Hypokinetic Dysarthria

HYPOKINETIC DYSARTHRIA Neurological System Affected: basal ganglia pathology/lack of dopamine Common Pt Complaints voice cannot be heard in noisy environments, speech is too fast, voice has no emotion, sound like they are stuttering, lips feel stiff/rigid. NOT uncommon for pt not to recognize speech difficulties- e.g. spouse says I mumble Associated neurological symptoms decreased mobility or ROM, resting tremor (decreases during movement), muscle rigidity, bradykinesia, akinesia, face has mask-like expression Possible Medical Dx Parkinson’s disease by far most common medical dx, multiple or bilateral strokes affecting the basal ganglia, toxic/metabolic caused by antipsychotic medications or toxic metal poisoning (manganese), infectious- viral encephalitis, stroke in the basal ganglia POSSIBLE SPEECH SYSTEM DEFICIT POSSIBLE TREATMENT Respiration- decreased support – reduced Speaking at beginning of exhalation, inhale deeply, slow and movement, faster breathing rate, shallow breath controlled exhalation, stop phonation early, optimal breath support, rapid short breathing cycles group Phonation- hoarseness, breathiness, tremors, decreased loudness, monoloudness Resonance- may have some hypernasality (10% with Parkinsons), severity is usually mild Articulation- changes in production with undershooting on articulatory targets Prosody- increased rate, monotone, short rushes of speech Phonation- pushing and pulling/effortful closure techniques or hard glottal attack if weak/breathy sounding,”, voice amplifiers Medical Intervention- some hypokinetic speakers have severe bowing or weakness of the vocal folds- medialization laryngoplasty or teflon/collegen injection may result in improved voice Articulator stretching briefly if rigid, intelligibility drills, exaggerated consonants, minimal contrast drills. Bite block. Rate reduction with pacing boards, finger tapping, alphabet boards, delayed auditory feedback, metronome. Pitch glides/pitch variation, Stress- contrastive stress drills. Intonation profiles. Chunking utterances into syntactic units Prosthetic assistance (if severe/if behavioral interventions unsuccessful) Delayed Auditory Feedback (DAF)- Pt’s speech is fed back through earphones in delayed intervals (which can be set by SLP). The effect is slow speech rate and presumably increased articulation time and accuracy. (EBP- Numerous articles about effectiveness of DAF with hypokinetic dysarthria.) LSVT- Well researched/ evidence-based procedure for speech of pts with Parkinson’s. Need to attend 2-day training to be certified in LSVT, but now the training is available on-line from LSVT Global. LSVT Loud forspeech, has corresponding LSVT Big for physical therapy with Parkinson’s. Doing research to integrate LSVT Big andLoud treatment. LSVT Loud Treatment parameters -Intense – 4x per week tx for 1 month. Requires high levels of physical effort to increase loudness and VF adduction. Focuses on respiratory-phonatory effort and sensory awareness of loudness and effort. -Exercises include vowel, word, phrase, sentence and conversation tasks. -Treatment Goals/Tasks -Increase VF adduction via pushing/lifting during phonation -Increase maximum vowel phonation at greater vocal intensity -Think loud -Improve vocal quality during sustained phonation and speaking -Increase maximum frequency range -High/low pitch glides and sustained phonation at high & low pitches -Required homework and carryover activities (HYPOKINETIC DYSARTHRIA CONTINUED) Surgical Medical Interventions to relieve movement disordersPallidotomy (placing a lesion in the posteroventral portion of the globus pallidus to abolish tremor) Thalamotomy (a lesion is placed in the ventrolateral nucleus of the thalamus with the intent of reducing severe Parkinsonian, cerebella, or essential tremors that have not responded to medication) Deep brain stimulation- stimulators are implanted in the thalamus, globus pallidus, or subthalamic nucleus. Treats same problems as thalamotomy and pallidotomy by reducing activity in overactive brain structures through inhibition **none are intended to improve speech, and may carry risk for speech impairment Pharmacologic Medical Interventions o Replace dopamine in the striatum Dopamine agonist medications such as carbidopalevodopa (Sinemet), levodopa and selegiline (Deprenyl) are sometimes associated with general improvements in speech for pts with PD, but often to a lesser degree than other motor functions Clonazepam (Klonopin) may be effective for treating hypokinetic dysarthria in some pts o Another pharmacological treatment approach is to correct the neurotransmitter imbalance in the basal ganglia by decreasing the amount of acetylcholine activity in the striatum. Anticholinergic drugs act to either deplete acety.choline in the basal ganglia or interfere with its effect on brain structures. **The effects of Parkinsonian medications, including on speech, can fluctuate as a function of the drug cycle ** High percentage of pts develop hyperkinetic dysarthria during treatment with levodopa (l-dopa) Neurological System Affected: Common Pt Complaints Associated neurological symptoms Possible Medical Dx POSSIBLE SPEECH SYSTEM DEFICIT UNILATERAL UMN DYSARTHRIA pyramidal UMN and extrapyramidal UMN – unilateral/one side slurred speech, thick tongue, drooling, face feels heavy on affected side often co-occurs with aphasia or apraxia if lesion in left hemisphere, or with cognitive deficits if lesion in right hemisphere; weakness and incoordination of tongue and face on opposite lesion (central facial weakness) lower face affected more than upper face, hemiplegia, weakness/hypotonia after acute lesion-spasticity may emerge later. vascular most frequent- right or left carotid or middle cerebral artery stroke, posterior cerebral and basilar stroke POSSIBLE TREATMENT **Generally mild to moderate deficits- may not be a concern – more tx time focus on aphasia or cog com Respiration- normal Phonation- harsh (39% harsh) Easy onset, yawn/sigh Resonance- normal (11% hypernasal) Articulation- imprecise consonants Intelligibility drills, phonetic placement, exaggerating consonants, minimal contrast drills If speech deficits seem to be influenced by weakness, can work on nonspeech oral motor exercises if pt concerned and motivated – may not be necessary often