Integral Stimulation Therapy for Apraxia of Speech

Acquired apraxia of speech is a speech disorder caused by damage to the parts of the brain that coordinate speech movements (Duffy, 2013).

A popular apraxia treatment is integral stimulation.

In this article, you’ll learn:

• How to do integral stimulation
• Who to use it with
• Rosenbek’s 8-Step Continuum protocol (with a free PDF!)

What is Integral Stimulation? 

Integral stimulation is a sensory cueing treatment.

Sensory cueing is a treatment approach for acquired apraxia of speech. 

This approach uses sensory input (visual, tactile, auditory, etc.) to teach a target movement and give extra sensory feedback to patients who need it (ASHA, n.d.)

Integral stimulation follows the basic sequence of, “listen to me, watch me, do what I do.” It focuses on using multiple sensory cues and is a part of many apraxia treatments (Rosenbek et al., 1973).

You can combine sensory cues (visual and auditory) or give them separately (just visual). But be sure to provide enough feedback to facilitate motor learning!

When to Use Integral Stimulation?

Patients with acquired apraxia of speech post-stroke may be good candidates for integral stimulation (Philippine Academy of Rehabilitation Medicine, 2017).

Integral stimulation is also recommended for people who need extra cues to improve intelligibility, such as those with more severe apraxia of speech. 

More Apraxia Articles

• Apraxia Treatments
• Apraxia Goal Bank
• How to Assess Apraxia

How To Do Rosenbek 8 Step Continuum

Rosenbek’s 8-step continuum is an integral stimulation protocol. It uses a hierarchy of sensory cues to help patients learn a target sound, word, etc. and then gradually say it more independently.

Here are the 8 steps:

1. Model. Model the word. Say, “Listen to me, watch me, do what I do.”
   • Patient: Listens and watches then repeats the word together with the clinician.
2. Model then mouth. Model the word again, then only mouth the target (no sound).
   • Patient: Listens and watches the model, then repeats back the word as the clinician mouths the word.
3. Model then pause. Model the word again. Next, pause for the patient to imitate the word.
   • Patient: Listens and watches the model, then repeats back without assistance.
4. Model then pause longer. Model the word aloud, then pause long enough for the patient to repeat the word back 3 times.
   • Patient: Listens and watches the model, then repeats back without assistance 3 times.
5. Write. Write down the word (and/or show an image). Show the written word without saying or mouthing it. Ask the patient to say the word.
   • Patient: Views the written word/image as they say the word without assistance.
6. Write then remove. Present the written word/image to the patient, remove it, and then ask the patient to say the word.
   • Patient: Views the written word. Then says the word after it’s removed.
7. Question. Ask a question that prompts the word.
   • Patient: Answers the question by saying the word without assistance.
8. Role play. Role-play a situation to elicit the word.
   • Patient: Responds to the role play by saying the word without assistance.

Rosenbek 8-Step Continuum PDF

Clinician	Sensory Cue	Patient
1. Model. “Listen to me, watch me, do what I do.”	Auditory, Visual	1. Patient first listens and watches, then repeats the target in unison with the therapist.
2. Model then mouth. First model the target. Then mouth the target as the patient repeats it aloud.	Fading Auditory, Visual	2. Patient listens and watches. Then repeats the target in unison as the therapist mouths it.
3. Model then pause. Pause as the patient repeats back without assistance.	Fading Visual, Fading Auditory	3. Patient listens and watches the model. Then repeats back without assistance.
4. Model then pause longer. Ask the patient to repeat it back without assistance 3 times.	Fading Visual, Fading Auditory	4. Patient listens and watches the model. Then repeats back 3 times without assistance.
5. Write. Present the written target (and/or image) without saying or mouthing the target. Ask the patient to say the target.	Written, No Visual, No Auditory	5. Patient views the written target/image. Says the target aloud without further assistance.
6. Write then remove. Present the written target, remove it, then ask the patient to say the target.	Fading Written, No Visual, No Auditory	6. Patient views the written target and then says the word after it’s removed.
7. Question. Prompt the target by asking a question.	No sensory cueing	7. Patient answers the question by saying the target word without assistance.
8. Role play. Role-play a situation to elicit the target.	No sensory cueing	8. Patient says the word in response to the situation without assistance.

An Example of Integral Stimulation

1. Clinician: “Listen to me, watch me, do what I do. “Tap”
   • Patient: Watches, then repeats “tap” with clinician

2. Clinician: “Tap (then mouths word ‘tap’)”
   • Patient: says “Tap” as the clinician mouths it

3. Clinician: “Tap (pause)”
   • Patient: Watches the clinician then repeats “tap” during the pause

4. Clinician: “Watch and listen then repeat the word 3 times. Tap (pause)”
   • Patient: Watches the clinician then says, “tap, tap, tap” during the pause

5. Clinician: Presents the written word ‘tap’ on a flash card, then asks the patient to say the word
   • Patient: Reads the word then says, “tap”

6. Clinician: Presents the written word ‘tap’ again on a flash card, then the patient says the ‘tap’ after it’s removed
   • Patient: Reads the word then says “tap” without assistance

7. Clinician: “What am I doing with my finger?” (clinician is tapping their finger)
   • Patient says, “tap” without assistance

8. Clinician role-plays, pretending to play the piano and says, “I am playing so lightly, I just barely _____  the keys”
   • Patient says “tap” without assistance to complete the sentence

More Resources

References

• American Speech-Language-Hearing Association. (n.d.). Acquired Apraxia of Speech. (Practice Portal). Retrieved April, 24, 2024 from www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/.
• Duffy, J. R. (2020). Motor speech disorders: Substrates, differential diagnosis, and management (4th ed.). Elsevier.
• Philippine Academy of Rehabilitation Medicine. (2017). Clinical Practice Guideline on Stroke Rehabilitation. Philippine Academy of Rehabilitation Medicine, (2nd Edition), 1-624.
• Rosenbek, J., Lemme, M., Ahern, M., Harris, N., & Wertz, T. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38(4), 462–472. https://doi.org/10.1044/jshd.3804.462