Motor Speech Disorders
Definition
Motor-speech disorders: speech disorders resulting from neurological damage that affects the motor control of speech muscles or motor programming of speech movements.
**Dysarthria
**Apraxia of speech
*Acquired Apraxia of speech
*Childhood Apraxia of Speech
Dysarthria
Dysarthria refers to a group of neurogenic speech disorders characterized by abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for breathing, phonatory, resonatory, articulatory, or prosodic aspects of speech production.
Dysarthria can adversely affect intelligibility of speech, naturalness of speech, or both
https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/
Types of Dysarthria
Flaccid—associated with disorders of the lower motor neuron system and/or muscle
Spastic—associated with bilateral disorders of the upper motor neuron system
Ataxic—associated with disorders of the cerebellar control circuit
Hypokinetic—associated with disorders of the basal ganglia control circuit
Hyperkinetic—associated with disorders of the basal ganglia control circuit
Unilateral upper motor neuron—associated with unilateral disorders of the upper motor neuron system
Mixed—various combinations of dysarthria types (e.g., spastic-ataxic; flaccid-spastic)
Undetermined—perceptual features are consistent with a dysarthria but do not clearly fit into any of the identified dysarthria types
Articulation
Imprecise consonants
Distorted vowels
Irregular articulatory breakdown
Articulatory blurring
Resonance (Velopharyngeal)
Hypernasality
Denasality or hyponasality (oral resonance on nasal consonants)
Audible nasal emission/nasal snort
Prosody
Aberrant rate (too fast/too slow/accelerating/variable)
Short rushes of speech
Reduced stress
Excessive and equal stress
Prolonged intervals
Inappropriate silences
Signs and Symptoms of Dysarthria
Dysarthria can alter speech intelligibility and/or speech naturalness by disrupting one or more of the five speech subsystems—respiration, phonation, articulation, resonance, and prosody.
Respiration (Breathing)
Short phrases
Reduced loudness
Monoloudness
Excessive loudness variation
Loudness decay
Forced expiration/inspiration
Phonation (Laryngeal)
Pitch level (too low/too high)
Monopitch
Pitch breaks
Aberrant voice quality (roughness, breathiness, strain; or harsh, hoarse, strain)
Diplophonia
Vocal flutter
Voice tremor
Voice stoppages
Audible inhalation/inhalatory stridor
Grunt at ends of phrases
https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/#collapse_2
Apraxia of speech (AOS) is a neurologic speech disorder that reflects an impaired capacity to plan or program sensorimotor commands necessary for directing movements that result in phonetically and prosodically normal speech
AOS has also been referred to in the clinical literature as verbal apraxia or dyspraxia
https://www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/
Signs and Symptoms of Acquired Apraxia
phoneme distortions and distorted substitutions or additions,
reduced overall speech rate,
syllable segregation with extended intra- and intersegmental durations, and
equal stress across adjacent syllables.
Different types of apraxia affect the body in slightly different ways:
Limb-kinetic apraxia
People with limb-kinetic apraxia are unable to use a finger, arm, or leg to make precise and coordinated movements. Although people with limb-kinetic apraxia may understand how to use a tool, such as a screwdriver, and may have used it in the past, they are now unable to carry out the same movement.
Ideomotor apraxia
People with ideomotor apraxia are unable to follow a verbal command to copy the movements of others or follow suggestions for movements.
Conceptual apraxia
This form of apraxia is similar to ideomotor apraxia. People with conceptual apraxia are also unable to perform tasks that involve more than one step.
Ideational apraxia
People with ideational apraxia are unable to plan a particular movement. They may find it hard to follow a sequence of movements, such as getting dressed or bathing.
Buccofacial apraxia
People with buccofacial apraxia, or facial-oral apraxia, are unable to make movements with the face and lips on command.
Constructional apraxia
People with constructional apraxia are unable to copy, draw, or construct basic diagrams or figures.
Oculomotor apraxia
Oculomotor apraxia affects the eyes. People with this type of apraxia have difficulty making eye movements on command.
Verbal apraxia
People with verbal or oral apraxia find it challenging to make the movements necessary for speech. They may have problems producing sounds and understanding rhythms of speech.
Childhood Apraxia of Speech
Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone)
The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.
https://www.asha.org/practice-portal/clinical-topics/childhood-apraxia-of-speech/
Currently, there are no validated diagnostic features that differentiate CAS from other childhood speech sound disorders. However, three segmental and suprasegmental features consistent with a deficit in the planning and programming of movements for speech have gained some consensus among those investigating CAS:
Inconsistent errors on consonants and vowels in repeated productions of syllables or words.
Lengthened and disrupted coarticulatory transitions between sounds and syllables.
Inappropriate prosody, especially in the realization of lexical or phrasal stress.
Other Reported Characteristics
Other characteristics that have been reported in children diagnosed with CAS and that represent difficulty with the planning and programming movement gestures for speech include
articulatory groping—articulatory searching prior to phonating;
consonant distortions;
difficulty with smooth, accurate movement transitions from one sound to the next;
increasing difficulty with longer or more complex syllable and word shapes;
schwa additions/insertions—insertion of schwa between consonants or at the end of words;
slower than typical rate of speech
syllable segregation—pauses between sounds, syllables, or words that affect smooth transitions;
voicing errors—voiceless sounds produced as their voiced cognates; and
vowel errors—vowel distortions or substitutions.
https://www.asha.org/practice-portal/clinical-topics/childhood-apraxia-of-speech/#collapse_2
Etiologies
Many neurologic illnesses, diseases, and disorders—both acquired and congenital—can cause dysarthria
Congenital—cerebral palsy, Chiari malformation, congenital suprabulbar palsy, syringomyelia, syringobulbia
Degenerative diseases—amyotrophic lateral sclerosis, Parkinson's disease, progressive supranuclear palsy, cerebellar degeneration, corticobasal degeneration, multiple system atrophy, Friedreich's ataxia, Huntington's disease, olivopontocerebellar atrophy, spinocerebellar ataxia, ataxia telangiectasia
Demyelinating and inflammatory diseases—multiple sclerosis, encephalitis, Guillain-Barré and associated autoimmune syndromes, meningitis, multifocal leukoencephalopathy
Infectious diseases—acquired immune deficiency syndrome (AIDS), Creutzfeldt-Jakob disease, herpes zoster, infectious encephalopathy, central nervous system tuberculosis, poliomyelitis
Neoplastic diseases—central nervous system tumors; cerebral, cerebellar, or brainstem tumors; paraneoplastic cerebellar degeneration
Other neurologic conditions—hydrocephalus, Meige syndrome, myoclonic epilepsy, neuroacanthocytosis, radiation necrosis, sarcoidosis, seizure disorder, Tourette's syndrome, Chorea gravidarum
Toxic/metabolic diseases—botulism, carbon monoxide poisoning, central pontine myelinolysis, heavy metal or chemical toxicity, hepatocerebral degeneration, hypothyroidism, hypoxic encephalopathy, lithium toxicity, Wilson's disease
Trauma—traumatic brain injury, chronic traumatic encephalopathy, neck trauma, neurosurgical/postoperative trauma, skull fracture
Vascular Diseases—stroke (hemorrhagic or nonhemorrhagic), Moyamoya disease, anoxic or hypoxic encephalopathy, arteriovenous malformations
Possible Causes of Acquired Apraxia
Acquired apraxia of speech (AOS) is caused by any process or condition that compromises the structures and pathways of the brain responsible for planning and programming motor movements for speech. Causes most often include
stroke,
traumatic brain injury (TBI),
tumor,
surgical trauma (e.g., tumor resection), or
progressive disease.
Occasionally, AOS is the first, only, or most prominent symptom in degenerative conditions (e.g., corticobasal degeneration, progressive supranuclear palsy). The term primary progressive AOS is used in such cases
Possible Causes of Childhood Apraxia of Speech
CAS can be congenital, or it can be acquired during speech development. Both congenital and acquired CAS can occur
As an idiopathic neurogenic speech sound disorder (i.e., in children with no observable neurological abnormalities or neurobehavioral disorders or conditions);
As primary or secondary signs within complex neurobehavioral disorders (e.g., autism, epilepsy, and syndromes, such as fragile X, Rett syndrome, and Prader–Willi syndrome
In association with known neurological events (e.g., intrauterine or early childhood stroke, infection, trauma, brain cancer/tumor resection
https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/#collapse_3
https://www.asha.org/practice-portal/clinical-topics/childhood-apraxia-of-speech/#collapse_3
Case History
Dysarthria
Medical diagnosis and history
Onset and course of symptoms
Associated deficits (e.g., language, cognitive-communication, and swallowing, problems)
Medical procedures, hospitalizations, prior treatments and their outcomes
Other medical and rehabilitation specialty referrals and interventions and their outcomes
Medications and potential side effects/symptoms
Review of auditory, visual, motor, cognitive, language, and emotional status (if not included as part of the assessment)
Education, vocation, and cultural and linguistic backgrounds
Patient and family report
Awareness, observations, and perspectives
Person-specific communication needs
Impact of the presenting problem on activities and participation
Identification of facilitators of and barriers to communication
Extent to which the level of effort for speaking changes in different contexts (e.g., when fatigued, at different times of day, relative to medication schedule)
Adaptability in different communication contexts (e.g., in noisy environments, with distractions, with multiple communication partners, with unfamiliar listeners)
Childhood Apraxia of Speech
Comprehensive assessment for speech sound disorders typically includes a case history, oral mechanism examination, speech sound assessment, and language assessments, if indicated.
Medical History
Communication History
Perception of:
Speech difficulties on communication and quality of life
Consistency of errors
Use of Prosody
Strategies that help with communication
Cultural/Linguistic Background
Psychosocial Support
https://nyu.app.box.com/s/qtk0mdq5ssr48rqwiccai6o7qnoa3t58/file/856982783907
Acquired Apraxia of Speech
This includes a review of current medical status, medical history, surgical history, prior level of function, education, occupation, and cultural and linguistic background. A case history may address activity/participation, contextual, and quality-of-life issues.
Self-Reported Areas of Concern
An SLP may evaluate functional communication status and the psychosocial impact of a given medical condition on the patient and caregiver(s) and identify meaningful functional goals for the individual and caregiver(s). An SLP may also identify communication difficulties, contexts of concern (e.g., social interactions, work activities), language(s) used in those contexts, and the individual’s goals and preferences.
Identification of Contextual Barriers and Facilitators
Facilitators—Examples are ability and willingness to use low- and high-tech augmentative and alternative communication systems (AAC), family support, and motivation to return to prior level of function.
Barriers—Examples are reduced confidence in verbal communication, cognitive deficits, and visual and motor impairments.
The identification of such barriers and facilitators assists the SLP in determining the potential for effective use of compensatory techniques and strategies, including the use of AAC.
Sensory and Motor Status
A person’s sensory and motor status may affect their ability to access nonspeech communication methods (e.g., writing, using gestures). Therefore, these factors may influence performance on speech assessment tasks. Consultation with members of the interdisciplinary team (e.g., occupational therapy) may be valuable.
Oral–Motor Mechanisms and Nonspeech Oral Praxis
This pertains to the integrity of the structure and function of the respiratory, phonatory, resonatory, and articulatory (lips, tongue, velum, hard palate, dentition) systems. Oral–motor mechanisms and nonspeech oral praxis includes the strength, speed, and range of movement of the components of the oral–motor system. It also refers to steadiness, tone, accuracy, and coordination of movements for speech and nonspeech tasks. Assessment of these systems is useful in differentiating AOS from dysarthria and oral apraxia.
https://www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/#collapse_5
Assessment Information
Screening
Apraxia of Speech
Signs of:
Comorbid language
Cognitive-communication
Executive function, memory etc.
Swallowing deficits associated with the neurological insult
Type of errors is relatively consistent, (e.g.,distortion, initiation of word)
Additional considerations:
Hearing screening to rule out hearing loss that might affect testing
Hearing aids should be inspected to ensure they are working & should be worn during screening
Tools:
OSME
The BIG 8
Symmetry, steadiness, tone, strength, range of motion, speed, accuracy, coordination
Diadochokinetic Rates
To judge speed and regularity of jaw, lip, and tongue movement and, to a lesser extent, articulatory precision
Assessment of alternating motion rates (AMRs)
May be normal
More difficulty on complex sentences
Sequential motion rates (SMRs)
Irregular articulatory breakdowns
Slow speech rate variations
Sequential motion rates more impaired than AMR
Conversational Speech
Phonation: altered prosody
Articulation: struggle initiating speech; difficulty sequencing; errors increase with longer words (thick, thicken, thickening); slow rate of speech; prolonged transitions between sounds, syllables, and words; distortions and/or sound substitutions; intrusive schwa
Repeating words of increase length
Deterioration of accuracy
Dysarthria
Screening for dysarthria is pass/fail.
Tools:
OSME
The BIG 8
Symmetry, steadiness, tone, strength, range of motion, speed, accuracy, coordination
Type of errors is relatively consistent, (e.g., distortion, initiation of word)
Diadochokinetic Rates
To judge speed and regularity of jaw, lip, and tongue movement and, to a lesser extent, articulatory precision
Assessment of alternating motion rates (AMRs)
May be normal
More difficulty on complex sentences
Sequential motion rates (SMRs)
Irregular articulatory breakdowns
Slow speech rate variations
Sequential motion rates more impaired than AMR
Vocal quality and ability to change loudness and pitch—to assess laryngeal/phonatory function
Speech Intelligibility
Use material unknown to the listener and with low semantic predictability.
Include words that provide a sampling of most of the phonemes.
Tasks include single-word production and sentence production
(Stewart, 2021) (ASHA, Apraxia, 2021) (ASHA, Dysarthria, 2021)
Table of Areas/Skills
ASSESSMENT AREAS
Oral Sensory (OSME)
Respiration
Phonation ( Voice onset/offset (e.g., delayed voice onset; quality of voice at onset)
Ability to sustain the voice to achieve appropriate phrasing during speaking
Ability to demonstrate strong and consistent rate of vocal fold valving during diadochokinetic
Articulation
Intelligibility
Groping
Resonance (Assess resonance quality (normal, hyponasal, hypernasal, cul-de-sac).
If abnormal, assess stimulability for normal resonance.
If normal, evaluate the focus of resonance (oral, pharyngeal/laryngeal, nasal).
Diadochokinetic rates (assessment of rhythmic syllable structure)
Suprasegmental features (rhythm, rate, stress, melodic pattern)
Placement of errors
Context of evaluation ( single word level versus sentence level; connected speech versus spontaneous speech)
NORMATIVE DATA
Non-Standardized Assessments
Connected Speech Samples
-Phonological error patterns
-Accuracy of speech
-Articulation (incorrect use)
-Assessed by using single word structure
-Assessed by using sentence structure
-Assessed using naturalistic speech samples
Dynamic Assessements
Hearing (expressive/receptive language)
Secondary Behaviors (ie; Groping)
(Shipley and McAffee 2016)
Differential Diagnosis
Dysarthria in Children
Dynamic Assessment needed to compare CAS in dysathric pediatric disorders
Inconsistent errors are primary concern to differentiate from adult dysarthria
Pollysyllabic production
*Review section Table of Area/Skills for differentiating dysarthia and apraxia
Dysarthria Vs.Apraxia
Dysarthria
Causes muscle weakness and spasticity
Effects all subsystems (respiration, phonation, articulation and resonation)
Ataxic Dysarthria damages coordination
Consistent errors
Effects AMR
Apraxia
Mainly disrupts two subsystems (articulation and prosody)
Inconsistent errors
Groping
Effects SMR
Assessment Summary
Assessment of Intelligibility of Dysarthric Speech (AIDS), Sample
Diagnosis:
Severity
Classification (i.e. Dysarthria, Apraxia)
Sub-classification (e.g., Flaccid Dysarthia or Limb Apraxia)
Contributing factors
Medical dignosis
Hearing/vision
Pharmacologoical factors
Age and gender
Primary language and culture
Motivation and levels of concern
Results from analysis
Types of errors
Consistency of errors
Intelligibility
Fluency
Rate of speech
Prosody
Respiratory Support
Maintaining factors identified in the OSME
Motor physiology results
Motor control of body
Motor control of speech structures
Motor control objective finds (e.g., articulation, reflexes, sensory)
Prognosis
Shipley and McAFee (2016)
Treatment
FACTORS TO CONSIDER
Fatigue
Speaking, eating, muscle spasms, activities of daily living, psychological impact, comorbid conditions, medication (e.g., side effects.
Medical Team Effort (e.g., collaborating with cardiologist, neurologist, laryngologist, PT, OT, dentist, etc.)
Patient-centered approach: Create opportunites that maximize the patient's communication skills and encourages perseverance- SLP maintain flexibility
FRAMEWORK for THERAPY
MOTOR LEARNING THEORY
Work on meaningful linguistic units
Monitor and Self-correction
Feedback
Drills - Blocked practice VS. Random practice
VERSUS
COGNITIVE LOAD
Give one stimulus at a time
Work on several areas in one session
(Stewart, C. Framework for Treatment 2021)
ADULT APPROACH
Restorative approaches focus on improving:
speech intelligibility,
prosody and naturalness, and
efficiency.
Compensatory approaches focus on:
improving comprehensibility by
increasing the speaker's use of communication strategies,
improving listener skills and capacity, and
altering the communication environment;
increasing effective use of AAC options; and
increasing use of non-AAC devices.
NOTE: Treatment is not always restorative or compensatory BUT preserving or maintaining function (e.g., individual has a slowly progressing degenerative disease)
ASHA, Dysarthria
Medical Intervention
Surgery (Muscular or Neurological)
Deep brain stimulation
Brain ablation (e.g., thalamotomy, pallidotomy)
Vocal fold medialization (e.g., thyroplasty, collagen, human fat)
Pharyngeal flap
Medications
For Disease (Dopamine, Mestinon)
For Depression
For muscle tone (e.g., BoNT)
For Dementia (e.g., Aricept)
Prosthetic Intervention
Prosthetic device to improve communication
Specialized chair for support/stabilization
Bite block/ palatal lift/ nasopharyngeal obturator
Abdominal support/girdle
Pacing board, metronome, DAF
Amplifiers (decrease effort/increase intelligibility
Augmentative communication (AAC)
Behavioral Management
Counseling and Support
Communication/Speech oriented treatments
Support and resource for family/caregivers
(Stewart, C. Framework for Treatment 2021)
Dysarthia
TARGETING SPEECH-PRODUCTION SUBSYSTEMS:
FACILITATE RESPIRATION
(Stewart, C. Framework for Treatment 2021)
Management Specific to Symptoms of Apraxia of speech
Apraxia
(Stewart, C. Framework for Treatment 2021)
Visuals
Flaccid Dysarthria CN-V Trigeminal Nerve
Stewart, C. 2021
Shipley and McAFee (2016)
Apraxia Cortical Level
Due to a lesion in the
parietal & premotor areas
References
ASHA. (2021).Apraxia. American Speech-Language-Hearing Association. Retrieved October 23, 2021, from https://www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/
ASHA. (2021).Dysarthria. American Speech-Language-Hearing Association. Retrieved October 23, 2021, from https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/#collapse_5
Hanson, E. K., & Fager, S. K. (2017). Communication supports for people with motor speech disorders. Topics in Language Disorders, 37(4), 375-388.
Stewart, C. (2021,October 23). Apraxia [PowerPoint slides]. Communicative Sciences & Disorders, New York University.
https://2nyu.speech.steinhardt.nyu.edu/ap/courses/1012/sections/f4cecbe0-e9f8-409f-af8a-5de598e750c6/coursework/module/ab6056fb-417e-4065-b3f2-f0e27f04b9eb/segment/06d32242-cd2f-46cf-afab-fbbdf801fbd5
Stewart, C. (2021,October 23). Assessment direct observation object assessment [PowerPoint slides]. Communicative Sciences & Disorders, New York University.
https://2nyu.speech.steinhardt.nyu.edu/ap/courses/1012/sections/f4cecbe0-e9f8-409f-af8a-5de598e750c6/coursework/module/ab6056fb-417e-4065-b3f2-f0e27f04b9eb/segment/06d32242-cd2f-46cf-afab-fbbdf801fbd5
Stewart, C. (2021,October 23). Differential diagnosis [PowerPoint slides]. Communicative Sciences & Disorders, New York University.
https://2nyu.speech.steinhardt.nyu.edu/ap/courses/1012/sections/f4cecbe0-e9f8-409f-af8a-5de598e750c6/coursework/module/ab6056fb-417e-4065-b3f2-f0e27f04b9eb/segment/06d32242-cd2f-46cf-afab-fbbdf801fbd5
Stewart, C. (2021,October 23). Objectives of course [PowerPoint slides]. Communicative Sciences & Disorders, New York University.
https://2nyu.speech.steinhardt.nyu.edu/ap/courses/1012/sections/f4cecbe0-e9f8-409f-af8a-5de598e750c6/coursework/module/ab6056fb-417e-4065-b3f2-f0e27f04b9eb/segment/06d32242-cd2f-46cf-afab-fbbdf801fbd5
Shipley, K. G., & McAfee, J. G. (2016). Assessment in speech-language pathology: A resource manual (6th ed.). Boston, MA: Cengage.
https://www.asha.org/practice-portal/clinical-topics/acquired-apraxia-of-speech/
https://www.asha.org/practice-portal/clinical-topics/childhood-apraxia-of-speech/
https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/