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Management of Flaccid Dysarthria in a Case of Attempted Suicide by Hanging

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Management of Flaccid Dysarthria in a Case of Attempted Suicide by Hanging Eastern Journal of Medicine 16 (2011) 66-71 S. Kumar et al / Flaccid dysarthria in attempted suicide Case Report Management of flaccid dysarthria in a case of attempted suicide by hanging Suman Kumar*, Indranil Chatterjee, Navnit Kumar, Ankita Kumari Department of Speech Language Pathology, AYJNIHH, ERC, Kolkata, India Abstract. Present study highlights a case of 26 year old male patient who was diagnosed as flaccid dysarthria due to delayed anoxic encephalopathy by attempting suicide through hanging. Assessment and management based on speech therapy has been emancipated. This case study concluded the importance of counseling and family centered approach regarding speech therapy outcome and alternative and augmentative communication (AAC). However, patient preferred verbal mode of communication and his lack of motivation failed the use of AAC with him. A composite therapy approach including traditional approaches, prosody and naturalness, increasing respiratory support along with visual biofeedback were used, which did not turned out to be effective. This dilemma to either direct therapy for verbal mode of communication which is not effective for the case or to use AAC needs further thinking and studies with more participants to find an appropriate solution which could lead us out of this impasse to some direction. Thus the challenge for speech therapists exists. Key words: Encephalopathy, anoxic encephalopathy, dysarthria, hyperkinetic dysarthria, flaccid dysarthria, hanging, suicidal attempt 1. Introduction process during the period when brain metabolism is restored or even increased (1). Longer the Hanging is one among several methods of period of unconsciousness, more likely the suicide. Hanging is suspension of full or partial development of irreversible damage. A wide body weight using a ligature, at neck, resulting in variety of motor disturbances may be found. compression of the neck that leads to Some cases have been associated with wide unconsciousness or death by causing an spread cerebral demyelization. Demyelination increasingly hypoxic state in the brain. The neck and abnormal metabolism in the brain may affect contains several vulnerable targets for the areas which controls fine motor functions like compression including the carotid arteries. speech that may cause one of the motor speech Blockage of carotid arteries deprives oxygen disorders-“dysarthria” supply whereas blocking of jugular vein prevents Dysarthria is lack of the ability to articulate deoxygenated blood to exit from the brain and words normally. It is a speech disorder resulting closing of the airway prevents respiration. Anoxic from a weakness, paralysis, or in coordination of encephalopathy is a disease of the brain due to the speech musculature that is of neurological temporary or permanent lack of oxygen supply to etiology (2). The prevalence of dysarthria is the brain. The phenomenon of delayed 46.3% in the acquired neurogenic communication progression is not understood but may be caused disorder (3). The ability to understand and use due to blockage or exhaustion of some enzymatic language is not usually affected; most people with dysarthria can read and write normally. * Flaccid dysarthria may result from anoxic Correspondence: Shri Suman Kumar encephalopathy, with involvement of central Department of Speech Language Pathology nervous system diffusely similar to traumatic AYJNIHH, ERC, B.T.Rd, Bon Hooghly brain injury (4). Flaccid dysarthria is a Kolkata, India,700090 perceptually distinguishable motor speech Tel: 91-9883193184 disorder caused by injury or malfunctioning of E-mail: [email protected] Received: 01.05.2010 one or more of the cranial or spinal nerves. Accepted: 06. 07.2010 Treatment plan for dysarthria aims at production 66 Eastern Journal of Medicine 16 (2011) 57-62 S. Kumar et al / Flaccid dysarthria in attempted suicide Case Report Table 1. Analysis of OPM Articulators At rest At sustained position During movement Lips Symmetrical Lip retraction, rounding and puffing Rapid repetition of lip but drooling symmetrical but range of movement is pursing, lip retraction and present. restricted and strength is decreased . cheek puffing is reduced in terms of rate and range. Jaw Lightly closed Cannot resist the examiner attempt to close Rapid opening and closing the jaw when told to hold it open. of jaw was slow. Tongue Symmetrical Slightly deviated, cannot resist the examiner. Elevation and lateral atrophic tongue, Attempt to push the tongue back into the movement is restricted and fasciculation. mouth. rate of motion was markedly slow. Velopharynx Symmetrical Asymmetrical. Asymmetrical during prolonged “ah”. of intelligible speech with appropriate stress. The Other perceptual features observed were prognosis of a treatment plan is ruled by the fact hypernasality, breathiness, diplophonia, audible that there are a number of factors that influence nasal emissions, short phrases, pitch break, the outcome in the treatment of dysarthria. monopitch, monoloudness, reduced loudness, Prognostic factors include neurological status and slow and regular AMRs, harshness, low pitch, history, age, automatic adjustment of the slow rate, short rushes of speech and reduced disorder, treatment, personality and intelligence, stress, hypotonicity, atrophy, facial myokymia, support system, sensory cognitive and language fasciculations, occasional nasal regurgitation, abilities, severity, motivation (5). dysphagia and drooling when leaning forward. The Oral Peripheral Mechanism (OPM) 2. Case study revealed lateral face and tongue weakness, small mouth opening, and poor lip seal, weak A 26 years old male was radiologically and glottal cough was observed when assessed in neurologically diagnosed as delayed anoxic three conditions i.e. at rest, at sustained position, encephalopathy (DAE) secondary to suicidal during movement, as shown in Table 1 (3). attempt. He was referred from neurology OPD of The cranial nerve assessment suggests facial, a hospital in Kolkata. Medical examination glossopharyngeal, vagus and hypoglossal nerves reports revealed episodes of convulsion after an involvement. Acoustic analysis of voice (Dr. attempt to suicide, and the immediate Speech, version 4) shown in Table-2a, shows repercussions were unconsciousness for 18 days. lowered habitual frequency and higher jitter and In severe hypoxia or anoxia, as occurs with shimmer. It revealed mild harshness, moderate cardiac arrest, consciousness is lost within hoarseness and severe breathy voice. The client’s seconds. There was gradual development of intelligibility was rated as 5 i.e. usually reduced weakness and clumsiness of fingers movement under adverse conditions when content is and loss of hand grip followed by progressive unrestricted even when repairs are expected (3). stiffness of both lower limbs. During the course The three qualified speech language pathologists, of rehabilitative management he was continuing perceptually rated his voice as severe on Buffalo physiotherapy and speech therapy. His pre- III voice profile i.e. severe impairment morbid educational and linguistic backgrounds (Laryngeal tone-hoarse- severe, pitch-too low- were graduation and competency in Bengali severe, loudness- too loud- moderate, hypernasal- (mother tongue), and English. Complete moderate, breath supply- moderate, muscles- assessment of speech mechanism has been done. hypotense- severe, rate- too slow- very severe, While assessing, speech mechanism during non- speech anxiety- very severe, speech speech tasks showed reduced loudness and intelligibility- very severe) (6). sharpness of the glottal coup. Weak cough and Psychological evaluation showed mild shortage of breath along with irregular breathing cognitive impairment (compared to pre-morbid rate, rapid deterioration and recovery with rest, mental state). Psychological analysis of labored breathing, audible inspirations was intellectual functioning showed memory affected observed along with absence of Gag Reflex. (recent/remote) – could not finish the task in due 67 Eastern Journal of Medicine 16 (2011) 66-71 S. Kumar et al / Flaccid dysarthria in attempted suicide Case Report time. Colored Progressive Matrices (CPM) and improvement prosody and naturalness, Gessel Figure Drawing test (GFD) score was high improvement of breathing and vital capacity, where immediate memory functions were better. improvement of voice quality and loudness and The Boston Diagnostic Aphasia Examination stress. (BDAE,3rd edition) was used to rule out aphasia The techniques included in therapy were used (7). An AQ of 95% on the Western Aphasia based on the efficacy and prognostic matrix over Battery(WAB) showed no aphasic component. a number of session observed using TOM model Photo Articulation Test revealed misarticulations (9). They were not used simultaneously in an in the form of consonant substitutions and individual session but after reviewing the omissions. The Apraxia Battery for Adults (ABA- prognostic indication over a number of therapy 2) was used to rule out presence of apraxia. The sessions for different approaches. Based on this a Frenchay Dysarthria Assessment (FDA) classified holistic view of management of dysarthria was him in group 5 i.e. Lower Motor Neuron posed (10, 11). The approaches used for the involvement (Reflex: cough-e-no cough reflex, therapy were: swallow-c- eating slow, drooling-c- drools when ¾ Visual Biofeedback – to develop lean forward, Respiration: at rest-b-inhalation maintenance of jaw elevation, with slow, in speech-c-short
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