Figure 1
Components of a speech motor evaluation. This figure describes the typical activities associated with the case history, quality of life self-report, and motor speech assessment (oral mechanism and speech assessment portions).
Figure 2
Mid-sagittal view of the speech structures. The speech structures shown in this figure are involved in breathing, articulation and resonance during speech and voice production. The speech structures include the tongue, jaw, lips, larynx, soft palate, and pharynx (i.e. pharyngeal wall).
Table 1
Examples of Instruments Developed to Evaluate the Impact of Dysarthria or Voice on Quality of Life
| Quality of Life Instruments for Dysarthria and Voice | General Description | Reference |
|---|---|---|
| Dysarthria Impact Profile | 48 statements are rated on a 5-point scale (1 = strongly agree to 5 = strongly disagree) that reflect 5 aspects of dysarthria impact: 1) The effect of dysarthria on the person, 2) Acceptance of dysarthria, 3) How the individual feels when others react, 4) Impact on communication with others, and 5) Other worries and concerns | Walshe et al.29 |
| Living with dysarthria | 50 statements divided across 10 sections of possibly impact that are rated from 1 (totally disagree) to 6 (fully agree) | Hartelius et al.30 |
| QOL for the dysarthric speaker questionnaire (QOL-DyS) | 40-item instrument in which each statement is rated from 0 (never) to 4 (always) across the domains of speech characteristics, situational difficulty, compensatory strategies, and perceived reactions of others. | Piacentini et al.31 |
| Voice Handicap Index | 30-item statements that are rated on a 5-point scale (0 = never to 4 = always) addressing 3 subscales of physical, functional and emotional impact of the voice problem on daily life activities | Jacobson et al.32 |
| Voice-Related Quality of Life (V-RQOL) | 10 statements are rated on a 5-point scale from 1 (none, not a problem) to 5 (problem is as “bad as it can be”) regarding voice function over the past 2 weeks. A standard score is then calculated across each domain of social-emotional, physical functioning, and total score | Hogikyan et al.33 |
| Voice Activity and Participation Profile (VAPP) | Uses a 10-cm visual analog scale to judge the degree to which the individual is affected as described in each of 28 statements (left side of line indicates never affected and right side represents always affected). Statements represent such aspects of voice use as Effect on the job, daily communication, social communication, and emotion | Ma and Yiu34 |
| Voice Symptom Scale (VoiSS) | 44-question items rated on a 5-point scale from 1 (never) to 5 (all the time). Items are linked to five domains including communication problems, throat infection, psychosocial distress, voice sound and variability, and phlegm | Deary et al.35 |
| Communication Participation Item Bank (CPIB) | The short form version of this instrument includes 10 question items rated on a scale from 0 (very much) to 3 (not at all). Items reflect the degree the individual experiences interference with participation in various situations due to their disorder | Baylor et al.36 |
Table 2
Simplified Overview of the Dysarthria Classification System Created by Darley et al.1 Based upon Clusters of Auditory–Perceptual Features
| General Perceptual Features | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Type of Dysarthria | Articulation Inaccuracy | Vowel Distortions | Prosodic Abnormalities | Breathy Voice Quality | Harsh Voice Quality | Strained–Strangled Voice Quality | Hypernasality | Nasal Emission | Mono Pitch | Mono Loudness |
| Spastic | √ | √ | √ | √ | √ | √ | √ | √ | ||
| Flaccid | √ | √ | √ | √ | √ | √ | √ | |||
| Mixed | √ | √ | √ | √ | √ | √ | √ | √ | ||
| Ataxic | √ | √ | √ | √ | ||||||
| Hypokinetic | √ | √ | √ | √ | √ | |||||
| Hyperkinetic (chorea) | √ | √ | ||||||||
| Hyperkinetic (dystonia) | √ | √ | √ | √ | √ | √ | √ | √ | ||
Table 3
Motor Speech Evaluation Characteristics Associated with Specific Hyperkinetic Dysarthrias
| Hyperkinetic Dysarthria | Chorea/Huntington’s Disease | Myoclonus | Oromandibular Dystonia | Hyoid Dystonia | Spasmodic Dysphonia | Essential Vocal Tremor |
|---|---|---|---|---|---|---|
| Physical findings | ||||||
| Quick non-rhythmic involuntary movements of speech structures at rest or during sustained postures | X | |||||
| Rapid rhythmic involuntary movements of the soft palate, pharyngeal, or laryngeal structures | X | |||||
| Sensory “tricks” | X | X | X | |||
| Involuntary contraction of anterior neck muscles associated with the hyoid bone resulting in “neck tightness” | X | |||||
| Involuntary spasms of laryngeal musculature during speech production | X | |||||
| Involuntary oscillation (tremor) of the head, tongue, jaw, lips, soft palate, pharynx, larynx, or respiratory musculature. | X | |||||
| Impaired volitional movement of the jaw (particularly opening or closing) that can sometimes involve the lips, tongue, and soft palate | X | |||||
| Speech characteristics | ||||||
| Voice stoppages | X | X | ||||
| Transient breathiness | X | |||||
| Vocal tremor | X | |||||
| Beat-like modulation of prolonged vowel | X | |||||
| Perceived clicking sound during speaking | X | |||||
| Intermittent hypernasality | X | X | ||||
| Inappropriate vocal noises | X | |||||
| Intermittent strained–strangled voice | X | |||||
| Intermittent breathy voice breaks | X | |||||
| Slow and irregular AMRs | X | |||||
| Variable speaking tempo | X | |||||
| Variable pitch and loudness patterns during speaking | X | X | X | |||
| Variable duration of sustained phonation | X | |||||
| Imprecise articulation and co-articulation | X | |||||
| Altered resonance | X | X | ||||
| Slowed speaking tempo | X | X | ||||
Figure 3
Example of shared speech features by two types of dysarthria. Speech characteristics and physical findings may be shared requiring that the entire clinical picture of individuals be considered to successfully differentially diagnose each type.
Figure 4
Process for identifying and evaluating dysphagia. This figure illustrates the recommended clinical practice pattern for speech-language pathologist identification and evaluation of individuals with dysphagia.
Table 4
Speech–Language Pathologist Treatment Approaches to Managing Impaired Respiratory, Voice, and Articulatory Functions in Those with Hyperkinetic Dysarthria
| Hyperkinetic Dysarthria Characteristic | Sign/Symptom | Treatment Options |
|---|---|---|
| Impaired respiratory drive, or coordination for speech production | Reduced or inconsistent loudness | Expiratory muscle strength training |
| Dramatic reduction in loudness during a single breath group during speaking | Lee Silverman Speech Treatment (LSVT) | |
| Inhalation appears inadequate, prolonged, or speaking initiation occurs at unusual locations within the respiratory cycle, or utterance | Maximum inhalation/exhalation tasks, or sustained phonation tasks to improve respiratory/phonatory coordination and steadiness | |
| Few words or syllables produced per breath group, runs out of air before taking a breath | Body positioning to optimize breathing and respiratory efficiency during speaking | |
| Paradoxical movements of the rib cage and abdomen during breathing or speaking | Accent Method of Voice Therapy | |
| Abnormal posture or movements associated with volitional respiratory-phonatory coordination during speaking | Rehearse taking deeper inhalations prior to speaking and implementing increased respiratory effort during speaking | |
| Reduced maximum phonation time (may also indicate impaired voice function) | Rehearse optimal breath groups during phrasing of spoken utterances | |
| Impaired voice function | Laryngeal relaxation techniques such as easy voice onset, yawn-sign, chanting, chewing method | |
| Poor integrity, loudness, and rate of laryngeal diadochokinesis (e.g., ee-ee-ee-ee) | Laryngeal Manipulation | |
| Accent Method of Voice Therapy | ||
| Confidential Voice Technique/Flow Phonation | ||
| Hyperadduction of the vocal folds | Biofeedback during voicing/speech tasks | |
| Impaired speech function | Articulation therapy | |
| Modify speaking rate (typically encourage slower) | ||
| Impaired articulation | Speech rhythm techniques | |
| Abnormal speech pattern or rate | Delayed auditory feedback | |
| Abnormal resonance (e.g., hypernasality) | Direct magnitude production | |
| Augmentative and alternative communication intervention | ||
| Referral for prosthetic device |
Table 5
Common Speech–Language pathologist Treatment Approaches to Dysphagia
| Diet Modification | Compensatory Strategies | Adaptations/Compensations | Indirect Treatment |
|---|---|---|---|
| Regular oral diet | Positional strategies | Assistance with feeding | Progressive resistive tongue exercises |
| PO with modification or dietary restrictions (select from the following): | Neck flexion (i.e., chin tuck) | Verbal cues | Shaker exercises |
| Water protocol between meals only (requires oral hygiene) | Head turn to left or right | Food placement on plate | Masako method |
| Liquids only (broth, nutritional supplements, milkshakes) | Lean or tilt to the right or left | Complete feeding assistance by other person | Expiratory muscle Strengthening exercises |
| Thickened liquids (specify viscosity of thin, nectar, honey, or spoon thickness) | Swallowing maneuvers | Adaptive feeding device or method | Neuromuscular electrical stimulation |
| Puree (specify runny versus thicker viscosity) | Multiple swallows per bolus | Alternate liquids with food | Tongue strengthening and ROM exercises |
| Soft and moist solids (easy to chew and easy to digest: avoid dry, dense, and stringy foods) | Breath hold prior to swallow | Reduce rate of eating | Lip strengthening exercises |
| Medication Form may require modification (e.g., pill, liquid) | Mendelsohn maneuver | Add moisture to dry foods (e.g., gravy, condiments, etc.) | Jaw strengthening and ROM exercises |
| NPO | Effortful swallow | Temperature of food (specify cold, room, hot) | Hawk exercise |
| NPO with supplemental intake | Audible exhalation after the swallow | Small and more frequent meals | Neck flexion against resistance in upright position |
| Supraglottic swallow | Oral tongue/finger sweep | Jaw depression against resistance in upright position | |
| Super supraglottic swallow | Biofeedback approaches (e.g., surface EMG, FEES, etc.) |