Evaluating Dysarthria

Written By Jennifer Truong

***Note that the following case below is inspired by my clinical work. All patient identifying information is fictionalized to protect patient privacy.

POV: You get a referral for an evaluation for a patient with a ICD-10-CM Diagnosis Code Dysarthria R47.1. Per ST evaluation, pt was admitted to hospital d/t sudden onset deterioration of speech characterized by significantly reduced volume and breathy vocal quality. The clinical impressions section included all relevant perceptual speech characteristics (e.g., hoarse vocal quality, reduced MPT), all consistent with dysarthric speech characteristics. Medical history unremarkable. Imaging, CT brain scan or other abnormal developments during speech decline onset were not noted in any hospital records.

During the course of treatment, the SLP trained the pt on vocal function exercises and phonation exercises, however no progress was demonstrated. He was then discharged to SNF for continuation of care.

If it were me on this case, I would have (1) refer to neurology (2) assess swallow function/weight loss. If swallow decline was present (which it typically is when the voice slowly becomes aphonic), I would order an instrumental study as well.

90% of neurological diagnoses depends on the patient’s history!!! As SLPs we are usually the first to refer patients to neurology for suspected degenerative conditions. Why?! Because decline in speech is usually one of the first signs. If we are not able to detect the signs early enough to make appropriate referrals, we place the patient’s life at risk. I want to share this as a reminder that our services can have the potential to provide more harm than good if we are not thorough. This is why I am a HUGE advocate for strong documentation so that we can facilitate communication for patient recovery.

We are trained and specialized from the head to the neck BUT THAT IS JUST ONE PART OF THE WHOLE PATIENT. Knowledge on neuroanatomy is KEY because it will allow us to make differential diagnosis to guide our treatment plan AND allow us to make appropriate referrals if needed. With that being said, below are key domains I make sure I assess or note in my POC for Motor Speech.

Clinical history/Present Issue

Consider obtaining information for the following

  • Age

  • Medical hx

  • Chief complaints

  • Onset/time course: when did your speech problems start? Who noticed it first?

  • Are there any medications or other factors (stress, fatigue, time of day) that impact your speech?

  • Any other atypical developments during your speech impairrment? Important signs worth noting:

    • Visible atrophy

    • Fasciculations 

    • Reduced normal reflex or presence of pathology reflexes 

    • Poorly inhibited laughter or crying

    • Impaired cough strength 

    • Gait impairment 

    • Pathologic reflexes of limbs

  • Do you have trouble swallowing liquids/pills/solids?

6 Salient Neuromuscular Features

  • Strength - reduced?

  • Speed - variable? reduced? increased?

  • Steadiness- rhythmic? arhythmic?

  • Range- reduced? excessive? variable? consistent?

  • Accuracy- inconsistent/consistent inaccuracy?

  • Tone- increased? decreased?

Important Cranial Nerves to Test

  • Trigeminal (CN V) – sensory + motor 

  • Facial (CN VII) – sensory + motor 

  • Glossopharyngeal (CN IX) – sensory + motor 

  • Vagus (CN X) – sensory + motor 

  • Spinal Accessory (CN XI) – motor only

  • Hypoglossal (CN XII) – motor only

Respiration

  • Sniff+pant

  • Maximum phonation time (Avg elderly male: 13-18 sec; avg elderly female: 10-15 sec)

  • Maximum loudness

  • Abnormalities to note: stridor, too soft, too loud, inability to whisper, short MPT, running out of air at the end of sentences

Laryngeal

  • Harshness

  • Pitch glides

  • Vocal flutter

  • Tremors

  • Impaired pitch range

  • Pitch breaks

  • Phonation

Velopharyngeal

  • Hypernasality

  • Nasal air emissions

Orofacial

  • Repetition of multisyllabic words

  • Diadokinesis

  • Articulatory precision

Rate

  • Too fast? too slow?

Prosody

  • Monotone

  • Variable

  • Equal/excess stress

Fluency

  • Stuttering/palilalea

  • Vocal tics

Check for apraxia

  • Automatic speech tasks (count 1-10)

  • Advancing syllable lengths

  • Groping

  • Phonemic distortion

  • Irregular syllable segmentation

Standardized Tests

  • Frenchay Dysarthria Assessment (FDA)

  • Assessment of Intelligibility in Dysarthric Speaker (AIDS)

Patient Reporting Outcomes

  • Communicative Effectiveness Survey (CES)

Jennifer Truong
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