MANAGING MOTOR SPEECH

DISORDERS: GENERAL
PRINCIPLES
 Management Goals:
• The primary goal of management is to
maximize the effectiveness, efficiency and
naturalness of communication (Rosenbek
and LaPointe,1985). The key words that
represent these directions are RESTORE,
COMPENSATE and ADJUST.
• Restore lost function: this effort attempts to reduce impairment. For
eg. A person with a mild to moderate unilateral UMN dysarthria due
to a single, unilateral stroke 2 days prior to speech assessment has
a reasonably good chance of nearly complete return of normal
speech on the basis of physiologic recovery alone. A person with an
isolated, idiopathic unilateral vocal cord paralysis might achieve full
or nearly complete recovery of voice as a result of nerve
regeneration or surgical thyroplasty.

• People with reduced physiologic support for speech such as

respiratory, laryngeal or lingual weakness may benefit from efforts to
increase strength to meet the strength demands of speech. It is
crucial that clinicians and patients realize that full restoration of
normal speech is not a realistic treatment goal in most cases.
• Promote the use of residual function( compensation): knowing that
restoration of normal speech will probably not occur should lead to
efforts to compensate for lost abilities. Compensation can take many
forms but is exemplified by modifications of rate and prosody; the
use of prosthetic devices to amplify voice, reduce nasal airflow, or
pace the rate of speech; modifying the physical environment or
behaviour of people within it in ways that enhance intelligibility.

• Reduce the need for lost function (adjust): depending on the course
of the underlying disease, the prognosis for speech recovery, and
the severity of the speech disorder, these adjustments may be
temporary or permanent. For those with degenerative disease,
planning for the progressive loss of speech may be necessary.
Factors influencing management
decisions
• Not all people with motor speech disorders are candidates for
treatment. The decision to treat or not to treat should be based on
consideration of many factors:

• Medical diagnosis and prognosis: did the underlying neurologic

disease develop acutely, subacutely or chronically? Is its predicted
course one of complete resolution or improvement with eventual
plateauing, or will it be chronic and stable, exacerbating-remitting or
progressive? Is there a medical treatment for the diseases that may
result in resolution or significant improvement of speech and will
such treatment take place soon and with subsequent rapid benefits?
Intervention will not be recommended if there is negligible
disability and no handicap associated with a motor speech
impairment.
• Environment and communication partners: the
environment and traits of communication partners may
have a significant impact on a patient’s prognosis for
benefiting from management as well as on specific
management goals and approaches.
• Motivation and needs: the need to communicate may be
the most important determinant to a decision to provide
treatment (Netsell and Rosenbek, 1985). Age,
educational level, premorbid personality, intelligence and
lifestyle, personal goals, coexisting motor, sensory and
cognitive deficits, general health issues and living
environment with an option to reassess direct
management options if the patient’s level of motivation
changes.
• Associated problems: cognitive deficits may significantly
influence the conduct of management, and all of the
CNS based dysarthrias (spastic, ataxic, hypokinetic,
hyperkinetic, unilateral UMN, mixed) frequently are
accompanied by them. 30% to 80% had associated
cognitive deficits, including difficulties with attention,
memory, learning, insight, planning and motivation. In
general, if accompanying cognitive deficits preclude
attention, drive or motivation to communicate, or result in
speech that has no functional communicative value, then
the motor speech disorder should not receive direct
treatment.
• The health care system: it is likely that
some treatment decisions will be
influenced by factors beyond the clinician-
patient relationship. The challenge to
clinicians will be to maintain quality while
increasing efficiency and reducing
demands on costly resources
• Focus of treatment:
• In general, the component of speech
that should be treated first is the one from
which the greatest functional benefit will
be derived most rapidly, or that will provide
the greatest support for improvement in
other aspects of speech.
• Duration of treatment and its termination:
• In general, no management program should begin
without a plan about when it will end. The clinician and
patient should have in mind how long it will take to
achieve goals, with an understanding that revision is
possible. This temporal plan will help some patients
decide if they wish to pursue treatment in the first place.
Many, for example, are willing to commit to therapy when
goals are likely to be reached within a short time. For
others, it may assist their need to know how long it will
take before they are “on their own” and able to function
independently.
• Duration of treatment is influenced by
many factors. The etiology, the predicted
course of recovery, the severity of deficits,
the specific goals and techniques of
management, patients motivation and
communication needs, the duration of
hospitalization, the ability to travel for
outpatient services and health care
coverage and insurance all have an
impact on the duration of the treatment.
 APPROACHES TO
MANAGEMENT:- 3 PRONGED
THERAPY
• There is no single approach to treating
motor speech disorders. Approaches to
management can be organized in several
ways, but they generally can be passed
into 3 distinguishable but frequently
overlapping and sometimes inseparable
areas of effort. They include medical
management, prosthetic and
instrumental management, and
behavioral management.
• Medical Intervention:
• Medical management includes pharmalogical and surgical interventions that
can directly or indirectly affect speech. In general, medical management
should always precede or be provided concurrently with other management
approaches since it may maximize physiologic functioning and have a rapid
or dramatic effect on speech.
• The primary responsibility of the medical speech pathologist in such cases
is to assess speech carefully and establish the need for medical or surgical
intervention; the likelihood that the patient will benefit from such
management; the specific benefits to be derived; what the intervention will
not accomplish for speech; the need for post procedural behavioral
management and the provision of such management; and clear
communication of all this information to the medical subspecialist and
patient. It is important to have an understanding of the medical risks and
costs of such procedures so that the decision to refer for such management
can weigh risks and costs against predicted benefits
• Pharmacologic management: pharmacologic management is
almost always directed at relieving symptoms, but sometimes it
effectively cures the disorder. Such approaches are directed to the
underlying disease process.
• Some neurologic diseases commonly associated with dysarthrias
are effectively managed by drugs, and their benefits can include
improved speech. These include, for eg. dopaminergic agents for
Parkinson’s disease, pyridostigmine bromide (Mestinon) for
Myasthenia gravis, dietary modifications and chelating agents for
Wilson’s disease and a variety of drugs that control movement
disorders. Injection of Botox in certain laryngeal muscles for the
treatment of spasmodic dysphonia or into the jaw, face or neck
muscles to treat orofacial dyskinesias or spasmodic torticollis is the
prime example of the use of a drug for the sole purpose of altering
the functions of specific muscles and sometimes for the sole
purpose of improving speech.
• NOTE: before beginning behavioral
management, the clinician should know if the
patient is receiving medication for the neurologic
problem, if there are pans to initiate such
treatment, or if drug therapy has been tried and
abandoned. Behavioral management should be
delayed until drug therapy that might improve
speech is started because such therapy may
make behavioral management unnecessary or
change its focus.
• Surgical management: surgery to manage neurologic
disease may have direct and indirect effects on speech.
Neurosurgery for aneurysms, hydrocephalus, tumors,
seizures, and occluded arteries are examples of
procedures directed to the causes of neurologic deficits
rather than the deficits themselves. In some cases,
surgery may “cure” the signs and symptoms. In others,
there may be improvement but not resolution,
stabilization but not improvement, deterioration, or the
development of new deficits. In still others, such as
neoplasm resection, gains may be temporary
• Prosthetic management:
• Some may be temporary, used only until physiologic
recovery or the effects of behavioral management allow
them to be discarded. Others may be permanent
because disability or handicap would be increased
without them.
• Some prosthetic devices directly modify what happens in
the vocal tract during speech and help to promote
perceptual normalcy. For eg. A palatal lift prosthesis may
facilitate VP closure during speech, with resultant
reduced Hypernasality and increased intraoral pressure
for pressure consonants
1. Other prosthetic devices modify speech
after it is produced. For eg. Voice
amplifiers may increase vocal loudness
in speakers whose primary speech
difficulty is reduced loudness or inability
to increase loudness to overcome noise,
distance, or reduced hearing acuity in
listeners.
1. Some prostheses are designed to modify the manner
of speech production rather than simply support
normal production or modify the speech signal. These
devices may actually alter the rate or prosody in the
direction of abnormality in order to improve
intelligibility. Examples include pacing boards,
metronomes and delayed auditory feedback (DAF), all
of which slow speech rate and increase syllabic stress.
Certain biofeedback devices may indicate to the
patient when speech is failing to meet certain preset
standards. For eg. A vocal intensity monitoring device
may provide an audible or visible signal when
loudness falls below a preset level that is necessary to
maintain intelligibility.
• Finally, prostheses are available to augment speech or
serve as alternatives to it. They belong under the
broad category of augmentative and alternative
communication (AAC) and are actually tools of
behavioral intervention.
• Decisions about the need for and benefits to be
derived from prosthetic management rest with the
speech pathologist. Implementation is very often
multidisciplinary, frequently requiring the skills of
prosthodontists, occupational and physical therapists,
rehabilitation engineers and others.
• Behavioral management: behavioral management includes all
intervention efforts that are neither medical nor prosthetic.
Behavioral management is probably provided to a larger proportion
of people with motor speech disorders than is medical and
prosthetic management. Behavioral management has a wide variety
of goals and may take many forms. Its primary goal, however, is to
MAXIMIZE COMMUNICATION by whatever means will produce the
most rapid, effective and natural results.
• The goals of behavioral management can be accomplished in a
number of ways, including improving physiologic support for
speech, modifying speech through compensatory speaking
strategies, developing alternative and augmentative means of
communication, and controlling the environment and
communicative interactions.
• The most basic divisions include a) speaker oriented approaches
and b) communication oriented approaches.
• Speaker oriented approaches work to restore or compensate for
impaired speech functions. Their goal is to improve communication
by IMPROVING THE SPEAKER. In contrast, communication
oriented approaches work to improve communication by altering
speaking strategies, the behavior of listeners, or the environment in
which communication occurs; their goal is to improve
communication by MODIFYING ASPECTS OF THE
COMMUNICATIVE INTERACTION. Treatment of mild impairments
tends to be speaker oriented; treatment of severe impairments tends
to be communication oriented. Both approaches can be employed at
all severity levels.
• Speaker oriented approaches: this focuses primarily on
improving speech intelligibility and secondarily on improving
the efficiency, naturalness, and quality of communication.
Motor speech is the focus of speaker oriented approaches.
These goals are accomplished by reducing impairment by
increasing physiologic support for speech or through
compensation by making maximum use of residual
physiologic support.
• Efforts to reduce impairment by increasing physiologic
support attempt to remediate the deficits in posture, strength
and tone that underlie the speech disorder. Brookshire (1992)
calls such approaches indirect because they may be conducted
independent of speech. Activities may include sensory
stimulation, strengthening exercises, the modification of
muscle tone, altering posture and positioning, and improving
respiratory capacity and efficiency.
• Making maximum use of residual physiologic support is
characterized as a behavioral compensation method by
Yorkston, Beukelman and Bell (1988) and as a direct approach
by Brookshire (1992) because it focuses directly on modifying
respiration, phonation, resonance, articulation or prosody in
order to compensate for residual impairment.
• Compensatory approaches also focus on improving
efficiency and naturalness. Efficiency means increasing
rate of communication without sacrificing intelligibility.
This may be done by manipulating speech directly, by
adopting certain augmentative strategies, by altering
language content or style, by manipulating the
environment, or by developing strategies for efficiently
handling breakdowns in intelligibility when they occur.
• Focusing on naturalness involves attention to prosody.
Rate, rhythm, intonation and stress carry important
syntactic information and increase substantially the
amount of redundancy in the speech signal. Thus efforts
to increase naturalness can be part of efforts to increase
intelligibility.
• Communication oriented approaches: these may improve
communication even when speech itself does not improve. It
includes a variety of modifications ranging from altering the number
of listeners, the amount of noise, speaker listener distance, and eye
contact to inform new listeners about the speech problem, its cause,
and the speakers preferred method of communicating. It also
includes identification of the most effective strategies for repairing
breakdowns in communication; for example, repeating utterances,
rephrasing, spelling, writing and answering clarifying questions.
• Communication strategies may change from one speaking
environment to another or from one listener to another
• Augmentative and Alternative Communication: the
tools of AAC are heterogeneous. They include gestural
communication that may not require the use of any
additional physical aid, such as eye gaze, body postures
and facial, head and hand gestures. They include a
variety of symbols beyond the spoken word, such as
pictures, photos, icons, printed words and letters.
• The use of AAC in the management of motor speech
disorders can be highly variable across and even within
individuals. For those who expected disease course is
one of improvement, AAC may be heavily relied on
before recovery begins and then faded as recovery takes
place. For people with degenerative diseases, there may
be no need for AAC early, but total reliance on it may be
necessary in the later stages.
•The decision to use AAC strategies is based on careful
assessment of speech and communication abilities and
needs, prognosis, and the individual’s potential to benefit
from them. Use of AAC may be minimal for many patients.
For eg. A person may learn to identify the first letter of each
word they say because it improves intelligibility, and they may
drop that strategy as soon as intelligibility is adequate without
it. In contrast, patients with locked-in syndrome may rely
entirely on alternatives to speech, using eye gaze or forehead
movements to identify symbols or trigger switches that
will transmit messages.
• It is clear that
• -treatment does not vary only as a function of severity,
• -that not all available management approaches are
appropriate for all dysarthria type,
• - And that some approaches may be contraindicated for
some Dysarthria types.
• Some of the communication oriented approaches are
relatively independent of Dysarthria type & are more
strongly tied to individuals’ communication needs and
desires and to severity of their disabilities.
• SPEAKER ORIENTED TREAMENT
•  RESPIRATION
• Darley, Aronson & Brown 1975, felt that respiration
usually does not require attention in treatment bcoz
respiratory demands for speech are not great & bcoz
improving function at the phonatory, resonatory, &
articulatory wise generally promotes efficient use of the
air stream.
• Similarly Yorkston et. al. 1988, indicated that presence of
abnormal respiratory function does not necessarily mean
that respiration is not adequate for speech
• However poor respiration may impact on other speech
function especially phonation – to maximize consistent
sub-glottal air pressure, speech without inducing fatigue.
• INCREASING RESPIRATORY SUPPORT
• (I) producing consistent sub glottal air pressure
– Linebaugh 1983, concept of the “optimal breath
group”, - special relevance for speech respiratory
control. It is the no. of syllables that a patient can
produce comfortably on 1 breath
– Contextual speech task – increasing the length of
phrases and sentences.
– Pushing, pulling & bearing down during speech or
non-speech task, may help to increase respiratory
drive for speech.
– Control exhalation task
• (II) Postural adjustment:
• Some patients with greater expiratory
then inspiratory difficulty for speech
may do considerably better in the
supine then sitting position bcoz of its
stabilizing effects & bcoz gravity &
abdominal contents may help push the
diaphragm into the thoracic cavity &
assist expiration (Netsell et. al. 1985
• Prosthetic Assistance/: may provide
postural support during respiration that
can help control expiration which can be
useful during speech. Abdominal binders
or corsets can enhance posture & support
weak stomach muscles, hence improving
respiratory support.
• One can also, use expiratory board or
paddle mounted on a wheel chair.
• (III) BEHAVIORAL COMPENSATION:
•  PHONATION
• Several medical interventions are available for
improving laryngeal function in dsyarthric speakers.
• LARYNGOPLASTY:
– Medialization, laryngoplasty or type 1 thyroplasty is a type of
phonosurgery or laryngeal frame work surgery that attends to
improve phonation in people with vocal cord paralysis or
weakness.
– So as to displace the paralyzed cord medially & facilitate
vocal cord approximation.
– This may lead to improvement in pitch & loudness.
– Breathiness, harshness & vocal fatigue may persist.
– This procedure may also help in managing abductor
spasmodic dysphonia.
• TEFLON / COLLAGEN INJECTION:
• Injection of Teflon into the submucousal tissue of a
paralyzed vocal cord has been a popular procedure.
• Injected into the middle third of the cord, it increases bilk
& narrows the glottis
• It is generally not used until about 1 year post onset bcoz
removal of the Teflon may lead to disturbances of normal
vocal cord anatomy.
• Collagen may be used though Teflon is prefaerrrable.
Collagen is similar to natural collagen in the vocal cord &
subject to only limited absorption.
• It reduces aspiration & airflow
• Improves glottal efficiency & intensity
• Improves the dysphonia associated with VC paralyses.
• RECURENT LARYNGEAL NERVER
RESECTION:
– Unilateral resection of the RLN has been used to treat
adductor SD
– By paralyzing one of the VC, the procedure, in effect,
prevents there hyper adduction & reduces
laryngospasm

• Other procedures are:

• Botulinum toxin injection
• PHONATION – PROSTHETIC MANAGEMENT:
• A vocal intensity controller may be used to warn patients
of excessive or inadequate intensity
•  Successful use of these devices as an aid in speaking
situations can help patients of degenerative diseases like
Parkinson’s
•  In contains a VU meter which acts a simple feedback
device for increasing loudness
•  Also, has a portable amplification system
•  A no. of artificial larynges can also be used
•  Patients with movement disorders- neck braces or
cervical collars
• PHONATION – BEHAVIORAL MANAGEMENT:
•  RESONANCE
• Managing VPI is important for some dsyarthric as
excessive nasal airflow can result in air wastage during
speech.
• Damping effects of the nasal cavity may reduce the
perceptual distinctiveness of consonants requiring
intraoral pressure.
• An effective way is to improve eth speech intelligibility,
loudness, phrasing & articulatory precision is to compare
speech with the nares occluded v/s unocculded or , with
the ppt upright v/s supine
• SURGICAL MANAGEMENT:
– Pharyngeal flap surgery is the preferred
method for managing VPI with repaired
palatal clefts.
– It is also used with VPI in dysarthric speakers
• PROSTHETIC MANAGEMENT
• MOST FOCES ON prosthetic management in the
form of palatal lift prostheses is considered.
• The palatal lift consists of a portion that covers the
hard palate & extends along the oral surface of the
soft palate.
• Best candidates are those with significant
VP weakness whose deficits at other
levels of speech system are minimal
•  ARTICUALTION
• In olden days, focus on articulation has
traditionally been viewed as a major part
of the dysarthria treatment.
• However now, the goal of many treatments
is to improve the accuracy and precision of
sound production.
• Surgical management
• Neural anastomosis is occasionally pursued to restore function to a nerve.
• Particularly, in an attempt to restore function to facial nerve for both
cosmetic & functional purposes.
• This usually involves connecting a branch of the XII the nerve to the
damaged VII the nerve.
• Anastomosis of the facial nerve to the accessory is usually done, but the
VIIth to XIIth anastomosis is generally preferred.
• MINGRINO et al, points out that hypoglossal-facial anastomosis sometimes
leads to facial synkinesis during speech, this may further interfere with
articulation
• The procedure is usually pursued in people wit normal hypoglossal function
and no clear evidence of dysarthria bcoz lingual weakness usually develops
after surgery.
• Botox injection can be used as an effective treatment for hemi facial spasm,
spasmodic toriticolis and oral mandibular dystonia.
• This decreases its associated hyperkinetic dysarthria.
• PHARMACOLOGIC MANAGEMENT:
• Some medicines such as antispasticity
drugs such as chlordiazepoxide,
diazepam, dantrolene, and baclofen are
used effectively in decreasing limb
spasticity, but their effects on articulation
are uncertain.
• PROSTHETIC MANAGEMENT:
• Prosthesis to aid articulation are limited. A bite-block is a
small piece of material that is custom fitted to be held
between the lateral upper and lower teeth.
• This will help ppts with jaw dissproportionality to
articulate.
• It may also help ppts with spastic and hyperkinetic
dysarthria.
• A bite-block may be of particular use to ppts with jaw
opening dystonia who are often able to inhibit jaw
opening.
• BEHAVIOURAL MNAGEMENT:
• This includes:
• 1) Strengthening: the use of strength training to
improve articulation is controversial. The jaw
can be opened, closed, lateralized, and pushed
forward against resistance, lips can be rounded,
spread, etc
• Ppts with marked weakness or limited
movement may be simply being asked to
perform movements without resistance. Such
exercise can be done with instrumentation
designed to measure force and strength.
• An imp issue is whether strengthening ex during
non-speech activity is necessary at all for most
ppts.
• Strengthening ex may be unnecessary is
supported by the fact that tongue and lips use
only 10% to 30% of the max force for speech,
and the jaw only 2% and that upto 1/3rd of motor
nerve fibres can be lost before functional
impairments are encountered.
• In general, non-speech strechght ex should be
used only after establishing that witness is
clearly related to speech impairment.
• 2) RELAXATION;
• Some clinician suggests that relaxation ex help to
improve muscle toning in ppts with spasticity or rigidity.
• 3) STRETCHING:
• The notion of stretching is one of the foundations of
managing spasticity in the limbs.
• It is generally recommended that stretching in the limbs
be steady, continopus, prolonged, and directional with
avoidance of sudden change in the force or direction coz
oscillating forces can stimulate muscle spindles activity
and can promote spasticity.
• 4) BIOFEEDBACK;
• Some evidence suggests that hypertonicty in
speech muscles can be modified by
biofeedback.
• 5) TRADIONAL APPPROACHES:
• Rosenbek, et al, emphasized the importance of
traditional methods of articulation therapy for
dysarthics speakers, including
• Integral stimulation(watch and listen imitation
tasks)
• Phonetic placement(hands on assistance
in attaining target and movt, pic illustration
of articulatory targets)
• Phonetic derivation(using an intact non-
speech gesture to establish a target, such
as blowing to facilitate production of u)
• Articulation work often emphasizes the
exaggeration of consonants to prevent
their slighting and improve precision.
• Some ppts need to learn compensatory articulatory
movt. They may include, use of the tongue blade instead
of tongue tip when the tongue is markedly weak.
• A careful inventory of arti error that contributes to
decrease intelligibility is imp to the ordering of stimuli
in treatment.
• In general, stops and nasals are easier than n
fricatives and affricates esp. when respiratory support is
decreased.
• Working on minimal-contrast may be particularly
helpful in achieving control over consonants.
• RATE:
• Rate may be the most powerful single, behaviorally modifiable
variable for improving intelligibility
• Rate modification is used with many dsyarthric speakers coz it
frequently facilitates arti precision and intelligibility by allowing time
for full range of movt, increased time for coordination , and improved
linguistic phrasing.
• Reducing rate also is easier to achieve than other motor goals
• 2 types of methods,
• Prosthetic devices and natural methods.
• Rate reduction must utilize pause time as much as reduced arti rate
to achieve its desired effects.
• Particularly imp to modify rayte in dysarthrias.
• PROSTHEIC MANAGEMENT:
• Delayed aud f/b (daf) it is an instrumental
procedure in which the rate at which an
individual speaks is feed bk. The effect of the
delay is to slow speech rate and presumably,
increased articulatory time and accuracy. The
DAF technique does tend to disrupt naturalness,
it may be cosmetically unacceptable to some
speakers, and adaptation to its effect may occur
• Pacing devices such as pacing board
requires the ppt to point sequently to each
slot in the board as syllable is produced.
This promoted rate, reduction and syllable
by syllable approach to speaking
• NON-PROSTHETIC RATE REDUCTION
STRATEGIES:
• hand or finger tapping:
• using visual feedback from a computer
screen
• rhythmic cuing, is a technique in which
clinician points to wds in a written passage
in a rhythmic fashion giving more time to
prominent wds and pauses.
• PROSODY AND NATURALNESS:
• Work on prosody can be appropriate at all severity levels. The goal
of this effort is to max the accuracy of prosodic patterns and their
naturalness. Naturalness can be defined as, “a perceptually derived,
overall descriptions of prosodic adequacy.”
• Yorkston, et al, suggested that acoustic analysis may be helpful in
prosodic deficits.
• Following are some strategies that may be useful in modifying
prosody and increasing naturalness:
• 1) Working at the level of the breath group
• 2) Contrastive stress tasks
• 3) Referential tasks
• 4) Across breath groups