Oral Motor Exam #3

Childhood Dysarthria

different types depending on etiology

congenital or acquired

The type of CP associated with childhood dysarthria reflects ________________ movement and ______________

predominant ; tone abnormality

The most common type of CP in childhood dysarthria is ______________

spastic

The characteristics of spastic CP in childhood dysarthria are...

may affect different body parts muscles affected by spasticity

may retain primitive reflexes

The second most common type of CP in childhood dysarthria is....

dyskinetic

Dyskinetic dysarthria affects the entire _______.

body

The characteristics of dyskinetic dysarthria in childhood dysarthria are...

dystonia and choreoathetosis

What is dystonia?

uncontrollable muscle contractions that results in abnormal postures or repetitive movements

What is choreoathetosis?

involuntary twitching

The least common type of CP in childhood dysarthria is...

ataxic

The characteristics of ataxic CP in childhood dysarthria are...

affects entire body

hypo or hypertonia movement - overshoot

The functional motor abilities in CP are...

Gross Motor Functional Classification System (GMFCS) and Manual Ability Classification System

The Gross Motor Functional Classification System...

describes functional gross motor skills

used for ages 6-12 yrs

The Manual Ability Classification System...

describes fine motor skills

used for ages 4-18 yrs old

Gross Motor Function Classification System (GMFCS) Level 1

walks without restrictions; limitation in more advanced gross motor skills

Gross Motor Function Classification System (GMFCS) Level 2

walks without assistive devices; limitation in walking outdoors and in the community

Gross Motor Function Classification System (GMFCS) Level 3

walks with assistive mobility devices; limitation in walking outdoors and in the community

Gross Motor Function Classification System (GMFCS) Level 4

self-mobility with limitations; children transported or use power mobility outdoors and in the community

Gross Motor Function Classification System (GMFCS) Level V

self mobility severely limited even with use of the assistive technology

Etiology of childhood dysarthria

degenerative diseases (ex: hereditary ataxias, myasthenia gravis)

infectious diseases (ex: sydenhams chorea)

fragile x (genetic disability w/ mild to mod intellectual disability)

TBI

stroke

types of dysarthria depending on the site of lesion

Childhood Apraxia of Speech is...

a Disorder of motor programming/planning

What are the basics of Childhood Apraxia of Speech?

difficult to diagnosis before age 3

Characteristics controversial no gold standard

Little research/data on severe CAS

Non-verbal oral apraxia may or may not be present

Often co-occurs with other diagnoses (ex: language disorder, gross/fine motor delay, oral apraxia, limb apraxia)

Childhood Apraxia of Speech is relatively _________ and _________% of all childhood speech sound disorders.

uncommon ; 5%

Childhood Apraxia of Speech is higher in ___________ than ____________.

The ratio is ____________

males than females ; 2-3:1

The reflags of Childhood Apraxia of Speech are...

little to no babbling

very reduced number of sounds

lack of differentiating vowels

CAS Assessment

Hearing screenings, language screenings/assessment

Multisyllabic words picture naming set (butterfly or baseball)

- % of consonants correct

- syllable segregation

- lexical stress problems

Oral motor exam including diadochokinesis

CAS Cultural Considerations

CAS will influence production across all languages

- errors may be manifested differently in each language

- may rely on earlier mastered sounds across all languages spoken

- may appear to favor or use one language over another (difference may be due to the relative ease of the phonemic inventory and word structure in that language rather than an indication of language choice or dominance)

Tonal Languages may have an impact on intelligibility and error frequency

Anarthria

speechlessness resulting from severe loss of neuromuscular control over speech

When someone has anarthria there _________ and __________ abilities may be intact

language ; cognitive

Anarthria may be the end stage of _________ for degenerative disease

dysarthria

What are the two types of dysarthria that can lead to anarthria?

spastic and hypokinetic

Locked-in syndrome

Mutism

Quadriplegia

Preserved consciousness and vertical eye movements or blinking

Usually severe dysphasia

What types of dysarthria is correlated to locked in syndrome?

Severe spastic or mixed spastic-flaccid dysarthria

What etiologies usually cause locked-in syndrome?

brain injury or stroke

AoS with Mutism

Only last a few days if stroke is etiology

Usually have concomitant non-verbal oral apraxia

Aphasia with Mutism

May be present initially

Usually transforms into transcortical motor aphasia

Prosody may be flat

__________ is the most severe disorder of arousal

coma

Coma

unarousable unresponsiveness and absence of sleep/wake cycles on EEG

Coma is usually caused by ________________, _______________, or _________.

bilateral cerebral hemisphere damage, brainstem injury, both

Vegetative state

wakeful unawareness often associated with severe bilateral cerebral hemisphere involvement without brainstem involvement

In a vegetative state, your ______________ are preserved

sleep/wake cycles

Minimally conscious state

have a degree of awareness and responsiveness; may not be entirely mute

Akinetic mutism

reduced motivation (abulia) to speak, difficulty initiating and sustaining the cognitive and motor effort required for speech

With akinetic mutism there is massive ________________ damage

bifrontal lobe

Speech arrest is caused by....

following seizure (mainly in frontal lobe)

Drug induced mutism is caused by...

organ transplants ; cancer treatments

What are the 5 things to include in a diagnostic statement?

severity, specific type of MSD, speech characteristics, etiology, prognosis

What are the severities of MSDs

Functional

Minimal

Mild

Mild-moderate

Moderate

Moderate-Severe

Severe

Profound

Speech Characteristics for MSD (Speech Subsystems)

Articulation: decreased accuracy, distorted vowels, irregular articulatory breakdown

Phonation: monoloud, mono pitch, vocal tremor, breathy, hoarse, harsh, strained

Respiration: Inhalatory stridor, grunt a the end of expiration

Resonance: hyper nasality, nasal emission

Prosody: short rushes of speech, reduced stress, variable rate, excess and equal stress

Intelligibility

Etiology

what MSD is caused by

Prognosis

Excellent, good, fair, guarded poor

What is Acquired Neurogenic Stuttering most common etiology?

stroke and closed head injury

Other Acquired Neurogenic Stuttering etiologies

Parkinson's disease, MS, dementia, seizure disorders, brain tumor, drug abuse

Acquired Neurogenic Stuttering characteristics

sound/syllable repetitions

prolongations

blocking/hesitations

may not be restricted to initial syllables

can occur within content and function words

awareness of dysfluencies but without significant anxiety or secondary struggle behavior

may not demonstrate an adaptation effect or improvement with choral reading or singing

Palilalia

compulsive repletion of words and phrases

Palilalia etiologies

Parkinson's disease/ Parkinsonism

AD and other dementias

closed head injury

stroke

tumor

MS

Palilalia characteristics

receptions of words and phrases

increased rate and decreased loudness with successive receptions (not invariable)

awareness of deficit possible but no anxiety or secondary struggle

Echolalia

unsolicited repetition of another's utterances

Echolalia characteristics

unsolicited reception of others utterances

compulsive, parrot like-quality

repetition may be complete or partial, sometimes with spontaneous correction of syntax

Types of Echolalia

mitigated: only some words, helping comp

ambient: portions of speech from other conversation

effortful: self generated response, repeat phrases before getting response out

silent/simultaneous: quietly echos

Echolalia associated deficits

aphasia and diffuse cognitive deficits

Attenuation of speech etiologies

closed head injury

Attenuation of speech characteristics

reduced speed of verbal responding

reduced linguistic and cognitive complexity of content

reduced vocal loudness and incomplete phonation

flattened prosody

Attenuation of speech associated deficits

cognitive and affective impairments

dysphonia/aphonia associated with postintubation

psychogenic

Disinhibited vocalizations

involuntary productions

Disinhibited vocalizations etiologies

AD

Tourette's syndrome

Disinhibited vocalizations associated deficits

diffuse cognitive impairment

Foreign accent syndrome

speech disorder that causes a sudden change to speech so that a native speaker is perceived to speak with a foreign accent

Foreign accent syndrome deviant speech characteristics

vowel changes :dipthongization, distortions and prolongations, omissions of unstressed vowels, epenthesis

Consonant changes: alterations in voicing, place, and manner features, leading to perceptions in substitutions

Prosodic changes: alterations in stress, rhythm, and intonation

Foreign accent syndrome associated deficits

aphasia, AoS, nonverbal oral apraxia

Aprosodia

disturbances in the prosodic components of speech that are tied to the expression of attitudes, emotion, emphasis

Aprosodia patient complaints

voice does not convey felt emotions

altered pitch, either lower or higher

reduced pitch range

reduced loudness

Aprosodia perceptual characteristics

flattened, robot like spontaneous prosody

reduced pitch and loudness variation

reduced or abnormal intonational variation

reduced affect, expression, emotion; indifferent

tendency to equalize stress

poor expression of irony and sarcasm

Aprosodia accompanying deficits

left sided neglect

paucity of spontaneous emotional and propositional gestures

cognitive-commuication weakness

UMN dysarthria

left hemiparesis

Aprosodia etiology

stroke most common

Stuttering-like dysfluencies

excessive variability: long stretches of fluent w/ brief severe stuttering or vice versa

excessive consistency: stuttering on every other sound or syllable

speech struggle behavior

absence of aphasia, AoS, and dysarthria

conversion disorder

involves physical symptoms that suggest a medical or neuralgic cause but for which there is no demonstrable organic cause

conversion disorder patient characteristics

may occur in health people when in stressful situations

may have history of drug or alcohol abuse

woman > men

somatization disorder

chronic illness characterized by recurrent, multiple physical complaints and belief that one is ill

Questions to ask

Can speech disorder be classified neurologically?

Are OME findings consistent with speech disorder and patterns of abnormality found in neurologic disease?

Is the speech deficit consistent?

Is the speech deficit suggestible?

Is the speech deficit susceptible to distractibility?

Does speech fatigue in a lawful manner?

Managing MSD Basics

wide variety of strategies and techniques

may involve improving speech intelligibility, comprehensibility, efficiency. naturalness, and AAC

baseline data is important

organization of sessions is important

management should start early

What are the 3 main goals for managing MSD?

restore, compensate, adjust

What are the factors that influence decision making when managing MSD?

medical prognosis

impairment, limitation, and restrictions

environment and communication partners

motivation and needs

associated problems

healthcare system

Treatment Duration and Intensity

Course of the disease

Severity of deficits

Specific goals of management

Prognosis

Motivation

Communication needs

Resources

Healthcare coverage

Approaches to Managing MSD

Medical

- Pharmacological and Surgical

Prosthetic

Behavioral

-Speech Orientated

What are the types of AAC?

gestures, symbols (pictures, icons, sings, etc) and aids

What are the principles of motor learning in MSD?

large number of trials

distributed practice

variable practice

random practice

complex practice

Neuroplasticity

Undamaged areas must resume function

Changes supporting recovery are similar to those underlying learning in typical brains (ex: synapses)

Compensatory behaviors develop that induce brain changes

Role of some changes remain controversial

Using the brain (experience) induces recovery

Compensatory strategies in neuroplasticity may be ____________ or ________________

adaptive and improve function ; maladaptive

What is an example of a maladaptive compensatory strategy of the brain?

The development of seizures

Principles of Exercise Dependent Neuroplasticity

Use it or Lose it

Use it or Improve it

Repetition Matters

Time Matters

Age Matters

Transference

Inference

Specificity

What are ways to organize a session for managing MSD?

Frequency, Task Ordering, Error Rates, Fatigue, Individual vs. Group Therapy

Influence of Aphasia when managing AoS

Comprehension of spoken and written stimuli

Difficult to distinguish aphasic from apraxic errors during verbal responses

Aphasia may be so severe that verbal communication will not be functional even if motor speech ability is intact

"How well would this person be able to communicate if they did not have AoS?"