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XXFlaccid Dysarthria
XXXFlaccidDysarthria
| Question | Answer |
|---|---|
| Flaccid Dysarthria | Etiology definition – Caused by impairment of the LMNs of the cranial or spinal nerves (i.e., damage to the PNS) |
| Flaccid Dysarthria is characterized by | Weakness in the speech and/or respiratory musculature and clinically characterized by: Weakness Hypotonia and reduced reflexes Atrophy Fasciculations Progressive weakness with use in some cases |
| Cluster for Flaccid Dysarthria: | Slow-labored articulation Hypernasal resonance Hoarse-breathy phonation |
| Neurological basis for Flaccid Dysarthria: | Damage to the lower motor neurons Any disorder that disrupts the flow of neural impulses along the LMN that innervate muscles of respiration, phonation, articulation, prosody or resonance. |
| With regard to the Cranial Nerves, if damage occurs to any of the following or a combination of the following, the motor impulses sent to the muscles for speech will be distorted or stopped completely: | – Trigeminal – Facial – Glossopharyngeal – Vagus – Accessory – Hypoglossal Specific acoustic features will depend on which nerves were affected and the resulting degree of weakness |
| Trigeminal CN V | Attached at the level of the pons and divides into three branches |
| What are the three branches of CN V? | Opthalamic, maxillary, mandibular |
| Which CN V branch is most important for speech production? | Mandibular branch is the most important for speech production – It innervates muscles that elevate and lower the jaw |
| Unilateral damage to Trigeminal CN V: | Weakness in the jaw muscles on the same side as the damage Jaw may deviate toward the affected side when opened Muscular atrophy will occur over time, resulting in asymmetrical appearance Minimal effect on speech production |
| Bilateral damage to Trigeminal CN V: | Person will have difficulty or will not be able to raise their jaw. Which sounds will jaw movement affect the most? – Bilabial – Labiodental, linguadental, linguaalevolar – Vowels, glides, & liquids Rate of speech will be reduced. |
| What are the two major branches of CN V, Facial Nerve? | Two major branches of the nerve 1. Cervicofacial branch: innervates lower face muscles 2. Temporofacial branch: innervates upper face |
| Upper Motor Neuron Lesion | UMNs of the corticobulbar tract innervate the LMNs of the two branches of the facial nerve Upper face receives bilateral UMN innervation Lower face only receives UMN innervation from the contralateral side of the brain |
| Lower Motor Neuron Lesion | Lesion occurring above the point of division entire ipsilateral face weakness – Lesion occurring below the point of division muscles innervated by the specific branch will be affected |
| UMN LMN innervation of Facial Nerve CN V: | what will happen if there is right LMN lesion above the point of division? What will happen if there is right corticobulbar tract damage? |
| Damage to CN V Facial Nerve | Unilateral – Mild distortion of bilabial & labiodentals – A flutter of the cheeks – Reduced precision of /pa/ for AMRs Bilateral – Distortion or inability to produce bilabials (p, b, m) & labiodentals (f, v) – Slow rate |
| Glossopharyngeal Nerve CN IX: | originates at medulla, runs closely with CN X and CN XI. Assists in elevating and opening the upper pharynx Gag reflex will test the function of CN IX |
| CN X Vagus Nerve | Very important for speech Originates at the medulla just below CN IX Courses near CN IX and CN XI CN X is long and serves many parts of the body (e.g., larynx, intestines, heart, velum) |
| Important branches of CN X | Important branches for speech production – Pharyngeal branch – External superior laryngeal nerve branch – Recurrent laryngeal branch |
| Pharyngeal Branch of CN X | Innervates: – Muscles of the pharynx & soft palate Responsible for: – Pharyngeal constriction – Palatal elevation and retraction |
| Unilateral damage to Pharyngeal Branch of CN X | Unilateral damage results in the affected side of the velum hanging lower than the unaffected side generally does not result in VPI |
| Bilateral damage to Pharyngeal Branch of CN X | Bilateral damage will result in hypernasality. – Pressure consonants will also be distorted. |
| External Superior Laryngeal Nerve Branch of CN X | Innervates the cricothyroid – Cricothyroid stretches and tenses the VFs, thus controls pitch |
| Unilateral damage to External Superior Laryngeal Nerve of CN X | – Unilateral damage will have a mild effect on varying pitch |
| Bilateral damage to External Superior Laryngeal Nerve of CN X | Bilateral damage can result in: Monotone (decreased pitch variation) |
| Recurrent Laryngeal Branch of CN X | Supplies motor innervation to all the intrinsic laryngeal muscles except for the cricothyroid Important for VF adduction and abduction |
| Unilateral damage to Recurrent Laryngeal Branch of CN X | Unilateral damage can result in one VF being fixed in the paramedian position – Causing breathy phonation and decreased loudness – Can also cause diplophonia |
| Bilateral damage to Recurrent Laryngeal Branch of CN X | Bilateral damage can fix both VFs in the paramedian position – Inhalatory stridor |
| 8 Accessory Nerve (XI) | Many of the motor neuron axons merge with the vagus nerve so damage to one often results in damage to the other. CN IX, X and XI run very close together... Spinal portions supply motor innervation for the sternocleidomastoid and trapezius |
| Hypoglossal Nerve (XII) | Provides motor innervation for all intrinsic lingual muscles and most of the extrinsic |
| Unilateral damage to Hypoglossal Nerve (XII) | Unilateral damage results in weakness on the same side as the nerve damage – Damaged side will atrophy – Protrusion will deviate toward the affected side – Mild articulatory distortions |
| Bilateral damage to Hypoglossal Nerve (XII) | Bilateral damage – Bilateral muscle atrophy and weakness – Reduced ROM Imprecise articulation Difficulty with pronouncing alveolars, and velars |
| Hypoglossal Nerve CN XII innervation: | Hypoglossal Nerve (XII) UMN innervation is contralateral only damage to the L UMNs results in weakness in the R side of the tongue |
| Etiologies of Flaccid Dysarthria | Physical Trauma Brainstem Stroke Myasthenia Gravis Guillain-Barre Syndrome Polio Tumors Muscular Dystrophy Progressive bulbar palsy |
| Physical Trauma | Surgical trauma, head injury, neck injury dysarthria most common cause. Procedures that are at risk – Carotid endarterectomy (removal of plaque) – Cardiac surgery – Removal of head and neck tumors – Dental surgery |
| Brainstem Stroke | Blood flow to the brain is interrupted A stroke in one of the brainstem arteries can result in damage of the neurons served by that artery. If blood supply is blocked, neurons will die. Severity of impairment depends on the number of LMNs dama |
| Myasthenia Gravis | Affects the neuromuscular junction where the LMNs meet muscle tissue Primary symptoms – Rapid fatigue of muscular contractions – Recovery after rest |
| What causes Myasthenia Gravis? | Caused by antibodies that damage parts of the muscle tissue that receive Acetylcholine – Decrease in Ach receptors results in the muscle not being able to use all the Ach produced by the motor neuron |
| Speech characteristics for Myasthenia Gravis for prolonged speaking task: | Speech characteristics during prolonged speaking tasks: – Hypernasality – Decreased loudness – Breathy voice quality – Decreased articulatory precision |
| Guillain-Barre Syndrome | Rapid, progressive dymyelinization in the PNS Can occur with some infections and immunizations but cause unknown Weakness and numbness in limbs early on. Other early symptoms include flaccid dysarthria and dysphagia. Some recover, 5% die. |
| Tumors can cause flaccid dysarthria: | Tumors – In the brainstem, neck, or orofacial structure |
| Muscular Dystrophy can cause flaccid dysarthria: | – Progessive degeneration of muscle tissue – Results in weakness of muscles served by cranial nerves |
| Resonance in flaccid dysarthria: | Resonance Hypernasality Nasal emission Weak pressure consonants Shortened phrases Resonance deficits primarily reflect bilateral damage to the pharyngeal branch of CN X |
| Articulation in flaccid dysarthria: | Imprecise consonants Large range in severity, depends on which nerves impacted and if unilateral or bilateral damage. |
| Flaccid Dysarthria = slow, labored articulation with: | Combined presence of hypernasality and breathy voice quality are strong indicators for the diagnosis to be flaccid dysarthria |
| Phonatory incompetence – Incomplete adduction of the vocal folds due to damage to the Recurrent Laryngeal Nerve symptoms? – Due to damage to which nerve? | RLN of CN X supplies motor innervation to all the intrinsic laryngeal muscles except for the cricothyroid Important for VF adduction and abduction |
| Respiration problems with flaccid dysarthria: | Inadequate amount of subglottic air pressure for speech, resulting in: – Reduced loudness – Shortened phrase length – Strained voice quality |
| Is it Respiration or Phonation? | how do you know if the person has poor respiratory support or decreased phonatory competence? – Have person produce a good cough – Ask person to produce a hard glottal stop |
| Prosody with flaccid dysarthria: | Monopitch (monotone) Monoloudness Reduced voice range profile The combination of reduced loudness and pitch range can occur in other types of dysarthria, thus are not diagnostic markers for flaccid dysarthria |
| Key Evaluation Tasks for Eliciting Specific Characteristics | Conversational speech sample – resonance – articulation – respiration – prosody Alternate Motion Rate (AMR) tasks – Slowed rate of phoneme production Prolonged Phonation of a Vowel – Voice quality Speech Stress Test (e.g., count to 100) |
| If damage to the CN X (& IX & XI) | Deficits in: – Resonance – Phonation – prosody |
| Treatment for Resonance Deficits | Behavioral Modifications, and then Surgery – Pharyngeal flap – Teflon injection Prostheses – Palatal lift |
| Palatal lift – Characteristics of a good candidate | Hypernasality is their most serious speech production deficit Stable medical condition Have enough teeth No hyperactive gag reflex or oral spasticity They have patience and motivation Ability to independently insert and remove the devi |
| 16 Treatments for Resonance Deficits first course of action: | Behavioral Modification of speech – Increase loudness (modeling + visual feedback) – Reduce rate of speech (while preserving prosody) e.g., increasing vowel length – More open mouth position: discrimination, exaggerated jaw movement, negative practi |
| Treatment for Phonation Deficits | Pushing and pulling – effortful closure techniques Holding breath Hard glottal attack Head turning toward the affected side in order to bring paralyzed vocal fold to midline Sideways pressure on larynx |
| Treating Prosody | Pitch range exercises Intonation profiles Contrastive stress drills Chunking utterances into syntactic units |
| Treatment for damage to the hypoglossal nerve | Traditional articulation treatment – Intelligibility drills – Phonetic placement – Exaggerating consonants – Minimal contrast drills |
| Treating Respiratory Weakness | Correct posture Speaking immediately on exhalation Cueing for complete inhalation |
| Treatment for Resonance Deficits: | Behavior Based 1st! Increase loudness (consider biofeedback device.), reduce rate of speed (increase vowel length) and open mouth position, decrimination, exaggerated jaw movement. |
| If damage to CN IX, X and XI, what damage? | If damage to the CN X (and 9 and 11 cause they run together.) Deficits in: RESONANCE, PHONATION, AND PROSODY. |
| Lee Silverman Voice Treatment | LSVT: voice treatment is an effortful closure technique! Used for Parkinsons but now with other motor speech disorders, like Flaccid Dysarthria. They cannot fully close vocal folds – use with Parkinsons and Flaccid Dysarthria. |
| Holding one's breath: | To hold a breath, you HAVE to close vocal folds. It is a vocal fold closure exercise. |
| Treating prosody: | Treating Prosody: see first if they can determine pitch, if can, have them make two to five sounds of diff pitch, both up and down, then work on stress in a word Come IN! OPEN the door. Then intonation profiles: Good MORning. Did you EAT? |
| Contrastive Stress Drills treat what? | Prosody - stress in a single word. When you change the stress in a single word you change meaning. Is the man playing baseball? No the man is playing FOOTBALL! No the MAN is playing football. Different stress on specific word to answer specific question. |
| Chunking utterances into syntactic units: | Prosody. Flaccid patients may have short breath, need to carefully control breathing ie: where to stop in sentence, where to breath, optimal breath group – how many words they can say, syntactically correct unit “I wake up, at six, in the morning.” |
| Treatment for damage to the hypoglossal nerve: | Treatment for damage to the hypoglossal nerve: intelligibility drills, phonetic placement, therapy mirror, exaggerating consonants, minimal contrast drills. |
| Treating Respiratory Weakness: | Treating Respiratory Weakness: Correct posture! Speaking immediately on exhalation. Cueing for complete inhalation. |
| Treatment for phonation deficits: | Effortful closure techniques, hold breath, hard glottal attack, head turn to affected side to bring paralyzed vocal folds to midline, sideways pressure on larynx. Pushing and pulling for closure in neck area (push on arms of chair and phonate.) |
| Phonation deficits treatment particular to hard glottal attack strategy: | Hard glottal attack: a bit more controversial. It is actually bad for vocal folds for most people – but with some take deep breath and then produce tight phonation. Once they can do it, move away from this activity. |
| Biofeedback devices | Biofeedback = nasal Ollie Visipitch |
| Behavior management is best because: | Behavior management – change the persons behavior in long term |
| Behavior Management relates to Compensatory Strategies and 3 things: | Compensatory strategies 3 things: doesn’t try to change physiology on a permanent basis. No goal of permanently changing any structure or function. Helps the person achieve the goal better NOW. |
| Perceptual means: | Perceptual = what you hear and possibly what you see (like nasal emissions) |
| Pitch range exercises with biofeedback | biofeedback like when patient does something they can visually see where they are, how much effort they need to put in to hit the target. Feedback on the person that they can see. Using visi-pitch gives visual feedback on frequency, loudness. |
| Easy Onset of Phonation and Yawn Sign | Helps relax the vocal folds. Some cannot do this right away so do yawn/sigh. Exhales while producing a sigh. Turn the sigh into a vowel. Yawn/sigh makes easy onset easy. Begin with open vowel like /a/. Makes it breathy and relaxes vocal folds. |
| Bilateraldamage to CN X | HYPERNASALITY AND DISTORTION OF PRESSURE CONSONANTS (stops, fricatives, affricates) can’t properly build up pressure for these sounds and so they get distorted. THESE ARE TWO SYMPTOMS plus nasal emission |
| Bilateral damage to External Superior Laryngeal Nerve Branch of CNX: | Monotone voice is ONE SYMPTOM because this branch innervates the cricothyroid. |
| Unilateral damage to Recurrent Laryngeal Branch of CN X: | supplies adduction and abduction. One side damage = paramedian: breathy, decreased loudness voice. BREATHY PHONATION AND DECREASED LOUDNESS are symptoms of unilateral damage to the RL Branch of CN X. Can also cause diplophonia. |
| Bilateral damage to Recurrent Laryngeal Branch of CN X: | Bilateral damage can fix both VFs in the paramedian position and cause inhalatory stridor (unwanted sucking of air noise and stress over breathing cannot breathe freely and clearly. |
| CN X and CN XI | Many neuron axons merge with the vagus nerve. They run together. The assessory nerve has spinal portions and cranial components. Damage to CN X often results in damage to CN XI. |
| Damage to CN XII | XII: motor innervations to the tongue. Unilateral damage is very mild, bilateral damage = atrophy and weakness bilaterally and a weak tongue which affects articulation more pronouncedly. |
| Compromised Articulation: | Something wrong with articulation but can still understand what person says. RANGES of articulation deficits that affect speech production. |
| What drives decision making about management and treatment? | Severity is the factor that drives decision about management and what kind of treatment. |
| Reduced Range of Motion can result in what? | Reduced Range of Motion = imprecise articulation. |
| Brainstem Stroke can cause FLACCID AND SPASTIC DYSARTHRIA. | Brainstem stroke could damage tract coming down or neuron. Lower motor neuron = flaccid dysarthria. Upper motor neuron = spastic dysarthria. |
| Resonance with flaccid dysarthria: | RESONANCE: HYPERNASALITY, NASAL EMISSION, WEAK PRESSURE CONSONANTS. You hear the first, see the second and can hear the third. Sometimes you can have two without the nasal emissions. |
| Which phonemes are problematic with damage to CN XII? | CN XII problems = problem with lingual sounds. |
| Flaccid Dysarthria cluster? | COMBINED PRESENCE OF HYPERNASALITY AND BREATHY VOCAL QUALITY ARE STRONG INDICATORS FOR THE DIAGNOSIS TO BE FLACCID DYSARTHRIA. |
| Vocal quality with flaccid dysarthria? | Respiration: if the patient doesn’t have sufficient air pressure for speech they may have decreased loudness and shortened phrase length and glottal fry – gravelly harse voice quality. |
| Can prosody be a diagnostic marker with flaccid dysarthria? | PROSODY CAN OCCUR WITH FLACCID DYSARTHRIA, but is NOT a diagnosic marker as can occur with othe types of dysarthria. |
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MayaMayaAlejandra
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