Motor Speech Disorders

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Motor Speech Disorders

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Speech disorders that occur due to neurologic impairment that affects:

- motor planning or programming,

OR

–Neuromuscular execution

-includes Dysarthria & Apraxia

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**Dysarthria**

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Collective name for group of neurologic speech impairs -reflect abnormalities in strength, speed, range, steadiness, tone / accuracy of movements req'd for all 5 aspects of speech.

-Characterized by slow, weak, imprecise, or uncoordinated movements of the speech musculature

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Dysarthria affects:

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Motor execution

(=Specification of precisely how the motor plan is to be achieved:

–Which muscles contract

–How much (movement range and direction)

–When (timing))

=Direct activation of motoneurons, muscle contraction, and movement

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Types of Dysarthria

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-Flaccid

-Spastic

-Ataxic

-Mixed

-Hypokinetic

-Hyperkinetic

-Unilateral UMN

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**Factors that Impact Dysarthria**

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*Age of onset (congenital or acquired (at any age))

*Cause (vascular, traumatic, infectious, neoplastic)

*Natural course (Developmental (CP), Recovering (stroke/TBI), Stable/Chronic (adult CP), Degenerative (ALS), Exacerbating-Remitting (some MS)

*Site of Lesion

*Underlying neurological diagnosis *Pathophysiology (spasticity, flaccidity, ataxia, tremor, dysmetria, involuntary movements) *Speech subsystems involved

*Perceptual characteristics

*SeverityFactors

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**Apraxia of Speech**

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Neurologic motor speech disorder reflecting an impaired capacity to plan / program sensorimotor commands needed for directing movements that result in phonetically & prosodically normal, volitional speech.

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Apraxia affects:

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Motor Planning

(=Selection of appropriate movement strategies in light of intended goals and prevailing physical conditions)

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**Intelligibility vs. Comprehensibility**

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INTELLIGIBILITY•Info only f/ speech signal

COMPREHENSIBILITY•Consideration of info f/ speech signal + context.

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Darley, Aronson, & Brown

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-Developed use of auditory-perceptual assessment to characterize types & physiologic bases of dysarthrias

•Their clusters of deviant perceptual dimensions formed impt framework for diagnosis & management of dysarthrias.

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Aspects of Disability / Disorder

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Impairment (body), Activity (limitation), & Participation (restriction - society),

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Role of SLP in MSDs

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*Differential diagnosis

*Intervention

-Rehab

-Mgmt / compensatory strategies

-Maint.

-Advocacy

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Gray Matter vs. White Matter

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Grey = Cells & Dendrites

White = Axons

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Action Potentials vs. Synaptic Transmision

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Action Potential: Electrical info down axon

Synaptic Transmission: Chemical info f/1 neuron to another

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Meninges

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*Dura

*Arachnoid

*Pia Mater

Spaces:

-Epidural

-Subdural

-Subarachnoid

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Supratentorial Level of N.S.

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*Hemispheres, Lobes, & CN I & II

*Basal Ganglia: Striatum (Caudate Nucleus & Putamen), Globus Pallidus

*Thalamus: Rt. & Lft.

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Posterior Fossa

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*Brainstem (Midbrain, Pons, Medulla)

*& Cerebellum

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Spine

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*Cervical: 8 S.N.s

*Thoracic: 12 S.N.s

*Lumbar: 5 S.N.s

*Sacral: 5 S.N.s

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Peripheral

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*CNs

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**IMPT CNs for Speech & Swallowing**

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CN V - Trigemnial: Motor for jaw, Sensory to face, teeth, anterior tongue

CN VII - Facial: Motor for face; taste; salivation

CN IX - Glossopharyngeal: Motor of pharynx & larynx; Sensory to posterior tongue & upper pharynx; taste; salivation

CN X - Vagus: Motor for palate; phonation; taste; & swallowing

CN XII - Hypoglossal: Motor for tongue

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**Name all Cranial Nerves**

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*CN I: Olfactory

*CN II: Optic

*CN III: Oculomotor

*CN IV: Trochlear

*CN V: Trigeminal

*CN VI: Abducens

*CN VII: Facial

*CN VIII: Auditory/Vestubular

*CN IX: Glossopharyngeal

*CN X: Vagus

*CN XI: Spinal Accessory

*CN XII: Hypoglossal

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**UMN vs. LMN**

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*UMN:

-originate in motor cortex;

-term. in CN nuclei of brainstem or ventral horn of spine

*LMN: Final Common Pathway; every neuron that exits brainstem / spine

-originate in CN nuclei of brainstem

-terminate on head & neck muscles
OR

-originate in ventral horn of spine

-terminate on all other muscles

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**Speech Subsystems**

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*Respiratory

*Phonatory

*Resonatory

*Articulatory

*Prosody

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**Direct Activation Pathway**

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*Pyramidal System = Conscious cntrl of voluntary motor

•Direct cntrl f/ cortex (1 synapse bxn origin & FCP)

•Tracts from cortex: Corticobulbar & Corticospinal

*UMN

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**Indirect Activation Pathway**

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*Extrapyramidal System = Automatic / Subconscious cntrl of muscle activities (posture, tone, & reflexes)

•Indirect cntrl f/ cortex (multiple synapses bxn cortex & termination in FCP)

•Tracts from cortex: Corticorubral to rubrospinal and Corticoreticular to reticulospinal

*UMN

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**General Functions of Cerebellum**

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Integrates & Coordinates execution of smooth, directed movements

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**Motor Speech Examination**

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-Differential Diagnosis (rule out / consistent w/ medical findings?)

-Chart Review

-Px History (signs v. symptoms)

-Oral Mech Exam (see other card)

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**Oral Mechanism Exam**

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Examination of muscles innervated by CNs: (@ min.: CNs V, VII, IX, X, and XII)

–Size, strength, symmetry, range, tone, steadiness, speed & accuracy

–Observe at rest, During sustained postures, During movement (Jaw ROM, etc)

•Intraoral exam

•Non-speech tasks

•Reflexes

•Respiratory exam

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Testing CN VII during Oral Mech

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Raise/lower eyebrows,

Smile,

Pucker,

Lip closure against resistance,

Puff cheeks full of air

& @ rest (symmetry) (LMN Impair: Upper & lower facial weakness; Weakness is unilateral to lesion; UMN Impair: Lower facial weakness; Weakness is contralateral to lesion)

Lagophthalmos: inability to shut eye completely

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Testing CN III observations

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Ptosis,

Double Vision (diplopia)

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Testing CN V during Oral Mech

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Clench teeth and feel masseter & temporalis

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Testing CN XII during Oral Mech

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Tongue deviation, atrophy, & fasciculations

Tongue deviates to weak side

LMN Impairment –Right side

UMN Impairment –Right side

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Testing CN IX during Oral Mech Exam

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Palatal Reflex (assymetrical, absent, etc.)

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Testing CN X during Oral Mech Exam

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Sustained Phonation

Wetness / Dryness of vocal quality

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**Flaccid Dysarthria**

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*Resulting from LMN pathology (CN / SN, Cranial or Spinal Nuclei, Neuromuscular Junction

-Can affect 1 or more speech subsystems:

**Respiration: short phrases, monoloudness **Articulation imprecision

**Laryngeal function: stridor, hoarseness, breathiness, diplophonia, monopitch **Velopharyngeal function: hypernasality / nasal air emission

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Etiologies of Flaccid Dysarthria

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•Trauma, (surgical, head / neck injury)

•Vascular disorders, (brainstem stroke) •Degenerative disease,(ALS)

•Demyelinating disease, (Guillain-Barre’ syndrome)

•Viral infections, (polio, herpes)

•Neuromuscular junction disease, (myasthenia gravis)

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Flaccid Dysarthria - CN V Lesions

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Typically not involved in isolation.

Etiologies: stroke, infection, AVM, tumors, & skull fractures.

•Unilateral Impair.: Jaw deviates toward weak side; Reduced contraction w/ bite

•Bilateral Impair: Jaw may hang open @ rest; can't close mouth; weakness w/ jaw closure & chewing

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Flaccid Dysarthria - CN VII Lesions

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•Etiologies: brainstem injuries, acoustic neuroma, herpes zoster, mono, vascular lesions, & trauma

•LMN damage impacts both upper & lower face muscles

•Unilateral impair: Ipsi hypotonia, unwrinkled forehead, droop eye/brow, eye [partially] open, asymmetry during movement

*Impact on speech:

–Unilateral impair: more visible than audible, mild artic imprec., Vowels OK

-Bilateral impair: Artic imprecision, flutter of cheeks when talking

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Flaccid Dysarthria - CN IX Lesions

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•Rarely damaged in isolation (b/c overlapping nuclei & proximity of other CNs: CNs IX & X impaired together)

•Etiologies: similar to others for lower brainstem•Reduced / asymmetrical gag reflex

•Pharyngeal elevation impact during swallowing •No taste f/ ipsilateral posterior 1/3 of tongue

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Flaccid Dysarthria - CN X Lesions

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-Etiologies: tumors, trauma f/ surgery, infection, stroke, G-B syndrome, motor neuron disease, aneurysms

*Nonspeech OME findings:

Pharyngeal Branch:

.UL: Soft palate hang low on side of lesion & uvula deviates to strong side;

.BL: Palate hang low @ rest & moves minimally/not at all during phonation; Gag reflex difficult to elicit; Nasal regurgitation occur during swallowing

-SLN branch: If recurrent laryngeal nerve branch isn’t affected, VFs may look normal; In unilateral lesions, affected VF vocal cord may appear shorter than normal; In bilateral lesions, both VFs may appear short & bowed

–Unilateral RLN (w/ or w/o SLN): Affected VF weak/paralyzed; May have dysphagia; weak cough & glottal coup

-Bilateral RLN (w/ or w/o SLN): Both VFs weak/paralyzed; Dysphagia; weak cough/coup, @ risk for airway compromise, Inhalatory stridor

*Speech findings:

-SLN & RLN affected: •Breathy / aphonia, Hoarseness, Reduced loudness, Diplophonia, Short phrases, Rapid vocal flutter•See these symptoms w/ UL damage & BL damage (worse)

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Flaccid Dysarthria - CN XII Lesions

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Etiologies: neck lesions, surgery, trauma, stroke, infection, tumor

-Unilateral lesions: Tongue weak (ipsilaterally) & deviate to weak side,

–Bilateral lesions: Bilateral atrophy & fasciculations; Protrusion (very) ltd in range; lateralization & elevation impaired

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Flaccid Dysarthria - Multiple CN Lesions

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•AKA “bulbar palsy”

•In brainstem, but, multiple CNs can be affected in diseases such as MG & ALS

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Flaccid Dysarthria - Spinal Nerve Lesions

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•Etiologies: SCI, MG, ALS, G-B Syndrome

•Nonspeech OME findings: Rapid, shallow breathing; Nasal flaring; use of upper chest & shoulder neck muscles to breathe; Unable to sustain subglottal air px

•Speech findings:Short phrases, red. loudness; Decr.pitch & loudness variability; speaking on residual air; Vx strained

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Vagus (X) Nerve Branches

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•Pharyngeal: Motor to pharynx & soft palate

•SLN (Superior laryngeal nerve)

–Internal: Sensory to laryngopharynx & supraglottic structures

–External: CT (cricothyroid muscle)

•RLN (Recurrent laryngeal nerve): Motor & Sensory to all intrinsic laryngeal muscles (except CT)