M4-M5 Motor Speech Disorders Exam 2

purpose of motor speech examination

Description- help us characterize the features of speech and structures and functions related to speech→ description of speech, language, or voice

• Establishing Diagnostic Possibilities- ask questions ex. is the problem neurogenic? etc.

• Establishing a Diagnosis- single or possibilities of diagnosis from most to least likely

• Establishing Implications for Localization and Disease

Diagnosis- other implications, certain characteristics in our motor speech examination that are compatible

• Specifying Severity-

1. can it be matched against patient’s complaints

2. influences partiosis and manages the disease and decision making

3. part of baseline data against which future changes can be compared

guidelines for examination

history-

oral mechanism exam

salient features

confirmatory signs

interpretation of findings

primary salient features of MSDs

muscle strength

speed of movement

range of movement

steadiness of movement

muscle tone

movement accuracy

muscle strength (primary salietn features of MSDs)

muscles have enough strength to perform their normal functions plus a reserve of excess strength→ allows rapid muscle contractions to happen over time without excessive fatigue

weak muscle- cannot contract to that level for even for brief periods of time

May affect all 3 major speech valves (laryngeal, velopharyngeal, and articulatory)

• Weakness most apparent in LMN lesions

speed of movement (primary salient features of MSDs)

typically routed and discrete→ phasic movement

can see single contractions or repetitive contractions

Too fast is rare (hypokinetic)→ associated with decreased range of motion

▪ Excessive rate is usually associated with decreased range

of motion

▪ Reduced speed is most common→ strongly affects prosody

range of motion (primary salient feataures of MSDs)

distance traveled by speech structures is precise for single and repetitive movements

if variation in range of repetitve movements→ normal but usually very small

More likely to be reduced than increased

• May be abnormally variable across range of motion

• Effects noted in prosody

steadiness of movement (primary salient features of MSDs)

Physiological Tremor

• Present in all normal people

• Not visible

• Can occur in all voluntary muscle groups

steadiness of movement pt 2 (primary salietn features of MSDs)

Tremor

• Most common involuntary movement

• Repetitive, involuntary movement, relatively rhythmic

• Commonly affects phonation

b. Involuntary, random, unpredictable movements

• Dystonia

• Dyskinesia

• Athetosis

• Chorea

muscle tone (primary salient features of MSDs)

May be reduced or excessive, may fluctuate

• Abnormal tone: Flaccid dysarthria

• Increased tone – spastic, hypokinetic

• Variable tone – hyperkinetic

movement accuracy (primary salietn features of MSDs)

Accuracy impairment may result from several causes

• Impairment in force and range

• Impairment in movement timing

• Articulation and prosody most affected

comfirmatory signs

Signs of lesion location or underlying neuropathophysiology

• Signs other than the deviant speech characteristics and features of speech muscles during speech that can help confirm a speech diagnosis

• Not diagnostic of a motor speech disorder

• Can be found in speech or nonspeech muscles

examples of confirmatory signs within the speech system

Atrophy

• Emotional lability

• Reduced reflexes

• Presence of pathological

reflexes

• Strength of cough

examples of confirmatory signs in nonspeech systems

Gait disturbances

• Abnormal muscle stretch reflexes

• Limb atrophy and fasciculations

• Loss of automatic movements

• Difficulty initiating limb

movements

• Abnormalities of strength, speed, accuracy, tone, steadiness and ROM at rest or during nonspeech tasks

history (motor speech examination)

History

• Introduction and goal setting

• Basic data

• Onset & course

• Associated deficits→ physical, cognitive, language

• Patient’s perception of the deficit

• Consequences of the deficit

• Management

• Awareness of medical diagnosis and prognosis

oral mech examination during non-speech activity

Face at Rest

• Face During Sustained Postures

• Face During Movement

• Jaw at Rest

• Tongue at Rest

• Tongue During Sustained Posture→ protrusion or detraction

• Tongue During Movement→ lateralization, etc,

oral mech examination during non-speech activity pt 2

Velopharynx at Rest

• Velopharynx During Movement

• Larynx

• Respiration

• Reflexes

• Volitional vs. Automatic Non-

Speech Movements

V trigeminal nerve (cranial nerve/oral mech exam)

Look for weakness, asymmetry, and incoordination of the muscles controlling jaw movement

ask patient to move jaw side to side

looking at rest, and if they can protrude or retract the jaw

• Evaluate Sequential Motion Rates (SMRs)→ papapa, tatata, kakaka, and pata ka etc.

• Listen for pace and rate of production→ ex. rate normal but gets worse over time and uneven or inconsistent loudness or pitch

• Articulatory Precision

• Reduced Intensity

• Disintegration of Rate or Production

• Uneven Loudness or Pitch

• Sensory Testing of Facial Area

VII facial nerve (cranial nerve/ oral mech exam)

Evaluate Muscles Controlling Lip and Facial Movements

• Use a variety of Non-speech Tasks→ ex. protruding and retracting lips, looking at lip seal by having patient blow air into their cheeks, and facial movements such as opening their eyes wide, creating large wide , scrunching their face up

• Repeat SMRs with bite block→ restrict contribution of jaw movement to look at lip movement in isolation

IX glossopharyngeal, X vagus , XI spinal accessory (cranial nerve/ oral mech exam)

As They Apply To Speech:

• Integrity Of Pharyngeal, Palatal and Laryngeal Musculature

• Look for Evidence of Dysphagia and Drooling

• Examine Palatal Musculature

• At Rest and During Forceful Phonation of /a/

• Paying Attention to Uvula, Asymmetry of Palatal Movements, and Fatigue on Extended Phonation

• Evaluate Resonance Features

• With and Without Nasal Clip Mirror

• Test For Nasal Air Flow

XII hypoglossasl (cranial nerve/ oral mech exam)

tongue at rest

Look for Tongue Atrophy, Fasciculations or Other Abnormal

Involuntary Movements or abnormal looking tongue

• Check Range, Speed, Strength, and Symmetry of Nonspeech Tongue Movements

• Evaluate Integrity of Tongue Movements for SMRs using /t - t - t/ for tongue tip and /k - k - k/ for tongue base - both with and without bite block

• Alternating Motion Rates (AMRs) using /p - t - k)

• As with other speech testing look for:

• Blurring of Articulation, Pace or Rate Abnormalities,

Unevenness in Loudness or Pitch

oral mech exam (respiratory, reflexes, oral programming)

Observation of:

• Posture

• Abdomen

• Thoracic vs Clavicular Breathing

• Evaluate Breathing Rate

• Evaluate Regularity Of Breathing

assess reflexes→ gag, cough, jaw jerk

assess nonspeech oral programming ability→ whether a person motor plan for non-speech movments, ex. blowing, kissing, smiling

series of motor speech evaluations

perceptual judgements

acoustical measures

physiological measures

perceptual analysis of speech

Gather Speech Samples (audio/video) or live or in person for Analysis

• Vowel Prolongation

• Alternating Motion Rates (AMR) and Sequential Motion Rates (SMR)→

• Standard Reading passage

• Narrative about Picture Scene

• Conversation Sample

• Stress Test (counting for 2-4 min)

• Repeat Complex Multisyllabic Words and Sentences

• Repeat Days of Week, Months of Year, CVC syllables with identical initial and final consonants, sing a familiar tune

• Identify and Rate Deviant Speech Characteristics

acoustical measures

Magnitude and timing of formant movement, intensity, variations during speech and sustained vowels (spectrogram)

• AMR/Diadochokinetic Rate (repetitions/seconds)

• Average rate

• Variation of rate

• Intensity variations during repetitions

• Voice Onset Time or VOT (generally measured from the voiceless stop to onset of vowel)

• Pitch (several instruments which measure pitch and vocal quality)

• Measures of nasal resonance (Nasometer)

spectrograms (motor speech evaluation)

look at many different aspects of motor speech, magnitude and timing of format movement, intensity or loudness, variations during speech, and sustained vowels

physiological measures

Articulatory Accuracy

▪ Strength

▪ Range of movement

▪ Electropalatography – technique used to monitor contacts between the tongue and hard palate during articulation

▪ Spectrograms

▪ EMMA - Electro-Magnetic

Midsagittal Articulometer

acoustic and physiologic measures

•               Perceptually based clinical assessment will probably always be most important component of clinical diagnosis

•               As expense of instrumentation decreases, many acoustic and physiological measures that have been used extensively in research have potential value for clinical diagnosis (and management)

assessment of intelligibility, comprehensibility, and efficiency

intelligibility- degree to which the listener understand the auditory signals

comprehensibility- degree to which the listener understands the auditory signal

\Quantify intelligibility using one of the following scales:

•               Assessment of Intelligibility of Dysarthric Speech (AIDS)

•               Sentence Intelligibility Test (portions of AIDS)

•               Frenchay Dysarthria Assessment (FDA-2)

•               Word Intelligibility Test

•               Munich Intelligibility Profile

•               Tikofsky Test of Intelligibility

rating scales

these look at the patient reported outcome measures→ how the MSD affecting their life or what consequences does the MSD have

 Functional Communication Measures

•                The Motor Speech Scale

•    Communication Effectiveness

•                The Communicative Effectiveness Survey (CES)

•    Psychosocial Impact

•                Dysarthria Impact Profile

•                Living With Dysarthria

•                Communicative Participation Item Bank

issues and decisions

Focus: Communication rather than Speech:

1. Places the focus where it should be – on effective transmission of thoughts and ideas

2. Broadens the goals of management

3. Broadens the criteria by which effectiveness of treatment is judged. Implicitly recognizes that the degree of speech abnormality often does not share a 1:1 relationship with the degree to which affected people are disabled

overarching goal

Maximize the Effectiveness, Efficiency, or Naturalness of Communication.”

1. Restore lost function

2. Promote the use of residual function (compensation)

3. Reduce the needs for lost function (adjustment)

factors influencing decision making

Medical prognosis

2. Impairment, limitations, and restrictions

3. Environment and communication partners

4. Motivation and needs

5. Associated problems

6. Healthcare system

treatment duration and intensity

treatment focus: begin with the speech component that is likely to have the greatest functional benefit or will provide the greatest support for improvement of other aspects of speech

Duration/Intensity

Staging of Management

*Caution about the notion of “plateau”

approaches to management

Medical Intervention

• Pharmacologic

• Surgical

• Prosthetic Management

• Behavior Management

• Speech-orientated approaches

• Communication-oriented approaches

• Augmentative and Alternative Communication

• Counseling and Support

foundations for behavioral management

1. Neuroplasticity: the organization of the nervous system is not fixed

2. Neural adaptation occurs with muscle use

3. The nervous system can recover and reorganize after injury

4. Motor reorganization after injury requires use

Behavioral management can reduce speech impairment, improve

physiologic capacity for speech, or improve speech in other ways

(see Table 16.2)

principles of motor learning

relevant to structure of speech-oriented

treatment

1. Improving speech requires speaking

2. Drill is essential

3. Instruction and self-learning each have value

4. External feedback and its conditions are important

5. Specificity of training and salience are important

6. Different practice conditions have different effects

7. Efforts to increase strength should follow some rules for strength

training

8. A trade-off occurs between speed and accuracy

9. Time for consolidation of motor skills is important

10. Therapy is a cognitive-motor process

treatment considerations

Timing

• Delaying treatment has not been demonstrated to have any effects

on eventual outcomes

• Likely does have effect on patient and family

• Candidacy –

• Mild – generally recovers spontaneously

• Severe – minimal recovery

• Some refuse / lack of motivation

treatment planning

Use assessment results as a guideline

• Discuss treatment plan with client and family (collaborative)

• Set long- and short-term goals

• Consider:

• Task design

• Psycholinguistic nature of stimuli

• Type of material

• Level of facilitation

• Duration and intensity of therapy

treatment planning pt 2

what a person

can do can do

cannot do → close ← needs to do

does do→ gap ← wants to do

treatment hierarchies

Simple → Complex

• Less Demanding → More Demanding

• More Support → Less Support

• Cuing hierarchy

• Make the hierarchy personal for the patient

goals for treatment

Identify Strengths and Weaknesses

• Use the strengths to compensate for the weaknesses

• Help increase effectiveness of communicator despite deficits

• Generalization

• Recovery must not be limited to the treatment room

• Does not “just happen” must be Planned, Worked Towards and

Tested For

flaccid dysarthria : weakness

• Injury to one or more cranial or spinal nerves

• Lesion to the Final Common Pathway / Lower Motor Neurons

• Between Brain Stem or Spinal Cord and the Muscles of

Speech

• May be manifest in respiratory, phonatory, resonatory,

and /or articulatory components of speech

flaccid dysarthria: etiology

Any Process that Damages the Motor Unit:

• Congenital Demyelinating Diseases

• Infectious /Inflammatory Diseases

• Degenerative Conditions

• Metabolic Disorders

• Neoplasm

• Trauma

• Vascular Disease

flaccid dysarthria: etiology terminology

Neuropathy

• Neuritis

• Peripheral Neuropathy

• Cranial Neuropathies

• Mononeuropathy

• Polyneuropathy

flaccid dysarthria: etiology terminology pt. 2

Radiculopathy

• Plexopathy

• Myelopathy

• Myelitis

• Myopathy

• Myositis

flaccid dysarthria: disorder possibilities

Single Muscle Group (e.g. tongue) or Speech Subsystem (e.g.

phonatory)

• Multiple Muscle Groups or Speech Subsystems

• Considered Problem of EXECUTION – Not planning or

programming

flaccid dysarthria: resulting conditions

Weakness – observed during single (phasic) contractions, repetitive

contractions, and /or during sustained (tonic) contractions.

• Hypotonia – Floppiness – reduced resistance to passive movement

• Reduced Reflexes

• Atrophy – loss of bulk- muscle shrinks, results in significant

weakness

• Fasciculations – Visible twitches in resting muscles

• Spontaneous motor unit discharge in response to nerve

degeneration

• Not usually present in muscle disease

flaccid dysarthria: primary effect on speech

Speed of movement

• Range of movement

• Accuracy of movement

flaccid dysarthria: primary speech characteristics

• Breathy Voice

• Short Phrases

• Imprecise Articulation

• Increased Nasal Resonance

flacid dysarthria: V trigeminal nerve

• Lesions - generally not isolated to only CNV

# of localized lesion types

• Etiologies: Aneurysm, infection, AV Malformation, tumors, surgical

trauma, non-surgical trauma

• Trigeminal Neuralgia:

• Sudden, brief periods of unilateral pain

• Often idiopathic

• May reflect compression or irritation of the trigeminal sensory roots

Non Speech Oral Mechanism:

• Jaw deviation on opening (unilateral) or hang open or be unable to

close (bilateral)

• Pt. complaints of decreased sensation, chewing difficulty, drooling

Speech disturbance apparent:

• Oral Reading

• Conversation

• Alternate motion rates (AMR)

• Decreased sensation results in imprecise articulation

• Manual assist with jaw elevation or restriction during speech

flaccid dysarthria: VII facial

• Motor & Sensory – role in speech is in motor component only

• Can be damaged in isolation or in combination with other CNs

• Lesions

• Unilateral CN VII Lesion – most common

• Near the internal auditory meatus where VII and VIII exit brain

stem

• Etiologies:

• Infections, neoplasms, vascular lesions /trauma

• Bell’s Palsy: Isolated unilateral upper and lower facial nerve

weakness

flaccid dysarthria: VII facial (speech and non-speech)

• Non-Speech:

• Unilateral: At rest, affected side sags /hypotonia, drooling may

occur, asymmetry, fasciculations and atrophy

• Bilateral: less common, mouth is lax, poor retraction,

fasciculations, poor sensation during speech

• Speech – most revealing evidence of facial nerve damage

• Cheek flutter

• Visual more telling then auditory during speech production

• Compensatory techniques to support weak side

flaccid dysathria: IX glossopharyngeal

Rarely damaged in isolation (CN X typicall y invol ved), May have lesion

and not be indicated – suggests CN X facilitates

• Non-speech: Assessed via gag reflex, difficulty clearing bolus

involved in dysphagia

• Speech: Unable to assess in speech due to the role of CN X

flaccid dysarthria: CN X vagus lesions

Intramedullary: damage to nerve within the brainstem

• Extramedullary: damage to trunk of nerve as it leaves

brainstem

• Extracranial: damage to nerve after it exits the skull

• Pharyngeal branch (M), internal laryngeal nerve (S) and recurrent

laryngeal nerve (S)

• Site, severity and lateralization determine the degree of

impairments

CN X vagus lesions (non-speech)

Unilateral

• Soft palate droops on side

of lesion

• Diminished gag reflex

• Bilateral

• Palate droops / minimal

movement

• Gag reflex probably absent

• Nasal regurgitation

CN X vagus lesions (speech)

Unilateral

• Little or no perceptual effect

• Breathy / Flutter

• Bilateral

• Hypernasality

• Reduced intensity

• Reduced MLU

• Reduced Voiced / Voiceless

distinction

X vagus physiological and acoustic measures

• Use of videofluoroscopy or nasoendoscopy

• Laryngoscopy essential to determine VF function

• Aerodynamic studies to determine air flow (nasal emission)

• Acoustic studies (pressure levels during consonant production)

** Strong relationship between velopharyngeal insufficiency and

hypernasality, nasal emission and weakened pressure consonants

XI accessory

Originates in the nucleus ambiguous: intermingles with CN

X to help innervate uvula, levator veli palatini, and

intrinsic laryngeal muscles

• Lesions and etiologies are comparable to CN X

• Effects shoulder elevation

• Generally, not directly related to speech

XII hypoglossla

Originates in the medulla

• Innervates all intrinsic and extrinsic muscles of the tongue

• Lesions generally result of surgery, often effect CN IX, X, & XI

• Nonspeech Mechanism

• Unilateral

• Atrophy and deviation to the weak side

• Inability to elevate tongue tip

• Inability to lateralize tongue

• Bilateral

• Exaggerated Unilateral effects

XII hypoglossla (speech mechanism)

Speech Mechanism

• Main characteristic unilateral & bilateral is articulatory imprecision

Unilateral

• Compensatory strategies result in non -perceptual influence

Bilateral

• Influence on all speech sounds

• Resonance – sometimes hyper and hypo nasal

• Most effective way to assess is AMRs

• Acoustic and Physiological measure demonstrate lingual weaknes

flaccid dysarthria: additional points

Spinal Nerve Lesions generally not responsible for Flaccid

Dysarthria

• May manifest as reduced or inconsistent respiratory support

for speech only

• May involve multiple Cranial Nerve Lesions

• Difficult to assess which lesions are contributing to speech

disorder - Generally referred to as Bulbar Palsy

• Progressive Weakness – With Use

• RAPID weakness - NMJ disease (Myasthenia Gravis

flaccid dysarthria : clusters of deviant speech dimensions

Phonatory Incompetence

• Breathy voice

• Audible Inspiration

• Short Phrases

2. Resonatory Incompetence

• Hypernasaity

• Nasal Emission

• Imprecise Consonant

• Short Phrases

Phonatory-Prosodic

Insufficiency

• Harsh Voice

• Monotone

• Monopitch