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Treatment often involves the use of behavioral modification and anticonvulsants, antidepressants and anxiolytics.
The U.S. Food and Drug Administration (FDA) has not approved any drug for the direct treatment of stuttering. However, the effectiveness of pharmacological agents, such as benzodiazepines, anticonvulsants, antidepressants, antipsychotic and antihypertensive medications, and dopamine antagonists in the treatment of stuttering has been evaluated in studies involving both adults and children.
A comprehensive review of pharmacological treatments of stuttering in 2006 concluded that few of the drug trials were methodologically sound. Of those that were, only one, not unflawed study, showed a reduction in the frequency of stuttering to less than 5% of words spoken. In addition, potentially serious side effects of pharmacological treatments were noted, such as weight gain, sexual dysfunctions and the potential for blood pressure increases. There is one new drug studied especially for stuttering named pagoclone, which was found to be well-tolerated "with only minor side-effects of headache and fatigue reported in a minority of those treated".
Altered auditory feedback, so that people who stutter hear their voice differently, has been used for over 50 years in the treatment of stuttering. Altered auditory feedback effect can be produced by speaking in chorus with another person, by blocking out the person who stutters' voice while talking (masking), by delaying slightly the voice of the person who stutters (delayed auditory feedback) or by altering the frequency of the feedback (frequency altered feedback). Studies of these techniques have had mixed results, with some people who stutter showing substantial reductions in stuttering, while others improved only slightly or not at all. In a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, such as the presence of control groups.
There is no cure for DVD/CAS, but with appropriate, intensive intervention, people with the disorder can improve significantly.
DVD/CAS requires various forms of therapy which varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). In children with DVD/CAS, consistency is a key element in treatment. Consistency in the form of communication, as well as the development and use of oral communication are extremely important in aiding a child's speech learning process.
Many therapy approaches are not supported by thorough evidence; however, the aspects of treatment that do seem to be agreed upon are the following:
- Treatment needs to be intense and highly individualized, with about 3-5 therapy sessions each week
- A maximum of 30 minutes per session is best for young children
- Principles of motor learning theory and intense speech-motor practice seem to be the most effective
- Non-speech oral motor therapy is not necessary or sufficient
- A multi-sensory approach to therapy may be beneficial: using sign language, pictures, tactile cues, visual prompts, and Augmentative and Alternative Communication (AAC) can be helpful.
Although these aspects of treatment are supported by much clinical documentation, they lack evidence from systematic research studies. In ASHA's position statement on DVD/CAS, ASHA states there is a critical need for collaborative, interdisciplinary, and programmatic research on the neural substrates, behavioral correlates, and treatment options for DVD/CAS.
Speech therapy is usually the most common treatment for asemia. Speech therapy allows the patient to be able to improve their speaking, comprehension, and writing skills. These patients have to learn all of these skills again since they are unable to understand or express anything. It usually depends on how long it takes for the speech therapy to work. If the condition is less severe, it will take less time, such as perhaps a couple of months to years. If the condition is more severe, it may take many years. The way speech therapy works is through speech practice as well as using special computer programs which let the patient practice their communication skills. By using simple and short sentences or writing down these phrases can aid the patients while going through therapy. Giving them enough time to communicate with their friends, family, or therapist will help them increase their skills and be able to manage them.
Complete success is usually achieved with treatment. However, sometimes only partial success is achieved and the patient cannot fully comprehend everything. With the partial restoration of some skills, the speech therapist may only focus on the skills which can be restored. In other cases, the therapist may work on the skills which may not retrieved and teach the patient how to handle those.
Medical studies conclude that certain adjunctive drugs effectively palliate the negative symptoms of schizophrenia, mainly alogia. In one study, Maprotiline produced the greatest reduction in alogia symptoms with a 50% decrease in severity. Of the negative symptoms of schizophrenia, alogia had the second best responsiveness to the drugs, surpassed only by attention deficiency. D-amphetamine is another drug that has been tested on people with schizophrenia and found success in alleviating negative symptoms. This treatment, however, has not been developed greatly as it seems to have adverse effects on other aspects of schizophrenia such as increasing the severity of positive symptoms.
Treatment is usually carried out by speech and language therapists/pathologists, who use a wide range of techniques to stimulate language learning. In the past, there was a vogue for drilling children in grammatical exercises, using imitation and elicitation, but such methods fell into disuse when it became apparent that there was little generalisation to everyday situations. Contemporary approaches to enhancing development of language structure, for younger children at least, are more likely to adopt 'milieu' methods, in which the intervention is interwoven into natural episodes of communication, and the therapist builds on the child's utterances, rather than dictating what will be talked about. Interventions for older children, may be more explicit, telling the children what areas are being targeted and giving explanations regarding the rules and structures they are learning, often with visual supports.
In addition, there has been a move away from a focus solely on grammar and phonology toward interventions that develop children's social use of language, often working in small groups that may include typically developing as well as language-impaired peers.
Another way in contemporary remediation differ from the past is that parents are more likely to be directly involved, but this approach is largely used with preschool children, rather than those whose problems persist into school age.,
For school-aged children, teachers are increasingly involved in intervention, either in collaboration with speech and language therapists/pathologists, or as the main agents of delivery of the intervention. Evidence for the benefits of a collaborative approach is emerging, but the benefits of asking education staff to be the main deliverers of SLT intervention (the “consultative” approach) are unclear. When SLT intervention is delivered indirectly by trained SLT assistants, however, there are indications that this can be effective.
A radically different approach has been developed by Tallal and colleagues, who devised a computer-based intervention, FastForWord, that involves prolonged and intensive training on specific components of language and auditory processing. The theory underlying FastForword maintains that language difficulties are caused by a failure to make fine-grained auditory discriminations in the temporal dimension, and the computerised training materials are designed to sharpen perceptual acuity. However, a systematic review of clinical trials assessing FastForWord reported no significant gains relative to a control group.
In this field, Randomized controlled trial methodology has not been widely used, and this makes it difficult to assess clinical efficacy with confidence. Children's language will tend to improve over time, and without controlled studies, it can be hard to know how much of observed change is down to a specific treatment. There is, however, increasing evidence that direct 1:1 intervention with an SLT/P can be effective for improving vocabulary and expressive language. There have been few studies of interventions that target receptive language, though some positive outcomes have been reported.,
One technique that is frequently used to treat DVD/CAS is integral stimulation. Integral stimulation is based on cognitive motor learning, focusing on the cognitive motor planning needed for the complex motor task of speech. It is often referred to as the "watch me, listen, do as I do" approach and is founded on a multi-step hierarchy of strategies for treatment. This hierarchy of strategies allows the clinician to alter treatment depending upon the needs of the child. It uses various modalities of presentation, emphasizing the auditory and visual modes. Experts suggest that extensive practice and experience with the new material is key, so hundreds of target stimuli should be elicited in a single session. Furthermore, distributed (shorter, but more frequent) and random treatment, which mix target and non-target utterances, produces greater overall learning.
The 6 steps of the hierarchy upon which integral stimulation therapy for children is loosely organized are:"
- The child watches and listens and simultaneously produces the stimulus with the clinician.
- The clinician models, then the child repeats the stimulus while the clinician simultaneously mouths it.
- The clinician models and provides cues and the child repeats.
- The clinician models and the child repeats with no cues provided.
- The clinician elicits the stimulus without modeling, such as by asking a question, with the child responding spontaneously.
- The child produces stimuli in less-directed situations with clinician encouragement, such as in role-play or games".
Treatment for LKS usually consists of medications, such as anticonvulsants and corticosteroids (such as prednisone), and speech therapy, which should be started early. Some patients improve with the use of corticosteroids or adrenocorticotropin hormone (ACTH) which lead researches to believe that inflammation and vasospasm may play a role in some cases of acquired epileptic aphasia.
A controversial treatment option involves a surgical technique called multiple subpial transection in which multiple incisions are made through the cortex of the affected part of the brain beneath the pia mater, severing the axonal tracts in the subjacent white matter. The cortex is sliced in parallel lines to the midtemporal gyrus and perisylvian area to attenuate the spread of the epileptiform activity without causing cortical dysfunction. There is a study by Morrell "et al." in which results were reported for 14 patients with acquired epileptic aphasia who underwent multiple subpial transections. Seven of the fourteen patients recovered age-appropriate speech and no longer required speech therapy. Another 4 of the 14 displayed improvement of speech and understanding instructions given verbally, but they still required speech therapy. Eleven patients had language dysfunction for two or more years. Another study by Sawhney "et al." reported improvement in all three of their patients with acquired epileptic aphasia who underwent the same procedure.
Various hospitals contain programs designed to treat conditions such as LKS like the Children's Hospital Boston and its Augmentative Communication Program. It is known internationally for its work with children or adults who are non-speaking or severely impaired. Typically, a care team for children with LKS consists of a neurologist, a neuropsychologist, and a speech pathologist or audiologist. Some children with behavioral problems may also need to see a child psychologist and a psychopharmacologist. Speech therapy begins immediately at the time of diagnosis along with medical treatment that may include steroids and anti-epileptic or anti-convulsant medications.
Patient education has also proved to be helpful in treating LKS. Teaching them sign language is a helpful means of communication and if the child was able to read and write before the onset of LKS, that is extremely helpful too.
No medications directly treat the core symptoms of AS. Although research into the efficacy of pharmaceutical intervention for AS is limited, it is essential to diagnose and treat comorbid conditions. Deficits in self-identifying emotions or in observing effects of one's behavior on others can make it difficult for individuals with AS to see why medication may be appropriate. Medication can be effective in combination with behavioral interventions and environmental accommodations in treating comorbid symptoms such as anxiety disorder, major depressive disorder, inattention and aggression. The atypical antipsychotic medications risperidone and olanzapine have been shown to reduce the associated symptoms of AS; risperidone can reduce repetitive and self-injurious behaviors, aggressive outbursts and impulsivity, and improve stereotypical patterns of behavior and social relatedness. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, and sertraline have been effective in treating restricted and repetitive interests and behaviors.
Care must be taken with medications, as side effects may be more common and harder to evaluate in individuals with AS, and tests of drugs' effectiveness against comorbid conditions routinely exclude individuals from the autism spectrum. Abnormalities in metabolism, cardiac conduction times, and an increased risk of type 2 diabetes have been raised as concerns with these medications, along with serious long-term neurological side effects. SSRIs can lead to manifestations of behavioral activation such as increased impulsivity, aggression, and sleep disturbance. Weight gain and fatigue are commonly reported side effects of risperidone, which may also lead to increased risk for extrapyramidal symptoms such as restlessness and dystonia and increased serum prolactin levels. Sedation and weight gain are more common with olanzapine, which has also been linked with diabetes. Sedative side-effects in school-age children have ramifications for classroom learning. Individuals with AS may be unable to identify and communicate their internal moods and emotions or to tolerate side effects that for most people would not be problematic.
After the initial diagnosis of speech delay, a hearing test will be administered to ensure that hearing loss or deafness is not an underlying cause of the delay. If a child has successfully completed the hearing test, the therapy or therapies used will be determined. There are many therapies available for children that have been diagnosed with a speech delay, and for every child, the treatment and therapies needed vary with the degree, severity, and cause of the delay. While speech therapy is the most common form of intervention, many children may benefit from additional help from occupational and physical therapies as well. Physical and occupational therapies can be used for a child that is suffering from speech delay due to physical malformations and children that have also been diagnosed with a developmental delay such as autism or a language processing delay. Children that have been identified with hearing loss can be taught simple sign language to build and improve their vocabulary in addition to attending speech therapy.
The parents of a delayed child are the first and most important tool in helping overcome the speech delay. The parent or caregiver of the child can provide the following activities at home, in addition to the techniques suggested by a speech therapist, to positively influence the growth of speech and vocabulary:
- Reading to the child regularly
- Use of questions and simple, clear language
- Positive reinforcement in addition to patience
For children that are suffering from physical disorder that is causing difficulty forming and pronouncing words, parents and caregivers suggest using and introducing different food textures to exercise and build jaw muscles while promoting new movements of the jaw while chewing. Another less studied technique used to combat and treat speech delay is a form of therapy using music to promote and facilitate speech and language development. It is important to understand that music therapy is in its infancy and has yet to be thoroughly studied and practiced on children suffering from speech delays and impediments.
The ideal treatment for AS coordinates therapies that address core symptoms of the disorder, including poor communication skills and obsessive or repetitive routines. While most professionals agree that the earlier the intervention, the better, there is no single best treatment package. AS treatment resembles that of other high-functioning ASDs, except that it takes into account the linguistic capabilities, verbal strengths, and nonverbal vulnerabilities of individuals with AS. A typical program generally includes:
- A positive behavior support procedure includes training and support of parents and school faculty in behavior management strategies to use in the home and school;
- An applied behavior analysis (ABA) technique called social skills training for more effective interpersonal interactions;
- Cognitive behavioral therapy to improve stress management relating to anxiety or explosive emotions and to cut back on obsessive interests and repetitive routines;
- Medication, for coexisting conditions such as major depressive disorder and anxiety disorder;
- Occupational or physical therapy to assist with poor sensory processing and motor coordination;
- Social communication intervention, which is specialized speech therapy to help with the pragmatics of the give and take of normal conversation.
Of the many studies on behavior-based early intervention programs, most are case reports of up to five participants and typically examine a few problem behaviors such as self-injury, aggression, noncompliance, stereotypies, or spontaneous language; unintended side effects are largely ignored. Despite the popularity of social skills training, its effectiveness is not firmly established. A randomized controlled study of a model for training parents in problem behaviors in their children with AS showed that parents attending a one-day workshop or six individual lessons reported fewer behavioral problems, while parents receiving the individual lessons reported less intense behavioral problems in their AS children. Vocational training is important to teach job interview etiquette and workplace behavior to older children and adults with AS, and organization software and personal data assistants can improve the work and life management of people with AS.
This condition is most often treated using voice therapy (vocal exercises) by speech-language pathologists (SLPs) or speech therapists who have experience in treating voice disorders. The duration of treatment is commonly one to two weeks.
Techniques used include:
- Cough: The patient is asked to apply pressure on the Adam's apple and cough. This results in the shortening of the vocal folds which is the physiological mechanism that reduces pitch. The patient can thus practice voicing at a lower pitch.
- Speech range masking: This procedure is based on the theory that when speaking in noisy backgrounds, people speak louder and more clearly in order to be heard. The patient practices speaking while a masking noise is playing. Then, the patient listens to a recording of his/her voice during the masking session and tries to match it without the masking. By doing this, the patient practices their 'loud and clear' voice.
- Glottal attack before a vowel: A glottal attack is when the vocal folds are fully closed and then pushed open by the air pressure from breathing out or making a sound. In this technique, the patient breathes in and then makes a vowel as he/she breathes out.
- Laryngeal musculature relaxation techniques: Laryngeal muscles surround the vocal folds and by relaxing them, there is reduced pressure on the vocal folds. This can be done by yawning and subsequently sighing, exaggerated chewing while speaking, and speaking or singing the 'm' sound.
- Lowering of larynx to appropriate position: The larynx is lowered by the patient by putting pressure on the Adam's apple. By lowering the larynx, the vocal folds relax, and thus pitch is lowered. The patient does this while speaking to practice speaking with a lower pitch.
- Humming while sliding down the scale: The patient starts humming at the highest pitch that they can reach and then keeps lowering the pitch while humming. This allows the patient to practice using a lower pitch and also to relax the laryngeal muscles.
- Half swallow Boom technique: The patient says 'boom" just after swallowing. This is repeated with the patient turning his/her head to either side and also while lowering the chin. After practice, the patient adds more words. This technique helps to close the vocal folds completely.
Indirect Voice Therapy
Indirect treatment options for puberphonia focus on creating an environment where direct treatment options will be more effective. Counselling, performed by the S-LP, a psychologist, or counsellor, can help patients identify the psychological factors that contribute to their disorder and give them tools to address those factors directly. Patients may also be educated about good vocal hygiene and how their behaviour could have long term effects on their voice.
Audiovisual feedback:
In puberphonia, the use of audiovisual feedback allows the patient to observe graphic and numerical representations of their voice and pitch. This allows the patient to determine an ideal pitch range based on normative data on age and gender, and incrementally work through speech tasks while working in that desired pitch range. As the patient improves, speech tasks progress to become more natural, involving tasks such as reciting automatic information, to reading, to spontaneous speech and conversation. Incorporating audiovisual feedback in speech and voice therapies has been successful in intervention by improving motivation and guidance.
Surgery:
In some cases when traditional voice therapy is ineffective, surgical interventions are considered. This can occur in situations where intervention is delayed or the patient is in denial, causing the condition to become resistant to voice therapy.
There are different types of surgical interventions which have been successful in lowering the vocal pitch in men with puberphonia who had previously received ineffective voice and psychotherapy. The first surgical intervention developed, called "Relaxation Thyroplasty" or "Retrusion Thyroplasty", involves a bilateral excision of 2 to 3 mm vertical strips of thyroid cartilage which lowers the vocal pitch through anteroposterior relaxation and shortening of the vocal folds. It can be performed under local or general anesthesia.
"Relaxation Thyroplasty by a medial approach" is a modified approach of traditional "Relaxation Thyroplasty". This version involves lowering the vocal pitch by creating an incision bilaterally in the thyroid lamina and then depressing the anterior segment of the thyroid cartilage.
A more recent, less invasive intervention is the "Window Relaxation Thyroplasty". This approach involves creating a window at the anterior commissure which is then displaced posteriorly.
In cases of acute AOS (stroke), spontaneous recovery may occur, in which previous speech abilities reappear on their own. All other cases of acquired AOS require a form of therapy; however the therapy varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). For severe forms of AOS, therapy may involve multiple sessions per week, which is reduced with speech improvement. Another main theme in AOS treatment is the use of repetition in order to achieve a large amount of target utterances, or desired speech usages.
There are various treatment techniques for AOS. One technique, called the Linguistic Approach, utilizes the rules for sounds and sequences. This approach focuses on the placement of the mouth in forming speech sounds. Another type of treatment is the Motor-Programming Approach, in which the motor movements necessary for speech are practiced. This technique utilizes a great amount of repetition in order to practice the sequences and transitions that are necessary in between production of sounds.
Research about the treatment of apraxia has revealed four main categories: articulatory-kinematic, rate/rhythm control, intersystemic facilitation/reorganization treatments, and alternative/augmentative communication.
- Articulatory-kinematic treatments almost always require verbal production in order to bring about improvement of speech. One common technique for this is modeling or repetition in order to establish the desired speech behavior. Articulatory-kinematic treatments are based on the importance of patients to improve spatial and temporal aspects of speech production.
- Rate and rhythm control treatments exist to improve errors in patients’ timing of speech, a common characteristic of Apraxia. These techniques often include an external source of control like metronomic pacing, for example, in repeated speech productions.
- Intersystemic reorganization/facilitation techniques often involve physical body or limb gestural approaches to improve speech. Gestures are usually combined with verbalization. It is thought that limb gestures may improve the organization of speech production.
- Finally, alternative and augmentative communication approaches to treatment of apraxia are highly individualized for each patient. However, they often involve a "comprehensive communication system" that may include "speech, a communication book aid, a spelling system, a drawing system, a gestural system, technologies, and informed speech partners".
One specific treatment method is referred to as PROMPT. This acronym stands for Prompts for Restructuring Oral Muscular Phonetic Targets, and takes a hands on multidimensional approach at treating speech production disorders. PROMPT therapists integrate physical-sensory, cognitive-linguistic, and social-emotional aspects of motor performance. The main focus is developing language interaction through this tactile-kinetic approach by using touch cues to facilitate the articulatory movements associated with individual phonemes, and eventually words.
One study describes the use of electropalatography (EPG) to treat a patient with severe acquired apraxia of speech. EPG is a computer-based tool for assessment and treatment of speech motor issues. The program allows patients to see the placement of articulators during speech production thus aiding them in attempting to correct errors. Originally after two years of speech therapy, the patient exhibited speech motor and production problems including problems with phonation, articulation, and resonance. This study showed that EPG therapy gave the patient valuable visual feedback to clarify speech movements that had been difficult for the patient to complete when given only auditory feedback.
While many studies are still exploring the various treatment methods, a few suggestions from ASHA for treating apraxia patients include the integration of objective treatment evidence, theoretical rationale, clinical knowledge and experience, and the needs and goals of the patient
With an interdental lisp, the therapist teaches the child how to keep the tongue behind the two front incisors.
One popular method of correcting articulation or lisp disorders is to isolate sounds and work on correcting the sound in isolation. The basic sound, or phoneme, is selected as a target for treatment. Typically the position of the sound within a word is considered and targeted. The sound appears in the beginning of the word, middle, or end of the word (initial, medial, or final).
Take for example, correction of an "S" sound (lisp). Most likely, a speech language pathologist (SLP) would employ exercises to work on "Sssssss." Starting practice words would most likely consist of "S-initial" words such as "say, sun, soap, sip, sick, said, sail." According to this protocol, the SLP slowly increases the complexity of tasks (context of pronunciations) as the production of the sound improves. Examples of increased complexity could include saying words in phrases and sentences, saying longer multi syllabic words, or increasing the tempo of pronunciation.
Using this method, the SLP achieves success with his/her student by targeting a sound in a phonetically consistent manner. Phonetic consistency means that a target sound is isolated at the smallest possible level (phoneme, phone, or allophone) and that the context of production must be consistent. Consistency is critical, because factors such as the position within the word, grouping with other sounds (vowels or consonants), and the complexity all may affect production.
Another popular method for treating a lisp is using specially designed devices that go in the mouth to provide a tactile cue of exactly where the tongue should be positioned when saying the "S" sound. This tactile feedback has been shown to correct lisp errors twice as fast as traditional therapy.
Using either or both methods, the repetition of consistent contexts allows the student to align all the necessary processes required to properly produce language; language skills (ability to formulate correct sounds in the brain: What sounds do I need to make?), motor planning (voicing and jaw and tongue movements: How do I produce the sound?), and auditory processing (receptive feedback: Was the sound produced correctly? Do I need to correct?).
A student with an articulation or lisp disorder has a deficiency in one or more of these areas. To correct the deficiency, adjustments have to be made in one or more of these processes. The process to correct it is more often than not, trial and error. With so many factors, however, isolating the variables (the sound) is imperative to getting to the end result faster.
A phonetically consistent treatment strategy means practicing the same thing over and over. What is practiced is consistent and does not change. The words might change, but the phoneme and its positioning is the same (say, sip, sill, soap, …). Thus, successful correction of the disorder is found in manipulating or changing the other factors involved with speech production (tongue positioning, cerebral processing, etc.). Once a successful result (speech) is achieved, then consistent practice becomes essential to reinforcing correct productions.
When the difficult sound is mastered, the child will then learn to say the sound in syllables, then words, then phrases and then sentences. When a child can speak a whole sentence without lisping, attention is then focused on making correct sounds throughout natural conversation. Towards the end of the course of therapy, the child will be taught how to monitor his or her own speech, and how to correct as necessary. Speech therapy can sometimes fix the problem, but however in some cases speech therapy fails to work.
Permanent lisps can often be corrected through extensive oral operations. Often, when a patient has extreme overbite, causing a lisp, having orthodontic braces and rubber bands for an extended period of time will correct the issue, and resolve the lisp.
Many researchers are investigating the characteristics of apraxia of speech and the most effective treatment methods. Below are a couple of the recent findings:
Sound Production Treatment:
Articulatory-kinematic treatments have the strongest evidence of their use in treating Acquired Apraxia of Speech. These treatments use the facilitation of movement, positioning, timing, and articulators to improve speech production. Sound Production Treatment (SPT) is an articulatory-kinematic treatment that has received more research than many other methods. It combines modeling, repetition, minimal pair contrast, integral stimulation, articulatory placement cueing, and verbal feedback. It was developed to improve the articulation of targeted sounds in the mid-1990s. SPT shows consistent improvement of trained sounds in trained and untrained words. The best results occur with eight to ten exemplars of the targeted sound to promote generalization to untrained exemplars of trained sounds. In addition, maintenance effects are the strongest with 1–2 months post-treatment with sounds that reached high accuracy during treatment. Therefore, the termination of treatment should not be determined by performance criteria, and not by the number of sessions the client completes, in order to have the greatest long-term effects. While there are many parts of SPT that should receive further investigation, it can be expected that it will improve the production of targeted sounds for speakers with apraxia of Speech.
Repeated Practice & Rate/Rhythm Control Treatments:
Julie Wambaugh’s research focuses on clinically applicable treatments for acquired apraxia of speech. She recently published an article examining the effects of repeated practice and rate/rhythm control on sound production accuracy. Wambaugh and colleagues studied the effects of such treatment for 10 individuals with acquired apraxia of speech. The results indicate that repeated practice treatment results in significant improvements in articulation for most clients. In addition, rate/rhythm control helped some clients, but not others. Thus, incorporating repeated practice treatment into therapy would likely help individuals with AOS.
Articulation problems resulting from dysarthria are treated by speech language pathologists, using a variety of techniques. Techniques used depend on the effect the dysarthria has on control of the articulators. Traditional treatments target the correction of deficits in rate (of articulation), prosody (appropriate emphasis and inflection, affected e.g. by apraxia of speech, right hemisphere brain damage, etc.), intensity (loudness of the voice, affected e.g. in hypokinetic dysarthrias such as in Parkinson's), resonance (ability to alter the vocal tract and resonating spaces for correct speech sounds) and phonation (control of the vocal folds for appropriate voice quality and valving of the airway). These treatments have usually involved exercises to increase strength and control over articulator muscles (which may be flaccid and weak, or overly tight and difficult to move), and using alternate speaking techniques to increase speaker intelligibility (how well someone's speech is understood by peers). With the speech language pathologist, there are several skills that are important to learn; safe chewing and swallowing techniques, avoiding conversations when feeling tired, repeat words and syllables over and over in order to learn the proper mouth movements, and techniques to deal with the frustration while speaking. Depending on the severity of the dysarthria, another possibility includes learning how to use a computer or flip cards in order to communicate more effectively.
More recent techniques based on the principles of motor learning (PML), such as LSVT (Lee Silverman voice treatment) speech therapy and specifically LSVT may improve voice and speech function in PD. For Parkinson's, aim to retrain speech skills through building new generalised motor programs, and attach great importance to regular practice, through peer/partner support and self-management. Regularity of practice, and when to practice, are the main issues in PML treatments, as they may determine the likelihood of generalization of new motor skills, and therefore how effective a treatment is.
Augmentative and alternative communication (AAC) devices that make coping with a dysarthria easier include speech synthesis and text-based telephones. These allow people who are unintelligible, or may be in the later stages of a progressive illness, to continue to be able to communicate without the need for fully intelligible speech.
The most effective course of treatment for dysprosody has been speech therapy. The first step in therapy is practice drills which consist of repeating phrases using different prosodic contours, such as pitch, timing, and intonation. Typically a clinician will say either syllables, words, phrases, or nonsensical sentences with certain prosodic contours, and the patient repeats them with the same prosodic contours. Treatment following the lines of the principles of motor learning (PML) was found to improve the production of lexical stress contrasts. Once a patient is able to effectively complete this drill, they can start with more advanced forms of speech therapy. Upon completion of therapy, most people can identify prosodic cues in natural situations, such as normal conversation. Speech therapy has proven most effective for linguistic dysprosody because therapy for emotional dysprosody requires much more effort and is not always successful. One way that people learn to cope with emotional dysprosody is to explicitly state their emotions, rather than relying on prosodic cues.
Over time, there have also been cases of people suffering from dysprosody gaining their native accent back with no course of treatment. Since the part of the brain responsible for dysprosody has not definitely been discovered, nor has the mechanism for the brain processes which cause dysprosody been found, there has not been much treatment for the disease by means of medication.
In addition to active speech therapy, pharmaceuticals have also been considered as a useful treatment for expressive aphasia. This area of study is relatively new and much research continues to be conducted.
The following drugs have been suggested for use in treating aphasia and their efficacy has been studied in control studies.
- Bromocriptine – acts on Catecholamine Systems
- Piracetam – mechanism not fully understood, but most likely interacts with cholinergic and glutamatergic receptors, among others
- Cholinergic drugs (Donepezil, Aniracetam, Bifemelane) – acts on acetylcholine systems
- Dopaminergic psychostimulants: (Dexamphetamine, Methylphenidate)
The most effect has been shown by piracetam and amphetamine, which may increase cerebral plasticity and result in an increased capability to improve language function. It has been seen that piracetam is most effective when treatment is begun immediately following stroke. When used in chronic cases it has been much less efficient.
Bromocriptine has been shown by some studies to increase verbal fluency and word retrieval with therapy than with just therapy alone. Furthermore, its use seems to be restricted to non-fluent aphasia.
Donepezil has shown a potential for helping chronic aphasia.
No study has established irrefutable evidence that any drug is an effective treatment for aphasia therapy. Furthermore, no study has shown any drug to be specific for language recovery. Comparison between the recovery of language function and other motor function using any drug has shown that improvement is due to a global increase plasticity of neural networks.
Transient paraphasias (as well as other language defects such as speech arrest) can be generated by artificially activating the brain's language network with Transcranial magnetic stimulation (TMS). With navigated TMS (nTMS), nodes of the language network can be located presurgically so that critical areas can be saved when performing tumor or epilepsy surgery. Marketed by Nexstim, this method has received Food and Drug Administration (FDA) clearance in the United States.
There is no curative treatment for this condition. Supportive management is helpful.
Many language impairments, including paraphasic errors, are reduced in number through spontaneous recovery of neurological function; this occurs most often with stroke patients within the first three months of recovery. Lesions associated with ischemic strokes have a shorter spontaneous recovery time, within the first two weeks, and lesions associated with hemorrhagic strokes, on the other hand have a longer period for spontaneous recovery, four to eight weeks. Whether spontaneous recovery occurs or not, treatment must begin immediately after the stroke. A traditional approach requires treatment beginning at the level of breakdown - in the case of paraphasia, at the level of the phoneme. There are commercially available workbooks that provide various activities such as letter, word-picture, or word-word matching, and sentence completion, among other things. The difficulty of these activities varies with the level of treatment. However, these treatments have not been proven to be clinically productive. Functional magnetic resonance imaging is the most widely used technique to study treatment-induced recovery, looking at activation of particular areas of the brain. There are many different ways to process fMRI scans, beginning with the pre-scanning process. Data must be normalized. There is also no consensus on whether or not single subject scans are more helpful than group scans to determine a general pattern of treatment. However, fMRI scans have a few disadvantages.
A 1988 study by Mary Boyle proposed a method focused on oral reading to treat phonemic paraphasias was partially successful, resulting in fewer phonemic paraphasias but a slower rate of speech. Treatments lasted for 50 minutes and occurred once a week. During these treatment sessions, the patient was instructed to look at twenty different phrases -each of these phrases consisted of one to three syllables - then read the phrase. If the patient failed to read the phrase, the process was repeated. If the patient failed to read the phrase again, the process was abandoned. To progress from a set of one syllable phrases to two syllable phrases and two syllable phrases to three syllable phrases, an 80% success rate was necessary. This treatment was partially successful. Although fewer phonemic paraphasias were produced due to this treatment, speaking efficiency was not improved by this study. This is partially because the focus of the treatment was on sound production rather than semantic content. Improvements lasted for six weeks before the patient regressed.
Many of these types of disorders can be treated by speech therapy, but others require medical attention by a doctor in phoniatrics. Other treatments include correction of organic conditions and psychotherapy.
In the United States, school-age children with a speech disorder are often placed in special education programs. Children who struggle to learn to talk often experience persistent communication difficulties in addition to academic struggles. More than 700,000 of the students served in the public schools’ special education programs in the 2000-2001 school year were categorized as having a speech or language impediment. This estimate does not include children who have speech and language impairments secondary to other conditions such as deafness". Many school districts provide the students with speech therapy during school hours, although extended day and summer services may be appropriate under certain circumstances.
Patients will be treated in teams, depending on the type of disorder they have. A team can include SLPs, specialists, family doctors, teachers, and family members.
Treatment for all types of aphasia, including transcortical motor aphasia, is usually provided by a speech-language pathologist. The SLP chooses specific therapy tasks and goals based on the speech and language abilities and needs of the individual. In general for individuals with TMoA, treatment should capitalize on their strong auditory comprehension and repetition skills and address the individual's reduced speech output and difficulty initiating and maintaining a conversation. New research in aphasia treatment is showing the benefit of the Life Participation Approach to Aphasia (LPAA) in which goals are written based on the skills needed by the individual patient to participate in specific real-life situations (i.e. communicating effectively with nurses or gaining employment). Based on the specific needs of the patient, SLPs can provide a variety of treatment activities.
To improve word retrieval and initiation difficulties, clinicians may use confrontation naming in which the patient is asked to name various objects and pictures. Depending on the severity, they may also use sentence completion tasks in which the clinician says sentences with the final word(s) missing and expects the patient to fill in the blank. Limited research suggests that nonsymbolic limb movement on the left side (i.e. tapping the left hand on the table) during sentence production can increase verbal initiations. The use of the left arm in left space stimulates initiation mechanisms in the right hemisphere of the brain which can also be used for language allowing individuals to produce more grammatical sentences with higher fluency and more verbal initiation.
To increase speech output, the clinician may provide a set of pictures and prompt the patient to describe or elaborate on the events pictured. The clinician can also provide spoken or written words and prompt the patient to use the words in a sentence. Additionally, the clinician can ask questions based on the patient’s experiences, opinions, or general knowledge and prompt the patient to answer with phrases or sentences. To work on more connected speech, the clinician may ask the patient to describe procedures such as making a sandwich or doing laundry. A study found that syntax training in which sentence constructions are elicited on a hierarchy of difficulty produced gains in grammatically complete utterances and utterances that successfully communicated novel and accurate information.
To improve conversational skills, SLPs may engage the patient in structured conversations in which supports are provided to help the patient take appropriate conversational turns, maintain the topic of conversation, and formulate appropriate sentences. Clinicians often need to provide pragmatic guidelines so that the patient’s responses go beyond the clinician’s request and so the clinician does not do the majority of the talking. Research shows that conversation therapy can improve percent of complex utterances, the efficiency of the utterances for expressing ideas, and total time spent talking over more traditional stimulation therapy.
In order to improve the patient’s abilities to functionally communicate in their natural settings, the SLP will provide strategies and techniques to enhance their success in communicative settings (i.e. supplementing speech with nonverbal communication). Research supports the use of reduced syntax therapy to help patients overcome the non-fluent speech and agrammatism that often occurs with TMoA. Because agrammatism inhibits the patient's ability to form grammatically correct sentences, this type of treatment involves reducing these agrammatic deficits and teaching the patient to simplify linguistic structures while still conveying the message in order for language used to be more productive in conversation.
Additionally, they may train the patient’s communication partners to support the conversational abilities of the patient by facilitating the use of preserved cognitive and social functions. Research supports the use of various partner training programs such as Supported Conversation for Adults with Aphasia from the Aphasia Institute. In this program, the focus is put on acknowledging the patient’s competence and helping them to reveal that competence. Strategies include saying “I know you know” when appropriate, using gestures to supplement messages, limiting background noise, and given sufficient time for response.
From a neuroscience perspective, research has found that a dopamine agonist, bromocriptine, taken by mouth, has provided positive outcomes during intervention for non-fluent types of aphasia, such as TMoA or adynamic aphasia. Studies have found that bromocriptine increased neural networks which assist with the initiation of speech in individuals who possess non-fluent characteristics of speech.
In order to capitalize on neuroplasticity for treatment of all types of aphasia, timing, intensity, duration, and repetition of treatment should be taken into consideration. Research has found that aphasia treatment initiated during the earlier acute post-injury phase is more effective compared to treatment initiated in the chronic phase. With regard to intensity and duration of treatment, studies reported maximum recovery occurred with intense weekly therapy (approximately 8 hours per week) was delivered over a 2–3 month period. Other research shows that distributed therapy may be more beneficial than high intensity therapy. More research is needed to determine which is best, but it may be found that the ideal duration and intensity of therapy is variable depending on the patient and their needs.
Intervention services will be guided by the strengths and needs determined by the speech and language evaluation. The areas of need may be addressed individually until each one is functional; alternatively, multiple needs may be addressed simultaneously through the intervention techniques. If possible, all interventions will be geared towards the goal of developing typical communicative interaction. To this end, interventions typically follow either a preventive, remedial, or compensatory model. The preventive service model is common as an early intervention technique, especially for children whose other disorders place them at a higher risk for developing later communication problems. This model works to lessen the probability or severity of the issues that could later emerge. The remedial model is used when an individual already has a speech or language impairment that he/she wishes to have corrected. Compensatory models would be used if a professional determines that it is best for the child to bypass the communication limitation; often, this relies on AAC.
Language intervention activities are used in some therapy sessions. In these exercises, an SLP or other trained professional will interact with a child by working with the child through play and other forms of interaction to talk to the child and model language use. The professional will make use of various stimuli, such as books, objects, or simple pictures to stimulate the emerging language. In these activities, the professional will model correct pronunciation, and will encourage the child to practice these skills. Articulation therapy may be used during play therapy as well, but involves modeling specific aspects of language—the production of sound. The specific sounds will be modeled for the child by the professional (often the SLP), and the specific processes involved in creating those sounds will be taught as well. For example, the professional might instruct the child in the placement of the tongue or lips in order to produce certain consonant sounds.
Technology is another avenue of intervention, and can help children whose physical conditions make communication difficult. The use of electronic communication systems allow nonspeaking people and people with severe physical disabilities to engage in the give and take of shared thought.