1 Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300 Malaysia
2 Centre for Healthy Ageing and Wellness (H-CARE), Universiti Kebangsaan Malaysia, Faculty of Health Sciences, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300 Malaysia
3 Department of Audiology and Speech-Language Pathology, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia (IIUM)
Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia
4 Speech Science Program, Centre of Rehabilitation & Special Needs, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Bangi, Malaysia
The development of assessment tools for individuals with dysarthria has been reported in many clinical and empirical studies.
A literature review was based on online resources including Google Scholar, EBSCO, Medline, PubMed, and BIOMED Central articles and journals.
Results and Conclusion:
In this paper, we summarized the commonly used formal and informal assessment tools and explained the assessment procedure when managing clients with dysarthria. We aimed to share the current practice of speech-language pathologists together with the allied health service providers in the management of patients with dysarthria.
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
* Address correspondence to this author at the Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300 Malaysia; Tel: +60132757359; E-mail: Abber.firstname.lastname@example.org
A Report of Assessment Tools for Individuals with Dysarthria
Dysarthria is a communication disorder resulting from acquired progressive neurological disorders such as Parkinson’s disease, motor neuron disease, multiple sclerosis, and Huntington’s disease [1Spencer K, Beukelman D. Evidence-based practice guidelines for dysarthria: Management of velopharyngeal function. J Med Speech-Lang Pathol 2001; 9(4): 257-74.]. Dysarthria could have an impact on the overall communication ability, speech intelligibility, and an individual’s ability to participate and interact in daily life situations.
Dysarthria is categorized based on the clinical signs and symptoms displayed by an individual. For instance, flaccid dysarthria is due to the damage to the lower motor neuron. On the other hand, upper motor neuron abnormalities could cause spasticity. Damage to the cerebellum causes ataxic dysarthria, while damage to basal ganglia causes hyperkinetic and hypokinetic types of dysarthria [2Lansford KL, Berisha V, Utianski RL. Modeling listener perception of speaker similarity in dysarthria. J Acoust Soc Am 2016; 139(6): EL209-15. [http://dx.doi.org/10.1121/1.4954384] [PMID: 27369174] ]. Other types of dysarthria include mixed dysarthria, when more than one symptom of the different types of dysarthria is present. Individuals with dysarthria have issues with strength, speed, volume, vocal quality, tone, breath control, pitch, range, and steadiness of speech [3Green JR, Yunusova Y, Kuruvilla MS, et al. Bulbar and speech motor assessment in ALS: challenges and future directions. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14(7-8): 494-500. [http://dx.doi.org/10.3109/21678421.2013.817585] [PMID: 23898888] ]. Treatment techniques are determined by the effects of the impairment and the affected speech motor components to reduce client’s difficulties in communication [4American Speech-Language-Hearing Association. Scope of practice in speech-language pathology 2016.]. The aims of therapy are targeted to improve their relationships and interaction with friends and family, as well as their participation at the workplace [5Dickson S, Barbour RS, Brady M, Clark AM, Paton G. Patients’ experiences of disruptions associated with post-stroke dysarthria. Int J Lang Commun Disord 2008; 43(2): 135-53. [http://dx.doi.org/10.1080/13682820701862228] [PMID: 18283594] ]. Recent studies have identified the inability to produce speech by individuals with dysarthria which is accompanied by a lack of cognitive function [6Levin BE, Llabre MM, Weiner WJ. Cognitive impairments associated with early Parkinson’s disease. Neurology 1989; 39(4): 557-61. [http://dx.doi.org/10.1212/WNL.39.4.557] [PMID: 2927680] -10Green J, McDonald WM, Vitek JL, et al. Cognitive impairments in advanced PD without dementia. Neurology 2002; 59(9): 1320-4. [http://dx.doi.org/10.1212/01.WNL.0000031426.21683.E2] [PMID: 12427877] ], neurological mental state [11Celesia GG, Wanamaker WM. Psychiatric disturbances in Parkinson’s disease. Dis Nerv Syst 1972; 33(9): 577-83. [PMID: 4649149] ], and language [12Murdoch BE, Arnott WL, Chenery HJ, Silburn PA. Dopaminergic modulation of semantic activation: Evidence from Parkinson’s disease. Brain Lang 2000; 74(3): 356-9.-14Altmann LJ, Troche MS. High-level language production in Parkinson’s disease: A review. Parkinsons Dis 2011; 2011238956 [http://dx.doi.org/10.4061/2011/238956] [PMID: 21860777] ]. In conclusion, the treatment process for individuals with dysarthria is focused on improving their speech production, social participation, and cognitive function abilities.
In the following sections, we will describe and summarize the assessment procedures and available assessment tools that speech-language pathologists commonly use when assessing individuals with dysarthria.
2. THE GOALS OF DYSARTHRIA ASSESSMENT
In general, the assessment focuses on the subsystems of speech, including respiration, phonatory, resonance, prosody, and articulation. At the same, speech-language pathologists also assess individuals with dysarthria’s social participation and the need of daily activities as recommended by the World Health Organization (WHO) [4American Speech-Language-Hearing Association. Scope of practice in speech-language pathology 2016.].
3. DYSARTHRIA ASSESSMENT TYPICAL COMPONENTS
3.1. Case History
Case history usually consists of obtaining information about hearing, vision, swallowing, and language problems that patients have, followed by medication history which could include any side effects that they may face with certain medication. Other information includes patient’s personal information such as information regarding family, education level, and patients’ language proficiency in all language modalities. Patient’s communication needs, as well as family’s expectation for therapy, will be noted during the case history taking session.
3.2. Oral Motor Examination
The oral motor assessment aims to assess the accuracy, range, strength, and speed of the lips, tongue, and jaw movements. The oral motor assessment consists of observation of the neck and facial muscle tone during non-speech “rest” state [15Clark HM, Solomon NP. Muscle tone and the speech-language pathologist: Definitions, neurophysiology, assessment, and interventions. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) 2012; 21(1): 9-14. [http://dx.doi.org/10.1044/sasd21.1.9] ], by performing the cranial nerve exam to identify oral and facial symmetry. Tongue movement coordination, speed of motion, range of motion, and strength will be assessed by performing sequential motion rates and alternating motion rates [16Kent RD, Kent JF, Rosenbek JC. Maximum performance tests of speech production. J Speech Hear Disord 1987; 52(4): 367-87. [http://dx.doi.org/10.1044/jshd.5204.367] [PMID: 3312817] ]. The speech-language pathologist may request the patient to perform sustained vowel prolongation (“aaaa”) in order to assess the sufficiency of respiratory support.
3.3. Speech Production Examination
During the assessment, the speech-language pathologist will ask the patient to count (from 1-10), read aloud (word, phrase, sentence), and engage the patient in a brief spontaneous conversation. The aim is to understand the ability of patients to follow simple and complex instructions, whether there are any changes in pitch, tone, and loudness with the conversation, accuracy of speech production, speech rate (i.e., talking too slow or too fast) and speech intelligibility. At this stage, a variety of words used and sentence complexity were used as criteria to exclude the presence of apraxia of speech.
4. ASSESSMENT TOOLS
The accurate diagnosis of the types of dysarthria is important in developing an effective treatment program for patients. At present, assessment tools used by speech-language pathologists could be divided into two types, namely formal and informal assessment tools [17Collis J, Bloch S. Survey of UK speech and language therapists’ assessment and treatment practices for people with progressive dysarthria. Int J Lang Commun Disord 2012; 47(6): 725-37. [http://dx.doi.org/10.1111/j.1460-6984.2012.00183.x] [PMID: 23121530] ]. In this paper, we summarize the commonly used assessment tools that speech-language therapists used in clinic settings as presented in (Table 1). The most commonly used formal assessment tool by speech-language pathologists is the Frenchay Dysarthria Assessment (FDA) [18Enderby PM, Palmer R. Frenchay dysarthria assessment 2008., 19Enderby PM, Palmer R. Frenchay dysarthra assessment 1983.]. According to Duffy [20Duffy JR. Motor speech disorders: Substrates, differential diagnosis, and management st louis, mo: Mosby-year book ^(Eds):‘Book Motor speech disorders: Substrates, differential diagnosis, and management 2005.], the FDA is the only standardized published test for the diagnosis of dysarthria. However, there are other assessment tools used for the diagnosis of dysarthria such as the Dysarthria Profile [21Robertson SJ. Dysarthria profile 1987.], Dysarthric Speech [22Yorkston KM, Beukelman DR, Traynor C. Assessment of intelligibility of dysarthric speech 1984.], and Voice Handicap Index [23Jacobson BH, Johnson A, Grywalski C, et al. The voice handicap index (VHI) development and validation. Am J Speech Lang Pathol 1997; 6(3): 66-70. [http://dx.doi.org/10.1044/1058-0360.0603.66] ]. Meanwhile, the informal assessment in terms of the oral motor examination is used alongside the formal assessment [17Collis J, Bloch S. Survey of UK speech and language therapists’ assessment and treatment practices for people with progressive dysarthria. Int J Lang Commun Disord 2012; 47(6): 725-37. [http://dx.doi.org/10.1111/j.1460-6984.2012.00183.x] [PMID: 23121530] ]. Perceptual assessment continues to be the golden standard practice for speech-language pathologists when assessing patients with dysarthria [24Darley FL, Aronson AE, Brown JR. Differential diagnostic patterns of dysarthria. J Speech Hear Res 1969; 12(2): 246-69. [http://dx.doi.org/10.1044/jshr.1202.246] [PMID: 5808852] ]. These perceptual judgments are subjective as the accuracy of the assessment finding depends on the clinicians’ expertise in active listening and analysing the speech [18Enderby PM, Palmer R. Frenchay dysarthria assessment 2008., 19Enderby PM, Palmer R. Frenchay dysarthra assessment 1983.].
Table 1 Assessment tools commonly used by speech-language pathologists.
Another assessment protocol used by speech-language pathologists is to assess the effectiveness of communication abilities in social contexts [25Sullivan P. Maintenance of speech changes following group treatment for hypokinetic dysarthria of Parkinson's disease. Disorders of motor speech 1996; 287-310.]. The idea is to incorporate the patient’s communicative impairment, limitation of activities and participation restriction brought about by dysarthria [26Hartelius L, Elmberg M, Holm R, Lövberg AS, Nikolaidis S. Living with dysarthria: Evaluation of a self-report questionnaire. Folia Phoniatr Logop 2008; 60(1): 11-9. [http://dx.doi.org/10.1159/000111799] [PMID: 18057906] ] and to improve these limitations through speech rehabilitation. When the speech-language pathologists have a clear understanding of the individuals’ condition, the treatment can be carried out guided by the assessment’s findings [18Enderby PM, Palmer R. Frenchay dysarthria assessment 2008.].
4.1. Outcomes of the Assessment
Through the formal and informal assessments, the speech-language pathologists could obtain their patient’s speech characteristics and severity, the differential diagnosis between the types of dysarthria, and the identification of the presence of associated impairments such as dysphagia. Such information could be used to develop an individualized intervention plan with the patients and their family, or referral to other specialists such as physiotherapist or audiologist.
CONCLUSION AND FUTURE STUDIES DIRECTIONS
In this paper, we described and summarized the current assessment tools for individuals with dysarthria. The procedure of a typical assessment of a patient is explained so that other allied health professionals could gain ideas on how speech-language pathologists assess individuals with dysarthria. It is recommended that individuals with dysarthria is assessed in a holistic manner, which includes formal and informal assessments, and to include their family members into the team of care providers with the incorporation of typical social situations. As allied health service providers, it is also recommended to implement the International Classification of Functioning, Disability, and Health (ICF) and Clinical Excellence (NICE guide) into speech rehabilitation management. While the ICF framework enhances the understanding and awareness of impairments for patients with dysarthria, the NICE guide aims at developing excellent clinical practices using guiding principle outlines for the efficient delivery of clinical services. It is hoped that these procedures will improve the quality of services and simultaneously enhance the clients’ satisfaction and assist in improving their quality of life.
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
Spencer K, Beukelman D. Evidence-based practice guidelines for dysarthria: Management of velopharyngeal function. J Med Speech-Lang Pathol 2001; 9(4): 257-74.
Clark HM, Solomon NP. Muscle tone and the speech-language pathologist: Definitions, neurophysiology, assessment, and interventions. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) 2012; 21(1): 9-14. [http://dx.doi.org/10.1044/sasd21.1.9]
Enderby PM, Palmer R. Frenchay dysarthria assessment 2008.
Enderby PM, Palmer R. Frenchay dysarthra assessment 1983.
Duffy JR. Motor speech disorders: Substrates, differential diagnosis, and management st louis, mo: Mosby-year book ^(Eds):‘Book Motor speech disorders: Substrates, differential diagnosis, and management 2005.
Robertson SJ. Dysarthria profile 1987.
Yorkston KM, Beukelman DR, Traynor C. Assessment of intelligibility of dysarthric speech 1984.
Sullivan P. Maintenance of speech changes following group treatment for hypokinetic dysarthria of Parkinson's disease. Disorders of motor speech 1996; 287-310.
Hartelius L, Elmberg M, Holm R, Lövberg AS, Nikolaidis S. Living with dysarthria: Evaluation of a self-report questionnaire. Folia Phoniatr Logop 2008; 60(1): 11-9. [http://dx.doi.org/10.1159/000111799] [PMID: 18057906]
Robertson SJ. Robertson Dysarthria Profile 1982.
Enderby P, John A, Petheram B. Therapy outcome measures 1997.
Sarno MT. The functional communication profile Manual of directions 1969.
Yorkston KM, Beukelman DR. Assessment of the Intelligibility of Dysarthric Speech (Manual) 1981.