Rosenbek Hierarchy of Apraxia Therapy

Why apraxia can feel like a brick wall

Apraxia causes difficulty coordinating the mouth & tongue to produce speech.

We use speech so often (and so effortlessly) that we forget just how complex and difficult it is to learn. If you've ever tried to teach a baby to speak, you know it's not easy. In addition, apraxia is often accompanied by expressive aphasia, causing difficulty with word-retrieval (thinking of the right word). I call that the double whammy: you have difficulty thinking of the word and then, even if you think of it, you have trouble saying it.

Trying harder is not the answer

The Rosenbek Hierarchy breaks a hard task (speaking on demand) into small doable steps. It's particularly useful for speech apraxia in adults (might be called dyspraxia outside the U.S.)

Imagine you are trying to get over a five-foot wall.

You can't jump five feet straight up no matter how hard you try. The solution is not to jump higher. Instead, get a ladder. That breaks the impossible five-foot jump into a series of achievable six-inch steps. Dr. Rosenbek provided similar therapy steps for acquired apraxia of speech.

The Rosenbek Hierarchy breaks apraxia therapy into small, achievable steps

A continuum of steps from easy to hard – for each word

Step 1 is the easiest, with maximum help. They see the following cues: picture, the word, and the therapist's mouth speaking the word.

Next steps get harder, with less help.
The survivor may not make it to the last step for that word. That's okay. If they get to a step they cannot do, they just go to step 1 of the next word.

Example: Patient gets stuck on step 3

Step-by-step instructions for the Rosenbek Continuum
	Helper gives cues		Survivor responds
1	Demonstrate with Integral Stimulation.		Watches demonstration then repeats in unison with the therapist 5 times.
2	Demonstrate, pause, then silently mouth the word.		Repeats back while watching a silent demonstration.
3	Demonstrate, then pause for survivor to repeat back without assistance.		Repeats back, seeing only picture and text.
4	Same as #3.		Same as #3 but repeat it 5 times, with only picture and text cues.
5	Show the written word and picture.		Names the picture.
6	Show the written word and picture, then hide them, and prompt the patient to say the word.		Names the picture from memory.
7	Prompt with a question. I'd like a cup of herbal_____		Answers the question with a single word (the target word).
8	Optional:  Role play a situation that would prompt the survivor to say the word.		Speaks the word in response to the situation.

Get your printable quick reference guide with our free SLP resources.

Video of Rosenbek's Hierarchy of Integral Stimulation

Demonstrated by speech-pathology grad student:

Clinician-oriented video of Rosenbek's Hierarchy, including research basis:

Practice the Rosenbek apraxia therapy

Two software programs provide therapy for apraxia of speech for adults or older children:

MoreSpeech.com

This web-based app includes apraxia skills, which are based on the above approach. It starts with easy words and works up to harder words.

Try it risk-free three ways:

1. Start a subscription to MoreSpeech with a money-back guarantee.
2. Request a free tour and mention Rosenbek.
3. Speech therapists: request a free trial of MoreSpeech with a work email and mention "Try Rosenbek".  Survivors, ask your therapist to request a trial and show it to you.

Speech Sounds On Cue

This is a better option for more severe apraxia of speech. It starts at the easier alphabet exercises and then moves on to easy words.  They also get more assistance, hearing their own speech played back. Speech Sounds On Cue is included in our monthly subscription.

Try it with a free therapy plan (choose the articulation skill).

Video demo

Footnotes and Research Summary

 The Rosenbek Apraxia Hierarchy was developed by Dr. John C. Rosenbek and his colleagues in the 1970s. It's sometimes called Integral Stimulation because it integrates sensory cues: seeing a picture and the word, seeing and hearing the therapist model the word.

The Apraxia of Speech protocol developed for the MoreSpeech.com app is based on accepted and commonly conducted clinical practice and research articles demonstrating improved outcomes published in peer-reviewed professional journals including the seminal work "A Treatment for Apraxia of Speech in Adults"

The treatment used in the MoreSpeech app incorporates the stimulation/facilitation model. Duffy & Coelho (2001) provides an excellent description and analysis of Schuell (1953, 1964, 1974) original theory and the subsequent work of researchers who support the concepts that:

1. Sensory stimulation influences brain activity;
2. Repetition of sensory stimulation is needed for acquisition, organization, and retrieval of patterns of behavior;
3. The auditory modality is central to acquisition and maintenance of language;
4. The auditory modality is severely compromised for most aphasic people; and
5. If aphasia is defined as a multimodal language impairment, then intense stimulation treatment should be directed through the auditory modality because of its essential role in language processing.

Research on treatment approaches to apraxia (and dyspraxia) in adults