MSD Exam 1 - Paramby

1960’s

Study of MSD’s including dysarthria began

Speech

Motor speech disorder is a _________ disorder

Brain injury

In order to diagnose an MSD, you must have a _______________

Disorder in clear speech (Disordered utterance)

Meaning of dysarthria

Speech

Unique, complex, dynamic motor activity

1. Cognitive linguistic process (memory, attention, EF, reasoning)

2. Motor speech planning and programming (apraxia)

3. Neuromuscular execution (dysarthria)

Motor Speech Process

MSD

“Speech disorders resulting from the neurological impairments affecting the motor planning, programming, neuromuscular control, or execution of speech”

Dysarthria

“Collective name for group of neurological speech disorders resulting from abnormalities in strength, speed, range, steadiness, tone or accuracy of movements required for speech control …. Aspects of speech production.”

Apraxia of Speech

“Neurological speech disorder reflecting impaired capacity to plan or program sensorimotor commands necessary for … normal speech. Can occur in absence of physiologic disturbances associated with dysarthria and in absence of disturbances in any component of language.”

NIH stroke scale

How neurologists are trained to score dysarthria

Palilalia (mimics MSD)

Compulsive repetition of words or phrases usually in context of accelerating rate and decreasing loudness

Echolalia (mimics MSD)

Repetition of sounds, words, or phrases

Aprosodia (mimics MSD)

Without rhythm, stress, etc.

• Most likely psychogenic

• Refer to psychiatrist (not treated like accent modification)

• Exercises - reading samples, speak in other accents, sing passages, emphasize stress on certain words in passage

Foreign accent syndrome

Dysarthria 53%

Aphasia 25.8%

Apraxia 3.9%

Prevalence of speech/lang disorders

• Age of onset (congenital, acquired)

• Course (congenital, chronic, progressive, degenerative)

• Site of lesion

• Neurological diagnosis

• Pathophysiology (spasticity, weakness)

Categorizing MSD’s

Flaccid (LMN) - Execution — Weakness

Spastic (Bilateral UMN) - Execution — Spasticity

Ataxic (Cerebellum) - Control — Incoordination

Hypokinetic (Basal ganglia) - Control — Rigidity

Hyperkinetic (Basal ganglia) - Control — Involuntary movement

UUMN (UUMN) - Control/execution — UUMN weakness, incoordination, spasticity

Mixed (>1) - Control and/or execution — >1

Apraxia - Left hemisphere - motor planning/programming — planning/programming errors

Mayo Clinic Classification & Table 1.1

1. Establish diagnostic possibilities

2. Establish diagnosis

3. Establish implication for localization and diagnosis

4. Specify severity

Purpose of MSD examination

Abnormal speech?

• Neurological?

  • MSD?

    • Dysarthria?

      • What kind?

    • Apraxia?

  • Other neurogenic lang disorder?

• Organic?

• Psychogenic?

Whether it is neurological or not, ask whether it is long standing? Recently acquired? Dev stuttering, lang disorder, lang disability?

Establishing diagnostic possibilities - questions to ask

Always determine the type (ex. Flaccid dysarthria not just dysarthria) = huge diagnostic value

Important to remember when diagnosing

No lab test can diagnose it - it is diagnosed based on med hx, symptoms, phys exam

Parkinson’s - usually hypokinetic dysarthria

Why is Parkinson’s a working diagnosis?

Neuromuscular junction Disorder

Type of Flaccid dysarthria

When they speak for prolonged periods of time, speech for the first few min is normal then begins to decline after minutes. When breaks are given, speech improves again

Myasthenia Gravis

Speech stress testing - have them read a passage out loud multiple times and see how long/how many times it takes for intelligibility to decrease. Give a break and have them read again. If speech improves after break, it is Myasthenia Gravis

How to assess for Myasthenia Gravis (we do not diagnose, but refer)

• measure progress

• Match patient complaints to reality

• Prognosis and management

Determining severity of MSD helps

90%; patient history

_____% of neurological diagnosis depends on __________

Looks at client’s

• Strength

• Speed

• Range

• Steadiness

• Tone

• Accuracy

Salient features

• reduced muscle weakness

  • Laryngeal (VF weakness = breathy voice)

  • Velopharyngeal (hypernasality)

  • Articulators (tongue weakness)

• LMN = CN & SN

Salient features: strength

Flaccid

Weakness is a sign of what type of dysarthria

Fast: uncommon (hypokinetic dysarthria)

Slow: common (spastic dysarthria - reduced speed)

AMR & SMR

Salient features: Speed

AMR (Alternating Motion Rate): pa pa pa

SMR (Sequential Motion Rate): pa ta ka

• people with apraxia will struggle with SMR

AMR vs. SMR

Increased range of motion: uncommon (some hyperkinetic dysarthria)

Decreased range of motion: common (majority of dysarthria’s)

Salient Features: range

Involuntary movements or hyperkinesis

• Resting tremor

• Action tremor

• Postural tremor (sticking tongue out, lifting arms)

• Terminal tremor (towards end of an action)

Abnormal movements

• Dystonia

• Dyskinesia

• Chorea

• Athetosis

Salient Features: Steadiness

• Increased (Spastic/Hypokinetic Dysarthria)

• Reduced (flaccid dysarthria)

Salient Features: Tone

• Regulation of tone, strength, speed, range, steadiness, timing

• Outcome of well coordinated features above

Salient Features: Accuracy (coordination)

• Do not need to diagnose MSD

  • Gait (wide shuffling walk)

  • Atrophy (weakness)

  • Fasciculations (twitching) [LMN lesion]

  • Laughing & crying excessively [UMN lesion]

Confirmatory Signs

Ask patient to cough

If they do not have good strong cough but have glottal coup, problem is at the respiratory level (do not have great breath support but VF are still working)

Assessing the larynx during non-speech tasks

Gag reflex

Stroke back of tongue, faucial pillars, pharyngeal wall

Jaw Jerk

Tongue blade under chin, tap with reflex hammer

Sucking Reflex

Stroke upper lip with tongue blade (lip pucker = unusual response)

Snout Reflex

Lightly tap the philtrum (pucker, protrusion, elevation of lower lip)

Palmomental reflex

Vigorously stroke blunt object on palm of hand

Automatic: numbers, names of months, happy birthday song

Volitional: speech you have to come up with

• AOS patients may do well producing common words (automatic speech) but not uncommon words, multisyllabic words, repetition, etc.

Automatic vs. Volitional Speech

Flutter: rapid, relatively low-amp voice

Tremor: slower, more rhythmic (more severe)

Vocal Flutter vs. Vocal Tremor

Standardized test for Dysarthria (not the types)

Frenchman Dysarthria Assessment (FDA)

Standardized test for Apraxia of Speech

Apraxia Battery for Adults 2nd edition (ABA-2)

Intelligibility

the degree to which a listener understands the auditory signal produced by a speaker

Comprehensibility

the degree to which a listener understands speech on the basis of the auditory signal plus all other information that may contribute to understanding what is said

Efficiency

rate at which intelligible or comprehensible information is conveyed

Important supplement to measure intelligibility and comprehensibility because it contributes to both the perception of speech normalcy and the normalcy of communication by whatever means is social context

Comprehensibility

________ is superior to intelligibility

1: abnormal

7: normal

Functional Communication Measures (FCM)

Communicative effectiveness survey

Dysarthria Impact Profile

living with dysarthria

QOL analysis (filled out by patient or fam members)

look at notes

CN chart

Cortical speech planning & Programing

• Direct activation pathway

  • Final common Pathway

  • Speech

  • Sensory system

• Control circuits

  • sensory system

  • Indirect activation pathway

  • Final common pathway

  • Speech

  • Sensory system

• Indirect activation pathway

  • Final common pathway

  • Speech

  • Sensory system

MSD Model

LMN

The final common pathway is a

PNS = CN & SN

LMN includes

final common pathway (nucleus, axon, neuromuscular junction)

When flaccid dysarthria occurs, the break down is in the ________________

weakness

Main issue associated with flaccid dysarthria

where the line ends & muscle begins (Myasthenia Gravis is a problem in the neuromuscular junction)

Neuromuscular junction - Final common pathway

CNS = brain and spinal cord

UMN include the

UMN: tracts

LMN: nerves

UMN are referred to as _______

LMN are referred to as ________

Speed, range, accuracy

Because there is weakness, ____, _____, & ______ can be the issue

• Weakness

• Hypotonia & reduced reflexes

• Atrophy (bulk of muscle is lost)

• Fasciculation (twitching)

• Fibrillation

• Progressive weakness with use

Characteristics of Flaccid Dysarthria

• Congenital

• Demyelinating

• Infectious/Inflammatory

• Degenerative (ALS)

• Metabolic

• Neoplastic (cancer)

• Traumatic (spinal cord injury)

• Vascular disease (stroke)

Etiologies of flaccid dysarthria

R side facial weakness

Chin fasciculations

R facial lesion (VII) =

affected resonance & voice

Glossopharyngeal lesion (IX) =

VF movement, breathiness, vocal flutter

(L vagus nerve affects VF more if there was a heart procedure)

Vagus nerve lesion (X) =

Tongue movement (fasciculations)

Hypoglossal Nerve (XII) lesion =

Jaw & Tongue = weak side

Everything else in oral cavity = strong side

Which structures deviate to the weak side and which ones deviate to strong side

we cannot be 100% certain where lesion is (could be UMN or LMN - LMN deviates to same side, UMN deviates to opposite side)

If there is atrophy or fasciculation, 100% LMN

If there is only tongue deviation (no atrophy or fasciculation), __________________

CN V

1. Ophthalmic (sensation)

2. Maxillary (sensation)

3. Mandibular (MOTOR) - mandible movement

Trigeminal Neve 3 Branches

Unilateral - Decent speech (other side compensates)

Bilateral - Imprecise Articulation & Prosody (slow rate)

Unilateral vs bilateral damage to Trigeminal nerve

• Jaw deviate to weak side (unilateral)

• Jaw hangs open (bilateral)

• Difficulty chewing, drooling, opening/closing jaw

• Decreased face, cheek, tongue, palate sensation

Trigeminal Nerve lesion - mandibular branch - flaccid dysarthria

Non speech Trigeminal nerve issues

Open/close jaw, move sideways (mandibular branch)

Touch face in areas and see if they can feel it (ophthalmic & maxillary branches)

Cranial nerve V (Trigeminal) examination

Sensory: Taste

Motor: Speech

R or L upper & lower weakness (ipsilateral) (LMN)

R or L lower weakness (contralateral) (UMN)

Facial Nerve lesions (VII)

Unilateral = articulation

Bilateral = articulation & prosody (slow rate)

Twitching of facial muscles (only jaw movement is CN V; every other facial movement is CN VII)

Unilateral & Bilateral Facial nerve (VII) lesions

Taste (sensory)

Tongue/velum movement (motor)

• Gag reflex (vagus also plays role)

Glossopharyngeal Nerve (IX)

CN IX

CN X

CN XI

Pharyngeal plexus consists of what cranial nerves

• Pharyngeal branch

• Superior laryngeal branch (SLN) - pharynx/larynx

• Recurrent laryngeal branch (RLN)

Vagus nerve (CN X) branches

• pharyngeal consrtriction

• Palatial elevation/retraction (speech/swallowing)

  • Hypernasality (resonance)

Pharyngeal branch of vagus nerve

1. Internal laryngeal branch (sensation)

   1. Epiglottis, mucous membrane of larynx, base of tongue, aryepiglottic folds)

2. External laryngeal branch (Motor)

   1. Inferior pharyngeal constrictors

      1. Cricopharyngeus muscle

      2. Thyropharyngeus muscle

   2. Cricothyroid muscle (lengthen VF for pitch adjustment)

Superior laryngeal nerve branch of vagus nerve

SLN - Cricothyroid only

RLN - all other intrinsic laryngeal muscles

Which intrinsic laryngeal muscles are innervated by SLN and RLN of vagus

• innervates all intrinsic laryngeal muscles

• Sensory fibers: vocal folds and below

• After it loops around subclavian artery, it becomes the RLN (not just vagus nerve)

Recurrent laryngeal branch of vagus nerve

Vagus (above pharyngeal branch)

• Uni/Bi respiratory-phonatory

• Uni/Bi resonance

• Uni/Bi articulation

• Uni/Bi prosody

Vagus (below pharyngeal branch, superior branch, recurrent branch)

• Uni/Bi respiratory-phonatory

• Uni/Bi Prosody

Cranial nerve lesions chart

Intermingles with CN X

Part of pharyngeal plexus

Clinically impossible to evaluate

Accessory nerve (CN XI)

• If tongue is weak - imprecise articulation

• Useful task: connected speech and AMR

• Innervates all intrinsic and extrinsic muscles except palatoglossus (innervated by CN X)

Hypoglossal nerve (CN XII)

Breathing

• short phrases (shortness of breath)

• Reduced loudness (not enough breath support)

Spinal nerve lesions are always associated with _______

Sounds like two voices

Diplophonia

F - Flaccid

L - LMN

I/P - Ipsilateral

Tips for dysarthria FLIP