Motor

Question 0

Spastic Dysarthria

Caused by:

Primary characteristics:

Answer 0

Bilateral damage to the upper motor neurons of the pyramidal and Extrapyramidal systems; often caused by brainstem strokes

Spasticity and weakness in the speech musculature that results in harsh or strained-strangled phonation, imprecise consonants, hypernasality, and abnormal prosody

Question 1

Flaccid Dysarthria

Caused by:

Primary characteristics:

Answer 1

Damage to the cranial nerves, spinal nerves, or neuromuscular junction

Muscle weakness that can result in imprecise consonants, breathy phonation, hypernasality, shallow breath support, and abnormal prosody.

Question 2

Unilateral upper motor neuron Dysarthria

Caused by:

Primary characteristics:

Answer 2

Unilateral damage to the upper motor neurons

Imprecise consonants are the most common characteristic*** some patients may have irregular articulatory breakdowns or harsh vocal quality.

Question 3

Ataxic Dysarthria

Caused by:

Primary characteristics:

Answer 3

Damage to the cerebellum or to the neural tracts that connect the cerebellum to the rest of the CNS

Problems controlling timing and force of speech movements, resulting in speech that often has a “drunken” quality, imprecise consonants, distorted vowels, irregular articulatory breakdowns, and abnormal prosody

Question 4

Hypokinetic Dysarthria

Caused by:

Primary characteristics:

Answer 4

A reduction of dopamine in part of the basal ganglia, Parkinsonism is the most common cause of this dysarthria***

A reduction in the range and speed of speech movements, harsh or breathy phonation, imprecise consonants and abnormal prosody; some patients have an increased rate of speech

Question 5

Hyperkinetic Dysarthria

Caused by:

Primary characteristics:

Answer 5

Often associated with damage to the basal ganglia, but in some conditions the cause is unknown

Involuntary movements that interfere with normal speech production, unexpected inhalations and exhalations, irregular articulatory breakdowns, and abnormal prosody

Question 6

Mixed Dysarthria

Caused by:

Primary characteristics:

Answer 6

Neurologic damage extends to more the one portion of the motor system

Any combination of the characteristics of the six pure dysarthrias. For example, a person with Parkinsonism can have a brainstem stroke that might result in a hypokinetic-spastic mixed dysarthria

Question 7

• Six salient features important during the evaluation of motor speech disorders

Answer 7

1. Muscle strength
   assessed by: Asking patient to press tongue against tongue blade or to count aloud from 1 to 100
2. Speed of movement
   Speed assessed by tasks concentrating on:
   –Alternate motion rates (AMR)
   –Sequential motion rates (SMR)
3. Range of motion
   Assessed by: Asking patient to extend or hold articulators in various positions

4.Accuracy of movement:
Assessed through: Conversational speech; spoken paragraph reading

5.Accuracy of movement:
Assessed through: Conversational speech; spoken paragraph reading

6. Muscle tone
   Assessed by:
   –Inferring when listening to patient’s speech
   –Looking at affected body parts

Question 8

• Auditory-perceptual evaluations of the motor speech mechanism:

Answer 8

In many cases, the clinician’s ear is the best instrument for evaluating motor speech deficits

Phonatory-Respiratory System:
•Specific tasks
–Deep breath and say /a/, holding as long and steadily as clearly can

–Examine Quality, pitch, loudness, and phonations

-Resonation System:
•Assesses velopharyngeal function
•Specific tasks
–Take deep breath and say /u/ as long as possible
–Same task as above, but clinician squeezes nose

-Combined Systems (phonation, respiration, resonation, and articulation):
•Alternate motion rate (AMR)
–Sequential motion rate (SMRs)

Question 9

• What are the various structures you would evaluate during motor speech examination?

Answer 9

oFace and Jaw (at rest and in movement)

oTongue (at rest and in movement)

oVelum and Pharynx (at rest and in movement)

oLaryngeal function

*must check the 6 features for each of these (muscle strength, speed of movement, range of movement, accuracy of movement, motor steadiness, muscle tone)

Question 10

•Describe the treatment for flaccid dysarthria if the vagus nerve is damaged*

1. RESONANCE:

Answer 10

(Surgical treatment)

Pharyngeal flap procedure – a flap of tissue from the pharynx is surgically attached to the velum.

Injection of Teflon: causes a bulge at that point on the pharynx and lessens the distance the velum must elevate before VP closure is achieved.

(Prosthetic treatment)

Palatal lift: essentially a dental retainer that has a rear extension that helps push upward on the velum.

(Velar strengthening and Nonspeech exercises)

debated; hardly any evidence to support it; CPAP has been shown to work on a small number of patients with dysarthria

(Modification of Speech)

• Reduce rate of speech
• More open-mouth position
• Increase loudness

Question 11

• Neurologic Basis of Flaccid Dysarthria

Causes of flaccid dysarthria:

Answer 11

Caused by damage to lower motor neurons (part of PNS)

Caused by any disorder that disrupts flow of neural impulses along lower motor neurons that innervate muscles of respiration, phonation, articulation, prosody, or resonance

Physical trauma, brainstem stroke, Myasthenia Gravis, Guillain-Barre, Polio, tumors, muscular dystrophy, Progressive bulbar paslsy

Question 12

Treatment of flaccid dysarthria if the vagus nerve is damaged

PHONATION:

Answer 12

• Pushing and pulling procedures: help the vocal folds adduct by providing an overall increase in muscle contractions
• Holding breath: requires the ability to fully adduct the vocal folds. Work to the point at which patient can hold a breath for about 15 sec over 10 consecutive trials

•Hard glottal attack:
*The basic steps are to have the patient hold a deep breath, bear down, and attempt to phonate a tight /a/. This tight phonation should be modified into a more normal vocal quality to avoid negative effects.

• Head turning and sideways pressure on the larynx: when there is unilateral weakness or paralysis of one vocal fold, phonation will be breathy because the weak fold will not be able to fully adduct to the midline.
• With some patients, a more complete vocal-fold adduction may be achieved when the head is turned toward the affected side or when the larynx is pushed by hand from the affected side.

Question 13

Treatment of flaccid dysarthria if the vagus nerve is damaged

PROSODY:

Answer 13

• Pitch range exercises: start with pitch perception exercises, and then proceed to production.
• Intonation profiles: uses lines to show intonation changes in written sentences.
• Contrastive stress drills: are designed for the clinical to ask a question, with the patient answering it by adding stress in key words to convey the intended meaning of the answer

•Chunking utterance into syntactic units: dividing utterances according to normal pauses within and between sentences.
*The patient is taught to inhale at the points in an utterance at which natural syntactic pauses occur. This allows the patient to maintain a more natural rhythm.

Question 14

What is the neurologic basis of spastic dysarthria?

Answer 14

Bilateral damage to upper motor neurons of the pyramidal and extrapyramidal systems

Question 15

Discuss the various treatment techniques for spastic dysarthria

Answer 15

PHONATION:

Head and neck relaxation = most based on head-rolling motion; tilt back, forward, left and right for 10 seconds each

Easy onset of phonation = make softer glottal closure during phonation; exhale while producing a smooth, quiet sigh, then add /a/

Yawn-sigh exercises = inhale slowly while fully opening mouth (like a yawn) and then as they begin to exhale while producing gentle, prolonged sigh, then shape into vowels

ARTICLUATION:
oStretching exercises
–Tongue-stretching
–Lip-stretching

Intelligibility drills: give the patient a word list, the clinician should not look at the patient, and tell the patient to read slowly and clearly

oPhonetic placement: clinician shows proper placement of the articulators

oExaggerating consonants: overemphasizing the sounds and placement, and gradually change to a more natural form of speaking after this is learned

oMinimal contrast drills: make the patient say as many minimal pairs as possible and still be intelligible –minimal pairs: two words with only one different phoneme

•RESONANCE: hypernasality results in slowness and reduced range of movement 
o	Surgical/prosthetic:
	Pharyngeal flap procedure
	Teflon injections
	Palatal lift
	
o	Exercise-based:
Visual feedback = use mirror to see nasal escape of air during the production of nonnasal phonemes; mirror held under nostrils so patient can see fogging; this helps them maximize velar closure

Increase loudness = have patient speak more loudly to mask hypernasality; sound pressure level meter can be used as a visual cue

PROSODY: help patient regain vocal tract flexibility needed to appropriately vary pitch and loudness

oPitch range exercises = patient’s ability to perceive obvious pitch changes in clinician’s voice; then have patient prolong /a/ at lowest pitch and then highest pitch possible; then have patient sing up and down this range; then read sentences with normal pitch changes for the words

oIntonation profiles = show intonation changes in written sentences

oContrastive stress drills = clinician asks a question and patient answers by adding stress on key words to convey intended meaning of the answer

oChunking utterances in syntactic units = teach patient to inhale at points in an utterance at which natural syntactic pauses occur

Question 16

Neurologic basis of Hypokinetic dysarthria

Answer 16

•Unique, as only dysarthria with:

o Increased rate as symptom

o Mainly one causative factor (parkinsonism)

•Symptoms caused by dysfunction to basal ganglia or to basal ganglia’s neural connections to other parts of CNS

•Hypokinetic (less motion)

Question 17

Characteristics of Parkinsonism

Answer 17

• Resting tremor
• Bradykinesia: slow, reduced range of movement
• Rigidity: resistance to movement from beginning to end; pipeled (very tight) or cogwheel (stop-go movements like a robot)
• Spasticity (different from rigidity): tight, but at some point it relaxes briefly/abruptly
• Akinesia: delay in initiation of movements; freezing of their gait
• Postural reflexes: stooped posture

Question 18

Explain the Lee Silverman Voice Treatment. Briefly explain the five guiding principles of the LSVT*

Answer 18

Effortful phonation program in which patients with parkinsonism are guided through a daily schedule of maximum effort in their phonations and in which they are constantly reminded to “THINK LOUD.” It is intense and requires homework. The 5 guiding principles are as follows:

1. Concentrates strictly on increasing vocal loudness = increasing loudness increases articulatory accuracy
2. Requires multiple repetitions of high-effort phonations from the patient = begin with prolonging a vowel with maximal effort and then move to words, sentences, and connected speech
3. Treatment sessions must be completed daily = total of 16 individual sessions within one month
4. Patients must be calibrated for what is normal loudness = Patients are given feedback in how their louder phonations actually sound to listeners; encouraged to be aware of how their phonations feel when they are producing them.
5. Progress must be quantified = SLM used to document loudness phonations, a tape recorder to document quality of phonations, and a stopwatch to measure duration of phonations.

• Treatment involves traditional pushing/pulling procedures, more open mouth posture, modeling, and repetition.
• Clinicians must attend a workshop to become certified in LSVT

Question 19

What is Apraxia of Speech and how would you evaluate it?

Answer 19

oDifficulty sequencing, esp. with multisyllables

Specific tasks:

Repeat or read words of increasing complexity, beginning with same CVC syllable

Repeat words with simple CVC consisting of identical initial and final consonants

Count from 1 to 20 and backward
Read sentences, including spontaneously and on demand

Question 20

Explain the Sound Production Treatment for Apraxia of Speech in detail.*

Answer 20

oStep 1 (saying the word) = the clinician says the word (mutt) and asks the patient to repeat it. If repeated correctly, he is asked to repeat it 5 more times independently. Then the next /m/ word is presented and Step 1 is started again.

If it is not repeated correctly, the clinician explains what is wrong and tries a different word (a minimal pair for “mutt”). If he repeats it correctly, they move to Step 2 using “mutt.”

If minimal pair word is not repeated correctly, the clinician says, “watch me and listen to me and say the word with me.” The clinician says it 3 times while the patient attempts to say it in unison. No matter what, the clinician moves to Step 2 with “mutt.”

oStep 2 (show the letter) = the clinician presents a card with a large M on it. The client is asked to repeat the word “mutt.” If he says it correctly, he is asked to say it 5 more times and then goes to Step 1 with the next word on this list.

If it is not repeated correctly, the clinician moves to Step 3.

oStep 3 (Watch me and listen to me) = the clinician says, “watch me and listen to me” and says “mutt” 3 times. The patient attempt to say it in unison with the clinician. If correct, he repeats it 5 times and then goes to Step 1 with the next word.

If incorrect, the clinician moves to Step 4.

oStep 4 (Articulatory placement cueing) = the clinician provides a combination of verbal, visual, or tactile cues on how to produce the target sound. After, the patient is asked to look and listen to the clinician say the word 3 times in unison. If productions are correct, he is asked to repeat 5 times.

If incorrect, they stop working on “mutt” for now and go to Step 1 with the next word.

Question 21

Name at least four clinical features that help a Speech-Language Pathologist in differentially diagnosing Dysarthria from Apraxia of Speech

Answer 21

Speech errors in apraxia increase as word length and complexity increase; errors of dysarthria fairly constant

Muscle range of motion, tone, coordination, and strength are within normal limits in apraxia of speech; at least one muscle quality impaired in nearly all dysarthrias

Apraxia of speech primarily affects articulation and prosody; dysarthria can affect all five

Apraxia of speech can have articulatory groping