Motor Speech Disorders Final

Ataxic Dysarthria - physiological characteristics

*Incoordination of muscles (gait difficulties - waddle, will fall backwards if looking up)
*Reduced muscle tone (hypotonia)
*Slowness
*Inaccuracy in force, range, timing, and direction of speech movements
Nystagmus
Cognitive deficits (sometimes)
Facial weakness
Titubation (tremor of head or body)

Ataxic Dysarthria - patient complaints

Sounds drunk (worse with alcohol)
Stumbling over words
Bites tongue/cheek while eating

Ataxic Dysarthria - perceptual characteristics

Cluster = *excessive prosody, articulatory inaccuracy, phonatory-prosodic insufficiency
Phonatory-Prosodic insufficiency
(irregular pitch, monoloudness, monopitch)
Respiration
(speak on expiratory reserve; impression of hypernasality)
Articulation
(imprecise consonants, vowel distortion, irregular AMRs (slushy, drunk sounding))
Prosody
(excessive stress, lack of inflection and pitch fluctuation, slowed rate)

Flaccid Dysarthria - physiological symptoms

Atrophy
Fasciculations
Progressive weakness of reflexive, automatic, and voluntary movement
Dysphagia (sometimes)

Flaccid Dysarthria - perceptual characteristics

Continuous breathiness
Diplophonia
Inspirational stridor
NAEs and hypernasality
Rapid deterioration and recovery with rest
Imprecise AMRs
Monotone (potential)
Slow rate (potential)
Vowel distortions (potential)
Imprecision of bilabials, labiodentals, linguodentals, lingual alveolars (potential)
Distorted vowels (potential)
Hoarseness (potential)
Low volume (potential)

Spastic Dysarthria (most common) - physiological characteristics

Combined effect of weakness and spasticity
Reduced ROM and force
Hypertonia
Loss of fine motor movement skills
Damage to distal muscles
Hyperactive gag reflex

Spastic Dysarthria (most common) - patient complaints

Slow speech
Increased effort
Fatigue when walking
Poor control of emotions
Drooling; difficulty swallowing

Spastic Dysarthria (most common) - perceptual characteristics

***Articulatory-Resonance: hypernasality, effecting intelligibility
***Phonatory Stenosis: strained vocal quality
Phonation: low pitch, some pitch breaks, little loudness variation

Respiration: running out of air, reduced max phonation

Articulation: imprecise consonants, reduced AMRs & ROM, distorted vowels

Prosody: reduced stress, slow rate, reduced loudness variation (inability to change loudness on command)

Hypokinetic Dysarthria - physiological characteristics

Rigidity
Slow individual but sometimes fast repetitive movements
*Infrequent swallow
Flat affect
Rapid tremulous jaw, lips, tongue
Resting tremor

Hypokinetic Dysarthria - patient complaints

Quiet/weak vocal quality (deny or minimize change)
Voice can't be heard in loud environments
Voice lacks emotion
Fast speech rate
Hard to get speech started
Sounds like stutter
Drooling/swallowing issues
Upper lip rigidity/stiffness

Hypokinetic Dysarthria - perceptual characteristics

*Prosodic Insufficiency is key!
Prosody: increased/variable rate, short rushes of speech, reduced stress
Phonation: hoarseness, breathiness, tremor/flutter
-decreased loudness, monoloudness, monopitch, poor pitch control
-reduced MLU; shimmer, jitter, decreased F0 in women, decreased max phonation time over disease course, inappropriate silences
Respiration: reduced strength/endurance, syllables per breath, max vowel prolongation, irregular breathing patterns
Resonance: mild hypernasality
Articulation: sounds slushy, imprecise, rapid/repeated, blurred
-irregular/reduced AMRs

Hyperkinetic Dysarthria - physiological characteristics

Bizarre, involuntary movements (tics)
Abnormal orofacial, head, respiratory movements
Dystonia
Tremors - lingual, head, extremities (pt unaware)
Motor unsteadiness
IMPROVES with alcohol
Normal reflexes
Facial grimace while speaking

Hyperkinetic dysarthria - patient complaints

Shaky/tight voice
Effortful speech
Short of breath
Dysphagia
Drooling
Hard to talk
Motor unsteadiness
Throat clearing/coughing/grunting

Hyperkinetic Dysarthria - perceptual characteristics

*Cluster depends on dx/etiology
Phonation - respiration: slurred speech
-breathiness, strained, harshness vocal quality
-stoppages
-excess loudness variation
-vocal tremor
Resonance - articulation:
-distortions/irregular breakdowns
-slow/irregular AMRs
-sniffling
Prosody:
-prolonged intervals and phonemes
-variable rate
-inappropriate noises and silences
-excessive/inefficient/variable patterns of stress
Articulation - prosody:
-humming, whistling, lip smacking, echolalia (ex. Tourette's)
Articulation:
-distorted vowels

UUMND - physiological characteristics

Hypertonia, sometimes spasticity
Hyporeflexia
Hemiplegia or hemiparesis
Unilateral lower face weakness at rest
Central face weakness apparent during expressive tasks
Unilateral lingual weakness without atrophy/fasciculations
Usually temporary!
Good prognosis!
No clusters!

UUMND - patient complaints

Slurred, thick, slow speech
Drooling
Deteriorates with fatigue and mental stress
Face feels heavy
Chewing and swallowing difficulties
Uncontrollable crying/laughing

UUMND - perceptual characteristics

Phonation: harsh, wet hoarseness, strained, breathy
-unilateral VF weakness
-decreased FF variation, glottal airflow, rate of adduction/abduction
-jitter, shimmer
-decreased loudness
Respiration: reduced drive/weakness
Resonance:
-hypernasality
-NAE
-both
Articulation:
-imprecise, slow, irregular AMRs
-irregular artic breakdowns
-vowel distortions
-repetition of sounds/syllables
Prosody:
-slow rate
-increased rate in segments
-monopitch/monoloudness

Apraxia of Speech - physiological characteristics

Difficulty imitating and initiating speech
Difficulty with volitional tasks
Motor programming deficit
Groping
Decreased tongue/jaw control
Hyperactive reflexes
NO swallowing/chewing issues (if they do it's not AoS)
NO comprehension issues

Apraxia of Speech - perceptual characteristics

Intelligibility okay
Doesn't impact 5 subsystems
Consonant errors more frequent than vowels
Asymmetrical AMRs
Poor imitations and repetitions
Errors increase with word length
False articulatory starts

What is Apraxia of Speech?

Neuro speech disorder localized to L hemisphere that impairs the capacity to plan/program sensorimotor commands. Occurs in absence of physiological disturbances and language components. No swallowing issues.

Apraxia of Speech - patient complaints

"I have words I want to say but they don't come out right"
"I'm not as fluent as I used to be"
Word/sound mispronunciation

Which dysarthrias are caused by PNS damage?

Flaccid Dysarthria

Which dysarthrias are caused by CNS damage?

Ataxic
Spastic
Hypokinetic
Hyperkinetic
UUMND
Apraxia of Speech

Which control circuit is damaged in ataxic dysarthria?

Cerebellar control circuit

What PNS problems are seen in flaccid dysarthria?

Problems in nuclei, axons, and neuromuscular junction that make up motor units of the final common pathway.

What are possible etiologies for flaccid dysarthria?

Degenerative (ALS) or demyelinating disease (Guillain-Barre)
Stroke
Surgery (ex. cardiac can clip RLN)
Trauma
Infectious disease (polio, meningitis, herpes)
Autoimmune disease

What are possible etiologies for spastic dysarthria?

Degenerative disease
Toxic/metabolic (drug overdose)
Inflammatory disease (leukoencephalitis)
Vascular disorders (CVA)
Trauma
TBI
Cerebral palsy

Mixed dysarthria is common in what type of etiology?

Degenerative disease (ex. ALS)

Hypokinetic dysarthria involves damage to what CNS control circuit?

Basal Ganglia control circuit

What is the common speech subsystem cluster in hypokinetic dysarthria?

***Prosody
Phonation
Articulation

Is there a common speech subsystem cluster in UUMND?

No

What is the typical prognosis for UUMND?

Usually temporary
Good prognosis

UUMND usually co-occurs with...?

Aphasia or apraxia (L hemi - usually no dysarthria with R hemi)

What is the common speech subsystem cluster in Apraxia of Speech?

None. It doesn't affect the speech subsystems

What is the common speech subsystem cluster in ataxic dysarthria?

*Excessive prosody
Articulatory inaccuracy
Phonatory-Prosodic insufficiency

Fasciculations are a common symptoms of which dysarthrias?

Flaccid

T/F: Physiological disturbances and language components are present in AoS

False. It occurs in the absence of physiological disturbances and language components

Dysphagia/swallowing/chewing difficulties are present in which dysarthrias?

All but it is not a distinguishing factor of ataxic dysarthria

What are the typical patient complaints of flaccid dysarthria?

Slurred speech
Thick tongue
Inability to sing
Breathiness
Weakness
Decreased sensation in face and mouth

What are the articulatory and prosodic characteristics of ataxic dysarthria?

Articulatory inaccuracy: imprecise consonants - slushy, drunk sounding

Excessive prosody: excessive stress, lack of inflection/pitch fluctuation, slowed rate

What is the most common type of dysarthria?

Spastic

What are the common cluster characteristics of hypokinetic dysarthria?

****Prosodic insufficiency: *short rushes of speech, *variable rate, *imprecise consonants, monopitch, monoloudness, reduced stress, shorter phrases

Phonation: hoarseness, breathiness, tremor/flutter

Articulation: sounds slushy, imprecise, rapid and repeated, blurred, irregular/reduced AMR

What are the typical patient complaints for UUMND?

Slurred, thick, slow speech
Drooling
Face feels heavy
Chewing and swallowing difficulties
Uncontrollable laughing/crying
Deteriorates with fatigue and psychological stress

What are the typical patient complaints of hyperkinetic dysarthria?

Shaky/tight voice
Short of breath
Improves with alcohol
Unaware of tremor - tremor gets worse with fatigue or stress

What are the classic physiological symptoms of hyperkinetic dysarthria?

Bizarre, involuntary movements
Visibly abnormal orofacial, head, respiratory movements
Dyskinesias (tremors of head or extremities)

What are typical physiological symptoms of hypokinetic dysarthria?

Rigidity
Reduced force and ROM
Slow individual but sometimes fast repetitive movement

What are classic physiological symptoms of spastic dysarthria?

Combined effect of weakness and spasticity
Hypertonia

What are classic physiological characteristics of flaccid dysarthria?

Hypotonia
Fasciculations
Progressive weakness in reflexive, automatic, voluntary movements

What are classic physiological characteristics of ataxic dysarthria?

Hypotonia
Gait difficulties
Deficits in coordination of movement and timing
Nystagmus
Titubation

Basal ganglia activities are strongly associated with...?

Actions of the indirect activation pathway aka extra-pyramidal system

What are the components of the Basal Ganglia and what is it's role?

Components:
Striatum (caudate, putamen)
Globus pallidus (internal, external)
Subthalamic nucleus
Substantia nigra (pars compacta, pars reticata)

Role: inhibit cortical directives, dampen excessive movement with intent of better control

Hypokinetic dysarthria can be a result of which disease?

Parkinson's (loss of dopamine, loss of motor control)

What is a core part of basal ganglia functionality?

Subthalamus - ultimate processing center of movement, emotion, cognitive nerve signals

Which dysarthrias are caused by a disorder of the basal ganglia control circuit?

Hypokinetic and Hyperkinetic

What are some known disorders related to hypokinetic dysarthria (caused by damage to BG circuit 3)?

Tremors
Dystonia
Parkinsonism
Myoclonus
Choreiform movements

What are the overall functions of the BG control circuit?

Regulate tone
Control postural adjustments
--Regulate movements, support goal-oriented tasks
--Scale the force, amplitude, and duration of movement
--Adjust movements to the environment (speaking with restricted jaw movement)
--Assist in the learning, preparation, and initiation of movements

Interconnections of control circuit 1

Cortical
Thalamic
Substantia Nigra

Interconnections of control circuit 2

Striatum
Substantia Nigra
Globus Pallidus

Interconnections for BG control circuit 3

Globus pallidus input to the
Thalamus
Subthalamic nucleus
Red nucleus
Reticular formation of the brainstem

The Direct Activation Pathway (DAP) forms part of the _____ and makes up the superhighways from motor cortex to the CNs via the _________ ______.

UMN system (aka pyramidal system or direct motor system)
Corticobulbar tract

Is the DAP unilateral or bilateral?

Bilateral
A message from the right hemisphere decussates before the brainstem to reach the appropriate CN on the contralateral (left) side. All CN muscles receive *redundant* messages from the right and left (bilaterally) pyramidal pathway (except for lower face (CN VII) and tongue (CN XII)) for compensation in times of damage.

What is the purpose of neural redundancy?

To minimize effects of unilateral UMN lesions affecting speech, swallowing, chewing, and airway protection

The Indirect Activation Pathway (IAP aka extrapyramidal tract or indirect motor system) is the "great regulator" of...?

Reflexes
Posture
Tone
Associated activities for skilled movements
*usually inhibitory affects*

What are the crucial connections within the IAP?

BG
Cerebellum
Reticular formation
Vestibular nuclei
Red nucleus

Ataxic dysarthria is associated with damage to the ____.

Cerebellar control circuit (input or output pathways)

What is Mixed Dysarthria caused by?

A combination (2+) of dysarthria types (one type may predominate) caused by focal or diffuse brain damage

What are common etiologies associated with mixed dysarthria?

Degenerative (ALS) or demyelinating (MS) diseases

T/F: ALS makes up 99% of all flaccid-spastic mixed dysarthria diagnoses.

True

What type of mixed dysarthria makes up majority of mixed dysarthria diagnoses?

Flaccid-Spastic (52%)
Other mixed types (21%)
Ataxic-Spastic (10%)

What artery is most impactful to Apraxia of Speech?

Anterior Cerebral Artery (could also cause UUMND)

??????T/F: Vowel errors are more frequent than consonants

False. Consonant errors are more frequent than vowel errors

Is intelligibility heavily affected in Apraxia of Speech?

No. It can, however, be heavily affected in Dysarthria.

What type of disorder is Apraxia of Speech and what does it impair?

It is a neurological speech disorder that causes impaired capacity to plan or program sensorimotor commands

Apraxia of Speech occurs in the ABSENCE of...

Physiological disturbances and disturbance of language components

T/F: AoS can co-exist with aphasia and dysarthria and is localized to the right hemisphere?

False. It is localized to the LEFT hemisphere

AoS exists independent of issues with verbal communication which include...

Reading comprehension
Writing
Errors unrelated to articulation and prosody

Motor speech control involves what?

Interactive, parallel, and sequential participation of all components of the sensorimotor speech system PLUS activities related to conceptualization, language, and motor planning/programming.

What is the main role of the Motor Speech Programmer (MSP)?

To establish the plans and programs for achieving the cognitive and linguistic goals of spoken messages.
1. create cognitive and linguistic goals
2. organize motor commands
3. produce temporarily ordered syllables, words, and phrases, with proper rates, patterns of stress, and rhythm

What sends messages to the MSP?

Left hemisphere's Perisylvian area (temporoparietal cortex, frontal lobe, insula, portions of BG and thalamus). Damage to this area WILL result in AoS.

Which hemisphere are MSP functions more closely tied to linguistic attributes of speech than to its emotional or affective attributes?

Left hemisphere (Perisylvian area)

Degenerative diseases make up what percent of AoS diagnoses?

Degenerative diseases 54%
Vascular disease 28%

Do people with Apraxia of Speech have chewing or swallowing problems?

No (if they do it's probably not AoS)

What are common patient complaints for Apraxia of Speech?

"I have words I want to say but they don't come out the right way"
"I'm not as fluent as I used to be"
Word/sound mispronunciation (articulation)

What is limb apraxia (LA)?

A disorder associated with left hemisphere pathological processes and characterized by deficits in the performance of purposive limb movements that can't be explained by impairments of strength, mobility, sensation, or coordination.
Usually affects right and left limbs but right side often masked by hemiparesis or hemiplegia.

T/F: Apraxia of Speech often co-occurs with Wernicke's Aphasia.

False. It commonly occurs with Broca's Aphasia.

Does Apraxia of Speech affect voluntary or involuntary movements more?

Voluntary movements are very difficult.

T/F: Apraxia of speech is caused by muscle weakness.

False. Apraxia of speech is caused by deficits in motor planning and programming in the brain. Dysarthria is caused by muscle weakness or paralysis.

What dysarthrias are associated with lesions at the spinal and peripheral levels of the nervous system and their associated vascular supply?

Flaccid Dysarthria

Why is flaccid dysarthria distinctive?

It can be produced by injury or malfunction of one or more of the cranial nerves

T/F: Flaccid dysarthria can affect various subsystems in different combinations.

True

T/F: Flaccid dysarthrias do not a share a lesion between the brainstem or spinal cord AND muscles of speech.

False.

In flaccid dysarthria, damage to the glossopharyngeal nerve (CN IX) can cause what?

Severe throat pain that radiates down neck to low lower jaw

What are common symptoms of Myasthenia Gravis?

Ptosis (eyelid droop)
Easily fatigued/progressive weakness
Swallow fatigue/dysphagia
Hypernasality/NAE
Hard to close eyes tightly/ flat affect
Respiratory weakness

Which neurological control circuits are affected by Hyperkinetic Dysarthria?

BG control circuit (BG, thalamus, cerebral cortex)
Cerebellar control circuit

???In terms of the control circuits, what is going on in hyperkinetic dysarthria?

BG circuit - reduction of inhibitory messages from subthalamic nucleus (BG) to the thalamus, resulting in increased thalamic and cortical firing. Thus, uninhibited abnormal movements are 'released' through the motor cortex tot he cortical bulbar pathways. There could be disequilibrium between excitatory and inhibitory neurotransmitters (i.e. increase in dopamine or decrease in cholinergic energy within circuit).
Cerebellar circuit - Lesions to dentate nucleus in cerebellum
Brainstem structures (inferior olive or red nucleus) - altered discharge patterns lead to abnormal motor cortex discharges through corticobulbar/spinal tracts causing abnormal involuntary movement

What is hyperkinetic dysarthria a product of?

Abnormal, rhythmic, or irregular and unpredictable rapid or slow movements

What is Chorea?

Type of hyperkinetic dysarthria exhibiting motor unsteadiness (quick, unpredictable involuntary movements - aka choreiform movements) with slow, slurred, effortful speech. Patient is aware of imprecise speech but is unable or reluctant to speak at normal/rapid rate.

What are some different types of Hyperkinetic Dysarthria?

Tourette's, Huntington's, Chorea, Myoclonus, etc.

What types of therapy are appropriate for hypokinetic dysarthria and what are the overall goals (this can be applied to most all dysarthrias)?

Facilitation techniques and compensatory techniques
Improve comprehensibility, intelligibility, efficiency, and naturalness

What are BG activities strongly associated with?

Indirect activation pathway aka extra-pyramidal system