124 Chapter 6
Stephanie suffered from migraine headaches all of her adult life. They started when she was
a teenager and occurred more frequently in her early 20s. Once, she was returning from snow
sledding when a migraine came on with such intensity that she lost the ability to speak. She
knew what she wanted to say, but her speech muscles did not work. Stephanie’s friends took
her to the emergency room of the hospital, where several tests were done, including magnetic
resonance imaging of her brain. The doctors prescribed several drugs to prevent migraines or
decrease their severity once they began. However, one day at work, a severe migraine rendered
her unable to finish her shift. An ambulance took her to the hospital, again without the abil-
ity to speak normally. This time the symptoms did not resolve spontaneously, and the doctors
diagnosed a cerebrovascular accident.
After 6 days in the acute care ward, Stephanie was transferred to the rehabilitation wing for
intensive speech therapy. The speech- language pathologist administered several tests to diagnose
her communication disorder and to design the appropriate therapies. Although Stephanie had
some word- finding difficulty in conversational speech, the main neurogenic communication
disorder was apraxia of speech. She had difficulty repeating vowels and consonants in isolation.
She also had prob lems repeating one- , two- , and three- syllable words and was able to repeat lon-
ger word combinations less than 50% of the time. When trying to speak normally, Stephanie was
aware of her errors, but she was rarely able to correct the programming mistakes. She also strug-
gled with the placement of her articulators during speech.
Although apraxia of speech and oral apraxia often co- occur in cerebrovascular accidents,
Stephanie’s ability to program and execute nonspeech oral movements was largely intact. She could
purposefully and easily program her muscles to blow air from her lungs, smile, bite her lower lip,
and puff her cheeks. She had no prob lem pretending to purse her lips as if kissing a baby. She could
voluntarily lick her lips and protrude, retract, elevate, lateralize, and depress her tongue. Her abil-
ity to make purposeful nonspeech oral movements proved to be helpful in dealing with a nagging
and per sis tent prob lem of apraxia of speech: placing her articulators properly during speech.
Stephanie was discharged from the rehabilitation unit and eventually returned to work. She
also received outpatient speech therapy for her residual apraxia of speech deficits. During reha-
bilitation, although she regained most of the ability to purposefully program her articulators for
speech production, she was frequently unable to produce the /f/ phoneme. In the hospital’s reha-
bilitation unit, she had drilled on several difficult phonemes and was eventually able to develop the
muscular programming and control necessary to produce them. For example, she had difficulty
with the /g/ phoneme. With her therapist’s guidance, she learned to create adequate breath sup-
port and then to expel it gradually. To get her vocal cords to vibrate on the voiced consonant, she
hummed during exhalation. Then the therapist showed her the proper positioning of the articula-
tors using photo cards and a mirror, and Stephanie practiced making the sound. Because the /g/
sound occurs in the back of the throat, out of sight, she also used several sounds to “lead into” the
/g/ phoneme. By progressing from easily programmed and executed sounds to the difficult /g/,
she eventually was able to produce it. However, Stephanie could not master the /f/ phoneme using
these therapies.