Assessment of Motor Speech Disorders

Goals of Evaluation

• Determine if the patient has a motor speech disorder.
• Determine the specific disorder/type of dysarthria.
• Determine which subsystems need treatment and are amenable to it.
• Determine how the MSD impacts the patient's ability to perform functional tasks.
• Determine if the patient participates in activities at home or in the community.
• Recommend level of care/elicit patient-centered goals.
• Assess/inform regarding disease progression.
• Plan treatment/modify goals/determine discharge vs. continuation of therapy.

Components of an Assessment

• Case History
• Formal and informal assessments
• Summary of findings with severity rating
• Prognostic statement
• Long term goals
• Short term goals
• Education

When Evaluation Begins

• When you first see the patient in their room or the waiting room.
• When they enter your office.
• When you greet them.
• When you call to schedule a home visit.
• Information obtained from observations.

Observations and Notes

• Need to observe/note patterns of movement and accompanying physical/physiological traits.
• Assess the client coming into your office:
  • Is the client able to ambulate? Using assistive device?
  • What side looks weak? Does the client need a wheelchair?
  • What's balance status? Posture?
  • Is there noticeable problem holding head up?
  • Is there an arm weakness/paralysis? Is arm loosely hanging down, in a sling? Are fingers and/or wrist contracted?
  • Is the client able to rise from a chair and sit down independently?
  • Is the client drooling?

Information Obtained in a Case History

• Begin to establish patient-centered goal
• Patient's description of the problem.
• Age at onset and time since onset of the problem.
• Course of deficit: sudden onset, improving, progressively worsening, plateauing
• Patient's perceived degree of disability or loss of communication caused by the problem
• Effects of problem on patient's daily living, occupation, etc.
• Patient's awareness of the neurological diagnosis if available.
• Site of lesion: primary goal is establishing site of lesion can predict certain speech deficits
• Pathophysiology: weakness, tremor, fasciculations, spasticity, breathiness
• Patient's and family's strategies to deal with the speech problem
• Co-existing physiological problems: paralysis, dysphagia, alexia, agraphia, anomia, etc.

Tools to Assess Motor Speech Disorders

• Perceptual
• Instrumental
  • Acoustic
  • Physiologic
• Visual imaging
• DAB's classification reflects presumed underlying pathophysiology and is related to nervous system localization, clinically useful.

Instrumental Methods

• Acoustic: sound pressure level meter, pitch analysis, nasometer
• Physiologic: electromyography, kinematic measures of electroglottography, magnetometry, and aerodynamic measures of spirometry, and nasal accelerometry, IOPI
• Functional magnetic resonance imaging (fMRI)
• Positron emission tomography (PET)
• Single-photon emission computed tomography (SPECT)
• Multi-channel encephalography (EEG)
• Transcranial magnetic stimulation (TMS)
• Magnetoencephalography (MEG)
• Stopwatch to measure MPT
• LSVT, PRAAT programs

Visual Imaging Methods

• Videofluoroscopy
• Nasoendoscopy
• Laryngoscopy
• Videostroboscopy
• FEES

Assess the Impact of the Motor Speech Disorder on the Client's Life

• Administer a Quality of Life assessment/Patient Reported Outcome Measure.
• Administer a Cognitive linguistic screening. (SLUMS, MoCA, etc.)

Perceptual Assessment

• Gold standard for clinical diagnosis, rating severity, planning treatment, and assessing change over time.
• Unreliable between clinicians, difficult to quantify, and cannot test hypothesis re: pathophysiological cause of problem.
• Experience matters-SLPs need “ear training”.
• First modern chart of features: Darley, Aronson, and Brown (DAB)-has expanded over time.

Assessment of Speech

• Subsystems of speech involved: respiration, phonation, resonance, articulation, prosody
• Perceptual characteristics
• Severity
• Rate intelligibility.

Assessment of Respiration

• Observe Posture and Body movement in sitting and standing. Are they slumped forward, to one side? How does posture affect respiration?
• Note breathing patterns. Is the pattern normal with abdominal and rib cage movement? Is there clavicular breathing?
• Inspiratory stridor? Wheezing?
• Duration Measures: MPT-Take a deep breath and say "ah' for as long as you can until you are completely out of air."
• Oral reading of a standard passage: count number of breaths, phrase length/number of syllables per breath
• Conversation: phrase length
• We need to see how respiration affects intelligibility, e.g. does the client have enough air to complete sentences or do they run out of air at the ends of sentences.

Sustained Vowel Data

• Young males- 22.6 to 34.6 seconds
• Young females- 15.2 to 26.5 seconds
• Elderly males- 13.0 to 18.1 seconds
• Elderly females 10.0 to 15.4 seconds

Assessment of Phonation

• Perceptual judgements of pitch, vocal quality and loudness can be assessed in structured speaking situations, during conversation, or when taking the case history.
• Loudness: assessment also relates to phonatory competence. Loud AH, average SPL in words, etc.
• Pitch: Appropriate for age, gender, size. Ascending and descending glides; stair step scales.
• Quality: diplophonia, strained- strangled, hoarseness, breathiness, tremor
• Formal Instrument

Prolonged Vowel

Assessment of Resonance

• Where is the signal resonating in the client's vocal tract?
• Nasal air emissions: puff of air out the nose on plosives, fricatives, and affricates
• Hypernasality
• Hyponasality
• Nares occluded/unoccluded
• Laryngeal mirror under nares
• Sentences: Mary is making muffins. (Nasals)
• Buy Bobby a puppy. Be good to other people. (no nasals!)

Assessment of Articulation

• AMRs and SMRs observe movements of jaw, lips, and tongue in speech-like tasks.
• (young and elderly adults 5.0-7.1 per second -puh; 4.8 to 7.1 tuh; 4.4 to 6.4 kuh)
• SMRs-young and elderly 3.6-7.5 per second.
• Speech sound inventory
• Connected speech sample

AMRS

SMRS

Assessment of Prosody-Involves respiration, phonation, and articulation.

• Stress: use of pitch/loudness and/or duration to emphasize syllables or words.
• Intonation: use of pitch inflections
• Rate: is rate abnormally fast, slow, or variable?
• Rhythm: is rhythm smooth or choppy

Oral Motor/Oral Peripheral Examination

• Crucial - Sometimes all you have.
• Assess motor and sensory functions
• Assess breathing, phonation, resonance, articulation, and prosodic aspects of speech production
• Flashlight, tongue blades, gloves, tissue or cotton ball/swabs, timer, Rainbow, Caterpillar, or Grandfather passage

Subsystems of Speech and Speech Components

• Respiration
• Phonation
• Resonance
• Articulation
• Prosody
• Muscle strength
• Speed of movement
• Range of movement
• Accuracy of movement
• Motor steadiness
• Muscle tone

Assessment of Structures at rest, during sustained postures and during movement

• FACIAL a/symmetry, strength, ROM, etc.
• MANDIBULAR a/symmetry, strength, etc.
• LINGUAL a/symmetry, range, rate, strength, precision
• VELAR a/symmetry, elevation, retraction, gag reflex
• Larynx cough and glottal coup-Report strength, quality, loudness
• LARYNGEAL/vocal quality: hoarse, strained, breathy, etc.)
• BREATH SUPPORT, coordination of respiration and phonation, etc.
• Reflexes-gag, snout, etc.

Assessment of nonspeech (physiologic) movements

• Can stress nonspeech programming ability
• Supratentorial lesions (dom. Hemisphere mostly) or apraxia or aphasia are suspected, the ability to imitate or follow commands for nonspeech movements needs to be assessed.
• Assess comprehension when following OME commands. Assess by verbal command if comprehension is okay. Can give a model and ask for imitation.
• Non-verbal apraxia indicated by either repeating the command, recognizing error and attempt to correct, increased errors with repetition. Dominant hemisphere damage most likely.

Salient Neuromuscular Features to Assess

• Symmetry
• Strength
• Speed
• Range of Motion
• Steadiness
• Tone
• Accuracy
• Sensation
• These are the Darley et al. Framework of salient features.

Strength

• Muscles need strength to perform natural functions, have reserves to work when tired.
• Weak muscles fatigue more easily.
• Weakness affects respiration, phonation, articulation, resonance:
  • 3 major speech valves: laryngeal, velopharyngeal, articulatory
• Weakness is cardinal sign of LMN deficit. (flaccid dysarthria)
• Usually reduced consistently, but in some cases, it becomes progressively worse.

Speed

• Speech movements are rapid: Think of how fast respiration, phonation, and articulation occur! We can produce up to 14 phonemes/sec in conversation.
• May see excessive speed in hypokinetic dysarthria, but most often in hyperkinetic dysarthria. If so, always associated with decreased range of motion.
• Slow movements are common with MSDs. Reduced speed can be at any of the levels/valves.
• Reduced speed affects prosody.
• Reduced speed most common in spastic dysarthria, but it may be present in others.

Range

• Distance traveled by speech structures is precise for single and repetitive movements, but it may have some variation…but think about all of the little differences.
• Abnormalities in range of movement (ROM) influence prosody as well as articulation.
• Not common to see consistent, excessive ROM in MSDs, but decreased ROM is common.
• Changes in ROM are seen in hypokinetic, ataxic, and hyperkinetic dysarthria.
• Typically reduced or variable; excessive in hyperkinetic dysarthria.

Steadiness

• No visible tremors or shakiness at rest or normal speech unless fatigued, emotional, or cold (shivering!)
• Unsteady in either rhythmic or arrhythmic fashion.
• Involuntary movements/hyperkinesias can be tremors. Tremors can affect mainly phonation, when severe prosody and rate. Seen best is sustained vowels.
• Random, unpredictable, adventitious movements that vary in speed, duration and amplitude—dyskinesia, dystonia, chorea, athetosis. Seen at rest and in movement. Can affect any valve or speech component, with changes in accuracy, prosody and rate.
• Seen in hyperkinetic dysarthrias.

Tone

• Excessive
• Reduced
• Fluctuating tone
• Occurs at any valve or level of speech production.
• Flaccid dysarthria has low tone.
• Spastic and hypokinetic with increased tone.
• Hyperkinetic dysarthria with variable tone.

Accuracy

• Properly executed speech needs enough precision and regulation of tone, speed, strength, range, steadiness, and timing of the speech muscles.
• If neuromuscular performance is normal, inaccuracies may be linguistic or motor planning/programming deficit
• Accuracy errors can occur in any of the speech valves or at any level of speech production.
• Inaccuracy can occur in all dysarthrias, but if the problems are in timing and coordination- ataxic dysarthria or AOS.
• Inaccurate on a consistent or inconsistent basis.
• If unpredictable movements—hyperkinetic dysarthria

Oral Mechanism Exam Tests

Trigeminal Nerve: Cranial Nerve V Review

• Assess the jaw for Strength, Speed, Range, Steadiness, Tone, and Accuracy
• Measure sequential motion rates (SMRs) using /p t k /
• Listen for pace and rate of production, articulatory precision, weak intensity, disintegration of rate or production and/or uneven loudness or pitch.
• Assess facial area sensation.
• Ipsilateral innervation for jaw, therefore, if jaw deviates, LMN not Cortical or UMN damage. Jaw deviates to the weak side when opened. Jaw hangs open with Bilateral mandibular branch lesions.

How do you assess the Trigeminal Nerve V?

• Suprahyoid muscles:
  • Gently touch the patient’s hyoid bone, ask them to swallow, and feel for hyolaryngeal elevation. Very minimal to no elevation can indicate an impairment here, but it is a very rough guide.
  • Put your hand under their jaw and ask them to tense their lower jaw muscles to feel for the ability to tense the floor of the mouth, hence roughly assessing the mylohyoid.
• Muscles of mastication: Have the patient clench their cheeks, if you feel the bulging at the jawline, Yahtzee!
• After clenching of the teeth, have them open their jaw, if there is a deficit, the jaw will deviate to the weak side add text

Facial Nerve Cranial Nerve VII Review

• Assess the muscles controlling lip and facial movements with speech and nonspeech tasks
• Repeat AMRs with /pə/ with bite block to restrict contribution of jaw movement and look at lip movement in isolation
• If you notice a facial droop to one side or the other, you know that the patient has facial nerve involvement and to which side. If you’re suspecting an upper motor neuron (UMN) lesion, the lower side of the face on the opposite side (contralateral) will be affected.
• If you have a (lower motor neuron) lesion, both the upper and lower sides of the face on the same side (ipsilateral) as the lesion will be affected. Forehead may be unwrinkled, eyebrow drooped, eye open and unblinking. Drooling, flattened nasolabial fold.
• If can't open or close eye or raise eyebrow on one side, know it's LMN/cranial nerve damage—Bell's Palsy.

How do you assess the Facial Nerve VII?

• Have the patient pretend to blow out some candles to assess the orbicularis oris.
• Puff out their cheeks assessing the buccinator which helps to prevent pocketing.
• Have the patient pucker their lips, smile wide, and then alternate the positions rapidly.
• Have the patient say, "OO" then "I", then alternate the vowels rapidly.

Glossopharyngeal Nerve IX Review

• Motor: CN IX only provides motor innervation to the stylopharyngeus, which is a laryngeal elevator (because it lifts the entire pharyngeal wall up) and also assists in relaxing and opening of the cricopharyngeus.
• How do you assess it?
  • You can’t! There is no way to reliably assess CN IX at the bedside, as there is an extremely high risk of false positives. The sensory input to the gag reflex is IX, but it is believed the motor innervation is from X. CONFUSING.
• How can this guide your treatment? If you do know the patient has damage to the motor fibers of CN IX, they may have difficulty moving food through the pharynx due to weak pharyngeal constrictor contraction, possibly leading to failure of opening of the UES/PES. Possible treatment strategies to improve UES opening include the Shaker, Mendelsohn, CTAR, and NMES.

Vagus Nerve X Review

• Motor:
  • The superior, middle, and inferior constrictors
  • The inferior constrictor includes the cricopharyngeus (innervated by the pharyngeal plexus) and is the primary muscle of the UES. It is tonically active but relaxes during swallowing to open so that the bolus can pass through.
  • All of the muscles of the soft palate EXCEPT the tensor veli palatini (which is CN V)
  • Salpingopharyngeus
  • ALL intrinsic laryngeal muscles (via the L recurrent laryngeal nerve)
  • Cricothyroid (via the external branch of the superior laryngeal nerve)
• How do you assess it?

How do you assess the Vagus Nerve?

• Inspecting the palate. If it is lower, and less arched, and you have the patient say “aaaaah”, and see a deviation to one side or the other, then you know there is CN X pharyngeal branch impairment.
• Listening to the patient’s voice. By having the patient converse or sustain phonation, listen for changes in vocal quality, pitch, loudness levels, and control. S/Z ratio, ascending/descending glides on /a/, max phonation time, vocal loudness measure (sound pressure level meter)
• Any sort of Vagus nerve involvement can lead to reduced laryngeal adduction, and/or poor cough effectiveness leading to aspiration during the swallow, poor UES opening leading to aspiration of residue after the swallow, and any type of sensory impairment of the vagus nerve can lead to the ever dreaded silent aspiration

Cough vs. Glottal coup Duffy, p.69

• Cough
  • A weak, "mushy," or breathy cough may relect vocal fold adductor weakness, poor respiratory support, or both. Most important feature to observe is the sharpness of the cough, not the loudness.
• Glottal Coup (Sharp glottal stop or grunt)
  • Sharpness of the coup is the important observation. Coup requires minimal respiratory force and sustained air flow. A weak cough but sharp coup may indicate respiratory weakness. A weak coup but normal cough, or equally weak cough and coup, may be associated with laryngeal weakness or combined laryngeal weakness and respiratory weakness.

Hypoglossal Nerve XII Review

• Sensory: NONE!
• CN XII has solely motor function Motor: All intrinsic and extrinsic tongue muscles (except palatoglossus).
• Have the patient protrude the tongue and push against the cheek. The tongue will deviate to the side that is WEAK.
• Protrude, retract, elevate, depress, lateralize in isolated and rapid repetitions.
• If it is an UMN lesion, weakness is contralateral to the lesion.
• If this is a LMN lesion, then weakness is ipsilateral to the lesion.
• Tongue fasciculations are also an indicator of a neurological impairment of LMN only – so loss of bulk, and fasciculations, both suggest LMN

How to assess the Hypoglossal Nerve

• Look for tongue atrophy, fasciculations or other abnormal involuntary movements
• Check range, speed strength and symmetry of nonspeech tongue movements
• Evaluate integrity of tongue movements for SMRs using /t t t / for tongue tip and /k k k / for tongue back both with and without bite block
• Assess alternating motion rates (AMRs) using
• Look for blurring of articulation, pace or rate abnormalities, unevenness in loudness or pitch etc.

Hypoglossal paralysis and examination

• paralysis:
  • upper motor neuron paralysis
    • tongue deviates opposite tothe lesion
    • mild weakness
  • lower motor neuron paralysis
    • tongue deviates to the side ofthe lesion
    • atrophy
    • fasciculation
• examination:
  • inspection
  • mobility of the tongue

In Summary: Perceptual Assessment of Speech

• Prolong "ah" - Assesses respiratory function and phonation (isolates the resp/phon system. Note max. Phonation time (>9seconds =normal) (<3seconds) marked deficit
• AMRs—Assess speed and regularity of reciprocal jaw, lip and ant/post tongue movements; permit observation of articulatory precision, adequacy of VP closure, and respiratory and phonatory support for sustaining the task. (3-4 seconds, 5-7/sec)
• SMRs (sequential motion rates p^ t^ k^) (3 secs) 3-7/sec
• Contextual speech –std paragraph, conversation, stress-testing for fatigue
• Motor Speech planning/programming: automatics, oral reading of words, imitation, oral reading of paragraphs, conversation

Confirmatory Signs

• Not necessarily diagnostic but can lead you to a more correct dx.
• See signs in both speech and non-speech muscles/systems
• Speech: atrophy, reduced tone, fasciculations, poorly inhibited laughter or crying, reduced normal oral reflexes, or pathologic oral reflexes.
• Non-speech: gait, muscle stretch reflexes, superficial and pathologic reflexes, limb atrophy, contractures, fasciculations, difficulty initiating movement, etc.

Formal Assessments for Motor Speech Disorders

• Frenchay Dysarthria Assessment
• Assessment of Intelligibility of Dysarthric Speech
• Perceptual Dysarthria Evaluation
• Newcastle Dysarthria Assessment Tool
• Assessment found in: Assessment of Communication Disorders in Adults, by M.N. Hegde and Don Freed
• Apraxia Battery for Adults-2nd Edition
• Duffy's book has several forms

Formal Assessments for Motor Speech Disorders

• Frenchay Dysarthria Assessment
• Assessment of Intelligibility of Dysarthric Speech
• Perceptual Dysarthria Evaluation
• Newcastle Dysarthria Assessment Tool
• Assessment found in: Assessment of Communication Disorders in Adults, by M.N. Hegde and Don Freed
• Apraxia Battery for Adults-2nd Edition
• Duffy's book has several forms

Frenchay Dysarthria Assessment

• OME and speech components
• Speech components-single syllable words through 4-syllable words,
• Functional phrases and sentences

Duffy Assessment for nonverbal oral praxis

Wertz. LaPoint, and Rosenbeck Test for Apraxia of speech

• Repeat these sounds after me:
  • /i/
  • /a/
  • /ai/
  • /au/
  • /p/
  • /t/
  • /k/
  • /s/
  • /f/
  • /ch/
• Repeat these words after me:
  • mom
  • Bob
  • peep
  • kick
  • fife
  • sis
  • church
  • shush
  • lull
  • roar
• Repeat these words 3 times
  • animal
  • snowman
  • artillery
  • stethoscope
  • rhinoceros
  • volcano
  • harmonica
  • specific
  • statistics
  • aluminum
• Repeat these words
  • cat
  • catnip
  • catapult
  • catastrophe
  • thick
  • thicken
  • thickening
• Repeat these sentences
  • We saw several wild animals.
  • My physician wrote out a prescription.
  • The municipal judge sentenced the criminal.
• Diadochokinetic measures
  • Count from 1-5
  • Say the Days of the Week
  • Sing "Happy Birthday," "Jingle Bells," or other song
  • Describe conversational and narrative speech

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

• Only commercially available test for apraxia of speech.
• 6 subtests for both limb and nonverbal apraxia, AOS
• Diadochokinetic rates, imitation of words of increasing length, latency and utterance time for naming of pictured multisyllabic words, articulatory adequacy during repetitions of polysyllabic words, and an inventory of 15 behaviors based on spontaneous speech, reading and counting,

Choosing a Formal Assessment

• Pick one.
• Be consistent.
• Make sure it assesses all of the components you need to make a complete assessment.
• Become familiar with it—practice, practice, practice!
• Learn how to give instructions while keeping the client at ease.

Informal Analysis of Speech Samples

• vowel prolongation
• alternating motion rates (AMR) and sequential motion rates (SMR)
  • using speech syllables and or words such as "puppy" "buttercup"
• standard reading passage
• narrative about pictured scene
• conversation sample
• stress test (counting to 100 or reading aloud for 2-4 minutes) -MG
• complex multisyllabic words and sentences
• repeat days of week, months, CVC syllables with identical initial
  • and final consonants, sing familiar tune
• identify and rate deviant speech characteristics

Intelligibility Assessment:

• ICE Rate Intelligibility -
  • degree to which listener understands the auditory signal produced by the speaker.
• Rate Comprehensibility—
  • degree to which a listener understands speech on basis of intelligibility and other info such as knowledge of the topic, semantic and syntactic content, general physical setting, gestures, and signs, etc.
• Rate Efficiency—
  • rate at which intelligible or comprehensible info is conveyed. (100% intelligible, but slow rate or use of AAC is slow and time-consuming) Listener burden is too high.

Intelligibility Influences

• Influenced by speaker variables
  • Severity of speech impairment
  • Use of compensatory strategies
• Also influenced by listener variables
  • Familiarity
  • Attention and effort
• Further influenced by task variables
  • Word, sentence, discourse level tasks
  • Word by word transcription

ASHA Functional Communication Measure (Motor Speech)

Motor Speech Intelligibility Scale

• Ratings should be based on the motor aspects of speech production, not language or cognitive characteristics that might detract from spoken communication.
• 10- NORMAL SPEECH. Patient denies speech difficulty. No abnormality on examination.
• 9-NOMINAL SPEECH ABNORMALITY. Only the pt or significant other notices any change in speech. Speech rate and loudness are normal. The pt may report that speaking is more effortful.
• 8- PERCEIVED SPEECH CHANGES. Speech is understandable, but changes are evident to others, especially under adverse conditions, e.g., fatigue, stress, in noisy environments.
• 7-OBVIOUS SPEECH ABNORMALITIES. Speech is obviously abnormal. Speech remains easily understood.
• 6- MUST REPEAT MESSAGES ON OCCASION. Rate may be noticeably slower or abnormally rapid. Pt must repeat some statements in adverse listening situations but complexity or length of utterance need not be reduced.
• 5- FREQUENT REPETITION REQUIRED. Speech may be labored/effortful. Frequent repetition or a “translator” is often needed. Pt may limit complexity or length of utterances.
• 4-SPEECH PLUS AUGMENTATIVE COMMUNICATION. Speech is often used but intelligibility problems often need to be resolved by other means (e.g. writing, spokesperson).
• 3-LIMITED SPEECH. Vocalizes one-word response beyond yes/no, otherwise writes or uses other non-speech strategies, or uses a spokesperson. May initiate communication non-vocally.
• 2-VOCALIZES FOR EMOTIONAL EXPRESSION. Vocalizes with inflection only to express emotion, affirmation, negation, etc.
• 1-NONVOCAL.Vocalization is not possible, or is effortful, limited in duration, or rarely attempted. May vocalize when laughing, crying or in pain.

Writing up the OME

• Client Name:
• Birthdate:
• Age:
• Referring MD:
• Clinician:
• Reason for Evaluation:
• Subjective:
  • History:
  • Past Medical History:
  • Educational History:
  • Employment History: