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Selection and sequencing of sensorimotor programs that activate speech muscles
Motor Speech Planning and Programming
Innervations of the respiratory, phonatory, resonatory & articulatory muscles
Combined processes of speech motor planning, programming, and neuromuscular execution
Motor Speech Processes
Changes in speech may announce the presence of...
The effects of neurologic disease on speech are often what 4 things?
- Clinically unique
What are the 4 reasons to understand neurophysiologic bases of speech disturbances?
- Nervous system organization for speech control
- Differential dx and localization of neuro disease
There's usually a direct correlation bet/ __________ and the symptoms/speech deficits that go along with it.
Sites of lesion
Neurologic disorders are common/uncommon?
Few neurologic disorders are _______.
Neurologic disorders are a major cause of _________.
Neurologic speech disorders represent a significant proportion of _________ communication disorders.
Neurologic speech disorders will increase in prevalence because of __________.
Increased Survival Rates
Understanding the underlying ___________ can help in planning treatment.
Group of neurologic SPEECH disorders resulting from abnormalities in strength, speed, range, steadiness, tone, or accuracy of movements req. for control of the respiratory, phonatory, resonatory, articulatory, and prosodic aspects of speech production.
The responsible pathophysiologic disturbances of dysarthria are due to _______ or _______ abnormalities.
What are possible symptoms of dyarthria?
- Involuntary movements
- Muscle tone (excessive, reduced, or variable)
What are the characteristics of dysarthria?
- Movement disorder
- Categorized differently by auditory-perceptual characteristics and neuropathology
Neurologic speech disorder reflecting an impaired capacity to plan or program (SEQUENCE) sensorimotor commands necessary for directing articulatory movements in voluntary speech production that result in phonetically and prosodically normal speech.
Apraxia of speech
What can occur in the absence of physiologic disturbances assoc. w/ dysarthria and in the absence of disturbance in any component of language such as aphasia?
Apraxia of speech
The __________ of apraxia of speech is different than that for most dysarthria types, and its ____________ is different from that for dysarthria and aphasia.
Speech disorders resulting from neurologic impairments affecting the motor planning, programming, neuromuscular control, or execution of speech (including dysarthrias and apraxia).
Motor Speech Disorders (MSDs)
Acquired neurologic stuttering, Palilalia, Echolalia, some Mutism, Pseudoforeign dialect, and Aprosodia are known as ________________.
Other Neurologic Speech Disturbances that are NOT defined as Motor Speech Disorders
Aprosodia is associated with _______ hemisphere dysfunction.
Changes in speech resulting from _______ and _______ deficits sometimes are difficult to distinguish from MSDs bec/ they often co-occur w/ them making dx difficult and are categorized as ______________disturbances.
- Cognitive, Linguistic, & Cognitive-Linguistic disturbances
What are the sensorimotor disturbances implicated in certain MSDs?
What are the NON-neurologic disturbances on speech that are localized outsid of nervous system and are neither neuromotor nor cognitive-linguistic in character?
- Musculoskeletal defects (laryngectomy, cleft, etc.)
- Voice Disorders (that are nonneurologic/nonpyschogenic)
- Psychogenic (& related nonorganic disorders)
___________ associated with hormones, neoplasms, or vocal abuse can be the effect of a nonneurologic/nonpsychogenic voice disorder.
What are some examples of abnormal psychologic states that can result in changes in speech?
- Conversion disorder
What are the 3 classifications of Normal Variations in speech production?
- Style variations (personality, emotion, roles)
Identification of deviant speech indicative of dysarthria often requires an awareness of the ____________ for the patient's age and general physical condition.
Range of Normal
Approximately _____% of noncomatose people who have had strokes suffer from some kind of speech or language impairment.
Dysarthria occurs in
____% w/ Lacunar (small) strokes
____% w/ TBI
- 25%-Lacunar strokes
Dysarthria is present in _____% of people w/ Parkinson's w/ increased prevalence as the disease progresses.
Dysarthria sometimes is a presenting sign for what disease and often emerges during the disease's course?
Amyotrophic Lateral Sclerosis (ALS)
What method for studying motor speech disorders is primarity based on the "ears" and is considered the gold standard for clinical differential dx, severity, mgmt, & assessment of funtional change?
What are the 3 Instrumental methods for studying motor speech disorders?
- Acoustic (speech lab)
- Physiologic (electromyography, aerodynamic, etc)
- Visual Imaging (videofluoroscopy, naso/laryngo/video)
What are the 8 components of characterizing motor speech disorders?
- Age of Onset
- Course of disorder
- Lesion site
- Neuro dx
- Pathophysiology (what we hear w/our ears)
- Speech Components involved
- Perceptual Characteristics
CP is an example of a/an ________ MSD
Parkinson's is an example of a/an __________ MSD.
The following are are categories of what component of characterizing MSDs?
What's the primary goal of neurologic evaluation, one to which differential dx of MSDs can contribute, and can predict certain speech deficits?
Lesion site establishment
What can raise doubts about presumed localization or suggest the presence of additional lesions or even different diseases?
Incompatibility of speech findings w/ lesion site
By itself, a MSD usually isn't ________ of a particular neurologic etiology or specific disease.
Because diseases can affect ________________, it's NOT useful to classify MSDs by disease.
Multiple/Variable portions of nervous system
When Parkinson's causes dysarthria, its type is always _________.
When Myasthenia Gravis causes dysarthria, its type is always ________.
The underlying pathophysiology (weakness, spasticity) determines the unique _________________ of speech in MSDs.
Deviant Perceptual Features
MSDs can be categorized according to the speech ________ that are affected.
What 5 speech components that may be impaired can contribute to speech dx & often has impact on mgmt decisions?
What component of a speech disorder is ALWAYS relevant to management decisions?
Severity (short/long term or improve speech/develop AAC)
What scheme of Darley, Aronson, & Brown (DAB) forms the framework around which MSDs are discussed?
Percecptually-based classification scheme
What are the 8 types of dyarthria?
- Type undetermined
-Controls voluntary movements
-Thought into movement
-Conscious and unconscious
-If damaged, result is debilitating movement disorder
-Dependent on location/extent of damage
PNS consists of :
____ pairs of cranial nerves
____ pairs of spinal nerves
What's the largest division of the brain?
Nerve cells located in this gyrus immediately in fron of central sulcus play an important role in controlling voluntary movements of the body.
Precentral Gyrus (Primary Motor Cortex or Motor Strip)
__________ damage can cause significant deficits in the performance of both gross & fine motor actions such as walking, writing, & speech.
What's the most common type of neuron?
Interneuron (links neurons w/ other neurons & important role in controlling movement)
What are 2 important neurotransmitters in the motor system?
In the motor system, an imbalance bet/ _______________ may be a cause of spasticity.
Exitatory & Inhibitory Neurotransmitters
Most planning for movement does NOT originate in the primary motor cortex. The initial planning of a movement is formulated primarily in the ______________.
Area of the cortex that is distributed over 4 areas of the cortex that makes sense of the sensory impulses that have been initally analyzed by the primary cortex.
- Association cortex
- (temporal, frontal, parietal, & visual)
Where is the neurotransmitter dopamine produced?
Substantia Nigra neural tract to striatum
What are the 2 reasons dopamine is decreased?
- Disease (Parkinson's)
- Antisychotic drugs (block the production)
Motor speech disorder caused by damage to the basal ganglia associated with Parkinson's
Motor speech disorder caused by damage to the basal ganglia associated with Huntington's
Fatal, inherited disease that results in progressive loss of neurons in striatum and other areas of the brain. Symptoms include rapid, involuntary movements of extremities face, & tongue.
Disease with decreased dopamine in striatum. Symptoms include muscular rigidity, tremor, gait disturbances, & difficulty initiating movement.
Because of its many ______________ with diverse parts of the nervous system, damage to the cerebellum can result in a variety of disorders.
Afferent & Efferent connections
Disturbance in speed, range, and direction of movements.
Muscle groups near the ______ & _______ in particular may be affected by ataxia. Gait is wide-based, lurching, & stumbling.
Tremor caused my lesions in the cerebellum and is observed only during the performance of voluntary movements & is not present at rest.
Other than drunken gait and intention tremor, what are some other symptoms of cerebellar damage?
- Muscle tone increase or decrease
- Equilibrium disturbance
What's the MSD usually associated with cerebellar lesions?
Doorway located behind basal ganglia through which subcortical systems of nervous system communicate with cerebral cortex.
Practically every sensory impulse from the body passes through the _______ on its way to the cortex; this sensory info is used to further refine motor impulses from basal ganglia & cerebellum.
Neurons in primary motor cortex have axons among longest that extend from cortex to lower spinal cord. These axons make up much of the descending motor tract called the _______________.
Primary motor cortex is NOT the designer of ___________ movements.
Principal role of the primary cortex is to take _________ movement patterns that are formulated elsewhere and to transmit them to the ____________ via a tract of motor neurons called the pyramidal system.
- Cranial or Spinal Nerves
The pyramidal system is responsible for carrying impulses that control _____________ movements.
Voluntary, Fine Motor
The extrapyramidal system transmits impulses that control the _____________ needed by fine motor movements.
What symptoms result from damage to the pyramidal system?
- Muscle Weakness
- Rapid Fatigue
- Decreased Mental Concentration
In the motor speech mechanism, unilateral damage to the pyramidal system results in loss of fine motor movement in the articulators known as...
Unilateral Upper Motor Neuron dysarthria (UUMN)
Damage that affects the __________ tract almost always will affect other neural tracts as well with results that complicate the clinical picture.
Spastic dysarthria is the result of _____________ damage and causing _________.
- Bilateral UMN damage
Flaccid dysarthria is the result of damage to the __________ in cranial nerves that innervate muscles of speech production causing ____________.
- Muscle paralysis or Paresis (weakness)
Name the 5 purposes of the Motor Speech Examination.
- Dx Possibilities (neurologic,organic,acquired, MSD type)
- Dx (differential)
- Localization implications
What are the 2 characteristics of EVERY dysarthria that can make it difficult to distinguish among types?
- Imprecise Consonants
- Harsh Vocal Quality
Successful eval of MSDs require clinicians to match what they hear in pt's speech w/ what they know about the functioning of ____________.
Human Motor System
What are the 7 questions asked in motor speech eval designed to lead to correct dx?
- Speech problem
- Describe it
- Onset (sudden or slow?)
- Strictly speech prod.?
- Phoneme sequencing? (apraxia)
- Speech error charac & assoc. motor probs (dysarthria)
Dysarthria results from _________ damage to the ________ or _________.
Dysarthria is strictly a SPEECH disorder caused by neuromotor damage; it is NOT...
The sequencing problem in apraxia of speech is NOT the result of ...
- Muscle weakness
- ROM reduction
- Cognition disorder
Apraxia of speech is nearly always associated with damage to the ______ hemisphere of the brain.
Dysarthria can be caused by damage to ___________.
- Left hemisphere
- Many parts of the nervous system
Respiration provides the ______________ that's needed to set the vocal folds into vibration.
Subglottic air pressure
Respiratory muscle innervation damage means less air for speech production which results in...
- Ability to speak in only short phrases
- Reduced loudness
- Breathy voice quality
Production of voiced phonemes through vocal fold vibrations in the larynx.
Normal phonation is dependent on the complete ________ of the folds and enough __________ to set the VFs into vibration.
- Subglottic Air Pressure
Neuromotor damage to the nerves that innervate the ____________ muscles can have several effects on speech production
Vocal Fold Adductor muscles
In flaccid dysarthria, the damage causes adduction to be __________ resulting in phonations that have ___________ quality.
- Weak or incomplete
- Breathy or Harsh
In spastic dysarthria, adduction is _________ which causes phonation to have a ____________ quality.
- Too tight
Neuromotor damage to laryngeal muscles reduces the ability to change ______ or _______ during phonation.
Proper placement of oral/nasal tonality into phonemes during speech accomplished by raising/lowering velum.
Shaping of vocal airstream into phonemes.
What articulation errors can be heard after neuromotor damage?
- Imprecise consonants
- Distorted vowels
- Inappropriate silences
- Irregulatory articulatory breakdowns
Prosody is the melody of speech and conveys meaning within an utterance through the use of ________ & ________.
Stress is accomplished by changing the _______, _______, & _________ of syllables within words to give them added importance or clarify meaning.
Use of pitch changes and stress to communicate for example whether an utterance is a question, assertion, or exclamation.
If neuromotor damage causes weakness or slowness the resulting speech may have a ______ & ________ quality.
If neuromotor damage casus involuntary movements of vocal muscles, the resulting speech may have ________, __________, & ____________.
- Irregular pitch variations
- Sudden increases/decreases in loudness
- Prolonged intervals bet/syllables or words
What are the 6 "salient features" that are the neuromuscular processes and should be constantly assessed as the MSD eval is administered?
- Muscle strength
- Speed of movement
- Range of motion
- Accuracy of movement
- Motor steadiness
- Muscle tone
Tasks that move articulators through a single series of rapid back and forth movements, such as repeating "puh, puh, puh" or "tuh, tuh, tuh" as rapidly as possible. Helpful in differential dysarthria dx.
Alternate Motion Rates (AMR)
Tasks that move the articulators repeatedly through a quick sequence of movements, such as repeating "puh, tuh, kuh" on one breath of air. Helpful in apraxia dx.
Sequential Motion Rates (SMR)
___________ speed of movement is a common characteristic of most dysarthrias?
In what dysarthria may there be an increased speed of movement?
What speech component can especially be affected by reduced range of movement in the articulators?
An accurate movement is one in which what features are precisely coordinated?
What tasks are good for assessing the accuracy of movement?
- AMR tasks
- SMR tasks
- Conversational speech
- Spoken paragraph reading
Involuntary contractions that can affect the laryngeal musculature
- can lead to a tremulous vocal quality during speech
How is motor steadiness assessed?
- Holding an articulatory position
- Prolonging a vowel (say "ahhh" and sustain)
Small, constant amt of muscle contraction that's always present even at rest and maintains a muscle in a "ready to move" condition and allows for quick movement when necessary.
Normal Muscle Tone
Decreased muscle tone is associated with...
Increased muscle tone is associated with...
What cranial nerve is being assessed on tasks that provide motor innervations to the facial muscles.
Facial Cranial Nerve (VII)
What cranial nerve is being assessed during the tasks that require jaw movements?
Trigeminal Cranial Nerve (V)
What are some specific tasks to assess cranial nerves for face and jaw?
- Mouth/smile symmetry
- Force lips open
- Flat affect
- Forehead wrinkling both halves
- Lip pucker
- Puff/hold air
- Jaw hang/deviate/right-left/keep closed/keep open
What cranial nerve is being assessed during tasks for tongue and rest and during movements?
Hypoglossal Cranial Nerve (XII)
What section of the MSD eval should be done if groping tongue movements are noted?
What are some specific tasks that test the tongue at rest and during movement?
- Keep midline
- Touch upper lip
- Keep pressed to inside cheek
- Move side to side
What cranial nerve is being assessed during the section of the evaluation that looks at the structure/function of the velum and pharynx?
Vagus Cranial Nerve (X)
What are specific tasks to assess velum and pharynx at rest and during movement?
- Velum rise symmetrically during /a/?
- Gag reflex when back wall of pharynx touched?
What are direct ways to observe the actions of the larynx?
- Laryngeal mirror
- Flexible Nasoendoscope
What are 3 tasks to indirectly assess laryngeal function?
- Able to produce sharp cough?
- Produce sharp glottal stop?
- Inhalatory stridor present?
One should listen crtically to what 3 characteristics of the patient's phonation because each can provide useful dx info?
What are some examples of the quality of phonations?
What are examples of the pitch of phonations?
What are examples of the loudness of phonations?
- Excessive loudness variations
- Decreased loudness
Hypernasality is most frequently a symptom of which 3 dysarthrias?
What is rarely present in the speech of individuals with dyarthria or apraxia of speech?
What's a specific task testing resonance?
Sustain /u/ then with squeezed nares
What's another name for Alternate Motion Rate (AMR)?
- Diadochokinetic Rate
- ability to move articulators rapidly, smoothly in repetitive motion
_______s are very important in motor speech eval bec/people w/ diff types of dysarthria perform differently on this task.
What kind of AMRs do people with flaccid & spastic dysarthria have?
Slow & Regular
What kind of AMRs do people w/ ataxic & hyperkinetic dysarthria have?
Slow and Irregular
Some w/ ___________ dysarthria have AMRs that are more rapid than normal; said so quickly that articulation of phonemes is blurred.
It's not unusual for people w/ _________ to complete AMR successfully but be unable to even attempt SMR sequence.
Task that screens for myasthenia gravis; count quickly from 1 to 100. Typical to have rapid deterioration and recovery after rest only to have performance decline again.
Disorder that causes rapid fatigue of muscles during sustained motor activity.
Vegatative movements such as smiling, puckering, tongue protrusion, lip biting, hesitations, groping, & revisions are examples of what type of apraxia?
Nonverbal Oral apraxia
MSD produced by any process that damages motor unit. Injury/malformation of cranial/spinal nerves reflecting probs in nuclei, axons, or neruomuscular junctions making up motor units of the final common pathway.
All of __________ dysarthrias share a lesion somewhere between the brainstem/spinal cord and muscles of speech.
What are the 3 primary characteristics of flaccid dysarthrias?
- Reflex reduction
What characteristics often accompany the primary characteristics of flaccid dysarthria?
- Progressive Weakness
What are the 9 main headings for diseases/conditions that cause flaccid dysarthria?
- Degenerative disease
- Muscle disease
- Neuromuscular Junction disease
- Vascular disorders
- Anatomic anomalies
- Demyelinating disease
-Progressive Bulbar Palsy
-Spinal Muscle Atrophies (progressive)
-Kennedy's disease (men only)
Degenerative diseases causing flaccid dysarthria
Muscle diseases causing flaccid dysarthria
-Lambert-Eaton Myastenic Syndrome
Neuromuscular Junction diseases causing flaccid dysarthria
-Wallenberg's Lateral Medullary Syndrome
-Medial Medullary Syndrome
Vascular disorders causing flaccid dysarthria
Anatomic Anomalies: just know that...
Babies can be born with diseases that cause flaccid dysarthria
-Chronic Demyelinating Polyneuritis
Demyelinating diseases causing flaccid dysarthria
Infectious Processes causing flaccid dysarthria
-Skull Base Tumors
OTHER causes for flaccid dysarthria
Surgical trauma to the laryngeal branches of the ________ nerve is a frequent cause of flaccid dysarthria.
What are the clusters of deviant speech dimensions for flaccid dysarthria?
- Phonatory Incompetence (breathy, audible, short phrases=inadequate VF adduction)
- Resonatory Incompetence (hypernasal, emission, consonants, short phrases=VP valve weakness)
- Phonatory-Prosodic Insufficiency (harsh, monopitch, monoloud=hypotonia of laryngeal muscles)
Which dyarthria is produced by bilateral damage to the direct (pyramidal) and indirect (extrapyramidal) activation pathways?
Most salient features of disordered movementin pts w/spastic dysarthria
- Reduced ROM
- Slow movement
Spasticity is a hallmark of ___________ disease.
Upper Motor Neuron (UMN) disease
Direct activation pathway (pyramidal tract) is predominantly _________ tending to lead to movement.
In the indirect activation pathway (extrapyramidal tract) many of its activities are _________.
-Fine/skilled movement loss
Pyramidal tract damage
-Muscle tone increase
-Clonus (repetitive reflex under tension)
-Stretch reflex hyperactive (too strong/sensitive)
-Gag reflex hyperactive
Extrapyramidal tract damage
___________ disorders are more frequently associated with spastic dysarthria than most other types.
Lesions in _____________ are required to produce the bilateral UMN damage usually associated with spastic dysartria.
Both Left & Right hemispheres
What 2 vascular disorders are usually associated with hypertension?
- Lacunar Strokes
- Vascular Dementia
Primary Lateral Sclerosis (PLS) is a _________ disease similar to ALS that can cause spastic dysarthria.
Leukoencephalitis is an ___________ disease that affects the white matter of the brain or spinal cord that can lead to spastic dysarthria.
Inflammatory Demyelinating disease
What % of spastic dysarthria cases are caused by degenerative & vascular disease?
_____________ strokes accounted for most of the vascular causes.
What are some patient perceptions & complaints w/spastic dysarthria?
- Slow/effortful speech
- Speaking against resistance
- Laughing/Crying uncontrollably*
What's a telltale sign of spastic dysarthria that is rare in other dysarthria types?
Laughing/Crying uncontrollably (lability/affect)
Dysarthria is common and sometimes severe in ________ dysarthria.
Spastic dysarthria is associated with impaired ___________ rather than weakness of individual muscles.
____________ dysarthria is associated w/ deficits of all the speech valves and for all components of the speech system.
What are the distinguishable features of spastic dysarthria?
- Strained-Harsh voice* (found in no other dysarthria)
- Slow rate
- Slow & REGULAR AMRs
What's respiration like in spastic dysarthria?
- Shallow/paradoxical breathing
- Vital Capacity reduced
Ataxic dysarthria affects which 2 speech components most?
Dyarthria associated with damage to the cerebellum
Common sign of cerebellar disease resulting in the over/undershooting of targets.
Tremor occurring during movement or sustained postures and is most obvious as a target is approximated.
-Friedreich's Ataxia (incapacitation/death)
-Multiple Sclerosis (demylinating)
Dengenerative diseases associated with ataxic dysarthria
Vascular disorders associated with ataxic dysarthria
Tumors within/outside cerebellum (16% of metastatic brain tumors)
Neoplastic disorders associated with ataxic dysarthria
Punch Drunk Encephalopathy (Mahammad Ali)
Trauma associated with ataxic dysarthria
Toxic or Metabolic Conditions associated w/ ataxic dysarthria
-Infections (rubella, Creutzfeldt-Jacof, Lyme, CNS tuberculosis)
OTHER causes of ataxic dysarthria
Degenerative, Demyelinating, & Vascular diseases account for more than ____% of cases of ataxic dysarthria
________ speech AMRs are a distinguishing characteristic of ataxic dysarthria.
Prosodic Excess/Scanning speech using slow word-by-word cadence with equal emphasis on each syllable or word is associated with what dysarthria?
Although uncommon, intermittent hyponasality is more frequently encountered in ________ dysarthria than any other type.
What are distinguishing features of ataxic dysarthria?
- Articulatory breakdowns
- IRREGULAR AMRs*
- Excess/equal Stress
- Excess Loudness
- Vowels distorted*