tibbs dysarthrias learning project

8/3/2019 Tibbs Dysarthrias Learning Project

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Connections, Classification &Considerations for Treatment

Presented by: Carmen TibbsCDIS 815: Development Seminar in Communication Disorders


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Dysarthria Oral communication problems due to weakness,

incoordination, or paralysis of speech musculature Collection of speech disorders

Impairments may be to multiple aspects of speechproduction: 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 aredegenerative (e.g., Parkinsons, multiple sclerosis,myasthenia gravis)


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Dysarthria: The Cranial Nerve ConnectionBecause 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 Function Type

I Olfactory Smell, taste Sensory

II Optic Vision Sensory

III Oculomotor Eye, eyelid, & pupil movement Motor

IV Troclear Eye movement Motor

V Trigeminal Jaw movement; sensation from jaw, face, & mouth Mixed

VI Abducens Eye movement Motor

VII Facial Facial movement; sensation from anterior tongue Mixed

VIII Acoustic -vestibulocochlear

Balance; hearing Sensory

IX Glossopharyngeal Pharyngeal & palatal movement; sensation from posterior tongue Mixed

X Vagus Movement & sensation from larynx, pharynx, esophagus, & internalorgans; branches into inferior & superior laryngeal nerves

Mixed

XI Spinal accessory Larynx, chest, shoulder, & neck movement Motor

XII Hypoglossal Tongue movement Motor


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Classification of DysarthriaThe 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 theidentification of the following seven major types of dysarthria based ondifferential patterns of neurological impairment and associated speechcharacteristics:

1. Flaccid

2. Spastic

3. Ataxic

4. Hypokinetic

5. Hyperkinetic

6. Mixed

7. Unilateral upper motor neuron


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FlaccidCause Site of Lesion Neuromuscular

StatusSpeech Characteristics

Bulbar palsyMyasthenia

gravis

Lower motorneuron

WeaknessLow muscle

tone

Indistinct & labored articHypernasality

Nasal emissionsBreathy & harsh voicequalityAudible inspirationMonopitch & loudnessShort phrases


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Flaccid: treatment considerationsMusclestrength &range ofmotion

Modifyrespiratorybehaviors

Modifyphonatoryproblems

Modify resonanceproblems

Modifyarticulationproblems

Modifyprosodicproblems

Ask client toincrease effortJaw exercisesLip muscles:resistance,

pucker, widesmilesIncreasetonguestrengthOverallstrength: pushon arms of

chair

Push/pullexercisesPosturaladjustmentsPhonate at

beginning ofexhalationDeep inhalation& controlledexhalationIncrease breathgroup durationsIncrease number

of words perbreath group

Model &reinforce louderspeechUse computerprograms for

feedback onloudnessConsiderTeflon orcollageninjections toimprove VFadductionPush/pullduring speakingfor VFapproximationIf unilateral,turn head toaffected side forbetter closure

Note: hypernasality isthe main resonanceproblem due to damageto the pharyngealbranch of the vagus

nerve; soft palate may beweak or paralyzedPalatal Lift ProsthesisPharyngeal FlapOperationPharyngoplastyShape by modeling,reinforcement &

feedback

Reduce rate ofspeech usefinger tappingcue, verbalreminders, etc.Reinforce articof speech soundsIntelligibilityDrillsPhoneticPlacementMethodExaggerated

consonantproductionMinimalContrastMethod

Clientdiscrimination ofpitch changes inmodeled speechProlong an /a/

with lower &higher pitchHave client readprinted sentencesindicatinghigher/lowerpitch (arrows)Model various

pitch levels inphrases &sentences withclient imitationCorrectivefeedbackContrastiveStress Drills


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Spastic

Cause Site ofLesion

NeuromuscularStatus

Speech Characteristics

Pseudobulbarpalsy

Uppermotorneuron

Increased muscletoneReduced ROM,

strength & speed

Slow, imprecise articHypernasalityStrained, strangled, harsh voice

qualityMonotonous pitch & loudnessShort phrasing


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Spastic: treatment considerationsNotes Modify

respiratorybehaviors


Modifyresonanceproblems



Consult withphysical remedicallycontrollingpathological

cryingConsiderbehaviormodification ofpathologicalcryingDo not teachpush/pull

exercises that onlyaggravatehyperadductionUse relaxation &stretching withcaution due tolack ofsubstantiated

efficacy

Not majorconcern; anyapparentrespiratoryproblems may be

to phonatoryproblems likehyperadduction of

VF

Note: reducedefforts to reducehyperadduction of

VF have not beenespecially

successful; thus,proceed withcaution.Head & neckrelaxationtechniquesEasy onsetModel soft glottal

closure; imitation;begin withexhaled sigh &add prolonged/a/; shaping /a/into words,phrases, etcYawn-sigh

Increase vocalloudness tocontrolhypernasality,because louder

speech tends to beperceived as lessnasalDiscussusefulness ofPharyngeal Flapor Palatal LiftProsthesis with

appropriateprofessionals

Use discretion fortongue & lipstretchingexercisesIntelligibility

drillsPhoneticPlacementMethodUse a mirror tomodel & reinforceExaggeratedmedial & final

consonants inwords, phrases &sentencesMinimalContrast Drills

Varied pitch onprolonged

vowelModel pitch

variations; fadeUse printedsentences ,indicating rise& falling pitchlevels witharrowContrastiveStress DrillsChunkingutterances intosyntactic units;modeling &reinforcingappropriatepauses ; inhaleat junctures


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AtaxicCause Site of

LesionNeuromuscularStatus


Cerebellardisorders

Cerebellum Inaccuraterange, timing, &directionLow muscletoneReduced speedof movement

Excess & equal stressIrregular articulatorybreakdownSlow, inaccurate articRhythm disturbancesPhoneme prolongationsSome excess loudnessHypotoniaProsodic difficulties


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Ataxic: treatment considerationsNotes Modify

respiratorybehaviors




Use behavioralmethods of Shaping &Differentialreinforcement toimproved control &coordination

Do not focus onincreasing musclestrength or reducingmuscle toneDo not recommendprosthetic or surgicalmethods to improveReinforce more

natural soundingconversational speechImplement aMaintenance Strategyto train familymembers & caregivers

who will help sustaintreatment gains

Inhale deeplyExhale in slow,controlled manner tosustain speechReinforceprogressively longer

(more controlled)exhalation

Reinforce promptphonation uponinitiation ofexhalationEnd utterance wellbefore running out of

air; stop when signs ofairflow dissipationare evident & askclient to breathe againStop & inhale atnatural junctures insentences -atbeginning of a

grammatical clause,etc.

Use words lists;judge intelligibilityindependent of visualcuesGive correctivefeedback to

encourageappropriateproduction of soundsin words notunderstoodUse PhoneticPlacement Method toteach correct

production of soundsReinforce OVERarticulation of medial& final consonantsUse MinimalContrast Method toimprove theintelligibility of

words that differ byonly one phoneme

Slow rate of speechusing metronomebeatsUse finger or handtappingUse cues such as

pointing to printedword to generate asteady or even oralreading rateTeach appropriatestress on words insentences; usecontrastive stress

exercisesTeach variations inpitch by using bothprinted sentences &conversationalspeech


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Hypokinetic

Cause Site of Lesion NeuromuscularStatus


Parkinsonism Basal GangliaExtrapyramidalsystem -

substantia nigra

Markedlyreduced range &speed of

movement marked musclerigidityRest tremors

MonopitchMonoloudnessReduced stressSlow speaking rate with shortrushes of speechLong, inappropriate pausesFluctuating articulationaccuracy; impreciseconsonantsHarsh, breathy voice


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Hypokinetic: treatment considerations

Modify respiratory

behaviors

Modify phonatory

problems

Modify articulations

problems

Modify prosodic

problems

Inhale deeply beforespeakingStart speaking wheninhalation beginsExhale slowly & in a

controlled mannerStop talking well beforeexhausting air supplyGradually increase thenumber of words spoken perbreath

Note: Individuals with

Parkinsons disease derivegreater benefit fromtreatment that targets bothrespiratory & phonatoryfunction than treatmentthat focuses on respiratoryfunction alone

Use voice therapytechniques to increase

vocal loudness & todecrease breathiness; use

various biofeedback

instruments such as theVisiPitchUse pushing & pullingtechniques to increase themovement of range oflaryngeals muscles (haveclient push down on armof chair while phonating,

etc)Use portable voiceamplifiers to increaseloudness

Use rate control for clientswho speak rapidly; use handor finger tapping to cueproduction of syllables or

words; use delayed auditory

feedback to slow down therate; use a Pacing Board or an

Alphabet BoardUse Intelligibility Drills in

which the client reads aloudprinted words; judge accuracybased on phonatory cues &give corrective feedback or

reinforcementUse Phonetic PlacementMethodProduce word medial & finalconsonants with exaggerationUse Minimal ContrastMethod

Note that slower ratecan improve clientsprosodyTeach proper intonationthrough printed

sentences that showrising & falling pitch byarrowsUse Contrastive StressDrillsTeach appropriatechunking of wordsaccording to syntactic

units such as pausing atthe end of a grammaticalclause & a sentence


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Hyperkinetic - QuickCause Site of Lesion Neuromuscul

ar StatusSpeech Characteristics

ChoreaTourettssyndrome

HuntingtonsChorea

Extrapyramidal Rapid, jerky,uncontrolledtic movements

Dominant symptom is prosodicdisturbancesImprecise consonants

Distorted vowelsVariable rate & loudnessHarsh voiceInappropriate pauses; prolongedintervalsAbrupt grunts & barks


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Hyperkinetic - SlowCause Site of Lesion Neuromuscular


AthetosisDystoniaDyskinesia

Extrapyramidal Slow, twisting,writhingmovements &

posturesVariable muscletone

Irregular articulatorybreakdownMonopitch & monoloudness

Harsh voice quality


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Hyperkinetic - TremorCause Site of Lesion Neuromuscular


Organicvoice tremorMyoclonus

Extrapyramidal Involuntary,rhythmicmovements

Voice tremors with rhythmicphonation breaksChoked-strained voice quality


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Hyperkinetic: treatment considerations

Medicationsthat control involuntary movements

Methods to help controlinvoluntary movements


NOTE: medical treatment does notalways eliminate the need for behavioral

management of dysarthria

Haloperidol controls chorea & ticsClonazepam & valproic acid controlmyoclonic jerksBotox injections control dystonia (moreeffective than other drugs listed intreating clients with hyperkineticdysarthria)

Easy onset to help reduce involuntarymovements that disrupt laryngeal

movements especially in clients withmild hyperkinetic dysarthriaRelaxation therapy to controlTeach habit reversal in which theclient is taught competing voluntarybehaviors to control involuntarybehaviors (e.g., asking the client toblink slowly before the tics occur)Use a Bite Block (small plastic cubethe client bites down on) to inhibit orreduce interfering jaw movementsduring speech in clients withmandibular Dystonia

Slower rate &increased

vocal pitchwhennecessary


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MixedCause Site ofLesion NeuromuscularStatus Speech Characteristics

Amyotrophiclateral sclerosis(ALS)Multiplesclerosis (MS)WilsonsdiseaseMultiplestrokes

Multiplemotorsystems

MuscularweaknessReduces range &speed of motionSome intentiontremors

ALS:severely defective articSlow rateNoticeable hypernasalityHarsh voice qualityMarked prosodic disturbances

MS:Harsh voice qualityInconsistent rate & articprecision

Wilsons disease:Similar to hypokineticdysarthria without sudden

bursts of speech


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Mixed: treatment considerations

Identify dominant type, if any, and describe the major speech problems

Select speech targets that when treated will immediately improvecommunication

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 inthat 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 whichproblems should be addressed first in treatment

Recommend Augmentative Communication devices for clients who needthem; note that clients whose mixed dysarthria is due to ALS are likelycandidates for augmentative communication


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Unilateral Upper Motor NeuronCause Site of

LesionNeuromuscularStatus


Stroke damage toUMN that

supply cranial& spinalnervesinvolved inspeechproduction

Posteriorfrontal lobe

Lower facialweaknesshemiparesis

Imprecise consonantsIrregular articulatorybreakdown

Harsh voiceMild hypernasalityGenerally slow rate of speechwith increased rate insegmentsExcess & equal stress


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Unilateral UMN: treatment considerations

Notes Modify articulation problems

In some cases, associatedlanguage deficits (aphasia) &apraxia may take treatmentpriority; dysarthria may not betreated, but it is recommended

A variety of behavioral therapyapproaches are effective forthose with stroke or TBI,including feedback of acousticinformation, respiratory &speech rate control, &physiological strategies such asbiofeedback & reaction timesDevices such as palatal liftsresult in gains in musclestrength & speech intelligibilityfor individuals with stroke ortraumatic brain injury

Use traditional methods to treat articulation disordersIntelligibility Drills accuracy judged on phonatory cues withfeedbackPhonetic Placement Method; use mirror; model & reinforceimitated & evoked productions of target words, phrases, &sentencesExaggerated medial & final consonantsUse Minimal Contrast Drills in which pairs of words that differ byonly one phoneme are used to teach correct productions of targetsounds


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Recommended Resources

Brookshire, R. H. (2003). Introduction to neurogenic communicationdisorders. St. Louis, MO: Mosby.

Duffy, J. R. (1995). Motor speech disorders: Substrates, differentialdiagnosis, 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. SanDiego, CA: Singular Thomson Learning.

Hegde, M. N. (2008). Hegdes PocketGuide to Treatment in Speech-

Language 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 ofspeech and swallowing in degenerative disorders. Austin, TX: Pro-Ed.


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References:

Hegde, M. N. (2008). Hegdes PocketGuide to Treatmentin Speech-Language Pathology. Clifton Park, NJ:Thomson Delmar Learning.

Roth, F. P., & Worthington, C. K. (2005). TreatmentResources Manual for Speech-Language Pathology, 3rdEdition. Clifton Park, NJ: Thomson Delmar Learning.

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