2nd Exam Flashcards
Types of dysarthria
- flaccid
- spastic
- ataxic
- hypokinetic
- hyperkinetic
- unilateral upper motor neuron
- mixed
types of motor speech disorder
- Apraxia of speech
2. Dysarthria
Flaccid dysarthria
lesion location?
impairment of the final common pathway (LMN pathway).
nuclei, axons, or neuromuscular junctions of cranial/spinal nerves
Flaccid dysarthria
- impairment affects:
- muscle strength.
- muscle tone.
- speed, range, and accuracy of movements.
- may affect only one muscle group.
- may affect only one speech subgroup.
flaccid dysarthria
- clinical characteristics
- weakness
- hypotonia
- diminished reflexes
- fasciculations
- atrophy
- progressive weakness with use.
flaccid dysarthria
- etiologies
- trauma
- degenerative diseases: ALS and Progressive bulbar palsy.
- muscular disease
- neuromuscular junction diseases: Myasthenia Gravis and botulinium toxin exposure.
- Brainstem stroke.
- demyelinating diseases: Guillain-Barre, Chronic demyelinating polyneuritis.
- infectious diseases: Poliomyelitis and herpes zoster
Spastic Dysarthria
- location of lesion
- bilateral damage to the upper motor neuron system (UMN)
spastic dysarthria due to impairment of direct activation pathway.
- Characteristics -
- loss of fine, discrete movements
- increased muscle tone.
- spasticity (muscles continuously contracted)
- babinski reflex
- pathologic oral reflexes
Spastic Dysarthria Characteristics
due to impairment of indirect activation pathway.
- increase muscle tone.
- spasticity
- hyperreflexia
Clinical characteristics of Spastic Dysarthria
- spasticity
- weakness (especially distal)
- reduced range of movement
- slow movement
Spastic Dysarthria
- etiologies
- vasculature problems (stroke- most likely brainstem stroke. vascular dementia)
- Primary lateral sclerosis (degenerative motor neuron disease)
- corticobulbar and corticospinal signs.
Ataxic Dysarthria
- location of lesion
- damage to cerebellum
Ataxic Dysarthria
- impairments
- coordination
- decreased muscle tone.
- slowness and inaccuracy of movement force, range, timing, direction.
Ataxic dysarthria
- clinical characteristics
- problems with standing and walking
- titubation (rhythmic tremor of body or head)
- nystagmus
- dysmetria
- dysdiadochokinesis
- decomposition of movement
- possible intention tremor.
- cognitive disturbances
Ataxic Dysarthria
- etiologies
- degenerative diseases (hereditary ataxias, multiple sclerosis)
- vascular lesions
- tumors
- trauma
- toxins (drugs and alcohol)
Hypokinetic Dysarthria
- location of lesion
- basal ganglia direct pathway
hypokinetic dysarthria
- impairments
- rigidity
- reduced force
- slow individual movements but sometimes fast repetitive movements.
hypokinetic dysarthria
- clinical characteristics
- resting tremor
- bradykinesia
- intermittent freezing
- pill-rolling movements
- masked facies (hypomimia) - decreased facial expressions.
- reduced arm swing
- micrographic writing
- festation
- impaired sensory functions
general management goals for motor speech disorders
- restore lost function when possible
- promote use of residual function (compensation, modifying aspects of speech, AAC, prosthetics)
- reduce the need for lost function (adjust)
General treatment strategies for MSD
- management goals
- begin treatment ASAP
- consider incorporating principles of motor learning
- provide opportunities for practice
- use drill
- provide instruction
- feedback is essential
- incorporate principles of experience dependent neuroplasticity.
- be cautious of “plateau”
- compensation requires conscious effort.
approaches to management of MSD
- medical (pharmacological or surgical).
- prosthetic
- behavioral management (pt and significant other(s))
- speech management
Dysarthria - VP dysfunction
treatment approaches
- biofeedback
- resistance treatment during speech (CPAP)
- Producing words containing pressure sounds with nares pinched closed.
- modification of speaking
- NO evidence for non-speech oral motor exercises or inhibition techniques.
Dysarthria- Respiratory dysfunction treatment
- postural adjustment
- try to incorporate respiration activities into speech tasks.
- sustaining phonation with feedback
- some non-speech tasks may be beneficial for improving respiratory support.
Dysarthria- phonatory dysfunction
- hypoadduction
- effort closure techniques
- Lee Silverman Voice Treatment (LSVT-LOUD)
- resonant voice exercises
- sirening
LSVT
- think loud and big
- intensive treatment
- used to increase loudness and effort
- must be certified.
- work from short (single words) to longer material
- use objective measure of loudness.
- provide home practice (1hr/day)
- provide lots of trails!! (15/item)
***Good quality “ahhhhh” 15 times - start each session this way!
phonatory dysfunctions-
Resonant Voice Exercises
- m, n, r, j, l
Dysarthria - Articulatory Dysfunction Treatment
- Traditional approaches (phonetic placement, phonetic derivation, integral stimulation).
- rate modification - slowing
- exaggeration of articulation
treatment for AOS
- rate and rhythm control approaches
- contrastive stress drills
- articulatory and kinematic approaches
- intersystematic facilitation/reorganization approaches (gestures and melodic intonation therapy)
- motor learning
Treatment for AOS
- rate and rhythm approaches
- metronome pacing (speech in time to metronome, usually 1 syllable per beat, start rate slow and gradually increase)
- stress patterning (model 2 syllable word, accenting stressed syllable- client imitates, gradually increase word length)
treatment for AOS - articulatory and kinematic approaches
- phonetic placement/derivation
- Key word approach
- PROMPT
AOS treatment with supporting evidence
- Eight step continuum/integral stimulation.
- PROMPT
- Sound production treatment
AOS treatment - motor learning
- cognitive phase: break movement into component parts.
- associative phase: linking parts into smooth action.
- autonomous phase: making movements automatic.
Hypokinetic dysarthria - etiologies
- Parkinson’s disease (most common)
- Parkinson-plus or atypical parkinsonism
- dementing diseases
- Toxic/metabolic conditions
- trauma
- infections
Parkinson’s Disease
- idiopathic & hereditary forms
- progressive loss of cells in substantia nigra.
- decreased dopamine in basal ganglia.
- imbalance between ACh and dopamine in the basal ganglia.
- treated with drugs that increase dopamine (side effects from these drugs)
- when drugs fail, may be treated with with deep brain stimulation
Side effects of parkinson’s drugs
- on-off effects
- worsening of hypokinetic dysarthria or appearance of hyperkinetic dysarthria.
- confusion and hallucinations
- dystonia and dyskinesia
- impulsivity control, paranoia
Deep Brain Stimulation
- electrodes surgically implanted, most often in subthalamic nucleus.
- may be unilateral or bilateral .
- electrical impulses sent to electrodes via stimulator implanted under the skin.
- stimulator connected to electrodes via wires
- electrical impulses disrupt tremors and other motor problems.
- limb movement problems responding to drugs and DBS better than speech problems do.
- speech may worsen with drugs or DBS.
types of parkinson-plus or atypical parkinsonism
- progressive supranuclear palsy
- shy-drager syndrome
- corticobasal degeneration.
Hyperkinetic Dysarthrias
- lesion location
basal ganglia indirect pathway
hyperkinetic dysarthria
- primary effects
- effects prosody
- involuntary movements
hyperkinetic dysarthria
- types of involuntary movement
- orofacial dyskinesia (orofacial movements)
- tardive dyskinesia (side effect of antipsychotic drugs)
- Myoclonus
- tics
- Chorea
- ballismus (flailing movements)
- athetosis (slow, writhing movements, twisting)
- dystonia
- spasm
- tremor
hyperkinetic dysarthria
- Myoclonus -
- involuntary single repetitive brief jerks.
- may be rhythmic or non-rhythmic.
- palatal or palatopharyngeal myoclonus
hyperkinetic dysarthria
- tics -
- rapid stereotyped movements
- often irresistible urge to make the movement
hyperkinetic dysarthria
- chorea -
- involuntary, rapid, random, purposeless movements
- can be subtle or very obvious
hyperkinetic dysarthria
- dystonia -
- relatively slow movement.
- focal mouth or orofacial dystonia
- blepharospasm (forceful, strained closure of eyes)
hyperkinetic dysarthria
- spasm -
- tonic: prolonged or continuous.
- clonic: repetitive and brief
hyperkinetic dysarthria
- tremor -
- most common involuntary movement
- resting tremor (repose)
- action tremor (movement)
- terminal tremor (as a target is approached, aka intention tremor)
hyperkinetic dysarthria
- etiologies -
- toxic- metabolic conditions (drugs, lead, mercury)
- degenerative diseases (huntington’s chorea, dementias)
- infectious diseases (Sydenham’s chorea, rubella, AIDS)
- stoke
- tumors
unilateral upper motor neuron dysarthria
- lesion location -
- damage to UMNs that innervate cranial or spinal nerves important to speech.
Unilateral UMN dysarthria
- Clinical characteristics -
- usually mild and short-lived.
- hemiplegia or hemiparesis.
- early: weakness, hyporeflexia, hypotonia.
- later: spasticity, hypertonia.
- contralateral lower face weakness.
unilateral UMN dysarthria
- etiologies -
- stroke (most common)
- tumors
- trauma
mixed dysarthria
- combination of 2 or more types of dysarthria
- more common than single dysarthrias
mixed dysarthria
- etiologies -
- degenerative diseases (1.motor neuron diseases: progressive bulbar palsy, pseudobalbar palsy, ALS. 2.multiple sclerosis.)
- toxic metabolic causes (Wilson’s disease and hypoxic encephalopathy)
- stroke (especially brainstem)
- tumor (especially brainstem)
Apraxia of Speech (AOS)
- Characteristics -
- no universal agreement on the characteristics or underlying nature.
- Darley (original characteristics)
- ANCDS (Wambaugh et al)
- Duffy’s (2013)
AOS characteristics
- Darley -
- struggle and groping
- errors recognized
- speech initiation a problem early but not later.
- secondary prosody problems.
- absence of weakness, incoordination, or change in muscle tone.
- substitutions and additions most common.
- better on involuntary/automatic speech than on voluntary.
- greater error variability.
- consonants more difficult than vowels and consonant clusters more difficult than singletons.
- imitation produces more errors than spontaneous speech.
- errors increase with word length.
Characteristics of AOS
- ANCDS -
- slow rate of speech.
- sound distortion.
- relatively consistent errors in terms of type and invariable in terms of location.
- prosodic abnormalities
Characteristics of AOS
- Duffy (2013)
- consonant and vowel distortions
- distorted additions, prolongations, voicing distinctions, anticipatory substitutions, perseverative substitutions.
- slow rate
- syllable segregations
- relatively consistent error location and type
- false articulatory starts and restarts
- effortful visible and audible trial-and-error groping for articulatory postures.
- error rate higher for nonsense words.
- initiation of utterance particularly difficult.
- error rates higher for volitional/purposeful speech vs automatic/reactive utterances
- consonant clusters more often in error than singletons
- errors not different for imitative vs spontaneous.
- severe AOS: limited speech sounds, speech may be limited to a few meaningful or unintelligible utterances, automatic may not be better than volitional, predictable errors.
ways to evaluate speech
- perceptually
- acoustically
- physiologically
purpose of assessment of speech
- description and problem detection
- establish diagnostic possibilities
- establish diagnosis
- establish implications for localization and disease diagnosis
- specify severity.
Salient features of MSDs
- muscle strength
- movement speed
- range of motion
- steadiness of movement
- muscle tone
- movement accuracy
features of MSD
- muscle strength -
- weakness most apparent in LMN lesions (flaccid dysarthria)
features of MSD
- movement speed -
- too fast is rare
- rapid rate usually associated with decreased ROM.
- reduced speed is more common.
- strongly affects prosody
features of MSD
- Range of motion -
- more likely to be reduced than increased.
- may be abnormally variable
- effects noted in prosody.
features of MSD
- steadiness of movement
- physiologic tremor (present in all normal people, not visible, can occur in all voluntary muscle groups)
- abnormal steadiness - involuntary movements (1. tremor: most common, repetitive, involuntary, relatively rhythmic, commonly affects phonation. 2. involuntary, random unpredictable movements: dystonia, dyskinesia, athetosis, chorea).
features of MSD
- muscle tone -
- may be reduced or excessive
- may fluctuate
- reduced tone: flaccid dysarthria
- increased tone: spastic, hypokinetic
- variable tone: hyperkinetic
features of MSD
- movement accuracy -
- accuracy impairment may result from several causes
- impairment of force and range
- problems in movement timing
/Case History should include what?
- basic data
- onset and course of the problem
- associated deficits
- patients perception
- consequences
- management
- patient awareness of medical diagnosis and prognosis
informal perceptual tools for speech assessment
- Mayo tests of motor programming (dysarthria)
- motor speech examination - Wertz et al 1984 - (apraxia)
formal perceptual tests
- Frenchay Dysarthria Assessment
- Assessment of Intelligibility in Dysarthric speech (AIDS)
- Speech Intelligibility Test (SIT) - computerized version of AIDS sentence test.
- Apraxia Battery for Adults
Assessment of non-speech movements
- cranial nerve exam
- Duffy’s (2013) examination
Motor Speech Examination (Wertz et al 1984) for AOS
- Ogar et al, 2006: 4 subsets especially difficult for persons with AOS.
- alternating diadochokinesis
- multiple repetitions of multisyllabic words.
- repetition of sentences
- reading of the Grandfather Passage.
