Motor Speech Disorders Exam 4

LMN overview

direct innervation to muscle motor end plate; FCP

UMN overview

direct - sends innervating signal

indirect - provides framework for adjusting innervation signal

Two control circuits

1. cerebellar control circuit

2. basal ganglia control circuit (BGCC)

Responsible for the integration and control of UMN output

parts of the BGCC

Striatum - Caudate nucleus and putamen

Lentiform Nuclei - globus pallidus and putamen

Substantia Nigra & Substantia Nuclei

what is the basal ganglia?

a group of deep brain nuclei that regulates voluntary movement and influences habit/motor learning

what are the functions of the basal ganglia?

initiation of movements, motor learning, and habit formation (creating automatic behaviors)

what are the major neurotransmitters of the BGCC?

acetylcholine and dopamine (activate and reward)

functions of the BGCC

-controls muscle tone

-maintians normal posture

-regulates amplitude and velocity of movement

-assists with initiation of movement

-cortex initiates more impulses for movement than needed

-dampens/modulates impulses for movement

effects of damage to the BGCC

hypokinesia (loss of dopamine)

hyperkinesia (loss of acetylcholine)

hypokinesia

the result of a loss of dopamine; characterized by reduced movement and is associated with PD

hyperkinesia

the result of a loss of acetylcholine; characterized by involuntary or excess movements and can manifest as chorea, dystonia, tremors, spasms, tics, athetosis, or ballism

abolished by sleep & exaccerbated by anxiety/emotions

dyskinesia

a general term used to refer to abnormal, involuntary movements, regardless of etiology

myoclonus

characterized by involuntary single or repetitive brief, lightning-like jerks of a body part that cannot be inhibited willfully; can be rhythmic or nonrhythmic

tics

rapid movement that can be controlled voluntarily for a time, but performed frequently due to compulsive desire; most commonly assocaited with Tourette's Syndrome

chorea

involuntary, non-stereotypic, random, purposeless movements of body structures that are dance-like

ballismus

movements that involve gross, abrupt contractions of axial and proximal muscles of the extremities that can produce wild flailing movements; most commonly caused by stroke

athetosis

characterized by slow, writhing, purposeless movements that tend to flow into one another; considered a major category of CP and is often considered a combination of chorea and dystonia

dystonia

a hyperkinetic movement disorder of muscle tone that causes involuntary, prolonged muscle contractions that interfere with normal movement or posture; slower/more sustained than chorea; can use sensory tricks

spasm

a general descriptive term that designates various abnormal muscular contractions; can be tonic (prolonged/continuous), clonic (repetitive), rapid, or brief

tremor

rhythmic (periodic) movements of a body part with relatively constant frequency; most common movement disorder

what areas of speech does hypokinetic dysarthria impact?

manifests in respiration, resonance, articulation, and phonation (RRAP) and is predominantly identified in voice, articulation, and prosody

what causes hypokinetic dysarthria?

damage to the basal ganglia control circuit (particularly dopamine pathways)

characteristics of hypokinetic dysarthria

-rigidity

-decreased range of movement

-reduced force of movement

-some movements may be fast (velocity) and repetitive

hypophonia

soft speech; reduced loudness

tachyphemia

rapid speech

4 main eitologies of hypokinetic dysarthria

1. degenerative (89.2%) - mostly PD (75%)

2. vascular (3%) - stroke

3. other (3%) - toxic/metabolic, TBI, infections, hydrocephalus

4. undetermined (5%)

tartive dyskinesia (TD)

an involuntary, repetitive movement disorder of the mouth, lips, and tongue that develops as a side effect of long-term treatment with dopamine-blocking medications

what is the most common etiology of hypokinetic dysarthria?

Parkinson's Disease (PD) (degenerative)

idiopathic and hereditary forms of PD

-progressive loss of cells in substantia nigra

-decreased dopamine in BG

-imbalance between acetylcholine and dopamine in BG

-can be treated w/ drugs that increase dopamine (carbidopa-levodopa)

carbidopa-levodopa

a medication that can be used to increase dopamine in the basal ganglia

clinical characteristics of PD

-resting tremor (head, limbs, pill-rolling, jaw, lips, tongue)

-rigidity

-bradkykinesia

-postural abnormalities

-hypomimia

-reduced arm swing and gesturing speech

-micrographic writing

-festination of gait (short, rapid, shuffling steps)

-impaired sensory function (problems estimating movement size and range; reduced visual, auditory, tactile discrimination)

rigidity

resistance to passive stretch in all directions of movement

bradykinesia

problems in movement planning, initiation, and execution, as well as slow initiation and speed of movement

postural abnormalities

stooped, sitting, standing, difficulty adjusting to tilt or fall

hypomimia

masked facies; can be a diagnosable trait of hypokinetic dysarthria

micrographic

small handwriting, can be an early detector of PD

patient perceptions and complaints of hypokinetic dysarthria

-quiet or weak voice

-words are too fast or indistinct

-hard to initiate speech

-fatiguing

-drug recovery cycle (drooling, swallowing difficulty, stiffening of the upper lip)

nonspeech clinical findings of hypokinetic dysarthria

-reduced blink frequency

-masked facies/expressionless

-lack of animation during discourse

-may have reduced swallowing (pooling/drooling)

-jaw, lip, or tongue tremor

speech clinical findings of hypokinetic dysarthria

-assessed through conversations, reading, AMRs, vowel prolongation, and writing samples

-most pronounced in phonation, articulation, and prosody

-speech movements/timing are generally accurate

-slow individual movements

-reduced repetitive movements

-tone is excessive w/ resistance to movement (rigid)

Deviant characteristics of hypokinetic dysarthria

prosodic insufficiency - monopitch, mono loudness, reduced stress, short phrases, variable rate, short rushes of speech, and imprecise consonants

respiration findings in hypokinetic dysarthria

reduced vital capacity, amplitude chest wall movement, respiratory muscle strength, and endurance, and irregular breathing patterns

phonation findings in hypokinetic dysarthria

reduced laryngeal efficiency, flexibility, and control of quality and prosody; result of rigidity

resonance findings in hypokinetic dysarthria

sometimes a result of slowed movement but not typically perceived as prominent

articulation findings in hypokinetic dysarthria

influence on precision, range of movement, rate, strength, and endurance in the presence of tremor, steadiness, and control

stress, pause, and other characteristics

flattened or indistinct ("fused")

assessment of hypokinetic dysarthria

comprehensive evaluation of the individual's speech and motor abilities; commonly used assessments include:

case history

oral mech exam

speech eval

intelligibility rating

assessment of respiration

perceptual analysis

assessment of motor control

instrumental assessment

case history

the act of gathering information about the individual's medical history, including any underlying conditions; includes medication history, as well as the onset an dprogression of the speech difficulties

oral mechanism examination

assessing the structure and function of the oral mechanism including the lips, tongue, jaw, and palate; looking to identify any weakness, rigidity, or abnormal movements that affect speech production

speech evaluation

analyzing the individual's speech characteristics including rate, loudness, articulation, phonation, prosody

key speech features of hypokinetic dysarthria

reduced vocal loudness (hypophonia), monotone speech, imprecise articulation, and rapid rate (tachyphemia)

intelligibility assessment

determining the individual's overall intelligibility and the impact of dysarthria on their ability to be understood by others; accomplished by having the individual read/repeat specific words, phrases, or sentences

assessment of respiration

evaluating respiratory support for speech production; assessed through tasks such as sustained phonation or connected speech tasks

perceptual analysis

using perceptual rating scales or subjective judgements to assess the severity and characteristics of the dysarthric speech; involves rating the individual's speech on scales related to loudness, pitch variability, and speech naturalness

assessment of motor control

evaluate motor control, coordination, and movement patterns in non-specific tasks (finger/foot tapping, hand movements, DDK rates)

instrumental assessment

looks at specific aspects of speech production including vocal intensity, respiratory function, and muscle activity; examples of assessments include acoustic analysis, aerodynamic measurements, electromyography (EMG)

6 treatment techniques (hypokinetic)

1. articulatory precision

2. prosodic control

3. breathing and phonation control

4. intensive speech programs

5. compensatory strategies

6. AAC

articulatory precision techniques

goal is to improve the accuracy and clarity of sound production by slowing down the rate and over-articulating; can use phonetic placement techniques

prosodic control techniques

pacing boards, delayed auditory feedback, and rhythmic cueing

breathing and phonation control techniques

respiratory training and phonation exercises

intensive speech programs

LSVT LOUD

SPEAKOUT!

speech intelligibility drills

compensatory strategies

self-monitoring, communication breaks

hyperkinetic dysarthria

a perceptually distinguishable group of motor speech disorders manifested in any or all levels of speech (especially prosody/rate); associated with/ visible orofacial, head, and respiratory movements

what causes hyperkinetic dysarthria?

damage to the basal ganglia control circuit (basal ganglia, thalamus, and cerebral cortex)

three etiologies of hyperkinetic dysarthria

1. degenerative (Huntington's disease)

2. toxic-metabolic (neurometabolic and medications affecting neurotransmitter balance (TD))

3. infections/vascular/trauma/neoplasm

patient perceptions of hyperkinetic dysarthria

-non-rhythmic (slurred, slow, halting, hard to get out)

-abnormal movements at rest or during speech

-"my muscles don't work right"

-shaky, tight, or closed-off voice

-use of tactile/proprioceptive sensory tricks

hyperkinetic dysarthria of chorea

a movement disorder distinguished by random involuntary movements of limbs, trunk, head, and neck; degree of chorea influences how severly speech is affected

nonspeech oral mech findings with chorea

-normal: jaw, face, tongue, palate, and reflexes

-occasional drooling w/ dysphagia

-motor unsteadiness, choreiform movements

speech findings with chorea

-conversation, reading, and AMRs, and vowel prolongation are useful

-careful visual observation: look for confirmatory evidence

deviant speech characteristics of hyperkinetic dysarthria

1. respiration

2. phonation

3. resonance

4. articulation

5. prosody

deviant characteristics: respiration (hyperkinetic dysarthria)

sudden forced involuntary inspiration/expiration; excess or alternating loudness

deviant characteristics: phonation (hyperkinetic dysarthria)

-harsh vocal quality

-strained-strangled quality

-excess loudness variation

-voice stopping

-audible inspiration/stridor

-vocal tremor

deviant characteristics: resonance (hyperkinetic dysarthria)

nasality changes due to pharyngeal cavity shape/movements (not very common); possible mild hypernasality

deviant characteristics: articulation (hyperkinetic dysarthria)

-imprecise consonants

-distorted vowels

-irregular articulatory breakdowns

-prolonged phonemes

deviant characteristics: prosody (hyperkinetic dysarthria)

-monopitch

-monoloudness

-inappropriate silences

-shortened phrases

-reduced stress

action myoclonus (hyperkinetic)

disorganized fine/coarse jerking of a muscle or group of muscles when a conscious attempt at precision is made (not at rest); caused by anoxic encephalopathy; has primary effects on:

articulation (slow rate, decreased precision)

phonation (voice arrests)

AMRs (deterioration)

What causes Tourette's Syndrome?

traced to mild brain damage or toxic reactions to medications in some cases, but no identifiable CNS disorder in most cases

primary distinguishing speech and speech-related findings in Hyperkinetic Dysarthria associated with/ Tourette's

1. phonation-respiration

2. resonance

3. articulation-prosody

4. physical

5. patient concerns

phonation-respiration findings in hyperkinetic dysarthria w/ tourette's

coughing, grunting, throat clearing, screaming, moaning

resonance findings in hyperkinetic dysarthria w/ tourettes

sniffing

articulation-prosody findings in hyperkinetic dysarthria w/ Tourettes

humming, whistling, lip smacking, echolalia, palilalia, coprolalia

physical findings in hyperkinetic dysarthria w/ tourette's

multiple motor tics (e.g., eye blinks, head twitch, facial grimacing, jumping, touching, obscene gestures

patient concerns in hyperkinetic dysarthria w/ tourette's

awareness of vocal and motor tics, compulsions to perform them, inability to inhibit them for sustained periods; behavioral and psychiatric disorders may be present (e.g. obsessive-compulsive phobias, hyperactivity, and attention-deficit disorder, learning disability)

nonspecch oral mech findings w/ dystonia

Normal: jaw, face, tongue, palate, and reflexes

-occasional drooling and dysphagia, globus sensation

-difficulty maintaining steady facial postures

speech oral mech findings w/ dystonia

conversation, reading, AMRs, and vowel prolongation are useful; pay careful attention to visual observations and confirmatory evidence

other hyperkinetic dysarthrias

-spasmodic dysphonia

-spasmodic torticollis (cervical dystonia)

-athetosis

-palatal tremor

-essential tremor

spasmodic dysphonia

a group of voice disorders (abductor, adductor, and mixed) that causes involuntary muscle spasms in the voice box, or larynx; mostly affects middle-age women

spasmodic torticollis (cervical dystonia)

a painful chronic neurological movement disorder that causes involuntary contractions of the neck muscles

palatal tremor (palatopharyngeal myoclonus)

rare disorder characterized by relatively abrupt, rhythmic or semirhythmic unilateral or bilateral movements of the soft palate, pharyngeal walls, and laryngeal muscles; caused by a lesion in the brainstem

essential tremor

a relatively benign hyperkinetic movement disorder that causes tremulous movements in affected body parts; the most common hyperkinetic movement disorder (idiopathic)

key evaluation tasks for hyperkinetic dysarthria

vowel prolongation, AMRs, conversational speech and reading, careful observation of associated involuntary movements

treatment for hyperkinetic dysarthria

diverse treatment options dependent on medical etiology or behavioral interventions

medical treatments for hyperkinetic dysarthria

•Pharmacologic - drugs that suppress involuntary movements that cause speech deficits

-Botox: most successful

•Deep brain stimulation

behavioral treatment for Huntington's disease

early stages: maintain normal prosody and optimal rate

middle stages: rate of speech, rhytmic breathing/relaxation, speaking in exhalation

progressive dementia: work closely with caregivers

behavioral treatments for dystonia

sensory tricks, bite blocks, early onset of phonation

sensory tricks

idiosyncratic strategies that can suppress involuntary movement for a time