Detailed Notes on Flaccid, Hypokinetic, and Hyperkinetic Dysarthria

Flaccid Dysarthria Speech Characteristics

• Hypernasality with nasal emissions.
• Shortened phrases because of air escaping through the nose.
• Imprecise consonant production.
• Slow and labored speech.
• Phonatory incompetence.
• Breathy voice.
• Audible inspiration.
• Decreased inhalation with exhalation.
• Mono pitch.
• Monoloudness.

Causes of Flaccid Dysarthria

• Anything that disrupts the flow of motor impulses along the cranial or spinal nerves that innervate the muscles of speech production.
• Physical trauma (surgical trauma, head or neck injury).
• Brain stem stroke.
• Myasthenia gravis.
• Guillain-Barré syndrome.
• Polio.
• Tumor.
• Muscular dystrophy.
• Progressive bulbar palsy.

Neurological Basis of Flaccid Dysarthria

• Damage to the lower motor neurons in the Peripheral Nervous System (PNS).
• Damage to the peripheral nervous system distinguishes flaccid dysarthria from other types of dysarthria.
• Six cranial nerves play a vital role in speech production:
  • Trigeminal (V): Innervates the jaw and rear nerves.
  • Facial (VII): Innervates the muscles of the upper and lower face.
  • Glossopharyngeal (IX): Innervates the pharynx.
  • Vagus (X): Innervates the larynx and the velum.
  • Hypoglossal (XII): Innervates the muscles of the tongue.
  • Accessory cranial nerve also innervates.
• Spinal nerves innervate respiration

Flaccid Dysarthria Treatment

• Phonation: Pushing and pulling exercises, harsh glottal attack, CPAP for velar strengthening.
• Resonance exercises.
• Pitch change pitch range exercises
• Patient chunk breathing passages
• Reading to cast of stress drills
• Articulation held ability drills
• Phonetic placement
• Exaggerating consonants
• Minimal pairs or contrast
• Respiration: Co-treat with other therapeutic fields, use prosthetic devices as a compensatory strategy.
• Speak immediately on exhalation
• Cue them for complete inhalation.
• Correct their posture
• Posture is key for respiration

Hypokinetic Dysarthria

• Hypo means less motion.
• Muscles have less movement and aren't defined, droopy, weak, and have no strength.
• Muscles can be considered paralyzed or have paresis (muscle isn't quite paralyzed, but it's definitely weak).
• Difference between hyperkinetic and hypokinetic dysarthria is the motion of the muscle.

Neurological Basis

• Basal ganglia involvement.
• Decrease in dopamine and acetylcholine neurotransmitters.
• Dopamine is a motivator, makes people happy.
• Lack of dopamine leads to a lack of motivation to continue with therapy in Parkinson's disease patients.
• Speak Out program understands the lack of motivation tied to the disease.
• Speak Out program addresses multiple issues, unlike LSVT which primarily addresses voice.

Parkinsonism

• Parkinsonism is an umbrella term under hypokinetic dysarthria.
• Parkinsonism means all of the symptoms seen in a person, they're not necessarily diagnosed as Parkinson's disease.
• Many other different diseases and disorders can fall under Parkinson's without being diagnosed with Parkinson's disease: idiopathic, toxic metal poisoning, head trauma.
• Idiopathic: Parkinsonism symptoms with no known cause.
• Toxic metal poisoning: Exposure to a toxin leads to a diagnosis of Parkinsonism and possibly Parkinson's disease.
• Head trauma: Can lead to encephalitic Parkinsonism.
• Muhammad Ali and Michael J. Fox were diagnosed with Parkinson's disease.
• Deep brain stimulation is a treatment option; involves an implant that the person can adjust through a phone app.
• Not everyone with Parkinson's disease has tremors, a decrease in volume, or tiny handwriting.
• Inability to smell can be an indicator of neurological issues.
• Not everyone with Parkinson's disease will have cognitive decline.
• Spouses often report lower volume and slower speech in individuals with Parkinson's disease.

Hypokinetic Dysarthria Symptoms

• Rapid rate of speech is a hallmark sign.
• Reduced voice/vocal loudness.
• Harsh or breathy voice.
• Parkinsonism is a collective term until a specific diagnosis is made.
• Extrapyramidal system in the basal ganglia is responsible for automatic movements.
• In Parkinson's disease, intention is emphasized to make muscles work.
• LSVT BIG (OT and PT) works on wide range movements since people with Parkinson's may not swing their arms when they walk.

Clinical Signs

• Resting tremor (tremor decreases once movement begins).
• Bradykinesia (slow rate of reduced motion).
• Rigidity of muscles (increased muscle tone).
• Akinesia (delay in initiating movements).
• Balance issues (stooped posture).
• Masked face (very little emotion).
• Short, shuffling steps.
• Lack of dopamine inhibits muscle function.
• Too much medication can induce Parkinson's disease-like symptoms.
• Repeated head injuries can cause traumatic brain injury.
• Toxic metal poisoning (manganese, pesticides) and stroke.

Causes of Parkinsonism

• Degenerative idiopathic Parkinson's disease is the most common form.
• Drug-induced: Antipsychotics can cause symptoms, but changing medications may have other consequences.
• Viral encephalitis can affect dopamine and impact children.
• Punch drunk encephalopathy: From head injuries.
• Cerebral anoxia: Lack of oxygen to the brain.
• Exposure to toxins.
• Multiple strokes.

Characteristics of Speech

• Reduced range of motion (neck, tongue, lips).
• Prosody affected (mono pitch, monoloudness).
• Masked face, flat affect.
• Inability to start speech right away.
• Short rushes of speech, increased rate.
• Impaired articulation.
• Palilalia (rapid repetition of a word or phrase).
• Voice may sound harsh due to pushing.
• Reduced breathing quality.
• Slight hypernasality.

Evaluation of Speech

• Conversational speech: Open-ended questions to hear speech patterns, hesitations, and voice maintenance.
• AMRs and SMRs: To hear rapid bursts of speech and imprecise consonants.
• Prolonged "ahs": To assess respiration and voice quality before and after inhalation cues.

Treatment

• Pharmacological treatment is most beneficial initially.
• Carbidopa-Levodopa to improve person's condition.
• Anti-cholinergic drugs for hypokinetic dysfunction.
• Drugs may have hallucinatory side effects.
• Deep brain stimulation to balance out electrical impulses (for tremors).

Surgical Treatments

• Ablative procedures are rarely done due to negative outcomes; involve burning tissue in the brain.
• Stem cell research being explored.

Behavioral Treatments

• Pacing board, alphabet board to slow down speech.
• Auditory feedback device (headphones) delays the person's speech, slowing down rate.
• Metronome for pacing.
• Oral motor exercises for range of motion (lip stretches, tongue exercises).
• Intelligibility drills, exaggerated consonants, over-articulation, minimal contrast drills.
• Voice amplifier for increased loudness.
• Feedback tools like the "Bla Bla Bla" app, but there is LSVT.

LSVT Protocol

• LSVT is a treatment that aims at fixing one's loudness because that's usually one of the big things that people notice right away.
• Emphasizes loudness is addressed.
• Address shallow breath support through deep breaths and posture.

Exercises:

• Prolonged ahs nice and long
• Making sure posture is at 90 degrees is
• Making sure we open and expand the lungs to accept all nice oxygen
• Speaking on exhalation

Other treatment Considerations:

• Chunk utterances
• Those clients need practice maintaining what their voice sounds like
• You need feedback for what you're saying and how you present verbally.

Hyperkinetic Dysarthria

• Excess movement.
• Basal ganglia is involved; damage causes increased, uncontrollable movements.

Hyperkinetic vs Hypokinetic:

• Hyperkinetic = too much movement.
• Hypokinetic = too little movement.

Impact on Speech

• Articulation errors.
• Errors in prosody.
• Errors in respiration.
• Voice affected.
• Intelligibility is complicated by excess movement.
• Too much movement of Muscles is called Dance-Like.
• Person has inability to coordinate their own movements based on what's happening in the nasal ganglia, they're going to produce these dance like movements that will hold them back having intelligent speech.
• Rapid dance-like movements will impair speech.

Causes

• Korea
• Myoclonus
• Tics
• Essential tremors
• Dystonia

Disorders:

• Sydenham's chorea: Affects pediatric population (ages 5-15) after rheumatic fever.
• Huntington's disease: Hereditary, terminal illness with cognitive components and uncoordinated motor movements. Genetic testing recommended.

Symptoms of Huntington's

• Progressive movement disorders, cognitive decline, and psychiatric disorders

Hyperkinetic Dysarthria Specific Components

• Prolonged intervals between speech. Person is trying to balance the movements and coordinate speech at the same time.
• Rate of speech might be varied.
• Errors on the pitch
• The articulation:
• Need precise movements in order to create sounds and need our tongues to be in certain places in the mouth
• In coordination

Spasmodic Dysphonia

• Breathy Speech and Effortful Speech.

Myoclonus

• Those little jolts, these are random and don't suppress
• The voice has that tremor in it and it can not go away.

Stroke Damage:

• Stroke damage near the basal region.

Tourette's

• People with Tourettes or people with Tourette Tic disorders are able to suppress those tics.

Essential Tremors

• Is seen in the hands.

Dystonia

• These interferences with posture happen more slower in the Korea and other neurological symptoms, these more affect one part of the body.

• Generalized Dystonia:

• Affect our forelimbs, our torso and our neck so what we see is those are the only places we are going to find those involuntary movements

• Hemidystonia:

• Affect two or more body parts on the same side of the body.

Damage:

• Conditions like strokes that are near traumatic head injuries

• Muscles Activate on its own

Speech Patterns

• Strained or strangled voice because the muscles don't know when the contractions are going to activate.

• Sounds Like there in a choke hold.

Adductor v Abductor spasmodic dystonia:

• Muscle spasms that can cause the vocal folds to either slam shut or open forcefully

Compensation Mechanisms:

• Inappropriate silent moment

Treatment:

• Voice therapy
• Botox to relax the muscle, and this is a shot based on those people who have a lot of muscle movements and the medication helps and decreased muscle movement,

Huntington's

• Improve Speech and swallowing with

  • Posture
  • Speaking at a rate that is optimal

• AAC is a last source for communication since they will lose complete control with their muscles and tongue.

Sensory Tricks

• We can give them a sensory that tricks the brain to do automatic movements. If somebody has drooling, gum might help the with swallowing. Other tricks are like a life savers that helps with speech.