Treatment of Dysarthria
1
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with Acute, Chronic, and Degenerative Conditions
Heather M Clark, Ph.D. CCC/SLP, BC-ANCDS
North Carolina Speech-Language and Hearing AssociationWinston-Salem NCApril 10, 2019
Treatment of Dysarthria In Adults
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Disclosures
• Financial and non-financial conflicts of interest• Salary from Mayo Clinic (ask me about career opportunities!)
• Book royalties received from Pro-Ed (book topic unrelated to this talk)
• Grant support• National Institute of Neurological Disorders and Stroke
• National Institute on Deafness and Other Communication Disorders
• Speaking honoraria• ANCDS
• Certification Board, Professional Affairs Committee
• SIG 2 • Coordinator
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Objectives
• Identify treatment targets addressing underlying functional impairments, activity restrictions, and participation limitations
• Incorporate principles of motor learning, including practice and feedback schedules to enhance carry over and retention of acquired skills
• Describe levels of evidence available to support several classes of interventions for dysarthria and identify sources for updates on EBP
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Treatment of Dysarthria
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?
Why
Where When
What
How
Who?
??
?
?
? ?
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We need to know what the options are…
And the rationale for the selecting among the options
Treatment of Dysarthria
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Treatment of DysarthriaConsidering Chronicity
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Treatment of Dysarthria: Acute Care
• Goals• Identifying or establishing reliable mode of
communication• Discharge planning
• For prolonged stays• On-going assessment as medical status
fluctuates• May be able to move forward with
rehabilitative goals
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Treatment of Dysarthria: Early rehabilitation
• Goals• Restoration of function• Optimizing activity, participation, quality of
life• Comprehensibility strategies• Home and work modifications• Conversation partner training
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Treatment of Dysarthria: Chronic Phase
• One task is to justify treatment • Involves identifying communication
difficulties that• Have never been treated
• Have been treated inappropriately
• Have been treated appropriately but may benefit from a different approach
• Have been treated optimally but patient and family have not effectively adapted to the “new normal”
• Much of the highest quality evidence supporting treatment of motor speech disorders is the setting of chronic impairments
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Treatment of Dysarthria: Chronic Phase
• Goals• Restoration of function• Optimizing activity, participation, quality of life
• Comprehensibility strategies• Home and work modifications• Conversation partner training
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Treatment of Dysarthria: Progressive Conditions
• Goals• Restoration (?), maintenance, and slowed decline, of
function• Optimizing activity, participation, quality of life
• Comprehensibility strategies• Home and work modifications• Conversation partner training
Treatment of Dysarthria
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Frameworks Guiding Decision Making
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ICFFrameworks Guiding Decision Making
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International Classification of Function: ICF
Health Condition
Activity and Participation
Contextual Factors
(Personal and Environmental)
Body Functions and
Structures
World Health Organization, 2001©2018 MFMER | slide-16
Health Condition
Disorder or disease
Informs• Prognosis
• Predicted comorbidities
• Tolerance for specific modalities
Treatment of motor speech disorders associated with neurodegenerative disease may differ from acute or chronic disease
• Goals
• Time course• Relatively frequent during
establishment of skills or strategies
• Relatively infrequent re-evaluation with updated recommendations
Health Condition
Activity and Participation
Contextual Factors
(Personal and Environmental)
Body Functions and
Structures
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Body Functions and Structures
Underlying impairments of or changes to anatomical structures or physiologic functions
In motor speech disorders, impairments are often described at the level of muscle or nerve impairment (e.g., weakness) or at the level of subsystem (e.g., impairments of voice)
Health Condition
Activity and Participation
Contextual Factors
(Personal and Environmental)
Body Functions and
Structures
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Activity and Participation
Describes the impact of health conditions, impairments, and contextual factors on performance of and participation in functional activities
Health Condition
Activity and Participation
Contextual Factors
(Personal and Environmental)
Body Functions and
Structures
Treatment of Dysarthria
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Contextual Factors
Personal factors• Age
• Life experiences
• Personality
• Co-morbidities‒ Speakers with dysarthria often
have concomitant impairments in speech praxis, language, cognition, and/or swallowing functions
Environmental factors• Technology
• Geography
• Support and relationships
• Attitudes
• Services
• Systems and policies
Health Condition
Activity and Participation
Contextual Factors
(Personal and Environmental)
Body Functions and
Structures
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Application: ICF
• Differential diagnosis• Mixed hypokinetic-hyperkinetic-spastic
dysarthria• Apraxia of speech• Cognitive communicative impairment
• Medical diagnosis• Corticobasal syndrome
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Application: ICF
Recommendation Rationale
Environmental modifications to maximize signal to noise ratio
• Increasing loudness exacerbated phonatory strain
Conversation partner strategies
• Cognitive deficits make it difficult for patient to use intentional strategies
• Include strategies addressing reduced output related to cognitive deficits
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Motor Speech Treatment HierarchyFrameworks Guiding Decision Making
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Speech Subsystems
Respiration
Phonation
ResonationArticulation
Prosody
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Motor Speech Treatment Hierarchy
• The speech subsystems do not act independently
• Adequate respiratory support and velopharyngeal valving supports phonation
• Articulatory precision is supported by respiratory, resonatory, and phonatory competence
Dworkin, 1991
Treatment of Dysarthria
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First Order Targets
Second Order Targets
Third Order Targets
Articulation
Phonation
Respiration Resonation
Prosody
Motor Speech Treatment Hierarchy
Dworkin, 1991©2018 MFMER | slide-26
First Order Targets: Respiratory support
(diaphragmatic breathing)
Loudness (e.g.,LSVT)
Third Order Targets: Overenunciation Articulation
Phonation
Respiration Resonation
Prosody
Application: Motor Speech Treatment Hierarchy
Prosody targets: Lexical stress
Slow rate
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Principles of Motor Learning
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Take-home Messages on Motor Learning
• Measuring Motor Learning• Performance during the treatment session is
not a sensitive measure of learning (retention/transfer)
• To best serve our patients and our profession, we need to diligently report progress/treatment success based on outcomes obtained outside of rehearsal (treatment sessions or at least targeted practice)
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Take-home Messages on Motor Learning
• Many training factors that enhance learning result in slower acquisition
• Random practice• Varied practice• Reduced feedback
• The more movement trials the better
• All evidence suggests that motor learning is highly specific
• Underlying ability cannot be improved by drills targeting speed or coordination
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Take-home Messages on Motor Learning
• Excessive verbal processing will direct attentional resources away from motor control processing
• Visual models• Reduced verbal feedback
• Reducing feedback allows the learner to attend to sensory consequences (more similar to the target context)
Treatment of Dysarthria
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Application: Motor learning
• Treatment targets• Loudness• Slow rate• Over-enunciation• Lexical stress
• Skill presentation• Direct and indirect modeling• “Loud” requires limited
verbal description
• Practice• Random and variable
(assuming the skill has been acquired but not generalized)
• Nonverbal feedback (sound level meter)
• Summary feedback
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Read the phrase
• Go for it
• Are you sure?
• The cat’s out of the bag
• Enormous hippopotamus
• I’m in!
• Don’t count your chickens before they’re hatched
• Coffee?
LOUD
SLOW
ENUNCIATE
CAREFUL STRESS
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Neuromuscular Treatment PrinciplesFrameworks Guiding Decision Making
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Neuromuscular Functions Thought to Impact Motor Speech
• Strength
• Muscle tone
• Stability and coordination
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Strength
• Weakness• Maximum force (strength;1Rmax)• Sustained/repeated submaximal force
(endurance)• Power (near maximal forces at high speed)
• Causes• UMN lesion (UUMN and spastic dysarthria)• LMN lesion (flaccid dysarthria)• Disuse atrophy & deconditioning (all
dysarthrias)
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Strength Training Principles
• Overload & Progression
• Intensity
• Recovery
• Reversibility
• Specificity of Training
Treatment of Dysarthria
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Overload & Progression
• Overload• Taxing the muscles beyond typical
functioning• Results in
• Hypertrophy of muscle tissue• Increased motor unit recruitment
• Progression• Systematic overload• Implies need for regular reassessment of
maximum performance
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Intensity
• Strength training• 60-80% 1Rmax
• 10 repetitions per set• 2-3 sets
• Endurance training
• 40-60% 1Rmax
• High number of repetitions (e.g., 60)
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Recovery
• Optimal interval between training sessions to allow recovery yet avoid reversal
• In large muscle groups, optimal interval is > 24 hrs
• Tongue strengthening studies: 3-7 days/week
• Respiratory muscle strengthening studies: 3-5 days/week
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Reversibility
• “Use it or lose it”
• Levels of strength must be used to be maintained
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Specificity of Training
• The effects of strength training are highly specific to the trained behaviors
• This is primarily related to motor unit recruitment and motor learning
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Motor unit
• Vary• Order of recruitment• Speed of contraction• Force of contraction• Resistance to fatigue
• Recruited according to• Direction of movement• Force and speed of
movement
• Motoneuron and the muscle fibers it innervates
Treatment of Dysarthria
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Movement factors subject to specificity
• Force
• Contraction velocity
• Duration
• Dynamics
• Integration
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Integration
• Results of motor learning experiments suggest that motor programs (specific patterns of motor unit recruitment) are highly specific
• Predicts that exercises that incorporate the entire movement pattern (e.g., all articulators) will result in greatest carryover
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Examining Training Specificity of Lingual Musculature – Competing Hypotheses
• Training Specificity• Predicts that greatest gains in strength will be
observed for movements that match the exercise
• Muscular Hydrostat (ala Luschei, 1991)
• Tongue is a muscular hydrostat, with fibers contracting against each other
• Exercise in any direction will recruit motor units involving most lingual muscle groups
• Predicts that generalized increases in lingual strength may be observed for untrained lingual movements
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Training Specificity StudyDirection of Exercise
• Healthy participants
• Performed daily tongue exercise• Elevation• Protrusion• Lateralization
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Hypothetical Results
Elevation Protrusion Lateralization
Elevation Training
Protrusion Training
Lateralization Training
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Actual Results
Elevation Protrusion Lateralization
Elevation Training
Protrusion Training
Lateralization Training
Treatment of Dysarthria
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Conclusions
• General training effects may be observed in the lingual musculature
• No given direction of lingual exercise was more effective than another
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• 5 subjects in each of 5 training conditions• Strength• Endurance• Power• Speed• No exercise
• After 4 weeks of exercise, changes in strength, endurance, power, and speed were assessed
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Exercise Protocol
• 40 healthy adult participants• 35 females / 5 males • Mean age 23.7 years (range 18 to 59)
• Assigned to one of three training conditions
• Tongue elevation + ES (N=15)• Resistance straw training + ES (N=18)• ES only (N=7)
• Daily exercise for 4 weeks• 3 sets of 10 repetitions
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Lingua-palatal swallowing pressure
0
10
20
30
40
50
60
PreTraining PostTraining PreTraining PostTraining
Non-effortful Effortful
Training x Effort F(1, 37) = 15.2 p = .000Noneffortful Training Effects t (39) = .703 p = .486Effortful Training Effects t (39) = 4.73 p = .000
Treatment of Dysarthria
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Negative Pressure Generation
-16.0
-14.0
-12.0
-10.0
-8.0
-6.0
-4.0
-2.0
.0
PreTraining PostTraining PreTraining PostTraining
Noneffortful Effortful
Ora
l Ne
gativ
e P
ress
ure
(kP
a)
Tongue + ES
Straw + ES
ES Only
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Conclusions
• Training effortful swallow (in isolation or with preparatory contraction) improves only effortfulswallows
• Training with high resistance straws improves only effortful sips.
• ES and/or tongue exercise did not improved sipping strength
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Summary of Specificity Research
• Specificity of training observed for • Strength, endurance and power (intensity of
contraction) and dynamics (isometric/isotonic) for lingual elevation
• Functional orofacial movement patterns• Effortful suck
• Intensity of effort for functional movement patterns
• Effortful suck• Effortful swallow
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Summary of Specificity Research
• Specificity of training not observed for• Speed of lingual elevation• Direction of lingual movement• Overall strength when trained within
functional movements
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Contra-indications for strength training
• Hypertonia• Rationale: High resistance exercise presumed to
increase spasticity, arose from principles of the Bobathapproach
• Evidence has failed to support this presumption• Stroke (Pak & Patten, 2008)
• Cerebral palsy (Dodd, Taylor & Damiano, 2002; Scholtes et al, 2012)
• MS (in combination with anti-spasticity medications; Motl, Snook & Hinkle, 2007)
• ALS (Ashworth, Satkunam, & Deforge, 2012 Cochrane Review)
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Contra-indications for strength training
• Fatigue Susceptibility• Neuromuscular junction deficits: the impairment does
not reflect reduced motor unit recruitment nor peripheral muscle weakness.
• Progressive neuromuscular disease• Rationale: resistance exercise induces fatigue
without potential benefit of increased strength• Evidence
• Low to moderate intensity exercise may improve functional activity (Kjolhede, Vissing & Dalgas, 2012; White & Dressendorfer, 2004)
• EMST was effective for ALS patients who tolerated the treatment
Treatment of Dysarthria
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Contra-indications for strength training
• Inflammatory Myopathy• Rationale: resistance exercise thought to exacerbate
inflammatory response• Evidence
• Case study of lingual exercise in IBM: strength, P-A scores, bolus clearance did not decline over course of 5 year progressive disease (Maladraki et al., 2012)
• No clear evidence for harmful effects of exercise, but insufficient evidence for benefit, either (Voet et al, 2013; Cochrane Review)
• Absence of Weakness• This assumption is not under scrutiny(?)
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Strength Training in Dysarthria (AJSLP, 2009)
• Sensory stimulation plus orofacial exercise improved intelligibility of adults (Roy 2002) and children (Roy 2001). AMR rates were unchanged in both studies
• Some studies failed to report any results
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Strength Training in Dysarthria
• Lower level evidence• A small number of “low n” controlled studies and/or
case studies provide limited support• Most authors caution against emphasizing strength
training over speech-directed treatment, but acknowledge the potential benefit for specific patients when appropriate principles are incorporated (Dworkin, Linebaugh, Hageman, Duffy, Yorkston, Love, Murdoch)
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Strength Training in Dysarthria
• Best evidence in support of strength training comes from exercise targeting
• Respiratory support• Phonatory support
*to be covered later in the presentation
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Flaccid dysarthria primarily affecting CN XII, subtle CN VII & X deficits
• Speech features• Mild nonspecific hoarseness with occasional fry • Imprecise articulation, particularly of lingual
consonants
• Non-speech features• Lip retraction was full, but lip rounding was mildly
reduced • Tongue
• Asymmetric size R>L (subtle)• Mild-moderate weakness bilaterally
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Flaccid dysarthria associated with myasthenia gravis
• Speech features• Reduced loudness• Hoarseness• Hypernasality• Articulatory imprecision• Short phrases
• Rapid fatigue
Treatment of Dysarthria
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Strength training: Application
• Are either of these speakers good candidates for strengthening?
• Would strengthening be the only line of therapy?
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Disrupted Muscle ToneNeuromuscular Principles
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Muscle Tone Defined
• Resistance of a resting muscle to passive stretch
• Influenced by tissue elasticity and resting motor unit activity
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Muscle tone versus muscle strength
• Muscle tone is a characteristic of muscle at rest
• Muscle strength is a characteristic of activated muscle
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Muscle Tone Regulation
• Peripheral Reflexes• Stretch (muscle spindles)
• Descending pathways• Indirect upper motor neuron pathways• Basal ganglia control circuit• Cerebellar control circuit
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Tone Impairments
• Hypotonia• Flaccid: diminished signals in reflex arc• Cerebellar: mechanism unknown
• Hypertonia• Spastic: released inhibition from descending
indirect pathway onto gamma motor neurons• Rigid: increased excitability of α motor neurons
• Variable Tone
Treatment of Dysarthria
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Muscle Spindle Action in Speech/Swallowing Muscles
• Jaw closing muscles• High density muscle spindles• Strong stretch reflex
• Face & lips• Low density or lack of muscle spindles• Do not exhibit stretch reflexes
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Muscle Spindle Action in Speech/Swallowing Muscles
• Tongue • Muscle spindle density similar to limbs• Do not exhibit typical stretch reflexes • (Neilson et al., 1979)
• Palate, Pharynx, Larynx• Presence of muscle spindles varies across muscles• No studies to date have demonstrated stretch reflexes in the
human larynx (Ludlow, 2005) or pharynx
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Assessment of Muscle Tone: Clinical
• Passive displacement of relaxed limb• Modified Ashworth Scale (6-point scale)
• Muscle palpation• Feel for resistance to tissue deformation
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Clinical Assessment ofMuscle Tone: Speech musculature
• Observation of resting position• Facial droop• Lip retraction
• Orofacial tone assessments• Dworkin & Culatta (1996)• Beckman (1988)
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Proximal Muscle Groups
Velum and pharynx• Slow, symmetrical movements may indicate
hypertonia• Droop, often asymmetrical, may indicate
hypotonia
• Larynx• Hypertonicity typically has bias for
hyperadduction (strained, strangled vocal quality)
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Evidence for Tone Impairments inDysarthriaDysarthria Hypothesized (Darley,
Aronson, Brown, 1969)
Data
Flaccid Flaccid hypotonia Flaccid: hypotonia (Solomon & Clark, 2010)
Spastic Spastic hypertonia Spastic: No hyperactive stretch reflexes in the tongue in spastic dysarthria (Nielson et al., 1979)
Ataxic Normal None
Hypokinetic Rigid hypertonia Hypokinetic: Increased lip stiffness (Hunker, Abbs, & Barlow, 1982; Chu et al., 2010)
Hyperkinetic Dystonic/variable None
Treatment of Dysarthria
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Management of Tone Impairments
• Pharmacologic• Spasticity
• Muscle relaxants (e.g., Baclofen)
• Muscle paralytics (e.g., botulinum toxin)
• Rigidity• Levodopa
• Surgical• Spasticity
• Tendon lengthening • Rhizotomy
• Rigidity• Pallidotomy• Deep brain stimulation
Effects on speech tend to be less dramatic than on postural and limb musculature
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Behavioral Management of Tone Impairments• Target sensory endings or afferent pathways of
reflex loops
• Examples• Slow stretch – inhibit stretch reflex• Quick stretch/tapping – stimulate stretch
reflex• Vibration – stimulate tonic vibratory reflex
(stimulates agonist, inhibits antagonist)
• Related modalities• Cold• Massage
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Sensory intervention on orofacial muscle tone: Preliminary study
• Participants • 16 women• Neurologically normal
• Tissue compliance measures• Tested on separate days• Before and after
• Icing• Vibration
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Submental Compliance Before & After Sensory Intervention
*
.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Vibration Icing
Pre-Tx
Post-Tx
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Summary: Submental compliance
• Submental tissue compliance decreased (stiffness increased) after icing but not vibration
• Increased tissue stiffness after icing could derive from
• Stiffening of non-muscular and muscle tissue• Changes in blood flow• Increased muscular activity
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Muscle tone in the speech musculature:Summary
• Perceptual assessment methods have not been validated with instrumental measures
• Instrumental measures are under exploration but have not yet met validity standards even in the research setting
• Muscle tone in the orofacial muscles is regulated in ways unique from the limb musculature
Treatment of Dysarthria
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Muscle tone in the speech musculature:Summary
• It is unclear how resting muscle tone affects speech movements
• Treatments described to address muscle tone in the limbs unlikely to affect speech muscles other than jaw closing muscles
• No evidence to demonstrate efficacy of tone altering treatments for speech
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Application: Tone altering therapies
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Specific Dysarthria Treatments
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Respiratory Treatments
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Respiratory Impairments
Impairments
• Reduced inspiratory capacity
• Reduced expiratory pressure
• Reduced control • Checking action• Involuntary
movements
Associated Speech Changes
• Reduced overall loudness
• Loudness decay
• Excessive loudness variation
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Supporting Respiratory Function
• Postural adjustments• Sitting upright or standing typically better
than lying supine• Avoid excess flexion
• Trunk/abdomen• Neck
• External supports• Expiratory boards
Treatment of Dysarthria
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Inspiratory Muscle Training
• Diaphragm is primary target (belly breathing)
• Discourage excess use of accessory muscles (shoulder breathing)
• Goal is to establish strong, quick inspiration followed by slow, controlled exhalation
• Early training may incorporate slowed and controlled inhalation and exhalation, discussed on next slide
• Strength training requires overload, which may be best achieved with an inspiratory training device
Sapienza, C. & Troche, M. (2012). Respiratory muscle strength training: Theory and practice. Plural Publishing.
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Diaphragmatic breathing
• Promotes solid respiratory support
• May help inhibit excessive activation of accessory inspiratory muscles and laryngeal musculature
• Visual and tactile feedback (“belly breathing”) often helpful
• Applications on hand-held devices can support independent practice
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Controlled Expiration (Inspiratory Checking)
• Can be combined with diaphragmatic breathing
• Focus on quick, strong inhalation
• Followed by slow, steady exhalation
Netsell, R & Hixon, T. J. (1992). Inspiratory checking in therapy for individuals with speech breathing dysfunction. ASHA 34: 152.
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• Pressure threshold trainer
• Resistance set at 75% maximum expiratory pressure
• Rule of 5’s• 5 repetitions• 5 times per day• 5 days per week
• 4-8 weeks
Expiratory Muscle Strength Training (EMST)
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• Training outcomes• Increased expiratory pressures• Reduced hypophonia• Improved intelligibility
• Patient groups studied• Parkinson disease• Multiple sclerosis• Ataxic disorders• ALS
Expiratory Muscle Strength Training (EMST)
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Phrase Grouping
• Targets strategic pauses for inhalation
• Phrase length selected according to• Respiratory support• Syntactic boundaries
Treatment of Dysarthria
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Resonatory Treatments
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Resonatory Impairments
Impairments
• Velar weakness
• Slowness of velar elevation
• Reduced control • Incoordination• Involuntary
movements
Associated Speech Changes
• Hypernasality
• Nasal emission
• Weak articulatory contacts
• Hyponasality
• Alternating resonance
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• Nonspeech exercise• Examples
• Horn-blowing• Straw-sucking
• No evidence for carry-over to speech tasks
• Speech exercise• Continuous positive airway pressure (CPAP)• Overloads the velopharyngeal musculature
during speech tasks
Velopharyngeal Exercise
Cahill, L. M., Turner, A. B., Stabler, P. A., Addis, P. E., Theodoros, D. G., & Murdoch, B. E. (2004). An evaluation of continuous positive airway pressure (CPAP) therapy in the treatment of hypernasality following traumatic brain injury: a report of 3 cases. [Case Reports]. The Journal of head trauma rehabilitation, 19(3), 241-253.
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Speech-based Resonatory Treatment
• Emphasis of appropriate oral and/or nasal resonance
• May incorporate augmented feedback• Nasal mirror • SeeScape• Nasometry
• May incorporate progressive difficulty• Vowels • Liquids• Plosives and fricatives• Phonetic context
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Prosthetic Management
• Palatal lift• Assessment and implementation in
collaboration with prosthodontist• Will be most helpful for speakers with
isolated hypernasality or nasality disproportionate to other features
• Keeping in mind that adequate velopharyngeal valving may support the benefit of interventions targeting phonation or articulation
• Behavioral intervention usually still neededYorkston, K. M., Spencer, K. A., Duffy, J. R., Beukelman, D.R., Golper, L. A., Miller, R. M., Strand, E. A., & Sullivan,M. (2001). Evidence-Based Practice Guidelines for Dysarthria: Management of Velopharyngeal Function. Journal of Medical Speech-Language Pathology, 9(4), 257-273. ©2018 MFMER | slide-102
Prosthetic Management
• Nose plugs
• Nasal obturator• Occlude the nares to prevent excess nasal
air escape• Short term solution while a palatal lift is being
fabricated• Long term option for patients who are not
candidates for palatal lift
Hakel, Marshall, & McHenry (2009). Understanding palatal lifts and nasal obturators. Presented at the ASHA Convention (http://www.asha.org/events/convention/handouts/2009/1915_hakel_mark/)
Treatment of Dysarthria
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Surgical Management
• Examples• Pharyngeal flap• Injection augmentation
• Candidacy issues• Stable velopharyngeal impairment• Patency of airway
• Behavioral intervention may still be needed
©2018 MFMER | slide-104
Injection Augmentation for VPI
Video Courtesy Dr. Shelagh Cofer, Mayo Clinic
©2018 MFMER | slide-105
Phonatory treatments
Speyer, R. (2008). Effects of voice therapy: A systematic review. Journal of Voice, 22(5), 565-580.
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Phonatory Impairments
Impairments
• Hypo-adduction
• Hyper-adduction
• Reduced flexibility
• Reduced stability
Associated Speech Changes
• Strained voice
• Breathiness
• Reduced loudness
• Monopitch/monoloudness
• Tremor
• Flutter
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Supporting Phonatory Function
• Hypo-adduction• Head turn to facilitate approximation of vocal
cords• Manual lateralization of the thyroid cartilage• Surgical management
• Vocal cord injection augmentation• Thyroplasty
• Hyper-adduction• Relaxation• Massage
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Reducing Laryngeal Strain
• Direct speaker’s attention to somatosensory aspects of excess muscle tension
• Some aspects of laryngeal tension/strain may not respond completely to behavioral approaches
• dystonia in hyperkinetic dysarthria• strain-strangled quality in spastic dysarthria –
but may overcorrect!
• Excess laryngeal tension may result from poor respiratory support or poor coordination with respiration (see Respiratory Treatments)
Treatment of Dysarthria
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Laryngeal Exercise
• Increasing medial compression (adduction)• Push-pull• Grunt• Cough
• Increasing pitch range and control• Pitch glides and/or steps• Pitch matching
©2018 MFMER | slide-110
Loudness Treatment
• Lee Silverman Voice Treatment (LSVT)• Systematic hierarchy of exercises, focusing
on a single goal “speak LOUD!”• Targets respiratory, laryngeal and articulatory
subsystems• Incorporates high intensity, high frequency
practice
• SPEAK OUT with LOUD Crowd
• Non-standardized loudness treatment
Smith, M. & Ramig, L. (2014). Neurologic disorders and the voice. In J.S. Rubin, G. Korovin & R. T. Sataloff (Eds.), Diagnosis and Treatment of Voice Disorders. Plural Publishing
©2018 MFMER | slide-111
Coordinating Respiration & Phonation
• Potential targets• Lung volume at onset of phonation• Initiating phonation at the top of inhalation• Phrase grouping (ceasing phonation before
respiratory support wanes)• Rapid inhalation between phrases
Spencer, K. A., Yorkston, K. M., & Duffy, J.R. (2006). Practice guidelines for dysarthria: evidence for the behavioral management of the respiratory/phonatory system.Academy of Neurologic Communication Disorders and Sciences, Technical Report No. 3, 50 pages. ©2018 MFMER | slide-112
Articulatory treatments
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Articulatory Impairments
Impairments
• Weakness and/or fatigue
• Reduced range of motion
• Reduced speed
• Reduced coordination
• Involuntary movements
Associated Speech Changes
• Articulatory imprecision
• Slow rate
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Supporting Articulatory Function
• Velopharyngeal support (see Resonatory Treatments)
• Jaw support (bite block)
• Sensory tricks (hyperkinetic dysarthria –dystonia)
• Stretching/massage• Hyper-reflexia (spasticity) in jaw muscles• Would not be expected to facilitate muscle
functions in lips, face, tongue
Treatment of Dysarthria
20
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Articulatory Exercise
• Candidates for exercise• Detectable weakness is a primary contributor
to articulatory imprecision• Weakness may be detectable in spastic
dysarthria, but slowness of movements may be the greater detriment
• No contra-indications for resistance exercise (e.g., susceptibility to fatigue)
• Tongue strengthening programs well studied for dysphagia outcomes; speech evidence is less compelling, even in dysarthria
McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009). Evidence-based systematic review: effects of nonspeech oral motor exercises on speech. American Journal of Speech-language Pathology, 18(4), 343-360. ©2018 MFMER | slide-116
Articulatory Treatments
• Exaggerated articulation (over-articulation)
• Alternative place/manner/voicing
• Coordination of complex phonetic sequencing• Be mindful of task specificity• Often targeted in concert with lexical stress
(see Prosody treatment)
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PROSODY TREATMENTS
©2018 MFMER | slide-118
Prosody Targets
• Speaking rate
• Lexical stress
• Sentential stress
• Phrase groupings (see respiratory treatments)
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Speaking Rate
• Even for patients with slow rate, increasing overall speaking rate is almost never an appropriate target
• Reducing speaking rate, even for patients with normal or slow rate, typically improves intelligibility
• Speakers with hypokinetic dysarthria often have rapid rate, but may have difficulty intentionally reducing rate
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Rate Reduction Strategies
• Pacing board/hand tapping
• Metronome
Yorkston, K. M., Hakel, M., Beukelman, D. R., & Fager, S. 2007). Evidence for effectiveness of treatment of loudness, rate or prosody in dysarthria: A systematic review. Journal of Medical Speech-Language Pathology, 15(2), xi-xxxvi
Treatment of Dysarthria
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Rate Reduction Strategies
• Delayed auditory feedback
• Indirect strategies• Increased loudness (see phonatory
treatments)• “Clear” speech (see intelligibility treatments)
Yorkston, K. M., Hakel, M., Beukelman, D. R., & Fager, S. 2007). Evidence for effectiveness of treatment of loudness, rate or prosody in dysarthria: A systematic review. Journal of Medical Speech-Language Pathology, 15(2), xi-xxxvi ©2018 MFMER | slide-122
Lexical and Sentential Stress
• Visual cueing/feedback• Hand gestures signalling change in
loudness, pitch, and/or duration• Acoustic software
• Activities/stimuli• Contrastive stress• Metric pattern across various word lengths• Verbal repair
©2018 MFMER | slide-123
Treatment of DysarthriaComprehensibility Strategies & AAC
©2018 MFMER | slide-124
Operational Definitions
Intelligibility
The listener’s success in understanding the acoustic signal produced by a speaker
Comprehensibility
The listener’s success in understanding the message/meaning produced by a speaker
• Both intelligibility and comprehensibility are influenced by the communication environment and the behaviors of the speaker and listener.
• Comprehensibility strategies include behaviors that improve intelligibility
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Helpful resources
Yorkston, K. M., Beukelman, D., Strand, E., & Hakel, M. (2010). Management of motor speech disorders in children and adults (3 ed.). Austin, TX: Pro-Ed.
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Comprehensibility Strategies
• Seek to improve activity and participation
• Include• Optimization of
environmental factors• Exploiting facilitating
personal factors• Compensating for limiting
personal factors
Health Condition
Activity and Participation
Contextual Factors
(Personal and Environmental)
Body Functions and
Structures
Treatment of Dysarthria
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Introducing Comprehensibility Strategies
• Initial visit• Providing recommendations• In order to obtain history
©2018 MFMER | slide-128
Comprehensibility Strategies
Optimizing the environment
Speaker behaviors
Listener behaviors
©2018 MFMER | slide-129
Optimizing the environment
pixshark.com
©2018 MFMER | slide-130
Reducing background noise
• Obvious, controllable sources• TV, radio, computer, etc
http://www.susieburrell.com.au/rise-nutrition-haters/
©2018 MFMER | slide-131
Reducing background noise
• Obvious, not-so-controllable sources• Crowd noise
• Move away
• Take advantage of barriers
©2018 MFMER | slide-132
Reducing background noise
• Not-so-obvious controllable sources• Appliances• Open windows
• Turn ‘em off
• Close ‘em
• Move away
Treatment of Dysarthria
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©2018 MFMER | slide-133
Reducing background noise
• Not-so-obvious not-so-controllable sources• Road/traffic noise
• May require other strategies
©2018 MFMER | slide-134
Optimizing lighting
• Avoid backlighting
• Avoid dim lighting
©2018 MFMER | slide-135
Optimizing the environment
• Be in the same environment!
• Avoid communication over a distance
©2018 MFMER | slide-136
Optimizing the environment
• Reduce distractions
• Auditory and visual distractions
• Multi-tasking
©2018 MFMER | slide-137
Optimizing the environment
• Choose the time and place for communication
Avoid important conversations when the speaking or listening will be difficult
©2018 MFMER | slide-138
Speaker Behaviors
Treatment of Dysarthria
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©2018 MFMER | slide-139
Speaker behaviors
• Speech-focused
• Language-focused
• Communication-focused
©2018 MFMER | slide-140
Speaker behaviors: Speech-focused
• Speak slowly
Clinician Pearls• Acknowledge this is challenging • Suggest “tricks”
• Speak loudly• Speak clearly
©2018 MFMER | slide-141
Speaker behaviors: Speech-focused
• Speak very slowly* • Pause briefly between each word• Pay attention to the small words• Do not separate syllables within words• Include every syllable• Maintain intonation (may have to slow even
further)
*when intelligibility is more dramatically impacted
©2018 MFMER | slide-142
Speaker behaviors: Speech-focused
• Speak clearly• Imagine you’re speaking to someone who is
hard of hearing or doesn’t understand your language very well
• Over-enunciate• Speak carefully
Tjaden, K., Sussman, J. E., & Wilding, G. E. (2014). Impact of clear, loud, and slow speech on scaled intelligibility and speech severity in Parkinson's disease and multiple sclerosis. Journal of speech, language, and hearing research : JSLHR, 57(3), 779-792.
Instructions may focus on over-articulation (hyper-articulation), but effects are broader
Slow rateWider loudness and pitch variation
©2018 MFMER | slide-143
Speaker behaviors: Speech-focused
• Speak up!• Not just for hypokinetic dysarthria• Great in the context of reduced background
physiologic effort• Often improves articulatory precision• May reduce rate
©2018 MFMER | slide-144
Speaker behaviors: Language-focused
• Use complete, simple sentences
• Use predictable wording
Treatment of Dysarthria
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©2018 MFMER | slide-145
Speaker behaviors: Language-focused
• When repeating• The first repetition, say it exactly as you said
it the first time• Rephrase, but make sure the listener knows
you’re rephrasing
©2018 MFMER | slide-146
Speaker behaviors: Communication-focused
• Get the listener’s attention
• Call his/her name• Wait until the listener is watching
your face
©2018 MFMER | slide-147
Speaker behaviors: Communication-focused
• Help the listener predict what you’re going to say
• Identify the general topic• Take advantage of contextual cues
(point to objects in the environment, headlines, etc.)
• Signal topic changes
©2018 MFMER | slide-148
Speaker behaviors: Communication-focused
• Use all modalities available• Speak• Point• Gesture• Facial expression• Pictures (points or draw)• Write• Text• Type
©2018 MFMER | slide-149
Speech Supplementation
• Incorporated during spoken expression
• Strategies provide listeners with additional information to help make sense of the spoken message
• Typically involves “signal-independent” information about the message
• Includes gestures
Hanson, E., Yorkston, K., & Beukelman, D. (2004). Speech supplementation techniques for dysarthria: A systematic review. Journal of Medical Speech-Language Pathology, 12(2), ix-xxix.
©2018 MFMER | slide-150
Alphabet Supplementation
• Point to initial letter of word as each word is spoken
• Also serves as a pacing strategy
• Identification of initial letter facilitates word prediction by listener
A B C DE F G HI J K L M NO P Q R S TU V W X Y Z
Example of alphabet board with vowels aligned on left margin.
Treatment of Dysarthria
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Semantic/Topic Supplementation
• Identifies the topic of discussion to help listener’s word prediction and comprehension
• Topics can be identified through• Spoken expression• Written expression• Photographs/pictures• Other artifacts
• Calendars• Souvenirs• Newspapers
©2018 MFMER | slide-152
Speaker behaviors: Communication-focused
• Interact
• Use turn-taking signals• Visible• Audible• Conspirator• Let listeners know “the rules”
©2018 MFMER | slide-153
Listener Behaviors
©2018 MFMER | slide-154
Listener behaviors
• Give your undivided attention
• Move close to the speaker• Watch the speaker
©2018 MFMER | slide-155
Listener behaviors
• Know (ask for) the topic
• Watch for topic-changing signals
©2018 MFMER | slide-156
Listener behaviors
• Piece together the clues• Speech• Gestures• Facial expression• Pointing• Writing• Texting
Treatment of Dysarthria
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©2018 MFMER | slide-157
Listener behaviors
• Signal to the speaker as soon as you don’t understand
A nonverbal signal is often best so the speaker doesn’t feel interrupted
©2018 MFMER | slide-158
Listener behaviors
• Avoid the least helpful question in the English language
http://propercourse.blogspot.com
©2018 MFMER | slide-159
Listener behaviors
• Avoid the least helpful question in the English language
http://propercourse.blogspot.com
• Repeat the part of the message you heard
• Ask yes/no questions for clarification
©2018 MFMER | slide-160
Listener behaviors
• Know the rules
• How does the speaker signal a turn?
• Should you “word predict”?• What is the back-up plan?
©2018 MFMER | slide-161
Speaker & Listener Behavior
• Glossing• Listener repeats each word as the speaker
says it• Speaker has to pause briefly between words
so listener can repeat• Correct breakdowns as they occur• Combine with alphabet supplementation
©2018 MFMER | slide-162
Instruction in Comprehensibility Strategies and Developing Recommendations
Treatment of Dysarthria
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©2018 MFMER | slide-163
Presenting Comprehensibility Strategies
• Explain that the goal is successful exchange of information, not word for word intelligibility
• Highlight the value of being understood the first time
• Emphasize that successful communication is the responsibility of all participants
• “Good advice for all of us” philosophy
©2018 MFMER | slide-164
Presenting Comprehensibility Strategies
• Allow speaker and family members to practice and respond
• Troubleshoot obstacles• Listeners who “can’t hear”• Listeners who only talk• “Fast talkers”
• Give feedback and additional guidance
©2018 MFMER | slide-165
Evaluate success
• Some patients may be proficient after initial session
• Some may need additional instruction• Follow-up consultation• Component of on-going therapy
• Value of individual strategies may vary across recovery, progression, and/or context
©2018 MFMER | slide-166
Comprehensibility StrategiesIn Context
©2018 MFMER | slide-167
Acute CVA
• UUMN dysarthria• Reduced loudness• Nonspecific hoarseness• Imprecise articulation• Intermittent hypernasality
©2018 MFMER | slide-168
Considerations
• Right vs Left hemisphere CVA• Flat affect• Awareness of deficits• Concurrent AOS and/or aphasia
• Position restrictions
• Speaker versus listener burden
Treatment of Dysarthria
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©2018 MFMER | slide-169
Chronic conditions
• Identification of maladaptive habits
• Reassurance that functional changes might still be achieved
©2018 MFMER | slide-170
Progressive conditions
• Identifying “least restrictive” strategies
• Introduce strategies before they are needed
• Regular reassessment to update strategies
©2018 MFMER | slide-171
AAC
• Augmentative and alternative communication (AAC) is an appropriate option for speakers with poor intelligibility
• Temporary as speech improves• Introduced early in degenerative disease
©2018 MFMER | slide-172
Evidence-Based Practice Resources
©2018 MFMER | slide-173
EBP Resources
©2018 MFMER | slide-174
Treatment of Dysarthria
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©2018 MFMER | slide-175
EBP Resources
www.ancds.org©2018 MFMER | slide-176
©2018 MFMER | slide-177
EBP Resources
www.speechbite.com©2018 MFMER | slide-178
EBP Resources
• Clinical Aphasiology Conference Proceedings• www.clinicalaphasiology.org• Proceedings published in AJSLP
• Conference on Motor Speech• http://www.madonna.org/res_conferences• Proceedings published in AJSLP
• ASHA• Special Interest Group 2
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Mayo ClinicLocations
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Questions & Discussion