Assessment of Acquired Dysarthria (SLU22004) PDF

Assessment of Acquired Dysarthria (SLU22004) DR. PAUL CONROY [email protected] W I T H T H A N K S TO D R J U L I E R E G A N F O R D E V E LO P M E N T O F S L I D E S This P...

Assessment of Acquired Dysarthria (SLU22004) DR. PAUL CONROY [email protected] W I T H T H A N K S TO D R J U L I E R E G A N F O R D E V E LO P M E N T O F S L I D E S This Photo by Unknown Author is licensed under CC BY-SA-NC  On successful completion of this module, students will be able to: 1. Critically evaluate the diagnostic process related to disorders of speech [PO 2] 2. Construct and rationalize a plan for assessment that will allow differentiation of factors impacting on activities of speech [PO 2] Module 3. Construct and rationalize an assessment plan that is maximally efficient, problem-driven and solution focused [PO 2] Learning 4. Analyse and synthesize assessment data related to the activities of Outcomes- speech and interpret this information with reference to information on social participation [PO 2] SLU22004 5. Identify the opportunities for interdisciplinary working, and the indicators for onward referral, recognising the roles of other professionals and respecting the client and significant others as active and informed partners in all assessment processes and referral decisions [PO 1, 3, 6] 6. Communicate assessment findings appropriately and effectively to relevant stakeholders [PO 4]  Diagnostic – medical perspective Diagnostic – SLT perspective: differential diagnosis within communication disorders Report findings for a conference or research paper or medico-legal report What makes a Extend dysarthria evidence base, to e.g. ensure funding ‘good dysarthria Baseline pre-therapy assessment’ or Determine priorities for therapy Why do we Examine discreet effects of specific speech systems need it? Measure intelligibility & functional communication Evaluate psycho-social impact e.g. social participation/ self- esteem  Diagnostic – medical perspective Diagnostic – SLT perspective: differential diagnosis within communication disorders Report findings for a conference or research paper or medico-legal report Extend dysarthria evidence base, to e.g. ensure funding * What makes a Baseline pre-therapy ‘good dysarthria Determine priorities for therapy assessment’ or Examine discreet effects of specific speech systems Why do we Measure intelligibility & functional communication need it? Evaluate psycho-social impact e.g. social participation/ self-esteem * Measures need to be replicable, reliable and valid https://www.youtube.com/watch?v=0yQbsOY9BPA  Frenchay Dysarthria Assessment (FDA 2), Enderby (2008) Common (Norms are provided for ages 12 to 97). Dysarthria Clinical Assessment of the Intelligibility of Dysarthric Assessments Speakers, Yorkston & Beukleman (1984) Dysarthria Impact Profile (Walshe, 2009) 1. Purposes of Dysarthria Assessment To describe perceptual characteristics of the individual's speech and relevant physiologic findings To describe speech subsystems affected (i.e., articulation, phonation, respiration, resonance, and prosody) and the severity of impairment for each To identify other systems and processes that may be affected (e.g., swallowing, language, cognition) To assess the impact of the dysarthria on speech intelligibility and naturalness, communicative efficiency and effectiveness, and participation. Differential Diagnosis MSDs may be the first (or even the only) sign of a neurological disease Specific MSD diagnosis can expand or narrow the diagnostic possibilities or provide confirmation. Many neurologists will expect this type of precise diagnosis to aid them Recognising symptoms that are not in keeping with a particular diagnosis may help in modifying a diagnosis we have an active role to play in contributing to the medical diagnosis (Duffy, 2013)  1. Case history 2. Oro-facial Examination 2. Assessment 3. Perceptual Assessment of Speech Components 4. Assessment of intelligibility, comprehensibility, efficiency 5. Assessment of activities and participation restriction  Onset and course Chart Review Co-occurring deficits Medical history Education, vocation, and Investigations: MRI/CT Brain- cultural and linguistic lesion site? backgrounds MDT involvement Report from client/family Relevant (awareness/needs) surgery/hospitalisation Medication facilitators of and barriers to communication 2a. Case Interview for history is essential: Key information History Remember pre-clinical Perceptual information about skills and the skills in the patient’s speech taking a history Create hypothesis for next stage of assessment What do you want to know? Basic demographic and personal Why are you here? Medical history Onset and course details (incl home. Occupational etc) Associated Current status in Perception of their Influencing factors difficulties terms of speech speech Expectations, Consequences of Management to awareness of their difficulties date medical diagnosis, prognosis etc. Assessment of speed, strength, range, accuracy, coordination, and steadiness of nonspeech movements and assessment of the speech subsystems using objective measures, as available. The following are typically included: Cranial nerve exam (CN V, VII, IX, X, XI, XII)—to assess facial, oral, velopharyngeal, and laryngeal function and symmetry 2b. Oro- Facial Observation of facial and neck muscle tone—at rest and during nonspeech activities (Clark & Solomon, 2012) Examination (see video on Assessment of sustained vowel prolongation—to determine if there is adequate pulmonary support and sufficient laryngeal valving for phonation Blackboard!) Assessment of alternating motion rates (AMRs) and sequential motion rates (SMRs) or diadochokinetic rates—to judge speed and regularity of jaw, lip, and tongue movement and, to a lesser extent, articulatory precision (see Kent, Kent, & Rosenbek, 1987) Oro-Facial Examination Face, Lips, tongue, cheeks, jaw, palate- usually a combination of features is present Strength Speed 1. At rest Range Steadiness 2. During sustained posture 3. During movement Tone Accuracy Oro-Facial Exam Quiz! Oro-Facial Exam Quiz! What cranial nerve is damaged in this image? Oro-Facial Exam Quiz! What cranial nerve is damaged in this image? Oro-Facial Exam Quiz! What cranial nerve is damaged in this image? 2c. Speech Evaluation Perceptual assessment and classification are the “gold standard” (Duffy 2013) Relies on auditory Reliability depends on perceptual First and most crucial 1. Perceptual skill of clinician and it characteristics of the component is difficult to quantify patient’s speech Acoustic measures Physiologic measures (visually represent (electromyography, 2. Instrumental Visual imaging features of the speech kinematic, signal) aerodynamic) Sam New York – consider BRAV parameters: Breathing, Resonance, Articulation, Voice  Jim BRAV https://www.stroke4carers.org/wp-content/uploads/DYSARTHRIA.mp4 parameters: Breathing, Resonance, Articulation, Voice Perceptual speech assessment Mayo clinic classification of dysarthria (DAB) Based on distinctive speech characteristics 38 dimensions which cluster in distinct ways in the different types of dysarthrias, fall into several categories (see full list in Duffy 2013) Pitch Loudness Voice Resonance Respiration Prosody Articulation Other related related quality related related related related  Task Instructions Parameters of interest Key values 1. Vowel Take a deep breath and say Pitch, Loudness, voice 10-15 secs prolongation “ah” as long, steadily and quality, breath support Perceptual clearly as you can 2. Alternating Take a deep breath and say Speed & regularity of 5-7 reps per Speech Motion Rates (DDK) “puh, puh, puh” as long, as fast and as evenly as you movements of articulators; articulatory precision sec Assessment: can” 3. Sequential Now I want you to say those Rapid sequential 3-7 reps per Motion Rates three sounds together (“puh, movement from one artic sec (SMRs) tuh, kuh”) position to another Key Speech & 4. Contextual Speech paragraphs Evaluating integrated N/A Non-Speech speech (Grandfather Passage, Rainbow passage) function of all components Tasks Conversation, narratives 5. Speech stress Count from 1-100 Evaluate for deterioration Test for testing related to fatigue change in speech in counting 1- 100 Fasiculations and lingual atrophy Reduced Vowel Prolongation Time? And quality ‘aaaaaaaaaaaaa’ Reduced length of vowel prolongation? Limited breath Impaired vocal cord support (inadequate adduction for subglottic air phonation (air escape pressure) during phonation)? Aaaaaahhhhhhhh sample Role play vowel prolongation https://www.youtube.com/watch ?app=desktop&v=zz0oE7yfBw8 Get some time measures in pairs……  Alternating Motion Rates (AMR) (see Pierce, Cotton & Perry 2013 on BlackBoard) Diadochokinesis is the ability to perform rapidly repeating or alternating movements. Alternating motion rate (AMR) and sequential motion rate (SMR) are the two traditional tests of oral diadochokinesis used to assess motor speech production. AMR involves a single syllable being repeated at maximum rate, whereas for SMR a sequence of syllables is repeated at maximum rate. The syllables traditionally employed are /pa/, /ta/ and /ka/ for AMR and the sequence /pataka/ for SMR Role of age and gender? Record AMR and playback to improve reliability (Gadesmann & Miller, 2008- see Blackboard) AMRs- typical presentations across dysarthria subtypes Flaccid/spastic dysarthria- slow and regular AMRs Ataxic and hyperkinetic dysarthria- low and irregular AMRs Hypokinetic dysarthria- rapid AMRs (blurred phonemes) (Freed, 2012) Watch this video demonstration of AMR/SMR evaluation: https://www.youtube.com/watch?v=hP8r0h1PeSI SMRs (sequential motion rates) More difficult than AMRs Useful to observe features of AOS (delay beginning task; phoneme substitution; incorrect sequencing; groping) Normal scores: Median: 5 (3.6-7.5) (Kent et al, 1987) This Photo by Unknown Author is licensed under CC BY-NC-ND Dysarthria v Apraxia of Speech Muscle weakness or spasticity are present in several dysarthria types; AOS does not present with muscle weakness or spasticity unless there is a concomitant dysarthria. Several subsystems can be affected in dysarthria—unlike AOS, which is predominated by articulatory and prosodic deficits. In contrast to AOS, dysarthric speech may present with more consistent error patterns and is generally not influenced by automaticity of speech production, stimulus modality, and linguistic variables (Duffy, 2013). Other apraxic speech characteristics, such as a larger variety of articulatory errors and groping for articulatory postures, are typically not seen in dysarthria. Poorer performance on SMRs than on AMRs in AOS may distinguish it from ataxic dysarthria (Duffy, 2013). Analysis of Connected Speech Example of connected speech… “you wish to know…” Example of connected speech… “you wish to know…” Stress Testing of the Motor Speech Mechanism Used for screening for myasthenia gravis (disorder that causes a rapid fatigue of the muscles during a sustained motor activity) ‘Count quickly from 1-100’ Watch for rapid deterioration of articulation/resonance or phonation during counting This Photo by Unknown Author is licensed under CC BY Perceptual Speech Evaluation Considered the gold standard in dysarthria evaluation- perceptual (auditory, visual, tactile) so important in differential diagnosis Subject to unreliability Difficult to quantify Subsystem Perceptual Assessment Possible Findings Respiration Vowel prolongation Inability to generate enough air or pressure to vibrate the vocal folds Counting from 1-5 altering the loudness on each number Breathy speech, shorter sentences / phrases per breath and decreased loudness or loudness decay, forced expiration/inspiration Vocal volume in connected speech. (caused by respiratory muscle weakness) Phonation Vowel prolongation Pitch breaks Ask to count from 1-5 altering the loudness on each number Inhalatory stridor Elicit cough or sharp “uh” sound – why? Strained strangled voice (increased tension) Note vocal quality, pitch and loudness in conversation and in connected Weak breathy voice (reduced tension) speech Difficulty changing volume or pitch. Weak monotonous voice (laryngeal Ask to sing scale. dysfunction) Articulation Speech production at word and sentence level Imprecise consonants, distorted vowels (tongue weakness or paralysis) Picture description Imprecise bilabial sounds (lip weakness) Connected speech Imprecise consonants, Irregular articulatory breakdowns (in-coordinated tongue, lip, jaw, laryngeal and palatal movements) Resonance Place small mirror under the nose and ask person to say /u/ for as long as Hyponasal speech (Adenoids, deviated septum) possible. Hypernasal speech (unilateral/bilateral velar paralysis or weakness) Say “nay/bay” –Say “may/pay” ” – can you differentiate between phonemes? Note resonance in conversation and in connected speech. Prosody Connected speech Low pitch, tremor, pitch break Listen for dysprosody, monotonous speech, uneven and equal stress Aberrant rate (too fast/too slow/accelerating/variable) patterns in speech Short rushes of speech Abnormal stress (reduced, excessive) Prolonged intervals/Inappropriate silences Stress = changing the pitch, loudness and duration of syllables within words and words within phrases. Intonation = Use of pitch and stress Instrumental Speech Evaluation Visually display and numerically quantify frequency, intensity and temporal components of speech Do not always differentiate between dysarthric and non- dysarthric speech Visual feedback during therapy Speech spectrogram Computerised Speech Lab See https://www.youtube.com/watch?v=2yO3JZB-yvU 3. Formal Dysarthria Assessment Frenchay Dysarthria Assessment- 2 (FDA) (Enderby 2008) Assessment of Intelligibility of Dysarthric Speech (AIDS) (Yorkston & Beukelman 1981) Sentence Intelligibility Test (SIT) Yorkston et al 1996) Word Intelligibility Test (Kent et al 1989) Robertson Dysarthria Profile (Robertson 1995) (Conway & Walshe, 2015- see Blackboard)  C B A D RATING E no function normal function cough REFLEX swallow dribble at rest RESP in speech at rest LIPS spread seal alternate in speech at rest JAW in speech fluids PALATE maintenance in speech time pitch LARYNGEAL volume in speech at rest Frenchay Dysarthria Assessment (FDA) TONGUE protrusion elevation lateral alternate in speech repetition INTELL. description conversation rate Frenchay Dysarthria Assessment See video demonstration here: https://www.youtube.com/watch?v=m2ZR1JCmkmw&t=552s  Assessment of Intelligibility of Dysarthric Speech (AIDS) Quantifys single-word intelligibility, sentence intelligibility, and speaking rate of adult and adolescent speakers with dysarthria. See video demonstration here: https://www.youtube.com/watch?v=4- 4FJa84daw Robertson Dysarthria Profile- Revised (Robertson, 1995) See Blackboard 4. Assessment of Intelligibility, Comprehensibility and Efficiency (ICE) Intelligibility Comprehensibility Efficiency  Speech intelligibility is broadly defined as the accuracy with which an acoustic signal is conveyed by the speaker and recovered by the listener Traditionally a deficit belonging to the speaker with no consideration of the role of communication partner A. Word level Assessments: 1. Multiple Word Intelligibility Test, (Kent et al. 1989). 2. Word section of Assessment of Intelligibility of Dysarthric Speech (Yorkston & Beukelman, 1981). Intelligibility B. Sentence Level Assessments: 1. Sentence section of Assessment of Intelligibility of Dysarthric Speech (Yorkston & Beukelman, 1981). C. Connected speech level 1. Reading passage (Grandfather passage) 2. Structured task (Map task) 3. Conversational speech Intelligibility Measurement Index of severity Does not provide information on nature or cause of problem (listener or speaker) Index of functional limitation Intelligibility influenced by many other factors Can measure change over time  Comprehensibility The extent to which a message can be understood by the listener within a communication context. The emphasis is not on the speech signal itself but on signal independent information such as the semantic or syntactic or physical context. Realisation that communication is dyadic- speaker and listener play equally important roles This Photo by Unknown Author is licensed under CC BY-NC-ND (Yorkston, Strand and Kennedy, 1996)  ‘refers to the rate at which intelligible or comprehensible information is conveyed’ What are the person’s communication environments? (work Efficiency / home/ social) What are the demands placed on intelligibility? (Duffy 2005; 96)  1. How does the speaker communicate his/her message to the listener? Verbal/non-verbal 2. What strategies does he/she use? 3. How does the communication partner facilitate communication? 4. What would enhance the comprehensibility of the speaker’s message? Assessing CONVERSATION ANALYSIS Comprehensibility https://www.ucl.ac.uk/pals/research/language-and- cognition/language-and-cognition-research/better- conversations/better-17 INTELLIGIBILITY PODCAST https://link.brightcove.com/services/player/bcpid19184 27312001?bckey=AQ~~,AAAAkPubcZk~,_5wRjVEP- 2SClLMxsiujzeH817ZdNbZS&bctid=2071650900001 5. Assessment The severity of dysarthria does not necessarily determine the degree of disability. of activities and Speech-related disability will depend on the communication participation needs of the individual and the comprehensibility of his or restriction her speech in salient contexts.  Assessment needs to consider: impairments in body structure and function, including underlying strengths and weaknesses in speech production and verbal/nonverbal communication; Impairment the individual's limitations in activity and participation, including functional status in communication, interpersonal interactions, self- versus Disability care, and learning; (ICF contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication and life participation; Framework) and the impact of communication impairments on quality of life and functional limitations relative to the individual's premorbid social roles and abilities and the impact on his or her community. What it really means for your patient and their life Impact of Dysarthria what does it really mean Look at the psychological impact of Dysarthria Impact Living with dysarthria on the speaker and his/her Profile (Walshe, Dysarthria family. Peach & Miller, (Hartelius et al, Dysarthria must be assessed in the 2008) 2008) context of activity limitations and barriers to participation. Communicative Communication Participation Item Effectiveness Bank (Baylor et al, Survey (CES) 2009) The IMPACT  Dysarthria Impact Profile (SECTIONS A-E) A. THE EFFECT OF DYSARTHRIA ON ME AS A PERSON Please tick one box for each question Strongly agree Agree Not sure Disagree Strongly disagree 1 My speech problem has had a negative effect on how I see myself √ 2 When I speak I think I sound like everyone else, not me 3 Even when I am not speaking I feel that I am a different person now 4 My speech does not make me feel inadequate 5 I am as confident now as I was before I had a speech problem 6 Because of my speech I am more dependent on people now than I was before 7 My speech problem does not make me feel self-conscious 8 My speech problem does not make me feel incompetent 9 I do not feel foolish when I am misunderstood 10 I feel stupid when someone asks me to repeat 11 I feel less in control of my life now because of my speech 12 My speech difficulty has not changed me fundamentally as a person 13 Are there any other items you consider important? Communication Effectiveness Survey (CES) Severity Rating of Functional Speech ASHA NOMS Motor Speech Workshop: Watch this clip and rate the persons speech using the ASHA NOMS scale: https://www.youtube.com/watch?v=R- 3oasbo-28 Have we all given the same rating? Therapy Outcome Measure (TOM) Activity Scale: Dysphasia / Aphasia http://www.communitytherapy.org.uk/slides/Measuring_Impact_Stroke_on_Conversation_ABowen.pdf 0 Unable to communicate in any way. No effective communication. No interaction. 1 Occasionally able to make basic needs known with familiar persons or trained listeners in familiar contexts. Minimal communication with maximal assistance. 2 Limited functional communication. Consistently able to make basic needs/conversation understood but is heavily dependent on cues and context……(abbrev) 3 Consistently able to make needs known but can sometimes convey more information than this. Some inconsistency in unfamiliar settings. ……..(abbrev) 4 Can be understood most of the time by any listener despite communication irregularities. Holds conversation; requires occasional prompts particularly with a wider range of people. 5 Communicates effectively in all situations.  TOMS Dysarthria: IMPAIRMENT ACTIVITY 0 Profound: Severe dysarthria – severe persistent 0 Unable to communicate in any way – No effective articulatory/prosodic impairment. Inability to produce any communication. No interaction. distinguishable speech sounds. No oral motor control. No respiratory support for speech. 1 Occasionally able to make basic needs known with familiar persons or trained listeners in familiar contexts. Minimal 1 Severe/moderate dysarthria: with consistent communication with maximal assistance. articulatory/prosodic impairment. Mostly open vowel sounds with some consonant approximations/severe 2 Limited functional communication. Consistently able to festination of speech. Extremely effortful or slow speech; make basic needs/conversation understood but is heavily only 1 or 2 words per breath. Severely limited motor dependent on cues and context. Communicates better with control. trained listener or family members or in familiar settings. Frequent repetition required. Maintains meaningful 2 Moderate dysarthria: With frequent episodes of interaction related to hear and now. articulatory/prosodic impairment. Most consonants attempted but poorly represented acoustically/moderate 3 Consistently able to make needs known but can sometimes festination. Very slow speech: manages up to 4 words per convey more information than this. Some inconsistency in breath. Moderate limitation oral motor control. unfamiliar settings. Is less dependent for intelligibility on cues and context. Occasional repetition required. 3 Moderate/mild dysarthria: consistent Communicates beyond here/now with familiar persons, omission/articulatory of consonants. Variability of speed. needs some cues and prompting. Mild limitation of oral motor control or prosodic impairment. 4 Can be understood most of the time by any listener despite communication irregularities. Holds conversation; requires 4 Mild dysarthria: slight or occasional special consideration, for example, patience, time, attention, omission/mispronunciation of consonants. Slight or especially with a wider range of people. occasional difficulty with oral motor control/prosody or respiratory support. 5 Communicates effectively in all situations. 5 No impairment PARTICIPATION: WELLBEING/ DISTRESS: 0 Unable to filfil any social/educational/ family role. 0 Severe constant – High and constant levels of distress/ upset/ Not involved in decision-making/ no autonomy/ no concern/ frustration/ anger/ embarrassment/ withdrawal /severe depression or apathy. Unable to express or control control over environment, no social integration. emotions appropriately. 1 Very limited choices. Contact mainly with 1 Frequently severe - Moderate distress/ upset/ concern/ professionals, no social or family role, little control frustration/ anger/ embarrassment/ withdrawal /severe over life, limited ability to make lifestyle choices, food depression or apathy. Becomes concerned easily, requires choices, treatment options. constant reassurance/support, needs clear/tight limits and structure, loses emotional control easily. 2 Some self-confidence/some social integration. Makes some decisions and influences control in 2 Moderate consistent - distress/ upset/ concern/ frustration/ anger/ embarrassment/ withdrawal /severe depression or familiar situations. apathy in unfamiliar situations. Frequent emotional encouragement and support required. 3 Some self-confidence; autonomy emerging. Makes decisions and has control of some aspects of life. Able3 Moderate frequent - Distress/ upset/ concern/ frustration/ to achieve some limited social integration/educationalanger/ embarrassment/ withdrawal /severe depression or activities. Diffident over control over life. Needs apathy. Controls emotions with assistance, emotionally encouragement to achieve potential. dependent on some occasions, vulnerable to change in routine, spontaneously uses methods to assist emotional control. 4 Mostly confident. Occasional difficulties integrating 4 Mild occasional - Distress/ upset/ concern/ frustration/ anger/ or in fulfilling social/role activity. Participating in all embarrassment/ withdrawal /severe depression or apathy. Able appropriate decisions. May have difficulty in to control feelings in most situations, generally well achieving potential in some situations occasionally. adjusted/stable (most of the time/most situations), occasional emotional support/encouragement needed. 5 Achieved potential. Autonomous and unrestricted. Able to fulfil social, educational and family role. Takes5 Not inappropriate - Distress/ upset/ concern/ frustration/ responsibility for own health. anger/ embarrassment/ withdrawal /severe depression or apathy. Measure Practicability Scope (ICF) Goal setting Pros/Cons Oro-motor Assessment Frenchay AIDS Dysarthria Impact Scale TOMS Conversation Analysis Pros & Cons of Dysarthria Assessments: consider different settings: acute, intensive rehab, community (score /10; total /30)  Dysarthria assessment should consider all aspects of ICF framework Assessment can be perceptual (key speech & non-speech tasks) or instrumental Summary Formal dysarthria assessment Differentiate between intelligibility, comprehensibility and efficiency  Key References Lowit, A, Kent, RD. (2011).Assessment of Motor Speech Disorders. Plural Publishing: San Diego. Duffy,J. (2013).MotorSpeechDisorders:Substrates,DifferentialDiagnosis,andManagement,3rdedition.ElsevierMosby:StLouis. Freed,D. (2012).MotorSpeechDisordersDiagnosisandTreatment,2ndedition.DelmarCengageLearning:NewYork. YorkstonKM, BeukelmanDR, StrandEA, HakelM.(2010). ManagementofMotorSpeechDisordersinChildrenandAdults,3rdedition.Pro-Ed:Texas. Duffy, J. R & Kent, R.D. (2001) Darley’s contribution to the understanding, differential diagnosis and scientific study of the dysarthrias. Aphasiology, 15, 275-289. Weismer, G. (2006) Philosophy of Research in Motor Speech Disorders. Clinical Linguistics and Phonetics, 20 (5) 315- 349. https://www.asha.org/Practice-Portal/Clinical-Topics/Dysarthria-in-Adults/