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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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
Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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De-mystifying ultrasound
� 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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De-mystifying ultrasound
◦ 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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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Sagittal view of /r/
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Preston: Residual Speech Sound Disorders 10/9/2013
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Rhotics: Video examples
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� U005 /ar/, /or/
Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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Our Treatment Procedures
� 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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Our Treatment Procedures
� 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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Preston: Residual Speech Sound Disorders 10/9/2013
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Our Treatment Procedures
� 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
Preston: Residual Speech Sound Disorders 10/9/2013
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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
1
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/
0
0.2
0.40.6
0.8
1
1 5 9 13 17 21Probe
Accuracy /ne/
0
0.2
0.4
0.6
0.8
1
1 5 9 13 17 21Probe
Accuracy /dr/
Preston: Residual Speech Sound Disorders 10/9/2013
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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
1
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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Preston: Residual Speech Sound Disorders 10/9/2013
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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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