Comd 555 Final

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  1. what is hyperkinetic Dysarthria
    Disease of the basal ganglia or extra pyramidal pathway. It means too much movement; it produces involuntary movements (excessive involuntary movements: chorea, myoclonus, tics, dystonia and essential tremor); the impression is that it interferes with normal speech production and that if involuntary movements could be eliminated, speech production might be normal.

    The movements are unpredictable and variable.

    • a group of various MSD 
    • can be: 
    • Hyperkinetic Dys of the ___ type.
    • chorea, tics, tremor, dystonia,
  2. What can cause hyperkinetic Dysarthria?
    Any condition that causes too much Dopamine to be released into the basal ganglia 

    Has an excitatory effect
  3. Huntington's Disease
    Progressive genetic disorder of the basal ganglia

    Child has a 50% chance of inheriting the disease

    Symptoms appear at about 35 - 40 y/o

    15yr life expectancy 

    Chorea, dementia, emotional instability, cognitive decline, personality changes

    associated with hyperkinetic dysarthria of the chorea type.

    choreic movements interfere with voluntary actions
  4. Hyperkinetic Dysarthria of the Chorea Type
  5. most subsystem impacted in Hyperkinetic Dysarthria?
  6. Dyskinesia
    (abnormal excessive involuntary movement)

    Orofacial dyskinesia: face

    Tardive Dyskinesia : (specific to face) late onset/common side effect of using antipsychotic drugs
  7. Hyperkinesia:
    Too much movement
  8. Myoclonus
    single or repetitive, brief sharp jerk of the body
  9. Tics:
    Simple or Complex, non-purposeful under partial voluntary control
  10. complex Tics
    Complex: has a purpose: Ex. scratching, throwing, chewing, word
  11. Tic: Coprolalia:
    When the person involuntarily swears (inappropriate derogatory comments)
  12. Diagnosis for Tourette Syndrome
    Most commonly associated with Tourette syndrome. Must have tics for 1yr, have a motor and vocal tics and never a period of more than 2 months when they didn’t have the ticks, client must report significant impairment to get diagnosis.
  13. Chorea
    Quick, irregular, rapid, involuntary purposeless movements. Variable tone present in the muscles. Seen in Huntington’s disease, encephalitis.

    Dance like movements. appear smooth and coordinated (they are unpredictable)
  14. Ballismus
    • Abrupt contractions of the muscles of trunk or head.
    • Can effect the whole or half (hemi Ballismus) of the body (depends on nuclei damaged).

    Damage to the sub-thalamic nucleus.
  15. Athetosis
    Abnormal muscle contractions cause involuntary writhing movements.

    Seen in people with CP
  16. Dystonia
    Involuntary abnormal postures that occur with co-contraction of antagonist muscles.

    Can appear focally. Ex. mouth
  17. Spam
    A sudden involuntary movement

    Tonic: a prolonged or continuous spam

    Clonic: a short repetitive spam
  18. Blepharo Spasm
    Forceful closing of the eyes
  19. Tremor
    The most common involuntary movement.

    The origin can be at the cerebellum or a pathway (cerebellar pathway).

    Resting: Body is in repose

    Postural: Body part is maintained against gravity

    Action: During movement

    Terminal: As the body nears the target
  20. Distinctive Speech Characteristics: of the Chorea type
    • Prolonged intervals between words and sounds
    • Variable rate
    • Inappropriate silences
    • Excess loudness variations
    • Prolonged phonemes
    • Sudden inhalations/exhalations
    • Voice stoppages
    • Transient breathiness

    (in order from most common)
  21. Hyperkinetic Dysarthria of the dystonia-type
    • Affects Articulation the most
    • Slower movements than Chrorea
    • (waxing and weaning)

    AMRs help you best observe the dystonia

    • Deviant speech characteristics:
    • Distorted vowels
    • Harsh vocal quality
    • Irregular articulatory breakdowns
    • Strained-strangled vocal quality
    • Inappropriate silences
    • Excess loudness variations
    • Voice stoppages
    • Audible inspiration Voice tremor
    • Alternating loudness

    (in order of most common)
  22. non speech characteristics of hyperkinetic Dysarthria of the dystonia type
    • Anterior spillage
    • dysphagia
    • Blepharospasm
    • facial grimacing
    • Mouth opening, closing
    • lip pursing or retraction
    • rotary tongue movements & protrusion
    • (due to sustained muscle spasms)
    • Neck torsion
    • elevation of larynx
    • slower movements that chorea
  23. UUMN Dysarthria

    Who does it primarily manifest?
    weakness and coordination specially in central face and tongue

    Most common cause Stroke

    can be masked by other co-occurrences 

    often temporary and mild in nature
  24. UUMN Dysarthria patient complaints:
    • Slurred, thick, or slow speech
    • Chewing and swallowing difficulties Pseudobulbar crying or laughter
    • Drooling
  25. UUMN Dysarthria Clinical signs:
    • imprecise consonants (most pervasive) 
    • Slow AMRs (2nd most common)
    • Irregular & imprecise AMRs
    • Irregular articulatory breakdowns
    • Reduced strength/endurance/speed of lip and tongue movement

    • phonation:
    • Harsh vocal quality may be present
    • Reduced loudness
    • Mild vocal fold spasticity

    Resonance: mostly not affected

    Prosody: affected by slower rate

    • Respiration:
    • mild incoordination issues with phonation                        reduced loudness                       
    • Loudness decay                       
    • Short phrases                       
    • reduced vowel duration
  26. UUMN Dysarthria: Subsystems affected?
    • Articulation
    • Phonation
    • Prosody
  27. What are the most common mixed dysarthrias?
    Flaccid/spastic (ALS)

    Ataxic/Spastic (MS, most caused by stroke)

    Hypokinetic/Spastic (associated with degenerative disease)
  28. What determines the prominent components of mixed dysarthria?
    Severity and extent of damage

    remember is can change over time.
  29. ALS and Mixed Dysarthria
    • Progressive degeneration of motor neurons.
    • Most common MND
    • death is usually to respiratory failure

    a mixed UMN and LMN disease

    • Flaccid/spastic
    • Prosodic excess

    Prosodic insufficiency

    Articulatory-resonatory incompetence

    Phonatory stenosis

    Phonatory incompetence

    Resonatory incompetence

    • Distinguishing Deviant Speech Characteristics:
    • Prolonged intervals
    • Prolonged phonemes
    • Inappropriate silences

    • *all impact prosody
    • (bad date)
  30. Multiple Sclerosis (MS)
    most common demyelinating disease

    Etiology unknown

    Can occur anywhere in CNS

    most do not have dysarthria

    • Most common speech complaints:
    • Loudness control, harshness and impaired articulation
  31. MS and mixed dysarthria

    • Deviant Speech Characteristics: MS
    • Impaired loudness*
    • Harshness+
    • Defective articulation
    • Impaired emphasis
    • Impaired pitch control*
    • Hypernasality+
    • Inappropriate pitch level
    • Breathiness
    • Sudden articulatory breakdowns*
    • Reduced Pitch Variability +
    • Slow rate of Speech +

    • * characteristic of Ataxic
    • + characteristic of Spastic
  32. TBI and mixed Dysarthria
    60% the dysarthria resolves, 10% have chronic dysarthria.

    Any kind can present due to diffused damage.

    tend to see: Flaccid/Spastic

    • Characteristics: 
    • Reduced vocal intensity
    • Hypernasality
    • Slowed rate of speech 
    • Syllable lengthening
  33. Wilson's Disease and Mixed Dysarthria
    rare Hereditary

    prevents metabolism of dietary copper

    • Symptoms:
    • reduced stress
    • monopitch
    • monoloudness

    • with 
    • Cognitive, motor and psychiatric problems

  34. Apraxia of speech
    Impaired planning or programming the voluntary movements for speech production
  35. Nonverbal oral apraxia
    Impaired planning or programming of nonverbal oral movements Apraxia of speech

    • Inability to sequence nonverbal, voluntary movements of the tongue lips, jaw, and other oral structures:
    • protruding the tongue, whistling, biting the lower lip and puffing out the cheeks

    left hemisphere damage

    often co-occurs with aphasia

    does not affect spontaneous or reflexive orofacial movements
  36. The Motor Speech Programmer Network
    Broca’s area & supplementary motor area

    May be a primary storehouse and integrative processor for previously acquired, highly practiced speech routines

    Often identified as a lesion site in people with AOS
  37. Insula
    has been identified as a site of damage from stroke in people with AOS

    Sometimes the only site of damage

    Has a role in the acquisition of new speech routines

    No damage to the left insula may be a good prognosis sign
  38. Basal ganglia
    Lesion here have been associated with AOS

    known role in motor control
  39. Lesions of stroke induced AOS are usually located in the:
    • Left posterior frontal lobe
    • Left parietal lobeLeft
    • insula
    • Basal Ganglia
  40. Ideomotor apraxia
    A disturbance in the performance of the movements needed to use an object, make a gesture or complete a sequence of individual movements; Apraxia of speech is one of the ideomotor apraxias; a deficit in carrying out the motor plan needed to use the object or make a gesture.
  41. Limb apraxia
    Deficits in performing purposeful limb movements that can not be explained impairments in strength, mobility, sensation, or coordination

    Usually affects both r/l limbs

    May interfere with writing/nonverbal communication (gestures)
  42. Apraxia for phonation
    Can’t produce voicing upon command.

    Can’t coordinate respiration and phonation to get the sound out. 

    Usually resolves on its own. 1-2 weeks
  43. Etiologies of Apraxia
    Stroke: most common cause

    Tumor/Trauma (sometimes)

    Degenerative diseases: not commonly associated with AOS

    Primary progressive AOS

    Demyelinating: MS (occasionally)
  44. site of lesion for Apraxia
    Anything that damages the Motor Speech Programmer Network
  45. Apraxia Errors
    SMR, imitation of graded in complexity syllables, words, multisyllabic words and sentences are most sensitive to AOS

    Apraxia: distorted sound substitutions and additions. Dysarthria is rarely associated with additions or substitutions and distortions are closer to the intended phoneme.

    Articulation distortions are not helpful in distinguishing

    Fluency abnormalities common in apraxia/uncommon in aphasia

    Difference in performance of SMRs (more diff.)/ARMs (apraxia)

    More diff. with volitional speech than automatic (apraxia). Dysarthria shows no difference.

    Narratives more diff. than pic description, conversation is easier (have control): Apraxia

    Do better if they can see and hear the model and repeat immediately (apraxia )

    Syllable lengths effects (longer syllables are more difficult): Apraxia

    Syllabicity effects: more powerful influence on AOS than word frequency effects

    Syllable length effects, syllable boundary effects, word complexity effect (pg. 279)

    See box 11-3 pg. 278 for all salient characteristic of AOS

    The clustering of several of these characteristics help distinguish AOS from Dysarthria

    Variability is considered by many to be a hallmark of AOS
  46. Apraxia: Patient Perceptions & Complaints
    My speech won’t come out right

    I know what I want to say

    Similar to people with aphasia

    Speech is not fluent

    Try to be more careful to reduce errors

    More diff. with longer multisyllabic words
  47. Apraxia and Articulation
    Recognize errors and try to fix them

    Grouping for articulatory postures

    Describe as stutter
  48. Praxia and Rate and Prosody
    Issues are present even when the articulatory errors are not present

    Disturbances are a defining feature of AOS

    Rate: is generally slower and more variable than normal
  49. Apraxia and Fluency
    Problem worsen under conditions of stress or fatigue
  50. Apraxia and task variables
    SMR’s more difficult than AMR’s

    Automatics should be less difficult than conversation speech

    more familiar easier than novel speech

    more complex, more difficult
  51. Severe Apraxia
    Masked by aphasia

    Tend to co-occur

    Limited to a few utterances May or many not be meaning full (ex. stereotypie)

    Ask them to count, imitate CVC syllables, sing, AMRs

    Use overlearned/or automatically produced (less demand on programming abilities)

    Look for a threshold at which patients succeed and fail on tasks
  52. Apraxia of phonation (muteness)
    Usually an early and transient problem, when confined to broca’s area.

    Persistence for longer than 2wks should raise suspicions about a different diagnosis. (e.g., severe aphasia)

    Display frustration and confusion

    Non-verbal oral apraxia Usually present with apraxia of phonation
  53. What is the goal of therapy for AOS?
    to reestablish the motor plan/program for speech production. Help activate the program and to obtain effective/efficient communication.
  54. What are the principles of motor learning?
    We should be using this

    Practice is very important, but must be the correct movements

    Trying to create a new motor plan

    Hands on assistance that is gradually faded

    Relies on modeling, experience, and practice/drill of the movements

    *DAB: people have lost the pre-program of speech, so intensive practice is needed. Hundreds!
  55. Massed versus Distributed Practice
    • Massed practice (one target, over and over again)
    • Results in good learning of a single motor pattern but doesn’t generalize easily to other contexts 

    • Distributed practice (working on multiple targets in a single session)
    • Results in slower learning that is better generalized and retained
  56. Random versus Blocked Trials
    • Random (variable) practice:
    • (stimulus is mixed up, each stimulus is repeated 30-40 times, may work on same stimulus several times, its random) Stimuli are mixed up throughout a session
    • Better for development of motor learning (per literature) 

    • Blocked (consistent) practice:
    • One stimulus is practiced repeatedly followed by repeated practice of a second stimulus and so on (never working on the same stimulus more than once)
    • You work on stimulus for 5 minutes, and then move on to the next stimulus.
  57. Varying the Context in Apraxia Treatment
    Varying the contexts facilitates motor learning

    Select a particular movement sequence with different co-articulatory contexts and different manners of production

    Vary prosody and loudness

    Always model new contexts and alterations in prosody
  58. Intergral Stimulation
    a behavioral management and motor approach.

    Research to support it’s use with kids with Apraxia of Speech

    Most commonly used method for speakers with moderate or severe apraxia

    Emphasizes multiple input modes Tactile, visual, auditory Gestures can be added as cues if needed Involves a hierarchy of steps
  59. The eight-Step Continuum
    you can start at any point in the continuum. Most clinician begin at step 4(1: most powerful cueing) at each-step you need to include 30-40 repetitions of skill. You move up and down the continuum based on the feedback you get from your client.

    • 1. Watch and listen
    • Clinician says word first, then both say word together

    • 2. Watch and listen
    • Clinician says word first, then clinician mouths word while client says it

    • 3. Watch and listen
    • Clinician says word, client repeats independently (you can add a delay time here. makes it more difficult)

    • 4. Watch and listen
    • Clinician says word, client repeats independently multiple times

    • 5. Written word cue
    • Clinician presents target word on paper; client reads aloud with written cue If you don’t read, use a picture

    • 6. Written word no cue
    • Clinician presents target word on paper; client reads aloud without written cue

    • 7. Response to question
    • Clinician asks Q to elicit target word

    • 8. Role play
    • Role play with clinician, family, friends to evoke target word in conversational contexts
  60. Sound Production Treatment for Apraxia
    (other more commonly used approach for indv. with adults)

    Improve accuracy of spatial targeting and timing at the syllable level (GOAL)

    Good efficacy data Emphasis is a minimal pairs approach
  61. Steps for Sound production Treatment:
    1. Modeling & Imitation Target is /p/: Say, “Pie/bye”, if able to produce /p/, give another repetition. If they CAN’T, you go to step

    2. Repeat step 1 with a written cue point to word while modeling target production, if correct, give feedback and have them repeat it gain. If no, go to step 3

    3. Integral stimulation” Focus only on the target sound: /p/ Using the single item, Pie “watch me, listen to me, and say it with me”. if correct give feedback and do again. If missed go to step 4

    4 Articulatory Placement & Model Specific to the speakers perceived errors. Model the word and ask them to repeat it If correct give feedback and do again, if missed provide feedback and go to step 5

    • 5. Isolated Sound Production
    • modeling: repeat the sound only if correct, give feedback and go to next minimal pair.
    • If incorrect, move on to another pair. 

    Ten exemplars counts as one trial. (you will have 10 minimal pairs).

    Continue treatment until 90% of the trained items are produced correctly in 3 out of 4 sessions.Sentence level means working at the target sound at the phrase completion.Ex. Clinician: “I came home and ate__” Child: “pie”
  62. Multiple Input Phoneme Therapy (MIPT) for Apraxia
    For adults with severe acquired apraxia who have few verbal stereotypies

    Sterotypies serve as initial stimuli

    Clinician and client produce utterance while tapping on arm

    Clinician fades voice but mouths words and continues to tap arm

    Introduce new words with same initial phoneme as stereotypies
  63. Efficacy of Apraxia Treatment
    Must consider available evidence

    Integral stimulation and sound production treatment have strongest evidence to date

    Other treatments appear to be beneficial
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Comd 555 Final
hyperkinetic vocabulary
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