2/15/2016 1 Dysphagia and Dysarthria: The Relationship of Sensorimotor- Speech and Swallowing Duane Trahan, MS, CCC-SLP Page 2 Types of Dysarthria Duffy (2005) Page 3 Dysarthria May effect the Aerodigestive System related to Timing Vocal quality Pitch Volume Breath control Speed Strength Steadiness Range Tone
21
Embed
Trahan-Dysarthria - alabamashaa.org 2016/Trahan-Dysarthria... · Pseudobulbar affect ii. Dysphagia, Drooling, ... Pseudobulbar Palsy Slow/Inadequate chewing, Difficulty with bolus
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
2/15/2016
1
Dysphagia and Dysarthria:The Relationship of Sensorimotor-
Speech and Swallowing
Duane Trahan, MS, CCC-SLP
Page 2
Types of Dysarthria
Duffy (2005)
Page 3
Dysarthria
May effect the Aerodigestive System related to
Timing
Vocal quality
Pitch
Volume
Breath control
Speed
Strength
Steadiness
Range
Tone
2/15/2016
2
Page 4
Dysarthria and Dysphagia
Comparing Swallowing and Speech
Swallowing
Generally reflexive
One of the most primitive behaviors
Controlled in large part by the Medulla
Speech
Voluntary
Uniquely human behavior
Controlled by several higher brain elements
Cerebral Cortex
Cerebellum
Basal Ganglia
Page 5
Common Neurologic Conditions resulting in Dysarthria & Dysphagia
(Nishio et.al.) Strong correlation between Dysarthria and Dysphagia in patients with Neuromuscular disease
(Jani et.al.) Co‐occurrence of Dysarthria and Dysphagia in patients with Neurological disorders was 45%
(Yorkston et.al. & da Costa) Strong relationship between Swallowing and Dysarthria with ALS & significant correlation of Dysphagia and Dysarthria scales
(Litvan et. al.) Dysphagia is associated with Dysarthria with Progressive Supranuclear Palsy (PSP)
(Kluin et.al.) Dysphagia was more severe than Dysarthria with Myasthenia Gravis
(Daniels et.al. & Leder et.al.) Significant relationship between dysarthria and aspiration with Acute Stroke
(Logemann et.al.) The best predictor of the presence or absence of an oral stage problem in Dysphagia is Dysarthria
(Horner et.al.) Aspiration strongly correlated with the severity of dysphagia (mild, moderate, and severe)
Nishio (2004)
2/15/2016
3
Page 7
Occurrence of Communication and Swallowing Disorder
Jani (2014)
Page 8
Occurrence of Communication and Swallowing Disorder
Jani (2014)
Page 9Jani (2014)
Dysphagia with Dysarthria
• 0%
• CNT
• 100%
• 100%
• 0%
• 100%
• 100%
• 100%
2/15/2016
4
Page 10
Prevalence amongst Etiology
Nishio (2004)
Page 11
Dysphagia Severity by Type of Dysarthria
Nishio (2004).
Page 12
Rating Scale of Dysphagia
Nishio, Masaki M (2004). Adapted from Yorkston et.al.
2/15/2016
5
Page 13
Prevalence of Dysarthria with Dysphagia
Overall agreement that Medullary infarcts have high correlation of both
Impaired tongue movement is significant for both
Negative correlation between conversational intelligibility and swallowing function is significant
Regarding neuromuscular dysfunction there is no significant difference between gender or age
Page 14
Distinguishing Oral Mechanism Findings
i. = Distinguishing when present; ii. = May be present Flaccid
i. Atrophy, Fasciculations, Rapid deterioration & recovery with rest, Nasal regurgitation, Unilateral palatal weakness
ii. Hypoactive gag, Hypotonia, Dysphagia, Drooling, Unilateral lingual weakness without atrophy
Weakness, Reduced Reflexes, Atrophy, Fasciculations, Progressive weakness with use
Page 17
Dysphagia Severity by Type of Dysarthria (Flaccid)
Nishio (2004).
Page 18
Flaccid Dysarthria
Considerations for Oral Swallowing
Trigeminal (V)
Jaw deviation to weak side (U) or hang open (B), Decreased bite, Impaired sensation to face, lip, cheek, tongue, teeth, or palate, Decreased tension of floor of mouth
Facial (VII)
Lower face weakness and loss of tone including lip and cheek (U/B)
Glossopharyngeal (IX)
Reduced gag, Brief attacks of severe pain in throat, neck, lower jaw with tongue protrusion or swallowing
Translation into potential deficits
(V): Impaired mastication, Impaired extreme jaw opening, Drooling, Buccal/Lingual/Floor of mouth stasis due to sensation, Decreased hyoid elevation
(VII): Drooling, Impaired sucking, Impaired lip seal, Anterior loss of bolus, Buccal stasis/pocketing
(IX): No significant issues
*U/B = unilateral (U) or bilateral (B)
2/15/2016
7
Page 19
Flaccid Dysarthria
Considerations for Oral Swallowing Vagus (X)
Palatal weakness (U/B)
Accessory (XI)
Reduced shoulder elevation and weakened head turn
Hypoglossal (XII)
Tongue weakness (U/B) and deviation (U), Decreased anterior excursion of hyoid
Translation into potential deficits (X): Nasal regurgitation, Main issues
are pharyngeal and laryngeal
(XI): Postural issues affecting respiration, may predispose to drooling and anterior loss of bolus; Issues for postural strategy consideration
(XII): Most significant. Global oral deficits: Bolus manipulation & cohesion, Posterior bolus transport, Tongue base retraction, Buccal/Lingual/Floor of mouth stasis due to weakness, Palatal/Roof of mouth stasis, Premature pharyngeal spillage, Vallecular stasis, Stasis at pyriforms/UES inlet (2/2 hyoid excursion)*U/B = unilateral (U) or bilateral (B)
Page 20
Flaccid Dysarthria
Considerations for Pharyngeal Swallowing
Respiratory Reduced vital capacity,
Abnormal chest wall movements, Neck and glossopharyngeal breathing (compensatory)
Laryngeal Incomplete glottal closure (U/B),
Increased breaths per minute, Reduced pause frequency and duration, Reduced range and variability
Translation into potential deficits
Respiratory
Poor breath support, Diminished cough, Abnormal respiratory cycle during swallowing, Decreased apneic period during swallowing, Delayed onset of oropharyngeal swallow,
Predisposition to penetration and/or aspiration before swallow, Penetration and/or aspiration after the swallow
Penetration (U/B) and/or aspiration during and/or after the swallow, Incomplete clearance of residual from the laryngeal vestibule
*U/B = unilateral or bilateral
Page 21
Flaccid Dysarthria
Considerations for Pharyngeal Swallowing (cont…)
Velo- & Hypopharyngeal
Reduced or absent palatal movement (U/B), Reduced or absent pharyngeal wall movement (U/B), Increased nasal airflow, Reduced pitch range, Reduced overall intensity and intensity range, Extra resonances
Lingual Reduced sustained lingual force
Translation into potential deficits (cont…)
Velopharyngeal Nasal regurgitation, Impaired/loss of
Damage to Pyramidal Tract/Direct Activation Pathway/Upper Motor Neurons and Extrapyramidal Tract/Indirect Activation Pathway bilaterally
Degenerative (40%), Vascular (29%), ALS (14%) Traumatic, Demyelinating, Tumor, Undetermined
Speech deficits
Generalized hypertonicity, weakness, immobility, abnormal force physiology, and exaggerated reflexes of virtually all muscles of the speech mechanism produce obvious dysfunction of the articulation subsystem. Speech is slow-labored, and imprecise articulatory efforts, compounded by disturbances of respiration; resonation, and phonation often render speech unintelligible
Dysphagia is common and sometime severe
2/15/2016
9
Page 25
Dysphagia Severity by Type of Dysarthria (Spastic)
Nishio (2004).
Page 26
Spastic Dysarthria
Considerations for Oral Swallowing
Diminished chewing
Decreased frequency of swallowing
Slowed jaw, lip and facial movements
Reduced ROM of and strength of tongue
Slowness and reduced range of individual and repetitive movements
Reduced force of movements
Excessive muscle tone
Hyperactive gag
Oral reflexes may be present Sucking, Snout, Jaw Jerk
Translation into potential deficits
Food avoidance, Increased mastication time, Impaired mastication, Piecemeal deglutition
exhalatory volumes, respiratory intake, vital capacity, maximum vowel prolongation; Paradoxical breathing in which abdominals fail to relax during inhalation
Laryngeal
Decreased laryngeal airflow, Increased: subglottal pressure, glottal resistance, Hyperadduction of true & false cords during speech (? compensative for underlying hypofunction), Slowed laryngeal movements
Translation into potential deficits
Respiratory
Poor breath support, Diminished cough, Abnormal respiratory cycle during swallowing, Decreased apneic period during swallowing, Delayed onset of oropharyngeal swallow,
Predisposition to penetration and/or aspiration before swallow, Penetration and/or aspiration after the swallow
Laryngeal Incomplete laryngeal vestibule closure,
Incomplete vocal fold closure, Incoordination of pharyngeal/laryngeal structures
Penetration (U/B) and/or aspiration during and/or after the swallow
*U/B = unilateral or bilateral
2/15/2016
10
Page 28
Spastic Dysarthria
Considerations for Pharyngeal Swallowing (cont…) Velo- & Hypopharyngeal
Oral mechanism exam is often normal and reflexive swallow is usually normal on casual observation
2/15/2016
11
Page 31
Dysphagia Severity by Type of Dysarthria (Ataxic)
Nishio (2004).
Page 32
Ataxic Dysarthria
Considerations for Oropharyngeal Swallowing
Usually reported with progressive ataxias
Related to discoordination of oral, pharyngeal, laryngeal, and respiratory mvmtsmainly during volitional mvmts
Issues are usually involved in the Oral stage of swallowing
Translation into potential deficits
Incoordination of bolus preparation & mastication
Diminished mastication
Premature spillage
Piecemeal deglutition
Oral stasis (labial and buccal sulci)
Page 33
Ataxic Dysarthria
Considerations for Oropharyngeal Swallowing
Respiratory &/or Laryngeal
Abnormal and paradoxical rib cage and abdominal mvmts, Reduced vital capacity 2/2 incoordination, Voice tremor, Increased shimmer & jitter, Increased voice onset time, Increased pitch, Poor laryngeal control or laryngeal-supraglottictiming errors
Translation into potential deficits
Respiratory
Poor breath support, Diminished cough, Abnormal respiratory cycle during swallowing, Delayed closure of vocal cords, Decreased apneic period during swallowing, Delayed onset of oropharyngeal swallow,
Predisposition to penetration and/or aspiration before and during swallow with liquids, Penetration and/or aspiration after the swallow with solids
2/15/2016
12
Page 34
Ataxic Dysarthria
Considerations for Oropharyngeal Swallowing
Velopharyngeal Inconsistent velopharyngeal
closure
Lingual Difficulty initiating purposeful
mvmt, Slow tongue mvmt, Reduced range and velocity, Reduced or restricted anterior-posterior mvmt during vowel production
Translation into potential deficits
Velopharyngeal Intermittent nasal regurgitation
Lingual Impaired bolus control/cohesion,
Premature spillage, Impaired bolus transit, Incoordination between lingual and pharyngeal structures, Impaired bolus propulsion
Abnormal respiratory cycle during swallowing, Decreased apneic period during swallowing, Fatigue
Predisposition to penetration and aspiration before swallow, Penetration and/or aspiration after the swallow; Silent aspiration
Laryngeal Incomplete vocal fold closure, Impaired
laryngeal elevation
Penetration and aspiration during and/or after the swallow, Inability to clear penetrated or aspirated material
Page 42
Hypokinetic Dysarthria
Considerations for Pharyngeal Swallowing (cont…)
Velo- & Hypopharyngeal
Increased nasal airflow during speech, Reduced velocity and degree of velar movement
Lingual Reduced: amplitude & velocity
of tongue & jaw stability, tongue endurance and strength, speech rate
Abnormal tremor at rest and active/passive movement
Translation into potential deficits (cont…)
Velopharyngeal Nasal regurgitation, Impaired/loss of
positive pressure generation of bolus, Diminished pharyngeal stripping wave
Penetration/Aspiration after the swallow, Stasis in valleculae/lateral channels/pyriform sinuses
Lingual
Impaired tongue base retraction, Decreased pressure generation, Impaired anterior hyoid excursion, Secondary PES dysfunction,
Oral stasis, Stasis on base of tongue/valleculae, Stasis in pyriforms/UES inlet, Predisposition to penetration and aspiration after swallow from residual
2/15/2016
15
Page 43
Hypokinetic Dysarthria
Parkinson’s
Lingual tremor, Multiple lingual gestures, Increased oral transit time, Premature spillage, Pharyngeal swallow delay, Decreased laryngeal elevation and closure, Decreased UES relaxation, Oral and pharyngeal residue, Penetration, Aspiration as the disease progresses
Considerations for Oropharygneal Swallowing Variable depending on
characteristics
Chorea
Oral: Quick/unpredictable involuntary mvmts of tongue/velum/mouth/ jaw, Inability to sustain steady head/tongue/ jaw/facial postures, Reduced ROM and incoordination of tongue & lips
Pharyngeal: Choreiformmvmts of laryngeal structures, Sudden/forced/involuntary inspiration or expiration
Translation into potential deficits Chorea
Oral: Disordered oral prep, Impaired mastication, Impaired bolus cohesion, Premature spillage of inadequately masticated solids and liquids, Nasal regurgitation, Anterior loss of bolus, Impaired bolus transit
Pharyngeal: Loss of bolus pressure generation, Penetration or aspiration of liquids and solids, Risk for inhalation of food/liquid, Inability to maintain breath hold during swallowing, Valleculae stasis, Pyriform stasis
2/15/2016
16
Page 46
Hyperkinetic Dysarthria
Considerations for Oropharygneal Swallowing Dystonia- dysphagia is often
underdiagnosed (>50%)
Oral: Spasms leading to mouth opening/closing, lip pursing/retraction, & protrusion or rotary mvmts of tongue;
Pharyngeal: Spasms may elevate larynx, Torsion of neck/torticollis
Myoclonus
Transient complaints of dysphagia; Mainly related to timing of swallowing
Spasmodic Dysphonia
Generally dysphagia stems from treatment (Botox)
Translation into potential deficits Dystonia
Oral: Disordered oral prep, Impaired mastication, Impaired bolus cohesion, Premature spillage of inadequately masticated solids and liquids, Anterior loss of bolus, Impaired bolus transit, Oral stasis
Pharyngeal: Asymmetric pharyngeal transit, Penetration or aspiration of liquids, Valleculae stasis, Pyriform stasis
Myoclonus
Penetration or aspiration before the swallow, Intermittent hypopharyngeal stasis clearing with repeat swallow
Postural and compensatory strategies, Early intervention to prevent maladaptive behaviors, Adaptive equipment, Dietary modifications and alterations, PEG for supplemental with transition to primary with disease progression
Some evidence to support respiratory retraining, Vocal fold adduction and Oral motor exercise in adjunct to pharmacological tx
Dystonia
Botox injections. May result in worsening of dysphagia symptoms and changes in impairment
2/15/2016
17
Page 49
Unilateral Upper Motor Neuron (UMN) Dysarthria
Damage to the Upper Motor Neuron pathways
Usually reflect the effects of weakness, but sometimes spasticity and incoordination are implicated
Vascular (90%), Traumatic (4%), Tumor(4%)
Swallowing correlates with severity of dysarthria
Speech is often slurred, thick, or slow and deteriorates under fatigue or stress
May occur in conjunction with Apraxia, Aphasia, and/or Cognitive deficits
Page 50
Dysphagia Severity by Type of Dysarthria (Unilateral Upper Motor Neuron)
Nishio (2004).
Page 51
Unilateral UMN Dysarthria
Considerations for Oropharyngeal Swallow Dysphagia is usually mild and recovery
is good. More severe maybe related to confounding cognitive issues
Next to Spastic Dysarthria, has highest rate of co-existing Dysphagia ranging in all severities
Page 56
Degenerative Disease
Identifying typical changes in speech and swallowing that occur at the onset of each disease that can be used to identify the disease entity
Are there progressive and predictable changes
How long can the patient continue to eat by mouth
What techniques can prolong oral feeding
Page 57
Sudden-Onset versus Degenerative Neurologic Disorder
Sensitivity to aspiration appears to be significantly reduced, indicated by failure to cough
If there is a cough, may be non-productive in clearing aspirated material
Unaware of swallowing disturbances and deny swallowing problem
Lack of awareness of residue material in the pharynx; therefore, often do not dry swallow to clear residue
High potential for silent aspiration before, during, and even distantly after swallowing
Sensory deficits may be result of sudden neurologic deficit; or of desensitization by the presence of residue and aspiration chronically
Fatigue
2/15/2016
20
Page 58
Management/Treatment
Medical management
Pharmacological/Surgical
Communication needs
Nutritional needs
Restoring lost function
Promoting use of residual function
Prosthetics/AAC.
Structures/Functions involved in both deficts
Similarities/Differences
Page 59
References
Abdulmassih, Edna Márcia da Silva EM (01/2013). "The evaluation of swallowing in patients with spinocerebellar ataxia and oropharyngeal dysphagia: A comparison study of videofluoroscopic and sonar doppler.". International Archives of Otorhinolaryngology(1809-9777), 17(1), p.66. PMID:26038680DOI:10.7162/S1809-97772013000100012
Camargo, C. H. F., da Silva Abdulmassih, E. M., Santos, R. S., & Teive, H. A. G. (2015). “Dysphagia in Dystonia.”
Campisi, G G (06/2009). "Oral dysphagia. An unique symptom for a wide spectrum of diseases.". Panminerva medica(0031-0808), 51(2), p.125. PMID:19776713
Cordato, N. J., Halliday, G. M., Caine, D. and Morris, J. G.L. (2006), Comparison of motor, cognitive, and behavioral features in progressive supranuclear palsy and Parkinson's disease. Mov. Disord., 21: 632–638. doi: 10.1002/mds.20779
da Costa Franceschini, Andressa A (2015). "Dysarthria and dysphagia in Amyotrophic Lateral Sclerosis with spinal onset: a study of quality of life related to swallowing.". NeuroRehabilitation (Reading, Mass.)(1053-8135), 36(1), p.127. PMID:25547774
Daniels, S. K. (2006). Neurological disorders affecting oral, pharyngeal swallowing. GI Motility online.
Daniels SK, Mahoney MC, Lyons GD. Persistent dysphagia and dysphonia following cervical spine surgery. Ear Nose Throat J1998;77:470,473–475.
De Pauw A, Dejaeger E, D'Hooghe B, Carton H. Dysphagia in multiple sclerosis. Clin Neurol Neurosurg 2002;104:345–351.
Duffy, Joseph (2005). Motor Speech Disorders: Substrates, Differential Diagnosis, and Management. St. Louis, Mo: Elsevier Mosby
Edmonds C. Huntington's chorea, dysphagia and death. Med J Aust 1966;2:273–274.
Ertekin C, et al. Electrophysiological evaluation of pharyngeal phase of swallowing in patients with Parkinson's disease. MovDisord 2002;17:942–949.
Page 60
References
Ertekin C, et al. Pathophysiological mechanisms of oropharyngeal dysphagia in amyotrophic lateral sclerosis. Brain2000;123(pt 1):125–140.
Giddens, C. L., & Ramig, L. “Speech and Swallowing Disorders in Chorea.”
Gregory RP, Smith PT, Rudge P. Tardive dyskinesia presenting as severe dysphagia. J Neurol Neurosurg Psychiatry1992;55:1203–1204.
Higo R, Tayama N, Nito T. Longitudinal analysis of progression of dysphagia in amyotrophic lateral sclerosis. Auris NasusLarynx 2004;31:247–254.
Hussar AE, Bragg DG. The effect of chlorpromazine on the swallowing function in chronic schizophrenic patients. Am J Psychiatry 1969;126:570–573.
Jani M, Gore G. Occurrence of communication and swallowing problems in neurological disorders: Analysis of forty patients. Neurorehabilitation [serial online]. November 2014;35(4):719-727 9p. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed January 14, 2016.
Johnston BT, Li Q, Castell JA, Castell DO. Swallowing and esophageal function in Parkinson's disease. Am J Gastroenterol1995;90:1741–1746.
Knuijt, Simone S (2014). "Dysarthria and dysphagia are highly prevalent among various types of neuromuscular diseases.". Disability and rehabilitation(0963-8288), 36(15), p.1285. PMID:24151818DOI:10.3109/09638288.2013.845255
Leopold NA, Kagel MC. Dysphagia in progressive supranuclear palsy: radiologic features. Dysphagia 1997;12:140–143.
Leopold NA, Kagel MC. Pharyngo-esophageal dysphagia in Parkinson's disease. Dysphagia 1997;12:11–18; discussion 19–20.
Litvan, I I (06/1997). "Characterizing swallowing abnormalities in progressive supranuclear palsy.". Neurology(0028-3878), 48(6), p.1654. PMID:9191782
Litvan I, et al. Natural history of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome) and clinical predictors of survival: a clinicopathological study. J Neurol Neurosurg Psychiatry 1996;60:615–620.
2/15/2016
21
Page 61
References
Logemann JA. Evaluation and Treatment of Swallowing Disorders. Austin: Pro-Ed, 1998.
Mackay LE, Morgan AS, Bernstein BA. Swallowing disorders in severe brain injury: risk factors affecting return to oral intake. Arch Phys Med Rehabil 1999;80:365–371.
Martin RE, Neary MA, Diamant NE. Dysphagia following anterior cervical spine surgery. Dysphagia 1997;12:2–8; discussion 9–10.
Nagaya, Masahiro M (05/2004). "Videofluorographic observations on swallowing in patients with dysphagia due to neurodegenerative diseases.". Nagoya journal of medical science(0027-7622), 67(1-2), p.17. PMID:15279064
Nishio, Masaki M (2004). "Relationship between speech and swallowing disorders in patients with neuromuscular disease.". Folia phoniatrica et logopaedica(1021-7762), 56(5), p.291.
Ray, Jayanti J (11/2002). "Orofacial myofunctional therapy in dysarthria: a study on speech intelligibility.". The International journal of orofacial myology(0735-0120), 28, p.39.
Robbins J. Swallowing in ALS and motor neuron disorders. Neurol Clin 1987;5:213–229.
Rosenbek, J. C., & Jones, H. N. (2006). Dysphagia in patients with motor speech disorders. Motor Speech Disorders: Essays for Ray Kent, 221.
Tjaden, Kris K (2008). "Speech and Swallowing in Parkinson's Disease.". Topics in geriatric rehabilitation(0882-7524), 24(2), p.115. PMID:19946386DOI:10.1097/01.TGR.0000318899.87690.44