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