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by Debra K. Smith and Amy Draper Outline I. II. III. IV. Neurological Basis of Dysarthria Case History A. Assessment B. Treatment Classification of dysarthrias Implementation of SpeechViewer III as Therapy Tool A. Loudness Range B. Pitch Range C. Pitch Control D. Voice Timing
What is Dysarthria? Dysarthria is a motor speech disorder that results from muscular impairment. Muscular weakness, slowness, or incoordination can affect all the basic processes of speech respiration, phonation, resonance, articulation, and prosody. Articulation errors are the most common feature of dysarthria, followed by impairments of voice, resonance, and fluency. Etiology and Course of Disease Dysarthrias are often defined by their etiology and course of progression. Dysarthrias may be acquired or congenital and may follow a variety of courses. Dysarthrias may be developmental (Cerebral Palsy), recovering (post stroke), stable (long term post stroke), or degenerative (Amyotrophic Lateral Sclerosis). Different types of lesions or damage in the central and peripheral nervous systems cause different types of dysarthria. Assessment There are six types of dysarthrias, each characterized by a different etiology and different speech behaviors. During a diagnostic evaluation, it is easy to confuse the dysarthrias, as
many of their characteristics overlap and more than one type may be present. To complete an assessment of dysarthria, it is important to obtain a complete oral-facial examination and a good speech sample at structured levels and in continuous speech. These samples will be the basis for identifying the primary speech characteristics your client exhibits. Formal tests such as Enderby's (1983) Frenchay Dysarthria Assessment or Yorkston, Beukelman, and Traynor's (1984) Assessment of Intelligibility of Dysarthric Speech are useful assessment tools. Classification/Characteristics of Dysarthrias Flaccid Dysarthria Site of lesion: Lower motor neuron Possible causes: Viral infection, Tumor, CVA, Congenital conditions, disease, palsies and trauma. Primary Speech Characteristics: Hypernasality, imprecise consonants, breathiness, monopitch, nasal emission. Spastic Dysarthria Site of Lesion: Upper motor neuron Possible Causes: CVA, Tumor, Infection, Trauma, Congenital Conditions Primary Speech Characteristics: Imprecise consonants, monopitch, reduced stress, harsh vocal quality, monoloudness, low pitch, slow rate, hypernasality, strained-strangled voice, short phrases. Mixed Dysarthria (Flaccid/Spastic) Site of Lesion: Upper and Lower motor neuron Possible Causes: ALS, Trauma, CVA Primary Speech Characteristics: Imprecise consonants, hypernasality, harsh vocal quality, slow rate, monopitch, short phrases, distorted vowels, low pitch , monoloudness, excess and equal stress, prolonged intervals. Ataxic Dysarthria Site of Lesion: Cerebellar system Possible Causes: CVA, Tumor, Trauma, Congenital Condition, Infection, Toxic effects
Primary Speech Characteristics: Imprecise consonants, excess and equal stress, irregular articulatory breakdowns, distorted vowels, harsh voice, loudness control problems, variable nasality. Hypokinetic Dysarthria Site of Lesion: Extrapyramidal System Possible Causes: Parkinsonism, Drug induced Primary Speech Characteristics: Monopitch, reduced stress, monoloudness, imprecise consonants, inappropriate silences, short rushes of speech, harsh voice, breathy voice. Hyperkinetic Dysarthria Site of Lesion: Extrapyramidal system Possible Causes: Chorea, Infection, Gilles de la Tourette Syndrome, Ballism, Athetosis, CVA, Tumor, Dystonia, Drug induced, Dyskinesia. Primary Speech Characteristics: Imprecise consonants, distorted vowels, harsh voice quality, irregular articulatory breakdowns, strained-strangled voice, monopitch, monoloudness. Case History Mrs. "A" is a 70 you with a history of stroke and right hemiparesis. Speech /Language evaluation was recommended by physician. Portions of the Minnesota Test for Differential Diagnosis of Aphasia (MTDDA) were administered. Results were as follows: Auditory Comprehension: Mrs. "A" was able to recognize common objects with 100% accuracy. Identifying items named serially, understanding sentences and repeating up to 7 digits were performed with 100% accuracy. Oral Expression: Pt. Was able to repeat monosyllabic words and phrases upon request. Mrs. "A" was able to complete sentences, give biographical information, express ideas and define words. Patient was also able to name pictures of common objects with 100% accuracy indicating the absence of anomia. Cognitive: Mrs. "A" was oriented x3. She was able to generate and recognize ideas in categories, sequence four steps and functional problem solve. Oral Mech. Exam: An oral mechanism exam was given to assess labial lingual strength, ROM and coordination. Labial and madibular strength was adequate. Tongue movement and strength was also adequate. During prolongation of "ah" it was noted that voice quality was "harsh and breathy" while the duration of the vowel was 3 seconds indicating the lack of respiration needed for speech. Speech was also monopitched and very soft. Sequential motion rate was WNL for speed indicating the absence of apraxia. Impressions: Mrs. "A" is a well oriented, pleasant individual. She presents with a harsh, breathy voice, monopitch, soft and lack of adequate respiration for speech secondary to
dysarthria. Recommendations: It is recommended that Mrs. "A" receive speech/language services to increase respiration during speech and improve voice quality. Implementation of SpeechViewer III SpeechViewer III is an IBM Independence Series product for speech/language pathologists, teachers, and other professionals to use in modifying speech patterns. The SpeechViewer III (SPV3) consists of speech exercises for direct client therapy and clinical management functions for keeping client records. SPV3 uses visual and auditory feedback to analyze and improve the speech skills of people who have speech, language, or hearing disorders. It is also useful for people who are trying to modify inflection, pronunciation, and vocal quality when learning new languages, relearning language/speech, or improving an accent. Using the SPV3, speech professionals and their clients can monitor and gain control over such speech attributes as voicing, pitch, loudness, phoneme accuracy, and speech timing. SPV3 is a sophisticated, clinical tool that takes advantage of high-resolution graphics and high-performance sound capability in personal computers. It has a menu-bar format for access to speech exercises, pointand-click capability, and enhanced phoneme model creation. Implementation of the SpeechViewer III can be used in the treatment of clients with dysarthria. There are a variety speech attributes in the SpeechViewer III program that can be applied to clients with dysarthria. The speech attributes included in the exercise menu include, loudness exercises, pitch exercises, and voicing and voice timing exercises. Exercises Loudness Range This exercise uses volume or movement of an object to show the loudness range of sound. As a client makes sounds into the microphone, the volume or movement of an object varies according to the loudness of the sound, as long as the sound is above the loudness threshold. Since many clients with dysarthria exhibit difficulties with adequate breath support and appropriate loudness levels for speech, the Loudness Range exercises provide targets and models for addressing these issues. Clients with ataxic, flaccid, hyperkinetic, hypokinetic, and spastic dysarthria may benefit from this exercise. Loudness Range Statistics Statistics for the Loudness Range exercises are collected over a series of "trials." A "trial" is one sustained sound, above the loudness threshold, that causes an object to move, inflate, or deflate. Statistics are collected from the start of the exercise and continue to accumulate until you reset them. Pitch Range
This exercise shows changes in pitch in the form of a mobile moving up and down a vertical pitch scale. As a client voices into the microphone, varying your pitch, the mobile indicates the upper and lower limits of the pitch range. This exercise may be implemented with clients who exhibit problems with breath support. The client must have adequate respiration to sustain pitch levels. Clients with spastic dysarthria exhibit pitch breaks and may benefit from this exercise. Pitch Range Statistics Statistics for the Pitch Range exercises are collected over a series of "trials." A "trial" is one sustained voiced sound that causes the mobile to rise or fall. Statistics are collected from the start of the exercise and continue to accumulate until you reset the statistics. Pitch Control This exercise shows pitch control in the form of a mobile moving through a obstacle course. Voicing controls the horizontal movement, while pitch controls the vertical movement. This exercise would be useful for clients with spastic dysarthria because while speaking, clients must maintain pitch control. Pitch Control Statistics Statistics for the Pitch Control exercises are collected for each "trial." A "trial" is the movement of the mobile from the starting position to the right side of the screen, beginning with all targets in place. Statistics are collected from the start of the exercise and continue to accumulate until you reset them. This chart lists the statistics kept for the Pitch Control exercises. Voice Timing This exercise shows voice timing in the form of a mobile moving horizontally. When voicing is present, the mobile rises to a fixed height and continues at that level; when voicing is absent, the mobile returns to the lower level and continues at that level. This exercise would be useful for clients with hyperkinetic dysarthria because clients often exhibit voice stoppages in speech. The following exercises would be beneficial with the client mentioned in the case history section. All exercises require proper breath support, which is the primary clinical concern with this particular client. Loudness exercises would also be beneficial for Mrs. "A" because she exhibits difficulties with appropriate loudness levels during speech. The SpeechViewer III is an excellent tool for clients with dysarthria in conjunction with other exercises for breath support, loudness, and articulation. Voice Timing Statistics
Statistics for the Voice Timing exercise are collected for each "trial." A "trial" is the movement of a mobile from its starting position, over a pattern of obstacles, to its ending position. Statistics are collected from the start of the exercise and continue to accumulate until you reset them. Additional Internet Links Healthtouch Dysarthria EPG for Dysarthria Dysarthria and Apraxia of Speech PAS 444 - Neuropathologies of Speech
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