Speech–language pathologists use primarily auditory–perceptual methods to evaluate speech disorders, although the use of instrumental assessment techniques, such as direct laryngoscopy, acoustic analysis of speech, and kinematic measurement, is becoming increasingly common.

              History

              Examination of the speech mechanism with nonspeech activities

Figure 18.1
Key components of a traditional clinical motor speech evaluation.

              Evaluation of speech performance during a variety of speaking tasks (See Appendix A for a typical paragraph that a patient is asked to read to evaluate speech.)

      Swallowing function is typically considered to comprise three stages:

              Oral stage

              Pharyngeal stage

              Esophageal stage

      The assessment and treatment of the oral and pharyngeal stages of swallowing are within the scope of practice of speech–language pathologists as part of an interdisciplinary team that includes physicians, surgeons, occupational therapists, dieticians, nurses, dentists, and other health care professionals. Esophageal dysphagia is managed primarily by physicians (ie, gastroenterologists).

      The evaluation of oropharyngeal swallowing typically begins with a clinical swallowing evaluation. The traditional components include the following:

              History

              Oral motor examination, often with sensory testing

              Physical examination to assess voice quality and strength of cough, and palpation of laryngeal excursion during swallowing

              Observation of how foods and liquids are swallowed

      Instrumental assessment techniques may also be necessary, such as videofluoroscopic swallowing evaluation (VFSE) and/or fiber-optic endoscopic evaluation of swallowing (FEES), which allow a skilled clinician to accomplish the following:

              Assess the integrity of the oropharyngeal swallowing mechanism

              Make appropriate recommendations with regard to oral intake, therapeutic intervention, and consultations with other health care professionals

      VFSE and FEES also allow the assessment of penetration and aspiration, which are often critical because of their potential negative effects on health.

      Behavioral treatments for dysphagia in patients with movement disorders are based primarily on the biomechanical abnormalities observed during evaluation. Treatments for dysphagia tend to be less condition-specific than those for speech. Therefore, the most common methods are discussed next, and this list is referenced in subsequent sections. Specific treatment approaches with application to particular patient populations follow later in this chapter.

      Regardless of the medical diagnosis, if swallowing (a) remains unsafe, (b) is inadequate to maintain hydration and nutrition, or (c) requires more effort than the patient can tolerate, a variety of behavioral treatments should be considered.

      Behavioral treatments can be categorized into rehabilitative and compensatory approaches. General behavioral treatments for patients with dysphagia are described below.

      Rehabilitative treatments include the following:

              Supraglottic swallow is an airway protection technique in which forceful laryngeal adduction is followed by throat clearing/coughing and a repeated swallow.¹¹

              Super-supraglottic swallow is airway protection technique similar to the supraglottic swallow, but in which the patient bears down while holding his or her breath.^11,12

              Effortful swallow is used to increase posterior tongue base movement and improve bolus clearance from the vallecula by squeezing the muscles forcefully during swallowing.¹³

              The Mendelsohn maneuver is primarily a technique to prolong upper esophageal sphincter (UES) opening.¹⁴ The larynx is held for 1 to 3 seconds in its most anterior–superior position, followed by completion of the swallow.¹¹

              Shaker head raise is an exercise for increasing UES opening in which the patient lies supine and repetitively raises and lowers his or her head.^15,16

              Lee Silverman voice treatment (LSVT) is a series of maximum performance exercises primarily associated with dysarthria rehabilitation. LSVT may also have a general therapeutic effect on swallowing movements.¹⁷

              Expiratory muscle strength training (EMST) is an exercise in which a pressure threshold device is used to overload the muscles of expiration. EMST may have a general therapeutic effect on speech and swallowing movements.¹⁸

              The Showa maneuver requires forceful elevation of the tongue against the palate followed by a long, hard swallow, during which the patient is instructed to squeeze all the muscles of the face and neck. This technique appears to influence oral and pharyngeal movements during swallowing.

              The Masako technique is an exercise to increase posterior pharyngeal wall movement. The patient protrudes and holds the tongue while executing a forceful dry swallow.¹⁹

              In the falsetto exercise, the patient elevates the larynx by sliding up a pitch scale and holding the highest note for several seconds with as much effort as possible.¹¹

              Sensory therapies include stimulation with cold, sour, and electrical current. These treatments may improve oral and pharyngeal stage function.^21,22

              Intention/attention treatment is a new type of treatment with no formal protocols established.²³

      If rehabilitative treatments are unsuccessful or impractical, a variety of compensatory treatments can be considered.

              General postural stabilization

              Postural adjustments to the swallowing mechanism, including the chin tuck and head turn

              Throat clearing or coughing to clear the airway after swallowing

              Repeated swallows to clear oropharyngeal residue

              Use of a “liquid wash” to clear oropharyngeal residue

              Controlling bolus size with instruction or adaptive equipment

              Increasing the frequency and reducing the size of meals to optimize nutritional intake and swallowing function, especially if swallowing is effortful or causes fatigue

              Eliminating troublesome foods from the diet or preparing them in a softer, moister form

              Using dietary supplements

              Timing eating and drinking to coincide with maximal medication effects

              Thickening liquids and pureeing foods as a last resort

      If rehabilitative and compensatory strategies are inadequate, decisions about enteral nutrition may become necessary.

      Hypokinetic dysarthria occurs in most individuals with Parkinson’s disease (PD) at some point in the progression of the disease, with approximately 90% of patients with PD having dysarthria in some series.^24,25 See Appendix B for a description of the perceptual features of hypokinetic dysarthria.

      The term hypophonia is often used to describe the decreased vocal loudness of patients with PD.

      Inappropriate silences may occur frequently and be associated with difficulty initiating movements for speech production.

      Neurogenic stuttering, consisting most often of sound and word repetitions, may also be observed in some patients with PD.

      Patients with PD appear to have a perceptual disconnect between their actual loudness level and their own internal perception of loudness.

      When patients have insight into their speech problem, they often describe the presence of a “weak” voice. They may report avoiding social situations that require speech.

      The severity of dysarthria may not correspond to the duration of PD or the severity of other motor symptoms.

      Hyperkinetic dysarthria, rather than hypokinetic dysarthria, may also be encountered. This most often occurs in the presence of dyskinesia, particularly after prolonged levodopa therapy. Other “communication disorders” commonly encountered in patients with PD include cognitive impairments, masked facies, and micrographia.

      Although a variety of medical and surgical approaches have been attempted to improve the speech of patients with PD, behavioral treatments have shown the most sustained beneficial effect.²⁶

      LSVT has a robust literature supporting its beneficial effects and is considered the treatment of choice for individuals with PD and hypokinetic dysarthria.^27–30

      Other maximum performance treatments, such as EMST, may also be beneficial.³¹

      A variety of other behavioral techniques may be indicated.

              Speaker-oriented treatments focus on compensatory strategies to improve intelligibility.³²

              Communication-oriented strategies are often used along with speaker-oriented strategies to improve understanding between speaker and listener.³²

              Rate control techniques, such as delayed auditory feedback (DAF), pitch-shifted feedback, and pacing boards, may be used.

      For many patients with PD, pharmacologic treatment does not appear to have a significant beneficial impact on speech production, although speech function may be improved in some patients.

      Surgical treatments for PD also do not appear to have a consistently significant benefit for the speech disorders encountered in PD. Although speech performance may be improved in some patients after surgery, this is not considered an expected outcome. Speech may be unchanged or worsened following surgery.

      General treatment strategies can be found in the earlier section on the behavioral treatment of swallowing disorders.

      Patients with PD often respond well to active range-of-motion and falsetto exercises, effortful swallow, Mendelsohn maneuver, and effortful breath-hold.¹¹

      Maximum performance techniques typically used in the rehabilitation of speech disorders in PD, such as LSVT and EMST, may also improve oropharyngeal swallow function.¹⁷

      Although dopaminergic medications are not typically associated with significant improvements in swallow function, in some patients these medications may provide benefit. In these selected cases, “on” effects can be timed to coincide with meals.

      The surgical treatment of PD does not appear to improve swallowing function for most patients, and postoperative dysphagia has been described in the literature as an adverse event.

      Although dysphagia is common in PD, it rarely is severe enough that patients require an alternative means of nutritional support.