Flaccid Dysarthria

Question 1

Upper Motor Neurons

Answer 1

• descending motor fibers in the CNS
  ** synapse with motor neurons in PNS
• UMNs = motor fibers in CNS
• Tract and nerves are the same
  ** nerves are in PNS
  ** tracts are in CNS
• everything that we try to do is from the cortex

Question 2

Lower Motor Neurons

Answer 2

Motor fibers in the PNS
- cranial nerves: most head & neck muscles
- spinal nerves: trunk & limb muscles

Question 3

Cranial nerve nuclei

Answer 3

• points at which cranial nerves attach to brainstem
• cell bodies of LMNs
• synapse with UMNs

Question 4

Movement chain

Answer 4

UMN > CNN > LMN > muscles

Question 5

Neurological basis

Answer 5

1. Damage LMNs: motor neurons in PNS
   - Final common pathway (aka. LMN)
   - nerves never cross
2. Flaccidity of affected muscles - can cause weakness
   - are not synonymous
3. Hypotonia: low tone; con’t contrast and lose tone
4. Hyporeflexia: lose reflexes
5. Atrophy: loss of muscle bulk and mass

Question 6

what is flaccidity?

Answer 6

a pathophysiological state of the muscle, which can cause weakness

Question 7

What is weakness?

Answer 7

a functional outcome

less ability to contract and to perform “work”
- push or pull against an object
- but spastic or rigid muscles can also be “weak,” like PD

Question 8

Etiologies - physical trauma

Answer 8

• surgeries
• TBI

Question 9

Etiologies - brainstem stroke

Answer 9

near cranial nerve nuclei

Question 10

Etiologies - myasthenia gravis

Answer 10

• it affects neuromuscular junction
• symptom: rapid fatigue of muscle contractions
• recover after a rest
• antibodies damage acetylcholine receptors
• acetylcholine

Question 11

Etiologies - tumors

Answer 11

• grow near the brainstem
• occur along CN
• isn’t always in the brain itself

Question 12

Etiologies - Moebius Syndrome

Answer 12

• CN Vll absence or underdevelopment
• Other CNs can also be involved (VI)
• Swallowing issues
• Open mouth posture
• Surgery: the “smile operation” - help the drooping side of the lip to come up

Question 13

Etiologies - Bell’s Palsy

Answer 13

• CN VII; facial m, weakness
• Viruses, environmental conditions, immune diseases, diabetes, high BP
• less ability to close eye
• audiology issue > stapedius muscle
• about 70-75% recover normal facial function

Question 14

Speech characteristics - resonance

Answer 14

• hypernasality
• nasal emissions
• weak pressure components
• shortened phrases
• CN (pharyngeal branch) - also, possible IX and XI

Question 15

Speech characteristics - articulation

Answer 15

• imprecise consonants
• mild to unintelligible
  CNs V, VII, XII

Question 16

Speech characteristics - phonation

Answer 16

• breathiness (continuous)
• monochrome
• monoloudness
• inhalatory stridor
• harsh quality
• CN X:
  ** external superior laryngeal n.
  ** recurrent laryngeal

Question 17

Speech characteristics - respiration

Answer 17

• reduced loudness
• mono pitch
• monoloudness
• harsh voice quality
• shortened phrase length
• spinal nerves

Question 18

Speech characteristics - prosody

Answer 18

• monopitch
• monoloudness

Question 19

key evaluation tasks

Answer 19

1. conversational speech & reading
2. AMRs - alternating motion rate
   a. pay attention to both rate and rhythm
   b. flaccid: slow but regular
3. vowel prolongation - if vagus is affected

Question 20

Treatment - Damage to CN VII (facial)

Answer 20

Lip Muscle Strengthening - needs resistance
- button & string: put button in the mouth, right in front of the teeth
- lip puckering
- smile: hold it up by the gravity for 10 seconds
- lip rounding: pressing in with tongue depressor
- lip press: use finger to try to open the lips
- resistance to movement exercises: use evaluation tasks for ideas
- use resistance, like when you work out : tongue depressor, your finger to hold for 5 seconds against resistance for 5 times

Question 21

Treatment - Damage to CN X: Resonance Deficits

Answer 21

Modification of speech:
- increase loudness: SPL meter, CSL or Visi-Pitch
- reduce speech rate
- exaggerate mouth opening - start with VC shape

Question 22

Important note for treatment

Answer 22

biofeedback is only successful if patient is anatomically and physiologically capable of achieving adequate VP closure

Question 23

Prosthodontist

Answer 23

• prosthetic devices to replace or improve appearance of teeth and orofacial structures
• makes and fits devices to assist with feeding and VP closure (palatal lifts, speech bulbs, obturators)

Question 24

Prosthetic treatments: palatal lift - adequate patients

Answer 24

• severe hypernasality
• no deteriorating medical condition
• adequate dentition
• no hyperactive gag reflex or spasticity
• motivation to use/care for prosthetic
• ability to see prosthodontist & SLP

Question 25

Recommendations for prosthetic treatment

Answer 25

- If prosthesis is insufficient > follow-up fiber optics > possible incomplete rest leak > possibly a pharyngeal flap - superiorly-based 1. cut flap of tissue, side-bottom-side 2. keep it attached to the top - inferiorly-based 1. cut top side, keep it attach inferiorly - depends on the preference of the surgeon

Question 26

Good candidates for therapy

Answer 26

Associated with oral-motor dysfunction - trial therapy before surgical decision - prosthetic management Surgery has been done, but patients need to learn to use "new structure" - same with a prosthesis - train proper articulatory placement and oral airflow - reduction therapy - possible with palatal lift - might work better with speech bulb

Question 27

Techniques for hypernasality

Answer 27

Tactile-Kinesthetic Training - have client raise/lower velum during vowels - use tongue blade to raise velum - may be a candidate for a palatal lift Lower back of tongue - use yawn (think yawn) - produce vowels and anterior consonants - VC > "up"

Question 28

Techniques for nasal emission

Answer 28

Visual feedback - see scape (Pro ed) - air paddle Cul-de-Sac technique - occlude nares (or nose clip) - during production of pressure consonants - "feel" air pressure in mouth - direct airflow from mouth

Question 29

Treatment - Damage to CN X: phonatory deficits

Answer 29

Pushing/pulling: - effortful closure - holding breath - falsetto /i/ HGA - high glottal attack - after vowels, adding in voiced consonants

Question 30

Treatment - Damage to CN X: prosodic deficits

Answer 30

Pitch range exercises: - Visi-Pitch - Use scale or glide Intonation profiles - written sentences - Visi-pitch: have clients copy the clinician's curve Lexical stress drills - example: record - record - N vs. V - activities: words, sentences, sentences with both words Sentence stress drills - example: may won the contest - don't say "no" before the sentence

Question 31

Minimal contrast drills

Answer 31

- one word has that feature, the other word does not - you don't just change the sound; you change one feature - P, M, V, cluster, etc - example for cluster: top - stop - example for nasals: bop - mop

Question 32

Treatment for respiratory weaknesses in FD

Answer 32

- cueing for complete inhalation - speak immediately on exhalation - start with vowel in isolation - add final consonants or a word