COE



Impairment-Based Treatments for the Dysarthrias

GOAL = change underlying physiology (STARSS) to improve function of speech systems

TREATMENT TARGETS = STARSS characteristics of speech systems

**When evaluating any impairment-level treatment, ask about the effects on speech!

**Differential diagnosis is essential when intervening at the impairment-level!

Impairment-Level Approaches to Treatment

• Pharmacological management (also see specific Disorder Summaries)

• Surgical intervention (also see specific Disorder Summaries)

• Biofeedback techniques

o VisiPitch from Kay Elemetrics:

o Electropalatography (expensive research tehqniue)

o Nasometer from Kay Elemetrics:

o See-Scape from AliMed ($121.00):

• Direct behavioral interventions to improving functioning of the speech systems

Treatment Options by Dysarthria Type (see Duffy pp. 485-493)

|Hypokinetic dysarthria |Pharmacological management (e.g., Levodopa) |

| |Surgical intervention (e.g., deep brain stimulation) |

| |SPEAK OUT! Voicei Therapy to improve intent, loudness, and intelligibility |

| |Lee-Silverman Voice Therapy (LSVT®) to improve respiration/phonation |

| |Biofeedback (e.g., delayed auditory feedback) to reset rate control |

| |Biofeedback (e.g., VisiPitch) to reset prosody |

| |Rate control (pacing boards) to reset prosody |

|Hyperkinetic |Pharmacological management for excess muscle contractions (e.g., Botox for spasmodic dysphonia) |

|dysarthrias |Pharmacological management to restore neurotransmitter imbalance |

| |Sensory tricks for some people with dystonias |

| |Rate control (for some people?) to reset prosody |

|Ataxic dysarthria |Biofeedback to increase loudness awareness & coordination of breathing with speech |

| |Rate control (e.g., pacing boards) to reset prosody |

| |Stress/Intonation drills to improve prosody |

|Spastic dysarthria |Pharmacological intervention (e.g., Baclofen for spasticity?) |

| |Biofeedback (e.g., Nasometer or See-Scape) to reduce hypernasality (?) |

| |Biofeedback (e.g., VisiPitch) to reset prosody |

| |Relaxation/stretching techniques to improve function (?) |

|UUMN dysarthrias |Biofeedback (e.g., Nasometer or See-Scape) to reduce hypernasality (?) |

| |Biofeedback (e.g., VisiPitch) to reset prosody |

| |Oral-motor exercises to improve articulation (?) |

| |Articulation drills to improve articulation |

| |Rate control to reset prosody |

|Flaccid dysarthrias |Pharmacological management (e.g., Mestinon for MG) |

| |Surgical intervention (e.g., nerve anastomosis; TVF medialization & thyroplasty) |

| |Biofeedback (e.g., Nasometer or See-Scape) to reduce hypernasality |

| |Biofeedback (e.g., VisiPitch) to reset prosody |

| |Oral-motor exercises to improve articulation (?) |

| |Articulation drills to improve articulation |

| |Stress/Intonation drills to improve prosody |

Direct Behavioral Interventions to Improve Functioning of the Speech Systems:

• Follow a hierarchical progression (Dworkin, 1991):

o 1st Order: Resonance Respiration

o 2nd Order: Phonation

o 3rd Order: Articulation Prosody

Principles of Motor Learning Essential to Impairment-Level Direct Interventions:

(Duffy, 2005; Maas et al., 2009)

• Use speech to improve speech

• Drill is essential to (re)train neurological pathways & movement patterns

o Neurons that fire together wire together.

o Large amounts of variable practice, distributed over time.

• Active movement is better than passive movement

• Goal is to have a learner (who retains/transfers knowledge) rather than a performer who only performs with clinician cues

• Self-learning has added value (when cognitively able)

• Instruction improves performance

• Feedback is essential to motor learning

o Fade to delayed feedback about general knowledge of results

Two Principles of Strength Training Programs (Clark, 2003):

• Overload

o If the goal is to strengthen (increase force of muscle contraction), then exercise must tax a muscle beyond its typical workload, to the point of fatigue

o Intensity is essential to achieve overload

o Overload can be achieved through:

▪ Resistance (progressively increase resistance/duration)

▪ Number of Repetitions (reps/set; sets/session)

• Specificity of Training

o The effects of strength training are highly specific to the trained behavior (movement)

o Oral muscles work in groups (unlike limb muscles that work in pairs), so target them as a group, not individually

o Only strengthen movements that are directly relevant to the target behavior/movement (i.e., speech-related movements)

Improving Respiratory Support:

• Inspiratory Muscle Strength Training

o Goal = increase physiological inhalatory support to allow functional speech

o Devices to train inspiratory muscles:

▪ Incentive spirometer for feedback

• Encourage slow, controlled, deep breaths

• Available in most medical settings

• 1 per patient

• $7-15 on

• See Handout for instructions to use

▪ Tactile feedback for diaphragmatic breathing

• Feel difference between “belly” and “chest” breathing

• May co-treat with PT/OT

• See Handout for specific instructions

▪ Inspiratory Muscle Strength Training device

• Provides progressive resistance to tax/overload diaphragm

• 1 device per patient

• Threshold® Inspiratory Muscle Trainer ($39.95):

• Exhalatory Muscle Strength Training

▪ Minimum driving force: 3-5 cm H2O of subglottal air pressure

▪ Typical conversational force: 7-10 cm H2O of subglottal air pressure

o Devices to train expiratory muscles:

▪ Water glass manometer for controlled exhalation with adequate pressure

• Minimal: 5 cm H2O of air pressure for 5 seconds

• See Handout for specific instructions

▪ Expiratory Muscle Strength Training Device

• Provides progressive resistance to tax/overload muscles

• 1 device per patient

• EMST 150 device ($39.95):

• Feedback for Coordinating Breathing with Speech

o Goal = increase coordination between breathing & speech to support more natural & effective speech

o Breathing for life (at rest) is different from breathing for speech, in terms of timing and amounts of air

o For speakers with ataxic dysarthria, may also consider providing feedback on loudness with a Sound Level Meter to improve awareness of loudness

▪ $49.99 at Radio Shack

Improving Resonance:

• Goal = increase velopharyngeal closure to support efficient speech production

• ***Non-speech activities do NOT change physiological support for speech (e.g., blowing, sucking, pushing, whistles, straws, horns, stroking, brushing, cold)

• To improve velopharyngeal closure with behavioral interventions at the impairment-level, during speech tasks, there are two options:

o Biofeedback

▪ Goal = increase physiological function to support VP closure during speech tasks

▪ Utilizes “discovery learning” for client to learn how to control their own motor movements during successful speech

▪ Example devices: See-Scape, Nasometer, mirror

o Continuous Positive Airway Pressure (CPAP) resistance training

▪ Goal = improve physiologic function of VP closure through progressive resistance training to strengthen VP closure muscles, during speech tasks (David Kuehn & colleagues)

▪ **Work with a respiratory therapist

▪ The major muscle of VP closure is the ____________ ______ ___________ muscle, innervated by CN X.

Yorkston et al. (2001) Practice Guidelines for Velopharyngeal Management:

[pic]

Improving Phonation:

• Goal = increase TVF adduction to support vocal quality & efficient speech

• TVF Closure Exercises

o Goal = improve effortful TVF adduction to support phonation

o Inconclusive evidence for improving function of weak (not paralyzed) TVF

o Techniques: push/pull (aka Valsalva/ isometric); hand clasping

o **If you try it, be wary of vocal strain/hyperfunction!!!

• LSVT® (Lee Silverman Voice Therapy) – [Lorraine Ramig, Cynthia Fox et al.]

o Goal = increase range of motion of respiratory/phonatory systems to improve loudness (and speech intelligibility)

o Rationale: PD results in small, restricted movements, so LSVT stimulates the person to make BIGGER movements (i.e., LOUD voice)

o Strong evidence to support LSVT for speakers with mild-moderate hypokinetic dysarthria; see EB summary for other dysarthria types

o 5 Main Treatment Principles for simplicity:

▪ Focus on VOICE

▪ Focus on HIGH EFFORT

▪ Focus on INTENSIVE TREATMENT

▪ Focus on CALIBRATION

▪ QUANTIFICATION (i.e., measure outcomes)

o Tasks/Procedures during therapy sessions:

▪ First 30 minutes – practice loud voice in structured tasks

▪ Last 30 minutes – practice generalization with a speech hierarchy

o See Handouts for additional information & materials on LSVT

Spencer et al. (2003) Practice Guidelines for Respiratory/Phonatory Management:

[pic]

Improving Articulation:

• Goal = increase oral musculature (jaw, lips, tongue) to support efficient speech

• Oral Strengthening Exercises

o Goal = improve physiological functioning when oral muscles weakness impacts on speech

o Two principles: Overload muscles + Specificity of speech-related movements

o See handout for additional information and details

• Articulation Drills

o Goal = improve accuracy of articulatory placement to support speech

o Based on principles of motor learning:

▪ Drill is essential

▪ Self-instruction has added value (“discovery learning”)

• Client “discovers” ways to improve his/her speech through trial & error, without explicit instruction from the clinician

• Most appropriate for clients who are able to learn from their own mistakes (i.e., without frontal lobe injury)

▪ SLPs job is to carefully select stimuli to target difficult articulatory placements (and minimal contrasts)

o Procedures:

▪ Set-up a “barrier” game & carefully select appropriate stimuli

▪ Client says the target word, without the clinician knowing the word

• If clinician understands, praise & move on

• If clinician does not understand:

o Ask client to try again

o Ask client to try again, but “try it a different way”

o Model a clear production, but don’t give explicit instructions for articulatory placement

Improving Prosody:

• Prosody refers to speaking rate, as well as stress/intonation contours

• Goal = reset timing or stress/intonation systems for all speaking contexts to increase speech intelligibility & naturalness

• Stress Drills for stress/intonation/emotion

o VisiPitch may be useful for biofeedback on these tasks. Auditory or videotape self-analysis may also be useful.

o Use drills that require the client to place emphasis on the correct syllables in words (stress) or words in sentences (intonation)

▪ Stress: minimal contrasts (e.g., contract ~ contract); start at word level, then move to sentences & connected speech

▪ Intonation: use Q/A format and ask questions about statements; client is to respond in complete sentences

EXAMPLE: Beyoncé travelled to France for a concert.

Who traveled? Beyoncé traveled to France for a concert.

What did she do? Beyoncé traveled to France for a concert.

Where did she go? Beyoncé traveled to France for a concert.

Why did she go? Beyoncé traveled to France for a concert.

o Use drills that require the client to use different emotional intonations (e.g., say neutral sentences in a happy, sad, angry, surprised, neutral tone).

▪ Fade from imitating models to cued productions to conversational speech about emotional topics.

Example sentences:

▪ The dog ran away.

▪ Tomorrow I’m leaving for Chicago.

▪ The girl threw the ball over the fence.

▪ We sold our beach house last week.

• Internal Rate Control

o Teach pausing at appropriate boundaries (word, phrase, sentence) or by prolonging vowels

o Use metronome or pacing strategies (e.g., pacing boards or finger tapping) with the goal of resetting internal pacing representations & gradually fading external supports

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