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3/4/13Sec0on 2: Apraxia Therapy: Exploi0ng Neuroplas0city <strong>USHA</strong> Conven0on March 8, 2013 • The second pressing clinical ques2on a3er aphasia recovery: how can we offer clinical management that truly takes advantage of neural plas2city and most efficiently maximizes pa2ent recover for the <strong>apraxia</strong> and related disorders (abulia: asymbolia; etc.): skills? • Client sample 1 2 The Motor Reconnect Apraxia Program (MRAP) MRAP Treatment Principles • Refer to Appendix F for a comparison of Motor Learning and Motor Reconnect Principles. • Refer to Appendix G for a discussion about Motor Reconnect Principles. •3 4 What is Apraxia? • We are not teaching the acquisiCon of a new language or motor skill in an unsophisCcated context in which repeCCon plays a key role (Corrigan, 1980; Strand, 2005). • Since we are working on reconnecCng the neural pathways for a process that generates speech and language, we need to facilitate thousands of self-‐generated neural flows. What is Apraxia? “The problem in the relaCon of brain structure to funcCon is that we think of funcCon as acCve and dynamic and structure as fixed and stable. The result is that mental acCvity is arCficially stabilized in compartments that can be localized,…” “…what is needed is an enlivened concept of structure in terms of process,” (Brown, 2003) 5 6 1
CRITIQUE OF THE CONCEPT OF DEVELOPMENT AND REGIONAL STUDIES23nearly throughout the whole 20 th century was regarding it as a process ofchanges which were teleological, uniform, linear, normalising and instrumental(technical) in character.The powerful appeal of looking at development as a uniform historicalprocess is undoubtedly due to the fact that it entails the image of the world asa certain harmonised, ordered whole, governed by regularities which apply toall its constituent parts. This order can express itself in the linear character ofdevelopment, where the subsequent stages inevitably mean changes for thebetter. As a result, development in fact involves normalisation – it aims to leadthe features of different regions to a state which is the most desirable (optimal).From the perspective of state or regional authorities, activities promotingdevelopment are a task of a technical nature, and involve a rational selectionof relevant measures (methods of actions) to achieve the desired goal (intendedstate). This intended state is determined by the qualities of regions regarded aswell-developed. Therefore, in geographical terms, development means assumingthe features of well-developed regions.This kind of approach to development can be found in various forms intheories informed by Keynesian, neo-Classicistic, Marxist and institutionalthought in economy after World War II. The notion of development as a linearinevitability is easily visible in Rostov’s popular theory, according to whichnational economies undergo five stages of development, and in Bell’s conceptof post-industrial society. In addition, many such developmental features canbe found in contemporary analyses of globalisation processes.Development as EuropeanisationThe approach to the process of socio-economic transformation in Centraland Eastern Europe after the collapse of the socialist system can be seen asa peculiar version of development understood as modernisation. The processof post-socialist transformation is frequently reduced to an assimilation of thepatterns which evolved in Western Europe. The inhabitants of the eastern andcentral part of the continent can be simply regarded as underdeveloped societies,which proved unable to produce modern ideas, economies and political institutions.This would imply that they should attempt at closing the gap byimitating the features which can be encountered in Western Europe.This in turn leads to a peculiar understanding of the EU enlargementprocess eastward. Firstly, this is an act that normalises the area characterisedby economic and political chaos. Secondly, the new members are in theposition of applicants or petitioners, which justifies the adoption of valuesand views of modern Europeans from the core EU countries, who may seethemselves as benefactors and educators for the ‘new Europeans’. Thereforedevelopment in post-socialist Europe is tantamount to the process of their‘Europeanisation’, involving the assimilation of features which are characteristicof Western Europe, and rejecting other features. The term ‘European’
3/4/13The Motor Reconnect Apraxia Program (MRAP) Treatment Modules • Syllabifica0on Module: for vowel and syllable pulsing; pre-‐syllabic work The Motor Reconnect Apraxia Program (MRAP) Treatment Modules • SyllabificaCon Module for vowel and syllable pulsing; pre-‐syllabic work 19 20 MRAP module steps – Syllable structure work • Vowels Become Pronouns • Oral-‐Motor CoordinaCon Program • Sound Embedded Verbs • Increasing Syllables • Sentence IntonaCon Pa\erning • Heteronyms • Ideas? 21 The Motor Reconnect Apraxia Program (MRAP) Treatment Modules • Limb Module: for addressing limb <strong>apraxia</strong> and keyboarding skills. 22 MRAP module steps – MRAP for Limb <strong>apraxia</strong> • Praxis for number digits • Morr<strong>apraxia</strong> (h\p://www.morrasociety.com/) – Single number Morra – Simple math Morra – Morra • Digital number concepCng with keyboarding MRAP module steps – MRAP for Limb <strong>apraxia</strong> • Gestural representaCon of present objects • Gestural representaCon of missing objects (VAT) • TradiConal-‐ Visual Acton Therapy • In conversaCon-‐verificaCon 23 24 4
3/4/13MRAP module steps -‐ MRAP for Limb <strong>apraxia</strong> • Keyboarding – Typing – Touch screen – Touch pad – Hovering The Motor Reconnect Apraxia Program (MRAP) Treatment Modules • Blending with BCAT module: to fold in semanCc-‐linguisCc areas of focus, work in phrases and sentences, and address link to prosodic skills 25 26 MRAP module steps – Blend with BCAT work: 1. speech; 2. language; 3. discourse; 4. symbolic representaCon. 5. phoneCcize The Motor Reconnect Apraxia Program (MRAP) Treatment Modules • Online Group Module: for peer engagement, pracCce and support 27 28 The Motor Reconnect Apraxia Program (MRAP) Treatment Modules • The Aphasia CommunicaCon Café for peer engagement, pracCce and support • ARC group online • Treatment Groups MRAP module steps – GROUPS: • Oral Motor CoordinaCon -‐ Apraxia • Scatpraxia • Coaches 29 30 5
3/4/13MRAP module steps • Whole person <strong>apraxia</strong> recovery module: TradiConal Approaches Melodic IntonaCon Therapy (MIT) Melodic intoning>Rhythmic Speech>common phrases. 31 32 MRAP module steps • Physical Fitness for Life Program • A rising <strong>apraxia</strong> rehabilitaCon Cde lips all boats. • HolisCc treatment • Abulia; adynamia; asymbolia; alien arm • Exercise; physical trainer; yoga; religion • Ideas? Issues-‐Possibilites: • Refer to Appendix G for outcome discussion. • PPA • Young adults with persistent <strong>apraxia</strong> and language problems. • TesCng: The Online Aphasitoolbox Assessment 33 34 Telerehabilita0on: • Professional Issues (Brown, 2012; ASHA-telepracCce, 2012) • Conferencing services • EBP Telerehabilita0on • What’s in a name? • Tele – is a Greek prefix • Prononced / 0 lu / • Can be word meaning television-‐ BriCsh, Spanish, Italian • Telespeech • Telerehabilitaiton • Teletherapy 35 36 6
3/4/13Telerehabilita0on: • Professional Issues (Brown, 2012; ASHA-telepracCce, 2012) • h\p://www.putmebacktogether.com/MediaRoom/MediaViewer/TabId/152/VideoId/145/Speech-‐Therapy-‐TelepracCce-‐.aspx ASHA Video • h\p://www.putmebacktogether.com/MediaRoom/MediaViewer/TabId/152/VideoId/145/Speech-‐Therapy-‐TelepracCce-‐.aspx • h\p://www.asha.org/academic/quesCons/Telehealth-‐and-‐TelepracCces/ 37 38 Telerehabilita0on: • Conferencing issues • www.oovoo.com • www.skype.com • Bigbluebu\on.com • Webex • eVoxaCve; It’s Never Too Late • Unaffordable to those of us in the trenches • Remote Access Assessment of Articulation by Telepractice: A Pilot StudyASHA Convention – Philadelphia – November 18, 2010Sena Crutchley (Crutchley, Dudley, & Campbell, 2010)The University of North Carolina at GreensboroSchool of Health and Human Performance • Reliable and valid assessment of arCculaCon by telepracCce has potenCal. Further study with a larger subject pool and more stringent research protocol is needed. Also, it would be of value to determine the minimum equipment and infrastructure standards necessary to achieve reliable and valid assessment of arCculaCon by telepracCce. 39 40 Telerehabilita0on • Privacy-‐HIPAA • PracCcal aspects (Berger, 2010; Gould 2012) • Advantages Telerehabilita0on • Disadvantages; glitches • Human factor • Type of disorder 41 42 7
3/4/13Telerehabilita0on-‐Human factor: • "How can a company ever truly be dispersed without losing the [Human] Factor and compromising the key elements of a successful business, such as innova=on, morale, produc=vity, and flexibility?"hBp://news.yahoo.com/telepresence-‐everyone-‐053613885.html Eric Savitz | Forbes – Mon, Aug 22, 2011 • "How can we provide truly dispersed aphasia treatment without losing the Human Factor and compromising the key elements of successful therapy, such as clinical innova=on, posi=ve interac=on and morale, client produc=vity and improvement, and flexibility?"• It ends up it is easy to do. 43 Telerehabilita0on • Group possibiliCes • Focus and a\enCon • Get used to it: digital naCves-‐digital immigrants • It has become passé to quesCon the effecCveness of telepracCce; Has it become passé to discuss advantages vs. disadvantages? 44 Apps, applica0ons and websites Apps, applica0ons and websites To be discussed with a separate handout. • Apps can be therapeuCc • If all the app does is computerize Cred, meaningless tradiConal drills, does it add any value to the client's program,(Boo, 2010; Dechene, 2011)? • An overabundance of useful technology exists beyond apps. • h\p://www.psha.org/pdfs/PSHAiPadsSurvery.pdf • SelecCon criteria: – Can be downloaded and installed by a second grade, digital naCve. – It can be used without reading the instrucCons. – It can be made truly therapeuCc for PWA 45 46 Aphasia Centers • Wonderful, nice people who add a lot of value to people’s lives. • My job….. Aphasia Centers Simmons-‐Mackie N and Holland A, Aphasia Centers in North America: A Survey, Aphasiology, , 2010 The Adler Aphasia Center, hZp://www.adleraphasiacenter.org/media/?id=3 The Stroke Comeback Center 47 48 8
3/4/13Augmenta0ve and Alterna0ve Communica0on devices for PWA • Just get an iPhone. • Is it needed? • What is the track record? • Can it help? 49 50 Summary and Conclusions • See Appendix I for references 51 9
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