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Definition of dysarthrias (Part A)
Collective name for group of MSDs associated with disturbed control of speech due to CNS or PNS damage. Include abnormalities in speed, strength, strength, range, timing, or accuracy of speech movements. May affect respiration, phonation, resonance, articulation, and prosody.
Definition of dysarthrias (Part B)
Includes several different types, each corresponding to damage to particular part(s) of the nervous system & presumably each having a different underlying neurophysiology.
Definition of dysarthrias (Part C)
Each type has different auditory perceptual characteristics which can be distinguished clinically. Accurate identification has implications for localization; accurate description provides clues for management
Five possible abnormalities found in dysarthrias:
- 1. speed
- 2. strength
- 3. range
- 4. timing
- 5. accuracy of speech movements
Five systems possible affected by dysarthrias:
- 1. respiration
- 2. phonation
- 3. resonance
- 4. articulation
- 5. prosody
Locus of flaccid dysarthria
Lower motor neuron
Primary deficit in flaccid dysarthria
Locus of spastic dysarthria
upper motor neuron (bilateral)
Primary deficit in spastic dysarthria
Locus of ataxic dysarthria
Primary deficit of ataxic dysarthria
Locus of hypokinetic dysarthria
Primary deficit of hypokinetic dysarthria
rigidity & reduced range of motion (ROM)
Locus of hyperkinetic dysarthria
Primary deficit of hyperkinetic dysarthria
Eight parts of evaluation of motor speech disorder basic clinical protocol:
- 1. History of speech deficit
- 2. Oral mechanism exam
- 3. Contextual speech
- 4. AMRs (DDK; Alternating Motion Rates)
- 5. SMRs (Sequential Motion Rates)
- 6. Stress testing
- 7. Prolonged "ah"
- 8. Contrastive stress tasks
Flaccid dysarthria is associated with __________ motor neuron lesions.
T/F: Flaccid dysarthria is not only associated with LMN, but also muscle diseases.
TRUE (e.g. muscular dystrophy)
Seven primary LMNs for speech:
- 1. Trigeminal (V)
- 2. Facial (VII)
- 3. Vagus (X)
- 4. Hypoglossal (XII)
- 5. Phrenic nerve
- 6. Spinal intercostal nerves
- 7. Other (e.g glossopharyngeal (IX) and accessory (XI))
Which three CNs are associated with articulatory valve?
- 1. Trigeminal (V) - jaw
- 2. Facial (VII) - Face
- 3. Hypoglossal (XII) - Tongue
Which CN is associated with the velopharyngeal and laryngeal valves?
Which three branches of Vagus are associated with the velopharyngeal and laryngeal valves?
- 1. pharyngeal
- 2. superior laryngeal
- 3. recurrent laryngeal
What anatomical structure is the phrenic nerve associated with?
diaphragm (4th cervical segment of spinal cord)
What abnormalities does the jaw manifest in flaccid dysarthria? (2)
- resists closing and opening
- bulge on clenching
How does the jaw demonstrate a unilateral lesion in flaccid dysarthria?
Deviate to weak side when open
How does the jaw demonstrate a bilateral lesion in flaccid dysarthria?
T/F In flaccid dysarthria, if signs demonstrate involvement of VII, you can rule out V.
FALSE -- V and VII are closely inolved, thus it is rarely only VII.
What are three facial signs of flaccid dysarthria?
- 1. chin/perioral fasciculations
- 2. a)Asymmetry when weakness is unilateral;
- b) flat nasolabial fold
- c) droop at corner of mouth
- d) saliva accumulation
- e) reduced retraction and puffing
- f) cheek flutter
- g) poor lip seals
- 3. synkinesis (eye/face movements due to faulty re-innervation)
What are three symptoms of flaccid dysarthria manifested on the tongue?
- 1. Deviates on protrusion to weak side when unilateral; reduced range of motion when bilateral
- 2. Fasciculations and atrophy
- 3. Reduced strength (lateral and anterior)
What are two symptoms of flaccid dysarthria manifested on the palate?
- 1. Asymmetry (down on weak side at rest; pulls up to strong side during gag and "ah")
- 2. Reduced gag
What percent of populace does not have gag reflex?
T/F While lack of gag reflex on oral inspection may not be sign of concern, 1-sided gag is.
T/F: A thorough oral peripheral inspection can result in solid inferences about VP closure.
What is another name for flaccid dysarthria?
What is the primary finding in flaccid dysarthria?
Weakness or reduced strength or force of muscle contraction + hypotonia +<reflexes
Two signs of flaccid dysarthria manifested in larynx:
- 1. weak cough
- 2. weak glottal coup -- sounds like grunting
Overall generalities in flaccid dysarthria (3)
- 1. May involve isolate valve or all speech valves
- 2. Muscle tone and ROM may be reduced. Atrophy anhd fasciculations may be present.
- 3. Nearly everything heard can be traced to weakness or reduced force of muscle contraction.
Speech characteristics of flaccid dysarthria (3)
- 1. Breathiness, hoarseness, diplophonia, stridor, harshness, monopitch, monoloudness, short phrases
- 2. Hypernasality and nasal emission
- 3. Imprecise articulation
Per Duffy, what are the four best distinguishing features of flaccid dysarthria?
- 1. hypernasality
- 2. nasal emission
- 3. continuous breathiness
- 4. audible inspiration (stridor)
Which dysarthria is myasthinia gravis associated with?
For which musculature does myasthinia gravis show a prediliction for?
What are the distinguishing speech characteristics of myasthinia gravis? (2)
- 1. rapid deterioration (weakness) of speech with continuous speaking
- 2. significant recovery with rest
What is another name for spastic dysarthria?
Which two motor systems make up UMN?
- 1. direct motor system
- 2. indirect motor system
What is another name for direct motor system?
Which two tract make up the direct motor system?
- 1. corticobulbar
- 2. corticospinal
Which direct motor system tract contributes to speech?
When are the origin and insert of corticobulbar tracts?
- Origin: cortex
- Insert: cranial nerves
____% of the direct motor system arises from the motor cortex.
Which motor system is responsible for skilloed, discrete, quick or phasic movements?
direct motor system (pyramidal system)
What do lesions in the direct motor system cause? (4)
- 1. weakness
- 2. loss of skilled movements
- 3. decreased tone
- 4. Babinski
What is another name for indirect motor system?
Why is unilateral damage to direction motor system usually minor?
CNs V, IX, X, and XI are all bilaterally supplied.
T/F One rarely sees damage only to direct or indirect system because fiber tracts usually overlap/are intermixed.
How does indirect motor system contribute to speech?
Helps to maintain tone -- sustained postures required to support phasic movements of the direct system
What does disturbance of indirect motor system cause?
- increased resistance to stretch
- increased muscle stretch reflexes
If one sees spasticity and increaased reflexes, which motor system is implicated?
If one sees a Babinski and loss of skilled movement, which motor system is implicated?
What are seven confirmatory signs of spastic dysarthria?
- 1. paralysis of other body parts
- 2. hyperactive reflexes
- 3. pathological reflexes
- 4. chewing and swallowing problems
- 5. pseudobulbar affect
- 6. drooling
- 7. + suck and snout reflexes
What causes the prominent speech characteristics of spastic dysarthria? (4)
- 1. spasticity
- 2. slowness of movement
- 3. reduced ROM
- 4. weakness (to a lesser degree)
What are the four prominent speech characteristics of spastic dysarthria?
- 1. strained-strangled voice quality, harshness, low pitch, reduced pitch & loudness variability
- 2. hypernasality
- 3. imprecise articulation
- 4. slow rate but regular AMRs
What are the best distinguishing features of spastic dysarthria? (4)
- 1. slow rate
- 2. harsh, strained-strangled voice quality
- 3. reduced variability of pitch and loudness
- 4. slow regular AMRs
What is the primary structure involved in ataxic dysarthria?
What does the cerebellum do?
Imposes control on posture and movement initiated elsewhere. COORDINATES
What systems' activities does the cerebellum coordinate? (3)
- 1. LMN
- 2. vestibular/reticular system
- 3. indirect and direct motor systems
T/F Ataxia can be confounding -- the person looks normal with no other symptoms.
From where does the cerebellum recieve input?
motor cortex and periphery
To where does the cerebellum send output?
- cortex (through thalamus)
- then to periphery
In ataxic dysarthria, what could happen to loudness on prolongation?
Could get louder
What can happen to pitch on vowel pronlongation in ataxic dysarthria?
abnormal rising of pitch
Where else can one look for signs of cerebellar dysfunction?
What happens to SMRs and AMRs in ataxic dysarthria?
They have an uneven rhythm
What is the major function of the cerebellum?
What are the confirmatory signs of ataxic dysarthria? (8)
- 1. hypotonia
- 2. slow voluntary movements
- 3. jerkiness of movement
- 4. wide-based gait
- 5. intention or terminal tremor
- 6. dysmetric jaw, face, tongue AMRs
T/F: Lesions in cerebellum are usually unilateral.
FALSE: usually bilateral in vermis (midline) or generalized
What do lesions in the cerebellum cause? (6)
- 1. hypotonus
- 2. errors in force
- 3. errors in speed
- 4. errors in timing
- 5. errors in range
- 6. errors in direction of movement
What are the salient speech features in ataxic dysarthria? (3)
- 1. inaccuracy of movement
- 2. slowness of movement
- 3. dyrhythmia
What are the six best distinguishing features of ataxic dysarthria?
- 1. irregular & transient articulatory breakdowns
- 2. irregular AMRs
- 3. vowel distortions
- 4. excess & equal stress ("scanning")
- 5. excess loudness variations
- 6. dysprosody
What is the prototype for hypokinetic dysarthria?
Where does hypokinetic dysarthria originate?
basal ganglia control circuit
Which nerve tract is affected in hypokinetic dysarthria?
What does the basal ganglia control? (5)
- 1. tone required for posture & changing position
- 2. facilitates freedom and automaticity of movements for skilled automatic acts
- 3. helps organize primary and associated movements for walking and other acts
- 4. Integrates and controls comnponent parts comprising complex movement patterns
- 5. Inhibits fortuitous movements
What are the components of basal ganglia in basal ganglia control circuit? (3)
- 1. caudate
- 2. putamen
- 3. globus pallidus
What are primary components of basal ganglia control circuit? (3)
- 1. basal ganglia
- 2. subthalamic nucleus
- 3. substantia nigra
What occurs from a damaged substantia nigra?
What occurs from a damaged subthalamic nucleus?
What are the neurotransmitters in basal ganglia? (2)
What does deficiency in dopamine cause?
What does deficiency in ACH cause?
What are six associated problems witih hypokinesia?
- 1. rigidity
- 2. limited ROM
- 3. slow movements (brady kinesia)
- 4. hesitations and false starts
- 5. slow or fast repetitive movements
- 6. resting tremor
How does the masked expression and tremulousness associated with hypokinesia differ from tremor in ataxia?
The tremulousness is consistent and small
Is there a difference between rigidity and spascitiy?
What are the best distinguishing features of hypokinetic dysarthria?
- 1. fast rate
- 2. reduced stress
- 3. monopitch and loudness (reduced)
- 4. inappropriate silences
- 5. only one with worse breathiness is flaccid
What is the only dysarthria that includes a rapid rate?
How does flaccid dysarthria differ from hypokinetic dysarthria?
No prosody issues
Pathological reiterative utterances (repetition of words/phrases)
Which dysarthria is palilalia associated with?
Characteristics of palilalia (5):
- 1. increased rate and decreased loudness with successive repetitions (not invariable)
- 2. most common toward end of utterances
- 3. reps can be inhibitied temporarily, but with effort
- 4. not invariably associated with hypokinetic dysarthria
- 5. usually associated with basal ganglia pathology
The most prominent features of hypokinetic dysarthria are related to _________.
What system is hyperkinetic dysarthria associated with?
Definition of hyperkinetic dysarthria:
A perceptually distinguishable MSD most often associated with diseases of basal ganglia control circuit
Five characteristics of hyperkinetic dysarthria:
- 1. May be manifest in any aspect of speech, and often has prominent effects on prosody
- 2. Deviant characteristics are product of abnormal, rhythmic or irregular and unpredictable, rapid or slow involuntary movements
- 3. Can be manifest in all aspects of speech, especially prosody
- 4. Can result from abnormal movement at only one level of speech production
- 5. Abnormal underlying movements may be present only during speech
T/F: There is not variation in hyperkinetic dysarthrias.
What are the seven major types of hyperkinetic dysarthrias?
- 1. action myclonus
- 2. chorea
- 3. dystonias
- 4. dyskinesia
- 5. tics
- 6. tremor
- 7. palatopharyngeallaryngeal myoclonus
What are the most common etiologies of hyperkinetic dysarthrias? (3)
- 1. multiple
- 2. toxic-metabolic
- 3. idiopathic
Do hyperkinetic dysarthrias have a universal anatomic locus?
Which dysarthria's diagnosis is facilitated most by visual observation?
Why would hyperkinetic dysarthrias be diagnosed more than any other disorder as psychogenic?
Does the "hyper" in hyperkinetic refer to a fast speech rate?
No -- rate in hyperkinetic is usually slow
Arythmic fine or course jerking of a muscle or group of muscles in disorderly fashion, excited mainly by muscular activity when a conscious attempt at precision is required, worsened by emotional arousal, suppressed by barbituates, and often superimposed on a mild cerebellar ataxia.
T/F: action myoclonus is a common disorder.
What is the general symptom of action myoclonus?
jerks that occur singly or in a series
How do you distinguis action myclonus in a speech exam?
Compare slow, habitual, and fast rates
What are the primary patient complaints in action myclonus? (2)
- 1. aware of imprecise speech
- 2. inability or reluctance to speak at normal or rapid rates
Primary nonspeech orofacial findings: (2)
- 1. usually normal at rest unless other deficits present
- 2. may be present during sustained postures
Five primary distinguishing perceptual speech characteristics:
- 1. effects mostly on articulation> phonation
- 2. fine or gross quick jerky movements during speech attempts
- 3. repetitive fluctuation of phonation and adductor voice arrests synchronous with myoclonic spasms of lips
- 4. slow rate (compensatory vs. periods of inability to contract muscles following jerks)
- 5. myoclonic movements and imprecision worsen with increased rate
Rapid, unsustained, unpredictable movements that tend to be worse during movement; can interrupt course of intended movement.
What are primary patient complaints in chorea? (4)
- 1. effortful
- 2. inability to get it out
- 3. involuntary movements
- 4. dysphagia
Description of movements in chorea:
quick, unpatterned movements at 1 or multiple levels of speech mechanism at rest or during attempts to sustain postures.
What are confounding factors of chorea? (3)
- 1. difficult to distinguis from normal unsteadiness
- 2. cognitive problems
- 3. motor impersistence
What are the phonation-repiratory distinguishing characteristics of chorea? (5)
- 1. sudden forced inspriation or expiration
- 2. excess loudness variations
- 3. strained-strangled voice
- 4. voice stoppages
- 5. transient breathiness
What are the resonatory distinguishing characteristics of chorea? (2)
- 1. intermittent hypernasality
- 2. weak pressure consonants
What are the articulatory distingushing characteristics of chorea? (4)
- 1. distortions
- 2. irregular breakdowns
- 3. distorted vowels
- 4. slow and irregular AMRs
What are the prosodic distinguishing characteristics of chorea? (4)
- 1. prolonged intervals and phonemes
- 2. inappropriate silences
- 3. variable rate
- 4. excessive-inefficient-variable stress patterns
What is the difference between chorea and dystonia?
- Dystonia is:
- more prolonged
What are the client compaints in dystonia? (3)
- 1. effortful speech
- 2. awareness
- 3. swallowing issues "food gets stuck"
Nonspeech, orofacial findings in dystonia:(6)
- 1. often normal in size, strength, symmetry
- 2. gag often normal
- 3. pathologic oral reflexes may not be present
- 4. occasional drooling
- 5. dysphagia not uncommon
- 6. blepharospasm, facial grimacing
Characteristics of orofacial exam in dystonia:(3)
- 1. relatively slow, waxing/waning movements on 1 or multiple levels.
- 2. present at rest, during sustained postures, but sometimes only during speech
- 3. may improve with sensory tricks
Which dysarthria is associated with sensory tricks? (light touch to jaw, cheek, back of neck)
What are the primary phonation-respiration characteristics in dystonia?(5)
- 1. voice stoppages
- 2. strained-harsh voice
- 3. audible inspiration
- 4. excess loudness
- 5. unsteady/tremor-like voice
What are the primary resonatory characteristics in dystonia?
What are the primary articulatory characteristics of dystonia? (3)
- 1. distortions & irregular breakdowns
- 2. distorted vowels
- 3. slow and irregular AMRs
What are the primary prosodic characteristics of dystonia?(3)
- 1. inappropriate silences
- 2. excess loudness variations
- 3. excessive-inefficient-variable stress patterns
T/F Speech abnormalities in spasmodic torticollis are secondary to effects of neck and portural positions.
What is the primary nonspeech orofacial finding in spasmodic torticollis?
Relatively sustained deviation of head to right or left, forward (antecollis) or back (retrocollis)
T/F: One generally finds abnormal cranial nerve in spasmodic torticollis.
What are the pimary phonation-respiratory characteristics in spasmodic torticollis?(2)
- 1. reduced pitch & pitch variability
- 2. dysphonia (increased shimmer & jitter & reduced harmonic/noise ratio)
What are the primary articulatory/prosodic charateristics in spasmodic torticollis? (4)
- 1. reduced rate
- 2. delayed speech initiation
- 3. slow AMRs
- 4. reduced maximum duration of utterance
What are the characteristics of deficits in spasmodic torticollis?
- Deficits, when present, are usually subtle/mild with maintained intelligibilty
- When isolated rarely referred for Tx for dysarthria
What is the primary nonspeech orofacial finding in Tourette's?
multiple simple or complex motor tics
What is the male/female ratio in Tourette's?
What are the primary phonatory-respiratory characteristics of Tourette's?
- 1. coughing
- 2. grunting
- 3. throat clearing
- 4. screamihng
What is the primary resonatory characteristic of Tourette's?
What are the primary articulatory-prosodic characteristics of Tourette's?
- 1. humming
- 2. whistling
- 3. lip smacking
- 4. echolalia
- 5. palilalia
- 5. coprolalia
What is the most common movement disorder?
What percentage of people with essential tremor develop organic voice tremor?
Three characteristics of organic voice tremor:
- 1. onset usually gradual; when mild, patient may be aware of its presence.
- 2. worsens with fatigue and stress; may improve with alcohol
- 3. often accompanied by head or extremity tremor
What is the essential element of the speech exam in diagnosing an organic voice tremor?
Primary physical findings in organic voice tremor (3):
- 1. rhythmic, vertical laryngeal movements and abductor & adductor oscillations of cords synchronous with voice tremor
- 2. Jaw, lip, tongue & palate/pharynx tremor may be present, especially during phonation
- 3. Lingual & jaw tremor may be secondary to laryngeal tremor
What are two phontory-respiratory characteristics of organic voice tremor?
- 1. quavering, rhythmic, waxing/waning tremor, most obvious on vowel prolongation (4-7Hz)
- 2. voice arrests possible
What are two articulatory characteristics of organic voice tremor?
- 1. usually normal
- 2. rate may be slowed
What are two prosodic characteristics of organic voice tremor?
- 1. pitch/loudness variablity may be restricted/altered by voice tremor
- 2. rate may be slow
Which hyperkinetic dysarthria is associated with lesion in Guillain-Mollaret triangle? (loop among dentate nucleus, red nucleus, and inferior olive)
What is main patient complaint with palatopharyngolaryngeal myclonus?
ear clicks -- don't usually complain about speech
What are two primary findings in orofacial exam of palatopharngolaryngeal myoclonus?
- 1. abrupt rhythmic or semi-rhythmic unilateral or bilateral movements of palate, pharynx, larynx (sometimes seen on neck)
- 2. sometimes includes lips, nares, tongue and respiratory muscles
What is essential part of speech exam in palatopharyngolaryngeal myoclonus?
T/F: palatopharngolaryngeal myoclonus is usually found without other confounding dysarthrias.
General term used to refer to abnormal, hyperkinetic, involuntary movements, regardless of etiology
Dyskinesias reflecting a side effect of prolonged use of drugs (often antipsychotic or neuroplastic)
Involuntary movements of mouth, face, tongue and jaw that can occur without hyperkinesia elsewhere in the body.
T/F: Most hereditary and acquired diseases that cause orofacial dyskinesias are associated with basal ganglia pathology.
neurogenic spasmodic dysphonia
A group of relatively isolated voice disorders characterized by strained or breathy voice quality resulting from adductor or abductor laryngospasm.
What disease is chorea usually associated with?
Dystonias are the __________ movement while choreas are the _________ movement.
Three kinds of speech activities that can tell everything about articulation, respiration and phonation:
- 1. vowel prolongation
- 2. reading of passage
- 3. AMRs
Perceptive symptoms of flaccid dysarthria: (5)
- reduced loudness
- short phrases
- inhalatory stridor
Which dysarthria is characterized most often by diplophonia?