evaluation.of.motor.speech.disorders

CHAPTER

Evaluation o/MotorSpeech Disorders

(contlnuec;l)

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14 • MOTOR SPEECH DISORDERS

E. Auditory Perceptual Evaluations of the Motor SpeechMechanism1. Phonatory-Respiratory System2. Resonation System3. Combined Systems4. Stress Testing of the Motor Speech Mechanism5. Testing for Nonverbal Oral Apraxia6. Testing for Apraxía of Speech7. Analysis of Connected Speech

F. Summary of the Evaluation ef Motor Speech DisordersG. Study QuestionsH. Appendix 2-1: Motor Speech Examination

Most beginning clinicians find evaluating and diagnosing motorspeech disorders to be a challenging task for several reasons. First, itcan be difficult to distinguish among the dysarthrias, because many ofthe speech characteristics of one dysarthria will be present in one ormore of the other dysarthrias. For example, imprecise consonants andharsh vocal quality are characteristics of every one of the dysarthrias.Second, an accurate diagnosis requires clinicians to listen very careful-ly to determine which of their patient's speech errors are most charac-teristic of a suspected motor speech disorder. This skill usually isdeveloped with experience, which, of course, is something that begin-ning clinicians will not have yet acquired. Finally, a detailed knowl-edge of the human motor system is an invaluable asset in determiningwhich speech errors are most important in making a correct diagnosis.It takes a concerted effort to leam about the motor system, because itis such a complex organization of nerve cells and nervous systemstructures. However, when a clinician understands the parts and func-tions of the motor system, the many symptoms of motor speech disor-ders are less confusing than they would be otherwise. In short, thesuccessful evaluation of motor speech disorders requires clinicians tomatch what they hear in a patient's speech with what they knowabout the functioning of the human motor system.

For beginning clinicians, the primary challenge is to becomefamiliar with how the speech of patients with different motor speechdisorders varies from one another. Inexperienced clinicians need toleam what makes flaccid dysarthria different from spastic dysarthria

and what makes ataxic dysarthria different from hypokinetic dysar-thria and so forth. Fortunately, the evaluation and diagnosis of motorspeech disorders can be accurate if beginning clinicians leam the char-acteristics of motor speech disorders, become familiar with the neuro-muscular bases of these disorders, and acquire hands-on practice inclinical practicum.

There are two basic methods of evaluating motor speech dis-orders: instrumental and perceptual analysis. The instrumentationmethod uses sophisticated devices to objectively measure the compo-nents of speech production. For example, nasal and oral airflow dur-ing speech can be measured precisely by computerized instruments..Other instruments can accurately detect changes in voice onset time,atypical formant frequencies in vowels, subtle loudness variations,and many additional aspects of speech production. In contrast, theperceptual analysis method of assessment employs the ears of anexaminer to detect motor speech disorders. The value of the perceptu-al analysis method is that the ear is the ultimate judge of whether ornot there is problem with an individual's speech. If a motor speechdisorder cannot be detected by ear, is there actually a disorder thatneeds to be treated?

For several reasons, this textbook concentrates on the perceptualanalysis method of evaluating motor speech disorders. Although theimportance of instrumental assessment of these disorders is withoutquestion, most practicing clinicians do not have access to such devicesand must rely primarily on what their ears tell them. Furthermore,instrumental assessment is described in great detail in a number ofother sources. Readers wishing to leam more about instrumentationin the assessment and treatment of motor speech disorders shouldexamine such texts as Dysarthria and Apraxia of Speech: Perspectiveson Management (Moore, Yorkston, & Beukelman, 1991) or Disordersof Motor Speech: Assessment, Treatment, and Clinical Characterization(Robin,Yorkston, & Beukelman, 1996).

EVALUATION OF MOTOR SPEECH DISORDERS • 15

GOALS OF A MOTOR SPEECH EVALUATION

In many ways, the goals of a motor speech evaluation are no differentfrom the goals of any speech-Ianguage evaluation. Haynes andPindzola (1998) said that a speech-Ianguage evaluation is done tounderstand a patient's problem and to establish the beginning level oftreatment. This certainly applies to a motor speech evaluation. Duringa motor speech evaluation, the clinician collects relevant background

19EVALUATIONOF MOTORSPEECHDISORDERS •Table 2-1. The Primary Etiologies and Characteristics of the VariousDysarthrias Table 2-1. (continued)

Type of Dysarthria Caused By Primary CharacteristicsType of Dysarthria Caused By Primary Characteristics6. Hyperkinetic Often associated with

damage to the basalganglia, but in someconditions the cause isunknown.

Involutarymovementsthat interferewith normalspeech production.Unexpected inhalationsand exhalations,irregulararticulatorybreakdowns, andabnormal prosody.Anycombination of thecharacteristics of the sixpure dysarthrias. Forexample, a patient withparkinsonism could havea brainstem stroke thatmight result in ahypokinetic-spasticmixed dysarthria

1. Flaccid Damage to the cranialnerves, spinal nerves, orthe neuromuscularjunction.

Muscle weakness thatcan result in impreciseconsonants, breathyphonation, hypernasality,shallow breath support,and abnormal prosody.Spasticity and weaknessin the speechmusculature that resultsin harsh or strained-strangled phonation,imprecise consonants,hypernasality, andabnormal prosody.Imprecise consonantsare the most commoncharacteristic. Theremay be irregulararticulatory breakdownsor harsh vocal quality insome patients.

Problems controllingthetiming and force ofspeech movements,resulting in speech thatoften has a "drunken"quality. Impreciseconsonants, distortedvowels, irregulararticulatory breakdowns,and abnormal prosody.A reduction in the rangeand speed of speechrnovements. Harsh orbreathy phonation,imprecise consonants,and abnormal prosody.In some patients, thereis increased rate ofspeech.

2. Spastic Bilateraldamage to theupper motor neurons ofthe pyramidal andextrapyramidal systems;often caused by brain-stem strokes.

.7.Mixed Neurologicaldamagethat extends to morethan one portion of themotor system.

3. Unilateral UpperMotor Neuron

.Unilateraldamage toupper motor neurons.

exchanging these gases, respiration maintains life. Respiration also isessential for speech production. It provides the subglottic air pressurethat is needed to set the vocal folds into vibration. Speech productiondepends on a full, steady supply of air--especially for connectedspeech. If the air supply is not full or steady, speech production isaffected. For example, if the nerves that innervate the respiratory mus-des are damaged, those musdes will be weak and may not be able tomove as much air into and out of the lungs as they normally would.Therefore, nerve damage means less air for speech production, whichlimits the affected individual's ability to speak in anything but shortphrases. In addition, respiratory deficits that reduce the amount of airavailable for speech can also cause reduced loudness and breathyvoice quality.

4. Ataxic Damage to thecerebellum or the neuraltracts that connect thecerebellum to the rest ofthe central nervoussystem.

5. Hypokinetic A reduction of dopaminein part of the basalganglia. Parkinsonism isthe most common causeof this dysarthia.

Phonation

Phonation is the production of voiced phonemes through vocal foldvibrations in the larynx. Normal phonation is dependent on the com-plete adduction of the vocal folds and enough subglottic air pressureto set the vocal folds into vibration. The adduction of the vocal foldsneeds to be at just the right amount of tension to produce a dearphonation. Neuromotor damage to the nerves that innervate the vocal

18


fold adductor muscles can have several effects on speech production.In conditions such as flaccid dysarthria, the damage may cause theadduction to be weak or incomplete. This weakness results in phona-tions that have a breathy or harsh quality. In conditions such as spasticdysarthria, the damage can cause the adduction to be too tight, whichcauses the phonation to have a strained-strangled quality. Neuro-motor damage to the laryngeal muscles also may reduce the ability tochange pitch or loudness during phonation.

Resonance

In motor speech disorders, resonance is the proper placement of oralor nasal tonality onto phonemes during speech. This is accomplishedby the raising and lowering of the velum. Oral resonance is producedwhen the velum is raised and closes off the nasal cavity from the vocalairstream. This sends the sounds through the oral cavity. Nasal reso-nance is produced when the velum is lowered and the oral cavity isblocked by the lips or tongue, which thereby directs the entireairstream out through the nose. The key factor in this process is themovement of the velum. The muscles in the velum need to respondquickly to the different resonance requirements of the phonemes beingproduced during speech. When the nerves innervating these velarmuscles are damaged, the muscles may be weakened or their move-ments slowed. Weak or slow velar muscles cannot raise the velumcompletely to separate the nasal cavity from the vocal airstream dur-ing the production of nonnasal speech phonemes. The resultingspeech will have a hypemasal quality because nasal resonance isbeing applied to phonemes that ordinarily have only oral resonance.

Articulation

Articulation is the shaping of the vocal airstream into phonemes. Theshaping of the airstream is accomplished in different ways. Theairstream may be blocked for stop and affricate phonemes, tight1yrestricted for fricative phonemes, slightly restricted for semivowels, orrelatively unrestricted for vowels. The shaping of the airstream hap-pens at various points along the vocal tract. It also is accomplished bydifferent structures within the vocal tract, known as articulators.Correct articulation requires the articulators to perform movementsthat have the appropriate timing, direction, force, speed, and place-

EVALUATION OF MOTOR SPEECH DISORDERS 21•

ment for any given phoneme. By any measure, accurate articulation isthe result of a very complex series of movements.

Unfortunately, neuromotor damage often affects the articulators,because most of them use muscular contractions to shape the vocaltract. When neuromotor damage affects the muscles of the lips,tongue, jaw, velum, or vocal folds, articulation is impaired. Th.edegr~eof impairment depends on the severity of the damage and which artic-ulators are affected most severely. The articulation errors that canbe heard after neuromotor damage include imprecise consonants,distorted vowels, inappropriate silences, and irregular articulatorybreakdowns.

Prosody

Prosody is the melody of speech. In most instances, prosody conveysmeaning within an utterance through the use of stress and intonati?n.Stress is accomplished by changing the pitch, loudne.ss, and durationof syllables within words to give those wor~s added ímportance or toclarify meaning. Intonation is the use of pitch ch~nges an~ stress tocornmunicate, for example, whether an utterance IS a question, asser-tion, or exclamation. Adding prosody to an utterance is not a simpletask. If the prosodic features of a message are to b~ accurat~ ~d clear,it requires the coordinated participation of ~honation, rcspíratíon, res-onance and articulation. For example, to mcrease the loudness of asyllable or word, there must be an increased exhalati~n of air from thelungs that is coordinated with a simultaneous tensmg of the vocalfolds. To change pitch, the vocal folds must be lengthened or short-ened, which is accomplished by the simultaneous actions of s~verallaryngeal muscles. To increase the duration of a syllable, the arhcul~-tors must be held in their position for a moment longer than usual mcoordination with a prolongation of phonation. The interactions of allof these vocal tract structures must be precise or prosody will soundabnormal.

Given that prosody is so dependent on the complex interaction ofthe other components of speech production, it should be easy tounderstand that neuromotor damage can affect prosody in a numberof different ways. For example, if the damage causes weakness orslowness in the muscles of respiration and phonation, the streng~h ofthese muscles and the timing of their contractions will be imp~lfed.The resulting speech may have a monopitch and monoloud quahty. Ifthe damage causes involuntary movements of the vocal tract muscles,

22

Clear speech production requires accurate movements by the articula-torsoAn accurate movement is one in which strength, speed, range,direction, and timing are precisely coordinated (Darley et aL, 1975). Ifany of these are out of sync, the result can be an inaccurate movement,causing such problems as a distorted consonant or intermittent hyper-nasality. The AMR and SMR tasks are good for assessing the accuracyof movement, as are conversational speech and spoken paragraphreading.

EVALUATION OF MOTOR SPEECH DISORDERS • 23MOTOR SPEECH DISORDERS•

asked to count out loud from 1 to 100 (a task known as stress testingthe speech mechanism).the involuntary movements will interfere with voluntary speech

movements. The resulting speech may have irregular pitch variations,sudden increases or decreases in loudness, and prolonged intervalsbetween syllables or words. Speed 01 Movement

CONDUCTING A MOTOR SPEECH EXAMINATIONAccurate speech requires very rapid muscle movements. The tongueand vocal folds, in particular, make many rapid movements duringthe production of even a short utterance. Reduced speed of movementis a cornmon characteristic of most dysarthrias. There also is onedysarthria, hypokinetic dysarthria, in which there may be increasedspeed of movement. Speed of movement is assessed through tasks'that concentrate on altemate motion rates (AMR) and sequentialmotion rates (SMR).AMR tasks move the articulators through a singleseries of rapid back and forth movements, such as repeating "puh,puh, puh" or "tuh, tuh, tuh" as rapidly as possible. SMR tasks, in con-trast, move the articulators repeatedly through a quick sequence ofmovements, such as repeating "puh, tuh, kuh" on one breath of air.Both AMR and SMR tasks are included in the protocol.

The following pages of this chapter contain a complete, detailed motorspeech examination form (Appendix 2-1). The tasks on this evaluationwere collected and adapted from a variety of sources including theMarshfield Clinic Motor Speech Examination (unpublíshed), Darleyet al. (1975), and Wertz et al. (1991). When conducting this motorspeech examination, a clinician will be assessing the components of apatient' s motor speech system.

Respiration, phonation, articulation, resonance, and prosody areall examined by the evaluation' s tasks. However, a clinician alsoshould be careful to assess more than just the five components ofspeech production. As the evaluation is administered, the clinician needs toconstantlyassess the patient's muscle strength, speed 01 movement, range 01motion, accuracy 01 movement, motor steadiness, and muscle tone. Theseneuromuscular processes are the foundation of all voluntary move-ment in the body. Darley et al. (1975) called these six processes the"salient features" of neuromuscular function. Each of these salient fea-tures makes its own contribution to normal speech production. If anyof these are defective, the motor speech system will be affectedadversely. Moreover, the nature and degree of a defect can provideimportant information for making a correct diagnosis. That is whythe features need to be examined carefully during a motor speechexamination.

Range 01 Movement

Range of movement is how far the articulators can travel during thecourse of a movement. Instances of reduced range of movementinclude an inability to fully open the jaw or completely adduct thevocal folds. Darley et al. (1975)and Duffy (1995)both mentioned thatprosody, especially, could be affected by reduced range of movementin the articulators. Range of movement is assessed most directly in thefirst portion of the protocol where the patient is asked to extend orhold the articulators in various positions.

Accuracy 01 Movement

Muscle Strength

If a muscle within the motor speech mechanism does not have ade-quate strength, it may not be able to perform its speech productiontasks adequately. Decreased muscle strength anywhere in the motorspeech mechanism can affect respiration, articulation, resonance,phonation, and prosody. Muscle strength is assessed in numerous sec-tions of this book's motor speech evaluation protocol. For example, apatient is asked to press his or her tongue against a tongue blade or

24 • MOTOR SPEECH DISORDERS_iEfiSl~~~ rJ,! 'ARPl-'

EVALUATION OF MOTOR SPEECH DISORDERS •.fIlLIOIZOa

25

Motor Steadiness Background Information and Medical History

Motor steadiness is the ability to hold a body part still. There are sev-eral disorders in which involuntary movements prevent motor steadi-ness. The most common is tremor. These involuntary contractions canaffect the laryngeal musculature and lead to a tremulous vocal qualityduring speech. Other disorders can cause larger, more obvious invol-untary movements that interfere with all voluntary movements. In theprotocol in Appendix 2-1, motor steadiness is assessed by the tasksthat require a patient to hold a position or prolong a vowel. A break-down in motor steadiness will reveal itself in an inability to maintain astill position or to produce a prolonged vowel that is smooth andsteady. .

Muscle Tone

This first portion of the evaluation usually is completed without toomuch difficulty. The information can be obtained from the patient,family members, other medical professionals, and medical records. Itis important to be as thorough as possible when collecting this infor-mation, because it can provide many clues leading to a correct diagno-sis. For example, a slow development of the problem may indicate aprogressive neurological disorder. On the other hand, a rapid onsetmight suggest that an acute condition caused the disorder, perhaps astroke. Medical records can provide important information on the-patient's medical history, possible site of lesion, and current status ofthe problem. Rosenbek, LaPointe, and Wertz (1989)recornmended thatthe following information be obtained from medical records:

1. The primary and secondary medical diagnoses, along withdescriptions of the major symptoms

2. The date when the condition was first noted, sometimes calledthe "date of onset"

3. Information on the site of lesion (i. e., the place in the nervoussystem where the damage has occurred)

4. Earlier instances of nervous system damage5. Evidence of limb involvement, such as weakness, involuntary

movements, or motor sequencing problems (limb apraxia)6. Information on the patient's visual acuity, including any evi-

dence of visual field deficits7. Information on the patient' s hearing acuity

Normal muscle tone is the small, constant amount of muscle contrae-tion that is always present, even when a muscle is fully relaxed.Muscle tone maintains a muscle in a "ready to move" condition andallows for quick movement when necessary. Damage to the nervoussystem can alter muscle tone either by decreasing or increasing it,depending on where the damage occurs. Both circumstances can havedetrimental effects on movement. Decreased muscle tone is associatedwith muscle weakness or paralysis. Increased tone is associated withmuscle spasticity or rigidity. In the Appendix 2-1 protocol, abnormalmuscle tone can be inferred by listening to the patient' s speech or bylooking at the affected body parts.

INSTRUCTIONS FOR THE MOTOR SPEECHEXAMINATION

If the patient is being interviewed for this section, the clinicianalso can leam much about the patient's awareness and reaction to theproblem. Some individuals may recognize that their speech is differ-ent, yet are not worried about it. Others may appear to be very trou-bled by a problem that is so mild as to be imperceptible to most listen-ers. Such information is valuable in making recornmendations fortreatment.

Because most readers of this textbook probably have not administeredmany motor speech evaluations, the following pages offer a step-by-step explanation of what each task is assessing. When appropriate, anexplanation of the importance of a task is provided. The entire evalua-tion takes between 30 and 60 minutes to administer, depending on thecapabilities of the patient. Once the evaluation is completed, the clini-cian will have fully assessed and described the patient's speech pro-duction abilities. From the information collected about the patient, theclinician should be able to make an accurate diagnosis of a motorspeech disorder that may be present.

Face and Jaw Muscles at Rest and During Movement

The muscles of the patient's face are examined in this section of theevaluation. The clinician is looking for any abnormal muscle tone orstrength, asyrnmetrical facial features, and restricted range of move-

5. Is the patient's smile symmetric? This task, as well as thenext two, looks at voluntary movement of the lower facemuscles. The examiner is checking for any evidence of weak-ness or reduced range of motion. In addition, the clinicianneeds to check for signs of the patient appearing to grope forthe correct position to accomplish this task. If groping is pres-ent, it may be evidence of a nonverbal oral apraxia. In such acase, be sure to administer the portions of the protocol cover-ing apraxia. Apraxia is covered in Chapter 11.

6. Is the patient able to pucker his or her lips? This task ass~ss-es muscular strength and range of movement of the orbicu-laris oris muscles of the lips. Weakness on one side of themouth may result in an asymmetrical puckering of the lips.

7. Is the patient able to puff out his or her cheeks and hold theair in the oral cavity as you squeeze the cheeks? Here theexaminer is assessing the strength of the lips and the velumto maintain an aírtight seal. Weakness at either end will resultin leakage of air out of the mouth or the nose when pr~ssureis applied to the patient's cheeks. Look closel~ at the hp~ ~sthe cheeks are squeezed to determine if that 1Swhere air 1Sescaping. If you are confident that the lip seal is tight, anyleakage is probably occurring at the velopharyng~~l port. Thefunction of the velum is assessed on several additional taskslater in the protocol. . .,

8. Does the jaw hang loosely? If so, this would suggest signifi-cant bilateral damage to the trigeminal cranial nerve (V),which innervates the jaw muscles. However, bilateral d~m-age is not cornmon. Typically, damage affects only one side.When the damage is only on one side of the jaw, the muscleson the unaffected side will provide more than enoughstrength to hold the jaw in a normal position. .,

9. Does the jaw deviate to one side when the mouth 1~ wld.eopen? This task checks for unilateral damage to th~ mgerru-nal cranial nerve. When the jaw muscles on one side of theface are weaker than on the other side, the jaw may deviateto the weaker side when the mouth is opened widely.

10. Is the patient able to move the jaw from to the right andleft? An inability to do this suggests bilateral weakness of thejaw muscles. However, hesitations or gr~ping on this taskalso might indicate a nonverbal oral aprax1a.

11. Is the patient able to keep the jaw closed while the exam-iner attempts to open it? This task assesses the strength ofthe muscles that elevate the jaw, primarily the masseter and

EVALUATION OF MOTOR SPEECH DISORDERS •26 • MOTOR SPEECH DISORDERS

ment. The functioning of the facial cranial nerve (VIl) is beingassessed on most of these tasks, because it provides motor innervationto the facial muscles. The trigeminal cranial nerve (V) is examinedduring the tasks that require jaw movements.

Explanation of Specific Tasks

1. Is the mouth symmetric? Here the examiner is looking for anysigns of lower face paralysis or weakness, which can cause oneside of the mouth to droop lower than the other side. Be aware,however, that a small amount of mouth asyrnmetry is normaland does not necessarily indicate a neuromuscular disorder.

2. Can the examiner force the lips open? On this task the exam-iner is checking for muscle strength. Of course, the side of themouth that is drooping will almost always be the weaker side.This will be the side that one should be able to force openmore easily with the fingers.

3. Does the face have an expressionless, masklike appear-ance? This task checks for one of the more obvious symp-toms of parkinsonism (see Chapter 8). Individuals withparkinsonism frequentIy have a reduced ability to expressemotion through their facial expressions. Individuals withmoderate and severe parkinsonism may consistently showa blank facial expression, no matter what their internal emo-tional state may be.

4. When the patient looks up, is there wrinkling on bothhalves of the forehead? This task assesses the possible site ofneurological damage. If the damage has occurred to the facialcranial nerve (VII) near where it branches out from the brain-stem, the entire half of the affected side of the face will beweakened or paralyzed. In this situation, there will be nowrinkling of the skin of the forehead when the patient looksup, because the forehead muscles will not contract normally.If, however, the damage has occurred to either the left or righttract of the upper motor neurons, there will most likely bemovement in the muscles on both sides of the forehead, withonly the lower face showing evidence of weaknéss or paraly-sisoThis is beca use the upper branch of the facial cranial nervethat serves the forehead muscles receives bilateral innervationfrom the upper motor neurons, but the lower branch servingthe lower face receives only unilateral innervation from theupper motor neurons. The innervation of the facial muscles isexplained in more detail in Chapter 4.

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12.

tempo~alis. If you are able to manually open the jaw, it sug-gest~ bilateral weakness in these muscles-possibly the resultof bilateral damage to the trigeminal cranial nerve.Is the patient able to keep the jaw open while the examin-er attem~ts to close it? This task examines the muscles thatopen the jaw. These muscles are the digastricus mylohyoidan~ geniohyoid. If you can manually close the j~w while th~patient attempts to keep it open, bilateral weakness of thesemuscles is indicated.

Tongue at Rest and During Movement

Of course, the ton.gue is one of the key articulators. Impairments to itsstructure or function can have significant effects on the articulation ofspeech s.ounds. It is especially ~~ortant to evaluate the tongue at resta.n~ durrng ~ovement. Both posítíons can provide important diagnos-tic infor~ahon. Most of the assessment tasks in this section examinethe function of the hypoglossal cranial nerve (XII) which . tth . tri . ' mnerva es

e m rnS1Cand extrinsic muscles of the tongue. If groping tonguemove~ents. are noted in any of these tasks, be sure to complete theapraxla section of the evaluation.


1. Does the size of the tongue appear normal at rest? Whendam~ge occurs to lower motor neurons (such as those in thecramal nerves), the muscles normally innervated by those neu-rons will shrink because of atrophy. If there is unilateral dam-age to the hypoglossal nerve, the half of the tongue that is onthe same side as the damage can take on a furrowed, shrunk-e~ appearance. When this damage occurs to both the left andnght hypoglossal cranial nerves, the muscle atrophy will affectthe whole tongue, leaving the entire tongue shrunken.

2. Is th.e tongue symmetric at rest? If damage to the hypoglossalcramal ner:e (XII) is restricted to only one side, the resultingat:0phy will be restricted to that same side. The tonguewill consequently have an asymmetrical appearance withthe unaffected side looking normal and only the other sidedemonstrating the atrophy.

3. Are .fasci~ulations present when the tongue is at rest?Fasciculations are small involuntary movements that may


occur in a muscle when motor innervation has been lostthrough damage to lower motor neurons. If fasciculations arepresent after damage to the hypoglossal cranial nerve, youwill see small, nonrhythmic dimpling along the surface of thetongue, or you might see subtle "wormlike" movements of theentire tongue.

4. Does the tongue remain still while at rest? In addition to fas-ciculations, other conditions can result in involuntary move-ments when the tongue is supposedly at rest. Such hyperki-netic movement disorders as chorea and dystonia may causethe tongue to involuntarily protrude, retract, rotate, and movesíde-to-síde. Hyperkinetic movement disorders are discussedin Chapter 9.

5. Is the patient able to protrude the tongue completely? Thisassesses range of motion for the posterior fibers of thegenioglossus muscle, which protrudes the tongue, and the ver-tical and transverse intrinsic muscles, which give the tongueits "pointed" shape when protruded. If there is bilateral weak-ness of these muscles, the tongue can only be protruded a lim-ited distance, if at all. If the weakness is unilateral, the pro-truded tongue will deviate to the affected side. This deviationto the affected side is the result of unequal contractions of theleft and right sides of the genioglosssus muscle in the tongue.The contractions of the unaffected side of this muscle willovercome the weakened contractions on the other side of themuscle, thereby causing the tongue to point to the affectedside. You can check the strength of tongue protrusion by hav-ing the patient push the tongue against a tongue blade heldfirmly in front of the mouth.

6. Can the patient keep the tongue tip at midline while theexaminer pushes the tongue to the left and right? This taskchecks the strength of several tongue muscles, including thegenioglossus, superior longitudinal, and inferior longitudinalmuscles.

7. Is the patient able to touch the upper lip with the tongue tip?Here you are assessing the range of motion of the tongue pro-trusion muscles (genioglossus, vertical and transverse intrinsicmuscles) and the superior longitudinal muscle, which elevatesthe tongue tipo

8. Can the patient keep the tongue tip pressed against theinside of the cheek as the examiner pushes the cheek inward?This is an examination of strength for a number of tongue mus-cles, primarily the longitudinal muscles. The tongue tip will

30 • MOTOR SPEECH DISORDERS EVALUATION OF MOTOR SPEECH DISORDERS • 31

deviate to the left or right with simultaneous contraction ofeither the left or right superior and inferior longitudinal mus-cles, respectively. Unilateral weakness in these muscles is evi-dent through comparison of the amount of outward force thetongue is able to apply to either the right or left cheek.

9. Can the patient move the tongue from side-to-side? This taskexamines range of motion for the superior and inferior longi-tudinal muscles. These muscles are used to lateralize thetongue from one comer of the mouth to the other. Reduced lat-eral tongue movement to one side of the mouth will revealunilateral weakness of these muscles.

cult to detect visually when there is mild bilateral weakness.When there is unilateral muscular weakness of the velum andpharynx, the unaffected side should demonstrate nearly nor-mal movement. The impaired side will show Iittle or nomovement. The uvula will be pulled toward the stronger,unaffected side as that side of the velum rises.

2. Is there a pharyngeal gag reflex when the back wall of thepharynx is touched? The gag is a protective reflex. Its purposeis to clear the upper pharynx of an obstruction that mightthreaten to block the airway. Testing this reflex assesses theneuromuscular loop that starts with the sensory nerves in pha-ryngeal musdes and tissue. When the sensory nerves in thepharynx are stimulated by the touch of a foreign object, theysend a sensory impulse through the glossopharyngeal cranialnerve (IX) to the brainstem. From the brainstem, a motorimpulse is sent directly out to the pharyngeal and velar mus-cles via the vagus cranial nerve (X),which causes those mus-des to rapidly contract. Damage at any portion of this loopleads to a decreased or absent gag reflex. Note, however, thatmany individuals without neurological damage are quiteinsensitive to pharyngeal stimulation and do not readilydemonstrate a gag reflex.

Velum and Pharynx at Rest and During Movement

This section of the evaluation looks at the structure and function of thevelum and pharynx. Most of the muscles in these structures are inner-vated by the vagus cranial nerve (X).It is difficult to obtain much in-depth information about these structures in this portion of the exami-nation because they are difficult to see clearly. In truth, you are onlyable to look for the most obvious anatomical and functional devia-tions. Additional information about the velum and pharynx can beobtained in later sections of this examination.

Explanatian af Specific TasksLaryngeal Function

1. Does the velum rise symmetrically each time the patient says¡al? Have the patient repeat I al 4 or 5 times. Make sure thereis a brief pause between each production. This will allow thevelum to retum to its resting position after each Ial, givingone a better opportunity to observe the full range of velarmovement. A normally functioning velum and pharynx worktogether to close the velopharyngeal port during the produc-tion of nonnasal sounds. You should see the entire velum risepromptly just before phonation. At the same time, the sidesand back of the upper pharynx should move slightly inwardto meet the rising velum.

In cases of moderate to severe bilateral weakness of thevelum and pharynx, you should be able to observe reducedspeed and range of motion of these structures when thepatient repeats Ial. However, these reductions may be diffi-

The function of the larynx cannot be observed directly. To actuallyobserve the actions of the larynx, you need instrumentation, such as alaryngeal mirror or a flexible nasoendoscope. However, there are pro-cedures to indirectly assess laryngeal function. The following threetasks evaluate the strength and range of movement of the laryngealadductor and abductor muscles. Other tasks later in the evaluationassess phonation, which is a key function of the Iarynx.

Explanatians ot Specific Tasks

1. Is the patient able to produce a sharp cough? This taskassesses the strength of vocal fold adduction. Producing asharp cough requires tight vocal fold adduction for buildingup subglottic air pressure. In cases in which adduction isweak, the cough will have a soft, breathy quality beca use the

32

Explanations of Specific Tasks

1. "Take a deep breath and say laI as long, steadily, and c1ear1yas you can." This task assesses both the adequacy of breathsupport and vocal fold adduction for phonation. If there ~sto.olittle breath support, there will be inadequate subglottic airpressure to prolong the Ial for 15 seconds. If the vocal foldsare not adducted fully, excess amounts of air will escape fromthe larynx during phonation. This wastes subglottic air andlessens the length of the phonation. To determine if a reducedlength of phonation is the result of poor breath support orincomplete vocal fold adduction, check the results from theprevious section of the evaluation, which provided for assess-ment of the adequacy of vocal fold adduction.

2. Is there a latency period between the signal to say laI and theinitiation of phonation? If there is a delay, it may be the resultof weakness in the phonatory-respíratory system. It also couldbe the result of a problem of sequencing the motor movementsneeded to produce the Ial. Such sequencing difficulties ar~characteristic of apraxia, which is assessed in greater detalllater in the evaluation.

3. Quality, Pitch, and Loudness of Phonations. In a normalphonation, the vocal quality is steady, even, smooth, and clear.The presence of hypernasality indicates inadequate velopha-ryngeal closure. Breathiness can indicate incomplete vocalfold adduction during phonation. Harshness is an abnormalvocal quality that is caused by the friction of air being p~ssedthrough vocal folds that are almost adducted fully. Diplo-phonia is the simultaneous production of two pitch levels dur-ing phonation. In motor speech disorders, it is usually theresult of unilateral vocal fold paralysis.

MOTOR SPEECH DISORDERS EVALUATION OF MOTOR SPEECH DISORDERS ••

adductor muscles are not strong enough to hold air in thelungs. In some instances, this task also assesses the adequacyof the respiratory system. If the respiratory muscles are notstrong enough to provide a forced exhalation of air, the result-ing cough also will have that soft, breathy quality. The nextstep of this evaluation presents a procedure for determiningwhether a breathy cough is the result of laryngeal or respira-tory weakness.

2. Can the patient produce a sharp glottal stop? In this task thepatient is asked to produce an abrupt glottal stop (or a forcefulgrunt) to assess the strength of vocal fold adduction. Duffy(1995) recommended this procedure to help determine if aweak cough is the result of inadequate vocal fold adduction orpoor breath support. If a patient who produces a weak coughcan bring the vocal folds together with enough force to makea sharp glottal stop, then he or she has sufficient adductormuscle strength to close the glottis tightly. This would suggestthat a weak cough is the result of poor breath support, notadductor muscle weakness.

3. Is inhalatory stridor present? If abductor muscle paralysis pre-vents the vocal folds from being abducted completely, a patientmay demonstrate inhalatory stridor, which is a breathy wheezethat can be heard during inhalation. This vocal fold abductorparalysis may be caused by unilateral or bilateral damage tothe vagus cranial nerve. In severe cases, the stridor is actually aphonation on inhalation. Although stridor may be evident onquiet breathing, you will probably need to ask most patients totake a quick, deep breath before it will be noticeable.

Phonatory-Respiratory System

It is logical to assess the phonatory and repiratory components. ofthe speech mechanism at the same time, because normal phonationis so dependent on an adequate supply of subglottic air pressur~. Inthis protocol section, the clinician will determi~e the l~~gth of timethe patient can prolong an I al. One should listen critically to thequa lity, pitch, and loudness of the p~tient's phonation,. becau~eeach of these characteristics can provide much useful díagnosticinformation.

AUDITORV-PERCEPTUAL EVALUATIONS OF THEMOTOR SPEECH MECHANISM

In most cases, the ear is the best instrument for evaluating deficits ofthe motor speech mechanism. A clinician with an experienced ear canoften make a quick, accurate diagnosis based only on the acousticcharacteristics of a patient's speech. The importance of developing asharp ear for the assessment of motor speech disorders cannot beoverstated. After all, what a listener hears with his or her ears pro-vides the ultima te judgment of whether speech production is defec-tive. Accordingly, most of the remaining evaluation tasks reIy on aclinician's perceptual analysis of a patient's speech.

33


Pitch can be affected by motor speech disorders. It maybe too low, as in spastic dysarthria and several of the hyperki-netic dysarthrias. There may be a tremor in the phonations,which usually is present in essential voice tremor, one of thehyperkinetic dysarthrias. Pitch breaks are sudden shifts inpitch during phonation. These are heard most often in flaccidand spastic dysarthria.

Loudness can be affected by motor speech disorders. Theinvoluntary movements in hyperkinetic dysarthria can causeexcessive loudness variations during phonations. Poor respí-ratory support or inadequate phonation can cause decreasedloudness, perhaps most often heard in flaccid and hypokinet-ic dysarthria.

Resonation System

This portion of the evaluation assesses velopharyngeal function.Weakened or paralyzed velar muscles result in incomplete velopha-ryngeal closure, which is heard perceptually as hypernasality. Inmotor speech disorders, hypernasality is most frequently a symptomof flaccid, spastic, and hypokinetic dysarthria. Hyponasality, the coun-terpart of hypernasality, is rarely present in the speech of individualswith dysarthria or apraxia of speech. Because other tasks in this motorspeech evaluation have already evaluated elements of the resonatorysystem (velar movement, hypernasal voice quality), the findings of thefollowing two tasks should be combined with the results of the preví-ous tasks to arrive at the most accurate assessment of the patient' svelopharyngeal function.

Explanations of Specific Tasks

1. "Take a deep breath and say fui for as long as you can." Onthis task, the clinician asks the patient to prolong the high,back vowel /u/, which usually maximizes velopharyngealclosure. While the patient says / u/, the clinician holds a smallmirror first under one nostril and then under the other. Nasalemission of air during this phonation will be revealed as fog-ging of the mirror. You should disregard any momentary fog-ging of the mirror at the very beginning or end of the phona-tion. However, the mirror should remain clear during the mid-dle of the phonation.


2. "This time I'm going to squeeze your nose. Don't let it both-er you." Here the clinician makes a perceptual judgment ofwhether hypernasality is present during the prolongation of/u/. By alternately squeezing and releasing the nostrils whilethe patient is producing /u/, you are intermittently stoppingany nasal airflow during phonation. If there is hypernasality,you will hear a difference in resonance as the patient' s nose issqueezed and released.

Combined Systems (Phonation, Respiration, Resonation,~nd Articulation)

Altemate motion rate (AMR) is an assessment of a patient's ability tomove the articulators rapidly yet smoothly in a repetitive motion. Italso is known sometimes as the diadochokinetic rateoAMRs are a keyevaluation task for motor speech disorders. They provide valuableinformation on the speed and rhythm of syllable production. AMRs arevery important in a motor speech evaluation, because individuals withdifferent types of dysarthria typically perform differently on this task:

• Individuals with flaccid and spastic dysarthria usually haveslow and regular AMRs.

• Individuals with ataxic and hyperkinetic dysarthria often haveslow and irregular AMRs.

• Some individuals with hypokinetic dysarthria have AMRs thatare more rapid than normal. In certain individuals with thisdysarthria, the AMRs are said so quickly that their articulationof the phonemes is blurred.

By carefully analyzing the patient's AMR performance, one canoften obtain important diagnostic information about the patient' sdysarthria.

Explanation of Specific Task

"Take a deep breath and say "puh, puh, puh" as long, as fast,and as evenly as you can." After saying these directions, be sureto demonstrate for the patient how the syllables should be pro-duced. To obtain an accurate count of the patient's AMRs, it isimportant to always use some type of instrumentation duringthis task, either a Visi-Pitch, a tape recorder, or some otherrecording device. Even experienced clinicians have difficulty


timing and counting syllable repetitions, if the patient's perfor-mance is not recorded. In this task, you are primarily listeningfor the speed and rhythm of the productions, but loudness, pitch,and articulation also are important. For example, excessive varia-tions in syllable loudness are typical of ataxic and hyperkineticdysarthria; blurred articulation can be a characteristic of hypoki-netic dysarthria.

Sequential motion rate (SMR) is a task that assesses a patient'sability to move the articulators in a rapid, smooth sequence ofmotions. Typically, SMRs are more difficult to perform accuratelythan AMRs. This task is especially useful in bringing out the symp-toms of apraxia of speech. It is not unusual to have individualswith apraxia of speech complete the AMR task successfully but beunable to complete even the first attempt at the SMR sequence.Some of the errors individuals with apraxia of speech may demon-strate on the SMR task include delays in beginning the task,phoneme substitutions, incorrect sequencing of syllables, and artic-ulatory groping for the correct phoneme placement. This is not tosuggest, however, that all individuals with apraxia of speech areable to complete the AMR task successfully. Many have difficultywith both tasks.

Explanatían ot Specífíc Task

"Now 1 want you to make those three sounds together." Aswith the AMRs, it is important to record the patient's trials onthe SMR task to obtain an accurate syllable count. One shouldalso be sure to demonstrate for the patient how the syllablesshould be produced.

Stress Testing of the Motor Speech Mechanism

This task is a screening for myasthenia gravis, a disorder that causes arapid fatigue of the muscles during a sustained motor activity (seeChapter 4). To test for myasthenia gravis, ask the patient to countquickly from 1 to 100. Listen for a relatively rapid deterioration ofarticulation, resonance, or phonation while the patient is counting.Typically, there will be a recovery of muscle function after a rest peri-od, but performance will decline if the muscles again are taxed in asustained activity.


Testing for Nonverbal Oral Apraxia

Apraxia is a disruption in the ability to voluntarily sequence complexmovements accurately. It is not the result of muscle weakness, reducedrange of motion, or a cognitive inability to plan the target movement.Apraxia is a problem in sequencing the steps of a complex movementthat has already been planned by the higher centers of the brain. Thereare two types of apraxia that can affect the speech musculature: non-verbal oral apraxia and apraxia of speech. Nonverbal oral apraxia is adisruption in the sequencing of oral movements that are nonverbal,sometimes described as vegetative movements. Examples of nonver-bal oral movements include smiling, puckering the lips, protrudingthe tongue, and biting the lower lip. Individuals with this type ofapraxia will demonstrate hesitations, groping, and revisions whenattempting to perform nonverbal oral movements. It is possible forsomeone to have nonverbal oral apraxia but not have apraxia ofspeech. It is also possible for someone to have apraxia of speech butnot nonverbal oral apraxia. Usually, however, these two types ofapraxia are cooccurring disorders, which means that if one is present,so is the other.

Explanatían af Specific Task

"Now 1want you to do some things." These tasks assess thepatient's ability to perform voluntary nonverbal oral move-ments. Do not demonstrate the desired movement for thepatient immediately after reading the command. Wait until thepatient has attempted the task independentIy before demon-strating the movement. The patient's performance is graded onan 11-point scale, which ranges from a prompt response to nooral movement. Such a scoring system allows the clinician toobtain a much more detailed picture of a patient's performancethan a simple right or wrong scoring. One should become famil-iar with the 11 points before administering this portion of theevaluation.

Testing for Apraxia of Speech

Apraxia of speech is the other type of apraxia that can affect thespeech musculature. It is a disruption in the sequencing of voluntarymovements for speech production. Individuals with apraxia of speech


often demonstrate numerous sequencing errors when they areattempting to speak, especially when trying to say multisyllabicwords. These errors include groping to position the articulators cor-rectly, transpositions of syllables within a word, and phoneme substi-tutions. Interestingly, both automatic and emotional speech are usual-ly free of apraxic errors, which means that such verbal tasks ascounting, uttering an expletive, or replying to a social greeting areoften produced correctly.Apraxia of speech is discussed in more detailin Chapter 11.


1. "5ay these words for me." This task has the patient repeatingor reading a list of words. The list starts with a two-syllableword and progresses to a complex sequence of increasinglylonger words that all start with the same CVC syllable. Itshould be extremely difficult for an individual with apraxia ofspeech to complete this list without demonstrating numeroussequencing errors. Not only are most of the words multisyl-labic, most of them also are low frequency words, whichmeans that they are words that do not occur frequentIy ineveryday conversations. Apraxic speakers usually have moredifficulty pronouncing low frequency words than hígh fre-quency words.

2. "Now these." Individuals with apraxia of speech typicallyhave little difficulty producing single-syllable words with asimple CVC construction in which the initial and final con-sonants are identical. Words of this type are included in theevaluation for two reasons. First, the patient should findthem to be a successful change of pace from the difficult pre-vious task. Second, the words provide a strong indication ofseverity if the patient demonstrates many apraxic errors onthese words. Because they should be fairly easy for mostindividuals with apraxia of speech, a patient who has diffi-culty with these words is probably severely affected by theapraxia.

3. "Now repeat these sentences after me." The sentences onthis task should be difficult for individuals with apraxia ofspeech. These items are uncommon sentences that containnumerous multisyllabic words. They should evoke someapraxic errors in most individuals suspected of having aprax-ia of speech.


4. "Count from 1 to 20." Because this is an overleamed, auto-matic verbal task, many individuals with apraxia of speechshould be able to complete it with far fewer errors than theywill demonstrate on the next task.

5. "Now count backward from 20 to l." Most individuals withapraxia of speech should make multiple errors on this task, ifthey can complete it at all. Although they are producing thesame words as in prior task, counting backwards is not anoverleamed verbal activity. ConsequentIy, this should be a dif-ficult task for most patients with apraxia of speech.

6. "Tell me what is happening in this picture." This task isdivided into two parts. In the first portion, the patient is askedto describe the Cookie Theft picture from the Bastan DiagnasticExaminatian lar Aphasia. The clinician writes down four of thesentences spoken by the patient during the description of thepicture. (If the picture description does not provide four sen-tences, write down any sentences spoken by the patient dur-ing the evaluation.) In the second portion of this task, the

. patient is asked to repeat the four sentences written during thepicture description.

The rationale for this task is that fewer apraxic errors aretypically noted in spontaneous utterances compared to pur-poseful utterances. When describing the picture, the patient isengaging in a much more spontaneous speech act than whenbeing asked to repeat sentences. Consequently, one shouldexpect to hear fewer errors during the picture description taskthan when the patient repeats his or her own utterances justminutes after first producing them.

Analysis of Connected Speech

In this final portion of the evaluation, the clinician should have thepatient read one of the standard reading passages such as theGrandfather passage or the Rainbow passage. To ensure an accurateanalysis of the patient's connected speech, it is very important toobtain a good quality audio or video recording of this task. Rate thecharacteristics of the patient's speech according to the questions listedat the end of the examination (Darley et al., 1975).A complete analysisof connected speech should provide much of the information neededto distinguish one dysarthria from another.


SUMMARY OF THE EVALUATION OF MOTORSPEECH DISORDERS

• Evaluating motor speech disorders can be a challenging taskfor inexperienced clinicians. There are numerous elements ofspeech production that must be assessed if a proper diagnosisis to be made. The clinician needs to evaluate a patient's respi-ration, phonation, resonance, articulation, and prosody duringa motor speech examination.

• Instrumentation and perceptual analysis are the two primarymethods of assessing motor speech disorders. Most cliniciansuse perceptual analysis to make their diagnosis. With thismethod, clinicians use their eyes and ears to determine if amotor speech disorder is present in a given patient.

• In addition to evaluating the elements of speech production(e.g., respiration, phonation, and so forth), a complete motorspeech examination will examine the six processes that are thefoundation of all voluntary movements: muscle strength,speed of movement, range of movement, accuracy of move-ment, motor steadiness, and muscle tone.

• At the most basic level, a motor speech examination allows aclinician to fully describe a patient's speech production abili-tiesoWith this complete description of the patient's abilities, theclinician should be able to logically answer pertinent questionsabout the patient's deficits and arrive at a correct diagnosis.

STUDY QUESTIONS

1. What are the two basic methods of evaluating motor speechdisorders?

2. According to Haynes and Pindzola, what are the two goals ofany speech-Ianguage evaluation?

3. What are the five components of speech production?4. Define dysarthria.5. Define apraxia of speech.6. What are Darley, Aronson, and Brown's salient features of

neuromuscular function, and why are they important?7. Name two evaluation tasks that assess tongue strength.8. What are AMRs and SMRs, and why are they important?9. What might inhalation stridor indicate?

10. Why might an individual with apraxia of speech have diffi-culty counting backwards from 20 to 1?


Patient's Name:

Date of Examination:

Patient's Age:

Neurologic Diagnosis:

APPENDIX 2-1

Motor Speech Examination

Relevant Personal Information:

Medical History:

Instructions: Answer each item yes or no and indicate the degree ofimpairment as follows:

o = no impairment1 = mild impairment2 = moderate impairment3 = severe impairment

Also be sure to answer all other questions in the space indicated.


1. STRUCTURAL-FUNCTIONAL SPEECH MECHANISM Yes No DegreeEXAMINATION 2. tIs groping present? D D

3. Can patient move mandibleYes No Degree voluntarily to the right or left? D D

A. Facial Musculature at Rest: CN VII 4. Can patient resist examiner's1. Is mouth symmetrical? D D attempt to open lower jaw when teeth

If no, describe: are clenched? D D5. Can patient keep mouth wide open

2. Can patient resist examiner's attempt as examiner attempts to force itto force lips open? D D closed? D D

3. Are eyes open? D D E. Tongue Musculature at Rest: CN XII4. Are eyes partially closed? D D 1. Is tongue normal in size? D D5. Is facies rigid or masked? D D If no, describe:6. Is there wrinkling of forehead (when

looking up without moving head?) D D 2. Does tongue lie midline? D D7. Is nose symmetrical? D D If no, describe:

If no, describe:3. Is the tongue symmetrical in shape? D D

B. Facial Musculature During Voluntary If no, describe:Movement: CN VII1. Is smile symmetrical? D D 4. With tongue resting atop edges of

If no, describe: lower incisor teeth, isfasciculation observable? D D

2. tIs groping present? D D 5. Does tongue remain at rest? D D3. Can patient pucker the lips? D D If no, describe:

If no, describe:F. Tongue Musculature during Voluntary

4. "Is groping present? D D Movement: CN XII5. Can patient puff out cheeks and 1. Can patient protrude tongue

maintain lip seal when pressure completely? D Dis applied? D D If no, describe range andIf no, describe: deviation:

C. Mandibular Musculature at Rest: CN V 2. tIs groping present? D DDoes mandible hang lower than normal? D D 3. With tongue protruded, can patient

D. Mandibular Musculature During resist examiner's attempt to forceVoluntary Movement: CN V tongue to other side? D D1. When mouth is open as widely as 4. With tip of tongue, can patient resist

possible, is there deviation to examiner's attempt to force tongueone side? D D to one side or other? D DIf no, describe:

"Any groping should be followed up with the complete apraxia battery. "Any groping should be followed up with the complete apraxia battery.


Yes No Degree 11.ACOUSTIC MOTOR SPEECH EXAMINATION5. With tip of tongue, can patient A. Phonatory-Respiratory System:

touch: upper lip? D D 1. Directions to patient: "Take a deepalveolar ridge? D D breath and say la:1 as long, steadily,If no, describe: and clearly as you can."

a. Duration: Trial1:6. With tongue in cheek, can patient Trial2:

resist examiner' s effort to force Trial3:tongue inward? D D Average:

7. Can the patient move the tongue (average is 15 s for adultsfrom side-to-side? D D & 10 s for school-agedIf no, describe: children)

G. The Velum and Pharynx at Rest and Yes No DegreeDuring Movement: CN X b. Latency: Is there a latency period1. Does the velum rise symmetrically between signal to say la:.! and

each time the patient says I al? D D initiation of phonation? D DIf no, describe: c. Quality:

Steady and even D D2. Is there a gag reflex when the back Smooth and clear D D

wall of the pharynx is touched? D D Hypemasality D DH. The Function of the Larynx: CN X Breathiness D D

1. Is the patient able to produce a Harshness D Dsharp cough? D D Diplophonia D D

2. Can the patient produce a sharp d. Pitchglottal stop? D D Toohigh D DIf no, describe: Too low D D

Normal D D3. Is inhalatory stridor present? D D Tremor D D

If yes, describe: Pitch breaks D De. Loudness

Excessive loudness D DInadequate loudness D DNormalloudness D D

f. Describe Abnormalities:


YesB. Resonatory System:

1. Directions to patients: "Take a deepbreath and say /u:/ for as long as youcan." Hold a (laryngeal) mirrorbeneath one nostril and then the other.Leakage from (L. R. Both) nostrils. D D

2. Directions to patient: "Now I want youto do the same thing, but this timeI'm going to squeeze your nose.Don't let it bother you; just keep the/u:/ going."Change in resonance when occluding(L. R. Both) nostrils. D DConnected speech without nasal. D D

C. Combined Systems (Phonatory,Respiratory, Resonatory, and Articulatory)1. Altemate Motion Rate (diadochokinetic)

Directions to patient: "Take a deepbreath and say (e.g., /pApApA/) aslong, and as fast, and as evenly asyou can." Demonstrate.IsAMRslow? D DIs AMR excessively fast? D DIs AMR dysrhythmic? D DIs AMR uneven in loudness? D DIs AMR uneven in pitch? D DIs there a tremor? D DIs there equal spacing betweensyllables? D DIs there blurring (lack of differentiationbetween syllables)? D DIs there hypernasality? D DIs there nasal emission? D DIs there restriction in amplitude ofmotion of lips and jaw? D DAre there imprecise or distortedconsonants? D D

No Degree


Indicate rate per 5-second interval on this table:

/pA/ /tA/ /kA/ IPAtAkA/

Trial1

Trial2

Trial3

Average

Average rate for /pA/ and /tA/ is about 30-35 repetitions for 5. seconds; /kA/ is somewhat slower.2. Sequential Motion Rate

Directions to patient: "Now I wantyou to make those three sounds,'puh,' 'tuh,' and 'kuh' together."Demonstrate. Note: Record theresults (per 5-second trial) on thetable above.

Yes No Degreea. Is patient able to move smoothly

from syllable to syllable?b. Are sounds blocked, transposed

or omitted?If yes, describe: _

D D

D D

3. Stress Testing of the Motor SpeechMechanism (screening for myastheniagravis)Instruct the patient to count rapidly(approxirnately two numbers persecond) at least up through 100.Demonstrate 1-10.Is there audible deterioration ofphonation or articulation?If yes, describe: _

DD


11I.TESTING FOR NONVERBAL ORAL APRAXIAA. Tests for Nonverbal Oral Apraxia

Directions to patient: "Now 1want youto do some things. Listen closely anddo everything as completely and as we11as you can. Are you ready?"

Response Test Item1. Stick out your tongue.2. Show me how you blow

out a match.3. Show me your teeth.4. Round your lips.5. Touch your nose with the

tip of your tongue.6. Bite your lower lip.7. Show me how you whistle.8. Lick your lips a11around.9. Clear your throat.

10. Move your tongue inand out.

11. Click your teeth togetheronce.

12. Show me how you smile.13. Click your tongue.14. Chatter your teeth as

if cold.15. Touch your chin with

the tip of your tongue.16. Show me how you cough.17. Puff out your cheeks.18. Wiggle your tongue from

side to side.19. Pucker your lips20. Alternately pucker and

smile.

Graded Response Scale1. Accurate and

immediateresponse with nohesitation.

2. Accurate aftertrial-and -errorsearchingmovement oncommand.

3. Crude, defective inamplitude, accuracy,or speed oncommand.

4. Partial response (animportant partmissing) oncommand.

5. Same as (1) afterdemonstration.




9. Perseverativeresponse.

10. Irrelevant response.11. No oral

performance.


IV. TESTING FOR APRAXIA OF SPEECH(ORAL VERBAL APRAXIA)

Directions to patient: "Say those words for me." If patient is unable torepeat to verbal stimuli, present words as printed on cards. As patientreads or repeats the fo11owing, tape record and transcribe errors.

1. slowpoke _2. conference _3. Tahiti _4. dressmaker _5. Armapolis _.6. kindergarten _7. condominium _8. industrial revolution _9. Winnie-the-Pooh and Tigger too _

10. stiff - stiffer - stiffening _11. base - baseba11 - baseba11 cap _12. fan - fancy - fantastic - fashionable _13. glow - glowing - glistening - glamorously _14. rid - riddle - ridicule - ridiculous _

"Now these."mime _George _pipe _babe _

shush _dude _tent _Nan _

"Please repeat these sentences for me."

1. The beautiful girl was dancing. _

2. Open this birthday present first. _

3. The stranger walked into the store. _

4. The birdwatcher saw a Norwegian Blue parrot. _

50 MOTOR SPEECH DISORDERS•

"Count from 1 to 20." Note: Indicate pauses for breath by a slash (/)after the appropriate number.

1. 2. 3. 4.

5. 6. 7. 8.

9. 10. 11. 12.

13. 14. 15. 16.

17. 18. 19. 20.

"Now count backward from 20 to 1."

20. 19. 18. 17.

16. 15. 14. 13.

12. 11. 10. 9.

8. 7. 6. 5.

4. 3. 2. 1.

"Tell me what is happening in this picture." Use the Boston's "CookieTheft." Evoke at least 1 minute of ongoing speech. If necessary pointout neglected features of the picture by asking, "What's happeninghere?"

Write down any four sentences that the patient says. If the patientprovides an insufficient speech sample here, use any (four) sentencesproduced at any point in the evaluation.

1. _

2. _

3. _

4. _


"5ay these sentences after me." Use any (four) sentences just writtenabove. Write down (and if necessary, phonetically transcribe) thepatients imitations.

1. _

2. _

3. _

4. _

V. CONNECTED SPEECH SAMPLEHave the patient read "My Grandfather" or another standard readingpassage and rate the following questions.

Yes No Degree1. Are vowels and consonants

produced clearly? D D2. Is the patient' s rate of speech

too slow? Or is it too fast? D D3. Does the patient show inappropriate

silent intervals between words? D D4. Does the patient show hypemasality? D D5. Is nasal emission present? D D6. Does the patient vary loudness

normally? D D7. If not, is there evidence of

monoloudness? D D8. Is there evidence of tremor in the

patient's voice? D D9. Does the patient show abnormal

pitch variations? D D10. Does the patient's voice have a

harsh vocal quality? D D11. Does the patient's voice have a

strained-strangled vocal quality? D D12. Does the patient' s voice have a

breathy vocal quality? D D13. Does the patient speak in

abnormally short phrases? D O


Yes No Degree14. Are there moments of involuntary

inhalation or exhalation? O O15. Is inhalatory stridor present? O O16. Does the patient use normal

stress on the appropriate syllablesor words? O O

17. If not, is there a reduction innormal stress? O O

18. Or is there excess and equalstress? O O

CHAPTER

The Motor System

A. Components of the Motor System1. Brain '

a. Cerebrumb. Brainstemc. Cerebellum

2. Nervous System Cellsa. Types of Neuronsb. Other Nervous System Cellsc. Tracts and Nervesd. Transmission of Neural Impulses

3. Summary of Motor System ComponentsB. Structure and Function of the Motor System

1. Desire to Move2. Primary and Association Cortex3. Basal Ganglia and Cerebellum4. Thalamus5. Primary Motor Cortex6. Descending Motor Tracts7. Cranial and Spinal Nerves8. Neuromuscular Junction

C. Summary of the Motor SystemD. Study Questions

53

evaluation.of.motor.speech.disorders

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motor speech mechanism5

motor speech examinationmost

speech of patients

motor speechmechanism1

patients speech errors

human motor system

determiningwhich speech

ofthe speech characteristics