April 11 Notes

Disorders of Amount of Movement

Disorders of Amount of Movement

Movement disorders related to the basal ganglia

Movement disorders related to the basal ganglia

Hypokinesia and hyperkinesia

Hypokinesia

Decreased/lack of movement without weakness or spasticity

Hyperkinesia

Excess/Abnormal movements

Hypokinesia disorders

akinesia, bradykinesia, muscle rigidity

Hyperkinesia disorders

tremors, dystonia, chorea and tics

Hyperkinetic Dysarthria

• Basal ganglia damage

• Perceptual features vary based on types of movements and degree of movements interacting with speech

  • Respiration

    • Sudden, forced inspiration or expiration

  • Phonation

    • Harsh voice quality

    • Strained-strangled voice quality

    • Transient breathiness

    • Voice tremor

  • Articulation

    • Imprecise articulation

  • Prosody

    • Excess and equal stress

What type of damage results in hyperkinetic dysarthria?

basal ganglia

Why do perceptual features in hyperkinetic dysarthria vary?

based on types of movements and degree of movements interacting with speech

Hyperkinetic dysarthria respiration features

sudden, forced inspiration or expiration

Hyperkinetic dysarthria phonation features

harsh voice quality, strained-strangled voice quality, transient breathiness and voice tremor

Hyperkinetic dysarthria articulation features

imprecision

Hyperkinetic dysarthria prosody features

excess and equal stress

Possible Principles and Features of Treatment for Dysarthria

• Considers any and all relevant subsystems of speech

• Considering differences in prognosis for specific conditions

• Restorative treatments (if appropriate)

• Compensatory strategies

  • Exploring multimodal communication/AAC

  • Conversational strategies

(CHECK YOUR WORD DISCUSSION DOCUMENT AND ADD THAT STUFF TO THIS SET)

What is the difference between disorders of speech (like apraxia of speech and dysarthria) and disorders of language (like aphasia)?

i completely zoned out but you can figure it out

acquired apraxia of speech

• NOT a type of dysarthria

• Damage typically occurs in the premotor cortex

• Speech errors are irregular

• Perceptual characteristics include:

  • Consonant and vowel distortions

  • Distorted substitution of phonemes

  • Slowed rate

  • Unusual stress patterns

What is NOT a type of dysarthria?

acquired apraxia of speech

Acquired apraxia of speech damage typically occurs in the ___

premotor cortex

In acquired apraxia of speech, speech errors are ___

irregular

Acquired apraxia of speech perceptual characteristics include

• Consonant and vowel distortions

• Distorted substitution of phonemes

• Slowed rate

• Unusual stress patterns

Possible Principles and Features of Treatment for Acquired Apraxia of Speech

• Intensive speech therapy to optimize motor learning

• Compensatory strategies

  • Exploring multimodal communication/AAC

  • Conversational strategies

• Potential for therapies that build on more intact functions like Melodic Intonation Therapy

  • language vs. speech question

Other Speech Disorders

• Neurological underpinnings of fluency disorders

  • Developmental stuttering

    • Not damage, but structural and functional differences present

    • Findings suggest that for people who stutter, differences include (shown):

      • Increased brain activity during speech in the right hemisphere

      • Reduced auditory activations

• Neurogenic stuttering

Language: What is it really?

• Language is:

  • A set of arbitrary symbols

  • Agreed upon by a community or society

  • Which can be combined to communicate an infinite number of concepts between community members

• Language is also about knowing how to put strings of sounds, symbols, or handshapes together into phrases, sentences and narratives, to express our thoughts and beliefs, opinions and preferences

Aphasia

• Acquired neurogenic language disorders

• Varying degrees of difficulty across:

  • Language expression, comprehension, and naming

  • Different modalities

• Most commonly associated with strokes

Aphasia

• Acquired neurogenic language disorder

• Varying degrees of difficulty across:

  • Language expression, comprehension, and naming

  • Different modalities

• Most commonly associated with strokes

____ is an acquired neurogenic language disorder

aphasia

In aphasia, there are varying degrees of difficulty across

Language expression, comprehension, naming and different modalities

Types of Aphasia

Global, Mixed Transcortical, Broca’s, Transcortical Motor, Wernicke’s, Transcortical Sensory, Conduction and Anomic

Aphasia Classification

Broca’s-like Aphasia

• Damage to anterior areas of the left frontal lobe

• Language production is typically telegraphic, agrammatic, and effortful

• Comprehension is relatively intact

• Produces paraphasia

• Repetition is affected due to overall expressive difficulties

Broca’s-like Aphasia is caused by damage to which areas?

anterior areas of the left frontal lobe

What is language production like in Broca’s-like Aphasia?

typically telegraphic, agrammatic, and effortful

What is comprehension in Broca’s-like Aphasia like?

relatively intact

What does Broca’s-like aphasia produce?

paraphasias

Repetition in Broca’s-like Aphasia

affected due to overall expressive difficulties

Wernicke’s-like Aphasia

• Damage to the left posterior temporal lobe

• Language production is typically grammatically and syntactically correct, but may be defined as “lacking meaning” (jargon)

• Comprehension is impaired

• Presence of paraphasias and neologisms

• Repetition is affected due to comprehension difficulties

Wernicke’s-like Aphasia is caused by damage to these areas

left posterior temporal lobe

Language production in Wernicke’s-like Aphasia

typically grammatically and syntactically correct, but may be defined as “lacking meaning” (jargon)

Comprehension in Wernicke’s-like Aphasia

impaired

These are present in Wernicke’s-like Aphasia

paraphasias and neologisms

Repetition in Wernicke’s-like Aphasia

affected due to comprehension difficulties

A note on paraphasias

not a surprising phenomenon when you consider the language activation process in the brain

Anomic Aphasia

Mostly fluent, somewhat hard to categorize. Predominant difficulty in word-finding/naming

Fluency in anomic aphasia

mostly fluent, somewhat hard to categorize

Transcortical Forms of Aphasia

• When repetition is fairly preserved

• Transcortical motor (more expressive and Broca’s-like)

  • Damage is around Broca’s area, but not the area itself

• Transcortical Sensory (more receptive and Wernicke’s-like)

  • Damage is around Wernicke’s area, but not the area itself

• Mixed Transcortical

  • Relatively rare

Global Aphasia

• expressive and receptive difficulties

• most severe form of aphasia

• may produce very few words

  • what is present is often paraphasias and/or verbal stereotypes

Neural Substrate of Language Recovery Following Stroke

• Natural recovery of language:

  • Activation of brain areas immediately surrounding the damaged brain

  • Increased activation in undamaged speech and language association areas in the language dominant hemisphere

  • Activation of homologous areas in the non-dominant hemisphere

• Varying levels of recoveryHa

Harnessing the ability of the brain to change

• attempting to capitalize on neuroplasticity

• Requires:

  • repetitive training of the system or behavior being targeted

  • challenging tasks

  • neural system or behavior in which change is desired must be engaged in training

  • repetitive engagement of brain networks

Neurogenic Cognitive-Communicative Disorders

visual processing, processing speed, working memory, attention, auditory processing, long term memory, logic and reasons

Dementia

• progressive disorder with multiple subtypes

• memory and at least one other cognitive function must be impaired

• language difficulties are often semantic in nature

Types of dementia

Alzheimer’s, Vascular, Lowy body, Frontotemporal

Other, including Huntington’s, Mixed dementia: Dementia from more than one cause

Frontotemporal Dementia (FTD)

• Progressive nerve cell loss specifically in the frontal and temporal lobes

• Typically diagnosed earlier than Alzheimer’s

• Includes multiple subtypes:

  • Behavioral variant frontotemporal dementia (bv FTD)

  • Primary progressive aphasia

  • FTD that mainly affects movement

Traumatic Brain Injury

• Not strokes

  • strokes and TBIs are both acquired brain injuries

  • However, strokes are not traumatic (i.e., caused by an external force)

• Typically more diffuse, unless it’s a penetrating head injury

Primary Progressive Aphasia

• a type of frontotemporal dementia

• a very unique dementia

• doesn’t fit in neatly to our classification of aphasia

• main concern is language, rather than cognition

Traumatic Brain Injury difficulties and impacts

• difficulty is less likely to impact language directly

• More likely to impact:

  • attention

  • memory

  • social communication

  • executive functioning

TBI Physical Symptoms

• Headaches

• Neck pain

• Dizziness

• Easily fatigued

• Numbness or tingling

TBI Sensory symptoms

• Sensitivity to light

• Sensitivity to sound

• Blurred or double vision

• Lost sense of taste or smell

• Ringing in ears (tinnitus)

TBI cognitive symptoms

• memory problems

• difficulty concentrating

• difficulty making decisions

• difficulty finding words

• difficulty sequencing info

TBI emotional symptoms

• easily agitated

• mood swings

• persistent anxiety

• feelings of shame or guilt

• feeling inept or worthless

behavioral symptoms

• impulsive behavior

• verbal outbursts

• physical outbursts

• getting lost easily

• changed sleep patterns

TBI Symptoms

• Physical: headaches, neck pain, dizziness, easily fatigued, numbness and/or tingling

• Sensory: sensitivity to light, sensitivity to sound, blurred or double vision, lost sense of taste or smell, ringing in ears (tinnitus)

• Cognitive: memory problems, difficulty concentrating, difficulty making decisions, difficulty finding words, difficulty sequencing info

• Emotional: easily agitated, mood swings, persistent anxiety, feelings of shame or guilt, feeling inept or worthless

• Behavioral: impulsive behavior, verbal outbursts, physical outbursts, getting lost easily, changed sleep patterns

Right Hemisphere Language Deficits

• Include communication difficulties, attention deficits, and cognitive effects

  • Most interestingly, left neglect

• Right hemisphere communication deficits may include, but are not limited to:

  • difficulty processing emotion

  • impaired prosodic abilities

  • disrupted content and organization of connected speech

  • impaired comprehension of connected speech

  • difficulty with abstract language

Left neglect is a ___ deficit

right hemisphere

Right hemisphere language deficits include

communication difficulties, attention deficits and cognitive effects

Neuroscience of Autism Spectrum Disorder

• findings are mixed and complex, but some differences in autistic individuals/people with ASD include (Ha et al. 2015):

  • increased gray matter in frontal and temporal lobes

  • Differences in the cerebellum and limbic system

  • Differences in activation for executive functioning (shown)

Swallowing (deglutition)

• Complex activity incorporating motor, sensory, and cognitive skills

• Includes multiple phases based around movement of a bolus

  • oral (buccal) preparatory phase

  • oral phase

  • pharyngeal phase

  • esophageal phase

Oral (buccal)

the voluntary part of swallowing, the food is moistened with saliva and chewed, food bolus is formed and the tongue pushes it to the back of the throat (the pharynx). This process is under neural control of several areas of the cerebral cortex including the motor cortex

Pharyngeal phase

Starts with the stimulation of tactile receptors in the oropharynx by the food bolus. The swallow reflex is initiated and is under involuntary neuromuscular control. The following actions are taken to ensure the passage of food or drink into the esophagus:

• The tongue blocks the oral cavity to prevent going back to the mouth

• The soft palate blocks entry to the nasal cavity

• The vocal folds close to protect the airway to the lungs. The larynx is pulled up with the epiglottis flipping over covering the entry to the trachea. This is the most important step since entry of food or drink into the lungs may potentially be life threatening

• The upper esophageal sphincter opens to allow passage to the esophagus

Esophageal phase

Food bolus is propelled down the esophagus by peristalsis- a wave of muscular contraction that pushes the bolus ahead of it. The larynx moves down back to original position

Swallowing Disorders and the Cranial nerves

• Includes cranial nerves more likely to be associated with:

  • Oral phase of swallowing

  • Pharyngeal phase of swallowing

• Damage to specific cranial nerves or widespread damage

Cortical Areas Associated with Swallowing Disorders

• Especially relevant to strokes

• Primary motor cortex

  • difficulty swallowing in correct and precise manner

  • potential one-sided paralysis or weakness

• Primary somatosensory cortex, along with temporal areas

  • Damage can be associated with oropharyngeal residue

  • Potential one-sided decrease in sensation

• Insula

  • Hub for swallowing function

• Basal ganglia

  • related to strokes or degenerative conditions

  • affecting the efficiency of swallowing

  • Parkinson’s Swallowing

• Thalamus

  • Associated with difficulties in sensory-motor integration

  • Affecting hyoid/laryngeal movement; how much someone can consume at a time

Cognition and Swallowing

• Difficulties with memory, attention, executive functioning, etc. that impact swallowing

• Includes issues like:

  • Distractibility

  • Forgetting to eat/drink

  • Forgetting that one is in the process of eating/drinking

• Dementia and Swallowing

Neuromuscular Electrical Stimulation (NMES)

• Electrical stimulation of the affected peripheral nerve

• Provided by trained professionals

• Variable effects and variable recommendations

hearing and the Nervous system

• Involves one critical cranial nerve and the remainder of the central auditory pathway

• Series of brainstem structures interconnected via nerve pathways

Causes: Brain Injuries

• potential for a variety of hearing and/or balance

• May not be identified initially

• Of a particular concern for blast injuries

Blast injuries can lead to

hearing loss

Auditory Processing Disorders

• Normal pure-tone hearing, difficulty recognizing patterns of complex sounds or speech in noise

• Can be developmental or acquired

• Several viewpoints exist on types and associations with language disorders

Cortical Deafness

• Also referred to as cerebral deafness

• Extremely rare (~12 reported cases_

• Inability to process speech and nonspeech sounds in the presence of normal or near-normal objective peripheral auditory function up to the level of the brainstem

• Typically associated with bilateral temporal lobe damage