Motor Speech (+ Voice Final)

Who is the father of modern neurology?

Charcot

Dysarthria

motor speech disorder/speech production deficit that results from neuromotor damage to the PNS or CNS
Involves the five components of speech production.

Standardized tests for dysarthria (4)

1. Frenchay Dysarthria Assessment-2
2. Assessment of Intelligibility of Dysarthric Speech
3. The Speech Intelligibility Test for Windows
4. DDK rate

Apraxia of speech (definition and cause)
NOT due to ??

Inability to sequence movement of articulators for voluntary speech.
NOT due to muscle weakness/slowness. Caused by CNS damage.

The only standardized test for apraxia is

Apraxia Battery for Adults-Second Edition (ABA-2)

Five components of speech production

Hint: It's a wrap!

RRAPP

respiration, resonance, articulation, phonation, prosody

Respiration

Provides subglottic air pressure needed to set vocal folds into vibration

Phonation

Production of voiced phonemes through vocal fold vibrations in larynx

Resonance

placement of oral or nasal tonality onto phonemes

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Articulation

the shaping of the vocal air stream into phonemes

Prosody

The melody of speech (stress and intonation)

Salient features: STAR__SS__ (for motor eval)

How do you assess each? (What are its compromises?)

•__Strength__: press tongue against a tongue blade, or stress test

(affects all 5 components)

•__Tone__: Listen to speech or assess body parts

(rigidity/spasticity = hypertonia, paralysis/weakness = hypotonia)

•__Accuracy of movement__: inaccurate movement can be assessed with AMR and SMR tasks, conversation, or reading

(distorted consonants, hypernasality)

•__Range of motion__: Assess reduced ROM by extending/holding articulators in various positions

(inability to completely open jaw or completely adduct vocal folds)

•__Speed of movement__: AMR and SMRs

(reduced speed of movement)

•__Steadiness:__ Hold a position or prolong a vowel

(tremors/involuntary movement, tremulous vocal quality)

Alternate Motion Rate (AMR) - definition and usefulness

assessment of patient's ability to move articulators rapidly and smoothly in repetitive motion ( p^ p^ p^)

Useful to see dysarthria symptoms

Sequential Motion Rate (SMR) - definition and usefulness

Assesses patient's ability to move articulators in a rapid smooth sequence (p^ t^ k^)

Useful to see apraxia of speech symptoms

CNS consists of the ____ and _____

brain and spinal cord

The PNS consists of _________ and ______

cranial nerves and spinal nerves

Neurons: Function and 3 parts

Transmits electrochemical signals that control body functions

Parts: Cell body, dendrites, and the axon (which is covered by myelin)

Efferent neurons vs Afferent neurons

Efferent neurons transmit their impulses __away__ from the CNS

\*Hint: Get the __eff__ away from me!

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Afferent neurons transmit their impulses __toward__ the CNS

\*Hint: Afferent = __Affe__ction (you want to be close)

12 Cranial Nerves

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Note which CN controls pharynx and velum.

Oh, oh, oh, to take a family vacation go vegas and hawaii


1. Olfactory - smell
2. Optic - sight
3. Oculomotor - ability to move eyes
4. Trochlear - *up and down* eye movement
5. Trigeminal - Jaw, chewing muscles 3 sensations (touch, temp, pain)
6. Abducens - *side to side* eye movement
7. Facial - facial muscles
8. Vestibulocochlear - hearing and balance
9. Glossopharyngeal - swallowing, shaping pharynx, __controls pharynx and velum__
10. Vagus - heart rate, respiratory rate, digestion (think of winning jackpot in Vegas)
11. Accessory/Spinal - Head, neck, shoulder movements (think of where you wear accessories)
12. Hypoglossal - tongue muscles

Cranial nerves for speech production (5, 7, (8), 9, 10, 11, 12)

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Kahoot Q: Which one is the most important for speech production?

"Take family vacation***, go Vegas and Hawaii"

CN V - Trigeminal

CN VII- Facial

CN VIII - Vestibulocochlear\* (Not on PPT)

CN IX - Glossopharyngeal

CN X - Vagus

CN XI - Accessory spinal

CN XII - Hypoglossal

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Kahoot: Vagus

3 Branches of the Vagus Nerve are…..

\-What does the Vagus nerve innervate? Which other CN works with Vagus to innervate these?

\-Damage to which of these branches will result in damage to the velum?

Recurrent nerve branch, the Superior laryngeal nerve branch, and the Pharyngeal branch

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Innervates pharynx, larynx, and velum. Spinal Accessory nerve works with Vagus to innervate these as well.

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pharyngeal branch innervates the velum and pharynx

Primary Cortex (Function)

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What are the 4 primary cortices?

Areas of cerebral cortex that first receive sensory impulses from the body


1. Primary visual cortex
2. Primary motor cortex
3. Primary auditory cortex
4. Primary sensory cortex

\*Think VMAS - visual, motor, auditory, sensory - and how it’s a big show that *first gives you sensory impulses*

Association Cortex (Function, Areas)

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Sends neural signals of intended motor movements to __________ and _________

Interprets and integrates sensory info from the primary cortex

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1. Frontal association
2. Parietal association,
3. Occipital association
4. Temporal association

\*Think FPOT - fuck pot since it affects your ability to *interpret and integrate sensory info*

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basal ganglia and cerebellum

Basal Ganglia: 3 Parts

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What 2 parts make the striatum?

putamen, caudate nucleus, and globus pallidus

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striatum: caudate nucleus and putamen

Basal Ganglia: Function and Compromises (2)

Acts like a filter to prevent unwanted movements

Compromises: Huntington's (hyperkinetic dysarthria) and Parkinson's (hypokinetic dysarthria) disease

BG: Parkinsonism causes _______________ and ________________ movements while Huntington's disease causes ___________ and _________________ movements

PD: rigid, restricted

HD: Rapid, dance-like

Basal Ganglia: To function properly it needs a balanced interaction of __________________ and _____________________.

Dopamine (inhibitory) and Acetylcholine (excitatory)

Cerebellum ("little brain") function and compromises

Coordinates movement of limbs

Compromises: ataxia and intention/essential tremors

Intention/Essential tremors vs Resting tremors

Intention/Essential: Occurs during voluntary movement. Absent at rest

Resting: Occurs at rest

Thalamus: Function and 2 compromises

Receives neural inputs of planned motor movements from BG and cerebellum on its way to the primary cortex; “sensory gateway”, refines?

Compromises: Thalamic aphasia, thalamic pain syndrome

Dysarthria Main Assessment Tasks (3)

• AMRs
• Conversational speech or reading
• Vowel prolongations

Upper Motor Neurons (UMN) definition and damage

CNS motor neurons that descend to the lower motor neurons in the PNS

Damage: spasticity, spastic dysarthria

Lower Motor Neurons (LMN) definition and damage

PNS motor neurons that connect the UMNs in the CNS to the innervated muscle to perform a movement

damage: muscle paralysis/paresis, flaccid dysarthria

Flaccid Dysarthria is caused by damage to _______________

Lower motor neurons in the PNS, which cause muscle weakness

Causes of Flaccid Dysarthria (8)

What is the most common cause?

• Surgical/physical trauma (most common cause)

• Strokes

• Tumors

• Muscular Dystrophy

• Myasthenia Gravis

• Guillain-Barré Syndrome

• Progressive Bulbar Palsy

• Polio

SLPs stress test (ex: counting quickly from 1-100) the motor speech mechanism to screen for what?

Myasthenia Gravis (A cause of Flaccid dysarthria)

All cranial nerves are affected in which dysarthria?

Flaccid

Ischemic Stroke vs Hemorrhagic Stroke

Ischemic: blocked artery in brain

Hemorrhagic: ruptured artery in brain (causes bleeding)

Myasthenia Gravis is a cause of _______________ dysarthria

What is MG?

Flaccid dysarthria

NMJ disease causing progressive muscle weakness

Guillain-Barré Syndrome is a cause of ________________ dysarthria

What is GBS?

Flaccid

Disease due to progressive demyelination in the PNS

Polio is a cause of _____________ dysarthria

What is Polio?

Flaccid

Viral disease that attacks LMNs

Progressive Bulbar Palsy is a cause of ________________ dysarthria and _________________ dysarthria

What is Progressive Bulbar Palsy?

Flaccid and Mixed (flaccid-spastic)

Disorder that can affect both LMNs and UMNs.

Flaccid Dysarthria Speech Characteristics (5)

•Hypernasality (most evident)
•Breathy phonation
•Imprecise consonants
•Abnormal prosody
•Shallow breath support

Flaccid Dysarthria: Treatments

Surgical treatment for velopharyngeal incompetence:

\- Pharyngeal flap procedure

\- Teflon injection

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

\- Palatal Lift

\- Velar strengthening exercises (CPAP)

\- Hard glottal attacks

\- breathy cough, frequent inhalations

Spastic Dysarthria is caused by _________________

Bilateral damage to the upper motor neurons (in pyramidal and extrapyramidal systems of the CNS)

- Must have had more than one stroke!

Spastic Dysarthria Causes (6)

What is the most common cause?

•Strokes (most common)
•ALS and MS (degenerative diseases)
•TBIs
•Infections
•Tumors
•Cerebral anoxia

Amyotrophic lateral sclerosis (ALS) is a cause of _____________dysarthria and _____________dysarthria

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What is ALS?

Spastic and Mixed (flaccid-spastic)

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Degenerative disease that results in progressive degeneration of LMNs and UMNs

Should patients with ALS learn AAC with no detectable speech sound disorder?

Yes

Multiple Sclerosis (MS) is a cause of ___________dysarthria and __________ dysarthria

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What is MS?

Spastic and mixed

Progressive degeneration of CNS myelin sheath

Spastic Dysarthria Speech (5) & Muscle (2) Characteristics

Speech
•Harsh or strained-strangled phonation
•Slow rate, effortful speech
•Imprecise consonants
•Hypernasality (no nasal emissions)
•Abnormal prosody

Muscle
•Abnormal/Hyper reflexes
•Hypertonia/Spasticity in articulators

Spastic Dysarthria Non-Speech Characteristics (2)

Pseudobulbar affect (uncontrollable laughing/crying)

Drooling

Spastic Dysarthria Treatment

Primary treatment goals: Target 4 or 5 components of speech production

reduce hyperadduction and hypertonia via relaxation/stretching exercises

Spastic vs Flaccid dysarthria (3 things each)

Spastic
•Bilateral UMN lesion
•Strained, strangled, and/or harsh vocal quality
•Emotional lability (Pseudobulbar affect)

Flaccid
•LMN lesion
•Hypernasality + nasal emissions
•Breathy vocal quality

Unilateral UMN Dysarthria is caused by _____________

Unilateral damage to the upper motor neurons

UMN Dysarthria Causes (3)

What is the most common cause?

•Stroke - frontal lobe (most common cause) •Tumors

•TBI (least common cause)

UMN Dysarthria: Speech Characteristics (4)

Most common is ____________

•Imprecise consonants (most common)
•Mild-moderate harsh vocal quality
•Mild Hypernasality
•Irregular articulatory breakdowns

UMN dysarthria is primarily a disorder of __________________________

Articulation

UMN dysarthria: If lesion is on left side of brain, the lower _____ side of the face and tongue and limbs show weakness.

right

UMN Dysarthria: Damage in left vs right hemisphere

Left hemisphere: Aphasia and apraxia

Right hemisphere: Visual and cognitive deficits

Unilateral UMN Dysarthria vs Spastic Dysarthria (lesion sites)

UMN: Damage to UMNs on one side of the brain

Spastic: Damage to UMNs on both sides of the brain

Unilateral UMN: Extra Assessment Tasks

Know the site of lesion!

Unilateral UMN Dysarthria: Articulation Treatment Tasks (4)

Traditional articulation tasks such as
• Phonetic placement
• Intelligibility drills
• Over-articulation
• Minimal contrast drills

Ataxia

poor muscle control, impaired coordination (clumsy movements)

Ataxic Dysarthria is caused by damage to the __________________

cerebellum

Cerebellar Ataxia: Symptoms (6)

* problems coordinating voluntary movements
* problems controlling timing and force of speech movements
* staggering, wide-based gait
* intention tremors
* hypotonia
* problems with motor learning

Ataxic dysarthria: Causes (6)

Most common causes are ______________ and ___________________.

•Degenerative diseases (most common)
•stroke (most common too)
•toxic conditions
•TBI
•Tumors in cerebellum
•Infections

Ataxic dysarthria:
What are the two main speech deficits?

Speech characteristics (5)

Main deficits are in: Articulation and Prosody

• Drunken/slurred speech
• Imprecise consonants
• Abnormal prosody (monotone)
- Equal stress!!!
• Distorted vowels
• Irregular articulatory breakdowns

Ataxic dysarthria: Scanning speech is _________

slow deliberate production of syllables with each syllable in a word receiving equal stress

Friedrich's ataxia is a cause of ________ dysarthria and ________ dysarthria

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What is FA?

Ataxic, mixed (ataxic-spastic)

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Progressive disease that affects spine and cerebellum

Olivopontocerebellar Degeneration/Atrophy
is a cause of ____________dysarthria

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What is Olivopontocerebellar degeneration?

Ataxic.

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A progressive cerebellar disorder

Ataxia dysarthria: Extra Assessment Task

Repeating sentences with multisyllabic words

Ataxic Dysarthria: Treatment concentrates on what 3 things?
Name an example assessment task for each.

• Controlling respiration (Ex: Stop phonation early)
• Increasing articulatory accuracy (Ex: Intelligibility drills)
• Developing optimal rate and intonation in connected speech (Ex: Intonation profiles)

Hypokinetic means

Less motion

Hypokinetic Dysarthria is caused by a reduction of ________________ in the ___________________.

A reduction of dopamine in the basal ganglia.

Hypokinetic dysarthria: Causes (7)

The most common cause is ________________

• Idiopathic Parkinsonism (most common)
• Stroke
• Neuroleptic-induced Parkinsonism

• Punch Drunk Encephalopathy/CTE

• Infection (Postencephalitic Parkinsonism)

• TBI

• Cerebral anoxia

• Toxic metal poisoning

Parkinsonisms are seen in patients with ____________________ dysarthria and is due to reduction of _________________ to the ________________

Hypokinetic, dopamine, Basal Ganglia

Hypokinetic Dysarthria: Speech Characteristics (5)

________________________ is the only distinctive feature of this dysarthria.

• Bradykinesia
• Harsh or breathy phonation (voice)
• Imprecise consonants (artic)
• Abnormal prosody (prosody)
• Rapid rate of speech (in some patients - only distinctive feature of this dysarthria)

Hypokinetic Dysarthria: Palilalia (Unusual disfluency)

Compulsive rapid repetition of words or phrases (I like like like like that bag)

Hypokinetic dysarthria: Bradykinesia is the ________________.

Reduction in the range and speed of speech movements

Hypokinetic dysarthria: Repeated phonemes are _____________

Repetitions that usually take place at the beginning of an utterance or after a pause

Hypokinetic dysarthria: Treatment concentrates on _________, ___________, and __________

• Improving articulatory precision (Articulation)

• Increasing phonatory effort (phonation)

• Promoting more natural prosody (Prosody)

Hypokinetic Dysarthria: Treatment Options (4)

Most commonly used treatment is _____________

• Drug-based or Pharmacologic (most commonly used)
• Surgical

• Ablative or Deep brain stimulation

• Stem-Cell Implantation

• Behavioral (Delayed auditory feedback)

Hyperkinetic means

Too much movement

Hyperkinetic Dysarthria is caused by damage to the

Basal Ganglia

Hyperkinetic Dysarthria is caused by hyperkinetic movement disorders such as (6)

• Chorea
• Huntington's disease
• Dystonia
• Tic disorders
• Myoclonus
• Essential tremors

Chorea is a cause of __________________ dysarthria

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What is chorea?

Hyperkinetic dysarthria

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Movement disorder that causes unpredictable dance-like movements

Huntington's disease is a cause of _________________________ dysarthria.

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What is HD? Movements it causes?

Hyperkinetic

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Progressive disorder due to degeneration in BG that causes rapid dancelike movements

Myoclonus is a cause of ___________________ dysarthria.

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What is myoclonus?

Hyperkinetic

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Brief involuntary muscle contractions/ muscle jerks

Essential tremor is a cause of __________________ dysarthria.

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What are essential tremors?

Hyperkinetic

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Occurs during voluntary movement. Absent at rest.

Dystonia is a cause of ______________ dysarthria.

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What is dystonia?

Hyperkinetic

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movement disorder that causes involuntary, prolonged contractions

Hyperkinetic dysarthria:
Four types of dystonias and their definitions

• Focal
- only one part of body
• Segmental
- 2 or more body parts
• Generalized
- all 4 limbs
• Hemidystonia
- 2 or more body parts on same side of body

Tic disorders are a cause of ___________ dysarthria

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What is a tic disorder?

Hyperkinetic

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Rapid movement that is performed often due to __compulsive__ desire (unlike myoclonic contractions)

Motor tics vs Vocal tics (name 2 each)

Motor tics: eye blinks, hand gestures, shrugs, twitches

Vocal tics: palilalia (repetitions of one word), coprolalia (inappropriate words), grunts, barking

For _____________dysarthria, speech characteristics vary depending on the movement disorder

Hyperkinetic

Hyperkinetic Dysarthria: Speech Characteristics (4)

• Involuntary movements
• unexpected inhalations and exhalation
• irregular articulatory breakdowns
• abnormal prosody

Hyperkinetic Dysarthria: Extra Assessment Task

Observation of associated involuntary movements

Hyperkinetic Dysarthria: Treatment Options (3)

What is the most successfully used treatment?

• Pharmacologic (most commonly used)
- Botox injections
• Deep brain stimulation
• Behavioral

BG Damage: Huntington's disease is a cause of _____________ dysarthria while Parkinson's disease is a cause of _______________ dysarthria (Think of movements)

hyperkinetic, hypokinetic

Mixed Dysarthria

There is brain damage in two or more parts of the motor system

ALS is a cause of _____________dysarthria and ____________ dysarthria

Mixed and Spastic