SPH528 - Dysarthria Treatment Flashcards
Targets for intervention for dysarthria: Restore
- Oral-muscular exercises (limited circumstances – not generally useful as speech doesn’t use much muscle)
- Exercises targeting “deviant” speech characteristics (drills)
Targets for intervention for dysarthria: Compensate
- Speaker, listener and Environmental strategies (communication strategies)
- Augmentative communication
- Reduced rate
Targets for intervention for dysarthria: Substitute
- Alternative communication
* Different life roles and activities (colouring-in with grandkids instead of reading stories, photojournalist…)
Implementing treatment: Prepractice stage
- Client acquires a basic knowledge of what the task is and how to perform it through conscious and focused attention on the movement
- Need for intervention/calibration
- Perceptual training
- Knowledge of performance feedback (and knowledge of results)
- Modelling
- Motivation
Implementing treatment: Practice (“treatment”) stage
- the client improves their proficiency, accuracy and speed of performing the targeted skill such that the movement is “learnt” (Maintained and generalised) and produced without conscious attention to its execution.
- Knowledge of results
- Exercise / repetitions
Would learning what 60 dB sounds like fit into the prepractice or practice phase?
Prepractice
“Take a deeper breath, hold that in, make that sound a bit louder…” what kind of augmented feedback is this and what stage of treatment is it more appropriate in?
- KP – knowledge of performance
2. Prepractice stage
What kind of practice is required from a novice (high cognitive requirements) and how fast should improvement be?
- Simple tasks
- Blocked / constant
- High frequency knowledge of performance and results feedback.
- some part training for some tasks (ie breath support)
- Modelling/guidance
- Mental practice
- > fast improvement
What kind of practice is required from a patient with advanced practice experience (associative -less cognitive requirements) and how fast should improvement be?
- Complex tasks
- Random / variable
- Lower frequency knowledge of results feedback
- Mental practice
- > slower improvements
What kind of practice is required from an expert (autonomous - few cognitive requirements) and how fast should improvement be?
- Complex tasks
- Transfer and generalisation (ie they have learnt to say “latte” -> “order” it in a simulation on the ward with pre-recorded café noise -> now order it in the hospital café (do it louder, softer, faster, slower) -> to promote generalisation
Why is it important to give the patient a means of communication ASAP when speech isn’t clear?
Safety – communicate they need the toilet (and get help so they don’t fall), communicate they have a terrible headache (brain haemorrhage) etc…
Communication is also a basic human right.
What are the 5 subsystems of speech?
- Respiration
- Phonation
- Resonance
- Articulation
- Prosody
Factors that influence the decision about whether or not someone with a motor-speech disorder is a candidate for therapy:
- Medical prognosis
- Impairment, limitations, and restrictions
- Environment and communication partners
- Motivation and needs
- Associated problems
- Other priorities
- The health care system
The decision to treat is not an all-or-nothing decision. Options might be:
- Immediate intervention
- Defer intervention pending review
- Plan for future intervention
- No intervention
- Onward referral
Why is a communication focus better than a speech focus, when dealing with people with motor-speech disorders?
- Speech may become a non-viable means of expression, but people can still express themselves.
- Allows a broader focus of intervention
- Allows a broader focus with outcome measurement
An overriding goal for intervention with MSD (Duffy, 2013):
“Maximise the effectiveness, efficiency, or naturalness of communication.”
Three general goals for intervention with people with MSDs to achieve effective, efficient, and natural communication:
- Restoring lost function (Restore)
- Promoting the use of residual function (Compensate)
- Reducing the need for lost function (adjustment -> Substitute)
* for most clients, we do a little bit of each…
Restore:
- Aims to reduce impairment and restore functions
- > ICF levels of “body function” and “structure”
- Fully restoring normal speech is often not a realistic goal for intervention
- > Restoration may not always imply “back to normal”
Compensate:
- May be a focus when full restoration of body structure and function is not possible or expected
- Can take many forms:
- Reducing speech rate in order to improve intelligibility
- Prosthesis
- Modifying physical environment and/or the listener’s behaviour
Substitute (adjustment):
- Adjustments to lifestyle and participation activities i.e. change of career…, change of activities to do with grandkids…, change of volunteer roles…
- Alternative communication
2 important places to start when looking at what to focus on with motor speech intervention:
- What aspect(s) of speech production are having the largest negative impact (go down the tree and get the lowest subsystem with biggest knock-on effects).
- > Where is there the most impairment? - What aspect of speech or communication will have the greatest functional benefit to the speaker/communicator?
- > What is causing the most challenge in terms of the client’s overall ability to get their message across?
How long should intervention be provided for?
- Long enough to achieve goals
* As short a time as possible
Beginning at the end:
- ”Ultimate goals” mapped out from the start
- What does that goal look like? (Able to resume work – full/part-time? Supports needed? Same position as before, or another?…)
- How will we know when we’ve achieved that goal?
- Keep “ultimate goals” in mind throughout all activities
- Still applies in case of degenerative conditions
- Outcome measures decided – ie AustTOMs, Mayo form, speech sample (intelligibility)…
1. Baseline
2. Tracking progress (mid-treatment?)
3. Final outcomes for discharge/measuring goal achievement
What do AustTOMs measure?
SLP rating of: 1. Impairment of either structure or function 2. Activity Limitation 3. Participation restriction 4. Distress/wellbeing Across different ROPAs
What are the 5 broad approaches to intervention for MSDs, used by Duffy (2013)?
- Medical interventions
- Prosthetic management
- Behavioural management
- Augmentative and alternative communication (AAC)
- Counselling and support.
- An intervention plan usually involves more than one approach
- Approach(es) applied in intervention may change over time
For MSDs, medical interventions include:
- Pharmacological treatments
- Surgical treatments
- > Medical options usually trialled prior to other options, if available.
Medical interventions for MSDs require input from a medical SLP and other health professionals. They will require Ax of speech, and:
- Establishing a need for the medical intervention and likely benefit to patient
- Identifying specific benefits that will be present
- Identifying what (in terms of speech) will NOT be affected by the medical intervention
- Identifying the need for post-procedure interventions
- Communicating this information to patient, family, other health professional involved.
Things to be aware of with pharmacological interventions:
- Medications may exacerbate or cause MSDs (meds for psychological disorders).
- Medication cycles may cause fluctuations in MSDs
Things to ask a patient with Parkinson’s Disease re: medication:
- What medications are you on?
- When do you take your medication?
- What kind of impact do the meds have on your speech/swallowing?
- Are there periods when you notice your speech/swallowing deteriorating? Is that associated with when you are taking your meds? How?
Prosthetic devices for MSDs, that aim to influence resonance?
- Palatal lifts
* Nasal obturators
Prosthetic devices for MSDs, that aim to influence loudness?
*portable voice amplifier
Prosthetic devices for MSDs, that aim to influence rate of speech?
- Metronome
- Pacing board
- Delayed Auditory Feedback devices (DAF)
Behavioural management approach to intervention can focus on SPEECH or COMMUNICATION. What do these approaches target?
**Speech Oriented approaches, where used, should be used with Communication oriented approaches.
- Speech Oriented Approaches – target improvements in intelligibility, efficiency, and naturalness of communication.
- Communication Oriented approaches – Target improvements in communication, that may occur in the absence of improvement to speech itself (i.e., environmental modifications, education and communication training for communication partners).
How do SPEECH Oriented approaches to behavioural management for MSDs act?
(Speaker is solely responsible for the success of their communication, when communicating)
- Reducing impairment – increasing physiological support for speech production.
- Compensation – making most effective use of residual physiologic support for speech production.
How do COMMUNICATION Oriented approaches to behavioural management for MSDs act?
The Speaker is NOT solely responsible for the success of their communication, when communicating. Listeners and environment can be changed to improve their chance of communicative success
- > Environmental modifications
- > Education and communication training for communication partners
AAC is the 4th broad approach to MSD intervention (Duffy, 2013).
*Implement early, so people don’t see it as a ‘last resort’ or ‘less-than…’.
*Can be a temporary measure in acute phase, or a more permanent measure.
AAC assessment should be considered when speaking rate is <100 wpm with associated decrease in intelligibility (Duffy, 2013. p.387)
AAC implementation may include:
- Gestural methods of communication (eye-gaze, facial gesture, hand gesture, body posturing)
- Symbolic methods (pictures, photos, icons, printed words/letters, real objects)
- Aids to facilitate message transmission (speech output devices)
Counselling and support is the 5th broad approach to MSD intervention (Duffy, 2013). What kind of things might this address?
- Why aspects of speech are now not normal
- Prognosis
- What can be done to restore, or compensate for the impairment?
- Likely outcomes
**Go carefully. Don’t give people too much information at once. Give information through different inputs (spoken, written, pictures..) More information can be given later if appropriate. Client specific.
Effectiveness
Ability to communicate. 60% intelligibility = 60% effectiveness (if only speech is used)
Efficiency
How EASILY and ACCURATELY communication is done.
- Is it effortful to communicate X amount?
- Is repeated repetition or conversational repair necessary?
Naturalness
Prosody, pitch changes, rate, rhythm, volume.
*These are the last things to work on, and some of the more difficult things to work on. Can work on prosody with other subsystems of speech if appropriate.
Where to start with intervention?
Treat the speech component that will result in the greatest functional benefit most rapidly, or that will provide the greatest support for improvements in other aspects of speech/swallowing.
Experience-dependant plasticity (1): Principles
- Use it or lose it
- Use it and improve it
- Experience specific
- Repetition matters
- Intensity matters
Relevance to dysarthria intervention:
- Patient may be less inclined to speak -> they NEED to use speech mechanism
- THERAPEUTIC speaking
- Speech treatment needs to work on speech
- Extensive and prolonged practice required to affect neural change
- Determine optimum intensity of treatment (intensity Vs fatigue etc)
Experience-dependant plasticity (2): Principles
- Time matters
- Salience matters
- Age matters
- Transference
- Interference
Relevance to Dysarthria Intervention
1. Start early. Long term change
2. Use meaningful communication
3. Younger greater adaptive neural plasticity – older more reps/time
4 & 5. Plasticity in one neural circuit can facilitate or impede plasticity in others (e.g. ReST)
There is no strong evidence for any behavioural interventions for dysarthria, verbal dyspraxia, or dysphagia. So what do you do?
Rely on the other parts of E3BP – Clinical expertise/experience, Patient/family factors and preferences (+ health service delivery factors)
