Chapter 3: MSD exam Flashcards
What are the three components of the motor speech examination?
The three components of the motor speech examination are the 1. history 2. identification of salient features 3. identification of confirmatory signs.
History
The history provides information about time of onset, course of development, patients complaints and observations. It also provides an opportunity to listen to the patient’s speech without them knowing you are listening to their speech.
Salient Features
Features that contribute most directly to the diagnosis and most influence the diagnosis.
What are the Salient Neuromuscular features?
- Strength
- Speed
- Range
- Steadiness
- Tone
- Accuracy
Strength
In oder to perform appropriately, muscles have to have a certain strength. Muscle weakness can affect the 3 major speech valves: laryngeal, velopharyngeal, and articulatory. Muscle weakness can also impact the other components of speech production such as respiration, phonation, resonance, and prosody. Muscle weakness is the most prominent in flaccid dysarthria.
Speed
All speech movements require speed. Speech requires quick, unsustained and discrete movements which are called phasic movements. Phasic movements can be single muscle contractions or repetitive contractions. Phasic movements are controlled primarily through UMN input.
Speed cont.
The affects of slow movement is most seen in spastic dysarthria.
Range
decreased ROM is common and can be associated with slow or excessive speeds. ROM can vary with ataxic dysarthria. Patient’s can over or undershoot the targets- dysmetria.
Steadiness
lack of steadiness manifest itself in motor speech disorders as a tremor or other hyperkinesias.
Steadiness cont.
Tremors may be mild to severe and may affect speech as well as other parts of the body. Tremors can affect phonation and sometimes prosody. The effects of tremors in speech can best be heard in vowel prolongation. Tremors may be seen in non speech task involving the oral mechanism. Tremors can be resting tremors, intentional tremors, and terminal tremors ( at the end of a movement).
Steadiness cont.
The other hyperkinesias include dystonias, choreas, athetosis which may interfere with or be present during speech.
Tone
Tone refers to muscle tone and may either be hypo or hyper.
Accuracy
accurate movements are required for speech. inaccurate moments can result in speech errors. If there is too much f ROM the articulators may overshoot the target and vice versa. Innacurate movements also affect the major speech valve which are laryngeal, velopharyngeal and articulatory.
Confirmatory Signs
Confirmatory signs are additional clues about the pathology in the nervous system. These are signs other than the problematic speech characteristics noted and other than the neuromuscular symptoms. Confirmatory signs help support the speech diagnosis.
Confirmatory signs within the speech system
Confirmatory signs within the speech system are : atrophy, fasciculations, reduced tone, emotional lability ( spastic dysarthria), reduced normal reflexes, and pathological reflexes (spastic dysarthria)
Confirmatory signs of the nonspeech motor system
Confirmatory signs of the non speech motor system are : gait, muscle stretch reflexes, pathological reflexes, hyperactive limb reflexes, limb atrophy and fasciculations.
What does the history consist of?
introduction and goal setting basic data Onset and course of speech deficit Associated deficits Patient's perception of deficits Consequences of the disorder Management Awareness of diagnosis and prognosis
The history consist of?
Introduction and Goal setting- ask the pt why they are there. This gives you information about the patients perceptions, complaints etc.
The history consist of?
Basic data- basic information such as age, married status, education, occupation, etc. Determine any speech problems and treatment if any.
The history consist of?
Onset and course of speech deficit-When did the speech problem begin, how did it begin, i.e. suddenly, gradually, etc? How has the problem changed, if it has? Is the problem variable? Does the speech return to normal at any time? if so when? Taking any medications? Does fatigue affect speech?
The history consist of?
Associated deficits- swallowing/chewing/controlling bolus/ drooling problems?
Nasal regurgitation?
Emotional expression changes? Laugh or cry more easily and without apparent cause?
The history consist of?
The patient’s perception- Describe your problem with speech. Give examples. Is your speech slower or faster than usual;louder or softer; is speaking effortful; less intelligible, does it feel different when you talk?
The history consist of?
Consequences of the disorder- Do you have difficulty being understood by others? Do you still maintain your social network or do you go out less often?
The history consist of?
Management- How have you tried to compensate for your speech problem? What kind of professional help have you had?
The history consist of?
Awareness of diagnosis and prognosis- Do you know the cause of your problem? What has the doctor told you? Do you know how the disorder will progress?
Oral mechanism
Normally the face at rest should be symmetrical, with normal tone and little or no extraneous movement. it shouldn’t droop or be rigidly fixed or show uncontrollable emotion
Oral mechanism
Ask the pt to relax, look ahead and open lips slightly to breathe through the mouth. Notice if face is asymmetrical in this posture, angles of mouth symmetric, drooping on one side of face, eyelids, or corner of mouth, flattening of nasolabial fold.
Oral mechanism
Are there any involuntary movements, or tremors, in the face? Are there any fasciculations in the face, especially note the mouth and chin.
Oral mechanism
Face during sustained postures- have pt retract lips, round lips, puff cheeks, open mouth, and how each a few seconds. In this sustained postures, note symmetry or asymmetry, rom (normal or restricted), sagging or drooping mouth. Look for tremulousness in sustained postures. Can postures be held for several seconds?
Oral mechanism
Face during movement- Watch face during speech and non speech movements. Look for expressiveness, symmetry/asymmetry, emotional response, range of movement. Compare both voluntary and involuntary movements, i.e. smiling when something is funny and retracting lips on request.
Oral mechanism
Jaw at rest- is it tightly closed or open a little at rest? Does it hang lower than normal? Are there tremors or other involuntary movements, fasciculation’s? Does it pull to one side? Does the patient compensate by clenching teeth?
Oral mechanism
Jaw during sustained posture-Observe jaw during sustained postures such as opening of the mouth. Watch for jaw deviations to one side. Attempt to open the jaw when pt is asked to clench teeth. Can pt resist this? Palpate masseter/temporalis muscle with pt clenching teeth. Is there normal bulk? With pt holding mouth open, try to close it. can pt resist this?
Oral mechanism
Jaw in movement- watch for symmetry and ROM in speech and spontaneous movements of jaw. Have pt rapidly open and close mouth. Note speech and regularity. Are there involuntary movements which interfere with opening and closing?
Oral mechanism
Tongue at rest-Have pt open mouth and observe tongue in mouth. It should be relaxed on the floor of the mouth. Is tongue symmetrical and normal of bulk and size? Is there atrophy? Is there fasciculations? Are there other movements? Is tongue wet or dry? If dry, it may be due to zerostomia which is dry mouth associated with various causes such as meds or radiation.
Oral mechanism
Tongue in sustained posture- Have pt pot rude the tongue and hold it. Look for tongue deviations to one side. Look for ROM of tongue protrusion. Use tongue blade to push against tongue tip. Have pt push against inside of each cheek with tongue as you press against check with finger. With tongue protruded, try to push tongue to one side.
Oral mechanism
Tongue during movement - ask pt to move tongue rapidly from side to side of mouth. Look for speech regularity, ROM.
Oral mechanism
Velopharynx at rest-Have pt open mouth widely. Push gently on tongue with tongue blade. Look at palate- does it hang low, is it symmetrical?
Oral mechanism
Velopharynx during movement- Have pt say prolonged “ah” . ah- ah -ah look at palatal movement. If asymmetric, does the palate elevate more strongly on opposite side to that which hung lower at rest? Hold mirror at nose during vowel prolongation and repetition of pressure consonants. Is there evidence of nasal airflow? Hold patient’s nose during vowel prolongation. Is there a difference in resonance? Have pt puff out cheek and contain air while you try to push against cheeks. Can pt resist this?
Oral mechanism
Larynx- Assess vocal fold adduction through coughing- listen for “sharp” cough, not its loudness. A weak cough can indicate either poor vocal fold closure or poor respiratory support.
Oral mechanism
Larynx- Have pt produce glottal “coup”. This should also be sharp and requires little respiratory effort. If cough is weak and coup is sharp, implications are poor respiratory support. If both are weak, implications are poor vocal fold closure but this may be combined with poor respiratory support.
Oral mechanism
Larynx- Inhalatory stridor may indicate poor vocal fold abduction. Can be heard in quiet breathing but is more prominent usually in inspiration before speech. Laryngoscopy may be done to actually observe folds
Oral mechanism
Respiration- note if posture is normal is the to slouched or bent forward? Is head drooped forward? Does pt complain of shortness of breath? Is the breathing shallow or rapid? iis there shoulder movement or neck extension during inspiration? Is there flaring of the nares in breathing? Is breathing rate regular? Are there persistent hiccups? May be indication of medulla lesion.
Gag reflex
Elicited by touching back of tongue, posterior pharyngeal wall, or faucial pillars. The glossopharyngeal nerve provides this sensory information to the brain. The motor response is through the glossopharyngeal and vagus nerves. The reflex is characterized by palatal elevation, tongue retraction, and contraction of the pharyngeal walls. If gag reflex is present on one side and not the other, this is clinically significantly. If one side feels different its an afferent component, if it does not feel different it may be a motor component.
Jaw Jerk
Have pt relax and drop jaw. Tap with tongue blade on pts chin. Tap the blade with finger.
Sucking reflex
stroke the upper lip tongue blade, starting at the sides of the upper lip and moving toward midline.
snout reflex
lightly tap finger on philtrum- protrusion of the lower lip
palmomental reflex
vigorously stroking tongue blade on palm of hand. positive response is indicated by slight elevation of ipsilateral chin.
