Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Assessment of VP Function

History Taking

This phase of the assessment involves gathering pertinent   information   from the patient, the medical records and the referral source. Information should be gathered on areas such as the following:

• The onset of symptoms and medical/ dental history.

•  the nature, duration, and natural course of velopharyngeal (VP) impairment.

•  Reports of previous treatment.

• The level of concern about the problem.

• The patient’s motivation relative to treatment.

    High

Strong recommendation

Systematic Review

              5

Assessment of VP Function

 Search for etiological factors

  Very low

 Strong recommendation

Expert opinion

4

The perceptual assessment of speech

Determining the severity of the velopharyngeal impairment and the degree to which the velopharyngeal impairment disrupts speech   production is critical to establishing the need for intervention and for accurate therapeutic intervention.

     High

 Strong recommendation

Systematic Review

               5

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Examination

Physical Examination

This involves an assessment of the structure and function of the oral mechanism, including the velopharynx at rest and during movement.

    High

 Strong recommendation

Systematic Review

       5

Instrumental examination of the velopharyngeal mechanism

It is necessary to directly observe and measure velopharyngeal activity.

Instrumentation                                   may  include videoflouroscopy,               nasoendoscopy, aerodynamic (pressure-flow).

assessments, and acoustic assessment. This instrumentation allows for the evaluation of

•  Intraoral air pressure and nasal airflow during production of pressure consonants.

• Palatal movement.

• Lateral pharyngeal wall movement.

•   Sphincteric activity during speech.

• Nasal airflow and intraoral air pressure.

• The timing of velopharygeal movements.

  High

   Conditional recommendation

Systematic Review

       5

Instrumental examination of the velopharyngeal mechanism

It is necessary to directly observe and measure velopharyngeal activity.

Instrumentation                              may  include videoflouroscopy,                                                          nasoendoscopy, aerodynamic (pressure-flow).

assessments, and acoustic assessment. This instrumentation allows for the evaluation of

•  Intraoral air pressure and nasal airflow during production of pressure consonants.

•Palatal movement.

•  Lateral pharyngeal wall movement.

•  Sphincteric activity during speech.

•  Nasal airflow and intraoral air pressure.

• The timing of velopharygeal movements.

   High

  Conditional recommendation

Systematic Review

       5

Documentation by audiorecording and nasofibroscopic examination

*Audio   recording   of   speech    sample to compare between before and after therapy.

*Nasofibroscopic examination determine degree of palatal mobility and lateral pharyngeal wall mobility.

 Very low

 Conditional recommendation

Expert opinion

       2

 Resonance Intervention goal

 Enhancement   of speech and communication function is a fundamental target of intervention.

    High

        Strong recommendation

Systematic Review

        5

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Prosthetic intervention

Palatal lift fitting has a long history associated with improved speech function in selected cases of dysarthria.

High

Strong recommendation

Systematic Review

5

Surgical intervention

It is not considered unless all other interventions have failed.

High

 Strong recommendation

Systematic Review

5

Measurement of Outcomes

It is increasingly important to document the outcomes of intervention. A variety of outcome measures may be obtained and can be categorized.

High

Strong recommendation

Systematic Review

           5

Respiratory and phonatory disorders in dysarthria

Respiratory/phonatory impairment is a common manifestation of dysarthria   and can have a major impact on the adequacy of speech production. Treatment of the respiratory     and    phonatory    subsystems. It is often given priority because improvements at this level generate improvements in other aspects of speech as well.

High

 Strong recommendation

Metanalysis

           2

Assessment of respiration and phonation

History of the problem

1. Onset and medical history.

2.   Nature,            duration   and          course  of dysfunction.

3.Report of previous treatment.

4.Level of patient’s concern about the impairment and social limitations.

5. Patient’s motivation relative to treatment. Specific attention should be paid to the patient’s presenting complaints as they may provide the initial evidence of respiratory or phonatory involvement.

 low

Strong recommendation

Observational study

           4

Assessment of phonation and respiration

Speech characteristics can provide a window into the nature and existence of respiratory and/or phonatory subsystem involvement. perceptual evaluation of loudness and breath patterning. Inadequate loudness and improper control of loudness, as well as abnormal patterning of inhalation and exhalation during speech, may serve as indicators of impaired respiratory and function.

Moderate

 Strong recommendation

    Metaanalysis

           2

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Assessment of respiration and phonation

Loudness

• Overall loudness level.

•   Inconsistent loudness level.

•   Sudden, uncontrolled alterations in loudness.

•  The patient is unable to increase loudness.

•   The patient is unable to speak quietly.

•   The patient is unable to emphasize words in a sentence by increasing loudness.

Breath Patterning

•  The   patient   does   not   demonstrate the normal pattern of quick inhalation followed by prolonged exhalation and

•  Does not inhale to appropriate lung volume levels (Chenery, 1998)

• Speech is interrupted by sudden, forced inspiratory/expiratory

• The patient runs out of air before inhaling

•   The patient produces few words/syllables on one breath.

•   Breaths  occur  at syntactically inappropriate locations in the utterance.

    high

        Strong recommendation

Metaanalysis

          2

Assessment of respiration and phonation

Determination of Overall grade of dysphonia (Breathy, rough, asthenic or strained) Determination of pitch and associated vocal fry.

Very low

 Strong recommendation

Expert opinion

          5

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Physical Examination

Physical Examination

A physical examination of the structure and function of the speech mechanism should be conducted, particularly if there are concerns of respiratory involvement.

*  The body position of the patient during evaluation (and treatment) should be con- sidered.

Audible breathy inspiration, inhalatory stri- dor, or an audible grunt at the end of ex- piration.

*  Observation of these symptoms may pro- vide insight into the presence of respirato- ry/phonatory impairment, and whether the dysfunction stems from weakness, incoordi- nation, involuntary movements, and/or mal- adaptive strategies.

Very low

       Strong recommendation

Observational study  

        2, 4

Clinical screening

Clinical Screening

• A simple water glass manometer.

•   A hand-held respirometer is an economical device for gathering data on vital capacity.

• Contrasting the sharpness of the patient’s cough with the glottal coup.

• Sustained phonation time is also used as a very general estimate of respiratory/ phonatory capacity.

•  Sustained phonation with changes in loudness may also be implemented to estimate respiratory drive.

Very low

Conditional recommendation

Observational study

       2,1,3

Instrumental Measures

A number of valuable respiratory/airflow measures (e.g., vital capacity, forced expiratory volume, functional residual capacity, inspiratory capacity, and expiratory/inspiratory reserve volumes) and subsequently compare them to predicted values based on the patient’s age, height and sex.

Additionally, kinematic assessment allows the SLP to infer the airflow volume.

Very low

      Strong recommendation

Observational study

       1,2,3

Instrumental Measures

*Maximum phonation time is often used as a global assessment of phonatory capacity.

*laryngeal adduction can be inferred from the sharpness of a patient’s cough and glottal coup.

Very low

       Strong recommendation

    Observational            study

       1,2,3

Phonatory assessment

Phonatory Function/ laryngeal assessment.

A formal laryngeal assessment should be conducted when structural lesions or lesions of the vagus nerve are a possibility or prior to intensive voice therapy, such as the Lee Silverman Voice Treatment program.

Very low

         Strong       recommendation

 Observational               study

       1,2,3

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Instrumental assessment of phonatory dysfunction

• Endoscopy.

• Videostroboscoopy.

•  High-speech photography.

• Optically precise rigid laryngoscopes.

•  Flexible fiberoptic laryngoscopy.

•  Aerodynamic measures have demonstrated utility in documenting perceptual     voice     characteristics and differentiating speakers with hypokinetic dysarthria.

• Photoglottography.

•    Electroglottography.

• Spectrographic/acoustic analyses.

•   Laryngeal aerodynamics.

• Indirect mirror laryngoscopy.

    high

Strong recommendation

Systematic review

         6

Individual Intervention

Interventions vary as a type of dysarthria, severity of dysarthria, and co-existing factors. Therefore, individual intervention plans must be developed.

High

Strong recommendation

Individual Intervention

Staging of Intervention. Dysarthria   often is not a stable condition. For example, children with developmental dysarthria may experience physiologic changes affecting speech production as they mature. Adults with acquired dysarthria may experience phases of recovery; as in dysarthria associated with traumatic brain injury; or phases of degeneration. (i.e., the timing of treatment) is critical for successful outcomes.

High

Strong recommendation

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Management of Reduced Function

The symptoms of respiratory/phonatory impairment may be categorized as reductions in:

1. Respiratory support.

2.Respiratory/phonatory coordination and control.

3.  Phonatory functioning.

High

Strong  recommendation

Systematic review

Improving the respiratory support

The following techniques have demonstrated clinical utility for improving respiratory support:

• Controlled exhalation tasks.

• Maximum inhalation and exhalation tasks.

•  Pushing and pulling techniques.

• Breathing against resistance.

• Using an air pressure transducer with feedback from an oscilloscope or computer screen.

•  Sustaining phonation with feedback from Visipitch or the VU meter on a tape recorder.

High

Strong recommendation

Systematic review

Prosthetic Assistance

Expiratory boards or paddles provide a stationary object for the patient to lean into while speaking, thus increasing expiratory force.

high

     Conditional recommendation

Systematic review

Speech Tasks

Manipulations of breathing patterns during speech production can provide a means of improving respiratory support

high

Conditional recommendation

Systematic review

6

Improving Coordination/Control

Nonspeech Tasks

Rehearsing a speech-like breathing pattern (i.e., quick inspirations and slow, controlled expirations)

•  Implementing                 “inspiratory checking” without accompanying speech (if it is problematic for the patient to speak on controlled exhalations).

• Facilitating inspiratory coordination and speed through sniffing, or exhalatory coordination through blowing.

• Practicing switching between inspiration and expiration; the speed of the task can eventually be increased.

high

 Strong recommendation

Systematic review

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Speech Tasks

Initiate speech at variable points in the respiratory cycle and need more consistent inspiratory control.

•      Initiate speech at inappropriate lung volume levels and need to vary the depth of consecutive inhalations.

•      Terminate speech late in the expiratory cycle with resultant diminished loud- ness.

•      Exhibit abnormal or maladaptive respiratory patterns, such as speaking on inhalation and forced expiration, often seen in patients with hyperkinetic dysarthria or patients with a concomitant cognitive impairment.

•      Adopt a fatiguing pattern of breathing, such as excessive shoulder elevation.

The speaker can then practice read ing paragraphs in which the respira tory patterns or breath group boundaries have been marked.

•      Cued conversational scripts. Conver- sational scripts for two speakers are prepared. The patient can practice modifying inhalations according to the marked respiratory patterns while speaking with another person.

•      Un cued reading/conversation. The patient reads aloud or speaks conver- sationally without the aid of respiratory pattern markings.

High

Strong recommendation

 Systematic review

6

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Improving Phonatory Function

Physical Strategies to Enhance Adduction: Clasping hands together and squeezing palms together as hard as possible

• Interlacing hands and pulling outward.

• Pushing down on the speaker’s raised arms in a rapid, uninterrupted motion.

• Sitting in a chair, grasping the bottom with both hands, and pulling upward.

• Sitting in a chair and pushing down on the seat bottom with both hands.

•   Pushing against a lap board, the arms of a wheelchair, or against any other firm surface.

• Pushing the head forward against resistance provided by the examiner’s hands placed on the forehead of the speaker.

• Grunting and controlled coughing (To elicit phonatory behavior).

Trigger Better Speech with Increased Loudness

•   High phonatory and physical effort

• Intensive treatment:      Daily practice opportunities are requisite; treatment is administered four times a week for 16 sessions in one month.

•  Sensory                         calibration/perception: Speaker learns to identify the appropriate amount of effort.

•  Quantification:   Quantified feedback by the clinician is key to motivating speakers.

high

Strong recommendation

Measurement of Outcomes

Perceptual measures.

Measure of activity. Measures of impairment.

high

          Strong recommendation

Alternative and augmentative communication tools

If a speaker remains unable to communicate satisfactorily following intervention, AAC modes should be pursued.

high

Strong recommendation

Candidacy

The most common explanation for selecting a particular intervention for a speaker with dysarthria was based on physiologic features.                           Because the respiratory subsystem provides the energy source and the phonatory system provides the sound source, both are critical to speech production.

high

Strong recommendation

Articulation therapy

Working with articulatory deficits as an isolated error of articulation.

Low

Conditional recommendation

Cross sectional study

7

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

Reference

Prognostic indicators were provided for intervention.

* In speakers with flaccid dysarthria, improved phonation with pushing exercises was used as a rationale for a complete program to enhance respiratory drive.

* In persons with Parkinson disease, improved phonation with instructions to speak loudly was cited as a positive indicator of candidacy for treatment.

high

Strong recommendation

Systematic review

6