Lecture 1: Introduction to Motor Speech Disorders PDF

Overview SHSC 4033 Motor Speech Disorders Course design Lecture 1: Introduction to Motor Speech Disorders...

Overview SHSC 4033 Motor Speech Disorders Course design Lecture 1: Introduction to Motor Speech Disorders Course assessment items 04 September 2024 Ivy Cheng, PhD Assistant Professor The motor speech system Speech production system Some materials are adapted from Prof Edwin Yiu 2022-23 HKU MSD course This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 1 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 2 Course description Course Learning Outcomes (CLOs) This course will guide the student to acquire an understanding of motor speech By the end of this course, you will be able to: disorders, including dysarthria and apraxia of speech. The course will develop the 1. Apply knowledge of the normal anatomy and physiology of phonation and articulation to children and student’s proficiency in the clinical assessment and management of individuals with adults with motor speech disorders; 2. Identify health and medical conditions that may lead to motor speech disorders; motor speech disorders. Materials will contain the structure and function of the speech 3. Propose evidence-based clinical and instrumental assessment protocols for individuals with motor speech production mechanism, evidence-based clinical and instrumental assessment, differential disorders; diagnosis and prognosis, evidence-based treatment and the development of intervention 4. Differentiate signs and symptoms of motor speech disorders and propose appropriate diagnosis with goals. justifications, adhering to the principles of the ICF; 5. Accurately perform auditory-perceptual evaluation of speech samples from individuals with motor speech disorders; Course objectives: 6. Critically evaluate and demonstrate evidence-based assessment and management techniques and strategies for individuals with motor speech disorders; To equip students with knowledge and skills required to undertake assessment and 7. Recognize cultural and linguistic issues in motor speech disorders assessment and management, management of adults with motor speech disorders particularly those relevant to Hong Kong 8. Describe the roles of other professionals in motor speech disorders assessment and management. This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 3 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 4 Textbook Duffy, J. R. (2019). Motor speech disorders: substrates, differential diagnosis, and management. (4th Ed) St. Louis, Elsevier Mosby. Lecture notes and images All available in Moodle All videos played in lectures are from YouTube or a referenced public access source. This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 5 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 6 HKU policies (student handbook) 2 pieces of You are warned that notes taken in lectures, and course materials assessment: supplied to you by departments, are to be used by you only for the purposes of research or private study. Mid-term in-class Test Similarly, lectures may not be recorded without the permission of the Final exam on observational lecturer. If the lecturer permits recording, it must be subject to any diagnostic skills and conditions which are stipulated at the time of granting permission. treatment knowledge The copyright of each lecture delivered in the University is vested in the lecturer delivering it and/or the University. Failure to heed this warning may result in an infringement of the copyright laws. This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 7 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 8 End of Semester Mid-term Test (50%) Examination (50%) In-class assessment (1 hour) 1 hour Using your own computer accessing Moodle You will need to use headphones connected to your computer Assessment of knowledge covered by lectures 1-5. Students will watch video samples of patients with motor speech disorders, then answer questions related This will be in short answer and to the clinical features of the patients and the diagnosis. multiple-choice format. You will also need to recommend a management strategy for 1 patient based on the video sample. This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 9 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 10  Online via Moodle Change of time and venue The motor speech system Revision on neural control of speech production This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 11 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 12 Speech production The speech production process Speech production is a dynamic and complex process Requires the integrity and integration of numerous neurocognitive, neuromotor, neuromuscular and musculoskeletal activities. Cognitive-linguistic Motor speech Neuromuscular processes planning, programming execution Form idea, emotion, and control Beatboxing MRI (Schnepf, 2018). Retrieved from sthg to express Planning of movement Execution of action https://youtu.be/wj7iM0BCWMQ (thinking part before X planning of message based on the planning speaking) (linguistic level) in brain This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 13 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 14 The Nervous System The brain Voluntary movement The nervous system is divided Cerebrum: higher cognitive function into 2 parts: Little brain Cerebellum: coordination CNS: brain and spinal cord Brainstem: automatic functions PNS: 12 pairs of cranial nerves and 31 pairs of spinal nerve Voluntary: involve the brain (e.g. planning) -> speech production/ swallowing Involuntary: reflex -> swallowing This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 15 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 16 The cerebrum – four lobes Damage: degenerative disease/ stroke The cerebellum Little brain below the cerebrum Frontal: cognitive functions e.g. Processes sensory information reasoning, problem solving, planning and adjusting goals, initiation of Balance, muscle contractions, movement tone, trajectory of body movements Temporal: hearing, memory E.g. speech production Parietal: Perception and interpretation Coordinates fine motor activities of sensory signals (important for timing and accuracy of movements) Occipital: Perception and interpretation of visual signals. Motor learning and adaptation Refine movements Grey matter vs white matter Different color -> Dense part of the The legs of different densities brain (outer latter) neuron/ axons cell body located located, no cell This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng (cerbral cortex) bodies found 17 18 Grey matter The brainstem The neuron Carry signal away from cell body Regulates vital processes such a Sensory neurons: transmit White matter / cell body heartbeat, breathing, swallowing sensory signals from body to and maintaining consciousness the brain Motor and sensory neural pathways Motor neurons: transmit pass through the brainstem motor signals from the brain Contains cranial nerve nuclei (upper to the body motor neurons meet lower motor Interneurons: connects neuron) Divide into 3 parts sensory and motor neurons This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 19 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 20 The motor system The parts of nervous system that create and control movement Activate neurons in Association Plan Basal ganglia + Desire to move Thalamus Cortex cerebellum Responsible for thinking Refine the plan Further refine the plan (E.g. decision making) (Accuracy)/ relay center Neuromuscular Cranial and Primary motor Pyramidal tract junction spinal nerves cortex Involuntary movement Execution of movement Motor neuron fire (send, Upper motor neuron Lower motor neuron receive signal) M - Plan and program postural and supportive components of motor activity Filters planned movements Regulate Cerebellum Integrates and coordinates execution of smooth, directed movements Ensures that the timing, force, speed and direction of the movement are correct This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 23 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 24 Inverted Primary motor cortex Transmits motor signals based on the movement plan through the pyramidal tracts (upper motor neurons) to the cranial and spinal nerves (lower motor neurons). This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 25 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 26 Upper motor neuron system Upper motor neuron system Located in CNS Extrapyramidal system (pathways from cortex to LMN with multiple Pyramidal system (direct activation pathway) Primarybulbar motor cortex to brainstem = ) synapses) Bulbar = brainstem Indirect activation pathway Have synapses in middle (corticospinal tract) and spinal cord Spinal (corticobulbar tract) Regulates reflexes and maintains posture and muscle tone Directly innervates the lower motor neurons Indirectly modulates speech motor control through its influence on the Responsible for rapid, volitional movement of pyramidal tract Voluntary articulators Regulates movements such as prosody, rhythm, and coordination of speech Mainly talking about the peri middle tract Involuntary action will pass track with multiple neutral synapse with unknown function and then go cortical-spinal/bulbar tract This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 27 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 28 Lower motor neuron system Located in PNS “Final common pathway” Connection of muscle and nervous system Transmit signals from the brain to the muscles involved in speech production Muscle movement execution Innervates the muscles of the face, jaw, tongue, lips, and larynx, Speech production system providing the necessary muscle activation for speech This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 29 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 30  Speech Production System Respiration Respiratory drive  driving source of 1. Respiration speech production 2. Phonation Requires full, steady air supply 3. Resonance Subglottic air pressure  vocal fold 4. Articulation vibrations 5. Prosody Nerve damage results in muscle weakness, leading to reduced air for speech production Impacts phrase length, impacts speech volume, and voice quality e.g. breathy Fig. 3. Voice production (Thornton et al., 2019). Retrieved from https://koper Speech production (Kirk et al., 2009). Retrieved from https://images.slideplayer.com/25/7683887/slides/slide_11.jpg quality nio.com/viewer?doi=10.3390/app9091963&route=6 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 31 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 32 Respiration E.g. not enough respiratory support to produce loud enough speech -> soft voice How do we breathe? /a/ Lung volume Retrieved from: https://youtu.be/JF8rlKuSoFM?t=75 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 33 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 34 Phonation Resonance - Nasal Regulates airflow as it moves from pharynx to nasal or oral Regulates speech prosody cavities Tonality placed on phonemes Voiced production  achieved through raise/lower velum  vocal fold vibrations  larynx Non-nasal sounds Velum raised Driven by subglottic air pressure Nasal cavity sealed Nasal sounds Air passes through nasal cavity Damage to the nerves innervating Velum lowered Oral cavity sealed vocal fold adductors Damage to nerves innervating velar muscles Flaccid dysarthria Weakness in muscle Retrieved from https://youtu.be/JF8rlKuSoFM?t=108 Hypernasality; Hyponasality; mixed nasality Spastic dysarthria Strained voice, increased muscle tone (note the concept of “heavy nasal sound” 重⿐⾳in Velopharyngeal insufficiency (Fauquier ENT, 2018). Chinese may indeed be hypo-nasality) LaryngealThismuscles Affect pitch, loudness content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Retrieved from https://youtu.be/WM5fVCdBPHs This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 35 36 Resonance – Oral Articulation Coming from lungs Air stream shaped  phonemes Tonality influencing production of phonemes and vowels  Articulator movements  structures within impacted by jaw/mouth opening, pharynx dimensions, & tongue position vocal tract Changing resonance Timing Mouth / Jaw opening : limiting oral space for resonance Direction Controlled by cerebellum Positioning of the tongue : retraction etc Force Dimensions / tightness in pharynx : reducing pharyngeal resonance quality Speed Placement Space and resonance: https://youtu.be/VmgZJ3F0jm8?t=22 Neurological damage  articulation errors Damage to the nerves innervating tongue, jaw, pharynx  Impaired motor control of articulators: lips, changes in resonance tongue, jaw, velum, vocal folds muscle tension disorders E.g. Imprecise consonants, distorted vowels Articulation system (Speech Graphics, 2013). This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 37 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 –from Retrieved https://youtu.be/wYwk07QM4rc Prof Ivy Cheng 38 Prosody Stress & intonation speech output  convey meaning Stress Changing pitch, loudness, duration of syllables e.g. Importance of words Intonation Pitch & stress changes e.g. Questions, assertions, exclamations Motor Speech Disorders Neurological damage Mono-pitch & Mono-loudness Prosody speech sample (Eugene Speech Therapy, 2018). Involuntary movements Control circuit is impaired Cannot refine the movement Retrieved from https://youtu.be/zO3odDn1y6Q  irregular pitch, loudness, prolonged intervals This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 39 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 40 Definition of Motor Speech Disorders Motor speech disorders A heterogeneous group of neurological impairments that affect: Planning, programming, timing, and/or execution of speech Dysarthria Apraxia of speech Neurologic in origin Neurologic in origin Disorder of movement Disorder of planning or Several or all aspects of speech may be affected: programming Not about execution Respiration, phonation, resonance, articulation, and prosody. Can be classified into different types, based on perceptual Intact articulators Inconsistent movement/ search for characteristics and underlying connected movement to produce speech Dysarthria, Apraxia of speech pathophysiology Strangled voice, breathing ok, resonance, Drooling, cannot close mouth properly, jaw and lip muscle Masked by aphasia Spastic, flaccid, hyperkinetic, intonation, prosody is affected, saliva dripping problems, articulation not precise, tongue movement not accurate to produce distinct speech sound, prosody affected ↑ Weakness in muscle X substitution error (motor programming problem) *Searching movement of articulators hypokinetic, ataxic, unilateral Not developmental articulation/speech problems (but beware of upper motor neuron, mixed developmental verbal apraxia) Asymmetrical face (unilateral damage to the nerve) This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 41 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 42 Potential causes of Motor Speech Disorders Characterising MSD Neurological Conditions Basal ganglia filter too much movement Age of onset Affect prognosis Stroke, TBI, Parkinson’s Disease, Multiple Sclerosis (MS), Amyotrophic Lateral Course of disease Sudden/ gradual onset? ↑ Sclerosis (ALS), Huntington's Disease, Progressive Supranuclear Palsy Important for ↑ Basal ganglia does not suppress Site of lesion Region of speech production Brain tumours Cancers enough movements -> movements are Neurological diagnosis Irreversible management excessive and irregular planning!! Genetic and Developmental Disorders Pathophysiology Underlying cause of MSD Childhood Apraxia of Speech (CAS) Down Syndrome Cerebral pulsy This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 43 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 44 Characterising the speech OME The speech components impaired (lips, tongue, laryngeal function) SHSC4033 Motor Speech Disorders Severity of deficits (mild / moderate / severe) Features of the speech signal – rating the perceptual characteristics Lecture 2: Assessment for Motor Speech Disorders Part 1 11 September 2024 Some materials are adapted from 2019-20 and 2020-21 HKU MSD course by Prof Liz Ward and Prof Edwin Yiu This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng 45 1 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Importance of motor speech assessment Evaluation questions 1. Is there a problem with the patient’s speech? Rule out structural To verify the presence of MSD 2. If there is a problem, what is the best way to describe it? problem -> MSD due to neurological damage 3. Does the problem seem to be the result of a neurological disorder? Onset of the MSD -> happen gradually/ degenerative (X recover to normal status) 4. If it seems to be neurogenic in origin, did it appear suddenly or slowly? To gain an indication of severity 5. Is the problem related strictly to speech production, or is it more of a problem with language, such as aphasia? Differential diagnosis To provide starting points & targets for treatment 6. If it is a problem of speech production, do most of the problems seem to Set priority be related to the sequencing of phonemes? Irregular performance? Apraxia: programming Dysarthria: execution Not apraxia 7. If there are no phoneme sequencing errors, what are the characteristics To rate progress over time of the patient’s speech errors & any associated motor problems? Maybe dyarthria 2 3 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng The clinical process Motor speech examination Expectations Three essential components Talk to caregiver too 1. History 2. Salient features Non-speech/ speech 3. Confirmatory signs Not diagnostic -> give underlying problem Description Structures/functions related to speech Features of speech E.g. mixed dysarthria + other lang/ cognitive problem Diagnostic possibilities & diagnosis Implications What are the impact of MSD on their life/ activities Speech disorders (Gill, 2019). Retrieved from Severity https://www.medicalnewstoday.com/articles/324764.php 4 5 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng  Features laughing uncontrollably, emotion lability -> suggestion of damage to limbic system or frontal lobes Unintelligible speech Hand movement: spastic (cannot extend hand fully) -> suggest bilateral damage in brain and upper motor neuron damage 6 7 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Case History Informal Oromotor assessment Primary concerns & treatment aims Informs goal setting Medical history information Onset & course Stroke patient may have spontaneous discovery Vs Degenerative patient Medical diagnosis/prognosis Speech and non-speech task Deteriorating disease -> not good prognosis (compare the function of structures) Associated difficulties Patient’s perception of difficulties Consequences of the disorder Any prior management Hospital/ acute-based Intubation -> neuro problem Duffy (2013) 8 9 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Informal Salient features Oromotor assessment Oro-motor examination (OME) Main CN for SLPs CN V → trigeminal CN VII → facial CN IX → glossopharyngeal CN X → vagus CN XII → hypoglossal Muscle + tone function Change articulatory position Reflex testing -> dysarthria may have problems (move the articulators) Duffy (2013) Cranial nerves (Lynch, 2019). Retrieved from https://teachmeanatomy.info/head/cranial-nerves/summary/ 10 11 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Assessment framework Size and symmetry Normal, enlarged, shrunken/atrophic Evidence of deviation (tongue) or weakness (face/ palate)? Size & Strength Speed Range symmetry Steadiness Tone Accuracy 12 13 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Strength Speed Consistently reduced or weakening over time? Often slow in motor speech disorders Moving muscle is slow Against resistance? Slow in starting, during and stopping Slow in initiating movement -> PD Most dramatic in LMN lesions (flaccid) Most often in spastic dysarthria but common in all dysarthrias Excessive speed may occur in hypokinetic dysarthria because of decreased range of motion Damage to basal ganglia circuit -> filter is screened very actively -> small range of motion/ low intensity 14 15 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Range Small in dysarthria Steadiness Distance travelled by speech structures Break down in motor steadiness results in Resting tremor/ tremor when moving Usually small range Tremor (repetitive, relatively rhythmic oscillation of body parts) Involuntary movement (hyperkinesias) Basal ganglia not working well -> less filter -> move Abnormal variability in range is common in ataxic and hyperkinetic Random unpredictable movements (dystonia, dyskinesia, chorea, athetosis) dysarthrias Commonly affect phonation, prosody Abnormal range affects speech prosody Can be evident in speech and non-speech movements of the articulators 16 17 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Tone Accuracy Spastic dysar Flaccid dysar Can be excessive or reduced Accuracy requires adequate functioning of all other salient features Can also fluctuate Precision in speech production or articulatory movement Reduced tone in flaccid dysarthria Increased tone in spastic and hyperkinetic dysarthrias 18 19 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Confirmatory signs E.g. uncontrolled laughter -> inform underlying physiology Additional clues for diagnosis but are not necessarily required for diagnosis e.g. atrophy, fasciculation, disinhibited laughter or cry, reduced normal reflexes or exaggerated abnormal reflexes Duffy (2013) 20 21 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Cranial nerve exams Non-speech examination—Face At rest Symmetry → face/mouth Non-facial expression: Expression problem with basal ganglia Involuntary movements PD: masked face (no expression) Sustained postures Lip symmetry in movement (e.g. smile) Mouth opening Lip Seal (e.g. cheek puffing) Movement Rate, accuracy symmetry & ROM Protrusion/retraction (e.g. pursing lips & ‘oo-ee’) Volitional & non volitional Facial nerve (Epomedicine, 2016). Retrieved from Cranial nerve examination (OSCE PASS, 2015). Retrieved from https://youtu.be/PG4zrRfocoQ https://epomedicine.com/clinical-medicine/examination -of-facial-nerve-7th-cranial-nerve/ 22 23 This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng This content is copyright protected and must not be shared, uploaded or distributed without permission. Copyright © 2024 – Prof Ivy Cheng Non-speech examination—Jaw Non-speech examination—Tongue At rest At rest Position Position Involuntary movements (e.g. fasciculations) Involuntary movements Wet/dry Sustained postures Sustained postures Protrusion → deviation Mouth opening → deviation/range