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  • Duffy - Exploracion de Desordenes Motores Orales

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    DUFFY

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    19 vistas19 páginas

    Duffy - Exploracion de Desordenes Motores Orales

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    yanni
    DUFFY

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    chapter Examination of Motor Speech Disorders ‘Haver OUTUNE a odin voor spech eaminati spsech problem as newnologe and thon ie diagness The ifleences pies ae hat sph tye Il that spec ically the only detestable nour agnosis mss pit hac fenttive disease diagnosis, Speceh examination is ‘huis an important componcitof' many. neunoaie This chapter discusses he examination of speech in people with sinpecied motor speech divers (MSDs. eis nocthe intent here to discuss the ine Petation application of examination findings ta slxgnesis or management, beyond some istrative ‘examples. ‘The relationship between examination results and speci speech digenone sakes in «sich chapter on spect MSDs (Chapters 4 1) si in Chaptr 8 Phen ionship of examination re uduossed in Chapter 16 [PURPOSES OF MOTOR SPEECH EXAMINATION, The motor specch examination ret several gots * thal are evant to diagno. Diller ‘ollen pursed simultanouty but they ed al sequenced in may that helps ive the ati tal mabe up the examin alk include destino. estasing ig, sablishing 3 diagnos eta ns For kvazation and sean Description sara’ nd fon 70__ Substrates cannot establish a diagnosis or even a limite lis of ‘iagnontie possibilities, The bases for description Aerive from the pation’ history and description of the problem, the oral mechanism exanination, the perceptual chiactenstis of speech and rests of andar linia tess, aa instrumental analyses oF speech ‘Once speech is described, the elinician asks i the haricterisicn ae nomnal or abnormal This fs the Fist step in diagnosis and an imporant one. I all aspect of spocch re within the range of normal, the agnosis 1 normal speech, If some aspects of Speech are abnormal, then their meaning must be Imerpreted. The process of narowing diagnostic possbilies and arrivine at a specie diagnosis is Known as diferenial diagnosis Establishing Diagnostic Possibilities speech i abnormal, then alist of diagnostic pos siblties can be generated. Because the empliasis here is on MSDs, the ist ean grow out of ansivers questions such as the following 1. the problem neurologic? 2. the problem isnot neurologic, sit nonethe less organic? For example, it de to dental for occlusal abnormality. mass lesion of the laryns, or ist payehogeni? 3. IF the problem is or is not neurologic, is it recently aeguited or longstanding? For fxample, might it reflect unresolved devel. ‘opmental stuttering. articulation disorder, of language disaily? 4. Tete problems nourlogi, i tam MSD or another neurologic disorder that is aflecting ‘verbal expression (eg. aphasia, dementia, kinetic usm) Iran MSD is present, ii a dysarthria or aprasia of speech? S._dysartn is present, what i its ype? Establishing a Diagnosis Once all reasonable diggnostic possibilities fave heen recognized, a single diagnosis may et atthe least the possibilities may be ond most to leas ikl. For example, concdng that speech is not normal, that it 8 not psyehogenic in ‘ongin and that i sara but of uetermined type, is of diagnostic vale. I implies the existence fof an organic process and places the lesion within ‘motor components of the nervous system, I also fan be concluded thatthe dysarthria mot lac, then the lesion is further localize to he venta and not the peripheral nervous system and ern ne rologie diagnoses can be climinated of consuered Unlikely. I the characterises of the sender are unambiguous and compatible with only single diagnosis, then a single speech ditgnosis can be iiven along with is implication fr localization Establishing Implications for Localization and Disease Diagnosis When an MSD is idemied, itis appropriate wo aeess explicitly is implications for neurologic localization especially if the releral source is uni iillar with the method of lasification. For {example if spastic dysarthria isthe diagnosis its propriate sate that the disorder is Usa a0 ‘ated wth bilateral involvement of upper motor neuron (UMN) pathways. Ifa tentative neurologic thiagnoss has aleady heen made, is appropriate 0 adress the compatibility of the speech diagnosis ‘vith it For example, ifthe working neurolosie dag hosis is Parkinson's disease but the patient hit mixed spasic-atnie dysarthria, itis important 10 Fepor that this mixed dysarthria is not compatible With Parkinson's disease. Finally. if- neurologic iagnosis is uncertain ori speech isthe only sign fof disease, i is appropriate to dently: posible Siagnoses ifthe MSD fs “classically” ted to them, For example. a faced dysarthria that emerges only with specch ste testing and recovers with rest has a very sttng association with myasthenia ‘Specifying Severity ‘The soverity of a MSD should always be estimated, ‘This estimate is important fora east three reasons: (4) subjective or abjective measures of severity ean toe matched! against the patient's complaints: gross rismatches berween patient ad clinician judgment ‘ay inte the possiblity of psychogenic conti hhuuons, poor insight. oF timited concern about speech on the patient’ put: (2) i inluences prog nosis and management decision making: (3) severity ‘estimates the time of inital examination represent hascline data against which future changes ean be compared ‘Specifying severity is atally pat of the descrip tive proces. It is highlighted re because of rel fevance 10 estimating fonction, Tmitations and Aisabilty imposed BY the MSD.” ax apposed ‘determining the presence of impairments which i tore relevant to diagnosis: Limitations and dsai ity are more relevant wo decisions abot management than diagnos ‘Once severity s established, i is appropriate to ares the implications ofthe findings Tor progoo- sisand management. These are considered in Chap ters 16 (0 20, Chapter 3_ Examination of Motor Speech Disorders 71 ex GENERAL GUIDELINES FOR EXAMINATION ‘The motor speech examination Is thee essential procedural components: (1) history. (2) entiation Sr saliea speech features, and (3) Mentifieation of ontnmatory signs, With ths information. digi Sis is made. recommendations. formulated, and results communicated tothe patient referring pro- fessional and others History ‘An anonymous sage has sa hat 90% of neurologic “isgnonn depends onthe patent's history" A wise ‘euislogy colleague of the author his aid that most ‘inca Neurologic diagnoses are based on speech, biter its conten or ifs manner of expression. It ‘would be dificult to argue thatthe spoken history provided by dhe patent 5 less important to motor fheech evaluation and diagnosis, Experienced clinicians often reach a diagnosis by the time pretings and amenities ave been fxchanged “anda history bined. Subsequent formal examination coats, documents, refines, sind sometimes revises the diagnosis. The history fveals the time course of complains and the Potion’ observations about the disorder. also pats ontextual speech on display when ancy is gence ally less than during formal examination when piysial effort ask comprehension and cooperation $= no esentl: and when the patent may not fee Iis over speech i the sujet of seating Sallent Features Salient features are those that contribute most ‘directly and influential to diagnosis, They ince “oviant speech characteristics and their presumed neuromuscular substrates. In 1975 Darley. Aronson, nd Brown (DAB) discussed six salient neuroma ‘ular features that influence speech pedcton. They Form a usefl Framework for integrating observations nade during examination. They include strength, Speed of movement ange of movement steadiness, tone, and accuracy. Abnormalities associated with tose Features are summarized in Table 1 Senge Muscles have suflicent strength to perform their Dorma Tanctions, plus reserve of excess strength, Reserve strength permits comiraction over tie without excessive Ttigve, a8 well a contraction ‘When a muscle is weak, it cannot contact to a ested level sometimes even for bie periods. I ‘Sven Read, uty conten bt metines pemescvey Speed Reseed or vara teed en akin dyer) ange Reced or vara pecan exces ory in hyperenate Syste) Steatiness Unsteady, athe etme or armynmic Tone Ireeneed, doses. vale Aeteacy —racuti, eer consort or "reoreioy ray fatigue more rapidly than norm, Sometimes 3 esi evel of contraction can be oblaned. but abilty to sustain it decreases dramatically afer & ‘hort time, "Muscle weakness can affect ll thee ofthe major speech valves (laryngeal, velopharyngedl, nd ute- ‘latory, and it can be apparent inal components of speech production (respiration, phonation, reso- nance, atiulatia, and prosody), Weakness is most apparent and dramatic in lower mevor neuron (MIN) ‘or fina common pathway (FCP) lesions sn there fore in Maced dysarhrias. Consequences of can be interred from poreepual and acoustic analyses, observed viialy 5 etl dine pec dere “during al mechanism examination, or messed physiologialy Speed Movements daring spech ate rapid, expecially the laryngeal. velopbaryngeal, and aticultory moves ments tha valve expired art produce the spon mately 14 phonemes per second that characterize convenational speech, These quick, unsistined, and discrete movements are known as phasic move ‘ments, They can cocur as single contractions. or epeivel- They” begin promply, reach targets |quieky and relax rapidly. Pasi speech movements fare mediated. primatily though sivectctvation UMN pathway’ input to alpha motor neurons see Chapter 2), [Excessive sped is uncommon ia MSDS, although it may cccur in hypokinetic dysarthria, Excessive speek rate in people with dysanhrias nearly always also associated with decreased range of mation ‘Slow movements are common in MSDs. Move ments may be sls to st, sls in their course, oF 72__ substrates slow 10 stop or relat. Single as well as repetitive -mowements may be lo Reduced speed can occur at all major speech valves and ding all components of speech peedac tion. Slow movement strongly affects the prosodic features of speech becaune norma prosody i 80 dependent om quick muscular ajostments hit in fence rate of syllable production and pth and lou ness variabiiy. The ellis of redaved speed are ‘most apparent in spastic dysarthna but aso ae present in other dysarthria types. The effects of tered speed can be perceived in speech, visibly ‘apparent during. speech und ral mechanism fkamination, and measured physiologically and coastal ange ‘The distance traveled by speech structures is quite precise for single and repetitive movements. Vaia~ tion in the range of repetitive movement s nora ‘resent bu ually sll. Consistent but mappropratly excessive range of ‘motion during voluntary specch i not common in neurologic disease. In contrast, decreased range is common and may occur in the context of sow: ora, or excessively rapid rate For example, hypo- Kinetic dysrtria is often associated wi decreased range of mosion and, sometimes, excessively rapid rate In ater instances. range may be variable and ‘unpredictable. Abnormal arity” in range is common in ataxic and hyperkinetic dysarvias. ‘Abnormalities in range of mation often have a ‘major influence on the prosodic Features of speceh, Sometimes” resulting” tn restricted or excessive prosodic variations. Such abnormalities ean occur at bof the major speech valves and doing all com ponents of speech prduction. They canbe infered from acoustic and perceptual analyses of speech, ‘sie daring spech un nonspeech movements of ‘he anculatrs, and measured physiologically Steadiness At rest, there is a measurable 8 to 12 Hz oscillation ofthe body musculsture During normal movernent ‘Mere ace val no vsileinteraptions or oscil ins of body parts. but oscillation amplinde some ives increases o visibly detectable levels in ealthy people. This visblepysiologi remo can occur in xtome fatigue, under emotional siress oF daring Shivering ‘Whet motor steadiness breaks down in neuro- logic disse, the results can be broadly categorized involuntary movement or hyperkinesias. Tremor isthe most common involuntary movement. H con Sats of repetitive, relatively esti osilations of «body part. generally ranging in frequeney from 3 to 12 He Tt may occ at rest sting tremor), when {structure is muintained against gravity (postural Inemor). during mevement faction tremor) OF toward the end of a movement terminal rem ‘Mild wemoe may not have any perceptible effect con spooch chariteistics dependent on respiration, resonance, or atculation. Ht commonly affects phonation and, when severe, it can affect prosody: lseifecs are most easly perceived during sustained ‘vowel pradiction, The effects of tremor on speech may be heard or seen during speech, may be seen luring oral mechanism examination, and can be ‘measured physiologically and acoustical "Another major category of inveluntary movement consiss af fandom, unpredictable, adventitious movements that may vary in thei speed duration, and amplitude. Thee absormal movements inelude ‘trtona, dyskinesia, chorea, and ahetosis. They ‘nay be severe enough 1a inesrupt or alee the digee- thom of intended movement, They may be present at est, during sustained postures daring movement ‘They ca affet movement a al ofthe major speech valves and all components of specch production, ‘They can affect aocuracy and often alter prosody. ‘They are the primary source of absonmal specch in hyperkinetic dysarthria, The effects of unpre= Aicable"hyperkinesis can be perecived during speech seen during speech and! oral mechanism ‘tamination, measured physiologiealy snd feted From acoustic measinemcnts Tone Muscle tone is discussed in Chapter 2. The gamma Toop and indzet activation pathway are eri for proper maintenance of tone, which erates a stable Framework upon which rapid voluntary movements an be superimposed Tn nearoogic disease, muscle roae may be exees- sive or reduced. Itmay fluctuate slowly of rapidly in 4 regular or unpredictable fasion. Alterations in fone may occur ata spech valves and daring all components of speech production. Abnormal tone is ‘sssoiated with acid dysartrias when consistently reduced, with spastic o hypokineie dysarthria when Consistently increased,” and with hyperkinetic Asaavas when arable. The effec of born tone can be infeed from perceptual speech charac- terns, seen during spetsh and oral mechanism ‘xamination, measured physiologically, and infeed From acoustic measurements Accurcy Individual, repetitive, complex sound sequences are normally executed with enough precision fo ene Chapter 3_ amination of Motor Speech Disorders 73 ineligible and effcien ansmisson of igus {nd cmotonl meaning They res fom reeset Gf tone, strength, speed, ange. eadness, ant Sining OF muscle acy "Prom his. tpn, ‘Svuraey isthe ouone of weltimed an! cord fate ates ofall he oer neuroma fa fires Ifswengh sped range, sean nd toe fave bean procly regulated, speech movements wibe accra I spec conan inca Desronmseular perfomance formal posible tha the ng plan rational content dee tv, lacing the sauce ote problem outs oth tow pena erative explanation shat the bem erin the Panning or programing. of ‘ovement an nti neomuscuar ecco Inacerteovernnts can rest in varous spstch emer. For example, i foge an range of oon ae eacensive, smeies may overioat tget Io and ange of ton a deceased target undersoting may cea ming is pooch {irecton and mths of movements ay be fol andthe shyt of repetitive movements ay ‘emsnaned poy Inaceatetovemets resulting from consantly essen defects of aength speed ange, and fone fay reskin pedicle depres of acute Inpression or Otber speech borates It the foures of naccracy Hes in Untag orn une: dictate variations in other neuroma compo nent, emors muy Be unpeeictable, anda or Inaccurate movements may occur at ll of the iajr speech aves and ata eves of spss pr ction bt ave senrallypetcived ont cai In ‘Src and psn Taceray a occu in al jaca, bat when i ete rest of eae timing or cooninaton, ts lly sociated th sta data or pans of speech, When aoc ted wih arom or unpredictable ivory var dons in movement i efen rect Rypedinis dean 1 should be apparent tht the sen neurmus- colar features of movement iter and nen ich other For example reed set lly ‘scold with eed tone, age of maton, act ‘acy. an sometimes stains There ore 21 tone is usally assoc wih edad or “arale speed range of mato, Sealine, accuracy Reduoed ange of motion ir asciaed ‘ith vans n sped, toe, and aca. are ‘hat ota single abnormal neomascular fone 1s presem t someone wih deri Confirmatory Signs Confrmatory signs are addtional clues about the locaton of pathology inthe nervous system. In the context of speech examination, they ae signs other than ceviant speech characteris and the alent neuromuscular features that characterize them that help suppor the speech diagnosis or icteasecont- dencein it. MSD diagnosis does nt require that con firmatory signs be present. Therefore observations ‘of anonspeech nature. even if ofthe speech muscles, Imust 3e_ considered cicunstantial(confimatory) {evidence ac not salient. Nonetheless, they ea be helpful in establishing a diagnosis Coafinatory signs can be manifest i speech or nonspeech muscles, Examples of eonfirmatny signs within the speec system ae atrophy, redaced tone, fasciculations, poorly inhibited laughter or crying, reduced poral reflexes or the presence of patho” logic eles, andthe strength of the cough Ris import to Keep in mind that Such signs ate not ‘iagnostic of MSDs. For example. ing fascial ions. without any perceivable impairment of Hing aniculation, would not warant diagnose of sari. fe might reflect x lesion on nerve XI ad require farther investigation, but a diagnosis of dysarthria would eguie the presence of a peeepli- be speech deci. ‘Corfrmatory signs from the nonspesch motor system come from observations of gait, muscle stretch reflexes, superficial and pathologic reflexes, hyperactive limb reese, limi trophy’ and faci Iakions difficulty initiating limb mewemens, and x0 fon. They also include observations of strength, ‘peel, curacy. tone steanes. and range of move ments n nonspeech muscles CConmatory signs are discussed within each chapter om the speiie dysrtving and apeain of Speech and aso. brietly during the Tollowing overview of the mor spech examination, Interpretation of Findings—Diagnosis ‘Once the history and salen speech Features and con- fimatry signs have Been established, they are inte rated fo formulate an impression about ther ‘meaning. This constitutes diagnosis ‘Nocxamination i complete without am atempt to establish the meaning of ts findings." Tis reason. bl to state as principle that when the results ofa fxaminaion cannot go beyond description, the reasons why should be sated explicit The abvence i interpretation represents an assem ‘valuable medial information and ean 74__subseates convey an impression tht although a patient has teen assessed, perhaps thoroughly the rests have been neither inerpreted nor unersood. This ean Tead «oan interpretation by refer sources that speech-language pathology does not contibute 10 the localization a understanding of =pocch, hn ‘zig, and communication disorders. “The manner in which diagnostic statements are expressed i invenced bythe examination ndings pl the intends purposes ofthe evaluation eB provide an opinicn aout the nature of the speech Tehcit to a neurologist who is uncertain about the neurologic diagnosis; lo determine the nature and ‘every of an MSD forthe purpose of management planning), The stength or certainty of diagnostic Statements can vary considerably. In some cases Fings may he so ambiguous tat dey justify ony statement that the diagnose uncertain, fa others, they may jasiy formulation of diagnostic posi- bites, petaps inorder fom mos to least likly 19 sill ethers, they may’ permit astaement about shat the disorder is not. And some permit confidenly ated, unambiguous” diagnosis. Finally findings Sometimes—perhipe often 10 combination fof some of the proceding possibiliis, such as "the Patent hasan unambignos spastic dysarthria, po Sibly with an_sceonpanying. ataxic component ‘There is no evidence of aprania of speech” The proces of fferential diagnosis is discussed in detail sm Chapter 15 {Ea THE MOTOR SPEECH EXAMINATION ‘The motor speech examigation canbe divided ita four parts (1) history: (2) examination of the ora mechanism during nonspeech activities: (3) asess- ent of perceptual speech characteristics: and (3) assessment of intelibli,comprehensibility, and fffciency. Instrumental analyses using acoustic Plysiologic or visual imaging methods may also be pat ofthe clinical examination, but in general they fre not essential, Their une during various portions Of the examination fs noted when appropriate History ‘The history provides hase inrmation about the ‘onset and course ofthe problem, the patient's aware hess impairment, ahd the degree 0" which the problem lite basi activities or reduces partici tion in various aspects of Hie. The spoken history tko puts on display the salient Features, comma tony sigs, and severity ofthe problem. ‘No two histris are the same, andthe specific questions tha elicit histories will vary considerably is approached include patients’ cognitive ability and personality, ‘whether ot not they poreive a problem, what has already been establisied by other professionals, and the seventy of the speech deficit IF paints have cognitive limitations, significa reduced itelligh bay, or an naoquaie augmenttive means of ‘munication. or Hf they donot perceive a. speech ‘etc then the history from them may be Limited IW the etiology and tine course are already know, they noed not he pursued beyond confirmation. The history sometimes must be provided or supple ‘mented by someone who Koows the patient wel History taking should usualy be concolled by the clinician and not the patent, with questions and their Sequence strony influenced by the facts provided by the patient ad by tele manner of doing 0. “The format of history taking often includes the following Introduction ond Goal Seting nce hsic amenities have been exchanged, the examination can often begin with a simple ut Jmponant question, "Why are you here?” Some rep- resentative reponses include "0 find ou what's ‘wrong with mer” "%o find out what's rom with my speech." find out if you can help me with my sSpocch" "because my doctor tld me to come here.” “here's nothing wrong with me," don’t kre why they brought me here!” The answers are fan index of pens” orientation, awareness, nd sncernahout their speceh the priority they place on their speech versus other aspects oftheir ess he relative importance to them of diagnosis versus man Sgzment: their ability to provide a histor the depth Sind manner in which the history wil have to be taken: and the acta seve ofthe speech disorder “Tis troduction also allows the clini to inform, the patient abo and management fe purposes and proceres of ts place in ehcr ovcral evaluation Basie Dato ‘Age. education, oeupation, and marital and faily Stas shold be noted. Ii important to establish i there wae a history of childhood speech, lange hearing dit if treatment for those problems was rnecessry an if they had resolved before the current itness began, This i essential when abooemaites tue inconsistent with other carent mic findings hut could be longstanding or developmental in nature The most common longstanding. speech ‘efcts encountered in adults with suspected neuro logic disease are persisting developmental aticla- tion errors, articulatory distortions associated ith ‘ental or clus abnormalities, and developmental storing Chapter 3_txaminalion of Motor Speech Disorders 75 Const and Course Information about the onset and course of the speech

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