COVER STORY / HOW I USE EPG (1)

How I use electropala

Ann and Gabriel, www.sergiojoselovsky.se

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atography
When articulation difficulties seem intractable, a visual feedback system called Electropalatography (EPG) may be of benefit - but its availability is still mainly limited to specialist centres and networks. Our two case based articles consider the practicalities and scope of using EPG, the first for two boys with dysarthria as a result of cerebral palsy and the second for a man in his thirties with articulatory dyspraxia following a stroke.

Moving forward with EPG

Ann Nordberg

How I use electropalatography (1)

When traditional therapy techniques were not proving effective with two boys who have dysarthria due to dyskinetic cerebral palsy, Ann Nordberg, Elvira Berg, Goran Carlsson and Anette Lohmander offered them the chance to try real-time visual feedback through Electropalatography, with promising results.

he exact prevalence of communication disorders associated with cerebral palsy is not known, but many children with this Elvira Berg diagnosis experience difficulties ranging from a mild motor speech disorder to being fully non-verbal (Pennington et al., 2005). In children with dyskinetic (also known as athetoid) and spastic cerebral palsy, omission errors tend to exceed substitutions of phonemes, a feature that typically developing children normally do not show in their speech development. Children with dyskinetic dysarthria may also experience respiratory problems, such as paradoxical or reverse breathing and air rushes through the vocal tract that result in no phonation (Hardy, 1983), which may have negative effects on speech performance. Limitations in pitch and loudness due to increased subglottal pressure are common as is velopharyngeal dysfunction. In traditional speech and language therapy approaches for children with cerebral palsy, clinicians have used a variety of techniques to help establish a particular articulation placement (Strand, 1995). Such techniques include mirrors for visual feedback, providing verbal descriptions of target placements, and using fingers to manipulate the articulators. These techniques may help the children to move on to imitation or responding to auditory stimulation, which can be a starting point for many conventional treatment regimes. However, effectiveness has not been Figure 1 Palatal plate proven.

We were working with two Swedish boys aged 7;4 and 10;1 years who both presented with moderate to severe motor speech disorders including deviant articulation of /t/ due to dyskinetic cerebral palsy. They had received lots of speech and oral motor therapy without significant improvement, and we were looking for an alterative. Electropalatography (EPG) is a technique which records the location and the timing of tongue contacts with the hard palate during continuous speech. In Europe, the EPG system was originally developed at Reading University, UK. It consists

of 62 electrodes in an individually designed palatal plate (figure 1) connected to either a computer or a Portable Training Unit (figure 2) (Hardcastle et al., 1991). On the screen the participant is presented with real time visual feedback on tongue palate contacts (figure 3, p.24). The use of visual feedback through EPG represents a relatively new approach to clinical management of speech disorders. Results have suggested positive outcomes for at least some clinical populations, especially those who have failed to respond to other treatment approaches and those who, having received speech and language therapy for some time, have reached a plateau where no progress is being made (Hardcastle et al.,1991). One previous case study reported outcomes using EPG in therapy for velar fronting for a

READ THIS IF YOU WANT TO EXPLORE ALTERNATIVES TO TRADITIONAL TECHNIQUES CARRY OUT CLINICAL CASE STUDIES GET INSIDE A CLIENTS MOUTH

Figure 2 Portable Training Unit

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COVER STORY / HOW I USE EPG (1)

Figure 3 Real time visual feedback

child with articulation disorders associated with mild cerebral palsy (Gibbon & Wood, 2003). In their study successful outcomes as well as important diagnostic features of the childs articulation disorder were revealed. We therefore felt it would be worth trying visual feedback of tongue positions through EPG with the two boys. We met with them and their parents to discuss our plans for a clinical study, and they gave their informed consent.

Bjorn

Our first participant has a mild dyskinetic cerebral palsy due to severe perinatal asphyxia. By the time of the study he was 10;1 years old, had been assessed by an educational psychologist to be of average intelligence and was successfully integrated into a mainstream school. He presented with a mild general motor coordination disorder and walked without aids. There was no documented visual or hearing impairment. Using a screening test (Hellquist, 1982) we found his comprehension to be at an average level. Pre-school, between 4;0-6;0 years, Bjorn had received regular speech and language therapy once a week. At the end of this he produced phonemes with a retracted oral articulation, so that dental phonemes were articulated at a posterior oral place, often velar. At school between 7;0-9;10 years he received speech training from 24

one of his teachers supervised by a speech and language pathologist. The training included different oral non-speech exercises. Multiple auditory-visual stimulation was also used - Bjorn looked and listened to the teacher who produced a sound or a word which he then tried to imitate. The sessions often took place in front of a mirror to try to get more awareness of the speech movement patterns. At the start of the study an impressionistic auditory analysis by Ann Nordberg showed that Bjorn had a generally retracted oral place of articulation in production of some phonemes, for example /t/. Intelligibility in spontaneous speech was significantly reduced and he had difficulty sustaining intensity when he was tired.

Gabriel

Our second participant, Gabriel, has a moderate dyskinetic cerebral palsy due to severe asphyxia. He walks with a walker and with high braces. At the start of the study he was 7;4. Like Bjorn, he had been assessed by an educational psychologist to be of average intelligence and was successfully integrated in a mainstream school. There was no documented visual or hearing impairment and we found his comprehension to be at an average level on a screening test (Hellquist, 1982). From the age of 4;0-6;2 years Gabriel had lots of speech training, often once a week with a

speech and language pathologist. After starting school at the age 6;5 years his personal assistant and teacher were supervised by a speech and language therapist and, until the beginning of our study, he had had short periods of oral motor and speech training up to three times a week. The speech exercises were very much the same as the ones described for Bjorn. At the start of our study an impressionistic auditory analysis by Ann Nordberg showed that Gabriel had a severe motor speech disorder and, according to his parents and teachers, the intelligibility of his speech in spontaneous speech / conversation was poor. His speech rate was slow and he had difficulty coordinating breathing and speech production. His speech errors varied in different words. He had both omissions (such as the initial phoneme /t/ for the Swedish word /ti:gr/) and substitutions of the same phoneme. The initial /t/ in another Swedish word /to:/ sounded more like a velar plosive. He also reduced consonant clusters. The movement of his articulators varied a lot, causing many types of speech errors.

The study

For the study, Bjorn and Gabriel each had a personal individual EPG palatal plate made in cooperation with the Department of Odontology, Gteborg University, Sweden and Incidental Ltd in Newcastle, UK.

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Figure 4 Exercises and goals Week Exercises 1 Learn to place the EPG palate correctly. Test different tongue-palate patterns. Goal Discover the relation between the movements of the tongue and different tongue palate patterns on the display of the Portable Training Unit. To reach an anterior place of articulation when producing /t/, /d/, /n/ and /s/. Manage to create a horseshoe shape for /t/, /d/, /n/ and /s/. Stabilise an anterior production of /t/, /d/, /n/ and /s/. To reach an anterior place of articulation when producing /t/, /d/, /n/ and /s/. To reach an anterior place of articulation when producing /t/, /d/, /n/ and /s/.

Production of syllables with the sound initial /t/, /d/, /n/ and /s/ followed by a vowel and look at the display; vary between anterior and posterior place of articulation. Production of words containing /t/, /d/, /n/ and /s/ in an initial position. Production of /t/, /d/, /n/ and /s/ (all positions) in words. The boys were told to do this a) looking at the EPG display and b) not looking at it. Production of two word phrases containing /t/, /d/, /n/ and /s/ (initial position).

3 4

5 6 7 8

Production of two word phrases containing /t/, /d/, /n/ and /s/ (all positions).

Production of three and four word sentences containing To generalise the anterior place of /t/, /d/, /n/ and /s/. articulation for /t/, /d/, /n/ and /s/ in single words to sentences. Short stories containing words and sentences with /t/, /d/, /n/ and /s/ (all positions). To generalise the anterior place of articulation for /t/, /d/, /n/ and /s/ in words and sentences to a more complex short story.

word, were presented with the first seven words from the pre-treatment recording, the following seven from the post-treatment recording, alternating in this way until the end of the test. We instructed the listeners simply to write down what they perceived the participants said. We inserted a five second pause between each word to ensure that the listeners would have enough time to write down their answers. Out of the three judgments for each boy, we are reporting the median (where two correct and one incorrect answer is considered as correct, while two incorrect and one correct answer is considered incorrect). We calculated agreement between the listeners point by point as a percentage. The agreement between listeners, including all words and both participants, was 75 per cent. Agreement in words without the target sound was 72 per cent (Bjorn) and 59 per cent (Gabriel).

Bjorns results
Before EPG therapy Bjorn consistently produced the target /t/ with retracted tongue-palate contact, mostly at the palatal (figure 5) and velar place of articulation. The contact pattern varied, even for words with the same vowel context. Fricative pronunciation of the targeted initial /t/ was noticed, for example in the word /to:g/.
Figure 5 Bjorn saying Swedish word /to:/ before EPG therapy

We assessed them with EPG on two occasions, once before EPG therapy and then again after 8 weeks of therapy. For Bjorn we made a third registration with EPG at a follow-up after 11 weeks, when he asked for additional training. The boys articulation was assessed with the palatal plate using EPG (computer-based), and without it, through recording the same words on an audio tape. All recordings took place at the Institute of Neuroscience and Physiology, Division of Speech and Language Pathology, Sahlgrenska Academy at Gteborg University. In the assessment with the EPG palatal plate, we encouraged Bjorn and Gabriel to name 35 pictures from the Swedish Articulation and Nasality TEst (SVANTE) (Lohmander et al., 2005) and another 35 which we added to increase the number of test words. There were five words with initial /t/ (teve, t, tg, tng, trta) and three with final /t/ (vit, hatt, katt) among the 70. As each was repeated three times, the total number of words containing /t/ was 15 with an initial /t/ and 9 words with a final /t/. To assess intelligibility 35 of the single words in SVANTE (Lohmander et al., 2005) were audio recorded without the EPG palatal plate before the treatment and 35 after. We used a digital tape recorder (Sony Digital audio Recorder PCMR300) and a microphone (Sony Microphone ECM-M3957). The word lists contained different consonants but nine with initial or final /t/. We lent each family a Portable Training Unit, and the therapy took place primarily at home where the boys practised with the unit 15 minutes each day, five days a week over eight weeks, supervised by their parents. Bjorn followed this instruction, but for Gabriel and his family this intensity was too high because he also had a physiotherapy program to complete. He therefore practised approximately 15 minutes a day for three days a week. Once a week the boys and one of their parents met their speech and language

pathologist for advice on how to practise during the coming week. All other speech training was cancelled during this period. As both boys had a retracted oral articulation of the targeted /t/ before therapy, the exercises contained syllables and words with /t/. However, the exercises also contained material with the other Swedish dental phonemes based on our belief that this would facilitate establishment of the target place of articulation. The phonemes were placed in initial, medial and final positions followed by a vowel. At the beginning of the training period there were syllables and words containing the phonemes and later on in sentences and at last in a short story (figure 4). The participants constantly had visual feedback from the Portable Training Unit in the training phase. We located the EPG frame of maximum contact between tongue and palate for each /t/ in the test words and, in order to find differences in production before and after therapy, we calculated values for Centre of Gravity and Alveolar Total. Low Centre of Gravity values correspond to posterior tongue palate contact and high values to anterior tongue palate contact. The Alveolar Total value ranges from 0 to 14 where 14 indicates that all the14 contacts in the first two anterior rows of the EPG palatal plate are activated (Hardcastle et al., 1991). We compared the measures before and after therapy using the Wilcoxon matched pair test. We engaged three adults with no experience of deviant speech for each participant to evaluate any change in the intelligibility of the boys speech. To avoid a learning effect, we only allowed the listeners to listen to the speech material once. During the recordings we suspected that the performance of the boys differed across the test due to loss of concentration and tiredness, especially towards the end. We therefore split the 70 words of the test into ten parts and the listeners, who were blinded as to the timing of the recording of the

After EPG therapy Bjorn showed a more correct anterior placement for his tongue palate contacts for the targeted initial /t/. In 10 of the 15 words with initial /t/ he had full alveolar contact from row 1 as is illustrated in figure 6, which is similar to the adult target in figure 7. Figure 6 also highlights an unusually long stop closure duration which we would not have been aware of without EPG. After EPG therapy Bjorn no longer had fricative pronunciation of initial /t/.
Figure 6 Bjorn saying Swedish word /to:/ after EPG therapy

Figure 7 Adult target of Swedish word /to:/

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COVER STORY / HOW I USE EPG (1) For the targeted final /t/ the placement of the tongue varied before therapy. Out of the nine words five showed some alveolar contact. After therapy there was a stable anterior placement of the tongue, with full alveolar contact, for all words with final /t/. The number of alveolar contacts increased from 1.33 to 11.27 and the measure of the greatest concentration contact (Centre of Gravity) changed significantly from 2.88 to 4.18. A similar change was seen for final /t/. Bjorns extra follow-up showed no change in the values of Centre of Gravity and Alveolar Total for either initial or final /t/. The perceptual evaluation indicated that the intelligibility of single word utterances for Bjorn increased from 22/35 words from the pre-treatment recording to 29/35 words from the post-treatment recording (63 per cent to 83 per cent accuracy) including all words, that is both with and without /t/. However, the agreement between listeners was only 72 per cent. The perceptual evaluation showed that Gabriel had generally very low intelligibility scores before therapy and showed no improvement after therapy. His intelligibility score for single word utterances was constant at 9/35 words, that is, 26 per cent accuracy. However, the agreement between listeners was only 59 per cent. production of different phonemes are so subtle and automatic. EPG therefore seems to be a very useful tool in providing the feedback and awareness required to remediate speech errors even in relatively severe motor speech disorders. Another advantage is the fact that the feedback provided through EPG is objective and offered in real time (Hardcastle et al., 1991). Before any generalisation can be made further evaluation with an amended study design is needed. In future we would want to explore the ecological validity of the treatment to find out whether it can improve intelligibility in a social context (WHO, 2001). What we can say is that it seems to us a promising tool for individuals with speech disorders due to cerebral palsy. Ann Nordberg is a speech and language pathologist with the Disability Administration, Region Vastra Gotaland, Sweden, e-mail ann.nordberg@ vgregion.se. Elvira Berg is a speech and language pathologist with Habiliteket AB, Taby, Stockholm, Sweden, Goran Carlsson is a psychologist at the Department of Pediatrics, University of Schleswig-Holstein/Campus Kiel, Germany and Anette Lohmander is Professor at the Department of Clinical Neuroscience and Rehabilitation, Division of Speech and Language Pathology, Sahlgrenska Academy at Gteborg University, Sweden.

Overall aim

Rating of intelligibility in connected speech may have been more revealing. Gabriels results
Before EPG therapy Gabriel had varying tongue-palate contacts for the target /t/. Initial /t/ showed no tongue-palate contact at all because the plosive /t/ was omitted. At other times there was a little lateral velar contact. After EPG therapy the tongue-palate contact patterns for the target initial /t/ were more stabilised at the correct alveolar place of articulation. He also succeeded in producing closure in all the targeted initial /t/, which he did not before EPG therapy, and initial /t/ was not omitted in any of the words. The number of alveolar contacts increased from 2.43 before therapy to 13.33 after and the Centre of Gravity values significantly from 2.43 to 13.33.

The overall aim of this clinical study was to find out if Electropalatography could be at all useful in treating and diagnosing speech errors related to dyskinetic cerebral palsy. Both boys had changes in EPG patterns which demonstrated a more stable anterior place of articulation. The EPG also highlighted Bjorns unusually long stop closure duration. A merit of EPG in the therapeutic work with Gabriel was that the visual feedback made it possible to see that he reached the dental place of articulation for the target /t/. In his case treatment needs to address respiration and phonation instead of articulation to try to improve his intelligibility. We didnt know this before his speech was evaluated by EPG, so it gave a secondary diagnostic benefit. Only Bjorn showed improvement in intelligibility in the perceptual evaluation. Perhaps Gabriels severe motor speech disorder made it difficult for the listeners to understand him? Low agreement between listeners was a problem, however, and it was interesting to note that the parents of both the boys said they understood them better following the EPG. Rating of intelligibility in connected speech may have been more revealing. As EPG records and displays details of the tongue-palate contact during continuous speech, it provides new insight into articulatory patterns. This is important for a range of clients where traditional treatment techniques have failed. It also enabled our participants to learn where to place their tongues, something that other speech and language therapy had failed to achieve. Many parts of speech and articulation can be difficult for therapists to explain or raise awareness about, as the differences in

Acknowledgments

We express our thanks to the parents, who gave consent for publication of their childrens case reports. We also want to express our gratitude to Professor Fiona Gibbon, Queen Margaret University College, Edinburgh, UK and Per Lindblad, Senior Lecturer at the University of Lund, Sweden, for exquisite advice and guidance. The present research was financially supported by grants from the Research Council of Disability Administration, Region Vastra SLTP Gotaland, Sweden.

References

Gibbon, F. & Wood, S. (2003) Using electropalatography (EPG) to diagnose and treat articulation disorders associated with mild cerebral palsy: a case study, Clinical Linguistics and Phonetics 17, pp.365-374. Hardcastle, W., Gibbon, F. & Jones W. (1991) Visual display of tongue-palate contact: electropalatography in the assessment and remediation of speech disorders, British Journal of Disorders of Speech Communication 26, pp.41-74. Hardy, J.C. (1983) Cerebral Palsy. Englewood cliffs, NJ: Prentice-Hall. Hellquist, B. (1982) SIT- Sprkligt Impressivt Test fr barn (Language Comprehension Test for Children) (Malm: Tryckeriteknik). World Health Organisation (2001) International Classification of Functioning, Disability and Health (ICF). Geneva: WHO. Lohmander, A., Borell, E., Henningsson, G., Havstam, C,. Lundeborg, I. and Persson, C. (2005) Swedish Articulation and Nasality Test. Pedagogisk Design, www.dop.se Pennington, L., Goldbart, J. and Marshall J. (2005) Direct speech and language therapy for children with cerebral palsy: findings from a systematic review, Developmental Medicine and Child Neurology, 47, pp.57-63. Strand, E.A., (1995) Treatment of motor speech disorders in children, Seminars in Speech and language, 2, pp.126-139. 26
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

REFLECTIONS DO I FACILITATE AND REACH AGREEMENT ON REALISTIC LEVELS OF HOME PRACTICE? DO I SEEK WAYS OF CAPTURING SMALL CHANGES IN THE DIRECTION OF A TARGET? DO I USE A VARIETY OF METHODS TO ASSESS THE IMPACT OF THERAPY ON INTELLIGIBILITY?
What questions does this article raise for you? Have you been able to access Electropalatography for any of your clients? Let us know via the Winter 08 forum at http://members.speechmag. com/forum/