You have a client who had a stroke and now has aphasia. They clearly have trouble finding words. How can you best help them?
If after a thorough assessment you believe they have anomia due to an underlying impairment in phonology and phonological processing, implementing a course of Phonomotor Treatment (PMT) may help your client improve their word-finding skills.
Phonomotor Therapy Theory
If you can understand the theory motivating PMT, you’re off to a good start in implementing the treatment program.
How it Works: Everything is Connected
No sound lives in its own corner of the brain. All sounds are represented in the brain by their acoustic, articulatory motor, and orthographic connections.1 In other words, when your brain turns on a certain sound, all information about that sound is activated in the brain at the same time. Though subconscious, you think of:
- How it sounds
- How it is made with the mouth and throat
- How it is written
In clients with aphasia, this process is no longer instantaneous or automatic as it was prior to stroke. PMT makes this knowledge explicit and more automatic through multi-modality tasks that engage all aspects of phonological networks.
Why it Works: Everything is Connected …to Everything Else
When you want to say a word, you get a mental image or concept of what you want to say. That word is written a certain way, and it also sounds a certain way. Once your brain knows the sound sequence for that word, you can say it aloud. (This process also happens in reverse when you hear a word.)
If the sounds in the word don’t turn on fully, the brain will not be able to retrieve the full word form. This is when clients with aphasia have word-finding difficulties. Research into PMT shows that in order to best treat anomia, primarily non-word phonological sequences are best in order to isolate phonology, which later “spreads” to word level processing.2
Phonomotor Therapy Components
PMT is a multi-faceted therapy. Here are some of the essential components:
An essential component of PMT is the pervasive use of Socratic Questioning (SQ). SQ is the systematic questioning of client productions to build strong self-awareness skills. Rather than telling clients right/wrong or how to produce a sound/word, the clinician asks a series of questions to help clients explore productions on their own:
- “What did your mouth do to make that sound?”
- “Is it a quiet sound?”
- “Are we saying the word in the same way?”
Treatment tasks involve a variety of stimuli to turn on phonological representations for clients:
- Mouth pictures in various articulatory postures
- Icons to represent voicing
- A mirror for visual feedback about articulatory postures
- Letter tiles/writing
- Clinician productions for acoustic models
Treatment tasks begin with consonants (C) and vowels (V) in isolation, but the real goal of PMT is to train phonological sequence knowledge (because we speak in multi-syllabic utterances, not single sounds!). Treatment tasks progress from simple to more complex, e.g., C, V, VC, CV, CVC, CVCC, CVCV, etc.
Phonological awareness skills can be targeted in a number of ways, such as:
- Parsing – “Say the sounds in ‘chootee’” : “ch-oo-t-ee”
- Blending – “Say the word for “ch-oo-t-ee” : “chootee”
- Elision – “Say ‘chootee’ without saying /ch/” : “ootee”
- Minimal Pair Discrimination – “Do these sound the same? “ch-oo-t-ee, j-oo-t-ee” : “No”
“I don’t have 60 hours with my client…is PMT still worth it?”
Research into the efficacy of PMT has looked at an intense dosage – 60 hours of therapy over 6 weeks.2 Research into more clinically-feasible doses is forthcoming, but not yet available. However, as a research clinician who has administered thousands of hours of PMT, I absolutely support its use in a clinical setting. We may not have an evidence-based gold standard for clinical application of PMT but you can still use the available evidence to determine if PMT is appropriate for your client. For example, perhaps your client has relatively preserved single sound knowledge, but sound combinations are still difficult. Skip sounds in isolation and move directly into multi-syllabic combinations.
More resources and information on phonomotor treatment can be found at the University of Washington Aphasia Research Lab site.
- Nadeau, S. E. (2001). Phonology: A review and proposals from a connectionist perspective. Brain and Language, 79, 511–579. doi:10.1006/brln.2001.256
- Kendall, D.L., Oelke, M., Brookshire, C.E., and Nadeau, S. (2015). The influence of phonomotor rehabilitation on word retrieval abilities in 26 individuals with chronic aphasia: An open trial. Journal of Speech Language and Hearing Research, 58(3).