Motor speech and dysphagia Flashcards
what are the characteristics of AOS
- slower rate of speech
- distorted speech sound substitutions
- syllable segmentation
- articulatory groping, false starts and restarts
- prosodic impairment
- more errors on longer utterances
what are the characteristics of AOS in adults
unimpaired reflex and automatic acts. The difficulty is with voluntary movement
what does AOS typically associate with
- aphasia, especially Brocas
2. less frequently with unilateral uppermotor neuron dysarthria
what is primary progressive apraxia of speech
- when AOS is the only dominant symptom in primary progressive aphasia or dysarthria
- insidious onset and slow progress as compared to stroke induced AOS which is sudden with some improvement then stabilized
what is the neuropathology of AOS
- most often from a single left hemisphere stroke
- progressive AOS may be caused by degenerative diseases that cause primary progressive aphasia
- can be caused by left hemisphere trauma
what are the general symptoms of AOS
- impaired oral sensation in some
- language disorders may coexist if aphasia present
- if dysarthria coexists, facial and lingual weakness
what are the communication deficits in AOS
- auditory processing deficits
- have general awareness of speech problem which causes frustration
- slow or delayed initiation of speech
- may use compensatory strategy of reduced rate
- speech production errors
- prosodic problems
what are the speech production errors seen in AOS
- problems in volitional or spontaneous sequencing of movements with unaffected automatic speech
- high variability of speech errors that change on repeated attempts
- speech sound substitutions more common that distortions and omissions
- voicing errors (voiceless for voiced)
- more difficulty with consonants than vowels
- regressive assimilation
- progressive assimilatio
- metathetic errors ( switched positions of phonemes)
- insertion of schwa into consonant clusters
- increased frequency of errors on longer words
- trial and error groping
- greater difficulty with word initial sounds
- attempts at self repair
what prosodic problems are associated with AOS
- slower rate with difficulty changing the rate when requested
- impaired intonation becuse of increased duration of consonants
- even stress and restricted range of loudness, limited pitch
- fluency problems (silent pauses especially at initiation
How is AOS assessed
- check for aphasia when the patient shows coexisting signs
- tape record speech sample and transcribe. Note groping, self correction, repetition, dysfluencies, facial grimacing etc.
- evoke imitation of speech sounds
- diadochokinesis
- imitate progressively longer words, phrases, sentences
- evoke counting
- picture description
- oral reading
- check for oral apraxia or dysarthri
- assess limb apraxia
- standardized test: Apraxia Battery for Adults
How is AOS treated
behavioral treatment
- treatment should include instructions, demonstration, modeling, shaping, phonetic placement, frequent cueing, use of rhythm, immediate positive or corrective feedback
- treatment targets include artic accuracy, slower rate, systematic practice, gradual increase in rate, and normal prosody
- more difficult words promote better generalization
- include practice with a variety of sounds and sound combinatins
- repeated trials on same target response necessary to start
- cueing includes tactile cues for artic placement, simultaneous production, modeling, delayed imitation
- contrastive stress, phonetic cotrasts, carrier phrases, and singing may be useful
- push on abdomen to get vocal fold closure
- metronome or pacing board may be useful
- emphasize total communication
- teach self monitoring
- teach family members to speak slower when client is focused and use total communication
what is SPT or sound production treatment
minimal contrast therapy
what is the pathology of ataxic dysarthria
- appears only during movement
- will be manifested in other motor movements
- neuropathology is bilateral or generalized cerebellar lesions
- Friedreich’s ataxia is a degenerative form
- ataxic gait, nystagmus, and dysmetria may be present
what is dysmetria
undershooting and overshooting a target
what are the characteristics of ataxic dysarthria
- gait disturbance
- movement disorder (overshoot, undershoot, jerky, etc)
- respiratory disorder: exaggerated and paradoxical movement during speech
- artic disorders:imprecise consonants, irregular artic breakdown, distorted vowels
- prosodic disorder: excessive and even stress, prolonged phonemes, intervals between wors or syllables, slow rate
- phonatory disorder: monopitch, monoloudness, harshness
- speech quality: sounds drunk
- resonance disorder: intermittent hyponasality on some
what is flaccid dysarthria
- damage to LMN for volitional and nonvolitional movement
- characterized by hypotonia
- can be caused by degenerative disease (ALS),motor neuron disease, progressive bulbar disease, MS
what are the major characteristics of flaccid dysarthria
- muscular disorders: weakness, hypotonia, atrophy, diminished reflexes, fasiculations, fibrillations, rapid and progressive weakness with use
- respiratory weakness: reduced subglottic air pressure, weak inhalation
- phonatory disorder: breathy voice, audible inspiration
- resonance disorder: hypernasality, nasal emission
- artic disorder: imprecise consonants, weak pressure consonants
- cluster: phonatory incompetence, resonatory incompetence, phonatory-prosodic insufficiency
what is the etiology of hyperkinetic dysarthria
- results from damage to the basal ganglia
- produces variable muscle tone and involuntary movement
- commonly caused by degenerative disease (Huntington’s), vascular disease (brainstem stroke), trauma, toxic condition,
what are the major characteristics of hyperkinetic dysarthria
- orofacial dyskinesia: abnormal, involuntary, movement of orofacial muscles
- myoclonus: involuntary jerks of body
- tics: patterned, rapid, commonly of face and shoulders
- chorea: purposeless, random, involuntary
- athetosis: slow, writing,
- Ballism: bilateral, involutary movement of extremities
- hemiballism: unilateral ballism
- dystonia: contractions of antagonistic muscles that cause abnormal postures
- respiratory problems: audible inspiration, forced sudden inspiration not typical of other dysarthrias
- phonatory disorder: voice tremor, strained voice, voice stoppage, vocal noise
- resonance disorders: hypernasality
- artic problems: impreise consonant production with distorted vowels and slow rate
- prosodic problems: prolonged interword intervals, inappropriate silent periods, phoneme prolongations, excess and equal stress
what are the characteristics of hypokinetic dysarthria
- resting tremors
- mask face with infrequent blinking, no smiling
- micrographic writing
- walking disorder
- postural disturbances
- decreased swallowing: drooling
- respiratory problems: reduced vital capacity, irregular breathing
- phonatory disorders: monopitch, low pitch, harsh and breathy voice
- prosodic disorder: reduced stress, inappropriate silent intervals, short rushes of speech
- artic disorders: imprecise or distorted consonants, stops sound like fricatives
what is the etiology of spastic dysarthria
bilateral damage to upper motor neuron
- most commonly caused by multiple strokes that damage both the pyramidal and extrapyramidal systems
- Cerebral palsy in children
what are the characteristics of spastic dysarthria
- spasticity and weakness
- movement disorder: reduced range, force, and speed, loss of fine and skilled movement, increased muscle tone
- artic: imprecise consonants and distorted vowels
- prosody: excess and equal stress, slow rate, reduced stress, short phrases
- phonatory: hyperadduction of folds,
- resonance disorder: predominant hypernasality due to inadequate closure of velopharyngeal port
what are the most common mixed forms of dysarthria
- flaccid-spastic: associated with ALS
2. ataxic-spastic: associated with MS
what is the etiology of UUMN dysarthria
- purely anatomical
2. most common cause is stroke
what are the characteristics of UUMN dysarthria
- neurologic impairmet: unilateral lower face, tongue, palate weakness, and hemiplegia
- artic disorder: imprecise production of consonants, irregular artic breakdown, some vowel distortion
- phatory disorder: harsh voice, reduced loudness, strained, hoarse etc
- prosodic disorder: slow rate, equal and excess stress
- resonance : hypernasality or nasal emission
how do you assess the dysarthrias
- conversational speech sample and reading sample
- speech tasks including imitation of syllables, words, etc
- diadochokinetic rate AMR’s, and SMR
- oral mech exam
- observe patient posture and breath
- assess phonation: ahs
- assess artic, prosody, resonance, intelligibility,
- assess muscle strength, speed, range, accuracy, tone, and steadiness of movement
- use a standardized test
what are some standardized tests for dysarthria
- Assesment of Intelligibility of Dysarthric Speech
- Quick assessment for dysarthria
- Frenchay dysarthria assessment
how do you treat respiration in dysarthria
- train maximum vowel prolongation
- production of longer phrases
- controlled exhalation
- have patient push, pull, or bear down during speech tasks
- use resistive breathing devices to increase breath support
- use a manual push on the clients abdomen
- teach client to inhale more deeply and exhale slowly with greater force
how do you treat resonance
- provide feedback on nasal airflow by mirror, nasal flow transducer, or nasendoscope
- train the client to open mouth wider to increase oral resonance and vocal intensity
- use a nose clip
how do you modify articulation in dysarthria
- use a bite block to improve jaw control
- model, shape, immediate feedback, phonetic placement, slow rate
- minimal constrast pairs
- relaxation techniques such as jaw shaking exercise to loosen up muscles
- teach compensatory artic movements
what is the most common causes of dysphagia
- brainstem strokes
- tumors and neurologic disease
- surgery or radiation treatment
- TBI
what are disorders of the oral prep phase
- chewing problems because of reduced movement, buccal tension, and poor alignment of mandible and maxilla
- difficulty forming and holding bolus
what are disorders of the oral phase of swallowing
- begins with anterior to posterior tongue action.
- ends when food passes through the faucial arches
- anterior instead of posterior tongue movement, weak tongue movement, reduced range of movement and elevation
- tongue thrust
- decreased tongue sensation may cause premature loss of bolus
- residue due to incomplete swallow
- premature swallow before swallow
- piecemeal swallow
what are disorders of the pharyngeal phase of swallowing
- involves velopharyngeal closure, laryngeal elevation, opening of UES
- delayed or absent swallow reflex
- pharyngeal stripping problems
- residue in valleculae due to reduced base of tongue strength
- aspiration before and after swallow
what are disorders of the esophageal phase of swallowing
- not under voluntary control
- food propelled through peristaltic action and gravity
- difficulty passing the bolus through the cricopharyngeal muscle
- backflow from esophagus to pharynx
- diverticulum (pouch that collects food)
- tracheoesophageal fistula
what is achalasia
esophageal swallowing disorderdue to esophageal motility impairment. Food remains in the esophagus
how are swallowing disorders assessed
- assess ethnocultural background, food habits, restrictions
- screen speech, voice, language, and writing skills during clinical interview. Note voice quality, hypo and hypernasality
- screen concrete and abstract language comprehension through verbal commands and patient defining proverbs and phrases
- oral mech for strength and range of motion
- bedside swallow test
- examine laryngeal elevation by placing fingers on chin, hyoid, and larynx
how should you position the patient for test swallows
- tilt head downward as food is placed in mouth, and tilt head back when swallow is initiated in the case of tongue weakness
- for hemilaryngectomy, delayed swallow, inadequate laryngeal closure, tilt head down to hold food in valleculae until the reflex is triggered
what are direct treatments of swallowing disorders
- food or liquid is placed in mouth to shape appropriate swallowing
how do you treat disorders of the oral prep phase of swallow
teach the patient to
- press tongue against hard palate
- keep food on more mobile side of the tongue or mouth
- apply pressure to damaged cheek to increase tension
- tilt head to stronger side
how do you treat disorders of the pharyngeal phase of swallowing
- chin tuck to compensate for delayed or absent swallow reflex. Widens the valleculae so the bolus can collect there before the swallow
- alternate liquid and semisolid swallows to help clear the pharynx with reduced peristalsis
- multiple swallows
- tilt head to strong side for unilateral paralysis, decreased laryngeal elevation, poor epiglottic inversion, or decreased PES opening
- tilt head to weak side if there is weak pharyngeal contraction on one side. It forces the bolus down the intact side
- tilt head forward while placing pressure on thyroid cartilatge on damaged side to improve laryngeal closure
how do you treat disorders of the esophageal phase of swallowing
- avoid foods
- small portions, 2-3 hours before bed, elevate head
- lose weight, stop smoking
- remain upright for 30 minutes after eating
what are indirect treatment of swallowing disorders
does not involve food
exercises and skill training designed to improve muscle strength
how do you increase the range of tongue movement
raise tongue, hold as high as possible, alternate raising and lowering
how do you increase buccal tension
stretch lips tightly and say “ee”
round lips tightly and say “oh”
alternate
how do you increase range of lateral movement of the jaw
wide opening and sideways movement of jaw
how do you increase tongue resistance
push tongue against a tongue depressor
how do you stimulate the swallow reflex
- thermal stimulation of anterior faucial arch with laryngeal mirror dipped in ice water
- ask patient to swallow after stiulation without food
- practice liquid swallow after stimulation
- increase consistency
how do you improve adduction of folds
- holding breath, patient pushes down on chair
2. lift or push with simultaneous voicing
how do you increase base of tongue strength
- Masako maneuver: patient holds anterior tongue between teeth and dry swallows
- can also be strengthened by sucking a thick consistency through a straw
what is the supraglottic swallow maneuver
- helps close airway at folds
- patient holds food in the mouth and takes a deep breath, exhales, then holds breath
- swallow while holding breath then cough
what is the super-supraglottic swallow
- promotes false vocal fold closure
- patient inhales and holds breath by bearing down
- patient swallows while doing this, then coughs
what is the effortful swallow
- increases posterior motion of tongue and increases pharyngeal pressure
- patient squeezes hard as possible while swallowing
- may be more effective with electrical stimulation
what is the Mendelsohn maneuver
- helps elevate the larynx and widen the cricopharyngeal opening
- educate patient first about laryngeal elevate by having them feel the larynx while they swallow salive
- patient holds the laryngeal elevation during swallowing for progressively longer durations
what are some medical treatments for swallowing disorders
- cricopharyngeal myotomy: cricopharyngeal muscle is split to create an open sphincter
recommended for Parkinsons ALS
what is an esophagostomy
designed for those who cant take oral food
feeding tube inserted into esopharus
what is nasogastric feeding
tube inserted through the nose into the stomach
what is a pharyngostomy
tube inserted into esophagus and stomach through a hole in the pharynx
what are the muscles of mastication and their innervation
- temporalis: trigeminal
- masseter: trigeminal
- lateral and medial pterygoid: trigeminal
which face muscles are used for swallowing and their innervation
1.orbicularis oris: labial seal
2.buccinator : cheeks
3depressor labii inferioris: depress lower lip
4levator labii superioris, zygomaticul minor and major: elevators
all facial nerve VII
what are the supra hyoid muscles and innervation
- geniohyoid: cervical nerve
- digastric and mylohyoid: trigeminal
- stylohyid: facial nerve
what happens in the oral phase of the swallow
- masticatory mucles form bolus and place on tongue
- tip of tongue eevated and moves bolus back into the oro-pharynx
- sensory receptors in posterior guid initiation of pharyngeal swallow
what happens during the pharyngeal phase
- velopharyngeal closure
contraction of posterior tongue and forward movement of the LPW and PPW - bolus moves from high pressure to low contributing to pharyngeal stripping
- suprahyoid muscles move the hyoid up and forward
- larynx is closed through epiglottic inversion and laryngeal squeeze
- food reaches UES
what does the trigeminal nerve innervate
maxilary branch: sensory: upper lip, maxillary teeth and palate
Mandibular branch: sensory: anterior 2/3rd tongue, mucous membranes of mouth, cheeks, gums
motor: masticatory muscles, tensor veli palatine, mylohyoid and digastric
what does the facial nerve innervate
sensory: chorda tympani: taste anterior 2/3rd tongue
motor: lip sphincter
what does the glossopharyngeal nerve innervate
sensory: visceral afferent: taste from posterior 1/3rd tongue
motor: stylopharyngeus, pharyngeal constrictors
what does the vagus nerve innervate
sensory: hypopharynx, larynx
motor: velum, pharynx, larynx, esophagus
what does the hypoglossal nerve innervate
all tongue muscles except palatoglossus
how is the brainstem involved
sensory info terminate in nucleus of tractus solitarius
motor info goes through the nucleus ambiguous
what are the 2 pathways for swallowing control
- sensory info to cortex via thalamus, motor commands through cortico-bulbar pathways
- sensory info reaches nucleus tractus solitarius, is relayed to reticular formation and commands modulated by nucleus ambiguous
what do lesions in the insula cause
reduced magnitude of sensory input resulting in delayed swallow, decreased taste, volume, and temperature
what does a high volume bolus create
- more hyoid displacement
2. prolonged UES opening
what does a viscous bolus create
- increased oral pressure
- high chance of aspiration for thin consistency
- more residue with thick
what are symptoms of impaired oral bolus prep
- prolonged mastication
- prolonged oral transit time
- premature spillage of bolus anteriorlyy or posteriorlly
- oral residue
what are symptoms of delayed swallow initiation
- pre swallow pooling before swallow
2. laryngeal penetraion before swallow
what is the symtom of impaired tongue base retraction
residue in valleculae
what is the symptom of impaired epiglottic inversion, laryngeal vestibule squeeze
laryngeal penetration during the swallow
what is the symptom of impaired UES opening, hyoid excursion
- residue in pyriform sinuses
2. penetraion after the swallow
what is the difference between non nutritive and nutritive sucking in an infant
infant breathes with non nutritive
nutritive suck swallow ration is 1 : 1
what is the difference between suckle and sucking
suckle is backward-forward, sucking is up and down
what is the tongue thrust reflex
when lips are touched, tongue moves out of the mouth to allow for feeding from breast or bottle
what are swallowing issues associated with aging
1. muscle atrophy decreased range of motion, speed, strength diminished sensory respiratory compromise 2. prolonged mastication, poor dentition 3. delayed swallow initiation 4. inadequate hyolaryngeal excursion 5 increased laryngeal penetration 6. sensory and motor impairments leading to residue
what are the side effects of radiation therapy
- reduced blood supply which damages nerve endings
- nausea
- fibrosis
- skin irritation
- xerostomia
- peripheral neuropathy
- necrosis of tissue
- reduced range of motion, flexibility of structures, speed
- reduced sensation of bolus
- reduced synchrony
what are characteristics of lip cancer
- present as non healing ulcers
- pain in advanced stage
- treated with radiation
- mostly oral stage deficits
- radiation may affect other structures
what are characteristics of floor of mouth cancer
- can spread to bone and tongue causig glossectomy
what are characteristicsof tongue cancer
- mostly oral stage
- partial or total glossectomy
- cant create bolus or create enough pressure to push it back
what is retro moar trigone
cancer in triangular space behind last molar
affects mastication, oral control, posterior propulsion
what is achalasia
insufficient LES relaxation and loss of esophageal peristalsis
feels like something stuck in throat
symptoms: dysphagia, regurgiotatin, chest pain
what is diffuse esophageal spasm
contractions of smooth muscle portiaon of esophagus
striated portion and LES relax normally
corkscrew esophagus
peristaltic action compromised
what are strictures
loss of lumen area in esophagus
normal esophagus is 20 mm
strictures is when lumenal diameter is less than 15 mm
what are schatzki rings
narrowing of lower esophagus by rings of mucosal tissue
what is Zenkers diverticulum
small pouch close to UES
associated with cough, bad breath, regurgitation of undigested food
what is scleroderma
connective tissue disorder that weakens LES causing GERD
affects mostly smooth mucle (lower 2.3)
what is necrotizing enterocolitis
food reacts with bacteria in mucosa causing throwing up and diarrhea
reflux impacts swallowing
what is infant respiratory distress syndrome IRDS
when infant first egins to breathe, alveoli open, collapse then stick together after each breath
surfactant deficiency
what is transient tachypenea
poor clearance of lung fluid during birth
what is bronhopulmonary dysplasia
chronic lung disease due to prematurity
most common cause is mechanical ventilation
primary problem is poor separation of oxygenated and deoxygenated blood
what is atrioventricular septal defect
malformation of heart from failure of normal separation of ventricular inlet
characteristic feature of Down syndrome
what is included in a bedside swallow screening
- history
- cranial nerve exm
- trial swallows
what should you observe during screening
- mental status, nutritional status, respiratory status
what is included in the history
- sympotms such as signs of choking, weight loss, complaints of food going down wrong pipe or getting stuck
- past and current medical history
- any previous swallowing assessments
- socio cultural status
how do you examine the trigeminal nerve
- facial sensation using cotton wisp or sharp object
- corneal reflex: touching cornea with cotton wip to look for asymmetries in blinking
- jaw jerk reflex: tap on jaw with mouth slightly open
what do you examine the facial nerve
- look for asymmetry
- ask patient to smile, puff cheeks, wrinkle brow
- check taste with sugar, salt, or lemon juice to lateral aspect of each side of tongue
- UMN lesions: contralateral lower face weakness
- LMN weakness whole ipsilateral face
how do you examine the glossopharyngeal nerve
- palatal elevation and gag reflex
2. taste in posterior tongue
how do you examine the vagus nerve
- vocal functions
2. ability to cough voluntarily
how do you examine the hypoglossal nerve
- note atrophy or fasiculations
- patient sticks out tongue and see if it curves to one side
- patient moves tongue side to side and pushes against cheek
- listen for artic errors
what is a dye test
blue dye determines if there is aspiration in a trach patient
2. dye placed in mouth, trach cuff deflated and suctioned for secretions resting on or above the cuff
what are compensatory strategies for swallowing
- chin tuck: initiation and airway protection
- head back: oral stage deficits: uses gravity
- small sips and bites
- repeat swallows
- thickening viscosity
- head tilt to strong side
- head turn to weak side
- supra glottic maneuver
what exercises target delayed initiatin of swallow
- thermal tactile stimulation
2. air pulse application
what exercises target BOT to PPW
- Tongue back/ Masako
- Effortful Swallow
- Tongue pull back maneuver
which exercises increase hyolaryngeal excursion
- mendelsohn maneuver
- chin tuck against resistance
- Shaker
what exercises strengthens the pharynx
supraglottic swallow
what is FEEST
fiberoptic endoscopy evaluation with sensory testing
- adds device that sends air pulses
- laryngeal adductor reflex in response to air
what is a J tube
inserts predigested food into intestines
what is a PG tube
feeds directly into stomach
what is the Shaker exercise
1 minute sustained head raise for isometric
30 consecutive head raises for isokinetic
improves premature bolus loss, residue in valleculae, laryngeal elevation, epiglottic closure, residue in pyriform sinuses, pharyngeal transit time, and aspiration
which exercises aid pharyngeal stripping
mendelsohn and Shaker
what is the Masako maneuver
aids base of tongue to posterior wall
tip of tongue between teeth while patient dry swallows
what is effortful swallow
imagine you have ping pong ball in mouth that you have to swallow
10 reps
helps BOT-PPW
what is supraglottic swallow
for airway protection
- hold breath
- swallow hard
- cough
- swallow again 10-12 times
what is mendelsohn maneuver
for hyolaryngeal extension-UES
at peak of swallow patient squeezes and holds as long as they can
how does pitch gliding help
increases length and tension of folds to improve airway protection
what does chin tuck and head tilt help
residue in vallecuae
what does head rotation help
residue in pyriform sinuses
what affect does a trach have on swallowing
increased risk of aspiration due to
- poor sub glottic pressure
- poor laryngeal elevation
- reduced airway sensitivity
- general muscle weakness
what consistencies are used for trial swallows
thin: 5 ml 10 ml 20 ml continuous
puree or pudding: 5 ml 10 ml 20 ml continuous
solid
what should you observe during a bedside swallow
- laryngeal palpation: laryngeal elevation
- timing/ complete swallow/ number of swallows
3pre-post voice quality - coughing/clearing
- oral residue
