Connections, Classification & Considerations for Treatment

Presented by: Carmen Tibbs CDIS 815: Development Seminar in Communication Disorders

Dysarthria
Oral communication problems due to weakness, incoordination, or paralysis of speech musculature Collection of speech disorders Impairments may be to multiple aspects of speech

production: respiration, articulation, resonance, & prosodic elements Impaired ability to execute motor movements Consequence of damage to cortex, cerebellum, brainstem, or peripheral nervous system Major causes: stroke, brain tumors, head trauma, toxins, & neuromuscular diseases, many of which are degenerative (e.g., Parkinsons, multiple sclerosis, myasthenia gravis)

Dysarthria: The Cranial Nerve Connection

Because Dysarthria is a consequence of damage to the cortex, cerebellum, brainstem, or peripheral nervous system; it is critical to consider the cranial nerves, which consist of 12 pairs of neuron bundles emerging from the brainstem Nerve I II III IV V VI VII VIII IX X XI XII Olfactory Optic Oculomotor Troclear Trigeminal Abducens Facial Acoustic vestibulocochlear Glossopharyngeal Vagus Spinal accessory Hypoglossal Function Smell, taste Vision Eye, eyelid, & pupil movement Eye movement Jaw movement; sensation from jaw, face, & mouth Eye movement Facial movement; sensation from anterior tongue Balance; hearing Pharyngeal & palatal movement; sensation from posterior tongue Movement & sensation from larynx, pharynx, esophagus, & internal organs; branches into inferior & superior laryngeal nerves Larynx, chest, shoulder, & neck movement Tongue movement Type Sensory Sensory Motor Motor Mixed Motor Mixed Sensory Mixed Mixed Motor Motor

Classification of Dysarthria
The most frequently cited classification system for the dysarthrias is based on the Mayo Clinic research studies conducted by Darley, Aronson, & Brown (Roth, 2005) whose work has resulted in the identification of the following seven major types of dysarthria based on differential patterns of neurological impairment and associated speech characteristics:
1. 2. 3. 4. 5. 6. 7.

Flaccid Spastic Ataxic Hypokinetic Hyperkinetic Mixed Unilateral upper motor neuron

Flaccid
Cause Site of Lesion Neuromuscular Speech Characteristics Status Weakness Low muscle tone Indistinct & labored artic Hypernasality Nasal emissions Breathy & harsh voice quality Audible inspiration Monopitch & loudness Short phrases Bulbar palsy Myasthenia gravis Lower motor neuron

Flaccid: treatment considerations

Muscle strength & range of motion
Ask client to increase effort Jaw exercises Lip muscles: resistance, pucker, wide smiles Increase tongue strength Overall strength: push on arms of chair

Modify respiratory behaviors

Push/pull exercises Postural adjustments Phonate at beginning of exhalation Deep inhalation & controlled exhalation Increase breath group durations Increase number of words per breath group

Modify phonatory problems

Model & reinforce louder speech Use computer programs for feedback on loudness Consider Teflon or collagen injections to improve VF adduction Push/pull during speaking for VF approximation If unilateral, turn head to affected side for better closure

Modify resonance problems

Modify articulation problems

Reduce rate of speech use finger tapping cue, verbal reminders, etc. Reinforce artic of speech sounds Intelligibility Drills Phonetic Placement Method Exaggerated consonant production Minimal Contrast Method

Modify prosodic problems

Client discrimination of pitch changes in modeled speech Prolong an /a/ with lower & higher pitch Have client read printed sentences indicating higher/lower pitch (arrows) Model various pitch levels in phrases & sentences with client imitation Corrective feedback Contrastive Stress Drills

Note: hypernasality is the main resonance problem due to damage to the pharyngeal branch of the vagus nerve; soft palate may be weak or paralyzed Palatal Lift Prosthesis Pharyngeal Flap Operation Pharyngoplasty Shape by modeling, reinforcement & feedback

Spastic
Cause Pseudo bulbar palsy Site of Lesion Upper motor neuron Neuromuscular Status Increased muscle tone Reduced ROM, strength & speed Speech Characteristics Slow, imprecise artic Hypernasality Strained, strangled, harsh voice quality Monotonous pitch & loudness Short phrasing

Spastic: treatment considerations

Notes Modify respiratory behaviors
Not major concern; any apparent respiratory problems may be to phonatory problems like hyperadduction of VF

Modify phonatory problems

Note: reduced efforts to reduce hyperadduction of VF have not been especially successful; thus, proceed with caution. Head & neck relaxation techniques Easy onset Model soft glottal closure; imitation; begin with exhaled sigh & add prolonged /a/; shaping /a/ into words, phrases, etc Yawn-sigh

Modify resonance problems

Increase vocal loudness to control hypernasality, because louder speech tends to be perceived as less nasal Discuss usefulness of Pharyngeal Flap or Palatal Lift Prosthesis with appropriate professionals

Modify articulation problems

Use discretion for tongue & lip stretching exercises Intelligibility drills Phonetic Placement Method Use a mirror to model & reinforce Exaggerated medial & final consonants in words, phrases & sentences Minimal Contrast Drills

Modify prosodic problems

Varied pitch on prolonged vowel Model pitch variations; fade Use printed sentences , indicating rise & falling pitch levels with arrow Contrastive Stress Drills Chunking utterances into syntactic units; modeling & reinforcing appropriate pauses ; inhale at junctures

Consult with physical re medically controlling pathological crying Consider behavior modification of pathological crying Do not teach push/pull exercises that only aggravate hyperadduction Use relaxation & stretching with caution due to lack of substantiated efficacy

Ataxic
Cause Cerebellar disorders Site of Lesion Cerebellum Neuromuscular Speech Characteristics Status Inaccurate range, timing, & direction Low muscle tone Reduced speed of movement Excess & equal stress Irregular articulatory breakdown Slow, inaccurate artic Rhythm disturbances Phoneme prolongations Some excess loudness Hypotonia Prosodic difficulties

Ataxic: treatment considerations

Notes Modify respiratory behaviors
Inhale deeply Exhale in slow, controlled manner to sustain speech Reinforce progressively longer (more controlled) exhalation

Modify phonatory problems

Reinforce prompt phonation upon initiation of exhalation End utterance well before running out of air; stop when signs of airflow dissipation are evident & ask client to breathe again Stop & inhale at natural junctures in sentences -at beginning of a grammatical clause, etc.

Modify articulation problems

Use words lists; judge intelligibility independent of visual cues Give corrective feedback to encourage appropriate production of sounds in words not understood Use Phonetic Placement Method to teach correct production of sounds Reinforce OVER articulation of medial & final consonants Use Minimal Contrast Method to improve the intelligibility of words that differ by only one phoneme

Modify prosodic problems

Slow rate of speech using metronome beats Use finger or hand tapping Use cues such as pointing to printed word to generate a steady or even oral reading rate Teach appropriate stress on words in sentences; use contrastive stress exercises Teach variations in pitch by using both printed sentences & conversational speech

Use behavioral methods of Shaping & Differential reinforcement to improved control & coordination Do not focus on increasing muscle strength or reducing muscle tone Do not recommend prosthetic or surgical methods to improve Reinforce more natural sounding conversational speech Implement a Maintenance Strategy to train family members & caregivers who will help sustain treatment gains

Hypokinetic
Cause Parkinsonism Site of Lesion Basal Ganglia Extrapyramidal system substantia nigra Neuromuscular Status Markedly reduced range & speed of movement marked muscle rigidity Rest tremors Speech Characteristics Monopitch Monoloudness Reduced stress Slow speaking rate with short rushes of speech Long, inappropriate pauses Fluctuating articulation accuracy; imprecise consonants Harsh, breathy voice

Hypokinetic: treatment considerations

Modify respiratory behaviors Modify phonatory problems Modify articulations problems Modify prosodic problems
Inhale deeply before speaking Start speaking when inhalation begins Exhale slowly & in a controlled manner Stop talking well before exhausting air supply Gradually increase the number of words spoken per breath Note: Individuals with Parkinsons disease derive greater benefit from treatment that targets both respiratory & phonatory function than treatment that focuses on respiratory function alone Use voice therapy techniques to increase vocal loudness & to decrease breathiness; use various biofeedback instruments such as the VisiPitch Use pushing & pulling techniques to increase the movement of range of laryngeals muscles (have client push down on arm of chair while phonating, etc) Use portable voice amplifiers to increase loudness Use rate control for clients who speak rapidly; use hand or finger tapping to cue production of syllables or words; use delayed auditory feedback to slow down the rate; use a Pacing Board or an Alphabet Board Use Intelligibility Drills in which the client reads aloud printed words; judge accuracy based on phonatory cues & give corrective feedback or reinforcement Use Phonetic Placement Method Produce word medial & final consonants with exaggeration Use Minimal Contrast Method Note that slower rate can improve clients prosody Teach proper intonation through printed sentences that show rising & falling pitch by arrows Use Contrastive Stress Drills Teach appropriate chunking of words according to syntactic units such as pausing at the end of a grammatical clause & a sentence

Hyperkinetic - Quick
Cause Chorea Touretts syndrome Huntingtons Chorea Site of Lesion Neuromuscul ar Status Speech Characteristics Dominant symptom is prosodic disturbances Imprecise consonants Distorted vowels Variable rate & loudness Harsh voice Inappropriate pauses; prolonged intervals Abrupt grunts & barks Extrapyramidal Rapid, jerky, uncontrolled tic movements

Hyperkinetic - Slow
Cause Athetosis Dystonia Dyskinesia Site of Lesion Extrapyramidal Neuromuscular Status Slow, twisting, writhing movements & postures Variable muscle tone Speech Characteristics Irregular articulatory breakdown Monopitch & monoloudness Harsh voice quality

Hyperkinetic - Tremor
Cause Organic voice tremor Myoclonus Site of Lesion Extrapyramidal Neuromuscular Status Involuntary, rhythmic movements Speech Characteristics Voice tremors with rhythmic phonation breaks Choked-strained voice quality

Hyperkinetic: treatment considerations

Medications
that control involuntary movements
NOTE: medical treatment does not always eliminate the need for behavioral management of dysarthria Haloperidol controls chorea & tics Clonazepam & valproic acid control myoclonic jerks Botox injections control dystonia (more effective than other drugs listed in treating clients with hyperkinetic dysarthria) Methods to help control involuntary movements Easy onset to help reduce involuntary movements that disrupt laryngeal movements especially in clients with mild hyperkinetic dysarthria Relaxation therapy to control Teach habit reversal in which the client is taught competing voluntary behaviors to control involuntary behaviors (e.g., asking the client to blink slowly before the tics occur) Use a Bite Block (small plastic cube the client bites down on) to inhibit or reduce interfering jaw movements during speech in clients with mandibular Dystonia Modify prosodic problems Slower rate & increased vocal pitch when necessary

Mixed
Cause Site of Lesion Neuromuscular Status Speech Characteristics

Amyotrophic lateral sclerosis (ALS) Multiple sclerosis (MS) Wilsons disease Multiple strokes

Multiple motor systems

Muscular weakness Reduces range & speed of motion Some intention tremors

ALS: severely defective artic Slow rate Noticeable hypernasality Harsh voice quality Marked prosodic disturbances
MS: Harsh voice quality Inconsistent rate & artic precision Wilsons disease: Similar to hypokinetic dysarthria without sudden bursts of speech

Mixed: treatment considerations

Identify dominant type, if any, and describe the major speech problems
Select speech targets that when treated will immediately improve communication Treat those targets like you would in the case of pure dysarthrias Note that some clinicians recommend that problems of respiration, resonation, phonation, articulation & prosody, if all present, be treated in that order Treat the most severe problem first if multiple problems exist in a single category (e.g., prosody). Find out the clients preference to determine which problems should be addressed first in treatment Recommend Augmentative Communication devices for clients who need them; note that clients whose mixed dysarthria is due to ALS are likely candidates for augmentative communication

Unilateral Upper Motor Neuron

Cause Stroke damage to UMN that supply cranial & spinal nerves involved in speech production Site of Lesion Posterior frontal lobe Neuromuscular Speech Characteristics Status Lower facial weakness hemiparesis Imprecise consonants Irregular articulatory breakdown Harsh voice Mild hypernasality Generally slow rate of speech with increased rate in segments Excess & equal stress

Unilateral UMN: treatment considerations

Notes
In some cases, associated language deficits (aphasia) & apraxia may take treatment priority; dysarthria may not be treated, but it is recommended A variety of behavioral therapy approaches are effective for those with stroke or TBI, including feedback of acoustic information, respiratory & speech rate control, & physiological strategies such as biofeedback & reaction times Devices such as palatal lifts result in gains in muscle strength & speech intelligibility for individuals with stroke or traumatic brain injury

Modify articulation problems

Use traditional methods to treat articulation disorders Intelligibility Drills accuracy judged on phonatory cues with feedback Phonetic Placement Method; use mirror; model & reinforce imitated & evoked productions of target words, phrases, & sentences Exaggerated medial & final consonants Use Minimal Contrast Drills in which pairs of words that differ by only one phoneme are used to teach correct productions of target sounds

Recommended Resources
Brookshire, R. H. (2003). Introduction to neurogenic communication disorders. St. Louis, MO: Mosby. Duffy, J. R. (1995). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis, MO: Mosby. Dworkin, J. D. (1991). Motor speech disorders: A treatment guide. St. Louis, MO: Mosby. Freed, D. (2000). Motor speech disorders: Diagnosis and treatment. San Diego, CA: Singular Thomson Learning. Hegde, M. N. (2008). Hegdes PocketGuide to Treatment in SpeechLanguage Pathology. Clifton Park, NJ: Thomson Delmar Learning. McNeil, M. R. (1997). Clinical management of sensorimotor speech disorders. New York: Thieme. Yorkston, K. M., Miller, R. M., & Strand, E. A. (2004). Management of speech and swallowing in degenerative disorders. Austin, TX: Pro-Ed.

References:
Hegde, M. N. (2008). Hegdes PocketGuide to Treatment in Speech-Language Pathology. Clifton Park, NJ: Thomson Delmar Learning. Roth, F. P., & Worthington, C. K. (2005). Treatment Resources Manual for Speech-Language Pathology, 3rd Edition. Clifton Park, NJ: Thomson Delmar Learning.