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Piper Doering
CSD 748: Motor Speech Disorders
December, 2013
Final Case Study: Spastic Dysarthria
Case Overview
Brian is a 21-year-old male who sustained a farming accident two years ago. He lives with his parents in Fall Creek, Wisconsin. His strengths include independence within his parent’s home, driving, awareness of his current condition, and participation in part-time employment for his mother’s company. Brian presents with mild to moderate cognitive deficits. He has undergone multiple rounds of speech therapy, including 18 months of inpatient rehabilitation.
Motor Speech Overview
Brian’s most deviant speech characteristics include decreased rate, shortened phrases, prolonged phonemes, monopitch, monoloudness, and a strained/strangled voice quality. No concerns with resonance were noted. Comprehensibility is +/- 70%. ASHA NOMS rating is 4. This indicates Brian can communicate in simple structured conversations with familiar communication partners, using simple words and phrases intelligibly. Motor speech characteristics are consistent with moderate spastic dysarthria, indicating bilateral upper motor neuron damage.
Implications to the WHO-ICF (2001) Model
Body/Function Structure Implications:
Brian’s speech mechanism is characterized as slow, with a reduced range of movement. He presents with decreased respiratory support due to the decreased movement of his respiratory musculature. This is evidenced by shallow inhalations and short phrase lengths. Hyperadduction of his vocal folds is signified by a hoarse voice quality (Duffy, 2013). Articulation remains fairly intact, with the exception of perceptual vowel prolongation. Function of the velopharyngeal port is within functional limits, due to no perceptual deviations in resonance. Reduced range of movement is also evident at the laryngeal level, resulting in monopitch and monoloudness.
Activity/Participation Implications:
Brian currently lives with his parents. He helps his mother at work by filing paper a couple times a week. However, he has minimal social contact. Brian’s peer support and social interactions have decreased dramatically. His speech difficulties restrict him from seeking out social contact or activities, leaving him with a lot of time on his hands and nothing to do.
Goals and Objectives
Goal 1: To increase performance of anatomical structures and physiological functions
Long-term objective (LTO) 1: In order to increase comprehensibility, Brian will demonstrate appropriate respiratory, prosodic, and articulatory management during structured conversation with family members and clinician.
Short-term objective (STO) 1: In order to increase respiratory support, Brian will imitate appropriate phrasing and breath coordination in connected sentences and conversation with 80% accuracy.
STO 2: In order to increase pitch variation, stress patterns, and intonation within speech, Brian will imitate prosodic patterns of sentences modeled by the clinician when provided visual and real time feedback through Audacity computer software with 80% accuracy as judged the clinician.
STO 3: In order to decrease vowel prolongations, Brian will decrease his vowel length within sentences by 1 second utilizing Audacity as judged by the clinician.
Goal 2: To increase life participation
LTO 1: In order to increase participation in age appropriate socialization activities, Brian will self-report participating in two activities of choice per week.
STO 1: In order to increase successful communication exchanges, Brian and communication partners will demonstrate their knowledge of speaker and listener strategies (e.g., gestures and maintaining eye contact) during a 15-minute conversation.
STO 2: In order to increase comprehensibility, Brian will independently utilize topic supplementation to initiate conversations or repair communication breakdowns as necessary during conversations as judged by clinician.
Management Plan
Impairment Level Treatment
Impairment level treatment for Brian will target respiration, prosody, and articulation. Phonation will not be targeted due to motor speech characteristics being consistent with spastic dysarthria. Behavioral treatment of dysarthria-related strained voice quality is not recommended because it may not contribute greatly to improving intelligibility and it is often difficult to modify (Duffy, 2013). Resonance will not be targeted as it is not a deviant motor speech characteristic. The sequence of all therapy activities will begin with highly structured tasks and then transition gradually to spontaneous speech, perhaps through use of short dialogues or scripts of conversation (Duffy, 2013). Following is a management plan for respiration, prosody, and articulation components of intervention.
Respiration
Due to Brian’s reduced length of phrases, poor phonation, and decreased intelligibility, it is appropriate for respiration to receive attention in the treatment plan. To begin working on breath support, Brian will be encouraged to change his posture while speaking, sitting upright to enhance his breath support. Inhalation and exhalation techniques will be provided. Respiratory exercises will be done during speech, for there is limited evidence that non-speech respiratory exercises are effective (Duffy, 2013). Brian will participate in a speech-like task that consists of producing prolonged vowel sounds of increasing durations. He will practice exhaling at a steady rate and attempt to increase duration of the vowel sounds with multiple trials (Duffy, 2013). Brian will also be encouraged to inhale more deeply or use more force when exhaling during speech. Working to increase inspiratory range can assist with attempts to sustain isolated vowel sounds for 5 seconds, while keeping intensity and quality constant (Duffy, 2013). As Brian’s breath support improves, treatment will also include increasing his frequency of pauses without inhalation and increasing the number of words per breath group. Additional speech tasks will include reading sentences and paragraphs marked for appropriate pauses and inhalation with gradual fading of cues (Duffy, 2013). The ultimate goal will be for Brian to produce appropriate breath support for conversation.
Prosody
Prosody will be targeted to increase naturalness and intelligibility of Brian’s speech production. Working on prosody will contribute to the identification of speech segments and provide clues to meaning. Rate, rhythm, intonation, and stress carry important syntactic information and substantially increase the amount of redundancy in the speech signal, thus efforts to increase naturalness can improve intelligibility (Duffy, 2013). The scientific computer software package known as Audacity, would aim to promote prosodic patterns such as pitch variation, intonation, stress, and intensity within Brian’s speech. Audacity provides visual and real time feedback of one’s prosodic patterns. Palmer and Enderby (2007) explored literature for dysarthria management and found that using visual feedback is beneficial to provide models for imitation. Real time visual feedback also provides opportunities to reflect on intensity and stress patterns in the moment and make adjustments as needed.
In order to increase expression of emotions through prosody, the clinician will model stress patterns exemplifying emotions such as bored, puzzled, happy, angry, surprised, and sad. These productions will be recorded and analyzed through Audacity in order to provide opportunities for reflection and feedback. Brian will imitate each of the clinician’s productions and compare his visual feedback to the clinician’s. Linguistic stress, such as raising intonation during questions, may also be targeted through the use of visual feedback. For example, while reflecting with Audacity, Brian would aim to increase his pitch and stress at the end of sentences. The clinician would again provide models and Brian would imitate productions. Duffy (2013) also describes the use of contrastive stress tasks as a way to facilitate overall naturalness of stress and prosodic patterns. This would include providing contrastive phrases such as statements versus questions (e.g., “John loves Mary” versus “John loves Mary?”), and the same phrase said with different emotions (e.g., “John loves Mary” with a happy affect versus “John loves Mary” with a surprised affect). Working on contrastive stress has resulted in improved ratings of naturalness and speech precision (Duffy, 2013). Using Audacity to record and save Brian’s speech productions will provide opportunities for Brian to reflect throughout management sessions.
Articulation
Audacity will also be incorporated into articulation management, following similar procedures as described above for prosody. The aim is for Brian to decrease his vowel duration within words and eventually generalize this into conversation. This will indirectly assist respiratory management by increasing Brian’s number of words per breath.
Activities and Participation Treatment
Activities and participation based treatment will target relevant speech characteristics by increasing Brian’s communication competence in daily life. Treatment will be based on a life participation approach, which emphasizes client-centered service delivery that supports individuals in achieving their immediate and longer-term life goals (Chapey et al., 2009). Goals will focus on re-engaging Brian in life activities of choice, providing him with the opportunity to collaborate in jointly-created therapy. Management will incorporate direct practice with augmentative devices (e.g., topic board and identification card), in addition to speaker and listener strategies.
Augmentative and alternative communication (AAC) devices will be offered to Brian to supplement his verbal output. To increase Brian’s comprehensibility to communication partners, topic supplementation techniques will be introduced to increase listener awareness of the semantic context or topic (Beukelman & Miranda, 2013). Research supports an average of 28% increase in word intelligibility and 10.7% increase in sentence intelligibility when topic supplementation is used by speakers with dysarthria (Hanson, Yorkston, and Beukelman, 2004). In addition, contextual information may lead to more positive listener attitudes towards Brian (Duffy, 2013). Topic supplementation will allow Brian to narrow down the range of topic possibilities at the beginning of interactions by referring to a symbol on a display. This strategy may also be used to resolve communication breakdowns. Incorporating AAC into conversation will increase the likelihood listeners will comprehend Brian’s message, allowing them to assist in co-constructing conversations as needed. To increase partner awareness, Brian may also supplement conversation with an identification card that explains his condition and offers strategies to increase communication success. Brian will be provided with opportunities to practice these supplementation strategies within activities of choice.
In addition to AAC, additional speaker and listener strategies will be incorporated into therapy to improve the comprehensibility of messages. To increase the effectiveness and generalization of these strategies, Brian’s communication partners will be encouraged to participate in therapy. Speaker strategies may include: preparing listeners with alerting signals, modifying sentence structure, incorporating gestures, and monitoring listener comprehension (Duffy, 2013). Brian’s communication partners will also be provided with strategies to incorporate as the listeners of conversation. Listener strategies may include: maintaining eye contact, listening attentively, actively working towards comprehension, and modifying the physical environment (Duffy, 2013). Modifying the physical environment will depend on the specific context, but may involve the management of background noise, lighting, and seating arrangements (Palmer & Enderby, 2007). The strategies that are found to be most useful based on Brian’s report will be emphasized in the management process.
Promoting Aphasics’ Communicative Effectiveness (PACE; Davis, 2005) therapy will provide a context for Brian to directly practice newly learned devices and strategies with various communication partners. Brian and his communication partners will take turns exchanging new information, similar to a natural conversational context. Conversations will be personally-relevant to Brian. Within PACE activities, the receiver provides natural feedback aimed at problem-solving the sender’s message (i.e., co-constructing the conversation). In other words, the receiver must make educated guesses on the sender’s message that simulates a natural conversation. The turn ends when the sender’s message is conveyed, not when a pre-determined linguistic form is produced (Davis, 2005). In essence, emphasis is placed on the transaction of information. During treatment tasks, Brian will incorporate strategies that are most useful for him to convey his message naturally. In addition, partners will make contributions that increase conversational flow and facilitate jointly-created communication competence (Bloch & Beeke, 2008). PACE therapy will require Brian and his communication partners to adapt strategies to the specific communicative context.
The aim of management is for Brian to generalize these communication strategies into his daily life. To increase his participation, Brian will be offered opportunities to increase his communicative competence within activities of choice outside of the therapy context. For example, Brian may choose to volunteer at a work setting of interest. Volunteer work can be perceived as less threatening than traditional work environments and provides an opportunity for communicative participation (Dykstra et al., 2007). In addition, this would provide Brian with the opportunity to gain experience towards the potential of future employment.
Motor Learning
Principles of motor learning will be incorporated throughout intervention, including practice amount, distribution, variability, and schedule. Initially treatment will be implemented with high frequency and will be adjusted as Brian demonstrates progress. The schedule of Brian’s treatment will be implemented in a blocked format to facilitate initial motor learning. As treatment progresses, techniques and strategies will be implemented within a randomized format to facilitate his retention. Variability and distribution of treatment will be adjusted to meet Brian’s endurance and cognitive level. The frequency of feedback will initially be provided every 5th trial and progress to every 15th trial to increase overall retention and self evaluation. Feedback will incorporate knowledge of results and knowledge of performance depending on the task. Multi-modal feedback will be delayed to provide Brian time to process his performance due to his mild to moderate cognitive deficits (Mass et al., 2008).
References
Beukelman, D.R. & Mirenda, P. (2013). Augmentative and Alternative Communication: Supporting Children and Adults with Complex Communication Needs (4th ed.). Baltimore: Brookes Publishing Co.
Bloch, S., & Beeke, S., (2008). Co-constructed talk in the conversations of people with
dysarthria and aphasia. Clinical Linguistics and Phonetics, 22(12), 974-990.
Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, A., Lyon, J., & Mackie, N. (2009). Life
participation approach to aphasia. American Speech-Language-Hearing Association.
Davies, G. (2005). A critical look at PACE therapy. Clinical Aphasiology. 248-257.
Duffy, J. (2013). Motor speech disorders: Substrates, differential diagnosis, and
management. 3rd Edition St. Louis, Missouri. Elsevier Moseby.
Dykstra, A., Hakel, M., & Adams, S. (2007). Application of the ICF in reduced speech
intelligibility in dysarthria. Seminars in Speech and Language, 28(4), 301-311.
Hanson, E., Yorkston, K., & Beukelman, D.R. (2004). Speech supplementation techniques for
dysarthria: A systematic review. Journal of Medical Speech Language Pathology, 12 ix-xxix.
Mass, E., Robin, D., Hula, S., Freedman, S., Wulf, G., Ballard, K., & Schimdt, R. (2008).
Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17 277-298.
Palmer, R., & Enderby P., (2007). Methods of speech therapy treatment for stable dysarthria: A
review. Advances in Speech-Language Pathology, 9(2), 140-153.
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