Treatment ppts Flashcards
1
Q
Treatment for Respiration
A
priority because it affects all other speech aspects
2
Q
How dysarthria affects respiratory system
A
weakness of respiratory musculature; abnormal tone (hypo & hypertonia); incoordination of respiratory musculature
3
Q
Amount of air needed for speech production is _______ than that required for normal breathing activities at rest
A
no greater
4
Q
Speakers with dysarthria and their breathing
A
Either do not follow normal speech breathing patterns of inhalation and exhalation
5
Q
Address respiration in therapy if…
A
pt doesn’t have consistent air pressure when producing more than 1 word per breath
6
Q
SLP’s focus on respiration:
A
only on strength training to improve respiratory support necessary for speech; address inspiration & expiration strengthening
7
Q
4 ?s to consider when making respiratory tx decisions:
A
- Can the pt improve respiratory drive?; 2. Is the pt using the maximum respiratory drive possible?; 3. What compensations can pt make to lessen the disability/handicap?; 4. What is prognosis for favorable outcomes at each level?
8
Q
Respiratory Relaxation Exercise Step 1
A
Obtain baseline for tonal status of muscles in pt’s head, neck, trunk; head/neck: stand behind pt & gently move head backward, forward, side to side for 1 minute & rate observations; trunk: have pt touch toes w/o bending @ knees, & bend @ hips from side to side & front to back several times: look for fluidness of movement & rate
9
Q
Respiratory Relaxation Exercise Steps 2-4
A
2: Relax muscles in limbs & trunk-abdomen & diaphragm: pt lays in supine position on floor/table in quiet environment; 3: In supine position, pt exhales & inhales via nose to count of 5 each; 4: once breathing pattern produced, pt places hands on abdomen to feel movement feedback
10
Q
Respiratory Relaxation Exercise Step 5(6)
A
5: See-Scape via nose: Inhalation=float should stay @ bottom; Exhalation=float should rise & stay @ top for 5 counts;
Exhalation+Inhalation=1 trial (pt should perform 30 consecutive trials)
6: tissue folded in half & placed over pt’s mouth & nose clip on nose if See-Scape not available; inhalation, it should flatten against mouth & exhalation, it should flutter away from mouth
11
Q
Respiratory Postural Exercise Step 1
A
Make modifications to wheelchairs to allow pt to have ideal posture because: prevents or corrects abnormal posture, enables neuromuscular activity, provides good head support, prevents abnormal rotation of trunk & hips
12
Q
Respiratory Postural Exercise Step 2
A
If wheelchair-bound pt has involuntary shifts in posture or poor volitional control, add sling or static head/trunk support to chair
13
Q
Respiratory Postural Exercise Step 3
A
If wheelchair-bound pt needs additional help w/ trunk support, lap tray can be added; pad facing pt’s trunk can be added to tray for assistance in inducing abdominal contraction; SLP can identify needs, but PT or biomedical engineer should do design and fitting
14
Q
Respiratory Pressure Generating Exercise Step 1
A
See-Scape to obtain baseline of subglottal air pressure-generating capability: take off rubber cap & put 4-28mm paperclips on top of float; nasal olive off rubber hose & attach to drinking straw that extends 2” from end of hose; poke hole in straw 1/2way between free end & beginning of hose
15
Q
Respiratory Pressure Generating Exercise Step 2
A
Have pt blow into straw 2/ goal of raising float w/ paperclips to top of tube; goal: keep float on top for 5 seconds each trial
Complete 5 trials w/ 15 seconds rests in between
Give score of 1 for complete trial: score less than or =to 3 continue to step 3; score greater than 3, continue to next exercise
16
Q
Respiratory Pressure Generating Exercise Step 3 & 4
A
3: Repeat step 2 until pt performs task correctly for 10 consecutive trials
4: Discontinuation rule: stop if no improvement over baseline after 30 consecutive trials
17
Q
Respiratory Inhalation Exercise Step 1
A
Obtain baseline of pt’s inhalation prolongation capability: pt breathes in as long & steadily as possible (use stopwatch to time length)
pt should make airstream audible so SLP can hear inhalation
Pt repeats this 5x & record mean # of seconds: less than 10 seconds…intervention needed & proceed to next step; more than 10 seconds, continue to next exercise
18
Q
Respiratory Inhalation Exercise Step 2
A
Improve strength of diaphragmatic contraction/air intake potential: pt should sit upright in armless chair; pt takes as deep a breath as possible & holds it-SLP applies degrees of light counterforce against pt’s abdomen & pt opposes deflating compression
19
Q
Respiratory Inhalation Exercise Step 3
A
Repeat step 2 for 10 minutes (rest periods permitted); test effects of this exercise by repeating step 1 & comparing to baseline score; continue w/ step 3 until pt improves 75% over baseline or @ 10 seconds
Discontinuation rule: stop if no improvement after 30 consecutive minutes
20
Q
Respiratory Exhalation Exercise Step 1
A
Obtain baseline of pt’s exhalation prolongation capability: pt breathes out as long & steadily as possible (stopwatch to time length)
Pt should make airstream audible so SLP can hear it; pt repeats 5x & record mean # of seconds
score less than 10seconds…intervention needed & proceed to next step; more than 10 seconds, continue to next exercise
21
Q
Respiratory Exhalation Exercise Step 2
A
See-Scape so pt has visual feedback of exhalation capability: remove paperclips from float, but still use straw in same manner; pt places straw lightly in mouth & takes breath in
pt prolongs exhalation as long & steady as possible: float will rise to top of tube & remain there until pt stops exhaling (SLP stopwatch or counts out loud to time exhalation)
22
Q
Respiratory Exhalation Exercise Steps 3-4
A
3: Pt should place hand on abs during exercise to feel its retraction
4: SLP records # of secs pt prolongs exhalation: allow 15 secs of rest between trials; continue exercise til pt’s score is 75% improved over baseline or @ 10 secs
discontinuation rule: stop if no improvement after 30 consecutive trials
23
Q
Respiratory Quick Breathing Exercise Step 1
A
Baseline of pt’s ability to breathe in & out quickly & continuously: pt breaths in & out continuously & as quickly as they can for 5 secs (SLP records # of complete cycles)
Pt repease 4x w/ 15sec breaks between trials: SLP calculates mean of cycles achieved: less than 5, proceed to step 2, more than 5, next exercise
24
Q
Respiratory Quick Breathing Exercise Steps 2-3
A
2: See-Scape & make sure pt is comfortable; position straw in pt’s mouth & fasten nose clip on nose
3: See-Scape for visual feedback: pt inhales via straw for 2 secs & exhales for 2 secs for a total of 20 secs=1 trial; complete 12 trials w/ 1 minute rest periods
25
Respiratory Quick Breathing Exercise Step 4
Test effects of step 3 by repeating step 1 & comparing score to baseline
26
Respiratory Quick Breathing Exercise Step 5
Continue until pt's mean score is 75% improved over baseline; Discontinue rule=stop exercise if no improvement after 30 consecutive minutes
27
Respiratory Inhalatory/Exhalatory Synchronization Exercise1 Step 1
Obtain baseline by having pt prolong inhalations & exhalations alternatively for 5 secs continuously for 1 minute==1 trial; record # of trials w/o abnormal, interruptive, oppositional, dysrhythmic respiratory features
Repeat 4x w/ breaks between trials; calculate mean score
less than 4: proceed to step 2 & more than 4: next exercise
28
Respiratory Inhalatory/Exhalatory Synchronization Exercise1 Steps 2-3
See-Scape: use nasal olive & tape to bridge of nose & have pt perform following breathing task via nose w/ mouth closed
3: pt prolongs inhalation then exhalation for 5 secs each for 1 minute==1 trial
29
Respiratory Inhalatory/Exhalatory Synchronization Exercise1 Step 4
Record abnormalities in cycle characteristics; pt has trouble with given cycle: incorrect; no breakdown occurs in given cycle: correct
30
Respiratory Inhalatory/Exhalatory Synchronization Exercise1 Step 5
Repeat procedure 10x w/ 30sec breaks in between minute-long trials
Calculate mean # of correct cycles after 60 trials have been completed
Continue exercise until pt improves 75% over baseline
Discontinuation rule: stop if no improvement after 120 trials
31
Respiratory Inhalatory/Exhalatory Synchronization Exercise2 Step 1
Obtain baseline by having pt take short breath & upon exhalation prolong the /m/ for 2 full secs, then take another breath & prolong /m/ again for 2 secs until 10 complete trials are attempted
Repeat 2 more times so that 30 trials are attempted; score less than 21, step 2; score more than 21, next exercise
32
Respiratory Inhalatory/Exhalatory Synchronization Exercise2 Step 2
See-Scape in same was as previous exercise; pt performs task they completed in step 1 via See-Scape
33
Respiratory Inhalatory/Exhalatory Synchronization Exercise2 Step 3
Explain adverse airflow effects of the antagonistic & asynchronous respiratory musculature contractions as it is measure & observed by deviant float dynamics during present exercise
34
Respriatory Inhalatory/Exhalatory Synchronization Exercise2 Step 4
Repeat procedure until 30 trials are completed; continue until pt achieves score 75% improved over baseline; discontinuation rule: stop if no improvement after 60 trials
35
Isolated Sound Production Exercises
For pts who can breathe well but do not when speaking (transfer); also for those who have made significant progress on preceding breathing exercises
Note: during all these exercises, SLP may press on abdomen to facilitate exhalation
36
Respiration Isolated Speech Exercise 1 Step 1 & 2
Pt sustains /i/, /o/, /u/ sounds for as long as possible & mean; if under 15 secs, continue; if not, skip to exercise 2
2: See-Scape: put straw in mouth, nose clip if needed
37
Respiration Isolated Speech Exercise 1 Step 3 & 4
3: Pt sustains /u/, SLP stopwatches & makes sure float doesn't sink more than 1"
4: Repeat step 3 20x. Allow pt 30 sec breaks between efforts; vary vowel sounds. record
38
RespirationIsolated Speech Exercise 1 Step 5 & 6
5: Mean efforts. Chart. Continue until mean improves by +75% of initial score or 15-20x success.
6: If no progress, quit after 30x tries. Move on.
39
Respiration Isolated Speech Exercise 2 Step 1
Pt holds /i-o-u/ sounds as long as possible; each sound = time; no looping; need smooth transition
40
RespirationIsolated Speech Exercise 2 Step 2
If 1 done smoothly, according to pt's potential award point; if not, no point; repeat 10x; if score is less than 8, continue, if greater than 8, exercise 3
41
RespirationIsolated Speech Exercise 2 Step 3
Repeat with See-Scape; float cannot drop lower than 1"; score as before
42
RespirationIsolated Speech Exercise 2 Step 4
Continue step 3 until +75% of baseline or 10 points; record scores after each set; do 3x sets; move on after 30 trials even if not improving
43
RespirationIsolated Speech Exercise 3 Step 1
Pt. to hold /u/ sounds for 10 sec. with one second break, 3x (33 sec. per trial). Need 22 sec. of holding. Record. If worse than 22 sec, continue. If not, ex. #4
44
Respiration Isolated Speech Exercise 3 Step 2
See-Scape; must use nose clip
45
Respiration Isolated Speech Exercise 3 Step 3
Set metronome for 60 beats per minute. Patient float floats, then pulses /u/ with beat for 10 sec. Float can’t sink more than 1". Inhalation sinks float. This is illustrative, once pt. understands, start.
46
Respiration Isolated Speech Exercise 3 Step 4
Record pt. air pulses successfully as explained above. pt needs +75% improvement or 30 seconds among three tries. Record. Carry on after 30x tries.
47
Respiration Isolated Speech Exercise 10 Step 1
Prepare CVC, CVCVCV words with only /i,o,u/ & plosives, affricates or fricatives. List on cards, 15 per.
48
Respiration Isolated Speech Exercise 10 Step 2
See-Scape. Nose clip required
49
Respiration Isolated Speech Exercise 10 Step 3
Pt inhales deeply, then reads as many cards as possible. Float cannot sink more than 1" (fail). Make sure pt. understands, can read words
50
Respiration Isolated Speech Exercise 10 Step 4
Pt. complete as many words as possible. Intelligibility is inconsequential. Complete 10 trials with 20 second breaks between. Derive mean & record
51
Respiration Connected Speech Breathing Step 1
Use See-Scape with 2 in. drinking straw. Circumference thin tape to tube at midpoint. Prepare list of 10 sentences on a card (10 syllables per card)
52
Respiration Connected Speech Breathing Step 2
Secure nose clip. Pt. breathes deeply, reads sentences #1 as float rises above tape. Float sinks when pt. inhales/stops. In this step, only inhalatory scored to allow calculation for syllables per breath
53
Respiration Connected Speech Breathing Steps 3-4
3: Once pt. grasps, record # of breaths to read all cards with 15 second break between each card
4: Pt. tries 3x per sentence. When done, take total breath # and divide by 300 (baseline of syllables per breath)
54
Respiration Connected Speech Breathing Steps 5-6
5: Record score. If score is less than 20, carry to step 6. Otherwise go on to next exercise.
6: Repeat until +75% improvement or “30” reached. After each set, find breaths per syllable. Quit after 30 min. even if goals unmet/no progress.
55
Velopharyngeal insufficiency causes what disturbances in speech production?
nasal air emissions, reduced ability to generate intraoral air pressure, weaker acoustic energy
56
Speech production issues related to vp insufficiency result in
hypernasality, articulatory imprecision, reduced phonatory volume
57
Goal of resonation dysarthria exercises
in increase intraoral air pressure-generating capability & to improve velopharyngeal valving
58
Who can benefit from resonation dysarthria exercises?
all pts with dysarthria who exhibit velopharyngeal insufficiency
59
Patient's with underlying hypertonicity & hyperactivy pharyngeal reflexes will begin this exercise regimen...
After completing, whether successfully or not, the preceding exercise program
60
Pts with moderate to severe velopharyngeal insufficiency...
Will not be able to meet the criteria recommended for the exercise regimen that follows
61
Resonation exercises discontinue rule
after 30 trials if no improvement is shown
62
If pt has lip seal difficulty...
Allow him/her to use fingers for assistance during exercises (record any compensations)
63
Resonation Exercise 1 Steps 1-2
1: Explain purpose of exercise to pt.
2: See-Scape in front of pt; connect a 2" piece of straw to rubber hose; punch hole in 1 wall of straw about 1/2way b/t the top of the hose & the free end of the straw
64
Resonation Exercise 1 Step 3
Instruct pt to take deep breath, then blow steadily into straw; goal is to raise float to top of tube & maintain it for 5 secs; repeat 3x for baseline
65
Resonation Exercise 1 Step 4
Repeat same exercise w/ 15secs of rest between trials until pt demonstrates ability to raise the float to the top of the tube for 5 full secs over 10 consecutive trials (Clean condensation inside the tube w/ a tissue to prevent interference with float capability)
66
Resonation Exercise 2
Follows same objective as ex. 1, except now drop a small paper clip into tube on top of float, which makes task more difficult; if pt has no difficulty on baseline trials, proceed to ex 3; once criterion has been achieved move to ex 3
67
Resonation Exercise 3
Also follows same objective as ex 1, except now drop 2 paper clips into tube to resist float dynamics; if pt has no difficulty w/ baselines, proceed to ex. 4
once criterion has been achieved, proceed to ex. 4
68
Resonation Exercise 4
Follows same objective as ex.1, except drop 3 paper clips into tube prior to intraoral air pressure-generating measurements; if pt has no difficulty w/ baseline trials, proceed to ex.5
Once criterion has been achieved, proceed to ex.5
69
Resonation Exercise 5
Follows same objective as ex.1, except drop 4 paper clips into tube; if pt has no difficulty w/ baseline trials, proceed to ex.6
Once criterion is achieved, proceed to ex.6
70
Resonation Exercise 6
Follows same objective as ex.1, except drop 5 paper clips into tube; if pt has no difficulty w/ baseline trials, proceed to ex.7
Once criterion is achieved, proceed to ex.7
71
Resonation Exercise 7 Step 1
Follows same objective as ex.1, except drop 6 paper clips into tube; also, the straw with bleed hole is substituted for the plastic nasal olive
72
Resonation Exercise 7 Step 2
Ask pt to take a deep breath & blow as hard as possibly into straw; goal is to cause the paper clips to wedge & remain w/in the hole of the rubber cap that sits on top of tube as float descends to the bottom w/ cessation of air pressure
Repeat task 3x to obtain baseline
Unless pt achieves perfect score during baseline measures, don't skip to next step
73
Resonation Exercise 7 Step 3
Continue w/ the same exercise, allowing 15 seconds of rest between trials, until the pt demonstrates ability to achieve objective on 5 consecutive trials.
74
People with phonation issues:
have adequate respiration but difficulty synchronizing breathing & speaking
75
Phonation issues manifested as:
excess loudness variations, inappropriate silences, inappropriate breath patterns, or inaccurate timing & range of movement in ataxia
76
Hypoadduction
results in hoarse, breathy voice with reduced loudness; usually associated with decreased tone & overall weakness & reduced range of motion
77
Hyperadduction
associated with increased tone; results in harsh/strained vocal quality & low pitch
78
Group 1 of potential Phonation pts
consisten & predictable/acoustic abnormalities
| Spastic, flaccid, hypokinetic (parkinsonian) dysarthria
79
Group 2 of potential Phonation pts
those with variable, fluctuating, & unpredictable features
| Ataxic, hyperkinetic (quick, slow, & fluctuating) dysarthria & apraxia of phonation
80
General Principles of Phonation Therapy
Surgical intervention generally not recommended (FV augmentation)
Pharmaceutical intervention
Voice therapy techniques
Augmentative device
81
Phonation Surgical Interventions: VF Augmentation
Teflon Injection, Thyroplasty, Nerve Transfer, Botulinum A Toxin Injection
82
Teflon Injection
injection into paretic VF which increases bulk of the pathologic VF & augments glottal closure
83
Thyroplasty
Involves the use of alloplastic implant in the thyroid cartilage aimed at displacing paralyzed VF to improve contact w/ the opposing
84
Nerve Transfer
Involves reinnervating the recurrent laryngeal nerve w/ the hypoglossal nerve
85
Botulinum A Toxin Injection
Clostridium botulinum is injected transcutaneouly or intraorally into laryngeal musculature & decreases laryngeal spasms
86
Pharmaceutical Intervention
no pharmacologic agents prescribed specifically to treat neurogenic voice disorders, but those w/ other disorders may be placed on meds that will help
87
Voice Therapy Techniques
Yawn-Sigh, Vowel prolongation, sentence production, holding breath, nonspeech vocal fold valving, hard attack phonation, laryngeal timing & coordination
88
Phonation Yawn-Sigh Exercise 1 Steps 1-2
1: Baseline perceptual rating for speech characteristics
2: Baseline of Phonation Subsystem Behavioral Treatment
89
Phonation Yawn-Sigh Exercise 1 Step 3
Demonstrate slow inspiratory yawn w/ a wide open mouth posture, followed by a prolonged expiratory sigh accompanied by soft phonation of /a/; SLP should alternate vowels
90
Phonation Yawn-Sigh Exercise 1 Step 4
Use tape recorder to allow pt to hear feedback; have pt repeat this using the the vowel /i/, rate the performance
91
Phonation Yawn-Sigh Exercise 1 Step 5
After each set of 10 trials, allow a 30-second rest period and continune with the same exercise until the patient achieves the criterion
92
Phonation Yawn-Sigh Exercise 2
Pt is requested to replace yawn component by as normal as possible an inspiratory maneuver followed by the prolonged sigh of the vowel stimulus. Use tape recorder for feedback
93
Phonation Yawn-Sigh Exercise 3
Both yawn & sigh conditions are faded during each trial as pt is required to try to prolong vowel stimulus w/ as nearly normal vocal quality as possible
94
Phonation Vowel Prolongation Exercise 1 Step 1
See-Scape device on table & connect 2" piece of drinking straw to rubber hose; draw line on tube about 1" from top
95
Phonation Vowel Prolongation Exercise 1 Step 2
Demonstrate by placing straw between lips; inhale normally & steadily prolong vowel /i/ until styrofoam floats up & remains @ the line
96
Phonation Vowel Prolongation Exercise 1 Step 3
Have pt do this until they reach 80% correct over 10 consecutive trials or 30 trials elapsed w/o evidence that the criterion will be realized; allow rest in between each set of 10 trials
97
Phonation Vowel Prolongation Exercise 2
same steps as Vowel Prolongation 1 & ask pt to try compensatory vocal quality technique
98
Phonation Sentence Production Exercise 1 Step 1
Chose 3 sentences & have patient state them
99
Phonation Sentence Production Exercise 1 Step 2
See-Scape device & substitute straw for nasal olive; demonstrate task by placing straw between lips & reading aloud a stimulus sentence; float should remain @ the top except during normal breaths
100
Phonation Sentence Production Exercise 1 Step 3
Request pt to perform this task beginning w/ simple sentences; continue until pt achieves 80% accuracy over 10 consecutive trials or 30 trials without reaching criterion. Allow the patient to rest 30 seconds in between each set (Can use a mirror instead of the See-Scape device)
101
Phonation Sentence Production Stimulus Sentences
Hurry up, don't cry, pet the puppy, mary makes beautiful music, the washing machine is broken
102
Phonation Holding Breath Exercise 1 Goal
Try to induce glottal closure by requiring pt to hold the breath for set periods of time
103
Phonation Holding Breath Exercise 1 Step 1
Assemble See-Scape on tabletop in front of patient, & place nasal olive in either nostril. Draw line on tube @ approximately the 1/2way mark.
104
Phonation Holding Breath Exercise 1 Step 2
Instruct pt to close mouth & lips, inhale deeply through nose & hold breath. When breath-holding starts, start stopwatch; when the float moves & remains above the line for 2 secs, clock stops
105
Phonation Holding Breath Exercise 1 Step 3
After each set of 10 trials, tally the mean # of secs & give the patient a 30 second break in between.
106
Phonation Nonspeech VF Valving Exercise 1 Step 1
Request pt to hold breath as long as possible to get baseline
107
Phonation Nonspeech VF Valving Exercise 1 Step 2
Tape nasal olive of See-Scape to most patent nostril of patient; tell patient to either: clasp hands together @ chest level w/ arms bent 90 degrees @ elbow & squeeze palms together as hard as possible; grasp bottom of seat w/ both hands & pull up as hard as possible; push down on seat bottom w/ both hands
108
Phonation Nonspeech VF Valving Exercise 1 Step 3
To determine which method promotes glottal closure most efficiently, have pt take deep breath & then begin a slow exhalation; when float meets 1/2way mark, it signals start of exhalation cycle; use these valving exercises to lengthen breath holding; time method just like holding breath exercise
109
Phonation Nonspeech VF Valving Exercise 1 Step 4
Then request that pt inhale deeply & then begin exhaling; as soon as float travels past 1/2way mark on tube, instruct the pt to invoke the chosen valving maneuver in concert w/ conscious effort to cease exhalation. clock starts when the float drops below the mark & stops upon exhalation.
110
Hard Attack Phonation 1 Purpose
To facilitate the hard glottal attack adduction of VFs during voice production for flaccid & hypokinetic dysarthric pts
111
Hard Attack Phonation 1 Step 1
Establish baseline by having pt prolong /a/, sing up & down an octave scale @ comfortable pitch & loudness levels, & answer background ?s so that context voice characteristics can be measured
112
Hard Attack Phonation 1 Step 2
Place an open palm on pt's abdomen; request pt to inhale deeply & hold it. Press intermittently & firmly on abdomen to cause exhalation. Instruct pt to resist which should cause audible straining of the VFs. If this does not result, tell the patient to bear down in a fashion like that required to bench press a weight. @ moment of perceptible strangled voice quality, instruct pt to try to bellow & prolong /a/ w/ best vocal quality. Once voice is produced, pumping of abdomen is stopped
113
Phonation Laryngeal Timing & Coordination 1 Steps 1-2
Establish baseline
| 2: Use See-Scape & substitue a 2-3" straw for nasal olive; divide tube into 4 = parts; put straw between pt's lips
114
Phonation Laryngeal Timing & Coordination 1 Step 3
Place nose clip on pt & instruct him/her to inhale deeply thru mouth & then repeat the CV syllable /pi/ 3x, prolonging vowel portion each time for 3 secs w/o breathing b/t productions; foam should remain fixed @ the top throughout the 3 sec prolongation phase. If this is performed correctly, the float will remain fixed @ the top. Sudden inspiratory activity &/or intermittent VF hyper adduction causes the float to descend to or below the 3/4 mark which is incorrect. Repeat until 80 % accuracy is achieved w/ 10 consecutive trials. (May use other stimuli such as /pu; ti; tu; ki; ku; si; su; fi; and fu/)
115
Phonation Laryngeal Timing & Coordination 2 Step 1
Use same See-Scape setup as ex.1; request that pt inhale deeply thru mouth then repeat CV syllable /pi/ 3x, prolonging vowel each time for 3 secs w/ a breath-holding pause of 1 sec duration between repetitions
116
Phonation Laryngeal Timing & Coordination 2 Step 2
Float should ascend rapidly to & remain fixed @ top as the vowel is prolonged; immediately following production, breath must be held for 1 sec & will be evident by the slow descent of the float
117
Phonation Laryngeal Timing & Coordination 3 Step 1
Use same See-Scape & have pt inhale deeply thru nose & then produce the following vowel train on that 1 breath, prolonging in sequence each vowel roughly 2 seconds: /u-a-i-E-o-I/
118
Phonation Laryngeal Timing & Coordination 4 Step 1
Use same See-Scape model as in Ex.3 but vowels are prolonged in variable time intervals; for the /u-a-i-E-o-I/ train, we begin the /u/ prolongation for 3 secs, followed by the /a/ for 1 sec, the /i/ for 2 secs, the /E/ for 3 secs, the /o/ for 1 sec, and finally the /I/ for 2 secs; stopwatch & verbal cue should be used to prompt pt
119
Phonation Laryngeal Timing & Coordination 5 Step 1
Establish baseline regarding pt's ability to produce sequentially on 1 breath the train of words that follow, prolonging final sound of each word for a length of time different from that of the preceding word & varying the amt. of pause time b/t words on the train
Stimuli options: pea, tea, tie, key, tee-pee, she, see, bee, bye-bye, baby
120
Phonation Laryngeal Timing & Coordination 5 Step 2
Use same See-Scape in preceding exercises. Request pt produce sequentially on 1 deep breath the train- paper, cookie, fee, show, sue; 1st pt produces word "paper" & prolongs final sound 2 secs, noting float should be fixed @ top; 2nd pt pauses which causes float to descend to 1/2way mark & then produce word "cookie" for 3 secs which propels float back up to top; pt then pauses til float descends to 3/4 mark then produces word "fee" & prolongs it 1 sec to raise float back up; 4th pt pauses until float descends to 1/4 mark & produces word "show" & prolongs it 2 secs to raise it back up; finally pt pauses til float descends to bottom then produces "sue" for 3 secs which should cause float to ascend to top again; use verbal cues & stopwatch to signal switch
121
Pitch, loudness, silence, segment duration
suprasegmental factors
122
coloring, melody, rhythm, stress, intonation patterns
prosody
123
prosodic features result from....
interactions of the suprasegmentals
| Normal speech is constantly modified by prosodic variation
124
Majoriy of patients w/ motor speech difficulties...
exhibit prosodic insufficiency to some degree
125
2 primary classes of prosodic insufficiency
dysprosody & aprosody
126
Pts will primarily have ______
dysprosody, which contributes significantly to speech intelligibility
127
Damage where causes prosodic disturbances?
focal as well as diffuse lesions of right cerebral hemisphere, including all lobes
Can result from left hemisphere lesions, but right is more common
128
Commonly occurring prosodic difficulties
slow rate, short rushes, prolonged intervals, prolonged pauses, reduced loudness variation, reduced pitch variation, etc
129
When should prosody treatment begin?
usually performed last in relationship to other speech subsystem difficulties
Must have proper respiration, resonation, phonation, & artic to achieve proper prosodic productions
Usually b/c gains during tx of other areas facilitates improvement in prosody
Sometimes, tx of prosody is recommended in conjunction w/ artic, if d/o is mild
130
Tx of Pitch Alteration Abnormalities
many dysarthric pts exhibit problems; most common are monopitch, inappropriate & intermittent pitch outbursts or changes; important to remember fundamental frequency of voice normally varies considerably among individuals relative to age & sex
131
Pitch Control Exercise 1 Step 1
Establish baseline pitch discrimination & listening skills by identifying whether pairs of vowels sung are same or different pitch & if different, which is higher
Ask pt to practice by singing 2 vowels grossly different in pitch
Provide pt w/ example of 2 vowels that are same pitch
Step necessary to determine if pt can discriminate b/t 2 sounds
132
Pitch Control Exercise 1 Steps 2-3
Begin with /a/ & /u/; Sing /a/ for 3 secs @ low pitch followed by /u/ for same amt of time @ clearly higher pitch: have pt respond to whether sounds were same or different & if different, which higher
Record correct/incorrect; score each task separately
Repeat procedure 10x but select different vowel pairs, periodically & creatively vary pitch distinctions across trails to make task perceptually challenging
If score =to or less than 75%, proceed w/ step 4; otherwise go to next exercise
133
Pitch Control Exercise 1 Steps 4-5
Continue w/ same basic procedure as step 2, being sure to produce some pairs that are same to ensure pt can distinguish gross & fine pitch discriminations; continue w/ this until pt has achieved mean %age correct score at least 75% improvement over baseline or 100% correct, whichever is less, over 10 consecutive trials; discontinuation: after 30 consecutive trials if no discernible trend of improvement to warrant continuation
134
Pitch Control Exercise 2 Step 1
Establish baseline pitch modulation ability by engaging pt in conversation & tape record speech sample: should be around 5 minutes; if possible, have pt read aloud passage & record it; be sure to instruct pt to read as naturally & comfortably relative to pitch, loudness, phrasing patterns as possible; tape record pt singing up & down scale, starting @ whichever pitch he/she may choose; repeat these procedures 3x, randomizing order of presentation
review & rate tapes on 1-7 scale; 1 no pitch disturbance & 7 being marked pitch disturbance
if pt scores 3 or worse on any 2 or more of tasks, proceed to 2, otherwise next exercise
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Pitch Control Exercise 2 Step 2-3
Demonstrate for pt 2 vowels sung @ grossly different pitch levels; 1st demonstrate lowest pitch possible accompanied by hand gesture, 2nd sing highest pitch w/in chest register accompanied by hand held high above head; ask pt to perform task, encourage hand gestures; correct score awarded if sounds produced are perceptually @ least 3 whole notes apart in fundamental frequency; continue until pt achieves target criterion on 10 consecutive trials
By now, pt should be able to perceive differences b/t these 2 sounds; if not, prognosis is poor; tally %age correct
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Pitch Control Exercise 3 Steps 1-3
Repeat baseline from Ex.2, proceeding to step 2 if necessary; this is same basic exercise except have pt 1st singe a vowel @ highest pitch possible, then the lowest pitch possible; same criteria as previous exercise
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Tx of Rate Disturbances
It influences articulatory precision as well as intelligibility
Avg. adult rate of speech: 150-200 wpm; between 3 & 5 syllables per second
Avg. youth rate of speech & reading is slower
Abnormalities may occur in duration, pause time, or both
Universal problem in those with motor speech disorders
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Goals of Rate-Related Prosodic Treatment
Increase rate of speech, decrease rate of speech, modulation control
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Rate Control Exercise 2 Step 1
establish baseline & oral reading rates by engaging pt in conversation & having him/her read familiar passage while recording, repeat; count the # of spoken words & log total# of secs that the pt actually spoke in each; avg the # of words spoken & secs that elapsed during each condition; compute mean words per minute
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Rate Control Exercise 2 Step 2
If pt. is perceived as speaking too slowly, set a metronome @ 150 bpm; have pt recite alphabet, 1 letter per beat, w/ no breaks until the end; repeat procedure until pt achieves mean correct %age of 80 or better over 10 consecutive trials; invoke usual discontinuation rule if necessary
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Rate Control Exercise 12 Step 1
Use same baseline date from exercise 2
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Rate Control Exercise 12 Step 2
Rate Modulation Control: using familiar reading materials, insert following symbols throughout: I---I, I------I, I----------I which describes speed @ which words following should be read
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Rate Control Exercise 12 Step 3
Use tape recorder for biofeedback; request that pt read passage according to symbols; perceptually rate effort on scale of 1-7 (1 is proficient, 7 is deficient); repeat procedure periodically until pt achieves @ least a mean score of 3 on perceptual scale over 10 trials
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Intonation
the rise, fall, & variability in pitch of the voice; frequently associated w/ stress
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Intonation disturbances tx
Inappropriate pitch levels can obscure true meaning of info that is to be conveyed by speaker
Pitch levels indicate purpose & meaning in msg: low, modal, high
Strong interrelationship between intonation, pitch control, loudness: contingent on outcome of previous pitch & loudness exercises
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Objective of Intonation Exercises
Use pitch changes effectively to impart emphasis & to convey accurate attitudes, feelings, & intentions
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Intonation Contour Activity Exercise 1 (practicing declarative statements)
prepare both simple & complex declarative statements on index cards for pt to read aloud
Use numerals I, II, III to the left of the sentence to govern low, modal, high pitch use, respectively
Inform pt that in declarative statement, most emphasized wd is spoken @ highest pitch level & last wd ends on low note
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Intonation Contour Activity Exercise 2 (practicing questions)
prepare both simple & complex ?s on index cards for pt to read aloud
Remind pt that sentence can usually be converted into ? by raising pitch on last word or syllable; when ? calls for a response from a listener, it is necessary for speaker to glid from high (3) to even higher (3+)
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Loudness Control Exercise 1 (discrimination): Step 1
Establish baseline vocal loudness discrimination & listening skills; explain that task will be to: identify whether a pair of vowels briefly spoken are of the same loudness or different & if they are different, which 1 is louder or softer; present an example pair & discuss pt's answer until pt seems to understand task
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Loudness Control Exercise 1 Step 2
Begin present pairs of phonemes, 1 at a time, each @ varying or similar levels of loudness; pt may correctly identify 2 sounds as different but fail to specify accurately the louder 1; repeat procedure 10x
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Loudness Control Exercise 1 Step 3
Tally total # of correct scores & calculate % score; this is baseline for loudness discrimination; if %age score is higher than 75% then you move to another exercise; if not, continue w/ discriminatory exercise throughout tx & continue to step 4
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Loudness Control Exercise 1 Step 4
Continue w/ this task until the pt achieves a mean %age correct score of at least 75% improved over baseline or 100% correct, whichever is less, over 10 consecutive trials; if no discernible progress made after 30 trials, discontinue
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Loudness Control Exercise 3 (Characteristics & Abilities) Step 1
Establish baseline vocal loudness characteristics; move pt through 3 tasks: 1: engage pt in conversation & tape record speech sample; 2: if pt can read, have them read aloud passage from book or standard text; 3: have pt produce vowel starting at a certain at a certain loudness & increase then decrease the loudness as if on a “scale” of loudness. Audio Record all 3 of these tasks & score each task on a scale 1-7. If the pt scores a “3” or worse on 2 or more of these baseline measures, proceed w/ step 2. Otherwise move on
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Loudness Control Exercise 3 Step 2 & 3
Be sure to make notes detailing characteristics of the pt’s loudness difficulties for records; Demonstrate for the pt 2 vowels produced @ very different loudness levels. Accompany the 1st vowel (very loud) with a very high hand position & the second vowel (very soft) w/ a low hand position to illustrate the difference b/t the 2 sounds. Ask the pt to perform the same task, encouraging them to use hand gestures w/ respective level of loudness. Score effort using the correct/incorrect scale. A correct score is given if the pt can produce 2 vowels & markedly varied loudness. Continue w/ task until the pt achieves 10 consecutively correct trials
Step 3: Tally and record scores to develop a percentage score
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To reduce vocal abuse
the duration of each utterance should be restricted to less than 5 seconds
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Loudness Control Exercise 5 Step 1 (Variation Ability)
Establish baseline by having pt prolong /m/ for 5 secs using a very soft loudness level; be sure they don't whisper; have pt do this 4x w/ growing degrees of loudness; 1st should be very soft, 2nd moderately soft, 3rd moderately loud, 4th very loud; on notepad, rate performance as correct/ incorrect; correct does not use whispered phonation & can be determined as appropriate loudness level; repeat 4 trials to give pt 2nd chance to develop baseline; tally & record %age correct as your baseline data
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Loudness Control Exercise 5 Step 2
See-Scpae & audio recorder w/ visual loudness indicator; mark 1/4 down tube from top; cut a 3/4" section of straw & place in tube on top of float; using nasal olive in 1 nostril, instruct pt to produce a prolonged /m/ & generate loudness sufficient to raise the straw to line drawn on tube & maintain for 5 secs; utilize visual loudness indicator to provide pt w/ biofeedback of loudness; allow for 1 min of practice b4 recording data
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Scoring of Loudness Control Exercise 5
Task is scored as correct if it meets 3 criteria: vocal quality intact; straw remains in the zone of line dawn or above it but doesn't tough cap for a full 5 secs; any straw level deviation only happens once & is corrected w/in 2 secs; otherwise trial is scored incorrect; repeat task until pt achieves 75% over baseline or higher over 10 consecutive trials
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Loudness Control Exercise 8 (Modulating Ability) Step 1
Establish baseline; have pt engage in conversation & description about an action picture; use 7-pt rating scale, rating overall flexibility in loudness control; this is baseline; scores of 3 or less continue to step 2; if higher, then move to next exercise
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Loudness Control Exercise 8 Step 2
Demonstrate varying levels of loudness for pt using the visual loudness indicator in single vowels, continuant voiced consonants, words & short sentences. purpose is to demonstrate how these different utterances can have impact on loudness & vice versa
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Loudness Control Exercise 8 Step 3
Using note cards w/ various speech stimuli to have the pt read. Try to choose words & sentences that are as meaningful as possible & w/in pt's speech repertoire. Request pt to produce the sound, word or sentence w/ varying degrees of loudness control as demonstrated earlier & measured by the responsive movements of the Visual Indicator. Allow the patient 1 minute w/ each card. Use the 7-point rating scale & repeat the procedure until 10 1-minute trials have been permitted
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Scoring of Loudness Control Exercise 8
Calculate the mean perceptual rating from this scale. After 30 consecutive trials of no marked progress, discontinue the exercise.
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Pathophysiology underlying articulatory imprecision in pts with motor speech d/o's...
is not usually uniform, either w/in or between patient subgroups
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Generally, when articulation imprecision is moderate or severe, exercises...
should be exclusively administered after necessary treatments of respiration, resonation & phonation subsystems, but before those for prosody
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Mild disturbances of articulation treatment...
can be co-treated with prosody exercises for simultaneous treatment
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Articulation exercises for spastic dysarthria
tone reduction, strengthening, force physiology training, phonetic stimulation
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Artic exercises for hypokinetic dysarthria
tone reduction, force physiology training, phonetic stimulation
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Artic exercises for hyperkinetic & ataxic dysarthria
force physiology training & phonetic stimulation
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Artic exercises for flaccid dysarthria
strengthening, force physiology training, phonetic stimulation
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Artic exercises for apraxia of speech
phonetic stimulation, motor planning activities
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Tongue Hypertonicity Exercise 1 Step 1
Request pt to stick out tongue so it can be grabbed lightly w/ gauze pad; instruct pt to relax tongue to allow forward & lateral passive movement to measure tissue elasticity; maintain tongue in each manipulated direction for at least 3 secs; repeat technique 3x before calculating baseline for overall muscle tone
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Tongue Hypertonicity Exercise 1 Steps 2-3
2: Complete same technique as step1, but this time stretch tongue in forward direction only drawn out from mouth to level of natural anatomical resistance & hold for 10 secs
3: record perceived degree of hypertonicity when tongue was in fully extended position; repeat procedure until pt achieves a mean tone rating at least 3 scale values improved over baseline or 0 if baseline was 2 or 3 (-4 to +4) over 10 consecutive trials (allow 10 sec rest after each measurement)
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Tongue Hypertonicity Exercise 1 Step 4
After each set of 10 trials, enter mean rating; if pt fails to demonstrate trend of improvement after 30 consecutive trials, discontinue & proceed w/ next exercise
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Lip Hypertonicity Exercise 1 Step 1
w/ pt's mouth at rest, gently grasp pt's lower lip w/ gauze & pull slightly outward & then downward toward chin; hold lip in this position for 3 secs; repeat procedure 3x; next, grasp upper lip & pull outward then upward toward nose; hold for 3 secs; repeat 3x; conclude mean baseline rating of overall lip tone; proeceed to next step if mean rating is above 1.5 (-4 to +4)
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Lip Hypertonicity Exercise 1 Step 2
Focus is only on lower lip; instruct pt to relax as much as possible so that lip can be pulled toward chin; hold this position & count aloud for 10 secs & then relax for 10 secs; rate degree of hypertonicity perceived
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Lip Hypertonicity Exercise 1 Steps 3-4
3: Repeat procedure until pt achieves mean tone score that is at least 3 scale values improved over baseline, or 0 if baseline was 2 or 3 over 10 consecutive trials
4: After each set of 10 trials, enter mean result; discontinue if pt fails to demonstrate trend of improvement after 30 consecutive trials
