Chapter 3 Motor Speeh Disorders Exam Flashcards
(182 cards)
1
Q
What is the purpose of a motor speech disorders exam?
A
- To give a description
- to establish diagnostic possibilities
- to establish a diagnosis
- to establish implications for localization and disease diagnosis
- to specify a severity
2
Q
What does the clinician describe during a motor speech disorders exam?
A
The patient’s speech and the structures and function of those structures.
3
Q
What does the clinician need to determine after the description of the patient’s speech, structures and functions of those structures have been made?
A
Clinician needs to determine if the characteristics are normal or abnormal.
4
Q
What happens if an aspect of speech structures or functions is abnormal?
A
The clinician attempts to make a differential diagnosis.
5
Q
What happens in a differential diagnosis?
A
The clinician narrows the diagnostic possibilities and tries to arrive at a specific diagnosis.
6
Q
What kind of information is described in the motor speech disorders exam?
A
The information provided is about the features of speech and the structures and function associated with speech.
7
Q
What must occur after clinician determines that speech is not normal?
A
The clinician should determine some possible diagnoses.
i.e. is it neurological, developmental or acquired, is there a speech disorders present?
8
Q
How does the clinician establish a diagnosis after a motor speech disorders exam?
A
The clinician should attempt to make a diagnosis from the acquired, developmental, neurological, motor speech. If that is not possible then put the list in order of most possible to least possible.
9
Q
How does clinician establish implications for localization and disease?
A
The clinician should state the diagnosis and the localization associated with the diagnosis. For example, the clinician can state that the diagnosis is spastic dyasrthria which is associated with UMN involvement, or that the diagnosis is ataxic dysarthria which is associated with cerebellar involvement.
10
Q
What should be done if a neurological diagnosis has already been made and it is inconsistent with the SLPs findings?
A
It should be noted.
11
Q
What happens if the patient has been diagnosed with ALS, but the SLP finds a mixed dysarthria of ataxic-hypokinetic?
A
It should be noted that the dysarthria findings are inconsistent with a diagnosis of ALS.
12
Q
What happens if a diagnosis is uncertain?
A
The SLP may indicate possible diagnoses. For example, if a stress test indicates a strong possibility of myasthenia gravis, SLP should note this.
13
Q
What does the SLP have to do if a stress test indicates a strong possibility of myasthenia gravis?
A
The SLP needs to make note of it, NOT diagnose myasthenia gravis (not within our scope).
14
Q
Why should an SLP always comment on the severity of a diagnosis?
A
1) To compare the patient’s complaints - it may provide information about a possible psychogenic component or lack of insight on the part of the patient.
2) It influences prognostic statements and decisions about how to manage the disorder.
3) It provides baseline information against which to compare progress or changes.
15
Q
Severity statements usually refer to the what categories?
A
Mild, moderate, and severe
16
Q
Provide an example of how the clinician establish implications for localization and disease of spastic dysarthria.
A
The diagnosis is spastic dysarthria which is associated with UMN involvement.
17
Q
Provide an example of how the clinician establish implications for localization and disease of ataxic dysarthria.
A
The diagnosis is ataxic dysarthria which is associated with cerebellar involvement.
18
Q
What are the general guidelines for exam?
A
- History
- salient
- confirmatory signs
- interpretation of findings
19
Q
What information does history provide?
A
- time of onset
- course of development
- patient’s complaints and observations
- It provides an opportunity to listen to patient’s speech without them knowing you are listening to the speech.
20
Q
Describe salient features:
A
Those features that contribute most directly to the diagnosis and most influence the diagnosis.
21
Q
______ features are those that contribute most directly to the diagnosis and most influence the diagnosis.
A
Salient
22
Q
List the salient features:
A
- strength
- speed
- range
- steadiness
- tone
- accuracy
23
Q
Muscle weakness is most prominent in what type of dysarthria?
A
flaccid dysarthria
24
Q
The weakness of muscles affect what 3 major speech valves?
A
- laryngeal
- velopharyngeal
- articulatory
25
Describe why strength is a salient feature.
In order to perform appropriately, muscles have to have a certain strength. If muscles are weak, they can't work properly and may fatigue more quickly than usual.
26
What happens if muscles are weak?
They can't work properly and may fatigue more quickly than usual.
27
Muscle weakness affects laryngeal, velopharyngeal, and articulatory valve. What are the other components of speech production that can also be impacted?
- respiration
- phonation
- resonance
- prosody
28
Why is speed a salient feature?
All speech movements require speed, especially the laryngeal, velopharyngeal, and articulatory valve movements.
29
Speech requires quick, unsustained and discrete movements which are called _______ ________. These can be ______ muscle contractions or _______ contractions.
phasic movements
single
repetitive
30
All speech movements require _______, especially the laryngeal, velopharyngeal, and articulatory valve.
speed
31
What are phasic movements?
Quick unsustained and discrete movements. These can be single muscle contractions or repetitive contractions. They start quickly, reach their target quickly and relax quickly.
32
Phasic movements are controlled primarily through _____ input.
UMN
33
What is associated with decreased range of motion?
too much speed
34
In which dysarthria is there too much speed?
hypokinetic dysarthria
35
What happens when there is too much speed?
The articulators move so fast they can't reach their targets.
36
What is most common in motor speech disorders, slow or fast movements?
slow
37
How are the slow movements demonstrated?
- slow initiating
- slow throughout the movement
- slow to stop or relax
38
What do slow movements affect?
All valves and prosody
39
The affects of slow movement is most seen in what type of dysarthria?
spastic dysarthria
40
Decreased _____ is common and can be associated with slow or excessive speeds.
ROM
41
Decreased ROM is common and can be associated with what?
slow or excessive speeds
42
ROM can vary with what dysarthrias?
ataxic dysarthria
| hyperkinetic dysarthria
43
Patient's can ____ and _____ the targets.
over
| undershoot
44
What does tone refer to?
muscle tone and can be hypo or hyper.
45
When there is no steadiness, it manifests itself usually in MSDs as a ______ or other ______.
- tremor
| - hyperkinesias
46
Tremors can be ____ to ____ and may affect _____ as well as other parts of the body.
mild, severe
| speech
47
What can tremors affect?
Phonation and sometimes prosody
48
The effects of tremors in speech can best be heard in _____ _____.
vowel prolongation
49
Tremors may be seen in _____ tasks involving the ____ _____.
nonspeech
| oral mechanism
50
What are the types of tremors?
- resting tremors
- intentional tremors
- terminal tremors (at the end of a movement)
51
List other hyperkinesias besides the tremors which may interfere with or be present during speech.
- dystonias
- choreas
- athetosis
52
Why is accuracy a salient speech?
Accurate movements are required for speech.
53
What happens if inaccurate movements are present?
They can result in speech errors.
54
What if there is too much force or too much ROM?
The articulators may overshoot the target and vice versa. Inaccurate movements also affect all major speech valves.
55
What are confirmatory signs?
Additional clues about the pathology in the nervous system. These are signs other than the problematic speech characteristics noted and other than the neuromuscular symptoms.
56
Confirmatory signs are signs other than the ______ ______ _______ noted and other than the _________ ______.
problematic speech characteristics
| neuromuscular symptoms
57
What do confirmatory signs help support?
speech diagnosis
58
Confirmatory signs have to be present or not present?
Present
59
What are examples of confirmatory signs within the speech system?
- atrophy
- fasciculations
- reduced tone
- emotional liability
- reduced normal reflexes
- pathological reflexes
60
What are the confirmatory signs of the non-speech system?
- gait
- muscle stretch
- reflexes
- pathologic reflexes
- hyperactive limb reflexes and limb atrophy
- fasciculations
61
What should the SLP integrate to formulate a diagnosis?
- information from the history
- salient speech features
- confirmatory signs
62
The SLP should make a ____ diagnosis if possible, if not, what should you do?
definitive
| make a formulation of diagnostic possibilities.
63
What is an example of a definitive diagnosis?
The patient presents with (an unambiguous) spastic dysarthria, with a possible accompanying ataxic component. There is no evidence of apraxia.
64
History: Introduction and goal setting-
-Ask the patient why they are there. this gives you information about the patient's perceptions, complaints, etc.
65
History: Basic Data -
Get basic information such as age, married status, education, occupation, etc
Determine any previous speech problems and treatment, if any.
66
History: Onset and course of speech deficit.
-When did the speech problem begin
- how did it begin?
-how has the problem changed?, if it has changed.
-Is the problem variable?
Does teh speech return to normal at any time? If so when?
-Taking any medications, if so what?
-Does fatigue affect speech?
67
History: Associated deficits:
-swallowing/chewing/controlling bolus/drooling problems? Nasal regurgitation?
emotional expression changes? Laugh or cry more easily and without apparent cause?
68
History: Patient's perception of deficit
Describe your problem with speech. Give examples
- . Is your speech slower or faster than usual;
- louder or softer;
- is speaking effortless;
- less intelligible
- does it feel different when you talk?
69
History: Consequence of disorder -
Do you have difficulty being understood by others?
- does this vary throughout the day or in different places?
- Do you still maintain your social network or do you go out less often?
- What changes have you made in your life due to the speech changes?
70
History: management -
- How have you tried to compensate for your speech problem?
- What works and what doesn't work?
- What kind of professional help have you had?
- Do you need help not?
71
History: Awareness of diagnosis and prognosis
- Do you know the cause of your problem?
- What has the Dr. told you?
- What does this diagnosis mean to you?
- Do you know how the disorder will progress?
72
What is part of the examination of speech mechanism in non-speech activities?
- face
- tongue
- jaw
- reflexes
- larynx
- velopharyngeal port
- palate
- respiration
73
What do you look for when you examine face at rest during the examination of speech mechanism in non-speech activities?
- face should be symmetrical
- normal tone and little or no extraneous movement
- it shouldn't droop or be rigidly fixed, or show uncontrollable emotion.
74
How do you examine face at rest?
- Ask patient to relax, look ahead and open lips slightly to breathe through the mouth.
- Notice if face is symmetric in this posture, angles of mouth is symmetric, drooping on one side of face, eyelids, or corner of mouth, flattening of nasolabial fold, etc.
- slight differences in symmetry are OK.
- Look for mask-like expressions, stiffness anywhere in face.
- Are there any involuntary movements, or tremors, in the face? Are there fasiculations in the face, especially note the mouth and chin.
75
How do you assess face during sustained postures for the examination of speech mechanism in non-speech activities?
- have the patient retract lips, round lips, puff cheeks, open mouth, and hold each a few seconds.
- Try to push upper or lower lip toward mid-line while in retracted sustained posture to see if patient can resist this movement. While lips are rounded, try to spread lips and see if patient can resist this.
76
What do you look for in face during sustained postures?
- symmetry or asymmetry
- range of motion (normal or restricted)
- sagging or drooping of mouth
- look for tremulousness
- can postures be held for several seconds?
77
How do you assess face during movement?
Watch face during speech and non-speech movements.
78
What does the clinician look for when assessing face during movement?
- expressiveness
- symmetry/asymmetry (mild asymmetries are ok)
- compare both voluntary and involuntary movements, smiling when something is funny and retracting lips on request
- emotional responses
- range of movement
79
What does the clinician look for when jaw is assessed at rest?
- is it tightly closed or open a little at rest?
- Does it hang lower than normal?
- Are there tremors or other involuntary movements, fasciculations?
- Does it pull to one side?
- Does the patient compensate by clenching teeth?
80
What are you assessing when observing jaw during sustained posture?
-jaw deviations to one side
81
What are you observing for when you attempt to open jaw when patient is asked to clench teeth?
With patient holding mouth open, try to close it?
Can patient resist this?
palpate masseter/temporalis muscle with patient clenching teeth.
-Is there normal bulk?
can patient resist this?
82
How is jaw assessed during movement?
Have Patient rapidly open and close mouth.
83
What is the clinician looking for when assessing jaw during movement?
symmetry and ROM in speech and spontaneous movements
- note speed and regularity
- are there involuntary movements which interfere with opening and closing?
84
How do you assess tongue at rest?
Have patient open mouth and observe tongue in mouth. it should be relaxed on the floor of mouth. Some slight movement is normal.
85
What are you looking for when assessing tongue at rest?
- is tongue symmetrical and of normal bulk and size?
- is there atrophy (sometimes you might see grooves -which occurs as part of atrophy?
- are there fasiculations?
- are there other movements?
- is tongue wet or dry?
86
If the tongue is dry, what does it indicate?
Might be indication of zerostomia which is dry mouth associated with various causes (too little water intake, meds radiation).
87
If the tongue is inappropriately wet, what does it indicate?
patient is not handling secretions well
88
How does the clinician assess tongue in sustained postures?
Have patient protrude tongue and hold it. it's hard to hold this posture so small movements are normal.
89
What do you look for when assessing tongue in sustained position?
- Look for tongue deviation to one side
| - look for ROM of tongue protrusion
90
What happens if tongue deviation is subtle when assessing tongue in sustained position?
Have patient repeat the process several times and look for consistent deviation.
91
When assessing tongue in sustained position, what is the clinician looking for when the tongue blade pushes against tip of tongue, or client pushes against inside of each cheek with tongue as clinician press against cheek with finger, or when tongue is pushed to one side when protruded?
If patient can resit these actions.
92
How is the tongue assessed during movement?
Ask patient to move tongue rapidly from side to side of mouth.
93
What do you look for when assessing tongue during movement?
- speech regularity
| - ROM
94
How does the clinician assess the velopharynx at rest?
Have patient open mouth widely, Push down gently on tongue with tongue blade.
95
What do you look for when assessing the velopharynx at rest?
Look at palate-does it hang low, is it symmetrical.
96
How do clinicians assess the velopharynx during movement?
Have patients say a prolonged "ah" and intermittent "ahs"
97
What do you look for when assessing the velopharynx during movement?
- palatal movement
- is there symmetry of movement? If asymmetric, does the palate elevate more strongly to opposite side to that which hung lower at rest?
98
How do you check for evidence of nasal airflow while assessing velopharynx during movement?
Hold mirror at nose during vowel prolongation and repetition of pressure consonants.
99
How do you check if there is a difference in resonance while assessing the velopharynx during movement?
Hold patient's nsoe during vowel prolongation.
100
Why do you have patient puff cheek and contain air while you try to push against cheeks during the velopharynx assessment during movement?
TO check if client can resist movement
101
If possible what should be done to examine VP activity?
videoflouroscopy
102
How does the clinician assess for vocal fold adduction?
Through coughing
103
What are you looking for when a client coughs (checking vocal fold adduction)?
Listen for a sharp cough, not its loudness.
104
What does a weak cough indicate when assessing the larynx for vocal adduction?
Either poor vocal fold closure but this may be combined with poor respiratory support.
105
Why would clinician ask patient to produce glottal "coup".
To compare cough and coup. If cough is weak and coup is sharp, implications are of poor respiratory support.
106
How should the glottal "coup" be produced?
The coup is sharp and requires little respiratory effort.
107
What are the implications if the coup is sharp and and the cough is weak?
Poor respiratory support
108
What if the coup and cough are both weak, what are the implications?
Poor vocal fold closure but this may be combined with poor respiratory support.
109
What does inhalatory stridor indicate?
poor vocal fold abduction.
110
How is inhalatory stridor heard?
can be heard in quiet breathing but is more prominent usually in inspiration before speech.
111
What may be done to actually observe vocal folds?
laryngoscopy
112
What are the different types of langyoscopy?
- flexible fiberoptic laryngoscope
- rigid oral laryngoscope
- videostroboscopy
- electroglottography
113
What does the clinician look for when assessing respiration?
- Note if posture is normal- is patient slouched or bent forward?, is head drooped forward?
- Does patient complain of shortness of breath? is it at rest or during activity?
- is breathing shallow or rapid?
- is there shoulder movement or neck extension during inspiration?
- is there flaring of the nares in breathing?
- is berthing rate regular?
- are there persistent hiccups?
114
While assessing respiration you can also contrast sharpness of what?
cough to glottal coup
115
What happens if there is abnormal posture?
It can constrict diaphragm, abdomen or chest wall and make breathing difficult.
116
What is the normal breathing rate?
16-18 breaths per minute
117
What is shoulder movement or neck extension during inspiration associated with?
respiratory weakness and reduced loudness
118
If breathing rate is irregular it may be related to ______ disorders.
movement
119
What do persistent hiccups indicate?
may be indication of medulla lesion
120
How can you assess for respiratory support?
Fill glass with water (at least 12 cm deep). Attach a straw to the glass with paper clip. Have patient blow into straw to maintain a stream of bubbles for 5 seconds. Straw must be at least 5 cm into the water.
121
What does the client do that demonstrates respiratory support is ok?
Client will blow into straw to maintain a stream of bubbles for 5 seconds.
122
What must clients maintain in order to blow into a straw to demonstrate respiratory support?
maintain labial seal around straw and be able to impound through VP closure.
123
What do reflexes provide during assessment?
confirmatory information
124
What are the two types of reflexes?
1. normal reflexes
| 2. pathological reflexes
125
What do normal reflexes indicate?
Normal nervous system function
126
What are pathological reflexes?
Primitive reflexes that are present during infancy but disappear as the nervous system matures.
127
_______ reflexes may reappear due to CNS diseases and are associated with a release phenomena or poor inhibitory mechanism in the brain.
Pathological
128
Why will pathological reflexes reappear?
Due to CNS diseases
129
What are pathological reflexes associated with?
A release phenomena or poor inhibitory mechanism in brain.
130
Normal reflexes are ______ among normal individuals and some normal individuals demonstrate _____ reflexes, so these results must be interpreted with caution.
variable
| pathological
131
How is the gag reflex elicited?
By touching back of tongue, posterior phrayngeal wall, or faucial pillars.
132
What nerves are involved in the gag reflex?
- glossopharyngeal nerve provides the sensory information to the brain.
- glossophrayngeal and vagus nerves provide the motor response
133
How is the gag reflex characterized?
Palatal elevation, tongue retraction, and contraction of pharyngeal walls.
134
Why must you assess both sides when checking for gag reflex?
Looking for asymmetrical gag reflex.
135
Why is it clinically significant if the gag reflex is present on one side and absent on the other side?
- If it feels different on each side - afferent component may be impaired.
- If it doesn't feel different - motor component may be impaired
136
Why is the absence of a gag reflex not clinically significant?
Some normal people don't have strong gag reflex.
137
What is the primary think you should look for when assessing the gag reflex?
asymmetry in the gag reflex
138
How does a clinician assess for a jaw jerk reflex?
Have patient relax and drop jaw. Put tongue blade on patient's chin. Tap the blade with finger or reflex hammer.
139
How if the jaw jerk reflex characterized?
The reflex is indicated if the masseter and temporalis muscles contract and the jaw jerks toward closing.
140
Which nerve handles both the afferent and efferent components of the jaw jerk reflex?
Trigeminal nerve
141
The trigeminal nerve is responsible for what reflex?
efferent and afferent components of the jaw jerk reflex
142
About what percent of normal people have the jaw jerk reflex?
10%
143
What does the presence of the jaw jerk reflex indicate for most people?
Indicates UMN disease above the level of trigeminal nerve nuclei in the mid pons.
144
How does a clinician asses the sucking reflex?
Stroke the upper lip with tongue blade, starting at the sides of upper lip and moving toward mid-line. Do it on both sides.
145
What is the normal response when people are assessed for the sucking reflex?
No response
146
What is a positive response for a sucking reflex?
The reflex is present, pursing or pouting of lips.
147
What does the presence of sucking reflex in adults indicate?
UMN disease above the level of facial nerve nuclei in the pons.
148
The presence of the sucking reflex is often in people diagnosed with what disease?
dementia
149
How does clinician assess for the snout reflex?
Lightly tap finger on tip of nose or philtrum or by pushing backward on upper lip and philtrum at midline with your finger.
150
How is the snout reflex characterized?
Puckering or protrusion of lower lip and depression of side of mouth.
151
What is the perceptange of adults with the presence of the snout reflex?
17%
152
There is a greater occurrence of the snout reflex after age ____ in normal adults/
60
153
How is the palmomental reflex elicited?
Primitive reflex elicited by vigorously stroking tongue blade on palm of hand.
154
How is the palmomental reflex characterized?
Slight elevation of ipsilateral chin.
155
What is the palmomental reflex associated with?
Projection fivers to paracentral cortex
156
What is the percentage of normal adults that may exhibit the palmomental reflex?
17%
157
In nonverbal oral apraxia (NVOA) ________ movements are OK whereas ________ movements are impaired.
automatic
| voluntary
158
Explain volitional versus automatic movements in nonverbal oral apraxia.
Automatic movements are OK whereas voluntary movements are impaired.
- May be able to cough spontaneously, but not be able to do so upon command.
- May be able to pucker lips to kiss someone,but not be able to do so upon command.
159
If patient can't do a movement upon command how else can clinician assess it?
Check if they can do it with imitation.
160
What is Nonverbal oral apraxia (NVOA) often but not always associated with?
verbal apraxia
161
If the patients has apraxia of speech of aphasia, the patient should also be assessed for what?
Nonverbal oral apraxia (NVOA)
162
Nonverbal oral apraxia can happen with what lesions?
left hemisphere lesions
163
Mayo clinic dysarhtria studies are used to categorize what type of speech characteristics?
perceptual
164
Read Distinctive speech characteristics from book.
Pg 90
165
What are the tasks used for speech assessment?
- vowel prolongation
- AMrs (diadochokinetic rates of individual syllables)
- SMRs (putuku)
- contextual speech
- Fatigue
- Assess speech motor planning
166
How does clinician assess for vowel prolongation?
- Tell patient to take a deep breath and say "ah" for as long as they can.
- Note maximum vowel duration as well as other salient characteristics.
- Notice face, jaw, tongue and neck in vowel prolongation
167
Check for norms of vowel prolongation.
Pg 91
| Table 3-2
168
How does a clinician assess for AMRs?
Tell patient to take deep breath and say the syllables required. SLP should model first.
169
What do you note for during AMRs?
speed, regularity, movements of jaw/tongue, articulation precision
170
What do you measure in SMRs (putuku)?
ability to move rapidly from one articulatory posture to another.
171
______ particularly are helpful in determining apraxia?
SMRs
172
Which task for speech assessment is particularly helpful in determining apraxia?
SMRs
173
How do you assess for contextual speech?
Grandfather passage as well as conversational speech
| Use open-ended questions.
174
What do you note during contextual speech?
- articulation precision
- speed
- intelligibility
- prosody
- monotone
- loudness
175
How do you assess for fatigue?
Assess by counting, reading aloud for 2-4 minutes. Provide 1 to 2 minutes to rest and listen to speech again..
176
How do you assess for speech motor planning?
SMRs and ability to say multisyllabic words
177
What do you look for when assessing speech motor planning?
- groping
- self-correction
- delayed response
- awareness of errors
178
If apraxia is suspected what kind of speech motor planning assessment do you do?
- SMRs
| - ability to say multisyllabic words
179
Name a dysarthria assessment.
Frenchay Test of Dysarthria Assessment
180
Name apraxia tests.
- Apraxia battery for adults-2nd edition
- Nonverbal Oral movement Asessment
- Assessing speech programming
181
What do intelligibility tests assess?
- intelligibility
- comprehensibility
- efficiency
182
Name intelligibility tests
- Assessment of intelligibility in Dysarthric speakers (AIDS)
- Sentence Intelligibility Test-updated Windows version of sentence part of AIDS
- Intelligibility part of Frenchay
- Word Intelligibility Test-developed by Kent and is not standardized
