Neurogenic Speech Disorders Course Outline

Motor Speech Disorders Lecture Notes

Introduction & Overview

Definitions

Motor speech disorders: disorders of speech resulting from neurologic impairment affecting the motor programming or neuromuscular execution of speech (Duffy , 1995)

Dysarthria: a collective name for a group of speech disorders resulting from disturbances in muscular control over the speech mechanism due to damage of the central or peripheral nervous system. It designates problems in oral communication due to paralysis, weakness, or incoordination of the speech musculature (Darley, Aronson, & Brown). Dysarthria is defined perceptually (heard, seen or felt), NOT instrumentally (McNeil, 1998).

Apraxia of Speech: neurogenic speech disorder resulting from impairment of the capacity to program sensorimotor commands for the positioning and movement of muscles for the volitional production of speech. I can occur without significant weakness or neuromuscular slowness, and in the absence of disturbances of conscious thought or language.

MSD are NOT:

aphasia
cognitive disturbance
neurogenic stuttering (?)
aprosodia
sensory deficits (?)
musculoskeletal deficits
organic voice disorders
psychogenic disorders
age-related changes
stylistic variations

Prevalence of MSD: Approximately half of individuals with neurogenic communication disorders demonstrate a motor speech disorder. Dysarthria is more common than AOS.

Characterizations of impairment (World Health Organization):

	Definition	Measurements	Examples
Impairment	Any loss or abnormality of psychological, physiological or anatomical structure or function	Often instrumental	muscle weakness loss of hair cells missing limb
Disability	Any restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal	Often perceptual	articulatory imprecision reduced hearing sensitivity reduced speed of ambulation
Handicap	A disadvantage for a given individual (resulting from an impairment or disability) that limits or prevents the fulfillment of a role that is normal	Always perceptual, often self-report	unable to work at chosen profession no effect on lifestyle must allow additional travel time

Methods of Observation

Level	Definition	Methods	Examples	Features
Perceptual	Characterized by perceptual judgments unmediated by significant instrumentation	Auditory perception Visual perception Tactile perception	slurred speech monoloudness slow rate	most commonly used may be best indicator of disability
Acoustic	Analysis of the acoustic energy of a speech sample	speech spectogram visipitch computerized speech analyzers	fundamental frequency, voice onset time, format transitions	particularly useful for analyses of phonatory features may be more sensitive to subtle variations in the acoustic signal than are perceptual judgments * becoming more common in the clinical setting
Kinematic	Analysis of the movements of the articulators	strain gauges palatography	displacement, velocity, acceleration, interarticulator timing	particularly useful in the examination of upper articulators measures primarily at the level of impairment, but can also provide information about disability
Physiologic	Instrumental measurements of physiologic characteristics (other than kinematic)	EMG Spirometry EGG Nasometry PET	muscle activity vital capacity blood flow	*almost always at level of impairment
It is not possible to perfectly predict from one level to another. While prolonged segment durations in an acoustic signal may be related to prolonged movement times, it is not necessarily so. Individuals with reduced articulatory displacements and velocities may have perceptually normal speech, and normal EMG patterns. Each level of description can be useful.

Neurological Substrates:

Review of Neural Physiology

Neurons: excitable (are able to generate an action potential)

cell body (soma)

area around the nucleus
one per neuron
contains machinery for keeping the cell alive

dendrites

"input" side of the neuron
CNS

stout
near the soma
do not conduct action potentials

PNS:

long and thin
no spines

conducts action potentials

axon:

"output" side of the neuron
one per neuron

Upper motor neuron: neuron from cortex to brain stem or spinal cord
Lower motor neuron: neuron from brain-stem or spinal cord to terminal muscle (cranial or spinal nerve)

"Peripheral mechanism through which all motor activity is mediated"
Final neuron connecting brainstem or spinal cord to muscle fibers

Cranial Nerves:(Webster, p.104; Luschei, p. 69-70)

Cranial Nerve Type Nucleus/Central connections Function

I. Olfactory S olfactory bulb Smell

II. Optic S Lateral geniculate body Vision

III. Oculomotor M Oculomotor Eye movements; extraocular muscles except superior oblique and lateral rectus
Striated muscle of eyelid
Autonomic fibers for pupillary constriction and accommodation of lens for near vision

IV. Trochlear M Trochlear Eye movements; superior oblique muscle (rotates eyeball down and out)

V. Trigeminal S

M
Trigeminal (descending and mesencephalic nuclei)

Masticator Nucleus
Cutaneous and proprioceptive sensation for skin, muscles & joints in face and mouth, sensory for teeth
Muscles of mastication

VI. Abducens M Abducens Eye movements; lateral rectus (abducts eyeball)

VII. Facial S
M
Tractus solitarius
Geniculate
Taste for anterior 2/3 tongue, soft palate
Muscles of facial expression

VIII. Auditory (Vestibulocochlear) S Vestibular and Medial geniculate Audition, equilibrium, postural reflexes, orientation of head in space

IX. Glossopharyngeal S
M
Tractus solitarus
Nucleus ambiguus
Posterior 1/3 of tongue, tonsil, pharynx, middle ear,
Autonomic for salivation
Stylopharyngeus, pharyngeal musculature

X. Vagus S

M
Nucleus solitarus

Nucleus ambiguus
Caudal pharynx, larynx, thorax, abdomen, taste from epiglottis
Autonomic for smooth muscle (heart, blood vessels, trachea, bronchi, esophagus, stomach, intestines)
Striated muscle in larynx, and part of pharynx

XI. Spinal Accessory M Nucleus ambiguus Neck muscles

XII. Hypoglossal M Hypoglossal nucleus Intrinsic tongue muscles

LMNs and Speech

cranial nerves

supply innervation for muscles of articulation, resonation, phonation

spinal nerves

supply innervation for muscles involved in respiratory activities

Trigeminal Nerve (V)

largest of the cranial nerves
bilateral UMN innervation with input from both hemispheres going to both nerves
branches

Ophthalmic
Maxillary
Mandibular

Sensory: mucous membrane of the mouth, side of the head and scalp, lower jaw, anterior two thirds of tongue.
Proprioceptive: from muscles of jaw movement to the mesencephalic nucleus in the midbrain
Motor: muscles of mastication

all originate from trigeminal ganglion
Unilateral lesions do not usually affect speech
Bilateral lesions cause the jaw to hang open or move with limited range

Facial Nerve (VII)

Upper face, bilateral UMN innervation
Lower face, contralateral UMN innervation (primarily)
Motor

supplies the stapedius muscle and the muscles of facial expression, arise from the facial nucleus, leave the cranium from the internal auditory meatus
lesions can paralyze the entire ipsilateral side of the face, causing facial asymmetry.
Fasciculations may be seen in the perioral area and the chin

Sensory: Taste anterior two thirds of tongue

Glossopharyngeal Nerve (IX)

Bilateral UMN innervation
Motor

supplies the stylopharyngeus muscle

Sensory

carries sensation from pharynx and posterior 1/3 of tongue.

Lesions often accompanied by lesions to the vagus. Often results in reduced pharyngeal sensation and a decrease in the gag reflex

Vagus (X)

Bilateral UMN innervation
Motor

Pharyngeal branch

joins branches of glossopharyngeal and external laryngeal to make up "pharyngeal plexus."
Supplies the muscles of the soft palate and pharynx.

Superior laryngeal nerve

external laryngeal nerve

supplies the inferior pharyngeal constrictor and cricothyroid (makes pitch adjustments).

internal (sensory)

Recurrent laryngeal branches

Right is shorter
Left is longer because is has to loop around the heart
They innervate all of the intrinsic muscles of the larynx except for cricothyroid.

Sensory

internal laryngeal branch of the superior laryngeal nerve carries sensations from mucous membrane lining the larynx down to the level of the vocal cords, the epiglottis, the base of the tongue. Also information from muscle spindles and other stretch receptors in the larynx.

Accessory Nerve (XI)

Bilateral UMN innervation
Motor:

cranial branch intertwines with vagal nerve fibers to innervate uvula, levator veli palatini, and intrinsic laryngeal muscles.
Spinal branch innervates the sternocleidomastoid and trapezius muscles.

Hypoglossal Nerve (XII)

Bilateral UMN innervation but with more input from contralateral hemisphere
Motor

innervates all intrinsic and extrinsic muscles of the tongue (except for palatoglossus).

Sensory

taste and tactile information from tongue via nucleus of tractus solitarius.

Pyramidal Tract (Direct activation pathway) (Duffy, p 44; Webster, p.293; Luschei, p.83)

corticospinal tract: spinal nerves

primary motor cortex, and premotor cortex (in each hemisphere)

Organization

Striated muscles represented in an upside down fashion
greater the need for fine control, the greater the number of motoneurons
columns from surface to deep structures

corona radiata
internal capsule
cerebral peduncle
pons
medulla (decussation)

crossed: lateral corticospinal tract
uncrossed: anterior corticospinal tract

corticobulbar tract: cranial nerves

cortex
internal capsule
cerebral peduncle
motor nucleus of brainstem
cranial nerves

UMN generally innervate LMN on the opposite side of the body
Speech cranial nerves are mostly bilaterally innervated, except for the tongue and the lower face

Extrapyramidal System (Indirect activation system) (Duffy, p.46; Luschei, p. 86)

"Indirect" because there are many synapses between the cortex and the LMN
Helps regulate reflexes and maintains posture, and tone. Activities are subconscious, but do affect voluntary movements.
corticoreticular tract: projects from cortex to reticular system (medulla and pons), from there project to LMN but also back to the cortex, also to cerebellum and cranial nerve nuclei.

Reticular formation: mediates consciousness, contributes to muscle tone. Stimulation of the reticular formation can facilitate or inhibit reflex activity or voluntary movement, affect phasic respiratory activities.

Corticorubral tract: cortical efferents which course through the red nucleus and then through the pons and medulla to the spinal cord.

"Control Circuits"

Neural circuits which serve to integrate and control movement, but do not have direct synapses with LMNs.
Sometimes considered part of the extrapyramidal system but are conceptually separate.
Basal ganglia:

caudate nucleus, putamen (together constitute the striatum), and globus pallidus
as a group are important for maintaining normal posture, regulating the amplitude, velocity, and possibly the initiation of movements.
striatum (afferent)

receives input from frontal cortex, thalamus, and substantia nigra
rich in acetylcholine and dopamine

globus pallidus (efferent)

receives input from striatum
reciprocal projections to subthalamic nuclei
outputs to the premotor cortex via the ventralis anterior of the thalamus
outputs to the motor cortex via the ventralis lateralis of the thalamus

Cerebellum

involvement of midline cerebellar structures typically produces postural sway and tremor, and difficulties with locomotion
involvement of the more lateral structures produces loss of coordination of limbs, often with large amplitude and low frequency tremor
Involvement in speech:

vermis (midline area) and cerebellar hemispheres (based on lesion studies)
Information from the cortex about intended speech goals activates cerebellums long term planning
Cerebellum's Perkunje cells filter cortical output
Cerebellum can fine tune muscle spindles to optimize sensory input

Motor Planning

Premotor and Supplemental motor areas: planning on an abstract level
Broca's area (part of premotor cortex): closely tied to language processes
somatosensory cortex & supramarginal gyrus: help integrates sensory information for planning
insula: separate from the other lobes, between temporal and parietal lobes
control circuits (basal ganglia): probably play role in modification of programs
limbic system: regulate learning and memory, important for emotional activities
right hemisphere: probably not implicated
reticular formation/ thalamic influences: maintains alertness, focuses attention

Classification systems for Dysarthria (McNeil, 1998)

Unidimensional

Age of Onset (cerebral palsy)
Disease (Parkinsons)
Etiology (TBI)
Site of lesion (UMN)
Speech process (phonatory)
Anatomical area (CN VII)

Multidimensional (Darley, Aronson & Brown)

disease process
anatomical areas
cranial nerves
speech process
perceptual characteristic

Flaccid Dysarthria

Duffy: Dysarthria caused by a damage to the nuclei, axons, or neuromuscular junction that make up the motor units of the final common pathway. (Damage to the LMN)
Weakness is the primary impairment, and can be manifest at any level of the speech production mechanism. It can isolated to a single group of muscles.
Characteristics:

Impairments:

weakness: resulting from damage of any portion of the motor unit or the muscle
hypotonia: reduced resistance to passive movement
diminished reflexes (i.e., all aspects of movement are affected by LMN damage)
atrophy: muscle loses bulk, also contributes to weakness
fasciculations

repetitive dimpling or highly localized twitchlike movements
caused by spontaneous motor unit discharges in response to nerve degeneration or irritation.

fibrillations (slow, repetitive action potentials in individual muscle fibers observable on EMG)
progressive weakness with use and recovery with rest: results from damage to the neuromuscular junction
Effect of flaccid dysarthria on speech is dependent upon which neuromotor units are damaged and the nature of the disease

Trigeminal Lesions

usually occurs in the presence of damage to other cranial nerves
common etiologies include stroke, tumors, trauma
impairments

weak jaw
decreased sensation of face, cheek, tongue, teeth

Facial Lesions

common etiologies

infection
neuromas
Bell's palsy

unilateral lesions more common than bilateral
impairments

facial droop
Food pocketing
Complaints of biting cheek when chewing
Fasciculations and atrophy on affected side
abnormal movements of the face: synkinesis, hemifacial spasm

speech

cheek flutter
Poorer "puhs" than "tuhs" or "kuhs"
Possible distortion of labial sounds

Glossopharyngeal lesions

rarely damaged in isolation (often damaged with Vagus)
impairments

asymmetry of gag reflex

speech: see Vagus

Vagus lesions

damage depends on location of lesion (See Table 4-4, Duffy, p.112)
lesions can be caused by stroke, tumor, infection, or surgical damage during thyroidectomy, CEAs

Accessory lesions

damage often associated with damage to IX and X
can be associated with spinal cord injuries or damage during radical neck dissections
impairments: reduced shoulder elevation and head turning to side opposite lesion
speech: can affect respiration, phonation, and resonance secondary to postural changes

Hypoglossal lesions

associated with lesions to IX, X, or XI
impairment

tongue atrophy on affected side
fasciculations
tongue will deviate to weak side on protrusion

speech

imprecise articulation of lingual phonemes
resonance may be affected

Common Etiologies of Flaccid Dysarthria

Neuromuscular junction disease: myasthenia gravis:
Vascular disorders: brainstem stroke affecting cranial nerve nuclei
Infections

polio
herpes
meningitis

Demyelinating disease

Guillain-Barre

Muscle disease: Muscular dystrophy
Degenerative disease

progressive bulbar palsy
ALS (mixed)

Spastic Dysarthria:

bilateral damage to direct and indirect activation pathways

direct activation: facilitatory
indirect activation: inhibitory
rarely see damage of only one because tracts are near to each other

primary characteristics

spasticity

resistance to movement
caused by over-active stretch reflex
results in increased muscle tone

increased muscle tone
pathological oral reflexes
weakness
reduced range of movement
slowness of movement

etiologies

vascular: a single brainstem stroke can produce a spastic dysarthria, whereas a single cerebral hemisphere stroke cannot
lacunar strokes (small deep infarcts in the basal ganglia, thalamus, brain stem and deep cerebral white matter)
degenerative disease
TBI
MS

site of lesion

cortex
corona radiata
basal ganglia
internal capsule
pons
medulla

patient complaints

speech is slow and effortful
fatigue
nasal (more common in flaccid)
swallowing problems
drooling
difficulty controlling their expression of emotion (pseudobulbar affect)

speech movement characteristics

impaired movement patterns rather than weakness of individual muscles
slowness and reduced range of individual and repetitive movements
reduced force of movement
excessive muscle tone, spasticity

perceptual characteristics

prosodic excess:

excess and equal stress
slow rate

articulatory-resonatory incompetence

imprecise consonants
Distorted vowels
Hypernasality

prosodic insufficiency

monopitch
Monoloudness
Reduced stress
Short phrases

phonatory stenosis

low pitch
Harshness
Strained-strangled voice
Pitch breaks
Short phrases
Slow rate

Ataxic Dysarthria

Results from damage to the cerebellum (a control circuit)
Clinical characterization:

ataxic gait
titubation (tremor)
nystagmus
dysmetria (under and overshoot of targets)
Dys-coordination

Etiologies

degenerative diseases
vascular disorders
tumors
trauma (boxers)
toxic disorders, chronic alcoholism

Patient perceptions and complaints:

slurred speech / sound drunk
may have to slow down

Clinical findings:

nonspeech

normal strength, tone, and range
Coordination of nonspeech movements is poor

speech

irregular speech AMR
Impaired coordination of movement patterns
Primarily articulatory and prosodic
(Prosody involves vocal control)

Deviant clusters:

imprecise consonants
irregular breakdowns
distorted vowels
excess and equal stress
prolonged phonemes
prolonged intervals
slow rate

harshness
monopitch
monoloudness

Hypokinetic Dysarthria

Results from damage to the basal ganglia (control circuit)

regulates muscle tone
postural adjustments
compensatory adjustments

Clinical characteristics:

resting tremor

pillrolling
jaw, lip, tongue

rigidity

resistance to passive stretch

bradykinesia

slow initiation, freezing

akinesia

reduced overall movement
masked facial expression

postural abnormalities

stooped posture
difficulty changing position

Etiologies:

degenerative: Parkinson's (can also result in dementia)

Damage to the substantia nigra
Associated with reduced dopamine levels
Side effects of medication, on-off effects

vascular: multiple or bilateral strokes
toxic/metabolic conditions: antipsychotic/neuroleptic medications
trauma
infections
NPH

Patient perceptions and complaints:

quieter, weak, can't be heard in noise
too fast
fatigue

Clinical findings:

nonspeech

masked facial expression
Excessive drooling due to decreased swallowing
Facial tremor
Range of motion for single movements greater upon command than spontaneous movements
ROM reduced for repetitive movements

speech

monopitch
Monoloudness
Reduced stress
Short rushes of speech **fast rate
Imprecise consonants
Short phrases

other

reduced vital capacity
Increased respiratory rate
Paradoxical rib cage and abdominal movements
Bowed vocal cords

Hyperkinetic dysarthria

Due to damage to the basal ganglia (control circuit).
Characterized primarily by involuntary movements
Clinical characteristics

dyskinesia

general term
Tardive dyskinesia secondary to Psychotropic drugs

myoclonus: involuntary single or repetitive jerks (hiccups)
tics

rapid, stereotyped, patterned movement
Under partial voluntary control (can be temporarily suppressed)
Tourette's syndrome

chorea: rapid involuntary, random, purposeless movements
ballism: gross, abrupt contractions (ballismus)
athetosis: slow, writhing, purposeless movements
dystonia

abnormal postures resulting from excessive co-contraction of agonists and antagonists
Blepharospasm
Spasmodic torticollis

spasm

tonic: prolonged and continuous
Clonic: repetitive, rapid in onset, brief

tremor

Resting
Action
Essential/familial

Patient perceptions and complaints:

dependent on type of hyperkinesias
sometimes complain of chewing and swallowing difficulties
Chorea:

sudden forced inspiration/expiration
irregular articulatory breakdowns
variable stress patterns
inappropriate silences

Dystonia:

strained vocal quality
excessive loudness variations
irregular articulation breakdowns
inappropriate silences

Spasmodic torticollis:

reduced pitch and pitch variability
dysphonia
reduced rate

Action myoclonus:

adductor voice arrests
slow rate

Organic voice tremor:

4-7 Hz vocal tremor
tremor of face and head

Spasmodic dysphonia:

see Table 8-13 p. 216

Unilateral Upper Motor Neuron Dysarthria

manifest primarily by weakness and coordination
often mild and of short duration
may be the only symptom
Clinical Features:

Pyramidal

hemiplegia or hemiparesis
Impairment of skilled movements
Abnormal reflexes
Facial and lingual weakness

Extrapyramidal

increased muscle tone
Spasticity
Clonus (repetitive reflexive contraction)
hyperactive stretch reflexes
Decerebrate or decortate posturing
central facial weakness during emotional expression

Patient perceptions and complaints:

slurred speech
drooling
speech becomes poor under stress and with fatigue

differences between volitional and emotional movements
central facial weakness
unilateral tongue weakness

Speech:

imprecise consonants
irregular articulatory breakdowns
abnormal AMR's
mild-moderate dysphonia

Mixed Dysarthrias

combination of two or more types of dysarthria
ALS: UMN & LMN degeneration
Progressive Bulbar Palsy: ALS primarily in the bulbar muscles
Progressive Supranuclear Palsy: due to neuronal atrophy (hypokinetic, spastic, & ataxic)

Apraxia of Speech

Other terms

Speech apraxia
verbal apraxia
Broca's aphasia

A disturbance in the programming of movements for speech

muscles are capable of normal functioning
appropriate message has been formulated
"Difficult to enact the planned message"

related primarily to left hemisphere damage
may be accompanied by limb apraxia
most often associated with stroke
"pure" AOS is extremely rare
Patient perceptions and complaints:

"Doesn't come out right"
articulation most often cited
stutter-like

Nonspeech:

right-sided weakness secondary to UMN dysarthria may be seen
may have oral nonverbal apraxia (obvious or subtle)

Speech:

sound and prosodic errors
perceived substitutions, but usually distortions
greater errors with increased complexity
greater errors with increased volitionality
difficulty with repetition
groping behaviors
awareness of errors
severe AOS will be manifest in all forms of speech, and usually oral nonspeech movements

Assessment

Goals of Assessment:

Identification
Description
Diagnosis
Severity determination
Prognosis
Treatment planning

General approach:

"problem solving"
Consider the assessment process as on-going
Can assess at impairment, disability, or handicap level
Can assess at perceptual, acoustic, kinematic, or physiologic level
Must assess several speech subsystems, keeping in mind that the subsystems are very interdependent and impairments in one speech subsystem may affect functioning in another

History:

Chart Review:

History of current problem:

date of onset
associated history
admission assessment

Symptoms
Neuro findings

Cranial nerves
Extremities

Orientation
Imaging
Other
Admitting diagnosis

hospital course
discharge assessment

discharge diagnosis
Dispensation

Previous history:

other neurological episodes
other significant medical history
significant developmental history
family history

Current medications:

if any medications may be contributing to speech disorders

Previous speech/language assessment/therapy
Other:

social work
psychology/psychiatry
physical/occupational therapy

Interview:

General principles:

open-ended questions
ask for patient's opinions
include family and/or caregivers but direct questions to appropriate individuals
explain the format of the evaluation

See interview handouts

interview questions
handicap scale

Darley, Aronson, Brown perceptual characteristics

phonatory/respiratory

low pitch
pitch breaks
monopitch, monoloudness
excessive loudness variation
loudness decay
alternating loudness
overall loudness
harsh voice
wet hoarseness
continuous breathy voice
transient breathy voice
strained-strangled voice
voice stoppages
forced inspiration/expirations
audible inspiration
grunt at end of expiration

resonance

Hypernasality
hyponasality
nasal emission

prosodic/respiratory

rate increases/decreases
short phrases
increased rate in segments
variable rate
reduced stress
prolonged intervals
inappropriate silences
short rushes of speech
excess and equal stress
repeated phonemes

articulatory

imprecise consonants
prolonged phonemes
irregular articulatory breakdown
distorted vowels

other

overall reduced intelligibility
overall speech bizarreness

naturalness
normalcy
acceptability
bizarreness

Respiratory System:

Respiratory functioning affects prosody and vocal quality & intensity, also articulation in extreme circumstances
Four parameters of respiratory assessment for speech:

pressure (pressure of air)
volume (amount of air)
flow (amount of air per unit of time)
shape (relative displacement of the rib cage versus the abdominal wall)

General:

tasks

tidal breathing
deep inspiration and expiration
sniff
pant
speech tasks

must consider all four parameters

Auditory perceptual:

pressure

loudness variations
Have pt vary stress
vary vowel loudness while sustaining a vowel
change stress during syllable strings

volume: phrase length
flow: voice quality and breath groups
shape

slow inspirations
inappropriate unpredictable loudness changes

Acoustic:

timing
intensity measures

Physical examination
Instrumental measures:

pressure

blow bubbles (5 x 5 rule)
Water manometer
Pressure transducer

volume: spirometer
flow

pneumotachometer
respirometer

shape

magnetometers
strain gauges

Voice Assessment

Perceptual measures:

pitch: level, control, range
loudness: level, control, range, decay
quality: hoarseness, harshness, breathiness
s:z ratios

large ratio suggests VF involvement
Small numbers for both suggest respiratory involvement

Acoustic: (visipitch, cspeech, computerized speech lab)

fundamental frequency
intensity
spectographs

Physiologic:

flow (can indicate breathiness)
electroglottograph (temporal patterns of vocal cord closure)
electromyography (muscle activities)
stroboscopy (visually examine vocal cord functioning)

Resonatory Assessment

Perceptual

Hypernasality/ hyponasality/ nasal emissions
visual inspection of VP port
pressure consonant test (part of Templin-Darley)
nasal versus non-nasal productions with the nares closed

Acoustic: limited instruments
Physiologic

nasal air flow and pressure
nasal mirror
endoscopy

Articulatory System

Perceptual Measures:

articulation tests
may need to use narrow transcription
repeated trials in a variety of contexts

Acoustic:

VOT, vowel frequency, transition durations
requires training, relationships to speech clarity may not be straightforward

Physiologic:

Oral Motor Exam

Many formats
purpose is to evaluate the general structure and functioning of the speech articulators

size
strength
symmetry
range of motion
tone
steadiness
speed and accuracy

Dworkin-Culatta Deep Test

IOPI
EMG
Force and movement transduction

Prosody

Definition: variations in the speech wave that signal differences in meaning

Linguistic

Question vs. Statement
Sentence level stress
Word level stress
Syntactic juncture and stress
Phonologic stress (furry vs. free)

Emotional

Happy, sad, angry, frustration
Often associated with facial expression

Can alter prosody with pitch, intensity, or duration (not everyone uses the same strategies)
Generally, duration is a LH function, while frequency is a RH function
Need to assess prosody comprehension, too, to determine if problem is more "central"
Duffy:

rate: fast, slow, variable
short phrases
stress: reduced, variable, inappropriate
prolonged intervals, inappropriate silences

Intelligibility

One of the main indexes of disability
Intelligibility plus speech rate can give you a give estimate of the severity
Intelligibility involves the speaker, the listener, and the environment

Speaker:

speech sample
speech rate
appearance of the speaker
motivation

Listener:

manner of responses

sentence completion
transcription

familiarity with dysarthria
familiarity with speaker
motivation
capacity/sensory system

Environment:

linguistic
signal to noise ratio
distractions
natural versus clinic environment

Tests: AIDS

Special Assessment Issues with AOS

Key features of AOS:

groping of the articulators
variable errors
increased difficulty with volitionality and complexity
difficulty with repetition
usually articulatory and prosodic errors

Tasks to include in AOS assessment:

"automatic speech"

counting
alphabet
days of the week

DDK of increasing complexity

V
CV
C₁V₁C₂V₂

words of increasing complexity

seem
seeming
seemingly

repeated trials of the same words
nonverbal tasks of increasing complexity (oral apraxia)
right handed tasks upon verbal command (limb apraxia)

Differential Diagnosis

Why?

Lesion detection
Treatment planning

Refer to Duffy charts

Treatment

General Approach:

Management of the communication disorder may be addressed at several levels:

impairment
disability
handicap

patient
partners
environment

Candidacy for tx:

Cognitive status
Medical status
Motivation
Insurance coverage

Issues to consider:

Progression

acute
static
progressive

Goal

improvement
maintenance
slow declination

General principles

compensation
purposeful activity
monitoring
early start

new strategies
reduce maladaptations

motivation

Motor Learning Principles

Theoretical foundations

acquisition is not learning
must differentiate learning from performance variables
some factors that produce faster acquisition deter learning

Implicit/Procedural versus Explicit/Semantic learning:

Explicit: with awareness, learning "that"
Implicit: without awareness, learning "what"

Transfer appropriate processing

Schemas

concepts developed from multiple experiences with similar stimuli
allows for identification and production of novel items.
Recall schema

invoked to produce movements
includes memories of

initial conditions
response specifications
outcome

Recognition schema

used to evaluate correctness of movements
includes memories of

initial conditions
outcome
sensory consequences

Conditions of Practice

Pre-practice

Motivation

rationale
encouragement

Elicitation

instructions: avoid wordiness, verbal explanations
modeling: active better than static (pictures)

Practice Schedules:

Massed vs Distributed practice:

massed: minimal interval between trials
distributed: greater interval between trials
**distributed practice promotes learning, massed practice promotes acquisition**

Variability:

constant practice promotes acquisition, variable practice promotes learning

Mental practice: aids in motor learning

Feedback:

Knowledge of results
feedback about the outcome of the movement (right or wrong)

Knowledge of performance
feedback about the movement pattern

**Research indicates that KR is more critical than KP**

Temporal Locus of KR

KR Delay Interval: pt is processing internal information related to movement (sensory consequences)

length is not critical
should be kept "empty"

talk
movements

Post KR delay interval: pt is incorporating KR and refining schemas

length is not critical
should be kept "empty"

Frequency of KR

High KR frequency improves acquisition, but negatively affects learning
Summary KR facilitates learning
Self evaluations (moderate frequency and/or summary)

KP: (recall principles of implicit versus explicit learning)

Provide KP at the sensory-perceptual level
Encourage pt to attend to sensory consequences
Biofeedback is KP

Attention

Pt has to be able to attend
Speech is now more effortful

Memory

Keep in mind explicit versus implicit memory capabilities

Other Therapy Principles (do these mesh with principles of motor learning?)

Intensive treatment

daily, or more
length of tx depends on stamina of pt
**balance intensity with functionality, motivation factors

Multiple repetitions

practice, practice, practice
be cognizant of frustration
variable practice, random trials

Progressive complexity

easy to hard (OK to perfect)
nonspeech
isolated phonemes

vowels
consonants

component movements
voiceless
voiced

syllables

variable contexts

increase utterance length

Auditory discrimination necessary for adequate self-monitoring
MUST PROVIDE SUCCESSFUL EXPERIENCES!

Treatment: Dysarthrias

Focus of therapy is dictated by affected subsystems and nature of damage.

Impairment Level

Flaccid: Increasing tone & strength
Spastic: Decreasing tone, increasing ROM
Hypokinetic: increasing ROM, strength
Hyperkinetic: increasing control
Ataxic: increasing control

Disability level: increasing speech accuracy, communication efficacy
Handicap level: improving level of independence and functional communication, specific to individual patients

Treatment: Subsystems

Respiration

Goals:

Impairment:

To establish correct breathing pattern (intercostal diaphragmatic)
To increase vital capacity
To facilitate control of inhalation and exhalation
To improve strength and coordination of respiratory muscles

Disability:

To establish breath support for speech production

Strategies:

Modify posture:

Pts for which posture affects breath control for speech, sitting upright will often be the best position. However, for obese individuals, standing or lying flat may be more appropriate.

Establish diaphragmatic breathing:

Use hands on diaphragm to feel downward and outward movement
Model on yourself
May have to put hands on shoulders to get pt to attend to clavicular breathing

Practice slow, deep breathing
Sustained phonation

maintain intensity
increase intensity
decrease intensity
increase then decrease intensity

Rhythmic exhalation
Monitoring breath groups
Other:

Girdles
Trach considerations

Phonatory System

Goals:

To establish good coordination of respiration and phonation
To achieve an appropriate vocal onset
To control loudness
To achieve optimum pitch
To facilitate variation of pitch and inflection
To achieve appropriate resonance and projection

Strategies:

Yawn-sigh
Easy onset
Massage and relaxation
Vocal strengthening exercises (push-pull)

hold breath and bear down
bear down and sustain ah
bear down and repeat ah

Cough-voice
Sustaining vowels
Forward resonance training (handout)
Volume control (see respiratory strategies)
Pitch expansion
Glides

high-low-mid
two differences
three differences

Nonsense inflection-> real word inflection
"Speak up Therapy"
Biofeedback

Other:

Surgical management of vocal cord paralysis
Amplification
Electronic voice

Resonation

Goals:

Improve velopharyngeal closure
Improve oral flow

Strategies:

Intra-oral pressure (blow cheeks up with air)
Blowing (straws, Kleenex, balloon)
Oral vowels
Pressure consonants
Alternate oral and nasal consonants

Other:

Prostheses
Surgical management

Articulation

Goals:

Impairment:

Increase strength
Increase/decrease tone
Increase ROM
Improve coordination within and among articulators

Disability:

Improve phoneme precision
Increase co-articulatory coordination

Strategies:

1. Strengthening:

Tongue

IOPI protocol
Maximum contractions

lateral, superior, inferior
anterior, midportion, and posterior tongue

Lips & Face

Maximum contractions

retraction, protrusion, closure

Resistance movements
neuromuscular facilitation

ROM/Reduce tone

Tongue, lips, face
Massage, stretching
Negative practice
Biofeedback (EMG)

Articulatory precision

reduce rate
overarticulate
articulation drill
modify articulation difficulty

Intelligibility

Goals:

Intelligibility within specific contexts

clinic
with spouse
with strangers
in noise
on the phone

Self-monitoring
Clarification strategies

Strategies:

Reduce rate

even if already slow
careful below 60 wpm (normal is 180wpm)
pacing board

Overarticulate
Increase effort
Modify environment

background noise
lighting
contextual cues

Train listeners
Teach nonverbal communication strategies
Augmentative devices

Prosody

Goals:

To improve emotive stress
To improve linguistic stress
To produce natural speech melody

Strategies:

Pitch control (see voice)
Loudness control (see voice)
Imitation of stress patterns
Production of specified stress patterns

excited sarcastic
bored puzzled
happy angry
surprised sad

Terminal declination
Question inflection
Intra-word stress

ADDress -- addRESS
PRESent -- preSENT

Treating AOS

Strength or ROM is not the problem
Speech difficulties may increase with increased effort
Facilitate increasing automaticity of speech
Strategies:

Progressive complexity

automatic
oral/nasal, voicing, manner, place
bilabial->alveolar-> velar
singletons->clusters
high frequency -> low frequency
short -> long length of utterance

Many repetitions
Visual cues
Tactile cues
Decreasing rate MAY help

Treating Severe MSD

Goals:

Reliable yes/no system
determine modality
determine reliability
train others
post written directions

Total communication imperative
Augmentative communication may be necessary
TRAIN PARTNERS

Cranial Nerve	Type	Nucleus/Central connections	Function
I. Olfactory	S	olfactory bulb	Smell
II. Optic	S	Lateral geniculate body	Vision
III. Oculomotor	M	Oculomotor	Eye movements; extraocular muscles except superior oblique and lateral rectus Striated muscle of eyelid Autonomic fibers for pupillary constriction and accommodation of lens for near vision
IV. Trochlear	M	Trochlear	Eye movements; superior oblique muscle (rotates eyeball down and out)
V. Trigeminal	S M	Trigeminal (descending and mesencephalic nuclei) Masticator Nucleus	Cutaneous and proprioceptive sensation for skin, muscles & joints in face and mouth, sensory for teeth Muscles of mastication
VI. Abducens	M	Abducens	Eye movements; lateral rectus (abducts eyeball)
VII. Facial	S M	Tractus solitarius Geniculate	Taste for anterior 2/3 tongue, soft palate Muscles of facial expression
VIII. Auditory (Vestibulocochlear)	S	Vestibular and Medial geniculate	Audition, equilibrium, postural reflexes, orientation of head in space
IX. Glossopharyngeal	S M	Tractus solitarus Nucleus ambiguus	Posterior 1/3 of tongue, tonsil, pharynx, middle ear, Autonomic for salivation Stylopharyngeus, pharyngeal musculature
X. Vagus	S M	Nucleus solitarus Nucleus ambiguus	Caudal pharynx, larynx, thorax, abdomen, taste from epiglottis Autonomic for smooth muscle (heart, blood vessels, trachea, bronchi, esophagus, stomach, intestines) Striated muscle in larynx, and part of pharynx
XI. Spinal Accessory	M	Nucleus ambiguus	Neck muscles
XII. Hypoglossal	M	Hypoglossal nucleus	Intrinsic tongue muscles