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Oral Motor - Exam I

neuroanamtomy, dsyarthrias, respiration, phonation

Major anatomical levels of the brain Supratentorial, posterior Fossa (infratentorial), spinal, peripheral
Supratentorial Boundaries above the tentorium cerebelli membrane upper border of posterior fossa, cerebellum seperates anterior, middle fossae and posterior fossa
Supratentorial includes cerebral hemisphere (frontal, temporal, parietal, occipital lobe pairs basal ganglia, thalamus, hypothalamus Cranial nerve I (olfactory) and II (optic)
supratentorial possible motor speech disorders AOS, Dysarthrias - spastic, unilateral UMN, hypokinetic, hyperkinetic
Posterior Fossa Level Boundaries infratentorial, below tentorium cerebelli
Posterior Fossa includes brainstem - pons, medulla, and midbrain cerebellum origins of Cranial nerves III - XII
Posterior Fossa Motor speech disorders spastic, unilteral UMN, hyperkinetic, ataxic, flaccid dysarthria
Spinal level boundaries foramen magnum
spinal level includes vertebral column - 7 cervical, 12 thoracic, 5 lumbar 31 pairs spinal nerves - dorsal/posterior roots = sensory - ventral/anterior roots = motor
peripheral nerves includes spinal nerve and cranial nerves serving speech
speech production occurs from complex interaction of cognitive, linguistic and motor processes
MSD are speech disorders resulting from impairments in planning and execution of neuromotor control
dysarthria is marked by impaired execution resulting from abnormalities in strength, steadines, tone, or accuracy of movements required for control of the respiratory, phonatory, resonatory, articulatory and prosodic aspects of speech production
Pathophysiologic disturbances are due to CNS/PNS abnormalities and reflect weakness, spasticity, incoordination, involuntary movements; or excessive, reduced, or vairables muscle tone of the speech musculature
need to take speech production that we hear and evaluate the subsystems (respiration, phonation, resonance, articulation, prosody) for strength, range, steadiness, tone, and accuracy
Apraxia of Speech neurologic speech disorder caused by impaired planning/programming sensorimotor commands needed to direct movements of phonetically and prosodically standard speech
ideation begin with thoughts, feeling and emotions
linguistic processes retrieve words from storage and perform phonologic encoding and assemble syntactic frame
motor planning intended message is organized for nueromuscular execution
neuromuscular execution execution involves direct activation of motor neurons, muscle contraction, and movement. CNS & PNS combine to regulate and execute all of the processes by which motor plan results in
neuromotor signal includes CNS, PNS, basal ganglia, propriceptive and tactile sensory, descendign motor tracts and cerebellar control circuits
prevelance of acquired communication disorders that fall in neurological domain 41%
Comprehension involves intelligibility - speech signal only comprehensbility - info independent of the speech signal, context communication conditions - complexity of message both conceptually and linguistically and adversity of listening conditions
Clinical Process of speech disorders 1. identify the perspectives 2. Identify treatment candidates 3. setting treatment goals 4. Assessing treatment efficacy
World Health Organization - International Classification of Functioning includes Body Structure Body Function Activity Participation Environmental factors
Body function integrity physiological function of body systems (speech, language, cognitive and respiratory) Impairment - problems in body function (respiration, phonation, articulation, velopahryngeal function)
Body structure integrity anatomical parts of body (tongue, lips teeth) impairments - problems in body structure (cleft palate, flaccid tongue, flaccid muscles)
Activity execution of task or action (learning, applying knowledge, communication) activity limitation - difficulty executing activities
Participation involvement in life situations, ability and desire to participate in real life situation
environmental factors physical, social, attidunal environmental factors (living situation, rehab situation) environmental barrier - noise, distance, lighting, limited access, societal bias
Personnel Framework includes finder/identifier facilitator general practice clinician specialist expert
Evidenced Based Practice levels Authoritative - expert opinion, accept rationale Observational - case studies (single or series), qualitative research, structured behavioral observations Experimental - randomized controlled studies, studies with controls, single subject designs
Purpose of Clinical Evaluation -detect or confirm suspected problem - establish differential diagnosis - classify with a specified disorder group - determine site of lesion/disease process - specify severity of involvement - establish prognosis -specify precise treament focus
purpose of clinical eval cont'd... - -establish criteris for tx termination - measure change resulting from Tx, lack of Tx or exacerbation
clinical examination components 3 major processes - history of speech problem - physical examination - motor speech examination
Assess for differential diagnosis detect problem classify with a specific disorder group (cognitive, language, motor planning, motor execution) document severity
Asses for dif. diagnosis cont'd... is communication disorder consistent with medical diagnosis? characteristics, severity determine necessary referral
monitor impact of medical intervention communication characteristics, severity, secondary symptoms
Assess for intervention Planning Assesment of impairment, activity, participation Plan intervention strategy
Assessment of impairment communication characteristics subsystem performance (respiratory, laryngeal, velopharyngeal, oral articulation)
Assessment of functional communication Activity - speech only , clinical Participation - in contextualized social situations
Assessment of Activity - speech signal only intelligibility speaking rate naturalness (prosody)
intelligibility a measure of the inderstandability of the speech signal only
AIDS Assesment of intelligiblity of dysarthric speech - standardized assessment tool to measure intelligibility
AIDS measures intelligiibiltiy of single word intelligibility of sentences speaking rate (on sentence task) communication efficiency ratio intelligible word per minute/190WPM
Tally for Windows Computerized measurement of habitual speaking rate. reading passages aloud
Pacer for Windows standard passages and sentences for computerized test
typical adult speaking rates paragraph out loud 160-180 wpm sentences 190 wpm conversation - highly variable
naturalness/prosody the extent to which speech conforms to a listener's standards of rate rhythm intonation and stress patterning
impairment assessment - functional components approach what aspects of the speech motor activity are impaired? how have weakness, slowness, incoordination or abnormal tone affected speech?
oral peripheral exam assess structure assess non-speech movement assess speech (like) movement assess movement during speech
subsystem impairment respiration phonation velopharyngeal function oral articulation
Standarized tests used Iowa Oral Pressure Instrument Experimental Phonetic Intelligibility test Phoneme indentification test optical motion capture Electromagnetic Articulography
purposes of assessment screening - detect or confrim problem differential diagnosis specify severity and prognosis plan treatment measure changethat occurs as a result of treament
CAS - Child Apraxia of Speech speech disorder due to delays or deviances in those processes involved in planning and programming movement sequences for speech
dysarthria disrupted or distorted oral communication due to paralysis, weakness, abnormal tone or incoordination of the muscles used in speech
dysarthria processes affected phonation respirations resonance articulation prosody
movements may be affected such as force, timing, endurance, direction and range of motion
dyskinesias involuntary movements
sites of lesions include bilateral cortical damage, cranial nerve involvement, spinal nerve involvement (respiration), basal ganglia and cerebellum
dysarthria characteristics slurred speech imprecise articulation weak respiratory support and low volume incoordination of the respiratory system hypernasality involuntary dyskinesias of the oral facial muscles spasticity of flaccidity of the oral facial muscles
respiratory system source of aerodynamic energy for speech
essential parameters of respiration air pressure lung volume air flow repiratory shape
Tidal Volume - TV total of resting inspiration and expiration
resting expiratory at end of expiration during resting breathing
expiratory reserve volume - ERV air that is left after bottom of expiration during tidal volume
inspiratory reserve volume - IRV what remains after resting inhalation
Vital Capacity - VC the total amount of air that can be exhaled following maximal inhalation TV+IRV+ERV
inspiratory checking ability to produce low sunglottal air pressure at high lung volume levels
residual volume - RV volume remaining after forced exhalation
TOtal Lung capacity - TLC volume lungs can be expanded with greatest inspiration TV+IRV+ERV+RV=VC+RV
FUnctional Residual Capacity - FRC ERV+RV
Inspiratory Capacity - IC TV+IRV
Forced vital capacity FVC amount of air that can be forcefully expelled from a fully inflated lung position
subglottal air pressure levels 4-8 cm H2O Conversational speech, 1 to 1 relationship btwn sunglottal air pressure and speech intensity
breath groups 10-20% of vital capacity across time average of 15 syallables per breath group 50cc of airflow per syllable (1/3rd of a mouthful of air)
breath pattern Inspiratory :expiratory ratio for speech 1:6
overall goal for respiratory treatment consisten, adequate subglottal pressure during speech produced with minimal fatigue and appropriate breath group lengths
vocal intensity sound energy percieved as loudness
fumndamental frequency rate of VF opening / closing perceived as pitch
vocal quality regularity of VF vibratory cycle perceived as roughness, harshness, hoarseness
hypoadduction weakness/reduced closure of vocal folds from inflammatory myopathies, muscular dystrophies, breathy, quiet, aperiodic, hoarse, nasal
hyperadduction closure is too tight - strained, strangled, pressed, harsh, loud/soft/normal, HUntington's, Pseudobulbar Palsy, some brain injuries
phonatory instability variations in frequency/intensity = tremors, rough, hoarse with pitch breaks and fry
mixed phonatory impairments aspects of above = MS, ataxic (cerebellar), dyspohonia
phonatory coordination impairment poor coordination of phonatory system with articulation results in lack of voiced-voiceless distinctions or aspiration anomalies
hypoadduction - myotonic muscular dystrophy (MMD) aperiodic, hoarse, hypernasal
hypoaddcution - myasthenia gravis hypernasal, stridor, "vocal weakiness"
hypoaddcution - peripheral nerve (recurrent laryngeal) damage unilateral - hoarse, breathy voice, reduced loudness OR voice may be normal
hypoaddcution - preipheral nerve (superior laryngeal) damage mild hoarseness, vocal fatigue
hypoadduction- Xth cranial nerve injury to LMN laryngeal paralysis,
hypoadduction - brainstem stroke and Parkinson's disease reduced loudness, monotone, hoarse, tremor
hypoadduction - closed TBI hypophonia
hyperadduction UMN lesions, quick hyperkinesia of Huntington's disease, dysphonia, adductor spasmodic dysphonia
Phonatory assessment history, structural integrity perceptual quality voiced, voiceless, pitch, loudness acoustic - range of frequency physiologic - laryngeal function
range of frequency in men and women men 110-150 Hz women 175-210 Hz 25-50dB
Phonatory assessment cont'd... intelligibility - with/without background noise predictable/unpredictable changes in phonation - voice breaks, ptich shifts, monotone timing of laryngeal - articulatory function - voiced, voiceless, distinguish cognates, aspirated sounds?
evaluating reflexive phonation crying, laughing, coughing, choking
flaccid dysarthria vocal fold immobility, incomplete glottal closure, reduced palatal movement, reduced pharyngeal wall movement, breathy, diplophonic, reduced loudness, decreased pitch and range
which disorders present with flaccid dysarthria myasthenia gravis, vascular disorders (brainstem CVA affecting CN nuclei), infections (polio, herpes, meningitis), demyelnating disease (Guillain-Barre), muscle disease (Muscular Dystrophy), degenerative disease (progressive bulbar palsy, ALS)
Flaccid dysarthria treatment head turn, digital manipulation of thyroid artilage, speak at onset of exhalation, use of optimal breath groups portable amplification, vocal fold injection, pharmacologic
Spastic dysarthria reduced inhalatory/exhalatory volume, hyperadduction of vocal folds, slow velopharyngeal movements, reduced speech and range of tongue, lip and jaw, reduced tongue strength, incomplete lingual articulatory contacts
spastic dysarthria - what do we hear? harsh, strained quality, pitch breaks, monopitch, monoloudness, low pitch
which disorder present with spastic dysarthria vascular (brainstem CVA), lacunar CVA (deep:basal ganglia, thalmus, brainstem, deep cerebral white matter), degenerative disease, TBI
behavior mod for spastic dysarthria speak at onset of exhalation, speak on deep breath, increase ptich, breathy onset, optimize breathing group, relaxation or massage
ataxic dysarthria irregular chest wall movement, voice tremor, slow lip, jaw and tongue movement
ataxic dysarthria - what do we hear? harsh, monopitch and mono loudness
which disorder presents with ataxic dysarthria degenerative diseases, vascualer disorders, tumors, trauma, toxic disorders, chronic alcoholism
hypokinetic dysarthria difficulty altering automatic breathing patterns, bowed vocal folds, tremulousnessof arytenoid cartilages, reduced lip and jaw amplitude, lip rigidity
hypokinetic dysarthria - what do we hear? monopitch and loudness, reduced loudness, breathy
which disorders present with hypokinetic dysarthria? degenerative desease (Parkinson's disease), vascular (multiple or bilateral CVA), certain medications, trauma TBI, infections
hypokinetic dysarthria treatment behavior mod - effortful closure technique, Lee Silverman voice treament, speak at onset of exhalation, high phonatory effort, optimize breath groups, surgical fixes
hyperkinetic dysarthria abnormal involuntary movements, may be rapid or slow, maybe irregular or rythmic
hyperkinetic dysarthria - what do we hear? strained quality, excessive loudness variation, reduced ptich and variability, dysphonis, adductor voice arrests, vocal tremor, contiuous or intermittent aphonia
hyperkinetic dysarthria presents in which disorders? idiopathic, tardive dyskinesia, HUntington's chorea, MS, Tourette's syndrome
unilateral UMN dysarthria mild to moderate dysphonia, in single hemisphere CVA (cortical or lucanar), usually mild
ataxic site of lesion cerebellar circuit
flaccid site of lesion lmn, one or more cranial nerves
hyperkinetic site of lesion basal ganglia circuit
hypokinetic site of lesion basal ganglis circuit
spastic site of lesion umn (usually bilateral)
Articulation assessment speaking mode speaking task speaking context cueing level
speaking mode habitual, clear
speaking task imitative, reading, spontaneous
speaking context single word, carrier phrase, sentence, paragraph
cueing level simultaneous imitation (choral), immediate imitation, delayed imitation, spontaneous, answer questions
Created by: germanne08



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