motor speech disorders

MSD

☆ disorders of speech production resulting from neurologic impairment affecting the motor programming OR neuromuscular execution of speech

MAD

☆ M - motor speech disorders

☆ A - apraxia of speech

☆ D - dysarthrias

cause of motor speech disorders

☆ CVA (leading cause)

☆ TBI

☆ brain tumors

☆ degenerative disorders

what is apraxia

☆ a speech disorder which results from an impairment in motor programming for speech (prior to execution of speech movements)

☆ planning

apraxia

☆ disorder of voluntary motor placement and sequencing

→ unrelated to muscle weakness, slowness, or paralysis

☆ limb apraxia 

→ difficulty with voluntary movements of limbs

→ reflexive movements are okay

☆ oral apraxia

→ difficulty with voluntary movements of the mouth

☆ apraxia of speech

→ affects the initiation and execution of movements for speech

→ core impairment in planning and/or programming of speech movement sequences

common characteristics of apraxia of speech

☆ inconsistent errors - multiple repetitions not the same 

☆ more errors as complexity of word(s) increase (thick/thicken/thickening)

☆ more errors on nonsense words, as compared to real words

☆ may be aware of errors and try to correct

☆ restarts and repeated attempts at producing a word or sound, frequent syllable repetition

☆ articulatory groping, sometimes with facial grimacing - groping/searching artic movements

☆ initiation of utterances especially problematic

what is dysarthria

☆ a speech disorder resulting from weakness, paralysis, or incoordination of the muscles of the speech mechanism (actual execution of speech movements)

☆ execution

dysarthria

☆ group of neuromuscular impairments

→ results from weakness, paralysis, or discoordination of the muscles 

→ may affect speed, range, direction, strength and/or timing of motor movement

→ may affect respiration, phonation, resonance, and/or articulation

→ if no other complications: intact with language skills (spoken comprehension; written language)

respiration

breath support, breath control, impact to loudness

phonation/voice

☆ quality - harsh/hoarse/breathy vocal quality

☆ loudness - too loud/too soft, monoloudness

☆ pitch - monotonous, too high, too low, too variable

articulation

☆ imprecise consonants

☆ imprecise vowels

☆ consistent errors across phonemic contexts and complexity of the utterance

resonance

☆ hypernasal/hyponasal

prosody

☆ rate - too fast/too slow, rushed uneven

☆ phrasing - too short, too long, impedes meaning

types of dysarthria

☆ spastic

☆ flaccid

☆ ataxic

☆ hypokinetic

☆ hyperkinetic

☆ mixed

spastic dysarthria

☆ too much tightness

☆ characterized by hypertonia (stiff and rigid muscles)

☆ commonly caused by strokes or degenerative disease affecting bilateral motor cortices or tracts of the brainstem

distinguishing characteristics of spastic dysarthria 

☆ phonation - “strained-strangled” voice quality 

☆ articulation - imprecise consonants

☆ prosody - slow rate, monopitch/monoloudness

flaccid dysarthria

☆ characterized by hypotonia (weak, soft, flabby, muscle tone)

☆ reduced oral movements, drooling, problems chewing and swallowing (CN damage)

☆ commonly caused by damage in CN or neuromuscular junction, impairing muscle contraction

☆ associated with bell’s palsy, myasthenia gravis

distinguishing characteristics of flaccid dysarthria

☆ hypernasality (too much air escaping)

☆ nasal emission

☆ low pitch, monopitch

☆ imprecise articulation

☆ continuous breathy voice

ataxic dysarthria

☆ lesion - cerebellum

→ cerebellum is important for motor control, including coordination, precision, and timing

☆ characterized by disrupted motor coordination and timing, usually accompanied by loss of muscle tone (hypotonia)

☆ slowed and awkward volitional movements (ataxia)

☆ sound/look “drunk”

distinguishing characteristics of ataxic dysarthria

☆ slow rate, “drunken quality”

☆ inconsistent consonant misarticulations

☆ excess, equal stress

☆ irregular articulatory breakdown

☆ irregular, excessive loudness variability

hypokinetic dysarthria

☆ characterized by hypokinesis (decreased movement)

☆ lesion in basal ganglia control circuit

☆ most often associated with Parkinson’s disease

distinguishing characteristics of hypokinetic dysarthria

☆ monopitch/monoloudness

☆ reduced stress

☆ imprecise articulation

☆ reduced loudness

☆ short rushes of speech

☆ rapid rate

hyperkinetic dysarthria

☆ characterized by hyperkinesis (excessive movements) in the form of involuntary tremors and tics

☆ lesion in basal ganglia control circuit

☆ excessive unwanted involuntary movements of speech and respiratory muscles result in uneven, jerky quality speech and imprecise articulation 

☆ association with huntington’s disorder

distinguishing characteristics of hyperkinetic dysarthria

☆ movements which are rapid, involuntary, random and without purpose

☆ speech and voice characteristics

→ prolonged intervals between phonemes and abnormal silent intervals

→ monopitch and monoloudness

→ imprecise consonants

→ distorted vowels

→ irregular articulatory breakdowns

mixed dysarthria

☆ caused by diffuse brain damage 

assessment FACE

☆ observe facial symmetry

→ weakness involving entire face? one side of face?

→ forehead moves symmetrically?

→ weakness involving just lower face (lips and cheeks)?

assessment JAW

☆ strength and range of motion

☆ ask the patient to keep their mouth closed. tug tightly on their chin in an attempt to open their mouth. a healthy individual should be able to keep it closed

☆ ask the patient to open their mouth. push lightly upwards on their chin in an attempt to close their mouth. a healthy individual should be able to keep it open. 

assessment LIPS

☆ pucker: asses lips range of motion

☆ smile: access lips range of motion and symmetry

☆ puff cheeks and hold air: assess lips strength and nasal emission

assessment TONGUE

☆ visualization: check for fasciculations, surface color, overall health, size

☆ assess symmetry and range of motion

☆ assess tongue strength. ask your patient to press their tongue into the left/right cheek and resist pressure

assessment PALATE

☆ visualization: check for color, symmetry, growths, fistula, cleft, arch height

☆ asses velum ROM/symmetry: evaluate symmetrically, nasality

assessment batteries

☆ apraxia - apraxia battery for adults-2nd edition

☆ dysarthria - frenchay dysarthria assessment-2nd edition

intervention

☆ early intervention - once pt is medically stable

☆ pharmacological - modify neurotransmitter function important for movement

☆ surgery - palatal/pharyngeal flap

☆ AAC

☆ intelligibility 

☆ rigid rate control

hypokinetic dysarthria treatments

☆ LSVT Loud

☆ SPEAK OUT!

☆ the LOUD Crowd

☆ lombard effect

LSVT Loud

☆ trains PD pt to use voice at more normal loudness level

☆ 4 weeks of individual clinical sessions (4x per week) plus daily homework and carryover exercises

☆ treatment protocol

→ ”ahhh” as loud as you can, pt pays attention to voice

→ short phrases, sentences, connected speech, then generalization to daily life

→ vary pitch: from low to high and from high to low

SPEAK OUT! and LOUD Crowd

☆ standardized speech therapy program

→ 12 individual treatment sessions (SPEAK OUT!) with ongoing weekly group sessions (the LOUD Crowd) for individuals with dysarthria due to Parkinson’s disease

→ SPEAK OUT! – speaking with intent

→ The LOUD Crowd –maintenance of treatment gains

SPEAK OUT!

☆ warm-up: produce connected vocalizations using nasal phoneme-initial words (“May, me, my, mo, moo”)

☆ vowel: sustain /a/ with good quality voice for maximum of 10 s

☆ glides: sustain /a/ and glide up the scale starting and ending with modal pitch

☆ numerical sequences: count aloud pausing after every three to five numbers

☆ reading: start with phrases and progress to paragraphs

☆ cognitive-linguistic exercises: structured activities to improve word retrieval and cognitive processing speed while focusing on intentional speech

the LOUD Crowd

☆ up to 2 LOUD Crowd sessions during Week 3 and 4 for SPEAK OUT!

☆ same as individual treatment but in a group setting

☆ emphasis on accountability, practice, and support

lombard effect

☆ implicit treatment

→ lombard effect refers to an increase in the intensity of an individual’s voice to adjust to increases in background noise

→ SpeechVive

→ plays multi-speaker babble noise in one ear

→ 3 – 5 dB increase in voice loudness

→ advantage of choosing an implicit treatment is that the patient does not have to be consciously aware of their volume