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This paper examines the efficacy of repeated practice in
conjunction with rate/rhythm treatment on the accuracy of articulation of
adults with acquired Apraxia of Speech. 
A literature search was conducted using the following databases: CINAHL,
MEDLINE, and PubMed.  Searches were
conducted using key terms such as “acquired apraxia,” “treatment,” and “speech
therapy.”  The study chosen for analysis
examines the efficacy of repeated practice as well as rate/rhythm control
treatments on articulation in a population of adults diagnosed with chronic
apraxia of speech and Broca’s aphasia post-stroke.

            Though data
on the prevalence of acquired apraxia of speech is limited, Duffy (2005) found
it to be the most devastating communication disorder for approximately seven
percent of individuals with more than one neurologically based communication
disorder.  As Wambaugh, Nessler, Cameron,
& Mauszycki (2012) state, acquired apraxia of speech due to stroke most
often co-occurs with aphasia.  Due to the
relatively high prevalence of acquired apraxia of speech and the drastic impact
it can have on an individual’s communication abilities, it is crucial to
investigate the effects of treatment with this population.  Following consideration of the research
backing various treatment techniques for the disorder and the success reported
by Wambaugh et al. (2012), repeated practice will be administered by a
speech-language pathologist to an elder adult diagnosed with apraxia of speech
and Broca’s aphasia within one year of a cerebrovascular accident (CVA) to
determine whether repeated practice with rate/rhythm treatments is a suitable
intervention technique for adults receiving treatment within one year of a
stroke.

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Study
Summary and Critique

            Wambaugh et
al. noted that there are 4 common approaches to treating Acquired Apraxia of
Speech: “(a) articulatory-kinematic treatments, (b) rate/rhythm control
treatments, (c) intersystemic facilitation/reorganization treatments, and (d)
alternative and augmentative communication treatments” (as cited in Wambaugh et
al., 2012, p. S6).  The authors went on
to explain that there is little research on apraxia treatment that looks at
each of these facets individually, particularly because most apraxia treatment
involves a combination of all of these approaches, with a common denominator of
repeated practice (as cited in Wambaugh et al., 2012).  When designing this study, the authors were
careful to design their study solely around the approach of repeated practice
with rate/rhythm control treatments as a facilitator without using other common
apraxia treatment methods.  The study
sought to determine “if repeated practice treatment would result in increased
accuracy of sound production in trained and untrained utterances” and
secondarily to “determine if repeated practice plus rate/rhythm treatment would
result in additional gains beyond that achieved with repeated practice alone”
(Wambaugh et al., 2012, p. S23-S24).

            The authors
thoroughly and concisely explained their methodology, as well as the reason for
choosing it.  The authors used a
single-subject experimental design with an ABCA component.  The A phase represented the baseline for all
patients, the B phase “consisted of repeated practice treatment applied to
target items,” and the C phase incorporated altered rate/rhythm therapy
techniques for specific patients depending on how they were performing
(Wambaugh et al., 2012, p. S8).  By
incorporating an ABCA component as well as a multiple probe across behavior
component, the authors were able to accurately study rate/rhythm treatment
across a small sample size while taking into account individual variances in
therapy techniques.  Therefore it was
determined that the methodology was appropriate for the goals listed by the
authors.  There were ten adults (three
female, seven male) who varied in ages from 37 to 60 years old.  All participants had acquired apraxia of
speech secondary to a single stroke which had occurred between 1 and 19 years
prior to the study.  The authors stated
that all participants had normal hearing and an absence of psychological
disorders and neurological conditions, but it was never specified how this
information was acquired or who conducted these screenings. Participants were
diagnosed with AOS using several assessments such as the Increasing Word Length
and Repeated Trials subtests of the Apraxia Battery for Adults – 2nd Edition
(ABA-2; Dabul, 2000) and Assessment of Intelligibility of Dysarthric Speech
(Yorkston & Beukelman, 1981).  The
authors also identified multiple key diagnostic indicators that were seen in
all of the participants such as consistent sound errors on specific classes of
sounds, and sound distortions rather than additions, submissions, or omissions;
however, presence of these symptoms did not affect eligibility for
participation as symptomology of apraxic patients vary individually (Wambaugh
et al., 2012).

            During treatment, all data was
scored using a binary system (i.e. each production was marked as either correct
or incorrect), but target productions varied from patient to patient.  Two of the participants’ therapy sessions
focused on specific target sounds, whereas the other eight participants
received scores based on the production of an entire word.  This scoring system represents realistic
individual variances in therapy targets, which makes the results of the study
more readily applicable to all patients of apraxia of speech regardless of what
their therapy goals are.  However, the
variability in the type of target also contributes to a degree of unreliability
in scoring due to the subjectivity of scoring longer production.  All therapy sessions adhered to the same
schedule (three times per week) and were administered by the same group of
people (the first three authors). The only variance was in the location of the
therapy session which was primarily based on convenience and preference for
each participant.  In addition to the
above listed precautions to ensure overall reliability of results, the authors
also randomly selected ten percent of scores to be rescored by a
speech-language pathologist who was not familiar with the study or its
participants. The authors reported that “Agreement across lists ranged from 83%
to 97%, with the average being 91%.” (Wambaugh et al., 2012 p. S11)  This ensured an appropriate level of
interrater reliability for the study. 
The similarity in treatment administration, data collection, and
rescoring by a nonaffiliated speech-language pathologis show that, overall, the
results of this study are reliable.

            The results
of this study yielded that the treatment designed by the researchers had a
positive effect on most of the participants. 
Two of the participants did not require rate/rhythm treatment as
repeated practice in isolation increased their sound production accuracy to
85%.  Essentially, these participants
only required the “AB” portion of the “ABCA” study design.  Six participants required one or two
applications of rate/rhythm treatment, but all were ultimately able to reach
85% accuracy on their target sound or word productions.  Lastly, the remaining two participants did
not show a positive response to either repeated practice or rate/rhythm control
treatments.  Based on the success rates of
the participants, the authors disproved their original hypothesis.  While they initially believed that repeated
practice alone would not suffice in improving articulatory accuracy, the
results of this study yielded that a statistically significant portion of the
participants benefited from repeated practice treatment in isolation.  The authors attributed the varying success
rates with multiple treatments to two primary causes: (1) whether or not
participants had received therapy similar to the methods used in this study or
(2) individual variances in personal difficulty with specific stimuli (Wambaugh
et al., 2012).

            The results
of this study indicate that both rate/rhythm control treatment as well as
repeated practice with minimal feedback are both successful measures of
treatment for adults with AOS secondary to a stroke. While there is other
research that supports repeated practice as a therapy technique for Childhood
Apraxia of Speech (CAS), little research has been done on rate/rhythm treatment
for CAS. This difference in etiology is important to note so as to not
overgeneralize the results of this study.

            The authors
did not designate a portion of the article to discuss limitations of the
methodology chosen and results.  They
briefly mentioned that the effects of repeated practice could have “facilitated
the effects of rate/rhythm control” throughout the study but went on to dismiss
this limitation by stating that it appeared “unlikely on the basis of previous
rate/rhythm control investigations that did not employ repeated practice first”
(Wambaugh et al., 2012).  They also mentioned
that separating the results of the different treatment methods has been a
challenge across multiple studies of AOS therapy, but they did not specify why
this was the case or how that affected the results of their own study.  There are, however, multiple limitations to
how this study was conducted, including: a relatively small sample size, a
sample size of convenience as opposed to randomization, lack of specificity of
which target productions were scored during the data collection (e.g. initial production,
second production, etc.), and differing difficulty levels for each list used by
each participant.

Based on the results from this
study, the clinical question posed is this: Are repeated practice and
rate/rhythm control treatments appropriate intervention strategies for stroke
patients less than one year post stroke?

PICO

            Population.  The subject of this study will be Shawn, a 55 year old male,
who had a stroke 6 months ago.  He was
referred to Saint Louis University’s Speech and Language clinic by a hospital
speech-language pathologist to acquire speech and language services.  The hospital speech-language pathologist
mentioned that due to a stroke in the left hemisphere of his brain, he now has
Broca’s aphasia and apraxia of speech. 
Diagnosis of apraxia of speech will be confirmed using the same criteria
described in Wambaugh et al. (2012).  Intervention will
target the diagnosis of acquired Apraxia of Speech.  Shawn has normal hearing, normal oral motor
structure, and mildly impaired oral motor function, cognitive abilities, and
language comprehension skills.  Shawn
will not have had speech therapy prior to his visit to Saint Louis University’s
speech and language clinic.

Intervention.  This study will be a
single subject, multiple baseline design with an ABCA component directly
mirroring Wambaugh et al.’s (2012) study. 
One of the limitations was that the authors did not identify which
target production was scored during data collection; in order to increase
replicability of this study, data will be taken on all productions of targets
as apraxia is notoriously known for its inconsistent productions.  Scoring all productions will capture a better
picture of the client’s motor abilities. 

This study will be divided into
three components.  These will include:
baseline, intervention, and follow-up. 
One limitation of the Wambaugh et al. study (2012) was that the
treatment schedule involved more frequent and longer sessions than is typical
of an adult client in a speech and language clinic.  The client will be seen for two one-hour long
therapy sessions per week, as is typical for an adult receiving services at
Saint Louis University’s speech and language clinic.  As in Wambaugh et al. (2012), a minimum of
ten sessions will be used to conduct this study.  Baseline data will be collected over the
course of two sessions as opposed to the five sessions in Wambaugh et al.’s
(2012) study due to the fact that denoting five session times strictly for
baseline data collection is largely unrealistic for most speech-language
clinics.  Keeping with Wambaugh et al.’s
(2012) study design, a follow-up session will be scheduled for four to eight
weeks following the termination of the study.

The format of treatment sessions
will share similarities with those described in Wambaugh et al. (2012). These
similarities include: stimuli specifically developed for this particular
client, data collected using a binary system, and the probing schedule (e.g.
baseline phase, treatment phase, and maintenance/follow up phase) will remain
the same.  However, the methodology will
be changed slightly to accommodate for the variances in the Wambaugh et al.
(2012) study that partially compromised the overall reliability of the results.  Specifically, the primary change will be the creation of lists that are of the same
difficulty level, with difficulty level being denoted by the same syllable
structure, the same number and type of consonant clusters per word (i.e. CC or
CCC), and one-two problem sounds per word.  1 In total, five word lists will be
created just as in Wambaugh et al.’s (2012) study.  The first two lists will be used throughout
the treatment phase: one list that is targeted during treatment, and one that
is not directly targeted during treatment and serves to assess carryover and
generalization of skills targeted in therapy. 
Both of these lists will be probed daily.  There will be 2 separate lists that will be
targeted only during the baseline phase and the end of the clinical session in
order to measure the client’s progress. 
A fifth and final list will created only for repeated practice plus rate/rhythm treatment if it is
deemed necessary to incorporate rate/rhythm treatment into the therapy
session.  A limitation of Wambaugh et
al.’s study (2012) was that the experimental lists differed in difficulty which
may be one reason for the variability in treatment performance.

Outcomes. Data will be analyzed using a protocol similar to that
described in Wambaugh et al. (2012). Productions will be scored using a binary
plus/minus system with plus representing a correct production and minus
representing an incorrect production. Wambaugh et al. (2012) do not specify
which productions were scored and analyzed; however, this is an important
aspect to consider due to the nature of apraxia of speech and the instability
of the disorder. In this study, all productions for each target will be scored.
In addition, the percentage of consonants produced correctly (PCC) will be
determined for each item targeted in the session. Data will be analyzed in
terms of improvement compared to baseline. A measure of effect size will also
be calculated to determine how much benefit the client gained from repeated
practice as an intervention for acquired apraxia of speech.

            Inter-rater
reliability will be calculated following the procedure outlined in Wambaugh et
al. (2012). That is, another speech-language pathologist who did not administer
the intervention sessions will rescore ten percent of all targets chosen at
random. These data will be compared to the scores obtained by the original
speech-language pathologist for agreement. In addition, though Wambaugh et al.
(2012) did not include precautions for intra-rater reliability, this study will
take such precautions to ensure data is scored objectively. Ten percent of all
targets will be randomly chosen for re-scoring by the original speech-language
pathologist five days after termination of treatment. These will be compared to
her original scores for agreement.

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