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2/15/2016 1 Dysphagia and Dysarthria: The Relationship of Sensorimotor- Speech and Swallowing Duane Trahan, MS, CCC-SLP Page 2 Types of Dysarthria Duffy (2005) Page 3 Dysarthria May effect the Aerodigestive System related to Timing Vocal quality Pitch Volume Breath control Speed Strength Steadiness Range Tone

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Page 1: Trahan-Dysarthria - alabamashaa.org 2016/Trahan-Dysarthria... · Pseudobulbar affect ii. Dysphagia, Drooling, ... Pseudobulbar Palsy Slow/Inadequate chewing, Difficulty with bolus

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Dysphagia and Dysarthria:The Relationship of Sensorimotor-

Speech and Swallowing

Duane Trahan, MS, CCC-SLP

Page 2

Types of Dysarthria

Duffy (2005)

Page 3

Dysarthria

May effect the Aerodigestive System related to

Timing

Vocal quality

Pitch

Volume

Breath control

Speed

Strength

Steadiness

Range

Tone

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Dysarthria and Dysphagia

Comparing Swallowing and Speech

Swallowing

Generally reflexive

One of the most primitive behaviors

Controlled in large part by the Medulla

Speech

Voluntary

Uniquely human behavior

Controlled by several higher brain elements

Cerebral Cortex

Cerebellum

Basal Ganglia

Page 5

Common Neurologic Conditions resulting in Dysarthria & Dysphagia

Parkinson’s

Alzheimer’s/Dementia

Amyotrophic Lateral Sclerosis (ALS)

Multiple Sclerosis (MS)

Myasthenia Gravis

Polymyositis & Dermatomyositis

Guillain-Barré

CVA

TBI/ABI

Neurosurgical procedures (acoustic neuroma, tumor)

Cerebral Palsy

Progressive Supranuclear Palsy

Page 6

Prevalence of Dysarthria with Dysphagia

(Nishio et.al.) Strong correlation between Dysarthria and Dysphagia in patients with Neuromuscular disease

(Jani et.al.) Co‐occurrence of Dysarthria and Dysphagia in patients with Neurological disorders  was 45%

(Yorkston et.al. & da Costa) Strong relationship between Swallowing and Dysarthria with ALS & significant correlation of Dysphagia and Dysarthria scales

(Litvan et. al.) Dysphagia is associated with Dysarthria with Progressive Supranuclear Palsy (PSP)

(Kluin et.al.) Dysphagia was more severe than Dysarthria with Myasthenia Gravis

(Daniels et.al. & Leder et.al.) Significant relationship between dysarthria and aspiration with Acute Stroke

(Logemann et.al.) The best predictor of the presence or absence of  an oral stage problem in Dysphagia is Dysarthria

(Horner et.al.) Aspiration strongly correlated with the severity of dysphagia (mild, moderate, and severe)

Nishio (2004)

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Occurrence of Communication and Swallowing Disorder

Jani (2014)

Page 8

Occurrence of Communication and Swallowing Disorder

Jani (2014)

Page 9Jani (2014)

Dysphagia with Dysarthria

• 0%

• CNT

• 100%

• 100%

• 0%

• 100%

• 100%

• 100%

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Prevalence amongst Etiology

Nishio (2004)

Page 11

Dysphagia Severity by Type of Dysarthria

Nishio (2004).

Page 12

Rating Scale of Dysphagia

Nishio, Masaki M (2004). Adapted from Yorkston et.al.

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Prevalence of Dysarthria with Dysphagia

Overall agreement that Medullary infarcts have high correlation of both

Impaired tongue movement is significant for both

Negative correlation between conversational intelligibility and swallowing function is significant

Regarding neuromuscular dysfunction there is no significant difference between gender or age

Page 14

Distinguishing Oral Mechanism Findings

i. = Distinguishing when present; ii. = May be present Flaccid

i. Atrophy, Fasciculations, Rapid deterioration & recovery with rest, Nasal regurgitation, Unilateral palatal weakness

ii. Hypoactive gag, Hypotonia, Dysphagia, Drooling, Unilateral lingual weakness without atrophy

Spastic

i. Hyperactive gag, Sucking reflex, Snout reflex, Jaw jerk reflex, Pseudobulbar affect

ii. Dysphagia, Drooling, Reduced ROM on alternate motion rates (AMRs)

Ataxic

i. Dysmetric jaw/face/tongue AMRs

ii. Hypotonia, Head tremor

Hypokinetici. Masked facies, Tremulous jaw/lips/

tongue, Reduced ROM on AMRs

ii. Dysphagia, Drooling, Head tremor

Hyperkinetici. Involuntary

head/jaw/face/tongue/palate/ respiratory movements, Sensory “tricks”, Torticollis, Myoclonus of palate/pharynx/larynx/lips/nares/ tongue/or respiratory muscles, Multiple motor tics, Jaw/lip/tongue/ pharyngeal/or palatal tremor, Facial grimacing during speech

ii. Dysphagia, Head tremor

Unilateral Upper Motor Neuroni. Unilateral lower face weakness

ii. Dysphagia, Drooling, Unilateral lingual weakness without atrophy, Nonverbal oral apraxiaDuffy (2005)

Page 15

Distinguishing Speech Findings

i. = Distinguishing when present; ii. = May be present Flaccid

i. Hypernasality, Breathiness, Diplophonia, Nasal emission, Audible inspiration, Speaking on inhalation, Short phrases

ii. Pitch breaks, Monopitch, Monoloudness, Reduced loudness

Spastic

i. Harshness, Low pitch, Slow rate, Strained-strangled quality, Pitch breaks, Slow & regular AMRs,

ii. Hypernasality, Short phrases, Excess & equal stress, Monopitch, Monoloudness, Intermittent breathy/aphonic segments

Ataxic

i. Excess & equal stress, Irregular articulatory breakdowns, Irregular AMRs, Distorted vowels, Excess loudness variation, Prolonged phonemes, Telescoping of syllables,

ii. Slow rate, Slow & irregular AMRs, Inconsistent articulatory errors

Hypokinetic

i. Monopitch, Reduced stress, Monoloudness, Reduced loudness, Short rushes of speech, Variable rate, Increased rate in segments, Increased overall rate, Rapid/”blurred” AMRs, Repeated phonemes

ii. Hypernasality, Breathiness

Hyperkinetici. Irregular AMRs, Distorted vowels, Excess

loudness variation, Prolonged intervals, Sudden forced inspiration/expiration, Voice stoppage/arrests, Transient breathiness, Voice tremor, Myoclonic vowel prolongation, Intermittent hypernasality, Marked deterioration with increased rate, Inappropriate vocal noises, Intermittent breathy/aphonic segments

ii. Hypernasality, Audible inspiration, Short phrases, Harshness, Low pitch, Slow rate, Strained-strangled quality, Irregular articulatory breakdowns, Monopitch, Variable rate, Inconsistent articulatory errors

Unilateral Upper Motor Neuroni. Ø

ii. Slow rate, Irregular articulatory breakdowns, Irregular AMRs, Reduced loudness

Duffy (2005)

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Flaccid Dysarthria

Generally Lower Motor Neuron (LMN) involvement

Cranial Nerves (Medulla, Pons, Midbrain)

LMN involving the intercostals & abdominals(12 Thoracic & 1st Lumbar segment)

LMN involving the diaphragm (4th Cervical segment)

All types of movement are impaired (Voluntary, Automatic, and Reflexive)

Trauma (32%), Surgical (28%), Neuropathies (25%), Degenerative (ALS, Multiple systems atrophy), Muscle disease (Muscular Dystrophy), Myasthenia Gravis, Neoplastic, Stroke, Infection (Meningitis), Anatomic Malformation, Demyelinating (GB)

Clinical characteristics

Weakness, Reduced Reflexes, Atrophy, Fasciculations, Progressive weakness with use

Page 17

Dysphagia Severity by Type of Dysarthria (Flaccid)

Nishio (2004).

Page 18

Flaccid Dysarthria

Considerations for Oral Swallowing

Trigeminal (V)

Jaw deviation to weak side (U) or hang open (B), Decreased bite, Impaired sensation to face, lip, cheek, tongue, teeth, or palate, Decreased tension of floor of mouth

Facial (VII)

Lower face weakness and loss of tone including lip and cheek (U/B)

Glossopharyngeal (IX)

Reduced gag, Brief attacks of severe pain in throat, neck, lower jaw with tongue protrusion or swallowing

Translation into potential deficits

(V): Impaired mastication, Impaired extreme jaw opening, Drooling, Buccal/Lingual/Floor of mouth stasis due to sensation, Decreased hyoid elevation

(VII): Drooling, Impaired sucking, Impaired lip seal, Anterior loss of bolus, Buccal stasis/pocketing

(IX): No significant issues

*U/B = unilateral (U) or bilateral (B)

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Flaccid Dysarthria

Considerations for Oral Swallowing Vagus (X)

Palatal weakness (U/B)

Accessory (XI)

Reduced shoulder elevation and weakened head turn

Hypoglossal (XII)

Tongue weakness (U/B) and deviation (U), Decreased anterior excursion of hyoid

Translation into potential deficits (X): Nasal regurgitation, Main issues

are pharyngeal and laryngeal

(XI): Postural issues affecting respiration, may predispose to drooling and anterior loss of bolus; Issues for postural strategy consideration

(XII): Most significant. Global oral deficits: Bolus manipulation & cohesion, Posterior bolus transport, Tongue base retraction, Buccal/Lingual/Floor of mouth stasis due to weakness, Palatal/Roof of mouth stasis, Premature pharyngeal spillage, Vallecular stasis, Stasis at pyriforms/UES inlet (2/2 hyoid excursion)*U/B = unilateral (U) or bilateral (B)

Page 20

Flaccid Dysarthria

Considerations for Pharyngeal Swallowing

Respiratory Reduced vital capacity,

Abnormal chest wall movements, Neck and glossopharyngeal breathing (compensatory)

Laryngeal Incomplete glottal closure (U/B),

Increased breaths per minute, Reduced pause frequency and duration, Reduced range and variability

Translation into potential deficits

Respiratory

Poor breath support, Diminished cough, Abnormal respiratory cycle during swallowing, Decreased apneic period during swallowing, Delayed onset of oropharyngeal swallow,

Predisposition to penetration and/or aspiration before swallow, Penetration and/or aspiration after the swallow

Laryngeal Incomplete laryngeal vestibule closure,

Incomplete vocal fold closure, Impaired arytenoid-to-epiglottic approximation, Impaired laryngeal elevation, Impaired thyroid-to-hyoid approximation, Reduced or Absent laryngeal sensation, Reduced subglottic pressure

Penetration (U/B) and/or aspiration during and/or after the swallow, Incomplete clearance of residual from the laryngeal vestibule

*U/B = unilateral or bilateral

Page 21

Flaccid Dysarthria

Considerations for Pharyngeal Swallowing (cont…)

Velo- & Hypopharyngeal

Reduced or absent palatal movement (U/B), Reduced or absent pharyngeal wall movement (U/B), Increased nasal airflow, Reduced pitch range, Reduced overall intensity and intensity range, Extra resonances

Lingual Reduced sustained lingual force

Translation into potential deficits (cont…)

Velopharyngeal Nasal regurgitation, Impaired/loss of

positive pressure generation of bolus, Impaired pharyngeal constriction (U/B), Impaired pharyngeal stripping wave

Posterior pharyngeal wall stasis, Penetration/Aspiration after the swallow, Stasis in valleculae/lateral channels/pyriform sinuses (U/B)

Lingual

Impaired tongue base retraction, Decreased pressure generation, Impaired anterior hyoid excursion, Impaired epiglottic inversion, Incomplete laryngeal vestibule closure, Secondary PES dysfunction

Stasis on base of tongue/valleculae (U/B), Penetration during swallow

*U/B = unilateral or bilateral

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Flaccid Dysarthria

ALS

Decreased lingual motility, Delayed pharyngeal swallow, Decreased laryngeal elevation, Delayed and reduced duration of UES opening, Aspiration

Stroke

Lateral sulci retention, Delayed oral transfer, Delayed pharyngeal swallow, Decreased hyolaryngeal elevation, Unilateral Pharyngeal paresis, Aspiration

Carotid Endarterectomy/Cervical Spine Surgery

Decreased hyolaryngeal elevation, Decreased pharyngeal movement, Decreased UES opening, Decreased epiglottic movement, Decreased pharyngeal constriction, Aspiration

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Flaccid Dysarthria

Myasthenia Gravis

Pharyngeal swallow delay, Reduced pharyngeal motility, Pharyngeal residue, Penetration, Silent aspiration

Polymyositis & Dermatomyositis

Pharyngeal, striated esophageal, and laryngeal muscle involvement, Xerostomia, Lingual weakness, UES dysfunction

Page 24

Spastic Dysarthria

Damage to Pyramidal Tract/Direct Activation Pathway/Upper Motor Neurons and Extrapyramidal Tract/Indirect Activation Pathway bilaterally

Degenerative (40%), Vascular (29%), ALS (14%) Traumatic, Demyelinating, Tumor, Undetermined

Speech deficits

Generalized hypertonicity, weakness, immobility, abnormal force physiology, and exaggerated reflexes of virtually all muscles of the speech mechanism produce obvious dysfunction of the articulation subsystem. Speech is slow-labored, and imprecise articulatory efforts, compounded by disturbances of respiration; resonation, and phonation often render speech unintelligible

Dysphagia is common and sometime severe

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Dysphagia Severity by Type of Dysarthria (Spastic)

Nishio (2004).

Page 26

Spastic Dysarthria

Considerations for Oral Swallowing

Diminished chewing

Decreased frequency of swallowing

Slowed jaw, lip and facial movements

Reduced ROM of and strength of tongue

Slowness and reduced range of individual and repetitive movements

Reduced force of movements

Excessive muscle tone

Hyperactive gag

Oral reflexes may be present Sucking, Snout, Jaw Jerk

Translation into potential deficits

Food avoidance, Increased mastication time, Impaired mastication, Piecemeal deglutition

Drooling, Impaired secretion management

Delayed oral prep and oral initiation of swallow

Impaired/Discoordinated bolus manipulation/cohesion/ posterior transport, Premature spillage; Oral stasis

Fatigue, Increased meal time

Reduced tongue base retraction

Palatal stasis, Vallecular stasis

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Spastic Dysarthria

Considerations for Pharyngeal Swallowing

Respiratory Reduced: inhalatory &

exhalatory volumes, respiratory intake, vital capacity, maximum vowel prolongation; Paradoxical breathing in which abdominals fail to relax during inhalation

Laryngeal

Decreased laryngeal airflow, Increased: subglottal pressure, glottal resistance, Hyperadduction of true & false cords during speech (? compensative for underlying hypofunction), Slowed laryngeal movements

Translation into potential deficits

Respiratory

Poor breath support, Diminished cough, Abnormal respiratory cycle during swallowing, Decreased apneic period during swallowing, Delayed onset of oropharyngeal swallow,

Predisposition to penetration and/or aspiration before swallow, Penetration and/or aspiration after the swallow

Laryngeal Incomplete laryngeal vestibule closure,

Incomplete vocal fold closure, Incoordination of pharyngeal/laryngeal structures

Penetration (U/B) and/or aspiration during and/or after the swallow

*U/B = unilateral or bilateral

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Spastic Dysarthria

Considerations for Pharyngeal Swallowing (cont…) Velo- & Hypopharyngeal

Slow velopharyngeal mvmt, Incomplete velopharyngeal closure

Lingual

Reduced: speed and range of tongue/jaw/palatal mvmts, tongue strength, sustain maximum tongue contraction, oral pressures

Translation into potential deficits (cont…) Velopharyngeal

Nasal regurgitation, Impaired/loss of positive pressure generation of bolus, Diminished pharyngeal stripping wave

Penetration/Aspiration after the swallow, Stasis in valleculae/lateral channels/pyriform sinuses (U/B)

Lingual

Impaired tongue base retraction, Decreased pressure generation, Impaired anterior hyoid excursion, Impaired epiglottic inversion

Oral stasis, Stasis on base of tongue/valleculae (U/B), Penetration during swallow

*U/B = unilateral or bilateral

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Spastic Dysarthria

TBI

Decreased oral control, Decreased BOT retraction, Delayed pharyngeal swallow, Decreased hyolaryngeal elevation, Aspiration

Pseudobulbar Palsy

Slow/Inadequate chewing, Difficulty with bolus formation and movement, Slowed initiation of swallow, Pharyngeal residue, Aspiration

Page 30

Ataxic Dysarthria

Associated with damage to the Cerebellar control circuit. Characteristics are more evident in articulation and prosody

Reflects the effects of incoordination and reduced muscle tone

Degenerative (35%) , Demyelinating (17%), Undetermined, Vascular, Toxic/Metabolic, Traumatic, Inflammatory, Tumor

Oral mechanism exam is often normal and reflexive swallow is usually normal on casual observation

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Dysphagia Severity by Type of Dysarthria (Ataxic)

Nishio (2004).

Page 32

Ataxic Dysarthria

Considerations for Oropharyngeal Swallowing

Usually reported with progressive ataxias

Related to discoordination of oral, pharyngeal, laryngeal, and respiratory mvmtsmainly during volitional mvmts

Issues are usually involved in the Oral stage of swallowing

Translation into potential deficits

Incoordination of bolus preparation & mastication

Diminished mastication

Premature spillage

Piecemeal deglutition

Oral stasis (labial and buccal sulci)

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Ataxic Dysarthria

Considerations for Oropharyngeal Swallowing

Respiratory &/or Laryngeal

Abnormal and paradoxical rib cage and abdominal mvmts, Reduced vital capacity 2/2 incoordination, Voice tremor, Increased shimmer & jitter, Increased voice onset time, Increased pitch, Poor laryngeal control or laryngeal-supraglottictiming errors

Translation into potential deficits

Respiratory

Poor breath support, Diminished cough, Abnormal respiratory cycle during swallowing, Delayed closure of vocal cords, Decreased apneic period during swallowing, Delayed onset of oropharyngeal swallow,

Predisposition to penetration and/or aspiration before and during swallow with liquids, Penetration and/or aspiration after the swallow with solids

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Ataxic Dysarthria

Considerations for Oropharyngeal Swallowing

Velopharyngeal Inconsistent velopharyngeal

closure

Lingual Difficulty initiating purposeful

mvmt, Slow tongue mvmt, Reduced range and velocity, Reduced or restricted anterior-posterior mvmt during vowel production

Translation into potential deficits

Velopharyngeal Intermittent nasal regurgitation

Lingual Impaired bolus control/cohesion,

Premature spillage, Impaired bolus transit, Incoordination between lingual and pharyngeal structures, Impaired bolus propulsion

Labial and Buccal stasis, Piecemeal deglutition, Penetration and/or aspiration before/during swallow, Vallecular stasis, Pyriform stasis

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Ataxic Dysarthria

Asp: 7/23PyS: 5/23Val: 8/23Pre: 9/23

*Stasis typically cleared with repeat swallow

Nagaya (2004)

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Ataxic Dysarthria

Multiple Sclerosis

Decreased bolus formation, Delayed pharyngeal swallow, Decreased pharyngeal constriction, Decreased UES relaxation

Progressive Ataxias

Dysphagia occurs less often than dysarthria

Premature spillage, Piecemeal deglutition, Pharyngeal residue, Aspiration

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Hypokinetic Dysarthria

Associated with Basal Ganglia

Characteristics are most evident in voice, articulation, and prosody

Effects of rigidity, reduced force and ROM, and slow individual but sometimes fast repetitive movements on speech

Degenerative (78%), Vascular, Undetermined, Toxic/Metabolic, Trauma, Infectious

Parkinson’s & Parkinsonism (58%)

Occurrence of swallowing problems in PD ranges from 40-80% and are usually preceded by Dysarthria

Questionnaire and Patient reports are not predictive of results related to swallowing when compared to instrumental studies

Suggestive of sensory deficits

Studies with Questionnaires only may significantly underreport presence of Dysphagia

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Hypokinetic Dysarthria

Occurrence of swallowing problems in PD ranges from 40-80% and are usually preceded by Dysarthria

Questionnaire and Patient reports are not predictive of results related to swallowing when compared to instrumental studies

Suggestive of sensory deficits

Studies with Questionnaires only may significantly underreport presence of Dysphagia

Progressive Supranuclear Palsy (16% initially, 83% later stages)

Very accurate in expressing swallowing difficulties via questionnaire

Suggestive of intact sensory perception

Dysphagia is most prominent; Dysarthria is common, but not as frequent as Dysphagia; Dysarthria is not always associated with Dysphagia

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Dysphagia Severity by Type of Dysarthria (Hypokinetic)

Nishio (2004).

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Hypokinetic Dysarthria

Considerations for Oral Swallowing

Decreased swallow frequency

Tremor of jaw/lips/tongue

Decreased peak mvmt of lips/jaw/tongue

Delayed initiation of mvmt

Sensory or Perceptual deficits

Translation into potential deficits

Drooling, Impaired secretion management

Increased oral prep and mastication time

Lingual pumping

Bolus cohesion and transit

Premature spillage

Oral stasis

Delayed initiation of pharyngeal swallow Predisposition to penetration

and aspiration

Lack of awareness of deficits

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Hypokinetic Dysarthria

Considerations for Pharyngeal Swallowing

Respiratory Reduced: vital capacity, amplitude of

chest wall mvmts, strength & endurance, intraoral pressure, max vowel duration; Increased: respiratory rate, latency to begin exhalation;

Irregular breathing patterns, Paradoxical rib cage and abdominal mvmts

Laryngeal Bowed TVCs, Tremulous arytenoid

cartilages, Asymmetry of laryngeal structures & mvmts, Decreased: intensity, pitch & loudness, speed to initiate phonation, max phonation time

Voice tremor, Dysphonia

Translation into potential deficits

Respiratory Poor breath support, Diminished cough,

Abnormal respiratory cycle during swallowing, Decreased apneic period during swallowing, Fatigue

Predisposition to penetration and aspiration before swallow, Penetration and/or aspiration after the swallow; Silent aspiration

Laryngeal Incomplete vocal fold closure, Impaired

laryngeal elevation

Penetration and aspiration during and/or after the swallow, Inability to clear penetrated or aspirated material

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Hypokinetic Dysarthria

Considerations for Pharyngeal Swallowing (cont…)

Velo- & Hypopharyngeal

Increased nasal airflow during speech, Reduced velocity and degree of velar movement

Lingual Reduced: amplitude & velocity

of tongue & jaw stability, tongue endurance and strength, speech rate

Abnormal tremor at rest and active/passive movement

Translation into potential deficits (cont…)

Velopharyngeal Nasal regurgitation, Impaired/loss of

positive pressure generation of bolus, Diminished pharyngeal stripping wave

Penetration/Aspiration after the swallow, Stasis in valleculae/lateral channels/pyriform sinuses

Lingual

Impaired tongue base retraction, Decreased pressure generation, Impaired anterior hyoid excursion, Secondary PES dysfunction,

Oral stasis, Stasis on base of tongue/valleculae, Stasis in pyriforms/UES inlet, Predisposition to penetration and aspiration after swallow from residual

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Hypokinetic Dysarthria

Parkinson’s

Lingual tremor, Multiple lingual gestures, Increased oral transit time, Premature spillage, Pharyngeal swallow delay, Decreased laryngeal elevation and closure, Decreased UES relaxation, Oral and pharyngeal residue, Penetration, Aspiration as the disease progresses

PSP

Decreased tongue mobility, Premature spillage, Pharyngeal swallow delay, Impaired laryngeal movement, Pharyngeal residue, Increased velar incompetency, Impulsive, Poor regulation of quantities placed in oral cavity

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Hyperkinetic Dysarthria

Most often associated with disease of the basal ganglia

Product of abnormal, rhythmic or irregular and unpredictable, rapid or slow involuntary movements

Clinical characteristics include: Dyskinesias, Myoclonus, Tics, Chorea, Ballismus, Athetosis, Dystonia, Spasm, Tremor

Unknown (67%), Toxic/Metabolic (12%), Degenerative (9%), Infectious, Vascular

Page 45

Hyperkinetic Dysarthria

Considerations for Oropharygneal Swallowing Variable depending on

characteristics

Chorea

Oral: Quick/unpredictable involuntary mvmts of tongue/velum/mouth/ jaw, Inability to sustain steady head/tongue/ jaw/facial postures, Reduced ROM and incoordination of tongue & lips

Pharyngeal: Choreiformmvmts of laryngeal structures, Sudden/forced/involuntary inspiration or expiration

Translation into potential deficits Chorea

Oral: Disordered oral prep, Impaired mastication, Impaired bolus cohesion, Premature spillage of inadequately masticated solids and liquids, Nasal regurgitation, Anterior loss of bolus, Impaired bolus transit

Pharyngeal: Loss of bolus pressure generation, Penetration or aspiration of liquids and solids, Risk for inhalation of food/liquid, Inability to maintain breath hold during swallowing, Valleculae stasis, Pyriform stasis

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Hyperkinetic Dysarthria

Considerations for Oropharygneal Swallowing Dystonia- dysphagia is often

underdiagnosed (>50%)

Oral: Spasms leading to mouth opening/closing, lip pursing/retraction, & protrusion or rotary mvmts of tongue;

Pharyngeal: Spasms may elevate larynx, Torsion of neck/torticollis

Myoclonus

Transient complaints of dysphagia; Mainly related to timing of swallowing

Spasmodic Dysphonia

Generally dysphagia stems from treatment (Botox)

Translation into potential deficits Dystonia

Oral: Disordered oral prep, Impaired mastication, Impaired bolus cohesion, Premature spillage of inadequately masticated solids and liquids, Anterior loss of bolus, Impaired bolus transit, Oral stasis

Pharyngeal: Asymmetric pharyngeal transit, Penetration or aspiration of liquids, Valleculae stasis, Pyriform stasis

Myoclonus

Penetration or aspiration before the swallow, Intermittent hypopharyngeal stasis clearing with repeat swallow

Spasmodic Dysphonia

After Botox: Thin liquid aspiration

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Hyperkinetic Dysarthria

Tardive Dyskinesia

MBS findings: Tongue thrust, disorganized tongue movements, pharyngeal pooling, aspiration

Huntington’s Disease: 85%

MBS findings: Lingual chorea, asynchronicity of respiration and swallowing, continual postural changes that impact oral and pharyngeal motility, tachyphagia –rapid unregulated swallowing, excessive belching (eructation)

Dystonia

Difficulty coordinating swallowing with respiration, Impaired chewing, Premature spillage, Pharyngeal swallow delay, Vallecular residue

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Treatment

Chorea

Postural and compensatory strategies, Early intervention to prevent maladaptive behaviors, Adaptive equipment, Dietary modifications and alterations, PEG for supplemental with transition to primary with disease progression

Some evidence to support respiratory retraining, Vocal fold adduction and Oral motor exercise in adjunct to pharmacological tx

Dystonia

Botox injections. May result in worsening of dysphagia symptoms and changes in impairment

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Unilateral Upper Motor Neuron (UMN) Dysarthria

Damage to the Upper Motor Neuron pathways

Usually reflect the effects of weakness, but sometimes spasticity and incoordination are implicated

Vascular (90%), Traumatic (4%), Tumor(4%)

Swallowing correlates with severity of dysarthria

Speech is often slurred, thick, or slow and deteriorates under fatigue or stress

May occur in conjunction with Apraxia, Aphasia, and/or Cognitive deficits

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Dysphagia Severity by Type of Dysarthria (Unilateral Upper Motor Neuron)

Nishio (2004).

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Unilateral UMN Dysarthria

Considerations for Oropharyngeal Swallow Dysphagia is usually mild and recovery

is good. More severe maybe related to confounding cognitive issues

Oral/Velopharyngeal Unilateral (U) lower facial weakness,

Decreased force of (U) jaw movement, Reduced strength/endurance/ speed of (U) lip and tongue mvmt, Mild palatal weakness

Respiratory Nonspeech respiratory functions may be

affected due to weakness, Reduced respiratory drive

Laryngeal/Pharyngeal If dysphonia is present may have (U) vocal

fold weakness, Decreased or Increased glottal airflow, Decreased rate of adduction/abduction, Mildly diminished laryngeal elevation, Mildly diminished pharyngeal constriction (U)

Translation into Potential Deficits Most often involves the face/ tongue;

sometime the larynx; and less frequent velopharynx, jaw, & respiration

Oral/Velopharyngeal Decreased bolus manipulation/ cohesion,

Mild buccal/FOM stasis, Diminished bolus transport, Trace nasal regurgitation, Fatigue with mastication

Respiratory Fatigue with meals, Diminished cough

Laryngeal/Pharyngeal Incomplete laryngeal vestibule closure,

(U) penetration during swallow, Aspiration risk during swallow, Hypopharyngealstasis

*U/B = unilateral (U) or bilateral (B)

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Mixed Dysarthria

Distributed across two or more divisions of the nervous system

Accounts for approximately 30% of all dysarthrias

Recognition of each component of a Mixed dysarthria may help rule out certain neurologic diagnoses or make other diagnoses more likely

Degenerative (66%), ALS (43%), Vascular (11%), Traumatic, Multiple causes, Demyelinating, Tumor

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Dysphagia Severity by Type of Dysarthria (Mixed)

Nishio (2004).

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Mixed Dysarthria

Flaccid-Spastic

42%

ALS (88%), Vascular (5%), Other

Ataxic-Spastic

23%

Vascular (17%), Demyelinating (13%), CNS degenerative disease (12%), Inflammatory, Cerebellar degeneration, Spino-cerebellar degeneration, Tumor, Trauma, Other

Hypokinetic-Spastic

7%

Degenerative CNS disease (30%), PSP (20%), Vascular (20%), Multiple (15%), Other

Ataxic-Flaccid-Spastic

6%

ALS (59%), Vascular (18%), Other

Hyperkinetic-Hypokinetic

3%

Parkinson’s (67%), Other

Other types

19%

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Mixed Dysarthria

Considerations for Oropharyngeal Swallow

Variable dependent on etiologies

Next to Spastic Dysarthria, has highest rate of co-existing Dysphagia ranging in all severities

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Degenerative Disease

Identifying typical changes in speech and swallowing that occur at the onset of each disease that can be used to identify the disease entity

Are there progressive and predictable changes

How long can the patient continue to eat by mouth

What techniques can prolong oral feeding

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Sudden-Onset versus Degenerative Neurologic Disorder

Sensitivity to aspiration appears to be significantly reduced, indicated by failure to cough

If there is a cough, may be non-productive in clearing aspirated material

Unaware of swallowing disturbances and deny swallowing problem

Lack of awareness of residue material in the pharynx; therefore, often do not dry swallow to clear residue

High potential for silent aspiration before, during, and even distantly after swallowing

Sensory deficits may be result of sudden neurologic deficit; or of desensitization by the presence of residue and aspiration chronically

Fatigue

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Management/Treatment

Medical management

Pharmacological/Surgical

Communication needs

Nutritional needs

Restoring lost function

Promoting use of residual function

Prosthetics/AAC.

Structures/Functions involved in both deficts

Similarities/Differences

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