SLP 567 - Final

hypokinetic: site of lesion

damage to the basal ganglia control circuit

hyperkinetic: site of lesion

damage to the basal ganglia control circuit

hypokinetic: hallmark features

- reduced range/force of movement

- rigidity

- associated with PD

hyperkinetic: hallmark features

- involuntary and excessive movements at different levels of the speech mechanism

- associated with many different etiologies and syndromes

basal ganglia functions

- force, amplitude, duration of movements

- regulate muscle tone

- postural adjustments during skilled movements

- movement scaling (changing intensity)

- set switching

- adjust movement to environment

- assist in learning, preparation, and initiation of movements

hypokinetic: motor speech features

- rigid

- reduced

- slow motor output

hyperkinetic: motor speech features

- jerky

- inconsistent

- involuntary motor output

hypokinetic: possible basal ganglia mechanisms

globus pallidus over-inhibits excitatory drive from thalamus

hyperkinetic: possible basal ganglia mechanisms

excessive thalamocortical excitation and/or reduced inhibitory output from globus pallidus

hypokinetic: common etiologies

- neurodegeneratives diseases (PD)

- vascular disorders

- undetermined

- toxic-metabolic conditions

- trauma

hypokinetic: non-speech system confirmatory signs

- facial masking

- reduced range of motion

- tremor

- rigidity

- shuffling gait

- bradykinesia

- cognitive impairment (lack of self-awareness, memory deficits)

hypokinetic: patient complaints

- reduced loudness

- rapid rate (sometimes slow rate, but never natural)

- mumbling

- stuttering

- difficulty initiating speech

- stuff lips

hypokinetic: perceptual characteristics

- monopitch, monoloudness

- reduced loudness (decay)

- rapid rate of articulation

- short rushes of speech

- hoarse and/or breathy voice

- flast/blurred AMRs

- palilalia or dysfluency

- tremor

palilalia

involuntary rapidly repeating one's own speech

hypokinetic: neuromuscular features

- normal direction

- regular rhythm

- slow individual movement rate

- fast repetitive movement rate

- reduced force

- excessive tone

hyperkinetic: common etiologies

- degenerative diseases (Huntington's)

- vascular disorders

- undetermined

- toxic-metabolic conditions

- trauma

hyperkinetic: non-speech system confirmatory signs

- involuntary movements

- tics

- myoclonus

- tremor

- grimacing

- chorea

- sensory tricks

myoclonus

single muscle tremor or twitch

chorea

uncontrolled gross motor movements

hyperkinetic: sensory tricks

can have a temporary relief of symptoms because of response to certain cues

hyperkinetic: patient complaints

- effortful speech

- involuntary orofacial movements

- chewing/swallowing problems

hyperkinetic: perceptual characteristics

- sudden, forced inspiration-expiration

- voice stoppages in continuous speech

- transient breathiness

- strained-harsh voice quality

- excess loudness variations

- hypernasality

- slow/irregular AMRs

- variable rate

- brief aphonia (spasmodic dysphonia)

hyperkinetic: neuromuscular features

- irregular direction

- irregular rhythm

- variable rate, sometimes with pauses

- variable force

- variable tone

unilateral upper motor neuron dysarthria (UUMN)

- usually mild and/or temporary

- can be difficult to identify

- variability across patient presentations

- often subtle and/or transient symptoms

UUMN: co-morbidities

- aphasia

- apraxia of speech

- other cog/ling deficits

UUMN: etiologies

- vascular

- tumor

- trauma

- degenerative

UUMN: non-speech system confirmatory signs

- unilateral central facial weakness

- lingual weakness (no atrophy or fasciculations)

- hemiparesis/hemiplegia

UUMN: perceptual characteristics

- weakness (face, tongue, larynx, velopharynx, jaw, respiration)

- hypertonicity (spasticity)

- incoordination (ataxia)

mixed dysarthria

- common (~ 25% of all motor speech disorders)

- results from many conditions or damage affecting more than one motor system component

mixed: etiologies

- degenerative diseases

- TBI

- multiple strokes, stroke + PD

- ALS

what type of mixed dysarthria is most prevalent in ALS?

flaccid-spastic

what type of mixed dysarthria is most prevalent in MS?

ataxic-spastic

what type of mixed dysarthrias are most prevalent in PSP?

- ataxic-hypokinetic

- spastic-hypokinetic

what type of mixed dysarthrias are most prevalent in multiple system atrophy (MSA)?

- ataxic-spastic

- ataxic-hypo/hyperkinetic

- spastic-hypokinetic

what type of mixed dysarthria is most prevalent in PSP?

ataxic-hyperkinetic

apraxia of speech: definition

impaired capacity to plan or program sensorimotor commands necessary for directing movements

apraxia of speech: lesion locations

- motor speech programmer network

- left fronto-parietal region and related subcortical structures

because of substantial overlap with language processing/planning regions, apraxia of speech frequently co-occurs with...

aphasia

apraxia of speech: etiologies

- neurodegenerative diseases

- vascular disorders

- tumor, trauma

apraxia of speech: non-speech system confirmatory signs

- right sided weakness or spasticity

- aphasia

- bilateral limb apraxia or bilateral non-verbal oral apraxia

- relatively intact function for non-speech tasks

apraxia of speech: "big four"

- effortful, trial and error, groping articulatory movements and attempted at self-correction

- persistent dysprosody without prolonged periods of normal rhythm, stress, or intonation

- articulatory inconsistently on repeated productions of the same utterance

- obvious difficulty initiating utterances

apraxia of speech: rate and prosody

- slow rate for multisyllabic utterances

- restricted intonational contours

- excess and equal stress

- inappropriate pauses or prolonged phonemes

apraxia of speech: fluency

- false starts and restarts

- effortful trial and error groping

- difficulty initiating

- fewer errors on automatic speech

apraxia of speech: conversation

- articulation errors

- abnormal prosody

apraxia of speech: sustained vowel prolongation

typically unaffected

apraxia of speech: AMRs/SMRs

- initiation difficulty

- slow rate

- substitution or rearrangement of syllables

apraxia of speech: multisyllabic words/short phrases

identifiable apraxic errors

features in both AOS and ataxic dysarthria

- excess and equal stress

- irregular articulatory breakdowns

- distorted vowels

- prosodic disturbances

how can we tell the difference between apraxia of speech and ataxic dysarthria?

- confirmatory signs and lesion sites (ataxic: cerebellum)

- consistency vs. inconsistency (ataxic more consistent, AOS worse with complexity)

- automatic vs. volitional speech (AOS better with automatic, ataxic not)

- groping (trial and error; AOS)

- impact of increased length/complexity (AOS gets worse, ataxic doesn't)

anarthria

severely unable to speak (motor)

echolalia

involuntary repeating someone else's word/phrases

tone

- body at rest

- posture, natural tension

- can have weakness with too much or too little

- think basal ganglia and other deep brain structures

aprosodia in dysarthria

- flat affect with monopitch/loudness

- regular rhythm

aprosodia in right hemisphere disorder

- no variation in emotional affect

- limbic system?

acquired (neurogenic) stuttering

- consistent repetitions (unlike developmental stuttering)

- not a specific lesion site

- event resulting in dysfluency

differential diagnosis

case history, imaging, observations -> initial hypothesis -> testing (non speech motor movement, speed findings) -> primary diagnosis -> check signs and symptoms -> tx planning

general diagnosis guidelines

- speech exam should always lean to an attempted diagnosis

- do not make a diagnosis if it cannot be determined

- address consistently with known or suspected dx/lesion

- different speech-lang disturbances can co-occur

why should "normal" speech still require an explanation?

- a change within the range of normal

- a change outside the motor system

- normal speech with an altered perception

goals of treating MSDs: maximize...

- effectiveness

- efficiency

- naturalness

how to maximize effectiveness, efficiency, and naturalness

- restore lost function

- promote use of residual function

- adjust environment and responsibilities

- consider socio-emotional aspect

outcomes frequently are indexed in terms of

- intelligibility

- naturalness

factors influencing treatment decisions

- medical diagnosis and prognosis

- disability and handicap

- environment and communication partners

- motivation and needs

- associated problems

- healthcare system

types of treatment

- medical (treat underlying disease)

- prosthetic (VF injection, palatal lift)

- behavioral

- alternative and augmentative communication

- counseling and support

rationale for motor learning

- organization of nervous system is not fixed

- neural adaptation occurs with muscle use

- nerve system is capable of recovery and reorganization after injury

principles of motor learning

- improving speech requires speaking

- drill is essential

- instruction and self-learning each have value

- external feedback and its conditions are important

- specificity of training and salience are important

- different practice conditions have different effects

- efforts to increase strength should follow rules for strength training

- a trade off occurs between speed and accuracy

- time for consolidation of motor speech is important

- therapy is a cognitive-motor process

other considerations for motor learning

- medical diagnosis and speech characteristics relevant to management

- management should start early

- baseline data is important for establishing goals and measuring change

- organization of sessions is important

- frequency, task ordering, error rates, fatigue, individual vs group therapy

improving respiratory support

- controlled exhalation tasks

- sustaining phonation with feedback

- speak at onset of exhalation

- terminate speech early during exhalation

- identify optimal breath group

- increase phrase length

improving phonatory function (weakness)

- improve glottal closure

- increase volume

- use airflow more efficiently

improving phonatory function (spasticity)

- promote easy onset

- muscle relaxation

- use airflow more efficiently

improving articulation

- biofeedback

- consonant exaggeration

- integral stimulation

- phonetic placement

- minimal contrasts

treatment approaches

- controlled exhalation

- inspiratory checking

- speaking at onset of exhalation

- use of optimal breath group

- over-articulation

task hierarchy

- controlled exhalation -> sustained phonation

- easy onset and continuous voicing during automatic speech tasks -> with natural productions of automatic speech

- sentence reading -> paragraph reading -> conversation with efficient use of airflow

other strategy notes to optimize communication (for speaker)

- gaining listener attention

- convey communication preferences

- set context and identity topics

- modify sentence content

- use gestures

- monitor listener comprehension

- alphabet supplementation

other strategy notes to optimize communication (for listener)

- maintain eye contact

- listen attentively and actively

- familiarize with dysarthric speech

- modify physical environment

- maximize listener hearing and visual acuity

other strategy notes to optimize communication (for both)

- schedule important interactions

- select conductive environment

- maintain eye contact

- identify breakdowns and feedback

- establish feedback methods

- repair breakdowns

- adapt strategies based on context

principles of treating AOS

- reestablishing plans/programs or improving ability to activate them

- frequent impact of aphasia

- primary treatment is behavioral

- emphasis on motor learning principles

examples of behavioral treatment approaches

- integral stimulation

- sound production treatment

- PROMPT

- isolated sound (phonomoter) work

- pacing, MIT

steps of integral stimulation

- step 1: simultaneous production

- step 2: model, then simultaneous production w/o auditory cue

- step 3: imitation w/o simultaneous cues

- step 4: imitation with several successive productions, no

simultaneous cues

- step 5: written stimuli w/o auditory or visual/articulatory cues

- step 6: written stimuli, delayed production after removal of written cue

- step 7: response elicited with question.

- step 8: response elicited in role playing situation

sound production treament

more structured approach with minimal pairs

PROMPT

uses tactile/physical cues

modified-response elaboration training

- targets verbal output by reinforcing/expanding patient responses

- promotes increased utterance length, lexical diversity, functional comm

- naturalistic contexts

combined aphasia and AOS treatment (CAAST)

- integrates language and motor speech practice

- pairs spoken word production with semantic and phonologic cueing

- supports simultaneous improvement in word retrieval and speech motor planning

counseling

- addressing emotional needs of patients and family members

- engaging readiness for change

- attend to differing priorities and perspectives

- consider psychosocial impact of disorder

readiness for change

- motivation to participate and work for goals

- contemplation and preparation

patient reported outcomes for dysarthria

- communicative effectiveness survey

- dysarthria impact profile

- living with dysarthria

- communicative participation item bank

- voice handicap index

counseling is a ____ process

activw

sympathy

feeling for

empathy

feeling with

counseling skills

- validate feelings

- show empathy

- ask open-ended questions

- no toxic positivity

sociocultural considerations

differences in intelligibility, prosody, and phonemes