Do You Know Apraxia When You See It?

Emily:
[0:15] Hi, everyone. I'm Emily.

Eva:
[0:17] And this is Eva.

Emily:
[0:18] And you're listening to Speech Talk.

Eva:
[0:21] We're your research book club, so you can do evidence-based practice in practice.

Emily:
[0:25] So let's start talking. All right, Emily.

Eva:
[0:27] How did you choose—oh, wait, no, we have to do fun for the week. Now, how did we choose this topic? That's ridiculous.

Emily:
[0:34] Yeah. Jumping the gun. Eva, start us off. What was interesting this week?

Eva:
[0:40] I've been flexed off of work so much recently. I feel like I've just been really, uh, living my best, uh, summer life since I was in school. Like I've been having a real summer vibe. I've gone swimming. I've gone shopping. But clinically, what could I say? I have some patients who are super smiley, which as I like to say, you know, come to therapy as you are. There's no obligation to be cheerful about where you're at. But I have to say it's a ton of fun when you get some folks who are laughing And it can really be a big pick-me-up at work. So I've been having a really good time just honestly laughing with some of my patients this last week.

Emily:
[1:22] That's so funny that you say that, though, because when you had first said it, I was thinking that movie. Have you seen that horror movie, Smile?

Eva:
[1:29] No, I don't watch any horror movies. I don't want to go in fear of walking around my house at night. I saw the trailer for The Purge, and I am terrified.

Emily:
[1:41] Oh, that's not scary. It's just, that's gory. I don't like a gory movie, but psychological thriller all day long. But this movie, people have, they're like infected by this demon and they smile. And when they smile at you really creepy, like, you know, this demon is coming after you. So like, that was my first thought when you said that everybody was smiley is like not a positive story, but like deep, someone is coming for you.

Eva:
[2:09] And suddenly my like in my head my uh medical tv show that's kind of constantly playing when i'm at work it takes a dark turn i of course i love to be scrubs scrubs for life baby

Emily:
[2:21] Oh my gosh scrubs is a good show.

Eva:
[2:24] I watch it once a year non non-paid advertising plug all right emily what are what about you what was good this week

Emily:
[2:31] I don't know i guess clinically the most exciting thing was i had a swallow study, which you know, in the sniff world, they are far and few between. But this one was like, It was just it was just not awesome. Like the only thing that wasn't aspirated was like single sip then and everything else was like horribly scary. And then like as soon as we're done, he's like, can I get some milk? It's like, let me catch my breath for a second, sir.

Eva:
[3:07] Yeah, speaking of watching scary movies, watching a swallow study where things are just obviously going into the airway is truly terrifying.

Emily:
[3:15] Yeah, you're like, please cough, please cough. Please cough. For the love, please cough.

Eva:
[3:20] 100%. Well, I'm so glad we've been having a good time with our patients this week. You know, we talk a lot about them on the show. And the important thing is that our patients exist inside a healthcare system overall. And that system is changing really fast. Yeah. If you're interested in keeping up to date with that, try listening to Medlines. It's a new show on our network for staying up to date on recent medical news. It's quick, credible medical news on the go. And guess what? I'm an anchor.

Emily:
[3:47] And I love that. I'm so excited for Eva.

Eva:
[3:52] And without further ado, let's get into today's topic. Emily, what are we talking about?

Emily:
[3:56] So this topic popped up for me recently when a patient came in baseline aphasia from like probably four years ago. I'm not totally sure, with an AAC device in hand and everything.

Eva:
[4:09] Oh, that's cool.

Emily:
[4:11] So I go in with a QAB, and while this person certainly did have aphasia, they also presented with apraxia. So just a quick thing for those who aren't familiar, aphasia is a language impairment where the word is just missing. So you look at an apple, you know what it is, you just can't place it. You can't think of what that actual word is for that thing. Apraxia is a language impairment when you know the word and you want to say the word. It's there, but your muscles of your face and mouth don't move to form the word. So more of a motor impairment as opposed to a pure language impairment.

Eva:
[4:51] Yeah, it's like you want to say please and thank you, but it comes out closer to a supercalifragilisticexpialidocious.

Emily:
[4:58] With all of those syllables. With all of those syllables.

Eva:
[5:01] Yes, 100%. And in case you don't know what the QAB is, it is a quick aphasia battery. It's this kind of quick clinical test we do to assess how severe somebody's aphasia levels are.

Emily:
[5:12] And we do have that in an episode, so go find that one. Quack, quack. And so I was thinking about how we actually say someone's apraxia is mild, moderate, severe, or if they have apraxia, because I have only ever really noticed an apraxia if there was visual groping and if they are stimulable for direct imitation. But, I mean, that's just me. So out here just looking for more clarity, trying to find the evidence based in my practice.

Eva:
[5:43] I love that for us and the whole purpose of our podcast. But no, I have to say that is really hard because we also know that with aphasia, people have nonsensical word production. So like their attempt to produce a word is kind of this jumbled quasi word sound. And as a clinician, you're like, oh, wait, is that an apraxia? Is that a jargon of aphasia? Like what is happening here? So I'm glad we're looking into it. All right, so before we get you that clarity, Emily, it's time for a quick ad break.

Emily:
[6:21] Okay, so this week we're looking at Diagnosing Apraxia of Speech with No Gold Standard by Haley et al.

Eva:
[6:29] I have to say, I really love that title, just alone. With no gold standard, because, you know, when we're in school and we talk about, you know, the Western aphasia battery, which is another aphasia test. People are like, oh, it's the gold standard. So this person's coming out, coming out hot. There is no gold standard.

Emily:
[6:47] Right. And so when they're saying gold standard in like this medical field, it's a little nuanced. So when they're talking about testing being the gold standard, they're talking about a test or making a medical diagnosis for a disease or a disorder where the characteristics of that disease or disorder are gathered together with similarities. And then they form this process where, you know, without a shadow of a doubt, we can clearly identify characteristics with accuracy and reliability. And that is the gold standard. If it is always consistent, reliable, perfect, it's a gold standard.

Eva:
[7:30] Got it. So what they're saying is that for a lot of other diagnoses, you can go through a checklist and be like, if you have this checklist, you have this diagnosis. And in this case, it's not really what's happening.

Emily:
[7:42] Right. And it's not just a problem with apraxia. The article lists out a few other diagnoses where it's just not great at determining, like, yes, you do in fact have this medical diagnosis.

Eva:
[7:56] There is a long list of features associated with apraxia, things like visible grouping, inconsistent errors, slow rates, syllable segmentation, distorted consonants and vowels, but the authors of the research are clear that this list alone does not fully encompass an apraxia diagnosis. The features can vary across individuals and overlap with other disorders, and there's no agreed-upon threshold for when enough of them are present to call it apraxia. So even if there is a really long list, we still aren't necessarily using it functionally as clinicians.

Emily:
[8:29] And the issue begins when we think about how this list is not all of what can be seen in apraxia. Apraxia presentations can vary between people, and these symptoms can also be present in other populations. So a lot of that big long list also happens with people who have aphasia.

Eva:
[8:47] Right. And I think something we see a lot within research is that there's no agreed upon collection of features that define apraxia the same way there are for, you know, across clinics and research groups. And so it can be really difficult. We've discussed this a lot where in a research article, the research team is trying to say, hey, this is what we were looking into. And what we found at the very beginning of this whole project is that there was no clear definition. So how do you assess something? How do you target it? How do you determine if something is effective as a therapeutic practice if we don't even have a clear definition?

Emily:
[9:24] Yeah. How do we test it and diagnose? That's perfect. Eva, one of those moments where you just said it like too good. So what was this research looking to find out? They want to know what kind of extent that people are putting these diagnoses out. Are they using their clinical impression, tests, consensus between different experts or other methods, and what steps they're using to reduce any bias in their diagnostic process.

Eva:
[9:58] Yeah, and I can only imagine the types of bias that they had to look into. I mean, you and I have talked a lot about, as clinicians, when you're speaking with a patient who has a motor speech disorder or an auraliophagia, that you're kind of adapting constantly to them and how hard it is to have an accurate or unbiased opinion on how they sound. So I can imagine that was a serious work for them.

Emily:
[10:28] So the diagnostic process references they looked at was that either A, it wasn't explained how they came to that diagnosis. Second, a clinical impression. So one person is going through and saying, yes, you have apraxia because I said so. The third is consensus. So two to three clinicians are using their subjective impressions to make the diagnosis. Checklist verification, so yes or no. And then formal test measures. So when we looked at the chart, and it's a.

Eva:
[11:08] Emily loves a chart.

Emily:
[11:09] Research out in front of you. Super clean. But the ones that they showed happened the most were a consensus or a confirmation between two or three clinicians. So, Eva... Thinking about the SNF world, what is wrong with this?

Eva:
[11:29] Like getting clinicians to have consensus is impossible.

Emily:
[11:35] Yeah, because there's only one speech therapist in the building 90% of the time. You hit the nail right on the head when I was talking about that. There's not like there's just not another speech therapist. So the checklist that they're talking about, it's something that you can find on ASHA. There's literally like a apraxia, dysarthria, aphasia checklist, and it's either like yes or no. So those ones are readily available. But there is nobody else in the SNF world. So like that's something that's on there that we just don't have access to in the setting that we're working in. Unless you have a mentor that you talk to regularly, but like not I.

Eva:
[12:19] Wait, so are you saying that their consensus had to be derived like by sight? Like where multiple clinicians had arrived at the same clinical impression for the patient?

Emily:
[12:31] They didn't say that like more than one person had to see the patient, but it sounded like they teamed about the patient and then they would come together based on whatever evaluation was done to say, either, yes, this looks like an apraxia diagnosis or no. It doesn't. And they actually go on to say that for that consensus or confirmation type of, validation system is inherently flawed because you don't know what the social constructs are around that group of people. Is there like one team lead who's pushing forward this diagnosis? Like, are they trying to, you know, just go with that? So I thought that was an interesting point, too, that they said.

Eva:
[13:22] That cracks me up. They're like, you need a consensus amongst clinicians. Problem A, there's not enough clinicians. Problem B, in the event that there are a group of clinicians, who's to say that they arrived at their conclusion appropriately? It's like, oh, there's no winning there, huh?

Emily:
[13:41] But this is just like what people have reported how they're doing.

Eva:
[13:45] Okay.

Emily:
[13:46] Then the next measure that people reported using the most was tests or measures. So... They discussed the apraxia rating scale, and we'll put a link to that article, which contains a PDF of the scale to print out and use. But overall, their article said it was easy to use and reliable. I haven't used it yet, but I will.

Eva:
[14:09] I know. We find so many things in our research process.

Emily:
[14:12] Right. And the other one they talked about using was apraxia battery for adults, which I think it's like a $200 test or something on Pearson.

Emily:
[14:24] You know, if you can get your building to pay for it, I'm sure it'll be nice.

Eva:
[14:29] So next I talk about reducing bias. And the easiest way is to use multiple reference methods to help with the diagnosis. So this would be a different test, a clinical impression, a checklist verification where we combine these scores to help ensure a proper diagnosis. So you take your initial attempt, you do a different type of attempt, and you compare them. So the article said that when it came to the use of clinical consensus, there was very little done to eliminate bias in the diagnosis.

Emily:
[15:00] So the next article went into their fallacies. So I won't go into everything they talked about, but one thing they discussed that I feel was important is that apraxia isn't a yes or no diagnosis. It can exist on a spectrum with aphasia and dysarthria, where one thing can be severe, one trait mild, et cetera, et cetera. There needs to be a greater understanding of like that diversity and approach when we're doing these diagnoses so that we can catch even the mild symptoms or, you know, be more brave about saying like, yes, they have maybe a severe aphasia, but also I'm seeing mild apraxia, via XYZ traits.

Eva:
[15:39] It sounds like what you're saying is that the issue with the yes-no diagnosis is that you may not end up catching it because it's so broad. And that the integration of more of a spectrum-based approach or a characteristics-based approach allows more people to get the diagnosis that will help them understand what they're going through and seek treatment. But it isn't as necessarily prescriptive. Is that kind of what you're saying? Yeah. It kind of runs the discussion around autism.

Emily:
[16:14] Mm-hmm. Yeah, I remember in school, they talked about childhood apraxia speech all the time and they're like, yeah, but you'll probably never ever see it because the population is so completely rare. But I don't work with children, but like that can't be totally true, right? Like I feel like people just hear those things And they're like, oh, they said it's really rare. So this can't be what I'm seeing. I'm not going to walk down that path because why bother? But I feel like, just like you said, we're missing out on treatment and counseling opportunities because we're not providing education on everything that could be happening or everything that we're seeing with this patient. And we're not treating those symptoms that we're seeing or addressing them in a way that might be helpful.

Eva:
[17:02] Yeah, it's funny you say that because in my pediatric rotation in grad school, I worked at a private clinic, and one of my patients was a kid with childhood apraxia of speech. And it was so crazy because this kid was literally unintelligible. And for those of you who are listening who are not familiar with apraxia, A lot of times when a person is attempting to say a word, it can come out different every time the motor pattern is distorted when they're trying to say a word. And so it doesn't always sound the same. And so this kid is like really trying to say these, you know, basic communication, you know, phrases like, I want to do this. Like, I want this toy. I want to go to this place. And like it requires complete like 100 attention from the parent from me from the supervising clinician to parse out what's going on and the level of

Eva:
[18:12] Just work that takes. This kid, you know, in retrospect, now that I have a kid and I have some context for kids' emotional bandwidth, I'm like, this kid was so patient. He was frustrated and having a hard time, but given how hard it was for him to get, like, any communication across and to be understood, I'm like, this kid is basically Zen. Like, I don't know how he was able to keep it together so well. And I think about that for our patients who they have an apraxia is also usually co-committing with something else because it's an acquired speech disorder, right? As an adult, if they're getting it, there is potentially a traumatic brain injury, a stroke, something like that. And so they're dealing with all these other life changes. And on top of it all, they can't, their words aren't making any sense. You know, it's just, ugh, it's rough. I'm mad people don't yell more.

Emily:
[19:12] It's so cool to see how they're persevering through like these hard things. And it's so cool to get to be a part of that sometimes. Even today, one of my patients, they have apraxia, very spot on apraxia. As soon as I make that initial mouth movement, they got the word. And one of my coworkers was like, had just met this person, he was coming in and just met him. And, um, she was like, what's your name? And I made, he was like, and she was like, what'd you forget? And then he like looked to me and I made that first mouth movement and he was able to say it back to her. And, um. So he and like his whole name. And I was talking to my coworker afterwards and I was like, yeah, it's, you know, she apologized. It was just like not he and he wasn't offended or anything like that. But it is cool to see like, you know, how we affect our patients sometimes and like how quickly like they come to us for help and feeling that we are helping them and, seeing them work through some of those frustrations, especially like how you talked about children.

Emily:
[20:33] I know how small children look whenever they're frustrated and they can't get out what they're trying to say, crying and temper tantrums, but adding a motor speech disorder on top of that.

Eva:
[20:43] Oof. Yeah, it's a tough situation all around. When you know that somebody is going in with an aphasia diagnosis, like it's in the chart, do you go in only looking for aphasia or do you think in the back of your mind like, oh, I need to also be looking for an apraxia?

Emily:
[21:03] I didn't really think about it too much until I started using the QAB more often, where they have that rating section in the back where it's like, do they have apraxia 0, 1, 3, 4? Like, do they, it's either like. Oh, yeah, that's true.

Eva:
[21:21] That is on there.

Emily:
[21:23] They either severely have it or they don't. And I'm like, I don't, I don't know.

Eva:
[21:27] Yeah, I think kind of to what you're saying there with the having it on the QAB that there's an apraxia component. If we have an apraxia rating scale, it's interesting that one, we aren't using it more as like standard practice when it's suspected. I think that's something that we could just more generally be reflecting on in terms of our, like, clinical workflow. Will we see a certain type of brain damage? We see a certain, you know, maybe there's a history of an aphasia diagnosis. Do we need to just start carrying around an apraxia rating scale with us just in the event that it's suspected? Right. Another question I have for you is, what do you feel like are the tradeoffs? What if we do an apraxia, more like a checklist? Like, do you have all these things? If so, yes, versus the spectrum. Because you and I love a good checkbox. It's so nice. It's so easy. Like when you go in and you're like, oh, the patient does this patient does that. Like, great. We're done. Like, what do you think are the maybe pros and cons?

Emily:
[22:37] I think what the checklist verification does is show maybe how many things they have in the aphasia column versus the dysarthria column versus the apraxia column. So it just is showing maybe which features are most prevalent. So maybe what needs to be targeted first for addressing a plan of care. So if the aphasia piece, if they're really not understanding, maybe building that language system receptively first and then working on speech output and motor patterns second so that they can at least understand maybe point. I mean, you know, they could have like a limopraxy or something like that. But if we could get like an AAC started with at least them receptively understanding what a picture stands for, then we can start working towards having them expressively communicate better. That's like how I might address it.

Eva:
[23:43] I love hearing your clinical workflow is good. I think you're really practical.

Emily:
[23:46] That's like my goal in like my practices so that everything is functional. If there is not a functional outcome. Yeah. What are we doing? If the goal is not making sure our patients can, communicate basically, then, you know, I don't want them to name pictures of animals just because I want them.

Eva:
[24:09] Yeah, yeah, yeah, yeah. It's funny you say that because, spoiler, I'm going to Italy. And I have been practicing Italian. And so I asked ChatGBT to make me a list of flashcards for the most 20 functional verbs. I was like, And nouns. I was like, don't give me flashcards with cat and dog on it. Like, I don't need that. I need restaurant check, like directions, map, train, things like that. So I hear you on the functionality.

Emily:
[24:46] Unless you're talking about some cat on the train, they don't care.

Eva:
[24:50] In which case, I'll just point to it.

Emily:
[24:52] Yeah.

Eva:
[24:54] So just kind of moving from there to that treatment aspect, treatments for apraxia versus aphasia and yet again versus dysarthria are different. So apraxia, we aren't rebuilding language in the same way we are rebuilding motor patterns. So things like VNEST, which is sort of a short grammar structure exercise that we do with aphasia or constraint language treatment.

Emily:
[25:19] So a constraint language treatment where they're forced to say the thing that they're missing. So you're not accepting other forms of that word to move them through that conversation. So they're not and they're not accessing other things. So they're not able to supplement their speech through gestures or mimic. So there's like this pull barrier thing.

Eva:
[25:43] Right. Basically, if you want them to say cup, then the only word they can say is cup. They're being constrained to that term. Those things are not going to work the same. But drills and scripting training will. So if we want to elicit change, then we have to recognize and diagnose the appropriate problem. And we have to put those things together. Like, you can't be operating under an aphasia diagnosis and trying to treat apraxia that way. It's just not going to work out. the treatment isn't going to be effective people are going to be frustrated time and money is going to be wasted you know and it got it really sours people i had so many patients who just tell me all of the times that they spent time in treatment and they just like felt it was wasted they were like that person wasted my time i felt like i wasn't believed because you know what i was reporting wasn't getting take wasn't being directly targeted so it's really important that like to the overall point of this episode that we can get the diagnosis correct so that

Eva:
[26:53] we can be doing things that hopefully work.

Emily:
[26:56] So what are our actionable items for this episode? Don't take an aphasia diagnosis at face value. Go into your evals with the QAB and the AASRS handy. So that's the apraxia... Checklist. I forget all the letters for that one. But, have it so you can look deeper at their speech patterns.

Eva:
[27:23] Yeah. And always reach out to other people, other SLPs, mentors, just collaborate.

Emily:
[27:30] And treat the person, not just the diagnosis. So at that eval, try different treatment methods to see what works for that person. If they are highly stimulable for repetitions or like those growing sets of words or growing sets of phrases, try some apraxia treatments. If they're, you know, doing better with more aphasia treatments, follow that lead. Don't let just that word alone determine your entire treatment sessions.

Eva:
[28:03] Definitely. Just because it's an approved treatment methodology does not mean that it's going to work for your patient.

Emily:
[28:10] We're out here being flexible. All right, guys, I hope you gain something from this apraxia. I hope you're a little bit less fearful about diagnosing apraxia and taking different tests with you to your evaluations.

Eva:
[28:25] Yeah, keep a giant binder of everything at all times.

Emily:
[28:30] Or like a rolling desk, like it's really convenient.

Eva:
[28:34] Dreams, a rolling desk.

Emily:
[28:36] Until next time, talk with your peers, trust your clinical gut, and we'll be here to discuss it all. You've been listening to Speech Talk.

Eva:
[28:45] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Emily:
[28:51] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations.

Eva:
[29:03] And if you like listening to us, you may like more podcasts from our network, Human Content, like How to Be Patient, Bendy Bodies, Knock Knock High with the Glock and Fleckens, and psychiatry bootcamp. If you have a research topic you want us to cover or you have episode comments, clinical experience you want to share or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Emily:
[29:28] If you want even more speech talk content, check out our website at speechtalkpod.com where you can find all of our resources we made for you, copies of articles covered and Eva's blog following these topics and more.

Eva:
[29:40] We're your hosts, Eva Johnson and Emily Brady.

Emily:
[29:43] Our editor and engineer is Andrew Sims.

Eva:
[29:46] Our music is by Omar Benzvi.

Emily:
[29:48] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Eva:
[29:52] To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Emily:
[30:04] Speech Talk is a proud member of the Human Content Podcast Network.

Eva:
[30:18] You overchopped it.