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Evidence Based racticeGuidelines for Dysarthria:Management ofVelopharyngeal Function

Academy of Neurologic Communication Disorders and Sciences:Writing Committee for ractice Guidelines in Dysarthria:Kathryn M. Yorkston Ph.D. BC NCD

Department of Rehabilitation MedicineUniversity of Washington

Seattle WashingtonKristie Spencer M.S.

Department of Speech and Hearing SciencesUniversity of Washington

Seattle Washingtonoseph Duffy Ph.D. BC NCD

Division of Speech PathologyDepartment of NeurologyMayo Clinic

Rochestei MinnesotaDavid Beukelman Ph.D.

Department of Special Education and Communication DisordersUniversity ofNebraska

Lincoln NebraskaLee Ann Golper Ph.D. BC NCD

Department of Hearing and Speech SciencesVanderbilt Bill Wilkerson CenterNashville nn ss

Robert Miller Ph.D. BC NCDDepartment of Rehabilitation Medicine

Veterans Administration Puget Sound Health SystemSeattle Washington

Journal of Medical Speech Language PathologyVolume 9 Number 4 pp 257274Copyright 2001 Singular an imprint of Delmar a division of Thomson Learning Inc.

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EVIDENCE BASED PRACTICE GUIDELINES FOR DYSARTI{RIA 2from the research literature as well as expert opinion. They address some of the major issues in themanagement of children and adults with dysarthria. Practice guidelines are intended for use inmaking clinical decisions about the management ofspecific clinical problems. In this article, guidelinesfor the management of velopharyngeal impairmentin dysarthria are reviewed.ustific tionThe Writing Committee of Practice Guidelines forDysarthria developed a list of clinical questionsfaced by speech-language pathologists caring forindividuals with dysarthria. The topic of management of velopharyngeal impairment was selectedfor a number of reasons. First, it is a common mnifestation of dysarthria and can complicate all spects of speech production. Second, variation in pproaches to management exists in clinical practice.Finally, the intervention literature is substantialand dates back to the 1960s.TerminologyThrough the years, a number of terms have beenused to describe velopharyngeal disorders in thecleft palate and motor speech populations. Theseinclude velopharyngeal impairment, inadequacy,insufficiency, incompetency, and dysfunction. In arecent state of the art review; Kuehn and Moller2000 suggest that there is no universal agreement on distinctions among these terms. They suggest use of the term velopharyngeal impairmentbecause it encompasses a wide variety of velopharyngeal disorders and because it is consistent withterminology used in the World Health Organizations classification system World Health Organi

zation, 1999 . The term velopharyngeal impment refers to any failure of the velopharyngmechanism to open or close in a normal fashionspeech Tomes Kuehn, 1996).

PROCEDURES: REVIEWINGTHE EVIDENCE

Development of practice guidelines can be viewas a process of translating evidence from bothsearch literature and expert opinion into recmendations for clinical practice. To evaluatequality of any practice guideline, it is importandocument exactly how they were developed. Tdevelopment process typically involves a seriesteps Trombly, 1995 as summarized in TablThe following section provides specifics aboutexperts including both the writing committeethe reviewers , the searches, criteria for inclusof studies, and rating of evidence.The Writing CommitteeFirst, a group of experts the writing commitwas convened. These individuals representebroad range of clinical experience in the manment of dysarthria. The initial tasks of the wricommittee were to clariIr assumptions upon whthe guidelines are based, to identify pertinent cical questions, and to define the scope of the litture to be evaluated.The e rchesNext, an intensive literature search was conducand appropriate intervention articles weretrieved. The following electronic databases w

TABLE 1. The sequence of activities for development of practice guidelines. A panel of experts the writing committee is convened Assumptions are clarified and pertinent questions are identified An intensive literature search is conducted and pertinent articles are retrieved Intervention studies are rated for quality of evidence A technical report is drafted that summarized the research literature as well as the expert opinion of thewriting committee Expert opinion is obtained Recommendations are drafted, reviewed, and revised Guidelines are distributed.

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EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIAthe current group of intervention studies focusingon prosthetic management, 186 individuals withdysarthria were included.

The psychometric adequacy of measurement wasassessed by indicating whether information wasprovided regarding reliability and stability of themeasurement of the outcomes. For example, inter-or intra-rater reliability, dispersion of judgesscores, and comparison of measures to a gold standard were all considered evidence of psychometricadequacy. Unfortunately, this type of evidence wasoften lacking. Although a trend over time towardmore rigorous measures was noted, the majority ofcurrent studies do not report evidence of psychometric adequacy. Overall, approximately 20 ofthe studies provided data about the psychometricadequacy of the measures used.

Another way of rating the quality of evidence is toevaluate the strength of control imposed by thestudy; In other words, does support exist for the assertion that the treatment of interest was responsible for the change in behavior/outcome measuresrather than some other explanation? Several studiesreported comparisons ofmeasures of speech adequacy with and without the palatal lift. This can providestrong evidence of internal validity (i.e., the palatallift was responsible for the change in outcome .Among other indicators that interventions such aspalatal lifts were successful was the fact that speechperformance had not improved with many years ofbehavioral intervention. Therefore, improvementscould be attributed to palatal lift intervention. Thetrajectory of the disease also was cited as support ofthe effectiveness of intervention. For some, the disease course was degenerative and intervention maintained a given level of speech production in the faceofprogression of the underlying impainnent. For others, improvement in chronic and stable conditionswas cited as support of intervention effectiveness.What Risks or Complications of alatalLifts Were Identified?The benefit of any intervention must be weighedagainst the risks or complications inherent to thetreatment. Generally, the risks or complications ofpalatal lift fitting were minor. Some studies suggested that tooth movement or injury to the soft tissue were risks, but none of the studies reported itsoccurrence in any subjects. The most common complication of palatal lift fitting was intolerance inthe form of initial discomfort, inability to inhibit agag, and prosthesis retention difficulty. Some negative speech-related changes were also reported,

such as difficulty with articulation, due tcreased tonicity in laryngeallpharyngeal musture in some patients with severe spasticitycreased swallowing difficulty and hypersalivfor short periods were also reported. Finally,authors reported a patients lack of acceptanthe device and unrealistic expectations.What Were the Outcomes ofthe Intervention Studies?Generally, the studies of palatal lift fitting reppositive outcomes. Although criteria for suvary; treatment was judged successful 76 otime in a series of 25 cases reported by Bedwand OBrian 1985 . Optimum results wertained in and positive outcomes in 96cases reported by LaVelle and Hardy 1979 .of the most common outcomes included imprarticulation, improved speech intelligibilitycreased hypernasality, and more efficient urespiratory support for speech. A more complescription of potential outcome measures cafound in the measurement of outcomes sectionfollows. Palatal lift fitting was found to be sucful, but more difficult, in individuals whoedentulous or had a spastic palate. The best rewere reported when the soft palate was flaccidwhen good pharyngeal wall movement wassent. Most improvement was noted in indiviwho wore their lifts the longest.

Some of the early descriptions of palatal liting e.g., Mazaheri Mazaheri, 1976 posnumber of questions for further investigationexample, what is the relationship betweenpalatal stimulation offered by palatal lift fiand the degree of neuromuscular function ancovery? Although many clinicians have wowith individuals who have experienced impment in neuromuscular function after palatawere fitted, studies of groups of patients fittedpalatal lift prostheses did not support a stronsociation between palatal lift fitting and recovvelopharyngeal function Witt et al., 1995).Personal testimonies of speakers with dysarwho use a palatal lift are also a source of infotion about treatment outcomes. Two of the induals with ALS who participated in the Esposal. study 2000 were interviewed by CBS Hewatch URL: www. cbshealthwatch.medscapecessed 6/00). Both linked use of the lift to theirtinued ability to work. One individual, a finaplanner stated, My livelihood is based on mymunication skills. It is vital for me to be able t

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264 JOURNAL OF MEDICAL SPEECHLANGUAGE PATHOLOG VOL.9 NO

press my thoughts. The other; business managerstated I doubt if I could work very effectivelywithout the palatal lift

CLINICAL DECISION MAKINGThe following presents an overview of clinical decisionmaking about management of velopharyngealimpairment in dysarthria. It is derived from conclusions drawn from the evidence examined earlieralong with expert opinion both from the publishedliterature and a panel of reviewers. Figure illustrates clinical decisionmaking flowchart for themanagement of velopharygeal impairment indysarthria. The following section provides a detailed explanation of various aspects the flowchartas well as a review of assumptions about the management of dysarthria

AssumptionsBefore describing the flowchart it is necessaryreview some of the assumptions upon which itbased. These assumptions are presumed to be truas they relate to the practice of speechlanguagpathology.Goal of ntervention Enhancement of speeand communication function is a fundamental tget of intervention.Uniqueness of Speech. Speech motor controlunique and different from other motor systemTherefore it must be assessed as part of a comphensive physical examination and cannot be psumed from neurologic deficits in other systemsuch as in limb function.

Figure iag ram for clinical decision mkin for management of velopharyngeal impairment indysarthria.

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EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 265Individual Assessment. The pattern and severity of impairment in the various speech subsystemsvaries from one population to another and from oneindividual to another within each population.Therefore, the pattern and severity of impairmentmust be assessed individually.Individual Intervention Interventions vary asa function of type of dysarthria, severity of dysarthria, and co-existing factors. Therefore, individual intervention plans must be developed.Staging of Intervention Dysarthria often is nota stable condition. For example, children with developmental dysarthria may experience physiologic changes affecting speech production as they mature. Adults with acquired dysarthria mayexperience phases of recovery; as in dysarthria associated with traumatic brain injury; or phases ofdegeneration, as in dysarthria associated withamyotrophic lateral sclerosis. Therefore, the staging of intervention i.e., the timing of treatment iscritical for successful outcomes. ppropriate Referrals. Practice will be conducted by competent speech-language pathologists whorefer to other disciplines when appropriate e.g., forprosthodontic consultation when a palatal lift prosthesis is considered appropriate .Clinical Competence. Practice will be conductedby competent speech-language pathologist in anappropriate and efficient manner.Disclosure Clinicians will communicate boththe benefits and risks including financial of thetreatment.

Assessment of VP unctionAssessment of velopharygeal function in speakerswith dysarthria assumes an understanding of normal function. While it is beyond the scope of this ticle to review normal velopharyngeal function, excellent sources of information are available e.g.,Kuehn Mollei 2000 . The following section summarizes the components of an assessment ofvelopharyngeal function in dysarthria that may beconsidered depending on the constellation ofdeficits and the desired outcomes of each client. Assessment consists of four components: history taking, speech evaluation, physical examination, andexamination of the velopharyngeal mechanism.

History TakingThis phase of the assessment involves gatheringpertinent information from the patient, the medicarecords and the referral source. Information shouldbe gathered on areas such as the following:

the onset of symptoms and medical/dentalhistory the nature, duration, and natural course ofvelopharyngeal VP ) impairment reports of previous treatment the level of concern about the problemNetsell, 1988) the patients motivation relative to treatment Wolfaardt, Wilson Rochet McPhee,1993)

Speech valuat ionDetermining the severity of the velopharyngeal impairment and the degree to which the velopharyngeal impairment disrupts speech production is criical to establishing the need for intervention andfor accurate therapeutic intervention Krummer Lee 1996 . The perceptual assessment of speechincludes an examination of the following:

stimulability for improved speech production perceptual judgment of presence anddegree of hypernasal resonance, audiblenasal emission, loudness as possiblydiminished by damping effects of the nasalcavity and strength and precision ofpressure consonants as a function of velopharygeal closure connected speech with ratings acrossaudiences e.g., untrained versus familiarlisteners phonation performance on articulation tests includingrelative differences in the accurate production of nasals and pressure consonantsYorkston, Beukelman, Honsinger, Mitsuda, 1989; Yorkston, Beukelman, Traynor;1988). difference in intelligibility, pressure consonants, speaking effort, syllables per breathgroup, and resonance with nares occludedversus unocciuded

Physical ExaminationThis involves an assessment of the structure anfunction of the oral mechanism, including thfollowing:

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EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 26Modifying the Pattern of Speaking. Examplesof such modifications include producing speechwith increased effort Liss, Kuehn, Hinkle, 1994or a slower rate Yorkston Beukelman, 1981;Yorkston, Beukelman, Strand, Bell, 1999 .Speakers can also be trained to produce clearspeech by mimicking the overarticulated speech ofa trained talker. Overarticulated speech can beelicited by prompting with comments like, openyour mouth more, speak more clearly, overarticulate, and talk slowly Picheny, Durlach, Braida, 1985).Resistance Treatment During Speech. Continuous positive airway pressure CPAP is anemerging intervention technique reported to be aneffective means of exercising the soft palate duringspeech in two individuals with traumatic brain injury The technique provides a resistance againstwhich the muscles of velopharyngeal closure mustwork Kuehn, 1997; Kuehn Wachtel, 1994 . Atheoretical rationale for strength training is available Liss, Kuehn, Hinkle, 1994).Feedback. The use of biofeedback techniques fortherapy has been suggested for velopharyngeal impairment in dysarthria. Some speakers may benefit from feedback from a mirror, nasal flow transducer, or nasoendoscope during efforts to decreasenasal air flow and hypernasality Rosenbek LaPointe, 1985 . The following are some of the instrumental feedback techniques discussed in a chapterby Murdoch, Thompson, and Theodoros 1997 onspastic dysarthria:

flexible endoscope provides visual feedback of the movements of the lateral pharyngeal wall fiberoptic nasopharyngoscopes obtainsclose observations of VP sphincter duringconnected speech Exeter Bio-Feedback Nasal AnemometerEBNA; Bioinstrumentation LTD Exeter

Techniques Focusing onNonspeech MovementsTherapy techniques appear in the literature thatare based primarily on nonspeech movements ofthe velopharyngeal mechanism. These have generally not been endorsed by experts for several reasons: a) speech and nonspeech velopharyngeal closures involve different underlying mechanisms; b)

no evidence exists that increasing soft palatstrength improves speech performance; and cmost of the methods do not provide the patienwith information on the timing of articulatory getures during speech Murdoch et al., 1997 . vdence and expert opinion suggest that the followintechniques for improving velopharyngeal functioare not effective Brookshire, 1992; Duffy 199Dworkin Johns, 1980; Hageman, 1997; John1985; Murdoch et al., 1997; Netsell Rosenbek1985; Yorkston et al., 1999):

Pushing techniques particularly for patients with spastic dysarthria Strengthening exercises, such as blowingand sucking Tasks that encourage the patient to controland modify the airstream using balls, whistles, candles, fluff; powder; paper; bubbles,straws, etc. Inhibition techniques, such as prolongedicing, pressure to muscle insertion points,slow and irregular stroking and brushing,and desensitization.

Prosthetic InterventionCandidacy for Palatal Lift ittingIf assessment reveals that velopharyrigeal impament is present and the speaker is not able to compensate for that impairment, a palatal lift prosthsis may be considered for selected cases, especialthose with a flaccid soft palate. A palatal lift isrigid acrylic appliance fabricated by a prosthodotist. It consists of a retentive portion that covers thhard palate and fastens to the maxillary teeth bmeans ofwires and a lift portion that extends alonthe oral surface of the soft palate. Issues regardincandidacy for palatal lift fitting have been dscribed extensively Bedwinek OBrian, 198Duffy 1995; Esposito et al., 2000; Murdoch et a1997; Netsell, 1998; Yorkston et aL , 1999). Becautiming of intervention is different for individuawith progressive as opposed to stable-recoveridysarthrias, candidacy in each population willdiscussed separately.Progressive Dysartbria. Table 3 ifiustrates chacteristics of better versus poorer candidates fpalatal lift fitting in progressive dysarthria. Bettcandidates are those with a slow rate of diseaprogression and intact cognition, memory, jud

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EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 269TABLE 4. Characteristics of better and poorer candidates for palatal lift fitting in stable or recovering dysarthria.

Better Candidates Poorer CandidatesNeurophysiology of the soft palateRate of neurologic changeRespiratory/phonatory functionArticulationChange in plosion/resonance with occlusionDifference between intelligibility of pressure and otherconsonants

Able to inhibit gagSwallowing and saliva managementDentitionCognition/memory/judgmentimpairmentManual dexterityPatient goals for speech

FlaccidityStable or slow improvementAdequate or recoveringAdequate or recoveringPresentPressure consonants muchless intelligible than others

YesAdequateAdequateWNL or mild to moderateAble to insert and remove lift

Severe spasticityRapid improvementPoorPoorAbsent or minimalNo or minimaldifference betweenpressure and otherconsonantsNoReducedPoorLess than LOCF VUnable to insert orremove liftDecreased functionis acceptable

thologist to adjust the length and torque ofthe lift to maximize fitting.Follow-up visits are planned to monitor theadequacy of the fitting. According to Esposito and colleagues 2000 , prosthetic treatment for progressive disorders must beongoing. Modifications to the prosthesis aremade on a regular basis to accommodate forthe progression of the disease. It is commonto make changes to the lift and the augmentation of the hard palate portion for speakers with increasingly severe dysarthria.

ehavioral Intervention for Poorandidates for Palatal LiftsIf the speaker is judged to be a poor candidate forpalatal lift fitting, several behavioral strategies areavailable to establish or maintain communicativefunction Hustad Beukelman, 2000; Yorkston etal., 1999 . Behavioral intervention may be employed so that speakers can improve the effectiveness of their communication. The following specifictechniques will be reviewed in subsequent modulesof the Practice Guidelines for Dysarthria:

Alphabet supplementation is a techniqueto improve intelligibility in severe

dysarthria. The speaker points to the firstletter of each word as that word is spoken. Partner techniques are strategies initiatedby the communication partner includingmaintaining the topic identity, paying undivided attention, and piecing together cuesfrom the speaker with dysarthria. Speaker strategies are used to heighten theintelligibility of severely dysarthric speech,including the use of gestures, selecting aconducive communication environment,and using turn maintenance signals. Augmentative and alternative communication techniques include use of devices toreplace or supplement highly distorted speechBeukelman, Yorkston Reichle, 2000).

Surgical InterventionSurgical management for velopharyngeal impaiment in dysarthric speakers also has been repored. Generally, it is considered less beneficial thanprosthetic management and is contraindicated ichildren with cerebral palsy Hardy et al 1961Lotz Netsell, 1989). Johns 1985), however, summarized his positive experiences with a substantianumber of dysarthric speakers with velopharyngeal impairment who had superiorly based pha

Improved speech is critical

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