DYSARTHRIA/APRAXIA SCREENING Oral Mechanism Exam INTELLIGIBILITY Observation: conversational speech intelligible intelligible with some difficulty unintelligible Characteristics: Spontaneous Speech: "Tell me about this picture." (Disability/Perceptual) intelligible intelligible with some difficulty unintelligible
RESPIRATION Observation: clavicle breathing short breath phrases irregular posture rapid shallow labored Bubble Test: Materials: glass of water with straw submerged at 5 cm and paper clipped to side (Impairment/Perceptual) sustain for 5 seconds control (can the client keep the water in the glass?) Ability to sustain /s/: (Impairment/Perceptual) "Take a deep breath then exhale, making the /s/ sound for as long as you can." ________ seconds 20 - 30 seconds = normal 15 - 19 seconds = good 10 - 14 seconds = fair 1 - 9 seconds = poor 0 seconds = none
PHONATION
Observation: vocal quality harsh strain-strangled breathy other_________________ Ability to sustain /a/: (Impairment/Perceptual) "Take a deep breath, then make the /a/ sound for as long as you can." ___________seconds 15 - 25 seconds = normal 11 - 14 seconds = good 6 - 10 seconds = fair 1 - 5 seconds = poor 0 seconds = none Ability to increase volume: (Impairment/Perceptual) "Take a deep breath, then make the /a/ sound again, but start at a whisper then get louder." yes no Ability to glide up and down a scale: (Impairment/Perceptual) "Begin at your conversational level of speech, say /a/ and sing up a scale, then sing down the scale." (provide a model) yes no PROSODY Observation: Ability to vary: stress rate intonation Ability to imitate different stress patterns: (Impairment/Perceptual) "Say these sentences exactly the way I say them using the same stress." I am hungry. I AM hungry. I am HUNGRY.
RESONATION
Observation: Nasality: hypernasality (d/n, b/m) hyponasality (n/d, m/d) Velar Movement (Disability/Perceptual) "Say /a/, /a/, /a/." yes no Nasal Emission: mirror (Impairment/Perceptual) "I am going to hold this mirror under your nose, say 'may may may', now say, 'pay, pay, pay'." yes no (pay)
ARTICULATORY Observation: groping behaviors___________________ Rate of Movement: (Disability/Perceptual) "Say 'buttercup' as fast as you can until I tell you to stop." model (5 seconds) 12 - 15 repetitions = normal 8 - 11 repetitions = good 4 - 7 repetitions = fair 1 - 3 repetitions = poor 0 repetitions = none Word Length: (Impairment/Perceptual) "Repeat each word after me." thick thicken thickening
cat catnip catapult catastrophe
Repetition: (Impairment/Perceptual) "Repeat each word 3 times." (Judge whether productions get better after repetitions) ashtray banana cigarette potatoes coffeepot newspaper animal volcano elephant refrigerator
Norms adapted from the Dysarthria Profile (Robertson, 1987)
SUBSYSTEM INVOLVEMENT OF MOTOR SPEECH DISORDERS DISORDER
SITE OF LESION
ARTICULATIO N
APRAXIA
Unilateral Cerebelar
X
UUMN
Unilateral Cortico-Bulbar Tracts
X
SPASTIC
Bilateral Cortico-Bulbar Tracts
X
X
HYPOKINETIC
Substantia Nigra
X
X
HYPERKINETI C
Basal Ganglia
X
X
ATAXIC
Cerebellum
X
FLACCID
Cranial-Spinal Nerves/Muscle s
X
X
X
X
X
MIXED
CentralPeripheral Nervous System
X
X
X
X
X
* Adapted from Hartman & Dworkin, 1994
PHONATIO N
RESONATIO N
RESPIRATIO N
PROSOD Y X
X
X X
X
X
X X
Motor Speech Disorders and Related Characteristics
Apraxia of Speech: Inability to perform volitional motor movements in the presence of normal comprehension, muscle strength, sensation, attention, and coordination (White, 1997) 1. Inconsistent Errors: Repetitions, Substitutions, Simplifications, Distortions Additions, Deletions 2. Articulatory Breakdowns Increase With: Word Complexity, Word Length 3. Well rehearsed utterances better than spontaneous utterances 4. Struggling behaviors to self correct articulatory errors 5. Initial phonemes more in error than final phonemes 6. Meaningful utterances better than non meaningful utterances
Dysarthria: A specific disorder of speech in which the muscles controlling articulation, respiration, phonation, prosody, and resonation are affected, while basic language remains in tact (White, 1997). Ataxic Dysarthria: Damage of bilateral or unilateral cerebellar hemispheric lesions or damage to the cerebellar outflow tracts produce discoordination and dysmetria in the oral
speech musculature as well as the muscles of the axial and appendicular skeleton.
Speech Characteristics: Consonantal imprecision, omissions, and distortions particularly at word, phrase, and sentence endings. Speech has an intoxicated quality. Diadichokinesis is slow and irregular, speaking rate and intonation patterns are irregular, and voice quality is harsh. Non-Speech Characteristics Signs of cerebellar disease include intention tremor, broad based gait, nystagmus, and dysphagia. Unilateral Upper Motor Neuron (UUMN) Dysarthria: Damage resulting from a focal corticobulbar tract lesion of an isolated lacunar, internal capsule. Speech Characteristics: Imprecise consonants, decreased loudness, limited pitch range, low pitch, short phrases and slow rate.
Non-Speech Characteristics: Contralateral central facial and tongue weakness, hemiparesis, and hyperreflexia.
Spastic Dysarthria: Damage resulting from bilateral corticibulbar tract lesion, bihemispheric disease along with involvement of periventricular white matter and internal capsules. Speech Characteristics: Imprecise articulation, slow diadochokinesis, variable hypernasality, nasal emissions, strain-strangled phonation, frequent lapses of laughing or
crying, decreased rate, and reduced breath support. Non-Speech Characteristics: Hypertonicity, weakness, slowness of movement, hyperreflexia, "primitive" signs of sucking, jaw jerk, biting, grasping, increased palatal reflexes, and Babinski responses. Weak oropharyngeal musculature places patient at risk for dysphagia and aspiration.
Hypokinetic Dysarthria: Damage caused by unilateral or bilateral lesions of the substantia nigra or its projections. Characteristic of Parkinson's Disease Speech Characteristics: Decreased loudness, reduced pitch inflections, and breathy-harsh voice. Variable articulatory precision and rapid diadochokinesis, decreased loudness, silent intervals or inappropriate pausing followed by short rushes of rapid speech. Non-Speech Characteristics: Masked facial expression, positive glabellar tap, resting tremor, festinating bradykinteic gait, and flexed truncal posture. Dysphagia is an early sign and dementia is a later one.
Hyperkinetic Dysarthria: Results from a lesion in the basal ganglia or biochemical imbalance.
and
Speech Characteristics: Imprecise articulation, irregular diadochokinesis, inappropriate prolongations of sounds, inappropriate silences between and among words, variable or fast rate, vocal harshness, reduced pitch and loudness variations, phonatory arrest, tremor. When there is velopharyngeal and respiratory involvement, variable hypernasality with nasal emission, and reduced and discoordinated respiratory support is also evident. Non-Speech Characteristics: Uncontrolled quick, slow, or tremulous movements of the orofacial, trunk, and limb musculature. Palatopharyngeal myoclonus presented in strap muscles of the neck, base of the tongue, posterior pharyngeal wall, soft palate, and laryngeal musculature.
Flaccid Dysarthria: Damage caused by neuropathy (e.g., progressive bulbar palsy, infarct, trauma), myoneuropathy (e.g., myastenia gravis, Eaton-Lambert syndrome), or myopathy (e.g., myotonis dystrophy, polymyositis).
Speech Characteristics: Severity and extent of speech involvement depends on the number of and degree to which the cranial nerves/ muscles and spinal nerves/muscles are involved. due
Bilateral IX and X nerve lesions - continuous hypernasality and nasal emission to velopharyngeal involvement; hoarse, gurgly voice, weak or absent cough, dysphonia, decreased loudness and unstable pitch, short phrases, reduced stress, decreased respiratory support for speech, inspiratory and/or expiratory stridor. V, VII, and XII nerve lesions - imprecise, slow-labored articulation, reduced diadochokinesis. Non-Speech Characteristics: muscle atrophy, fasciculations, diminished or absent reflexes, paralysis, paresis and limitation of movements.
Mixed Dysarthria: There are various combinations of dysarthria. Listed below are some disorders/diseases and the resultant mixed dysarthrias: Amyotrophic Lateral Schlerosis Multiple Schlerosis Wilson's Disease Progressive Supranuclear Palsy
flaccid-spastic spastic-ataxic ataxic-spastic and hypokinetic spastic-hypokinetic-ataxic and flaccid
REFERENCES Dabul, Barbara L. (1979). Apraxia Battery for Adults. Austin, Texas: PRO-ED, Inc. Duffy, J. R. (1995). Motor Speech Disorders: Substrates, Differential Diagnosis, and Management. St. Louis: Mosby - Year Book Inc. Enderby, Pamela M. (1983). Frenchay Dysarthria Assessment. Austin, Texas: PRO-ED, Inc. Hartman, D.E. & Dworkin, J. P. (1994). Aphasia, Apraxia of Speech, and Dysarthria. San Diego: Singular Publishing Group, Inc. Robertson, S.J. (1987). Dysarthria Profile. Tuscon, Arizona: Communication Skill Builders, Inc.