Clinically-proven drills for apraxia that you can easily apply to any word the survivor is working on.
Apraxia makes it difficult to form the complex mouth movements that produce speech. We use speech so often (and so effortlessly) that we forget just how complex and difficult it is to learn. If you've ever tried to teach a baby to speak, you know it's not easy. In addition, apraxia is often accompanied by Expressive Aphasia, causing difficulty with word-retrieval (thinking of the right word). I call that the double-whammy because you have difficulty thinking of the word and then, even if you think of it, you have trouble saying it.
Just as babies need to crawl before they can walk and walk before they can run, stroke survivors need to break apraxia treatment down into smaller steps.
Note: this is meant to be a layman's explanation for our non-therapist readers. The proper understanding of Apraxia would fill a textbook.
The Rosenbek Hierarchy breaks saying a word into a continuum of easier steps that take the survivor from being able to repeat the word with assistance to speaking the word independently in a real-world situation.
Imagine you are trying to get over a 5 foot wall. You can't jump 5' straight up no matter how hard you try. The solution is not to jump higher, but, rather, to get a ladder! You've broken down the impossible problem of 5 feet into a a series (a continuum) of achievable 6" steps. Literally. Dr. Rosenbek provided similar steps for speech therapy.
Assume you have a survivor who loves to drink tea but can't say "tea". That's a great word to start with: it's fairly easy and functional. Your goal: when you ask "what do you want to drink" she can reply "tea" The Rosenbek Hierachy provides those steps..
The patient works through this continuum of steps, with each step progressively more challenging. The first step provides maximum assistance (they see the picture, a word and see (and hear) the speech therapist's mouth demonstrate the word).
If they are successful, then they proceed to the next step, which is just a little more challenging (it has a bit less assistance) and so on, as they get reduced assistance at each step in the Rosenbek Continuum until they say the word with no assistance.
|Therapist (or Caregiver) Cues||Survivor Responds|
|1||Demonstrate ( Integral Stimulation)||Watches demonstration then repeats in unison with therapist 5 times.|
|2||Demonstrate ( Integral Stimulation) then pause and demonstrate silently (mouthing the word)||Repeats back while watching silent demonstration.|
|3||Demonstrate ( Integral Stimulation) then pause for survivor to repeat back without assistance.||Repeats back seeing only picture and text.|
|4||Same as #3||Same as #3 but repeats back 5 times.|
Ie., Repeats back 5 times with only picture and text.
|5||Show the written word and picture||Names the picture|
|6||Show the written word and picture, then hide them, and prompt patient to say word.||Names the picture from memory|
|7||Prompt with Question||Answers the question with a single word (the Target word)|
|8||OPTIONAL: Role play a situation that would elicit the word from the survivor.|
This can be difficult for some caregivers who lack acting skills.
|Speaks the word in response to situation.|
|9||OPTIONAL: Appropriate response in true life situation.|
I included it here only because it's in the original research paper. This can be a bit difficult to arrange in therapy.
|Speaks the word in response to situation.|
The web app, MoreSpeech.com, contains an Apraxia Skill area which is based on the above approach, in an easy to use treatment. If you currently seeing a speech therapist, we highly recommend you show it to them and see how best to fit it into your treatment.
Video of Rosenbek's 8-step Hierarchy
Demonstrated by speech-pathology grad student
Clinician-oriented video of Rosenbek's Hierarchy, including research basis
The Apraxia of Speech protocol developed for the MoreSpeech.com app is based on accepted and commonly conducted clinical practice and research articles demonstrating improved outcomes published in peer-reviewed professional journals including the seminal work "A Treatment for Apraxia of Speech in Adults"
The treatment used in the MoreSpeech app incorporates the stimulation/facilitation model. Duffy & Coelho (2001) provides an excellent description and analysis of Schuell (1953, 1964, 1974) original theory and the subsequent work of researchers who support the concepts that:
Research on Treatment approaches to apraxia
Rosenbek, J. C., Lemme, M. L., Ahern, M. B., Harris, E. H., & Wertz, R. T. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38, 462–472.Schuell, H. (1953). Auditory impairment in aphasia: Significance and retraining techniques. Journal of Speech and Hearing Disorders, 18, 14-21.Schuell, H., Jenkins, J. J., & Jiménez-Pabón, E. (1964). Aphasia In Adults. New York: Harper & Row.
Wambaugh, Julie L., Doyle, Patrick J., Treatment for Acquired Apraxia of Speech: A Review of Efficacy Reports, Clinical Aphasiology; Vol. 22, 1994, pp 231-243
Rosenbek J. C., Wertz, R. T., Darley, Oral Sensation and Perception in Apraxia of Speech and Aphasia, Journal of Speech, Language, and Hearing Research
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For over 20 years, Clay has helped patients, caregivers and speech pathologists with speech & language software. He shares the tips & tricks he's picked up along the way.
Clay is not a speech pathologist.
But he consults with the speech pathologists he works with (and has them review the blog articles). You should consult your speech therapist regarding any tips you read anywhere, including the Rehab Resources.