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- 1. Chapter 6:
Motor Speech Disorders:
Apraxia and Dysarthria
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 2. Focus Questions
• What is a motor speech disorder?
• How are motor speech disorders
classified?
• What are the characteristics of prevalent
types of motor speech disorders?
• How are motor speech disorders
identified?
• How are motor speech disorders
treated?
6.1
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 3. Introduction
• Speech production is one of the most
“impressive motor skills”
• Control of speech movements follows a course
of development up to age 12; humans acquire
adult-like speech motor control by adolescence
• Childhood motor speech problems most likely
caused by neurological difficulties, and adults
can experience also after injuries or illnesses
• Two major categories: apraxia and dysarthria
6.2
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 4. Case Study #1: Bob
• 42-year old bilingual, married with four
children, travels, coaches soccer, involved
in community activities
• Diagnosed with cerebellar tumor, removed
successfully, but effects from surgery…
• Severely ataxic, difficulties coordinating
voluntary movements, under- and over-
shooting movements, and tremor
• Now requires wheelchair and only about
30% of speech is intelligible
6.3
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 5. Case Study #1 Questions
• What are some ways Bob’s
communicative difficulties affect his
participation in life?
• What types of strategies might you
suggest to improve Bob’s participation in
life?
6.4
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 6. Case Study #2: Walter
• 60-year old professor, likes to read, play
tennis, improve the house, and play piano
• Age 59, left hemisphere stroke – now
slow, effortful, and inconsistently distorted
speech and weakness in right side of
body, including oral structures (e.g. lips)
• SLP diagnosed him with mild aphasia and
mild apraxia of speech – 95% intelligible
6.5
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 7. Case Study #2 Questions
• On which of Walter’s strengths might you
attempt to capitalize in developing a
treatment plan?
• Discuss some specific ways in which
Walter’s participation in life is affected by
his speech problems.
6.6
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 8. Case Study #3: Hikaru
• 5-year old came to U.S. from Japan at 2, primarily
English speaker, but understands Japanese also
• Referred to evaluation by mother – fewer sounds
during babbling stage, history of drooling and
hypotonia, asymmetries between L and R
hemispheres (cerebral palsy), delays in syntax and
phonology, speech is imprecise and weak
• Weakness limited to articulatory system, and does
not show characteristics consistent with apraxia of
speech
• Mother wants to hold back in kindergarten
6.7
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 9. Case Study #3 Questions
• Japanese is a language that does not
have consonant clusters and syllable-final
consonants (“truck”). Why is this
important information for evaluation and
diagnosis? What other differences
between Japanese and English might be
relevant for fully understanding Hikaru’s
problems?
• What are some pro’s and con’s of holding
Hikaru back for a second year of
kindergarten?
6.8
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 10. I. What is a Motor Speech
Disorder?
• Speech production deficit that results from
impairment of the neuromuscular and/or
motor control system
• May co-occur with other language
impairments
• Other oral movements (besides speech)
may be impaired, including chewing and
smiling
6.9
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 11. Terminology
Four Subsystems of Speech Production:
• Respiratory
• Phonatory
• Resonatory
• Articulatory
The muscles and muscle groups in these
subsystems must be coordinated in time
and space
6.10
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 12. Respiratory System
• Speech production requires airflow
• Pulmonary airstream mechanism: pushes air
out of lungs through trachea (windpipe) to
produce airflow
• Ingressive – inhalation
• Egressive – exhalation
-1:6 inhalation:exhalation ratio during
speech production
• Exhalation cycle needs to be extended in
time (for completion of utterance) and
modulation (to reflect stress)
6.11
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 13. Phonatory System
• Includes various muscles and structures in
the larynx, and regulates the production of
voice and the intonational aspects of speech
• Vocal folds are brought closely together, and
the airflow builds up to set the vocal folds
into vibration
• Vocal folds are stretched lengthwise to
manipulate the frequency or pitch of the
voice
6.12
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 14. Resonatory System
• Regulates the vibration of the airflow as it
moves from the pharynx into the oral and
nasal cavity
• Manipulates shape and size of vocal tract
for maintaining normal sound quality
• Manipulates the velo-pharyngeal port,
(whether nasal cavity is used as a
vibrating chamber) for determining nasality
of sounds
– oral vs. nasal sounds – b and p vs. m and n
6.13
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 15. Articulatory System
• Control of the articulators within the oral
cavity to manipulate the outgoing airflow
• Major structures: lower jaw, lips, tongue
(most important)
• Tongue: intrinsic muscles (fine-tuned
movements) and extrinsic muscles (coarse
movements – protrusion, retraction,
elevation, depression)
• Muscles contract to create constrictions in the
oral cavity to produce varying sounds
6.14
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 16. Motor Control
• To maintain speed and fluency, the
sequences of movements are programmed
together as a single movement unit
– Degrees of freedom: the number of elements
that can be independently controlled
– The greater the degrees of freedom, the greater
the challenge to the speaker
• Speakers reduce the number of degrees of
freedom by organizing motor actions into
motor units
6.15
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 17. Motor Units
• Motor unit: single control mechanism that
controls more than one degree of freedom
– Basic pattern of movement components remains
constant, while more specific aspects of
movements are influenced by specific
circumstances
• Producing speech involves producing both
linguistic units and acoustic events
– This requires coordination of muscle groups and
programming muscle activities into single motor
units to ensure fluent and accurate articulation
6.16
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 18. Planning, Programming, and
Execution
• Motor planning: processes that define and
sequence articulatory goals (prior to initiation
of movement)
• Motor programming: processes that establish
and prepare the flow of motor info across
muscle, as well as control timing and force of
movement (prior to initiation of movement)
• Motor Execution: processes that activate
relevant muscles (during and after initiation of
movement)
6.17
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 19. Motor Learning
• Extensive practice and experience
producing speech leads to motor learning
(“permanent changes in capability of
movement”)
• Schema Theory: memory representations
of motor specifications needed to reach a
desired speech outcome (schemas)
– become stronger with experience
– person uses stored schema to produce
desired speech outcomes
6.18
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 20. Prevalence and Incidence
• Reliable estimates are rare, however…
– Among adults with acquired communication
disorders, 51% have motor speech disorders
(46% dysarthria, 5% apraxia of speech)
– Among children with developmental
communication disorders, about 5% have motor
speech disorders
-Difficulty to find estimates because of
difficulties in identification and long standing
debates about diagnosing motor speech
problems in children
6.19
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 21. II. How are Motor Speech
Disorders Classified?
ETIOLOGY:
• Acquired: damage to a previously intact nervous
system
-caused by cerebrovascular accidents (strokes)
degenerative diseases, brain tumors or traumatic brain
injury
• Developmental: abnormal development of or damage
to the nervous system
-caused by congenital diseases, or damage to the
developing nervous system (different effects than
damage to an already intact system)
6.20
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 22. MANIFESTATION:
• Impairments of Planning/Programming:
coordination of relevant muscles and
muscle groups is disrupted (muscle
physiology and movement is intact)
• Impairments of Execution:
disruptions in muscle physiology –
affected by involuntary movements and
reductions in movement abilities (whether
speech is programmed normally or not)
6.21
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 23. SEVERITY:
World Health Organization (WHO):
• Disease: underlying physiological
condition or psychological cause
• Activity: actual behavioral or performance
deficits that result from the disease
• Participation in life: how the disease
impacts upon quality of life of individual at
home, school, work, and in the community
6.22
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 24. INDIVIDUAL DIFFERENCES:
• Differences occur between individuals in:
-ability to compensate
-ability to use unimpaired systems
-general life response
-response to treatment
6.23
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 25. III. Defining Characteristics of
Prevalent Types of Motor Speech
Disorders
• Motor Planning/Programming Disorders:
inability to group and sequence the relevant
muscle with respect to each other
-apraxia of speech (AOS) – acquired and
developmental
• Motor Execution Disorders: deficits in
physiology and movement abilities of muscles
-dysarthria – acquired and developmental
6.24
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 26. Acquired AOS
• Inability to transform an intact linguistic
representation into coordinated movements of
the articulators
• Characteristics: slow speech, sound distortions,
prolonged durations of sounds, reduced
prosody, consistent errors within an utterance,
difficulties initiating speech, groping of
articulators
• Caused by neurological damage to the left
frontal cortex surrounding Broca’s Area – due to
stroke, brain injuries, illness, and infections
6.25
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 27. Childhood AOS
• Salient characteristics of this disorder is
the same as acquired AOS
• Considerable delay in speech production,
limited sound inventory, unintelligibility,
and progress slowly in speech therapy
• Causes are not well understood; some
research points to hereditary component,
not clear there is specific neurological
damage
• Some cases caused by stroke or
traumatic brain injury
6.26
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 28. Acquired Dysarthria
• Disruption in the execution of speech
movements resulting from neuromuscular
disturbances to muscle tone, reflexes, and
kinematic aspects of movement
• Speech sounds slow, slurred, harsh or quiet,
or uneven depending on the type of
dysarthria
• Three concepts: spasticity, dyskinesia, ataxia
• Typically occurs because of a progressive
disease or trauma
6.27
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 29. Types of Acquired Dysarthria
• Spastic
• Flaccid
• Hypokinetic
• Hyperkinetic
• Ataxic
• Unilateral Upper Motor Neuron (UUMN)
6.28
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 30. Developmental Dysarthria
• Present at birth
• Usually occurs along with known
disturbance to neuromotor functioning
• Can be caused by pre-, peri-, or post-natal
damage to the nervous system
• Most common types:
-spastic
-dyskinetic
6.29
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 31. IV. How are Motor Speech
Disorders Identified?
The Assessment Process:
-professionals consider how the disorder
affects the individual’s life to determine the
impairment and the course for treatment
-assessment of motor speech disorders
should include measures of nonspeech
oral motor skills and should isolate
particular motor subsystems to determine
impairment
6.30
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 32. Measurement Methods
• Perceptual measures – perceptual
judgments of intelligibility, accuracy, and
speed of speech production (most common)
• Acoustic measures – visual representation of
the speech sound wave (e.g., spectogram)
for more detailed and objective view of
speech problems
• Physiologic measures – measurement of
physiologic aspects of speech motor system
not easily perceived otherwise (e.g., muscle
strength)
6.31
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 33. Referral and Screening
• Referral – typically from a hospital, school,
or parents of child – depending on
whether acquired or developmental
disorder
• Screening – includes interviews with
patient and family and review of medical
history
6.32
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 34. Comprehensive Motor Speech
Evaluation
• Should involve motor control tasks that
involve speech and nonspeech motor
activities
• Should assess the motor speech
problems at each of the levels of
functioning – disease, activity, and
participation in life
• Should include assessment of each of the
subsystems separately – respiration,
phonation, resonation, articulation, and
also include prosody
6.33
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 35. Diagnosis
• After assessment, findings are interpreted to
come up with a speech diagnosis
• In current practice, differential diagnosis is
based largely on auditory perceptual measures
(the professional’s perceptual observations), not
yet on objective acoustic and physiologic
indicators
• Diagnosis involves understanding the hit rate,
miss rate, false positive rate, and the correct
rejection rate
6.34
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 36. V. How are Motor Speech
Disorders Treated?
• Treatment focuses on (re)learning motor
aspects of speech production, which requires
acquisition, retention, and generalization
– Acquisition: temporary improvements during
treatment
– Retention: lasting performance enhancements
– Generalization: improvements in either related
but untrained behaviors (response) or in targeted
behaviors in different contexts, tasks, or settings
(stimulus)
6.35
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 37. Treatment Targets
• Use of nonspeech tasks (e.g., pursing the lips,
smiling, moving the tongue) in assessment does
not mean that nonspeech tasks should be used
in treatment
• Little research supports “oral motor activities” to
strengthen the articulators or improve their
movements
• Focusing on more complex targets results in
greater learning than focusing on simpler targets
6.36
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 38. Treatment Strategies
Primary Strategies: Two Approaches
– Improve impaired subsystem – focus on
specific functions in relevant speech tasks
• e.g., improve respiratory support for speech
– Compensatory strategies
… for the affected individual
… for the environment
… for the communication partners
6.37
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 39. Treatment Contexts
• Important indicator of treatment
effectiveness is generalization
• Speech production in other tasks and with
different conversational partners should be
included the routine assessment process
6.38
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 40. The Treatment Plan
• Pre-practice considerations – several
conditions should be considered and
discussed prior to treatment:
-memory
-attention
-motivation
-goal setting
-establishing a reference of
correctness
6.39
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 41. Treatment of Respiratory System
• Establishing respiratory support (e.g., making
postural adjustments)
• Modifying inhalation (e.g., increasing duration of
air intake)
• Modifying exhalation (e.g., vowel prolongation)
• Improving inhalation/exhalation relationship
• Increasing respiratory flexibility (e.g., producing
words with a variety of stress patterns)
6.40
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 42. Treatment of Phonatory System
• Improving voice quality (e.g., postural
adjustments, relaxation therapy)
• Controlling vocal folds to enhance
naturalness of speech
6.41
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 43. Treatment of Phonatory System
• Improvement of strength and control of
velo-pharyngeal port (e.g., practicing nasal
vs. oral airflow patterns)
• Might be necessary to use a palatal lift – a
device that helps raise the velum –
depending on severity of subsystem
impairment
6.42
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 44. Treatment of Articulatory System
• Focus the patient’s attention to the
accuracy, range, and direction of
movement during speech
• Feedback from the clinician can include
articulatory placement cues (e.g.,
modeling speech production)
6.43
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
- 45. Treatment of Prosody and Rate
Control
• Prosody involves manipulation of three
factors: loudness, pitch, and duration
• Each of these factors should be focused
on during treatment
• Approaches to reducing the rate of
speech:
-rigid control techniques
-non-rigid control techniques
6.44
Justice
Communication Sciences and Disorders: An
Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.