Hyperkinetic Dysarthria Flashcards
dyskinesia:
abnormal movements
Hyperkinetic dysarthria is due to lesions in the:
basal ganglia circuit – it’s extrapyramidal
Extrapyramidal refers to:
those motor pathways that do not pass through the pyramids at the medullary-spinal level
Hyperkinetic dysarthria can affect which subsystems:
any sub-systems. But it mainly affects prosody in speech
Lesions to the basal ganglia (extrapyramidal system) can cause speech characteristics related to (4):
abnormal
rhythmic or irregular (so may be regular or irregular)
unpredictable
rapid or slow involuntary movements.
What is the key thing to keep in mind with hyperkinetic dysarthria?
Involuntary movements
T/F
There is a variety of disorders in this category with a lot of variance among them
T
Are abnormal movements present during speech and other movements?
No.
Abnormal movements may only be present during speech – important feature
Why do abnormal movements occur in hyperkinetic dysarthria? (3)
Abnormal movements may be the result of a failure to inhibit cortical motor discharges.
Also there may be firing from the thalamus that isn’t inhibited causing these movements
Another cause of these movements may be that there is an imbalance between the excitatory and inhibitory neurotransmitters
AcH is _____
excitatory
Dopamine is ____
inhibitory
The term hyper in hyperkinetic means:
movements that don’t belong, extra movements
not too fast speed in movement
voluntary movements of hyperkinetic dysarthria patients may be
slow
Why do we subdivide categories of movement disorders in hyperkinetic dysarthria?
because even though involuntary movements are the theme that tie these together as hyperkinetic dysarthrias, there is considerable variability in each of them, in their character and underlying pathology
What is the underlying theme of movements with hyperkinetic dysarthrias?
involuntary movement
Are all involuntary movements with hyperkinetic dysarthria similar in nature?
No,
Considerable variability in movement, character and underlying pathology
Etiologies of hyperkinetic dysarthria:
multiple etiologies
- main known cause: toxic-metabolic
- idiopathic causes are the most frequent (Most are unknown etiologies)
How can these hyperkinetic dysarthrias be distinguished from other dysarthrias?
By visual observing-because of the strange movements
Some of the bizarreness of the movements with hyperkinetic dysarthrias may cause the person to be incorrectly diagnosed as having:
a psychogenic problem
Categories of hyperkinetic dysarthias (9):
- Dyskinesia (e.g. Tardive dyskinesia)
- Myoclonus
- Tics
- Chorea
- Ballism
- Athetosis
- Dystonia
- Spasm
- Tremor
Dyskinesia
Refers to abnormal, hyperkinetic, involuntary movements
A general term for abnormal movement
Dyskinesia can occur in various part of the body
Orofacial dyskinesias:
Dyskinesias that occur in the mouth, tongue and jaw and don’t have to have any other parts of body involved
Tardive dyskinesia:
Dyskinesis related to prolonged use of antipsychotic drugs
Often seen in patients with schizophrenia who have taken antipsychotic drugs.
Orofacial dyskinesias may be tardive dyskinesias
Akathisia (in the category of dyskinesias):
Motor restlessness demonstrated by pacing, moving around a lot, rubbing head, etc.
Due to damage in BG circuit
Myoclonus:
Single involuntary, brief movements of a body part – like a jerk, can be rhythmic or not
person cannot stop them
Can be spontaneous or brought on by certain stimuli, one such stimuli is voluntary movement itself
May occur in epilepsy.
Occurs with lesions from the cortex to the spinal cord.
Hiccups are a type of myoclonus – spasms of the diaphragm and adduction of vocal cords. Hiccuping can be a sign of involvement with the medulla
Tics:
- typically seen in Tourette’s syndrome
- rapid, patterned movement under partial voluntary control
- The person may have some voluntary control over them.
- There is usually a strong, irrepressible urge to do these but the person may be able to control them for a little while
- Simple tics may look like dystonia or myoclonus, but complex tics don’t (examples – jumping up, making noises, lip smacking).
(Read “Anthropologist from Mars” by Oliver Sachs)
Chorea:
- rapid-involuntary, random purposeless movements of a part of body
- nonrhythmic and random
- can be present at rest and in voluntary movement
- can be subtle or severe
Huntington’s Chorea:
- type of chorea
- it is progressive/degenerative
- It is inherited, genetic dz
- CNS disorder
- Damage occurs in the basal ganglia and in cortex
- Easily distinguished by chorea movements
- May also see dementia and personality changes
- Also dysarthria and dysphagia
If someone has Huntington’s Chorea, what are the chances their child will have it?
50%
Ballism:
- abrupt contractions of muscles of limbs
- so bad that the person can fall down
- large muscle contractions, not fine ones
Athetosis
- inability to keep a body part in one position
- slow writhing purposeless motion
CP is a type of:
athetosis
Dystonia
- slow hyperkinesias exhibited by involuntary abnormal postures due to problems with antagonistic muscles
- can have quick myoclonic movments involved
- can occur in one part of body or several
- If occurs in orofacial muscles – it may be called focal mouth dystonia (essentially the same as orofacial dyskinesia
- Writer’s cramp is a form of dystonia
- It is usually nonrhythmic
What is focal mouth dystonia?
Dystonia occuring inthe orofacial muscles (essentially the same as orofacial dysinesia)
What is a writer’s cramp?
a form of dystonia
Spasm
- when you have involuntary muscular contractions
- tonic ones are continuous
- clonic ones are repetitive and don’t last long
- Spasms can both cause motion and limit motion
(e. g. if you limit your movements because you are having a spasm of a muscle) - Spasm is also used to describe dystonia abnormal postures
Tonic spasms are:
continuous
Clonic spasms are
repetitive and don’t last long
Tremor:
- the involuntary movement that is most common
- rhythmic movement in one body part
- Can occur when the muscle is at rest or in action
- Also, toxic tremors
2 types of Tremors:
- at rest –> resting tremor
2. action –> intention tremor
Toxic Tremors
– due to meds, or other toxins, withdrawal from drugs/alcohol.
Cerebellar tremor is due to:
damage in cerebellum
Etiologies of hyperkinetic dysarthria (6):
Common disorders in which we see hyperkinetic dysarthria:
- Degenerative disease
- Toxic-metabolic conditions
- Vascular disorders
- Infectious processes
- Neoplasm
- Tourette’s
Where is the damage with hyperkinetic dysarthria?
Basal ganglia or cerebellar circuit (indirect activation pathway (extrapyramidal))
Degenerative disease that cause hyperkinetic dysarthria:
- Huntington’s chorea or Huntington’s Dz is probably most well known
Toxic-metabolic conditions that cause hyperkinetic dysarthria:
- due to antipsychotic drugs because they affect the neurotransmitters
- Tardive dyskinesia- often seen in patients with schizophrenia who have taken antipsychotic drugs
Why is it important to make the determination of drug induced dysarthria?
- because if the drugs are withdrawn early enough, speech can go back to normal
- if not, there may be permanent dysarthria
Vascular disorders causing hyperkinetic dysarthria:
– usually don’t see many of these causing hyperkinetic dysarthria unless there are strokes that affect basal ganglia or cerebellum
Infectious processes causing hyperkinetic dysarthria:
- inflammation can cause a disorder called Sydenham’s chorea- seen in young people and may be associated with strep throat. Typically it is temporary
Neoplasm causing hyperkinetic dysarthria:
- tumors of basal ganglia and thalamus may result in hyperkinetic dysarthria
Tourette’s and hyperkinetic dysarthria:
- causes both verbal and motor tics. Cause probably related to problems with dopamine receptor
Nonspeech Patient Complaints with Hyperkinetic Dysarthria:
Nonspeech-depends on the specific disorder
Many report can’t keep jaw, face, tongue still
Problems with swallowing or chewing
Some may be aware of abnormal movements, whereas others may not
Some have learned sensory tricks to hold back movement, i.e. holding or touching body part that is moving
Specific diseases with nonspeech and speech signs (8):
- Chorea
- Dystonia
- Spasmodic torticollis (cervical dystonia)
- Palatopharyngolaryngeal myoclonus
- Action myoclonus
- Tourette’s syndrome
- Organic voice tremor
- Spasmodic dysphonia (adductor and abductor)
Non-speech characteristics of Chorea with hyperkinetic dysarthria:
Nonspeech findings-usually normal size, strength, symmetry of oral facial features
Usually motor unsteadiness, when trying to round or retract lips, protrude tongue, or at rest, may see quick, unpatterned movements
Can sometimes be difficult to distinguish from normal unsteadiness. See page 227, Fig. 8.2.
Speech Characteristics of Chorea with hyperkinetic dyarthria:
Speech assessed through reading, conversation, AMRs, and vowel prolongation.
Look for unpredictable movements and breakdown in rate and prosody.
Phonation-respiration: sudden forced inspiration or expiration, excess loudness variations, strained-strangled voice, voice stoppages, transient breathiness.
Resonance – intermittent hypernasality and weak pressure consonants.
Artic - irregular breakdown, distortions, distorted vowels. Slow & irregular AMRs.
Prosody - prolonged intervals & phonemes, inappropriate silences, variable rate, variable stress patterns. Prosodic components are prominent.
Non-speech signs of dystonia and hyperkinetic dysarthria:
Slower than chorea, waxing & waning or near constant character
Oral mech normal size, strength etc. as in chorea.
May have problems with drooling, swallowing, may be problems with facial grimacing.
Primarily are movement problems at rest, but sometimes occur in speech.
Example of dystonia – tongue coming out while talking or jaw opening off and on while speaking – exacerbated by the action of speech. Botox is sometimes used to inject in tongue. The speech problem is caused by these involuntary movements.
See page 233.
May improve with sensory tricks. In speech exam look for/ask about sensory tricks. (Hold pipe in mouth to inhibit dystonia, etc.) Michael Fox - held book in hand to prevent tremors – but he had Parkinson’s DZ
Speech findings with Dystonia and hyperkinetic dysarthria:
Phonation –voice stoppages, strained-harsh voice, audible inspiration, excess loudness variation, alternating loudness, tremor-like voice.
Resonance-intermittent hypernasality
Articulation – distortions & irregular breakdown, distorted vowels, slow & irregular AMRs
Non-speech characteristics of Spasmodic torticollis (cervical dystonia) and hyperkinetic dysarthria:
- affects cervical neck muscles and not muscles innervated by cranial nerves
- Can also have facial spasms
- Speech deviances are related to deviancies in neck postures
Speech charcteristics of Spasmodic torticollis (cervical dystonia) and hyperkinetic dysarthria:
- Effects are usually mild on speech and are primarily at laryngeal level – pitch variability
- Articulation/Prosody level - may have reduced rate and delayed speech initiation, slow AMRs.
Page 235, figure 8.7
Non-speech characteristics of Palatopharyngolaryngeal myoclonus and hyperkinetic dysarthria:
- abrupt movements of soft palate, pharyngeal walls and laryngeal muscles
- Effects on speech are not great
- Can be mild intermittent hypernasality
- Patient often complains of “earclicks” which is the opening and closing of the Eustachian tube because of pharyngeal contractions
Speech characteristics of Palatopharyngolaryngeal myoclonus and hyperkinetic dysarthria:
- Effects on speech are not great
- Can be mild intermittent hypernasality
- Patient often complains of “earclicks” which is the opening and closing of the Eustachian tube because of pharyngeal contractions
Action myoclonus and hyperkinetic dysarthria:
- not often seen for SLPs
- It is different from other myoclonic disorders because it is induced by action and is more rhythmic
Tourette’s syndrome and hyperkinetic dysarthria:
- Most are genetically related
- Typically you see facial grimaces, eyeblinks, twitches of head
- Can also include larger movements, spinning, jumping, etc.
- May appear to be bizarre
- There are also vocal tics – which can include odd noises such as grunting, yelling, whistling, squeaking, etc.
- Can include echolalaia, palilalia and coprolalia – swearing compulsively
- Most cases are male – by 4 to 1
- Can be accompanied by OCD
Organic voice tremor and hyperkinetic dysarthria:
- the voice tremor is usually with gradual onset, and worsens with fatigue and stress, may improve with alcohol and is often accompanied by head or jaw or extremity tremor
- Do vowel prolongation in speech exam to really hear tremor
- Not much effective treatment. BOTOX helps some.
- Meds for limb tremors bay help but meds don’t usually help with voice tremor
Spasmodic dysphonia and hyperkinetic dysarthria:
- (may also be called spastic dysphonia but is somewhat different because there are no articulation or rate problems with spasmodic dysphonia.)
- Caused by spasms of the laryngeal adductor or abductor muscles due to different causes
- There are different kinds of spasmodic dysphonia depending on whether the cause may be related to neurogenic, psychogenic or unknown reasons
- Duffy says the ones that aren’t neurogenic are not MSD.
- It is characterized by strained or breathy voice quality
- onset is 45-50 years
- Can be exacerbated by stress and fatigue.
Adductor spasmodic dyphonia complaints:
– increased effort and fatigue, may improve with alcohol, tight strained voice
Abductor spasmodic dysphonia complaints:
- increased effort & fatigue with speaking, may improve with alcohol if tremor based, runs out of air
What helps to distinguish hyperkinetic dysarthria from other MSDs?
variable nature of the speech deviances
