animal difference neurogenic speech disorders - főoldal · 2013.11.09. 1 neurogenic speech...

2013.11.09.

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Neurogenic speechdisorders

Dr. Szabó EdinaUniversity of Debrecen, Medical and Health Scienc Center Faculty of Medicine, Dep. of Phisycal Medicineand Rehabilitation

Animal difference

Soul (church model)

Toolmaking ability

Thinking skills/Ability of thinking

Modeling capabilities

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Darwin's theory of language origin

Darwin about animal intelligence

Ancient human cognitiveAncient human cognitive function

Vocalization: rudimentary song

Articulated language3

Cerebral lateralization

Evolutionary backgroundSpeech and hemispheres

Left: verbal-logical Phineas Gage (1848)Phineas Gage (1848)

Right: visual-syntheticRight: primitive forms of

knowledge is keptResearch of Gazzaniga (1983)

Testing split-brain patients

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The brain without language

How can the human mindfunction without a functioning language system? (Lecours és Joanette, 1980)The case of Brother JohnThe case of Brother JohnDifferent stages of aphasiaAbilities remained intact even under attack: thinking, music, sound, face detection, use of objects, spatial orientation, mechanical intelligence, working memory, episodic memory, self-presentationChanged skills: cognitive operations that require symbolic representation

He could behave aHe could behave as a human being s a human being !! 5

The brain structure I.

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The communication of the brain

The basic structural and functional unit of the nervous system is: the neuronthe nervous system is: the neuron

Parts: cell body, nucleus, extensions (dendrites), axon (endings), myelin sheath

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Blood supply of the brain

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Introduction to the clinical aphasiology

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Cerebral infarction II.

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Cerebral infarction III.

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Hemorrhagic stroke I.

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Hemorrhagic stroke II.

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The communication-centered definition of aphasia

The aphasia is neurogenic

communication disorder, which hides

the competence ofthe competence of the person, which is

manifested in conversations.

(Aura Kagan, Aphasia Institute)

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Etiology of aphasia

Hemorrhagic strokeCerebral infarctionPrimary brain tumors or metastasesTrauma (concussion, skull fracture)

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Symptoms of aphasia

Fluency disorder: nonfluent vs. fluent aphasiaUnderstanding disorderAgrammatism/paragrammatismAgrammatism/paragrammatismPerseverationParaphase: semantic, phonemicNeologismVerbal automatism

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Syndroms of aphasia (Boston school)

Classical classification (BDAE, WAB)Evaluation of the spontaneous speech, speech repetition,naming and the understandingthe understandingLocalization principle: which language areas of the brain are responsible for different functions (FTP lobes parts of perisylvian)

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Global aphasia

Nonfluent speech Verbal automatismPerseverationsSevere understanding disorder

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Paul Broca and the Broca lesion

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Broca aphasiaNonfluent speechAgrammatism (missing suffixes, parts of sentences, suffixes)Phonemic paraphasesW d fi di diffi ltiWord finding difficultiesFaulty speech repetitionMild, or moderate understanding disorderMonotonous intonation

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Carl Wernicke and the Wernicke lesion

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Wernicke aphasia

Fluent, but empty speechMeaningless, jargon wordsPhonemic and semantic paraphasesSevere understanding disorder

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Conduction aphasia

Spontaneous speech: Fluent, but with a lot of phonemic paraphaseTh f l i i f d dThe faulty repetition of words and phrasesA striking difference between spontaneous speech and speech repetition

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Anomic aphasia

Fluent spontaneous speechWord finding disorderCircumscriptionCircumscriptionMild understanding disorderAdequate speech repetition

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Transcortical aphasias

TMA: nonfluent speech, adequate speech repetition

TSA: disorder of understanding S d so de o u de sta d gwords and sentences, speech repetition is good

Mixed TA: severe impairments in all language functions, repetition is slightly better

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Atypical aphasias

Crossed aphasiaSubcortical aphasiaSubco t ca ap as aBilingual aphasia

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Aphasia

They do not understand him, but

he knows what he wants to say

World is narrowing or completely

closing up around him

Becomes shipwrecked among

people

He needs help, he needs to

learn to express himself again!

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The aphasia – affectedThere is no exact data in

Hungary

If U.S. rates are considered,

we have more than 40 000

people suffering from

aphasia

It's probably just a gentle

estimate, as the main cause,

stroke, is higher in Hungary

than in the U.S.

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The aphasia – affectedEven more frightening picture

when we look at the range of

indirectly affected:

Families are also included in

this figure: 160 000 (40 000 * 4)

Tertiary affected people 640 000

(40 000 * 16)

With quaternary affetced people, the proportion is 25%, so it suggests that a quarter of the population can be in direct conctact with an aphasia affected person in Hungary (40 000 * 64)

Therefore, a quarter of our society must learn to communicate with them, todevelop them 33

Motor speech disorders

The speech is one of the most impressive motor activity yThe control of speech movements in childhood is possible The adults are forced to pay attention to their speech movements as a result of a cerebral accident Two large groups: the apraxia and Two large groups: the apraxia and dysarthriadysarthria

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What is considered as motor speech disorder?

The speech production deficit which developsas a consequence of neuromuscular and / or motor control system impairment

Sometimes occurs collectively with other language impairments (eg aphasia)

Other oral movements can be damaged besides speech, for example the smiling, chewing, etc..

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Determination of speech motor system

Four Subsystems of Speech Production:

Respiratory system Phonatory systemResonatory systemArticulatory system

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Frequency of motor speech disorders

Reliable estimates are rare, but ...51% of adult speech disorders are motor aphasia, dysarthria with 46%, 5% apraxia5% apraxia.Among children 5 % of developmental communication disorders are due to motor dysfunction

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What about nonfluent aphasias?

Why not discuss the motor speech disorder?Nonfluent speech in aphasia is just one component of a more complexone component of a more complex communication disorderDifferential diagnosis of motor speech disturbances: always understanding difference

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What about stuttering?

DysfluentiaSubcortical laesio, injury of basal ganglionsganglionsNeurogen dysfluentia/neurogenic stuttering

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The common definition of motor speech disorders according to their characteristics

We talking about motor planning / programming deficit when we experience inability to selectexperience inability to select appropriate muscle groups, difficulty to sychronize them: ApraxiaMuscles suffers physiological or motor function injuries: Dysarthria

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How can we classify motor speech disorders?

After etiology:Acquired:

Can be caused by cerebrovascular– Can be caused by cerebrovascular accident (stroke), degenerative diseases, traumatic brain injury or brain tumorDevelopmental:– Can be caused by congenital disease or injury caused to the developing nervous system

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ApraxiaThe failure of articulatory gestures in normal conversion, wrong linguistic representation (even in imitation tasks!)

Features: slow speech (rarely entire speech), sound distortions, prolonged vowels (extended release), reduced prosody, inconsistent defects, speech starting problems, searching

articulatory gestures

Speech disorder is a result of neurological damage: left frontal cortex, stroke near Broca’area then it is called kinetic / ideomotor apraxia and when the left parietal cortex is damaged it’s kinesthetic / ideativ apraxia Can appear due to cerebral injuries, illnesses, after infections.

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DysarthriaNeuromuscular disorder which affetcs execution of speech movements, regulation of muscle tone, reflexes, movement kinematic aspectsIt is characterized by a slow, erratic sounds harsh raspy or whisperingsounds harsh, raspy or whispering voice, consistent mistakes,or other features depending on the type of dysarthriaThree primal features (depending on model) spasticity, dyskinesia, ataxia.Its common causes are progressive neurological disease and stroke. 43

Etiology, symptoms, and classification ofand classification of dysarthria

Definition of dysarthria

Darley, Aronson, Brown (1975):

Muscular control weakness complexMuscular control weakness, complex muscle (neurogenic) dysfunction.

Consequence of organic injury in thecentral or peripheral nervous system

Cséfalvay Zsolt, 2007

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The speech control cranial nerves

Nervus trigeminus (V.)Nervus facialis (VII)Nervus glossopharyngeus (IX.)Nervus vagus (X.)Nervus accesorius (XI)Nervus hypoglossus (XII.)

Cséfalvay Zsolt, 2007Cséfalvay Zsolt, 200746

Bulbar (or flaccid) dysarthria

(a) lesion in the peripheral motor neuron (involement of cranial (nerves)

(b) muscle weakness (flaccid muscles)


Etiology of bulbar (flaccid) dysarthria

Injury to the nuclei of 5, 7, 9, 10, 11, 12 th. cranial nerves or the bulbar nucleiMonopathia: affects only one nerveMonopathia: affects only one nervePolypathia: more nerves are concerned


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Physical injury: surgery, cranial injury and neck injuries B i t t k (b i tBrainstem stroke (brainstem vascular involvement)Myasthenia gravis



Guillain Barré syndroma (progressive inflammatory disease, demyelinization)Tumor (near the brain stem)Tumor (near the brain stem)Muscular dystrophy (progressive degeneration of muscle tissue)Progressive bulbar paralyses.

Cséfalvay Zsolt, 2007Cséfalvay Zsolt, 2007 50

Symptoms of bulbar dysarthria

Resonance disorder : hypernasality

Artikulation disorder: slow artikulationartikulation

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Phonation disorder:phonation incompetence(insufficient closing of vocal cords) - dysphonia

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Respiratory Disorder: C., Th nerve problems only (diaphragm, damage to intercostal muscle movement, lack/insufficient subglottic ac / su c e t subg ott cpressure, poor sound intensity

Prosodic disorder


Symptoms of bulbar dysarthria(Summary)

n. trigeminus laesio: artikulation disorder, resonance disordern. facialis laesio: artikulation disordern. vagus laesio: resonance disorder, gphonation disordern. hypoglossus laesio: artikulation disorderUnilateral injury: milder symptomsBilateral injury – severe symptoms


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Spastic dysarthria

Bilateral central motor neuron involvementinvolvement


Etiology of Spastic dysarthria

Stroke

Cerebrocranial trauma

Sclerosis multiplex (when central motoneuron is affected)

Tumor


Symptoms of spastic dysarthria

Spastic slow articulation (especially consonants)Spastic dysphonia (due to hyperadduction of vocal cords)Hypernasality – the spasticity slows down and limits the movement of soft palate musclesDysprosodia: limited range of voice and volume, short phrases, slow speech rateRarely: respiratory problems


Accompanying symptoms of spastic dysarthria

(1) spastic laughter, crying (which is difficult to control voluntarily) y)

(2) hypersalivation (which may be the control of salivary dysfunction, or as a result of less frequent swallowing)


Ataxic (cerebellar) dysarthria

EtiologyLaesio of the cerebellum or cerebellar tracks


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Etology of ataxic dysarthria

Degenerative disease: Cerebellar ataxia, Friedreich ataxia (hereditary

spinocerebellar disease), Olivopontocerebellar degenerationOlivopontocerebellar degeneration Stroke – blood supply dysfunction in the

areas of the cerebellarToxic injury (chemical substances, alcohol,

drugs)Cranial trauma - cerebellarTumor ( eg. astrocytoma)


Symptoms of ataxic dysarthria

Disorder of speech cordination (artikulation, prosody)Vague, indistinct articulation: "Boozer" articulation, irregular intervals (more syllable words)Mild hyponasalityMild dysphonia


Hyperkinetic dysarthria

Hyperkinetic dysarthria

Hyperkinetic disorder: excessive involuntary movement (chorea, myoclonus, dystonia, essential tremor)

Etiology: Basal ganglia injury and areas around the BG (eg Huntington's disease).


Symptoms of hyperkinetic dysarthria

Involuntary movements of (resp., phon., artik., reson.) musclesChoreatic hyperkinesia due toChoreatic hyperkinesia –due to simultaneous or successive involvement of muscles (lip muscles and phonation muscles are involved)


Symptoms of Hyperkinetic dysarthria

CHOREA:Long intervals between syllables and wordsVariable speech rateInadequate breaks (silence)Variable volumeProlonged vowelsFast, and short inhalation, exhalation and phonation intervals


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Hypokinetic dysarthria

Occur due to pathological changes in p g gBG, their connection with other areas of CNS


Etiology of Hypokinetic dysarthria

Parkinson‘s disease

Postencephalopatic parkinsonism

Craniocerebral trauma (BG, substantia nigra)


Symptoms of hypokinetic dysarthria

Dysprosodia: monotone speech (limited vocal range and volume)

Long pauses (due to akinesia)

Fast speech rate.



Articulation disorder:

"blurry" articulation , atypic dysfluency: repetitionatypic dysfluency: repetition (initial phonemes)palilalia (very fast repetition of words)



Dysphonia: Due to incomplete closure of the vocal cords (breathy voice quality, rough, raspy voice)Mikrophonia: low sound levelMikrophonia: low sound levelRespiratory disorder: rapid, shallow breathingResonance abnormalities: mild symptoms (hypernasality)


Mixed dysarthria

Etiology:Sclerosis multiplex/multiple scerosisMultisystemic atrophy (Shy-Drager u t syste c at op y (S y agesy, progressive supranuklear paralysis, olivopontocerebellar atrophyALSWilson's disease


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Symptoms of mixed dysarthria

SM: ataxic-spastic form (phonatio-articulation disorder)Wilson‘s disease (BG involvement) hypokinetic form later spastic-hypokinetic form, later spastic-ataxic form ALS: initial stage


How we can identify motor speech disorders? Tests

Frenchay Dysarthria TestApraxia Battery for Adults-2nd editionAssessment of Intelligibility in Dysarthric Speakers (AIDS)(computerized version called CAIDS)( p )Sentence Intelligibility TestTOCS+ for children by Megan Hodge is this website:

http://www.tocs.plus.ualberta.ca/videodemo.htm

These testing procedures are not adapted in Hungary for motor speech disorders

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Diagnostic

A comprehensive assessment of communication disorder following a detailed diagnostic protocold ag ost c p otocoAt present, the differential diagnosis is based on the professional perceptual, acoustic monitoring, psychological testing as there are no objective acoustic and physiological indicators availableThe diagnosis itself should include the damage rate, the rate of mistakes, the rate of "false positive" responses and the rate of corrections

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Diagnostic process

Assessment of the oral motorium

Testing of phonatio and prolong phonatioTesting of phonatio and prolong phonatioThe examination shall include, detailed diagnostics of the individual subsystems: respiration, phonation, resonance, articulation and prosodyCognitive / Communication Skills Mappingobserve compensatory strategies used by patients

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The examination

Examination is carried out during speech and at restSpeech muscles of the peripheral nervousperipheral nervous system (specific tasks)Examination of cranial nerves: V.,VII., IX., X. XI. a XII. (neurological examination)

Darley, Aronson, Brown: Examination of motor speech

disorders 77

Examination of the facial muscles at rest (VII. n. facialis)

Is the face symmetrical?Can you move your lips?Can you show your teeth?y yEyes:open,or partially shut?The face rigid, mask-like? Are forehead muscles symmetrical when raising eyebrows/wrinkling/frowning?

Is the nose symmetrical?

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Examination the facial muscles in motion (VII. n. facialis)

Is the smile symmetrical?Looking for the right position when smiling (apraxia?)smiling (apraxia?)Pouching of lipsClose lipsPuffing up cheeksMuscle strength

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Examination the lower jaw muscles in resting position (V. n. trigeminus)

Is the jaw symmetric?

Is there deviation during resting?Is there deviation during resting?

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Examination of the lower jaw muscles during spontaneous movements

There is a deviation jaw when the mouth is open?Looking for the right position whilst opening (apraxia)?Is there possible side movement?Is there strong resistance against pressure?

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Examination of the tongue muscles at rest (XII. n. hypoglossus)

Is the size and shape of the tonguenormal?In the located in the middle of the

th?mouth?Is the shape of the tonguesymmetrical?Is there fasciculation muscle of the tongue?Can it remain inactive?

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The examination of the tongue muscle movements (XII. n. hypoglossus)

Can the tongue move out?Can the patient stick his tongue out?Can he resist lateral pressure to the tongue?Can patient produce lateral movements?

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Examination of the velum, pharynx and larynx at rest and during exercise(X. n. vagus)

Does velum elevates during fonation ?I l t i l?Is velum symmetrical?Can we trigger gag reflex?

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Examination of the larynx(X. n. vagus)

Is patient able to produce a loud cough?Able to developAble to develop adequate subglottic pressure?Can we hearinhalation stridor?

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SummaryMust be able to distinguish between disorder of motor planning (apraxia) and disorder of motor execution (dysarthria)Dysarthria: we must be able to determine the type of dysarthriaB bl t d t i h d t th tBe able to determine how damage to the motor subsystems affect intelligibility of speechWe have to know if the disease is acquired or developmentalDisorder emerged suddenly or graduallySet up the treatment plan accordingly

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From diagnosis to therapyA detailed

diagnostic protocol isan

t itopportunity for better trauma-specific treatment plan

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Vocalization and swallowing

Lungs provides air flowGlottis: vocal phonation and positioningR t h i dResonator areas: synchronized orientationSwallow: Preoral, oral, pharyngeal and oesophageal stagesSwallowing apnea, opening the top of the esophagus

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Dysphonias

Organic dysphonia

Functional dysphonia

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Functional dysphonia

Change in the tone (usually hoarseness), overuse of voice, larynx is less strainable without primary structural difference inthe larynx itself. All complaints are usually accompanied by paresthesia

Phonoponozis

PhononeurosisMészáros KrisztinaMészáros Krisztina 90

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Phonoponozis I.

Definition:

Improper use of sounds, vocalImproper use of sounds, vocal dysfunction due to overuse of the phonatory apparatus

Mészáros KrisztinaMészáros Krisztina 91

Phonoponozis II.

Complaints:

Gradually formed, altered, hoarse voice becomes asymptomatic aftervoice, becomes asymptomatic after relaxing, urged to croak and swallowing, globus sensation, foreign body sensation, pain sensation in the neck, sore throat, and cough.

Mészáros KrisztinaMészáros Krisztina92

Phonoponozis III.Symptoms:Changed, usually hoarse voice, but not

aphonic. Hard start-up sound, almost normal range of voice, prolonged sound shorter, limited volume.

Decreased, tight vocal movements, irregular, tight thoracic breathing. Face, tongue, jaw, g g , g , j ,neck under tension, neck veins visible during speech.

Larynx: false vocal cords distend due to straining, congestion in free margins of the vocal cords.

vocal knots, margin oedema appear, and failure of glottic closure at the back of the larynx


Phonoponozis IV.

Treatment:

Voice Therapy and in cases of existing tough vocal cord knotsexisting tough vocal cord knots , surgical removal is recommended.


Juvenilis dysphonia I.

Definition:

Formed in childhood, improper voice use excessive use of the phonationuse, excessive use of the phonation apparatus due to vocal dysfunction.


Juvenilis dysphonia II.

Complaints:

Hoarseness, deepening of the voice, croakingcroaking


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Juvenilis dysphonia III.

Symptoms:A sharp, deep-pitched, hoarse voice.

Urge to croak, hard starting volume. Fast speech, rhythm, inaccurate p , y ,articulation, irregular, tight thoracic breathing. Face, tongue, jaw, neck are tense, neck veins distended during speech.

Larynx: loose watery vocal cords, vocal bunch knots, failure of glottic closure.


Juvenilis dysphonia IV.

Treatment:

Voice therapy and in cases of existing tough vocal cord knotsexisting tough vocal cord knots, surgical removal is recommended.


Phononeurosis

Voice production disorder of psychogenic origin, sudden and severe voice symptoms.

Psychogenic aphonia: inability to produce sounds, immediate psychiatric treatment and voice therapy.


DysodiaThe functional voice disorders.

Respiratory defectsIncorrect setting of the articulation areaa ea4-6 hours of overstrainingCaffeine, drugsEarly singing lessonsIgnoring vocal hygene recommendations


Gastro-oesophageal reflux disease in phoniatrydisease in phoniatry implications

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The most common aspects in phoniatry of the GERD

DysphoniaPharyngitisDysphagiaDysphagiaexcess flow of mucus in the back of throat Stimulated cough Chronic Bronch.Asthma bronch.


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Top phoniatric result

Hoarseness

Etiology:gyThe acid-induced vagal reflex triggered recurrent coughing reflex.There is direct acid effect on the pharynx, larynx.


Diagnostic, anamnesis

Substernal burning sensation, painNocturnal regurgitation

Feeling of mucus flow in the throatFrequent throat painsregurgitation

Coughing, wheezing AspirationMorning hoarseness Croaking

pains Jugular discomfort Heartburn (rarely)


Diagnostic, examination

oto-nasal laryngological examinationexamination laryngial video-stroboscopy Auditory Sound Scanexamination of sound retention time and vocal rangeAnalysis of sound dynamics

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Stroboscop evidenceThe congestion of inter-ary region of the vocal cords, false vocal cords slight oedema of the vocal cords.Pronounced hyperplasia of the inter-ary region contact granulomaregion, contact granuloma.In general, the glottis level of vasoconstriction, decreased vocal cord vibration parameters, harsh sound start.In addition to harsh sound start, hypotonic vibration in front of the vocal cords


GERD and the phoniatry

Varying degrees of hoarsenessVocal holding time shortensSound stage renal

fDecreased ability of raising volume20% of phoniatric patients affected by clinical symptoms, 14% was proven in during gastroenterologicexamination


Treatment

Gastroenterology areas: Medication and lifestyle counseling.

Phoniatric Therapy: Sound Therapy treatment to the added functional components.

Mészáros KrisztinaMészáros Krisztina

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Thank you for your attention!

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animal difference neurogenic speech disorders - főoldal · 2013.11.09. 1 neurogenic speech...

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