Case Study: Apraxia

Here is one of the most successful therapy interventions i have planned. Initially i tried to set goals around gesture use, picture symbol use and comprehension. As i observed the client in OT and PT sessions it became clear that their apraxia of gestures and of speech made their comprehension appear more severely impaired on impairment based assessment than in reality. Once I set goals around speech, which was motivating for the client he progressed very quickly.

History

·       60, left MCA infarct, LPCA infarct affecting the left frontal lobe and left parietal lobe, history of alcohol excess and cannabis abuse. The patient was very musical, played 3 instruments and enjoyed singing. One nephew visited the patient. Previous SLT report – Comprehension- unable to consistently select the correct pic from verbal stimuli. Diff following simple instructions. Expression – ‘yes’ to all Q’s, no other verbal output, inaccurate pointing.

Assessment

·       Object to pic matching – able to do with everyday objects. Yes/ No response to orientation questions/ simple questions in context – patient was inconsistent due to ideational apraxia and apraxia of speech. Best Yes/no interpretation = from body language and tone of voice.

·       OT/ PT joint sessions – patient was able to follow simple instructions in context. Difficulties copying actions.

·       Word repetition/ apraxia assessment – patient presented with severe apraxia of speech.

·       Language screen – groping for words expressively, unable to follow complex directions e.g. 3-stage (thought to be due to apraxia of gestures). Pre-morbid literacy impairments.

Goals

Long term (0ver 2.5 months)

I will be able to consistently communicate my basic needs by using total communication strategies (pictures, gestures, drawing).

I will be able to spontaneously use 5 functional words in context.

Short term

I will be able to communicate a consistent Yes/No response when prompted to use a communication aid.

I will be able to use pictures to communicate functionally during a kitchen/ wash and dress task.

I will be able to consistently understand picture symbols relating to my everyday needs.

Smart goals

I will be able to imitate the following sounds consistently when given visual prompts: ‘mm’ ‘me’ ‘yo’ ‘yes’ ‘no’.

I will be able to spontaneously say ‘yes’ or ‘no’ appropriately when asked an appropriate question.

I will be able to consistently use 5 topic cards (Body, family, therapy, food, activities) with trained members of staff to communicate a piece of information.

I will be able to use ten functional words (tea, coffee, Bob Marley, physio, pain, medication, Thomas, toilet, shower) consistently and spontaneously in context.

I will be able to say 10 functional phrases within specific contexts (e.g. breakfast group, physiotherapy, with the doctors…).

My nephew will be able to identify strategies (using topic cards, yes/no questions, pauses…) to support me to communicate, during a short conversation.

Therapy Activities

1.     Joint sessions with the OT/ PT around comprehending instructions and responding consistently to yes/ No questions.

2.     Apraxia Exercises – starting with vegetal sounds/ sounds that were easy for the patient to make and using topping to facilitate speech. Phonemic prompts and finally modelling of the word were used as a step down.

Yawn (open mouth wide)	‘ah’
Hum (keep mouth closed and vibrate)	‘m’
La la (singing) (curl tongue up and down)	‘l’
Bite lower lip	‘f’
Damming the lips	‘p’
Tut tut	‘t’

Yeah	·       Tap (extended) ·       ‘y’ ‘air’
Oh Gosh	·       tap,  tap (extended) ·       O  gosh
Hello	·       tap tap ·       cough (humpf), laugh ·       he  lo
Yes	·       tap (extended) ·       yeah ·       yeah sss
No	·       tap ·       ‘nnn’ ‘ooo’
Good	·       Tap ·        ‘g’ ‘ood’
Got	·       Tap ·        ‘g’ ‘ot’
Gone	·       Tap (extended) ·        ‘g’ ‘one’
Bye	·       Tap ·        ‘b’ ‘I’
Down	·       Tap ·        ‘d’ ‘own’

3.     Apraxia exercises – semantic clues e.g. you might drink it, pictures and carrier phrases were used to elicit chosen functional words/ phrases. The patients accent was considered e.g. ‘th’ was difficult so ‘d’ was used instead, as with the Caribbean accent.

4.     Topic card use in supported conversations.

5.     Joint sessions with the psychotherapist  - talking about motivating topics e.g. family, coming to the U.K., spiritual beliefs, dealing with a stroke.

Outcomes

-        Consistent yes/ no responses for simple questions.

-        Some functional word/ phrase use in context.

-        Some spontaneous sentences/ and carry over to words not practised in therapy.

Referrals

·       Referral made to community services with potential goals around facilitated conversation with the patient’s nephew and functional communication goals around shopping etc.