Rehab Resources
for speech and language therapy

Rosenbek Hierarchy of Apraxia Drills

Clinically-proven drills for apraxia that you can easily apply to any word the survivor is working on.

Why Apraxia stops us like a brick wall

Apraxia seems like an  insurmnountable obstacleApraxia 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.

TRY HARDER is not the answer

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.

Rosenbek Hiearchy Steps
The Rosenbek Hierarchy breaks apraxia therapy into small, achievable steps

 

Example Rosenbek Steps

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..

Therapist using Rosenbek DrillsThe 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.

Rosenbek Cueing Hierarchy in 8 steps

Therapy Tips:

 

Rosenbek Steps

 Therapist (or Caregiver) Cues Survivor Responds
1Demonstrate ( Integral Stimulation)
Rosenbek Hierarchy Example

 Watches demonstration then repeats in unison with therapist 5 times.
2Demonstrate ( Integral Stimulation) then pause and demonstrate silently (mouthing the word) Rosenbek Hierarchy Demonstration Repeats back while watching silent demonstration.
3Demonstrate ( Integral Stimulation)  then pause for survivor to repeat back without assistance. Repeats back  seeing only picture and text.
4Same as #3 Same as #3 but repeats back 5 times.
Ie., Repeats back 5 times with only picture and text.
5Show the written word and picture
Rosenbek Hierarchy Explanation
 Names the picture
6Show the written word and picture, then hide them, and prompt patient to say word.
Rosenbek Hierarchy Demo
 Names the picture from memory
7Prompt with Question
Rosenbek Hierarchy Continuum Step 7 and 8
 Answers the question with a single word (the Target word)
8OPTIONAL:  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.
9OPTIONAL: 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.

Practice the Rosenbek therapy online

MoreSpeech APRAXIA lessonThe 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.

Try Rosenbek's Hiearchy now 

Video of Rosenbek's 8-step Hierarchy
Demonstrated by speech-pathology grad student




Clinician-oriented video of Rosenbek's Hierarchy, including research basis



Printable Worksheets for Apraxia

There are lots more worksheets in FreeForm, one of 18 programs included in our Silver Treatment Materials Subscription


Free Treatment materials

  • Printable Worksheets (Aphasia, Apraxia, Writing, Reading, Auditory Comprehension)
  • Clinically proven treatment protocols you can use today.
  • Clever Cognitive therapy activity with guaranteed carryover
  • And more, delivered free every week.

 

 

 


Footnotes and Research Summary

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:

  1. Sensory stimulation influences brain activity;
  2. Repetition of sensory stimulation is needed for acquisition, organization, and retrieval of patterns of behavior;
  3. The auditory modality is central to acquisition and maintenance of language;
  4. The auditory modality is severely compromised for most aphasic people; and
  5. If aphasia is defined as a multimodal language impairment, then intense stimulation treatment should be directed through the auditory modality because of its essential role in language processing.


Research on Treatment approaches to apraxia

Coelho, C.A., Sinotte, M. P. & Duffy, J. R. Duffy (2001). Schuells Stimulation Approach to Rehabilitation (403-449). In Chapey, R. (Ed.), Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders (Fifth Edition). Philadelphia: Wolters Kluwer/Lippincott Willians & Wilkins.
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.
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
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.
Schuell, H. (1974). Aphasia theory and therapy: Selected lectures and papers of Hildred Schuell (Sies, L. F., Ed.). Baltimore: University Park Press
Bailey, D. J., Eatchel, K., & Wambaugh, J. (2015). Sound Production Treatment: Synthesis and quantification of outcomes. American Journal of Speech-Language Pathology, 24(4), S798-S814.
Ballard, K. J., Wambaugh, J. L., Duffy, J. R., Layfield, C., Maas, E., Mauszycki, S., & McNeil, M. R. (2015). Treatment for acquired apraxia of speech: A systematic review of intervention research between 2004 and 2012. American Journal of Speech-Language Pathology, 24(2), 316-337.
 Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., & Rogers, M. A. (2006). Treatment guidelines for acquired apraxia of speech: Treatment descriptions and recommendations. J Med Speech-Lang Pathol, 14(2).
 

Discuss below

Free Speech-Language Treatment Course

Every day is an opportunity for recovery.  Don't miss a single day. I'll provide you the tools & knowledge for faster speech & language recovery

  1. How brain plasticity makes recovery possible even years later.
  2. Why just-work-harder is a recipe for failure
  3. The 4 types of Speech-Language Skills,
    and how to assess which are affected.
  4. Printable worksheets for home practice

Clay Nichols
Co-founder of MoreSpeech and Bungalow Software that both provide Speech & Language Software

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.

Free Speech-Language Course
Understand your loved one's deficits & get free recovery activities they can do at home.