Dysarthria in childhood
Intensive Voice Treatment (LSVT LOUD) for Children With Spastic Cerebral
Palsy and Dysarthria
Outline for Today’s Talk
The presentation consists two main parts First….
- Definition of Dysarthria - Dysarthria subtypes
- Speech characteristics of dysarthric patients.
- Management approaches
- System approach of Behavioral management
Second….
- (LSVT ) articleIntensive Voice Treatment (LSVT LOUD) for Children With Spastic Cerebral
Palsy and Dysarthria
Dysarthria
A group of motor speech disorders that affects the neuromuscular execution of speech as a result of central or peripheral nervous system damage.
It is not :
a language disorder , or cognitive disorder.
not a result of an abnormal anatomical structure (cleft palate), a sensory loss (deafness) or psychological disturbance.
It is strictly a speech production disorder caused by neuromotor damage.
The degree of impairment secondary to dysarthria can range in severity from quite mild to devastatingly profound.
Salient features of neuromuscular function
Muscles can be impaired in terms of:
• Range of motion
• Direction
• Strength
• Endurance
• Speed or timing
(these parameters or processes considered as a ) Foundation of all voluntary movements of the body.
• If any of these are defective, the motor speech system will be affected adversely
Motor speech subsystems
The lack of neurological control with dysarthria can affect the motor- speech subsystems of respiration, phonation, resonance, articulation,
and prosody.
Causes of Childhood Dysarthria
Congenital: Acquired:
Cerebral palsy TBI
Mobeius syndrome Brain tumors Neuromuscular diseases CVA
Muscular Dystrophy
Childhood dysarthria classified as being either acquired or congenital (developmental).
Congenital dysarthrias result from some disease or event at birth (developmental) like:
Cerebral Palsy, Mobeius Syndrome, Congenital Muscular Dystrophy.
Acquired dysarthrias result from some disease or event (traumatic brain injury,
cerebrovascular accident, brain tumor) with an onset during the pediatric period (0-15) years of age, but usually following a period of normal speech and language development .
Children versus adult
• The impact of central nervous system lesion on a child who is still developing adult speech is different compared to lesion that
occurred in adults.
• Potential recovery for children with dysarthria differ than potential recovery for the adults.
• Clinical diagnosis is challenging , since symptoms of childhood dysarthria overlaps with developmental speech characteristics
Dysarthria subtypes
Mayo clinic or DAB Classification (Darely, Aronson, and Brown)
• The most frequently cited classification system for the dysarthria is based on the Mayo clinic research studies based on site of lesion ,etiology and pathophysiology
Dysarthria subtypes
Dysarthria Type Site of lesion Clinical and speech characteristics
• Spastic Dysarthria Upper motor neurons (Bilateral) Voluntary movements affected Spasticity
• Hyperkinetic Dysarthria Basal Ganglia control circuit Both voluntary and involuntary
• Ataxic Dysarthria Cerebellar system damaged Slowness, movement incoordination
• Flaccid Dysarthria Lower motor neurons (spinal and cranial nerves)
Weakness
• Mixed Dysarthria Combination of signs of more than one subtypes
• Hypokinetic dysarthria (mostly seen in adults with Parkinson disease)
A reduction of dopamine in part of the basal
ganglia.
Rigidity, reduced range of movement
Unilateral upper motor neuron Unilateral damage to
upper motor neurons. irregular
articulatory breakdowns
Speech Characteristic
38 speech characteristics related to pitch, loudness, voice, resonance, respiration, prosody, and articulation according to DAB.
Speech Characteristic
Speech Characteristic that children with Dysarthria May exhibit
• Short breath groups (few words per breath)
• Abnormal voice quality (strained, breathy) and volume.
• Difficulty using contrastive stress (equal stress on all words)
• Slow rate of speech movements and speaking rate
• Nasal resonance and nasal air emission
• Imprecise vowels/consonant
• Particular difficulty with sounds that require more precise timing (speed) and accuracy-diphthongs, liquids, fricatives, affricates, consonant clusters.
• Overall sense that it requires effort to talk (effortful speech)
Management
The goal of the management is to improve intelligibility.
Goals setting is influenced by the type and degree of dysarthric impairment.
• For severely impaired individuals, establishing functional
communication through the use of augmentative or alternative systems may be the focus of intervention.
• In contrast, the aim of therapy for clients with mild dysarthrias is to reestablish speech patterns that closely approximate normal
production
Management
• (In general, there are) four basic approaches to dysarthria therapy:
Behavioral:
• This is the traditional approach, (in which progressively) more difficult
activities and feedback are used to improve client performance on both nonspeech and speech tasks. This may include use of verbal reinforcement, metronome, pacing,
biofeedback, delayed auditory feedback, and pacing boards.
• Prosthetic devices: The most common prosthesis used in the treatment of dysarthria is a palatal lift.
It is a mechanical device that elevates the soft palate toward the posterior pharyngeal wall to decrease hypernasal resonance in clients with velopharyngeal incompetence (VPI).
Medical and surgical procedures:
• A pharyngeal flap and phonosurgery are examples of surgical intervention approaches.
Pharyngeal flap surgery joins soft tissue from the posterior pharyngeal wall to the soft palate to improve velopharyngeal closure during speech.
• Augmentative/alternative devices:
It is a nonvocal modes of communication to supplement or replace speech. These may include communication boards, alphabet boards, gestural systems, computers, softwares.
Behavioral Management
(As SLPS our work is mainly focused on using the behavioral approach for management
There are numerous approaches to the behavioral treatment of dysarthria, and these are also varied and can be organized in a number of different ways.
• Treatment approaches related to Dysarthria type.
• Speech subsystem involvement (respiratory, articulatory,…)
• Some references organized treatment approaches according to the treatment goal (rate control or increased loudness)
Behavioral Management System approach
(here in the presentation I chose the system approach to discuss different treatment strategies and techniques)
• Dysarthria is an impairment that may affect all motor speech subsystems.
• System approach treatment of dysarthria is generally based on the affected/damaged subsystems: respiration, phonation, resonance, articulation, and prosody.
Behavioral Management
Respiratory Subsystem.
• The main respiratory problem of clients with dysarthria is inefficient use of the breath stream for speech, rather than a reduction of vital capacity (total volume of air in the lungs).
• The goal of intervention for this subsystem is to establish consistent, controlled exhalation of air to support speech production.
Behavioral Treatment Respiratory subsystem
• Improving Respiration efficiency through:
• Establish a stable base for respiratory function through adjustments of body posture.
(Note: Modifications of posture and seating should always be implemented in consultation with other health care professionals such as physical therapists, occupational therapists, or physicians.)
• Decrease shallow inhalation and improve control of sustained exhalation by manipulating inspiratory and expiratory cycles in nonspeech breathing.
• improve exhalation control by producing speech of increasing length and duration (beginning with isolated
phonemes and progressing gradually to longer segments).
For example,
• ask the client to produce and sustain a single phoneme (e.g., /s/) for as long as possible, gradually
progress to consonant series (e.g., /s-s-s-s-s-s/) and add vowels and other consonants (e.g., /sa/, /sap/);
Phonatory Subsystem
• Individuals with dysarthria exhibit a wide range of phonatory
abnormalities, which vary according to dysarthria type and underlying neurological damage.
• These problems can be classified into three main patterns of vocal fold movement: hyperadduction, hypoadduction, and incoordination.
• Increase control of glottal closure through sustained breath holding. For example, instruct the client to take a deep breath and hold it for as long as possible with a closed-mouth posture.
• One specific technique that addresses both phonatory and respiratory dimensions is the Lee Silverman Voice Technique (LSVT).
Articulation Subsystem
• Impairment of the articulators (lips, tongue, mandible, velum) has a greater negative impact on speech intelligibility than do disruptions of the respiratory or laryngeal systems.
• In dysarthria, the primary contributors to reduced intelligibility are distorted or omitted consonants and vowels.
The following strategies can be used to facilitate improved function in the articulation subsystem:
• Oral-motor exercises to normalize muscle tone and increase strength and mobility of articulatory
musculature (e.g., lip retraction and pursing, tongue elevation and depression, jaw opening and closing).
• Phonetic placement through explanation, modeling, and tactile stimulation of correct positioning of the articulators.
• Phonetic shaping
that utilize the use of intact articulatory movements associated with one phoneme (e.g., /t/ to shape a different phoneme, such as /n/).
• Over articulation of speech sounds through exaggeration of some characteristic feature of a specific phoneme (e.g., aspiration, stridency, voicing) or the exaggerated production of a particular consonant in medial or final word position.
Oral motor exrcises
Resonance Subsystem.
• The two main symptoms of dysarthric impairment in this subsystem are hypernasality and accompanying nasal air emission due to
impairment of the velopharyngeal musculature.
• Behavioral, prosthetic, and surgical approaches can be used to accomplish this goal.
• A behavioral regimen is most effective with clients who demonstrate mild resonance problems.
• For clients with moderate to severe impairments that significantly
impact speech intelligibility, a prosthetic or surgical approach may be recommended.
Prosody
The speech of clients with dysarthria is often characterized by prosodic and suprasegmental disturbances. Common characteristics include
monopitch, monoloudness, excessive and equal stress on each word, inappropriate phrasing and intonation contour patterns.
• Improve stress and intonation patterns through contrastive drills.
• This technique use identical pairs of stimuli that change in emphasis or meaning as a result of differences in stress or intonation.
• Modify speaking rate through manipulation of the number and duration of pauses. This can be accomplished through the use of metronomes, pacing boards, DAF, or tapping.
JSLHR Article
Intensive Voice Treatment (LSVT LOUD) for Children With Spastic Cerebral
Palsy and Dysarthria
Cynthia Marie Fox and Carol Ann Boliekb
Intensive Voice Treatment (LSVT LOUD) FOR
Children With Spastic Cerebral Palsy and Dysarthria
The purpose of this study was to examine the effects of an intensive voice treatment (Lee Silverman Voice Treatment, commonly known as LSVT LOUD) for children with spastic cerebral palsy (CP) and dysarthria.
LSVT LOUD
Has been developed for individuals with Parkinson's disease (PD) and has documented efficacy for that population.
• The training mode of LVST LOUD is consistent with principles that drive activity -dependent neuroplasticity and motor learning.
• LSVT uses intensive, high effort treatment coupled with proprioceptive feedback and auditory-vocal self monitoring to improve self-perception of speech motor output.
• Rationale:
is that increasing vocal loudness will trigger improved vocal quality, articulation and intonation as well as reduce rate of speech
Why it is suitable to be applied with CP
• The single focus on vocal loudness limits cognitive demands
associated with treatment, which may be important for children with low-average to below-average cognitive functioning.
• The target vocal loudness trained in LSVT LOUD is elicited through modeling behavior (e.g., “do what I do”), which minimizes detailed verbal instructions and may allow the child’s system to self-
organize in order to achieve the goal
The LSVT LOUD technique aims to:
• Increase vocal loudness.
• Improve articulation
• Improve intonation
• Modify sensory processing related to voice and speech.
Improvements due to LSVT LOUD training require work. Continued practice, self-monitoring, and attention to specific actions to sustain lasting change.
Method \Participants
Five children between the ages of 5 and 7 years with a medical diagnosis of spastic CP participated in this study (3 male and 2 female)
• Additional selection criteria:
• Dysarthria
• Hearing that was within normal limits or aided to normal limits
• No vocal pathology as determined by an otolaryngologist
• Ability to follow directions for the study tasks
• Stable medications.
Exclusion for:
• Children with severe velopharyngeal incompetence
• Structural disorders of the speech mechanism
• Concomitant speech disorder (stuttering)
• The severity of dysarthria for the participants range from mild to moderate.
• Intensive Voice Treatment
• LSVT LOUD treatment consisted of 16 individual 1-hour treatment sessions delivered on 4 consecutive days each week during 4 consecutive weeks.
• Homework and carryover exercises were assigned every day during the month of treatment.
• The first half of each treatment session consisted of three daily tasks:
• Maximum duration sustained vowels
• Maximum frequency range
• Repetition of 10 functional phrases five times each.
• The second half of the treatment sessions was spent on producing of speech progressing in difficulty from single words to conversational speech.
LSVT LOUD
• All exercises included a minimum of 15 repetitions of each training task.
• (while incorporating) sesnsory augmentation, such as cueing the children to increase vocal effort and loudness, and sensory
awareness by asking the children (did you feel your voice?)
• Children practiced one homework session on treatment days (lasting 5-10 min) and two homework sessions on non-treatment days (lasting 10-15 min).
Auditory-perceptual Analysis
• Auditory–perceptual analysis of speech, acoustic measures of vocal functioning, and perceptual ratings by parents of participants were
obtained at baseline, posttreatment, and 6-week follow-up recording sessions.
Results
Listeners consistently preferred the speech samples taken immediately post-treatment over those taken during the baseline phase for most perceptual characteristics rated in this study.
• Conclusions:
These findings provide some preliminary observations that the children with spastic CP in this study not only tolerated intensive voice treatment but also showed improvement on select aspects of vocal functioning.
This topic is about Dysarthria in Childhood, but I found that
In the majority of studies of childhood dysarthria reported in the literature to date, they used
clinical features, classification systems , models, management approaches, terminologies, borrowed from the literature on adult
dysarthria.
