7B: Neurogenic Communication Disorders 2

Assessment of Dysarthria (5 purposes)

• Determine if speech is abnormal

• Evaluate nature/severity of difficulties

• Determine cause of difficulties

• Determine need for intervention

• Identify directions for treatment

Motor speech examination (5 elements)

1. Respiration

2. Phonation

3. Resonance

4. Articulation

5. Intelligibility

Respiration

• Observe posture and general appearance

• Observe rate of respiration

• Sustained phonation of open vowels

• Measure respiratory pressure/flow (manometer)

Phonation

• Laryngeal mechanics

• Phonation time and voice quality

• Vocal flexibility and coordination

  • ask them to cough, grunt, make uhhhh sound

VP Function and Resonance

• Velopharyngeal mechanics

  • Visual assessment of resting palate

  • Observe palate during repeated /ah/

• Resonance

  • Perceptual evaluation of hyper nasality and distorted consonants

Articulation

• Articulatory mechanics (oral mech examination)

• Speech movements

  • Syllable and phrase repetitions

  • Puh-tuh-kuh (complex articulatory task)

  • Multisyllabic words

• Samples of speech in several contexts

Intelligibility

• Observation in multiple contexts

• Perceptual rating scales and measures

• e.g., Assessment of Intelligibility of Dysarthric Speech

  • % Intelligibility

  • Speech rate for sentences (words/minute)

  • Intelligible words/minute

  • Unintelligible words/minute

Intervention for Dysathria

• Focus on improvement of speech clarity and naturalness

• Type of intervention, course, and prognosis vary with dysarthria type

• Treatment may include:

  • Indirect activities or compensatory strategies

  • Direct interventions

  • Changes to the environment

  • Augmentative and Alternative Communication (AAC)

Indirect activities and compensatory strategies

• sensory stimulation

• muscle strengthening

• Posture and speaking position

Sensory stimulation

• To increase motor control

• *Controversial

Muscle strengthening

• Exercises to improve respiration, phonation, articulation and resonance

• *Controversial

posture and speaking position

• Modify posture to improve speech

• Done with OT and physician support

Direct Interventions

• Rate reduction therapy

  • Using metronome or Pacer software

• Amplification devices

• Delayed auditory feedback device

Lee Silverman Voice Therapy (LSVT)

• Intensive therapy for Parkinson speech

• Focus on laryngeal adduction, increased vocal effort, and recalibration of intended intensity (Think Loud)

Changing the environment

• Training patient and caregivers to minimize environmental impact on speech intelligibility

• Train patient to monitor listeners’ comprehension

• Train listeners to advise when they don’t understand

Example AAC Devices

• Communication boards and books

• Electronic devices

• Gesture and sign language

2 Identifying characteristics

1. Articulatory error patterns

2. Consistency of errors

1. Articulatory error patterns

Substitution, distortion errors common

2. Consistency of errors

• Phonemes are correct in one instance and incorrect at other times

• Related to variations in context

• Typically more consistent in natural settings

• Consistent = NOT apraxia

• Inconsistent errors = Apraxia

Major components of assessment include:

1. Non-speech oral motor movements

2. Non-speech movement sequences

3. Repetition of syllables

4. Repetition of words

5. Repetition of phrases

*at varying levels of complexity

Type of intervention depends on severity of impairment

• General treatment principles:

• Intensive treatment required (massed practice over a long interval)

• Many repetitions required

• Progress through a hierarchy of task difficulty (focused on sequencing)

• Overall goal = successful communication (not perfection)

example interventions

• Sound-sequencing therapy

• Pacing therapy

• AAC

Speech vs language problems

Apraxia and Dysphagia = speech disorder

Aphasia = Langauge disorder

Aphasia

• Acquired language disorder

• Collection of clinically diverse, acquired disorders that affect production and comprehension of spoken language, written language, and nonverbal communication

Location of Aphasia

• Different types and severity depending on location and size of region(s) involved

• Damage to cortical and/or subcortical regions known to support language functioning

Left hemisphere

• controls most language processes in most people

• Focal damage to left hemisphere results in aphasia

Right Hemisphere

• contributes (to lesser extent) language functions

• Right hemisphere damage does not usually result in aphasia but can lead to cognitive-communication disorders

Cerebrovascular Accident (CVA)

• AKA STROKE

• Majority of aphasia cases

• Subtypes

  • Ischemic (thrombotic, embolic)

  • Transient ischemic attack (mini stroke)

  • Hemorrhagic (includes aneurysm, arteriovenous malformation)

Other causes of Aphasia

• Traumatic Brain Injury (TBI)

• Brain infections

• Degenerative brain disorders

• Tumors

Language impairments in aphasia

• expressive deficits

• language comprehension deficits

Expressive deficits

• Word finding difficulties (anomia)

• Reduced vocabulary

• Omission/addition of words or grammatical markers

• Word substitutions

• Delayed or reduced output of language

• Stereotypic language

• Hyper-fluent speech

*all symptoms depend on the type

Language comprehension deficits

• Impaired interpretation of linguistic information (words, grammar, syntax, etc.)

Types of Aphasia

Fluent Aphasias

• Main problems in understanding spoken and written language

• Word substitutions, neologisms, and often verbose verbal output

• Site of lesion often posterior in left hemisphere

*talk a lot but don’t understand

Non fluent Aphasias

• Main problems in producing spoken and written language

• Slow, laboured speech, and word retrieval and syntactic problems

• Site of lesion often in or near left frontal lobe

*cannot produce spoken or written language

Fluent aphasia example:

• Wernickes aphasia

• Transcortical sensory aphasia

• Conduction aphasia

• Anomic aphasia

Wernicke’s Aphasia

• Damage in temporal lobe, sometimes reaching into parietal lobe, in language-dominant hemisphere

• Spoken language flows well with normal prosody, but content often lacks meaning

• Significant comprehension problems

• Limited awareness of problem

Transcortical Sensory Aphasia

• Damage to language-dominant hemisphere at temporal occipital border or parietal region

• Classic symptoms of Wernicke’s profile except stellar repetition skills and echolalia

• Similar to people with Wernicke’s expect your really good at repeating phrases (Wernicke’s are not good at echoing)

Conduction Aphasia

• Damage to connecting pathway in temporal-parietal region

• Hallmark difficulties in repetition

Anomic Aphasia

• Not identified with specific brain area/lesion site

• Relatively few deficits in language expression and comprehension except naming/word retrieval-

Nonfluent Aphasia examples

• Brocas Aphasia

• Transcortical motor aphasia

• Global aphasia

Broca’s Aphasia

• Frontal lobe damage

• Slowed, halting, laboured, “telegrahic” language

  • Mostly nouns and verbs

• Mild-to-moderate language comprehension problems

  • Longer and more complex messages

  • When contextual cues removed

• Awareness of problem

Transcortical Motor Aphasia

• Frontal lobe damage

• Symptoms similar to Broca’s Aphasia except have repetition skills that far exceed spontaneous speech

• really good repetition skills

Global Aphasia

• Large region of brain damage or multiple sites of brain injury in language-dominant hemisphere

• Deficits across all language modalities

• Limited functional communication

• Poor language comprehension

• Aware they have a problem

Cognitive communication disorders

• Wide range of communication problems that result from damage to regions of brain that control thinking (e.g., frontal lobe)

• Difficulties in communication that arise from problems with cognition

Communication vs cognition

Causes of CCDs

• Traumatic Brain Injury (TBI)

  • Often includes frontal lobe damage

• Stroke

• Encephalitis due to toxins or anoxia

• Tumours

• Dementia

Traumatic brain injury

• Wide range of deficits related to injury severity

• Commonly disturbed area is pragmatics, e.g.,

  • Inappropriate

  • Poor topic maintenance

  • Difficulties with conversational turn-taking

• May also have impairments in speech (dysarthria, apraxia), voice, and swallowing, and personality changes

Dementia

• Intellectual decline due to neurological causes

  • e.g., Alzheimer disease, Parkinson, ALS, AIDS, etc.

• Core areas of impairment

  • Memory

  • Language and communication

  • Visuospatial skills

  • Reasoning/judgment/abstract thinking

  • Social cognition/personality

Alzheimer disease

Early/Mild - word finding difficulty, problems understanding more abstract language (e.g., humour, sarcasm, metaphors)

Middle/Moderate - More obvious word finding difficulties, reduced vocabulary and syntax, pronoun confusion, topic digression, reading/writing errors

Later/Severe - Severe word finding difficulty, generic terms, repetitive, grammar/syntactic errors, minimal comprehension, jargon, echolalia, mutism

Assessment of Aphasia

Assessment occurs in multiple phases as client recovers

• Initial (bedside) assessment

• Formal testing postponed until patient is stable

• Primary assessments

Components include

• Medical history

• Interview with client and family

• Oral peripheral exam (to identify any co-occurring speech impairments)

• Hearing testing (to identify any co-occurring hearing impairments)

• Direct language testing

Asses overall communication skills and all modalities and aspects of language

These are the things an SLP might do to assess modalities of language

Methods to assess Aphasia

• Consideration of premorbid state

• Observation/interpretation of client behavior

• Caregiver interview

• Standardized tests

Standardized tests

• Boston Diagnostic Aphasia Examination

• Western Aphasia Battery (WAB)

• Boston Naming Test

Treatment: Therapy goals:

1. Maximize recovery of impaired function

2. Assist in development of compensatory communication strategies

3. Help patient adjust to residual deficits of brain injury

Treatment is effective when:

• It is delivered by qualified personnel

• Patients with irreversible aphasia are excluded from trials

• Intensity, content, duration and timing of intervention are appropriate

• Sensitive and reliable measures are used to document treatment effects

Treatment: Comprehension

• Auditory comprehension

  • Listening comprehension and memory

  • Single word comprehension

  • Understanding spoken sentences

• Discourse comprehension

• Reading comprehension

More treatment methods

• word retrieval

  • Sentence completion

  • Word/phrase repetition

  • Naming drills

  • Cueing

• Sentence production

  • Imitation, repetition-elaboration, story completion, question and answer

• Connected speech

  • Picture description

  • Prompted storytelling

  • Conversation

• Writing

  • survival writing skills

  • Writing treatment programs

• Group therapy

• AAC

• New interventions: Stem cell, transcranial magnetic stimulation

• melodic intonation therapy

  
  

Melodic Intotation therapy

Using intonation (melody, rhythm, and stress) to increase length of phrases and sentences

Communication tips

Predicting recovery

Amount and speed of language recovery influenced by…

• Spontaneous recovery (everyone will have different amounts)

• Language/communication therapy

• Severity of impairment at onset

• Aetiology

• Size and location of damage

• Type of aphasia

• Other factors (e.g., sex, education level)

Assessment of CCDs: Purpose

• Identify changes in language performance and behaviour

• Identify cognitive impairments (attention, memory, organization) impacting communication

• Identify impact of disorder on overall functioning

Assessment of CCD: How?

• Examine all aspects of communication, including listening, speaking, gesturing, reading, writing and pragmatics

• Evaluate cognitive-communication skills related to attention, orientation, memory, planning, organizing, reasoning, problem solving

• Include observations in daily environment, interviews with communicative partners

Assessment of CCD: Goals

• Emphasize intact abilities

• Compensate for deficient abilities

• Maintain highest level of functioning possible

• Help others maximize client’s communicative participation

Tailored to unique needs of individual and caregivers

Treatment of CCDs

• Memory training and memory aids

• Cognitive stimulation therapy

• Caregiver training in supportive communication techniques

• Environmental modifications

• AAC

• Improve specific aspect of language (e.g., reading comprehension, language formation)

FOCUSED Approach