Apraxia/Dysarthria

Question 1

Do patients with AOS typically have coexisting disorders?

Answer 1

Yes - pure apraxia of speech is rare

Question 2

AOS that is the only, or the dominant, symptom

Answer 2

Primary progressive apraxia of speech

Question 3

Is apraxia and AOS the same thing?

Answer 3

Not necessarily; Apraxia is a basic disorder of volitional movement; AOS is a special case of apraxia.

Question 4

Which disorder is caused by injury or damage to motor-speech programming area in the dominant hemisphere? Broca’s area and supplementary motor area are often involved.

Answer 4

Apraxia of speech

Question 5

When assessing AOS, it’s important to…

Answer 5

• Tape record patient’s speech samples and transcribing responses phonetically
• Evoking repetitive production of a speech sound, syllable or multiple syllables (ex. pataka)
• Evoking the imitative production of progressively longer words

Question 6

Primary concern with AOS Tx

Answer 6

• Primarily concerned with speech movements rather than non-speech movements
• Practice with a variety of sounds and sound combinations
• Repeated trials on the same target response (drills) is essential for initial learning

Tx targets should include articulatory accuracy, slower rate of speech, systematic practice, gradual increase in the rate, and normal prosody.

Question 7

How to differentiate apraxia from dysarthria
- Motor plans
- utterances
- Errors
- Bucco-facial apraxia (less or more likely to occur)
- Strength, tone and rom of pharyngeal muscles
- Non-speech motor tasks

Answer 7

———- Motor plans
A: Motor plans affected
D: Motor plans not affected, but neuromuscular weakness
———- Utterances
A: Unpaired/error-free automatic, involuntary utterances
D: Affects both voluntary and involuntary utterances
———- Errors
A: Greater amount of errors for words that are longer and more phonetically complex
D: Errors are consistent regardless of length or complexity of word
———- Bucco-facial apraxia
A: More likely to occur
D: Less likely to occur
———- Strength, tone and rom of pharyngeal muscles
A: Normal
D: Abnormal
———- Non-speech motor tasks
A: Can complete non-speech motor tasks during oral-mech exam without difficulty; breakdown will occur on speech tasks
D: Will have difficulty performing both non-speech and speech motor tasks

Question 8

Phases of a normal swallow

Answer 8

• Oral prep
• Oral
• Pharyngeal
• Esophageal

Question 9

Special form of esophageal swallowing disorder due to esophageal motility impairment/failure of the lower esophageal sphincter to relax; consequently, the food is not passed into the stomach but retained in the esophagus
It may be confused with eating disorders commonly reported in young females because of food avoidance, vomiting, and other symptoms associated with EDs

Answer 9

Achalasia

Question 10

What is the purpose of a flexible endoscopic evaluation of swallowing?

Answer 10

Evaluate laryngeal penetration of food, aspiration, food residue, and completeness of a swallow

Question 11

Are swallowing maneuvers great Tx ideas?

Answer 11

While they are designed to compensate for specific problems associated with dysphagia, they are supported by weak data.

Question 12

Indirect Tx of swallowing disorders

Answer 12

Oral-motor control exercises
- Each is designed to reduce a particular problem
- Ex. Increase ROM of tongue movements, increase buccal tension, increase ROM of jaw

Exercises to stimulate the swallow reflex

Question 13

Name the swallowing maneuver:
Helps close the airway at the level of the vocal folds to prevent aspiration.
Patient is asked to hold the food in the mouth, take a deep breath and hold it soon after initiating a slight exhalation, swallow while holding breath, and cough soon after the swallow

Answer 13

Supraglottic swallow

Question 14

Name the swallowing maneuver:
Helps close the airway before and during swallow; the procedure also promotes false vocal fold closure.
Patient is asked to inhale and hold the breath tightly by bearing down (action that tilts the arytenoids and helps close the false folds) and swallow while holding breath. Patient coughs soon after the swallow using this technique.

Answer 14

Super-supraglottic swallow

Question 15

Name the swallowing maneuver:
Helps increase the posterior motion of the tongue and increase pharyngeal pressure. Patient is asked to squeeze as hard as possible while swallowing
May be more effective when combined with infrahyoid motor electrical stimulation

Answer 15

Effortful swallow

Question 16

Name the swallowing maneuver:
Helps elevate the larynx, and thus, widens the cricopharyngeal opening. The patient is first educated about the laryngeal elevation, then asked to palpate the laryngeal elevation when swallowing saliva, and finally, taught to hold the laryngeal elevation during swallowing saliva, and finally, taught to hold the laryngeal elevation during swallowing for progressively longer durations

Answer 16

Mendelsohn maneuver

Question 17

3 main procedures of neuromuscular rehabilitation for swallowing disorders

Answer 17

1. Neuromuscular electrical stimulation (NMES) to of the neck muscles to improve swallowing
2. Transcranial magnetic stimulation
3. Transcranial direct current stimulation

Question 18

Medical Tx of swallowing disorders
- Cricopharyngeal myotomy
- Esophagostomy
- Gastrostomy
- Nasogastric feeding
- Pharyngostomy
- Teflon injection into the vocal folds

Answer 18

————- Cricopharyngeal myotomy ———–
Creates a permanently open sphincter for swallowing.
For patients with parkinson’s disease, ALS, whose main problem is cricopharyngeal dysfunction
————- Esophagostomy ————————
Designed for pts who cannot tolerate oral feeding
Inserting a feeding tube into the esophagus through a hole (stoma)
————– Gastrostomy ————————-
Designed for pts who cannot tolerate oral feeding
Insertion of a feeding tube into the stomach through an opening in the abdomen
————- Nasogastric feeding —————-
Designed for pts who cannot tolerate oral feeding
Tube, inserted through the nose, pharynx and esophagus into the stomach, feeds patient
————- Pharyngostomy ——————-
Non-oral surgical feeding method
Tube is inserted into the esophagus and stomach through hole that has been created through pharynx
————Teflon injection into the vocal folds ———–
Surgical implant method designed to improve airway closure during swallowing

Question 19

Which dysarthria is the only one that can increase speech?

Answer 19

Hypokinetic

Question 20

Rapid-fire articulation

Answer 20

Because the ROM of the articulators is reduced, the speech of an individual with hypokinetic dysarthria will often speed up until there is a breakdown.

Question 21

Describe Hyperkinetic dysarthria.
1. Disease related to it.
2. Speech symptoms
3. Cause

Answer 21

Hyperkinetic - Huntington’s disease

Sudden forced inhalation or exhalation
o Transient breathiness lasting only for a short time
o Transient vocal strain/harshness
o Vocal tremor
o Voice stoppage
o Intermittent hypernasality
o Marked deterioration with increased rate
o Inappropriate vocal voices
o Intermittent breathy or aphonic segments
o Distorted vowels
o Excessive loudness variation
o Irregular/unpredictable DDK
o Facial grimace during speech
o Multiple motor tics à stereotyped repetitive movement
o Myoclonus = sudden and involuntary jerking
o Palate, pharynx, lips, tongue, nostrils or respiratory muscles
o Involuntary head, jaw, face, tongue, velum, laryngeal and respiratory muscles

Cause: Damage to basal ganglia (extra pyramidal system)
o Indirect loop
o NO movement inhibition
o Excessive movement
o Hyperkinesia = extra and involuntary movement
o Variable muscle tone and involuntary movement interfere with speech production

Question 22

Dysarthria associated with Parkinson’s disease

Answer 22

Hypokinetic

Question 23

Most common cause of UUMN dysarthria

Answer 23

Stroke - 92%

Question 24

What is the normal swallowing apnea duration for healthy young people and healthy elderly people?

Answer 24

Young: 1 second
Elderly: 7.8 - 10 seconds

Question 25

Swallowing apnea

Answer 25

Brief, temporary cessation or pause in breathing that occurs during the act of swallowing.

Question 26

What is the likelihood of experiencing swallowing problems due to short term intubation?

Answer 26

Low.
However, individual factors and underlying medical conditions may influence the risk of complications.

Question 27

T or F? The age of a patient will determine the likelihood of swallowing problems due to intubation

Answer 27

False. Age does not matter

Question 28

Zenker diverticulum, symptoms and diagnosis / Tx

Answer 28

An outpouching of the pharynx mucosa just above the upper esophageal sphincter.
It occurs due to weakness or lack of coordination in pharyngeal muscles during swallowing, increasing pressure and the pouch to form.
Symptoms: Difficulty swallowing, regurgitation of undigested food, coughing/choking when eating.
Diagnosis: Imaging studies (ex. barium swallow)
Tx: surgery

Question 29

Chin tuck

Answer 29

Widens the valleculae, so the bolus collects there, giving more time for the swallow to be triggered

Question 30

Exercises designed to stimulate the swallow reflex

Answer 30

422

Question 31

Mixed type of dysarthria associated with ALS

Answer 31

Spastic-flaccid dysarthria

Question 32

Mixed type of dysarthria associated with MS

Answer 32

Ataxic-spastic

Question 33

AAC would be recommended for those who:

Answer 33

Has severely affected intelligibility and those with progressive disease (MS or ALS)

Question 34

Where could the lesions be in AOS?

Answer 34

Lesions may be in two areas: broca’s or the primary motor cortex.

Question 35

What must be true for a diagnosis of CAS?

Answer 35

Must be older than 36 months of age
Must have received a block of early speech intervention prior to 36 months, followed by at least one block of motor speech therapy after 36 months

Question 36

What are the three core features of CAS?

Answer 36

Inconsistent errors on consonants and vowels in repeated productions of syllables or
words
Lengthened and disrupted coarticulatory transitions between sounds and syllables
Inappropriate prosody, especially in the realization of lexical or phrasal stress
More specifically:
Vowel distortions (allows you to rule out a phonological disorder)
Vowels are based on positioning/grading
Prosodic errors- equal stress and segmentation. Awkward/imprecise transitions
Groping and/or trial and error behavior

Question 37

Discuss the psychosocial impacts of stroke.

Answer 37

Communication barriers may lead to reduced participation
Reduced autonomy/ ability to express needs
Accommodations for job/ keeping a job
Fatigue may impact memory reserves which may impact conversation exchange
Loss of self
Limited insight or reasoning may put person in dangerous situation
Increased functional dependency -> caregiver burnout
Mobility limitations in the community
Apathy leading to decreased participation

Question 38

Discuss the psychosocial impacts of laryngeal/head/lung cancer.

Answer 38

Loss of voice, appearance changes and functional limitations may disrupt self image and identity
Limited mobilization due to equipment needs and environmental barriers (O2, suctioning, noise, light, immunocompromised)
Anxiety/depression

Question 39

What are some coping mechanisms that can be used by clients and families with communication disorders?

Answer 39

Use of mental health/counselling resources
Attending support groups (Eg: Niagara aphasia Program)
Facilitating a strong support system
To avoid caregiver burnout → alternate role with other family members if possible
Working with HCP to promote effective strategies to mobilize and communicate with individual
Physical activity to help alleviate tensions, frustrations/ mental health challenges
Journaling
Taking breaks when necessary

Question 40

Describe motivational interviewing.

Answer 40

A collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
Involves:
- Partnership: involves mutual respect, not imposing idea of trying to “fix” situation
- Acceptance: See others’ perspective, acknowledge their right to make decisions and the ability to recognize the other person’s strength and effort
- Compassion
- Evocation

Question 41

What are the key principles to motivational interviewing?

Answer 41

Express empathy
Develop discrepancy: guide the client to see the discrepancy between goals and current behaviour
Roll with resistance: understand that this is a necessary part of the process.
Support self-efficacy

Question 42

What are some vital skills to counselling in SLP practice?

Answer 42

Listening: non-judgemental and active.
Empathizing
What do I say: clarifying, disclosing, affirming.