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Preston: Residual Speech Sound Disorders 10/9/2013

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Hands-on Clinical Training in Ultrasound Biofeedback

Dr. Jonathan Preston, CCC-SLP

Research Scientist, Haskins Laboratories &

Assistant Professor, Communication Disorders Dept, Southern Connecticut State University

Outline

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1:00-1:30 Introduction to ultrasound biofeedback: risks, strengths/limitations, candidacy

1:30-1:45 Hands-on practice in groups

1:45-2:15 Video demonstrations/therapy examples for specific sounds:

Alveolars and velars

Distortions of sibiants /s, z, ʃ/

2:15-2:40 Hands-on practice in groups, Break

2:40-3:00 Examples of rhotics

3:00-3:15 Hands-on practice in groups

3:15-3:30 Questions/Discussion

Ultrasound biofeedback

� Biofeedback: “The use of instrumentation to make covert physiological processes more overt; it also includes electronic options for shaping appropriate responses” (Huang, Wolf & He, 2006)

� Current biofeedback applications in speech therapy:◦ Mirrors◦ Electropalatography◦ Spectrograms◦ Nasal endoscopy

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De-mystifying ultrasound

� What is ultrasound?◦ Sound waves, acoustic energy

◦ NOT ionizing radiation

� What does it show? ◦ Border between soft tissues

◦ Can’t travel through bone

� The technology we use ◦ Seemore PI 7.5MHz probe by Interson

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Example

� U002 self-cueing

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Risks of Ultrasound

� General ultrasound risks include◦ Caviation (gas bubbles)

� Mechanical Index <0.3

◦ Heating of Tissue� Thermal Index <0.5

◦ Transmission of communicable diseases such as the common cold

� However, the low-output transducers we use:◦ “Minimal risk”

◦ Always follow the ALARA principle for ultrasound exposure (As Low As Reasonably Achievable)

◦ See: AIUM, 2012; Barnett et al, 2000; Epstein, 2005

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Risks of Ultrasound

� What do our participants usually report?

◦ “I had to push it hard under my chin”

◦ “The gel is cold and gooey”

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Advantages of Ultrasound Biofeedback

� Less guessing about the tongue

◦ Grooving for /s/

◦ Independent movement of tongue dorsum and tongue blade

◦ For /r/, elevation of the lateral margins of the tongue, or elevation of the tongue dorsum and/or blade, and tongue root retraction

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Advantages of Ultrasound Biofeedback

� Cues can be specific.

� Clients can understand what is expected and learn to self-cue and self-monitor.

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Candidates for Ultrasound Biofeedback

� Client’s speech:◦ Errors on lingual speech sounds (consonants

or vowels)◦ Not achieving correct production or are only

occasionally achieve correct productions◦ Problems sequencing sounds

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Candidates for Ultrasound Biofeedback

� Normal vision

� Good cognitive skills

� Can sustain attention and handle drill

� Older children and adults (age 7 and up?)

◦ It’s not for everyone

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Interpreting the Images: Sagittal view

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Image courtesy of Suzanne Boyce


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Sagittal view of /r/

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A wonderful resource

� http://www.seeingspeech.arts.gla.ac.uk/uti/

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� Demonstration

◦ 1. Plug in ultrasound. Open SeeMore

◦ 2. Adjust depth to 10 cm

◦ 3. Click “scan” or press blue button

◦ 4. Put gel on the probe and watch what happens

◦ 5. Place transparency over the screen

◦ 6. Put probe under chin, dot facing backward (sagittal view)

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◦ 7. Angle towards front of tongue to see tip/blade. Try alveolar sounds.

◦ 8. Angle towards middle of tongue to see the dorsum. Try velar sounds.

◦ 9. Angle towards the pharynx to see tongue root. Do you see a shadow?

� Try /i – a – i – a/

◦ Gently clean the probe between users

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Using ultrasound to cue specific sounds

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Alveolar Consonants

/t, d, n/

� What do you expect to see happening in a sagittal view?

/l/

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Velar Consonants

/k, g, ŋ/� What do you expect to see?

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Guess the place of articulation

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Alveolar & Velar Consonants

� Provide visual “targets” for the client to hit

� Provide “do not cross” lines to prevent movements of the wrong part of the tongue

� Can focus on sequencing movements

� Video examples

◦ /d/ U012 (mid-dorsal contact)

◦ /ne/ U012

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Sequencing

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Video: /kl/ U007 (sound sequences)

Fricatives /s, z/ and /ʃ/

� Ultrasound may be useful for

◦ Achieving a central groove and elevation of the lateral margins of the tongue for clients with lateralized distortions (coronal view)

◦ Facilitating a more posterior constriction for clients with dentalized distortions (sagittal view) (Lipetz & Bernhardt, 2013)

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Coronal view: tongue grooving for /s/

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Lateralized distortions of /s/

� 074 lateral s

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Alveoars, Velars,

� In your groups:◦ Using a sagittal view, Examine several

productions of alveolars /t, d, n/ vs. velars /k, g/

◦ Try to produce a mid-dorsal distortion for alveolar targets, then think about how to cue a clear production

◦ Pretend to be a child with velar fronting. What would you cue and how would you cue it?

◦ Try to cue your client to produce sequential movements that require different tongue placement, as in /kl/ or in a word like “neck”, “goat”

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Lingual Fricatives

� In a coronal view, try to produce a clear /s/ followed by a lateralized distortion of /s/

� Break

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2:30-2:40

Rhotics

/r, ɝ, ɚ/

� Remember the “bunched” vs. “retroflex” distinction?

� Need to allow for individual variation

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Rhotics

� Three major constrictions:

◦ Lips

◦ Oral constriction

◦ Pharyngeal constriction

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Locations of Constrictions: /r/

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Rhotics: Visualizing the tongue

� Oral constriction (in the palatal/ alveolar region) can be achieved with◦ tongue tip “curled up”

◦ tongue blade raised and “bunched”

◦ …or anything in between

� Tongue tip/blade should generally be off the floor of the mouth

� Tongue dorsum generally lowered behind the oral constriction

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Sagittal view of /r/

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Rhotics: Video examples

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� U005 /ar/, /or/


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Rhotics: Pharyngeal constriction

� The /ɑ/ vowel has tongue root retraction into the pharynx

� Front vowels do not have this retraction� Evaluate pharyngeal constriction using this

knowledge!◦ Try /ɑr/. What should you see the tongue root

do?◦ Try /ɪr/. What should you see the tongue root

do?

� Many children with /r/ misarticulations lack this pharyngeal constriction. ◦ What will you see during /ɑr/?

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089 r eval

Rhotics: Lateral bracing

� Sides of the tongue typically braced against the molars

� Can’t see teeth with ultrasound, but can see sides of the tongue raising

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Coronal view of /r/

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Videos of /r/

� U012 coronal error /r/

� U012 coronal view

� 012 pharyngeal constriction

� U012 establishing r short

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Common errors for rhotics

� Lacking pharyngeal constriction

◦ use sagittal view, probe angled back

� Tongue dorsum is “humped” and is too high; tongue tip/blade are low

◦ No differential movement of the front vs back of the tongue

◦ Use sagittal view, probe angled forward

� Rounded tongue with no lateral bracing (coronal view with ultrasound)

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Our Treatment Procedures

� To achieve stimulability:

◦ Model of clinician’s tongue shape

◦ Visual “targets” on the screen

◦ Shaping � /l/ � [ǭ] (cf. Shriberg, 1975)

� /a/ � [ǭ] (cf. Secord et a., 2007)

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� Remember overhead transparencies?

◦ Use them to give the client “targets” to hit or to draw lines of the client’s “best” tongue shape

� Save out images of “clear” productions to use as referents in future sessions

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� Once stimulability is achieved, work on syllables, monosyllabic words, multisyllabic words, phrases, sentences (all in a single session, if possible)

◦ We use chaining procedures

◦ Postvocalic: /ar/ – tar – guitar – loud guitar

◦ Prevocalic: /re/ – rake – raking – raking leaves

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� We combine ultrasound biofeedback with periods of non-ultrasound treatment (using motor learning principles)� Our long-term goal is to fade the use of ultrasound!

� Ultrasound is not terribly useful for working on connected speech (sentence/discourse level)

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Video/Audio Examples

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� U002 vary rate and intonation

� U002 audio pre/post

◦ U002_9-29-11_probe GR

◦ U002_11-28_probe GR

In groups: Rhotics

◦ Identify pharyngeal constrictions for /r/ during /ɪr/ and /ɑr/.

◦ Describe the tongue shape in a sagittal view. Try to observe elevation of the lateral margins of the tongue for /r/ in a coronal view

◦ Practice a distorted (derhoticized) /r/. What happens with your pharyngeal constriction? Tongue blade? Tongue dorsum?

◦ Try slow and fast speech

◦ What’s similar/different between people?

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3:00


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Are there disadvantages to utlrasound biofeedback?

� Drill and repetition are still required.

� Images are only of the tongue (cannot see palate or posterior pharyngeal wall)

� To visualize the target position, speech is slowed down.

� The probe moves so your image might change

� Cost/access/training

� The machine doesn’t do all the work!

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Evidence behind Ultrasound?

� The current research base includes case studies and single subject experimental designs replicated across multiple participants

◦ Residual articulation errors

◦ Childhood apraxia of speech

◦ Hearing Impairment

� No randomized control trials to date

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Evidence: A brief example

� 12 yr old with CAS

◦ (Preston, Brick & Landi, in press)

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0

0.2

0.4

0.6

0.8

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1 5 9 13 17 21Probe

Accuracy /ar/

0

0.2

0.4

0.6

0.8

1

1 5 9 13 17 21Probe

Accuracy /ɛd/

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0.2

0.40.6

0.8

1

1 5 9 13 17 21Probe

Accuracy /ne/

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0.2

0.4

0.6

0.8

1

1 5 9 13 17 21Probe

Accuracy /dr/


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Evidence: A brief example

� 13 yr old with CAS & flaccid dysarthria

◦ (Preston, Brick & Landi, in press)

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0

0.2

0.4

0.6

0.8

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1 5 9 13 17 21Probe

Accuracy /ar/

0

0.2

0.4

0.6

0.8

1

1 5 9 13 17 21Probe

Accuracy /kl/

0

0.2

0.4

0.6

0.8

1

1 5 9 13 17 21Probe

Accuracy /sk/

Summary

� Can you think of a client you have who might benefit from this feedback?

� Can you think of clients who would NOT be able to handle this type of treatment?

� Have you learned anything new about articulatory phonetics?

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Questions? Comments?

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References� Adler-Bock, M., Bernhardt, B., Gick, B., & Bacsfalvi, P. (2007). The Use of Ultrasound in Remediation of North

American English /r/ in 2 Adolescents. American Journal of Speech-Language Pathology, 16(2), 128-139.

� AIUM. (2012). Safety in training and research Retrieved June 9, 2012, from http://www.aium.org/publications/statements.aspx

� Barnett, S. B., Ter Haar, G. R., Ziskin, M. C., Rott, H.-D., Duck, F. A., & Maeda, K. (2000). International recommendations and guidelines for the safe use of diagnostic ultrasound in medicine. Ultrasound in Medicine & Biology, 26(3), 355-366.

� Bernhardt, B., Bacsfalvi, P., Adler-Bock, M., Shimizu, R., Cheney, A., Giesbrecht, N., et al. (2008). Ultrasound as visual feedback in speech habilitation: Exploring consultative use in rural British Columbia, Canada. Clinical Linguistics & Phonetics, 22(2), 149 - 162.

� Bernhardt, B., Gick, B., Bacsfalvi, P., & Adler-Bock, M. (2005). Ultrasound in speech therapy with adolescents and adults. Clinical Linguistics & Phonetics, 19(6/7), 605-617.

� Bernhardt, B., Gick, B., Bacsfalvi, P., & Ashdown, J. (2003). Speech habilitation of hard of hearing adolescents using electropalatography and ultrasound as evaluated by trained listeners. Clinical Linguistics & Phonetics, 17(3), 199 - 216.

� Epstein, M. A. (2005). Ultrasound and the irb. Clinical Linguistics & Phonetics, 19(6-7), 567-572.

� Modha, G., Bernhardt, B., Church, R., & Bacsfalvi, P. (2008). Ultrasound in treatment of /r/: A case study. Intl. Jnl. of Lang. & Communication Disorders, 43 (3), 43(3), 323-329.

� Preston, J. L., Brick, N., & Landi, N. (in press). Ultrasound biofeedback treatment for persisting childhood apraxia of speech. American Journal of Speech-Language Pathology.

� Strand, E., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech Language Pathology, 14(4), 297.

� Shriberg, L. D. (1975). A response evocation program for /er/. Journal of Speech & Hearing Disorders, 40(1), 92-105.

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