Study Guide Flashcards
What is apraxia?
An impaired ability to generate the motor programs for speech movements. Apraxia is a planning/programming problem, not a movement problem like dysarthria
Apraxia or Dysarthria?
The muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move at all after a stroke or other brain injury
Dysarthria
Apraxia or Dysarthria?
Errors are inconsistent and unpredictable
Apraxia
Apraxia or Dysarthria?
Errors are consistent and predictable
Dysarthria
Apraxia or Dysarthria?
Errors are mainly distortions and omissions
Dysarthria
Apraxia or Dysarthria?
Different errors occur in spontaneous speech versus repetition
Apraxia
Apraxia or Dysarthria?
Patient’s spontaneous speech contains fewer errors than does his/her speech in repetition tasks
Apraxia
Apraxia or Dysarthria?
Distortions are the most common type of error
Dysarthria
Apraxia or Dysarthria?
“Slurred speech”
Dysarthria
Apraxia or Dysarthria?
Speaking softly or barely able to whisper
Dysarthria
Apraxia or Dysarthria?
There are islands of clear speech; when producing over-learned material or material that has become automatic, the patient will speak clearly
Apraxia
Apraxia or Dysarthria?
Slow rate of speech
Dysarthria
Apraxia or Dysarthria?
Substitutions are the most common type of error, with others normally being approximations of the targeted phoneme
Apraxia
Apraxia or Dysarthria?
Anticipation of errors cause dysfluent speech
Apraxia
Apraxia or Dysarthria?
Hoarseness
Dysarthria
Apraxia or Dysarthria?
Breathiness
Dysarthria
Apraxia or Dysarthria?
Groping, trial and error types of articulatory movements
Apraxia
Apraxia or Dysarthria?
Changes in vocal quality
Dysarthria
What are tracts and pathways?
groups of fibers that travel together in the CNS that transmit impulses to other neurons
What are the commissural tracts?
They connect homologous areas in 2 hemispheres
What are the association tracts?
They connect cortical areas within a hemisphere
What are the projection tracts? And what are the fibers associated with it called?
They connect higher/lower centers in CNS
- corticobulbar fibers
- Thalamocortical fibers
- Corticorubral fibers
Name all the pathways and their associated tracts
- Final common pathway
- Direct activation pathway– corticobulbar and corticospinal tracts
- Indirect activation pathway– corticoreticular and corticorubral tracts
- Control circuits– cerebellar and basal ganglia tracts
What is another name for the final common pathway and why is it called “final common”?
AKA the LMN system;
“final”- it’s last link in the chain of neural events before movement
“common”- all motor activity is mediated
How are FCP and speech connected? (What are the cranial and spinal nerves responsible for?)
paired cranial nerves supply muscles for phonation, resonance, articulation, and prosody
paired spinal nerves contribute to breathing and prosody
What CN’s are involved with the FCP?
Cranial nerves V, VII, IX, X, XI, XII
LMNs that supply diaphragm are in what part of spinal cord?
Cervical
LMNs that supply intercostal and abdominals are in what part of spinal cord?
Thoracic
What is the most important respiratory muscle for speech?
Diaphragm
What is another name for the direct activation pathway and where does it originate?
aka pyramidal tract or direct motor system;
originates in the primary motor cortex of each hemisphere (frontal lobes)
What tracts and CNs are associated with the direct activation pathway?
Corticobulbar tract– cranial nerves V, VII, IX, X, XII
Corticospinal tract– spinal nerves (respiratory muscles)
What 2 tracts form part of the UMN system?
Corticobulbar tract
Corticospinal tract
What does the DAP DIRECTLY connect to?
It connects cortex to the FCP and is facilitative (movement that is controlled, dexterous and discrete… speech)
What are the impacts to a lesions of the UMN?
- loss/reduction of skilled movement, more gross but no fine motor movement
- Unilateral lesion- impacts the opposite side of the body
Which 4 cranial nerves get bilateral UMN innervation meaning impact on speech would be minor if damaged?
V, IX, X, XI
What impact should SLPs be aware of in a unilateral UMN lesion, what do you often see in the lower face and tongue?
Weakness on opposite side of lesion
Unilateral UMN lesions often lead to what type of dysarthria?
unilateral UMN dysarthria
What are the Impacts of bilateral UMN lesions?
They are mild-profound and lead to spastic dysarthria
What is another name for the indirect activation pathway and why is it considered “indirect”?
aka extrapyramidal tract or indirect motor system
Indirect- multiple synapses, primarily in brainstem
What tracts are associated with the indirect activation pathway (IAP)?
Corticoreticular- role in muscle tone
Corticorubral- relay station from cerebellum, to thalamus to cortex; motor activity can be modified
What is the overall role of the indirect activation pathway (IAP)?
helps regulate reflexes and maintain posture, tone, and associated activities giving framework for direct activation pathway to do skilled discrete actions
Are the activities of the indirect activation pathway (IAP) conscience or subconscience?
subconscience
What will lesions located outside of the brainstem for the indirect activation pathway impact?
lesions outside the brainstem for IAP affect muscle tone (spasticity) and reflexes (hyperreflexia)
What will lesions located in the brainstem for the indirect activation pathway (IAP) result in?
death
What will lesions above the brainstem in the indirect activation pathway (IAP) impact?
decorticate posturing
Are lesions of motor pathways from hemisphere common
or uncommon?
Common
Describe lesions to the UMN.
- involve direct and indirect pathways
- spasticity and loss of skilled movements
- may change over time
- spasticity on speech: slow movement; hyperadduction of VFs
- spastic dysarthria, bilateral
- unilateral UMN dysarthria, lesions are unilateral
What is the source of input to LMNs?
supports background of movements and fine tuning of all movements
How does the indirect activation pathway (IAP) support speech?
provides specific speech movements that can occur without interference and can maintain speed, range, and direction
How are lesions in the indirect activation pathway (IAP) manifested for:
- muscle tone?
- reflexes?
- movement in general?
- vocal cord action?
- for muscle tone: too tight
- effect on reflexes: hyperreflexive
- effect on movement in general: slow
- effect on vocal cords action: hyperadduction
What is the impact from a unilateral UMN lesion affecting indirect pathway?
- mild impact
A unilateral UMN lesion will result in what type of dysarthria?
unilateral UMN dysarthria
Bilateral UMN lesion affecting both direct and indirect pathways leads to what?
- spastic dysarthria
- pathologic reflexes
- more inhibited
- presence of dysarthria
- often labile
What are the tracts of the control circuits pathway?
Cerebellar and Basal Ganglia
Describe the 2 components of the cerebellum
- Cerebellum (2 components)
- Flocculonodular lobe- modulates equilibrium; orientation of head and eyes
- Body of cerebellum- fiber tracts enter/leave through: inferior, middle, or superior cerebellar peduncles
What type of dysarthria does a lesion in the Cerebellum control circuit (CCC) cause?
- Ataxic dysarthria
What is the function of the Cerebellum control circuit (CCC)?
helps coordinate timing of movement, size of movement, and coordinates sequencing of agonists/antagonists
What is the function of the Basal Ganglia Control Circuit (BGC)?
circuitry opens the gates to intended movements and closing gates to competing or unwanted movements, and preventing “locking up” of movement
What is the relevance of the Basal Ganglia Control Circuit (BGC) to speech?
- posture and tone regulation: muscle tone, normal posture, skilled movements
- movement scaling: force, amplitude, and duration
- set switching: respond to novel or changing circumstances
- movement selection and learning: build a repertoire movements
What damage can be caused by a lesion to the Basal Ganglia Control Circuit (BGC)?
- reduced mobility: increased muscle tone, rigidity (slow and stiff movements), hypokinetic dysarthria
- involuntary movements: vary in locus, speed, and regularity, hyperkinetic dysarthrias
UMN or LMN?
- Motor neurons originate in the primary motor cortex or on the brainstem
- Carry motor information down to the lower motor neurons
- Tracts: corticobulbar and corticospinal
UMN
UMN or LMN?
- Caused by: stroke, tumors, blunt trauma
UMN
UMN or LMN?
- Motor neurons originate in brainstem and spinal cord and directly innervate skeletal muscles
- Act as a link between UMN and muscles
- Cranial nerve LMNs control movements of the eyes and tongue, and contribute to chewing, swallowing and vocalization
LMN
UMN or LMN?
- Caused by: trauma to peripheral nerves
LMN
UMN or LMN?
- “Spastic paralysis”
UMN
UMN or LMN?
- Hypertonia- increased tone or resistance to movement
UMN
UMN or LMN?
- “Flaccid paralysis”
LMN
UMN or LMN?
- Hypotonia- loss of muscle tone
LMN
UMN or LMN?
- Hyperreflexia- exaggerated muscle stretch reflexes
UMN
UMN or LMN?
- Clonus
UMN
UMN or LMN?
- Hyporeflexia and areflexia
LMN
UMN or LMN?
- No clonus
LMN
UMN or LMN?
- Babinski sign
UMN
UMN or LMN?
- No Babinski sign
LMN
UMN or LMN?
- Little or no atrophy
UMN
UMN or LMN?
- No fasciculations or fibrillations
UMN
UMN or LMN?
- Marked atrophy
LMN
UMN or LMN?
- Fibrillations and fasciculations
LMN
UMN or LMN?
- Unusual laughing/crying (pseudobulbar affect)
UMN
UMN or LMN?
- Amyotrophic Lateral Sclerosis (ALS)
- Progressive bulbar palsy (starts with LMN needed for swallowing, speaking, chewing, etc.)
Mixed (UMN and LMN)
What is Romberg?
Ask the patient to stand with their feet together (touching each other). Then ask the patient to close their eyes. Remain close at hand in case the patient begins to sway or fall.
With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense. If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open. When the patient closes their eyes, however, visual input is removed and instability can be brought out. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open. Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia, so these should be tested for separately in other parts of the exam.
What cranial nerves are involved with speech production?
Cranial nerves V, VII, IX, X, XI, XII
V—Trigeminal
Sensory from face and mouth; motor to muscles of chewing
VI- Facial
Facial expressions, lacrimal glands, salivary glands
IX—Glossopharyngeal
Pharynx for swallowing, posterior 1/3 of tongue
X—Vagus
All intrinsic muscles of larynx; swallowing, phonation, involuntary muscle and gland control; taste; skin/organ sensitivity
XI—Accessory
Muscles that move the head, neck, and shoulders
XII—Hypoglossal
Movement of the tongue
What are the five systems that we assess with dysarthria?
Respiration Phonation Articulation Prosody Resonance
Duffy describes published tests for dysarthria and apraxia of speech. Can you name one of each?
Apraxia: Apraxia Battery for Adults–Second Edition (ABA-2)
This is the only commercially published measure for the assessment of Apraxia of speech in adults.
Dysarthria: Frenchay Dysarthria Assessment (FDA-2)
evaluates intellgibility of words, sentences, and conversation.
Duffy states that assessment should include intelligibility, comprehensibility, and efficiency. Can you describe what he means by these three (3) categories?
Intellgibility is the degree to which a listener understands the acoustic signal produced by a speaker.
In people with MSDs, estimates of intelligibility reflect the auditory product of the impaired speech system plus strategies used by the speaker to improve intelligibility
Comprehensibility is the degree to which a listener understands speech on the basis of the auditory signal plus all other information that may contribute to understanding what has been said.
The additional information is independent of the auditory signal and includes knowledge of the topic, semantic and synctactic context, the general physical setting, gestures and signs, orthographic cues, and so on.
Efficiency refers to the rate at which intelligible or comprehensible information is conveyed.
it’s important to measures of intelligibility and comprehensibility because it contributes to both the perception of speech normalcy and the normalcy of communication in social contexts.
For example, some people with MSDs are highly intelligible but very inefficient because rate is markedly slow.
Define palilalia
- Compulsive repetition of words or phrases, usually in a context of accelerating rate and decreasing loudness.
Define diplophonia
- Simultaneous perception of two different pitches
Define coprolalia
- Involuntary, compulsive, repetitive obscene language or swearing, uttered loudly, softly, or incompletely.
Define vocal flutter
- Rapid, relatively low-amplitude voice tremor (perceived as in the 7-12 Hz range), usually most apparent during vowel prolongation.
Define pitch breaks
- Pitch shows sudden and uncontrolled variation (falsetto breaks)
Define hypernasality-
Resonance is excessively nasal
Define hyponasality
- Resonance is hyponasal/denasal
Define monoloudness
- Voice is characterized by monopitch or monotone. Voice lacks normal pitch variation.
Define Inhalatory Stridor
- Similar to audible inspiration but characterized by actual rough phonation due to vocal fold approximation and oscillation during inhalation.
What is the purpose of the grandfather passage?
In 1963, Charles Van Riper published “My Grandfather,” a short reading passage that has evolved into a ubiquitous metric of reading ability and speech intelligibility. “The Grandfather Passage” represents a diverse inventory of English phonemes appearing both in isolation and also nested within an array of phonotactically improbable clusters (e.g., frock, zest). Alongside taxing articulatory demands, “The Grandfather Passage” batters its reader with syntactic and semantic complexity. As such, the passage offers an ideal mode of eliciting speech and reading errors. The diagnostic utility of the passage is also augmented by its brevity in that the original passage is composed of only 132 words (the one in Duffy on page 92 is only 115 words) and typically takes less than 3 min to administer (the one in Duffy on page 92 only takes about 35-50 seconds for normal speakers with fluent reading skills). The passage may be used for a quick survey of the student’s ability to produce correct speech sounds. It includes all of the speech sounds and may either be read by the student or be repeated phrase by phrase after the examiner.
Duffy states there are four parts of the examination. What are they?
- History
- Examination of the oral mechanism at rest or during non-speech activities
- perceptual assessment of speech characteristics
- Assessment of intelligibility, comprehensibility, and efficiency
What is HISTORY referring to during an examination?
- Basic data
- Onset and course of the problem
- Associated deficits
- Patient’s awareness of problem
- Degree to which it limits or alters activities or reduces life participation
- Management
What is EXAMINATION OF THE ORAL MECHANISM AT REST OR DURING NON SPEECH ACTIVITIES refer to during an examination?
Provides information about the size, strength, symmetry, range, tone, steadiness, speed, and accuracy or orofacial movements—particularly of the jaw, face, tongue, and palate.
What does PERCEPTUAL ASSESSMENT OF SPEECH CHARACTERISTICS refer to during an examination?
Identifying the perceptually salient deviant speech characteristics that lead to diagnosis.
What does ASSESSMENT OF INTELLIGIBILITY, COMPREHENSIBILITY, AND EFFICIENCY refer to during an examination?
- Intelligibility is the degree to which a listener understands the acoustic signal produced by a speaker
- Comprehensibility is the degree to which a listener understands speech on the basis of the auditory signal, plus all other information that may contribute to understanding what has been said (includes knowledge of the topic, semantic and syntactic context, physical setting, gestures and signs, orthographic cues, etc.)
- Efficiency refers to the rate at which intelligible or comprehensible information is conveyed
ASSESSING DYSARTHRIA VS APRAXIA–Anatomy and vascular distribution:
> _______ is almost always associated with left hemisphere pathology
> _______ can be associated with lesions in a much wider vascular distribution
> Apraxia
> Dysarthrias
ASSESSING DYSARTHRIA VS APRAXIA–Oral mechanism exam findings:
> T/F–Apraxia is rarely present without any abnormal oral mechanism findings?
False–Apraxia can be present without any abnormal oral mechanism findings. This is uncommon for the dysarthrias.
ASSESSING DYSARTHRIA VS APRAXIA–Oral mechanism exam findings:
> What are the 3 most common oral mech findings associated with apraxia, that are uncommon in the dysarthrias?
> Unilateral lower face weakness
Unilateral lingual weakness without atrophy or fasiculations
Nonverbal oral apraxia
ASSESSING DYSARTHRIA VS APRAXIA–Speech characteristics:
> T/F: In dysarthria, deviant speech characteristics are secondary to problems with strength, tone, ROM, and steadiness of movement
> True
ASSESSING DYSARTHRIA VS APRAXIA–Speech characteristics:
> ________ is frequently associated with aphasia
> Apraxia
ASSESSING DYSARTHRIA VS APRAXIA–Speech characteristics:
> Errors are inconsistent and unpredictable in ________.
> Errors are consistent and predictable in ________.
> Apraxia
> Dysarthria
ASSESSING DYSARTHRIA VS APRAXIA–Speech characteristics:
> Dysarthria affects which components of speech?
> Respiration > Phonation > Resonance > Articulation > Prosody
ASSESSING DYSARTHRIA VS APRAXIA–Speech characteristics:
> Apraxia predominantly affects which components of speech?
> Articulation
> Prosody
