Curiosity, Dialogue, and Knowledge
First session should always be educational.
If possible it should include client and family/significant others.
Want to educate client and family about the type of dysarthria he or she has.
Express what you feel can be done for the client.
Discuss possible short and long term treatment goals.
What is your prognosis- your expectations of improvement?
Always be positive, and hopeful, but always truthful.
It’s easier for you to say, “You’ll be fine,” than it is for you to explain to the client why you think their prognosis is poor, balance your response.
Involve the client in planning.
Involve the family in the treatment.
Above all structure your short term procedures for success, success is really important.
Posture, tone, and strength all effect respiration, phonation, and resonance.
Speaking is optimized and made easiest when someone is standing, sitting, or even lying on their back, as long as the spine is straight, and the head is in a straight line with the body.
Normal speakers can speak equally well in a variety of postures. For someone who has dysarthria, this is not so.
If they come to you wearing a neck collar for support of the cervical vertebra, this is positive for you because it maintains the head in a straight line with the body’s mid line.
Postural adjustment also includes the need for a palatal lift in cases of extreme hypernasality.
Typically, extreme hypernasality is caused by bilateral velum weakness.
Also keep in mind, hypernasality is more a quality issue than an intelligibility issue, if they talk low enough you can understand them.
If extreme hypernasality is accompanied by some other type of dysarthria, (hypoglossal, laryngeal) then everything becomes magnified and unintelligible.
Palatal lifts are never considered for a unilateral velum weakness, and are never considered for individuals with spasticity of the velum.
Typically, palatal lifts are severely compromised if the person has to wear upper dentures.
Palatal lifts have to be adjusted, to fit the client, but it will result in immediate improvement of overriding hypernasality.
Muscle tone is defined as resistance to passive movement.
Muscle tone provides the background for muscle readiness to move.
Even when muscles are relaxed they still have normal tone so they can be contracted quickly.
Tone reflects, to a large degree, the influence of the extrapyramidal system.
Primarily, this is a way for the extrapyramidal system to support skilled fine motor movements like speech.
Abnormally increased tone, hypertonia, that effects limited muscle groups, is called spasticity and might be seen in abductor muscles of the arm, but not in the adductor muscles.
Rigidity – is due to hypertonia across muscle groups, rigidity will effect both.
Both are caused by UMN damage.
Hypotonia results in flaccidity.
Dystonia – damage to extrapyramidal system – problem when tone comes and goes, hypertonia, hypotonia, and normal tone comes and goes.
Easiest form of abnormal tone to treat is flaccidity; strengthening exercises for flaccidity are not without controversy.
Spasticity, rigidity and dystonia are medically managed, but often times prove to be very resistant to that medical management.
Strength is defined as the ability of a muscle to do work, To be able to move structures of the body, and hold those structures against resistance.
All the different types of dysarthria result in reduced strength.
Hypertonia doesn’t mean more strength.
Strengthening is typically used for the lips, tongue, and vocal folds.
Two types of strengthening exercises – isotonic, isometric.
Isotonic exercises- involve repetitive movements without resistance (passive strengthening).
Isotonic exercises are the best place to start in cases of severe flaccidity.
Isometric exercises – involve movements made against resistance, if you’re trying to strengthen one side of the tongue, you can use a tongue blade to add resistance.
i. With these you have to proceed as systematically as you can, and incrementally increase the amount of resistance offered.
ii. Explain the rational and methods you’re going to use and explain the possible outcome from it , and always teach by demonstrating.
iii. Baseline data should always be obtained before you start any treatment.
The client by the end of the treatment period, shouldn’t be exhausted but should be taxed.
Make sure they can do this at home because two times a week won’t be helpful enough, there needs to be carryover.
Strengthening for the jaw is only done when you have bilateral weakness.
i. Doesn’t have to be completely bilateral.
ii. Because it’s so accessible it’s easy to address; might start out with isotonic – lower and raise or lower and protrude jaw without resistance.
iii. Move to isometric, provide resistance with your hands, so they have to work to close it, to strengthen the muscles.
iv. Same with side to side and protruding the jaw, make sure they aren’t moving the head.
Lips are easy, for isotonic – puckering and unpuckering, smiling and frowning, lip rounding, lip spreading, lip closing, lip opening, make sure they aren’t opening and closing the jaw.
Tongue- isotonic, easy; isometric – use tongue blade.
Exercise to strengthen protrusion and retraction of the tongue, (tongue blade for protrusion, rubber glove and gauze to provide resistance for retraction).
More than likely you will be strengthening due to unilateral weakness, make sure that the tongue blade is placed along margin of the stronger side.
Because you want that weaker side to push against blade on stronger side, you have to be careful with the tongue or you will wind up strengthening the strong side.
Strengthening the soft palate can be tough.
With someone with a flaccid velum, it’s too weak.
With a unilateral velum weakness you can help strengthen it, you can help by using many of the same exercises that you would use for a child: using a straw in water, trying to get a better velum seal, and blowing up balloons (because if you can’t get a good velar seal you won’t be able to blow up a balloon).
Cescape is used a lot with kids. It has a round clear plastic tube with a stopper, the tube runs to the nasal olive and goes inside the nostril and the other one is shut. The idea is progress can be measured by how little the air coming out of the nostril caused the stopper to rise.
If air is coming out of the nostril then you have hypernasality.
Unilateral velar weakness causing hypernasality is not a big treatment goal.
i. Not appropriate for spasticity, dystonia, or rigidity.
ii. Not when someone has myasthenia gravis (at least not at the same intensity).
iii. Not appropriate to delay speech work until strengthening is complete. Wastes a lot of time.
However that’s one side of the argument, the other side argues that:
iv. You should wait for strengthening to be finished before targeting the speech.
v. Work on it at the same time.
To check for adequate respiratory control, have them phonate with “ah” and see how long they can phonate “ah” with quality phonation. Any kind of respiratory goals or exercises that are done with you and respiratory therapy should always stress quality over length.
Primary thing you will see used it a wet/or dry manometer, calibrated tube, blow in tube and see if they can follow the 5 for 5 rule.
5 for 5 rule – are they able to move 5 cm (2 inches) and hold it for 5 seconds, this is the minimal respiratory amount needed for speech. If they cannot meet this standard, look closely at their main type of breathing: is it diaphragmatic or is it clavicular? If they are focused on breathing with their upper torso, then teach “belly breathing”. Proper respiratory support is crucial.
You really can’t separate respiration from phonation in speech therapy, nor do you want to. When you are working on respiratory exercises that will be prescribed by respiratory therapy you always want to include phonation.
If they have respiratory weakness, there will be improvement but it will plateau just like every other neurologic injury, it can be improved some past this but won’t go back to normal so you are always stressing quality over length of phonation.
Normal “ah” phonation 16-24 sec- 5 sec is low on this scale
Even if they plateau at 8 sec that’s fine because you want quality, this means your main goal is for them to express themselves in much shorter lengths of utterances.
Almost all dysarthria clients, especially with a client who has flaccid dysarthria, will need you to teach them to slow down their speech so that they can achieve as precise articulation, with the best quality phonation for the best period of time. Because the goal of the dysarthria treatment is compensated intelligibility.
Increasing respiratory support will be a fairly short term goal. Although it’s something that can be practiced briefly for every session.
If they also have deficits in phonation because of a unilateral vocal fold weakness, then you can target both at the same time.
If you target both phonation and respiration at the same time it will be taxing on the client, because of their severity and condition.
A unilateral left vocal fold paralysis is the most common phonatory problem because the left recurrent laryngeal nerve has the longest course. (goes around aorta)
Typical treatment for this is to call upon the biological function of the larynx.
The vocal folds are your bodies last defense against food or liquid entering the lungs, that’s their primary purpose, not phonation.
When you swallow the reflex is for the vocal fold to be adducted tightly.
By calling upon this reflex activity of the larynx you can help improve the adduction of the weak vocal fold, you do this by having the person lift something heavy, they will automatically adduct when you are lifting something heavy.
By having the client sit in front of you have them try to lift themselves and their chair off the ground, this will cause their vocal folds to adduct, as they are lifting you are asking them to phonate “ah” this can be very taxing for the client and you want them to be fatigued but not exhausted. Use this sparingly in therapy as muscle tension dysphonia may occur.
As they get better you go form ‘ah’ to words, one –two words, then go to three words, if this is all you can get with quality that’s fine, 4 or 5 words is perfect but there will be a neurologic wall at some point.
True vocal fold paralysis – the surgeon can close the vocal fold and suture it in place, every solution breeds new problems, the problem with this is it means they are not going to be able to have a completely open airways to take in enough air, so they may be shorter of breath walking longer distance, or climbing stairs because half of their larynx is shut off, phonation will be better though. Other treatments also exist.
The primary thing is going to be to try and strengthen the soft palate which creates certain challenges.
You can’t really feel it move, and it has very good tactile sensory receptors so gag may occur.
Strengthening exercises include same thing you would do for a kid who has had a tonsillectomy, use straws, balloons, etc.
Hypernasality – unless its overriding hypernasality is best left for last as a cleanup activity.
The easiest way to address mild hypernasality, it to have the client speak with a wider mouth opening.
A wider mouth opening will allow more of the energy of pharyngeal and oral resonance, to exit the mouth, less of it will enter the nasal cavity.
This solution also has a side effect, not only does it help reduce hyper nasality but it also makes the client speak more slowly, everything has further to go, so it naturally slows down speech which is always something you will want to do anyways.
Pharyngeal flap is always the last thing you would want to do, it’s not pleasant.
Dysarthria’s are named after articulation.
This is really an unfortunate medical term for the problem because it can negatively impact so many other things besides just articulation.
Modification of articulation is the primary place where isometric and isotonic exercises are going to be employed.
It’s always suggested in every articulation workbook for the dysarthriaa – use them they are good! You try not to strengthen in the absence of speech sounds.
So if you are working on bilabial lip function always have it in speech context, in a b/m/p sound.
Much of the standard articulation therapy for dysarthria comes from the Van Riper approach.
1. This is integral stimulation: watch me, listen to me, do what I do.
2. Decide on what artic targets you are going to address from what intact articulatory movements that client has. For instance, if he has no weak velum but his tongue is weak, then call on that normal soft plate and their articulatory target for the tongue might be to strengthen lingual velar back movements.
If you are working on plosives, which is a very common problem, you will hear plosives most often sound like fricatives, why? Because they can’t maintain the bilabial seal and air that should be trapped behind them escapes as it does with a fricative. Another of the other more common errors are fricatives that sound like plosives, why? Because of articulatory over shooting, this is particularly noticeable with a client who has problems with / s /, they over shoot where the tongue should be so they will move the tongue from a /s / and it will turn into a / t /.
People with dysarthria do not omit sounds they distort them.
Omissions are the most difficult articulatory things to correct.
Keeping this in mind – the best things to do to address articulation:
i. First, place client in best possible posture for speech.
ii. In the case of flaccidity (most common), through your strengthening exercises teach the client to increase their background of effort, strengthen the tongue have them use this strength.
iii. This is why you always do strengthening in the context of speech sounds- easier, saves time, and is more efficient.
iv. Teach the client that they have to increase conscious control over speech, depending on the severity, talking will never be an unconscious act for them, if they want to be the most intelligible with the best quality then they have to pay attention to what they are doing.
v. Teaching them to be slower also allows them to be more conscious.
vi. Artic for dysarthria involves a lot of drill work.
vii. Just like with a kid, you start off with a sound in isolation, for both strengthening and more precise placement, then move to syllable, then to word, then to phrase level.
viii. Lots of drill!
ix. It’s very important to involve family member because they need to practice every day, drill drill drill!
Really important and involves the entire speech system.
Particularly respiratory drive and the larynx.
This involves the recurrent laryngeal nerves and superior laryngeal nerves.
Superior laryngeal nerves allow for pitch change.
It’s really the recurrent that are primarily responsible for intensity changes.
If the problem is loudness, this has probably already been addressed if it was due to a weaken vocal fold.
If you find it necessary you can do pitch drills.
Stress drills- simple
i. Bob hit ted- they have to put the stress on the right part of the sentence.
The challenge comes from generalizing stress drills from the structured environment to natural speech.
They want to sound like they did before, part of this is that they want to express how they feel through their voice.
Prosody is important- they want to say I love you and sound like they mean it.
This isn’t a bad place to start off if this is really important to them.
It can be challenging, but very rewarding as long as you and the client and the family understand that the terminated target goal is compensated intelligibility.
Very often dysarthria accompanies TBI, unilateral spasticity is very common after TBI. Unilateral flaccidity is common after TBI.
Either may present with a positive prognosis.
Anything that is bilateral is much more challenging.
Spasticity when it effects the articulators is very difficult to improve, no way to make articulatory less hypertonic.
i. First goal with this is for them to speak slower.
ii. If it involves the larynx, they may well have a very tight voice, very effortful and may compensate themselves by speaking more slowly. But primarily for spasticity we assist with following medical management; new drugs.
iii. Slow speech and more precision with placement is a very good goal.
iv. /s / / t / / d / are very often involved in spasticity because of the tongue movements involved. There are many places in the mouth where you can produce / s / look for them through trial and error. What can they do to get the best quality? Because you cannot address hypertonicity.