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Adult Client Final Therapy Report


1600 HOLLOWAY AVENUE, BH114                       

SAN FRANCISCO, CA 94132                                   

PHONE: 415.338.1001                                               

FAX: 415.338.0916                                                                             



By: Student Clinician, Brenna Gall          

       Supervisor, D.A., M.S., CCC-SLP

 DATE OF REPORT: December 2, 2010                     


         A.W. is an **-year-old female who has been attending the Alaryngeal Speech Clinic (ASC) at the San Francisco State University Communicative Disorders Clinic (SFSU CD Clinic) since 2004.  A.W. underwent a total laryngectomy in April XXXX.  Client confirmed paralysis of the left side of the tongue and a decrease in side-to-side movement resulting from a severed nerve during the surgery.  A tracheoesophageal prosthesis (TEP) was fitted during surgery, but was removed five months post surgery because of tissue growth and granulation at the puncture site.

         In 1995, A.W. was diagnosed with pleomorphic liposarcoma on the left side of her neck, which was surgically removed.  One year later, she was diagnosed with breast cancer, which was also surgically removed.  A hearing screening in April 2009 done at the SFSU CD Clinic indicated A.W. has a hearing loss in the high frequencies.  At that time, she was informed of the significance of a high frequency hearing loss and its effects on speech production and advised to seek further treatment.  A previous report stated that A.W. did not feel the need to seek further treatment because she could understand her family and friends in daily conversation.  A.W. also reports recent difficulties with mobility, especially with walking.

         A.W. lives with her daughter, son-in-law and two grandchildren.  She is proficient in English and Cantonese.  A.W. enjoys watching Wheel of Fortune, reading the newspaper and playing Bingo and Mah Jong at the local Senior Center.  Her son P.W. accompanies her to ASC.



A.      Artificial larynx

      A.W. uses a TruTone electrolarynx as her primary mode of communication with her family and friends in daily interactions.  Assessment of A.W. was done on September 16, 2010 and using level VI stimuli from A Clinicians Guide to Alaryngeal Speech by Minnie Graham.  During spontaneous speech and extended conversation (level VI), A.W.'s placement, articulation and coordination of the "on" control while speaking were 90% accurate.   Her rate and phrasing was 30% accurate.  A noted increase in rate was observed when A.W. was passionate about a particular subject, like Mah Jong.  Her overall intelligibility was 85% to a trained, but unfamiliar listener.  A.W. maintained appropriate eye contact, volume, and turn taking throughout the conversation.  She also demonstrated use of gestures to enhance listener comprehension.

  B. Esophageal Speech-Injection Method for Obstruents (ES-IMO)

      Evaluation of A.W.'s use of ES-IMO occurred on September 16, 2010 using level I one-syllable words with unvoiced obstruents plus mid and low vowels.  A.W. achieved voicing 30% of the time with esophageal quality present 0% of the time.  Precise articulation was achieved 10% of the time.  Omission of one consonant in clusters (e.g. "top" for "stop" ) and omission of the word-final phoneme (e.g. "ta" for "tap") affected articulatory precision.  All items were produced without delay, repetitions were attempted if the first trial was imprecise.  A.W.'s productions had appropriate loudness and intonation 10% of the time.

 C. Hearing Assessment

      A hearing screening was conducted to determine A.W.'s hearing threshold.  The test was administered in a room where ambient noise could not be eliminated.  A.W. has a bilateral mild hearing loss in the lower frequencies (250-2000Hz), and a bilateral moderate loss in the higher frequencies (4000-8000Hz).  A full audiological examination was highly recommended, but refused.  Information about the effects of hearing loss on communication was given to A.W. and her son.


         A.Artificial larynx

Goal: Using the electrolarynx, A.W. will use appropriate rate and phrasing 80% of the time in conversational speech therapy activities with clinician monitoring.

   Baseline: 9/16/10  A.W. showed appropriate rate and phrasing 30% of the time at level VI with self monitoring.

   Progress:  11/18/10  Goal Met.  A.W. used appropriate rate and phrasing with clinician monitoring with 80% accuracy.

   Discussion:  It is notable that A.W. uses a fast rate and less frequent pausing when she is excited about a topic.  Verbal and visual reminders were useful to help A.W. achieve appropriate rate and phrasing.

[Evidence-based practice and research was used to determine A.W.'s goal regarding rate and phrasing using the electrolarynx.  A copy of the peer-reviewed journal article can be found here:  Kazi, R., Pawar, P., Sayed, S.I., & Dwivedi, R.C. (2010). Perspectives on voice rehabilitation following total laryngectomy. European Journal of Cancer Care, 19, 703-705.]

Goal:  Using the electrolarynx, A.W. will participate three times during each large group session without clinician prompting using an appropriate volume with 90% intelligibility.

 Baseline:  9/16/10  A.W. participated zero times in group therapy without clinician prompting.

  Progress:  11/18/10  Goal Met.  A.W. participated 17 times in client-led group therapy without clinician prompting. 

  Discussion:  A.W. met this goal while using an electrolarynx borrowed from the SFSU CD Clinic.  The volume was much louder and A.W. seemed more confident in her speaking abilities.  During the semester, A.W. typically participated in group therapy without clinician prompting one to two times per session.

[I used client-centered therapy during my treatment sessions with A.W.  Dialogue about what goals were important to her happened continually throughout our time together.  She specifically told me that she would like to "work on speaking in groups more."  An article discussing client-centered therapy can be found here: DiLillo, A., & Favreau, C. (2010). Person-centered care and speech and language therapy. Semin Speech Lang, 31(2), 90-97.]

          B.   Esophageal speech

   Goal: Using ES-IMO, A.W. will achieve precise articulation when producing single syllables (i.e. /pi/ or /ta/) with 80% accuracy on the first trial using level I stimuli with clinician monitoring.    

Baseline: 9/16/10  A.W. achieved precise articulation when producing single syllables with 30% accuracy with clinician monitoring.

Progress:  11/18/10  Goal Met.  A.W. achieved precise articulation when producing single syllables with 83% accuracy with clinician monitoring.

Discussion:  Reminders to over-articulate her sounds and to tighten her stomach muscles were helpful to A.W. while producing esophageal speech.  Word lists were given to A.W. and her son to practice esophageal speech at home over the winter break.

[Therapy techniques to teach esophageal speech were taken from Chapter 6, pages 99-133 in A Clinician's Guide to Alarayngeal Speech Therapy by Minnie Graham.]


A. It is recommended that A.W. continues to receive speech therapy at the SFSU CD Clinic in the 2011 spring semester to continue strengthening her skills in the use of her electrolarynx and esophageal speech.

a.       Recommendations for SFSU CD Clinic

          i.      Improve rate and phrasing while self-monitoring while using electrolarynx

          ii.      Improve production of final phoneme with level 1 stimuli with ES-IMO

b.       Recommendations for Home

          i.      Say 5-6 words per activation of electrolarynx

          ii.      With a family member, practice given word list using ES-IMO once a day while squeezing stomach muscles and over-articulating sounds

          iii.      Other Resources:  Nu Voice Club of San Francisco, the Lost Chord Club of Santa Clara, the New Voice Club of Marin, the Lost Chord Club of Northern California and the Lost Chord Club of San Mateo.  More information can be found at:

Reflection: Adult Client

My experience in the alaryngeal clinic was unique and rewarding.  I had very minimal training on alaryngeal speech therapy when I began the clinic, but with the help of my client, the other student clinicians, and the other laryngectomee clients, I began to understand the complexity of alaryngeal speech therapy.  The first day I met my client I was extremely nervous.  At the time, I still did not know much about this area, so I did not know what to expect!  A.W. arrived with her son and the three of us began to get to know each other.  As I began to interview my client, her son would often chime in if he thought I could not understand his mother, or if he had a different perspective on things.  Although I found this helpful, I really wanted to hear from my client first.  I was thrilled that her son came with her to therapy and wanted to be sure he felt welcome, so I gently asked that he allow his mother to do the talking so that I could get a good sample of how she talks.  Because I am a firm believer in family-centered therapy, I appreciated the supportiveness of her son, but also found it difficult to persuade him to allow his mother to do the talking.  I had to utilize the skills I had learned throughout my academic work, especially in my counseling class, to make sure I got the information I needed from A.W.  This incident was an amazing learning opportunity for me and a great insight into working with adult clients.  I would imagine that it is difficult for family members to "step aside" and let the client do the talking, especially if the client is cognitively impaired as well as language impaired.  My experience with A.W. and her son during the interview helped shape my view of family-centered therapy.  Having A.W.'s son come to therapy each week was a gift for her and for me!  I was able to give him word lists to practice at home and visual cues to use to help her slow down her speech when he could not understand her.  Seeing how they interacted was a wonderful example of how powerful family involvement in the therapy process can be.

This experience made me realize how important it is for me to involve family members in the therapy process as much as possible.  One of the professional goals I set for myself is to include family members in all aspects of therapy.  Keeping open communication with the family and the client is extremely important to me, and I feel it will yield the best results for the client.  Another goal I have set for myself is to become more effective at creating therapy activities that are functional and generalizable.  I found myself easily pulling out board games to do therapy activities.  However, I know that functional goals and real life experience during therapy will help the client take the newly learned skills and use them in everyday life.

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