Ch. 8: Neurologically Based Communicative Disorders & Dysphagia Flashcards
Aphasia
A neurologically-based language disorder caused by various types of neuropathologies (most commonly stroke). Can be classified as fluent, nonfluent, and subcortical. May or may not be accompanied by alexia, agraphia, or agnosia.
Ischemic Strokes
Caused by a blocked or interrupted blood supply to the brain. Blockage or interruption may be caused by two kinds of arterial diseases: thrombosis or embolism.
Thrombus
A collection of blood material that blocks the flow of blood.
Embolus
A traveling mass of arterial debris or a clump of tissue from a tumor that gets lodged in a smaller artery and thus blocks the flow of blood.
Hemorrhagic Strokes
Caused by bleeding in the brain due to ruptured blood vessels. Ruptures may be intracerebral (within the brain) or extracerebral (within the meninges, resulting in subarachnoid, subdural, and epidural varieties).
Primary Intracranial Tumors
Tumors that grow from within the brain.
Nonfluent Aphasias
Aphasia characterized by limited, agrammatic, effortful, halting, and slow speech with impaired prosody. Includes Broca’s, Transcortical Motor Aphasia (TMA), Mixed Transcortical Aphasia (MTA), and Global Aphasia.
Broca’s Aphasia
Nonfluent variety of aphasia caused by damage to Brodmann’s areas 44 and 45 in the posterior inferior frontal gyrus of the left hemisphere of the brain. Characterized by nonfluent, effortful, slow, halting, and uneven speech, limited word output, short phrases and sentences, misarticulated or distorted sounds, agrammatic or telegraphic speech, impaired repetition, impaired naming (especially confrontation naming), better auditory comprehension than production, difficulty in understanding syntactic structures, poor oral reading, poor comprehension of material that has been read, writing problems, and monotonous speech. Patients may also exhibit apraxia of speech and dysarthria. Patients may have right-sided paralysis or paresis. Some patients may be depressed or act emotionally when confronted with difficult tasks.
Transcortical Motor Aphasia (TMA)
Nonfluent variety of aphasia caused by lesions in the anterior superior frontal lobe, often below or above Broca’s area, which is not affected. Characterized by speechlessness, echolalia, perseveration, absent or reduced spontaneous speech, nonfluent, paraphasic, agrammatic and telegraphic speech, intact repetition skills (distinguishing characteristic of TMA), awareness of grammaticality, refusal to repeat nonsense syllables, unfinished sentences, limited word fluency, simple and imprecise syntactic structures, attempts to initiate speech with the help of motor activities, good comprehension of simple conversation, slow and difficult reading aloud, and seriously impaired writing. Patients tend to exhibit rigidity UE, akinesia, bradykinesia, buccofacial apraxia, and weakness of the legs. Patients with TMA may experience apathy, withdrawal, and little interest in communication.
Mixed Transcortical Aphasia (MTA)
Rare variety of nonfluent aphasia caused by lesions in the arterial border zone of the brain. Characterized by limited spontaneous speech, automatic, unintentional, and involuntary nature of communication, severe echolalia, severely impaired fluency, severely impaired auditory comprehension, marked naming difficulty and neologism, mostly unimpaired automatic speech, severely impaired reading, reading comprehension, and writing. Symptoms vary between patients. Patients may have bilateral upper motor neuron paralysis, quadriparesis, and visual field deficits.
Global Aphasia
Most severe form of nonfluent aphasia. Caused by extensive lesions affecting all language areas (perisylvian region). Characterized by profoundly impaired language skills, greatly reduced fluency, limited expressions, impaired repetition, impaired naming, auditory comprehension limited to single words, perseveration, and impaired reading and writing. Patients may have verbal and nonverbal apraxia, and strong neurological symptoms, such as right-sided paresis or paralysis, right-sided sensory loss, and neglect of the left side of the body.
Fluent Aphasias
Aphasias characterized by relatively intact fluency but generally less meaningful, or even meaningless, speech. Speech is generally flowing, abundant, easily initiated, and well-articulated with good prosody and phrase length. Includes Wernicke’s, Transcortical Sensory Aphasia (TSA), and Conduction Aphasia.
Wernicke’s Aphasia
Common variety of fluent aphasia caused by lesions in the posterior portion of the superior temporal gyrus in the left hemisphere of the brain. Characterized by effortlessly produced fluent speech, rapid rate of speech with normal prosodic features and good articulation, intact grammatical structures, severe word-finding problems, semantic and literal paraphasias, extra syllables in words, creation of meaningless words (neologisms), circumlocution, empty speech, poor auditory comprehension, impaired conversational turn taking, impaired repetition, reading comprehension problems, writing problems, and overall poor communication despite fluent speech. Less frustrated with failed communication attempts. Sometimes mistaken for psychiatric patients. Generally free from neurological symptoms and paresis and paralysis are uncommon.
Transcortical Sensory Aphasia
A variety of fluent aphasia caused by lesions in the temporoparietal region of the brain. Characterized by fluent speech with normal phrase length, good prosody, normal articulation, and appropriate grammar and syntax, paraphasic and empty speech, severe naming problems and pauses due to those problems, good repetition, poor comprehension, echolalia, impaired auditory comprehension, difficulty pointing, difficulty answering yes/no questions, normal automatic speech (e.g., counting), tendency to complete poems and sentences started by the clinician, good oral reading but poor comprehension, and writing problems parallel to their expressive speech. Neglect may be common. Similar to Wernicke’s aphasia, but repetition is intact in this aphasia.
Conduction Aphasia
Rare variety of fluent aphasia caused by lesions in the area between Wernicke’s and Broca’s areas of the brain. Characterized by disproportionate impairment in repetition (a distinguished impairment), variable speech fluency across patients, paraphasic speech, marked word-find problems (especially content words), empty speech because of omitted content words, efforts to correct speech, good syntax, good prosody, good articulation, severe to mild naming problems, near-normal auditory comprehension, variable reading problems, writing problems, and buccofacial apraxia. Similar to Wernicke’s aphasia, except patients with this aphasia have good to normal auditory comprehension. Some may have right-sided paresis or sensory impairment.
Anomic Aphasia
Variety of fluent aphasia characterized by a very debilitating and pervasive word-finding difficulty (most distinguished feature), pointing to named objects is unimpaired, generally fluent speech, normal syntax except for pauses, empty speech, verbal paraphasia (word substitutions), circumlocution, good auditory comprehension, intact repetition, good articulation, normal oral reading skills and good reading comprehension, and normal writing skills.
Subcortical Aphasia
Aphasia caused by lesions to either the basal ganglia or thalamus within the left hemisphere of the brain. Symptoms depend on location of lesion.
Subcortical Aphasia (Left Basal Ganglia)
Type of subcortical aphasia characterized by fluent speech, intact repetition skills, normal auditory comprehension, articulation problems, prosodic problems, word-finding problems, semantic paraphasia, relatively preserved writing skills, and limb apraxia if the lesions extend posteriorly to deep white matter in the parietal lobe.
Subcortical Aphasia (Left Thalamus)
Type of subcortical aphasia characterized by hemiplegia, hemisensory loss, right visual field problems, sometimes coma, initial mutism which may improve, severe naming problems, good auditory comprehension, good repetition skills, and impaired reading and writing skills.
Alexia
A loss of previously acquired reading skills due to recent brain damage.
Agraphia
Loss or impairment or normally acquired writing skills due to lesions in the foot of the second frontal gyrus of the brain, sometimes referred to as Exner’s writing area.
Agnosia
Impaired understanding of the meaning of certain stimuli even though there is no peripheral sensory impairment. Patients can see, feel, and hear stimuli but cannot understand their meaning. Impairment is often limited to one sensory modality. The meaning of stimuli may be grasped in another modality.
Auditory Agnosia
Associated with bilateral damage to the auditory association area. Characterized by impaired understanding of the meaning of auditory stimuli, normal peripheral hearing, difficulty in matching objects with their sound, and normal visual recognition of objects.
Auditory Verbal Agnosia
Associated with bilateral temporal lobe lesions that isolate Wernicke’s area. Often called pure word deafness. Characterized by impaired understanding of spoken words, normal peripheral hearing, normal recognition of nonverbal sounds, normal recognition of printed words, and normal or near-normal verbal expression and reading.
Visual Agnosia
A rare disorder often associated with bilateral occipital lobe damage or posterior parietal lobe damage. Characterized by impaired visual recognition of objects, which may be intermittent, and normal auditory or tactile recognition of objects.
Tactile Agnosia
Associated with lesions in the parietal lobe. Characterized by impaired tactile recognition of objects when visual feedback is blocked (as with a blindfold), impaired naming objects clients can feel in their hands, and impaired description of objects clients can feel in their hands.
Apraxia of Speech
A neurogenic speech disorder characterized by sensorimotor problems in positioning and sequentially moving muscles for the volitional production of speech. Primarily an articulatory-phonologic disorder, although its etiology and characteristics are different from those of similar disorders in children. Adult patients will have acquired articulation normally, with current problems being due to recent neuropathology. Patients have unimpaired reflex and automatic acts. Difficulty is mostly in executing the voluntary movements involved in speech. May be associated with prosodic problems. Not caused by muscle weakness or neuromuscular slowness. Thought to be a disorder of motor programming.
Apraxia
A basic disorder of volitional movement in the absence of muscle weakness, paralysis, or fatigue.
Nonverbal Oral Apraxia
A disorder of nonverbal movement involving the oral muscles.
Dysarthrias
Neurologically based speech disorders, distinct from similarly based language disorders such as aphasia. Distinct from apraxia of speech, a neurogenic speech disorder, or motor planning/programming of speech movements with no muscular weakness or paralysis. Oral communication problems that accompany dysarthria include respiratory, articulatory, phonatory, resonatory, and prosodic disturbances that are caused by weakness, incoordination, or paralysis of speech musculature. Different types share certain characteristics. Impaired muscular control of the speech mechanism and peripheral or central nervous system pathology are common to all forms. Differences in the nature and loci of pathology create different forms of the disorder. Etiological factors include degenerative neuromuscular diseases and nonprogressive neurological conditions. Common lesion sites include the lower motor neuron, unilateral or bilateral upper motor neuron, cerebellum, and basal ganglia (extrapyramidal system). Problems include:
- Muscle weakness
- Spasticity
- Incoordination
- Rigidity
- Variety of movement disorders (reduced or variable range and speed of movement, involuntary movements, reduced strength of movement, unsteady or inaccurate movement)
- Abnormal muscle tone (increased, decreased, or variable)
Ataxic Dysarthria
Dysarthria that results from damage to the cerebellar system. Characterized predominantly by articulatory and prosodic problems. Neuropathology includes cerebellar lesions, degenerative ataxia, cerebellar vascular lesions, tumors, TBI, toxic conditions, and inflammatory conditions. Major characteristics include:
- Gait disturbances (instability of the trunk and head; tremors and rocking motions; rotated or tilted head posture; hypotonia)
- Movement disorders (over- or undershooting of targets; uncoordinated, jerky, inaccurate, slow, imprecise, and halting movements)
- Articulation disorders (imprecise production of consonants; irregular articulatory breakdowns and distortion of vowels)
- Prosodic disorders (excessive and even stress; prolonged phonemes and intervals between words or syllables; slow rate of speech)
- Phonatory disorders (monopitch, monoloudness, and harshness)
- Speech quality (impression of drunken speech)
Flaccid Dysarthria
Dysarthria resulting from damage to the motor units of cranial or spinal nerves that supply speech nerves (lower motor neuron involvement). Neuropathology includes myasthenia gravis, botulism, vascular diseases, brainstem strokes, infections, demyelinating diseases, degenerative diseases, and surgical trauma to the brain, larynx, face, or chest. Characteristics include:
- Various muscular disorders
- Fasciculations and fibrillations
- Respiratory weakness, CN weakness
- Phonatory disorders (breathy voice, audible inspiration, short phrases)
- Resonance disorders (hypernasality, imprecise consonants, nasal emission)
- Phonatory-prosodic disorders (harsh voice, monopitch, monoloudness)
- Articulation disorders
Fasciculations
Isolated twitches of resting muscles.
Fibrillations
Contractions of individual muscles.
Hyperkinetic Dysarthria
Dysarthria resulting from damage to the basal ganglia (extrapyramidal system). Caused by degenerative, vascular, traumatic, infectious, neoplastic, and metabolic factors. Associated with involuntary movement and variable muscle tone. Prosodic disturbances are prominent. Characterized by:
- Movement disorders (abnormal and involuntary movements of orofacial muscles)
- Myoclonus, tics of the face and shoulders, tremor, chorea, abrupt and severe contractions of the extremities, writhing movements, spasms
- Dystonia, spasmodic torticollis, blepharospasm
- Communicative disorders depending on the dominant neurological conditions
- Phonatory disorders (voice tremor, intermittently strained voice, voice stoppage, vocal noise, harsh voice)
- Resonance disorders (intermittent hypernasality)
- Prosodic disorders (slower rate, excess loudness variations, prolonged interword intervals, equal stress)
- Respiratory problems (audible inspiration, forced and sudden inspiration and/or expiration)
- Inconsistent articulation problems, including imprecise consonant productions and distortion of vowels
Myoclonus
Involuntary jerks of body parts.
Athetosis
Writhing, involuntary movements.
Spasms
Sudden and involuntary contractions of a muscle or group of muscles.
Dystonia
Abnormal postures resulting from contractions of antagonistic muscles.
Spasmodic Torticollis
Intermittent dystonia and spasms of the neck muscles.
Belpharospasm
Forceful and involuntary closure of the eyes due to spasm of the orbicularis oris muscle.
Hypokinetic Dysarthria
Dysarthria resulting from damage to the basal ganglia (extrapyramidal system). Caused by degenerative diseases (commonly PD) and vascular disease (strokes), head injury, inflammation, tumor, drug toxicity, and hydrocephalus. Characterized by:
- Tremors in resting facial, mouth, and limb muscles that diminish when moved voluntarily
- Mask-like face with infrequent blinking and no smiling
- Micrographic writing
- Walking disorders
- Postural disturbances (involuntary flexion, difficulty changing positions)
- Phonatory disorders, such as monopitch, low pitch, monoloudness, and harsh and breathy voice
- Decreased swallowing (accumulation of saliva in mouth and drooling)
- Prosodic disorders, such as reduced stress, inappropriate silent intervals, short rushes of speech, variable and increased rate in segments, and short phrases
- Articulation disorders, such as imprecise consonants, repeated phonemes, resonance disorders, mild hypernasality
- Respiratory problems, including reduced vital capacity, irregular breathing, and faster rate of respiration
Spastic Dysarthria
Dysarthria resulting from bilateral damage to the UMN (direct and indirect motor pathways). Typically from lesions in multiple areas, commonly the cortical areas, basal ganglia, internal capsule, pons, and medulla. Characterized by:
- Spasticity and weakness (bilateral face weakness), jaw strength may be normal and lower face weakness may be mild
- Movement disorders, including reduced range and slowness, loss of fine and skilled movements, increased muscle tone
- Hyperactive gag reflex
- Hyperadduction of VF, inadequate closure of VP port
- Prosodic disorders, including excess and equal stress, slow rate, monopitch, monoloudness, reduced stress, short phrases
- Articulation disorders, including imprecise production of consonants and distorted vowels
- Phonatory disorders, including continuous breathy voice, harshness, low pitch, pitch breaks
- Resonance disorders with a predominant hypernasality
Mixed Dysarthrias
A combination of two or more pure dysarthrias. All combinations are possible. Two most common forms:
- Flaccid-spastic dysarthria
- Ataxic-spastic dysarthria
Mixed Flaccid-Spastic Dysarthria
Mixed dysarthria characterized by imprecise production of consonants, hypernasality, harsh voice, slow rate, monopitch, short phrases, distorted vowels, low pitch, monoloudness, excess and equal stress or reduced stress, prolonged intervals, prolonged phonemes, a strained and strangled quality, breathiness, audible inspiration, inappropriate silences, and nasal emission.
Mixed Ataxic-Spastic Dysarthria
Mixed dysarthria characterized by impaired loudness control, harsh vocal quality, imprecise articulation, impaired emphasis, hypernasality, inappropriate pitch levels, and sudden articulatory breakdowns.
Unilateral Upper Motor Neuron Dysarthria
Dysarthria resulting from damage to the UMNs that supply cranial and spinal nerves involved in speech production. LH lesions → dysarthria + aphasia or apraxia. RH lesions → dysarthria + RH syndrome. Characterized by:
- Unilateral lower face weakness, unilateral tongue weakness, unilateral palatal weakness, and hemiplegia/hemiparesis
- Articulation disorders, including imprecise production of consonants and irregular articulatory breakdowns
- Phonatory disorders, including harsh voice, reduced loudness, and strained harshness
- Prosodic disorders, including slow rate, increased rate in segments, excess and equal stress, monopitch, monoloudness, low pitch, short phrases
- Resonance disorders, predominantly hypernasality
- Dysphagia, aphasia, apraxia, and right hemisphere syndrome
Treatment Goals for Dysarthria
Treatment goals include modification of respiratory, phonatory, articulatory, resonatory, and prosodic problems and increasing efficiency, effectiveness, and naturalness of communication. Also include increasing physiologic support for speech and teaching self-correction, self-evaluation, and self-monitoring skills. Teaching compensatory behaviors for lost or reduced functions is important, and teaching the used of AAC may be necessary.
Treatment Procedures for Dysarthria
Treatment procedures include intensive, systematic, and extensive drill, instruction, demonstration, modeling (followed by imitation), shaping, prompting, fading, differential reinforcement, and other proven behavioral management procedures. When necessary, phonetic placement and its variations can be taught. Instrumental feedback or biofeedback may be used when needed.
