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Handbook of Clinical Neurology, Vol.

110 (3rd series)


Neurological Rehabilitation
M.P. Barnes and D.C. Good, Editors
# 2013 Elsevier B.V. All rights reserved

Chapter 22

Disorders of communication: dysarthria


PAM ENDERBY*
Department of Rehabilitation and Assistive Technology, School of Health and Related Research,
University of Sheffield, Sheffield, UK

DISORDERS OF COMMUNICATION DYSARTHRIA


A disorder of communication has a broad impact on Dysarthria refers to a group of motor speech disorders
every aspect of life. Not only does it prevent an individ- that result from a disturbance in neuromuscular con-
ual from expressing opinions, needs, and wants but also trol affecting respiration, phonation, resonance,
reduces the ability to express personality, exercise auton- articulation, and prosody. Speech impairments can re-
omy, and frequently has an impact on self-esteem and sult from damage to the central or peripheral nervous
relationships (Dickson et al., 2008). Individuals with system, leading to “weakness, slowing, incoordination,
speech and language problems come across barriers in altered muscle tone and inaccuracy of oral and vocal
education, employment, and recreation. movements” (Palmer and Enderby, 2007). This results
The most common disorders of communication asso- in speech that has abnormal characteristics in quality
ciated with a neurological impairment are aphasia, as well as reduced intelligibility. Dysarthria can be asso-
apraxia, and dysarthria. Aphasia is the focus of Chapter ciated with developmental disorders, due to brain dam-
27 within this volume. The motor speech disorder, dysar- age before or during birth or acquired later in life
thria, is the focus of this chapter. While the terms, anar- associated with, for example, cerebral vascular accident,
thria and dysarthria are often used interchangeably, head injury, or progressive neurological disease. There
anarthria is usually used to describe the most severe forms are six major types of dysarthria: flaccid dysarthria asso-
of the disorder. Darley Aronson and Brown (1975: p. 2) ciated with lower motor neuron impairment, spastic dys-
defined dysarthria as the collective term for a group of arthria associated with damaged upper motor neurons
related speech disorders that are due to disturbances in linked to the motor areas of the cerebral cortex, ataxic
muscular control of the speech mechanism resulting from dysarthria primarily caused by cerebellar dysfunction,
impairment of any of the basic motor processes involved and hyperkinetic dysarthria and hypokinetic dysarthria,
in the execution of speech. This limits the term to speech which are related to a disorder of the extrapyramidal
disorders associated with neurological impairment rather system. The sixth is generally termed a mixed dysarthria
than those associated with structural defects such as cleft associated with damage in more than one area and result-
palate or glossectomy. ing in speech characteristics of at least two groups.
Speech is a very complex behavior requiring the syn- There have been several classification systems, but
chronous and timely contraction of a large number of the most commonly used was developed at the Mayo
muscle groups associated with respiration, laryngeal Clinic in 1969 (Darley et al., 1969). This was based on
function, airflow direction, and articulation. This syn- short speech samples taken from 30 patients in each
chrony can be disturbed in different ways, which can of seven discrete neurological groups, each patient
be indicative of the underlying pathology. Accurately having been unequivocally diagnosed as being represen-
identifying the nature of the speech anomaly can assist tative of that diagnostic group. Three judges indepen-
with diagnosis of the underlying disorder as well as pro- dently rated each of these samples on each of 38
viding the basis of treatment. dimensions of speech and voice using a 7-point scale

*Correspondence to: Professor Pam Enderby, ScHARR, University of Sheffield, Regent Court, Regent Street, Sheffield S1 4DA,
UK. Tel: 0114 2220858, E-mail: p.m.enderby@sheffield.ac.uk
274 P. ENDERBY
Table 22.1 neural signals to the cranial nerves. Symptoms include
Classification of dysarthria bilateral facial paralysis, dysarthria with noticeable
hypernasality, dysphagia, and dysphonia. This syndrome
Type of is commonly associated with emotional lability and a
dysarthria Part of nervous system implicated hyperactive jaw reflex.
Based on the Frenchay Dysarthria Assessment
Flaccid Lower motor neurons (Enderby and Palmer, 2007) the major characteristics
Spastic Upper motor neurons of spastic dysarthria include hypernasality, poor control
Hypokinetic Extrapyramidal tract, substantia nigra of the volume of speech, reduced intelligibility, reduced
Hyperkinetic Extrapyramidal tract, basal ganglia, palatal elevation, reduced alternating movements of the
Ataxic Cerebellar
tongue, slow rate of speech, and poor intonation.
Mixed Upper and lower motor neurons
The extrapyramidal system controls muscle tone for
the maintenance of posture and to ensure a firm base for
of severity and classified dysarthria according to the as- supporting movements and if affected can cause hypo-
pect of the nervous system implicated (Table 22.1). kinesia, which results in a poverty of spontaneous move-
The lower motor neurons to the muscles of the speech ments and abnormal involuntary movements. These
mechanism, which, if damaged, can lead to flaccid dys- symptoms can be reflected in characteristic speech pat-
arthria, include the cranial nerves V, VII, IX, XI, and XII terns. Hypokinetic dysarthria is most commonly associ-
and the spinal nerves supplying muscles of respiration, ated with Parkinson disease or other diseases of the
i.e., the phrenic and intercostal nerves. The muscles of extrapyramidal system. Similar to the movement disor-
the speech mechanism, apart from those of respiration, der, speech is characterized by a marked reduction in
are innervated by the cranial nerves arising from the the amplitude of voluntary movements, difficulty
bulbar region (the pons and medulla oblongata) of the initiating, rigidity, which is particularly evident in the
brainstem. The deviant speech characteristics associated “masklike face,” and limitations in the range of move-
with flaccid dysarthria vary according to the nerves and ment. Therefore, speech tends to be quiet, increased in
muscles affected and the associated weakness and re- rate during the utterance, monotone, and poorly articu-
duced muscle tone. The main aspects of flaccid dysar- lated with reduced intelligibility. This is clearly distinct
thria by the frequency of occurrence listed by Enderby from hyperkinetic dysarthria, which is a term used to de-
(1986) include: poor lip seal, abnormality of lips at rest, scribe a diverse group of speech disorders resulting from
abnormality of spread of lips, dribbling of saliva, abnor- involuntary movements that disturb the rhythm and rate
mality of tongue at rest (with notable fasciculation), of motor activities producing a heterogeneous range of
poor alternating movements of the tongue, reduced pho- speech characteristics associated with the major subcom-
nation time, and poor intelligibility. ponents of speech production affected by the primary
Upper motor neuron lesions that may lead to spastic disorder, e.g., respiratory system, phonatory valve, reso-
dysarthria commonly involve the cerebral cortex, the in- nation, and articulation. Hyperkinetic dysarthria often
ternal capsule, or the cerebral peduncles of the brain- occurs in association with movement disorders such as
stem. This may involve cortical motor areas (primarily dystonia, chorea, myoclonus, and dyskinesia.
the precentral gyrus and premotor cortex) and the des- Although the cerebellum does not initiate any muscle
cending tracts as they pass through the internal capsule contractions, it is essential for the coordination of mus-
and brainstem. The speech characteristics reflect the ef- cle actions and provides regulation for movements to be
fects of hypertonicity and weakness of the bulbar mus- smoothly and accurately undertaken. Damage to the
culature, which slows and reduces the range and force of cerebellum has a particular impact on complex move-
movements. Commonly, there is little muscle atrophy ments such as those found in speech. Clinical signs of
apart from that associated with disuse, and the presence cerebellar dysfunction usually appear on the same side
of pathological reflexes, for example the sucking reflex. of the body as the cerebellar lesions. Ataxic dysarthria
Bilateral innervation to most cranial nerve nuclei has im- is characterized by “scanning speech,” a term used by
portant clinical implications for the resulting speech dis- Charcot (1877) to describe speech featuring pauses after
order. A unilateral lesion usually results in a mild and every syllable and with each syllable being pronounced
transient impairment of speech whereas bilateral cortical slowly. This feature is seen in many individuals with
bulbar lesions tend to produce a more severe and perma- ataxic dysarthria, who often have problems with:
nent dysarthria. A syndrome associated with upper
motor neuron damage, pseudo-bulbar palsy, also known ● articulatory inaccuracy with imprecise consonant
as supranuclear bulbar palsy, is associated with many production, irregular articulatory breakdowns, and
different neurological disorders bilaterally disrupting distorted vowels;
DISORDERS OF COMMUNICATION: DYSARTHRIA 275
● prosodic excess with excess and equal stress, pro- The impact of dysarthria
longed phonemes, prolonged intervals, and slow
rate; and Dysarthria can have a severe impact on the quality of life
● phonatory prosodic insufficiency with harshness of individuals, who often experience being laughed at, or
of vocal tone, mono pitch, and mono loudness ridiculed (Dickson et al., 2008). These authors sum up
(Murdoch, 2010). the psychosocial effects of dysarthria as follows:
● Reduced communication skills as a result of dysarthria
following a stroke can extend beyond the physiological
Speech characteristics of dysarthria to cause changes in self-identity, relationships,
The person with dysarthria has speech that sounds abnor- social and emotional disruptions, and feelings of
mal and has reduced intelligibility, making communica- stigmatization or perceived stigmatization (Dickson
tion labored. However, the nature of the speech et al., 2008: p 8).
● More than half of the participants with dysarthria in
disturbance usually reflects the underlying pathology
and if correctly identified can be of great assistance in the study by Dickson and colleagues reported nega-
the differential diagnosis of the underlying pathology tive changes in self-identity resulting from their
(Table 22.2). speech disorder. The reduced ability to communicate
Disturbance of phonation (dysphonia) is a common makes such adults vulnerable to social isolation.
● In children a lack of an effective method of commu-
feature in dysarthria and can be indicative of the under-
lying neuropathology. For example, a weak and breathy nication can lead to frustration, leading to emotional
voice would suggest lower motor neuron involvement and behavioral problems, and affects access to
whereas an effortful, strained, strangled voice would in- education and normal socialization. This all adds
dicate possible involvement of upper motor neurons. to the impact on potential for later employment
Spasmodic dysphonia is sometimes incorporated and participation in and contribution to society
within the classification of dysarthric disorders; how- (Morgan and Vogel, 2006).
ever, it is generally considered that it is more closely re- The potentially far-reaching and long-term effects of
lated to the pathology of a focal dystonia. dysarthria mean that it needs to be treated in a timely and
appropriate fashion, throughout the period that the indi-
vidual is affected by it. If this does not happen it is likely
Table 22.2 to have a highly detrimental effect on the patient’s long-
term health and social well-being, which will have an ul-
Speech characteristics of different dysarthrias timate cost to health and social care services.
The International Classification of Functioning, Dis-
Type Features
ability, and Health, known more commonly as the ICF
Flaccid Isolated areas of involvement depending on
(World Health Organization, 2001), is a classification
affected motor neuron/s. Some aspects of health and health-related domains. These domains
of speech may be normal are classified from body, individual, and societal
Spastic Strained hoarse voice, hypernasal, slow, perspectives by means of two lists: a list of body func-
imprecise articulation. Often tions and structure, and a list of domains of activity
accompanied by swallowing and drooling and participation. This allows one to consider the impact
difficulties of a health condition, say dysarthria, more broadly by
Hypokinetic Breathy, monotone voice with reduced placing this into the context of the resulting activity
loudness. Articulation tends to be restriction and psychosocial impact. Table 22.3 summa-
accelerated and imprecise rizes dysarthria using the ICF classification.
Hyperkinetic Strained hoarseness and voice arrests
Ataxic Excess loudness, tremor, and irregular
articulatory breakdowns. Intonation and
Epidemiology
vocal pitch will usually be affected. There have been few studies on the incidence and preva-
Difficulty with alternate tongue lence of dysarthria, but studies indicate that between
movements 50% and 90% of people with advanced Parkinson disease
Mixed Similar symptoms to spastic dysarthria
(Pinto et al., 2004), 20% of those who have had a stroke
accompanied by a wet sounding voice
(Enderby and Phillips, 1986), 90% of people with moder-
with rapid tremor, poor laryngeal and
tongue movements, and poor control ately advanced motor neuron disease amyotrophic lateral
of lips sclerosis (ALS) (Campbell and Enderby, 1984), and 40%
of those with cerebral palsy (Pennington et al., 2009) will
276 P. ENDERBY
Table 22.3 placed in the context of the history of the patient and
International Classification of Functioning: dimension and their expectations and environment.
impact of dysarthria Therapy techniques include strategies to improve
respiratory support, phonation, and resonance involv-
ICF ing exercises to reduce the limitations of muscle weak-
dimension Impact ness, and to improve range, consistency, and strength
of movement of the oral and vocal musculature.
Impairment Impaired muscle tone affecting power and Approaches to improve intelligibility may include, for
precision, and range of movement example: pausing, pacing, and exaggerated articulation.
affecting oral, vocal, and breathing Advice regarding behavioral and environmental modifi-
movements
cation can improve communicative effectiveness, which
Incoordination of the musculature for
speech production results in abnormal
includes techniques that support speech by adding facial
speech characteristics, e.g., expression and gesture, along with being aware of reduc-
misarticulated phonemes, altered voice ing competing noise, such as turning off the television
quality/tone/volume, altered resonance, when speaking. Intraoral appliances have been used
nasal emission, lack of breath support successfully to support and stimulate the soft palate,
Activity Reduced intelligibility of speech and to reduce hypernasality. Biofeedback devices can
Over-quiet voice assist by providing accurate feedback to the patient as
Reduced communicative ability they develop new skills (Palmer and Enderby, 2007).
Burden of communication may rest on Augmentative and Alternative Communication (AAC)
communicative partner refers to any system of communication that is used to
Participation Reduced communication skills can affect
supplement or replace speech, to help people with oral
self-identity, relationships, education and
employment
communication impairments to communicate. For indi-
Social participation and interaction viduals with dysarthria this could range from “low tech”
disadvantages and restrictions aids such as signing systems, drawing and writing, or
communication books, to “high tech” aids such as com-
puterized voice output communication aids (VOCAs).
have an associated speech disorder, which is generally dys- The objective of introducing AAC to any child or adult
arthria. The majority of patients with progressive neurolog- with a communication problem is to maximize their com-
ical disease will experience motor speech disorders that municative function in the areas of life that are seen as a
worsen during the course of the disease. This may be sec- priority to them and to reduce the burden on them and
ondary to increased respiratory difficulty or directly asso- their carers. For children it has been found that introduc-
ciated with the impact of the disease on the oral ing AAC can assist with the development of language and
musculature. other social skills. As the child develops, systems will need
to be changed to reflect development of cognition and lan-
guage skills. The changing needs of the patient (i.e.,
Speech and language therapy for
changes to their speech and physical abilities as well as
persons with dysarthria
changes in their environment) require regular review.
The aims and objectives of speech and language therapy According to Beukelman and Mirenda (1998) it is
will depend on the type, nature, and severity of the dys- necessary to:
arthria, the underlying cause, whether it is acute or pro-
● identify participation and communication needs;
gressive, and the communication needs of the individual.
● assess physical, cognitive, and language capabilities
For people with mild dysarthria the aim of therapy may
in order to determine appropriate options;
be to improve the quality and naturalness of speech,
● assess external constraints; and
whereas the aim of therapy for persons with severe dys-
● find strategies for evaluating the success of
arthria may be to improve intelligibility and communica-
interventions.
tion competence, possibly through alternative methods
of communication (MacKenzie and Lowit, 2007). To ensure appropriate access to the range of technical
The speech and language therapist will assess the na- resources available, individuals who may benefit from
ture of the speech problem frequently using a standard- communication aids should have access to an AAC spe-
ized assessment such as the Frenchay Dysarthria cialist or team are skilled in assessment and familiar with
Assessment (Enderby and Palmer, 2007). Additional the expanding technology.
biometric information may be gathered using peak flow Augmentative and alternative communication strate-
and acoustic analysis. The information from this will be gies and devices have great potential to improve the lives
DISORDERS OF COMMUNICATION: DYSARTHRIA 277
● evidence related to different therapy approaches;
of individuals with communication difficulties by facilitat-
● evidence related to approaches for chronic and
ing independence, the development of social relationships,
and enhancing education (Hodge, 2007). While there has stable dysarthria;
● evidence related to computerized therapy; and
been a rapid growth in available options and technologies
● evidence associated with augmentative commun-
in recent years it has been reported that practitioners
face challenges in successfully implementing AAC. ication.
Authors have highlighted that there is a paucity of research
evidence to underpin recommendations (Schlosser et al.,
2003), and that users may have limited access to available THERAPY APPROACHES
systems or services (Kent-Walsh et al., 2010). Lee Silverman Voice Treatment
The approaches to intervention can again be consid-
ered using the ICF classification (Table 22.4). There have been three systematic reviews bringing to-
gether research related to Lee Silverman Voice Treat-
ment (LSVT) in persons with dysarthria secondary to
Evidence base for speech and language
Parkinson disease. The two Cochrane reviews by Deane
therapy for dysarthria
and colleagues (Deane et al., 2001a, b) concluded that,
While there has been a considerable amount of research although there was insufficient evidence to make any
related to the treatment of dysarthria associated with firm recommendations about the effectiveness of the
various conditions of different severities and different different treatments for dysarthria, the trends were pos-
levels of chronicity, most studies have included few sub- itive. The other systematic review included a broad range
jects. This research is summarized below in the following of studies on LSVT in 16 patients with Parkinson disease
four sections: (Yorkston et al., 2003) and concluded that there was

Table 22.4
International Classification of Functioning: dimension and techniques for intervention in management of dysarthria

ICF
dimension Techniques

Impairment Normalization of muscle tone and/or increasing strength of movement precision and coordination
(Pinto et al., 2004)
Prosthetic methods for controlling some of the symptoms associated with dysarthria. Speech and language
therapists will work all alongside medical and surgical colleagues in the assessment and monitoring of progress
of any medical or surgical intervention
Behavioral techniques with the aim of “compensated intelligibility,” rather than “normal speech” (Deane and
Whurr, 2001). Examples include:
● The Lee Silverman Voice Technique, “an intensive, high effort speech treatment designed to rescale the
amplitude of motor output of speakers with PD dysarthria” (Pinto et al., 2004)
● Dysarthria Treatment Programme (Drummond et al., 2003, cited in Palmer and Enderby 2007), designed to
target all speech processes simultaneously
Activity The use of devices and biofeedback giving feedback to enable patients to monitor and modify speech
characteristics (Pinto et al., 2004)
Assistive devices can be used, ranging from the low-tech such as an alphabet board, to high-tech computerised
Augmentative and Alternation Communication systems. Voice amplifiers can be used to increase
effectiveness of communication
Altering the environment can improve function (Sellars et al., 2005), e.g. ensuring that the listener has full view of
the dysarthric speaker’s face (Palmer and Enderby, 2007). This approach puts responsibility onto the listener as
well as the speaker, building effective communication
Speech and language therapists will work with the family, teachers, carers, and others to ensure that approaches
to improving communication (communication aids or vocal strategies) are incorporated in all situations
Participation Providing education about dysarthria to patient, family, and/or school, and advice on promoting self-esteem, to
increase social interaction and participation in society, facilitate interaction in the workplace, and
communication in social settings. This will lead to increased autonomy, which is associated with general
well-being and quality of life
278 P. ENDERBY
strong evidence for immediate posttherapy improve- sessions. The study found that some of the subjects
ment and some evidence of long-term maintenance. benefited from the intervention and maintained their im-
Two research studies considered the effect of LSVT provement at 2-month follow-up. The results from this
on vocal loudness in patients with Parkinson disease small study indicate that such an approach could be use-
(Ramig et al., 2001; Sapir et al., 2007). In the RCT ful with some patients following a stroke.
(Sapir et al., 2007) subjects with Parkinson disease were Robertson (2001) considered the effectiveness of oro-
randomly assigned to receive either LSVT or no treat- facial and articulation exercises for patients with dysar-
ment and the results were compared with a control group thria following stoke. A group of speech and language
who did not suffer from Parkinson disease. In this small therapists agreed a clinic-based therapy program and ex-
RCT LSVT increased the vocal loudness of subjects with ercise routine for home practice for each of the patients.
Parkinson disease. In the controlled clinical trial (Ramig Of the eight subjects who completed the full trial, six im-
et al., 2001) patients who received LSVT were compared proved their overall dysarthria scores. One subject
with patients with Parkinson disease who received no scored lower and two were within 1 point of their original
treatment and a control group who did not have score. Subjects who completed more practice at home
Parkinson disease or any speech or voice abnormalities. made the greatest improvement overall.
Treated individuals increased their voice sound pressure
levels. Changes were statistically significant and percep- Speech supplementation strategies
tibly audible. These two studies investigated only a small
A systematic review (Yorkston et al., 2004) considered
number of patients but the findings with other studies
four general types of speech supplementation:
provide additional support for the efficacy of LSVT in
alphabet supplementation, semantic or topic supplemen-
the treatment of hypokinetic dysarthria secondary to
tation, gestures, and syntactic supplementation. Studies
Parkinson disease.
that were included considered patients with any severity
Further evidence is provided by Wohlert (2004) who
of dysarthria associated with any etiological condition.
investigated the effect of different intensities of LSVT
Word and sentence intelligibility increased in all patients
on patients with dysarthria as a result of Parkinson dis-
regardless of the supplementation strategy used. The
ease. Patients received treatment four times per week for
review concluded that speakers with severe or profound
4 weeks or twice per week for 8 weeks or twice per week
dysarthria regardless of medical diagnosis or type of
for 4 weeks. All participants, irrespective of the intensity
dysarthria might find supplementation strategies useful.
of their treatment schedule, increased their voice inten-
The case series study (Hustad et al., 2003) compared the
sity while reading aloud. All participants were requested
effectiveness of three speech supplementation strategies
to practice for the same amount of time at home, but this
on subjects’ intelligibility and speech rate. The three
may have varied and thus affected the study outcomes.
strategies were: topic (where the listener is provided with
The findings from these studies indicate that LSVT
information on the topic area prior to the communica-
could be effective in treating patients with dysarthria
tion), alphabet (where the speaker points to the first let-
as a result of Parkinson disease.
ter of each word as it is spoken), and combined (topic and
alphabet supplementation). Combined supplementation
Behavioral communication intervention and alphabet supplementation produced significantly
higher intelligibility scores and slower speech rate than
One systematic review (Yorkston et al., 2003) considered
the topic group and the control group who received no
different behavioral techniques for management of
supplementation. This study investigated only a small
respiratory/phonatory dysfunction in patients with dys-
number of subjects, which limits the generalizability of
arthria. The review included 35 studies separated into
these interesting findings.
four broad categories: biofeedback, device utilization,
LSVT, and several miscellaneous studies. Biofeedback
Systems approach
is most relevant for this section. Evidence from the
review suggests that biofeedback can be effective in One case series (Pennington et al., 2006) considered ther-
changing physiological variables. apy focusing on speech production for six students with
A pilot study (MacKenzie and Lowit, 2007) consid- cerebral palsy. The students received intensive individual
ered the effectiveness of a behavioral communication in- therapy 5 days per week for 5 weeks from two speech
tervention on patients with dysarthria following stroke, and language therapy students. All cerebral palsy stu-
which included strategies to increase volume, reduce dents were unable to attend all of the 25 therapy sessions
speed of speech, and improve intelligibility. Each of for various reasons. The cerebral palsy students’ average
the eight patients received an individually tailored pro- single word intelligibility increased but not their contin-
gram over an 8-week period which consisted of 16 uous speech intelligibility. However, when intelligibility
DISORDERS OF COMMUNICATION: DYSARTHRIA 279
was tested again 7 weeks after the end of the treatment summarized the different treatment techniques and
all but one student’s intelligibility had returned to pre- placed them into categories targeting rate, resonance,
treatment levels. The students felt that the therapy they oromotor, articulation, and prosody, including compen-
had received had been useful. A number of students satory strategies and treatment programs.
thought less frequent therapy would have been prefera-
ble. This systems approach to therapy could be beneficial COMPUTER-BASED INTERVENTIONS
to children with cerebral palsy by helping them increase
Three research studies that investigated the effect of
the intelligibility of their speech, and it appears to have
computer-based interventions on speech indicated that
been acceptable to the students in this study. Further re-
they could be effective in patients with dysarthria.
search investigating the use of the systems approach and
One study (Thomas-Stonell et al., 2001) investigated
also different intensities of therapy would be beneficial.
the effect of a computer-based program, Stepping
Stones, on the speech rate of children with dysarthria.
Timing of intervention
Subjects were aged 4 20 years and the study aimed to
There is evidence that certain individuals with dysarthria increase or decrease their speech rate as each individual’s
continue to benefit from speech and language therapy condition required. The program enabled all patients to
for a long time after its onset with improvement in the increase or decrease their speech rate and gains were
quality and intelligibility of speech (Enderby and Crow, generally maintained 4 weeks after treatment finished.
1990; Palmer et al., 2004, 2007). Another case series study (Palmer et al., 2007) compared
computerized and traditional therapy for speakers with
TYPES OF DYSARTHRIA longstanding stable dysarthria. The computer program
allowed individual practice with feedback. The comput-
Chronic dysarthria
erized treatment was found to be as effective as the tra-
A case series study (Palmer et al., 2004) considered the ditional therapy in improving the speech of patients with
effect of three different speech and language therapy stable dysarthria without needing extensive time and
practices on the articulation of single words in patients input from speech and language therapists. The use of
with chronic dysarthria. Dysarthria was described as speech recognition software in patients with dysarthria
chronic when the condition was experienced for more associated with a variety of etiological conditions was in-
than 5 years. Results in the study were compared with vestigated in a comparison study (Hird and Hennessey,
matched individuals without dysarthria. The three prac- 2007). The study investigated the effects of physiologi-
tices were reading of written target words, visual feed- cal, behavioral, and pragmatic treatment approaches on
back, and an auditory model followed by visual patient’s use of the PowerSecretary software. All pa-
feedback. All eight participants in the study altered their tients were able to use the software irrespective of their
speech production, reducing variation and increasing medical diagnosis or type of dysarthria. Patients with
accuracy of articulation. For speakers with chronic more severe dysarthria took longer to complete the initial
dysarthria copying an auditory target gave significantly training but were able to use it successfully to some de-
better recognition scores than only repeating the word; gree. The study measured dictation rates and found that
however, visual feedback was no more effective than they tended to be higher in patients who received the
repetition alone. physiological or pragmatic treatment compared with pa-
tients who received the behavioral treatment. Although
Stable dysarthria the results of this small study should be interpreted with
caution, the possibility that patients with any severity
A systematic review and a case series investigated
of dysarthria could successfully use such computer
speech and language therapy for patients with stable
software is worth further investigation.
dysarthria, that is, dysarthria associated with nonpro-
gressive conditions.
ALTERNATIVE AND AUGMENTATIVE COMMUNICATION
The systematic review (Palmer and Enderby, 2007),
which included 23 research studies investigating the Reviews regarding the effectiveness of AAC have
effect of different speech therapy treatments where par- tended to consider predominantly low tech aids, with
ticipants had longstanding nonprogressive dysarthria as evidence suggesting positive outcomes from use of
a result of traumatic brain injury, following stroke, or the Picture Exchange Communication System (Bondy
cerebral palsy, was unable to draw conclusions about and Frost, 1995) in particular. Reviews of the literature
the efficacy of the different treatments for stable dysar- relating to high tech aids and systems (for example,
thria as all of the studies incorporated small numbers of Schlosser and Blischak, 2001; Binger and Light, 2003;
subjects and different treatment techniques. The authors Lancioni et al., 2008; Schlosser and Wendt, 2008;
280 P. ENDERBY
Lancioni et al., 2010) suggest that these devices can be to assist the individual in overcoming the personal and
beneficial, although they highlight that much available psychosocial consequences and impact, which is some-
evidence is inconclusive. Authors emphasize the consid- times hard to measure.
erable individual variation in outcomes following inter-
vention, and the weak evidence regarding generalization REFERENCES
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