Mid-sem Assessment 1
Week 1: types of aetiologies
Explain the basic organization of motor control, in particular motor control of speech
production.
Prosody- pitch loudness duration- stress, questions/declarative, demands
Identify major neurological aetiologies causing different disorder types
Type
Flaccid dysarthria
Location
LMN/Final common pathway
(cranial nerves)
Spastic
dysarthria
Bilateral UNM (direct AP)
- Overactivation of p/w
- Speech muscles innervated
bilaterally
- Damage to one or both
sides of the brain
Unilateral UMN (direct AP)
Unilateral UMN
dysarthria
Hypokinetic
dysarthria
Basal ganglia (indirect AP)
- Small movements
- PD
Hyperkinetic
dysarthrias
Ataxic dysarthria
Basal ganglia (indirect AP)
- Increase movement
Cerebellum (indirect AP)
Mixed
dysarthrias
Apraxia of
speech
Multiple
Left premotor cortex (direct AP)
Dysarthria/anarthria
Disturbances in muscular control (PNS/CNS)
Features
- Weakness, fatigue
- Slurred words
- Breathy voice
- Slow speech
- Effortful speech
- Fatigue
- Difficulty with swallowing and
chewing
- Poor control of emotional exp
-
Reduced loudness
Rapid speech rate
Mumbling/stuttering
Difficulty initiating speech
Stiff lips
Jerky
Speech breakdowns
Drunken sounding  stumble
Poor coordination of speaking
Bite cheek/tongue/eating
-
Irregular rate + slow AMRs
Distorted speech
Varying pitch and loudness
Apraxia/dyspraxia
Inability to make voluntary movement speech
despite normal muscle function  brain can’t
control movement (CNS)
DYSARTHRIA
Flaccid dysarthria
Hypotonia, atrophy, fasciculations, hypernasality, nasal regulation
Dimension
Hypernasality
Imprecise consonants
Cranial nerve
X
Breathiness* more in flaccid dysarthria
Monopitch
Nasal emission
Audible inspiration
V
VII
X
XII
X
X
X
X
Harsh voice quality
Short phrases
Monoloudness
X
X
X
Level
Velopharyngeal
Articulation
Jaw
Face
Velopharyngeal
Tongue
Laryngeal
Laryngeal
Velopharyngeal
Laryngeal
Reflects abductor vocal fold
weakness
Laryngeal
Laryngeal +/- Respiratory
Laryngeal +/- Respiratory
Weakness – fluttering
X
Low amplitude, tremorlike
Spastic dysarthria
Hypertonia, hyperreflexia, clonus, pseudobulbar affect, dysphagia, drooling, slow and regular AMR
Dimension
Imprecise consonants*
Monopitch
Reduced stress
Harshness*
Monoloudness
Low pitch*
Slow rate*
Hypernasality
Strained-strangled voice* grunt like after
expiration
Present with vowel prolongation
Short phrases*
Distorted vowel
Pitch breaks*
Breath voice
Equal and excess stress
60% degenerative 17% vascular
Level
Articulatory
Laryngeal
Prosodic
Laryngeal
Laryngeal – respiratory
Laryngeal
Articulatory – prosodic
VP
Laryngeal
Articulatory – respiratory – laryngeal -VP
Articulatory
Laryngeal
Laryngeal
Prosodic
Unilateral UMN- central face weakness
Unilateral central facial weakness, lingual weakness without atrophy or fasciculations
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Mild features
Weakness
Some spastic characteristics
Can be confused with flaccid
Imprecise consonants
92% vascular
Hypokinetic dysarthria
Facial masking, tremulousness, decrease ROM on AMR
Dimension
Monopitch*
Reduced stress*
Monoloudness*
Imprecise consonants
Inappropriate silences*
Short rushes of speech*
Harsh voice
Breathy voice
Low pitch
Variable rate*
Repeated phonemes
Parkinson- rigidity in vocal fold
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Level
Laryngeal- prosodic
Prosodic
Laryngeal - respiratory
Articulatory
Prosodic
Articulatory – prosodic
Laryngeal
Laryngeal
Laryngeal
Prosodic – articulatory
articulatory
Too much tension in muscle
Sit in a bode pattern- little space creates hoarseness and breathy
o So by speaking louder
Hyperkinetic dysarthria
Varies with disease/damage, with adventitious movements being
-
Patterned/non-patterned
Quick/slow
Tics ballismus chorea athetosis myoclonus
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Depends on the type of hyperkinesia
Prolonged intervals
Variable rate
Excess loudness variations
Prolonged phonemes
Ataxic
Size, strength & symmetry are normal at rest and in sustained postures
-
No abnormal reflexes
Hypotonia
Dysmetric AMRs (errors in rate, range, force, direction, over/undershoot target, slow with
unpredictable character … but not relevant if speech AMRs are normal)
Dimension
Imprecise consonants
Excess and equal stress*
Irregular articulatory breakdown*
Distorted vowels*
Harsh voice
Prolonged phonemes*
Level
Articulatory
Prosodic
Articulatory
Articulatory – prosodic
Laryngeal
Articulatory – prosody
Prolonged intervals
Monopitch
Slow rate
Excess loudness variations*
Voice tremor
Prosody
Laryngeal – prosodic
Prosody
Laryngeal – prosodic – respiratory
laryngeal
Relate specific clinical features with the putative mechanisms and/or anatomical location
Apraxia of speech (AOS)]
Definition
Phonetic-motoric disorder that impairs the process of converting a retrieved phonological
representation into commands for coordinated articulator movement
-
Timing and spatial errors
Speech sounds and prosodic distortions
Perceived speech features
-
Distortion of sounds  intelligibility?
Prolonged sounds and sound transitions
Syllable segregation and equal stress
Diagnosis
1. Feature checklist/rating scales
a. Apraxia of speech rating scale (ASRS)
i. Conversational speech – case history
ii. Picture description – aphasia tests
iii. Word and sentence repetition – aphasia tests
iv. AMR (pa-pa-pa) and SMR (pa-ka-ta) – oromotor exam
Case study
 Reliability ranged from poor to moderate; poor for total score
 Total score is not reliable for non-experts/limited training in ASRS
2. Operationalised measures – more precise  acoustic measurement
a. Duration and frequencies – exploratory
i. Perceptual and some acoustic measures
1. Number of:
b. Durations and frequencies – targeted and specific
First descriptions of AOS referred to “inconsistent errors”
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Highly consistent in type and location of errors
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On average, did not get closer to target with repeated attempts
Outcome
Two measure sufficient to distinguish cases with and without AOS
I.
II.
-
Errors with words of increasing length
a. Apraxia battery for adults
Pairwise variability index for weak-strong words
Cant produce polysyllabic words and segments the weak-strong words
c. Data driven discovery of measures that predict expert decision
Dysarthria treatment
Respiratory/phonatory function

Improve respiratory support
o Pushing and pulling techniques (some evidence for improving respiratory support for
speech breathing)
 Stabilise trunk- and get more air volume
o Biofeedback of chest wall movement to increase abdominal movement and overall
lung volume (some evidence)
 Good respiratory function
o Postural adjustment
 Inspiratory problems: upright so gravity can assist lowering of diaphragm
(ALS, COPD) or better posture for speech breathing (PD)
 Expiratory: supine so gravity can assist upward movement (MS, TBI, spinal
cord injury) but can diminish inspiratory ability
 Unlikely to generalise to better speech breathing in upright position
 Expiratory muscle strength training (EMST)
o Produces effects similar to limb muscle strength training
 Work against resistance by blowing into valve
o Improves breathing, coughing, swallowing, and speech
 Spinal cord injury, MS, PD, COPD, voice disorders
1. Vary weight/load and duration of exercise
2. Frequency (mins/day, days/week, total weeks)
 Improving respiratory support
o Prosthesis- rare
 Expiratory board- lean against to increase expiratory force
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Abdominal trussing – supports weak muscles and posture for those with
good diaphragm (inspiratory) function (some spinal injuries, some cerebral
palsy cases)
o Speech tasks – best approach
 Modify inspiratory and expiratory patterns
 Inhale more deeply or use more force on exhalation during speech
 Inspiratory checking – let out air slow and evenly
 Use abdominal/diaphragmatic breathing (some evidence)
Biofeedback (some evidence)
o Control force and consistent air pressure for phonation in utterances of increasing
length
o Loudness, abdominal wall movement, spirometer during sustained movements
(magnitude and patterns of movement)
Improving respiratory/phonatory coordination and control
o Speech tasks
 Biofeedback of chest wall movements and phonation (some evidence)
 Using “optimal breath groups”/increasing awareness of speech-breathing
patterns and volumes
 Inspiratory checking
Improving phonatory function
o Hypoadduction: low in volume and breathy
 Effortful closure techniques (some evidence)- weak or paralysed VF
 Postural adjustment (head turn) – for better closure
 Physical manipulation of thyroid: increase adduction
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o
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AAC
o
o
o
o
o
Lee Silverman voice treatment - ample evidence
 Helps increase loudness- predominant for inspiratory
 Helps improve intelligibility
Hyperadduction: strained spastic quality
 Tension reducing strategies - easy onset (some evidence)
 Biofeedback to monitor tension: electrodes monitor tension
 Botox: (great evidence)- kills nerve endings but regenerate after a while
 Spasmodic contraction stopped  can become breathy (rather than
strained and strangled)
 Stroke hemipelgia- relax spasticity in limbs
Voice intensity controller: alerts with a beep when volume drops so they can speak
louder (some evidence)
Portable amplification system: so they can be better heard (some evidence)
AI (electronic/artificial larynx)
 Source- filter theory ( creates a vibration that vibrates)- no prosody and can
sound very robotic
 For those who are aphonic or severely breathy
 LARONIX: new gen device
Alphabet boards, gestures, semantic cues
Useful for speakers with severe or profound dysarthria
o
Imposes some cognitive demands
LOUDNESS, RATE AND PROSODY
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LOUDNESS- Lee Silverman voice treatment
Rate - intelligibility higher with slow speech
o External pacing (delayed auditory feedback (computer delays when they hear
speech), pacing board, metronome)
o Computer training
o Biofeedback
Slowing rate o Increase acoustic vowel space
o Naturalness no worse
o Sentence intelligibility improves- gives them more time
Things to consider
o Need to get them habituated to the new rate
o Then habituate the new rate
Prosody - focus
o Acoustic: contours
o Perceptual: stress patterns, pause structure, naturalness
Prosody - treatment option
o Biofeedback using acoustic measure- show spectrogram
o Behavioural instruction (e.g. Sentence/question, emphatic stress, lexical stress)
 Not running speech- invidual sounds
 REST treatment:
Velopharyngeal function
Cause: stroke, neurogenic (cranial nerves)
-
Exercise if there is still movement in palate- improve speech and swallowing
Palatal lift:
-
Pharyngoplasty- make a smaller pharyngeal port
Behavioural intervention: can they do more effortful movement by building up strength
MEASURE OUTCOMES
Motor neuron disease (amyotrophic lateral sclerosis) degenerative disease
1. Compensation
a. Palatal lift - reduce hypernasality, increase intelligibility and reduce effort
b. Low tech AAC
2. Exercise - not effective
a. To build strength- didnt do much
b. Intensive oral motor/lingual strengthening- decline
Conclusion: monitor speech rate
Treatments
- LSVT
- Living with dysarthria
- Be clear
La trobe university smooth speech program
DYSTONIA AND TREMOR
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Medical treatment
o Effective but wears off over time
 Botox injection into the problematic
o Works better for limbs , effect on voice not consistent
 Oral medication
 Neurosurgery
Behavioural therapy on voice
LSVT- lee silverman voice treatment
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BE LOUD- louder voice, greater pitch and loudness, increase facial expression, greater effort
WANT TO HABITUATE to make it automatic
Target
Mode
Global variation: has global effect i.e. More than one outcome
- Teach not to talk loud
○ Teach them that their louder voice is normal (habituate it)
○ Healthy vocal loudness- no strain, misuse
Precision, articulation, prosody
Cognitively easier
Respiratory
 Loud as a trigger : deep breath and open mouth
 Improved articulation reduced rate
e
Intensive and high effort
- 50-60 min sessions for 4 consecutive days a week for 4 weeks
- Daily homework and carryover exercises everyday
1. Repetition
2. Force/resistance
3. Accuracy
4. Healthy fatigue
Increase muscle activation
- Overload, progressive resistance
- Go again to constantly exercise the system
Generalisation
- By doing the tx intensely --> accommodate the task and habituate it
○ Understand input creates output
Generalisation  automaticity in daily communication
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Hierarchical
Quantification
LSVT
Evidence
Maximum fundamental frequency range, LOUD
o Improve range of cricothyroid for improved intonation
o Rescale amplitude of phonatory output for generalisation to
speech
 Start at modal pitch and glide or stairstep up/down
o 15 good attempts for each, at the target loudness
o No strain
 Personalised
 Transfer loudness from daily tasks to variable speaking activities
 Second 25 min (half) of session
 Multiple repetitions – patient is talking the whole time
 Tasks CHANGE every day and are tailored to be highly salient to each
patient
STOP, INTERRUPT, REDIRECT TO GET BEST SPEECH ON EVERY ATTEMPT
 Tasks get harder over the weeks
 Sound pressure level meter: loudness
 Stop watch: duration of ah
 Visipitch/digital tuner/PRAAT: range of fundamental frequency on
high/lows
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- MS
- TBI and stroke
- Ataxic dysarthria
- Cerebral palsy
- Parkinson disease – via telehealth – with deep brain stimulator
LOTS OF EVIDENCE
BE CLEAR
-
Start with thing that has biggest impact on their intelligibility
Rate- work on habituating speech rate (LSVT)
Measures: word and sentence intelligibility, speech rate (words/min)
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Loudness
Drop speech rate
Overenunciation - effortfully articulate (does it increase intelligibility)
Figure out how to get the best production, create more responses.
1.
2.
3.
4.
5.
Pre-practice
Pre-practice- intensive practice
Service request
Functional phrases
Functional speech tasks
6. homework
HABITUAL TASKS to lay out the skills
SpeechATAX
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intensive home based biofeedback driven speech treatment for hereditary ataxia BUT done
at home
who is it for: genetically confirmed diagnosis of hereditary ataxia including diagnosis os
spinocerebellar ataxia or Friedreich ataxia
o BUT- likely appropriate for any ataxia
RECOGNISES that loudness might not be a problem- push them to optimal performance to
get more consistency
IMPROVE: improve vocal control, prosody and intelligibility using principles of motor
learning and neuroplasticity
Give them feedback on loudness, slowness, pitch variation using a software
o Use self-monitoring of speech
Step 1: breath support and vocal control
Step 2: over-enunciate to be clear and intelligible
ReaDySpeech
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Delivered via phone, tablet, or computer
o Activities
 Articulation
 Breathing
 Rate of speech and intelligibility
 Volume
 Facial expressions
 Intontion
 Oro-motor exercises
o Instructions via video clips
o Practice amount each day/week and length of treatment not yet specified
Living with dysarthria
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Some evidence
Both patient and carer- partner training- active listening
o Educate patientImprovement on speech production not their but on understanding and more wellbeing for
patient and carer --> not enough practice