I.  Treatment goals will depend on the amount of co-existing aphasia: (Rosenbek handout, 1997)

 (1) If aphasia is absent or mild, meaningful stimuli can be used and the meaning will facilitate better movements
 (2) If aphasia is moderate, treatment will have to be designed to improve both language and movement
 (3) If aphasia is severe, emphasis will have to be on language and communication

 (2) pt  needs orderly, continuous repetition at a level at which he can expect a high level of success - provide successful experiences

 (3) treatment should emphasize movement and coordination of articulators with meaning of speech - so move to meaningful
        stimuli as soon as possible - focus on communication - and stress sequencing

 (4) the keys are careful stimulus selection, orderly progression of treatment tasks, intensive and systematic drill
       (use stimuli that increase in difficulty in small graduated steps)

 (5) Target prosody early in treatment

 (6) employ the concepts of intrasystemic and intersystemic reorganization

 (7) intrasystemic reorganization involves moving to more primitive or automatic tasks to improve
      production ( counting, singing social phrases) or higher level control (making speech more conscious
      through use of imitation, although see caution on imitation in IV-6 below)

 (8) intersystemic reorganization employs the use of nonspeech motor activities to facilitate speech
      (things such as hand, finger or foot tapping, head movements or common gestures such as waving
        and saying bye) - input from multiple modalities

 (9) Employ principles of motor learning (Robin presentation) which include:

   A. Motor learning requires practice and experience, feedback and repetition
   B. Practice should include time for prepractice (establish motivation for learning,
        make sure client understands the task,& establish a referent for correctness
   C. Get multiple repetitions (minimum of 50 repetitions per session)
   D. Use random, variable practice - constant practice may facilitate acquisition but
        variable practice facilitates learning - that’s what we are after - ways to get variable
        practice include: use different contexts (vowels with consonants), positions within words,
        complexity (singletons vs. blends; one syllable vs two)
   E. Two types of feedback possible: (1) knowledge of results (KR) gives correct/incorrect as
        well as degree or direction of inaccuracy while (2) knowledge of performance (KP) gives
        information about aspects of the movement itself
   F. Focus on KR - do not provide information on how the movement was produced
        (should be covered in prepractice) - if you do feel the need to provide KP, focus on
          sensory-perceptual level - attend to the sensory consequences
   G. Treatment should progress systematically through hierarchies of task difficulty

III.  Choice of treatment will also depend on the severity of the AOS (Rosenbek presentation,
        1997)

 (1) Severe AOS will usually require building speech up from basic units of sound and syllables
      using phonetic placement and derivation as well as imitation of carefully selected stimuli
 (2) Moderate and mild AOS will allow for typical treatment paradigms of imitation, contrastive
       stress drill and systematic expansions of clinician control over planning and execution
 

 (1) take inventory of spontaneous utterances and the conditions under which they are produced

 (2) try to get forceful and repetitive imitation of these utterances eliciting the longest meaningful
      stimulus possible ( basis behind VCIU and multiple input phoneme therapy (MIPT) described in Duffy text on page 426)

 (3) if imitation is not possible try phonetic placement  - if this doesn’t work go to phonetic derivation
       beginning with whatever verbal or nonverbal movements the speaker can make

 (4) may have to start with nonverbal movements if verbal can’t be imitated of derived - Dworkin text
        list a number of nonspeech oromotor planning exercises for the tongue, lips, jaw and respiratory control -
        many employing the use of the beat of the metronome for pacing.

 (5) Some guidelines for selecting stimuli for the severe apraxic speaker (1) stimuable sounds
        (2) sounds that are also words (3) select at least two targets from the beginning so that a
         contrast rather than a single movement is emphasized - remember that AOS is a movement
        disorder so working on contrasts emphasizes movement - also moving from one stimulus
        to another helps to prevent perseveration - lastly, working on more than one stimulus can improve treatment efficacy

 (6) while imitation is important at this stage, the brain probably treats imitation and spontaneous
       speech differently therefore even 100s of imitations may not make the response carry over
       outside the clinic - will eventually have to incorporate techniques to encourage less clinician control
        and more patient control of the utterance - teaching pt to silently plan the movement and then after the attempt
        to again silently evaluate what was said

 (1) contrastive stress drills
 (2) Rosenbek’s 8-step continuum
 (3) MIT
 (4) cuing strategies/hierarchies working toward self-cuing by the pt - should move away
      from imitation as soon as possible and use sentence formation with target words, answering
      open-ended questions, generating narratives about pictures, articles or movies etc.