Motor Speech Disorders Exam Flashcards
What are the purposes of the exam? (8)
1 To give a description
2 determine if the characteristics are normal or abnormal
3 To establish diagnostic possibilities
4 To establish a diagnosis
5 To establish implications for localization and disease diagnosis
6 If a neurological diagnosis has already been made and it is inconsistent with the SLPs findings, that should also be stated
7 If a diagnosis is uncertain
8 To specify a severity
A weak cough can be caused by:
poor vocal fold closure
respiratory problems
How do you tell if the problem is with the vocal folds or the respiratory system?
Test the glottal coup (glottal attack)
If they have a poor glottal attack, the problem is with the :
vocal folds not the respiratory system
After the evaluation, we describe (2):
- features of speech
- structures and function associated with speech
- The clinician describes the patient’s speech and the structures and function of those structures
Once the description is complete the clinician determines if the characteristics are:
- normal or abnormal
What are 2 ways we can increase volume?
Build up sub-glottal pressure
- take more air in
- keep vocal fold more tightly constricted
If some aspect found to be abnormal the clinician:
attempts to make a differential diagnosis
In a differential diagnosis, the clinician narrows the diagnostic possibilities and tries to arrive at a specific diagnosis
Structures =
the anatomy
Function =
the physiology
If the anatomy is ok, does that mean the function is ok too?
No, not necessarily
If the physiology is ok, does that mean the anatomy is ok too?
No, not necessarily
Making a diagnosis:
The clinician should attempt to make a diagnosis.
i.e. is this a neurological problem, is it an acquired or developmental problem, is there a motor speech disorder present, if so is it apraxia or dysarthria, if dysarthria, what type of dysarthia is it?
If that is not possible then put the list in order of most possible to least possible
Establishing implications for localization and disease diagnosis:
The clinician should state the diagnosis and the localization associated with that diagnosis.
For example, the clinician can state that the diagnosis is spastic dysarthria which is associated with UMN involvement, or that the diagnosis is ataxic dysarthria which is associated with cerebellar involvement
What’s on example of a neurological diagnosis being inconsistent with the SLPs findings?
If the patient has been diagnosed with ALS but the SLP finds a mixed dysarthria of ataxic-hypokinetic, it should be noted that the dysarthria findings are inconsistent with a diagnosis of ALS
IF a diagnosis is uncertain what does the SLP do?
Indicate possible diagnoses.
For example, if a stress test indicates a strong possibility of myasthenia gravis, the SLP should note this
Severity rating statement:
mild, moderate, or severe
The SLP should always comment on severity for the following reasons (3):
- To compare to patient’s complaints - it may provide information about a possible psychogenic component or lack of insight on the part of the patient.
- It influences prognostic statements and decisions about how to manage the disorder.
- It provides baseline information against which to compare progress or changes.
Parts of the Motor Speech Exam (General Guidelines):
4
1 History - very important
2 Salient Features
3 Confirmatory signs
4 Interpretation of Findings
What do we get from the Case History? (3)
- time of onset
- course of development
- patient’s complaints and observations
*provides an opportunity to listen to patient’s speech without them knowing you are listening to the speech
What are salient features?
Those features that contribute most directly to the diagnosis and most influence the diagnosis.
See page 71, table 3-1
What types of salient features do we look for? (6)
1 Strength 2 Speed 3 Range 4 Steadiness 5 Tone 6 Accuracy
“RATSSS”
Why do we assess strength?
In order to perform appropriately, muscles have to have a certain strength.
If it is weak, it can’t work properly and may fatigue more quickly than usual.
This weakness of muscles can affect the 3 major speech valves
Muscle weakness can also impact the other components of speech production such as respiration, phonation, resonance, and prosody.
Muscle weakness is most prominent in flaccid dysarthria
What are the 3 major speech valves?
1 laryngeal
2 velopharyngeal
3 articulatory
Why do we assess speed?
- all speech movements require speed, especially those involving the 3 major valves
- Speech requires quick, unsustained and discrete movements which are called phasic movements.
- These can be single muscle contractions or repetitive contractions. They start quickly, reach their target quickly and relax quickly. These phasic movements are controlled primarily through UMN input.
Assessing Range:
- decreased ROM is common and can be associated with slow or excessive speeds. ROM can vary with ataxic dysarthria. Patient’s can over or undershoot the targets
For which Motor Speech Disorder(s) is a fast rate of speech common?
Only in hypokinetic dysarthria is there too much speed.
What symptom is a fast rate of speech associated with?
decreased range of motion
The articulators move so fast they can’t reach their targets
What’s more common: slow or fast rate of speech?
**slow movements in MSDs
- This can be demonstrated in slow initiating, slow throughout the movement, or slow to stop or relax
- Slow movements affects all the valves and prosody. The affects of slow movement is most seen in spastic dysarthria
Steadiness and MSDs:
- when there is not steadiness, it manifests itself usually in MSDs as a tremor or other hyperkinesias.
- Tremors can be mild to severe and may affect speech as well as other parts of the body.
- Tremors can affect phonation and sometimes prosody.
- The effects of tremors in speech can best be heard in vowel prolongation
- Tremors may be seen in nonspeech tasks involving the oral mechanism.
Types of tremors (3):
1 resting tremors
2 intentional tremors
3 terminal tremors (at the end of a movement).
Other hyperkinesias (3):
1 dystonias 2 choreas 3 athetosis etc *May interfere with or be present during speech
Tone and MSDs:
refers to muscle tone and can be hypo or hyper
Accuracy and MSDs:
- accurate movements are required for speech
- Inaccurate movements can result in speech errors
- If there is too much force or too much ROM the articulators may overshoot the target and vice versa
- Inaccurate movements also affect all major speech valves
Confirmatory signs of MSDs:
- Additional clues about the pathology in the nervous system
- These are signs other than the problematic speech characteristics noted and other than the neuromuscular symptoms
- These confirmatory signs help support the speech diagnosis
- Confirmatory signs do not have to be present
Examples of confirmatory signs within the speech system:
- Flaccid dysarthria- atrophy, fasiculations
- Hypokinetic dysarthria- reduced tone
- Spastic dysarthria- emotional lability, reduced normal reflexes, and pathological reflexes
Confirmatory signs of the nonspeech motor system involve (6):
- gait
- muscle stretch reflexes
- pathologic reflexes
- hyperactive limb reflexes
- limb atrophy
- fasiculations
etc.
Interpretation of Findings:
- Diagnosis
- The SLP should integrate the information from the history, salient speech feature, and confirmatory signs and formulate a diagnosis
- If the SLP can make a definitive diagnosis, do it
- If not, then make a formulation of diagnostic possibilities.
- An example of a definitive diagnosis: The patient presents with (an unambiguous) spastic dysarthria, with a possible accompanying ataxic component. There is no evidence of apraxia.
- Non-definitive diagnosis states that the diagnosis is ambiguous. List symptoms
If patient comes in and hasn’t been to the Dr.
refer them immediately to a neurologist first!
- Getting the Case History involves (8 things):
1 Introduction and Goal Setting 2 Basic Data 3 Onset and course of speech deficit 4 Associated Deficits 5 Patient's Perception of Deficit 6 Consequences of Disorder 7 Management 8 Awareness of Diagnosis and Prognosis
Introduction and Goal Setting (get during the case history):
Ask the pt why they are there. This gives you information about the patient’s perceptions, complaints, etc.
Basic Data (get during the case history):
Get basic information such as age, married status, education, occupation, etc
Determine any previous speech problems and treatment, if any.
Onset and course of speech deficit (get during case history, 6 questions):
1 When did the speech problem begin, how did it begin, i.e. suddenly, gradually, etc.
2 How has the problem changed, if it has changed, i.e. gotten better, worse, stayed the same.
3 Is the problem variable?
4 Does the speech return to normal at any time? If so, when?
5 Taking any medications, if so what?
6 Does fatigue affect speech?
Associated Deficits (get during case history) (3 questions)
1 Swallowing/chewing/controlling bolus/drooling problems?
2 Nasal regurgitation?
3 Emotional expression changes? Laugh or cry more easily and without apparent cause?
Patient’s Perception of Deficit (get during case history):
1 Describe your problem with speech. Give examples.
2 Is your speech slower or faster than usual; louder or softer
3 Is speaking effortful; less intelligible, does it feel different when you talk?
Consequences of Disorder (get during case history) (4 questions):
1 Do you have difficulty being understood by others?
2 Does this vary throughout the day or in different places?
3 Do you still maintain your social network or do you go out less often?
4 What changes have you made in your life due to the speech changes?
Management (get during case history) (4 questions):
1 How have you tried to compensate for your speech problem?
2 What works and doesn’t work?
3 What kind of professional help have you had?
4 Do you need help now?
Awareness of Diagnosis and Prognosis (get during case history) (4 questions):
1 Do you know the cause of your problem?
2 What has the Dr. told you?
3 What does this diagnosis mean to you?
4 Do you know how the disorder will progress?
- Examination of Speech Mechanism in Nonspeech Activities (15):
1 Face at rest 2 Face during sustained postures 3 Face during Movement 4 Jaw at rest 5 Jaw during sustained posture 6 Jaw in movement 7 Tongue at rest 8 Tongue in sustained postures 9 Tongue during movement 10 Velopharynx at rest 11 Velopharyanx during movement 12 Larynx 13 Respiration 14 Reflexes 15 Volitional versus "automatic" nonspeech movements of speech muscles
Examining the Face at rest:
- Normally the face at rest should be symmetrical, with normal tone and little or no extraneous movement. It shouldn’t droop or be rigidly fixed, or show uncontrollable emotion.
- Ask the patient to relax, look ahead and open lips slightly to breathe through the mouth. Notice if face is symmetric in this posture, angles of mouth symmetric, drooping on one side of face, eyelids, or corner of mouth, flattening of nasolabial fold, etc. Slight differences in symmetry are OK.
Examining the Face at rest:
- Look for mask-like expressions, stiffness anywhere in face
PD
Examining the Face at rest:
- Are there any involuntary movements, or tremors, in the face?
Hyper
Examining the Face at rest:
- Are there fasiculations in the face, especially note the mouth and chin?
Flaccid
Examining the Face during sustained postures:
- Have patient retract lips, round lips, puff cheeks, open mouth, and hold each a few seconds.
- (if patient isn’t doing this, it might be due to patient being nervous, so make sure your observations/testing are accurate)
- In these sustained postures, note symmetry or asymmetry, range of motion (normal or restricted), sagging or drooping of mouth.
- Try to push upper or lower lip toward midline while in retracted sustained posture to see if patient can resist this movement. While lips are rounded, try to spread lips and see if patient can resist this. (use gentle but firm pressure)
- Look for tremulousness in sustained postures. Note other movements.
- Can postures be held for several seconds?
- helpful to videotape and watch later just in case the patient exhibited tremor and other characteristics while you were looking down to write something
Examining the Face during Movement:
- Watch face during speech and nonspeech movements.
- Look for expressiveness, symmetry/asymmetry, emotional responses, range of movement. (Mild asymmetries are OK)
- Compare both voluntary and involuntary movements, i.e. smiling when something is funny and retracting lips on request.
- If can do the movement involuntarily but not voluntarily = sign of apraxia
Examining the Jaw at rest:
- Is it tightly closed or open a little at rest?
- Does it hang lower than normal?
- Are there tremors or other involuntary movements, fasiculations?
- Does it pull to one side?
- Does the patient compensate by clenching teeth, etc?
Examining the Jaw during sustained posture:
- Observe jaw during sustained postures such as mouth opening.
- Watch for jaw deviations to one side.
- Attempt to open jaw when patient is asked to clench teeth. Can patient resist this?
- Palpate masseter/temporalis muscle with patient clenching teeth. Is there normal bulk?
- With patient holding mouth open, try to close it. Can patient resist this?
Examining the Jaw in movement:
- Watch for symmetry and ROM in speech and spontaneous movements of jaw.
- Have patient rapidly open and close mouth. Note speed and regularity (versus irregularity).
- Are there involuntary movements which interfere with opening and closing?
- make sure directions are clear. Patient may not open mouth all the way bc they didn’t realize that is what you wanted. Demonstrate what you want them to do.
Examining the Tongue at rest:
- Have patient open mouth and observe tongue in mouth.
- It should be relaxed on the floor of mouth. Some slight movement is normal.
- Is tongue symmetrical and of normal bulk and size?
- Is there atrophy? (Sometimes you may see grooves which occur as part of atrophy)
- Are there fasiculations?
- Are there other movements?
- Is tongue wet or dry? If dry, might be indication of zerostomia which is dry mouth associated with various causes (too little water intake, meds, radiation). If tongue is in appropriately wet, could be that patient isn’t handling secretions well.
- tongues tend to severely atrophy with ALS
Examining Tongue in sustained postures:
- Have patient protrude tongue and hold it. It’s hard to hold this posture so small movements are normal.
- Look for tongue deviation to one side, If deviation is subtle, have patient repeat the process several times and look for consistent deviation.
- Look for ROM of tongue protrusion.
- Use tongue blade to push against tip of tongue - can patient resist?
- Have patient push against inside of each cheek with tongue as you press against cheek with finger. Can patient resist this pressure.
- With tongue protruded, try to push tongue to one side. Can patient resist this.
Examining Tongue during movement:
Ask patient to move tongue rapidly from side to side of mouth.
Look for speech regularity, ROM.
Examining Velopharynx at rest:
Have patient open mouth widely. Push down gently on tongue with tongue blade.
Look at palate - does it hang low, is it symmetrical?
Examining Velopharyanx during movement:
- Have patient say a prolonged “ah”. Look at palatal movement.
- Is there symmetry of movement? If asymmetriac, does the palate elevate more strongly o opposite side to that which hung lower at rest?
- Hold mirror at nose during vowel prolongation and repetition of pressure consonants. Is there evidence of nasal airflow?
- Hold patient’s nose during vowel prolongation. Is there a difference in resonance?
- Have patient puff cheek and contain air while you try to push against cheeks. Can patient resist?
- Do modified tongue-anchor process. Patient sticks out tongue and puffs out cheeks. Does air escape from nose? If so, suspect VP problem. (May help to occlude patient’s nose initially then release to see if air escapes from nose.) Rationale: sometimes back of tongue used to help in VP closure are compensation. What we are looking for is weakness of the VP mechanism.
- IF possible observe VP activity in videoflouroscopy.
Examining the Larynx:
- Assess vocal fold adduction through coughing. Listen for a “sharp” cough, not its loudness. A weak cough can indicate either poor vocal fold closure or poor respiratory support.
- Have patient produce glottal “coup” (glottal attack). This should also be sharp and requires little respiratory effort. If cough is weak and coup is sharp, implications are of poor respiratory support. If both are weak, implications are of poor vocal fold closure but this may be combined with poor respiratory support. We want to hear a “sharp” glottal attack
- Inhalatory stridor may indicate poor vocal fold abduction. Can be heard in quiet breathing but is more prominent usually in inspiration before speech.
- Laryngoscopy may be done to actually observe folds. Can be done with a flexible fiberoptic laryngoscope or rigid oral laryngoscope, or with videostroboscopy or through electroglottography.
Examining Respiration:
- Note if posture is normal - is patient slouched or bent forward? Is head drooped forward? Abnormal posture can constrict diaphragm, abdomen or chest wall and make breathing difficult.
- Does patient complain of shortness of breath? Is it at rest or during activity? Is breathing shallow or rapid? Normal breathing is at rate of 16-18 breathes per minute.
Is there shoulder movement or neck extension during inspiration? This is often associated with respiratory weakness and reduced loudness. - Is there flaring of the nares in breathing?
- Is breathing rate regular? May be related to movement disorders
- Are there persistent hiccups? May be indication of medulla lesion.
- Contrasting sharpness of cough to glottal coup. Look for limited abdominal or chest wall movement with weak cough - indicates respiratory weakness.
- Fill glass with water (at least 12 cm deep). Attach a straw to the glass with paper clip. Have patient blow into straw to maintain a stream of bubbles for 5 seconds. Straw must be at least 5 cm into the water. If patient can do this, respiratory support should be OK. To do this the patient must be able to maintain a labial seal around straw and be able to impound through VP closure
Examining Reflexes:
- Reflexes can provide confirmatory information. Two types of reflexes - normal reflexes which indicate normal nervous system function, and pathological reflexes which are primitive reflexes that are present during infancy but disappear as the nervous system matures.
- Pathological reflexes may reappear due to CNS diseases and are associated with a release phenomena or poor inhibitory mechanism in the brain.
- Normal reflexes are variable among normal individuals and some normal individuals demonstrate pathological reflexes, so these results must be interpreted with caution.
Which reflexes do we examine (5)?
- Gag reflex
- Jaw jerk
- Sucking reflex
- Snout reflex
- Palmomental reflex
Gag reflex:
- a normal reflex
- Elicited by touching back of tongue, posterior pharyngeal wall, or faucial pillars
- The glossopharyneal nerve provides this sensory information to the brain. The motor response is through glossopoharyngeal and vagus nerves
- The reflex is characterized by palatal elevation, tongue retraction, and contraction of pharyngeal walls
- Look for asymmetrical gag reflex - so you must assess both sides. If the gag reflex is present on one side and not the other, this is clinically significant.
- Ask the patient if it “feels” differently on each side, if so the afferent component may be impaired. If it doesn’t feel different, the motor component may be impaired.
- An absence of gag reflex is not necessarily clinically significant because some normal people don’t have strong gag reflex. So look primarily for asymmetry in the gag reflex
Jaw jerk Reflex:
- have patient relax and drop jaw. Tap with tongue blade on patient’s chin. Tap the blade with finger or reflex hammer.
- This reflex is indicated is the masseter and temporalis muscles contract and the jaw jerks toward closing.
- The trigeminal nerve handles both the afferent and efferent components of this reflex.
- About 10% of normal people have this reflex but in most people the presence of this reflex indicates UMN disease above the level of trigeminal nerve nuclei in the mid pons.
Sucking reflex:
- stroke the upper lip with tongue blade, starting at the sides of upper lip and moving toward midline. Do it on both sides.
- Normal people usually have no response.
- A positive response, meaning the reflex is present, is indicated by a pursing or pouting of lips.
- It can indicate UMN disease above the level of facial nerve nuclei in the pons.
- Is often present in people with dementia
Snout reflex:
- lightly tap finger on tip of nose or philtrum or by pushing backward on uppler lipee and philtrum at midline with your finger.
- Indication of positive reflex is puckering or protrusion of lower lip and depression of side of mouth.
- 17% of normal adults have this - with greater occurrence after age 60 in normal adults
Palmomental reflex:
- primitive reflex elicited by vigorously stroking tongue blade on palm of hand.
- Positive response is indicated by slight elevation of ipsilateral chin.
- Has to do with projection fibers to paracentral cortex.
- 37% of normal adults may exhibit and 60% of those who are 90 years or older.
Examining Volitional versus “automatic” nonspeech movements of speech muscles:
- in nonverbal oral apraxia (NVOA), automatic movements are OK whereas voluntary movements are impaired.
- Patient may be able to cough spontaneously but not be able to do so upon command.
- Patient may be able to pucker lips to kiss someone, but not be able to do so upon command.
- If patient cannot be movement on command, see if they can do it with imitation.
- NVOA is often, but not always, associated with verbal apraxia.
- NVOA should be assessed for if the patient has apraxia of speech or aphasia. It occurs with left hemisphere lesions (dominant hemisphere).
- Assessment of perceptual speech characteristics (3 things)
1 Distinctive Speech Characteristics
2 Synthesize information
3 Tasks for speech assessment
Mayo Clinic Dysarthria Studies:
Darley, Aronson and Brown analyzed 212 patients with MSD (1975) and compiled a list of 38 speech and voice characteristics found in 7 groups of people.
These groups are equivalent to the groups of flaccid, spastic, ataxic, hypokinetic, hyperkinetic and mixed.
They also identified clusters of characteristics that appeared in patients.
The characteristics listed by Darley, Aronson, and Brown have been and are still used to categorize perceptual speech characteristics.
Distinctive Speech Characteristics (Assessment of perceptual speech characteristics):
Rate speech dimensions on a scale of 0 to 4.
Page 79. See page 90.
Synthesize information (Assessment of perceptual speech characteristics):
- compare list of speech characteristics to dysarthrias or apraxia
Tasks for speech assessment (Assessment of perceptual speech characteristics) (6):
1 Vowel prolongation 2 AMRs (alternating motor rate) (diadochokinetic rates of individual syllables) 3 SMRs (sequential motion rate) (putuku) 4 Contextual speech 5 Fatigue 6 Assess speech motor planning
Vowel prolongation (tasks for speech assessment):
- tell patient to take a deep breath and say “ah” for as long as they can.
- Note maximum vowel duration as well as other salient characteristics.
- Note face, jaw, tongue and neck in vowel prolongation.
(See text for norms for vowel prolongation times)
AMRs (alternating motor rate) (diadochokinetic rates of individual syllables) (tasks for speech assessment):
- note speed, regularity, movements of jaw/tongue, articulation precision.
- Tell patient to take deep breath and say the syllables required.
- SLP should model first.
SMRs (sequential motion rate) (putuku) (tasks for speech assessment):
- measure ability to move rapidly from one articulatory posture to another.
- SMRs particularly are helpful in determining apraxia.
(acceptable alternatives: pattycake or buttercup)
AMRs are more helpful for determining:
dysarthria
SMRs are more helpful for determining:
apraxia
Contextual speech (tasks for speech assessment):
- Grandfather passage as well as conversational speech.
- Use open-ended questions.
- Note articulation precision, speed, intelligibility, prosody, monotone, loudness, etc.
Fatigue (tasks for speech assessment):
- Assess by counting, reading aloud, etc. for 2 to 4 minutes
- Provide 1 to 2 minutes to rest and listen to speech again
Assess speech motor planning (tasks for speech assessment):
- if apraxia is suspected, assess SMRs and ability to say multisyllabic words.
- Look for groping, self-correction, delayed response, awareness of errors
Dysarthria Tests (1):
Frenchay Test of Dysarthria Assessment
Do you see more self-correction with apraxia or dysarthria?
apraxia
Apraxia Tests (1):
Apraxia Battery for Adults - 2nd Edition
When testing for apraxia, should you model?
No.
Ppl with apraxia are better at imitating than doing things on demand. If they do not do it on demand, then you can model
In apraxia, patients tend to break down more with single syllable or multisyllabic words?
multisyllabic words
Assessment of Intelligibility, Comprehensibility and Efficiency (Intelligibility Tests) (4):
1 Assessment of Intelligibility in Dysarthric Speakers (AIDS)
2 Sentence Intelligibility Test - updated Windows version of sentence part of AIDS.
3 Intelligibility part of Frenchay
4 Word Intelligibility Test - developed by Kent and is not standardized.
What do we look at during the Oral Motor Assessment (from the video) (6)?
1 Face (look for symmetry): mouth at test, naso-labial folds, smile, round lips, puff cheeks, open mouth to test sucking reflex, open mouth as far as they can, jaw alignment, resist open and closing the mouth Test the tongue: at Rest on protrusion wiggle strength (anteriorly and laterally)
2 Velo-pharynx: rest, phonation, pharynx, phonation, nasal emission, gag reflex
3 Larynx: quiet breathing, vowel prolongation, glottal coup, contextual speech
4 Speech: phonation and vowel prolongation
5 Resonation (mirror): non-nasal sentences (fricatives and stops a.k.a. pressure consonants) and nasal sentences
6 Speech Articulation: AMRs, SMRs, Contextual Speech
Case Study 1: Normalish connected speech Vocal flutter with sustained vowel Fasciculations seen on tongue Normal but slow AMRs Spontaneous speech: imprecise speech, weak articulators No tongue strength
Diagnosis?
Mixed flaccid-spastic dysarthria
Case Study 2: Contextual speech slow Lingual imprecision Hypernasal Slow and regular AMRs Vowel prolongation: rapid tremor/flutter Atrophy of tongue Chin fasciculations
Diagnosis?
Mixed flaccid-spastic dysarthria (most likely ALS)
