Slurred speech resident survival guide

Slurred speach resident survival guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Usman Ali Akbar, M.B.B.S.[2]

Synonyms and Keywords: Approach to dysarthria, Approach to slurred speech, Approach to difficulty in speaking,Approach to motor speech disorders.

Overview

Slurred Speech or Dysarthria is usually defined as difficulty in speech and is a motor speech disorder caused by a neurological deficit resulting in weakening or paralysis of the muscles responsible for speech formation. The causes of dysarthria are vast and depend upon the location of the lesion. The treatment of dysarthria depends upon the etiology. Treatment usually focuses on achieving independent daily living for the patients. These include Augmentative and alternative communication, Lee Silverman voice treatment and Pitch Limiting Voice Treatment.

Causes

The causes of slurred speech and dysarthria are vast and can be classified as follows.

Types of Dysarthria

	Flaccid Dysarthria	Spastic Dyasarthria	Mixed Dysarthria (Flaccid/Spastic)	Ataxic Dysarthria	Hypokinetic Dysarthria	Hyperkinetic Dysarthria
Site of Lesion	LMN neurons	Upper motor neurons	Upper and Lower motor neuron	Cerebellum	Substantia nigra, Medication induced	Extrapyramidal tract, specifically the basal ganglia; may be unilateral or bilateral
Causes	Viral infection, Tumor, CVA, Congenital conditions, disease, palsies and trauma.	CVA, Tumor, Infection, Trauma, Congenital Conditions	ALS, Trauma, CVA	CVA, Tumor, Trauma, Congenital Condition, Infection, Toxic effects	Parkinsonism, Drug-induced	Chorea, Infection, Gilles de la Tourette Syndrome, Ballism, Athetosis, CVA, Tumor, Dystonia, Drug induced, Dyskinesia.
Speech Characteristics	Hypernasality, imprecise consonants, breathiness, mono-pitch, nasal emission.	Imprecise consonants, mono-pitch, reduced stress, harsh vocal quality, mono loudness, low pitch, slow rate, hypernasality, strained-strangled voice, short phrases.	Imprecise consonants, hypernasality, harsh vocal quality, slow rate, mono-pitch, short phrases, distorted vowels, low pitch, mono loudness, excess and equal stress, prolonged intervals.	Imprecise consonants, excess and equal stress, irregular articulatory breakdowns, distorted vowels, harsh voice, loudness control problems, variable nasality.	Monopitch, reduced stress, mono loudness, imprecise consonants, inappropriate silences, short rushes of speech, harsh voice, breathy voice.	Imprecise consonants, distorted vowels, harsh voice quality, irregular articulatory breakdowns, strained-strangled voice, mono-pitch, mono loudness.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of dysarthria or slurred speech according the the The American Speech-Language-Hearing Association (ASHA) guidelines.

Patient with slurred speech

History Onset of Symptoms Course of Symptoms Associated Conditions such as language disorders Prior Medical Procedures Medications Adverse Events History of Educational, vocational, Linguistic Background Family's opinion of speech Identification of barriers to effective communication

Non-Speech Examination To assess the speed, strength, range, and accuracy of movements not related to the speech by doing clinical> Cranial nerve examination Facial and neck muscle tones examination To observe sustained vowel prolongation in order to assess adequate pulmonary and laryngeal support Judging the speed and regularity of jaw, lip and tongue movement

Speech Production Vocal quality and change in pitch production Stress Testing- 2-4 minutes of reading or speaking is given and an assessment of deterioration is done over time Motor speech planning or programming is done. To observe sustained vowel prolongation in order to assess adequate pulmonary and laryngeal support Judging the speed and regularity of jaw, lip, and tongue movement Assessment of Prosody Assessment of speech intelligibility Assessment of Comprehension and Efficiency of Speech

Wasted and weak tongue, weak voice nasal emission of air, dysphonia, poor or absent palatal deviation, absent gag and jaw jerk reflex

Non-wasted tongue, poor tongue movements, slurred speech, poor palatal elevation, brisk gag reflex, brisk jaw reflex

Scanning speech, irregular articulation, and poor voice volume and breathing control

Hypophonia, monopitch voice, slurring and fast rate speech

Poor coordination with breathing, harsh, superimposed bulbar involuntary movements, poorly modulated.

Combination of flaccid and spastic dysarthria symptoms

Lower Motor Neuron Lesion

Upper motor Neuron Lesion

Cerebellum/Outflow pathways lesion

Sustantia Nigra Lesion

Caudate/Putamen Lesion

Both upper and lower motor neuron Lesion

Flaccid Dysarthria

Spastic Dysarthria

Ataxic Dysarthria

Hypokinetic

Hyperkinetic

Mixed Flaccid-Spastic Lesion

Treatment

Shown below is an algorithm summarizing the treatment of dysarthria or slurred speech according the the The American Speech-Language-Hearing Association (ASHA) guidelines.

Treatment of Dysarthria/Slurred Speech Treatment is based on etiology and type of dysarthria

General Recommendations include Implementation of Speech Viewer III SpeechViewer III is an IBM Independence Series product. It is used for speech/language pathologists, teachers, and other professionals to use in modifying speech patterns. Exercises to modulate loudness, pitch range, and timing. A speech language pathologist assist in improving respiration, phonation, resonance, prosody and/or articulation using various techniques. These treatment includes exercises and techniques to adjust speech rate, strengthen muscles of articulation, increase breath support, improve articulation, safe chewing and swallowing, avoiding conversations when feeling tired, repeat words and syllables, and techniques to deal with the frustration while speaking. If dysarthria is severe, another possible technique includes using computer or flip cards to communicate more effectively. Augmentative and alternative communication (AAC) is used by speech language pathologist to supplement or replace natural speech. Lee Silverman voice treatment(LSVT) focuses on increasing vocal loudness and is found to be effective in patients with Parkinson's disease. Pitch Limiting Voice Treatment (PLVT) increases loudness without increasing pitch. Treat underlying cause and slowing progression of the disease causing motor speech dysfunction.

Do's

• Communication strategies should employed by the patient with dysarthria.
• Eye contact should be maintained with the communication partner.
• Repair strategies such as restating message in different words and using gestures to help convey messages should be used.
• Environmental modification such as reducing background noise and ensuring that good lighting is present.
• Face to face seating for conversations should be employed.

Don'ts

• Don't speak too fast. Speak slowly so that listeners may understand you better.
• Don't go for long topics. Ask the patient to start small and introduce the topic of conversation with one word or short phrase.
• Fatigue can make it difficult for patients to speak clearly.
• Background noise should be reduced.

References

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