Apraxia 1

Case example 1

About two and a half years prior to this videotaping, this 24-year-old patient had a major left-hemisphere stroke that resulted in severe Broca’s aphasia and severe AOS. Although he began speech tx immediately after the stroke, he made very little progress. The patient started a second series of speech txs about one and a half years later. In this second series of sessions, PROMPT tx procedures were used successfully to increase his expressive vocabulary from about 5 words to more than 40. Because the target words in tx were chosen for their high functionality, the patient was able to use them in many different situations, both at home and in public.  Unfortunately, his aphasia and apraxia made the acquisition of more words very difficult.  But even with this limited vocabulary, the video shows that the patient is a vibrant individual who has his own ways of expressing himself.

Apraxia 2

AOS (Case Example 2)

This 59-year-old patient had an anterior left -hemisphere stroke about a year prior to this videotaping. The stroke resulted in moderate Broca’s aphasia and significant AOS. This video contains a complete evaluation of the patient AOS; it is the longest clip on this CD-ROM (about 16 minutes).  The length of this video is justified by the patient.  Repeated viewing of this video may help beginning clinicians differentiate between the patient’s aphasia and his apraxia.

Flaccid 1

Flaccid Dysarthria (Case example 1)

This 25-year-old patient was in a serious motor vehicle accident that caused diffuse brainstem and cranial nerve damage.  His neurological injuries resulted in numerous gross and fine motor deficits. One of his most obvious motor deficits was flaccid dysarthria.  Over several years of tx, this patient tried many procedures to increase his intelligibility, including a palatal lift, which he ultimately rejected as being too uncomfortable.  Although difficult to determine with certainty, it seemed that reducing rate of speech and using a more open-position mouth were the two tx procedures that were most helpful in enhancing his intelligibility.

Flaccid Dysarthria (Case example 2)

This 74-year-old patient had a mild brainstem stroke about a week before this videotape was taken. He initially presented significant oral and pharyngeal swallowing difficulties in addition to the speech deficit.  Fortunately, his dysphagia improved noticeably during the first days of hospitalization.  By the time he was videotaped, his primary complaints were about his speech and unsteadiness while walking.  Tx for his FD consisted mostly of slowing his rate of speech and intelligibility drills.  When he was discharged, the patient had made nice progress on all of his rehabilitation tx goals.

Spastic Dysarthria

This 62-year-old patient had a moderate brainstem stroke that seemed primarily to affect his swallowing and speech.  The stroke obviously damaged the patient ‘s descending pyramidal and extrapyramidal tracts bilaterally, as evidenced by his spastic dysarthria.  He was videotaped about 45 days after the stroke, while being seen as an outpatient.  The patient primary complaint about his speech was slow and reduced ROM in his tongue.  He was very pleased with how gentle active tongue stretching exercises gradually increased his ability to accurately produce lingual phonemes, especially for the phoneme /l/.  He also reported that head and neck relaxation exercises helped reduce the spastic hyperadduction of his vocal cords, although the effects of this tx on conversional speech were subtle.

Ataxic Dysarthria

This 71-year-old patient was diagnosed with idiopathic sporadic late-onset cerebellar ataxia (described by one of his doctors as progressive cerebellar ataxia) about 13 years prior to this videotaping.  He actually first noticed mild difficulties with walking and balance approximately 10 years before the Dx was made.  The progression of his ataxia was slow butt steady.  The patient participated in many years of speech therapy.  Some of the most effective tx tasks concentrated on controlling his breathing during speech and improving his articulation. Phonetic placement and intelligibility drills are two articulation tasks that were especially productive.

Hypokinetic Dysarthria

Hypokinetic Dysarthria (Case example 1)

This 73-year-old patient was diagnosed with idiopathic Parkinson’s disease about 8 years prior to this videotaping.  Speech pathologist were evaluating him because of concerns about his swallowing abilities.  For several reasons, he was not being seen for speech therapy, one of which was that his speech was so intelligible.  On the video, the patient shows the effect of tremor and bradykinesia.  The bradykinesia is perhaps most evident in his lack of facial expression (masked facies) during the conversion, although a hint of smile is seen at one point in the video.  When first seen by a SLP, the patient gave a good example of how masked facies does not reflect the inner emotional state of an individual with parkinsonism.  The clinician knocked on his hospital room door and asked if she could see him for a minute.  He was sitting on his bed, empty handed, watching TV, but he said to her, “Sure. I’ve just sitting here playing my guitar.”  This was a darkly humorous reference to his resting hand tremor that really did make him look as if he were playing a guitar.  He meant it as a self-depreciating joke, but his lack of facial expression momentarily confused the clinician.  It was only when she looked closely at his face that she saw his very subtle smile.  She then realized that he was having a bit of fun at his own expense.  Incidentally, when he finished recording this video clip, the patient said he really hoped that students could learn something about Parkinson’s disease by watching it.

Hypokinetic Dysarthria

Hypokinetic Dysarthria (Case example 2)

This 76-year-old patient had about a 10-year history of idiopathic Parkinson’s disease at the time of videotaping. He demonstrated many of the general characteristics of this disease, as well as the specific characteristics of hypoD.  The video shows an overall reduction in bodily movement (bradykinesia) that is perhaps most evident in his infrequent eyeblinks and his lack of facial expression (masked facies).  This patient tried numerous tx options while he was being seen by SLP.  Most txs concentrated on reducing his rate of speech.  Although delayed auditory feedback had no effect on his rapid speaking rate, a pacing board worked remarkably well at slowing him down.  When using a pacing board, his intelligibility increased significantly.  Unfortunately, his wife reported that he would never use the board at home or in public, even when talking only on her.  All attempt to encourage him to use the board were unsuccessful.

Chorea

Hyperkinetic Dysarthria of Chorea

This 31-year-old patient was diagnosed with Huntington’s disease while she was still in her 20s.  it is unusual for the symptoms of this disease to appear at such a young age.  Typically, the symptoms first become evident when individuals are in middle age.  Speech pathologists followed this patient primarily to assess her swallowing abilities as the disease progressed.  Nevertheless, her visits also allowed informal examinations of her speech.  These repeated assessments showed that the steady increase of her involuntary movements caused a corresponding decline in the intelligibility of her speech.

Dystonia

Hyperkinetic Dysarthria of Dystonia

This 48-year-old patient initially complained of moderate intermittent stiffness in his tongue.  Over a period of several years, the stiffness developed into definite involuntary contractions of his tongue muscles.  He then was diagnosed as having a focal lingual dystonia.  The cause of the dystonia was unknown.  As can be heard on the videotape, the dystonic contractions of his tongue certainly affect his speech production.  The waxing and waning quality of contractions result in articulation errors that are variable in severity.  Although most of the contractions are relatively mild in their intensity and cannot actually be seen, there are brief observable protrusions of his tongue while he speaks, most notably when he says the word “cake.”  The most remarkable aspect of this videotape is the clear demonstration of a sensory trick.  When he puts the mint in his mouth, his articulation improves dramatically.  This sensory trick was discovered by the patient himself and, at the time of the videotaping, had served him well for many months.  Unfortunately, sensory tricks such as this one cannot be expected to be permanently effective.  In nearly all instances, they loose their effectiveness over time.

Mixed Flaccid-Spastic Dysarthria

This 66-year-old patient had a severe brainstem stroke about 11 years prior to this videotaping. As he describes in the video clip, he was almost totally paralyzed following the stroke and only after years of rehabilitation did he regain limited movement of his limbs.  The stroke initially left him without the ability to phonate (aphonia).

Gradually, he was able to produce audible phonations, and from there the slow process of regaining intelligible speech began.  The patient stated that he reacquired adequate articulation through many, many repeated trials at producing target phonemes.