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Apraxia Worksheets for Adults & 11 Step-by-Step Apraxia Treatment Approaches

When working with some patients with brain damage, have you ever found yourself skipping past their apraxia to focus only on aphasia treatment?

Maybe your patients have plateaued—and you know that you could get better results by adding in some apraxia drills.

So…what actually works for acquired apraxia of speech?

In this post we focus on 11 evidence-based treatment approaches and how to implement them, step-by-step.

We include apraxia worksheets for adults, word lists, and drills so that you can take this information and run with it.

For many of the worksheets, you’ll want to copy the image/text then paste it onto a Word or Google document. Others are linked to PDFs. Or, bookmark this page on your mobile device to use the worksheets as you treat.

Here’s to improved apraxia outcomes!

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Handouts, Worksheets, Goals Banks, Assessment Templates, Documentation Guides, and much more!

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Apraxia Treatment Approaches

  1. Articulatory Kinematic
  2. Rate and Rhythm Control
  3. AAC

Articulatory Kinematic Approaches

Articulatory Kinematic approaches aim to improve articulatory accuracy which can in turn increase intelligibility.

They’re based on the principles of motor learning. You can read our in-depth article on motor learning for a deep dive, but here are the quick-wins:

Principles of Motor Learning

principles of motor learning for speech therapy
  1. Do Pre-Practice
    • Before starting your motor treatment, do some pre-practice so that your patients are ready to learn. Set them up for success.

  2. Use a Large Number of Trials
    • Practicing a movement a lot leads to superior learning of that movement. Aim for at least 50 repetitions per target.

  3. Use Distributed Practice
    • Distributed practice is a longer duration of therapy with fewer sessions per week.

  4. Use Variable Practice (or combo with Constant Practice)
    • Variable practice is practicing a movement in different ways. An example of variable practice is practicing several different phonemes in different word positions.
    • Constant practice, on the other hand, is practicing the same movement over-and-over again. For example, practicing one phoneme in the same word position.

  5. Use Random Practice (or combo with Blocked Practice)
    • Blocked practice is practicing one movement first, then moving on to practice another movement. You ‘block’ out each movement. For example, you practice /f/ for the first half of a session then /z/ for the rest of the session.
    • Random practice is practicing these movements throughout the session, in random order. For example, the patient would practice both /f/ and /z/ in random order throughout an entire session.
    • Random practice results in better motor learning—although in the early stages of treatment or with a severe impairment, patients may need to practice each target individually.

  6. Use Complex Practice
    • Complex refers to the whole movement; the sum of all its parts. For example, saying a multisyllabic word is a complex movement while saying an individual phoneme in that word is a simple movement.
    • There’s some evidence that for patients with apraxia of speech, complex movements improve motor learning.

  7. Provide Feedback
    • Give patients feedback about how they performed.

  8. Provide Reduced Feedback
    • Reduced feedback is when you don’t give feedback every single time the patient tries a movement. Instead, you reduce your feedback to every other movement. Or maybe every 5 movements (50% or 20% of trials).
    • Reduced feedback helps patients self-monitor.

  9. Provide Immediate and/or Delayed Feedback
    • Immediate feedback is when you give feedback right after the patient does the movement. While delayed feedback is when you pause before giving the feedback.
    • Both delayed and immediate feedback resulted in similar gains in motor learning for apraxia of speech.

1. Multiple Input Phoneme Therapy (MIPT)

multiple input phoneme therapy

Who Is It For?

Patients with severe apraxia of speech who are caught in verbal motor loops.

How Does it Work?

MIPT uses multiple sensory stimuli to help patients regain volitional control and spontaneous expression of words and phrases.

The therapist first “controls” the patient’s stereotypic utterance. Then elicits a target phoneme to build consonant blends, multisyllabic words, and sentences. You’re essentially pulling the patient out of the loop of their stereotypic utterance.

How To Do Multiple Input Phoneme Therapy

  1. Record the patient’s stereotypic utterance(s). These utterances will be the starting point for treatment.

  2. Choose a target by using the initial phoneme of a steroetypic utterance.

    • For example, if the stereotypic utterance is “hello,” your target may be “help.”

  3. Model the stereotypic utterance while providing a gestural/prosodic cue.

    • For example, model “hello” (the stereotypic utterance) while tapping the patient’s arm.

  4. Next, fade your voice and silently model the target utterance (“help”) while the patient continues to produce the target.

  5. Build up to consonant blends, multisyllabic words, and sentence production, as appropriate.
    • For example, “help me.”

Resources

2. Sound Production Treatment for Apraxia

sound production treatment steps

Who Is It For?

Patients with apraxia of speech.

How Does It Work?

Sound production treatment can improve a patient’s production of targeted sounds (words, phrases, and sentences). The therapist begins with minimal cues then progresses to more cueing, as needed.

How To Do Sound Production Treatment

Preparation

Prepare a set of 30 or more minimal pairs (see below) that focus on the patient’s errors.

Progress to the next step only if the patient is incorrect.

At the first correct answer, ask for 5 repetitions: Provide feedback for accuracy around 3 out of the 5 repetitions to enhance motor learning.

Apraxia Worksheets for adults: sound production treatment
Apraxia Worksheets for adults: sound production treatment
Apraxia Worksheets for adults: sound production treatment
Apraxia Worksheets for adults: sound production treatment
Apraxia Worksheets for Adults: Sound Production Treatment

Apraxia Worksheets for Adults: Minimal Pairs

For more minimal pairs, check out our shop.

Ten/HenNose/NoteHope/PopeWise/Wine
Name/LameLet/LessSip/TipBin/Fin
Lane/LakeZone/BoneDeal/StealFeel/Feed
Cut/CupBad/BagGuess/MessGot/Goth
Knit/SitDock/RockJest/RestVan/Ban

Resources

3. Speech Motor Learning Treatment Approach (SML)

Speech motor learning approach

Who Is It For?

For patients with acquired apraxia of speech (and childhood).

SML is not language-specific. The sounds of any language can be used.

How Does It Work?

SML aims to improve motor speech planning and programming. It uses non-words as treatment stimuli.

The therapist identifies the 3-4 consonants and 3-5 vowels that are easiest for the patient to produce. These sounds are practiced in consonant, vowel, consonant, vowel nonwords. The easier consonant repertoire is gradually expanded followed by the easier vowel repertoire. The more difficult sounds are introduced later.

SML comes with free software and rating form templates to compile the nonwords. Their website also has lots of helpful guides and examples.

How to Do The Speech Motor Learning Approach

From SML Approach Summary of Methods

The SML Approach has 12 steps, broken down into Preparation, Pre-Treatment, then Treatment.

Along with the steps of treatment, there are also stages of treatment. See the charts below for the stages.

Preparation (3 Steps)

  1. Rate ease of production of vowels (V), consonants (C), diphthongs and clusters (CC) on a scale of 1-4.

    1 = easy and produced correctly
    most of the time.

    2 = quite easy and usually
    correct.

    3 = quite difficult to produce
    and usually incorrect.

    4 = very difficult and
    consistently incorrect.

    An exact rating is not always possible, A sound can be noted as a 1 – 2, or 2 – 3, or 3 – 4.

  2. Select the first set of target sounds consisting of 3 or 4 consonants that are not phonetically close, and 3 or more vowels.
    Of note: the author of this approach is based in South Africa. Part of SML’s protocol includes the use of “rounded vowels” which are distinct in some English dialects (including South African English) but are distinct not in many other English dialects.

    General Rules of the SML Approach
    Always start treatment with a set of the easiest sounds (Cs and Vs with the greatest ease of production) and then in stages across time (see Treatment steps below). Gradually add more sounds to the target set. In severe apraxia of speech, select only 2 consonants and 3 vowels as the first target set.

  3. Create Stimuli. Open the SML software and capture the first set of target sounds. Create CVCV nonwords on all the levels of variation

    The 5 Levels of Variation:

    Variation Level 1: C1V1C1V+ (+ indicates variation of sounds in that position in a series) : (e.g. baba, babe, babo, baboo, babi).
    Variation Level 2: C1V1C2V+ (e.g. baka, bake, bako, bakoo, baki).
    Variation Level 3: C1V1C+V1 (e.g. baka, bata, bafa).
    Variation Level 4: C1V+C2V1 (e.g. beka, boka, booka, bika).
    Variation Level 5: C1V+C+V+ (e.g. beka, botoo, boofe, biko).

Pre-Treatment (1 Step)

Rehearse production of first target sounds in CV and VC combinations a number of times. Correct production is not a prerequisite for progress to CVCV syllable structures.

Treatment (8 Steps)

We’ll summarize the steps below. Refer to the stages in these charts to guide your treatment.

Click for PDF version
  1. Model the nonword three times. The patient looks and listens.

  2. The patient then repeats the nonword to a model until they reach 80% accuracy (no groping, distortion, substitution, distorted substitutions, additions, omissions or trans-positioning).

  3. The patient continues to repeat the nonword while the clinician gradually fades the model.

  4. Once the patient reaches 80% accuracy, model the nonword again, wait 3-4 seconds, then ask the patient to repeat.

  5. The clinician then models a series of nonwords, one at a time, that the patient repeats.

  6. If the patient is able to read, they then repeat the same series of nonwords independently until 80% accurate and the series is fluent and rhythmic.

  7. The patient increases speech rate of series of nonwords until 80% accurate, speech rate is near normal, and speech is fluent.

  8. Identify real words and phrases and rehearse till criterion is reached and speech becomes fluent.

  9. Repeat same steps with all nonwords and series.

Providing Feedback:

  • Provide knowledge of results feedback (see below) for 100% of first trials. Reduce feedback gradually.

  • During repetition of a series, only provide feedback if a nonword is consistently produced incorrectly.

  • Delay feedback 3 to 4 seconds after the response and provide it only if the client did not successfully self-correct an error.
What is knowledge of results

Apraxia Worksheets for Adults: Speech Motor Learning Approach Rating Form

Click for PDF version

Resources

Sensory Cueing Approaches

Many approaches use sensory input to help teach the movement sequences for speech. Sensory cueing can be general tactile, visual, and auditory cues or follow more structured protocols.

4. Integral Stimulation (Rosenbek’s 8-Step Continuum)

integral stimulation 8-step continuum

Who Is it For?

Patients with acquired apraxia of speech.

How Does It Work?

Integral stimulation is used in many treatment approaches.

It’s a step-by-step method of practicing the movements of speech production by progressing through different sensory models:

  • the patient listens to the therapist then repeats
  • watches the therapist’s mouth shape the words then copies
  • reads the word aloud
  • says the target when prompted by questions and role playing

Use this approach with phonemic word lists (see our post, Apraxia Word Lists for Adults 1,300 Free Words & Sentences).

Apraxia Worksheets for Adults: Integral Stimulation

TherapistSensory CuePatient
1. Model the target. “Lisen to me, watch me, do what I do.”Auditory, Visual1. Patient first listens and watches. Then repeats the target in unison with the therapist.
2. Model the target again. Then mouth the target as the patient repeats out aloud.Fading Auditory, Visual2. Patient listens and watches the model. Then repeats the target in unison as the therapist mouths.
3. Model the target again. Pause as the patient repeats back without assistance.Fading Visual, Fading Auditory3. Patient listens and watches the model. Then repeats back without assistance.
4. Continue practicing modeling the target then pausing for the patient to repeat back.Fading Visual, Fading Auditory 4. Patient continues to practice listening and watching then repeating back without assistance.
5. Present the written target (and/or image) without saying or mouthing the target. Ask the patient to say the target.Written, No Visual, No Auditory5. Patient views the written target/image. Says the target aloud without further assistance.
6. Present the written target, remove it, then ask the patient to say the target.Fading Written, No Visual, No Auditory6. Patient views the written target then say the word once it is removed.
7. Prompt the target by asking a question.No sensory cueing7. Patient answers the question by saying the target word only
8. Role-play a situation to elicit the target.No sensory cueing8. Patient says the target in response to the situation.

Resources

5. PROMPT© (Prompts for Restructuring Oral Muscular Phonetic Targets)

Who Is it For?

Patient with speech production disorders, including acquired apraxia of speech.

How Does It Work?

First and foremost, PROMPT is a certification program (we’ll cover the costs and time commitment in a bit).

PROMPT is a tactile-sensory method of treatment (using touch pressure, kinesthetic cues, and proprioceptive cues). The therapist places their fingers on the patient’s face and neck, using sensations to cue speech production and to limit unnecessary movements.

Per their website, they also embrace the cognitive-linguistic and social-emotional aspects of motor performance.

Cost of PROMPT Certification

Total Cost: $1,775 to $2,175 (prices vary based on location)

Certification is broken down into 4 steps and you pay as you go:

  1. Introduction to PROMPT Workshop (3 days; discount for self-paced online version)
  2. PROMPT Technique Practicum Project
  3. Bridging Prompt Technique to Intervention (3 days)
  4. PROMPT Certification: A Self-Study Project (4 months)

How Long Does PROMPT Certification Take?

Short answer, 5+ years (!!)

BUT, after completing the Introduction to PROMPT Workshop, you can start using PROMPT with your patients.

Resources

6. Script Training

Who Is It For?

Patients with neurogenic communication disorders, including acquired apraxia of speech.

How Does It Work?

Script training is a functional approach because it helps patients to speak more fluently about a topic that’s important to them. For example, a patient may practice scripts to say during conversation.

The therapist helps the patient to come up with a personalized script. Then they repeatedly practice phrases and sentences that they can use during a monologue or conversation.

Script practice can include:

  • Listening to the script
  • Repeating the target utterances
  • Reading the target aloud
  • Producing the targets from memory
  • A combination of the above

* Don’t Forget to use Motor Learning!

How to Do Script Training with Apraxia

From The Effectiveness of Conversational Script Training for Acquired Apraxia of Speech

Creating personalized scripts is best—although this can take a lot of time. If therapy time is limited by insurance caps or otherwise, you can adapt pre-made scripts for your patients.

How to Create Scripts for Your Patients

  1. Choose a script topic that’s revelant to your patients

  2. Increase readability difficulty
    • By number of syllables, words, then sentences

  3. Increase grammatic difficulty

  4. Increase semantic difficulty

  5. Add personalized content
    • Change the name of their town, name of a loved one, and so on without changing other variables (readability, etc.)

  6. Match the script level with your patient’s apraxia severity

Adapted from Script Templates: A Practical Approach to Script Training in Aphasia

Cueing Hierarchy: Script Training for Apraxia

Phase 1: Blocked Practice

  • Therapist models target phrase
  • Target phrase in unison with visual cues
  • Target phrase with clinician fading voice
  • Independent productions with visual cues
  • Independent productions

Phase 2: Random Practice

  • Random trials with visual cues
  • Independent productions in structured conversation
  • Random trials with unfamiliar communication partners given visual cues
  • Independent productions in structured conversation with unfamiliar communication partners

* Don’t Forget to use Motor Learning!

Apraxia Worksheets for Adults: Script Training

Below you’ll find example scripts from the Rehabilitation Institute of Chicago. Click here for the complete PDF (4 pages).

Resources

Rate and Rhythm Control Approaches for Apraxia

Rate and rhythm control approaches assume that apraxia involves a disruption in the timing of speech production. They use melody, rhythm, and/or stress to improve articulation.

1. Contractive Stress

contractive stress for apraxia of speech

How Does it Work?

Contrastive stress is an emphasis on a particular word within a phrase or sentence—changing which word is stressed also changes the meaning of the phrase/sentence.

To treat apraxia of speech, the patient practices stressing different parts of a phrase/sentence. This helps them to produce a greater variety of intonation for more natural-sounding speech.

Apraxia Worksheets for Adults: Contractive Stress

How are YOU?
How ARE you?
HOW are you?

Where IS she?
Where is SHE?
WHERE is she?

I don’t KNOW
I don’t know
I DON’T know

What a FUNNY story!
WHAT a funny story!
What a funny STORY!

WHAT a lovely day.
What a LOVELY day.
What a lovely DAY.

* For more sentences, check out the Motor Speech Pack on our shop

2. Metronomic Pacing (Rhythmic Pacing Strategies)

metronome pacing for apraxia of speech

What Is It?

In this treatment, a metronome is set at a slower rate than the patient’s current rate of speech. The patient then produces a target at the rate of one syllable or movement per beat of the metronome.

Hand tapping is sometimes added.

How To Do Metronomic Pacing for Apraxia

Julie Wambaugh teaches a 5 Level protocol for Metronome Training.

Preparation

Examples of multisyllabic words:

Benefit: ↓ ___ ___

Spaghetti: ___ ↓ ___

Represent: ___ ___ ↓

What Feedback to give: About tapping accuracy, number of syllables, production to the beat (not about sound production)

How to Present Targets? In random order

Apraxia Worksheets for Adults: Metronome Pacing

Level 1: Multisyllabic Words

Protocol: Level 1 Multisyllabic Words
1. Therapist reviews schematic and tapping
2. Set metronome at a reduced rate (increase word durations about 50%)
3. Therapist models one production
4. Patient taps along while therapist models (4-5 times)
5. Unison production and tapping (3 times)
6. Patient production (1 time)

Level 2: Faded Clinician Model & Repeated Patient Productions

Protocol: Level 2
1. Therapist reviews schematic and tapping
2. Keep metronome at the reduced rate
3. Therapist models 1 time
4. Patient production and tapping 3 times
If correct: next word
If errors (tapping to beat or # syllables): Therapist models 1 time plus unison production and tapping

Level 3: No Clinician Model & Repeated Patient Production

Protocol: Level 3
1. Therapist reviews schematic and tapping
2. Keep metronome at the reduced rate
3. Therapist produces word with normal rate and d prosody (not to the beat and with no tapping)
4. Patient produces and taps, 3 times
If correct: next word
If errors (tapping to beat or number of syllables): therapist models 1 time plus patient produces and tapes 3 times
If errors remain: therapist models 1 time plus unison production and tapping 3 times

Level 4: Increased Rate of Production

Protocol: Level 4
1. Therapist reviews schematic and tapping
2. Metronome setting increased from previous levels
3. Therapist produces word with normal rate and prosody (not to the beat and with no tapping)
4. Patient produces and taps 3 times
If correct: next word
If errors (tapping to beat or # syllables): then therapist models 1 time plus patient produces and taps 3 times
If errors remain: therapist models 1 time plus unison production and tapping 3 times

Level 5: Syncopation

Protocol: Level 5
1. Therapist explains what sycopation is

Target word is produced in 2 beats: 1st syllable on first beat. 2nd syllable & 3rd syllable on second beat
2. Therapist reviews schematic and tapping
3. Set metronome to Level 4 rate (increased rate)
4. Apply syncopation to Levels 1-4

Resources

3. Metrical Pacing

What Is It?

Like the metronome pacing described above, metrical pacing asks the patient to produce a target on the beat.

However, the natural rhythm or prosody of the target is maintained by using computer-generated pacing tones. This natural rhythm/prosody is maintained no matter how fast or slow the rate of production is.

Metrical pacing also includes hand-tapping and choral speaking.

Resources

Acquired Apraxia of Speech: A Treatment Overview (ASHA page)

4. Melodic Intonation Therapy (MIT)

Melodic intonation therapy for apraxia of speech

Who Is It For?

MIT was first designed for patients with non-fluent aphasia.

According to a study by Helms-Estabrooks, Nicolas, and Morgan (link below), the best candidates for improved expressive language after MIT treatment are patients with:

  • a unilateral, left-hemisphere stroke
  • poorly articulated, nonfluent, or severely restricted speech output
  • able to produce some intelligible words while singing familiar songs
  • poor repetition, even for single words
  • moderately well preserved auditory comprehension
  • poorly articulated attempts at speech
  • good motivation, emotional stability, and good attention span

How Does It Work?

Modeling you, the patient will repeat a word, tapping pattern, and intonation pattern.

Apraxia Worksheets for Adults: Melodic Intonation Therapy

Steps to Melodic Intonation Therapy
1. Write down a word or phrase. Show it to the patient.
2. Sing the word or phrase twice. You tap the patient’s left hand on each syllable as you hum.
3. Sing the word or phrase in unison with your patient while tapping the patient’s left hand on each syllable.
4. Continue to sing the word or phrase together with the patient while tapping their left hand. Gradually fade your singing
• At this point, the patient is singing, and you are only tapping their left hand (no verbal or oral/facial cueing).
5. Sing and tap the word or phrase while the patient listens. Immediately after, the patient intones the word or phrase, assisted only by your hand tapping.
• To intone, the patient may use a sing-song voice. For example, with the word “apple,” the first syllable “ah” will be high-pitched and the second syllable “ple” will be low-pitched.
6. Immediately after their correct repetition, ask, “What did you say?” Provide hand-tapping as the patient intones the target word or phrase.
7. Complete steps 1-6 with a new word or phrase.

MIT Resources:

1. Melodic Intonation Therapy: Shared Insights on How it is Done and Why it Might Help
2. Melodic intonation therapy: back to basics for future research
3. MIT: Melodic Intonation Therapy Kit

AAC

AAC for acquired apraxia of speech

Who Is It For?

AAC can supplement or even replace spoken language for some patients with apraxia of speech.

AAC Strategies for Apraxia of Speech

  • Training communication partners

  • No-Tech AAC such as writing with dry-erase markers and a whiteboard or gesturing

  • Low-Tech AAC such as texting, using a communication board, or text-to-speech apps

  • High-Tech AAC with specialized technology (speech-generating devices, AAC apps on tablets)

Resources

More Resources

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