What Factors Are Involved in the Assessment of Dysarthria?

The main contents of dysarthria include respiratory function assessment, resonance function assessment, vocal organ function assessment (including subjective perception assessment and objective assessment), dysarthria function assessment, and psychosocial assessment. The purpose of dysarthria treatment is to promote the patient's vocalization and to restore the motor function of the dysarthria.

Basic Information

nickname: Motor dysarthria
Visiting department: Rehabilitation physiotherapy
Common causes: Cerebrovascular accident, brain tumor, cerebral palsy, Parkinson's disease, etc., congenital cleft lip and palate, congenital facial cleft, etc.

Common symptoms: Can't speak at all, abnormal vocalization, abnormal articulation, abnormal pitch and volume, and unclear speech

Knowledge of rehabilitation disorders

Definition of dysarthria

Dysphonia refers to congenital and acquired structural abnormalities of the articulation organs, dysphonia due to neurological and muscular dysfunction, and speech disorders caused by no structural, neurological, muscular, or hearing disorders. It is completely unable to speak, abnormal vocalization, abnormal articulation, abnormal pitch and volume, and articulation, and does not include abnormal pronunciation due to aphasia, children's language development retardation, and hearing impairment.

Clinical classification of articulation disorders rehabilitation

(1) Dysarthria refers to motor dysfunction caused by diseases of the muscle system and nervous system of organs (lung, vocal cord, soft palate, tongue, jaw, lips) involved in articulation, namely speech muscle paralysis Speech impairment caused by weakened contractility and uncoordinated movement can be divided into the following six types ^[1] :

(2) Organic dysphonia occurs due to abnormal morphology of the dysarthic organ, resulting in dysfunction.

(3) Functional dysphonia refers to the fact that the wrong articulation is fixed, but it cannot be found as the cause of the dysphonia, that is, there is no morphological abnormality and abnormal motor function of the articulatory organ, the hearing is at a normal level, and the language development has reached 4 years old. Above level, the articulation has been fixed.

Causes of rehabilitation of dysarthria

(1) The etiology of dyskinesia is common in cerebrovascular accidents, brain tumors, cerebral palsy, amyotrophic lateral sclerosis, myasthenia gravis, cerebellar injury, Parkinson's disease, and multiple sclerosis.

(2) The etiology of organic dysphonia is common in congenital cleft lip and palate, congenital facial cleft, macroglossia, abnormal occlusal occlusion, trauma-induced morphological and functional impairment of articulatory organs, and congenital dysphagia.

(3) Functional articulation disorders may be related to auditory acceptance, discrimination, cognitive factors, motor factors to acquire articulation motor skills, and certain factors of language development. Most of them can be completely cured through articulation training. It is more common in children, especially preschool children.

Clinical manifestations of articulation disorder rehabilitation

Patients with dysarthria are characterized by inaccurate pronunciation, unclear bite, changes in vocal and auditory characteristics such as abnormal sounds, tones, speed, rhythm, and excessive nasal sounds, that is, speech is ambiguous and fluent. When it is serious, the words are indistinguishable from each other and the sentence is difficult to understand. In the worst case, it is impossible to speak at all, and it is impossible to have articulation. However, the speech content and grammar of patients with dysarthria are often normal, and there is no difficulty in understanding the language of others, but only the expression barrier of spoken language. Dysarthria can be the patient's primary or sole symptom, or it can be a minor accompanying symptom.

Dysphonia caused by different etiology has different clinical characteristics, and often has specific accompanying symptoms. The dysarthria of upper motor neuron damage often has other manifestations of "pseudobulbar palsy" such as difficulty swallowing, drinking water and coughing, and is often accompanied by strong crying, laughing and other symptoms. The dysarthria caused by damage to the lower motor neurons also often have dysphagia, and severe cases may have difficulty breathing. Myogenic dysarthria often have weakness or atrophy of the trunk and limb muscles. Syndromes of articulation caused by cerebellar damage are often accompanied by ataxia of limb movement, decreased muscle tone, and unstable balance. Dysphagia caused by basal ganglia lesions may be accompanied by abnormal muscle tone and involuntary movements.

Rehabilitation assessment of articulation disorders

Frenchay Evaluation of articulation disorders in Frenchay

Dysarthria

The Frenchay dysphagia assessment is divided into eight parts, including reflexes, breathing, tongue, lips, jaw, soft palate, throat, and speech. Each item is divided into a to e grade according to the severity of the injury, a grade is normal, and e grade is severe injury ^[2] .

CRRC Evaluation of articulation disorders by CRRC version of articulation disorders rehabilitation

The assessment method includes two major items: articulation organ examination and articulation examination.

(1) Evaluation of articulation organs:

Evaluation of articulation organs (2 photos)

(2) Consonant check: Conversation check, syllable repeat check, essay check, articulation-like motion check and result analysis

Dysphonia rehabilitation rehabilitation

The purpose of dysarthria treatment is to promote the patient's vocalization and to regain the motor function of the dysarthria ^[3] .

Principles of rehabilitation for dysarthria

(1) The treatment of dysarthria based on speech performance can be designed according to different types, or a treatment plan can be designed for different speech performance. From the perspective of current speech therapies, treatment often focuses on abnormal speech performance, not on the type of dysphonia. Therefore, the design of the treatment plan should be based on speech performance as a treatment center, taking into account the characteristics of various types of dysarthria.

(2) Select the treatment order according to the evaluation results. Generally, training is performed one by one according to the movements of breathing, larynx, palate, and pharyngeal area, tongue, tongue tip, lips, and jaw. Follow the principle from easy to difficult. For light to moderate patients, the training is mainly based on their own active exercises. For severe patients, because the patients cannot perform autonomous movements or have poor autonomous movements, more therapists need to use manual assisted therapy.

(3) It is very important to choose the appropriate treatment method and appropriate intensity treatment method to improve the curative effect. Improper treatment will reduce the patient's training desire and enable the patient to learn the wrong articulation action mode. The more the number and time of treatments are, the better, in principle, but it should be adjusted according to the specific conditions of the patient to avoid excessive fatigue. Generally, a 30-minute treatment is appropriate.

Rehabilitation therapy for dysarthria

Relaxation training

1. Relaxation of feet, legs and hips

a. Flex your toes downward for 3-5s, then relax and repeat several times.

b. Rotate the ankle, one foot at a time, and then relax.

c. Sit with your feet flat on the floor, step down for 3s, then relax, repeat several times, and feel the gastrocnemius muscles firm and relaxed.

d. Straighten the knee joints for 3s, and then relax. The patient should feel thighs and relax.

e. Quadriceps and gluteus maximus contraction and tense exercises. Place your hands on your knees (take a seated position), move your torso forward, sit in an upright position for 3s, then sit down and relax, repeated several times. Encourage patients to experience the tension and relaxation of these muscles.

f. Remind patients that they should now feel relaxed in their lower limbs and hips.

2. Abdomen, chest and back relaxation

a. Focus on the abdomen, chest, and back, but keep your feet, legs, and hips relaxed.

b. Abdomen the abdominal muscles to contract continuously for 3s, then relax and repeat several times. Patients are required to notice that their back muscles and pectoral muscles are also tense when they are abdomen, and experience a sense of relaxation when they relax.

c. Encourage the patient to take a deep, smooth breath when the muscles relax.

3. Relaxation of hands and upper limbs

a. Focus on your upper limbs and hands while continuing to feel slack in your feet, legs, hips, abdomen, and chest and back.

b. Hold your fist firmly, then relax your throat for a few seconds, repeat several times.

c. Lift both upper limbs forward to shoulder level, hold for 3s, then lower, repeat several times.

d. Sit in combination with the above actions, hold your fists for 3s while lifting your upper limbs flat, then lower your arms and release your hands repeatedly several times.

e. Remind the patient to pay attention to the contrast between tension and relaxation. If the hand still feels tense, shake the wrist smoothly until it is relaxed.

4. Relaxation of shoulders, neck and head

a. Shrug your shoulders upwards for 3 seconds, then relax and repeat several times.

b. Sagging your head forward, then leaning back smoothly, slowly turning your head from one side to the other. Then turn your head slowly to close your eyes to prevent dizziness.

c. To ensure that the head moves smoothly and slowly, the therapist can stand behind the patient and hold the patient's head with his hands to perform the above actions.

d. Raise your eyebrows upwards, wrinkle your forehead, then relax, repeat several times and pay attention to the difference between feeling nervous and relaxed.

e. Close your lips tightly, hold for 3s, then relax, open your mouth, and repeat several times.

f. Slowly and smoothly move the jaw, rotate up, down, left and right, and then relax.

g. Wrinkle your face as hard as possible, hold it for 3s, then relax and repeat it several times.

Breathing training

A. Breathing training

1. Place one hand on the crotch and the other hand on the side of the ribs 11,12. If the patient is paraplegic, the therapist can stand behind the patient and place one hand on the patient's crotch, the other hand on the side of the ribs 11, 12 or both hands on the sides 11, 12 ribs. Inhale smoothly through the nose, then exhale slowly through the mouth. Note the outward movement of the condyles and the upward and outward movement of the ribs. Correct shoulder movement. There should be pauses between each breath to prevent excessive ventilation.

2. When the therapist counts 1, 2, and 3, the patient inhales, then counts 1, 2, and 3 breaths, and then counts 1, 2, and 3 exhales. Then gradually increase the expiration time until 10s. When exhaling, make friction sounds such as "s" and "f" as long as possible, but no sound is produced. After several weeks of practice, the exhalation sound reaches 10s and maintains this level.

3. Continuing the above exercise, during the exhalation, the fricative sound is from weak to strong, or from strong to weak, and the sound intensity of the fricative sound is strengthened and weakened. Make as many intensity changes as possible in one breath. Instruct the patient to feel the movement and pressure of the crotch, which indicates that the patient can control the exhaled airflow.

4. Exhale in one breath one long, one short, one long, two short, or one long, three short, and other rhythmic friction sounds, but no sound, such as s --- ---. Exhale for as long as possible and then vowel two or three vowels in one breath, and then rub the vowels together with the vowels. 5. whisper a breath number 1, 2, 3, and gradually increase to 1-10.

6. Change the sound intensity when counting, same as exercise 5.

B. Upper arm movements do upper limb lifting or rowing to increase lung capacity. Exhale as you raise your arms to assist in breathing.

C. To increase the air flow, use a transparent glass marked with a scale (cm), fill one-third of the water, put a straw into the water, and blow the air against the straw. Time, tell the patient the result of blowing bubbles, and record the progress.

Pronunciation training

A. Pronunciation start

1. When exhaling, open your mouth round, make an "h" sound, and then make an "a" sound. After repeating the practice, gradually reduce the time of the "h" sound, increase the time of the "a" sound, and finally practice the other sounds.

2. Same as the above exercise, make the fricative mouth shape, and then make the vowel shape, such as "s ... a, s ... u".

3. Hoarseness is caused by tension in the throat. Friction and relaxation techniques can be used. Massage and vibration massage can be performed on the geniohyoid muscle and the mandibular hyoid muscle. After the massage, the throat tension is reduced and pronunciation practice can be performed. Another method is to have the patient yawn with the exhalation and issue words in the yawning breath. When yawning, you can fully open the glottis and stop the vocal cord adduction.

4. The retarded articulation disorder may have different degrees of paralysis of the laryngeal adductor muscles. You can perform any of the following referral exercises.

a. Make a fist with both hands, raise it to the level of the chest, and then suddenly push down with both arms to expel gas.

b. Raise both hands to the level of the chest, the palms of both hands suddenly push the chest wall inward to expel gas.

c. Press the arm of the table or chair suddenly with both hands.

d. Raise your arms to the level of your shoulders, flex your elbows, cross your fingers, and suddenly force your hands apart. In all cases, the patient should expel the airflow loudly before continuing to practice vowels.

5. To further promote the activation of pronunciation, take a deep breath, cough when exhaling, and then change this pronunciation action to vowels. Once pronunciation is established, patients should be encouraged to sigh loudly to promote pronunciation.

6. Blast sounds can also be used to assist the activation of pronunciation, such as: ba, bu.

B. Continuous pronunciation

1. When the patient can start the pronunciation correctly, continuous pronunciation training can be performed. Breathe vowels as long as possible in one breath. Use a stopwatch to record the duration of the pronunciation, preferably 15-20s.

2. Make a single sound from one breath and gradually transition to two or three vowels.

C. Volume control

1. Instruct the patient to continue making "m" sounds.

2. The "m" sound is pronounced together with the vowels "a", "i", "u", etc., and gradually shorten the "m" and prolong the vowel.

3. If the patient continues to have difficulty with the lip sound "m", a nasal sound "n" may be issued.

4. Read the words, words, phrases, and sentences whose initials are "m". The purpose is to improve the exhalation and volume, to compare the vowels through the changes in the position of the lips, and to promote the resonance of the vowels.

5. Reciting the ordinal number of 1-20, reciting Sunday, you can breathe once, the volume should be as large as possible, maintain a relaxed position, and inhale deeply.

6. In order to improve the volume control, perform volume change training. You can count from 1 to 5, 6 to 10, the volume is from low to high, and then from high to low, or the volume is changed from high to low. Vowels are played, the volume is from low to high, and the volume is alternated. In retelling exercises, the use of maximum volume is encouraged, and the therapist gradually increases the distance from the patient until the longest distance the treatment room can accommodate. Encourage patients to fill the room with sound and remind them to relax as much as possible and take a deep breath.

D. Pitch control

1. Expand the pitch range and instruct the patient to sing the scales. You can sing any vowel or consonant vowel, such as "a, a, a", "ma, ma, ma". If the patient cannot sing a full scale (octave), he can focus on training three different pitches and then gradually expand the pitch range later.

2. After the patient's pitch is established, "slip" training can be performed, which is the premise of intonation training. Vowels are made from low-medium-high; high-medium-low; middle-high; middle-low; high-medium-high; low-high-medium sliding.

3. The patient imitates the therapist to do the following exercises: la-la Hello!

ma ma / ma ma ma have you eaten?

ma ma ma / ma do you want a pen?

4. When the patient listens, imitate these different pitch changes, it should be clear that these pitch changes represent different meanings or tone. If the patient has mastered the above exercises, repeat some exclamatory, interrogative and greeting sentences.

E. Nasal control

1. Inhale deeply, bulge for a few seconds, then exhale.

2. Use straws of different diameters to blow in the mouth, which will help to close the lips and increase the muscle strength of the lips.

3. Practice making lip sounds and back tongue sounds, such as "ba, da, ga".

4. Practice rubbing sounds, such as "fa, sa".

5. Alternate lip and nasal consonants, such as "ba, ma, mi, pai" soft palate training, please refer to the training of pronunciation organs.

Oral and vocal organ training

A. Proprioceptive neuromuscular facilitation method

1. Feeling the stimulus Use a piece of ice to stroke from the corner of the mouth to the upper and lower along the diaphragm muscle abdomen, and stimulate the laughing muscle, swipe from the bottom to the corner of the mouth for 3 to 5 seconds, repeated stimulation, the effect appears immediately, but the duration is short . The mechanism is to stimulate the temperature sensor, impulses reach the central nerve through the fibers, the sensitivity of the muscle spindle increases, neuromuscular excitement, and muscle contraction. Another method is to use a soft bristle brush to gently brush quickly along the above area for one minute. After brushing, the effect is 20-30 minutes after restimulation.

2. The activities of stress, traction and resistance to facial muscles are based on the coordinated movement of various muscle groups. Practice both sides at the same time.

a. The pressure is applied by the finger or thumb fingertips, such as applying pressure to the outside of the hypoglossal lingual muscle, and applying pressure to the hyoid bone to help swallow. b. Stretching refers to repeated tapping of contracted muscle fibers with fingers during re-exertion to stimulate greater contraction. Gently slap along the contracted smile muscles to promote smile action.

c. Resistance means applying a force in the opposite direction to the movement to strengthen the movement. It can only be performed when the patient is able to perform some degree of muscle contraction. Resistive force is applied to the key side, and only after the affected side is strong enough can it be applied to the affected side. When patients cannot perform a certain exercise without help, they can use pressure and traction techniques to promote exercise. Generally, pressure and traction techniques are implemented first, and resistance techniques are implemented as the function improves.

B. Pronunciation organ training

Lower jaw

a. Open your mouth as large as possible, lower your jaw, and then close it. Repeat 5 times slowly with rest. Speed up later, but need to maintain the maximum range of movement of the upper and lower jaws.

b. Mandibular extension, slowly moving from side to side. Repeat 5 times and rest.

2. Lip closure, corner abduction

a. Push your lips forward as far as possible (u sound position), and then push them back as far as possible (i sound position). Repeat 5 times and rest. Gradually increase the speed of alternate movements to maintain the maximum range of motion.

b. Gather the corners of one side of the mouth, maintain this action for 3s, and then rest. Repeat 5 times and rest. The key and the affected side move alternately.

c. Close your lips tightly and clamp the tongue depressor to increase the lip closing force. The therapist can pull the tongue depressor outward, and the patient closes his lips to prevent the tongue depressor from pulling out.

d. The gills for a few seconds, and then suddenly vented, which helps to generate a popping sound. The patient can also squeeze his cheeks with his fingers while the gills are in the air.

3. Tongue extension, tongue elevation, alternating motion and circular motion

a. The tongue is extended as far as possible, then retracted, rolled up and backward, repeat 5 times, rest, and gradually increase the number of exercises. A therapist can place the tongue depressor in front of the patient's lips, and the patient can extend the tongue to touch the tongue depressor. B use a tongue depressor to resist the extension of the tongue to strengthen the extension of the tongue. C maintain the maximum range of motion and increase the number of repetitions to increase the speed of motion. A stopwatch can be used to record the number of repetitions and speed of movement.

b. Lift the tip of the tongue as far as possible. Repeat this action 5 times with a break. Gradually increase the number of exercises. You can use your hands to support your jaw to prevent it from lifting. When the tongue's movement strength increases, a tongue depressor can be used to assist and resist the upward movement of the tongue tip to increase exercise strength.

c. Raise the tongue to hard palate. The tip of the tongue can be close to the lower teeth, and the tongue surface is raised. Repeat 5 times and rest. Gradually increase the number of exercises.

d. The tip of the tongue protrudes and moves from one corner to the other. A uses a tongue depressor to assist and resist the movement of one side of the tongue. B When doing the above exercise, gradually increase the speed of exercise.

e. The tongue tip performs a circular "sweep" action along the upper and lower gums.

4. Soft palate elevation

a. Sighing hard can promote soft palate elevation.

b. Repeat the "a" sound, with 3 to 5 seconds of rest after each pronunciation.

c. Repeat the burst and open vowel "pa, da"; repeat the fricative and closed vowel "si, shu"; repeat the nasal and vowel "ma, ni".

d. Stimulate the soft palate directly with a fine-bristled brush.

e. If the soft palate is paralyzed, quickly rub the soft palate with ice cubes and rest after a few seconds to increase muscle tone.

f. Immediately after the stimulation, imagine that the soft palate is raised, and then the nasal and lip sounds are alternately used as a control.

g. When making a vowel, place a mirror, finger or paper towel under the nostril, and observe if there is air leak.

5. Alternate movement

a. Alternating movements of the jaws open mouth.

b. The alternating movement of the lip requires anterior lip constriction and then retraction.

c. The tongue's alternate movement includes A tongue extending and retracting; B tongue tip raised and lowered in the oral cavity; C tongue moved from the corner of one mouth to the other.

d. Repeat the action as soon as possible, and then pronounce it.

Speech training

A. Speech training

1. Practice making a "b" sound. Encourage the patient to see the therapist's movements.

2. The patient looks in the mirror at the sound engineer so that he can correct his pronunciation in time.

3. Close the lips tightly and bulge the cheeks, which will increase the pressure of the gas in the mouth, and suddenly let the gas burst out between the lips while pronouncing. 4. Read the tongue twister consisting of "b". It is best to use real language for adults, and it is easy for patients to accept. For the therapist, at this stage, the establishment of language is more important than the application of words.

B. Compensation Techniques Muscle weakness of the articulation organs, limited range of motion, or slow motion prevents some patients from achieving fully accurate pronunciation. In this case, the patient can be taught a method of pronunciation compensation. These compensation methods can make the speech close to normal and can be heard by others.

Rhythm training

A. Stress rhythm training rhythm and stress are difficult to separate because they are interdependent. Therefore, in the treatment, the two treatments use a common method.

1. Breathing control can make the accent and light tone show a difference, thus producing the rhythmic characteristics of language. Therefore, breathing training not only helps to pronounce but also lays the foundation for rhythm and stress control.

2. To promote rhythmic control, patients can be read aloud. Poetry has a strong rhythm. The therapist taps the rhythm point with his hand or pen to help the patient control the rhythm.

3. Emphasis on stress: To emphasize the stress of the meaning or to express strong feelings, the stress that is read out with a strong volume, so that there is no certain law determined by the speaker's intention and emotion.

4. When the patient has established the concept of rhythm and stress, it allows the patient to recognize and monitor the stress in their own words in daily life. The patient and the therapist marked the stress of everyday conversational sentences, and the patient read aloud everyday words and essays marked with stress.

B. intonation training

1. Practice the ascending and descending vowels, such as: a a a a

2. Explaining different emotions to patients needs to be expressed in different intonations, and to demonstrate to patients, patients imitate different intonations and convey emotions. Such as, excited, bored, happy, angry, doubtful, disappointed, sad, encouraged.

3. Practice the intonation of simple declarative sentences and command sentences. These sentences should be used at the end of the sentence.

4. Practice interrogative sentences. These sentences require a rising tone at the end of the sentence.

Training of alternative speech communication methods

In patients with severe dysphonia, due to the serious impairment of speech movement function, even after language training, speech communication is difficult. In order to enable these patients to conduct social communication, the speech therapist can The actual requirements of communication are to choose and train some methods to replace verbal communication. At present, there are picture boards, word boards, and sentence boards commonly used in China. The drawing board contains many pictures of daily life, which can be helpful for patients with low cultural standards and disabled reading ability. Word boards and sentence boards are marked with commonly used words and sentences, and some sentence boards can also have a gap in the appropriate place, and the patient can add some information when needed. Word boards and sentence boards are used for patients with a certain cultural level and athletic ability.