Chapter 9: Motor Speech Disorders

Motor Speech Disorders

• Motor Speech Disorders - Damage to parts of the nervous system responsible for planning programming
• Results from the impairment of muscles to produce speech because they are weak, paralyzed, or uncoordinated
• Apraxia/Dysarthria

Dysarthria/Apraxia: The Football Analogy

• Dysarthria - football players are injured
• Apraxia - the coach is making the wrong play
• Dysarthria - the tongue, lips, cheeks are not working right
• Apraxia - the brain is sending out the wrong message (motor planning problem)

Childhood Apraxia of Speech

• Childhood Apraxia of Speech (CAS) – aka Developmental Apraxia (total loss of speech), Developmental Dyspraxia (not great speech)
• Experts do no agree on its characteristics or cause
• Delayed or mal developed areas of the brain that program movement sequences
• Infrequent
• Characteristics of CAS:
    * Simple syllable shapes
    * Vowel errors
    * Speech sound production is inconsistent
    * Intonation/word stress are altered
• Use gestures to supplement speech
• Extensive therapy needed
    * drill based work on speech movements
    * phonological process remediation
    * tactile/gestural approaches (PROMPT approach)
• Nothing has been proven to be uniquely effective
• Examples of different levels of severity in Childhood Apraxia of Speech

Apraxia Facts

• difficulty stringing syllables together in the appropriate order to make words
• minimal babbling during infacy
• difficulty saying long or complex words
• repeated attempts at pronunciation of wrods
• speech inconsistencies
• incorrect inflections or stresses on certain sounds or words
• excessive use nonverbal forms of communication
• distorting vowel sounds
• omitting consonants at the beginnings and ends of words
• seeming to grope or stuggle to make words
• limited vocabulary
• grammatical problems
• problems with coordination and fine motor skills
• difficulties chewing and swallowing
• clumsiness

Acquired Apraxia of Speech

• Acquired apraxia of speech (AOS) is a disorder in the planning and programming of speech movements
• Left frontal lobe brain damage
• AOS does not usually occur independently from Broca’s aphasia
• Characteristics:
    * Prosodic abnormalities - slow rate, prolonged consonants and vowels, pauses between words, even stress on syllables
    * Impaired speech fluency - (self-corrections, searching for articulatory positions)
    * Speech sound errors
• $Adult apraxia of speech - 4 months post cerebral vascular accident (video)$
• Treatment
    * Focuses on improving the ability to program movements of increasingly more demanding syllables, words, and phrases

Dysarthria in Children

• Most commonly associated with Cerebral Palsy (CP)
• Injury to the nervous system that occurs before, at the time of, or shortly after birth
• 1/500 births
• Prenatal - disease or metabolic problems of the mom
• Perinatal - umbilical cord is wound around the neck, premature separation of the placenta, birth process is delayed, trauma
• Postnatal - trauma

Cerebral Palsy

• Cerebral Palsy - Deficits
    * Visual
    * Auditory
    * Intellectual
    * Motor Functions
    * Speech/Language
    * Swallowing
• Motor dysfunction - weak, paralyzed, uncoordinated

Cerebral Palsy: Characteristics

• Communication impairments are common
    * 38% of children with CP have articulation disorders/impaired speech
    * Motor impairments restrict child’s access to language-learning experiences and opportunities

Speech and Language Development in Children with CP

Speech Development is delayed and impaired

• Respiration
    * Reduced vital capacity (the maximum amount of air a person can expel from the lungs after a maximum inhalation)
    * Impaired ability to generate/maintain pressure below the VF
• Phonation
    * Compromised by impaired tone resulting in breathiness, strangled harshness
    * Timing of respiration and laryngeal activity is also disrupted
• Resonance
    * Hypernasality and nasal emission
• Articulation
    * Hyperextension of the jaw

May use only 1-2 word phrases

Poor speech intelligibility

May rely on AAC device (point to pictures or words)

Cerebral Palsy: Characteristics

• 30%-50% of kids with CP have intellectual disability
• Hearing impairment
• Visual perceptual problems
• Feeding problems
• Growth difficulties
• Emotional/behavioral disorders (i.e. ADHD and learning disabilities)
• Learned helplessness

Classification of CP

• Orthopedic Classification:

based on limbs affected

Types of CP: Neuromuscular

Severity: ranges from mild to severe

Judged based on a degree of independence in communication, ambulation, and self-help skills

Spastic CP

• Increased muscle tone (hypertonicity)
• Tense and contracted muscles
• Stiff and jerky movements
• Increased infantile reflexes
• Abnormal resistance to muscle lengthening (muscle shortening)
• Muscle atrophy (weakness)
• Most common form; 70-80%

Athetoid CP

• Fluctuating Tone (hypertonicity to hypotonicity)
• Involves abnormal involuntary movements
• Involuntary movements disappear and tone appears to be normal during sleep and increase with stress
• Writhing and twisting motion
• Interferes with speaking, feeding, reaching, grabbing, etc.
• Basal ganglia and associated components of the extrapyramidal tract
• 20% of the CP cases

Ataxia CP

• Damage to the cerebellum
• Poor balance and lack of coordination
• Wide based gait
• Depth perception usually affected
• Tendency to fall and stumble
• Unable to walk in a straight line
• Movements are characterized by errors in speed, direction, and accuracy
• Lease common 5-10% of cases

Acquired Dysarthria

• Adult - developed speech and language prior to the onset of the disorder

Flaccid Dysarthria

• Interruption of normal input to the muscles from the peripheral nervous system
• Muscle weakness
• Atrophy (wasting)
• Hypotonicity
• Example: Myasthenia gravis
• Speech
    * Rate is slow
    * Breathy phonation
    * Hypernasality
    * Articulatory imprecision
    * Reduced phrase length
    * Little variation in loudness or pitch
    * Myasthenia gravis my symptoms

Spastic Dysarthria

• Excessive muscle tone, weakness
• All speech musculature is affected in spastic dysarthria
• Articulatory imprecision, slow rate, short phrases, harsh voice quality, reduced loudness, decreased pitch variation
• Pseudobulbar palsy

Ataxic Dysarthria

• Impairment in coordination
• Movements are inaccurate and dysrhythmic
• Minimal weakness
• Damage to the cerebellum
• Monotonous, impaired stress patterns, rate is slow, vowels elongated
• Intelligibility: mild

Hyperkinetic Dysarthria

• Huntington’s chorea
    * It is caused by a gene defect inherited from parents. Symptoms generally appear in midlife. Huntington's disease affects movement, cognitive functions, and emotions.
    * Huntington's disease is not curable, but treatments include medications, therapies, and lifestyle changes to help the patient cope with the condition.
• Dystonia
    * Unintentional sustained muscle contractions leading to abnormal postures.
    * Involuntary movements are superimposed on voluntary movements
• Hypokinetic Dysarthria
    * Muscles are rigid, resulting in reduced movement
    * Experience resting tremors
    * Difficulty starting or stopping movements
    * Parkinson’s Disease
    * Speech rate is fast (short rushes of speech)
    * Melody is flat with monoloudness, monopitch, and reduced intensity

Mixed Dysarthria

• MS – Multiple Sclerosis
• ALS - Amyotrophic Lateral Sclerosis
• Disease processes that affect more than one part of the motor system

Assessment

• Evaluate each subsystem of the speech production process to determine the type and extent of the dysarthria
    * Respiration
    * Phonation
    * VP function
    * Articulation

OME

• Determine the anatomic and functional integrity of speech production structures by completing an OME
• Careful examination of the tongue, lips, jaw during speech and nonspeech tasks

Speech Examination

• Diadochokinetic Rates
• Speech Samples
• Speech Assessments:
    * AIDS
    * Frenchay Dysarthria Assessment
• Determine overall speech intelligibility

Treatment

• Drugs and surgery
• Focus is to improve speech intelligibility
• Kids with CP: respiration
• Adults:
    * Dysarthria Compensatory Strategies
      * decrease speech rate
      * increase volume
      * exaggerate articulatory movements

Augmentative and Alternative Communication (AAC)

• May need to supplement speech output with gestures, communication boards
• Augmentative Communication refers to supplementing or augmenting speech using various techniques and aids
• Gestures, electronic devices, low-tech devices such as a communication book
• Sara Pyszka Dyna Vox AAC Cerebral Palsy Success Story
• AAC is slower
• Assess intellectual, sensory, motor and literacy skills prior to deciding on an AAC device for a client

Hands On AAC Device

• Go Talk
• iTalk 4
• TouchChat by Saltillo