Mind Over Motor Motor speech disorder treatment works best when clinicians emphasize the cognitive along with the physical. Features
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Features  |   March 01, 2017
Mind Over Motor
Author Notes
  • John C. Rosenbek, PhD, CCC-SLP, BC-NCD, is professor emeritus in the Department of Speech, Language, and Hearing Sciences at the University of Florida in Gainesville. rosenbek@phhp.ufl.edu
    John C. Rosenbek, PhD, CCC-SLP, BC-NCD, is professor emeritus in the Department of Speech, Language, and Hearing Sciences at the University of Florida in Gainesville. rosenbek@phhp.ufl.edu×
Article Information
Speech, Voice & Prosodic Disorders / Dysarthria / Attention, Memory & Executive Functions / Features
Features   |   March 01, 2017
Mind Over Motor
The ASHA Leader, March 2017, Vol. 22, 44-49. doi:10.1044/leader.FTR1.22032017.44
The ASHA Leader, March 2017, Vol. 22, 44-49. doi:10.1044/leader.FTR1.22032017.44
“I talk OK when I remember what you taught me” is a message I’ve heard frequently from people with dysarthria. I especially heard it when I was a young clinician.
Even those with no obvious cognitive impairment would tell me this. In the beginning, I would respond by redoubling my efforts and admonishing the client to concentrate and try harder. Ultimately, I wised up and began spending more time teaching clients with dysarthria to remember what to do and less time teaching them what to do.
In most—but certainly not all—cases, I began making treatment less about clinician-directed repetition using traditional methods such as rate manipulation, and more about patient-controlled self-evaluation, problem-solving and self-correction. In other words, my treatment became less motor and more cognitive-motor.
Cognitive-motor treatment includes six critical components. None of this information is unique to me—past and present practitioners have all contributed. And it all depends on a definition of cognition that I am sure many will consider to be—at best—loose.

In the beginning I would redouble my efforts and admonish the client to concentrate and try harder. Ultimately, I wised up and began spending more time teaching them to remember what to do.

Component one: recognizing difference(s)
In my experience, many people with dysarthria are only vaguely aware of what makes their speech different and hard for others to understand. Some, of course, are acutely aware of what has changed. For them, treatment begins with having the person describe what is different and to specify, in the case of multiple differences, which are most disturbing or otherwise critical.
The task is more complex for those who fail to appreciate differences. It begins with discussion: “What have people said about your speech? What does your spouse complain about, and do you agree?” Other times, more active approaches—including the use of voice recordings—are necessary. Perhaps the most effective is therapeutically manipulating a person’s recorded speech to sound more conventional (see sources below), and then contrasting the treated and untreated speech. The Communicative Effectiveness Survey is a quick tool for measuring a person’s awareness of difference, especially if also administered to the caregiver (see sources below).

Many people with dysarthria are only vaguely aware of what makes their speech different and hard for others to understand.

Component two: willingness to change
Hearing a difference, however, does not imply willingness to change—and creating willingness is not as easy as simply offering hope, a treatment and a likely outcome. Fortunately, we have tools to understand and quantify an individual’s willingness.
For example, readiness can be quantified by stage (see sources below). Many clients may be in Stage One, Pre-contemplation, which describes those who don’t recognize that change is necessary or who lack motivation to change. In Stage Two, Contemplation, clients are considering a commitment to begin therapy, and Stage Three, Preparation, is for the committed client who is bargaining for a start date: “How about after the holidays?”
We hope that clients are in or can be moved to Stage Four, Action. The ultimate goal is Stage Five, Maintenance, given that most treatment effects will dwindle if clients subsequently ignore the activities and concentration responsible for change.
We can help clients move out of Stage One.
  • For those who fail to recognize the need for change, we can help them complete the first component of cognitive-motor treatment (Recognizing Differences).

  • For folks stuck in Stage One because they aren’t willing, we can modify tools especially well-developed for voice disorders for use in motor speech disorders, such as URICA-VOICE (see sources below).

  • Self-efficacy, or belief in one’s ability to change or succeed, is another influence on willingness. We can measure self-efficacy with the University of Washington Self-Efficacy Scale (see sources below).

  • Other tools include a thorough history and special procedures such as motivational interviewing—a set of attitudes and methods for helping people consider change—and therapeutic manipulation (see sources below).

Creating willingness is not as easy as simply offering hope, a treatment, and a likely outcome. Fortunately, we have tools to understand and quantify an individual’s willingness.

Component three: setting goals
Traditionally, the clinician set treatment goals with little or no influence from the client with dysarthria. Today, however, mutual goal setting is (or should be) the norm.
“Here is what we will work on” is replaced by questions such as “What do you want to work on?” or “What bothers you most about your speech?” The answer might be “I don’t want to sound like I am sick” or “I don’t want to sound like I am stupid.” This response prompts more questions: “What do you think makes you sound sick? Or stupid?” Answers may include speaking rate, volume, voice quality, articulatory precision or something else.
Now the clinician has a goal: “OK, how about we try to make your speech faster? Or louder? Or less gravelly? Or more precise?” Shared goal setting is likely to require more than one session and, if treatment is succeeding, occur several times over the course of treatment as the client improves.

Traditionally, the clinician set treatment goals with little or no influence from the client with dysarthria. Today, however, mutual goal setting is (or should be) the norm.

Component four: talking therapeutically/flipping the switch
Clinicians are often taught that talking is the best treatment for disordered talking. I disagree; most people with dysarthria talk all the time without getting better. Instead, the best treatment for disordered talking is therapeutic talking, or talking purposefully while using whatever strategies or devices the clinician has suggested.
In the beginning, talking therapeutically may sound different from and no more acceptable than the disordered talking. Indeed, in the beginning, the client may prefer the disordered speech. Reassurance that therapeutic speaking is merely a first step toward the best approximation of the most “normal” speech each person’s nervous system will allow is often enough to convince the client to continue.
Even with this reassurance, however, few clients in the early days of treatment can talk therapeutically for an entire session. Hence the need for clinician tolerance and multiple sessions practicing specific skills—including “flipping the switch.”
Talking therapeutically begins with the client agreeing to “flip the switch.” The exact terminology is unimportant. The notion is that speaking therapeutically means not talking until the body is ready and the words of the utterance are in mind. Clinician and client agree on a simple motor response, such as a brief inhalation or slight shift in posture, to signal that the switch is being flipped.
Speaking therapeutically challenges clinical creativity, as well as the clinician’s and client’s patience, because I find most clients find it very hard to begin a response with posturing and planning rather than with speaking. “Flipping the switch” implies action. Failure to “flip” leaves speakers at the mercy of generally merciless physiological recovery.

The best treatment for disordered talking is therapeutic talking, or talking purposefully while using whatever strategies or devices the clinician has suggested.

Component five: learning to listen, evaluate and self-correct
Typical treatment for a motor speech disorder usually begins with a clinician telling the client what to do and then summarizing what was right or wrong about the performance. For example, traditional treatment might begin with the clinician asking the client to imitate the clinician’s production of a short sentence at a very slow rate. The clinician evaluates the client’s production, and if the client is successful, the usual practice is to repeat the procedure. If the client is unsuccessful, the clinician offers suggestions for improvement and repeats the procedure once or several more times. Throughout this process, the clinician is in charge.
In this scenario, a client may make substantial and rapid improvement in the clinic—but generalization, or talking equally well outside the clinic, is unlikely even after multiple sessions. For generalization to occur in the absence of physiologic recovery, the client must learn to judge what was right or wrong about each utterance before the clinician offers an opinion. Such self-evaluation is usually difficult, but learning to apply a three-, five- or seven-point scale can help. On a three-point scale, one means the trial utterance showed no improvement over pre-treatment speech; two indicates improved speech that is still not the best the person is capable of; three indicates best possible response.
Procedurally, clinician and client first agree on the number and definition of each point. (I have found that clients nearly inevitably expand the original scale as they get better at listening, so I usually start with just three points.) Second, they select a traditional method shown to improve dysarthric speech, such as “speak clearly and slowly” after taking a breath. The third and fourth steps overlap. In step three, clinician and client practice using the method until both are at ease with it. In step four, the client produces an utterance and scores it and, if client and clinician scores are the same, attempts a self-correction of any utterance scored less than “best possible.”
Step four can be complicated. The client’s and clinician’s scores are often different, and those differences need to be resolved with discussion and perhaps multiple repetitions of production and evaluation. Regardless of the number of points on the scale, there will be some slop in the scoring, which can be reduced with discussion and repetition.
Also, clients vary in their ability to self-correct, especially early on, and the clinician will need to intervene. Errors are important to learning but too many errors and the client will do no better in treatment than out of it.
Component six: add cognitive-linguistic load
Dysarthric speech adequacy declines with situations of greater cognitive-linguistic load, such as talking in a crowd, explaining a difficult notion, or speaking while hurried or distracted. Practicing under the best approximation of those conditions is important to generalization.
In the clinic, load can be increased by requiring progressively more self-generated complex statements, longer responses (such as retelling stories and describing processes), faster responses, client-generated questions, and responses after or during distraction (such as recorded noise). The clinician can also involve volunteers and family members in clinical sessions as much as possible, having them replace the clinician as principal communication partner. The number of situational manipulations is limitless. Therapeutic communication with others outside the clinic is preferable to homework involving word lists and workbooks.
Imitation—usually treatment’s inevitable starting point—should be a last resort, because even if progress is slowed and error rates increase, generalization is enhanced by production, evaluation and repair of the most complex utterances possible. Of course for clients with severe conditions, practice may have to start with imitation to be followed as quickly as possible by increased load.
For example, “Say the number five after me. How was that? Scored it a three? Yep, I agree. Now tell me how many people are in this room. Now tell me the number between four and six. Now count backward from eight and stop on the number we have been practicing.” Clients unable to cope with increasing demands because of behavioral, linguistic or cognitive deficits may well need treatment devoted to those deficits prior to, simultaneous with, or instead of cognitive-motor speech training.

We spent too much time on methods to change speech and too little time on methods to increase willingness and independence.

What’s in a name?
Usual treatment of motor speech disorders might have developed differently had they been called cognitive-motor disorders from the beginning. The expanded term’s implication is not that all clients with dysarthria are cognitively impaired, but rather that normal and abnormal speech and rehabilitation are influenced by cognitive factors even when cognition is normal.
The client who says, “I talk better when I remember what you told me to do” is not unknowingly announcing a dementia. Rather, the message is that we spend too much time on methods to change speech and too little time on methods to increase willingness and independence, too much time practicing what to do and too little on remembering to do it. We spend too much time on external cueing and feedback and too little on internal cueing, self-evaluation and self-correction, too much time guiding and too little time being guided.
Sources
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2 Comments
March 7, 2017
Genevieve Klein
Thank you
Thank you for this very helpful article! I will certainly be applying this viewpoint to dysarthria treatment.
March 28, 2017
Towino Paramby
Thank You!!
Excellent article. I will share this article in my motor speech disorder class.
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March 2017
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