Dysarthria Assessment Study Guide PDF

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Summary

This is a thorough and complete study guide on how to assess someone with a suspected motor speech disorder and what characteristics will guide your decisions....

Description

TEST TWO STUDY GUIDE!! Parts of a motor speech examination: 1. Case history! 2. Perceptual Speech analysis! 3. Intelligibility Rating! 4. Oral mechanism examination! 5. Communicative participation analysis ! 6. If other indicators suggest apraxia, do an apraxia assessment. ! When doing a MOTOR SPEECH EXAM you are looking for six characteristics OR NEUROMUSCULAR ATTRIBUTES 1) strength 2) speed 3) range of motion 4) tone 5) accuracy 6) steadiness ! 1) Strength: Is the strength reduced and is it consistent weakness or progressively getting worse. Impaired strength can affect all speech subsystems and is most apparent in FLACCID DYSARTHRIA.! 2) Speed: Excessive speed is uncommon in MSDs EXCEPT for HYPOKINETIC DYSARTHRIA. Slow movements are the most common but movements may also be variable and impaired speed can affect all subsystems and especially influences prosody. Slow speed is most apparent in SPASTIC DYSARTHRIA. ! 3) Range or ROM: reduced ROM is apparent in most MSDs and may occur in the context of slow, normal or rapid rate. Variable and unpredictable or excessive ROM is common in ATAXIC and HYPERKINETIC DYSARTHRIA. This ROM strongly affects prosody.! 4) Steadiness: Generally rhythmic or arrhythmic and a tremor would most commonly affect phonation and when it is severe enough it could affect prosody and rate and this tremor is detected easily in vowel prolongation. Hyperkinesias (dystonia or chorea) may be present at rest or doing movement/sustained postures and that may interrupt or alter direction of intended movement and most commonly affects prosody and rate. ! 5) Tone: REDUCED tone is evident mostly in FLACCID DYSARTHRIA and EXCESSIVE TONE is noted mostly in SPASTIC AND HYPOKINETIC DYSARTHRIA. VARIABLE tone is evident in HYPERKINETIC DYSARTHRIA and alterations in tone can affect all the speech subsystems ! 6) Accuracy: Accurate movements require proper regulation of all other neuromuscular attributes and alterations affect all speech subsystems but it is most easily perceived in articulation and prosody. All types of dysarthria may be characterized by inaccurate movements. ! Possible Acoustic and Physiological Measures: Acoustic measures could be phrase duration (rate of speech) amplitude variation (monoloudness) and Fundamental frequency (monotone) and Spirometry (respiratory function) electropalatography (articulatory function) and Nasometer (velopharyngeal function)!

Why do we use acoustic and physiological measures: Provides objective measurable information about breakdowns in the speech sinal and the subsystem functioning and it validates our perceptual analysis and justifies a need for treatment and helps to document treatment efficacy ! Key things in a case history: Important to 1) gain information from their medical history and previous medical charts 2) Important to ask them why they are here today to get a perception of their orientation and awareness 3) important to ask about the onset and progression of their speech 4) ask about associated deficits and then ask about their management and medical diagnosis and prognosis or how they perceive their speech to help build a management plan ! Background

Introduction

Basic Data

Onset and course

Primary and secondary medical diagnosis

Why are you here?

Age Education occupation and marital status

Date of symptoms

Provides info about patients orientation and awareness

History of childhood speech and language or hearing impairment

Site of lesion if identified

Provides patients concern about speech

Associated Deficits

Patient perception of deficit/ consequences of disorder

Management and Awareness of Medical Diagnosis and Prognosis

Onset and course Questions that of speech deficit is might reveal useful for confirmatory signs neurological prognosis and manegement

PD: May provide confirmatory information ! CD: address some of the functional consequences of the speech disorder

Management is important to prognosis and recommendations

Do you have difficulty with your speech if not has anyone else commented on your speech

Any saliva control problems?

Describe your What do you do speech difficulty is when others don’t it faster, slower, understand you? less precise, softer etc

When did the speech problem begin? Was it sudden or gradual?

Any difficulty chewing?

Have you noticed any changes in feeling of your mouth

Have you had any prior help?Do you think you need help now?

Background

Introduction

Medications

Discussion of functional communication and possible goals

Onset and course

Associated Deficits

Patient perception of deficit/ consequences of disorder

Management and Awareness of Medical Diagnosis and Prognosis

Has your speech problem gotten better/worse/ stable?

Any difficulty swallowing or do you cough or choke on food or fluids?

How do you feel about this problem? How has it affected you socially?

Awareness and prognosis is info of wha the patient understands about their diagnosis and prognosis influences explanation of speech diagnosis and management

Relevant medical or social history

Do you cry or laugh more easily than you did in the past?

Do people have a hard time understanding you?

Next of kin

Aware of any abnormal movements in your face or jaw

!

Basic Data

Four things to elicit during Perceptual speech analysis: Contextual speech

Vowel prolongation

Alternating Motion Rates

Sequential Motion rates

Best most natural way to elicit speech/most useful task

Ask them to take a deep breath and say “ahh” for as long and as steadily as they can

Ask a patient to take a deep breath and say “puh puh puh” as long and steadily as possible then repeat with “kuh” and “tuh”

Measure a person’s ability to move quickly from one articulatory position to another and is particularly useful when AoS may still be in the question

Conversation: ask them why they are here today, elicited during case history

You are examining pitch, loudness Normal speakers are 5-7 and vocal quality repetitions a second

Narrative: can ask about hobbies, use a picture elicitation task

Ask patient to “take a breath and repeat puh tuh kuh over and over again until I tell you to stop”

Enables you to determine speed and regularity of reciprocal movements of the jaw, lips, tongue and precision of articulatory movement as well as adequacy of VP closure

Read aloud a standard passage like the grandfather passage or the caterpillar passage

Assessment of Intelligibility Key features: An assessment of intelligibility is assessing the severity of the disorder and is necessary as a baseline measure when you are undertaking treatment ! ASSIDS Assessment of Speech Intelligibility of Dysarthria Speech

SIT Sentence Intelligibility test

Most widely used measure

This is a computer program

Measures both single word and sentence intelligibility

Program randomly selects sentences that increase in difficulty and the records the speaker

ASSIDS Assessment of Speech Intelligibility of Dysarthria Speech

SIT Sentence Intelligibility test

The single word task has the client read aloud 50 words and the sentence task has the client read aloud 22 sentences ranging in length from 5-15 words

A judge uses the program to transcribe the recordings and then the program will generate results

Productions are audio recorded and given to two judges to listen to and transcribe Intelligibility is scored on percentage of words that were correctly identified and more than one judge is best The judge must be a native speaker with normal hearing who is an unfamiliar listener and not the person who conducted the assessment

Estimates of communicative participation: Participation refers to the involvement in real life situations. This in essence is how badly is the dysarthria or AoS or other voice defect affecting participation in daily life and their enjoyment of the events.! To determine client’s level of speech usage/communication needs you should work through the “speech usage categorical rating scale” ! You should also complete an outcome measure of communicative participation through either the “communicative effectiveness survey CES” or the “communicative participation item bank CPIB”! Speech usage Categorical Rating Scale

Communicative Effectiveness Survey

Communicative participation item bank

Rated on “how do you use your speech”

This survey can be given to the speaker’s friends and family.

The patient rates themselves in different situations from 0-3

Asks how they have typically used their speech in the past year with a scale

Rateing from one being not effective to seven being very effective on how their communication is in certain events

THE PATIENT takes it

The scale is: undemanding, Intermittent, Routine, Extensive, Extraordinary

It covers a lot of information in a variety of communication situations and it is scored on a scale. It is for OTHER people to take it

Takes a look at their average speech, not just on a good or bad day and covers 10 conditions

CES

CPIB

These things would stand out and then lead you to believe it is Apraxia of Speech: ! 1) irregular articulatory breakdowns 2) The errors increase when the sentences get longer 3) there is more difficulty with multisyllabic words 4) Audible and visible groping or false starts and frequent re-starts ! If you suspect apraxia then you should… Complete the Apraxia Battery for Adults-2 ! The aim of this test is to 1) verify the presence of apraxia is an adult and 2) gain a rough estimate of the severity it also 3) assists in determining treatment targets and documenting progress ! Test Summary: ! Apraxia Battery for Adults (ABA 2)! Need a stop watch and a recording device and the booklet ! Subtest 1: DDK ! Single syllable puh, tuh, huh ! Then you start counting how many correct productions are made in three seconds (puh tuh) and then the for the three syllable is how many correct in five seconds (puh tuh kuh). ! Increasing word length:! Have client repeat after you and then the words get harder and longer as you go along and you score them on accuracy ! Limb apraxia and oral apraxia:! Ask them to do actions and rate them on how they do that. ! Latency time and Utterance for Polysyllabic words! Show patient pictures and have them name the pictures and then record the latency time and then the time from beginning of utterance until finishing the utterance.! Repeated trials:! Say a word and have patient repeat it back three times and then record their phonetic errors and the compare them across the trials and you must record it.! Inventory of Articulatory Characteristics of AoS!

Have them read, then spontaneous speech then automatic speech and then go back at a later time and then see if they present with any of the 15 behaviors in the booklet ! Note: the ABA isn’t deemed psychometrically valid and reliability has not yet been established but it does represent an organized approach to assessment and it has good face validity ! Oral Mechanism Examination: You are looking at the following structures FACE JAW VELOPHARYNX LARYNX TONGUE RESPIRATION/REFLEXES ! You are looking at each of them AT REST, DURING SUSTAINED POSTURES AND DURING MOVEMENT ! Structure

At Rest

Sustained posture

Movement

Face

Normally the face is really symmetrical and doesn’t move during rest !

This allows for additional observation of symmetry, ROM, Strength and Tone!

These not the range of motion and symmetry of facial movement !

Instruct patient to relax and say breathe through your mouth then observe!

Useful postures: retract the lips, lip rounding, puff the cheeks, sustained mouth opening and then observe is ROM normal or reduced and can the postures be maintained upon request ! -can the patient resist examiner attempts to push their lips towards the midline when lips are retracted or can they resist the examiner spreading the lips when they are rounded! -Does air escape when puffing their cheeks! -Do tremors appear or disappear during sustained postures

-is the face symmetrical! -if asymmetrical, why (facial droop)! -Are the expressions normal or mask like! -any spontaneous movements present and can the patient stop the movements upon request! -What are their lips like do they exhibit tremors?! -Are there fasciculations especially in mouth or chin?

Nonspeech movement tasks: rapid repetition of lip pursing and retraction and week puffing ! Note for lability or the difficulty in inhibiting laughter or crying

Structure

At Rest

Sustained posture

Movement

Jaw

Normally the mandible is lightly closed or slightly open at rest !

-Does the jaw deviate to one side when the mouth is open wide! -Can the patient resist examiner attempt to open jaw when clenching their tech! -can the jaw be closed against resistance

Looking for symmetry for the opening and closing and the ROM !

Ask patient to protrude their tongue and sustain this posture !

Ask patient to move tongue from side to side outside the mouth as rapidly as possible and then observe the speed and regularity of movement as well as the ROM

Note if the jaw hangs lower than normal or if there is any spontaneous involuntary movements or postural adjustments! TONGUE

Instruct the patient to open their mouth and breathe easily and let the tongue rest ! Observe the tongue symmetry and size and note any signs of atrophy or fasciculations

Velopharynx

Instruct the patient to open mouth as widely as possible and then use a tongue depressor ! -does the soft palate hang low in the mouth or rest on the tongue! -any spontaneous rhythmic or arrhythmic movements of the palate!

-does the tongue consistently deviate to one side ! -can the patient push out the cheek on each side with the tongue and can the patient resist examiner attempts to push the tongue back into the mouth

Ask patient to rapidly open and close their mouth and then observe the speed, regularity and symmetry

Ask the patient to prolong the “ah” sound!

- is palatal movement present and if so is it symmetrical !

- -Is there presence of nasal

airflow on pressure consonants like /p/ or /s/ or words and phrases with non nasal consonants (hold a mirror under their nose)

Structure

At Rest

Larynx

This is observed with a laryngoscopy or indirect mirror laryngoscopy

Respiration/reflexes

During quiet breathing note is posture normal? Does the patient Complain of shortness of breath at rest or during movement or speech? Is the patient breathing slow or rapid or shallow and are their any movements that accompany breathing! To test reflexes ! -Jaw jerk where the patient in relaxed with lips parted and the jaw halfway then place a fingertip on the chin and tap with other hand and if the jaw closes quickly that is a pathological reflex (indicates bilateral UMN involvement) ! -Sucking reflex test by stroking upper lip with a tongue depressor on either end of lips and towards the middle and if they start to purse their lips that is pathological and generally confirmatory of UMN disease !

Sustained posture

Movement you can examine the integrity of the VF adductions with two tasks ! -cough ! - glottal coup (glottal stop sound or grunting sound) ! You examine the sharpness of a glottal coup and cough

Reflex information:! Reflexes may provide confirmatory clues about gross localization of PNS or CNS involvement ! Normal reflexes are reflection of normal nervous system function and absent reflexes could be an impaired PNS function. Primitive/pathological reflexes are present during infancy but disappear with maturation. Their presence is often associated with CNS pathology. ! Normal reflexes: Gag: normally elicited following stroking of back of tongue, posterior pharyngeal wall or faucial pillars on both sides with a tongue depressor. Characterized by elevation of palate, retraction of tongue and sphincteric contraction of pharyngeal walls. Normal response varies from no response to vigorous gag!

Pathological reflexes like sucking and jaw jerk are high indicators for bilateral UMN disease (spastic dysarthria) ! Another indicator you can use for an oromotor examination is the French Dysarthria Assessment (FDA-2) ! FDA-2 test overview: it examines reflexes, respiration, lips, soft palate, jaw, tongue and larynx as well as there is an intelligibility portion and a speaking rate portion. It is standardized but the classification of dysarthria sub types has flaws so don’t trust it entirely. ! Differential Diagnosis: definition: the process of narrowing down possibilities and reaching conclusions about the nature of the deficit (is the speech disorder present? Is it Neurgenic? If so is it dysarthria or AOS? If it is dysarthria then what type? What are the implications of the lesion location?)! General guidelines for Differential Diagnosis: 1) speech diagnosis should be related to suspected or known neurological diagnosis or lesion location 2) speech diagnosis should not be made if one cannot be determined 3) when results go beyond description then explicitly state why 4) sometimes speech is normal and it is normal to report that !

Salient Features from and Oral mechanism examination that would lead to differential diagnoses Dysarthria type Flaccid

Atrophy

Fasciculations

Hypotonia

Nasal regurgitation

Spastic

Pathological oral reflexes present

Hyperactive gag reflex and hyperactive cough

Pseudobulbar affect (PBA) ! Dysphagia and Drooling

Dysarthria type Ataxic

Jaw, face and lingual non speech movements are frequently dysmetric

Intention tremors sometimes observed

May have normal oral mech

Hypokinetic

Orofacial tremor at rest

Masked facial expression

Reduced range of motion on non speech AMRs

Hyperkinetic

Presence of abnormal involuntary movements in the oral mechanism

Apraxia of speech

Can present with no obvious oral mech findings

Often there is right facial weakness

Nonverbal oral apraxia features

Salient Speech Features that would lead to differential diagnoses Dysarthria type

What subsystems it affects

Key characteristics

Other characteristics

Flaccid

Phonation ! Resonance

Breathiness, diplophonia, audible inspiration, short phrases!

Hoarse or harsh voice ! Imprecise articulation

Hypernasality, audible nasal emission Spastic

All usually

Ataxic

Articulation and prosody

Slow rate, Strained strangled vocal quality (especially prevalent in vowel prolongations) !

Imprecise consonants! Monopitch or monoloudness! Low pitch or pitch breaks

Slow and regular AMRs Irregular articulatory breakdowns! Irregular speech AMRs ! Excess and equal stress

Imprecise articulation, harshness, prolonged phonemes<...