Lecture 4 Flashcards
What are the goals of Ax in MSD?
- diagnosis
- determining severity of speech impairment (speech intelligibility)
- determining underlying reasons for reduced intelligibility and perceptual abnormalities
- determining Tx targets
- documenting progress
What are the 6 components of Ax for MSD?
- History (chart review & interview)
- Oral motor & sensory exam
- Intelligibility testing
- Perceptual evaluation of speech
- Instrumental assessment
- Diagnostic therapy probes
What are some questions to ask during an interview?
-Pt description of problem
-date of onset
-pattern of onset
-nature of symptoms
-medical/surgical history
-medications
-impact on daily functions
etc.
What information do we get from an OME?
Info on
- structural integrity (presence of structures, inflammation, changes in colour, proportionality)
- severity of physical change/damage
- localization of damage (UMN vs. LMN, CN)
- symmetry
- NO INFO ABOUT SPEECH
What is one way we can slightly decrease subjectivity of OMEs?
you create protocols that you follow for each person every time. This consistency allows us to understand the range of severities and symptoms
What are 3 ways you can organize an OME?
- by cranial nerve
- by structure
- by subsystem
Which parameters of muscle function do we assess during an OME?
- strength of muscle contractions
- range of non-speech movements
- speed of NS movements
- accuracy of NS movement
- muscle tone
- symmetry
- coordination of rapid, repeated, NS movements
Which structures do we assess for CN V?
Jaw
In regards to the jaw, what do we look at during an OME?
• Rest Position (skin over masseter & temporalis)
• Clench jaw – palpate masseter & temporalis for asymmetry, volume and tone.
• On opening – observe size & deviation of mandible
• During movement
• Test opening and closing of jaw against
resistance
• Elicit jaw-jerk
CN V has __________ innervation for UMNs
bilateral
What happens if there is unilateral UMN damage to CN V?
no effect
What happens if there is bilateral UMN damage to CN V?
open jaw,
positive jaw jerk
What happens if there is unilateral LMN damage to CN V?
jaw deviates towards WEAK side on opening
(felt as asymmetry during
clenching)
What happens if there is bilateral LMN damage to CN V?
open jaw, absent
(normal) jaw jerk
What structures do we assess for CN VII?
face and lips
In regards to the face and lips, what do we look at during an OME while they are at rest?
-Symmetry at angles of mouth • Flattening of nasolabial folds • Drooling • Eyelids partially closed • Eyes shut involuntarily or not at all • “Masked face” • Absence of wrinkling on forehead
In regards to the face and lips, what non-speech movements do we look at during an OME?
• Smile, pucker, rounding, pout • Alternating smile-pucker • Labial seal: puff cheeks, clinician pushes air out • AMR - /ba-ba/
What is special about the UMN supplying the face?
It has bilateral innervation for the forehead and the lower face has unilateral - contralateral innervation
What happens if there is unilateral UMN damage to CN VII?
lower face ONLY is affected (on pucker, lips deviate toward the weak side; contra- to the side of damage)
What happens if there is unilateral LMN damage to CN VII?
affects upper
and lower face. On pucker, lips deviate towards the weak side (ipsi to side of damage)
What happens if there is bilateral LMN damage to CN VII?
complete facial paralysis
List the signs of facial nerve paralysis
- Paralysis of all the muscles of facial expression:
- Facial asymmetry
- Eyebrow droop
- Loss of forehead & nasolabial folds
- Drooping of corner of mouth
- Uncontrolled tearing
- Inability to close eye
- Lips cannot be held tightly together
- Facial muscle atrophy (late stage)
What are 3 diseases that affect CN VII
- bell’s palsy
- acoustic neuroma
- lyme disease
Which structures do we assess for CN IX and X?
soft palate, pharynx and larynx
What do we look for in the soft palate & pharynx
• Velar symmetry at rest
• Velar symmetry on phonation – look for
elevation & movement of faucial pillars
• Nasal emissions (using mirror) – during
cheek-puff, modified tongue anchor test,
and non-nasal speech samples
• Gag reflex
What do we look for in the larynx
- Prolongation of /a/: maximum phonation time, quality, pitch, pitch breaks, diplophonia, tremor or WOW (slow) or flutter (fast), voice arrest, fluctuation in loudness
- Inhalatory stridor
- Cough on demand, clear throat on demand
- Glottal coup
The UMNs of CNs IX & X have _____________ innervation
bilateral
What happens if there is unilateral UMN damage to CN IX & X?
-no effect on velum & pharynx or the larynx
What happens if there is bilateral UMN damage to CN IX & X?
- symmetrically weak soft palate
- complete VF paralysis
What happens if there is unilateral LMN damage to CN IX & X?
-during
phonation, soft palate deviates
towards the STRONG side
-unilateral VF paralysis
What happens if there is bilateral LMN damage to CN IX & X?
-symmetrically
weak soft palate
-complete VF paralysis
For CN IX & X LMN lesions, the lower the lesion the more _________ the damage
isolated
Which structures do we assess for CN XII?
tongue
What do we assess when looking at the tongue?
• Symmetry at rest and on protrusion
• Tremor? at rest and with movements
• Fasciculations? at rest, and on
lateralization
• ROM: protrusion, lateralization (internal
& external), elevation to alveolar ridge, elevation external, depression external, lip-lick, tongue wag, DDK
• Strength: against resistance (tongue depressor & inside cheek)
The UMN of CN XII has __________ innervation
bilateral innervation, with the exception that the genioglossus has contralateral innervation
What happens if there is unilateral UMN damage to CN XII?
tongue deviates to the weak side on protrusion
What happens if there is unilateral LMN damage to CN XII
tongue
deviates to the weak side on
protrusion
What happens if there is bilateral LMN damage to CN XII
bilateral tongue
weakness. Observe fasciculations and atrophy -> LMN lesion
T or F: based purely on tongue deviation, we cannot distinguish between UMN unilateral damage and LMN unilateral damage
true
What do we observe during an OME in terms of respiration?
• Posture • Shortness of breath • Rapid, shallow, labored, noisy • Nasal flare on inhalation • Clavicular movement • Listen for changes in loudness, breath group duration, reduced phrase and word stress
What reflexes should be measured during an OME?
- gag
- pathological reflexes: jaw jerk, suck, root, snout
In terms of sensory modalities, what do we need to assess?
- vision
- hearing
- light-touch discrimination
- two-point discrimination
What are 4 formal tests related to OMEs?
- Frenchay Dysarthria Assessment (FDA)
- Oral Speech Mechanism Screening Examination (OSMSE-R)
- Robbins & Klee
- Verbal motor production assessment for children (VMPAC)
