Management of Motor Speech Disorders in Children and Adults 3rd Edition Kathryn M Yorkston David R Beukelman Edythe Ha Strand Mark Hakel
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Management of
Motor Speech
Disorders
in Children and Adults
Kathryn M. Yorkston
David R. Beukelman
Edythe A. Strand
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Mark Hakel
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Management of Motor Speech
Disorders in Children
and Adults
Third Edition
8ETHESOA MnCeWT£R DR
Mark Hakel
tRDA, MD 20892-ii50
1 2 3 4 5 6 7 8 9 10 18 17 16 15 14 13 12 11 10 09
To the speech-language pathologists of the University of Washington Medical Center,
Harborview Medical Center, the Madonna Rehabilitation Hospital, and the Munroe-
Meyer Institute for Genetics and Rehabilitation, whose commitment to clinical service has
created wonderful settings in which to learn about motor speech disorders.
To our families, who have understood and supported our personal commitments to
persons with severe communication disorders.
Contents
Preface xi
CHAPTER 1
CHAPTER 2
CHAPTER 3
Differential Diagnosis 81
a
CHAPTER 4
CHAPTER 5
CHAPTER 6
CHAPTER 7
CHAPTER 8
CHAPTER 9
Articulation and Prosody: Segmental
and Suprasegmental Aspects of Dysarthric Speech 267
viii © Contents
CHAPTER 10
CHAPTER 11
CHAPTER 12
CHAPTER 13
Dysarthria (Adult)
Dysarthria (Childhood)
AOS.la Conversation
IX
X 0 Video Segments
CAS.la Conversation
Demonstrations
Management of Motor Speech Disorders in Children and Adults was written for gradu¬
ate students and practicing speech-language pathologists interested in serving children
and adults with neurologic communication disorders. The third edition of this book
contains several noteworthy modifications. First, a DVD containing 27 video segments
has been added (see inside back cover). These segments show children and adults with
dysarthria and apraxia of speech engaged in a range of speaking tasks. Intelligibility,
aerodynamic, and endoscopic assessments of speech performance are illustrated; also
included are brief demonstrations showing equipment and procedures, as well as two
interviews, one with a prosthodontist and the other with a speech-language pathologist
involved in respiratory, palatal lift, and nasal obturation interventions. Brief descrip¬
tions of the video segments as well as case histories of the people with neurologic com¬
munication disorders who appear in the videos are provided in Appendix A. Second,
the content from eight recently published practice guidelines developed by the Academy
of Neurologic Communication Disorders and Sciences (ANCDS) for the motor speech
disorders field has been integrated into this edition. Third, the terminology and con¬
cepts of the International Classification of Functioning, Disability and Health (ICF)
model have been integrated throughout the book, reflecting the continuing emphasis in
medical education on clinical decision making. Finally, a chapter describing conditions
associated with motor speech disorders has been added to the book (Chapter 13). In this
chapter, readers are directed to appropriate websites for up-to-date information.
Like the field of medical management more generally, the field of motor speech dis¬
orders can be characterized as having gone through a series of phases. The first era, cul¬
minating in the mid-1970s with the classic Mayo Clinic studies, was the era of diagnosis;
disorders were described and differentiated from other disorders. This phase was fol¬
lowed by an era of treatment, during which a repertoire of interventions was developed
and tested. The field is now entering the era of clinical decisions—a more sophisticated
phase in which a rubric is provided to the clinician for the selection and timing of the
various interventions. Readers will note that many of the descriptions of populations
are organized into levels, or stages, in which speakers are characterized across a con¬
tinuum of severity. Similarly, approaches to intervention are organized by stages of the
disorders, so that clinical decisions can be guided by the level of functional limitation.
The organization of the book reflects this emphasis on clinical decision making.
The first chapter, “Perspectives on Motor Speech Disorders: A Clinical Point of View,”
reviews the perspectives from which motor speech disorders can be viewed, including
the viewpoints of the neurologist, the speech physiologist, the rehabilitationist, and the
xii S Preface
people experiencing the disorder. Motor speech disorders are defined within the frame¬
work of the ICF model.
Chapters 2, 3, and 4 deal with clinical decision making and assessment. In Chapter
2, “Clinical Examination of Motor Speech Disorders,” the components of the clinical
examination are described, including the history, the physical examination, and the
motor speech examination. Chapter 3 focuses on differential diagnosis of the various
motor speech disorders, including apraxia and dysarthria. The Mayo Clinic model of
differential diagnosis of the dysarthrias is presented. Chapter 4 discusses treatment
planning.
Chapters 5 through 12 provide detailed discussion of specific areas of intervention.
Chapter 5, “Management of Respiration Impairment,” outlines approaches for assess¬
ment and training of the respiratory aspects of speech: establishing respiratory sup¬
port, stabilizing the respiratory pattern, and increasing respiratory flexibility. Chapter
6, “Management of Laryngeal Impairment,” reviews such management topics as estab¬
lishing voluntary phonation, increasing loudness, reducing hyperadduction of the vocal
folds, and improving laryngeal coordination. Chapter 7, “Management of Velopharyn¬
geal Impairment,” reviews the assessment of and intervention for velopharyngeal dys¬
function in dysarthria, including behavioral, prosthetic, and surgical methods. Chapter
8, “Management of Speech Rate,” addresses candidacy for rate control and selection
of appropriate techniques. Included is a discussion of the rigid rate control techniques
used with speakers who have severe impairment as well as those techniques that attempt
to preserve prosody. Chapter 9, “Articulation and Prosody: Segmental and Supraseg-
mental Aspects of Dysarthric Speech,” presents management techniques designed to
improve the production of speech and sounds and also techniques that focus on the
prosodic aspects of speech, including stress patterning, intonation, and rate-rhythm.
Chapter 10, “Interventions for Participation Restrictions: Enhancing Social Function
in Motor Speech Disorders,” describes strategies designed to compensate for residual
speech limitations by integrating supplementation and augmentative communication
techniques; these strategies serve to enhance the social functioning of people with mo¬
tor speech disorders. Chapter 11, authored by Katherine C. Hustad, discusses the com¬
munication characteristics, assessment, and intervention associated with childhood
dysarthria stemming from cerebral palsy. Chapter 12, “Treatment of Childhood and
Acquired Apraxia of Speech,” summarizes treatment approaches for children and adults
with apraxia. Principles of motor learning are reviewed as they relate to a variety of
clinical decisions associated with treatment planning. Finally, Chapter 13 summarizes
the medical conditions and speech symptoms associated with motor speech disorders.
A project such as Management of Motor Speech Disorders in Children and Adults
reflects the contributions of many people. The work of numerous colleagues is refer¬
enced throughout the text. We are indebted to those clinicians and researchers who have
been disciplined enough to record their observations, insights, and conclusions. Unfor¬
tunately, space and confidentiality do not permit a listing of clients who have served as
our “teachers.” We also acknowledge the pervasive influence of the speech pathology
staff of the University of Washington Medical Center, Seattle; the Harborview Medi¬
cal Center, Seattle; the Barkley Memorial Center, Lincoln; the Madonna Rehabilitation
Preface i : XIII
Hospital, Lincoln; and the Munroe-Meyer Institute for Genetics and Rehabilitation at
the University of Nebraska Medical Center, Omaha. Although their contributions are
rarely referenced directly in this text, these colleagues have encouraged us, challenged
us, listened to seemingly endless audio recordings of speakers with dysarthria, critiqued
early versions of tests and software, and provided wonderful settings in which to learn
about dysarthria. We would also like to acknowledge Julie Marshall, DDS, MA, for
the informative interview she gave related to prosthetic management of velopharyn¬
geal dysfunction. Finally, we wish to thank Katie Hustad for contributing Chapter 11,
“Childhood Dysarthria: Cerebral Palsy,” and Vicki Philippi for filming and editing the
video segments included on the DVD. Vicki managed this task while providing ongoing
multimedia support to the education programs of Madonna Rehabilitation Hospital.
KMY
DRB
EAS
MH
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