Cranial Nerves & Speech

Basal Ganglia in Motor Control

• The primary role is motor initiation and inhibition.

Upper Motor Neuron Involvement

• Symptoms suggest upper motor neuron involvement.
• Hypo- means low.
• Upper motor neuron involvement leads to high tone.
• High tone due to spastic dysarthria.
• Decreased muscle tone indicates lower motor neuron involvement due to some movement with lower motor neuron if bilaterally innervated.
• Babinski sign: When stroking the bottom of someone's foot, their toes go up, which is a sign of upper motor neuron involvement.
• Muscle fasciculations occur with lower motor neuron damage or deficiency.

Cranial Nerves and Speech

• Trigeminal Nerve:
  • Controls jaw movement for speech and mastication.
• Facial Nerve:
  • Moves the lips for bilabial and labiodental sounds.
  • Damage can make it hard to do bilabials.
• Vagus Nerve:
  • Plays a key role in see elevation and velar elevation.
  • Contains the recurrent laryngeal nerve.
• Hypoglossal Nerve:
  • Number 12.
  • Innervates intrinsic and extrinsic tongue muscles except the palatoglossus.
  • Damage can result in tongue deviation, affecting place of articulation.
  • Need both sides of the tongue to be working, if one side is knocked out, it can lift the weakest side.
• Glossopharyngeal Nerve:
  • Number nine.
  • Contributes to speech primarily by innervating some elevators of the palate.
• Accessory Nerve:
  • Indirectly affects speech by helping maintain an upright position.

Nasal Emission and Breathy Voice

• May indicate damage to the vagus nerve (cranial nerve X).

Cranial Nerves Involved in Articulation and Resonance

• Glossopharyngeal and Vagus nerves (IX and X).

Impact of Neuromuscular Disorders on Posture

• Strokes or progressive neuromuscular disorders can cause posture changes impacting respiration, phonation, articulation, swallowing, and oral motor control, leading to drooling.

Goals of Motor Speech Evaluation

• Decide whether a motor speech disorder exists.
• Determine if it is dysarthria or apraxia.
• Identify which subsystems of speech are in need and are amenable to treatment.
• Assess the impact on the patient's ability to perform functional tasks (communication, swallowing).
• Determine whether a patient can take part in activities at home or in the community.
• Recommend a level of care for the patient at home.
• Elicit patient-centered goals.
• Assess and inform regarding disease progression, counsel patients about changes, especially in progressive neuromuscular diseases.

Steps in Evaluation

• Case history (formal and informal assessments).
• Summary of findings with severity ratings (rating scale or ASHA NOMS).
• Prognostic statement ("").
• Long-term and short-term goals.
• Education about condition, treatment options session by session.

Evaluation Begins

• Evaluation begins the moment you see the patient.
• Observe ambulation, assistive devices, side weakness.
• Wheelchair use, balance, posture (stooped posture may indicate Parkinson's).
• Head holding ability (spinal accessory nerves).
• Arm paralysis/weakness: note presence of sling, spasticity/flaccidity which can indicate lower motor neuron or upper motor neuron damage, wrist/finger contractures.

Case History Information

• Establish patient-centered goals and build rapport.
• Hear from the patient about the problem (description, effects).
• Onset of the issue, progression (sudden or gradual).
• Assessment of PROM (patients' degree or perceived degree of disability or loss).
• Effects on daily living, occupation (job loss, medical leave).
• Family support (or lack thereof).
• Understand the neurological diagnosis and site of lesion.
• Observe weakness, tremors, fasciculations.
• Ask about coexisting problems (alexia, agraphia, anomia).

Common Evaluation Tools

• Perceptual: in-person oral motor exam.
• Instrumental: video swallows, FEES
• Acoustic: spectrographic analysis
• Physiologic
• Visual imagery: CAT scan, PET scan, MRI

Visual Imaging

• Video fluoroscopy for swallowing.
• Laryngoscopy for vocal cord paralysis.
• Video stroboscopy for vocal cord problems.
• Nasal endoscopy to assess palate movement and polyps.

Quality of Life Assessments

• Patient-reported outcome measures (PROMs).
• Include cognitive or linguistic screening.
• Pursue further testing if there's concomitant aphasia or anomia.

Perceptual Assessment

• Gold standard for clinical diagnosis.
• Rate severity, plan treatment, assess change over time.
• Subjectivity is the problem but improves over time with more experience.
• Darley Aronson and Brown developed a chart of features of the different dysarthrias to delineate what the syndrome of dysphasia or dysarthria it is.

Subsystems of Speech

• Five Subsystems: respiration, phonation, resonance, articulation, and prosody.
• Assess how they sound and look, level of impairment, and intelligibility.

Assessment of Respiration

• Posture: ability to sit upright, head position.
• Breathing pattern: diaphragmatic vs. clavicular.
• Sounds during breathing: stridor, plaease.
• Maximum phonation time (MPT): how long can they say "ah" after inhaling
• Oral reading of standard passage (Rainbow passage): phrase length, number of words in the phrase.
• Conversation: small words vs. converse
• How respiration affects intelligibility.

Assessment of Phonation

• Assess pitch, quality, and loudness across speaking situations.
• Use sound pressure level meter, instruments on phones.
• Pitch assessment: ascending, descending, stair step.
• Listen for diplophonia, strained/strangled voice, hoarseness, breathiness, tremor.
• Formal assessment optional if vocal analysis software is available.

Prolonged Vowels

• Listen for tremors, strain, flutter.

Resonance Assessment

• Assess where the signal is resonating.
• Hypernasality or hyponasality, air emission, plosives, fricatives.
• Sentences to get a sense of resonance (Mary is making options, Bye-bye Bobby).
• Occlude the naries to detect changes in nasal resonance.

Articulation Assessment

• Alternating motion rate (AMR).
  • Pa, ta, ka..
• Sequential motion rates (SMR).
  • Pataka.
• Speech sound inventory (formal or from connected speech sample).

Prosody Assessment

• Assesses respiration, phonation, articulation.
• Assess pitch variation, rate, and rhythm.
• Oral reading, varying stress patterns, asking questions.

Motor and Sensory Functions Assessment

• Tools: flashlight, gloves, tissues, cotton ball, swabs, Rainbow passage, caterpillar or grandfather passage, timer.
• Assess speech components: muscle strength, speed, range.
• Accuracy of movement, steadiness, muscle tone.
• Observe and listen to streets and landmarks.

Oral Motor Exam Terms

• Facial symmetry, strength, ROM (range of motion).
• Mandibular movement.
• Lingual symmetry midline, range, rate, strength.
• Velar symmetry, elevation.
• Laryngeal cough: evaluates if the patient can protect from aspiration, have normal respiratory strength, and ability to adduct their vocal cords and blast it open.
• Glottal coup.
• Laryngeal quality and breath support.
• Gag reflex.

Non-Speech Movements

• Assess apraxia and aphasia.
• Can they follow commands or imitate?
• Nonverbal apraxia (difficulty with repeating). Example repeating the command.
• Inability to repeat tongue movements rapidly (stick tongue in and out five times).

Testing Strength

• Patients need to have reserve to work when they're tired (key symptom in patients with myasthenia gravis is that the more they talk, the weaker they may become.).
• Weak muscles fatigue more easily.
• Therapy sessions should be accordingly short, not 4,000 repetitions in 45

Speech Movements

• Very rapid.
• Approximately 14 phonemes a sencond.
• Occasionally, with hypokinetic dysarthria, you'll see excessive speed and fascinating speech
• But usually it's just with hyperkinetic dysarthria that they keep going really fast
• Which leads to decreased range of motion.

Range

• The distance articulators move point to point.
• Impacts prosody.
• Typically, you get decreesed range of motion change.
• Not common to see excessive ROM.
• But with Hyperkinetic dysartharia, you will see very variable.

Steadiness in Speech

• Look for tremoring in head, tongue, sentences.

• Involuntary moments

• Variations in Speeed, duration. Amplitutde

Tone

• Can be tight, reduced, variable.

• Flaccid - Low Tone

• Spastic & Hypokinetic - Increased Tone

• Hyperkinetic - Variable Tone

Accuracy

• Intelligibility, how intelligible are they?

• Important information to lead ot correct diangosis

Oral Mect Exam Components

Assess
1.) At rest.
2.) Have them look at you
3.) Smile
4.) Facker
5.) Blow up the cheeks w/ air- quickily and slow

Then follow with

• sensation ( Q tip)
• Jaw - symmetry look, coordinated not.
• Tongue Depressor with tongue.
• raise eyebrows, curle brow, etc..

Remember always asses all of the sub components. Muscle , Speech, etc..

Cramial Nerves - Roles

-Trigeminal - area speed, rate , tone. (assess with p,t,k)

• Facial -Assess with speech amrs/ facial drop ( Upper or lower)

Glossoph- Gag reflex,

Vagas-Constuctorss, Soft Palate, larynx ( Assess the larynx by assessing max. phonat time, vocal pitches.

• If soft palate is even on look inside the palate. Its the uneven on assessment

Hypoglossal paralysis study, helps with understanding which side to look at.

Testing

Assessments using AMRs with time frame normal is 9 with s or r
use and maintain same paragraphs
with MPT