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CASE STUDY ANALYSIS OF BARBARA

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Module HS837 (Speech and Language Therapy - Adults 2)

University of Essex

15 January 2024
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Introduction

The case study is about Barbara, a 75-year-old woman diagnosed with Parkinson’s

disease (PD), who is seeking the assistance of a Speech and Language Therapist

(SLT) to effectively manage the symptoms associated with PD. This case study

critically analyses Barbara’s PD diagnosis, identifies the tentative diagnosis of

hypokinetic dysarthria, provides suitable assessment strategies, and determines an

appropriate course of action.

Parkinson’s Disease

Barbara is diagnosed with PD. Parkinson’s disease is a chronic, progressive

neurodegenerative disorder, characterized by a premature loss of dopamine neurons

in the brain (Rizek, Kumar and Jog, 2016). Parkinson’s UK (2020) reports that

approximately 153,000 people live with PD, prevalent primarily in the elderly. While

the exact cause of PD is unknown, risk factors include age, genetic predisposition,

oxidative stress, exposure to toxins, and environmental and lifestyle factors

(DeMaagd and Philip, 2015; Jankovic and Tan, 2020).

There are no conclusive tests available for a PD diagnosis (NHS, 2019). A diagnosis

requires the key features of resting tremor, bradykinesia-slow movements, stiffness,

or postural instability to be present (DeMaagd and Philip,.2015). Some other unique

features of PD include dysarthria, dysphagia, depression, fatigue, shuffling gait,

freezing, dementia, and pain (Franceschi, Pina and Castillo, 2015; Rizek, Kumar and

Jog, 2016). As the disease progresses, motor and nonmotor symptoms worsen

(DeMaagd and Philip, 2015). Barbara’s clinical symptoms are resting tremor,

bradykinesia, dysphagia, and speech difficulties. She is currently managing some

symptoms with medication.

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Due to its progressive nature, PD can have a significant impact on the lives of clients

and their families (DeMaagd and Philip, 2015). Symptoms may contribute to an

overall poor quality of life. Individuals may experience further health complications

such as pneumonia, often associated with death (Kouli, Torsney and Kuan, 2018),

and impairments to daily functioning such as difficulties engaging in fine and gross

motor tasks (DeMaagd and Philip, 2015). Additionally, as the symptoms worsen,

individuals may lose their ability to live independent lives, causing added strain on

families or carers (Franceschi, Pina and Castillo, 2015), and may require care home

admission (Kouli, Torsney and Kuan, 2018).

Dysarthria

Barbara’s speech difficulties are described as dysarthric speech. Dysarthria is a

motor speech disorder characterized by slow, weak, or uncoordinated movements of

speech processes (Sellars, Hughes and Langhorne, 2002). It is caused by a

disturbance to the muscular control of speech production due to damage to the

peripheral or central nervous system (Roth, 2011). The SLT manages the symptoms

of dysarthria in PD.

In PD, dysarthric speech is typically characterised as hypokinetic dysarthria. This

may present as decreased vocal loudness, poor coordination of muscle movements,

abnormal speech speed, monotone, and breathy voice (Mitchell et al., 2017; Roth,

2011). The case study describes Barbara’s speech as low volume, monotone, and

80% intelligible.

Dysarthria can have a detrimental impact on functional communication, which often

leads to a reduced quality of life (Rowe et al., 2022). The presence of hypomimia can

result in misinterpretations (Moya-Galé and Levy, 2019). Dysarthria may cause

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negative psychological and social consequences for an individual, resulting in a poor

self-image and feelings of depression, isolation, and anxiety (Lansford et al., 2011;

Letanneux et al., 2013). Additionally, the frustration and effort required to overcome

limitations can result in social withdrawal or isolation (Moya-Galé and Levy, 2019).

According to Atalar, Oguz and Genc (2023) individuals with hypokinetic dysarthria

are linked to decreased levels of social communication, exhaustion, and cognitive

and emotional issues.

Diagnosis

Based on the symptoms mentioned in the case study, it is hypothesized that Barbara

is diagnosed with the hypokinetic dysarthria subtype. Hypokinetic dysarthria is

common in individuals with PD, with a prevalence of approximately 90% of the PD

population (Lansford et al., 2011). It is a motor speech disorder characterized as an

impairment to the basal ganglia control circuit, which impacts the amplitude of sound,

initiation of speech production, and speed of muscular movements (Moya-Galé and

Levy, 2019; Muñoz-Vigueras et al., 2020). Hypokinetic dysarthria characteristics are

most evident in voice, articulation, respiratory support, pitch, rate, or prosody

(Muñoz-Vigueras et al., 2020). The physiological characteristics of hypokinetic

dysarthria are associated with poor breath support, reduced loudness, monotone

voice, diminished articulation, short rushes of speech, and reduced range of motion

of the speech articulators (Lansford et al., 2011; Moya-Galé and Levy,

2019). Barbara’s speech profile is characterized as hypokinetic dysarthria, because it

follows the key physiological characteristics.

The (TOMs) severity rating scale was used to rate Barbara’s hypothesised

dysarthria. Barbara is rated as mild to moderate based on the way the dysarthria

impairment is presented, and the hypothesized impact it has on her participation and
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wellbeing (Enderby and John, 2019). However, medication use, and a detailed case

history analysis can impact this score.

Hypokinetic dysarthria can have a detrimental effect on individuals’ intelligibility and

ability to communicate effectively, which can significantly reduce their quality of life

(Moya-Galé and Levy, 2019). Due to her speech difficulties, Barbara may experience

frustration, poor self-image, anxiety, social withdrawal (Moya-Galé and Levy, 2019),

depression (Lansford et al., 2011), reduced speech and linguistic abilities, and

negative judgements from others (Atalar, Oguz and Genc, 2023).

Assessments

Assessments will allow the SLT to obtain vital information regarding Barbara’s

speech characteristics, co-occurring impairments, and functional impact (Altaher et

al.,2019; World Health Organization, 2001). Perceptual assessments are key in SLT

practice to assess patients with dysarthria. It allows the clinician to identify deviant

features in speech using auditory judgements. However, while perceptual

assessments are considered the golden standard for practice by SLTs, assessments

can be influenced by external factors such as the skill of the clinician, the

assessment, and the client’s medical and social history (Altaher et al., 2019)

In the selection of an appropriate assessment, it is important to identify information

concerning the client’s cultural and linguistic background because it can influence

communication abilities (ASHA, 2023). The assessment should be suitable based on

the participant’s background, and language abilities (Pert and Bradley, 2018).

Additionally, the SLT will consider the client’s medication use, fatigue, and motivation

level (Atkinson, 2023). Re-assessment of the clients’ abilities is important due to the

progressive nature of PD (DeMaagd and Philip, 2015).

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A holistic approach will be used to assess Barbara’s speech. This includes engaging

in case history, formal and informal assessments, and self-perception ratings.

Case History

Case history consists of obtaining comprehensive information about the client. It

contains data about the client’s medical history, speech, language, and

communication abilities, personal details regarding lifestyle, support, cultural

background, and cooccurring issues (Altaher et al.,2019). During the case history of

Barbara, the SLT will inquire specific information regarding Barbara’s medical

history, such as prior medical diagnoses and medication history, personal

information including client goals, support networks, cultural and linguistic

background, functional limitations to lifestyle, barriers and facilitators to speech,

language, and communication, including compensatory strategies and intelligibility,

and perceptions of abilities from service users and family (Atkinson,2023).

Formal assessment

The assessment chosen to evaluate Barbara’s speech production is the Frenchay

Dysarthria Assessment (FDA) (Enderby and Palmer,2008). The FDA is a widely

used standardized assessment tool by SLTs (Altaher et al.,2019). It assesses the

neuromuscular function of speech production. The client’s reflexes, respiration, lips,

palate, laryngeal, tongue, and intelligibility will be evaluated. This assessment is

appropriate because it allows the SLT to investigate Barbara’s vocal quality,

articulation, prosody, intelligibility, and comprehension level (Enderby and Palmer,

2008).

Intelligibility Assessment
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The case study gives basic information regarding Barbara’s intelligibility; however, a

more definite analysis will provide clarity to the clinician and the client. The

Intelligibility section of the FDA is an appropriate rating scale. It evaluates the

intelligibility of words, sentences, and speaking rates (Enderby and Palmer,2008). It

is suitable for identifying the extent of understanding an individual’s speech

production (ASHA,2023).

Informal assessments

Oral Motor Exam

Although evidence-based research is limited, an Oral Motor Exam is an appropriate

assessment, recommended by SLTs, to assess Barbara’s dysarthria (Altaher et

al.,2019). This assessment aims to assess the accuracy, strength, range, and speed

of the jaw, face, pharynx, palate, larynx, lips, and tongue (Duffy,2013). This

assessment is appropriate for Barbara because it will provide vital information

regarding flat-affect, facial tremor, movement range, initiation difficulties, and

festination (Duffy,.2013). Additionally, the assessment will include information on

body posture and breathing pattern (ASHA,2023) and diadochokinetic rates, which

are linked to intelligibility (Pierce, Cotton and Perry, 2013).

Functional/Social Impact

In the case study, the information regarding functional impact and the way Barbara

interacts socially is limited, therefore, an assessment to evaluate the effectiveness of

communication abilities in different social contexts is necessary. The SLT will seek to

observe instances of the client’s conversational skills, to identify communication

skills, and social participation levels (Atkinson, 2023). Additionally, the Functional

Communication Profile (Sarno,1969) assessment tool is appropriate for Barbara.

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This tool will provide a clear understanding of her communication impairment and

participation limitations and can be further used to measure progress (Altaher et

al.,2019).

Self-Perception

Self-perception is low in individuals with PD (Miller et al.,2011), as evident in the

case study, as Barbara does not notice her speech issues. Therefore, a self-

perception rating scale is appropriate for the client. The Communicative Participation

Item Bank (Bayler et al.,2013) is a suitable assessment tool. It is easy to use and

appropriate for the client’s fatigue level (Atkinson,2023). Additionally, it will bring

awareness to the speech difficulties impacting Barbara.

Management

A person-centred approach will be used to create an appropriate management plan

for Barbara. The management plan will be created in collaboration with the client and

consider the client’s goals, motivation, fatigue, medical history, culture and lifestyle,

and support networks (ASHA,2023). The ICF model will be used to incorporate a

holistic approach to management (CDC,2023). NICE guidelines will be followed to

establish an appropriate strategy that meets the standards for the efficient delivery of

services to improve Barbara’s quality of life (Altaher et al.,2019; NICE,2019).

The main goal of dysarthria management is to develop strategies for maximizing

intelligibility and shared understanding (Atalar, Oguz and Genc,2023). Behavioural

management is one of the main treatment options used to improve the speech

intelligibility of individuals with PD (Lansford et al., 2011). These techniques impact

speech-motor functions and communicative behaviour (Muñoz-Vigueras et al.,

2020). The management of hypokinetic dysarthria related to Barbara’s PD diagnosis

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will use both speaker-oriented and communication-oriented strategies (Atkinson-

Clement, Sadat and Pinto,2015).

Speech therapy is the main treatment for hypokinetic dysarthria (Atalar, Oguz and

Genc, 2023). Group therapy will be incorporated into Barbara’s management plan.

Group therapy has compelling evidence supporting the management of hypokinetic

dysarthria (Whillans et al., 2020). Research highlights that individuals with PD

require a more naturalistic, conversational setting, as context is important to learn

new behaviours (Moya-Galé and Levy, 2019; Tjaden,2008).

Speaker-Oriented Strategies

Speaker-oriented strategies focus on modifying speech by repairing the impairment

in speech production or by teaching strategies to compensate and enhance

intelligibility (Tjaden,2008). In hypokinetic dysarthria, strategies aim to improve the

speech production systems of phonation, articulation, rate, prosody, and respiratory

(Atalar, Oguz and Genc, 2023).

Phonation

Barbara’s management plan incorporates exercises to target voice strength, such as

vocal fold adduction and non-speech oro-motor exercises of the lips, face, and

tongue (Atalar, Oguz and Genc, 2023).

The compensatory speech treatment of the Lee Silverman Voice Treatment (LSVT)®,

also known as LSVT LOUD®, will also be incorporated (LSVT Global,2015). The

LSVT follows an intensive 4-week, 1-hour, 4-times weekly program with additional

daily homework tasks (Baumann et al., 2018), which seeks to improve loudness by

providing external cues (Moya-Galé and Levy, 2019). Research reports positive

results to the entire speech production system (Baumann et al., 2018; Yuan et
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al.,.2020). However, while improvements were seen, objective measures of

intelligibility are not widely reported (Tjaden,2008).

Articulation

Barbara’s management strategy targets articulation, using clear speech strategies

(ASHA,2023). This strategy will target speech production and intelligibility. The

compensatory strategy of over-articulation will seek to exaggerate phonetic

placement to increase precision and speech production (ASHA,2023).

Rate/Prosody

The SLT in the management plan will introduce devices to target rapid speaking

rates (Atalar, Oguz and Genc,2023). Based on Barbara’s preference, low-tech or

high-tech pacing devices will be incorporated. Additionally, the plan will include the

compensatory strategy of stress and pitch exercises during therapy to promote

natural speech (ASHA,2023).

Respiratory

Barbara’s management plan will include strengthening exercises using Expiratory

Muscle Strength Training (EMST), to target respiration (NHS,2023). The EMST is a

4-week, 5-days weekly, 5-times daily program aimed at improving expiratory muscle

strength. Research suggests that patients with PD who engaged in the EMST

program experienced positive benefits (Tjaden,2008; NICE, 2017).

Additionally, guidance will be given on improving breath-support. Therefore,

education on posture and syllabic grouping will be advised (ASHA, 2023).

Depending on Barbara’s lifestyle, Parkinsong can also be introduced as a form of

therapy (Tamplin et al.,2020).

Resonance
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The use of instrumental aids will be incorporated into the management to improve

speech intelligibility (Lansford et al.,2011). A key feature of hypokinetic dysarthria

speech is a low voice. Therefore, voice amplifiers can increase volume, thus

improving intelligibility (Xu et al.,2020).

Additionally, instrumental feedback, both visual and biofeedback, can produce

improvements to speech (Moya-Galé and Levy,2019). This can be accomplished

using clinic-friendly instrumentation such as sound level meters (Tjaden,2008) or a

dental mirror under the nose (ASHA,2023). This is particularly important due to the

progressive nature of PD, and it encourages self-monitoring (Nielsen,2016).

Critique

While some treatment strategies, such as oro-motor exercises, are widely used,

evidence-based research is limited. Additionally, although treatment strategies and

programs such as the LSVT and EMST are beneficial and evidence-based, due to

their intensive nature, clients must be motivated to learn and practice the

approaches outside of the clinic setting (Tjaden,2008). Furthermore, incorporating

multiple programs into a treatment plan might not be person-centred. The case

history will provide information concerning the client’s motivation and fatigue level,

which is important when recommending treatment strategies (Atkinson,2023).

Communication-Oriented Strategies

Communication-oriented strategies focus on the factors that contribute to effective

communication by modifying aspects of the communicative interaction.

Communication-oriented strategies will be used in conjunction with speaker-oriented

strategies (Tjaden, 2008).

Total communication approach

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Barbara’s management plan will include a total communication approach that

incorporates the use of all communicative methods appropriate for the client. The

client will be encouraged to incorporate body language into conversation. Therefore,

gestures, facial expressions, eye contact, and postural changes will be advised.

Additionally, alternative modes of communication such as writing, sign language, and

augmentative and alternative communication (AAC) will be explored. Furthermore,

environmental strategies such as providing the context for conversation, eliminating

background noise, and reducing communication distance will be advised (ASHA,

2023; Atalar, Oguz and Genc,2023).

Education

It is important to educate the client on strategies to maximize communication (Atalar,

Oguz and Genc,2023). Education on repairing communication breakdowns through

restorative strategies such as repetition, elaboration, and rephrasing will be

recommended (Tjaden,2008).

Additionally, educating the client and significant members on hypokinetic dysarthria

and the changes associated with the conduction will provide a deeper understanding

of Barbara’s diagnosis. The SLT will also seek to signpost the client to various

resources, such as Parkinson’s UK (Parkinson's UK,2020), and local support groups

and activities, such as choirs, based on Barbara’s interests (Atkinson,2023).

Training

Communication partner (CP) training will be conducted to improve communication by

targeting the way partners communicate and the environment. This allows partners

to be aware of the impairment and effective communication strategies (Tactus

Therapy,2020).
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AAC

The AAC options are suitable for individuals unable to use speech to meet their

communication needs. AAC recommendations may not be currently needed however,

due to the progressive nature of PD, they should be explored (Tjaden,2008).

Research highlights that integrating AAC into the lives of individuals with PD, is

effective in reducing speech rate and eliminating palilalia (Moya-Galé and

Levy,2019; NICE, 2017)

MDT

A multidisciplinary team (MDT) is characterised as health-care professionals that

collaborate to make decisions regarding the treatment of patients (NHS

England,2022). In Barbara’s case management, collaborating with the MDT is

appropriate due to the nature of PD and to establish person-centred care. The SLT

provides key information regarding the client’s speech, language, and

communication abilities (ASHA, 2023). Therefore, in addition to targeting speech and

language needs, the SLT may educate the MDT on the client’s communication

needs (Atkinson,2023).

Various professionals are involved in SLT management. The client’s primary doctor

is responsible for the client’s general health and referrals to other health-care

professionals. The neurologist plays a significant role in the diagnosis of PD and

disease progression. The clinical nurse specialist will have specialised skills and

knowledge on managing PD. Physiotherapists provide guidance on breath support

and are responsible for posture management. Occupational therapists target safety

and independence goals, linked to communication (Parkinson's UK,2022).

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Depression is linked to PD (Atalar, Oguz and Genc,2023). Therefore, collaboration

with mental health specialists, counsellors, and social workers contributes to

enhancing wellbeing (Parkinson's UK,2022). Additionally, inter-collaboration with

various charities and support groups, such as Parkinson’s UK Facebook group

(Parkinson's UK,2024) will provide a holistic approach to meet social and emotional

needs. Furthermore, working with carers and families play a role in providing support

and goal setting for clients (RCSLT,2024).

Conclusion

The case study analysed Barbara, a 75-year-old woman with PD, with a tentative

diagnosis of hypokinetic dysarthria. Hypokinetic dysarthria is characterised as a

speech impairment causing amplitude, initiation, and muscular movement difficulties.

This impairment can negatively impact an individual’s quality of life. This analysis

critically investigated suitable assessments for the client and considered an

appropriate person-centred management plan in collaboration with the MDT to

effectively meet the needs of the client.

Reflection

The case-study analysis contributed to the module HS837, which focused on

dysarthria in adults. It was interesting exploring the information available and gaining

a more in-depth understanding of dysarthria. My grandpa was diagnosed with PD,

and it was motivating and exciting to relate and learn about his diagnosis and the

various challenges that he faced. Additionally, the CP placement exposed me

clinically to dysarthria speech, as two clients were diagnosed with PD and had

dysarthria. Through the course, I was able to understand the theory behind the

practice. Additionally, I was able to expand my knowledge on the topic, which will
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help me in future clinical practice. Being able to have the practical experience and

the theoretical knowledge is essential as I continue to develop as an aspiring SLT.

Word Count: 3012

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