that the complexity account of treatment efficacy advanced by
Thompson et al. (2003) extends to the semantic domain. That is, like treatment for sentence production deficits in patients with agrammatic
aphasia (Thompson et al., 2003) and that for children with developmental phonological deficits (e.g., Geirut, 2001), the most effective
approach for training naming seems to be to train more complex material first.” (Kiran & Thomas, 2003)
Case Study #3- Treatment: Identify successful modalities

• Visual
• Write Key Words
• Alphabet Board
• Providing written phonemes (e.g. D_ _)
• Oral Spelling
• Utilize gestures
• Increase awareness of paraphasias
• Write words produced
• Target auditory comprehension
• Slow Speech Slightly
• Maintain eye contact/focus
• Limit verbosity
• Tactile feedback
Case Study #3- Treatment Tasks

• Repetition
• Answering basic Wh-questions
April 30, 2015
• “What’s Wrong” Color Cards

• Categorization of pictures/objects
• Correcting incongruities in sentences
• Thematic Language Stimulation
• Completing Applications
• Check Writing
• Gestural Training
• WALC
• HELP
• SOURCE
• Early Aphasia Therapy
• Applications
• Lingraphica
• Proloquo2go
• TherAppy
• Constant Therapy
• Language Activity Resource Kit (LARK)
• Alimed Cards: The Apraxia of Speech Stimulus Library
• Color Cards
• News for You- New Reader Press
• Language Games
• Incorporating language is common games
• Cards, Checkers, Etc.
Case Study #4- CM

• 21 year old female
• History of juvenile myoclonic epilepsy
• Jan 2014 mutli seizure episode due to non compliance
• Hypoxic Brain Injury
• Quadraparesis
• Dysarthria
• Dysphagia- PEG
• Cognitive Linguistic Deficits
• Balint’s Syndrome
• ACF Jan 2014
• Inpatient Rehab Feb-March 2014
• Home Care April 2014
• CT June 2014 revealing cortical atrophy
• Outpatient Therapy at another facility May- August 2014
• Discharge due to “plateau”
• Arrived at Kessler September 2014
• PT, OT, ST services
Case Study #4- Assessment Examination of Oral Mechanism

Case Study #4- Assessment Frenchay- Lips, Jaw, Tongue

• Examination of Oral mechanism
– Severe reduced strength and ROM
• Labial
• Lingual
• Mandibular
April 30, 2015
• Velum (assessed later due to poor access)

–Absent sensory reflexes
• Lips
• Tongue
• Gag
– AMR/SMR
• Absent precision for targets
• Compounding suspected apraxic errors
– Imprecision in phonemic targets
• Vowels>consonants
– Omissions of consonants in all but two opportunities
» E.g /owuh” for Totowa and /i-o-ei/ for Chipotle
• In absence of context 0% intelligibility
– Respiration-Phonation
• Incoodination for inhalation/exhalation with short, rushed utterances
• Phonatory incoordination versus paresis of VF (unable to voice target phonemes)
– MPT 3s avg
• Concomitant profound dysphagia and apparent cognitive linguistic deficits
– Absent initiation of swallow
– Copious anterior loss of secretions
– Poor comprehension of verbal instruction
– Verbosity/tangential/perseverative
– Episodic memory impairments
– Reduced sustained attention
– Avoidance behaviors

• LTG 1: Pt will utilize external aids such as simple text to speech or letter board supports in home and community for improved
intelligibility across settings and listeners.
• LTG 2: Pt will utilize internal strategies for intelligibility including slow rate and overarticulation for improved intelligibility
across settings and listeners.
• LTG 3: Pt. will convey simple biographical information and requests/verifications at phoneme-word level with 80% accuracy to a
familiar listener.
• LTG 4: Pt will tolerate at least one solid and one liquid consistency for pleasure intake.

• STG 1: Pt will utilize simple text to speech and letter board supports in structured therapy tasks for improved intelligibility
across settings and listeners with maximal prompts for identification of communication breakdown and cues technique for
use.
• STG 2: Pt will utilize overarticulation and slow rate for phoneme, CV, and CVC level productions for vowels and bilabials
with max cues/models and tactile sensory cue with 75% accuracy.
• STG 3: Pt will achieve approximations for up to 5 target functional word to phrase level output with max cues/models for use
of trained strategies for increased communication with familiar listeners.
• STG 4: Pt will complete repetitions of bilabial, lingualveolar, and velar stops in CV and CVC environments with max tactile
cues and models.
• STG 5: Pt will complete oral sensory and oral placement therapy exercises for mandibular stability, mandibular ROM, labial
closure, and lingual dissociation in sets of 5x4 with max cues/models for technique
• STG 6: Pt will achieve increased mandibular ROM for more appropriate articulation via passive and active stretch as
measured by production of open vowel /a/ in prompted output/drill in 4/5 trials.
• STG 7: Pt will exhibit increased reflexive oral sensory behaviors in stimulation for increased oral awareness.
• STG 8: Pt will exhibit increased secretion management/initiation of swallow with maximum multimodal cues as measured by
successful initiation of swallow at least 5 times in a treatment session.
April 30, 2015
• STG 9: Pt will sustain phonation for at least 5s (n=20s) with max cues/models.
Case Study #4- Treatment: Letter Board/AAC supplement and pacing strategy
Case Study #4- Treatment: Mandibular ROM
Case Study #4- Treatment: Bilabial Drills and Oral placement therapy
Case Study #4- Treatment: TTOS and Swallow Initiation

“Furthermore, there is evidence that changes in rate alone, even when listeners cannot see the alphabet cues, result in increased
intelligibility when speakers implement AS” (Beukelman, D., Yorkston, K., 1977).
“Research suggests that alphabet cues improve intelligibility by an average of approximately 25% (range = 5%–69%)” (Buekelman et.
al 2002)
“This study was designed to examine the effects of rate control treatment on the accuracy of sound production and total utterance
duration of multisyllabic words, phrases, and sentences with an individual with AOS and aphasia. Findings revealed that treatment
resulted in an improvement in sound production accuracy…” (Mauszycki & Wambaugh, 2008)
‘”Mandible may place leading role in not only normal articulatory development but also in the origin and persistence of certain
abnormal speech behaviors” (Green & Reilly 2003)
“…the mandibular operating system assumes dominant responsibilities in early normal speech development.” (Green & Reilly 2003)
“Slow stretching, in contrast, causes an inhibition of the stretch reflex and may decrease tone.” (Clark 2012)
“Nonetheless, given unique physiology, particularly with respect to muscle spindles, there is reason to believe that tone disruptions
may manifest differently in the orofacial musculature compared to the limbs. Only one muscle group in the orofacial system has a high
density of muscle spindles and exhibits clear stretch reflexes: the jaw-closing musculature.” (Clark, 2012)
“Icing is a therapeutic modality intended to decrease both nerve conduction velocity and muscle contraction speed, thus resulting in an
overall decrease in tone” Gracies, 2001; Katz, 1988; Michlovitz, 1986)
“superficial heating, thermotherapy, has been reported to decreased muscle tone, reduce muscle spasm…” (Smania et. al, 2010)
“passive stretching with prior heat treatment significantly increased hamstring extensibility” (Smania et. al, 2010)
“Response generalization to untrained exemplars paralleled trained productions and significant increases were seen incorrect
productions of untrained sounds.” (Wambaugh and Cort, 1998)
“Insufficient evidence to support or refute the use of OME’s to produce effects on speech was found in the literature” (McCauley,
Strand, Lof, & Frymark, 2009)
“Recent work suggests that an important signal is a sensory prediction error, which is the difference between the brain’s predicted
outcome of the movement and the observed outcome. Note that this is different than an error in target accuracy – it instead reflects
whether the body moved in the way that the brain thought it would. Sensory prediction errors can be used to calibrate the internal
representations of body dynamics and the environment and recalibrate for changes in either. Well calibrated internal representations
are important because they allow us to decrease reliance on time-delayed feedback from body sensors.” (Bastian 2008)
“While there may not be a one-to-one correspondence between the oral sensory-motor skills for feeding and the oral sensory-motor
skills for speech, there is an overlay of one system to another” (Rosen field-Johnson 2014)
April 30, 2015
“OPT activities are used in conjunction with traditional speech therapy and do not replace direct work on speech sound production.
However, working on the isolated muscle skills will facilitate standard movements for speech. All of the activities teach speech-like
movements and are not NSOME (Non-Speech Oral Motor Exercises). Research in the area of dysphagia suggests that improving
lingual strength through a sensory-motor exercise approach not only aids in swallow rehabilitation, it may also improve dysarthric
speech indirectly” (Rosenfeld-Johnson 2014)
Case Study #4- Treatment Tasks

 Heat & Passive Stretch (mandible)
 Oral Sensory inputs (tactile, temperature)
 Thermal Tactile Stimulation
 OME’s
o Lingual strength and ROM
o Labial seal
o Mandibular ROM
 Oral Placement Therapy
o Horns 1-3
o Bite Tube
o Bubbles
 Letter board and pacing training in structured conversation
o Revisions
 Phonemic Placement and Drill
 PROMPTs for Re-structuring Oral Muscular Phonetic Targets
Case Study #5- JB

 69 year old female
 Gradual onset of challenges in “getting words out”
 3 year decline with multiple diagnosis
o Ultimately PPA
 Prior speech therapy intervention at another site
o Communication strategies
 Pacing
 Writing
 Reducing communicative press
 PMH significant for HTN, parotid tumor, question of TIA
 NPE 2014 with strengths across domains of cognition
 Functional ADL participation with use of prior trained strategies however “strain” increasing
o Managing her own finances, medication, schedule
o Caring for grandchildren
 Strong caregiver support and familiar involvement
o Perceivable strain between patient and spouse
Case Study #5- Assessment BDAE- Cookie Theft

Case Study #5- Assessment BNT-Short Form

 Moderate non-fluent aphasia with suspected apraxic overlay
 Phonemic paraphasias
 Groping/halting prosody in connected speech
 Awareness of errors and over frustration
 Mild reduction in syntactic construction
 Expressive writing fair-good (1-2 letter omissions infrequently but generally discernable)
April 30, 2015
 Stimulable for pacing and “deep breathing” or cancellation technique

 Receptive < Expressive
 Preserved self-monitoring
 Auditory comprehension of information in clinical interview and per caregiver report in ADLs
• Reading Comprehension independent sentence paragraph level intact however did not test further

• LTG #1: The patient will utilize low tech strategies for enhanced expressive communication in episodes of non fluent revisions
with unfamiliar listeners given modified independence-minimum cues.
• LTG #2:The patient will effectively navigate to target information in trained SGD dynamic display with 80% accuracy and min
cues.
• LTG #3: The patient and a caregiver will demonstrate increased understanding of medical diagnosis and aphasia symptoms in
adjustment related counseling based discussions.
• LTG #4: The patient and family will exhibit independent abilities for SGD programming and management.

• STG #1: The pt will utilize low tech strategies for enhanced expressive communication including deep breathing, pacing, and
expressive writing in structured tasks of connected speech output at sentence to multi sentence level in 8/10 opportunities with
min prompts for use and cues for technique.
• STG #2: The patient will navigate to appropriate sub-categorical pages for biographical and medical information in dynamic
display of Lingraphica SGD device with 80% accuracy and min-mod supports.
• STG #3:The patient will utilize pacing strategy to complete “voice banking” and photo banking of target phrases within SGD
dynamic display with max cues for device programming.
• STG #4: The patient and caregiver/spouse will participate in verbal and written education regarding nature of primary progressive
aphasia and progressive impact on communication.
• STG #5: The patient and caregiver will demonstrate modified independence for simple SGD management (e.g. on/off, charging,
trouble shooting).
Case Study #5- Treatment: SGD navigation

Case Study #5- Treatment: Voice Banking

“For persons with PPA and their families, there is a need for education and counseling that emphasizes the progressive nature of the
disorder and the fact that behavioral treatment to maximize communication ability cannot be expected to retard or reverse progression
of the disease” (McNeil & Duffy 2001)
“Think of speech supplementation as the “augmentative” part of AAC. It is a way to add to the speech to increase intelligibility.”
(Hanson 2014)
“Keep in mind that this treatment progression from unassisted to assisted treatment resembles the hierarchy that is the standard for
individuals with neuromuscular disease such as ALS.” (Fried-Oken, 2008)
“Operationally…three treatment goals:
1. To compensate for progression of language loss (not stimulate the language system to regain skills)
2. To start early. Begin compensatory treatment as soon as possible. Be proactive so the person with PPA can learn to use
communication strategies and tools.
3. To include primary communication partners in all aspects of training, with outreach to multiple partners.” (Fried-Oken, 2008)
“The role of partners should not be underestimated for the person with PPA. As an individual loses skills, the partner assumes more
responsibility for interaction and message co-construction” (Fried-Oken, 2008)
“Prediction and anticipation are cornerstones of proactive management… individuals with PPA become less successful at learning
and incorporating augmentative means of communication to their daily lives” (Rogers & Alaron, 1999)
April 30, 2015

• Connected speech output/structured conversation with training for low tech strategies
• Naming tasks (responsive/convergent/divergent) with aims of strategy rehearsal
• Training AAC (e.g. iPhone application for text to speech, Lingraphica)
• Training for SGD programming including icon creation, photo storage, and voice banking
• Programming collaboration- designation of target functional phrases for SGD
• Rehearsal for SGD navigation in simulated social and ADL based “scripts”
• SGD HEP training
• Adjustment related counseling and resource/referral education
• Support groups
• Written materials
• Psychological support for all stakeholders
Summary
• Differential diagnosis
• Concomitant cognitive deficits
• Strong clinical decision making
• Functional Tasks
• Consider Motivation: Work, Social, etc.
• Group Therapy
• Well-rounded tasks/sessions
• Think “outside the box”
Contact Information:
Gzimmer@selectmedical.com
CGraboski@selectmedicalcorp.com
References
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501.

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Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning

Gabrielle Zimmer, M.S., CCC-SLP, CBIS

Case Study #1- AF

Case Study #1- Assessment BDAE- Cookie Theft

Case Study #1- Characteristics

Case Study #1- Long-Term Goals

Case Study #1- Short-Term Goals

Case Study #1- Treatment: Picture Description “What’s Wrong”

Case Study #1- Evidence Based Practice

Case Study #1- Treatment Planning

Case Study #2- RM

Case Study #2-RM

Case Study #2- RM

Case Study #2 Assessment: Diadochokinesis

Case Study #2- Characteristics

• Consonant and vowel distortions

Case Study #2- Long Term Goals

Case Study #2- Short Term Goals

Case Study #2-Treatment: Sequences

Case Study #2- Evidence Based Practice

Case Study #2- Treatment Planning

Case Study #3- TW

Case Study #3- TW

Case Study #3- TW

• Discontinued services and did not transition to outpatient rehabilitation

Case Study #3- Assessment: BDAE-4 Cookie Theft

Case Study #3- Characteristics

Case Study #3- Characteristics

Case Study #3- Long Term Goals

Case Study #3- Short Term Goals

Case Study #3- Treatment: Oral Reading

Case Study #3- Evidence Based Practice

Case Study #3- Treatment: Identify successful modalities

Case Study #3- Treatment Tasks

• “What’s Wrong” Color Cards

Case Study #4- CM

Case Study #4- Assessment Examination of Oral Mechanism

Case Study #4- Characteristics

• Velum (assessed later due to poor access)

Case Study #4- Long-Term Goals

Case Study #1- Short-Term Goals

Case Study #1- Evidence Based Practice

Case Study #4- Treatment Tasks

Case Study #5- JB

Case Study #5- Assessment BDAE- Cookie Theft

Case Study #5- Characteristics

 Stimulable for pacing and “deep breathing” or cancellation technique

Case Study #5- Long-Term Goals

Case Study #5- Short-Term Goals

Case Study #5- Treatment: SGD navigation

Case Study #5- Evidence Based Practice

Case Study #5- Treatment Planning

Augmentative and Alternative Communication, Vol 17, 99-104.

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