Section 4 Flashcards
1
Q
Describe the neurological response for listening.
A
The sound signal travels to the pinna and through the external acoustic meatus (EAM), which amplifies the
sound signal. From here, sound is transmitted through the tympanic membrane, which then vibrates, and causes the subsequent vibration of the ossicles (incus, malleus, stapes). The footplate of the stapes hits the oval window of the inner ear, which causes displacement of fluid. This fluid displacement disturbs the hair cells along the basilar membrane, and results in neuronal
activation of the 8th cranial nerve (CN VIII - Vestibulocochlear) to the cochlear nucleus,
otherwise known as the Central Auditory Pathway to the temporal lobe in the brain. Here, auditory processing and comprehension occurs. Wernicke’s area plays a vital role in language
comprehension and processing.
2
Q
What occurs after you hear something and want to respond?
A
Information processed in Wernicke’s area is now transmitted to the frontal lobe of the brain, whereby language production and the cognitive skills required for memory recall are stimulated. Broca’s area is responsible for language and production of coherent
speech. This information is then transmitted from Broca’s area in the frontal cortex, to the association cortex, basal ganglia, and cerebellum, whereby the motor hierarchy begins.
3
Q
Describe the motor control hierarchy.
A
Upper motor neuron -> LMN -> peripheral nerve -> neuromuscular junction -> muscle
4
Q
How are the basal ganglia association cortex and cerebellum involved in speech?
A
The association cortex, basal ganglia and cerebellum are related to quality of movement and tell
the muscle how to move. The association cortex regards the appropriation of movement, the basal ganglia is related to initiation of movement, and the cerebellum relates to smooth trajectory of movement, or coordination. The motor thalamus is also involved at this level of the
hierarchy. It is responsible to relay information between the cerebellum and the motor cortex, and between the basal ganglia and the motor cortex.
5
Q
What is the use of the LMNs in the motor control hierarchy?
A
The remaining components of the pathway are related to the quantity of movement and overall muscle strength. Lower motor neurons are called the “final common pathway” because they are the most distal connection between theCNS and the muscle.
6
Q
How might damage to Broca’s area impact speech?
A
Difficulty processing ideas into tangible language outputs, word finding difficulties
Influences the content of what is able to be spoken
A left hemisphere stroke can cause damage to Broca’s area, and result in Broca’s type aphasia
7
Q
How might damage to the pyramidal/extrapyramidal system impact speech?
A
Extrapyramidal system affects posture and tone; as well as the regulation of reflexes [which are involuntary in nature]
Can result in dysarthria if damaged
8
Q
How might damage to the basal ganglia impact speech?
A
Problems with initiating movements
Can result in abnormal, involuntary movements, or abnormal, involuntary postures
Disorders such as Parkinson’s disease and Huntington’s disease can cause involuntary tremors and continuous writhing
movements of the extremities
Long term use of antipsychotic drugs that target the dopamine
system can result in involuntary movements of the tongue, face, arms, lips and other body parts
9
Q
How might damage to the association cortex impact speech?
A
Difficulties with the appropriateness of movements
Fine motor movements and approximation of articulators will be impacted
10
Q
How might damage to the cerebellum impact speech?
A
Abnormal trajectory of movements, lack of coordination
Lesions to the vestibulocerebellum can affect posture
Can result in a staccato nature of speech, slow and disjointed
11
Q
How might damage to the UMN impact speech?
A
Weakness with heightened muscle tendon reflexes, hypertonia
12
Q
How might damage to the LMN impact speech?
A
Muscle fasciculations, atrophy
Decreased muscle tone
Muscle weakness is often profound in LMN disorders, in localized regions of the body
Damage can arise from diseases such as polio, or localized lesions near the spinal cord
13
Q
How might damage to the neuromuscular junction impact speech?
A
Decreases nerve-cell activity, and results in muscle weakness
This does not impact sensation of muscles (ie. tingling)
14
Q
How might damage to the muscle impact speech?
A
Muscle weakness, increased fatigue
Results in poor intelligibility, difficulty with articulation, muscle control of the tongue
Any damage directly to the muscles themselves will have limitations on movement, coordination and timing
15
Q
What causes dysarthria?
A
An impairment to either the cerebellum, basal ganglia, cerebral cortex or white matter tracts, pyramidal and extrapyramidal systems, cranial nerves, and lower motor neurons. Characterized by a difficulty with motor execution.
16
Q
What causes apraxia of speech?
A
An impairment to the left hemisphere (Broca’s area, motor cortex). Characterized by a difficulty with motor planning.
17
Q
What are the different disorders associated with difficulties with motor execution and their site of impairment?
A
Ataxic dysarthria: cerebellum
Hypokinetic dysarthria: basal ganglia control circuit, including substantia nigra
Hyperkinetic dysarthria: same as hypo kinetic.
Spastic dysarthria: cerebral cortex or white matter tracts, pyramidal and extrapyramidal systems.
Flaccid Dysarthria: cranial nerves, LMNs
18
Q
How might damage to an area of the motor hierarchy impact respiration?
A
Slow, restricted, weak, or uncoordinated muscle activity used in breathing for
speech
19
Q
How might damage to an area of the motor hierarchy impact phonation?
A
Difficulties producing smooth sound in the larynx
20
Q
How might damage to an area of the motor hierarchy impact resonance?
A
Difficulty to selectively amplify sound by changing the size, shape, or number of cavities through which it must pass
21
Q
How might damage to an area of the motor hierarchy impact articulation?
A
Difficulty with the movement or approximation of speech structures to each other when producing sounds of speech
22
Q
How might damage to an area of the motor hierarchy impact prosody?
A
Lack of intonation, stress, or rhythm during speech
23
Q
What is the motor speech treatment hierarchy?
A
The hierarchy stipulates that the speech subsystems do NOT act independently. Rather, adequate respiratory support and velopharyngeal valving supports phonation, and articulatory precision is supported by respiratory, resonatory, and phonatory competence. In other words, reflecting on the characteristics of dysarthria, there is no condition where only one subsystem is affected without impacting the functionality of the other systems.
24
Q
Describe the motor speech treatment hierarchy.
A
First order targets: respiration and resonation
Second order targets: phonation
Third order targets: articulation, prosody
25
What are the motor learning principles for treatment?
Amount: the more opportunities for practice, the better
Distribution: distributed practice results in better long term learning, while massed practice enhances performance
Variability: different contexts are beneficial for learning (ie. a phoneme with different
vowels)
Schedule: randomizing the targets rather than doing blocks of massed practice has benefit for learning (ie. ACBCAB vs. AABBCC)
Mediating variables include severity, cognitive level, and stage of practice
26
What are the key principles to neuroplasticity?
Use it or lose it: If a neural substrate is not biologically active, its function can degrade; disuse leads to weakening of synapses of neglected function, strengthening of synapses involved in more consistent behaviours.
Use it and improved: must consider what and how we are using and engaging the system to maximize functional outcomes.
Reprition matters: success typically corresponds with number of repetitions, treatment sessions, and duration.
Time matters: brain is often most amenable to change early on
Intensity matters: skeletal muscle does not adapt unless it is forced beyond to typical range of activity (overload principle)
Specificity matters: what is being repeated
Salience matters: important for therapist to know what is important and what pt takes away.
Difficulty matters: targets must be achievable, challenging, progress in difficulty (load, duration, skill)
Transference
Interference: may involve unlearning
Age matters: younger brains better
27
What is different about prosody in the motor speech hierarchy?
Prosody should be encouraged at each level, not just at the third. It could also be considered a first level target.
28
Sumarize motor speech development.
I: tone (body and facial tone, reflexes)
II: Phonatory control (airstreams, phonation, resonance)
III: jaw control vertical movement (range, grading, mid-line mov't)
IV: labial facial control horizontal (bilabials, rounding, retraction, individual lip)
V: tongue control (anterior/ posterior - independent mov't from jaw)
VI: Sequenced movement
VII: Prosody
29
Describe typical jaw movements.
Range needs to allow for the lips and tongue to move and make contact with other structures.
Jaw needs to be stable, with no sliding or thrusting. This allows for the development of controlled movement in other articulators and allows for development of differentiated and refined movement in other articulators. movement needs to be controlled in order to open and close, and grade movement in fine increments between the positions.
30
How must the lips move for development?
Lips must move independently without the help of the jaw to achieve closure,
rounding, retraction, and individual lip movement (ie. /f/)
31
How must the tongue be able to move for speech?
Must move independently without the help of the jaw to elevate the tip, elevate
the back, and create tension or constrictions at specific points from front to back
32
Describe the various aetiologies and speech characteristics of flaccid dysarthria.
Etiologies: surgical trauma, neuropathies (bell's palsy), muscle disease, myasthenia graves, degenerative disease, brainstem stroke.
Primary deficit: weakness
Characteristics: hyper nasality, nasal emissions, slow and slurred DDKs, tongue fasciculations, imprecise consonants, breathy, wet, horse voice, mono pitch/loudness
33
Describe the various aetiologies and speech characteristics of spastic dysarthria.
Etiologies: cerebrovascular (CVA), degenerative disease, TBI, infection (meningitis), CP
Primary deficit: spasticity
Characteristics: hyper nasality, harsh, breathy voice, strained and strangled voice, mono loudness, low or mono pitch, imprecise consonants, excess and equal stress.
34
Describe the various aetiologies and speech characteristics of ataxic dysarthria.
Etiologies: cerebellar stroke or injury, cerebellum atrophy.
Primary deficit: incoordination
Characteristics: slow, slurred speech, excess and equal stress, irregular incoordination, imprecise consonants, distorted vowels, mono pitch/loudness, prolonged phonemes
35
Describe the various aetiologies and speech characteristics of hypokinetic dysarthria.
Etiologies: parkinson's disease
Primary deficit: rigidity & decreased ROM
Characteristics: mono pitch/loudness, short rushes of speech, low, flat pitch, breathy, harsh voice, reduced stress, inappropriate silences, fast and imprecise DDK.
36
Describe the various aetiologies and speech characteristics of hyperkinetic dysarthria.
Etiologies: huntington's
Primary deficit:: involuntary movements
Characteristics: involuntary movements at rest and during speech, articulatory breakdowns, voice stoppages.
37
Describe the various aetiologies and speech characteristics of unilateral UMN dysarthria.
Etiologies: unilateral stroke
Primary deficit: weakness, incoordination, spacticity
Characteristics: unilateral facial weakness, harsh voice, articulatory imprecision.
38
Differentiate the types of dysarthria based on respiration symptoms.
```
Ataxic: Excessive loudness variation
Hypokinetic: reduced loudness
Hyper: interruptions, excessive loudness variation
Spastic: short phrases, reduced loudness
Flaccid: short phrases
UMN: reduced loudness
```
39
Differentiate the types of dysarthria based on phonatory symptoms.
Ataxic: may be harsh
Hypokinetic: tight, breathiness
Hyper: strain, tremor, voice interruptions
Spastic: strained, strangled
Flaccid: breathiness, diplophonia, flutter
UMN: weak, strained or hoarse.
40
Differentiate the types of dysarthria based on articulatory symptoms.
Ataxic: irregular articulatory breakdowns
Hypokinetic: imprecise, usually with reduced ROM during speech movements
Hyper: distortions, interruptions
Spastic: imprecise
Flaccid: imprecise, articulation
UMN: imprecise, irregular breakdowns.
41
Differentiate the types of dysarthria based on resontary symptoms.
Ataxic: often normal, otherwise may be variable
Hypokinetic: often normal
Hyper: constant or variable
Spastic: hypernasal
Flaccid: hypernasality, nasal air emissions
UMN: hyper nasality
42
Differentiate the types of dysarthria based on prosody symptoms.
Ataxic: slow rate, scanning speech, excess and equal stress
Hypokinetic: rapid rate, short rushes of speech, mono pitch, mono loudness.
Hyper: often slow
Spastic: slow rate, mono pitch, mono loudness
Flaccid: mono pitch, often normal rate
UMN: slow rate, reduced stress
43
Describe apraxia of speech.
a problem in assembling the appropriate sequence of movements for speech production or executing the appropriate serial ordering of sounds for speech. These problems cannot be explained by significant slowness, weakness, restricted range of movement or incoordination of the articulators. There is also no significant muscle involvement, and resonation is considered normal.
Lesions may be in two areas: broca's or the primary motor cortex.
44
Describe the typical articulation characteristics of apraxia.
Articulation difficulties are also characterized by inconsistent errors, prolonged vowels, and a heightened difficulty with consonants rather than vowels.
Groping to find the correct articulatory postures and sequences
Facial grimaces, moments of silence, and phonated movements
Consonant phonemes are involved more often than vowel phonemes
Articulation errors are inconsistent and highly variable
Articulatory errors are primarily substitutions, additions, repetitions,
and prolongations
45
Describe the typical prosody characteristics of apraxia.
Durational relationships of vowels and consonants are distorted
Rate of production is slow
Alterations of the intonation
46
What is CAS?
The difficulty executing the volitional motor plan for speech
in the absence of paralysis or neuromuscular deficits. It is characterized by many, many speech
errors (predominantly substitutions, omissions, and additions), a difficulty imitating, poor DDKs,
and inconsistencies in errors across productions.
47
What are the three core features of CAS?
Inconsistent errors on consonants and vowels in repeated productions of syllables or
words
Lengthened and disrupted coarticulatory transitions between sounds and syllables
Inappropriate prosody, especially in the realization of lexical or phrasal stress
More specifically:
Vowel distortions (allows you to rule out a phonological disorder)
Vowels are based on positioning/grading
Prosodic errors- equal stress and segmentation. Awkward/imprecise transitions
Groping and/or trial and error behavior
48
What must be true for a diagnosis of CAS?
Must be older than 36 months of age
Must have received a block of early speech intervention prior to 36 months, followed by at least one block of motor speech therapy after 36 months
49
Compare and contrast CAS, motor speech, and dysarthria in terms of number of errors, prodominant error type, ability to imitate, diadochokinesis, and error consistency.
#: much more (CAS), minimal-moderate (MS), moderate (dys)
Type: substitutions, omissions, and additions, substitutions, omissions, distortions, and additions, mostly omissions and distortions
Imitate: difficulty, easy to moderate, easy
DDK: poor, normal, slow
Consistency: no, yes, yes
50
What are the different aetiologies of neurologically based speech disorders?
Acute causes may be more likely to improve (such as a stroke or TBI)
Chronic conditions may be stable or worsen (dementia, tumor)
Acquired causes may worsen over time
Congenital may be stable, but is dependent on the condition, trajectory etc.
51
Describe how ALS might impact speech.
Progressive/degenerative nervous system disease that affects nerve cells in the
brain and spinal cord, causing loss of muscle control
Neurologically based speech disorders will worsen overtime
52
How might brain injury impact speech?
Dependent on the injury and localization of blow to head. Generally towards
improvement during the first few months, then stabilizes
Neurologically based speech disorders will: likely improve during early stages of
recovery, may or may not permanently improve.
53
How might a brain tumour impact speech?
Variable - dependent on stage of brain tumour, localization in brain, and treatment outcomes (recurrence)
Neurologically based speech disorders will: vary
54
How does CP impact speech?
Generally stable difficulty coordinating the muscles they use for speaking and the coordination of their breathing as they talk
Neurologically based speech disorders will: remain stable, depending on severity
of CP
55
How does guillain-barre syndrome impact speech?
Rapid onset of symptoms; denervation of muscles, which causes weakness, with expected improvement given treatment. Recovery time is generally 3 years.
Neurologically based speech disorders will: mostly improve given ongoing
intervention
56
How does huntington's disease impact speech?
Progressive brain disorder caused by a defective gene
| Neurologically based speech disorders will: worsen overtime
57
How does MS impact speech?
Dysarthria is considered the most common communication disorder in those with MS. It is typically mild, with severity of dysarthria symptoms related to neurological involvement
Neurologically based speech disorders will: likely remain stable with ongoing
treatment of disease, worsen later on in life expectancy
58
How does muscular dystrophy impact speech?
Varies according to the type and progression of the disorder, more severe MD with severe muscle weakness will result in ongoing speech difficulties
Neurologically based speech disorders will: likely worsen as disease progresses
59
How does myasthenia graves impact speech?
A chronic autoimmune disorder in which antibodies destroy the communication
between nerves and muscle, resulting in weakness of the skeletal muscles - lesions occur at neuromuscular junction
Neurologically based speech disorders will: likely worsen as disease progresses
60
How does PD impact speech?
A progressive, degenerative disease of the nervous system marked by tremor,
muscular rigidity, and slow, imprecise movement.
Neurologically based speech disorders will: likely worsen as disease progresses
61
How might a stroke impact speech?
Will have variable impacts on speech dependent on localization of lesion in
relation to speech production
Neurologically based speech disorders will: likely improve rapidly following stroke, as well as with ongoing intervention for support
62
How might wilson's disease impact speech?
A rare, progressive, genetic disorder characterized by excess copper stored in
various body tissues, particularly the liver, brain, and corneas of the eyes.
Prognosis depends on time of diagnosis and ongoing treatment. Causes tremor,
involuntary movements, lack of coordination, and muscle rigidity
Neurologically based speech disorders will: worsen overtime
63
Name the different types of dysarthria and when you may see them.
Flaccid: progressive bulbar palsy, myasthenia gravis, guillain-barre syndrome, lyme disease
Spastic: pseudobulbar palsy, stroke, anterior opercular syndrome.
Rigid: PD, chorea, myoclonus, CP
Ataxic: cerebellar lesions
Mixed: MS, ALS, TBI, neoplasm
64
Compare fluent and non-fluent aphasia.
Non-Fluent (Broca's/Expressive): posterior interior frontal gyrus in left hemisphere (broca's), effortful, telegraphic speech with impaired grammar, comprehension > expression
Fluent (Wernicke's/receptive): posterior, superior left temporal lobe (wernicke's), fluent, copious verbal output, poor auditory comprehension.
65
Describe a right hemisphere disorder.
Resuls in visuospatial deficits, visual (left) neglect, denial and poor awareness of impairment (anosognosia), prosodic, inferencing, and discourse deficits, sustained and selective attention deficits.
66
What is apraxia?
Caused by damage to the inferior posterior left hemisphere and results in deficits in motor planning with normal speech musculature. Articulation is characterized by groping, inconsistency, and errors of sound/syllable sequencing
Treatment can focus on auditory visual stimulation, oral motor repetition, phonetic placement, and slowing speech rate.
67
Name the different speech behaviours commonly seen in aphasia and provide an example of each.
Anomic pause: can you hand me the... er... remote?
Semantic paraphasia: can you hand me the TV?
Phonemic paraphasia: can you have me the rebote?
Anomic circumlocution: can you hand me the... other there... the clicker... for the tv?
Neologism: can you hand me the jazzlepam?
Jargon: Griss me the jazzlepam.
Agrammatism: you... uh... remote?
Paragrammatism/empty speech: fast the jazzlepam on the choose
68
How might impaired speech intelligibility impact psychosocially and vocationally?
Reduced intelligibility as a result of dysarthria has activity/participation limitations as related to the ICF
The patient will likely take less conversational turns, or the communication partner may also demonstrate difficulties responding to the patient if he/she is
unintelligible
Strategies targeting intelligibility and social interaction may be limited by
executive dysfunction
May result in the introduction of AAC to accommodate intelligibility as an
impairment (ie. Ipad)
69
How might neurological based speech disorders impact psychosocially?
Difficulty keeping up with conversations
Negative changes in self-identity, particularly those with a moderate-severe
impairment
Reports of feeling different, being treated different, embarrassment from speech
and new functioning abilities
Disruption with family relationships (particularly with those with young children)
Spouse may often speak on the patient’s behalf (positive or negative influence on
patient)
Social disruptions such as speaking in stores, or on the phone
Self imposed social isolation
Helplessness and scared about being unintelligible
Increased anger/annoyance with oneself
⅔ reported issues of stigmatization, particularly with strangers
70
How might a neurologically-based communication disorder impact education and vocation?
Avoidance behaviours, or saying only what’s necessary, and nothing more
When talking on the phone, there is an inability for communication partner to see lips or facial expressions
Difficulty performing work tasks that may involve making phone calls, attending and contributing to meetings, doing presentations etc.
Slow speech rate results in a longer amount of time needed to respond, can
decrease productivity
Difficulties completing housework, driving, shopping, using public transportation independently (caused by additional physical and cognitive impairments from
brain injury/lesion in motor pathway)
71
What might need to be included in clinical history to define characterize a motor speech disorder?
```
Age of onset
Course of the disordered speech (acute, chronic, progressive)
Site of lesion
Neurological diagnosis
Pathophysiology
Subsystems involved (phonation, respiration, resonance, etc)
Perceptual/accoustic characteristics
Severity
```
72
How might some medications impact communication assessments?
Neuroactive medications: dosage timing may affect observations made during assessment.
Sedatives: lethargy may influence communication function
Antihypertensives, antihistamines, diuretics: may affect vocal quality.
73
What instrumental assessment can be used to measure respiration?
Pulmonary function (eg. respiratory muscle pressure, VO2 max = maximum volume testing)
Measures physical abilities of breathing
including muscle strength and total volume of
breath
74
What are some non-instrumental measures of respiration?
Maximum phonation time: indicative of volume of air usable for speech sounds and ability to release air in a controlled manner
Words per exhalation during reading or counting
Observation of breathing patters: can indicate reasons for poor breath support when speaking
Ability to cough: suggestive of ability to generate positive pressure and air volume.
75
What are some instrumental measures of laryngeal function?
Nasoendoscopy: visualize the top of the larynx including the vocal folds during speech.
Videostroboscopy: visualize tope of the larynx and vocal folds during speech
Voice recoding/analysis: software can support assessment fo voice quality and other voice features
76
What are some non-instrumental measures of laryngeal function?
Perceptual voice assessment (CAPE-V): determine voice quality during speech
Varying pitch and volume: control of laryngeal abilities
Sustained phonation: voice quality during phonation and changes in quality across breath use
S/Z ratio: understanding as to whether the larynx may be impacting breath support or influencing ability to control air flow
Cranial nerve exam: which nerves may be impacted to help predict deficits observed in speech and support a diagnosis of a dysarthria type.
77
What is an instrumental measure of velopharyngeal function?
Nasometry: quantifies and tracks airflow from the nose during performed tasks.
78
What are some non-instrumental measures of velopharyngeal functions?
Resonance during speech
Cranical nerve exam
Nasal flow during speech
79
What are some non-instrumental measures of oral mechanism?
```
OME
Cranial nerve exam
Alternate motion rates (AMRs) and sequential motion rates (SMRs)
Articulation in speech tasks
Relevant oral habits/behavious
```
80
How might you differentiate between an UMN and LMN damage?
Strength: UMN has reduced weakness compared to LMN.
Reflexes: hyperseflexes in UMN vs. hypo in LMN
Atrophy: present in LMN
Fasciculations: present in LMN
81
How might we access phonation, both perceptually and acoustically?
Perceptual: quality of speech (breathiness, fluttler, strain, stoppages, harshness, wet/ general hoarseness), pitch, volume
Acoustic: using software to analyze voice quality for the same characteristics
82
How might we assess resonance, both perceptually and acoustically?
Perceptual: observations of nasal flow during speech, weak pressure for consonants
Acoustic: hyper nasality and nasal emissions, hypo nasality.
83
How might we assess articulation, both perceptually and acoustically?
Perceptual: accuracy during single words, reading, and connected speech, transcription of connected speech, articulation tests imprecise consonant production, consistency of errors
Acoustic: target across a variety of both speech and non speech task
84
How might we assess prosody, both perceptually and acoustically?
Perceptual: slow rate, fast rate/short rushes of speech, short phrases, inappropriate silences, reduced stress, excess or equal stress, telescoping of syllables
Acoustic: Praat can be used to observe features of prosody.
85
How might we assess intelligibility?
Word by word transcription, multiple choice, or subjective judgement of comprehensibility
Blinded listener or awareness of context/stimuli
Single words, sentences of varying length, connected speech, reading/repetition, spontaneous
speech, conversation
Environmental context of sample
Reports of intelligibility should always include: % understood, by the person assessing, in what context
(eg. 60% understood by clinician in a quiet room)
Intelligibility can also be assessed using tools such as:
- Assessment of Intelligibility of Dysarthric Speech (Yorkton & Beukelman, 1981)
- Apraxia of Speech Rating Scale (strand, 2014)
- Speech Intelligibility Test (Yorkton, Beukelman, and Hakel, 1996)
- Family & friends personal ratings
86
What are some factors that influence intelligibility?
Speaker variables
- The severity of their disordered speech (eg. precision of articulation, quality of voice, rate
of speech, etc.)
- Their use of compensatory strategies
- Personal factors (eg. fatigue, frustration, stress)
Listener variables
- Familiarity with the speaker
- Attention and effort in listening
Task variables
- Word, sentence, or discourse level speaking
- Supports available (eg. AAC, pacing boards, paper to write on, etc.)
Contextual variables
- Environment (quiet vs noisy, distractions)
- Time afforded to task/conversation
87
How does the environmental impact communication needs and effectiveness?
Reducing background noise
Ensuring good lighting for speaking
Being at a reasonable distance, being face-to-face
Reducing all other distractions if possible
Have multiple strategies prepared
88
What are the practice principles for motor learning?
Amount (small or large): a higher number of trials and amount of practice is encouraged, with
practice variability taken into consideration (high rates of practice without variability can be detrimental to learning)
Distribution (massed or distributed): practicing a number of trials in a small period of time (massed) can encourage development of the skill, while practicing a number of trials over a
longer period of time (distributed) can encourage the maintenance of the skill
Variability (constant or variable): practicing the same target in the same context (constant) allows for target predictability which may be beneficial in early stages, while practicing different targets in different contexts may be more beneficial for transfer of skills
Schedule (Blocked or random): different targets are worked on in succession (blocked) or integrated (random). Randomized practice has the potential to show greater transfer of skills over time.
Attentional Focus (internal or external): focusing on bodily movements (internal) such as
articulatory placement or effects of the movements (external) like the final sound. External focus has the potential to encourage more automatic movement for learning over focusing intently on the exact motions to achieve the target
Target Complexity (simple or complex): more easily acquired sounds and sequences or more
difficult sounds and sequences. Targeting more complex behaviours may positively impact more
easily acquired abilities in some cases. Evidence for Apraxia of Speech suggests targeting simple first is more effective
89
What are the different types of feedback conditions for the motor learning principles?
Type (knowledge of performance or results): either providing information of how the sound was produced (performance) or whether the production was correct or incorrect (results). There is no clear evidence for one over the other, but can use the speaker’s ability to identify their own
errors and practice self-correction
Frequency (high or low): after each production (high) or after a few productions (low). Some evidence is available for the benefit of reduced feedback frequency in treatment
Timing (immediate or delayed): either feedback is given immediately or after a short delay. There is some evidence for the benefit of a delayed feedback in treatment
90
Name some respiration approaches to treating dysarthria.
```
Postural adjustments + external aids
Inspiratory muscle training
Diaphragmatic breathing
Expiratory muscle strength training
Phrase grouping
```
91
How might postural adjustments + external aids impact dysarthria?
Creates more space
for the lungs to
expand for a more
full breath.
Advantages: may be immediate in results, gives more air to work with
Bad: does not necessarily relate to greater airflow control, some may have mobility or trunk control issues
92
What is inspiratory muscle training?
Targeting use of the diaphragm to increase inhalation strength and
diaphragmatic control on exhalation, to establish a strong respiratory foundation.
Good: encourages a speaking pattern of breathing, targets control of breath
Bad: not directly related to speaking and generalization will not occur without specific goals targeting breath control in speech, requires adequate trunk/diaphragm control
93
What is diaphragmatic breathing?
Targeting breath control for the speaker when breathing to establish solid respiratory support
Good: targets breath control, may inhibit excessive accessory muscle activation
Bad: not directly related to speaking and generalization will not occur with specific goals.
94
What is EMST?
Targeting strength of exhalation to increase intelligibility and reduce hypophonia.
Bad: requires a pressure threshold trainer, resistance may be created by other mean but they cannot be easily controlled across practice sessions
95
What is phrase grouping?
By strategically pausing and planning the phrasing of sentences, the speaker has greater control over respiratory support due to speaking “within their limits”.
Pros: can be immediately impactful on intelligibility, avoids potential overexertion and strain
Cons: Can be initially difficulty to navigate more natural pauses, speaking may take longer, may sound unnatural with pauses.
96
Name some approaches to resonance treatment for individuals with dysarthria.
Speech-based resonatory treatment
Resistance training through CPAP
Prosthetic management
Surgical intervention
97
What is speech-based resonatory therapy?
Targeting resonance issues by emphasizing appropriate oral and/or nasal flow of air in speech tasks will increase awareness and control in other speech tasks.
Pros: can use augmented feedback to increase awareness, can be combined with other methods, can result in functional targets/phrases being used.
Con: May not entirely resolve the issue if there is weakness or fatigue concerns.
98
How can resistance training treat resonance in dysarthria?
Continuous Positive Air Pressure (CPAP) is generated for the speaker during a speech task to overload the velopharyngeal musculature. The idea is to increase velopharyngeal strength to avoid fatigue during regular speech tasks.
Pros: uses speech tasks
when practicing which can increase the likelihood of carryover to regular speech tasks.
Cons: requires CPAP, effectiveness is unclear.
99
How can a prosthetic treat resonance in dysarthria?
This intervention addresses the resonance issue as a body structure and function concern. By altering the structure the resonance should change or control should be more easily achieved for the speaker
Pros: best for hypernasality, can support behavioural interventions and facilitate progress, temporary while waiting or long term support
Con: does not completely resolve issues.
100
How can surgery (pharyngeal flap, injections) treat resonance issues in dysarthria?
This also addresses resonance as a body structure concern, with the idea that proper resonance can be supported by a structural change for the speaker.
Pro: helpful for those who have lots of resonance issues, support progress with behavioural interventions
Con: not all candidates, does not resolve issues alone.
101
What are some treatments for phonation in dysarthria?
Reducing laryngeal strain
Laryngeal exercises (increasing medial compression, increasing pitch, range, and control)
Loudness treatment (eg. LSVT)
Coordination of respiration and phonation
Manual manipulation (head turn, manual lateralization, massage)
Surgical management
102
How can reducing laryngeal strain improve phonation in dysarthria?
Speakers may not be
aware of the excess
tension they are putting
on their larynx in attempting to be understood. Reducing
strain and tension may
improve vocal quality.
Pro: creates attention and awareness, prevent further injury
Con: may not treat cause of the strain, can reduce quality of the dysarthria
103
How can laryngeal exercises improve phonation in dysarthria?
Targeting non-speech exercises to increase strength and control of the larynx for speech tasks.
Pro: increased laryngeal strength and sensory awareness
Con: not functional for speech, requires extra goals/targets for generalization
104
How can loudness treatment improve phonation in dysarthria?
A systematic approach
using a hierarchy of
targets and exercises to
encourage speaking loud. Typically targets respiratory, laryngeal, and articulatory subsystems.
Pro: most evidence for some dysarthria, targets multiple subsystems in one program
Con: time-consuming and demeaning, difficult buy-in, requires specific training
105
How can coordination of respiration and phonation help phonation in dysarthria?
This method targets the
potential that speech may be imapired due to a mis-match in timing of breathing and speaking. Providing direct instruction of breathing patterns allows for speaker awareness and
therefore control over
breathing patterns when
speaking.
Pros: awareness of breathing patterns for speech, may also target prosody if phrasing is considered
Cons: may not address the phonatory issue if timing is not the main impairment of voice.
106
How can manual manipulation improve phonation in dysarthria?
```
By enacting a physical
change on the laryngeal
structures, the vocal
folds will be more easily
controlled to the target
voice.
Pros: not much practice required, can be done independently.
Cons: unlikely to use in social situations, can look unnatural.
```
107
How can surgical management improve phonation in dysarthria?
Targeting the structure of
the vocal folds can alter the speaker’s voice quality and control.
Pros: immediate change without practice
Cons: Routine visits (injections), may not resolve entirely.
108
What are some treatment approaches for articulation with dysarthria?
```
Articulatory exercise
Overarticulation
Alternative place/manner/voicing
Minimal contrasts
Phonetic placement techniques
External supports
```
109
How can articulatory exercises improve articulation in dysarthria?
When weakness of articulators is the main observable impairment, increasing strength should increase articulatory precision.
Pros: increased awareness and control
Cons: not directly functional, no evidence for some programs (eg. tongue strength), some etiologies lead to contradictions of exercises
110
How can over articulation improve articulation in dysarthria?
When speakers exaggerate their speech, it becomes more intelligible through more precision with articulatory targets.
Pros: immediate functional recommendation, functional speech task
Cons: may be fatiguing, problematic if intelligibility is severely impacted.
111
How can alternative place/manner/voicing improve articulation in dysarthria?
When an articulatory
target is too difficult for a speaker, swapping it for a
related sound that the speaker can produce will increase intelligibility.
Pros: can make some
targets more accessible for practice and functional use
through reducing some
challenging sounds/sequences
Cons: not always a long term solution depending on expectation, too many swaps in one word may make it hard to understand.
112
How can minimal contrasts help improve articulation in dysarthria?
Similar to the minimal
pairs approach, meant to emphasize the slight articulatory difference that
distinguishes two sounds.
Pros: works well when some sounds are well articulated, demonstrate important differences between phonemes
Cons: requires some clear articulation to work from.
113
How can phonetic placement techniques help improve articulation in dysarthria?
Using multiple supports (eg.
hands-on, pictures) to
illustrate positioning of the articulators. This is to target awareness with the hopes of increasing articulatory
control.
Pros: awareness of articulators, can target single sounds for more severely impaired clients.
Cons: may not resolve issues of weakness or incoordination, not very functional in speech tasks.
114
How can external supports help improve articulation in dysarthria?
Targeting the physical
structure of the articulators
(specifically the jaw) to increase the speaker’s ability to articulate by keeping a more open oral
cavity.
Pros: can help those who struggle with jaw grading, gives sensory information to jaw positioning, can increase jaw strength.
Cons: not a speech task (not functional), requires functional goals beyond bite blocks.
115
Name some approaches to improving prosody in dysarthria.
Rate reduction strategies (tapping, pacing boards, metronomes, delayed auditory feedback)
Lexical and sentential stress (eg. visual feedback, contrastive stress, metric patters for word length)
Improving intonation through alternative means
Phrasing
116
How can rate reduction strategies improve prosody in dysarthria?
By using an external support, the speaker’s rate will be reduced and intelligibility will increase through more careful speech production.
Pros: can boost intelligibility, can increase focus on tasks
Cons: difficult for speakers to monitor, expressing thoughts may take more time.
117
How can lexical and sentential stress improve prosody in dysarthria?
By targeting a speaker’s
stress patterns, stress can be used strategically to increase intelligibility and emphasize accurate articulation for specific words and phrases.
Pros: can be applied to spontaneous speech, can encourage exaggerated articulation at the phrasal level.
Cons: requires certain level of awareness of stress patterns first.
118
How can improving intonation through alternative means improve prosody in dysarthria?
Swapping out an intonation method (eg. rate, volume, pitch, durations) that is
challenging for a speaker for one that is more easily controlled can return some
variation to the speaker’s prosody.
Pros: can increase variation and return stress to communication
Cons: may feel unnatural, does not necessarily address original impairment.
119
How can phrasing improve prosody in dysarthria?
Same as the phrasing
found in the respiratory
interventions, by choosing phrases and sentences with strategic pauses, this gives the speaker more control over speaking clearly by using the prosody of speech.
Pros: can be immediately impactful on intelligibility, avoids potential overexertion and strain.
Con: can be initially difficult to navigate more natural pauses, speaking may take longer, may sound unnatural.
120
What are some treatment approaches that target intelligibility and external supports for dysarthria?
```
Separating words when speaking
Clear speech
Alphabet board
Semantic/topic supplementation
Amplification
AAC
```
121
How can separating words when speaking improve intelligibility in dysarthria?
```
This should naturally
slow the speaker’s rate
of speech in the hopes
of increasing intelligibility
Pro: simple to implement
Con: can sound unnatural, longer periods of speaking might not be suited to this formate.
```
122
How can clear speech improve intelligibility in dysarthria?
The suggestion of
speaking like someone is having a hard time hearing you encourages hyperarticulation as well as decreasing rate, and increasing variation in volume and pitch.
Pros: simple with more immediate results
Cons: increased rate of fatigue, must be able to remember instruction/cue
123
How can an alphabet board increase intelligibility in dysarthria?
The speaker points to the initial letter of each word spoken to give the listener more cues for comprehension. Also serves as a pacing strategy to increase intelligibility by
decreasing rate.
Pros: gives more information, can facilitate communication during breakdowns.
Cons: requires board, must have some literacy skills, not suitable with impacted working memory.
124
How can semantic/topic supplementation increase intelligibility in dysarthria?
The speaker identifies
the topic being discussed to support the listener’s ability to predict and
comprehend what is being said.
Pros: ensures both spearker and listener are on the same page, puts more effort on listener.
Cons: conversation can still breakdown, reliant on listener's topic knowledge, not most suitable for short interactions.
125
How can amplification increase intelligibility in dysarthria?
For speakers who struggle to increase volume and/or cause damage from strain/fatigue in their efforts, amplification can support volume increase without extra effort from the speaker.
Pro: works immediately and without effort, reduces fatigue and potential damage
Con: requires funding, tech issues, self-conscious, may not be portable
126
How can AAC increase intelligibility in dysarthria?
External support for
speakers to use instead of verbal communication when
they are struggling to be understood.
Pros: supports functional communication for more severe, helps communicate when difficulties to be understood.
Cons: dependent on AAC selection, does not target intelligibility while speaking
127
Name some approaches to treating apraxia of speech.
Auditory kinematic (multiple input phoneme therapy, sound production treatment, speech motor learning treatment approach)
Sensory Cueing Approaches
(Integral Stimulation, Tactile Cueing, PROMPT, Visual Cueing, Electropalatography,
Electromagnetic Articulography)
Word and Phrase-Focused Approaches (Script Training)
Prosodic Facilitation Approaches (Contrastive Stress, Melodic Intonation Therapy, Metrical Pacing
Treatment, Rhythmic Pacing Strategies)
128
How can auditory kinematic approaches improve apraxia?
```
Based on the principles of
motor programming and
planning. This involves
frequent and intensive
practice, external sensory
inputs, consider practice
schedules (eg. random vs
blocked), and appropriate
feedback methods
Pro: lots of practice, underlying theories grounded in motor learning principles, can target individual sounds or transitional movements
Cons: not all are immediately functional, frequently requires extra equipment which can be expensive, requires serious commitment/time
```
129
How can sensory cueing approaches improve apraxia?
Using sensory input
(visual, auditory, Proprioceptive, and tactile
cues) to show the movement sequences for speech. Either used individually or in a multisensory approach, they are tied to the importance of feedback and those aspects of motor learning. The theory
is that the external cues
provide additional feedback for those who do not receive or benefit from the intrinsic sensory feedback.
Pros: can provide clear instruction and detail to increase awareness of how arctic should happen, provides a lot of feedback
Cons: clients require intact sensory systems sufficient for input, expensive and specialized tech (some), attentional capacity to focus on multi sensory input and production.
130
How can word and phrase-focused approaches improve apraxia?
This is based on the idea
that automatic speech is
easier for those with AOS
and that with practice, short scripts can become more automatic and intelligible. Meant mostly for a few specific topics or phrases to target more functional speech.
Pros: functional goals that can be practical for daily tasks, tailored to specific client scenarios and needs.
Cons: cannot be generalized beyond scripts, likely unhelpful for those struggling with speech at sound word level
131
How can prosodic facilitation approaches improve apraxia?
These approaches change
the speaker’s intonation
patterns through melody,
rhythm and stress, to improve their speech
production. This change in
intonation may also improve articulation.
Pros: many can help target prosody initially to positively impact other subsystems later on in intervention
Cons: some methods require a lot of shaping before functional gains may be made, some methods are more socially acceptable than others.
132
What is the primary goal of therapy for a speech disorder?
Intelligibility
