Treatment Resource by Dysarthria Type PDF

SPASTIC DYSARTHRIA Neurological System Affected: Bilateral upper motor neuron lesions (pyramidal and extrapyramidal) Common Pt Complaints Slow speech rate, increased effort to speak, gets tired when speaking, poor control of...

SPASTIC DYSARTHRIA Neurological System Affected: Bilateral upper motor neuron lesions (pyramidal and extrapyramidal) Common Pt Complaints Slow speech rate, increased effort to speak, gets tired when speaking, poor control of emotions (note- medical intervention-Low dose of amitriptyline may be effective in managing psuedobulbar affect) Associated neurological symptoms -Excessive muscle tone/spasticity of limbs possible, loss of fine skilled movement -Abnormal reflexes may be present: suck, snout, jaw jerk, gag Possible Medical Dx CVA (bilateral lesions to internal carotid, middle, and posterior cerebral arteries, multiple lacunar strokes or single brainstem stroke, brainstem tumor, degenerative (Primary Lateral Sclerosis, Progressive Supranuclear Palsy), toxic/metabolic, inflammatory disease (leukoencephalitis) POSSIBLE SPEECH SYSTEM DEFICIT POSSIBLE TREATMENT Respiration- May have reduced vital Maximum inhalation tasks capacity (duration of ah). Short breath groups may be caused by excessive laryngeal valving. Phonation- strained, strangled, harsh Head and neck relaxation low pitch; some pitch breaks, little Easy onset of phonation loudness variation Yawn-sigh Best pitch- Probe if pitch change helps perception of voice Medical Intervention- Botox injection – may reduce spasticity of VF, less common but possible recurrent nerve resection to paralyze 1 vocal fold Medication-Dantrium may reduce strained voice in some pts with spastic dysarthria Resonance- may be hypernasal, usually Resonance- difficult to treat behaviorally. Increase loudness, increase not nasal emission open mouth articulation patterns Medical Intervention- Hypernasality may be difficult to manage with palatal lift if much spasticity is present in the palate. Nasal obturator, teflon injection into the pharyngeal wall or a pharyngeal flap are other options. Articulation- imprecise consonants Stretching or shaking exercises with articulators if spasticity interfering with attempts. Bite block. Exaggerating consonants/phonetic placement, minimal contrast drills. Intelligibility drills. Medical Intervention- Antispasticity medications such as Librium, Valium, Dantrium, Lioresal, and tizanidine are sometimes effective in decreasing limb spasticity, but their effects on articulation are uncertain, and sometimes results in side effects such as weakness which may harm speech. Prosody- slow rate, reduced stress, may May need to further reduce rate for articulatory precision. Pitch range be excess and equal stress exercises/intonation profiles. Contrastive stress drills. If reduced breath groups, may need teach chunking into syntactic units  ATAXIC DYSARTHRIA Neurological System Affected: cerebellum/cerebellar control circuit Common Pt Complaints sound as if they are drunk, feel as if they are stumbling over words, bite tongue or cheek when eating, speech deteriorates significantly with alcohol intake Associated neurological symptoms broad based stance and gait, instability of trunk Cerebellar deficits results in uncoordinated movements; disrupts timing force, range, and direction of movements (no problem with muscle strength/tone) Possible Medical Dx degenerative (Frederick’s ataxia), vascular disorders (aneurysm, arteriovenous malformations, hemorrhage in cerebellum), tumor in cerebellum, toxic/metabolic conditions (chronic alcohol abuse, severe malnutrition, neurotoxic effects of drugs like Dilantin, lithium, and valium), hypothyroidism POSSIBLE SPEECH SYSTEM DEFICIT POSSIBLE TREATMENT Respiration- may speak on low air b/c of Speaking at beginning of exhalation, hand on abdomen for cue coordination difficulties Stop Phonation Early- Teach pt to terminate earlier in expiratory cycle Phonation- may be normal or harsh, may If stumbles over voice/voiceless transitions- Continuous demonstrate continuous voicing phonation can be taught Resonance- normal Articulation- imprecise consonants, vowel Intelligibility drills, exaggerating consonants/overarticulation, distortions, irregular articulatory breakdowns, - minimal contrast drills, may have more breakdowns on multisyllabic Integral stimulation – say at same time as SLP, then follow direct words prolonged phonemes model, then independently Prosody- excess and equal stress, phoneme and May need to further reduce rate for articulatory precision – talk pause prolongations, bursts of intensity after with metronome, with model, hand tapping, cued reading pauses, slow rate material with pauses marked. Pitch range exercises/intonation profiles. Contrastive stress drills. Chunking into syntactic units Note: Pharmacologic treatment for cerebellar ataxia has not been successful in general. Diamox may be effective in treating episodic ataxia. In general, the focus of management activities is behavioral with the focus on improving or compensating for problems related to motor control/coordination. Most focus is on modifying rate and prosody to improve intelligibility and when possible, further modifying rate and prosody to improve naturalness  HYPOKINETIC DYSARTHRIA Neurological System Affected: basal ganglia pathology/lack of dopamine Common Pt Complaints voice cannot be heard in noisy environments, speech is too fast, voice has no emotion, sound like they are stuttering, lips feel stiff/rigid. NOT uncommon for pt not to recognize speech difficulties- e.g. spouse says I mumble Associated neurological symptoms decreased mobility or ROM, resting tremor (decreases during movement), muscle rigidity, bradykinesia, akinesia, face has mask-like expression Possible Medical Dx Parkinson’s disease by far most common medical dx, multiple or bilateral strokes affecting the basal ganglia, toxic/metabolic caused by antipsychotic medications or toxic metal poisoning (manganese), infectious- viral encephalitis, stroke in the basal ganglia POSSIBLE SPEECH SYSTEM DEFICIT POSSIBLE TREATMENT Respiration- decreased support – reduced Speaking at beginning of exhalation, inhale deeply, slow and movement, faster breathing rate, shallow breath controlled exhalation, stop phonation early, optimal breath support, rapid short breathing cycles group Phonation- hoarseness, breathiness, tremors, Phonation- pushing and pulling/effortful closure techniques or decreased loudness, monoloudness hard glottal attack if weak/breathy sounding,”, voice amplifiers Medical Intervention- some hypokinetic speakers have severe bowing or weakness of the vocal folds- medialization laryngoplasty or teflon/collegen injection may result in improved voice Resonance- may have some hypernasality (10% with Parkinsons), severity is usually mild Articulation- changes in production with Articulator stretching briefly if rigid, intelligibility drills, undershooting on articulatory targets exaggerated consonants, minimal contrast drills. Bite block. Prosody- increased rate, monotone, short rushes Rate reduction with pacing boards, finger tapping, alphabet of speech boards, delayed auditory feedback, metronome. Pitch glides/pitch variation, Stress- contrastive stress drills. Intonation profiles. Chunking utterances into syntactic units Prosthetic assistance (if severe/if behavioral interventions unsuccessful) Delayed Auditory Feedback (DAF)- Pt’s speech is fed back through earphones in delayed intervals (which can be set by SLP). The effect is slow speech rate and presumably increased articulation time and accuracy. (EBP- Numerous articles about effectiveness of DAF with hypokinetic dysarthria.) LSVT- Well researched/ evidence-based procedure for speech of pts with Parkinson’s. Need to attend 2-day training to be certified in LSVT, but now the training is available on-line from LSVT Global (www.lsvtglobal.com). LSVT Loud for speech, has corresponding LSVT Big for physical therapy with Parkinson’s. Doing research to integrate LSVT Big and Loud treatment. LSVT Loud Treatment parameters -Intense – 4x per week tx for 1 month. Requires high levels of physical effort to increase loudness and VF adduction. Focuses on respiratory-phonatory effort and sensory awareness of loudness and effort. -Exercises include vowel, word, phrase, sentence and conversation tasks. -Treatment Goals/Tasks -Increase VF adduction via pushing/lifting during phonation -Increase maximum vowel phonation at greater vocal intensity -Think loud -Improve vocal quality during sustained phonation and speaking  -Increase maximum frequency range -High/low pitch glides and sustained phonation at high & low pitches -Required homework and carryover activities (HYPOKINETIC DYSARTHRIA CONTINUED) Surgical Medical Interventions to relieve movement disorders- Pallidotomy (placing a lesion in the posteroventral portion of the globus pallidus to abolish tremor) Thalamotomy (a lesion is placed in the ventrolateral nucleus of the thalamus with the intent of reducing severe Parkinsonian, cerebella, or essential tremors that have not responded to medication) Deep brain stimulation- stimulators are implanted in the thalamus, globus pallidus, or subthalamic nucleus. Treats same problems as thalamotomy and pallidotomy by reducing activity in overactive brain structures through inhibition **none are intended to improve speech, and may carry risk for speech impairment Pharmacologic Medical Interventions o Replace dopamine in the striatum Dopamine agonist medications such as carbidopalevodopa (Sinemet), levodopa and selegiline (Deprenyl) are sometimes associated with general improvements in speech for pts with PD, but often to a lesser degree than other motor functions Clonazepam (Klonopin) may be effective for treating hypokinetic dysarthria in some pts o Another pharmacological treatment approach is to correct the neurotransmitter imbalance in the basal ganglia by decreasing the amount of acetylcholine activity in the striatum. Anticholinergic drugs act to either deplete acety.choline in the basal ganglia or interfere with its effect on brain structures. **The effects of Parkinsonian medications, including on speech, can fluctuate as a function of the drug cycle ** High percentage of pts develop hyperkinetic dysarthria during treatment with levodopa (l-dopa) UNILATERAL UMN DYSARTHRIA Neurological System Affected: pyramidal UMN and extrapyramidal UMN – unilateral/one side Common Pt Complaints slurred speech, thick tongue, drooling, face feels heavy on affected side Associated neurological symptoms often co-occurs with aphasia or apraxia if lesion in left hemisphere, or with cognitive deficits if lesion in right hemisphere; weakness and incoordination of tongue and face on opposite lesion (central facial weakness) lower face affected more than upper face, hemiplegia, weakness/hypotonia after acute lesion-spasticity may emerge later. Possible Medical Dx vascular most frequent- right or left carotid or middle cerebral artery stroke, posterior cerebral and basilar stroke POSSIBLE SPEECH SYSTEM DEFICIT POSSIBLE TREATMENT **Generally mild to moderate deficits- may not be a concern – more tx time focus on aphasia or cog com Respiration- normal Phonation- harsh (39% harsh) Easy onset, yawn/sigh Resonance- normal (11% hypernasal) Articulation- imprecise consonants Intelligibility drills, phonetic placement, exaggerating consonants, minimal contrast drills If speech deficits seem to be influenced by weakness, can work on nonspeech oral motor exercises if pt concerned and motivated – may not be necessary often  FLACCID DYSARTHRIA MYASTHENIA GRAVIS Neurological System Affected: acetylcholine at neuromuscular junction Common Pt Complaints fatigue/deterioration with speaking, better after rest Possible Medical/Prosthetic Pharmcological– pyridostigmine bromide/Mestinon; adrenal Intervention corticosteroids Surgical- thymectomy Prosthesis- Swigert mentions palatal lift for these pts, not mentioned in other sources. Voice amplifier may also be helpful for some pts. Speech Characteristics POSSIBLE SPEECH TREATMENT DETERIORATION WITH SPEAKING Duffy suggests the best that can be done is to teach pt to conserve energy, Respiration- respiratory weakness, limit speaking duration to durations without significant fatigue Short phrases, decreased intensity Swigert suggests strategies such as inhale deeply, speaking at onset of Phonation- progressively more breathy, exhalation, exaggerated articulation, phonetic placement, intelligibility decreased intensity drills Resonance- hypernasal and nasal emission Articulation- imprecise articulation Prosody- flat/monotone WHEN SEVERAL CRANIAL NERVES DEPENDS ON WHICH NERVES ARE DAMAGED DAMAGED- MAY BE CALLED BULBAR Pt complaints: swallowing difficulties, listeners find it difficult to hear PALSY voice, hypernasality, tongue feels thick, drooling Possible medical dx: Associated neurological symptoms: weakness, hypotonia, atrophy, and neuropathy secondary to radiation; fasciculation degenerative disease (progressive bulbar palsy); demylinating disease (Guillain-Barre syndrome); infectious process (poliomyelitis); neurological complications of AIDS (cryptococcal meningitis); muscle disease (muscular dystrophy); vascular (brainstem stroke); Wallenberg’s lateral medullary syndrome POSSIBLE SPEECH CHARACTERISTICS POSSIBLE SPEECH TREATMENT (DEPENDS ON CRANIAL Respiration: Blowing for strength/visual feedback, controlled exhalation, NERVES/BRANCHES INVOLVED) abdominal girdling, modify posture, inhale deeply, speaking at onset of Respiration- decreased respiratory inhalation support secondary to muscle weakness Phonation- pushing/pulling, head turn, hard glottal attack, high phonatory Phonation-if unilateral damage in effort brainstem- voice will depend on where Articulation- phonetic placement, compensatory strategies if necessary, chord is (e.g. paramedian); if bilateral may attempt strengthening if not enough strength for phoneme cord involvement ; breath; harsh voice; productions audible inspiration; decreased loudness MEDICAL/PROSTHETIC OPTIONS Articulation- imprecise articulation of Prosethic lingual phonemes Respiratory- abdominal trussing (weak trunk), expiratory boards Resonance- unilateral- no affect or mild Phonation- portable amplification system if has some voicing, artificial to mod hypernasality and nasal larynx if can’t get voicing emission; bilateral- severe Resonance- palatal lift; nasal obturator hypernasality, nasal emission, short SURGICAL phrases due to nasal air wastage Vocal fold paralysis-Medialization larygoplaysty/ type I thyroplasty- surgery which moves paralyzed VF medially to facilitate VF approximation Teflon, autologous fat, collagen injection- injection of teflon into tissue of paralyzed VF making it bulkier and narrows the glottis  Hypernasal Resonance due to weakness, Pharyngeal flap, Teflon injection into back pharyngeal wall has also been done, but infrequently HYPERKINETIC DYSARTHRIA- 67% unknown etiology ** Effective management approaches are primarily medical because the abnormal movements are not under voluntary control. TREMOR Neurological System Affected: basal Pt complaints: Voice sounds tight/doesn’t want to come out, voice is ganglia and related structures, possibly shakey,short of breath, some pt not aware of tremor if mild, others cerebellar control circuit complain tremor worsens with fatigue or stress- some say tremor Essential tremor can occur in isolation improves with alcohol. as a laryngeal tremor (essential voice Treatment tremor), but often accompanied by Phonation- can probe to see if easy onsets or continuous phonation tremors of head or extremities, lingual improves intelligibility – not behavioral approach to improve tremor itself tremor, tremors of the jaw/lips Articulation/Prosody –probe to see if stress/phrasing, intonation pattern apparent. Essential tremor is an action changes improves intelligibility tremor that disappears at rest (in Medical Interventions contrast to Parkinson’s tremor- Methazolamide (Neptazane) is reportedly effective in relieving essential Parkinsons is a resting tremor that tremor of the head and voice in some pts decreases during movement). Should Other medications that may help essential tremor in the limbs are noted to hear rhythmic voice tremor, but if only infrequently help head or voice tremor (these include Inderal, severe may have abrupt voice arrests primidone (Mysoline), carbamazepine (Tegretal), baclofen (Lioresal), and combinations of trihexyphenidyl (Artane) and lithium. Pallidotomy, thalamotomy and deep brain stim (DBS) surgeries may be done to manage tremor (see discussion in hypokinetic dysarthria) CHOREA Possible Medical Dx: Chorea is a shared SPEECH CHARACTERISTICS symptom of several neurological Respiration- rapid brief inhalations or exhalations of air; sudden forced disorders such as Syndemham’s chorea, inspiration/expiration Huntington’s Disease Phonation- strained, strangled, excessive loudness variation, voice Associated neurological symptoms: stoppages/errors, may have strained then breathy- variablity can be chorea= (quick) unpatterned/ random caused by choreic movements involuntary movements of the limbs, Resonance- typically none, may have occasional hypernasality if velum trunk, head, and neck. In mild cases of affected chorea, the motions may not be Articulation- imprecise consonants; distorted vowels, irregular articulatory immediately obvious to an observer; breakdown, prolonged phonemes they may give the impression that the Prosody- decreased or variable stress; prolonged intervals, variable rate, person is restless/jittery. When the inappropriate silences, (person could wait for interfering motion to be movements are infrequent, the affected finished before continuing with utterance- inappropriate silences, could individual may try to hide them by rush through utterance before next movement = variable rate) turning them into a purposeful gesture SPEECH TREATMENT such as scratching the chin/stretching Respiration- cannot behaviorally treat involuntary respiratory movements the arm. When the chorea is severe, Phonation- if voice is strained or harsh overall- try easy onset approaches the choreic motions may be nearly Resonance-No behavioral treatment will help with involuntary velum constant, stopping only when the movements person is asleep and interfering with all Articulation/Prosody –probe to see if stress/phrasing, intonation pattern aspects of voluntary movement. changes improves intelligibility MEDICAL INTERVENTION Choriform movements are sometimes decreased with reserpine, Haldol, or Lioresal  Pallidotomy, thalamotomy and deep brain stim (DBS) surgeries may be done to manage tremor, dyskinesia, and dystonia (see discussion in hypokinetic dysarthria) DYSTONIA AND ATHETOSIS DYSTONIA= a hyperkinetic movement SPEECH CHARACTERISTICS (depends which systems affected by involuntary disorder of muscle tone. Dystonia movement causes involuntary, PROLONGED muscle SPEECH INTERVENTION (limited options, not under voluntary control) contractions that interfere with normal Phonation- anecdotal evidence that easy onset procedures can lessen movement or postures. Dystonic involuntary movements affecting the larynx in mild cases movements are typically slower/more Articulation/Prosody –a well-known treatment for focal dystonic jaw sustained than those in chorea. Focal movements is the use of a bite block to stabilize the jaw during speech. dystonia- dystonic movement or The voluntary contractions of the jaw muscles that hold the block in place posture is present in only one part of seem to suppress dystonic jaw movements in many pts. Can probe for the body, such as the tongue, arm, or stimulability of more natural sounding prosody using imitation of hand. Generalized dystonia = the pitch/stress contours dystonic movement or posture affects Case report that EMG feedback help pt modify lip dystonia all four limbs and the torso or neck. Sensory tricks- help pt find and use postral adjustments to suppress ATHETOSIS- Form of cerebral palsy, involuntary mvmts. Drawback- sensory tricks often stop working after a frequently involves uncontrolled period of time and don’t work for some pts writhing movements (additional speech MEDICAL INTERVENTIONS characteristics = hypernasal, poor Pallidotomy, thalamotomy and deep brain stim (DBS) surgeries may be respiratory support) done to manage tremor, dyskinesia, and dystonia (see discussion in hypokinetic dysarthria) Botox injection is frequently effective in managing jaw opening & closing dystonias, and is potentially effective in lingual dystonias that cause involuntary tongue protrusion. Botox injection (botulinum toxin)- pts with spasmotic dysphonia – the toxin blocks the release of acetylcholine- VF not completely paralyzed- but adducts less after injection Spasmodic dysphonia - Recurrent laryngeal nerve resection- surgery which causes unilateral VF paralysis and prevents hyperadduction Artane (medication) has been used with significant benefit to speech to a pt w/ laryngeal and respiratory dystonia. Lioresal, combinations of Artane and lithium, and alprazolam (Xanax) are said to occasionally reduce symptoms of oromandibular dystonia and spasmodic dysphonia Intramuscular injection of diluted lidocaine and alcohol has reduce the severity of otherwise drug-resistant oromandibular dystonia in some pts but its effect on speech has not been reported