Purpose of the evaluation (Respiration, Phonation, Articulation, Resonance, and Prosody)
To determine whether the patient's speech is abnormal
To evaluate the nature and severity of speech abnormalities
To determine the cause or causes of speech abnormalities
To determine whether treatment is appropriate
To identify potential directions for t
Where do we start the eval?
Assessment begins with in-depth oral motor exam. Looking at:
- Breath support
- Phonation (voice)
- Resonance (control of nasal resonance)
- Articulation (shaping of consonants and vowels)
What does speech require?
Speech requires breath support
Speech requires voice
Speech requires control of nasal resonance
- Make sure soft palate is working
Speech requires shaping of consonants and vowels
- Make sure articulators are working appropriately
How are phonation and resonance rated?
Phonation and resonance are estimated with a rating scale in which a subjective judgment of pitch, loudness, voice quality, and nasality is completed.
Typical pitch for age/gender? Loudness typical?
Might ask if they were quiet beforehand. Ask if they hav
What do we need to do prior to checking phonation?
Need to check integrity of laryngeal muscles.
First ask pt: Grunt, cough, glottal stops
Patients who are weak in this area present with sharper glottal stops and grunts than coughs because grunts and glottal stops require less respiratory support than cou
What is the first step in checking phonation?
First step in checking phonation is sustained vowel until the patient runs out of air supply. At this time the clinician also evaluates the loudness, pitch, and quality of the patient's voice. (Take as deep of breath as possible then say "ah" until they r
Phonation times below ___ seconds are considered low and suggest problems either with glottal valving or with breath support for speech.
12 to 15
Poor phonation could represent what damage?
This could represent damage the laryngeal branches of the vagus nerve.
Weak muscles cannot fully adduct the vocal folds which allows air to leak out and be wasted. This manifests itself in diminished phonation time, plus breathy and weak voice quality and
Bilateral damage to upper motor neurons causes a _____ voice quality.
How many seconds of sustained phonation do these clients have skills to produce?
strained-strangled-harsh
Clients with bilateral upper motor neuron pathology have sufficient respiratory skills to produce 5 -10 seconds of sustained phonation, although with a strained-strangled-harsh quality.
Cerebellar pathology impact on phonation
Typically can produce 5 to 10 seconds of sustained phonation, although voice quality is likely to be abnormal and both loudness and quality may fluctuate.
Extrapyramidal diseases impact on phonation
Maximum phonation times for patients with extrapyramidal disease range from substantially reduced (3 to 4 seconds) to normal, depending on the efficiency of glottal valving and the degree to which respiratory muscles are affected.
Parkinson's disease impact on phonation
Typically have breathy, hoarse voices, with the maximum phonation time reduced by laryngeal muscle rigidity. Patients with Parkinson's disease often begin phonation normally but sound progressively more strangled as they continue to phonate. Often must te
Ideas for loudness, pitch, control assessment
Count aloud from 1 to 10, beginning in a whisper and ending in a shout, and from 1 to 10 beginning in a shout and ending in a whisper.
Progressively change the pitch of an open vowel up and down a musical scale.
If unable to do this (follow direction or p
Velopharyngeal Sufficiency and Resonation Assessment
Isolation of the pharyngeal and oral cavities from the nasal cavity during swallowing and production of denasalized speech sounds.
Accomplished by movement of the velum up and back to meet the posterior pharyngeal wall and by movement of the lateral phary
Exam of V-P function steps
1. Observe the palate and pharynx at rest.
2. Assess mechanics by asking the patient to puff out her or his cheeks with air.
3. Listen for nasal escape of air as the patient sustains phonation (use mirror or tissue)
4. Ask the patient to produce a sustain
Observe the palate and pharynx at rest - what to look for
Bilateral palatal droop suggests bilateral weakness of the muscles that elevate the palate. Unilateral palatal droop suggests weakness of palatal muscles on the drooping side.
Spontaneous rippling or dimpling of palatal muscles suggests loss of input from
Inability to puff out cheeks with air suggests...
Inability to perform this action, especially when attempts are accompanied by nasal air escape, suggests poor velopharyngeal closure.
Ability in puffing out the cheeks does not prove velopharyngeal closure. Some patients with weak velopharyngeal muscles c
A patient's failure to elevate the palate during phonation suggests....
bilateral weakness in palatal muscles. Asymmetric elevation suggests unilateral weakness of palatal muscles on the drooping side.
Resonance assessment
Can be challenging to assess as other distortions can impede accurate assessment
Hypernasality can be assessed by the clinician alternately pinching and releasing the patient's nostrils as the patient produces a sustained vowel.
If the patient is hypernas
Prosody assessment
Prosody typically is estimated with a rating scale with which the examiner judges characteristics such as rate, phrase length, stress, and intonation.
Respiration assessment
Estimated indirectly with measures such as forced expiration time, sustained phonation time, or maximum utterance length.
Seeing if individual is able to sustain phonation for x amount of time (must take in enough air to sustain phonation).
Measure maximu
What is Normal Respiration?
Diaphragm contracts, pushing abdominal contents down, which increases the lung volume. Exhalation during normal passive breathing is produced by relaxation of shoulder, chest, and abdominal muscles.
For speech, do we engage in passive or active respiration?
The forces present during passive breathing do not create enough breath pressure for speech, so normal speakers boost respiratory drive by actively contracting the abdominal muscles (Hixon, 1987).
How does posture impact respiratory sufficiency?
Posture impacts respiratory sufficiency. Patients who slouch and bend forward at the waist when standing or sitting and those who sit or stand with the chin lowered and the head drooping may compromise respiration for speech by compressing the chest cavit
During passive breathing, how much do normal adults inflate their lungs? During active respiration?
During passive breathing, normal adults inflate the lungs to about 20% of total capacity, but when they speak they inflate them to from 35% to 60% of total capacity (Hixon, 1987)
Normal passive respiration rates
Normal passive respiration rates range from 12 to 20 cycles per minute, and movement of the shoulders or head during passive breathing is not obvious.
How do we determine adequate respiration for speech?
Ask the client to sustain phonation and repeat long strings of syllables. Typical adults can sustain phonation of vowel for 8 to 10 seconds and can produce at least 15 to 20 monosyllables on a single breath.
How should sustained phonation sound?
Should sound strong, steady (not changing) for about 8-10 seconds. If it sounds strangled, that's not typical (not enough respiratory support).
Instructions to have patient do sustained phonation
I need you to take a deep breath and say ah as long, steady, and clearly as you can. (demonstrate) Please remember you need to take a deep breath all the way into your belly. Put your hands on your stomach and fill up your stomach with air.
True/False: If you are concerned that the patient is unable to produce adequate respiration, an instrumental exam may be warranted with a ENT or a SLP who specializes in voice.
True
Articulation assessment
Articulation is measured with a combination of rating scales and scoring of articulation in speech-production tasks
First, perform oral mech
Oral mech tasks for articulation
Look at:
facial muscles at rest,
jaw muscles,
lip movements,
tongue movement and strength,
speech movements
Intelligibility assessment
There is an assessment called Assessment of Intelligibility of Dysarthric Speech but using this is not necessary.
Instead, look at:
Percent intelligibility
Speech rate for sentences
Intelligible words per minute
Unintelligible words per minute
Communicati
Percent intelligibility
% consonants correct (at conversational level or at single syllable word level if lower ability)
Speech rate for sentences
Words per minute - the less intelligible they are, the fewer words per minute they'll produce.
Communicative efficiency ratio
Intelligible words per minute divided by normal speech rate