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Purpose of Evaluation

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- describe features of individual's speech - use GOOD description to reach a diagnosis - determine if normal or abnormal - differential diagnosis: narrowing the diagnostic possibilities and arrive at the specific diagnosis; classify the disorder - determine site of lesion or disease process (does it match overall diagnosis & symptoms) - define treatment focus - acquire baseline data

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Components of Diagnosis

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- neurologic problem? if not, organic? - problem recent or longstanding? - if neurological, MSD? - if MSD, apraxia or dysarthria? - if dysarthria, what type?

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Areas to Define in Eval

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- precise diagnosis - compare speech diagnosis to neurological localization & match any neuro diagnosis - if speech is ONLY symptom, may indicate an unidentified neuro problem - speech exam is often critical in neuro diagnosis & is valued by physician

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Skills of SLP

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- need good knowledge base to recognize what's seen and heard - need to know diseases associated w/ each MSD - if evaluating a child, need to know normal developmental expectations - look for the unexpected, not just what SHOULD be associated w/ disorder

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General Evaluation Guidelines

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1. Case History (gives sample of patient's speech; gives historical data) 2. Salient Speech Characteristics (what's most influential in speech disturbance?) - could be: 1.strength 2.speed 3.ROM 4.steadiness 5.tone 6.accuracy Overall, this will all affect tx: - what's person's response to instructions? - cognitive/language barrier? - able to self-correct? - able to perceive errors?

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Strength

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- decreased most in flaccid dysarthria - rarely a target - LMN damage

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Speed

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- usually decreased EXCEPT in hypokinetic dysarthria - movement may be slow to start, stop, or relax - decreases prosody - most obvious in spastic dysarthria - talker slower = universal compensation - w/ coordination: can speech components work together? can articulators move fast enough? can they make precise movements? DOES rate allow coordination...?

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ROM

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- distance traveled by articulators - decreased ROM is common - range may also be variable - decreases prosody

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Steadiness

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- involuntary movements or hyperkinesia results when steadiness breaks down - assess on prolonged vowel task /a/ - disturbances most commonly affect phonation & prosody - tremor = most common type of breakdown in steadiness - dystonia, dyskinesia, chorea & athetosis have random, unpredictable, involuntary movements - may be severe enough to disrupt movement & can affect all speech components, especially prosody

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Steadiness: Tremor

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- rhythmic, repetitive oscillations - may occur at rest or upon action or at end of movement

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Steadiness: Dystonia

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- freezing or cramping ......... slow involuntary contraction/prolonged cramping contraction/continuous writhing

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Steadiness: Dyskinesia

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- always moving - slow writhing

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Steadiness: Chorea

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- big jerking movement

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Steadiness: Athetosis

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- slow writhing movement

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Tone

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- may be excessive or decreased - may fluctuate & affect all speech components - see if person can vary between tense & relaxed - flaccid dysarthria = decreased muscle tone - spastic dysarthria = increased muscle tone - hyperkinetic dysarthria = variable tone

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Accuracy

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- reflects coordination of all previous skills - articulators may overshoot or undershoot - with poor timing, movements aren't smooth & have poor rhythm, articulatory imprecision - seen most in articulation and prosody of ataxic or hyperkinetic dysarthria

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Confirmatory Signs

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- signs in addition to deviant speech that help w/ diagnosis - may not be present - fasciculations - atrophy - decreased tone - aberrant reflexes - gait problems - spasticity - poor limb movements - adventitious movements = involuntary, uncontrolled movements = chorea, dystonia, fasciculations, myoclonus, spasm, tic, tremor - LOOK at the person overall...

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Adventitious Movements

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- chorea - dystonia - fasciculations - myoclonus - spasm - tic - tremor

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Chorea

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- rapid, uncontrolled, involuntary movement - big movements - of head, neck, trunk - ex: arm thrusting out (Huntington's Disease

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Dystonia

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- slow involuntary contraction - head/neck, tongue - continuous writing - or prolonged cramping contraction - ataxic CP

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Fasciculations

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- involuntary, synchronous contractions of muscles under the skin - crawling twitches - LMN damage - NOT tremor - stick tongue out straight

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Myoclonus

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- irregular, frequent, and brief muscle jerks - more focal than chorea - ex: eyes, hiccups

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Spasm

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- prolonged contraction of muscle - tonic = prolonged (cramp) - clonic = brief (dog leg)

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Tic

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- compulsive movements of muscles of face

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Tremor

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- rhythmic, fine movements - restoring or with intention - hands, chin, mouth, head

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Perceptual vs. Instrumental Assessment

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- perceptual assessment indicates symptoms but NOT underlying case... which can be different for the same symptoms in different people - instrumental means confirm the hypotheses formed from perceptual assessments - use CONSISTENT test procedures to be better at recognizing the wide range of normal - there aren't many standardized tests for MSD - oral mech = ALL perceptual

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Parts of Motor Speech Evaluation

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1. History 2. Oral Mech/Physical Exam w/ Non-Speech Tasks - determines impairment 3. Motor Speech Exam (Perceptual Speech Characteristics) - determines functional limitations 4. Intelligibility - "take home message" 5. Acoustic/Physiologic Analyses - exam varies based on suspected dysarthria or apraxia - may not include all parts for all people - start at lowest level for some and higher level for others - motor speech exam can provide info about swallowing as well (same system/muscles & those w/ MSD @ risk for dysphagia)

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1. History

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- medical records - interview - onset, course of disease, handicap, patient awareness - significant other may provide some info - components: introduction; personal data; onset & course; associated deficits (idea of which disease); patient's perceptions; consequences; management (meds, tx) - pre-morbid speech or language deficits - communication needs - functional limitations - medications or adaptive equipment used to manage problem - other neuro symptoms: memory? language? dysphagia? - education patient has received

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2. Physical Exam

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- assess each articulation & speech component for normalcy & functional limitations - looks at both structure & function (A & P) - check for loss of sensation as well (numbness)

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2. Non-Speech Eval of Face/Lips @ Rest

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- "I'm gonna look at you for a minute" - symmetry (droop at rest may not be as functionally problematic...) - smile - facial expressions (present? flat?) - abnormal or involuntary movements (esp. eyes) - tremors or fasciculation in lips/chin

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2. Non-Speech Eval of Face in Sustained Postures

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- lip retraction - rounding - puff cheeks (push back; move air side to side) - open mouth (wide; rapidly) - lip seal w/ smack - observe: symmetry, full ROM, ability to hold posture against force, tremulousness, ability to hold posture for sustained time period

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2. Non-Speech Eval of Face During Movement

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- observe speech & non-speech tasks - rapid repetitions of retraction, rounding & puffing cheeks - observe emotional reactions & expression in face

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2. Non-Speech Eval of Jaw

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1. Jaws @ rest: symmetry, tension, any involuntary movement 2. Sustained postures: open jaw - any deviations or limited excursion?; check resistance to examiner opening or closing jaw; palpate masseter & temporalis 3. Jaw in movement: symmetry of rapid opening/closing; check TMJ (masseter & temporalis again) - trismus = limited jaw opening from radiation/scar?

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2. Non-Speech Eval of Tongue

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1. tongue @ rest: relax tongue on floor of mouth; observe symmetry, size (good for mouth?), grooves (indicate atrophy), fasciculations, atrophy, involuntary movements 2. sustained postures: protrusion should be straight; resistance against pressure w/ tongue in cheek & anterior protrusion/to sides 3. tongue in movement: rapid lateralization; stabilize jaw for all tongue movements so it doesn't provide support

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2. Non-Speech Eval of Velopharynx

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1. velopharynx @ rest: hanging location; symmetry of palatal arches; observe any sign of myoclonus (beating movements of palate); don't lean head back 2. palatal movement: prolong /a/; rapid /a/; symmetry of movement; nasal airflow w/ pressure consonants or non-nasals; prolong vowels w/ nares occluded/unoccluded - if tongue hump... /hihihi/ or push down - listen for hyper/hyponasality - nasal emission sentences w/ mirror

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2. Non-Speech Eval of Larynx

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1. VF adduction: sharp, not loud cough; produce glottal coup; presence of inhalator stridor isn't normal; listen for weird habitual noises - if you suspect vagus damage, refer for further laryngeal exam (laryngoscopy - to show nodules, polyps, weakness, paralysis, involuntary movements... ENT) - videostroboscopy would show VF movement 2. listen for: wet phonation, breathy voice, phonation breaks, ability to sustain phonation, loudness, pitch breaks, diplophonia

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2. Non-Speech Eval Respiration

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- observe - postures that may inhibit abdominal or thoracic movements/respiratory support - shortness of breath - breathing rate - range of movements - shoulder/neck movements - regularity of breathing rate - weak cough but strong glottal coup is sign of respiratory, not laryngeal, problems - water manometer = measures if person can generate respiratory support needed for speech - spirometer = measures lung capacity and long volumes

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Cranial Nerve Testing

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- Trigeminal: open/close mouth; jaw lateralization; resistance to pressure - Hypoglossal: tongue ROM; tongue resistance - Facial: "where am i touching you?"; smile/pucker; observe - Vagus: phonate; cough; velar movement - Glossopharyngeal: gag reflex

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2. Non-Speech Gag Reflex

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- AKA pharyngeal reflex - normal to be present - stroke back of tongue, posterior pharyngeal wall, faucial pillars on each side (or velar area) - palate elevates - tongue retracts - pharyngeal walls sphincter in - normals vary greatly - only clinically significant if asymmetrical or if missing when it had been previously present or if hyperactive

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2. Non-Speech Jaw Jerk Reflex

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- present in 10% of normals - primitive reflex - may indicate UMN damage - place tongue blade on chin (horizontally) - tap with reflex hammer - positive = quick closing of jaw - mouth open to start

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2. Non-Speech Sucking Reflex

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- primitive - stroke upper lip with tongue blade - lateral to medial on both sides - positive = pursing lips & abnormal - UMN damage - often seen in dementia, CP, or significant neuro damage

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2. Non-Speech Snout Reflex

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- tap philtrum and tip of nose w/ finger - pucker or pretorians of lips is positive reaction

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3. Motor Speech Evaluation

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- evaluates affects of context on speech skills - individuals may seem normal in oral motor tasks and physical exam, but breakdown in speech - physical exam looks at each component isolated, but motor speech exam looks at the interdependence of components

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3. Voluntary v. Automatic Speech

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- use to check for apraxia - use verbal commands - watch for accuracy of movements to target, any groping movements, or inability to execute commands - use stimuli of increasing phonetic complexity & length

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3. Perceptual Speech Characteristics

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- Darley, Aronson & Brown Mayo Clinic Classification System - clusters of speech characteristics ten to occur w/ certain types of dysarthria - tasks are selected that get the most info - tape record!!!!

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3. Speech 1: Vowel Prolongation

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- deficits usually phonatory, not respiratory - hard to separate respiration & phonation - sustain /a/ as long as possible - info about: pitch, loudness, quality, tremor - 7-10 seconds acceptable if no other symptoms are present & they're old/sick

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3. Speech 2: AMR's

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- diadochokinetic rate - shows primarily speed & regularity of movement - shows secondarily articulatory precision, VP closure, respiratory/phonatory support - 3-5 seconds of /p/, /t/, /k/ - if can't do 3-5 seconds, may indicate poor respiratory support or VP problems or voicing problems - normal rate = 5-7 repetitions/second - observe range of lip and jaw movement, rhythmicity, presence of involuntary movements - with dysarthria, AMR's are slow

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3. Speech 3: SMR's

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- shows ability to move from one articulatory position to another - /putuku/ - identifies apraxia due to high sequencing demands of task

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3. Speech 4: Contextual Speech

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- shows integration of all speech components - often don't need to assess as low as word level - conversation, oral reading, narrative - verify person's reading skills/affect of aphasia on reading before so poor reading doesn't mimic dysarthria - try to get 3 samples of spontaneous speech

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3. Speech 5: Stress Testing

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- check for fatigue of speech system over time - have patient count continuously for 2-4 minutes - listen for speech changes - only check if needed (possible MG)

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3. Speech 6: Motor Speech Programming

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- suspect apraxia with blocks, phonemic substitutions/additions/deletions, hesitations in speech, groping movements, omissions - a mismatch between voluntary & automatic speech indicates apraxia - administer motor speech programming eval - hierarchy of speech tasks from vowels-> sentence repetition -> picture description -> narrative

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INTELLIGIBILITY

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- never ever do not put intelligibility level... - main goal for MSDs (esp. dysarthria) - speech naturalness is another target - intelligibility is a good measure of functional limitation

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Commercial Motor Speech Assessments: Frenchay

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- Frenchay Dysarthria Assessment - only standardized dysarthria assessment - brief & easy to give/score - distinguishes well among types - scoring gives graph of patient's abilities across: reflexes, respiration, lips, jaw, palate, larynx, tongue, intelligibility (words & sentences), associated factors - minimal materials needed - scoring is somewhat subjective "no difficulty" to "no ability" - doesn't give comprehensive description of deviant speech characteristics

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Commercial Motor Speech Assessments: DEB

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- Dysarthria Examination Battery - 1993 - need equipment (laryngeal mirror, spirometer, bite block, visipitch) - assesses respiration, resonation, phonation, articulation (words, sentences, oral reading), labial/lingual/mandibular movement, prosody, gag reflex, oral sensitivity - clinician determines normal/abnormal and rates severity - norms available

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Intelligibility Tests: AIDS

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- Assessment Intelligibility in Dysarthric Speakers - 1984 - most widely used standardized test - assesses intelligibility, rate, communicative efficiency - dysarthria may not necessarily affect intelligibility, but is a good measure of severity - formal estimate of intelligibility may be needed for medical, legal, insurance, baseline, research, document disease progression - can be base din client, family, or SLP impressions - SLP can give % rating - can use standardized instrument - good measure to show change over time (re-adminster) - needs at least 2 people: examiner, judge - person reads/imitates 50 words from random lists & 5-15 sentences - judge (anyone) listens to tape & transcribes what they hear - score reported as % correct - provides severity index - get an intelligibility word/minute count to show rate of intelligible speech - compare to normals who are 100% intelligible on these tasks

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Intelligibility Tests: Sentence Intelligibility Test

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- Yorkston - 1996 - measure intelligibility & rate - patient produces sentences of increasing length - sample is recorded - unfamiliar listener transcribes

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Instrumental Assessment

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- not used much clinically or w/ proven results - manometer = shows VP competence by comparing results of blowing/sucking w/ nares occluded/unoccluded; shows difference between oral & nasal pressure - spirometer = lung volumes & capacities - visipitch

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