Chapter 3 Motor Speech Disorders Exam

Question 1

Purpose of Exam (5)

Answer 1

> Give a description of the patient’s speech
To establish diagnostic possibilities
To establish a diagnosis
To establish implications for localization and disease diagnosis
To specify severity

Question 2

Purpose of Exam: Giving a description

Answer 2

> Describes patient’s speech and structures/functions associated with speech
Determines if the descriptions are normal or abnormal
Attempts differential diagnosis based on those descriptions

Question 3

Purpose of Exam: Establishing diagnostic possibilities

Answer 3

> Attempts to determine possible diagnosis
Type of disorder: Apraxia, Dysarthria, Aphasia
Type of problem: Neurological, Developmental, Acquired

Question 4

Purpose of Exam: Establishing diagnosis

Answer 4

> Attempt to make a specific diagnosis based on possibilites

>If undetermined than list possibilities in order of most likely to least likely

Question 5

Purpose of Exam: Establishing implications for localization and disease diagnosis

Answer 5

> Clinician should state the diagnosis and localization associated with that diagnosis
e.i. spastic dysarthria associated with UMN involvment
e.i. ataxic dysarthria associated with cerebellar involvement
State if the MSD findings are inconsistent with the previous disease diagnosis
Uncertain diagnosis indicate possibilities

Question 6

Purpose of Exam: Specifying severity

Answer 6

MILD, MODERATE, SEVERE
The SLP should always comment on severity in order to:
>Compare with the patient’s complaints and determine possible psychogenic component or lack of patient insight
>Influences prognostic decision and how to manage the disorder
>Provides baseline information to compare progress or changes

Question 7

General Guidelines for Exam (4)

Answer 7

> History
Salient features
Confirmatory signs
Interpretation of findings

Question 8

General Guidelines for Exam: History

Answer 8

>Very important
>Time of onset
>Course of development
>Patient's complaints and observations
>Provides an opportunity to listen to patient's speech  and evaluate without them knowing

Question 9

General Guidelines for Exam: Salient features

Answer 9

Features that most directly contribute to/influence the diagnosis
>Strength (muscle weakness most commonly associated with flaccid dysarthria)
>Speed (phasic movements controlled with UMN input) too much speed = Hypokinetic
>Range decrease ROM associated with slow/excessive speeds, varying ROM = Ataxic
>Steadiness lack of steady manifest as tremors or hyperkinesias and can affect phonation/prosody and vowel prolongation
>Tone (muscle tone, hyper or hypo)
>Accuracy associated with movements which can result in speech errors

Question 10

General Guidelines for Exam: Confirmatory signs

Answer 10

Additional clues about the pathology in the nervous system which help support speech diagnosis
>In speech: atrophy and fasiculations, emotional liability, reduced tone
>Non speech: Gait, limb reflexes, pathological reflexes

Question 11

General Guidelines for Exam: Interpretations of findings

Answer 11

Integrate information from the patient’s history, salient features, confirmatory signs to make a diagnosis

Question 12

Motor Speech Exam: History

Answer 12

>Intro and goal setting
>Basic demographic data
>Onset and course of deficit
>Associated deficits (swalliowing/drooling)
>Patient's perception of deficits
>Consequences (difficulty being understood)
>Management (how have compensated)
>Awareness of diagnosis and prognosis

Question 13

Motor Speech Exam: Face at rest

Answer 13

> Symmetry and tone should be normal
Shouldn’t droop, be rigidly fixed, have extraneous movements or uncontrollable emotions
Ask patient to relax and look ahead with mouth slightly open to breathe through
Look at corners of mouth, lips, eyes, chin, nasolabial fold, expression, facial posture, movements

Question 14

Motor Speech Exam: Face during sustained posture

Answer 14

> Have patient retract lips, round lips, puff cheeks, open mouth
Can postures be held for several seconds?
Is patient able to resist clinicians attempts change the posture?
Note symmetry, ROM, sagging. tremors, drooping

Question 15

Motor Speech Exam: Face during movement

Answer 15

During speech and non speech movements look for:
>symmetry
>emotional response
>ROM
Compare in voluntary and involuntary movements

Question 16

Motor Speech Exam: Jaw at rest

Answer 16

>Tightly closed or open at rest?
>Hanging lower than normal?
>Tremors or involuntary movements?
>Fasiculations?
>Pulling to one side?
>Patient compensation?

Question 17

Motor Speech Exam: Jaw during sustained posture

Answer 17

> Observe jaw in sustained posture such as mouth opening and watch for deviations
Attempt to open jaw with clenched teeth to check patient’s resistance
Palpate masseter/temporalis while clenching teeth to check for bulk
Attempt to close the patients open mouth to check for resistance

Question 18

Motor Speech Exam: Jaw in movement

Answer 18

Watch for symmetry and ROM in speech and spontaneous movements of jaw
>Have patient rapidly open and close mouth and not speed and regularity

Question 19

Motor Speech Exam: Tongue at rest

Answer 19

Have patient open mouth and observe tongue inside (slight movement is okay)
>Is tongue symmetrical and of normal bulk and size?
>Is there atrophy/fasiculations?
>Other movements?
>Is it wet or dry?

Question 20

Motor Speech Exam: Tongue in sustained posture

Answer 20

Have patient protrude tongue and hold it
>Look for Deviations and have patient repeat task
>Look for ROM of tongue potrusion
>Can patient resist pushing tongue to each side?
>Can patient resist pushing on tongue tip?
>Can patient resist pushing on cheek?

Question 21

Motor Speech Exam: Tongue during movement

Answer 21

> Ask patient to move tongue rapidly from side to side
Look for speech regularity
Look at ROM

Question 22

Motor Speech Exam: Velopharynx at rest

Answer 22

Look at palate
>Hanging low?
>Symmetrical?

Question 23

Motor Speech Exam: Velopharynx during movement

Answer 23

Have patient say a prolonged "ah"
>look for palatal movement
>Look at symmetry of movement
Hold mirror under nose during "ah" and pressure consonants
>is there nasal airflow?
Hold patients nose during vowel
>is there a difference in resonance?
Have patient puff cheeks with air 
>Can they resist pushing against cheeks?
Have patient puff up cheeks with tongue out
>Does air escape from nose?
If possible observe VP activity during videoflouroscopy

Question 24

Motor Speech Exam: Larynx

Answer 24

Assess VF adduction through coughing
>Listen for cough sharpness not loudness
>Weakness indicates either poor VP closure or poor respiratory support
Glottal Coup requires little respiratory effort
>If cough is weak and coup is sharp then there is weak respiratory support
>If both are weak then there is definitely poor VF but may also have weak respiratory support
>Inhalatory stridor may indicate poor vocal fold abduction
Observe VF through Flex scope, rigid scope, video strobe, EGG

Question 25

Motor Speech Exam: Respiration

Answer 25

> Note posture and possible affects on breathing
Patient complaints with breathing at rest or active
Is breath short, shallow, or rapid
Clavicular breathing associated with respiratory weakness and reduced loudness
Is breathing rate regular, flaring of nares, persistent hiccups (medulla)
Contrast sharpness of cough to glottal coup
Patient should be able to blow through a straw (placed at least 5cm deep) into a cup filled at least 12cm with water and produce and maintain a stream of bubbles for at least 5 seconds

Question 26

Motor Speech Exam: Reflexes

Answer 26

Two types: Normal (normal nervous system0 and Pathological (present during infancy and and reappear due to CNS disease)
>Gag reflex
>Jaw jerk
>Sucking reflex
>Snout reflex 
>Palmomental reflex (pathological)

Question 27

Motor Speech Exam: Volitional vs. Automatic non speech movements

Answer 27

Nonverbal oral apraxia (NVOA) patients are able to do involuntary oral movements but may not able to upon command
>Often but not always associated with AOS
>Have the client attempt to imitated if unable to execute movements on command

Question 28

Motor Speech Exam: Tasks for speech assessment

Answer 28

> Vowel prolongation
AMRs individual syllables
SMRs
Contextual speech (GF passage, conversational speech
Fatigue (read aloud for 2-4 minutes repeat after 1-2 minute rest period)
Speech motor planning: SMRs and multisyllabic words