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57 Cards in this Set
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Definition of Flaccid Dysarthria |
a. caused by impairments of LMNs of cranial or spinal nerves CN 5, 7, 9-12
b. weakness in speech/respiratory musculature c. weakness results in: slow, labored artic, hypernasal (reliable test), and hoarse/breathy phonation(most reliable) d. look for cluster of symptoms - diff forms of dysarthria have diff clusters* |
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**
Neurological Basis for Flaccid Dysarthria |
a. damage to LMN
b. any disorder that disrupts flow of neural impulses along LMNs that innervate musc of respiration, phonation, articulation, prosody, or resonance |
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***
Clinical Characteristics of Flaccid Dysarthria |
a. weakness
b. hypotonia and reduced reflexes c. atrophy (if you have LMN damage, you've got this) d. fasciculations - myasthenia gravis e. progressive weakness w/ use in some cases |
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****
Cranial Nerves of Speech Production |
a. if damage occurs to any of following or combo of following, motor impulses sent to muscles for speech will be distorted or stopped:
-trigeminal -facial -glossopharyngeal -vagus -accessory -hypoglossal b. specific acoustic feat. will depend on wh/ nerves or which combo of nerves were damaged/weakened |
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*****
Trigeminal |
a. attached at level of pons
b. divides into three branches: -opthalamic -maxillary -mandibular c. mandibular most imp for speech production d. musc elevate and lower jaw |
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a
Unilateral Damage to Trigeminal |
a. weakness in jaw musc on ipsilateral side of damage
b. jaw may deviate to affected side when opened c. musc atrophy always occurs - asymmetrical appearance d. minimal effect on speech production |
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aa
Bilateral Damage to Trigeminal |
a. difficult or impossible to raise jaw
b. bilabial sounds most affected (labio/lingual dental, vowels) c. rate of speech will be produced |
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aaa
Facial |
a. two major branches:
-cervicofacial (innervates lower face musc) -temporofacial (innervates upper face musc) |
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aaaa
UMN Lesion |
a. UMN of corticobulbar tract innervate LMNs of two branches of facial nerve
b. upper face gets bilateral UMN innervation c. lower face gets contralateral UMN innervation |
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aaaaa
LMN Lesion |
a. causes entire ipsilateral facial weakness
b. lesions above pt of division: entire ipsilateral facial weakness c. lesions below pt of division: musc innervated by specific branch will be affected |
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b
UMN & LMN Innervation of Facial Nerve |
a. if right LMN affected above pt of division - entire right half of face weak
b. right UMN/corticobulbar tract damage - all of top ok, bottom left weak |
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bb
Damage to Facial nerve |
a. unilateral: mild distortion of bilabial and labiodental, cheek flutter, reduced amr precission
b. bilateral: parysis (slow rate), distortion or inability ro produce bilabials and labiodentals (pbm) and (fv) |
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bbb
Glossopharyngeal Nerve |
a. originates at level of medulla
b. courses out to pharynx, innervating: -stylopharyngeus -superior pharyngeal constrictors -assist in elevating and opening upper pharynx -gag reflex will test function of nerv c. exact contribution to speech is unclear b/c of how close it is to vagus nerve |
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bbbb
Vagus Nerve X |
a. Very important for speech - main nerve
b. Originates at the medulla just below CN IX and Courses near CN IX and CN XI c. CN X is long and serves many parts of the body (e.g., larynx, intestines, heart, velum) d. Important branches for speech production – Pharyngeal branch – External superior laryngeal nerve branch – Recurrent laryngeal branch |
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bbbbb
Pharyngeal Branch |
a. Innervates muscles of the pharynx & soft palate
b. Responsible for pharyngeal constriction and palatal elevation/retraction c. Unilateral damage results in the affected side of the velum hanging lower than the unaffected side --> generally does not result in VPI (velo-pharyngeal insufficiency) d. Bilateral damage will result in: (audible symptoms) *HYPERNASALITY & DISTORTED PRESSURE CONSONANTS* |
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c
External Superior Laryngeal Branch |
a. Innervates cricothyroid
b. Cricothyroid stretches and tenses the VFs, thus controls pitch c. Unilateral damage will have a mild effect on varying pitch d. Bilateral damage can result in MONOTONE SPEECH* (decreased pitch variation) |
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cc
Recurrent Laryngeal Branch |
a. Supplies motor innervation to all the intrinsic laryngeal muscles except for the cricothyroid
b. Important for VF adduction and abduction c. Unilateral damage can result in one VF being fixed in the paramedian position, causing BREATHY PHONATION, DECREASED LOUDNESS AND DIPLOPHONIA d. Bilateral damage can fix both VFs in the paramedian position, causing Inhalatory Stridor |
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ccc
Accessory Nerve XI |
a. Many of the motor neuron axons merge with the vagus nerve
b. Spinal portions supply motor innervation for the sternocleidomastoid and trapezius c. It is difficult to discern the role of the vagus and the cranial components of the accessory nerve - damage to one generally results in damage to the other |
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cccc
Hypoglossal Nerve XII |
a. Provides motor innervation for all intrinsic lingual muscles and most of the extrinsic
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ccccc
Unilateral Damage to XII |
a. results in weakness on the same side as the nerve damage:
-Damaged side will atrophy -Protrusion will deviate toward the affected side -Mild articulatory distortions |
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d
Bilateral Damage to XII |
a. results in:
-Bilateral muscle atrophy and weakness -Reduced ROM --> Imprecise articulation -Difficulty with pronouncing alveolars, and velars |
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dd
Hypoglossal Nerve |
a. UMN innervation is contralateral only --> damage to the L UMNs results in weakness in the R side of the tongue
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ddd
Etiologies of Flaccid Dysarthria |
a. Physical Trauma
b. Brainstem Stroke c. Myasthenia Gravis d. Guillain-Barre Syndrome e. Polio f. Tumors g. Muscular Dystrophy h. Progressive bulbar palsy NB: PNS damage |
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dddd
Physical Trauma |
a. Surgical trauma, head injury, neck injury (33% at Mayo Clinic)
b. Procedures that are at risk -Carotid endarterectomy (removal of plaque) -Cardiac surgery -Removal of head and neck tumors -Dental surgery c. CHI (Closed Head Injury) can cause blows to the head and/or falls that will also damage the cranial nerves of speech production |
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ddddd
Brainstem Stroke |
a. CVAS: blood flow to the brain is interrupted (If blood supply blocked, neurons die)
b. A stroke in one of the brainstem arteries can result in damage of the neurons served by that artery. c. Severity of impairment depends on the number of LMNs damaged due to a stroke NB: Brainstem stroke can cause both flaccid AND spastic dysarthria (UMN damage = spastic) |
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e
Myasthenia Gravis |
a. Affects the neuromuscular junction where the LMN meets muscle
b. Primary symptoms is rapid fatigue of muscular contractions and recovery after rest c. Caused by antibodies that damage parts of the muscle tissue that receive Acetylcholine (ACH) - decrease in ACH receptors results in the muscle not being able to use all the ACH produced by the motor neuron (auto-immune disorder) |
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ee
Myasthenia Gravis (Continued) |
a. Speech characteristics during prolonged speaking tasks:
-Hypernasality (velum not functioning properly) -Decreased loudness -Breathy voice quality (laryngeal musc not contracting, correctly) -Decreased articulatory precision (musc of face not working properly) b. Mild symptoms can be treated with medication |
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eee
Guillain-Barre Syndrome |
a. Progressive inflammatory loss of myelin sheath (demyelination) in the PNS
b. Exact cause is uncertain - can occur after some infections and immunizations (another auto-immune disorder) c. Progression of the disease is rapid - people can recover from this syndrome over a few weeks/months, but 5% die during the acute stages d. Patient may complain weakness and numbness in limbs, flaccid dysarthria and dysphagia (all early on in disease) |
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eeee
Other Causes of FD |
a. Tumors
-In the brainstem, neck, or orofacial structure (causing pressure on vital nerves/ organs and surgical removal is tricky) b. Muscular Dystrophy -Progressive degeneration of muscle tissue -Results in weakness of muscles served by cranial nerves c. Progressive Bulbar Palsy (a type of ALS) |
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Speech Characteristics of FD |
Speech Characteristics of Flaccid Dysarthria
a. The most deviant speech characteristics encountered in Flaccid Dysarthria b. Rank Speech Production Errors: (Look for clusters) - often hypernasality and breathiness |
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f
Resonance |
a. Hyper-Nasality*
b. Nasal emission* c. Weak pressure consonants* d. You perceptually observe above three common symptoms |
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ff
Articulation |
a. Imprecise consonants
b. Large range in severity, caused by damage the facial and hypo-glossal nerves c. Bilateral damage to the CN V can result in difficulty elevating the jaw sufficiently to bring the articulators into contact with each other |
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fff
Articulation (Continued) |
a. Bilateral damage to CN VII will impact bilabials and labio-dentals and vowels requiring lip rounding
b. Bilateral damage to CN XII will have an effect on which phonemes? lingual sounds/velar probs) |
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ffff
Phonation |
a. Phonatory incompetence - incomplete adduction of the vocal folds due to damage to the RLN due to damage to CN X (Recurrent laryngeal branch)
b. Combined presence of hyper-nasality and breathy voice quality (CLUSTER) are strong indicators for the diagnosis to be flaccid dysarthria |
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fffff
Respiration |
a. Respiration may be a component of flaccid dysarthria if the C and T spinal nerves
responsible for innervating the diaphragm and intercostals are damaged b. Inadequate amount of subglottic air pressure for speech, resulting in: -Reduced loudness -Shortened phrase length -Glottal fry (when talk on residual air) |
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g
Distinguish b/w Respiration & Phonation |
a. Respiration and phonation are closely related, so how do you know if the person has poor respiratory support or decreased phonatory competence?
b. Have person produce a good cough c. Ask person to produce a hard glottal stop -If person has a breathy cough and a sharp glottal stop? -A breathy cough and weak glottal stop may indicate ? |
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gg
Prosody |
a. Monopitch (monotone)
b. Monoloudness c. Reduced voice range profile d. The combination of reduced loudness and pitch range can occur in other types of dysarthria, thus are not diagnostic markers for flaccid dysarthria |
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ggg
Evaluation Tasks |
a. Conversational speech sample: respiration, resonance, articulate, prosody
b. Alternate Motion Rate (AMR) tasks - slowed rate of phoneme production (Normal is ten words before breath) c.Prolonged Phonation of a Vowel - voice quality d.Speech Stress Test (e.g., count to 100) - fatiguing of the speech mechanisms |
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gggg
Treatment of FD |
a. Becomes redundant b/c dysarthria is persistent and b/c fixed number of options
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ggggg
If CN X is Damaged |
a. Deficits in following depending on branch of CN X being affected:
-Resonance -Phonation -Prosody |
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h
Treatments for Resonance Deficits |
a. Modification of speech - compensatory strategies to make person sound better (instead of trying to fix underlying neurological disorder)
-Increase loudness (modeling + visual feedback) -Reduce rate of speech (while preserving prosody) e.g., increasing vowel length (gives person time to move velum) -Use a more open mouth position during speech: discrimination, exaggerated jaw movement, negative practice (have pt read passages that to hear diff b/w oral and nasal sounds & correct vowel sound) & get family member feedback) |
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Additional Treatments for Resonance Deficits |
a. Prostheses
-Palatal lift - wear front, retainer piece and posterior extension that goes to back of pharynx and keeps velum in raised position b. Surgery -Pharyngeal flap -Teflon injection |
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hhh
Pharyngeal Flap |
a. Cut out tissue from back of pharynx, raise it, suture to velum to make continuous bridge from velum to pharynx = fake palatal lift (invasive, only 50% success rate at max)
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Teflon Injection |
a. Into back of throat to make it bulge out thus making it easier for velum to make contact
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Good Candidate for Prostheses |
a. Hyper-nasality is their most serious speech production deficit (prostheses is best option for these candidates, as long as they have good lateral wall closure)
b. Stable medical condition c. Have enough teeth onto which the lift can be attached d. No hyperactive gag reflex or significant oral spasticity e. They have the patience and motivation to use the lift f. Ability to independently insert and remove the device (ALS pt wouldn't be able to) g. Good lateral wall closure |
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i
Treatment for Phonation Deficits (2) |
a. Closure strategies
b. Compensatory strategies |
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ii
Closure Strategies |
a. Pushing and pulling – effortful closure techniques
(LSVT - closing vf by increasing effort and musc. contraction in torso* b. Holding breath - need to be able to close VFs c. Hard glottal attack - take deep breath, bear down, and produce tight phonation |
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iii
Compensatory Strategies |
a. Head turning toward the affected side in order to bring paralyzed vocal fold to midline
b. Sideways pressure on larynx |
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iiii
Treatment for Prosody (2) |
a. Address pitch level
b. More natural speech |
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iiiii
Addressing Pitch Level |
a. Pitch range exercises - have pt learn to change pitch level of 1 word (model for client)
b. Intonation profiles - change pitch level at utterance/sentence level (eg: w/ question vs statement) c. Contrastive stress drills - stress w/i a single word (is he playing baseball? no, he's playing FOOTball) |
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j
More Natural Speech |
a. Chunking utterances into syntactic units - pt might have short phrase length and will run out of breath in the middle of a sentence if not in control of their breathing pattern - have to teach them where's to cut/breath in sentence.
NB: Begin w/ clinician initiated behavior and graduate to pt initiated behavior |
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jj
Things to Think about in Tx Approach |
a. Repetitive process
b. Clinician feedback c. Patient awareness - have him try to figure out what to change before you give him feedback |
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jjj
Treatment for Damage to XII |
a. Traditional articulation treatment
- Intelligibility drills - Phonetic placement - instruction (and model) of where to place articulators - Exaggerating consonants - over-articulation (usually have particular trouble w/ medial and final consonants and this helps) - Minimal contrast drills (bat vs mat) NB: Give pt list of words to produce and you decide if you can understand words or not (clinician can't be familiar w/ list of words) --> if can't produce second time, you give feedback |
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Treatment for Respiratory Weakness |
a. Correct posture
b. Speaking immediately on exhalation (some don't have respiratory and phonatory systems in sync, so have to teach them to produce speech on exhale)c. Cueing for complete inhalation |
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Video 1 of FD
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a. Imprecise articulation --> mild distortion of /l/, /r/, /s/, and /z/ - all connected w/ tongue and therefore CN XII (state wh/ sounds are in error using phonetic alphabet transcription)
b. Flat prosody c. AMR /ka/ is distorted, so prob w/ tongue (poor lingual sounds) (compensate by trying to speak slowly and over articulate) d. Atrophy of tongue & can't move laterally (compensates by moving jaw) NB: Bilateral hypo-glossal nerve damage (CN XII) --> diagnosis |
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Video 2 of FD
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a. Hyper-nasality & continuous breathiness (Typical CN X damage = cluster of hyper-nasality and breathiness)
b. Imprecise articulation esp w/ lingual sounds, short phrase length, short duration, and weak cough c. AMR - imprecise, breathy, hyper-nasal, weak pressure consonant, (good rate) NB: Brain stem tumor unilaterally compressing CN V, VII, X, XII (If damage to X, automatically damage to IX and XI) |
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Video 3 of FD
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a. Deterioration of articulation and resonance during connected speech
b. Recovery w/ rest NB: Myasthenia Gravis |
