Motor Speech Evaluation

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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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