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Motor Speech Disorder Definition
A disorder of speech resulting from neurological impairment affecting the motor programming or neuromuscular execution of speech
Motor Speech Disorders Types/Impairments
Includes dysarthria and apraxia of speech
Other oral movements may be impaired, including chewing and smiling
May co-occur with language impairments
Speech disorder resulting from weakness, paralysis, or incoordination of the muscles of the speech mechanism
Dysarthria Definition
Speech disorder which results from an impairment in (sensori)motor programming for volitional speech
No problems with the muscles themselves, just the programming
Apraxia Definition
Motor Speech Disorders Causes
Acquired: stroke, TBI, degenerative diseases
Developmental: cerebral palsy, developmental disabilities
Upper and Lower Motor Neurons
Upper: motor areas of cerebral cortex & some subcortical structures
Initiate voluntary movement
Lower: connect brain & spinal cord to muscle fibers
“Final common pathway”: nerve impulses = contraction of muscle fibers
Types of Dysarthria
Flaccid
Spastic
Ataxic
Hypokinetic
Hyperkinetic
Mixed (1/3 of patients)
Lesion Site: Lower Motor Neuron
Primary Defect: Weakness
Flaccid Dysarthria
Lesion Site: Upper Motor Neuron
Primary Defect: Spasticity
Spastic Dysarthria
Lesion Site: Cerebellum
Primary Defect: Incoordination
Ataxic Dysarthria
Lesion Site: Basal Ganglia Circuit
Primary Defect: Rigidity, Reduced ROM
Hypokinetic Dysarthria
Lesion Site: Basal Ganglia Circuit
Primary Defect: Involuntary Movement
Hyperkinetic Dysarthria
Lesion Site: More than one of above
Primary Defect: Multiple
Mixed Dysarthria
Flaccid Dysarthria Causes
Uni/bilateral LMN stroke (brainstem stroke)
Myasthenia gravis
Muscular dystrophy
Flaccid Dysarthria Signs
Muscle weakness
Reduction of muscle reflexes
Loss of muscle tone
Atrophy of muscles
Fasciculations
Damage to nerves VI and VII
Clear speech with very little facial movement
Moebius Syndrome
Problem at neuromuscular junction: fluctuating muscle weakness and fatigue
ACh is attacked by antibodies so muscle can’t contract
Speech Sample: Slurred/imprecise speech, resonance problems, difficultly chewing & swallowing
Myasthenia Gravis
Muscular Dystrophy
Genetic
Degenerative & progressive
Diffuse, chronic effects
Main symptom is muscle weakness
Over 30 types but 9 major forms
Duchenne
Becker
Myotonic
Spastic Dysarthria Signs
Spastic paralysis (stiff, contracted muscles)
Hyperactive and pathological muscle reflexes
Strained/harsh voice, slow & labored speech
Ataxic Dysarthria Causes
Cerebellar lesions
Coordinates and sequences speech movements
Integrates sensory feedback into revised production
Ataxic Dysarthria Signs
Inaccurate/irregular movements
Impaired prosody
Can sound “drunk”
Hypokinetic Dysarthria Cause
Basal ganglia damage
Reduces movement or leads to failure to inhibit involuntary movement
Depletion/insufficiency of dopamine = reduced movement
Prototypical example: Parkinson’s disease
Hypokinetic Dysarthria Signs
Most evident in voice, articulation, and prosody
Reduced loudness
Short rushes of speech
Reduced respiratory movement
Medical Management
Levadopa (L-DOPA): precursor to dopamine, can cross blood-brain barrier whereas DA cannot
Given with another drug to prevent the peripheral synthesis of dopamine from L-DOPA
Side Effects of L-DOPA
Akinesia/dyskinesia
Rigidity/stiffness
“On-Off Response”: Phases of immobility and incapacity associated with depression alternating with jubilant “thaws”
Extreme emotional state (anxiety, hypersexuality), confusion, hallucinations
Hyperkinetic Dysarthria
Basal Ganglia Damage
Huntington’s Disease
Types of Involuntary Movements
Tardive Dyskinesia
Tardive Dyskinesia
Repetitive, involuntary, jerky, purposeless movements
Often a side effect of medication
Mixed Dysarthria
Amyotrophic Lateral Sclerosis (ALS): mixed flaccid/spastic
Cerebral Palsy: several types
CP Overview
Non-progressive (symptoms may change with age)
Muscles are weak, stiff, and/or uncoordinated
Most common childhood movement disability in US
1/3 of people DO NOT have cognitive impairment
Initial Signs of CP
Maintenance of primitive reflexes
Asymmetric tonic neck reflex
Positive supporting reaction: leg muscles contract in a straight standing position when balls of feet make contact with solid surface
Moro reflex: reaction to loss of support/feel of falling
Sucking, rooting, and biting reflexes
Delayed developmental milestones
Classifications of CP
Spastic
Dyskinetic (athetoid)
Ataxtic (dystonic)
Mixed
Mild Case
Acquired Apraxia of Speech
Result of brain injury
Impaired motor planning/programming
Difficulties only with voluntary movement for speech. Non-speech tasks remain unaffected
Prosody and articulation are disrupted
Articulation in Apraxia Patients
Slow/effortful
Initiation difficulty
Inconsistent errors (close to target)
Errors increase with complexity
Movement in Apraxia Patients
Groping Articulators
Silent Posturing
Prosody in Apraxia Patients
Due to compensation
Impaired stress, slow/effortful rate, prolonged phonemes, odd pauses
Apraxia of Speech: Fluency
Restarts and repeated attempts at producing a word or sound, and syllable repetitions
Articulatory groping, sometimes with facial grimacing
Initiation of utterances especially problematic
Not the same as stuttering!
Concomitant Apraxia
Oral apraxia
Limb apraxia
Oral Apaxia
Problems with voluntary oral nonspeech movements
e.g., blowing a kiss, smiling, etc.
Movements are okay when they are reflexive
Limb Apraxia
Problems with voluntary arm movements
Evaluation Components
History
Oral Motor Examination
Perceptual Assessment
Intelligibility Assessment
Acoustic & Physiological Measures
Dysdiadochokinesis
Measure how quickly and accurately a person can produce alternating and sequential articulatory movements
AMR: alternating motion rate
Say “pa-pa-pa-pa…” as fast as you can
SMR: sequential motion rate
Say “pa-ta-ka-pa-ta-ka…” as fast as you can
Speech Intelligibility Measure
Measure in connected speech, not single words most of the time
Two primary approaches to measuring intelligibility
Word-identification approaches
Scaled ratings
Differential Dx: Dysarthria, Spastic
Strained-strangled phonation, hypernasality, imprecise consonants, impaired stress
Differential Dx: Dysarthria
Flaccid
Breathy, imprecise consonants, hypernasal
Differential Dx: Dysarthria
Hypokinetic
Decreased loudness, poor vocal quality, imprecise consonants
Differential Dx: Dysarthria
Hyperkinetic
Involuntary movements, variable rate, strained phonation, hypernasality, imprecise consonants
Differential Dx: Dysarthria
Ataxia
Irregular articulatory breakdowns, impaired prosody
Differential Dx: Apraxia of Speech
Phonetic Complexity
Test along a hierarchy of phonetic complexity
rain → train → strain
come → compute → computer → computation → computational
Differential Dx: Apraxia of Speech
Cueing for Response
Test along a hierarchy of cues (no feedback → visual → tactile)
Test along a hierarchy of timing between cue and response (simultaneous → immediate → with delay)
Differential Dx: Apraxia of Speech
Length of utterance
Test along a hierarchy of lengths
I → I eat → I eat lunch and so on
Differential Dx: Apraxia of Speech
Linguistic complexity
Test along a hierarchy of linguistic load
Repetition → Conversation → Picture Description → Narrative
Management Approaches for Dysarthria
Medical Management
Surgical management
Pharmacologic management
Prosthetic management
Behavioral Management (speech therapy)
Surgical Management
Deep Brain Stimulation
Thyroplasty
Pharyngeal Flap Surgery
Pharmacologic Management
Usually directed at relieving symptoms of the larger disease/disorder
Improvement in general function may not be accompanied by commensurate change in speech function
Know the drug the client is taking and for what
Begin other therapy when the effects are stable
Prosthetic Management
Includes the use of any device to improve function
Palatal lift prosthesis, amplification system, AAC, pacing board, DAF, biofeedback devices
ACC can be used to replace or supplement existing speech
Consider surgery, prosthetics before behavioral therapy if possible
Behavioral Management
Improve impaired system(s)
Teach compensatory strategies
Therapy can be: speaker-oriented or communication-oriented
Establish alternative form of communication if needed in early stages
Begin with a feature which can be modified readily and with minimal instruction
Speaker-Oriented Therapy
Focus on changing the speaker behavior (improve function or compensations)
Communication-Oriented Therapy
Focus on changing the behavior of listeners or the environment
Progressive neurodegenerative disorder that affects nerve cells in the brain and spinal cord, leading to loss of muscle control
Muscle weakness, twitching, cramping, difficulty speaking, swallowing, and breathing, paralysis and significant respiratory issues
ALS/Lou Gehrig’s Disease
Neurodegenerative disorder caused by the loss of dopamine-producing neurons in the substantia nigra
Resting tremors, muscle rigidify and stiffness, bradykinesia, postural instability, cognitive decline in later stages
Parkinson’s Disease
Genetic disorder leading to the progressive breakdown of neurons, especially in the basal ganglia
Involuntary jerking, or writhing movements (chorea), cognitive decline, psychiatric symptoms, loss of motor control
Huntington’s Disease
Deep Brain Stimulation
Surgically implanting electrodes into specific brain regions to deliver controlled electrical impulses to help regulate abnormal neural activity
Dysarthria or Apraxia of Speech
Motor speech execution disorder
Dysarthria
Dysarthria or Apraxia of Speech
Motor speech programming disorder
AOS
Dysarthria or Apraxia of Speech
Muscles have reduced range, strength
Dysarthria
Dysarthria or Apraxia of Speech
Consistent errors
Dysarthria
Dysarthria or Apraxia of Speech
No island of clear speech
Dysarthria
Dysarthria or Apraxia of Speech
Consonants imprecise
Dysarthria
Dysarthria or Apraxia of Speech
No weakness or paralysis
AOS
Dysarthria or Apraxia of Speech
Inconsistent errors
AOS
Dysarthria or Apraxia of Speech
Island of clear speech
AOS
Dysarthria or Apraxia of Speech
Errors increase with complexity
AOS
Trigeminal Nerve (V)
Jaw Movements
Facial Nerve (VII)
Facial and lip movement
Vagus Nerve (X)
Larynx, pharynx, velopharynx
Controls phonation, resonance, and swallowing
Hypoglossal Nerve (XII)
Tongue movement
Prenatal Causes of CP
Genetics, agenesis, viruses, anoxia
Perinatal Causes of CP
Anoxia due to cord compression, blockage of the airways, aspiration pneumonia, hypoxia due to use of narcotics during birth
Postnatal Causes of CP
Brain injury, high fevers, meningitis encephalitis