About PROMPT Therapy
Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT), is a tactile-kinesthetic therapy technique used by trained Speech therapists to improve speech sound production. PROMPT’s multidimensional approach to speech production disorders is based on the dynamic systems theory. It is also consistent with neuronal group selection theory and Guenther’s neural model of speech production (Guenther, 2006; Tourville, Reilly & Guenther, 2008). The approach integrates well-known physical-sensory aspects of motor performance with cognitive-linguistic and social-emotional domains, in order to achieve positive communication outcomes. The PROMPT technique more specifically associates each speech sound with multiple movement parameters and coordinating actions. The premise is that the tactile input will provide the speaker with the information regarding where the movement begins, how it feels and how it should be produced. Therefore while the speaker is attempting to learn new motor movements, the clinician is providing tactile input to reinforce changes in sensory mapping to ultimately improve motor planning and execution (Hayden, 1994, 2004; Hayden, Eigen, Walker & Olsen, 2010).
The PROMPT technique is recommended by the PROMPT institute for use with all speech production disorders from 6 months of age and above, with varying intensity and focus depending on the client’s needs and abilities. PROMPT therapy is most commonly associated with Apraxia therapy, however a number of studies have shown positive results for the efficacy of PROMPT therapy’s use with a range of disorder populations. These populations include Adult Broca’s aphasia and Adult Apraxia, Childhood Apraxia of Speech (CAS), Phonological Disorders, Childhood Motor Speech Disorders, Autism Spectrum Disorder (ASD) and Dysarthria in Cerebral Palsy. This article reviews the most recent research supporting the efficacy of its use with such populations.
PROMPT Research with Adult Apraxia of Speech and Aphasia
There are four studies that support the use of PROMPT as an effective therapy method for adult clients with acquired apraxia of speech with aphasia. The first is by Square, Chumpelik and Adams (1985) who conducted a single subject investigation into a patient with severe apraxia of speech and moderate Broca’s aphasia. The individual’s intelligibility improved after receiving PROMPT therapy as measured by the Assessment of Intelligibility of Dysarthric Speech (Yorkston & Beukelman, 1981). No improvements were reported in a simultaneous comparison treatment group using integral stimulation. The individual was able to achieve 90-100% accuracy with phrase level production, and similar success with minimal paired words. No generalisation was reported by the authors however the subject‘s declining performance after a five month period indicated that little maintenance was achieved.
Square, Chumpelik, Morningstar and Adams (1986) later conducted a study comparing the PROMPT therapy method with repetition and integral stimulation therapy. Subjects consisted of three adult participants with acquired apraxia of speech and Broca’s aphasia. The researchers concluded that PROMPT therapy was the most effective treatment in measures of accuracy, phonemic contrast and bisyllabic words. The individual in the PROMPT treatment group achieved 98-100% accuracy in the production of functional utterances, 90-100% accuracy in the production of phonemic contrasts and 75-100% accuracy in the production of bisyllabic words.
Freed, Marshall and Frazier (1997) conducted a modified single subject, multiple baseline design to examine the effectiveness of PROMPT therapy at improving the core vocabulary of a patient with aphasia and acquired Apraxia of Speech. The researchers provided a thorough description of methods, including a detailed description of stimuli selection, enabling the study to be easily replicated. The stimuli consisted of 30 personally relevant functional words and phrases with treatment procedures following that of Square et al. (1986). Stimuli were grouped according to the participant’s preference in order to avoid perseveration errors. This unfortunately eliminated randomisation of the order of presentation and may have biased results. Probes were conducted weekly to measure improvements through accuracy of trained items without cueing. The 80% treatment criterion was met for all treatment sets, with the mean score of probes in the follow-up maintenance phase being 78.2%. Although treatment effects did not appear to generalise to untreated targets, the participant’s family reported that he was able to use ten to twelve untrained words appropriate in the correct contexts. As it was a single subject design, this study only provides suggestive evidence for the effectiveness of PROMPT therapy for patients with Apraxia of Speech and aphasia.
The final study by Bose, Square, Schlosser and van Lieshout (2001) was a similar single subject, multiple-baseline design that examined the effectiveness of PROMPT therapy with an adult presenting with moderate Apraxia of speech and Broca’s aphasia. The study’s main purpose was to examine the effectiveness of PROMPT therapy in improving the precision and automaticity of speech movements in imperatives, active declaratives, and interrogatives sentence types. The secondary purpose was to investigate changes in linguistic correctness of utterances aside from motor performance, secondary to supporting motor speech production in treatment. Bose et al. (2001) were the first researchers to attempt to investigate PROMPT therapy with speech movements in utterances of varying complexity and different sentence types. The researchers reported an increase in the accuracy of speech production for trained and untrained imperative sentences (mean; 42% trained, 53% untrained) and active declarative sentences (mean; 45% trained, 50% untrained), but not for interrogative sentences (mean; 24% for both trained and untrained) after the treatment phase. This same pattern was reflected in the maintenance phase and in the grammatical correctness of utterances. An improvement was found overall for the more simple sentence types.
PROMPT Research with CAS (Childhood Apraxia of Speech)
Dale & Hayden (2011) conducted a study investigating four children with CAS treated using PROMPT therapy. Participants in the study were between the ages of 3 years 6 months, and 4 years 8 months, and all met the criteria for CAS as outlined by the ASHA 2007 position paper. The four children received 8 weeks of PROMPT therapy by a certified PROMPT therapist two times per week. Two children received the full PROMPT treatment for all 8-weeks, and two children received 4 weeks of PROMPT therapy without tactile components and 4 weeks of the full PROMPT treatment. The study hypothesised that the two children in the 8-week full PROMPT treatment group would produce greater gains than the group without the tactile component on measures of articulation, consistency, quality and sequencing of speech movements. The results indicated that all children made significant gains during treatment. However, those who benefited most were those children who received the full PROMPT treatment with the tactile component.
PROMPT Research with Autism
Rogers, Hayden, Hepburn, Charlifue-Smith, Hall and Hayes (2006) conducted a single subject design study to compare the effectiveness of two models of intervention: The Denver Model (which merges behavioural, developmental, and relationship-oriented intervention), and the PROMPT therapy model. The subjects consisted of ten nonverbal children with autism between the ages of 2 and 4 years old. Participants were matched in pairs and randomised to each treatment type. They received 12 weekly 1 hour sessions of therapy, as well as 1 hour of daily home intervention implemented by their parents. Eight of the ten children used five or more novel, functional words spontaneously and spoke multiple times per hour by the conclusion of treatment.
Upon conclusion of the study, the researchers reported that “all four children in the PROMPT condition acquired and spontaneously used more novel, functional words. Some increasing their word output from less than 5 words per day, to more than 2000 words per hour. All children were reported to have an increase in expressive language, and all but one made receptive language gains. PROMPT was most effective for those autistic nonverbal children who were on the early linguistic stages, or had motor involvement as well as autism. This showed good evidence to support the use of PROMPT therapy with the ASD population as participants in the other intervention groups showed little or no change after their respective treatments.”
PROMPT Research with Phonological Disorders
A study by Dodd and Bradford (2000) explored the efficacy of three different therapy methods on three males between the ages of 3-5 years. The participants had two different types of moderate to severe phonological impairment: consistent non-developmental phonological disorder, and inconsistent phonological disorder. PROMPT therapy, the phonological contrast approach and the core vocabulary approach were the three therapies investigated. To determine the most effective treatment method, data was gathered using the Goldman-Fristoe Test of Articulation (Goldman & Fristoe, 1986), the 25 Word Test for Inconsistency (Dodd, 1995) and phonological analysis. Spontaneous speech samples and the Test for Auditory Comprehension of Language-Revised (Carrow-Wollfolk, 1985) were also used. The researchers reported that the phonological contrast approach was most successful for the child with consistent non-developmental phonological disorder. The two participants with inconsistent phonological disorder showed gains using the core vocabulary approach. However, the PROMPT therapy method failed to produce improvements in any of the children. The researchers concluded that therapy methods providing information about phonetic placement are not effective for children with phonological speech disorders.
Houston and Margaret (2003) later examined the effect of PROMPT therapy on children with severe persistent phonological disorders. The study consisted of a series of single subject case studies replicating the study by Square et al. (1986). The participants were five children between the ages of 3 years and 9 months, and 8 years, with severe persistent sound system disorders. The study excluded subjects with Dysarthria as the primary etiology, as well as subjects with hearing loss, oral facial or visual abnormalities. One of the final five participants did not complete all requirements of the therapy. The first hypothesis of the study predicted that children exhibiting severe persistent sound system disorders would display a significant increase in the percentage of accurate productions of the phonemes targeted, in words and functional phrases trained using PROMPT therapy. This hypothesis was accepted. Two of the participants who completed the study exhibited a significant increase in accuracy of targeted phonemes. The remaining two participants’ results were less clear. However, this may have been due to their failure to adhere to therapy protocol that would have had a negative impact on phoneme acquisition. The second hypothesis predicted that the accuracy of production of trained phonemes would increase in spontaneous utterances. This hypothesis was also accepted. It was supported by three participants that completed the study and were able to provide a spontaneous speech sample, including one who did not adhere to the study’s protocol. These three participants showed a significant increase in production accuracy in five of the six trained phonemes in spontaneous speech. The hypothesis could not be tested on the remaining participant as the participant has almost no spontaneous speech. This study provided sufficient evidence that further investigation into the PROMPT approach on children with severe persistent sound system disorders is warranted.
PROMPT Research with Childhood Motor Speech Disorders
Grigos, Hayden and Eigen (2010) conducted a study to investigate the effectiveness of PROMPT therapy when implemented with children presenting with motor speech disorders. The investigation was a single case study design examining articulator movement and accuracy of speech production in a child with severe articulation impairment. A typically developing child was followed longitudinally as a control and was compared with the prompt condition at pre-treatment, during treatment, and post treatment. The study hypothesised that the individual change over an eight-week treatment using PROMPT therapy compared to the control, showing significant improvements in speech sound accuracy and articulator movement (duration, displacement, velocity). The results revealed an increase in articulation accuracy and decreased movement duration, displacement, and velocity in the child with the articulation impairment over the 8-week PROMPT treatment. By the last treatment session, kinematic findings were most similar to those seen in the control. The results of this study suggested that PROMPT therapy facilitates changes in articulatory control in children with motor speech disorders.
PROMPT Research with Cerebral Palsy
The use of the PROMPT treatment method for children who had cerebral palsy with co-morbid speech impairment was recently investigated by Ward, Leitao and Strauss (2009). This single subject, multiple baseline study consisted of two levels of intervention. The first was at the participants’ priority level in the PROMPT hierarchy (Priority 1), and the second at a level higher in the PROMPT hierarchy (priority 2). The participants consisted of six children between the ages of 3 years and 11 years 9 months with Cerebral Palsy. Results were measured at 4 points during the study using the Children’s Speech Intelligibility Measure (Wilcox & Morris, 1999). An evaluation of percentage of consonants correct from a speech sample was also measured. The first was taken as a baseline measure pre-treatment, the second was after 10 weeks of priority 1 treatment for 45 minutes per week, the third after 10 weeks of priority 2 treatment for 45 minutes per week, and the final measures were taken at 6 and 12 weeks post treatment. The researchers hypothesised that subjects would show improvement in motor speech movement patterns and perceptual accuracy on trained and untrained word sets. The researchers reported positive results in all six participants after priority 1 treatment, and improvements on speech production in phase 2 for five of the participants. All participants showed some improvement on untrained word sets, indicating that the effects of treatment had generalised into everyday conversation.
From a clinical perspective the reviewed studies highlighted that there is evidence to support the use of tactile-kinesthetic input in articulation therapy. Although there are a number of methods that utilise tactile-kinetic input, the PROMPT technique is unique as each target has a prompt at sound, syllable, word, phrase or sentence level. PROMPT is able to provide cues for transitive movement. This is of particular importance in assisting for motor planning; a deficit in many of the above targeted populations.
A number of the papers reviewed in this article have some statistical and methodological weaknesses. The Ward et al. (2009) and Square et al. (1986) articles were very brief, making them difficult to evaluate and replicate in future studies. Square et al (1985, 1986) and Freed et al. (1997) did not report sufficient baseline data and the Square et al (1985, 1986) did not have a control comparison; making inferences of causality less conclusive. A number of the reviewed studies did not use criterion-referenced measures of treatment targets, which are essential for accurate comparison with baseline data and study replication. The majority of PROMPT studies to date are single subject designs. These types of studies do not provide convincing evidence, as the participant’s improvement may have occurred without any treatment. The studies using a multiple baseline design, which treats one target while the other remains in baseline allowed for treatment effect to be attributed to the treatment and not just spontaneous recovery. Measures of external validity are also limited in single subject designs, which make it difficult to determine whether results will generalise outside the respective studies.
There is sufficient evidence to warrant the use of PROMPT therapy with motor-based speech disorders such as Adult and Childhood Apraxia of speech, and Motor Speech Disorders such as Dysarthria in Cerebral Palsy. However, further research using randomised control trials are still required to provide strong conclusive evidence for the efficacy of its use with these populations. Further studies are also needed in the form of controlled longitudinal studies to validate the use of PROMPT Therapy in populations without underlying motor impairments and additional motor based communication disorders such as articulation disorders and Spastic Dysarthria.
For more information about voice therapy for children or any speech pathology topic, contact ENT Clinic and make an appointment with one of our speech pathologists.
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