Articulation therapy for dysarthria focuses on improving the speech mechanism itself. We can administer articulation therapy alongside teaching compensatory speaking strategies, AAC, partner strategies, and modifying the environment. Wonder why a gift is the featured image? Read on!
Free DIRECT downloads: Articulation therapy: Part 1 and 20+ speech tasks (cheat sheets). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Go beyond compensatory strategies.
- Practice what you want to improve.
- Choose the level of speech that matches the goal.
- Drill, drill, drill!
- Practice more than once a day.
- Begin by explicitly teaching the strategies.
- Informally assess carryover frequently.
- Repetition to start, then variable practice.
- Move up and down the articulation hierarchy.
- Make the task unpredictable.
- Be sensitive to your patient’s frustration level.
- Related Eat, Speak, & Think posts.
- More coming up in Part 2.
- References.
Go beyond compensatory strategies
We should include articulation therapy in our care plan unless our patient is unable to participate. Joseph Duffy, PhD, BC-ANCDS, F-ASHA, wrote that most clinicians focus on compensatory strategies, which may be a disservice to our patients. He went on to say:
Focus on compensation may actually limit activity-dependent neural reorganization that is necessary to the reduction of specific impairment.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby, page 442.
Not only can we directly reduce the specific impairment, we can also begin teaching our patient to be independent with their speech work from day one. This is especially important when insurance or other factors don’t allow a patient to stay on caseload very long.
Practice what you want to improve
Specificity is a key principle of motor learning. If someone wants to improve talking, then they have to talk (a lot).
…recovery of speech in people with MSDs, at least when they have a nonprogressive disease, requires speaking, and probably lots of it.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby, page 446.
One exception is if our patient doesn’t have any ability to produce speech, in which case we can work on non-speech movements or eliciting sounds that can be shaped into speech sounds.
Another exception is if we have to focus on the foundations of speech, such as posture, breath support, and laryngeal strength, before our patient is able to produce speech.
So skip the non-speech exercises, unless you have a good rationale for doing them with that particular patient.
Talking “a lot” is not sufficient for recovery
Most people do not improve simply by talking.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby, page 450.
Just talking a lot is not sufficient for most people to recover speech function. That’s where skilled intervention comes in, determining the what, when, and how of speech work, following the principles of motor learning.
Choose the level of speech that matches the goal
Most of our patients likely want speech therapy to improve their ability to communicate natural-sounding, comprehensible messages to others.
Joseph Duffy says that we shouldn’t practice skills that are less advanced than what our patients demonstrate in assessment. And we shouldn’t work on improving skills beyond what is necessary to achieve the goals of treatment. (Duffy, 451)
And Maas et al (2008) points out that motor learning is better when we practice the whole movement sequence rather than repeatedly practicing individual movement elements.
Therapy tip
Since we generally communicate in multi-word units, we should progress to phrases and sentences as quickly as possible. If we want to maximize motor learning, it would be a mistake to target speech sounds in the traditional hierarchy, mastering one level before progressing to the next.
In most cases, spending time on word lists is not functional. At least put each word in a phrase, even if it’s a carrier phrase!
Drill, drill, drill!
Maximize outcomes by getting in as many trials as you can in each session. Although you may repeat each target many times in a row in the beginning of a session (constant practice), move into variable practice as soon as you can during the same session.
Example of constant practice for /k/: Repeating the word “car” over and over.
Example of variable practice for /k/: Repeating words with /k/ in different places. “Car, take, parking, skirt”.
Practice more than once a day
Distributed practice is better than massed practice for overall outcomes. It’s the same concept we know from our own learning experiences. If we practice a skill for 15 minutes every day, we’re much more likely to master it than if we only practice for 90 minutes on Saturdays.
Ideally, we’d distribute articulation practice in smaller sessions over the course of the day. So on days with speech therapy, our patient may practice for a short period of time later in the day. And on days without speech therapy, they may do two practice sessions on their own.
Begin by explicitly teaching the strategies
In the beginning, we should deliberately teach and demonstrate what we want our patients to do. People generally have better outcomes when they understand their problem and why we want them to follow our instructions.
We shouldn’t assume that our patient will connect the dots on their own.
Actively engaging our patient, we can ask them to tell us in their own words what strategy they’re using and why. Or we can ask them to tell a family member who wasn’t present during the session. This allows us to gauge how well they understand.
Informally assess carryover frequently
Although our patients are likely to improve their speech during structured speech therapy, it doesn’t mean they’ll be able to carryover those new skills.
We can probe spontaneous performance at the beginning and end of each session to get a sense of how well our patient is retaining what we’re teaching.
Be a little patient though. Following the principles of motor learning means that immediate performance will be less accurate in the early stages, but if therapy is successful, our patient will have better recovery.
Repetition to start, then variable practice
Repeating the same movement over and over is constant practice. You may find this useful at the start of the session, to help your patient achieve success. Constant practice can be done at any level of speech. You can repeat any sound, word, phrase, or sentence over and over.
While a person will be more likely to have higher accuracy with constant practice, this is a short-term effect. So once your patient achieves a reasonable level of success, it’s time to switch to variable practice.
Reasonably successful can be defined as >50% accurate or close approximation on 3-5 trials.
With variable practice, we change up the movement patterns. This can be done in many ways, and we can change things in more than one way at the same time. For instance, we can:
- Use different words with the same target sound in different positions.
- Increase the length of utterance.
- Change the speech task difficulty, for instance from repetition to sentence completion.
- Increase the cognitive load, for instance by randomly inserting a working memory task.
The literature from motor learning indicates that we see better outcomes from varying the tasks we practice during a session. We’re likely to see less accurate performance during the session, but long-term motor learning is better.
Move up and down the articulation hierarchy
Start at the highest level you think the person will be successful. Move from one level to the next as soon as the patient can produce the target reasonably well. Drop down a level if a person has too much difficulty.
- Single sound: “k”.
- One syllable words, no consonant blends:
- Initial: Car, coat, cup.
- Final: Back, neck, take.
- Medial: Bacon, hockey, making.
- Increasing syllable length, no consonant blends.
- One syllable words, consonant blends in each word position.
- Initial: Clean, crumb, quit.
- Final: Milk, dark, box.
- Medial: Likely, secret, parking.
- Increasing syllable length, with consonant blends.
- Phrases: Come here. Can you? Find coat.
- Short sentences: Come here now. Can I eat? I like cake.
- Longer sentences: Can you come here now? Can you find my coat? I like to eat birthday cake.
Work at the level the person is reasonably successful, and occasionally probe the next higher level in the hierarchy. We can move up and down the hierarchy many times over the course of a single session.
It’s ok to skip a level. Our focus is on helping our patient to produce the longest utterances they can, not to make sure we hit every level in the hierarchy.
Example therapy sequence for a mod-severe dysarthria
Here’s an example order of stimuli used when working with someone who has a moderate to severe dysarthria. We practiced each level a couple of times before moving to the next, until we reached a level that was too hard.
- Establish /k/ sound: “k”.
- Put it at start of one-syllable word: Come.
- Add a word: Come here.
- Add another word: Come here now.
- Make a longer sentence: Can you come here now?
- Oops, too hard. Drop back down: Come here now.
- Now do the other part: Can you?
- Now add a word back in: Can you come?
- Finally, repeat the longer sentence: Can you come here now?
This is an example of a patient who needed a lot of cueing to even make the /k/ sound, but after several minutes was able to say “Can you come here now?” reasonably well.
Not only is this following the principles of motor learning, but imagine how the patient felt at successfully saying a complete sentence with the difficult sound!
Make the task unpredictable
Why we should make the task unpredictable
If the next trial is predictable, then our patient may already have the motor plan activated. It’s a mental short-cut. They’re more likely to be accurate during the session, but it doesn’t reflect normal conversation which requires activating each motor plan as we use it.
Instead, we should make our patient start from scratch for each trial. This will probably decrease accuracy during the session, because they’ll be more likely to make an error. However, over the long run, they’ll likely have better recovery.
This is such an important principle, and one that we may not remember to follow, that I highlighted the concept of surprise with my featured image.
How we can make the next trial unpredictable
To maximize outcomes, we can mix two or more therapy targets together. We have a lot of flexibility for what counts as a therapy target. For instance:
- Targeting the impaired sound in different word positions.
- Treating multiple impaired sounds.
- Moving between different levels on the articulation hierarcy.
- Switching between speech strategies (for example, speaking slowly vs loudly).
- Changing the emotion we convey (pretend to be happy, angry, surprised, etc…).
- Varying the speaking context (talk to a different person, move to a different area, imagine different scenario).
- Changing the difficulty of the speech task.
- Non-articulation therapy goal (for example, memory or word-finding).
20+ speech tasks, from simple to hard
This hierarchy of task difficulty is not fixed. It changes according to the abilities of your patient and other factors of the speech work you’re doing. But this list may give you some ideas for how to adjust the difficulty of the speech task to be appropriate for your patient at that moment.
- Choral speech (speaking in unison).
- Automatic speech (example, counting to 10).
- Imitate (repeat).
- Recite familiar material (example, a poem).
- Cloze sentence completion. (example, “Roses are red, violets are ____.”)
- Open-ended sentence completion.
- Convergent naming.
- Confrontation naming.
- Divergent naming.
- Name by function or attribute.
- Generate synonyms, antonyms, or homonyms.
- Create a sentence around a given word.
- Picture description.
- Answer wh-questions.
- Ask wh-questions about picture or using a given word.
- Describe steps to complete a task.
- Personal narrative.
- Answer problem-solving questions.
- Working memory tasks.
- Provide opinions.
- Read passage aloud, then restate in own words.
- Watch short video and recall key points.
- Listen to passage and recall key points.
- Do something while talking (walk, move objects from one bin to another, sort cards by suit, etc).
Be sensitive to your patient’s frustration level
Always bear in mind the frustration level of your patient. If we make it clear to them WHY we’re practicing the way we are, they are more likely to persist with the difficult exercise. But we all have our limits for tackling difficult work.
If you sense frustration, try one of these:
- Drop down the articulation hierarchy.
- Make the speech task easier.
- Pick a different therapy target.
- Honestly praise the good aspects you noticed.
- Make a recording and compare to one from evaluation day.
- Take a break.
Try to begin and end each session with success.
Related Eat, Speak, & Think posts
- Motor learning for articulation: Focus and feedback.
- Tips for dynamic speech assessment.
- Free multimedia resources for the SLP.
More coming up in Part 2
I’m continuing this post in Part 2, which will include two very important topics: focus of attention and the role of feedback. It will include the cueing hierarchy, and how to use dynamic cueing during articulation therapy with specific examples.
References
- Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby.
- Maas, E., Robin, D.A., Austermann Hula, S.N., Freedman, S.E., Wulf, G., Ballard, K.J., & Schmidt, R.A. (2008). Principles of Motor Learning in Treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology, 17, 277-298. [PubMed]
Free DIRECT downloads: Articulation therapy: Part 1 and 20+ speech tasks (cheat sheets). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
I had a stroke Dec. 2018 I have dysarthia and dysphagia.. I attended inhouse Rehab for 4 months and out patient speech therapy for over a year. My speech is still not normal. I have found more information on this site that will help me regain my normal speech than over 18 months of therapy
Thank you for letting me know! I’m happy I’ve given some helpful information.
Here’s another site you might want to check out, written by another speech-language therapist: Tactus Therapy (https://tactustherapy.com/).
Good luck!
[…] Articulation therapy for dysarthria: Part 1. […]
I was diagnosed with ataxia and dysarthria three years ago. I’ve been fortunate to have regular speech therapy sessions. This article has helped me understand more clearly the strategies my therapist uses. Additionally this article has given me a new ways to look at my personal practice. I will first split my time up, and instead of practicing for 30 minutes a day, commit to 15 minutes twice a day. Next rather than just drilling stumble words, I like the idea of using them in novel ways, or even combining them with other stumble words.
My therapy today was reading this article aloud, thinking about volume and support and mastering stumble words in context.
Ascot, thank you for your feedback on the article. I’m happy it helped you understand the therapy approach better, and that it’s given you ideas on how to maximize your practice! Good luck with your practice!