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SLP 525 Motor Speech Disorders Exam I Study Guide
Terms in this set (48)
Be able to explain the difference between restorative, compensatory, supplementation, and substitution treatment strategies.
Restoration: Decreasing the impairment
Goal is the normalization of function to greatest possible extent
§ Direct attempts to reduce the degree of impairment
§ Increase the physiologic support for speech in selected physiologic systems
§ May involve improving muscle tone or increasing strength & movement precision
§ Reducing the impairment will produce a corresponding improvement in functional ability or a decrease in disability
-like specifically targeting weakness
-could involve some exercise
-or anything that involves the subsystems directly
Compensation: reducing the activity limitation directly
§ Prosthetic Compensation
§ Behavioral Compensation
§ Social/Environmental Compensation
§ Use of alphabet/communication boards or low-tech strategies to supplement speech in combination with poken speech
§ Supplementing oral communication with other communicative strategies (writing, gesturing, etc.)
-refers to idea when more severe speech, having them continue saying things while using other means of communication
-can be supplemented with low tech too (gestures, etc.)
§ Use of augmentative communication
§ When natural speech alone does not serve as functional means of communication
-situations where they need more high tech
-refers to situation where speech really is no longer an option anymore
-still encourage as much talking as you can
-for quality of life purposes
For compensatory therapy strategies, be able to explain/provide examples of behavioral, prosthetic, and social/environmental compensation.
§ Supplement/replace impaired function
§ Uses a mechanical/electronic device to offset aspects of the impairment
§ Usually require very little training & often have immediate effect
-fairly common sense to use
1. Soft voice: amplifier that helps their voice and speech sound louder
2. Abdominal binder: difficulty with adequate respiratory support, might be an option to impove
3. Palatal obturator: hole in hard palate, can cover with prosthesis
§ Encourage speaker to minimize their functional limitation by using techniques that alter their communication behaviors
1. Hard articulatory contacts
2. Chunking phrases
3. Slow rate
§ Involving the listener in interaction training activities so he/she can become a better communication partner
§ Contrast noisy, poorly lit environ. in which communication partners are yelling from adjacent rooms vs. quiet familiar setting in which significant others communicate face to face with their family members
-very good with family education
-train and educate in what you are doing
-help them facilitate compensations when you are not around, taking the reigns outside of therapy
-help client advocate for themselves in more challenging speaking situation
WHO International Classification of Functioning, Disability & Health (ICF)
-Interdisciplinary taxonomy to provide classification of the components of health & the consequences of health conditions
-Model emphasizes that consequences of health conditions include a complex interaction of physical, social & psychological components
-Provides a standard language for the domains of health & disability
Understand how the WHO-ICF framework is used during assessment (what are we assessing at each level?)
Review of the World Health Organization (WHO), International Classification of Functioning, Disability, and Health (ICF)
1. Participation Restrictions: affecting life situations
2. Activity Limitations: speech, function to what they feel/think about it
3. Impairment: what's physiological wrong (through physical, oral mech and motor speech exam)
How do we assess at each level?
-Through interview and observation
-Often initial clinical examination is carried out with minimal equipment
-With more in-depth assessment, instrumentation may supplement perceptual measures
-Interview/conversation to assess activity and participation
-Only need eyes and ears
WHO ICF as applied to Motor Speech Disorders
-Problems in body function or structure
-Slow, weak, imprecise or uncoordinated movements of speech musculature OR inability to plan sequences of speech movements
-Physiologic measures such as respiratory support, phonatory or VP function, articulation; integrity of speech structures
-Execution of a task or action
-Act of speaking; speech
-Speech intelligibility, speaking rate, articulatory adequacy, or naturalness
-Involvement in life situations
-Involvement in everyday situations that involve speaking
-Self-reported interference in everyday communication situations
-activity and participation: within individual or larger life results of speech issues
-not communicating what you want at starbucks
How might you assess how a MSD is affecting a patient's participation in life events?
-Communicative participation is taking part in life situations and if disability is present, communication (and thus participation) may be restricted
-Persons with mild impairments in speech may experience severe restrictions in participation if they are unable to fulfill valued roles such as working
-Communicative participation is influenced by
1. Severity of speech impairment
2. Social factors
3. Personal factors
4. Environmental factors
-so many things from outside can affect
-how well can they live their life?
-noisy environment, etc.
-what we do in therapy targets this
-we want someone to live their life how they want to live with
How might you assess how a MSD is affecting a patient's participation in life events? cont.
2. Quality of Life Scale
3. Talking to family members
-interview and observation
When given a structure to assess during an oral mechanism examination, (e.g., velopharynx, tongue, lips, jaw, etc). Be able to provide one example of an activity you might use and several examples of things to look for when assessing function during this activity.
Look at OFSME
Identify the 4 major functional divisions of the motor system and the 2 control circuits of the motor system. Know which dysarthrias are associated with damage to each division/circuit.
1. The final common pathway (LMN)
2. The direct activation pathway
-Unilateral Upper Motor Neuron Dysarthria
3. The indirect activation pathway
-Unilateral Upper Motor Neuron Dysarthria
4. The control circuits (cerebellar and basal ganglia)
-Basal Ganglia: Hypokinetic and Hyperkninetic
Discuss the role the basal ganglia plays in speech motor control, including how the neural circuitry behind movements are made and modified occurs (look at notes)
-system in brain called basal ganglia
-cluster of neurons with thalamus, putamen, globus pallidus, caudate nucleus
-work in coordination so that we can make movements
-we can make speech movements and gross motor movements
-when not functioning correctly, certain speech disorders
Basal Ganglia: Direct vs Indirect
Direct Pathway—Making Movements
-focused on making voluntary movements
Indirect Pathway—Not Moving
-focused on not moving
-regulating how much volitional movement there is
-same terms; however how these function in someone's brain higher up than the brainstem
Damage to the basal ganglia control circuit
1. Reduced mobility, or hypokinesia (too little
-Rigidity: increased resistance to movement; movements are slow and stiff and may be initiated or stopped with difficulty
2. Involuntary movements, or hyperkinesia (too
-Chorea, athetosis, dystonia
-much more rare https://www.youtube.com/watch?v=kXMydlXQYpY https://www.youtube.com/watch?v=J_wIDm1_ax4
Assessing Restrictions in Participation
Restrictions in participation are the result of the interaction of a person's impairment & activity limitation with external environmental factors
• Assessing restrictions in participation has 2 components:
1. Understanding the communication needs of the person (activity limitations).
2. Restrictions in participation
Discuss why severity level alone cannot predict how a person's MSD affects their participation.
§ Establish if speech subsystem(s) and effectors are impacted and the severity of the impact (impairment)
§ Site of lesion diagnosis or confirmation
§ Differential diagnosis—Keep in mind might be evaluating language and swallowing at the same time
§ Identify the impact on speech/communication function (activity)
-how negatively impacted
§ Determine the impact on individual's life (participation)
-some folks may be severe, but not restricted in living their life the way they want to live with
-impairment + activity + participation restrictions leads to how you treat, whether you treat at all
Be able to provide and explain examples of ways to improve respiratory support for speech.
Establishing respiratory support
-more or less appropriate for certain individuals than others
3. Postural adjustments
Be able to provide and explain examples of ways to stabilize respiratory patterns for speech.
Stabilizing the respiratory pattern
1. Behavioral training
2. Eliminating maladaptive behaviors
Know the general treatment goals for patients with mild vs moderate vs severe speech deficits
Goals of Treatment: Mild Impairment
§ Maximizing communication efficiency and speech naturalness to allow full participation in activities important to the person.
-how do I make their speech more natural sounding so they are less negatively impacted
-intelligible yet not completely natural sounding
-still can be severely affected and require lots of therapy so they can deal with negative impact
-however severity is mild
Goals of Treatment: Moderate Impairment
§ Maximizing intelligibility - "compensated intelligibility"
-do this in many ways
§ E.g. effort to control speaking rate for individuals with coordination problems, palatal lift for individuals with little velopharyngeal movement.
-chip away at making speech more intelligible
Goals of Treatment: Severe Impairment
§ Establishing functional means of communication with any means possible (often w AAC)
-even if short-term
§ Educating family/significant others about ways to increase communicative efficiency
§ If degenerative impairment → may select AAC to prepare for increasing level of impairment
-hard conversation to have
-we want you to learn this so you can communicate with loved ones when you need it
Discuss several reasons why nonspeech (oral motor) strengthening exercises are not usually recommended as part of a treatment plan for people with MSDs. On the other hand, be able to give an example of when you might incorporate them into therapy.
-Not all exercises are equally effective
-FOR MOST PATIENTS, SPEECH AND NOT NONSPEECH TASKS SHOULD BE THE FOCUS OF TREATMENT ACTIVITIES
§ Highly controversial
§ "...have face validity only for individuals with weakness as a cause of their speech disability who are willing and able to invest the time and effort required for a strengthening program, and in whom there are no contraindications to strengthening exercises." Duffy p.392
§ The number of people for whom nonspeech strengthening exercise to improve speech is appropriate is probably relatively small and will likely complement rather than replace activities that focus directly on speech.
-why would you work on strengthening if not weakness issue?
Neuromuscular Functions Thought to Impact Motor Speech
-not much needed for speech sounds
-not much needed for speech sounds
§ Stability and Coordination
§ Motor planning and programming
Three parameters to evaluate an exercise
1. Is the exercise static or dynamic?
-dynamic preferable for speech
2. Is the exercise task specific?
3. Does the exercise involve overload?
§ Overload can be achieved by low-resistance/high repetition exercise or by high-resistance/low repetition exercise.
-things to ask yourself
We discussed differential diagnosis. Be able to provide features that distinguish MSD from cognitive deficits or aphasia, and how we differentially diagnose dysarthria from apraxia.
Dysarthria v Dementia
-Dysarthria is observed only in a subgroup of dementias associated with movement disorders (e.g., Parkinson's, Huntington's)
-Language problems are manifest due to damage to areas of intellectual function
-attention, working memory, etc.
Dysarthria vs Aphasia
-Auditory comprehension & reading skills are preserved
-No word-finding deficits
-Impairments in respiratory/ phonatory aspects of speech may be present in dysarthria (not present in aphasia)
-Lesions may occur at variety of site
-Language disorder that can involve listening, speaking, reading, writing
-Deficits in understanding of verbal & written language
-Fluent aphasia may have articulatory errors, but are usually an error of selection (rather than production as in dysarthria)
-Lesions restricted to cortical language areas & related subcortical connections (usually L hemisphere) but will also see right
Apraxia of Speech and Aphasia
-AOS frequently co-occurs with aphasia or speech sound disorders in children
-AOS usually occurs with Broca-like or receptive aphasia
-"Pure" acquired AOS is uncommonly rare without aphasia co-occurrence. And, aphasia severity can mask AOS.
-Differentiating Wernicke-like or fluent aphasia from AOS is very difficult, however...
-Phoneme substitutions are often more distorted in AOS.
-In aphasia, they are less distorted. Phoneme errors are usually more consistent in location and type in aphasia than AOS.
-People w/ AOS grope but people with aphasia rarely grope.
Dysarthria vs Apraxia of Speech
-Disorder of motor production involving abnormalities in movement rates, precision, coordination & strength in both speech & nonspeech movements
-Strength, tone, steadiness of movement (not so in AOS).
Apraxia of Speech
-Impairments in motor programming for speech production, volitional tasks, but not automatic or involuntary tasks
-Groping (PWD rarely grope)
-Primarily deficits are seen with articulation and prosody, not in other speech systems as in dysarthria
-Sound distortion inconsistency
Both are motor speech disorders!
When conducting a motor speech examination, be able to provide examples of things you might have the person say/do and what you might see/hear if there was an impairment in one of the speech subsystems.
What is the main respiratory goal for any speaker?
maintain adequate subglottal pressure
§ The main respiratory goal of the speaker is to generate steady Ps during an utterance with slight variations to support stress patterning.
Know the location of impairment to the motor system associated with the different types of dysarthria that we discussed
-Cranial and Spinal Nerves (LMN)
-Cerebral Cortex Motor Areas (bilaterally)
-UMN damage bilaterally
6. Unilateral Upper Motor Neuron
-Cerebral Cortex Motor Areas
Describe the differences between primary, compensatory, and maladaptive respiratory impairments.
1. Primary Respiratory Impairment- primary symptom of the neurologic conditions that is causing the dysarthria
2. Compensatory Respiratory Impairment-
-compensation for other aspects of the speech mechanism that cause excessive air wastage during speech
-not the direct cause of their dysarthria
3. Maladaptive Respiratory Strategies- using maladaptive strategies for current or previous speech problems (e.g. vocal tract inefficiency)
-things no longer helpful or never helpful
Discuss perceptual indicators of poor respiratory support and uncoordinated respiratory patterns.
Weak respiratory musculature (Flaccid, Hypokinetic)
• Difficulty generating stable levels & durations of subglottal air pressure (Ps) needed for speech
• Severe → unable to phonate (rare)
• Moderate → overall reduced loudness or decreasing loudness toward end of utterance. Fatigue is common
-difficulties with phrasing and breath pauses
Uncoordinated respiratory movements (CP, Ataxic)
• Mistiming of speech movements may lead to air wastage, which involves release of a portion of air supply prior to initiation of an utterance
Indicators for breath patterns
§ Initiations at very high or very low LV
§ Terminations at very low LV
-A lag between inspiration and onset of phonation
-Sudden inspirations or expirations
-Gasping/Running out of air
-Excessive movement of the shoulders or chest wall
-Inadequate inhalation before speech onset
-Paradoxical movements (backwards of what you would expect, someone who inhales while they are heavily contracting their abdomen)
If given a hypothetical patient or patients, be able to indicate the most likely type of dysarthria, what division of the motor system is impaired, and if given provided with an oral motor or speech motor task, how they might perform on this task, given their type of dysarthria.
Understand the differences between blocked vs. random trials in speech motor training.
Motor Learning—2. Skill Acquisition and Retention via Increased Difficulty
§ Blocked vs. randomized learning experiments
-more traditional therapy: over and over again, however hard to generalize
-vary what they are doing randomly: helps them learn, outside of motor learning as well
-randomized is good and should be incorporated into therapies
Motor Learning—2. Skill Acquisition and Retention via Increased Difficulty cont.
§ Performance during learning does not necessarily predict performance later.
§ Blocked conditions help during acquisition
-especially for those more severely impaired
-need to learn first
§ Randomized conditions facilitate retention
-Randomized trials prevent learners from generating a stable "set" -Must retrieve & organize slightly different movements for every trial
Explain the potential effects of providing feedback on different frequency schedules.
§ Performance during learning does not necessarily predict performance later.
§ Receiving feedback every trial facilitates acquisition of the task more rapidly
§ Summary feedback after every 15th trial facilitated retention
-traditionally, scaffold this as you can
Motor Learning—3. Instruction and Self-Learning
§ Each have value
§ Patients often need some instruction and demonstration
-Demonstration may stimulate activity in muscles
§ There is evidence that discovery learning may lead to better retention and generalization than learning that is highly prompted.
§ Balance 🡪 set a general goal (e.g. slow rate)
-rather walking through in artificial fashion, have them define slow rate and work on it
-help individual try things on their own so they can learn = discovery learning
When might speech therapy not be recommended for a patient—or at least delayed?
§ Not all people with MSDs are candidates for Treatment
• Medical Prognosis
• Environment and communication partners
• Associated problems
• Health care system: related with what you can and cannot do
Be able to match a cranial nerve (its roman numeral) to an example of impairment to that nerve
Look at notes
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