Neurogenics Exam 3

CN V: Trigeminal Nerve

chewing, motor control of mastication muscles

CN VII: Facial Nerve

production of saliva, facial muscles such as orbicularis oris for mouth closure

CN IX: Glossopharyngeal Nerve

pharyngeal phase of swallow, lifts up throat

CN X: Vagus Nerve

closure of the nasal pathway
pharyngeal portion of swallow
closure of the vocal folds

CN XII: Hypoglossal Nerve

tongue muscles for oral and oral prep phase of swallow, moves the bolus

Oral Prep Phase (Buccal Phase)

i. VOLUNTARY PROCESS
ii. Mastication
1. Labial seal and salivation are two important processes, the tongue is helping form the bolus along with the saliva
2. We need sensory feedback for the correct positioning of the bolus on the teeth, prevents tongue injury during chewing
3. Tension in the buccal area prevents food from falling into gap between mandible and teeth
4. Rotary movement by jaw and tongue continues until bolus is formed
iii. Bolus formation
1. After chewing, the tongue will form the bolus
2. Tongue will contract to push the bolus against the soft palate and into the oropharynx

Oral Transport Phase

i. Once bolus formation is complete, the tongue will be the
primary mover of it to the pharynx
ii. Sensory receptors in the oropharynx are stimulated and a reflex (involuntary) known as the pharyngeal swallow reflex is triggered
iii. The tongue will elevate, the sides and the tip pressed against the alveolar ridge
iv. This process lasts for 1-1.5 seconds
v. NEED VOLUNTARY AND INVOLUNTARY portions of the swallow for it to work

Pharyngeal Phase

i. Complete closure of the velopharyngeal port to prevent material from moving upward into nasal cavity
ii. Hyoid and larynx move superior and anterior
1. Elevation opens airway
2. Forward movement opens upper esophageal sphincter
iii. Closure of VFs to prevent food or liquid penetration
1. Laryngeal vestibule closes, where the true and false vfs contract, arytenoids move in a downwards, forward, and inward direction (narrows opening), larynx is elevated and pulled forward, epiglottis inverts
iv. Top to bottom contractions of pharyngeal constrictor muscles begin
v. Opening of cricopharyngeal sphincter to allow material to pass from pharynx to epiglottis

Esophageal Phase

i. This phase begins when the bolus passes through the cricopharyngeal muscle
ii. Esophageal propulsion begins through muscles contractions along the esophagus (peristalsis) ((also propelled by pressure changes))
iii. Proximal to distal (anterograde) sequence of contractions that propel material distally toward the digestive system
iv. Lower esophageal sphincter relaxes so the bolus can enter the stomach
v. This process as a whole can take 8-20 seconds, and it normally takes two peristaltic waves to clear the esophagus
vi. Once the bolus has entered the stomach, the swallowing process is finished and digestion begins

What is a bolus?

the combination of saliva and masticated food that will be traveling through the swallow

List several clinical signs of dysphagia

choking and coughing while or after eating
food sticking in the throat or vallecula
regurgitation
pain while swallowing
drooling
weight loss and nutritional deficiencies
recurrent (aspiration) pneumonia

Videofluoroscopy

also known as modified barium swallow
exposes the client to radiation
visualizes all phases of the swallow
x-ray video

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

dyed food is swallowed by client
fiberoptic camera is introduced through the nose
cannot see the pharyngeal phase, just the results
also cannot evaluate the full function of the esophageal phase

List the components of a bedside swallow exam

i. No instruments to see if instrumental assessment is necessary
ii. Make sure dentures are worn if needed
iii. Observe feeding history, respiration patterns, mental and neurological status, cough, and voice quality
iv. Sit the patient upright 90 degrees
v. Two-ounce water screening test (high specificity, low sensitivity)
vi. Feed different textures
vii. Meal observation
viii. Note any difficulty chewing, swallowing coughing, or breathing

What medical complications can occur due to untreated dysphagia?

Recurrent pneumonia

What are the four treatment methods for dysphagia?

diet modifications
postural adjustments
environmental modifications
training of swallowing maneuvers
muscle strengthening
other

What is important to keep in mind with diet modification

texture, temperature, taste

Outline the stages of the NDD (national dysphagia diet)

NDD I -> pureed foods, such as veggies, fruits, and meats
NDD II -> mechanically altered foods, mashed fruits or veggies, soft or ground meats with gravy
NDD III -> advanced foods, soft-solids like meat, fruit, or veggies that are easy to cut or mash, avoid crackers, nuts, and other snacks
NDD IV -> regular foods, all foods allowed

What are some NDD liquids?

honey, nectar, pudding, overall should be a thin consistency

What are the five postural adjustments?

sit up
chin down
chin up
head rotation
head tilt

Postural Adjustment
Sit up

avoid aspiration, good advice for anyone

Postural Adjustment
Chin-down

Tongue base closer to posterior pharyngeal wall
Keep bolus in oral cavity until voluntary movement

Postural Adjustment
Chin-up

use gravity to help bolus move through the oral cavity

Postural Adjustment
Head Rotation

Turn head to the damaged side to force the bolus to go through the stronger side of the pharynx

Postural Adjustment
Head Tilt

Use gravity to help keep food on stronger side during oral phases

List the three environmental modifications

increase alertness
decrease distractions
improve vision

List the four swallowing maneuvers

Mendolsohn
Effortful
Supraglottic
Super-supraglottic

Swallowing Maneuver
Mendolsohn

hold larynx up longer than usual

Swallowing Maneuver
Effortful Swallow

high effort, lips closed

Swallowing Maneuver
Supraglottic Swallow

1. Take small sip of liquid
2. Hold breath
3. Swallow, cough, swallow again

Swallowing Maneuver
Super-supraglottic Swallow

Same as supraglottic, except with high effort and bearing down during swallow

List the four muscle strengthening exercises

Masako
Shaker
Laryngeal elevation
Lingual isometrics

Muscle Strengthening
Masako

put tongue tip in between teeth and do a dry swallowM

Muscle Strengthening
Shaker

1. Lay on a flat surface
2. Raise your head (look at your toes)
3. Either hold there for a time or lift and relax multiple times in a sequence

Muscle Strengthening
Laryngeal Elevation

lift larynx and hold (glide up a scale and hold a high note)

Muscle Strengthening
Lingual Isometrics

tongue strengthening against resistance

Other Methods of Dysphagia tx

respiratory swallow training (exhale, swallow, exhale)
transcutaneous electrical stimulation

Where is Broca's area?

left frontal lobe, inferior frontal gyrus

Where is Wernicke's area?

left temporal lobe, superior temporal gyrus

Where is the arcuate fasciculus?

it runs from Wernicke's to Broca's area, superior to the lateral sylvian fissure in the left hemisphere

What is aphasia?

an acquired selective impairment of language modalities and functions resulting from a focal brain lesion in the language-dominant hemisphere
it affects a person's communicative and social functioning, quality of life, and the quality of life of caregivers/family members

Speech Production Errors
Paraphasia

something is wrong with what is being produced

Speech Production Errors
Semantic Paraphasia

using the wrong word, often related to the intended word semantically

Speech Production Errors
Phonological Paraphasia

some of the phonemes are not produced correctly

Speech Production Errors
Perseveration

try to move on to a new task, keep answering the previous task

Speech Production Errors
Neologism

creation of a new word, maybe a combination of other words

Speech Production Errors
Jargon

incomprehensible language, frequent distortions, semantic erroes, and new words (neologism)

Speech Production Errors
Circumlocution

talking around the topic, can be used if a person cannot find the word

Speech Production Errors
Echolalia

repetition of words or phrases produced by another person

Speech Production Errors
Stereotypy

one word is used frequently, does not make sense

Broca's Aphasia

Lesion location: Broca’s Area
Output: nonfluent, slow, pauses, mostly just content words
Comprehension: mostly intact
Repetition: poor
Writing: nonfluent, matches speech (typically not cursive)

Wernicke's Aphasia

Lesion location: Wernicke's Area
Output: fluent, relatively effortless, but with paraphasias, jargon, and circumlocutions
Comprehension: impaired
Repetition: poor
Writing: fluent, matches speech (cursive, effortless and fast)

Global Aphasia

Lesion location: large area of the MCA region
Output: nonfluent, may be limited to a stereotype or two
Comprehension: poor, even yes/no difficulty
Repetition: poor
Writing: poor or absent

Conduction Aphasia

Lesion location: arcuate fasciculus
Output: fluent with paraphasias
Comprehension: good
Repetition: poor (often dramatically compared to fluent output)
Writing: fluent with paraphasias

Anomic Aphasia

Lesion location: not clearly localized
Output: fluent, problems with word finding may result in long pauses, nonspecific words, and circumlocutions
Comprehension: good
Repetition: good
Writing: probably good (although with anomia)

Transcortical Motor Aphasia

Lesion location: anterior superior frontal lobe (Broca's intact, although isolated)
Output: nonfluent
Comprehension: okay
Repetition: good
Writing: nonfluent

Transcortical Sensory Aphasia

Lesion location: upper parietal lobe, isolating the perisylvian area
Output: fluent
Comprehension: poor
Repetition: good
Writing: fluent

Transcortical Mixed Aphasia

Lesion location: areas surrounding the perisylvian area, complete isolation of speech area
Output: poor
Comprehension: poor
Repetition: good
Writing: probably poor

What must the clinician decide on based on the outcome of an evaluation for the treatment of specific language modalities and cases?

mild and severe may benefit from communication tips and modifications

What are examples of language aphasia treatments?

global aphasia
auditory comprehension
reading comprehension
speech production
writing
functional communication

When should a clinician focus especially on functional communication?

when a patient has a low number of appointments

Global Aphasia Treatmnet

Treatment of Aphasia Perseveration Program (TAPP) -> involves imposing delays, increase awareness to improve inhibition of perseverative responses

Voluntary Control of Involuntary Utterances -> take what is already being said, make it the right answer, vary the questions, order, responses required, to obtain propositional and volitional control over it

What are some goals to keep in mind when treating global aphasia?

tx focus: consistent yes/no response
simple gestures
small set of "communicative intentions"
improve auditory comprehension for one-step commands
improve patient's writing of daily life word
improve patient's drawing

Where should you start with treatment for auditory comprehension deficits?

Where your patient can at least get it right thirty percent of the time, levels of single word vs. sentence vs. discourse

Auditory Comprehension Treatment

i. picture identification: can build up to multiple words
ii. answering yes/no questions (questions can vary on many level: general knowledge, sentence length, semantic or phonemic discriminations, syntactic analysis, semantic information
iii. following spoken directions (hierarchy of complexity)
iv. sentence verification (e.g., based on clinician-provided picture descriptions)
v. task-switching
vi. answering questions about discourse samples (play sample recording, then ask questions)
vii. may need to adjust: topic familiarity, sample length, redundancy, cohesion, coherence, salience, directness (not implied), speech rate

Reading Comprehension Treatment

i. reading comprehension requires word comprehension, syntactic analysis, semantic mapping
ii. initial question: how much of a priority is reading for the patient?
iii. starting point: single-word vs. discourse comprehension?
iv. surface dyslexia vs deep dyslexia
v. flash cards, retraining grapheme to phoneme correspondence, comprehension drills
vi. adjust difficulty as needed as in treatments for auditory comprehension deficits

Speech Production Treatments

i. repetition drills
ii. confrontation naming
iii. sentence completion
iv. semantic feature analysis (SFA)
v. phonologic components analysis (PCA)
vi. response elaboration treatment (RET)
vii. verb network strengthening treatment (VNeST)
viii. helm elicited language program for syntax stimulation (HELPSS)
ix. melodic intonation therapy (MIT)
x. script training

Confrontation Naming Treatment

i. present stimulus (object, picture, etc.)
ii. use cueing hierarchies to facilitate (semantic, phonological)
iii. examples that seems to work for multiple aphasia types: first sound, sentence completion, rhyme, function, and superordinate

Semantic Feature Analysis (SFA)

i. assisted analysis of the meaning of the word
ii. frequent association of the word’s sound with the word’s meaning

Response Elaboration Treatment (RET)

i. a loose training technique designed for aphasia patients in order to increase the length and information content of verbal responses
ii. how it works...
1. clinician elicits spontaneous response from client using picture stimuli
2. clinician models and reinforce initial response
3. expand and elaborate response through scaffolding
4. reinforces client's attempts at elaboration
5. repeats and expands the client's utterance
6. models and the expansion by scaffolding the client's response
iii. overall idea is to have less structured treatment to increase creative language use (more content words)

Melodic Intonation Therapy

i. for a person with severe auditory comprehension and limited telegraphic speech output (Broca's/Global aphasia)
ii. uses rhythm and melody to facilitate verbal production (right hemisphere)
iii. rhythm and melody gradually faded down to that of typical speech
iv. DO NOT USE POPULAR SONGS

Script Training

i. the client and the clinician work together to create scripts.
ii. a script is a predictable sequence of sentences
1. can be a story that the person with aphasia tells (monologue).
2. can also be between two people, such as ordering food in a restaurant.
3. try to select scripts where words/sentences are easy to predict.
4. examples: getting to know you, talking about your feelings, story of your stroke, retelling a personal event, etc.

Treatments for Writing

can usually give to OT, often a less important goal for us than speech
i. Anagram and Copy Treatment
ii. Copy and Recall Treatment

Treatments focused on Functional Communication

i. PACE (promoting aphasics’ communicative effectiveness)
1. convey information to a partner (info unknown to the partner), with the clinician modeling behaviors he/she would like the PWA to use.
2. emphasizes that communication requires sender and receiver.
3. provides practice with comprehension and production.
ii. supported communication training for conversation partners
iii. life participation approach to aphasia (LPAA)
1. focus on functional activities of daily living and participation in life

Benefits of Group Aphasia Treatment

i. economical, efficient
ii. provides support network
iii. share techniques, strategies
iv. provide opportunities for communication practice with a variety of communication partners in a supported environment

Group Aphasia Treatment Disadvantages

i. requires homogenous grouping of patients so everyone experiences success (can’t couple severe with mild – frustrating for both)
ii. scheduling issues
iii. billing/third party payment issues

List the neurologic processes of speech and language production with their corresponding disorder

i. Conceptualization; dementia/cognitive impairments
ii. Symbolization; aphasia
iii. Motor Speech Planning; apraxia
iv. Motor Speech Execution; dysarthria

What represents the issue with the "musical score" in the orchestra analogy?

apraxia

What represents the issue with the "musicians playing instruments" in the orchestra analogy?

dysarthria

What does motor speech execution involve functionally?

the direct activation pathway (precentral gyrus, supplemental motor area, primary motor area)
the indirect activation pathway (basal ganglia and cerebellar control circuit)
the final common pathway (lower motor neuron in peripheral nervous system)

Apraxia of Speech

i. impairment at the level of motor speech planning and programming
ii. often co-occurs with Broca and is hard to differentiate
iii. may display as difficulty transitioning between sounds, transposition of phonemes, increasing difficulty with increasing complexity of words, slow/inconsistent rate of speech, and trial or groping behaviors of articulators
iv. its developmental form is developmental or childhood apraxia of speech

What are some speech characteristics of apraxia of speech?

i. Prosodic and segmental abnormalities
1. Distortions and distorted substitutions
2. Slow or inconsistent rate of speech
3. Syllable segregations and/or segmentations
4. Transpositions of phoneme/syllables (metathetic errors)
5. Increased difficulty with increased phonetic complexity (not specific to AOS)
ii. Abnormal Speech gestures
1. Trail-groping movements of articulators, as if searching for the correct positions

Dysarthria

i. impairment at the level of motor speech execution (control and/or performance)
ii. deficits in various parameters of neuromuscular movement for any part of the speech subsystems
1. range of motion
2. force
3. tone
4. speech (rate)
5. accuracy (direction)
6. rhythm

Functional Motor Speech System

Direct Action Pathways

influences the excitation of the motor cortex, increasing motor activity
corticobulbar and corticospinal tracts, primary motor cortex, UMN to LMN

Indirect Action Pathways

decreases activity of the cortical motor neurons and suppresses extemporaneous movement
has modulating loops, including the thalamus, basal ganglia, and cerebellum control centers
important for regulating reflexes, posture, and TONE

Final Common Pathway

lower motor neuron system of PNS
impairments can result in atrophy, flaccid dysarthria

What are examples of treatment for apraxia of speech?

the overall focus is to rehab speech movements (not postures or non-speech oral mvmts)
i. Sound Production Treatment
ii. Visual feedback
iii. Rate/Rhythm treatments
1. metrical pacing treatment

Flaccid Dysarthria

i. Final common pathway damage
ii. Variability of nerves involved
iii. Cranial nerves, spinal if severe, or diaphragm (c3 -c5)
iv. Impairment of motor execution results in hypotonia, hyporeflexia, decreased voluntary movement, involuntary movement (fasciculations and fibrillations)
v. Low tone, reduced force, speed can be reduced or normal, ROM reduced, often normal ACCURACY and RHYTHM
vi. Common speech characteristics: breathiness, imprecise consonants, hypernasality, short phrases, audible inspiration (no full adduction of VFs)

Spastic Dysarthria

i. Bilateral DAP and IAP damage (UMN or LMN, basal ganglia or cerebellum)
ii. Unilateral will have different pattern
iii. Can happen in ALS, also with strokes
iv. Impairment in motor execution, results in spasticity, hypertonia/excessive tone, reduced force, speech and ROM, normal accuracy and rhythm
v. Common speech characteristics: harsh phonatory quality (strangled), monopitch and monoloudness, slow speech rate, slow and regular AMRs
vi. Pseudobulbar (emotional excitability)

Ataxic Dysarthria

i. Cerebellar control circuit damage
ii. Impairment in motor control leads to ataxia (jerky movment), can have gait problems, impaired check and excessive rebound, under/overshoot, dysdiachokinesis
iii. Normal to excessive ROM and force, reduced tone and speed, inaccurate direction, irregular rhythm (problems with coordinating space and time)
iv. Common speech characteristics: sound drunk or slurred, excessive variations in volume and pitch, inconsistent sound errors, slow rate, irregular speech AMRs (everything went wrong)

Hypokinetic Dysarthria

i. Basal ganglia control circuit damage
ii. TOO MUCH INHIBITION (lack of dopamine)
iii. Typically associated with Parkinson’s
iv. Symptoms
1. Rigidity
2. Resistance spread more evenly
3. Bradykinesia (reduced movement, range)
4. Akinesia (freezing or lack of movment)
5. Masked facies
6. Festination (involuntary gait quickening)
7. Resting tremor
v. Reduced ROM and force, excessive tone (rigidity), excessive speed for repetitive movements but slow for individual movements, normal accuracy and rhythm
vi. Common speech characteristics: monopitch, reduced stress, monoloudness, inappropriate silences, short rushes of speech, sort and breathy voice, repeated phonemes

Hyperkinetic Dysarthria

i. Basal ganglia control circuit damage
ii. Abnormal and involuntary
iii. Damage to inhibitory components results in extra movements, may also be a result of increase in dopamine (excitatory) and decrease in acetylcholine (inhibitory)
iv. May affect jaw, face, tongue, palate, larynx, or respiratory system
1. Usually a combination of structures
2. isolated effects are also possible
v. reduced intelligibility estimated in around 27% of cases
1. appearance and discomfort of Hyperkinesias themselves may impact verbal and nonverbal communication
2. etiologies: Tourette’s, Huntington’s, vocal tremor
3. Hyperkinesias: dystonia, chorea, athetosis, myoclonus, stereotypies

Hyperkinesias
Dystonia

involuntary muscle contraction, causes repetitive or twisting movements

Hyperkinesias
Chorea

jerky, involuntary movements

Hyperkinesias
Athetosis

abnormal muscle contractions cause involuntary writhing movements

Hyperkinesias
Myoclonus

involuntary, lightning-fast muscle twitches, brief and sudden jerks

Hyperkinesias
Stereotypies

ritualistic movements, rhythmic, repetitive, fixed, predictable, purposeless movments

Unilateral Upper Moter Neuron Dysarthria

i. Unilateral DAP and IAP damage
ii. No highly distinctive perceptual features
iii. Diagnosis typically made by considering a variety of perceptual features and knowledge from case history, etc.
1.Typically involves unilateral central face and tongue weakness, stroke etiology, moderate or greater articulatory imprecision, sometimes mild irregular articulatory breakdowns, slow rate, slow/irregular AMRs, harsh or strained or hoarse-breathy dysphonia, and reduced loudness (no distinctive perceptual features)

List the four areas of treatment for motor speech disorders (dysarthria)

Behavioral
Prosthetic
Pharmacological
Augmentative and/or Alternative Communication