SPH528 - Dysarthria Intervention Flashcards
Specific interventions for respiration:
Evidence level:
- Accent method
- EMST/IMST (device you blow into with set resistance)
- Banding/paddles
Evidence-> Low-evolving
Specific interventions for Phonation:
Evidence level:
- Stemples VF exercises
- Focus of resonance exercises, SOVTs etc…
- LSVT (inc. apps. Re volume etc)
- Amplification
Evidence -> Low-moderate
Specific interventions for resonance:
Evidence level:
- CPAP
- Over articulation/mouth opening
Evidence -> Low
Specific interventions for articulation:
Evidence level:
- Clear speech / Be Clear / over articulation
- ”Traditional” (e.g., rate reduction, minimal pairs…)
Evidence -> Low-evolving
Specific interventions for Prosody:
Evidence level:
“Traditional” (contrastive stress drills etc)
Evidence -> Low
Why is a request to ‘speak clearly’ often quite effective?
People really try to do so, which often makes them reduce rate, over-articulate, increase loudness and work on respiration, phonation, articulation and maybe prosody all at once.
Why is “slow down” not a specific enough instruction for people with dysarthria?
They need a pause between words, not to lengthen vowels. Emphasising each word as separate has a large positive effect on intelligibility.
-> Find Anne – Fine Dan / Icecream – I scream…
Intervention approaches to dysarthria will aim to improve one or more of…
- Respiration
- Phonation
- Resonance
- Articulation
- Prosody
- Intelligibility
If a client with dysarthria appears to have a problem with respiration and phonation, further assessment may reveal…
- Decrease in respiratory support for speech
- Decrease in respiratory and phonatory coordination and control
- Compromised laryngeal function
- > important to work out just what is going on… to tease these out.
Overall goal for respiratory impairments ->
Achieve a consistent subglottic pressure, thus allowing non-fatiguing production of speech with adequate loudness and breath group length.
Approaches for targeting improved respiration for speech:
- Establishing and/or increasing respiratory support for speech
- Stabilising respiratory support for speech
- Improving flexibility of respiratory support for speech
How to begin… establishing and/or increasing respiratory support for speech?
May require use of non-speech tasks to begin with (if respiration can’t support speech, then it’s difficult to start with speech tasks)
- Speech tasks may work to:
- increase ‘comfortable’ syllables/words per breath
- increase time to talk e.g., without fatigue
Examples of non-speech tasks to begin with if respiration can’t support speech..
- postural support (in conjunction with PT and OT)
- Manometer / water blowing
- Sustaining phonation (MPT ‘ahhhh’,
- Increasing number of syllables that can be produced on one breath ‘puh puh puh’ The cat, The cat sat….
- Can use these with biofeedback
Tasks to help stabilise respiratory support for speech: If client begins speaking when: *lung volume is too low or too high *Without preparatory inhalation *Variable loudness of speech *Speaks on end of respiratory volume
- Biofeedback e.g., spirometry – to identify and get used to speaking within the functional respiratory range
- can work with PTs on stabilising respiratory support
Tasks to improve flexibility of respiratory support for speech:
If client has good respiratory support but lacks the ability to vary function and control, speech may sound unnatural
*Utterances all the same length as dictated by breath group
*Regular pauses with inhalation
*Inability to perform ‘normal’ quick inhalations within natural conversation
*practicing scripts with pause markers to have a breath
Phonatory Impairments in people with MSDs may be indicated if there are:
- Pitch disturbances
- Vocal tremor
- Loudness disturbances
- Vocal quality
- Harsh, Hoarse (wet), Breathy, Strained-strangled
Further assessment may suggest:
- Hypoadduction
- Hyperadduction
- Phonatory instability
- Mixed phonatory impairments
- Phonatory coordination impairment
Approaches for targeting improved phonation for speech:
- Establishing voluntary phonation in cases of severe vocal fold adduction
- Increasing loudness in cases of hypoadduction of vocal folds
- Increasing loudness and voice quality
- Reducing hyperadduction of vocal folds
- Improving laryngeal coordination
Establishing voluntary phonation in cases of severe vocal fold adduction:
- Deriving voluntary phonation for speech from phonation associated with… laughing, sighing, coughing etc… So: Involuntary phonation -> voluntary phonation -> shaping this into speech sounds.
- Tracking when phonation occurs
Increasing loudness in case of hypoadduction of VF:
- Surgical (Reposition VF to midline, Laryngoplasty, collagen injection to increase bulk of VF reinnervation
- Increasing VF tension and subglottal air pressure… how?
May involve “effortful closure” techniques;
- Pushing
- Pulling
- Lifting/ “bearing down”
- controlled coughing
- **Make sure ENT has seen them.
Increasing loudness and voice quality in patients with MSDs, simultaneously. i.e., Increasing loudness and reducing breathiness, increasing control and degree of VF adduction
Example…
Lee Silverman Voice Treatment (LSVT) for PD and other conditions. Involves:
- Intensive treatment program
- Increasing effort of vocal production
- Recalibration of vocal effort/loudness
- Shifting towards self-monitoring
Resonatory impairments result because of poor contact between soft palate and posterior pharyngeal wall. What are some behavioural interventions to treat hypernasality?
NOT much evidence Lee Silverman Voice Treatment (LSVT) for PD and other conditions. Involves:
- Intensive treatment program
- Increasing effort of vocal production
- Recalibration of vocal effort/loudness
- Shifting towards self-monitoringfor behavioural interventions, but may involve:
- Increasing or reducing vocal effort
- Slowing speaking rate
- Over-articulation
- biofeedback??
- > LSVT is associated with a reduction of hypernasality in PD
When would you consider a patient a candidate for a palatal prosthesis:
-possibly a last resort…patients can find the use of the device very challenging
*Resonatory impairment has significant negative impact
*Addressing resonatory impairment will likely have significant positive impact
*Possibility that the palatial lift would also open doors to other approaches for other subsystems.
*Client cooperation / acceptance
Course/prognosis of condition
What is the most common subsystem of speech to work on with patients with dysarthria?
Articulation (but usually in conjunction with another approach/subsystem target)…
What are 2 broad approaches for targeting improvements in articulation? (Yorkston et al., 2010)
- Reducing the impairment, or normalising function (via medical interventions, biofeedback approaches, or strengthening exercises)
- Compensatory techniques/strategies (such as behavioural interventions, or prosthetic devices, incl. AAC)
When would the use of non-speech oromotor exercises as a behavioural intervention for dysarthria be indicated?
NOT RECOMMENDED except in very limited cases where weakness which directly affects speech (unusual, as speech doesn’t take a lot of strength), and may reasonably improved.
Articulation therapy - Behavioural interventions: Speech tasks
Integral stimulation
Think: how am I going to promote generalisation beyond the clinic? How can I get them to use internal feedback and self-correct?
“Watch me, listen to me say it with/after me..”
- promote self-monitoring
- Drill
Articulation therapy - Behavioural interventions: Speech tasks
Phonetic Placement
Think: how am I going to promote generalisation beyond the clinic? How can I get them to use internal feedback and self-correct?
- > Instruction and feedback
- Getting patient to place articulators in the right position.
- promote self-monitoring
- Drill
Articulation therapy - Behavioural interventions: Speech tasks
*Moving from one producible sound/sequence to make it sound like another, e.g., ‘one, two’ -> ‘I want to…’
Phonetic Derivation
Think: how am I going to promote generalisation beyond the clinic? How can I get them to use internal feedback and self-correct?
- promote self-monitoring
* Drill
Articulation therapy - Behavioural interventions: Speech tasks
Over-articulation
Think: how am I going to promote generalisation beyond the clinic? How can I get them to use internal feedback and self-correct?
- Very simple – just ensure the patient over-articulates every sound.
- slows down speech rate
- promote self-monitoring
- Drill
- Practice at word, phrase, sentence, conversation level to make it automatic and so it generalises outside of the clinic.
Articulation therapy - Behavioural interventions: Speech tasks
Minimal Contrast Production
Think: how am I going to promote generalisation beyond the clinic? How can I get them to use internal feedback and self-correct?
Pin / bin Peg / Leg Pie / sigh -> trying to get good contrast between different sound types *promote self-monitoring *Drill
Articulation therapy - Behavioural interventions: Speech tasks
Intelligibility Drills
Think: how am I going to promote generalisation beyond the clinic? How can I get them to use internal feedback and self-correct?
- Words
- Phrases
- Sentences
- > use functional words/phrases that the client will use in their everyday life -> meaningfull
- promote self-monitoring
- Drill
Prosodic impairment of speech:
- Speech may be intelligible, but doesn’t sound ‘natural’
- Prosodic impairment can reduce intelligibility
Examples:
- Monoloudness
- Monopitch
- Reduced Stress
- Excess Stress
- Reduced/increased Rate
- Variable Rate
- Excessive Pauses/Silences (e.g., delayed initiation/execution)
Prosodic impairments in MSDs are very different between patients. Some ways to target loudness?
Prosodic impairments in MSDs are very different between patients. Some ways to target loudness?
Prosodic impairments in MSDs are very different between patients. Some ways to target rate?
- Most aim to reduce speaking rate. Gives speaker more time to:
- Make use of full range of articulation
- More time to sequence and coordinate articulations
- Gives the listener more time to process
Think: how well can the client use this outside of the clinic? Think generalisation
**Make sure the patient finds it acceptable, or they won’t use it.
LOTS and LOTS of practice to generalise – generalisation is hard
PROSTHETIC APPROACHES
*Delayed Auditory Feedback (DAF)
*Pacing Boards
*Metronome
*Alphabet Board supplementation (point to first letter of each word)
NON-PROSTHETIC APPROACHES
- Hand/finger tapping
- Rhythmic cueing while reading
- Prolonging speech
- Visual / Auditory feedback
Behavioural interventions for improving ‘naturalness’ of speech:
Working on breath groupings, e.g.,
*Increasing breath group capacity (words produced per breath)l
Consider generalisation -> want the gains to transfer to everyday speech. To do this, progress tasks from highly structured to more naturalistic tasks. Going down the hierarchy… *Words *Phrases *Sentences *Passage *Conversational scripts *Conversation
*Increasing flexibility of breath groups
->Make a sentence and add to it so it gets longer… “the bushfire…”
———–
Working on Stress/Intonation – improving application and variation for meaningful contrasts
Ie same sentence as a statement, question, in different moods…
-> Naïve clinician must guess..
———
Referential tasks – similar structure to some intelligibility tasks
1. Client selects a sentence card and an emotion card. Client reads sentence aloud in manner of the emotion.
2. Clinician feedback “That sounds like you were excited/scared/sad:
3. If incorrect, client uses feedback to inform another attempt
What must you build into therapy for the client to be able to generalise new ways of speaking outside of the clinic?
- Self-monitoring
* Self-correction
