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
Modifyphonatoryproblems
Modifyresonanceproblems
Modifyarticulationproblems
Modifyprosodicproblems
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
Speech Characteristics
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
Modifyphonatoryproblems
Modifyarticulationproblems
Modifyprosodicproblems
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
Speech Characteristics
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
StatusSpeech Characteristics
AthetosisDystoniaDyskinesia
Extrapyramidal Slow, twisting,writhingmovements &
posturesVariable muscletone
Irregular articulatorybreakdownMonopitch & monoloudness
Harsh voice quality
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Hyperkinetic - TremorCause Site of Lesion Neuromuscular
StatusSpeech Characteristics
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
Modifyprosodicproblems
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
Speech Characteristics
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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