Chapter 5: Assessment and Diagnosis

Question 1

Why is assessment important in SALT?

Answer 1

Must lead to a diagnosis.
Diagnosis informed by results of assessment.
Also by nosology of communication disorders and diseases, as well as general disability.

Question 2

What answers must a SLT provide regarding assessment? 6.

Answer 2

1. What aspect(s) of a client’s communication skills/swallowing requires evaluation?
2. How can these skills best be evaluated?
3. What knowledge, training and clinical expertise are required to evaluate these skills?
4. What equipment is required to evaluate these skills?
5. Are the required equipment/expertise available?
6. Are there any circumstances that preclude the use of an assessment in this case?

Question 3

What are the advantages of formal assessment? 5.

Answer 3

1. Standardized - uniform tests.
2. Norm-referenced - results can be compared to other groups.
3. Administration - quick and easy.
4. Intervention - permits comparison of pre- and post- intervention skills.
5. Common language - terms e.g. Z scores will be understood by other professionals.

Question 4

What are the disadvantages of formal assessment? 5.

Answer 4

1. Poor ecological validity - doesn’t resemble everyday communication.
2. Discrete skills - aspects of language which typically interact (e.g. grammar and phonology) are isolated.
3. Formal situation - client anxiety.
4. Equipment and stimuli - test stimuli/equipment may not be culturally appropriate/disadvantage certain social backgrounds.
5. Normative data - limited normative data may restrict us of tests to certain ages/educational/social backgrounds.

Question 5

What are the advantages of informal assessment? 5.

Answer 5

1. Language use - can evaluate pragmatics and discourse.
2. Good ecological validity - everyday conversation.
3. Compensatory strategies - can assess effectiveness of spontaneous strategies.
4. Conversation partners - can assess the extent to which partners facilitate and hinder communication with the client.
5. Informal situation - relaxed communication.

Question 6

What are the disadvantages of informal assessment? 5.

Answer 6

1. Transcription and analysis - time and labour intensive.
2. Non-standardized - lack of standardized procedures may not reflect client’s real abilities.
3. Intervention - unclearer progress.
4. Normative data - data lack makes it difficult to compare client.
5. Reduced structure - clients with cognitive deficits may not cope with reduced structures.

Question 7

Why is it important for speech assessments to be conducted with a client who had reduced intelligibility?

Answer 7

Should be conducted with reduced intelligibility.
Aim of assessment - uncover which disorder is causing this.
E.g. structural defect of articulation organs such as palate or jaw or tongue.
E.g. Programming of motor movements is impaired (apraxia).

Question 8

What does an oral mechanism examination involve?

Answer 8

Structural and functional adequacy of lips, teeth, tongue, mandible (jaw) and hard/soft palate.
Note symmetry, muscle tone, movement symmetry, tongue strength.
E.g. tongue depressor - SLTs can screen cranial nerves.

Question 9

What is dysarthria?

Answer 9

Unclear articulation of speech.
Spastic dysarthria - increased muscle tone (hypertonia), reduced movement range, weakness, hyperactive gag reflex and pathological oral reflexes (suck).
Other subsystems - respiration, resonation.
E.g. reduced pitch variability (monopitch) and loudness (monoloudness).

Question 10

What is the GFTA test?

Answer 10

Goldman-Fristoe Test of Articulation (2015).
Used for unintelligible speech but no motor speech disorder suspicions.
Ages 2-21 years.
Spontaneous sound production is examined in word-initial, medial and final positions.
1. Sounds in words - picture plates and verbal cues e.g. An apple is a fruit, a carrot is a ____.
2. Sounds in sentences - retell short story based on picture cue. Intelligibility rating.
3. Stimulability section - measures ability to correctly produce a previously misarticulated word after examiner models word.

Question 11

What is the KLPA test?

Answer 11

Khan-Lewis Phonological Analysis (2015).
Detects if articulatory errors are related to the presence of phonological processes.
Requires administration of 60 target sounds in words from GFTA test.
Grouped by manner, place, reduction and voicing.
Standard scores and percentiles are used.

Question 12

What instrumental techniques can be used to assess?

Answer 12

Nasometry, videofluoroscopy and electropalatography can be used to assess structural anomalies.
Nasometry - measures acoustic correlate of nasality. Confirms hypernasal resonance.
Video - radiographic tool used to assess velum movement and velopharyngeal port closure.
Electro - assess lingual involvement of range of aberrant articulations. Palatable plate worn. Electrodes record any contact between tongue and hard and soft palates. Provides visual feedback to clients. Becoming increasingly popular but not suitable for all clients.

Question 13

Why does formal assessment dominate assessment of language in SLT?

Answer 13

Aim is to see if child’s language skills are age-appropriate - comparison (norm-referenced).
SLTs must demonstrate efficiency to caregivers - comparison made between pre and post-intervention.
Ease of administration and scoring - analysing a conversation can take hours.
Small formal - 10-20 mins.
Large formal - 30-45 mins.

Question 14

What is a widely used test for aphasia?

Answer 14

BDAE-3 (Goodglass et al., 2001).
Three versions: standard, short and extended.
16+ years and takes 90 mins (40-60 mins - short).
5 tests: Conversational and Expository Speech, Auditory Comprehension, Oral Expression, Reading and Writing.
Extended - contains four subtests: natural, conventional gestures, use of pretend objects and bucco-facial respiratory movements.
Can also calculate three other scores: Severity Rating Scale, Rating Scale of Profile of Speech Characteristics and Language Competency Index.

Question 15

What are some simple assessment tools that can help assess pragmatic and discourse features?

Answer 15

Topic management, turn-taking, conversational repair and story grammar.
Checklists, pragmatic profiles and rating scales can help guide the analysis.

Question 16

What is the definition of stuttering?

Answer 16

Unique anomaly in the flow of speech characterised by iterative and/or perspective speech elements involving word/syllable word/syllable initial position.
In prolongations - phoneme prolonged beyond its normal duration.

Question 17

How can stuttering develop?

Answer 17

2.5-4 years - developmental.
TBI - acquired neurogenic stuttering.
Traumatic event - acquired psychogenic stuttering.

Question 18

What is the definition of cluttering?

Answer 18

Often occurs alongside stuttering.
Rapid/irregular speech.
Accompanied by: excessive non-stuttering like dysfluencies (related to thought formation).
Excessive collapsing/deletion of syllables.
Syllable stress or speech rhythm.
Can be developmental or acquired - linked to TBI and Down’s.

Question 19

How do SLTs assess fluency regarding stuttering?

Answer 19

Aim is to characterise the nature and the extent of a client’s dysfluency.
Percentage of stuttered syllables (words) in a speech sample divided by the total number of words and multiplying by 100.

Question 20

What is the Stuttering Severity Instrument - Fourth Edition (SSI-4: Riley, 2009)?

Answer 20

Average stutter duration of the longest three stutters.
Included are: distracting sounds, facial grimaces, head movements and extreme movements.
Can be done in 15-20 mins.

Question 21

What is the KiddyCAT test? (Vanryckeghem and Brutten, 2007)?

Answer 21

Only kind of assessment that includes beliefs.
12-item binary (yes/no) questionnaire - designed to elicit 3-6 child responses to their own communication attitudes.
E.g. is it hard for you to say words?

Question 22

What is the Overall Assessment of the Speaker’s Experience of Stuttering? (OASES)

Answer 22

Takes 15-20 mins and 5 mins to score.
5 point Likert scale.
Address stutters’ quality of life.
Available for school-age, teenagers and adult.
Addresses:
Speaker’s perceptions about stuttering.
Negative behavioural and cognitive reactions they have to stuttering.
Functional everyday communication issues.
Impact on quality of life.

Question 23

What is the Predictive Cluttering Inventory? (Daly, 2006)

Answer 23

33 descriptive statements.
Pragmatics, speech-motor, language-cognition, motor coordination writing problems.
Maximum PCI score is 198.
Usually between 80-120.
Can be diagnosed as a pure clutterer or a clutterer-stutterer.

Question 24

What is the Cluttering Severity Instrument?

Answer 24

CSI - computer-based assessment.
Assesses 8 sections:
1. Overall intelligibility.
2. Speech rate regularity.
3. Speech rate.
4. Articulation precision.
5. Typical dysfluency.
6. Language disorganisation.
7. Discourse management.
8. Use of prosody.

Question 25

Why is it important for SLTs to know the client case history regarding fluency?

Answer 25

Biological stuttering relatives - provides genetic aetiology.
Motor milestone delays.
Environmental factors.
Traumatic events.
Adults with developmental stuttering - can shed light as to why previous interventions failed.
Can highlight avoidance behaviours e.g. words the speaker is afraid of or social situations.

Question 26

How can voice disorders arise?

Answer 26

Laryngeal injury or disease.
Presence of vocal nodules and polyps.
Tumours.
Paralysis of vocal folds.

Question 27

What are functional voice disorders?

Answer 27

No structural or neurological abnormalities.
Hyperfunctional voice disorders - related to larynx overuse.
Psychogenic dysphonias - psychological factors.
Boundaries often overlap - organic, psychological and misuse/overuse factors play a role in aetiology.
E.g. gastroesophageal reflux disease (GERD) - organic basis.
Excessive coughing - exasperates dysphonia - behavioural overuse response.
May then face anxiety/depression - psychological.

Question 28

What can help SLTs assess voice disorders?

Answer 28

Laryngoscopy and Stroboscopy:
Helps visualise the larynx structure and movement during phonation.
Can be used to detect organic pathologies.
E.g. hoarseness - vocal nodules.
Perceptual assessments e.g. reduced voice intensity in Parkinson’s disease.
Acoustic techniques e.g. frequency, jitter and shimmer.

Question 29

How is a Laryngoscopy carried out?

Answer 29

To establish if organic pathology is responsible.
Performed by an otolaryngologist.
Indirect (mirror) laryngoscopy - client says high pitch ‘ee’ whilst examiner places laryngeal mirror against elevated soft palate.
Tongue is wrapped in gauze and held by examiner - examiner wears mirror on head.
Light is used to reflect this head mirror onto client mirror - reflected into the pharynx and larynx.
Not suitable for all patients.

Question 30

What is a fibreoptic laryngoscopy?

Answer 30

Flexible endoscope is passed transnasally into a position above larynx.
Advantage - phonation can be observed through connected speech.
Presence of larynx mirror in oral captivity prevents visualisation.

Question 31

What is Strobovideolarynoscopy?

Answer 31

Common technique for assessing vocal fold vibration.
Intermittent light flashes - stimulates slow motion of vocal folds.
Allows to examine different stages of vibratory cycle.

Question 32

How common are instrumental techniques regarding assessing voice disorders?

Answer 32

SLTs less likely to perform aerodynamic assessment that any other voice evaluation.
81% likely to use stroboscopy but only 17% likely to use aerodynamic measurement.
42% don’t have aerodynamic equipment access.

Question 33

What are some aerodynamic measures?

Answer 33

.Instrumental measures - includes airflow, mean subglottal pressure and glottal efficiency.
Airflow - divided air mask used to measure oral and nasal flow.
Airway resistance, sound pressure levels, adduction/abduction rate of vocal folds.

Question 34

What is Electroglottography?

Answer 34

Instrumental technique used to measure patterns of vocal fold approximations.
Electrode is placed at the side of the thyroid cartilage at the vocal fold levels.
Distinct waveforms are generated as the client phonates.
Waveforms correspond to clinically judged voice qualities e.g. hoarseness and breathiness.

Question 35

What is the Consensus Auditory-Perceptual Evaluation of Voice? (CAPE-V)

Answer 35

1. Overall severity.
2. Roughness.
3. Breathiness.
4. Strain.
5. Pitch.
6. Loudness.
   Regions marked as MI (mildly deviant), MO (moderately deviant) and SE (severely deviant).
   Score out of 100.
   Also marked by C (consistent) and I (intermittent).

Question 36

What is the GRBAS scale? (Hirano, 1981)

Answer 36

Five parameters:
1. G (overall hoarseness).
2. R (roughness).
3. A (asethenic).
4. B (breathiness).
5. S (strained quality).
0-3 rating (3 - severe).
Often used to assess breathiness in the ageing female voice.
However not fully comprehensive - doesn’t contain vocal pitch.
Is reliable - is related to quality of life.

Question 37

What is the computer-assisted voice analysis system?

Answer 37

Multi-Dimensional Voice Program (MDVP).
Examines 33 acoustic variables including jitter and shimmer.
Non-invasive.
Variables compared graphically/numerically.

Question 38

What do self-report measures for voice disorders involve?

Answer 38

Voice-Related Quality of Life (V-RQOL) and Voice Handicap Index (VHI).
Valid and reliable.
Series of statements - 1-5.
Describes physical e.g. I have trouble speaking loudly and social-emotional domain e.g. I am anxious.
VHI - 30 item questionnaire - functional, physical and emotional impacts.
0-4 rating.
Functional - people have difficulty understanding me.

Question 39

When can dysphagia occur?

Answer 39

Involves 30 nerves and muscles.
Result of structural and functional impairments of the oral cavity, pharynx, larynx or oesphagus.
Only 50% clients display overt dysphagia symptoms e.g. coughing, repeated swallowing and throat clearing.

Question 40

What are some examples of how structural/functional dysphagia can occur?

Answer 40

Oral cavity compromised - oral cancer - glossectomy/cleft palate.
Cerebral palsy - pharyngeal walls - reduces wall contraction strength.
Larygneal cancer - supraglottic laryngectomy - reduced larynx elevation.
Tumour - mechanical obstruction.

Question 41

How can neurogenic, viral, neuroplastic and traumatic dysphagia occur?

Answer 41

Neurogenic - Stroke.
Viral - bacterial/fungal agents - candida albicans.
Neoplastic - maligant larygneal tumours.
Traumatic casuses - cervical spine trauma.

Question 42

How is a Videoendoscopy used to assess dysphagia?

Answer 42

Essential for visualising oral/pharyngeal swallowing stages.
Fibreoptic endoscopic examination (FEES).
Small, flexible scope is passed through nose to soft palate level.
Pharyngeal and laryngeal strictures can be viewed before/after swallowing - but not during.
Allows assessment of airway protection, timing of swallowing, occurrence of swallowing, presence of residue and ability to clear residue and reflux presence,

Question 43

What are the advantages/disadvantages of a videoendoscopy?

Answer 43

Advantages:
1. No X-ray exposure.
2. Portal - beside procedure.
Disadvantages:
1. Doesn't allow visualisation of oral stage of swallowing and critical aspects of the pharyngeal phase of swallowing e.g. laryngeal evaluation, tongue-based motion and upper oesophageal sphincter.

Question 44

What does a videofluoroscopy involve?

Answer 44

Client swallows contrast agent (barium sulphate preparation).
Different barium volumes/viscosities can affect timing/organisation of swallowing.
1,3,5 and 10 ml of thin liquids, cup-drinking thin liquids, straw-drinking liquids, 3ml of pudding-thick barium and 1/4 cookie dipped in barium to be chewed so that mastication (chewing) can be seen.
Client starts off seated - ends with anterior-posterior view to assess swallow symmetry and vocal cord function.
Can be completed in 90-120 seconds.

Question 45

What are the advantages/disadvantages of videofluoroscopy?

Answer 45

Advantages:
1. Permits visualisation of all aspects of orpharyngeal swallowing (exception of vocal fold closure).
Disadvantages/should not be performed if:
1. Medically unstable/not able to cooperate - unsuitable.
2. Patient pregnancy and severe obesity.
3. Nil by mouth.
4. Adverse reaction to X-ray contrast.

Question 46

What are some points re. the oesophageal stage of swallowing?

Answer 46

Oesphageal dysphagia is evaluated by gastroenterologists and radiologists.
Standard barium swallow is used to evaluate structural abnormalities of the upper gastrointestinal tract.
Manometry - provides clinicians with information of the strength of oesphageal contractions.
pH monitoring - to monitor reflex e.g. GERD.