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Presentation 10/30/12- Spastic, Flaccid, and Mixed Dysarthrias

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Transcript of Presentation 10/30/12- Spastic, Flaccid, and Mixed Dysarthrias

Dysarthria: Spastic, Flaccid, Mixed
By Sarah Shanahan
October 30, 2012 What is Dysarthria?

“Abnormalities of spoken language resulting from disturbances in muscular control over the speech mechanisms due to damage of the central (upper motor neuron) or peripheral (lower motor neuron) nervous system.”
-Hermann Ackermann

Many Kinds of Dysarthrias:
Spastic, Flaccid, Ataxic, Hyperkinetic, Hypokinetic, Mixed Spastic Dysarthria:
Signs and Symptoms

-Reduced range of movement
-Inappropriate emotional outbursts
-Slow, repetitive movement
-Hypertonia and hyperreflexia
-Bilateral facial paralysis (bilateral upper
motor neuron lesion)
-Facial nerve causes spastic paresis due to a
unilateral upper motor neuron lesion
-Drooling Spastic Dysarthria Spastic Dysarthria Speech and Voice Deficits:

-Imprecise consonants
-Monopitch
-Monoloudness
-Reduced stress
-Harsh voice quality (over-adducting vocal
folds)
-Breathy voice
-Hypernasality
-Slow rate of speech
-Strained or strangled voice Spastic Dysarthria-
Neurological Relation to SLP:

Cranial nerves and the phrenic nerve (diaphragm) control the muscles of speech

Respiration:

-Damage to the phrenic nerve effects respiration which
leads to speech deficits.
-Breathing is effected in that muscles are weakened and
unable to contract or forcefully retract to create forced
breathing for speech.

Results in:
Poor control of lung volumes, intensity of voice, and length of utterances. Spastic Dysarthria-
Neurological Relation to SLP:

Resonance:

This is due to damage of the vagus nerve (X) which controls the soft palate.

Slow and incomplete elevation of the velum directs the airstream through the nasal cavities, causing hypernasality

Client has to exert more effort in lifting the velum, causing fatigue and more weakness. Spastic Dysarthria-Neurological Relation to SLP:

Articulation:

Damage to the facial nerve (VII), hypoglossal nerve (XII), and the motor component of the trigeminal nerve (V) results in articulation problems

Facial nerve (VII) affects lip movement

Hypoglossal nerve (XII) affects tongue movements

Trigeminal nerve (V) affects jaw movement

Spastic dysarthria results in slower movements with less range of motion, affecting the rate and prosody of speech

Exact placement of the tongue becomes difficult, resulting in articulation errors

Consonants are particularly difficult for the client Spastic Dysarthria-
Neurological Relation to SLP:

Voicing:

Damage to the vagus nerve (X) causes malfunction of the larynx, resulting in voicing problems during speech

Voicing is effected in that spasms cause hyperadduction of the vocal folds which creates the strangled voice

Decreased ability to abduct the vocal folds

This in turn creates higher sub glottal air pressures, poor coordination between vocal fold valving and forced expiration
Current SLP Treatments:
Flaccid and Spastic Dysarthria

Every client is different. There is no ‘one-size-fits-all’ strategy for any client with dysarthria.

Treatments for all dysarthrias have at most three components

1. Behavioral approaches
2. Employment of biofeedback tools-helps the client to have a deeper awareness and control over body functions
3. Surgical options

Treatments should be approached targeting the more urgent factors first, moving on integratively.

The effectiveness of each of these treatments are debated by many experts.

Proceed with an understanding that some may work, while others will not. Current SLP Treatments:
Spastic and Flaccid Dysarthria
(Breathing)
Goal: Aid the client in increasing control over breathstream and tidal volume

-Behavioral treatments
Adjustments to posture
Help the client to be aware of how to relax head, neck, shoulders and upper chest
‘Accent method’ (diaphragmatic breathing)
Combine relaxation with helping the client transfer energy to the lower chest and abdomen. This energy will be used for breathing techniques.
Assists the client in using accessory muscles for breathing, which in turn, may gain a longer and higher volume during breath groups. Current SLP Treatments:
Spastic And Flaccid Dysarthria
(Breathing)
‘Inspiratory checking’
Taking deep breaths and encouraging them to let them out slowly.
Allows the client to practice controlling subglottic pressure, which will help with phonatory control, and length of utterances.

‘Breathy sighs’
Basically inspiratory checking + phonation during exhale.
Start with the easiest sounds first /h/ and vowels.
Progress to syllables
Try to incorporate consonants while working on articulatory issues. Current SLP Treatments: Spastic And Flaccid Dysarthria
(breathing)

Tools that we use for the treatment of dysarthria:

U-tube water manometer
Measures ability to sustain expiatory air pressure at certain speeds
Straw in water, blow out bubbles for a given amount of time.
Add more water to add more pressure.

-Biofeedback techniques
Kinematic approach
Electrodes are placed on the client, information about breathing patterns, and muscle coordination are displayed to the patient.
Helps the client’s ability to regulate their own body movements and hit target goals Current SLP Treatments:
Spastic And Flaccid Dysarthria
(phonation)

Goal: Increase the function of the vocal folds

- Behavioral
• ‘Breathy onset’ phonation (refer to ‘Breathy sighs’)

-Biofeedback
• EMG
Displays information regarding laryngeal function
• Respitrace signal
Displays exhalation length and breathing coordination to the client in the form of waves.
• Visipitch
Information regarding pitch and intensity
•Nasopharyngoscope
Watching your vocal folds may help you control them. Current SLP Treatments:
Spastic And Flaccid Dysarthria
(resonance)

Goal: Treat velopharyngeal port closure, help the client to increase control

- Behavioral approach
‘Oral resonance therapy’
Training the client to speak with opened jaw and protracted tongue can help

- Biofeedback approach
Nasopharyngoscope
Nasometer

- Surgery
Palatal lift
Current SLP Treatments:
Spastic And Flaccid Dysarthria
(articulation)

Goal: Increase intelligibility

Gentle approximations are recommended

Behavioral Techniques:
Begin with open-mouth vowels
Add on consonants to create syllables
Refer to 'breathy sighs'
Minimal Contrast Drills

Biofeedback
Visispeech
Electropalatetography Flaccid Dysarthria Flaccid Dysarthria-
Signs and Symptoms:

May effect all aspects of speech (respiration, phonation, resonance, articulation and prosody)
–Poor lip seal
–Drooling
–Reduced elevation of tongue
–Poor intelligibility
–Diplophonia
–Imprecise consonants
–Monopitch
–Short phrases

•Ipsilateral hypotonic muscles
•Ipsilateral muscle weakness
•Ipsilateral loss or reduction of reflex activity
•Degrees of atrophy
•Breathy speech

Flaccid Dysarthria-
Neurological Relation to Speech and Language:

•When the cranial nerves are assaulted in the lower motor neuron region, flaccid dysarthria takes place. All the same nerves mentioned above are effected, the location of the lesion changes the outcome:

Spastic dysarthria =bilateral upper motor neuron damage

Flaccid dysarthria =unilateral lower motor neuron damage Flaccid Dysarthria-
Neurological Relation to Speech and Language:

•Respiratory system
–Reduction in vital capacity
–Poor control in exhalation

•Laryngeal function
–Vocal fold on the side of the lesion is flaccid and difficult to control (adduct)
This causes diplophonia, short phrases, air wastage during phonation, breathy voice Flaccid Dysarthria-
Neurological Relation to Speech and Language:

•Resonatory system
–The velopharyngeal port may be flaccid and difficult to lift, creating hypernasal quality of speech

•Articulatory system
–Unilateral trigeminal damage (jaw movement) usually results in minor issues.
–Bilateral lesions to trigeminal nerve can be devastating
-Ability to produce vowels effected as well as consonants
-Unilateral flaccid paralysis occurs in the facial nerve, affects the lips.
-Ability to produce plosives, and bilabial and labiodental consonants become difficult Mixed Dysarthria Mixed Dysarthria-

Dysarthria usually occurs in the mixed form, very rarely will you see a pure form

–Flaccid & Spastic (42%)
–Ataxic & Spastic
–Hypokinetic & Spastic
–Ataxic, Flaccid & Spastic
–Hyperkinetic & Hypokinetic Mixed Dysarthria-
Signs and Symptoms:
•All of the signs and symptoms that were mentioned for flaccid and spastic dysarthria are are apparent in mixed dysarthria. They are co-occurring

Symptoms depend upon the area where lesion occurred. Mixed Dysarthria-
Neurological Relation to Speech Disorders:

It is important to know the etiology of the dysarthria.

The following list includes a few the many neurological disorders that may cause dysarthria:

–Amyotrophic lateral sclerosis (ALS)
–Multiple Sclerosis (MS)
–Wilson’s Disease
–Traumatic Brain Injury

It is important to know the cause, so that you can know what to expect for the course of treatment. Mixed Dysarthria-
Treatments:

Understanding the cause of the dysarthria will better prepare you as a clinician to create a treatment plan which anticipates the clients needs.

For example, an adult with ALS:

Stage 1- Educate the client about what to expect in the future (if there are no dysarthria symptoms as of yet)
Stage 2- If the client is experiencing issues with any of the speech mechanisms, be ready to treat accordingly
Stage 3- As the ALS progresses, the use of prosthetic devices may be needed
Stage 4- If the client is rendered with an inability to produce speech, AAC devices will be needed References: Testing and Evaluation
(for all dysarthria types)

Perceptual Analysis
-Frederick Darley first to classify dysarthria

Frenchay Dysarthria Assessment-2
-Focuses on motor components
-Scale of 1-9
1= most severe disruption
9= normal function

Assessment of Intelligibility of Dysarthric Speech
-word level
-sentence level
-speaking rate
-intelligible words per minute
-overall communication efficiency Current SLP Treatments
***Where Spastic and Flaccid Differ*** Assessments Treatments
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