Dealing with Dysarthria and CAS CASANA Webinar October, 2013 Ruth Stoeckel, Ph.D., CCC-SLP

Dealing with Dysarthria and CAS CASANA webinar October, 2013 Ruth Stoeckel, Ph.D., CCC-SLP

Disclosures

Nonfinancial: CASANA Professional Advisory Board

Financial: CASANA DVD and speaker fees

Objectives of this course:

1. Identify characteristics that help to differentiate impairment in motor execution from motor planning/programming

2. Explain how speech subsystems can be affected in children with dysarthria

3. Demonstrate knowledge of how principles of motor learning inform decision‐making in treatment for dysarthria

Introduction

There are interactions among cognitive, language, and speech development (Nip, Green & Marx, 2010)

We need to discern the relative contribution of various factors in children with communication disorders

Today, discussion will center on identification and treatment of an impairment in motor execution (dysarthria) when it occurs in conjunction with an impairment of motor planning and programming (Childhood Apraxia of Speech)

Diagnosis can be challenging: Speech sound disorders do not occur in isolation

Phonologic Disorder

 The primary factor is thought to be linguistic rather than motor  Etiology is most often unknown

Childhood Apraxia of Speech

 The primary factor is thought to be praxis: planning/programming movements  No obvious weakness or impaired ability to move articulators  Can be acquired (e.g., stroke, TBI) or “developmental”

Dysarthria(s)

 Difficulty with execution of movements  Weakness, paralysis, or abnormal tone resulting in decreased range of motion, decreased speed, or impaired movement of the articulators  Usually caused by impairment in the central or peripheral nervous system

The term “dysarthria” may be used as a general term by some people

“dys” = partial impairment of

“arthria” = speaking

SLPs use the term in a more specific sense

• Usually differentiated by the site of neurologic damage, the observed impairment of the speech muscles, and the characteristics of speech production

• Disturbances in strength, speed of movement, range of movement, and timing, which disrupt accuracy

• Depending on the type of condition causing the dysarthria, one or more muscle groups may be affected, meaning difficulty with respiration, phonation, resonance, articulation and/or prosody

• The nature and severity of neuromuscular dysfunction can vary across muscle groups within a child

• Classifications are based on adult acquired dysarthrias

• May not fully account for issues related to disruption in the system of a child who is still developing speech and language skills

Differential Diagnosis

There is no published test that is adequate to give a definitive diagnosis of dysarthria (McCauley & Strand, 2008)

Assessment procedures are used to

• determine the relative contribution of linguistic/phonologic and/or motor impairments

• assist in planning treatment

• “A significant research challenge is to determine the diagnostic boundaries between CAS and some types of dysarthria with which it may share several speech, prosody, and voice features.” ASHA Technical Report, 2007

History

• Birth history

• Family history

• Developmental milestones

• First words,word combinations

• Motor milestones

• Co‐existing problems

• Sensory function issues

• Seizures, hearing loss, learning issues

• Feeding history, abnormal reflexes

• Dysarthria and CAS can be either congenital or acquired

• Dysarthria is often a part of a more general motor disorder, e.g., cerebral palsy or genetic disorders

• Clumsiness

• Oral hypo‐ or hypersensitivity

• With dysarthria, muscle control is generally disrupted for both nonspeech (swallowing, chewing, blowing, etc.) and speech movements

• With CAS, there may have no problem or there may be different difficulties with nonverbal oral‐motor skills (e.g., overstuffing vs trouble swallowing)

Structural‐Functional Examination

These are subjective observations

• Structures

• Function of each structure

• Range of motion

• Coordination

• Strength

• Ability to vary muscular tension

• Speed

• Muscle tone refers to the degree of muscle contraction or tension at rest

• Damage to upper motor neuron system is usually related to spasticity, lower motor neuron system to hypotonia

• It is not the same as weakness, although a child with low tone may be weak

• Hypotonia may be seen in structures at rest, but does not always affect movement

• Muscle weakness occurs when not enough muscle fibers are contracting. May be due to

• Too few fibers available (muscle atrophy)

• Disruption of the pathway so the muscle fibers are not activated

• Inadequate levels of activation

• Ability to vary muscular tension

• Very little strength required

• Needed for precise differentiation of sounds within a sequence (e.g. “man” vs”pan”)

Observations of Physiologic Functioning

Observed in spontaneous output and as part of the motor speech exam

• Respiration

• Articulation

• Phonation

• Resonance

• Prosody

Possible Impairments in Dysarthria (adapted from Hodge & Wellman, 1999)

Respiration Muscles of rib cage, diaphragm, and abdomen Reduced loudness; poor regulation of loudness Reduced breath group length Inhalation poorly coordinated with speech (speech initiated at end of inhalation; inhalation within words) Difficulty initiating phonation Articulation Lips, tongue, jaw Imprecise (“mushy”) production of consonants Reduced vowel space, vowel distortions Slow initiation and slow rate of articulator movements Inability to move articulators independently (e.g., jaw vs tongue after age 4-5) Involuntary movements of muscles of articulation Phonation Laryngeal muscles interacting with airstream from lungs under control of muscles of respiration Difficulty initiating phonation Inappropriate pitch (too high or low) Reduced range of pitch and/or loudness Voice quality deviations (breathy, strained, hoarse) Involuntary “extra” phonation Resonance Muscles of soft palate, pharyngeal walls, tongue and mandible Nasal emission on pressure consonants Hyper- or hyponasal resonance Reduced breath group length Articulatory error patterns: nasal additions, weak pressure consonants, nasal assimilation, voicing errors Prosody Muscles of respiration, phonation, resonance, articulation Difficulty regulating pitch, duration, or loudness for lexical or phrasal stress Poorly regulated breath groups

Articulation: Speech Sound Inventory

• Phonetic Inventory (Independent analysis)

• What sounds is the child producing spontaneously?

• What types of errors? Consistent?

• Error Inventory (Relational analysis)

• How does the child’s sound system map onto adult forms? Distortions?

Articulation: Speech Motor Skills

• Observations regarding

• Precision and consistency of movements

• Ability to vary rate and/or loudness

• Slower rate may improve accuracy for both CAS and dysarthria

• Ability to vary muscular tension

• Accuracy with increasing length or phonetic complexity of utterances

Phonation

• Difficulty initiating phonation (also in CAS)

• Difficulty controlling loudness (also in CAS)

• Reduced loudness/breathy voice

• Reduced pitch or loudness range

Resonance

• Hypernasal resonance (also in CAS, possibly due to timing)

• Hyponasal resonance

• Nasal emission or nasal assimilation

Prosody

• Reduced pitch/loudness range

• Poor regulation of breath support for lexical or phrasal stress (expressiveness)

Comparison of Childhood Apraxia of Speech, Dysarthria and Severe Phonological Disorder

Verbal Apraxia Dysarthria Severe Phonological Disorder

No weakness, incoordination or paralysis Decreased strength and coordination of No weakness, incoordination or paralysis of speech musculature speech musculature that leads to of speech musculature imprecise speech production, slurring and distortions

No difficulty with involuntary motor Difficulty with involuntary motor control No difficulty with involuntary motor control for chewing, swallowing, etc. for chewing, swallowing, etc. due to control for chewing and swallowing unless there is also an oral apraxia muscle weakness and incoordination

Inconsistencies in articulation performance‐‐the same word may be Articulation may be noticeably "different" Consistent errors that can usually be produced several different ways due to imprecision, but errors generally grouped into categories (fronting, consistent stopping, etc.)

Errors include substitutions, omissions, Errors are generally distortions Errors may include substitutions, additions and repetitions, frequently omissions, distortions, etc. Omissions in includes simplification of word forms. final position more likely than initial Tendency for omissions in initial position. position. Vowel distortions not as Tendency to centralize vowels to a common. "schwaa"

Number of errors increases as length of May be less precise in connected speech Errors are generally consistent as length of word/phrase increases than in single words words/phrases increases

Well rehearsed, "automatic" speech is No difference in how easily speech is No difference in how easily speech is easiest to produce, "on demand" speech produced based on situation produced based on situation most difficult

Receptive language skills are usually Typically no significant discrepancy Sometimes differences between receptive significantly better than expressive skills between receptive and expressive and expressive language skills language skills

Rate, rhythm and stress of speech are Rate, rhythm and stress are disrupted in Typically no disruption of rate, rhythm or disrupted, some groping for placement ways specifically related to the type of stress may be noted dysarthria (spastic, flaccid, etc.)

Generally good control of pitch and Monotone voice, difficulty controlling Good control of pitch and loudness, not loudness, may have limited inflectional pitch and loudness limited in inflectional range for speaking range for speaking

Age‐appropriate voice quality Voice quality may be hoarse, harsh, Age‐appropriate voice quality hypernasal, etc. depending on type of dysarthria

Compiled by members of the Advisory Committee of the Childhood Apraxia of Speech Association of North America (CASANA) Can be found at www.apraxia-kids. org

Intervention

• There is a lack of clinical research addressing effective treatment approaches for childhood dysarthria (Cochrane database review, 2010)

• Understanding the child’s neurologic status and prognosis will be important

• Use a team approach that promotes caregiver involvement

• Childhood dysarthrias will likely be chronic, with goals adapted over the course of the child’s development

• Introduction of AAC early in treatment will be important to support language development and social interaction

Intervention: Dysarthria and CAS

Similarities

• Consider cognitive and linguistic needs of the child

• Functional stimuli

• Incorporate principles of motor learning

• Address nonspeech skills as appropriate (remembering that muscle activation is task‐ specific)

Differences

• Principles of motor learning applied to different skills

• CAS may be “resolved”, dysarthria is chronic

• Some children with CAS have no impairment of nonspeech skills, all children with dysarthria do

Intervention: Best Available Evidence

• What may need to be added when dysarthria co‐occurs with CAS:

• Stabilize respiratory support and control of phonation

• Control speech rate

• Control phrase length and number of syllables per breath

Stimuli

• Stimulus choices should include consideration of how to:

• promote early success in therapy

• promote generalization of learning

• improve movement gestures for accurate production of targets or best approximations

• encourage good prosody

• increase effectiveness of verbal communication Functional Stimuli for *speech* needs

Increase sound repertoire ‐‐‐ new sounds in existing syllable shapes

Increase syllable repertoire – existing sounds in new syllable shapes; expand phrases

Improve prosody – lexical and phrasal stress

Functional Stimuli for *language* needs

Vocabulary – nouns, verbs, conceptual vocabulary

Grammar/Syntax – length and complexity of utterances; grammatical morphemes

Social Interaction – Greeting; requesting/directing; commenting

Principles of Motor Learning Summary Chart:

Principle Acquisition Retention Practice Distribution Mass Distributed

Practice Variability Consistent context, consistent Varied context, varied prosody, pitch, rate prosody, pitch, rate Practice Schedule Blocked, predictable order Random unpredictable order Feedback Type Knowledge of performance Knowledge of results

Feedback Frequency Often, immediate Inconsistent, delayed

Rate Slow Normal, varied

Summary

There is overlap in treatment techniques for CAS and dysarthria, but there are also differences due to presumed difference in motor processes involved

• Treatment for dysarthria may emphasize respiratory support and control of rate and phonation

• Motor speech intervention also needs to take into account cognitive and linguistic factors References

ASHA (2007). Childhood Apraxia of Speech. Technical Report

Caruso, A. J., & Strand, E. (1999). Clinical Management of Motor Speech Disorders in Children. New York: Thieme Publishing Co.

Hodge, M. (2002). Nonspeech oral motor treatment approaches for dysarthria: perspectives on a controversial clinical practice. Neurophysiology and Neurogenic Speech and Language Disorders Special Interest Division 2 Newsletter

Maas, E., Robin, D., Austermann Hula, S., Freedman, S., Wulf, G., Ballard, K, & Schmidt, R. (2008). Principles of Motor Learning in Treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology, 17, 277-298

McCauley, R.J., and Strand, E.A. (2008). A review of standardized tests of nonverbal oral and speech motor performance in children. American Journal of Speech-Language Pathology, 17, 81-91

Nip, I.S., Green, J.R., Marx, D.B. (2010). The co-emergence of cognition, language, and speech motor control in early development: A longitudinal correlation. Journal of Communication Disorders