Motor Speech Disorders Exam 1

CNS and PNS

Dysarthria profiles are variable and based on speech and physiological characteristics that are the result of damage to

1)

2)

Spastic

This type of dysarthria is caused by bilateral upper motor neuron damage

Recurrent Laryngeal nerves, Pharyngeal Plexus, Superior Laryngeal nerves

In flaccid dysarthria, which 3 branches of the Vagus (V)nerve are damaged?

Vagus (V)

If this CN is damage, it leads to difficulty tensing the vocal folds and modulating pitch during speech?

respiration

when there is widespread spinal nerve damage in flaccid dysarthria, what area related to speech production is predominantly affected?

motor

upper motor neurons take _______ impulses created in the brain and transmit them to the lower motor neurons in the cranial and spinal nerves

Trigeminal (V, 5)

Damage to which CN leads to the inability to elevate the mandible for speech and mastication?

F

T or F:

Fast speech rate is a hallmark characteristic of Spastic Dysarthria

F

T or F:

Distorted vowels and consonants are most likely to result when there is a widespread of spinal nerve damage

Ataxic

In what type of Dysarthria are the following tasks useful to assess speech characteristics:

1. conversational speech

2. sentence repetition tasks

3. reading

4. non-speech AMR's of the jaw

Hypokinetic

Damage to the Basal ganglia and the subcortical structures will result in this type of dysarthria:

cerebellum

ataxic dysarthria is caused by damage to the _______

hyperkinetic

this is a group of Dysarthria's with perceptual effects of involuntary movements resulting in distorted and/or interrupted execution of speech. The impact on speech output will vary depending on the type, severity, and location of excessive movements

Stroke, Parkinson's Disease (PD), Chronic Traumatic Encephalopathy (CTE)

What etiologies are associated with Hypokinetic Dysarthria?

Chorea

Involuntary, quick dancelike movements of the feet, hands, extremities, head, and neck

hypokinetic

In Sally's case history, she reports that people have difficulty understanding her. They often ask her to repeat and speak up because they cannot hear her, but she feels like she is speaking at an adequate level. She fatigues and her speech intelligibility diminishes over time. Sally's symptoms are most in line with which type of dysarthria?

Hyperkinetic

Per MD report, the patients exhibiting failed connections that properly inhibit cortical motor discharges. Therefore, the patient presents with unrefined motor plans that present as excessive uncontrolled movements. This is most representative of which dysarthria?

Flaccid

The patient presents with weakness or paralysis of musculature used to produce speech and hyporeflexia (lack of appropriate reflexes). Lesion site is indicative of Final Common Pathway (FCP) involvement. This most likely represents what kind of dysarthria?

right side

Upon reviewing the electronic medical record, the CT scan indicates a cerebrovascular infarct (stroke) on the right cerebellar region. What side of the body would the clinician expect the patient to have difficulty moving?

This is representative of Ataxic Dysarthria:

Damage to the cerebellum or to the neural tracts that connect the cerebellum to the rest of the central nervous system (CNS)

1. Each cerebellar hemisphere is connected to the opposite thalamus and cerebral hemisphere

2. Each cerebellar hemisphere helps control movement on the ipsilateral side of the body.

Motor Speech Disorders (MSDs)

- speech disorders resulting neurological impairments affecting the planning, programming, control, or execution of speech

- Malfunction of the tactile (touch), kinesthetic (movement), and proprioceptive (awareness) sensations

Dysarthria

control vs. execution

- Group of neurological speech disorders produced by damage to the CNS or PNS that affect speech production

- Symptoms vary based on the type and location of brain lesions

- Reflect abnormalities in strength, speech, range, steadiness, tone, or accuracy

Apraxia

planning vs. programming

- Lack of movement or action for speech production

- Different types: Inability to move eyes, limbs, oral structures

Telltale signs:

1. groping

2. no pattern

3. no muscle coordination

CN V (5)

Trigeminal

Sensory and motor

Controls the muscles of mastication

CN VII (7)

Facial

Sensory and motor

Controls the muscles of mastication, including the lips

CN VIII (8)

Vestibulocochlear (auditory)

Sensory

Serves the sense of hearing

CN IX (9)

Glossopharyngeal

Sensory and motor

Contributes to the pharyngeal movement.

Bilateral innervation - single muscle not bilateral symmetry.

CN X (10)

Vagus

Sensory and motor

Contributes to movements of the pharynx and larynx and serves a sensory function for the pharynx, larynx, trachea, bronchi, and lungs.

Bilateral.

CN XI (11)

Spinal Accessory

Motor

Controls the movements of the muscles of the neck, thus indirectly influencing the position of the larynx. Controls turning of head & shrugging shoulders.

CN XII (12)

Hypoglossal

Motor

Controls the tongue movements. Bilateral except cells serving genioglossus muscle; which receives only contralateral fibers

bringing lips together

Bilateral facial weakness results in difficulty

spinal nerves (because it feeds into the diaphragm and Intercostals)

What type of nerves effect respiration when they are extensively damage

cerebral palsy

Spastic dysarthria occurs in children due to

unilateral

on one side

bilateral

on both sides

ipsilateral

on the same side

contralateral

on the opposite side

paresis

partial or incomplete loss of movement (weakness)

paralysis

total loss of movement

lesion

abnormal change in body tissue usually as a result of disease or trauma

speech systems

systems supporting the production of speech which includes articulator, phonatory, and respiratory systems

hypotonic

lack of appropriate muscle tone

hypertonic

excess/tightness of muscle tone

hyporeflexia

lack of appropriate reflexes

hyperreflexia

excess/overactive reflexes

fasciculations

visible isolated twitches in resting muscle

fibrillations

invisible, spontaneous contractions of individual muscle fibers

slurred speech

a hallmark characteristic characteristic of ataxic dysarthria is

F

T or F:

cognitive deficits in ataxic dysarthria are a result of damage to the cerebral hemisphere: _____: damage to the cerebellum itself

Parkinson's Disease

The most common movement disorder associated with hypokinetic dysarthria:

(key: shuffle, tremor, articulation, prosody, expressionless, slow movements, low intensity)

quiet or weak voice

a hallmark characteristic of hypokinetic dysarthria is report of:

static/resting tremor

- present in limbs, jaw, lips, and tongue

- pill-rolling movement: movement between thumb and forefinger, can be unilateral

cogwheel rigidity

- resistance of the limbs to passive stretch in all directions and full of ROM, has a jerky character

- different from spasticity where resistance to movement is greatest at beginning of the stretch and biased in one condition

posture

- involuntary flexion of the head, trunk and arms

- difficulty w/turning in bed, moving from sitting to standing position, adjusting to tilting or falling

bradykinesia

- difficulty w/movement, planning, initiation, and execution

- delay/false starts. slow and difficult to stop, reduced amplitude and speed of repetitive movements

akinesia

- "freezing"

- inability to move

hypomimia

reduced movement in the face resulting in masked or expressionless and unblinking facial expression

dyskinesias

general term used to refer to abnormal, involuntary movements regardless of etiology

dystonia

involuntary, slow, irregular, painful twisting of extremities and body that are manifested as abnormal and involuntary twisting of the body

spasm

involuntary, sudden muscle contraction

tics

involuntary, quick, repetitive, stereotyped movement

tremor

involuntary, rhythmic, quick movement occurring 3-5 times per second

athetosis

involuntary slow writhing movement

ballism

Bilateral, involuntary, irregular, possibly wild or violent flinging of extremities

Hemiballismus

unilateral, involuntary, irregular, possibly wild or violent flinging of extremities

myoclonus

- involuntary single or repetitive brief, lighting

-like jerks of a body part

- can be rhythmic or non-rhythmic

- cannot be inhibited willfully

Spastic Dysarthria (Hallmark Characteristics)

- Strained/strangled/harsh vocal quality

- Reduced pitch and loudness variability

- Slow speech rate

- Slow and regular speech alternating motion rates (AMRs)

articulation, phonation, respiration (of the speaker)

speaker oriented approaches target

indirectly affect speech function (medication affects the whole body)

the aim of pharmacological treatment serves to

patient is unable to produce no more than 1 word per breath group

clinicians should work towards increasing support for speech breathing if

addressing articulation in conjunction with respiration and intensity

accuracy and precision of articulation is solely accomplished by

t

T or F

the focus of speaker Orientec approaches is to restore to precious state or compensate for impairment

improve comprehensibility of messages and efficiency of transmission

focus of communication oriented approaches is to

surgical and pharmacological

effective management approaches for hyperkinetic dysarthria are primarily

myasthenia graves

behavioral treatment approaches are contraindicated for

presence of specific dysarthria types and underlying causes

management for mixed dysarthria is determined by

F

T or F

if you have implemented treatment do not change until you have reached the time period indicated in your plan of car

flaccid dysarthria (clinical characteristics)

- Flaccid weakness or paralysis of musculature to produce speech

- Paralysis is indicative of Final Common Pathway Damage: Hyporeflexia

- Diminished reflexes

- Low muscle tone (hypotonia) and weakness in the muscle

- Atrophy

- Hypoactive gag reflex

- Nasal backflow while swallowing

flaccid dysarthria (etiologies)

- Muscle disease: muscular dystrophy & polymyositis

- Vascular disorders

- The result from damage of varying degrees to 1 cranial nerve or multiple cranial nerves (Bulbar Palsy)

flaccid dysarthria (site of lesion)

Peripheral nervous system OR lower motor neuron (LMN) involvement

CN V (Trigeminal-flaccid)

jaw weakness, reduced sensation from face, jaw, lips, tongue, articulatory imprecision.

specific site of lesion?

type of dysarthria?

CN VII (Facial-flaccid)

unilateral facial weakness; mild articulatory distortions

specific site of lesion?

type of dysarthria?

CN IX (Glossopharyngeal -flaccid)

- Rarely damaged in isolation

- May present with reduced gag reflex

- May affect pharyngeal elevation: 1. During swallowing and 2. During resonant or phonatory functions

CN X (Vagus-flaccid)

weakness of velopharyngeal and laryngeal muscles; hypernasality, nasal emmision, breathiness

All 3 branches are damaged

1. Pharyngeal plexus: innervates muscles of pharynx and velum

2. Superior Laryngeal Nerves: monotone voice, tenses the VF and modulates pitch

3. Recurrent laryngeal nerves: breathy/hoarse voice bc paresis/paralysis of VF

CN XI (Accessory-flaccid)

- Unclear what the damage may cause

- Works with the vagus nerve to innervate the velum, pharynx, and larynx

tongue weakness; imprecise articulation specific site of lesion?type of dysarthria?

spinal nerves (flaccid)

- When damage is widespread, it can affect respiration for speech production

Results in:

1 decreased in speech loudness

2 shortened utterances

3 impaired prosody

4 strained vocal quality

Flaccid dysarthria (speech characteristics)

Respiration

- Speech on residual air

- Slow respiratory rate

Resonance

- Hypernasality

- Nasal emission

Phonation

- Harsh or hoarse

- Breathiness

- Audible inspirations (stridor)

Articulation

- Imprecise consonants and vowels

- Prolonged segments

- Decreased force

Prosody

- Reduced utterance length (short phrases)

- Reduced rate

- Mono pitch

- Monoloudness

flaccid dysarthria (confirmatory characteristics)

- Breathiness, hoarseness, diplophonia, short phrases, reduced maximum vowel duration, vocal flutter

- Audible inspiration, inhalatory stridor, weak cough, weak glottal coup

spastic dysarthria (clinical characteristics)

- Spasticity is hypertonia (excessive muscle tone) and resistance to passive movement: Tense

- Difficulty with neuromuscular execution

spastic dysarthria (etiologies)

- Anything that may produce damage to the Bilateral Upper Motor Neuron (UMN) pathways

- Vascular disorders

- Degenerative diseases: Peripheral lateral sclerosis (PLS) and amyotrophic lateral sclerosis (ALS)

- Trauma or cerebral palsy in children

spastic dysarthria (speech characteristics)

Respiration

- Shallow inhalations/exhalations

Resonance

- Hypernasality

- Phonation

- Low pitch, pitch breaks

- Harshness

- Strained, strangled voice

Articulation

- Labored

- Reduced range of motion

- Decreased oral section control

- Imprecise consonants

- Distorted vowels

Prosody

- Reduced utterance length (short phrases)

- Reduced stress

- Mono pitch

- Monoloudness

- Slow rate

spastic dysarthria (confirmatory signs)

- Strained, strained-harsh, strained-strangled voice quality

- Grunt at end of expiration

ataxic dysarthria (clinical characteristics)

- Presence of abnormal uncoordinated movements

- Non-Aphasic Cognitive-Communication Deficits

- Specific localization to the cerebellum OR cerebellar control circuit

When listening to a patient with dysarthria

1. Underlying weakness

2. Resistance to movement

3. Restriction of movement

4. Poor timing, control, and coordination

ataxic dysarthria (etiologies)

- Any process that damages the cerebellum or cerebellar control circuit

- Degenerative

- Vascular

- Traumatic

- Demyelinating

ataxic dysarthria (site of lesion)

- Damage to the cerebellum or to the neural tracts that connect the cerebellum to the rest of the CNS

- Each cerebral hemisphere is connected to the opposite thalamus and the cerebral hemisphere

- Each cerebellar hemisphere helps control movement on the ipsilateral of the body

ataxic dysarthria (speech characteristics)

- Most evident in articulation and prosody

Phonatory- respiratory-prosodic

- Monoloudness

- Excessive loudness variations

Phonatory- prosodic insufficiency

- Harshness

- Mono pitch

Articulation

- Imprecise consonants

- Irregular articulatory breakdowns

- Distorted vowels

Prosodic excess

- Excess and equal stress

- Prolonged phonemes

- Prolonged intervals

- Slow rate

ataxic dysarthria (tasks to assess)

- Conversational speech, sentence repetition tasks, reading and non-speech AMR’s of the jaw, lips, and tongue

- Oral mech exam

Patient description of Symptoms

1 *Slurred speech

2 *“Drunken” speech

3 Rapid deterioration of speech

4 *Reducing their rate of speech improves intelligibility

Hypokinetic Dysarthria (clinical characteristics)

- Rigidity, reduced force, reduced range of movement, and slow/sometimes fast repetitive movements on speech

Problem with motor control

1 Preparation

2 Maintenance

3 Switching motor programs

Hypokinetic Dysarthria (etiologies)

- Any process that interferes with basal ganglia control circuit

- Degenerative: Parkinson’s Disease (PD)

hypokinetic dysarthria (site of lesion)

- Damage to the Basal Ganglia Control Circuits and their structures

Striatum

Circuit

1 Regulates muscle tone, controls postural adjustments

2 Regulates movements

3 Scales the force, amplitude, and duration of movements

4 Assists with learning, preparing, and initiation of movements

hypokinetic dysarthria (speech characteristics)

- Most evident in voice, articulation, and prosody

Phonatory- respiratory-prosodic

- *Monoloudness

Phonatory-prosodic

- *Mono pitch

Phonatory

- Harsh voice quality

- Breathy voice

- Low pitch

Articulation

- Imprecise consonants

- *Repeated phonemes

Articulatory-prosodic

- *Shorts rushes of speech

- *Variable rate

Prosodic

- *Reduced stress

- *Inappropriate silences

- *Increased rate in segments

- *Increase of rate overall