COVER STORY / HOW I USE EPG (2)

How I use electropalatography (2)

Therapy on a plate
had however moved into a flat of his own again and seemed to be spending more time with a couple of close friends, albeit to play computer games. Perhaps as a result of this he seemed more relaxed and was feeling motivated for therapy. On assessment, the consonants that were either disordered, absent or highly variable in production were sh (realised as s), r, l, ch, j. The aims of the treatment were to improve overall tongue control, increase understanding of articulation, make a clear distinction between production of sh and s, and to achieve production of target sounds l and r with evidence of carry-over into single word production. Chris received six weeks of therapy, with three sessions each week. Ideally he would have taken the equipment home but in the past he had not taken good care of aids and also failed to complete work independently. The solution was to offer as much time as we could afford to make maximum impact. One session per week was with a speech and language therapist with two repetitions of that session each week with a technical instructor. Chris used a portable visual feedback device borrowed from the paediatric service, through which his tongue-palate contact patterns were displayed. The therapist did not have a palate but instead used static images of articulatory positions. Static images were ideal for Chris because he could look at them for as long as he needed in order to replicate the position. Meanwhile the therapist could provide verbal prompts to support him.
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A stroke at the age of 33 left Lesley Anne Smiths client with impairments which affected his ability to return to work and his motivation to socialise. With the help of colleagues, she introduced Electropalatography, which had a small but important impact on his articulatory dyspraxia and intelligibility.

yspraxia of speech has been described as a disorder impairing the volitional movement of the vocal organs in speech production in the absence of any impairment to muscle tone or speed, range and strength of the articulators as is present in dysarthria (Miller, 1989; Howard & Varley, 1995). It can further be distinguished from dysarthria by characteristic groping or searching for articulatory placements. Chronic articulatory dyspraxia following head injury is notoriously difficult to remediate and traditional therapeutic methods can often be limited once the client reaches a plateau. Electropalatography (EPG) provides a dynamic visual display of lingual palatal contact and can be used as a visual biofeedback system (Hardcastle et al., 1985). Although much of the literature on EPG describes its potential to improve the speech of children with repaired cleft palates or functional articulation disorders, EPG has also been used to analyse dyspraxic speech (eg. Hardcastle et al., 1985) and also as a treatment method (eg. Howard & Varley, 1995). It has been identified as a useful method of providing speakers with dyspraxia with crucial visual feedback on their attempts at speech production and thus facilitating the gradual modification of abnormal articulatory patterns (Howard & Varley, 1995). Hartelius et al. (2005) also found that EPG therapy improved sentence and word intelligibility in an adult with disordered articulation by 10 per cent.

speech. Speech in conversation was estimated to be 60 per cent intelligible with a familiar listener and was heavily dependent upon contextual cues. Treatment involved a variety of traditional methods, including: using a listen and watch me approach (Rosenbek et al., 1984) describing how sounds are made using articulatory diagrams to reinforce these imitation of sounds in isolation then CV, VC, CVC combinations. Chris was always unwilling to use aided communication, likely due to embarrassment. He would only use writing when prompted and had difficulty with word selection and spelling. Following discharge from the Centre he received two blocks of therapy as an outpatient but made minimal improvement in intelligibility. His motivation for therapy was low at this point. Additionally, Chris did not recover functional

Chronic articulatory dyspraxia following head injury is notoriously difficult to remediate

movement of his right arm and could therefore not return to work as a plasterer. He was spending less time with his friends and had moved home to his mothers house. Although his social life was already quite limited before his stroke, Chris was becoming more and more socially isolated as a result of his embarrassment about his impairments. At this point my colleague and I began to consider the benefits of using an alternative to traditional therapeutic methods and the potential of electropalatography (EPG). With a significant amount of help from a specialist colleague from the Dundee paediatric service, I designed a plan of assessment and treatment using EPG for Chris. We deemed the Edinburgh Articulation Test (Anthony et al., 1971) to be the most useful method of identifying target sounds. Although traditionally a paediatric assessment, the simple vocabulary meant that word-retrieval errors were not an issue. I discussed the method and requirements with Chris and his mother who supported him to attend therapy. The Dundee adult speech and language therapy department agreed to fund the cost of the palatal plate at 325. Arranging and making dental impressions followed by production of the specialist palate took six months. During this time Chris received no therapy. When I met Chris again his speech had not changed. He

Chris

One of my clients well call him Chris - had a stroke in 2005 at 33 years old and has physical, cognitive and communication impairments as a result. Initially Chris presented with severe articulatory dyspraxia and mild dysarthria, which made his speech completely unintelligible out of context. He was unable to use any consonants in spontaneous speech and used writing when prompted as his primary method of communication. Language assessment indicated mildmoderate impairment resulting in difficulties with spelling, verb selection and sentence construction. Comprehension was sufficient for everyday conversation although neuropsychological assessment highlighted difficulty learning new information. Chris was also found to have impaired reading and spelling, but this may reflect his pre-morbid performance. Chris received intensive in-patient treatment at the Centre for Brain Injury Rehabilitation in Dundee for two months after which he was able to imitate 60-70 per cent of all consonant sounds with some generalisation into everyday

Warm-ups

In week one, Chris practised a number of nonspeech articulatory exercises to familiarise himself with the palate and the Portable Training Unit. From this we devised a set of warm-up exercises which he carried out at the beginning of each session. These included: Making full contact, achieved initially by asking Chris to swallow Making lateral contact by producing ee Alveolar and lateral contact by producing eat but delaying the release of the plosive Lateral and velar contact by producing eek and delaying the release of the plosive Minimal alveolar contact with prompts Velar contact only with production of egg Running the tip of the tongue from front to back and vice-versa. Chris quickly achieved most of these articulatory positions and showed that he could use the visual feedback to modify his tongue movements. During the first week we were able to discuss some speech sounds and the contrast 27

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

COVER STORY / HOW I USE EPG (2) between front and back sounds, adding these labels to the feedback device. In weeks two and three, the aim was to increase awareness of articulatory movements for speech sounds established as present in assessment. Starting with alveolar sounds, the visual feedback highlighted lateral air escape on the plosives t and d and incomplete closure on the nasal n. Chris achieved complete closure in t and d using visual feedback and practised this with and without the palate. He was unable to achieve lateral contact in production of n, however the sound produced was satisfactory in isolation. With velar sounds, he achieved optimum articulation when the consonant was preceded by a close vowel. It was difficult for Chris to modify production of velar consonants preceded by an open vowel and they continued to be produced too far back. At this point, Chris came to the realisation independently that his articulation improved if he reduced his rate of speech. Weeks four and five concentrated on production of target sounds. The fricative s was present veolar contact but by week five he was able to produce l accurately in isolation and in wordinitial position with modelling. We got Chris to practise production of l both with and without the palate. There was continuing variation in production and l was still vulnerable to distortion depending on the adjacent vowel but Chris was having more success in attempts to correct his errors in simple words. sounds but became more difficult to interpret for some of his target sounds. He made some significant gains but was limited in terms of how well he could apply his newly acquired knowledge to improve his output. In saying that, for a person whose intelligibility is severely reduced and who - for whatever reason - cannot use AAC, EPG could be worth pursuing even for small gains. It certainly seems likely that a person with strong cognitive abilities could make even more progress with this method. In terms of cost, Chris had a palate while the therapist used static images and verbal prompts to support him. Ideally both would have their own palate, particularly if there were a larger number of sounds being targeted, or for connected speech. This has cost implications but, at 325 each, the combined cost would still not equal that of a basic communication aid. Of course I couldnt even have attempted this therapy without the help of senior colleagues and specialists from other areas. This really demonstrates the importance of being aware of professional resources on your doorstep that you can tap into. My experience suggests that EPG has a place as a therapy tool as well as a method of analysis for acquired motor speech disorders, particularly those that are chronic and where traditional methods have failed to have an impact. Lesley Anne Smith is a speech and language therapist at the Centre for Brain Injury Rehabilitation, Royal Victoria Hospital, Dundee, e-mail lesleyannesmith@nhs.net.

Gains maintained

Chris was able to achieve a satisfactory s both with and then also without the palate.
in assessment but production was variable in conversational speech. Using visual feedback and with prompts to increase air pressure, Chris was able to achieve a satisfactory s both with and then also without the palate. However, he was unable to achieve the fricative sh in isolation or in CV/VC syllables using visual feedback. This prompted us to try to make a contrast between s and sh by emphasising lip rounding on sh. However, this technique had been unsuccessful in previous attempts and was again difficult for Chris to master. Similarly, we had little impact on Chriss production of r. He was initially able to achieve in r in word-final position and in some VC syllables and this was unchanged following treatment. However, Chris achieved better results with l, which he previously tended to produce in an interdental position with audible air escape. Initially he required lots of prompts to make al-

By the end of week six there were no further improvements in production of target sounds and it seemed as if Chris was again nearing plateau. His motivation again appeared reduced and he failed to attend two appointments. Although Chris had shown increased awareness of the benefits of reducing his rate of speech, he was finding it difficult to modify this in real conversations. After a break of four weeks I reassessed Chris using the Edinburgh Articulation Test, which suggested that some of the gains had been maintained. Chris seemed to have better control in s-clusters, more successful corrections of l with some variability, but no change in production of r or sh, which continued to be produced as s in all positions. There appeared to be an overall improvement in tongue control and Chris reported he felt increased confidence in his speech, although I am not sure of the social impact of this. In conversation Chriss intelligibility was now approximately 70 per cent. It is difficult to know whether my perception of this was due to increased familiarity with his speech but there certainly seemed to be a qualitative change and perhaps the assessment measures I used were too limited to show measurable changes. I felt as if Chris had a much better understanding of articulation in general and was now in a position to attempt to correct some of his errors. However, further benefits of EPG appeared unlikely due to limited progress with target sounds. It is therefore even less likely that Chris would achieve the more complex affricates that were not addressed. It is clear that there are limitations with this treatment. Given that learning and retaining new skills may be problematic for a person with a brain injury, so it may be difficult to achieve the desired results with this method. For Chris, the visual feedback really worked for simple

Acknowledgements

I would like to thank my client for agreeing to me sharing this work, as well as Laorag Hunter, Senior Speech and Language Therapist, CBIR, Dundee, Jan Wilson, Senior Speech and Language Therapist, Centre for Child Health, Dundee and Jan Brodie, Chief Speech and Language Therapist, Ninewells Hospital for their support SLTP and guidance.

References

Anthony, A., Bogle, D., Ingram, T.T.S. & McIsaac, M.W. (1971) The Edinburgh Articulation Test. Edinburgh: Churchill Livingston. Hardcastle, W.J., Morgan Barry, R.A. & Clark, C.J. (1985) Articulatory and voicing characteristics of adult dysartric and verbal dyspraxic speakers: an instrumental study, British Journal of Disorders of Communication 20, pp.249-270. Hartelius, L., Theodoros, D. & Murdoch, B. (2005) Use of electropalatography in the treatment of disordered articulation following traumatic brain injury: a case study, Journal of Medical SpeechLanguage Pathology 13(3), pp.189-204. Howard, S. & Varley, R. (1995) EPG in therapy: Using electropalatography to treat severe acquired apraxia of speech, European Journal of Disorders of Communication 30, pp.246-255. Miller, N. (1989) Apraxia of Speech, in Leahy, M.M. (ed.) Disorders of Communication: The Science of Intervention. London: Taylor & Francis. Rosenbek, J.C., McNeil, M.R. & Aronson, A.E. (1984) Apraxia of Speech: Physiology, Acoustics, Linguistics, Management. California: College Hill Press. 28
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REFLECTIONS DO I CONSIDER THE SOCIAL IMPACT THAT EVEN SMALL GAINS WOULD HAVE FOR A CLIENT? DO I TAKE SUFFICIENT ADVANTAGE OF SUPPORT FROM LOCAL EXPERTS? DO I HAVE A REALISTIC EXPECTATION OF INDEPENDENT HOME PRACTICE FOR EACH INDIVIDUAL AND OFFER THERAPY ACCORDINGLY?
What has this article got you thinking about? How have local experts from different specialties helped you in your work? Let us know via the Winter 08 forum at http://members.speechmag.com/forum/.