Assessment of Motor Speech Disorders

the purpose of Ax varies based on

setting

examples of priority of Ax

• to establish a speech diagnosis and its implications for localization and neurological Dx

• Developing a Tx plan

Overall what are the five goals of a MS Ax

• Description

• Establishing a Dx possibility

• Establishing a Dx

• Establishing implicactions for localization and disease Dx

• Specifying severity

Goals of Ax- Description

• characterizes the features of speech and the structures and functions related to speech

• represents the data on which Dx and Tx decisions are made

• May be the end of the Dx process if a Dx can’t be established or a list of possibilities

• Derived from Pt history, description of the problem, oral mech, perceptual speech characteristics, results of standard clinical tests, and instrumental analyses of speech

• allows a clinician to determine if findings are normal or abnormal

Goal of Ax- Establishing a Dx Possibility

• to determine possibilities, answer the following questions

  • Is the problem neurologic?

  • if not, is it organic? (laryngeal pathology or dental abnormality)

  • Is it a recently acquired or longstanding problem? (artic disorder)

    • if MSD is present, is it dysarthria or apraxia of speech?

  • If dyarthria, what type?

Goal of Ax- Establishing a Dx

• after determining reasonable possibilities,

  • one Dx may emerge or possibilities can be ordered from most to least likely

Goal of Ax- Establishing Implications for localization and disease

• explicitly address the implication for localization if a specific MSD can be identified

  • If Dx has already been made, note if the speech Dx is consistent with neurologic Dx

  • If neurologic Dx is unclear and speech is the only sign of disease, it is appropriate to identify possible Dx if the MSD is traditionally tied to it

Goal of Ax- Specifying Severity

• always estimate the severity of the MSD for 3 reasons

  • can be compared to pt’s complaints

  • can influence prognosis and treatment decision making

  • part of baseline data which can be compared to future changes

  • part of the descriptive process but relevant to determining functional limitations and disability from MSD (usually more relevant to treatment planning)

what are the three essential components of assessment

1. case history

2. identification of salient speech features

3. identification of confirmatory signs

Ax components- Case History

• Dx can happen with data gathered during exchange of greetings and pleasantries

• Later examination confirms, refines, or revises the Dx

• Reveals the time course of complaints and Pt’s observations abou the disorder

• Opportunity for contextual speech usually before more anxiety- formal assessment

Ax components- Identificaiton of Salient Speech features

• features that contribute most directly and influentially to Dx

• 6 features that influence speech

  • strength

  • speed

  • ROM

  • steadiness

  • tone

  • accuracy

Ax Components- ID salient speech features: Strength

• should be sufficient to perform normal functions with a reserve of excess strength to permit contraction over time without excessive fatigue and contraction against resistance

• weak muscles cannot contract to desired level, sometimes even for short periods

  • fatigue more rapidly

  • sustaining a desired level of contraction decreases quickly

• weakness can affect all three major subsystems for speech (laryngeal, velopharyngeal, articulatory)

• weakness is most apparent in LMN lesions

• results of weakness may be present in perceptual analysis, visually at rest, during speech, during oral mech, or measured physiologically

Ax Components- ID salient speech features: Speed

• Movements for speech are rapid (14+ phonemes/sec)

  • quick unsustained and discrete movements are called phasic movements

    • produced as single contractions or repetitively

    • begin quickly, reach targets quickly, and relax quickly

  • usually increased speech rate is associated with decreased ROM

  • slow movements can occur during any component of speech production

    • affecting prosidic features

  • can be perceived in speech, visible during speech and oral mech, and measured physiologically and acoustically

Ax Components- ID salient speech features: Range

• distance traveled by structures

• variation between people is present but small

  • Ataxic dysarthria often presents with increased variability of ROM and unpredictability of ROM

• Consistent excess ROM is uncommon in MSD

• Reduced ROM is common in MSDs

  • can occur at any speed

• Can occur during any componenet of speech production

• can be perceived in speech and acoutic analyses of speech, visible during speech and nonspeech movements of articulators, and measured physiologically

Ax Components- ID salient speech features: Steadiness

• At rest, presenece of 8-12 Hz oscillation of body musculature

• Usually no visible interruptions or oscillations at rest or when moving

  • can visibly occur in healthy people- physiologic tremor- occurs under extreme fatigue, emotinal distress, or when shivering

• consistent excess ROM is uncommon in MSDs

• Breakdowns in neurological disease result in involuntary movements

  • tremor is most common

  • mild tremor may not be perceived in speech characteristics dependent on respiration, resonance or articulation; most commonly affects phonation, if severe affects prosody

  • can be perceived in speech, seen during oral mech, and measured acoustically and physiologically

• Other major category of involuntary movement can vary in speed, duration, and amplitude

  • dystonia

  • dyskinesia

  • chorea

  • athetosis

Ax Components- ID salient speech features: Tone

• can be excessive or reduced

• can fluctuate slowly or rapidly in regular or unpredictable ways

• effects can be inferred from perceptual speech characteristics, seen during speech and oral mech, measured physiologically and inferred from acoustic measures

Ax Components- ID salient speech features: Accuracy

• individual, repetitive and complex phoneme sequences are normally executed precisely enough for intelligible and efficient transmission of speech intent

• results from proper regulation of tone, strength, speech, range, steadiness and timing of muscle activity

• overshooting or undershooting targets, impaired smoothness and rhythm

• accuracy is the outcome of well timed and coordinated activities of all other neuromuscular features

  • if speech is normal and neuromuscular performance is normal, inaccuracies may reflect a defect in linguistic plan or ideational content or in the planning or programming of movements

• rare for only 1 abnormal neuromuscular feature to be present in a person with dysarthria

Assessment components- confirmatory signs

• additional cues about the location of pathology

• signs other than deviant speech characteristics and salient neuromuscular features that characterize them that help support a Dx

• MSDs do not require confirmatory signs to be present

• confirmatory signs may not have any direct causal or explanatory relationship with the MSD

• Observations of a nonspeech nature should be considered circumstantial evidence, not salient

• examples:

  • atrophy, reduced tone, poorly inhibited laughter or crying, reduced normal reflexes or presence of pathological reflexes

diagnosis

this is made after establishing case history, salient speech features, and confirmatory signs and formulate an impression about their meaning

the ___ of diagnostic statements can vary

certainty

Assessment Tasks

1. case history

2. oral mech exam at rest or during nonspeech activities

3. perceptual assessment of speech characteristics

4. assessment of intelligibility, comprehensibility, and efficiency

Ax Tasks: Case History

• Intro and goal setting

  • talk about why the pt is there, explain purpose of ax

• Basic data

  • demographics, occupation, family, Hx of child related deficits (artic errors, stuttering, etc)

• Onset and course

  • useful for dx, prognosis, decisions

• Associated deficits

  • might show confirmatory symtoms

• Pt perception of deficits

• Consequences of the disorder

  • how has it impacted their daily living

• management consequences of the disorder

  • what have they done to manage

• awareness of medical dx and prognosis

  • what they understand, if they know what is going to happen

Ax Tasks: oral mech exam at rest or nonspeech

• structures and functions to assess rest and during movement and sustained postures

  • face

  • jaw

  • tongue

  • velopharynx

  • larynx

  • respiration

  • volitional vs automatic nonspeech movements

Ax Tasks: perceptual assessment of speech characteristics

• presence of deviant speech characteristics is generally more important to differential dx than severity

• can be completed using tasks designed to isolate the respiratory-phonatory, velopharyngeal and articulatory systems for independent assessment and then to observe them working together

• Vowel prolongation

  • gives habitual pitch and volume

  • 9+ seconds is WNL in absence of other respiratory or laryneal abnormality

  • acoustic analysis

  • observe jaw, face, tongue, and neck- look for adentitious movements

• AMRs or DDKs

  • help judge speed and regularity of reciprocal jaw, lip, and ant/ post tongue movement

  • observe ROM and rhymicity of jaw and lips- note interruptions

  • normal, slow, or fast in MSDs

• SMRs- sequence motion rates

  • measure ability to move quickly and in proper sequence from one articulatory position to another

  • particularly useful when apraxia is suspected

  • puh tuh kuh or buttercup

• Contextual speech

  • conversation, narratives, and reading aloud

• Stress testing

  • should be completed if LMN of unknown cause is present or when pt complains of rapid or dramatic changes in speech with continued speaking or general physical exertion

• Assessing motor speech/ programming

  • if distorted articulatory subsitutions, omissions, repetitions, additions, hesitations, or trial and error groping- further MS assessment

  • can use tasks with minimal demands if necesary