Disclosure Statements

Deborah Hayden (Presenter 1) Relevant Financial Relationships:

• Salaried Research Director, The PROMPT Institute, Santa fe, NM.

Hayden, D. & Namasivayam, A.K., (2015, November). PROMPT Overview of a Program of Research: Where Are We Now? Seminar session at the American Speech-Language and Hearing Association Annual Convention, Denver, Colorado.

Aravind Namasivayam (Presenter 2)

Relevant Financial Relationships:

• Consultant Research Scientist (part-time) with The PROMPT Institute, Santa Fe, NM.

Relevant Nonfinancial Relationships:• Adjunct Faculty – Dept. of Speech-Language Pathology University of Toronto. • Adjunct Scientist – Toronto Rehabilitation Institute & • Adjunct Scientist - Toronto Western Hospital and Medicine - Neurology,

Toronto Western Hospital, Toronto. • Serves as reviewer for several peer reviewed journals. ‐

Disclosure Statements

Hayden, D. & Namasivayam, A.K., (2015, November). PROMPT Overview of a Program of Research: Where Are We Now? Seminar session at the American Speech-Language and Hearing Association Annual Convention, Denver, Colorado.

PROMPT Overview of a Program of Research: Where Are We Now?

Deborah Hayden M.A. S-LP CCCResearch Director – The Prompt Institute, Santa Fe, NM

Aravind Namasivayam Ph.D. S-LP (C)Research Scientist - The Prompt Institute, Santa Fe, NMAdjunct Faculty – Dept. of SL-P, University of Toronto.

Email: deb@promptinstitute.com ; a.namasivayam@utoronto.ca

Hayden, D. & Namasivayam, A.K., (2015, November). PROMPT Overview of a Program of Research: Where Are We Now? Seminar session at the American Speech-Language and Hearing Association Annual Convention, Denver, Colorado.

Definition of PROMPTPrompts for Restructuring Oral Muscular Phonetic Targets

A holistic, dynamic, sensory-motor,

tactile-kinesthetic system designed to help

organize, plan and execute the

phonetic/phonemic elements of speech

production for the development or

redevelopment of language within functional

interactions.

EnvironmentExternal

PROMPT Conceptual Framework

Client

Internal

CulturalPhysical Social

intrapersonal

interpersonal

Physical SensorySkeletal StructureNeuromuscular IntegritySensation

Cognitive LinguisticPerception sensation discrimination recognitionConcept Formation

Social EmotionalInterpersonal InteractionTrust

Sensory-Motor

Communication

BehavioralOutcomes

5

PROMPT APPROACH• Motor speech goals targeted in PROMPT reflect insights

from current models of speech production (Green & Nip 2010, Hayden et al. 2010) and assume a hierarchical or non-uniform development of speech subsystems known as the Motor Speech Hierarchy (MSH; Hayden et al. 2010).

• There are acoustic, perceptual and kinematic data to

suggest that development of speech involves the integration of later developing labiofacial and lingual movements into a relatively stable and well-established mandibular movement pattern (e.g. Green & Nip 2010).

MOTOR SPEECH HIERARCHYMSH is based on the interactive development of control of seven key motor speech subsystems.

PROMPT framework aims to facilitate the hierarchical establishment, refinement and integration of normalized movement patterns within these speech subsystems.

PROMPT APPROACH• Overall, the PROMPT approach aims to achieve

normalized movement patterns for speech production via hierarchical goal selection (MSH) and the use of systematic, coordinated multi-sensory inputs embedded into contextual/age-appropriate lexicon.

• Clinicians integrate information across domains (i.e. cognitive, social, pragmatic, behavioral, sensory-motor, and physical) to maximize a client’s potential for communication. The ultimate goal is functional, interactive & verbal communication.

Evidence-Based Practice involves a cycle of enquiry:Source: http://libguides.mq.edu.au/content.php?pid=275601&sid=2356769

(Critically appraise literature evidence)

Question?

ACT(Implement guidelines

based on literature evidence/patient

values/clinical experience)

Level 1a

Level 1bLevel 2

Level 3/4

Level 5

Oxford levels of Evidence for therapeutic study designs

There is usually 1 pyramid constructed per disorder/per treatment approach

Where were we (PROMPT) on theHierarchy of Evidence Quality?

Grigos et al., 2010-SSD

Rogers et al., 2006 – Autism

Bose et al. 2001- Adult apraxia

Freed et al., 1997- Adult apraxia

PROMPT experimental data stacked on the evidence pyramid

Circa: 2012

NEW RESEARCH : 2013-2015•Neurophysiological mechanisms • Kinematic changes underlying PROMPT intervention. • Temporal coordination between phonatory & articulatory sub-systems. • Cognitive-Linguistic effects of tactile priming on phoneme recognition.• Cortical changes due to PROMPT intervention.

•Treatment Effects• Relationship between speech motor control & Speech Intelligibility.• New data indicating effectiveness in SSD-MSD, CP, CAS.

•Process standardization • Probe word scoring system • Outcome measures• Reliability and Fidelity

PROMPT APPROACH

Ward et al., 2013, 2014- Children with Cerebral Palsy

Neurophysiological mechanisms: KINEMATICS

• An A1BCA2 single subject research design.

• A = baseline; B = first intervention priority ; C = one level higher on MSH.

• The speech probes were analysed for motor-speech movement parameters and perceptual accuracy.

• Statistically significant improvements in movement patterns were observed only when they were targeted in the intervention.

Neurophysiological mechanisms: KINEMATICS

Ward et al., 2013, 2014- Children with Cerebral Palsy

Neurophysiological mechanisms: KINEMATICS

•Kinematics: Systematic changes in mandibular and labiofacial sub-systems result in improved speech intelligibility.

Ward et al., 2013, 2014- Children with Cerebral Palsy

VOT (ms)

Num

ber o

f Occ

urre

nces

(%)

Controls MSD-PRE group significantly higher VOT variability (CoV) than control group (p=.013)

Significant difference in CoV between MSD-Pre and MSD-Post (p=.006)

Importantly: No significant difference between MSD-Post & controls (p=.47)

MSD-Pre

MSD-Post

Sig

Sig Not

Sig

nific

ant

[+/- voice contrast] ?

PROMPT treatment improves coordination between phonation & articulation?

Data from Yu et al., (2014)

Neurophysiological mechanisms: Coordination

Relationship between Voice Onset Time (VOT) & PROMPT Therapy

/p/ release

VOT

Vowel onset

Masseter spindle information controls: -Jaw height (grading)-Phonation onset-Phonation variability

Most of the children with MSD in the study had jaw control issues. Stabilizing the jaw in PROMPT tx provides = stable & reliable proprioceptive information from the masseter muscle = improves coordination between phonation and articulation!

Data from: Neufeld, C., Namasivayam, A., Van Lieshout, P. (2013 a, b).

Neurophysiological mechanisms: Coordination

Word frequency effects: May suggest that the influence of TKP inputs on pre-lexical selection is biased by the usage sensitivity of how lexical information is stored in the mental lexicon (Luce & Pisoni, 1998). Low frequency words usually take longer to be recognized & the additional TKP information can facilitate this process at the input stages of lexical cohort selection (Marslen-Wilson, 1987).

Oro-Facial Tactile Cues Improve Phoneme RecognitionExogenously delivered TKP inputs improve speech production but can they also be utilized by the cognitive-linguistic system to facilitate phoneme perception and word retrieval?

Neurophysiological mechanisms: Tactile Priming

Data From: Namasivayam, Law, Yan, Hyunh, Bali, Hayden & Van Lieshout, 2015

Cortical changes in children receiving PROMPT for motor speech disorders

Left Post Superior Temporal Gyrus (Wernicke’s area): Significant (p< 0.05) thinning Pre-Post PROMPT tx in MSD

What does thinning of Wernicke’s area following (Pre-Post) PROMPT tx Mean?

•Wernickes area: Role in the formation “speech sound representation” .

•Lt. PSTG participates both speech perception and speech production.

•PROMPT with TKP inputs may allow for formation of more accurate speech sound representation.

•Which in turn allows the development of accurate & stable motor programs that can be retrieved and sequenced efficiently.

Data from Kadis et al., 2014

Neurophysiological mechanisms: Cortical Changes

Neurophysiological mechanisms in children receiving PROMPT for motor speech disorders

Kinematics: Systematic changes in mandibular and labiofacial sub-systems result in improved speech intelligibility.

•Inter-system Coordination: PROMPT treatment may provide stable & reliable proprioceptive information from the masseter muscle which improves coordination between phonatory and articulatory sub-systems.

•Cognitive-Linguistic effects: Low frequency words usually take longer to be recognized & the additional TKP information can facilitate this process at the input stages of lexical cohort selection.

•Cortical: PROMPT intervention promotes thinning and possible maturation of Wernicke’s area (possibly improving and refining speech sound representations and associated sensory-motor maps). This may be one possible neural target for therapeutic action of PROMPT.

Summary

Treatment Effects in children receiving PROMPT for motor speech disorders

•Treatment Effects• Relationship between speech motor control & Speech

Intelligibility.

• New data indicating effectiveness across :• Speech Sound Disorder – Motor Speech Difficulties (SSD-MSD).• Childhood Apraxia of Speech (CAS).• Cerebral Palsy (CP)

• Note previously (Circa 2012) established for SSD, Autism and Adult aphasia/apraxia.

What Drives Speech-Intelligibility?

GFTA-2 VMPAC-FOC VMPAC-SEQ0

0.10.20.30.40.50.60.70.80.9

FOCSEQCSIMBIT

Pear

son

Corr

elati

on r

****

*

**

**

**. Correlation is significant at the 0.01 level (2-tailed).*. Correlation is significant at the 0.05 level (2-tailed).

• Single-word testing is a poor indicator.

• Oro-motor control and sequencing significantly correlated with intelligibility in MSD.

• 40-50% variance in Intelligibility accounted for by FOC

• 50-70% variance in Intelligibility accounted for by SEQ

PROMPT possibly works because it targets underlying motor system.Data From Namasivayam et al., (2013).

Speech-Motor Control & Intelligibility

Sentence-level Speech Intelligibility0

5

10

15

20

25

30

35

40

27.6

18.5

10.9

Group AGroup BGroup C

Mea

n Pr

e-Po

st In

crea

se (%

)

= Artic + Phonology= Artic + Phonology + FOC= Artic + Phonology + FOC + SEQ

All participants had moderate-to-severe articulation & phonological issues.

Greater the speech motor control difficulty the lesser the progress/gains in connected speech intelligibility following treatment.

Service Delivery: 8 weeks, 2x week 45 min, individual sessions –PROMPT

treatmentData From Namasivayam et al., (2013).

New Single-Subject Experimental data

*Speech Sound Disorder – Motor Speech Difficulties (SSD-MSD).

(Across behaviours & across subjects)

*Cerebral Palsy (CP).(Across behaviours & across subjects)

*Childhood Apraxia of Speech (CAS).(Across subjects & experimental conditions +/- tactile input)

Speech Motor Accuracy for S2

Data from Square et al., (2014)

PROMPT Approach for Children with SSD-MSD

Lingual –Set B

Jaw/Lip–Set A

Data From: Ward et al., 2013, 2014- Children with Cerebral Palsy

PROMPT Approach for Children with Cerebral Palsy

PROMPT Approach for Children with Cerebral Palsy

In CAS, effectiveness of 16 sessions (8 weeks) of Full PROMPT treatment Vs 8 sessions (4 weeks) of Prompt Without Tactile followed by 8 sessions (4 weeks) of Full Prompt .

What is the effectiveness of the initiation of Full PROMPT in the second four weeks in the kids that started without tactile input:

a)Improved oro-motor control and sequencing & intelligibility

b)Improved quality of speech movements in untrained words (generalization)

Image source: http://www.donnalederman.com/services/prompt-therapy.php

PROMPT Approach for Children with CAS

Data From Dale & Hayden (2013).

Labio-Facial

Lingual

Sequencing

With TactileWithout Tactile

Participant B.B (Prompt Without Tactile: Phase I) on Untreated Word Probes. Larger markers indicate performance > 2 SD above baseline. Scores on the y-axis are the percentage of the maximum score (30 = 10 words x 3 points/word) achieved by the child.

Data From Dale & Hayden (2013).

PROMPT Approach for Children with CAS

Treatment Effects

Findings: 1) Improved accuracy: PROMPT treatment resulted in improved

speech on both speech movement and auditory accuracy.2) Generalization: improvements across trained & untrained

words. 3) Post-treatment gains: were statistically significant (Baseline -

maintenance phase) . 4) Speech Intelligibility: Significant changes in speech

intelligibility. 5) Implication: PROMPT intervention may be an effective

treatment approach for children with CAS, CP, SSD-MSD.

SUMMARY

What have we learned? 2013-2015 MECHANISM OF TREATMENT EFFECTS: Significant improvements in movement

patterns, speech intelligibility & neuroplastic changes can be achieved following PROMPT treatment.

FOR WHOM: In addition to adult aphasia-apraxia & ASD (crica:2012), we now have experimental data to show PROMPT is effective for Cerebral palsy, SSD-MSD, CAS.

SERVICE DELIVERY: 2x week PROMPT treatment sessions provided for 8-15 weeks of group or individual therapy results in significant change (in SSD/CP/CAS).

• We have:– Quantified PROMPT effectiveness: Large effect sizes (<0.8) across varied

populations (~ 1 S.D./in 8-10 weeks). – Identified a possible “key ingredient” (tactile cues) underlying therapeutic effects /

therapeutic action of PROMPT.– Cognitive-linguistic processes can be facilitated by tactile inputs.– Identified a possible mechanism and neural target for therapeutic action of

PROMPT (thinning & possible maturation of Wernicke’s area).

Next Steps:

Process Standardization

Process Standardization

Assessment Probe word Scoring System(Hayden, Namasivayam, Hard & Van Lieshout, 2014)

InterventionDefining Treatment outcomes (Kearney et al., 2015)

Treatment Fidelity • Reliability & Fidelity (Hayden, Namasivayam & Ward, 2015)

• Accuracy & Consistency of Tactile-Kinesthetic-Proprioceptive inputs (Namasivayam, Bali, Yan, Hayden & van Lieshout, 2015)

Process StandardizationAccuracy & Consistency of Tactile-Kinesthetic-Proprioceptive inputs(Namasivayam, Bali, Yan, Hayden & Van Lieshout, 2015)

• Methodology to assess the consistency of TKPs inputs during speech therapy. • Evaluate whether TKP inputs are more accurate and consistent with more training

and experience.

Accuracy & Consistency of Tactile-Kinesthetic-Proprioceptive inputs(Namasivayam, Bali, Yan, Hayden & Van Lieshout, 2015)

• cyclic-Spatio-Temporal Index (cSTI): Adequate for analyzing consistency of oro facial TKP inputs by S -LPs.

• S-LP with more training/experience is more:• Accurate in judging the range of jaw motion of a participant.• Consistent in inducing oro-facial movements in a participant.

S-LP generated passive jaw movements for vowel /a/plotted over the 95% CI derived from the participant’s active jaw movements.

cSTI based on upper lip displacement trajectories from sensors placed symmetrically on either side of the philtrum.

Next Major Step!

RANDOMIZED CONTROLLED TRIAL (RCT)

2013-2016

RANDOMIZED CONTROLLED TRIAL (RCT)

Independent Variable: PROMPT treatment Dependent Variable: i. Measures of speech motor control (VMPAC and Probe Words)ii. Measures of change in the speech sound system (articulation/phonology-DEAP)iii. Measures of speech intelligibility (word level and sentence level)iv. Measures of change in functional communication (FOCUS)

GOLD STANDARD To establish

causality between

independent & dependent variables

RANDOMIZED CONTROLLED TRIAL (RCT)

Data Monitoring & Randomization (external agency) Applied Health Research CentreSt. Michael's Hospital, Toronto

John McGivney Children’s Centre of

Essex County

The Speech & Stuttering Institute

Erinoak Kids Centre for Treatment and

Development

Where are we now (PROMPT) in theHierarchy of Evidence Quality?

How high have we climbed the pyramid?

Namasivayam et al. 2013- Speech Sound DisordersKadis et al. 2013- Childhood Apraxia of SpeechYu et al. 2014- Speech Sound Disorders

Multi-Centre RCT Clinical Trials in Ontario: In progress: 2013-2016

Square et al. 2014- Speech Sound DisordersDale & Hayden 2013 - Childhood Apraxia of SpeechWard et al. 2013 a & b - Cerebral palsyGrigos et al. 2010- Speech Sound DisordersRogers et al. 2006 - AutismBose et al. 2001- Adult apraxiaFreed et al. 1997- Adult apraxia

PROMPT Evidence-Base: Where Are We Now?

Image Source: http://www3.mdanderson.org/library/evidence-based/img/pyramid.gif (EBM Pyramid copyright 2006 Trustees of Dartmouth College and Yale University.).Note: There is usually 1 pyramid constructed per disorder/per treatment approach

SPECIAL THANK YOU

- To the PROMPT research committee: - Roslyn Ward & Cheryl Small Jackson and 40+ PROMPT instructors.

- To ~15 Research Assistants/ Volunteers:- Jennifer Hard, Stephanie Wong, James Le, Francesca Granata, Elaine

Kearney, Tina Yan, Vina Law, Michelle Chui, Vanessa Sandir, Rohan Bali, Neil Fletcher, Anna, Alexandra, Menghan & Fan Zhang,

- Lab Facilities: Dr. Pascal van Lieshout- Director, Oral Dynamics Lab. University of Toronto

- Collaborators and Partners: - John McGivney Children’s Centre of Essex County - The Speech & Stuttering Institute- Erinoak Kids Centre for Treatment and Development.

References:

Bose, A., Square, P. A., Schlosser, R., & van Lieshout, P. (2001).Effects of PROMPT therapy on speech motor function in a person with aphasia and apraxia of speech. Aphasiology, 15(8), 767–785.

Dale, P., & Hayden, D. (2013). Treating speech subsystems in CAS with tactual input: The PROMPT approach. American Journal of Speech Language Pathology, 4, 644-661.

Freed, D. B., Marshal, R. C., & Frazier, K. E. (1997).Long term effectiveness of PROMPT treatment in a severely apraxic-aphasic speaker. Aphasiology, 11(4/5), 365–342.

Green, J.R., & Nip, I. S. B. (2010). Some organization principles in early speech development. In B. Maassen & P.H.H.M. van Lieshout (Eds.) Speech motor control: New developments in basic and applied research (pp. 171-188). NC: Oxford University Press.

Grigos, M, Hayden, D. & Eigen, J. (2010).Perceptual and articulatory changes in speech production following PROMPT treatment. Journal of Medical Speech Pathology, (18) 4, 46-53.

Hayden, D., Namasivayam, A. K., & Ward, R. (2015). The Assessment of Fidelity in a Motor Speech Treatment Approach. Speech, Language & Hearing, 18 (1), 30-38.

References:

Hayden., D, Namasivayam A.K., Hard, J., & Van Lieshout, P.H.H.M. (2014). Probe wordlist for the assessment of treatment progress and generalization in children with motor speech disorders. Poster presented at the 17th Conference on Motor Speech: Motor Speech Disorders & Speech Motor Control, Sarasota, FL (Feb 27-March 2).

Hayden, D., Eigen, J., Walker, A., Olsen, L. (2010).PROMPT: A tactually grounded model. In Williams, L, McLeod, S. & McCauley, R.(Eds.)Interventions for Speech Sound Disorders in Children. Baltimore, Maryland; Brookes.

Kadis, D. S., Goshulak, D., Namasivayam, A., Pukonen, M., Kroll, R., De Nil, L. F., Pang, E. W., & Lerch, J. P. (2014). Cortical thickness in children receiving intensive therapy for idiopathic apraxia of speech. Brain Topography, 27, 240–247.

Kearney, E., Granata, F., Yunusova, Y., van Lieshout, P., Hayden, D., & Namasivayam, A. K. (2015). Outcome Measures in Developmental Speech Sound Disorders with a Motor Basis. Current Developmental Disorders, 2, 253-272.

Luce, P. A. & Pisoni, D. B. (1998). Recognizing spoken words: The neighborhood activation model. Ear and Hearing, 19, 1-36.

References:

Marslen-Wilson W. D. (1987). Functional parallelism in spoken word-recognition. Cognition, 25(1-2), 71-102.

Namasivayam A, K., Bali, R., Yan, T., Hayden, D., & Van Lieshout, P. H. H. M. (2015, November). Accuracy & Consistency of Oro-Facial Prompting for Speech. Poster to be presented at the American Speech-Language and Hearing Association Annual Convention, Denver, Colorado.

Namasivayam, A. K., Pukonen, M., Goshulak, D., Yu.V.Y., Kadis, D.S., Kroll, R., Pang, E.W., & De Nil, L.F. (2013). Changes in speech intelligibility following motor speech treatment in children. Journal of Communication Disorders, 46(3):264-80.

Namasivayam, A. K., Law, V., Yan, T., Hyunh, A., Bali, R., Hayden, D., & Van Lieshout, P. H. H. M. (2016, March). Effects of Tactile Repetition Priming on Phoneme Recognition. Poster to be presented at the International Motor Speech Conference, Newport Beach, CA.

Neufeld, C., Namasivayam A.K., van Lieshout, P.H.H.M. (2013a). Articulatory phonatory coupling in people who stutter. Meeting of the Canadian Association for Neuroscience. Neufeld, C., Namasivayam, A.K., van Lieshout, P.H.H.M. (2013b). Bimodal sensory influence in speech control. Progress in Motor Control IX.

References:

Rogers, S. J., Hayden, D. Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36(8), 1007–1024.

Square, P. A., Namasivayam, A. K., Bose, A., Goshulak, D., & Hayden, D. (2014). Multi-Sensory Treatment for Children with Developmental Motor Speech Disorders. International Journal of Language and Communication disorders, 49(5), 527-542.

Ward, R., Strauss, G., & Leitão, S. (2013). Kinematic changes in jaw and lip control of children with cerebral palsy following participation in a motor-speech (PROMPT) intervention. International Journal of Speech-Language Pathology, 15(2), 136-155.

Ward, R., Leitão, S., & Strauss, G., (2014). An evaluation of the effectiveness of PROMPT therapy in improving speech production accuracy in six children with cerebral palsy. International Journal of Speech-Language Pathology, 16(4), 355-371.

Yu.V.Y., Kadis, D.S., Oh, A., Goshulak, D., Namasivayam, A. K., Pukonen, M., Kroll, R., De Nil, L.F., & Pang, E.W. (2014). Changes in voice onset time and motor speech measures in children with motor speech disorders after PROMPT therapy. Clinical Linguistic and Phonetics, 28(6), 396-412.

THANK YOU