Student Placements: Positives

What has worked well and why?

Good outcome	Reasoning
Sandwich feedback – one good, one constructive, one good comment.	Motivating, built up the students self belief and self efficacy, directs CPD.
Timetable for the whole placement with meetings, supervisions, and joint sessions (SLT/OT/PT) organized for the first week.	Modeled timetabling skills and facilitated the students to book their own sessions. Structured their placement.
Careful caseload planning – choosing three patients for the student’s caseload who they will do individual sessions with and the student shadowed the SLT with other patients.	This allowed the student to focus their planning and readings and develop therapy resources.
Contacting IT and RIO early on	Allows the patient’s to have an NHS email, Rio access and computer access earlier on.
Providing journal articles/ direction for readings	Facilitated the student’s self efficacy.
Creating an introduction pack with tasks.	Prevented me from omitting any important information. Gave the student an activity to complete during down time.
Allowing the student to lead a structured session early on in their placement e.g. dysphagia history/ structured therapy task. Also stepping in to support them to have a successful session.	Student reported that she felt less pressure/ stress if I stepped in occasionally during sessions to support/ direct her.

Journal Review: apraxia of speech

Reference: Aichert, I and Zeigler, W. (2013) Segments and syllables in the treatment of apraxia of speech: An investigation of learning and transfer effects.

Background information

·   Isolated phonemes are often used as targets in the treatment of severe AOS.

·   Isolated phoneme’s however occur rarely in natural speech and do not play a role in language acquisition (bablling is based on syllabic units).

·   The syllable is assumed to be the basic unit of articulatory programming in speech.

·   Levelt et al (1999) – Phonetic level – there is a long-term store of motor patterns for frequently occurring syllables.

·   AOS – syllable structure and frequency impact on production accuracy.

·   Hypothesis: In AOS patients have access to a mental syllabary but the motor programs stored there are partially destroyed.

Study Question

·   Which out of segments or syllables (both phonological units) can be more efficiently trained in patient’s with severe AOS.

·   Learning effects and transfer effects into larger units were analysed.

Methods

·   4 patients used with AOS diagnosis (diagnosed by looking at spontaneous speech and repetition) + associated aphasia.

·   Diagnosis (Zeigler 2008): 1. Presence of phonemic errors (e.g. substitutions/omissions) 2. Inconsistent occurrence of phonetic distortions 3. Dysfluency due to: inter/intrasyllabic pauses, phoneme lengthenings, groping/repairs.

·   Screening lists of syllables + consonants were administered (target+control syllables/consonants).

Therapy

·   Four 45 minute sessions a week.

·   Segments/syllables presented orally and visually in a repetition + reading aloud format.

·   Feedback was given regularly e.g. auditory stimulation, visual cues (therapists mouth shape), and tactile/kinesthetic cues were given.

·   Syllables were always trained as a whole.

Results

·   Only one patient did not improve – they were the only patient to demonstrate severe perseveration.

·   Clear advantage of syllable training rather than segmental training. ¾ patients improved on target syllables, 2/4 showed transfer effects compared to ¼ and 0/4 for segmental training.

Key discussion points

·   Communicative expressions with single vowels/dipthongs/consonants which do constitute natural speech units e.g. sh, mm, ah, ai = good candidates to facilitate first speech sounds in patients with severe AOS.

·   The coarticulation of consonants with vowels (this occurs in syllables) is likely to be in the speech motor plan that needs to be re-learned. This has been found in several studies.

·   Transfer effect was noted form single syllables – two syllable words.

·   Perseveration may be due to disinhibited speech motor programs, when defective phonetic encoding fails to generate new motor patterns.

·   Different treatment protocals could be chosen for patient’s who perseverate.

Criticisms

·   Small cohort.

·   Multiple factors such as degree of aphasia could impact on the results.

·   Segments and syllables tend to be trained together and embedded in words.

Learning Outocomes

·   Perseveration – negative prognositic indicator – consider a different treatment protocal e.g. more participation based.

·   Train syllables rather than phonemes and try to use communicative individual segments to begin with e.g. mm, ah, ai…..

Locked in syndrome case study

Diagnosis – multiple brainstem strokes due to basilar artery thrombosis

Presentation – Severe dysarthria and dysphonia (<10 % intelligible), severely limited body movements (only able to oppose fingers on his right hand inconsistently).

Diagnostic assessments – FEES + VF – moderate oro-pharyngeal dysphagia, reduced strength + coordination of oral manipulation, reduced base of tongue to posterior pharyngeal wall approximation. Decreased vocal fold approximation/adduction and some evidence of overcompensation.

Therapy in hospital – consistent yes/no response via head nodding/ no movement was established + use of an AEIOU alphabet chart (listener assisted) utilising the yes/no response.  The patient disliked the use of AAC and predominantly attempted to communicate via speech.

Communication Guidelines

Understanding

·   T can understand what you are saying.

·   T can find it harder to understand if he is tired or upset.

·   On these occasions you may need to slow down your speech/ repeat yourself.

Speaking

Following his stroke T has:

·   Dysphonia- a difficulty with using his voice and vocal cords effectively and consistently.

·   Dysarthria – a difficulty using his mouth, tongue and lips to articulate clearly.

T finds it difficult to speak loudly and clearly. You can use these tips to help him maximise his communication:

·   Listen carefully and watch T’s lips when he is talking.

·   Prompt T to break words up; if he says one word at a time it is easier to understand him.

·   Remind T to exaggerate sounds.

·   If you are stuck on a word ask T to spell it out aloud.

·   If you are really stuck ask T to take a break and try again in a while.

Communicating

T is able to use strategies to aid communication when speaking is too hard to understand.

·   Ask him yes/no questions and get him to shake or nod his head clearly.

Goals

To improve consistency of strategy use to increase intelligibility with mouthing. Strategies 1. Break up the words and syllables 2. Over-articulation 3. Respond to forced choices.

To improve reliability of low tech AAC use.

Tasks

·   Based around T’s interests and family in order to keep him motivated/engaged.

·   Practicing breaking family names into syllables, getting T to count the syllables. Breaking down short phrases into words.

·   Practice spelling of words using the alphabet board e.g. places he has visited

Goals

To improve timing, depth and consistency of in-breath and out-breath.

To increase the frequency of voicing. Within task and conversation.

Tasks:

1.     Head and neck mobilisation and relaxation

Ø  Head and neck stretches and relaxation exercises.

2.     Breathing

Ø  Support T to put a hand on his abdomen and upper chest for feedback. Practice diaphragmatic breathing exercises, blowing exercises (blowing tissue/ imaginary candle/ imaginary letters/ blow on a mirror).

3.     Voice

Ø  Yawn/sigh, ‘h’ words (turning voicing on and off).

Ø  Blah blah blah app on ipad – saying ah and maintaining the sound

4.     Conversation

Ø  Pracice strategies within a conversation about one of T’s interests. Aim is to understand 3 keywords/ phrases.

Outcomes

Ø  T became around 65 % intelligible at a single word level and 50% intelligible at a short phrase level.

Ø  Inconsistent voicing but consistent controlled exhalation for short phrases.

Ø  T was able to participate in conversations with his family.