Evidence-Based Practice Guidelines for Dysarthria: Management of Velopharyngeal Function

Academy of Neurologic Communication Disorders and Sciences: Writing Committee for Practice Guidelines in Dysarthria: Kathryn M. Yorkston, Ph.D., BC-NCD

Department ofRehabilitation Medicine University of Washington Seattle, Washington

Kristie Spencer, M.S.

Department of Speech and Hearing Sciences University of Washington Seattle, Washington

Joseph Duffy, Ph.D., BC-NCD Division of Speech Pathology Department ofNeurology Mayo Clinic Rochestei Minnesota

David Beukelman, Ph.D. Department of Special Education and Communication Disorders University ofNebraska Lincoln, Nebraska

Lee Ann Golper, Ph.D., BC-NCD Department ofHearing and Speech Sciences Vanderbilt-Bill Wilkerson Center Nashville, Tennessee

Robert Miller, Ph.D., BC-NCD Department ofRehabilitation Medicine Veterans’ Administration Puget Sound Health System Seattle, Washington

Journal of Medical Speech Language Pathology Volume 9, Number 4, pp. 257—274 Copyright © 2001 Singular, an imprint of Delmar, a division of Thomson Learning, Inc. 258 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL.9, NO. 4

Edythe Strand, Ph.D., BC-NCD Division of Speech Pathology Department ofNeurology Mayo Clinic Rochester; Minnesota

Marsha Sullivan, MA. Munroe-Meyer Institute for Genetics and Rehabilitation University ofNebraska—Omaha Omaha, Nebraska

The Academy of Neurologic Communication Disorders and Sciences (ANCDS) estab lished writing a committee to develop evidence-based practice guidelines for speech-lan guage pathologists who treat individuals with dysarthria. The current guidelines draw from both the research literature and expert opinion and address the issues of man agement of velopharyngeal impairment in dysarthria. A search of electronic databases (PsychlNFO, MEDLINE, and CINAHL) and hand searches of relevant edited books yielded 33 intervention studies in the categories of prosthetics, surgery and exercise. A summary of quality of evidence is provided along with a clinical decision-making flow chart for the management of velopharyngeal impairment in both degenerative and sta ble/recovering dysarthria. Palatal lift intervention was found to be effective in selected individuals with dysarthria. The best candidates have a flaccid soft palate, pharyngeal wall movement, good oral articulation and respiratory support, and a stable disease course. Recommendations for future research are provided.

BACKGROUND sclerosis, and so on), and pathophysiology (flaccidi ty, spasticity, ataxia, rigidity, and so on). The chal Dysarthria is a heterogeneous group of neurologi lenges inherent to the clinical management cal speech disorders of per whose characteristics reflect sons with dysarthria are numerous. Speech-language abnormalities in the strength, speed, range, timing, pathologists are faced with a myriad of assessment or accuracy of speech movements as a result of approaches and treatment techniques—many with pathophysiologic conditions such as weakness, potential utility for an individual client—but some spasticity, ataxia, rigidity and a variety of involun with dubious validity and utility. Converging evi tary movements (e.g., dystonia, tremor). Dys dence in the research literature can serve as the arthrias can affect the respirators laryngeal, velo foundation for the development of guidelines for pharyngeal, and oral articulatory subsystems, clinical practice. singly or in combination. The impact of dysarthria ranges from a barely appreciable speech disorder to Mission Statement a reduction in the intelligibility of speech to an in- ability to speak. This group of disorders varies The Writing Committee for Practice Guidelines in along a number of dimensions, including age of on Dysarthria is charged by the Academy of Neurolog set (congenital or acquired at any age), cause (vas ic Communication Disorders and Sciences (ANCDS) cular, traumatic, neoplastic, and so on), natural with developing evidence-based practice guidelines course (developmental, recovering, stable, degener for speech-language pathologists. (For a review of ative, and so on), site of lesion (many sites in the evidence-based practice and practice guidelines as central or peripheral nervous system or both), neu applied to the field of speech-language pathology rologic diagnosis (Parkinson disease, traumatic see Yorkston et aL, 2001.) These practice guidelines brain injury, cerebral palsy, amyotrophic lateral stem from an evidence-based review that draws EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTI{RIA 259 from the research literature as well as expert opin zation, 1999). The term velopharyngeal impair ion. They address some of the major issues in the ment refers to any failure of the velopharyngeal management of children and adults with dys mechanism to open or close in a normal fashion for arthria. Practice guidelines are intended for use in speech (Tomes & Kuehn, 1996). making clinical decisions about the management of specific clinical problems. In this article, guidelines for the management of velopharyngeal impairment PROCEDURES: REVIEWING in dysarthria are reviewed. THE EVIDENCE

can viewed Justification Development of practice guidelines be as a process of translating evidence from both re The Writing Committee of Practice Guidelines for search literature and expert opinion into recom Dysarthria developed a list of clinical questions mendations for clinical practice. To evaluate the faced by speech-language pathologists caring for quality of any practice guideline, it is important to individuals with dysarthria. The topic of manage document exactly how they were developed. The ment of velopharyngeal impairment was selected development process typically involves a series of for a number of reasons. First, it is a common man steps (Trombly, 1995) as summarized in Table 1. ifestation of dysarthria and can complicate all as The following section provides specifics about the pects of speech production. Second, variation in ap experts (including both the writing committee and proaches to management exists in clinical practice. the reviewers), the searches, criteria for inclusion Finally, the intervention literature is substantial of studies, and rating of evidence. and dates back to the 1960s. The Writing Committee Terminology First, a group of experts (the writing committee) Through the years, a number of terms have been was convened. These individuals represented a used to describe velopharyngeal disorders in the broad range of clinical experience in the manage cleft palate and motor speech populations. These ment of dysarthria. The initial tasks of the writing include velopharyngeal impairment, inadequacy, committee were to clariIr assumptions upon which insufficiency, incompetency, and dysfunction. In a the guidelines are based, to identify pertinent clin recent state of the art review; Kuehn and Moller ical questions, and to define the scope of the litera (2000) suggest that there is no universal agree ture to be evaluated. ment on distinctions among these terms. They sug gest use of the term velopharyngeal impairment The Searches because it encompasses a wide variety of velopha ryngeal disorders and because it is consistent with Next, an intensive literature search was conducted terminology used in the World Health Organiza and appropriate intervention articles were re tion’s classification system (World Health Organi trieved. The following electronic databases were

TABLE 1. The sequence of activities for development of practice guidelines.

• A panel of experts (the writing committee) is convened • Assumptions are clarified and pertinent questions are identified • An intensive literature search is conducted and pertinent articles are retrieved • Intervention studies are rated for quality of evidence • A technical report is drafted that summarized the research literature as well as the expert opinion of the writing committee • Expert opinion is obtained • Recommendations are drafted, reviewed, and revised • Guidelines are distributed. NO. 4 260 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL.9,

more fully else searched: PsychINFO covering 1,300 journals (1967 The rating scheme is described table of evidence to July 2000), MEDLINE covering 3,900 journals where (Yorkston et al., 2001). A a summary ofeach (1966 to July 2000), and CINAHL covering 600 jour was then created that contained studies and nals (1982 to July 2000). The initial searches were study and allowed comparisons among keywords paired with the term dysarthria, for ex over time. ample, dysarthria and velopharyngeal, dysarthria and hypernasality, dysarthria and resonance. Later Reviews searches paired terms such as velopharyngeal, hy Expert the terms speech pernasality, and resonance with The quality of evidence found in the intervention out and treatment. Because the intent was to carry literature along with the expert opinion of the writ of evi the broadest possible search, other sources ing committee was summarized in a technical re the electron dence were also sought. In addition to port. A draft of this report was made available to a edited books ic searches, hand searches of relevant larger panel of expert reviewers. In the case of searches of in the field of dysarthria and ancestral these practice guidelines for management of within an arti extant references (e.g., studies cited velopharyngeal impairment, the technical report cle or chapter) were conducted. was reviewed by 28 experts in addition to the writ ing committee. A majority of these individuals hold Criteria for Inclusion of Studies doctoral degrees (6 1%). The average length of clini cal practice was 19 years. Although most of the ex yield The general search on the topic of dysarthria pert reviewers were members ofANCDS (68%), the search, refer ed 1,042 references. From this large opinion of reviewers from outside of the organiza were ences related to velopharyngeal function tion’s membership with known expertise on were identified, and those related to intervention velopharyngeal function was also sought. The com were de obtained and rated. Intervention studies ments of the expert reviewers were carefully con the velopha fined as those focusing on treatment of sidered and used to modify the technical report. Fi one per ryngeal system that was applied to at least nally, the guidelines were distributed in the form of excluded son with dysarthria. Thus, articles were both a technical report, made available on the web- that (a) described but did not treat velopharyngeal sites of ANCDS (http://www.duq.edulancds/) and ap function in dysarthria, (b) applied treatment ASHA (http:llwww.asha.org[), and published in this and proaches to individuals without impairment, clinically focused article. (c) studied techniques for management of velopha ryngeal impairment associated with disorders other articles than dysarthria, (e.g. cleft palate). Review SUMMARY OF EVIDENCE FROM and chapters that surveyed intervention served as INTERVENTION STUDIES supportive documentation for a flowchart of man this article. agement decisions described later in A total of 33 intervention studies were identified, obtained, and rated by at least two members of the Rating the Evidence writing committee. A sunirnary of the table of evi dence in which the studies were rated can be found method Each intervention study was analyzed for in the technical report. The following section pro was rated ac ological rigor. Strength of evidence vides an overview of the evidence, including the American Psy cording to principles outlined by the types of interventions and management ofvelopha chological Association (Chambless & Hollon, 1998) ryngeal impairment in dysarthria. and was determined by asking the following series of questions: What Interventions Are Reported Literature? How well were the subjects described? in the Research into three How well was the treatment described? The intervention studies were classified categories: prosthetic, surgical and exercise. Pros imposed in the What measures of control were thetic intervention included palatal lifts, nasal, or study? nasopharyngeal obturators and palatal desensiti Surgical Were the consequences of the intervention well zation associated with palatal lift fitting. flap surgery, described? intervention included pharyngeal EVIDENCE-BASED PRACTICE GUIDELfl’ES FOR DYSARTHRIA 261 pharyngeal implants, and teflon injections. Exer type speech in the absence of cleft palate” (Randall, cise included palatal training devices and resis Bakes, & Kennedy, 1960). Other studies published tance exercises with continuous positive airway prior to 1970 are called “preliminary” reports pressure (CPAP). Table 2 contains a summary of (Hardy, Rembolt, Spriestersbach, & Jaypathy, 1961) the types of interventions for velopharyngeal im and lack both the detailed case descriptions and pairment reported in research articles over a 30- comprehensive outcome measures needed for docu year period. Also included in Table 2 is the number mentation of effectiveness. Often surgical interven of subjects in each category The largest category tion was described in complex cases, such as the case was prosthetic intervention with 21 studies (61% of reported by Johns (1985) of an individual with a the total) followed by the surgical category with 9 gunshot wound to the left frontal lobe and the articles (27% of the total), and the exercise catego mandible or in cases where behavioral and prosthet Thus, the corn ry with 2 articles (6% of the total). When interven ic intervention had already failed. a broad tion options were compared in terms of the number plenty of the cases makes generalization to lift intervention was of cases or subjects reported, palatal lift interven er population difficult. Palatal first reported a response to apparent dissatisfac tion was by far the most common with 83% of sub as tion with pharyngeal flap surgery. Hardy and his jects (186 of 224) receiving palatal lifts. Sixteen colleagues, who had in 1961 authored one ofthe first percent of subjects received pharyngeal flap reports of pharyngeal flap surgery, published a surgery. However, since 1990, only 2 cases of pha study of palatal lift intervention in 1969. As a ratio ryngeal flap surgery were reported. nale for the palatal lift intervention, they cited diffi It is also important to note interventions that culty in predicting the successful outcome with pha were not documented in the literature. This exten ryngeal flap surgeries. Thus, recommendations for sive search of the published literature found no ev the appropriateness of surgical intervention cannot idence supporting the following techniques: push be offered at this time given the insufficient founda ing techniques; strengthening exercises, such as tion of applicable research. blowing and sucking; tasks that encourage the pa tient to control and modify the airstream using balls, whistles, candles, fluff; powder, paper bub Evidence for the Effectiveness bles, straws, and so on; and inhibition techniques, of Prosthetic Intervention such as prolonged icing, pressure to muscle inser in the area of pros tion points, slow and irregular stroking and brush Because intervention studies and pro ing, and desensitization. thetic management are the most common A review of the current research suggests that vide an adequate picture of candidates and out there is not sufficient evidence to assess the effec comes of intervention, the following sections will tiveness of surgical management or exercise for highlight the effectiveness prosthetic intervention. velopharyngeal impairment in dysarthria. In the area of exercise, only two case reports have been Who Is a Good Candidate for published. In the area of surgical intervention, evi Prosthetic Intervention? dence is insufficient to make recommendations. Ear ly reports draw from the field of cleft palate. In fact, Because dysarthria represents a heterogeneous the first report of pharyngeal flap intervention in group of disorders, identifying good candidates for neurologic populations was entitled, “Cleft palate- intervention is dependent in part upon the quality

TABLE 2. Number of articles in various intervention categories and total number of participants.

Timeframe Prosthetic Surgical Exercise Total

< 1970 3 (12) 3 (9) 6 (21) 1970s 8 (77) 3 (18) 1 (1) 12 (96) 1980s 6 (63) 1 (1) 7 (64) 1990 thru 7/00 4 (34) 2 (6) 1 (2) 7 (42) Total 21 (186) 9 (35) 2 (3) 33 (224)

Parentheses indicate the total number of subjects. 262 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY VOL.9, NO.4 of the description of subjects. Studies reviewed for intervention. At times, this premise was ex here included descriptions of subject characteris pressed in procedural phrases, such as “improved tics that ranged from comprehensive to minimal. production of plosives and fricatives with manual The following characteristics were reported in at occlusion of the nares” (Stewart & Rieger, 1994, p. least 50% of the studies: age, gender, medical diag 151). nosis, time post onset, speech characteristics, treat ment history, severity of dysarthria, physiologic da History of Previous Intervention. The history ta, and data from the neurologic examination. of previous interventions was a common rationale Intervention for velopharyngeal impairment was for decisions made about the chosen course of ther studied most frequently in individual s with trau apy. For example, behavioral speech treatment had matic brain injury (TBI), cerebrovascular accident been unsuccessful or progress had plateaued at the (CVA), and cerebral palsy (CP). Although motor time when intervention was undertaken. neuron disease was only reported in 5 of the 32 ar ticles (16%), a recent study (Esposito, Mitsumoto, & Natural Course of the Disease. The course of Shanks, 2000) reported the results of palatal lift fit the disease also was used to determine candidacy. ting in a group of 25 speakers with amyotrophic For example, cases with the diagnosis of traumatic lateral sclerosis. brain injury were reported where the time post on The type of dysarthria was not specified for some set suggested that no further speech recovery was or all of the subjects in 75% of the articles. Howev likely. er, when the type of dysarthria was specified (as it was in 37% articles), flaccidity was a component in Professional Judgment. Generic statements most cases. The second most common type of about professional judgments also served as a ra dysarthria was a mixed flaccidlspastic dysarthria. tionale for intervention. These included statements The relatively low rate of reporting dysarthria type such as a “multidisciplinary evaluation was used to likely reflects the historical development of the determine candidacy” (Stewart & Rieger, 1994, p. field. The first study reporting type of dysarthria 151). The category of professional judgments also (flaccid reported in Netsell and Daniel, 1979) oc included statements such as “other approaches curred only after the publication of the classic such as surgery were contraindicated” (Gonzalez & Mayo Clinic studies of differential diagnosis in Aronson, 1970, p. 92) and “interventions were dysarthria (Darley, Aronson, & Brown, 1969a, judged to be effective for other populations particu 1969b; Darley, Aronson, & Brown, 1975). larly those with craniofacial abnormalities” (Crike In reviewing the description of candidacy and the lair, Kastein, & Cosman, 1970, p. 182). rationale for intervention contained in the studies, the following general categories emerged: Patient Preferences. Statements that can be categorized as patient preferences also emerged in Speech Characteristics. Several speech charac discussions of candidacy (e.g., the patient was not teristics were associated with candidacy including satisfied with the palatal lift, the palatal lift was hypernasality, nasal emission, and severe reduc inconvenient and embarrassing in social situa tion in intelligibility. tions, and the patient desired to permanently re duce the impairment). Physiologic Factors. The deficient functioning of the velopharyngeal mechanism was identified fre How Do We Know That Treatment Works? quently as a rationale for intervention under this One of the traditional ways of evaluating the qual category This included characteristics such as ity of evidence that treatment works is to rate the velopharyngeal incompetence, palatopharyngeal type of study. Studies that randomly assign sub paralysis, inconsistent soft palatal contact with the jects into groups are generally considered the high pharyngeal wall, and inability to achieve adequate est quality. Nonrandomized group studies or case oral pressure. Poor respiratory support also was in subjects are generally considered to provide less dicated as a physiologic rationale for management. powerful evidence. Given the heterogeneity of the dysarthria population, rating of evidence by type of Resolution of Symptoms. The notion that reso study has been called into question. (See Yorkston lution of the velopharyngeal incompetence would et al., 2001, for a more complete discussion of the lead to speech improvement was cited as a rationale merit of various systems for rating evidence.) In EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 263 the current group of intervention studies focusing such as difficulty with articulation, due to in on prosthetic management, 186 individuals with creased tonicity in laryngeallpharyngeal muscula dysarthria were included. ture in some patients with severe spasticity. In The psychometric adequacy of measurement was creased swallowing difficulty and hypersalivation assessed by indicating whether information was for short periods were also reported. Finally, some provided regarding reliability and stability of the authors reported a patient’s lack of acceptance of measurement of the outcomes. For example, inter- the device and unrealistic expectations. or intra-rater reliability, dispersion of judges’ scores, and comparison of measures to a gold stan What Were the Outcomes of dard were all considered evidence of psychometric the Intervention Studies? adequacy. Unfortunately, this type of evidence was often lacking. Although a trend over time toward Generally, the studies of palatal lift fitting reported more rigorous measures was noted, the majority of positive outcomes. Although criteria for success current studies do not report evidence of psycho vary; treatment was judged successful 76% of the metric adequacy. Overall, approximately 20% of time in a series of 25 cases reported by Bedwinek the studies provided data about the psychometric and O’Brian (1985). Optimum results were ob adequacy of the measures used. tained in 32 and positive outcomes in 96% of 44 Another way of rating the quality of evidence is to cases reported by LaVelle and Hardy (1979). Some evaluate the strength of control imposed by the of the most common outcomes included improved study; In other words, does support exist for the as articulation, improved speech intelligibility, de sertion that the treatment of interest was responsi creased hypernasality, and more efficient use of ble for the change in behavior/outcome measures respiratory support for speech. A more complete de rather than some other explanation? Several studies scription of potential outcome measures can be reported comparisons of measures of speech adequa found in the measurement of outcomes section that cy with and without the palatal lift. This can provide follows. Palatal lift fitting was found to be success strong evidence of internal validity (i.e., the palatal ful, but more difficult, in individuals who were lift was responsible for the change in outcome). edentulous or had a spastic palate. The best results Among other indicators that interventions such as were reported when the soft palate was flaccid and palatal lifts were successful was the fact that speech when good pharyngeal wall movement was pre performance had not improved with many years of sent. Most improvement was noted in individuals behavioral intervention. Therefore, improvements who wore their lifts the longest. could be attributed to palatal lift intervention. The Some of the early descriptions of palatal lift fit trajectory of the disease also was cited as support of ting (e.g., Mazaheri & Mazaheri, 1976) posed a the effectiveness of intervention. For some, the dis number of questions for further investigation. For ease course was degenerative and intervention main example, what is the relationship between the tained a given level of speech production in the face palatal stimulation offered by palatal lift fitting ofprogression ofthe underlying impainnent. For oth and the degree of neuromuscular function and re ers, improvement in chronic and stable conditions covery? Although many clinicians have worked was cited as support of intervention effectiveness. with individuals who have experienced improve ment in neuromuscular function after palatal lifts What Risks or Complications of were fitted, studies of groups of patients fitted with Palatal Lifts Were Identified? palatal lift prostheses did not support a strong as sociation between palatal lift fitting and recovery of The benefit of any intervention must be weighed velopharyngeal function (Witt et al., 1995). against the risks or complications inherent to the Personal testimonies of speakers with dysarthria treatment. Generally, the risks or complications of who use a palatal lift are also a source of informa palatal lift fitting were minor. Some studies sug tion about treatment outcomes. Two of the individ gested that tooth movement or injury to the soft tis uals with ALS who participated in the Esposito et sue were risks, but none of the studies reported its al. study (2000) were interviewed by CBS Health- occurrence in any subjects. The most common com watch (URL: www. cbshealthwatch.medscape, ac plication of palatal lift fitting was intolerance in cessed 6/00). Both linked use of the lift to their con the form of initial discomfort, inability to inhibit a tinued ability to work. One individual, a financial gag, and prosthesis retention difficulty. Some nega planner stated, “My livelihood is based on my com tive speech-related changes were also reported, munication skills. It is vital for me to be able to ex VOL.9, NO. 4 264 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOG

press my thoughts.” The other; a business manager, Assumptions stated, “I doubt if I could work very effectively with Before describing the flowchart, it is necessary to palatal lift.” out the review some of the assumptions upon which it is based. These assumptions are presumed to be true CLINICAL DECISION MAKING as they relate to the practice of speech-language pathology. The following presents an overview of clinical deci about management of velopharyngeal sion-making Goal of Intervention. Enhancement of speech impairment in dysarthria. It is derived from con and communication function is a fundamental tar clusions drawn from the evidence examined earlier get of intervention. along with expert opinion both from the published literature and a panel of reviewers. Figure 1 illus of Speech. Speech motor control is trates a clinical decision-making flowchart for the Uniqueness different from other motor systems. management of velopharygeal impairment in unique and assessed as part of a compre dysarthria. The following section provides a de Therefore, it must be and cannot be pre tailed explanation of various aspects the flowchart hensive physical examination in other systems, as well as a review of assumptions about the man sumed from neurologic deficits agement of dysarthria, such as in limb function.

in Figure 1. Diagram for clinical decision making for management of velopharyngeal impairment dysarthria. EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 265

Individual Assessment. The pattern and severi History Taking ty of impairment in the various speech subsystems This phase of the assessment involves gathering varies from one population to another and from one pertinent information from the patient, the medical individual to another within each population. records and the referral source. Information should Therefore, the pattern and severity of impairment be gathered on areas such as the following: must be assessed individually. • the onset of symptoms and medical/dental Individual Intervention. Interventions vary as history a function of type of dysarthria, severity of dys • the nature, duration, and natural course of arthria, and co-existing factors. Therefore, individ velopharyngeal (VP) impairment ual intervention plans must be developed. • reports of previous treatment • the level of concern about the problem Staging of Intervention. Dysarthria often is not (Netsell, 1988) a stable condition. For example, children with de • the patient’s motivation relative to treat velopmental dysarthria may experience physiolog ment (Wolfaardt, Wilson, Rochet, & McPhee, ic changes affecting speech production as they ma 1993) ture. Adults with acquired dysarthria may experience phases of recovery; as in dysarthria as Speech Evaluation sociated with traumatic brain injury; or phases of Determining the severity of the velopharyngeal im degeneration, as in dysarthria associated with pairment and the degree to which the velopharyn sclerosis. Therefore, the stag amyotrophic lateral geal impairment disrupts speech production is crit ing of intervention (i.e., the timing of treatment) is ical to establishing the need for intervention and critical for successful outcomes. for accurate therapeutic intervention (Krummer & Lee, 1996). The perceptual assessment of speech Appropriate Referrals. Practice will be conduct includes an examination of the following: ed by competent speech-language pathologists who refer to other disciplines when appropriate (e.g., for • stimulability for improved speech production prosthodontic consultation when a palatal lift pros • perceptual judgment of presence and thesis is considered appropriate). degree of hypernasal resonance, audible nasal emission, loudness (as possibly Clinical Competence. Practice will be conducted diminished by damping effects of the nasal by competent speech-language pathologist in an cavity) and “strength” and precision of appropriate and efficient manner. pressure consonants as a function of velo pharygeal closure Disclosure. Clinicians will communicate both • connected speech with ratings across the benefits and risks (including financial) of the audiences (e.g., untrained versus familiar treatment. listeners) • phonation • performance on articulation tests including Assessment of VP Function relative differences in the accurate produc tion of nasals and pressure consonants Assessment of velopharygeal function in speakers (Yorkston, Beukelman, Honsinger, & Mitsu with dysarthria assumes an understanding of nor da, 1989; Yorkston, Beukelman, & Traynor; mal function. While it is beyond the scope ofthis ar 1988). ticle to review normal velopharyngeal function, ex • difference in intelligibility, pressure conso cellent sources of information are available (e.g., nants, speaking effort, syllables per breath Kuehn & Mollei 2000). The following section sum group, and resonance with nares occluded marizes the components of an assessment of versus unocciuded velopharyngeal function in dysarthria that may be considered depending on the constellation of Physical Examination deficits and the desired outcomes of each client. As sessment consists of four components: history tak This involves an assessment of the structure and ing, speech evaluation, physical examination, and function of the oral mechanism, including the examination of the velopharyngeal mechanism. following: 266 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY VOL.9, NO. 4

• the velopharynx at rest and during movement • changing the level of effort (e.g., increasing • the modified tongue-anchor test (Duffy; effort for an individual with mild velopha 1995) ryngeal weakness or decreasing effort for • dental occlusion individuals with ataxia who exhibit a pat • the sensitivity of the gag reflex tern of excess effort) • swallowing ability and saliva management • monitoring excess nasal airflow and reso • signs of a submucous cleft (Kruminer & nance features Lee, 1996; Wolfaardt et al., 1993). • increasing the precision of speech by exag gerating articulatory movements (“clear speech”) Instrumental Examination of the patients with Velopharyngeal Mechanism Decisions about how to treat velopharyngeal impairment of moderate severity Instrumental examination of the velopharyngeal can be difficult. For example, expert opinion differs mechanism is necessary to directly observe and somewhat regarding the timing of palatal lift in measure velopharyngeal activity (Duffy, 1995; Till, tervention hi moderately severe cases. Some argue Jafari, & Law-Till, 1994; Wolfaardt et al., 1993). that velopharyngeal management should be car Instrumentation may include videoflouroscopy, ried out prior to phonation, articulation, andlor nasoendoscopy, aerodynamic (pressure-flow) as prosody exercises for speakers who are recovering sessments, and acoustic assessment. This instru function. Others would suggest that velopharyn mentation allows for the evaluation of geal management should occur only after the speaker can phonate voluntarily. The clinician • intraoral air pressure and nasal airflow needs to consider several factors, including the rel during production of pressure consonants ative severity of involvement in other functional • palatal movement components, to determine whether treatment of • lateral pharyngeal wall movement the velopharynx would enhance function in other during speech • sphincteric activity areas (e.g., tax respiration less), and whether and intraoral air pressure • nasal airflow velopharyngeal function would benefit from treat of velopharygeal movements • the timing ing other components first or from modifying the patient’s speaking rate or effort (Netsell & Rosen Behavioral Intervention bek, 1985). The assessment ofvelopharyngeal function leads to one of two conclusions (see Figure 1): adequate Techniques Focusing on Speech Production velopharyngeal function or velopharyngeal impair A variety of behavioral interventions have been ment. Ifvelopharyngeal function is judged to be ad recommended for individuals with dysarthria. Be equate, those individuals with progressive disor cause velopharyngeal impairment may be mild and ders are followed and reassessed. Ifvelopharygneal part of a pattern of impairment crossing multiple impairment is identified, then decisions are made speech subsystems, this type of intervention is con about the appropriateness of behavioral interven the most common treatment ofvelopharyn tions. Generally, those individuals who are appro sidered in dysarthria. It should be noted priate for behavioral intervention are those who geal impairment interventions for velopharyn can compensate (or will be able to compensate if re that most behavioral suggested here arise from expert covery continues) for the velopharyneal impair geal impairment research findings. It ment (Netsell & Rosenbek, 1985). The question of opinion rather than from there is little guidance whether or not speakers are able to compensate for should also be noted that about how long velopharyngeal impairment can be addressed by from the evidence or expert opinion before either evaluating stimulability (the ability to improve these interventions should be applied aban performance under certain conditions). The follow an effect can be expected or the intervention ing techniques can be used to assess stimulability: doned. These techniques will be reviewed in more detail in subsequent modules of the Practice Guide • changing speaking rate (e.g., slowing the lines for Dysarthria. Generally, the behavioral speaking rate) techniques include the following: EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 267

Modifying the Pattern of Speaking. Examples no evidence exists that increasing soft palate of such modifications include producing speech strength improves speech performance; and (c) with increased effort (Liss, Kuehn, & Hinkle, 1994) most of the methods do not provide the patient or a slower rate (Yorkston & Beukelman, 1981; with information on the timing of articulatory ges Yorkston, Beukelman, Strand, & Bell, 1999). tures during speech (Murdoch et al., 1997). Evi Speakers can also be trained to produce clear dence and expert opinion suggest that the following speech by mimicking the overarticulated speech of techniques for improving velopharyngeal function a trained talker. Overarticulated speech can be are not effective (Brookshire, 1992; Duffy, 1995; elicited by prompting with comments like, “open Dworkin & Johns, 1980; Hageman, 1997; Johns, your mouth more,” “speak more clearly,” “overartic 1985; Murdoch et al., 1997; Netsell & Rosenbek, ulate,” and “talk slowly” (Picheny, Durlach, & Brai 1985; Yorkston et al., 1999): da, 1985). • Pushing techniques (particularly for pa Resistance Treatment During Speech. Con tients with spastic dysarthria) tinuous positive airway pressure (CPAP) is an • Strengthening exercises, such as blowing emerging intervention technique reported to be an and sucking effective means of exercising the soft palate during • Tasks that encourage the patient to control speech in two individuals with traumatic brain in and modify the airstream using balls, whis jury The technique provides a resistance against tles, candles, fluff; powder; paper; bubbles, which the muscles of velopharyngeal closure must straws, etc. work (Kuehn, 1997; Kuehn & Wachtel, 1994). A • Inhibition techniques, such as prolonged theoretical rationale for strength training is avail icing, pressure to muscle insertion points, able (Liss, Kuehn, & Hinkle, 1994). slow and irregular stroking and brushing, and desensitization. Feedback. The use of biofeedback techniques for been suggested for velopharyngeal im therapy has Prosthetic Intervention pairment in dysarthria. Some speakers may bene fit from feedback from a mirror, nasal flow trans Candidacy for Palatal Lift Fitting ducer, or nasoendoscope during efforts to decrease nasal air flow and hypernasality (Rosenbek & La If assessment reveals that velopharyrigeal impair Pointe, 1985). The following are some of the instru ment is present and the speaker is not able to com mental feedback techniques discussed in a chapter pensate for that impairment, a palatal lift prosthe by Murdoch, Thompson, and Theodoros (1997) on sis may be considered for selected cases, especially spastic dysarthria: those with a flaccid soft palate. A palatal lift is a rigid acrylic appliance fabricated by a prosthodon • flexible endoscope (provides visual feed tist. It consists of a retentive portion that covers the back of the movements of the lateral pha hard palate and fastens to the maxillary teeth by ryngeal wall) means ofwires and a lift portion that extends along • fiberoptic nasopharyngoscopes (obtains the oral surface of the soft palate. Issues regarding close observations of VP sphincter during candidacy for palatal lift fitting have been de connected speech) scribed extensively (Bedwinek & O’Brian, 1985; • Exeter Bio-Feedback Nasal Anemometer Duffy 1995; Esposito et al., 2000; Murdoch et aL, (EBNA; Bioinstrumentation LTD Exeter) 1997; Netsell, 1998; Yorkston et aL, 1999). Because timing of intervention is different for individuals opposed to stable-recovering Techniques Focusing on with progressive as each population will be Nonspeech Movements dysarthrias, candidacy in discussed separately. Therapy techniques appear in the literature that are based primarily on nonspeech movements of Progressive Dysartbria. Table 3 ifiustrates char the velopharyngeal mechanism. These have gener acteristics of better versus poorer candidates for ally not been endorsed by experts for several rea palatal lift fitting in progressive dysarthria. Better sons: (a) speech and nonspeech velopharyngeal clo candidates are those with a slow rate of disease sures involve different underlying mechanisms; (b) progression and intact cognition, memory, judg 268 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL.9, NO. 4 TABLE 3. Characteristics of better and poorer candidates for palatal lift fitting in progressive dysarthria.

Better Candidates Poorer Candidates Neurophysiology of the soft palate Flaccidity Severe spasticity Rate of neurologic change Slow Rapid Respiratory/phonatory function Adequate Poor Articulation Adequate Poor Change in plosionlresonance with occlusion Present Absent or minimal Difference between intelligibility of pressure and other consonants Pressure consonants much No or minimal less intelligible than others difference between pressure and other consonants Able to inhibit gag Yes No Swallowing and saliva management Adequate Reduced Dentition Adequate Poor Cognition/memory/judgment Intact Reduced Manual dexterity Able to insert and remove lift Unable to insert or remove lift Patient goals for speech Maintenance of functional Decreased function is speech is important to the acceptable speaker

ment, swallowing, and manual dexterity. Respira Palatal tory/phonatory Lift Fitting Procedures and oral articulatory function is ad equate in these individuals, while the soft palate The following provides an outline of the typical movement is impaired steps by weakness from flaccidity taken to construct a palatal lift (Yorkston et versus severe spasticity. Speech is characterized by al., 1999). Variations of the procedures will occur a disproportionately reduced ability to produce (Netsell, 1998; Wolfaardt et al., 1993). Discussions pressure consonants. Maintenance of functional of the use of instrumentation as part of palatal lift speech is critical to the speakers. Because only in design also are available (Turner and Williams, rare cases are all ofthese candidacy issues positive, 1991; Karnell, Rosenstein, & Fine, 1987). clinical judgment is needed to weigh positive ver sus negative factors. • The speaker’s teeth and gums are checked and needed restoration is completed. Stable or Recovering Dysarthria. Table 4 il • Orthodontic bands or acrylic ridges are lustrates characteristics of better versus poorer secured to selected teeth (optional). candidates for palatal lift fitting in stable or recov • An oral cavity desensitization program ering dysarthria. is As in degenerative dysarthria, begun for those speakers with hyperactive the better candidate has a stable or slow rate of gag reflexes (Daniel, 1982). change. Those with rapid improvement are typical • An impression mold of the maxillary arch ly not considered good candidates because enough is taken. function may soon return to support good speech • A dental retainer (the portion covering the without prosthetic intervention. Unlike progressive hard palate) of the lift is fabricated with a dysarthria, good articulation is not as critical for wire loop extending posteriorly as an individuals with a recovering pattern because ar anchor for the posterior portion of the lift. ticulation and respiratory function can be expected • The posterior portion of the lift is to improve once the lift is fitted, cus especially with tomized to meet the needs and concurrent speech treatment. tolerances of In better candidates, the individual speaker. speech is characterized by disproportionately re • Follow-up visit are conducted with duced ability to produce pressure consonants. the prosthodontist and speech-language pa- EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 269

TABLE 4. Characteristics of better and poorer candidates for palatal lift fitting in stable or recovering dysarthria.

Better Candidates Poorer Candidates Neurophysiology of the soft palate Flaccidity Severe spasticity Rate of neurologic change Stable or slow improvement Rapid improvement Respiratory/phonatory function Adequate or recovering Poor Articulation Adequate or recovering Poor Change in plosion/resonance with occlusion Present Absent or minimal Difference between intelligibility of pressure and other Pressure consonants much No or minimal consonants less intelligible than others difference between pressure and other consonants Able to inhibit gag Yes No Swallowing and saliva management Adequate Reduced Dentition Adequate Poor Cognition/memory/judgment WNL or mild to moderate Less than LOCF V impairment Manual dexterity Able to insert and remove lift Unable to insert or remove lift Patient goals for speech Improved speech is critical Decreased function is acceptable

thologist to adjust the length and torque of dysarthria. The speaker points to the first the lift to maximize fitting. letter of each word as that word is spoken. Follow-up visits are planned to monitor the • Partner techniques are strategies initiated adequacy of the fitting. According to Espos by the communication partner including ito and colleagues (2000), prosthetic treat maintaining the topic identity, paying undi ment for progressive disorders must be vided attention, and piecing together cues ongoing. Modifications to the prosthesis are from the speaker with dysarthria. made on a regular basis to accommodate for • Speaker strategies are used to heighten the the progression of the disease. It is common intelligibility of severely dysarthric speech, to make changes to the lift and the augmen including the use of gestures, selecting a tation of the hard palate portion for speak conducive communication environment, ers with increasingly severe dysarthria. and using turn maintenance signals. • Augmentative and alternative communica Behavioral Intervention for Poor tion techniques include use of devices to Candidates for Palatal Lifts replace or supplement highly distorted speech (Beukelman, Yorkston, & Reichle, 2000). If the speaker is judged to be a poor candidate for palatal lift fitting, several behavioral strategies are Surgical Intervention available to establish or maintain communicative function (Hustad & Beukelman, 2000; Yorkston et Surgical management for velopharyngeal impair al., 1999). Behavioral intervention may be em ment in dysarthric speakers also has been report ployed so that speakers can improve the effective ed. Generally, it is considered less beneficial than ness of their communication. The following specific prosthetic management and is contraindicated in techniques will be reviewed in subsequent modules children with cerebral palsy (Hardy et al, 1961; of the Practice Guidelines for Dysarthria: Lotz & Netsell, 1989). Johns (1985), however, sum marized his positive experiences with a substantial Alphabet supplementation is a technique number of dysarthric speakers with velopharyn to improve intelligibility in severe geal impairment who had superiorly based pha PATHOLOG VOL.9, NO. 4 270 JOURNAL OF MEDICAL SPEECH-LANGUAGE

dynamic assessments, which is perhaps the most ryngeal flaps. Because of the drawbacks to surgery direct means of documenting the impact of a (e.g., risks inherent to the procedure itself perma palatal lift (McHenry, Wilson, & Minton, 1994; nence of the procedure, possibility of new Yorkston et al., 1999); radiographic measurements speechlresonance problems, and so on), it is typi (Aten, McDonald, Simpson, & Gutierrez, 1984; cally considered only after behavioral and pros Kipfixieuller & Lang, 1972); and acoustic analyses thetic management have been tried and failed. (Johns, 1985). Surgical management of velopharyngeal impair ment warrants further study especially for those speakers with severe and stable impairment. Activity Limitations Activity is the nature and extent of functioning at the level of the person. Activities may be limited in MEASUREMENT OF OUTCOMES nature, duration, and quality. For example. mea sures of the intelligibility, speaking rate, and natu It is increasingly important to document the out ralness ofspeech may be used as a measure of func of intervention. A variety of outcome mea comes tioning in dysarthria. Activity limitations are be obtained (Table 5) and can be catego sures may typically measured perceptually. Listener percep terminology from the World Health rized using tions frequently are assessed through phoneme in model of disablement (World Health Organization telligibility and/or sentence intelligibility, but may Frattali, 1998). Organization, 1999; also include perceived changes in hypernasality and nasal emission. Phoneme intelligibility allows with Impairment an examination of articulatory error patterns and without the lift in place (e.g., Yorkston, Beukel abnormality of body An impairment is a loss or man et al,, 1989). Sentence intelligibility is one of psychologic func structure or of a physiological or the best means of assessing the functional changes the velopharyn tion. For example, airflow through brought about by the palatal lift (Yorkston et al., pressure consonants geal port during production of 1999). may be measured. Physiologic or psychophysical measurements of behavioral change should be con Participation Restriction sidered whenever possible (Netsell, 1978; Netsell & include aero Rosenbek, 1985; Johns, 1985). These Participation is the nature and extent of a person’s involvement in life situations in relation to impair ments, activities, health conditions, and contextual TABLE 5. Examples of outcome measures factors. As with activity limitations, participation used to evaluate velopharyngeal manage may be restricted in nature, duration, and quality. ment in dysarthria. For example, report of use of speech in natural com munication situations, such as public speaking, may Impairment be used as a measure of participation. Measures of • Radiographic are not commonly reported in the in • Physical examination results participation They are, however; important. • Aerodynamic measures tervention literature. speech pathologists are • Phonation time As stated by Johns (1985), as possible, • Rating of severity by speech subsystem urged to measure, as objectively status, • Pulmonary function tests changed aspects of a patient’s psychological adaptation to the environment. Activity Limitation that is, his/her • Perceptual changes in hypernasality • Perceptual changes in articulation • Perceptual changes in voice SUNMARY • Perceptual changes in intelligibility • Reduction in effort A variety of techniques are available for the man in dysar Participation Restriction agement of velopharyngeal impairment of the in • Return to work thria. This summary is based on a review • Speaking without fatigue tervention studies that emerged from a search of • Reports of self-confidence, self-esteem the literature and from expert opinion. It suggests • Reports of improved quality of life the following: EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 271

1. Prosthetic intervention, particularly palatal lift of speech production. Behavioral intervention is ap fitting, has a long history associated with propriate in these individuals, and includes such improved speech function in selected individuals strategies as rate and effort modification, monitor with dysarthria. ing of emission/resonance, and exaggerated articu 2. Surgical intervention is generally not considered lation. unless all other interventions have failed. Cur The following is a listing of some needs of future rently, there is not sufficient evidence in the liter research in the management of velopharyngeal ature to make recommendations about surgical impairment: intervention for the general dysarthria popula tion. • Better descriptions of fitting protocols 3. Exercise as a treatment ofvelopharyngeal impair • More complete description of current clini ment in dysarthria has been reported in a small cal practice focusing on prevalence of vari number of cases, but evidence is so preliminary ous types of intervention that reconunendations for its use cannot be made • Better descriptions of speech function at this time. (other than palatal function) • A more comprehensive set of outcome mea Because dysarthria is a heterogeneous disorder, sures (including measures of communica a single intervention or type of intervention cannot tive participation) be expected to be effective for all speakers with • Better description of the psychometric ade dysarthria. Palatal lift intervention has been the quacy of the outcome measures most carefully studied. Even in this case, making • Efficacy studies focusing on post-fitting general statements about the appropriateness of behavioral intervention and distinguishing palatal lift fitting in dysarthria is difficult. Rather, the natural accommodation to palatal lift it is more useful to describe a candidacy profile. The placement from the benefits of additional better candidates for palatal lifts have the charac behavioral speech treatment teristics listed in Tables 3 and 4. The most critical • Studies of the timing of intervention, for indicator of candidacy is weakness in the soft example, a comparison of early versus later palate that prevents closure of the velopharyngeal palatal lift fitting in individuals with trau mechanism during speech. Other candidacy indica matic brain injury tors include pharyngeal wall movement, good oral • Documentation of the best techniques for articulation and respiratory support, and a rela palatal lifting fitting in challenging cases, tively stable clinical course. Some nonspeech fac such as children with mixed dentition, tors that may also contribute to being a good can adults with dentures, individuals with didate include intact swallow, cognition, and hyperactive gag reflexes, and so on manual dexterity along with the desire to maintain • Better documentation of the impact of or regain speech. For individuals with all of these behavioral intervention and other treat characteristics, palatal lift fitting would be strong ment approaches including surgical man ly recommended as a standard of practice. Most agement dysarthria speakers do not fit the profile of the • We need to determine the relative effec “better candidate.” Therefore, as the characteristics tiveness of various treatments or “what of the speakers move away from the ideal, the rec works best and for whom” by comparing ommendation for palatal lift fitting becomes less different approaches to management of and less strong. For an individual with all of the velopharyngeal impairment (e.g., palatal characteristics of a “poorer candidate,” palatal lift lift versus behavioral management versus fitting would not be an appropriate clinical option. both; behavioral nonspeech techniques ver The preponderance of palatal lift interventions sus speech techniques.) found in the literature does not reflect the distrib ution of interventions found in typical clinical prac tice. In fact, palatal lifts are fitted only in the mi Acknowledgment This work was supported in nority of speakers with dysarthria, specifically part by the Academy of Neurologic Communication Dis those with a particular candidacy profile. In the orders and Sciences (ANCDS) and a personal training majority of speakers with dysarthria, velopharyn grant (T32DC00033) from the National Institute on geal impairment is part of a complex pattern of Deafness and Other Communication Disorders, Nation subsystem involvement and affects many aspects al Institutes of Health, to the University ofWashington. 272 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL.9, NO. 4

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