Did you know that you can improve your patient’s outcomes by using the right focus and feedback? There’s more to articulation therapy for dysarthria than manipulating how your patient speaks. Regardless of which articulation therapy approach you use, it’s important to teach in a way that’s consistent with the principles of motor learning. This post covers the motor learning principles of focus of attention and the role of feedback. Check out Part 1 for the rest.
Free DIRECT download: Motor learning for articulation therapy (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Our teaching should take motor learning into account.
- Focus of attention.
- Feedback.
- How often should we give feedback?
- Should feedback be immediate or delayed?
- What works best in therapy may not be best for outcomes.
- Try out a new teaching strategy.
- Related Eat, Speak, & Think posts.
- References.
Our teaching should take motor learning into account
The principles of motor learning underlie evidence-based treatment programs for dysarthria (e.g., LSVT LOUD) and apraxia of speech (e.g., Sound Production Treatment).
Some treatment approaches for dysarthria have strong research evidence to support them, while others are supported by theory and limited but (hopefully) growing evidence.
Why is this? Well, we have tons of research identifying the principles of motor learning when it comes to skills using the arms and legs. But we don’t yet have a solid understanding of how all the principles apply to speech production.
This isn’t a reason to despair though!
Understanding the principles of motor learning can help us improve HOW we teach whichever articulation therapy approach we use. Because how we direct our patient’s attention and the feedback we give can have a big influence on the outcomes.
Focus of attention
Our patient’s focus of attention can be internal to their own body or external.
Internal focus of attention versus external
Focusing attention inward means paying attention to how the body is moving (Maas et al). For example:
- Limbs: Am I moving my arm correctly as I swing the golf club?
- Speech: Am I pressing my lips together correctly as I make the /p/ sound?
Alternatively, an external focus of attention means paying attention to some effect of the movement. For example:
- Limbs: Am I swinging the golf club correctly?
- Speech: Does this /p/ sound right?
We don’t actually know what the best external focus of attention on speech would be. Possible options include paying attention to how the speech sounds, observing an ultrasound of the tongue while talking, or watching a visual representation of the sound in real time. (Maas et al, 2008; McAllister Byun et al, 2016)
External focus of attention is better
The research for limb movement strongly supports an external focus of attention. An external focus of attention leads to more accurate and less variable performance. (Maas et al, 2008)
While there doesn’t seem to be much research for speech, I did find a couple of articles that support an external focus of attention for dysarthria.
Byun and Hitchcock (2012) compared traditional articulation therapy with biofeedback therapy in the same group of children for /r/ remediation. They found that the children didn’t improve with traditional therapy, but did improve with biofeedback.
McAllister Byun et al (2016) manipulated the focus of attention while training children to produce /r/ correctly. Both groups viewed visual-acoustic biofeedback (spectograms) of their auditory production in real-time. The external focus group was instructed to watch the monitor, while the internal focus group received articulatory placement cues. There was no different between groups, and 6 of 9 children showed improvement. The authors concluded that a visual display is sufficient to get an external focus of attention.
The role of an external focus of attention is well-established in limb motor learning, and there’s evidence for oral non-speech motor learning, but the jury is still out for speech motor learning.
How to encourage external focus
In general, we should try to direct our patients to focus on something task-related beyond how their mouth is moving.
In order to encourage an external focus of attention, we could direct our patients to:
- Pay attention to own speech production and make occasional judgments.
- Listen to their recording immediately after speaking, make a judgment, then repeat.
- Try to match our model.
- Listen to a baseline recording, then make a new recording and compare.
- Watch visual biofeedback of loudness of speech (for example, Bla Bla Bla or Speak Up for Parkinson’s).
When internal focus may be better
We may find that some patients benefit from short periods of internal focus. If our patient is struggling to hit the target, we could switch to an internal focus of attention.
For instance, we could:
- Give direct instruction for how to move the articulators.
- Emphasize our own movements and ask them to imitate.
- Bring out a mirror.
Then as soon as they have success, we can have them repeat the movement without the external cueing and then move into an external focus of attention.
Feedback
Two types of feedback: Results versus performance
Research on learning skills involving the body indicates that, in most cases, knowledge of results is better than knowledge of performance.
Knowledge of results: the correctness of the outcome in relation to the goal. For example, we could give feedback related to:
- Limbs: Did my client swing the golf club correctly?
- Speech: Did my client say the /p/ sound correctly?
Knowledge of performance: the correctness of body movement. For example, we could give feedback related to:
- Limbs: Did my client twist their hips correctly?
- Speech: Did my client move their lips correctly?
Emphasize knowledge of results
Knowledge of results (feedback) is crucial to motor learning, especially in its early stages. Feedback can be provided by the clinician (or other people) or be instrumental.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby, page 450.
Duffy goes on to say that specific feedback seems to be more helpful than general feedback. We should provide specific feedback about articulation errors rather than simply indicating it wasn’t correct.
When knowledge of performance may be helpful
Maas et al (2008) states that providing feedback to increase our patient’s knowledge of performance “may be more beneficial early in treatment, or for clients who cannot reliably distinguish correct from incorrect productions” (p. 289).
They go on to say that knowledge of results “may be critical later in therapy and for clients who can better evaluate their own errors” (p. 289).
We should be careful when providing feedback about performance. Providing feedback to enhance knowledge of performance while our patient is talking can actually hinder learning (Hodges & Franks, 2001).
How often should we give feedback?
Research indicates that providing feedback less often (low frequency) is better for long-term retention of the skill. Low frequency feedback works best with variable practice. (Duffy et al, 2005; Maas et al, 2008)
Use high frequency for earliest learning
High frequency feedback may be better in the earliest stages of learning, and should be immediate and specific. High frequency feedback works well with blocked practice. ( Duffy et al, 2005; Maas et al, 2008)
Then switch to low frequency
But don’t provide high frequency feedback for too long!
Data on motor and verbal learning suggest that frequent feedback during acquisition may actually degrade performance on long-term retention and generalization.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby, page 451.
For example, we could provide feedback on every 5th trial, or provide summary feedback about several trials as a group.
Should feedback be immediate or delayed?
Delaying feedback by a few seconds appears to be more beneficial than providing immediate feedback. As stated above, summary feedback or intermittent feedback is better than feedback after every trial. (Duffy, 2005)
We can ask our patients to judge their own performance before we provide feedback. Another teaching strategy is to record our patients and have them listen to themselves before judging. Research indicates that this may enhance motor learning. ( Duffy, 2005; Maas et al, 2008)
An exception is in the earliest stages of learning, when specific, immediate, and frequent feedback can help people.
What works best in therapy may not be best for outcomes
Many factors tend to improve immediate performance during our sessions:
- Giving frequent, immediate, and specific feedback.
- Providing feedback to enhance knowledge of performance.
- Encouraging an internal focus of attention.
- Repeating the same movement many times in a row.
- Selecting predictable targets.
However, while these teaching strategies can improve accuracy during the session, they can hinder long-term learning!
We may use the above strategies in the earliest stages of learning, or at the very beginning of sessions early in treatment.
But as soon as our patient is achieving success, we should switch our teaching strategies to enhance long-term learning. Teaching methods in line with the principles of motor learning include:
- Providing delayed, summary feedback.
- Encouraging our patients to judge their own performance.
- Providing feedback to enhance knowledge of results.
- Encouraging an external focus of attention.
- Employing variable practice – switch up the movement patterns.
- Making each trial unpredictable.
Using these teaching methods is likely to reduce the accuracy during our sessions, particularly in the beginning. However research indicates that long-term outcomes will be better.
Try out a new teaching strategy
As speech-language pathologists, our goal is to help people regain the ability to talk as normally as possible. I’m sure we’ve all had the experience of a client improving their speech in the therapy room without carrying it over into their day-to-day life.
When we find something that helps their speech, how do we make it stick?
If your teaching isn’t in line with the principles of motor learning, consider trying out some new strategies. You just may see improved learning and maintenance of the skills you’re teaching!
Related Eat, Speak, & Think posts
References
- Byun, T. M., & Hitchcock, E. R. (2012). Investigating the use of traditional and spectral biofeedback approaches to intervention for /r/ misarticulation. American Journal of Speech-Language Pathology, 21(3), 207–221. https://doi.org/10.1044/1058-0360(2012/11-0083)
- Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, Mo: Elsevier Mosby
- Hodges, N. J., & Franks, I. M. (2001). Learning a coordination skill: Interactive effects of instruction and feedback. Research Quarterly for Exercise and Sport, 72, 132–142.
- 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]
- McAllister Byun, T., Swartz, M. T., Halpin, P. F., Szeredi, D., & Maas, E. (2016). Direction of attentional focus in biofeedback treatment for /r/ misarticulation. International Journal of Language and Communication Disorders, 51(4), 384–401. https://doi.org/10.1111/1460-6984.12215
Free DIRECT download: Motor learning for articulation therapy (cheat sheet). (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.
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