Neurogenic speech disorders - University of Debrecen T ... · Neurogenic speech disorders Dr. Szabó Edina University of Debrecen, Medical and Health Scienc Center Faculty of Medicine,

Neurogenic speech

disorders

Dr. Szabó Edina

University of Debrecen, Medical and

Health Scienc Center Faculty of

Medicine, Dep. of Phisycal Medicine

and Rehabilitation

Animal difference

Soul (church model)

Toolmaking ability

Thinking skills/Ability

of thinking

Modeling capabilities

2

Darwin's theory of language origin

Darwin about animal intelligence

Ancient human cognitive function

Vocalization: rudimentary song

Articulated language

3

Cerebral lateralization

Evolutionary background

Speech and hemispheres

Left: verbal-logical

Right: visual-synthetic

Right: primitive forms of

knowledge is kept

Research of Gazzaniga (1983)

Testing split-brain patients

Phineas Gage (1848)

4

The brain without language

How can the human mind

function without a functioning

language system? (Lecours és

Joanette, 1980)

The case of Brother John

Different stages of aphasia

Abilities remained intact even under

attack: thinking, music, sound, face

detection, use of objects, spatial

orientation, mechanical intelligence,

working memory, episodic memory,

self-presentation

Changed skills: cognitive operations

that require symbolic representation

He could behave as a human being ! 5

The brain structure I.

6

http://nf.hungary.googlepages.com/agy2.jpg/agy2-full;init:.jp

The communication of the brain

The basic structural and functional unit of

the nervous system is: the neuron

Parts: cell body, nucleus, extensions

(dendrites), axon (endings), myelin sheath

7

8

Blood supply of the brain

9

Introduction to the

clinical aphasiology

11

Cerebral infarction II.

12

Cerebral infarction III.

13

14

15

Hemorrhagic stroke I.

16

Hemorrhagic stroke II.

17

The communication-centered

definition of aphasia

The aphasia is

neurogenic

communication

disorder, which hides

the competence of

the person, which is

manifested in

conversations.

(Aura Kagan, Aphasia

Institute)

18

Etiology of aphasia

Hemorrhagic stroke

Cerebral infarction

Primary brain tumors or metastases

Trauma (concussion, skull fracture)

19

Symptoms of aphasia

Fluency disorder: nonfluent vs.

fluent aphasia

Understanding disorder

Agrammatism/paragrammatism

Perseveration

Paraphase: semantic, phonemic

Neologism

Verbal automatism

20

Syndroms of aphasia (Boston school)

Classical classification (BDAE, WAB)

Evaluation of the spontaneous

speech, speech repetition,naming and

the understanding

Localization principle: which language

areas of the brain are responsible for

different functions (FTP lobes parts of

perisylvian)

21

Global aphasia

Nonfluent speech

Verbal automatism

Perseverations

Severe understanding disorder

22

Paul Broca and the Broca lesion

23

Broca aphasia

Nonfluent speech

Agrammatism (missing suffixes, parts of sentences, suffixes)

Phonemic paraphases

Word finding difficulties

Faulty speech repetition

Mild, or moderate understanding disorder

Monotonous intonation

24

Carl Wernicke and the Wernicke lesion

25

Wernicke aphasia

Fluent, but empty speech

Meaningless, jargon words

Phonemic and semantic

paraphases

Severe understanding disorder

26

Conduction aphasia

Spontaneous speech: Fluent, but

with a lot of phonemic paraphase

The faulty repetition of words and

phrases

A striking difference between

spontaneous speech and speech

repetition

27

Anomic aphasia

Fluent spontaneous speech

Word finding disorder

Circumscription

Mild understanding disorder

Adequate speech repetition

28

Transcortical aphasias

TMA: nonfluent speech, adequate speech repetition

TSA: disorder of understanding words and sentences, speech repetition is good

Mixed TA: severe impairments in all language functions, repetition is slightly better

29

Atypical aphasias

Crossed aphasia

Subcortical aphasia

Bilingual aphasia

30

They do not understand him, but

he knows what he wants to say

World is narrowing or completely

closing up around him

Becomes shipwrecked among

people

He needs help, he needs to

learn to express himself again!

31

The affected

There is no exact data in

Hungary

If U.S. rates are considered,

we have more than 40 000

people suffering from

aphasia

It's probably just a gentle

estimate, as the main cause,

stroke, is higher in Hungary

than in the U.S.

32

The affected

Even more frightening picture

when we look at the range of

indirectly affected:

Families are also included in

this figure: 160 000 (40 000 * 4)

Tertiary affected people 640 000

(40 000 * 16)

With quaternary affetced people, the proportion is 25%, so it suggests that a quarter

of the population can be in direct conctact with an aphasia affected person in

Hungary (40 000 * 64)

Therefore, a quarter of our society must learn to communicate with them, to

develop them 33

Motor speech

disorders

The speech is one of the most impressive motor activity

The control of speech movements in childhood is possible

The adults are forced to pay attention to their speech movements as a result of a cerebral accident

Two large groups: the apraxia and dysarthria

34

What is considered as motor

speech disorder?

The speech production deficit which develops

as a consequence of neuromuscular and /

or motor control system impairment

Sometimes occurs collectively with other

language impairments (eg aphasia)

Other oral movements can be damaged

besides speech, for example the smiling,

chewing, etc..

35

Determination of speech motor

system

Four Subsystems of Speech

Production:

Respiratory system

Phonatory system

Resonatory system

Articulatory system

36

Frequency of motor speech

disorders

Reliable estimates are rare, but ...

51% of adult speech disorders are

motor aphasia, dysarthria with 46%,

5% apraxia.

Among children 5 % of

developmental communication

disorders are due to motor

dysfunction

37

What about nonfluent aphasias?

Why not discuss the motor speech

disorder?

Nonfluent speech in aphasia is just

one component of a more complex

communication disorder

Differential diagnosis of motor

speech disturbances: always

understanding difference

38

What about stuttering?

Dysfluentia

Subcortical laesio, injury of basal

ganglions

Neurogen dysfluentia/neurogenic

stuttering

39

The common definition of motor

speech disorders according to their

characteristics

We talking about motor planning /

programming deficit when we

experience inability to select

appropriate muscle groups,

difficulty to sychronize them:

Apraxia

Muscles suffers physiological or

motor function injuries: Dysarthria

40

How can we classify motor

speech disorders?

After etiology: Acquired:

– Can be caused by cerebrovascular accident (stroke), degenerative diseases, traumatic brain injury or brain tumor

Developmental:

– Can be caused by congenital disease or injury caused to the developing nervous system

41

Apraxia

The failure of articulatory gestures in normal conversion, wrong linguistic representation (even in imitation tasks!)

Features: slow speech (rarely entire speech), sound distortions,

prolonged vowels (extended release), reduced prosody,

inconsistent defects, speech starting problems, searching

articulatory gestures

Speech disorder is a result of neurological damage: left frontal

cortex, stroke near Broca’area then it is called kinetic /

ideomotor apraxia and when the left parietal cortex is damaged

it’s kinesthetic / ideativ apraxia

Can appear due to cerebral injuries, illnesses, after infections.

42

Dysarthria

Neuromuscular disorder which affetcs execution of speech movements, regulation of muscle tone, reflexes,

movement kinematic aspects

It is characterized by a slow, erratic sounds harsh, raspy or whispering voice, consistent mistakes,or other features depending on the type of dysarthria

Three primal features (depending on model) spasticity, dyskinesia, ataxia.

Its common causes are progressive

neurological disease and stroke. 43

Etiology, symptoms,

and classification of

dysarthria

Definition of dysarthria

Darley, Aronson, Brown (1975):

Muscular control weakness, complex muscle (neurogenic) dysfunction.

Consequence of organic injury in the central or peripheral nervous system

Cséfalvay Zsolt, 2007

45

The speech control

cranial nerves

Nervus trigeminus (V.)

Nervus facialis (VII)

Nervus

glossopharyngeus

(IX.)

Nervus vagus (X.)

Nervus accesorius

(XI)

Nervus hypoglossus

(XII.) Cséfalvay Zsolt, 2007

46

Bulbar (or flaccid) dysarthria

(a) lesion in the peripheral motor neuron (involement of cranial nerves)

(b) muscle weakness (flaccid muscles)


47

Etiology of bulbar (flaccid) dysarthria

Injury to the nuclei of 5, 7, 9, 10, 11,

12 th. cranial nerves or the bulbar

nuclei

Monopathia: affects only one nerve

Polypathia: more nerves are

concerned

Cséfalvay Zsolt, 2007 48

Etiology of bulbar (flaccid)

dysarthria

Physical injury: surgery, cranial

injury and neck injuries

Brainstem stroke (brainstem

vascular involvement)

Myasthenia gravis


Etiology of bulbar (flaccid) dysarthria

Guillain Barré syndroma (progressive

inflammatory disease,

demyelinization)

Tumor (near the brain stem)

Muscular dystrophy (progressive

degeneration of muscle tissue)

Progressive bulbar paralyses.


50

Symptoms of bulbar dysarthria

Resonance disorder : hypernasality

Artikulation disorder: slow

artikulation

51


Phonation

disorder:phonation

incompetence

(insufficient

closing of vocal

cords) - dysphonia

52


Respiratory Disorder: C., Th nerve

problems only (diaphragm, damage

to intercostal muscle movement,

lack/insufficient subglottic

pressure, poor sound intensity

Prosodic disorder


53


(Summary)

n. trigeminus laesio: artikulation disorder,

resonance disorder

n. facialis laesio: artikulation disorder

n. vagus laesio: resonance disorder,

phonation disorder

n. hypoglossus laesio: artikulation

disorder

Unilateral injury: milder symptoms

Bilateral injury – severe symptoms


54

Spastic dysarthria

Bilateral central motor neuron

involvement


Etiology of Spastic dysarthria

Stroke

Cerebrocranial trauma

Sclerosis multiplex (when central

motoneuron is affected)

Tumor


Symptoms of spastic dysarthria

Spastic slow articulation (especially

consonants)

Spastic dysphonia (due to hyperadduction

of vocal cords)

Hypernasality – the spasticity slows down

and limits the movement of soft palate

muscles

Dysprosodia: limited range of voice and

volume, short phrases, slow speech rate

Rarely: respiratory problems Cséfalvay Zsolt, 2007

57

Accompanying symptoms of spastic

dysarthria

(1) spastic laughter, crying (which is

difficult to control voluntarily)

(2) hypersalivation (which may be the

control of salivary dysfunction, or as

a result of less frequent swallowing)


Ataxic (cerebellar)

dysarthria

Etiology

Laesio of

the

cerebellum

or

cerebellar

tracks


Etology of ataxic dysarthria

Degenerative disease: Cerebellar ataxia,

Friedreich ataxia (hereditary spinocerebellar disease),

Olivopontocerebellar degeneration

Stroke – blood supply dysfunction in the areas of the cerebellar

Toxic injury (chemical substances, alcohol, drugs)

Cranial trauma - cerebellar

Tumor ( eg. astrocytoma)


Symptoms of ataxic dysarthria

Disorder of speech cordination

(artikulation, prosody)

Vague, indistinct articulation: "Boozer"

articulation, irregular intervals (more

syllable words)

Mild hyponasality

Mild dysphonia


62

Hyperkinetic dysarthria

Hyperkinetic dysarthria

Hyperkinetic disorder: excessive involuntary movement (chorea, myoclonus, dystonia, essential tremor)

Etiology: Basal ganglia injury and areas around the BG (eg Huntington's disease).


Symptoms of hyperkinetic dysarthria

Involuntary movements of (resp.,

phon., artik., reson.) muscles

Choreatic hyperkinesia –due to

simultaneous or successive

involvement of muscles (lip muscles

and phonation muscles are involved)


Symptoms of Hyperkinetic dysarthria

CHOREA:

Long intervals between syllables and

words

Variable speech rate

Inadequate breaks (silence)

Variable volume

Prolonged vowels

Fast, and short inhalation, exhalation and phonation intervals


Hypokinetic dysarthria

Occur due to pathological changes in

BG, their connection with other areas

of CNS


Etiology of Hypokinetic dysarthria

Parkinson‘s disease

Postencephalopatic parkinsonism

Craniocerebral trauma (BG, substantia nigra)


Symptoms of hypokinetic

dysarthria

Dysprosodia: monotone speech

(limited vocal range and volume)

Long pauses (due to akinesia)

Fast speech rate.


69

Symptoms of hypokinetic dysarthria

Articulation disorder:

"blurry" articulation ,

atypic dysfluency: repetition

(initial phonemes)

palilalia (very fast repetition of

words)


Symptoms of hypokinetic dysarthria

Dysphonia: Due to incomplete

closure of the vocal cords (breathy

voice quality, rough, raspy voice)

Mikrophonia: low sound level

Respiratory disorder: rapid, shallow

breathing

Resonance abnormalities: mild

symptoms (hypernasality)


Mixed dysarthria

Etiology:

Sclerosis multiplex/multiple scerosis

Multisystemic atrophy (Shy-Drager sy, progressive supranuklear paralysis, olivopontocerebellar atrophy

ALS

Wilson's disease


Symptoms of mixed dysarthria

SM: ataxic-spastic form (phonatio-

articulation disorder)

Wilson‘s disease (BG involvement)

hypokinetic form, later spastic-

ataxic form

ALS: initial stage


How we can identify motor

speech disorders? Tests Frenchay Dysarthria Test

Apraxia Battery for Adults-2nd edition

Assessment of Intelligibility in Dysarthric Speakers (AIDS) (computerized version called CAIDS)

Sentence Intelligibility Test

TOCS+ for children by Megan Hodge is this website:

http://www.tocs.plus.ualberta.ca/videodemo.htm

These testing procedures are not adapted in Hungary for motor speech disorders

74



Diagnostic

A comprehensive assessment of communication disorder following a detailed diagnostic protocol

At present, the differential diagnosis is based on the professional perceptual, acoustic monitoring, psychological testing as there are no objective acoustic and physiological indicators available

The diagnosis itself should include the damage rate, the rate of mistakes, the rate of "false positive" responses and the rate of corrections

75

Diagnostic process

Assessment of the oral motorium

Testing of phonatio and prolong phonatio

The examination shall include, detailed diagnostics of the individual subsystems: respiration, phonation, resonance, articulation and prosody

Cognitive / Communication Skills Mapping

observe compensatory strategies used by patients

76

The examination

Examination is carried out during speech and at rest

Speech muscles of the peripheral nervous system (specific tasks)

Examination of cranial nerves: V.,VII., IX., X. XI. a XII. (neurological examination)

Darley, Aronson, Brown:

Examination of motor speech

disorders 77

Examination of the facial muscles at

rest (VII. n. facialis)

Is the face symmetrical?

Can you move your lips?

Can you show your teeth?

Eyes:open,or partially shut?

The face rigid, mask-like?

Are forehead muscles symmetrical

when raising

eyebrows/wrinkling/frowning?

Is the nose symmetrical?

78

Examination the facial muscles in

motion (VII. n. facialis)

Is the smile symmetrical?

Looking for the right position when smiling (apraxia?)

Pouching of lips

Close lips

Puffing up cheeks

Muscle strength

79

Examination the lower jaw muscles in

resting position (V. n. trigeminus)

Is the jaw symmetric?

Is there deviation during resting?

80

Examination of the lower jaw muscles

during spontaneous movements

There is a deviation jaw when the

mouth is open?

Looking for the right position whilst

opening (apraxia)?

Is there possible side movement?

Is there strong resistance against

pressure?

81

Examination of the tongue muscles at

rest (XII. n. hypoglossus)

Is the size and shape of the tongue normal?

In the located in the middle of the mouth?

Is the shape of the tongue symmetrical?

Is there fasciculation muscle of the tongue?

Can it remain inactive?

82

The examination of the tongue muscle

movements (XII. n. hypoglossus)

Can the tongue move out?

Can the patient stick his tongue out?

Can he resist lateral pressure to the tongue?

Can patient produce lateral movements?

83

Examination of the velum, pharynx

and larynx at rest and during exercise (X. n. vagus)

Does velum elevates during fonation

?

Is velum symmetrical?

Can we trigger gag reflex?

84

Examination of the larynx (X. n. vagus)

Is patient able to produce a loud cough?

Able to develop adequate subglottic pressure?

Can we hear inhalation stridor?

85

Summary

Must be able to distinguish between disorder of motor planning (apraxia) and disorder of motor execution (dysarthria)

Dysarthria: we must be able to determine the type of dysarthria

Be able to determine how damage to the motor subsystems affect intelligibility of speech

We have to know if the disease is acquired or developmental

Disorder emerged suddenly or gradually

Set up the treatment plan accordingly

86

From diagnosis to therapy

A detailed diagnostic protocol is an opportunity for better trauma-specific treatment plan

87

Vocalization and swallowing

Lungs provides air flow

Glottis: vocal phonation and

positioning

Resonator areas: synchronized

orientation

Swallow: Preoral, oral, pharyngeal

and oesophageal stages

Swallowing apnea, opening the top

of the esophagus 88

Dysphonias

Organic dysphonia

Functional dysphonia

89

Functional dysphonia

Change in the tone (usually hoarseness),

overuse of voice, larynx is less strainable

without primary structural difference in

the larynx itself. All complaints are

usually accompanied by paresthesia

Phonoponozis

Phononeurosis

Mészáros Krisztina 90

Phonoponozis I.

Definition:

Improper use of sounds, vocal

dysfunction due to overuse of the

phonatory apparatus


Phonoponozis II.

Complaints:

Gradually formed, altered, hoarse

voice, becomes asymptomatic after

relaxing, urged to croak and

swallowing, globus sensation,

foreign body sensation, pain

sensation in the neck, sore throat,

and cough.


Phonoponozis III. Symptoms: Changed, usually hoarse voice, but not

aphonic. Hard start-up sound, almost normal range of voice, prolonged sound shorter, limited volume.

Decreased, tight vocal movements, irregular, tight thoracic breathing. Face, tongue, jaw, neck under tension, neck veins visible during speech.

Larynx: false vocal cords distend due to straining, congestion in free margins of the vocal cords.

vocal knots, margin oedema appear, and failure of glottic closure at the back of the larynx


Phonoponozis IV.

Treatment:

Voice Therapy and in cases of

existing tough vocal cord knots ,

surgical removal is recommended.


Juvenilis dysphonia I.

Definition:

Formed in childhood, improper voice

use, excessive use of the phonation

apparatus due to vocal dysfunction.


Juvenilis dysphonia II.

Complaints:

Hoarseness, deepening of the voice,

croaking


Juvenilis dysphonia III.

Symptoms:

A sharp, deep-pitched, hoarse voice. Urge to croak, hard starting volume. Fast speech, rhythm, inaccurate articulation, irregular, tight thoracic breathing. Face, tongue, jaw, neck are tense, neck veins distended during speech.

Larynx: loose watery vocal cords, vocal bunch knots, failure of glottic closure.


Juvenilis dysphonia IV.

Treatment:

Voice therapy and in cases of

existing tough vocal cord knots,

surgical removal is recommended.


Phononeurosis

Voice production disorder of psychogenic origin, sudden and severe voice symptoms.

Psychogenic aphonia: inability to produce sounds, immediate psychiatric treatment and voice therapy.


Dysodia

The functional voice disorders.

Respiratory defects

Incorrect setting of the articulation area

4-6 hours of overstraining

Caffeine, drugs

Early singing lessons

Ignoring vocal hygene recommendations


Gastro-oesophageal reflux

disease in phoniatry

implications

101

The most common aspects in phoniatry

of the GERD

Dysphonia

Pharyngitis

Dysphagia

excess flow of mucus in the back of throat

Stimulated cough

Chronic Bronch.

Asthma bronch.


Top phoniatric result

Hoarseness

Etiology:

The acid-induced vagal reflex

triggered recurrent coughing reflex.

There is direct acid effect on the

pharynx, larynx.


Diagnostic, anamnesis

Substernal burning

sensation, pain

Nocturnal

regurgitation

Coughing, wheezing

Aspiration

Morning hoarseness

Croaking

Feeling of mucus

flow in the throat

Frequent throat

pains

Jugular

discomfort

Heartburn (rarely)


Diagnostic, examination

oto-nasal laryngological

examination

laryngial video-stroboscopy

Auditory Sound Scan

examination of sound retention

time and vocal range

Analysis of sound dynamics 105

Stroboscop evidence

The congestion of inter-ary region of the

vocal cords, false vocal cords slight

oedema of the vocal cords.

Pronounced hyperplasia of the inter-ary

region, contact granuloma.

In general, the glottis level of

vasoconstriction, decreased vocal cord

vibration parameters, harsh sound start.

In addition to harsh sound start,

hypotonic vibration in front of the vocal

cords


GERD and the phoniatry

Varying degrees of hoarseness

Vocal holding time shortens

Sound stage renal

Decreased ability of raising volume

20% of phoniatric patients affected

by clinical symptoms, 14% was

proven in during gastroenterologic

examination

Mészáros Krisztina

107

Treatment

Gastroenterology areas: Medication

and lifestyle counseling.

Phoniatric Therapy: Sound Therapy

treatment to the added functional

components.

Mészáros Krisztina

108

Thank you

for your

attention!

109

Documents

Neurogenic speech disorders - University of Debrecen T ... · Neurogenic speech disorders Dr. Szabó Edina University of Debrecen, Medical and Health Scienc Center Faculty of Medicine,