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Compensatory and Restorative Application of AAC in Chronic, Severe Aphasia

c is incorrect. Again, fine motor skills as they relate to access to device (touch, mouse, eye gaze, as examples) are considerations that should be made in all cases, but this should not be the primary focus at this time.

3. A 67-year-old man post MCA distribution CVA is referred to

you for AAC. Results of his testing show severe expressive (verbal and written) language deficits, moderate receptive (spoken and written) language deficits, and a working memory span of 3 units. Additional testing revealed impairment in semantic access. Which of the following will most likely be the greatest barrier to success with dynamic display AAC? a) Amount of information they can “hold onto” at one time

(i.e., input and output span). b) Comprehension/distinction of semantic relationships. c) Comprehension of written words.

Answer: b is correct. Inability to understand and determine accurate semantic relationships will likely inhibit the patient’s ability to make correct/desired selections within categorical fields (even small numbers)—he/she will not be able to accurately specify a want/need with choices from closely related items.

a is incorrect. Whereas input/outspan should be a careful consideration when choosing/using AAC, a span of 3 in this case might suggest that the patient can accurately complete some navigation and chain some information together if organized appropriately.

c is incorrect. For some PWA, written words in combination with icons/photos can enhance comprehension. In this case, however, the ability to determine specific semantic characteristics (as above) would likely not be overcome with the addition of a wr itten word.

54.6 Description of Disorder and Recommended Treatment

companion application as well as home practice between sessions. Functional and concrete visual scenes were initiated to enhance functional communication regarding preferences in daily life (▶ Fig. 54.3). Device navigational support was recommended and GA’s family was trained and included in this process.

54.7 Outcome

Following 6 weeks of modified CART + R treatment, GA demonstrated learning and retention of trained nouns less than five letters in length. However, no generalization to untrained nouns was observed, and his verbal perseveration limited the consistency of his accurate productions. Although he consistently generated one or two letters of the treatment targets, he was unable to use these fragments functionally for written communication or to prime verbal productions. Given these factors, the treatment plan was adjusted to trial modified script training, models for home practice. Consistent with other restorative treatment attempts, gains were limited by verbal perseveration and short input/output span.

pensation, employing AAC with a visual scene display to enhance participation in daily activities. Using photographic images and recorded hot spots (a selectable area on the screen embedded with text and/or audio), with navigational support from family, GA could play a larger role in selection of activities and meals. The content of the scenes was driven by GA’s moti- vation (▶ Fig. 54.4). The concrete photograph with some context appeared to assist with semantic impairment where a grid display was less eﬀective. Given his strength in single word repetition, he was aﬀorded the opportunity, when able, to repeat the message himself. Ongoing training and work in this regard continued with the goal of increased participation in everyday interactions.

again using flashcard applications with audio/video

Treatment and training transitioned to solely focus on com-

GA was diagnosed with chronic, severe aphasia, severe apraxia of speech, and moderate-to-severe nonverbal oral apraxia. Additionally, he was diagnosed with moderate-to-severe attentional impairment and mild memory deficits. Relative strengths appeared in word repetition, copying, and verbal/written simple sentence level comprehension. It was postulated that context enhanced comprehension.

Restorative as well as compensatory treatment was ini tiated. Follow i ng training and in-h o m e trials wi t h “low tech” paper communication boards, several assistive communication applications (GoTalkNow, SnapScene) were procure d to translate items into accessible verbal output with hopes of priming GA’s repetition and overall verbal output. For restorative treatment, a modified versio n of Beeson and Egnor’s Copy and Recall Treatment with Repetition (CART + R) was attempted with a flashcard app to allow visual (static and video of production) and auditory input from treatment targets (▶ Fig. 54.2). Functional vocabulary was provided by the family and divided into trained and untrained stimuli. Trained treatment targets were practiced in sessions with

Fig. 54.2 Screenshot of INKids Kids Flashcard Maker adapted as tool for copy and repetition practice. (Note option for embedded video of verbal production in upper right corner.)

209

Compensatory and Restorative Application of AAC in Chronic, Severe Aphasia

Fig. 54.3 Screenshot of Tobii Dynavox’s SnapS- cene with recorded “hot spots.” Optional text support.

Fig. 54.4 Screenshot of Tobii Dynavox’s SnapS- cene with recorded “hot spots” to discuss this GA’s interests.

●

Anecdotally, despite marginal gains toward restorative treatment goals and limited observation of carryover of skills by clinicians, GA’s family and other health care providers reported increased meaningful and appropriate verbal output to request wants/needs, such as asking for a “cup of coﬀee” or “socks” as opposed to tapping the table and pointing.

Functional communication page set layouts must be designed to maximize a PWA’s residual language strengths and modified throughout the treatment process.

●

AAC can be a successful tool in restorative treatment approaches if careful device selection and treatment planning occurs from the outset.

●

Family/caregiver support and engagement is paramount for successful outcomes when using AAC with PWA.

54.8 Key Points

●

Use of AAC in PWA should not be considered until a thorough evaluation of language and cognitive function has been completed.

210

Suggested Readings

[1] Beukelman DR, Hux K, Dietz A, McKelvey M, Weissling K. Using visual scene

displays as communication support options for people with chronic, severe

Compensatory and Restorative Application of AAC in Chronic, Severe Aphasia

aphasia: a summary of AAC research and future research directions. Augment Altern Commun. 2015; 31(3):234–245

[2] Beukelman DR, Fager S, Ball L, Dietz A. AAC for adults with acquired neuro-

logical conditions: a review. Augment Altern Commun. 2007; 23(3):230–242

[3] Wilkinson KM, Jagaroo V. Contributions of principles of visual cognitive sci-

ence to A AC system display design. Augment Altern Commun. 2004; 20(3): 123–136

[4] Vigneau M, Beaucousin V, Hervé PY, et al. Meta-analyzing left hemisphere

language areas: phonology, semantics, and sentence processing. Neuroimage. 2006; 30(4):1414–1432

[5] Helm-Estabrooks N. Cognitive Linguistic Quick Test: CLQT. Toronto, Canada:

PsychCorp; 2001

[6] Swinburn K, Porter G, Howard D. Comprehensive aphasia test. East Sussex:

Psychology Press; 2004

References

[1] Beeson PM, Egnor H. Combining treatment for written and spoken naming. J

Int Neuropsychol Soc. 2006; 12(6):816–827

[2] Youmans G, Holland A, Muñoz M, Bourgeois M. Script training and automa-

ticity in two individuals with aphasia. Aphasiology. 2005; 19(3–5):435–450

211

Functional Language Rehabilitation in Nonfluent Aphasia

55 Functional Language Rehabilitation in Nonfluent Aphasia

Lisa McQueen

55.1 Introduction

This case describes a patient presenting in an acute rehabilitation facility for assessment and treatment of language poststroke. Of particular interest, this report outlines the patient’s language presentation, concomitant mental health considerations, and lack of social support at discharge.

55.2 Clinical History and Description

FG was a 65-year-old man who presented to an acute rehabilitation facility 6 days following cerebral vascular accident. Computed tomography scan confir med an acute stroke in the left middle cerebral artery region with specific areas of foci noted in the left frontal operculum, left insular cortex, a nd left parietal lobe. Prior to the insult, FG lived alone and had no immediate family. A neighbor and family doctor were listed as next of kin. FG was a retired ultrasound technician and had been receiving government support for an unknown disability prior to the stroke. His friend described him as “reclusive.” Previous medical history included high blood pressure, diabetes, high cholesterol, and depression. He had been treated pharmacologically for these conditions, but medication compliance was often poor, according to his friend.

55.3 Clinical Testing

FG presented with low frustration tolerance, which limited testing. FG was also given a very short length of stay, further limiting assessment. FG was admitted on a regular texture diet. No dysphagia was identified. A formal oral-motor exam was not completed as there was no evidence of change to vocal function or motor speech.

Portions of the Boston Diagnostic Aphasia Exam (BDAE, 3rd edition) Short Form were administered. Results are summarized in ▶ Table 55.1 and ▶ Fig. 55.1, ▶ Fig. 55.2, ▶ Fig. 55.3.

▶ Table 55.1 summarizes the BDAE test results; ▶ Fig. 55.1:

depicts the BDAE rating scale profile; ▶ Fig. 55.2: cookie theft transcription pretreatment (admission); and ▶ Fig. 55.3: cookie theft transcription posttreatment (discharge).

55.4 Questions and Answers for the Reader

1. Based on the assessment findings, suggest a possible aphasia

type for FG: a) Broca’s aphasia. b) Conduction aphasia. c) Transcortical motor aphasia. d) Anomic aphasia.

Table 55.1 BDAE assessment results

Subtest Score Comments

Aphasia severity rating scale

Word comprehension

Commands 6/10 Perseveration noted

Complex ideational material

Automatized sequences

Repetition of words

Repetition of sentences

Responsive naming

Boston Naming Test (short)

Reading: words 4/4

Oral word reading 15/15

Oral reading sentences

Comprehension of orally read sentences

Reading comprehension sentences and paragraphs

Writing Not formally

Answer: c is correct. Many patients with aphasia do not fall definitively into one category; given the assessment findings for this case, this category would be the best choice. Transcortical motor aphasia is a nonfluent aphasia and as such one would expect short phrases, lack of content words, and diﬃculty with grammatical structures. FG exhibited this presentation. In addition, he had strong repetition and oral reading, which are often hallmarks of transcortical motor aphasia.

a is incorrect. Most individuals with Broca’s aphasia have much less verbal output and dramatically reduced prosody. Additionally, these patients generally present with poor repetition and poor oral reading. Comprehension may be relatively preserved despite severe verbal expression deficits.

1 “All communication through

12/16 Impulsivity in responses

3/6 Written cues increased accuracy

3/4 Perseveration

5/5

1/2 Difficulty with longer sentences

1/10 No response or “I can’t” for

4/15 Phonemic paraphasias = 4

5/5 Fluent, no hesitations, no

2/3

3/4 Impulsive responding

completed due to frustration

fragmentary expression; great need for inference, listener carries burden of communication”

when trialed informally

most trials

Semantic = 5 Multiword = 2 Phonemic cues helpful approximately 50% of the time

pausing

Wrote single words to dictation (three to four letters) with 70% accuracy, unable/unwilling to do narrative writing task. Able to write name and address accurately

212

Functional Language Rehabilitation in Nonfluent Aphasia

Fig. 55.1 BDAE rating scale profile.

213

Functional Language Rehabilitation in Nonfluent Aphasia

Fig. 55.2 Cookie theft admission.

Fig. 55.3 Cookie theft discharge.

b is incorrect. A defining feature of conduction aphasia is poor repetition. Additionally, patients may produce more sound and word repetitions in speech. This presentation is often referred to as “conduit d’approche.”

d is incorrect. This type of aphasia has a more fluent presentation with longer phrases and stronger melodic lines. Production of nouns and verbs is impaired. Grammar is frequently intact.

2. When considering a starting point for treatment for this

patient, which technique may yield greatest success given the assessment profile? a) “PROMPT” type therapy. b) Script training. c) Semantic feature analysis–based therapy. d) Picture–word matching tasks.

Answer: b is correct. Based on assessment findings, treatment tasks that capitalize on FG’s intact oral reading may provide a feasible therapeutic starting point. Script training may be beneficial because the patient could practice various grammatical structures and functional vocabulary in practical contexts that may generalize well to other environments.

a is incorrect. This technique is very useful for patients with motor planning deficits and diﬃculties sequencing sounds in words. It is often useful for patients who have an apraxia of speech in addition to a nonfluent aphasia.

c is incorrect. Results from the Boston Naming Test suggest that phonemic cueing might enhance therapeutic progress and

a phonological approach may be more useful. However, given that this patient demonstrated both semantic and phonemic paraphasias, it is unclear whether semantic-based therapy may yield benefits with FG.

d is incorrect. This technique is often used to treat reading comprehension impairments. FG did not identify reading comprehension as a goal for therapy. In fact, reading comprehension was relatively preserved based on assessment results.

3. What are some factors to consider when planning specific

treatment tasks aside from the patient’s language presentation?

Answer: This patient was provided a very short length of stay in rehab. Treatment activities that allow for greatest generalization with significant functional impacts in terms of a safe discharge must be prioritized. Given FG’s limited familial support, soliciting the help of friends/neighbors may be useful to learn about his baseline conversation partners and language requirements and contexts. Maximizing rehabilitation intensity would also be an important factor in treatment planning. Ideally, patients with aphasia poststroke should receive at least 1 hour of therapy daily for optimal outcomes. Providing homework and utilizing assistants/students or volunteers can potentially increase therapy exposure each day. Another important factor is this patient’s mental health status. Depression may impede overall recovery. Patient mood and engagement should be observed and discussed with the treatment team. Finally, given FG’s limited social support, the clinician should work closely

214

Functional Language Rehabilitation in Nonfluent Aphasia

with other team members to provide the communication skills for the safest discharge possible. Treatment may involve spending more time on targeting functional language tasks such as calling a pharmacy or phoning the police in an emergency.

4. Completing formal assessment of speech and language in the acute rehabilitation setting poststroke can be challenging due to issues with patient fatigue, tolerance of testing, and impaired insight. What are some informal tasks that could be used to gather useful baseline data and guide with treatment planning?

Answer: Routine conversational interaction is useful for gaining information about functional verbal expression and can often yield a more robust language sample than formalized testing. Engaging the patient in discussion about hobbies or asking them to describe a typical day provides themes for conversations. Asking the patient to share what they know and understand about stroke can provide insight into their level of awareness and education needs. Spending your first session explaining what to expect during the rehabilitation process can provide information about verbal expression and auditory comprehension as well as increase patient comfort. Yes/no or multiple choice questions should be employed to determine patient comprehension. A food menu choice card or a bedside brochure such as “falls prevention” can yield basic information about reading ability. Additionally, the speech-language pathologist (SLP) plays a fundamental role in overall patient education related to safety. When informally assessing written expression, ensure that the assessment targets tasks that are functional for the patient’s baseline status. For example, many patients will indicate that their common writing tasks prior to stroke included simple tasks such as checks, grocery lists, and to-do lists.

55.5 Description of Disorder and

Recommended Treatment

Based on the initial assessment (formal and informal), FG presented with a moderate-to-severe communication impairment with characteristics most consistent with a nonfluent aphasia, quite possibly transcortical motor in nature. Deficits were identified across all modalities, but verbal expression was most severely impaired and was determined to be the most important goal for treatment. FG’s communication impairment was expected to have a significant impact on his ability to function independently at home. Given his short length of stay and lack of familial/social support, it was critical to select and develop treatment targets that would provide maximal functional outcomes to help him achieve his goal of returning home safely.

FG was physically quite well and consequently could tolerate intensive speech and language therapy. He agreed to participate in daily 45-to-60 minute speech therapy sessions five times per week. Additionally, he had 30-minute sessions with a therapy assistant, which provided further practice. Recommended treatment included training of scripts using an oral reading

technique. tient using facilitative language techniques (picture support, yes/no questions, written choices) and practiced in a variety of contexts (face-to-face, over the phone, small groups) and with multiple communication partners in the hospital. The focus of therapy was twofold. First, the scripts provided sentence production practice using intact skills that enhanced grammatical formulation as well as word finding for functional vocabulary. The material was motivating given that it was generated by the patient with multiple opportunities for repetition. Second, the patient saved all the scripts in a binder and was able to use them as a low-tech communication aid in various scenarios (e.g., when he had to request medication from nursing staﬀ during training in self-medication). This secondary benefit was very important in terms of increasing independence at discharge.

Topics for scripts were generated together with pa-

55.6 Outcome

FG was discharged home on his target discharge date. His communication improved such that he was able to use the telephone for simple conversations, request assistance as needed, ask for directions, make appointments, and participate in simple interactions with friends. On admission, his verbal expression was assessed with the hospital-based outcome tool FIM (Functional Independence Measure) and he scored a 1/7 (able to communicate basic information less than 25% of the time). At discharge, his FIM verbal expression score increased to a 4/7 (able to express basic information 75% of the time). On admission, he spoke in one-to three-word utterances with limited content. On discharge, he produced utterances over 10 words in length and his content improved significantly, both in spontaneous speech and on reassessment (▶ Fig. 55.3).

Functionally, at time of discharge, FG managed his medications and was able to take public transit and use the phone. He agreed to further therapy as an outpatient. Given his ongoing diﬃculties with sentence formulation and grammatical usage, treatment using techniques such as “Verb Network Strengthening Treatment (VNeST)” were suggested.

55.7 Key Points

●

Therapy techniques should be chosen based on assessment findings, patient strengths, and pat ient interests/goals. A patient will be most engaged by tasks he/she finds valuable and motivating, which will yield increased generalization and improved outcomes. The clinician may be the “expert” in his/ her field, but it is the patient who is the expert in his/her impairment. Patient partnership in the rehabilitation process is paramount.

●

For patients in the acute phase of rehabilitation, in-depth assessment may be deferred. Patient presentation may change rapidly in the first 2 weeks poststroke. Choosing to spend too much time in the early phase on assessment may not be the best use of time. Consider collecting initial baseline

215

Functional Language Rehabilitation in Nonfluent Aphasia

assessment information and then moving into diagnostic therapy. Allowing time for education and counseling in these early days poststroke is also critical.

●

Depression is common poststroke, particularly in the context of aphasia, and can impact rehabilitation outcomes. An SLP can help screen for depression and should engage team/family doctor as required.

Suggested Reading

[1] Graven C, Brock K, Hill K, Ames D, Cotton S, Joubert L. From rehabilitation to

recovery: protocol for a randomised controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke. BMC Neurol. 2011; 11(1):73

References

[1] Cherney LR. Oral reading for language in aphasia (ORLA): evaluating the eﬃ-

cacy of computer-delivered therapy in chronic nonfluent aphasia. Top Stroke Rehabil. 2010; 17(6):423–431

[2] Edmonds LA, Mammino K, Ojeda J. Eﬀect of Verb Network Strengthening

Treatment (VNeST) in persons with aphasia: extension and replication of previous findings. Am J Speech Lang Pathol. 2014; 23(2):S312–S329

216

Diﬀerential Diagnostics in Spasmodic Dysphonia vs Muscle-Tension Dysphonia

56 Diﬀerential Diagnostics in Spasmodic Dysphonia versus Muscle-Tension Dysphonia

Shirley Gherson

56.1 Introduction

Referrals for diagnostic evaluation and treatment for a patient with possible spasmodic dysphonia (SD) can be challenging given that symptoms are not always categorical. In addition, symptoms related to muscle-tension dysphonia (MTD), a much more common dysregulation of muscle coordination, can mimic those of SD, making accurate diagnosis even more diﬃcult . This case represents an example of a clinical pathway for the diﬀerential diagnosis of SD and MTD.

56.2 Clinical History and Description

C is a 29-year-old female marketing professional referred for evaluation and diagnostic therapy to define whether her symptoms were related to MTD or SD. C summa rized her problem with the following statements: “I sound nervous even whe n I’m not. It feels like my voice just sort of seizes up, but it feels shaky.” She reported a functional voice until late 2012 when she noticed asubtle and intermittent tremor in her voice, especially while on the telephone; her tremor often occurred in the absence of anxiety or stress. In October 2012, C developed an upper respiratory infecti on with several days of hoarse ness. Upon recovery, her vocal symptoms became much more frequent and exacerbated in severity to the point where her fr iends began commenting on the quality of her voice. Her voice was characterized by worsening voice quality while on the telephone, primarily during conference c alls, and when init ially arriving somewhere and initiating voice. Her voice progressively improved with increased use. She denied significant improvement in voice with alcohol. She stated, “It’s hard for me to know since it seems to be better, but then once I star t to notice it, the voice breaks start to happen.” She a lso repor ted some voice symptoms dur ing singing.

C’s work required substantial voice use. At the time of referral, her symptoms were increasingly evident and she found them to be limiting both social and occupational activities. C was otherwise in good health and denied any past voice problems. With respect to family history, she reported a possibility of a cousin with the same type of voice symptoms, although she was unsure.

C was evaluated by an otolaryngologist who performed laryngostroboscopy, which revealed some signs of a possible neurological voice issue. In this case, behavioral therapy was indicated to attempt to diﬀerentiate between SD and a more functional presentation.

56.3 Clinical Testing

C underwent extensive acoustic and functional testing. Stimuli included sentences loaded with unvoiced and voiced consonants. In addition, she was instructed to perform the following tasks: sustain a comfortable /a/ at modal pitch, whisper voicedconsonant stimuli, sing “happy birthday,” yell “taxi!,” and count in her normal voice and count again in her falsetto voice (▶ Table 56.1).

56.4 Questions and Answers for the Reader

1. A 55-year-old man presents to your clinic with a strainedstrangled voice quality that has developed gradually over the course of 2 years. The patient was diagnosed with MTD and referred for eight sessions of speech therapy. Speech therapy was ineﬀective despite the patient compliance with exercises. During the evaluation, you notice that the patient’s strained-strangled voice quality improves with sustained vowels, whispering, and falsetto voicing. Voice quality worsens when reading “We rode along rainy island avenue” and improves slightly when reading “The puppy bit the tape.” Laryngeal palpation reveals moderate-to-severe muscle tone in the neck muscles and tongue base during speech. Muscle tone normalizes at rest. What is the most likely diagnosis given the findings of your evaluation?

a) Adductor SD (ADSD) without compensatory MTD. b) Abductor SD (ABSD) with compensatory MTD.

Table 56.1 Diagnostic tasks for diﬀerentiating spasmodic dysphonia from muscle-tension dysphonia

Task Result

Falsetto voice/singing/yelling Significantly improved vocal qual-

Mid-vowel, mid-word voice breaks Present

Sustained vowel vs. speech Significant difference in quality

Unvoiced consonant-heavy phrases vs. voiced consonantheavy phrases

Laugh/cry/coughing/throat clearing

Digital manipulation and laryngeal massage

Change in voice with masking N/A

ity

with greater vocal stability noted on sustained tones

Increased frequency of spasms noted during voiced consonantheavy phrases

Voice improved during laugh. No other activities noted

Palpation revealed mild tongue base tension with excellent range of motion of the larynx

217

Diﬀerential Diagnostics in Spasmodic Dysphonia vs Muscle-Tension Dysphonia

c) ADSD with compensatory MTD. d) Mixed ADSD with a tremor component. e) MTD.

Answer: c is correct. The most likely diagnosis for the patient’s evaluative findings is ADSD with a component of compensatory MTD. Clues to this diagnosis include failure to respond to speech therapy treatment, strained-strangled voice quality that worsened with a vowel initial, voiced consonant-heavy sentence and improved with an unvoiced consonant-heavy sentence, and improved quality with non-speech-related tasks such as falsetto voicing, whispering, and sustained vowels. MTD can develop in compensation to the primary SD diagnosis.

a is incorrect. Although the patient does present with ADSD, he is also presenting with signs and symptoms of MTD with positive finds of laryngeal palpation.

b is incorrect. ABSD is characterized by breathy voice breaks and typically triggered by unvoiced consonant-heavy phrases.

d is incorrect. The patient did not present with a tremorous voice during sustained voice tasks.

e is incorrect. MTD is characterized by positive findings on laryngeal palpation, improved voice quality with ongoing voice therapy (given a lack of secondary gain), and improved voicing with masking and diversion tasks (e.g., lip trills). Voice quality would not typically improve with non-speech-related tasks such as falsetto voicing, whispering, or sustained vowels.

2. What might account for the abrupt improvement in vocal

quality with non-speech-related tasks (e.g., singing, laughing, crying, falsetto voicing) for a person with SD? a) A relaxation of their lar yngeal musculature. b) These tasks t rigger an alternate motor pathway that is not

speech related. c) Nonspeech tasks are less psychologically stressful. d) Emotional voicing is cathartic and releases pent-up

tension.

Answer: b is correct. The defining characteristic of SD is that it is a task-specific condition that presents itself mainly in speech tasks. Therefore, when triggering alternate pathways of phonation such as those used in singing, SD symptoms can be seen to drop significantly.

a is incorrect. Although laryngeal musculature may relax by way of using a non-speech-related motor pathway and having reduced triggers of spasms, release of muscle tension is a symptom and not a cause of the improved voice quality.

c is incorrect. SD has historically been misdiagnosed as a psychological condition because of this phenomenon. It is now understood to be related to the use of an alternate motor pathway rather than a psychological release.

d is incorrect. This observation is related to C in that the task specificity of improved voicing with emotive speech is more related to the brain using an alternate motor pathway.

3. A reading task during perceptual testing finds that voice

quality is worse with frequent breathy voice breaks during sentences such as “He is hiding behind the house” and “The puppy bit the tape,” and better with “We rode along rainy island avenue” and “We eat eels every day.” All things considered, what diagnosis would you start to consider? a) ADSD. b) Mixed SD.

c) Vocal tremor. d) ABSD. e) MTD.

Answer: d is correct. ABSD is characterized by breathy voice breaks that are triggered by unvoiced consonants. An increase in symptom frequency can be observed with sentences that use a significant number of unvoiced consonants as compared to those that use primarily voiced consonants.

a is incorrect. ADSD is characterized by vocal spasms that are triggered by voiced consonants and vowel-initial heavy sentences.

b is incorrect. Mixed SD has components of both ABSD and ADSD and possibly a component of tremor. Therefore, symptoms can be appreciated in both voiceless-consonant and voiced-consonant/vowel-heavy sentences.

c is incorrect. Vocal tremor is characterized by a rhythmic wavering of the voice. Although severe tremor may also present as ADSD, symptoms are not triggered by speech-specific tasks.

e is incorrect. MTD is characterized by tension of the peripheral nervous system and would not present with abrupt changes based on speech-specific tasks.

56.5 Description of Disorder and Recommended Treatment

SD is a task-specific focal dystonia characterized by involuntary, action-induced muscle spasms of the larynx during speech. The two most common subtypes of SD are ADSD, where the vocal folds abruptly adduct causing voice breaks and a strainedstrangled quality, and ABSD, where the vocal folds abduct inappropriately causing breathy voice breaks. The subtypes can be identified by their phonetic patterns: ADSD is triggered by voiced consonants and ABSD by unvoiced consonants. In mixed SD, characteristics of both types are present.

Approximately one-third of patients with SD have concurrent tremor. “Islands” of normal speech may be present and voicing may also be normal during emotional vocal expression (e.g., laughing, crying), singing, sustained vocalizations, or with nontypical speech patterns (e.g., speaking in falsetto, shouting). The disorder is chronic, can be progressive, and is thought to be a central motor-processing disorder of the basal ganglia and its connections. between the sensory and motor regions, which could theoretically result in the disruption of sensory processing and subsequent processing by the motor cortex. using magnetic resonance imaging (MRI) and functional MRI, by Simonyan and Ludlow, relationships in key areas of the speech control system, including the laryngeal sensorimotor cortex, inferior frontal gyrus, superior/middle temporal and supramarginal gyri, and in the cerebellum. The pathophysiology of SD may involve a multilevel disruption of speech-controlling networks involving both sensorimotor output and auditory monitoring.

Current standard treatment for SD is type A botulinum toxin or BT. however, evidenced-based research has not been conclusive as to whether this combined modality treatment increases eﬃcacy. Murry and Woodson

Recent studies suggest reduced brain activation

found abnormal structure–function

BT has been traditionally combined with voice therapy;

suggest that the combination of BT

A brain imaging study

218

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31.08.202628 Мб0Книга_4531_Библиотеки_им_академика_М_И_Перельмана.epub