Treatment of articulatory impairment in a child with spastic dysarthria associated with cerebral palsy

Clinical Practice in Childhood Dysarthria: An Online Survey of German-Speaking Speech-Language Pathologists

PURPOSE

This survey study aimed to establish current clinical practices of German-speaking speech-language pathologists (SLPs) regarding their assessment and treatment of communication disorders in children with neurological conditions, with a particular focus on the management of childhood dysarthria.

METHOD

A 23-question cross-sectional online survey was disseminated to practicing SLPs in Germany, Austria, and Switzerland via relevant professional bodies. SLPs were invited to provide information on their current assessment and treatment practices. Demographic data including case load and clinical settings were also gathered to contextualize practices.

RESULTS

One hundred two SLPs responded to the survey, of which 68 valid responses were analyzed. German-speaking SLPs comprehensively assess and treat various aspects of overall communication, language, and swallowing functions in children with neurological conditions. Speech motor aspects did not represent a main intervention focus. In cases where the dysarthric component was targeted, specific approaches for childhood dysarthria were rarely used. Instead, SLPs reported using approaches developed for speech disorders other than dysarthria.

CONCLUSIONS

German-speaking SLPs working with children with neurological conditions use various assessment and treatment methods to support children's communication. However, dysarthria-specific approaches were not an established part of clinical practice. Results of the survey highlight the need for access to relevant developments in German and for evaluation of current curricula for speech-language pathology students and continuing education opportunities for practicing clinicians.

Naive Listener Ratings of Speech Intelligibility Over the Course of Motor-Based Intervention in Children With Childhood Apraxia of Speech

PURPOSE

The aim of this study was to describe changes in speech intelligibility and interrater and intrarater reliability of naive listeners' ratings of words produced by young children diagnosed with childhood apraxia of speech (CAS) over a period of motor-based intervention (dynamic temporal and tactile cueing [DTTC]).

METHOD

A total of 120 naive listeners (i.e., listeners without experience listening to children with speech and/or language impairments; age range: 18-45 years) orthographically transcribed single-word productions by five children (age range: 2;6-3;11 [years;months]) across three time points over an intervention period (baseline, post-treatment, maintenance). Changes in intelligibility and interrater and intrarater reliability were examined within and across time points.

RESULTS

Speech intelligibility significantly increased in children with CAS over the course of treatment, and these gains were also maintained at 6 weeks posttreatment. There was poor-to-fair consistency between listeners (interrater reliability) and excellent consistency within listeners (intrarater reliability) in ratings of speech intelligibility within and across time points.

CONCLUSIONS

Motor-based intervention increases speech intelligibility following a period of DTTC treatment. Variability among naive listeners of speech intelligibility was also present, with intrarater reliability (within listeners) yielding greater consistency than interrater reliability (between listeners). The implications for including naive listeners as raters of speech intelligibility for research and clinical purposes are discussed.

The Effectiveness of Rapid Syllable Transition Treatment in Improving Communication in Children with Cerebral Palsy: A Randomized Controlled Trial

Cerebral palsy (CP) is a movement disorder and majority of children with CP have communication impairments which impact participation with this population. Rapid Syllable Transition Treatment (ReST) is a motor speech intervention primarily for children with Childhood Apraxia of Speech (CAS). A recent pilot study in which ReST was trialed with children with CP showed improved speech performance. Therefore, a single blind randomized controlled trial to compare ReST to usual care with 14 children with moderate-to-severe CP and dysarthria was conducted. ReST was provided on telehealth. ANCOVA with 95% confidence intervals indicated significant group differences in favor of ReST in speech accuracy (F = 5.1, p = .001), intelligibility (F = 2.8, p = .02) and communicative participation on both the FOCUS (F = 2, p = .02) and Intelligibility in Context Scale (F = 2.4, p = .04). ReST was found to be more effective than usual care.

Motor Speech Interventions for Children With Cerebral Palsy: A Systematic Review

PURPOSE

Dysarthria is common among children with cerebral palsy (CP) and results in poor speech intelligibility and subsequently low communicative participation. Neuroplasticity evidence suggests that adherence to principles of motor learning (PML) improves motor speech intervention outcomes. Motor speech interventions aim to improve speech intelligibility and ultimately facilitate participation, but the effectiveness of these interventions and their inclusion of PML are not clear. Aims are as follows: (a) evaluate the effectiveness motor speech interventions in improving speech intelligibility; (b) summarize the aims, outcome measures, and outcomes relating to the International Classification of Functioning and Disability Child and Youth; and (c) summarize the principles of motor learning used in the intervention.

METHOD

Eight databases were searched, complemented by a hand search. Studies of any level of evidence were included if they used a motor speech intervention and measured speech in children with CP aged 0-18 years. Studies before 2000 or not in English were excluded. The review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was rated using the Single Case Experimental Design Scale and Physiotherapy Evidence Database-P rating scales. The strength of evidence was evaluated with Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Of 1,036 initial articles, 21 were included. Eight interventions were identified including 131 participants aged 3-18 years. All studies aimed to improve speech intelligibility or articulation and reported improvement at sound, word, or sentence level. One study reported improvements in communicative participation. The strength of evidence ranged from very low to moderate for one intervention. Adherence to PML was inconsistent.

CONCLUSIONS

The quality of evidence is very low to moderate. More research on motor speech interventions that adhere to PML is required.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21817959.

Effect of boost articulation therapy (BArT) on intelligibility in adults with dysarthria

BACKGROUND

The articulatory accuracy of patients with dysarthria is one of the most affected speech dimensions with a high impact on speech intelligibility. Behavioural treatments of articulation can either involve direct or indirect approaches. The latter have been thoroughly investigated and are generally appreciated for their almost immediate effects on articulation and intelligibility. The number of studies on (short-term) direct articulation therapy is limited.

AIMS

To investigate the effects of short-term, boost articulation therapy (BArT) on speech intelligibility in patients with chronic or progressive dysarthria and the effect of severity of dysarthria on the outcome.

METHODS & PROCEDURES

The study consists of a two-group pre-/post-test design to assess speech intelligibility at phoneme and sentence level and during spontaneous speech, automatic speech and reading a phonetically balanced text. A total of 17 subjects with mild to severe dysarthria participated in the study and were randomly assigned to either a patient-tailored, intensive articulatory drill programme or an intensive minimal pair training. Both training programmes were based on the principles of motor learning. Each training programme consisted of five sessions of 45 min completed within one week.

OUTCOMES & RESULTS

Following treatment, a statistically significant increase of mean group intelligibility was shown at phoneme and sentence level, and in automatic sequences. This was supported by an acoustic analysis that revealed a reduction in formant centralization ratio. Within specific groups of severity, large and moderate positive effect sizes with Cohen's d were demonstrated.

CONCLUSIONS & IMPLICATIONS

BArT successfully improves speech intelligibility in patients with chronic or progressive dysarthria at different levels of the impairment. What this paper adds What is already known on the subject Behavioural treatment of articulation in patients with dysarthria mainly involves indirect strategies, which have shown positive effects on speech intelligibility. However, there is limited evidence on the short-term effects of direct articulation therapy at the segmental level of speech. This study investigates the effectiveness of BArT on speech intelligibility in patients with chronic or progressive dysarthria at all severity levels. What this paper adds to existing knowledge The intensive and direct articulatory therapy programmes developed and applied in this study intend to reduce the impairment instead of compensating it. This approach results in a significant improvement of speech intelligibility at different dysarthria severity levels in a short period of time while contributing to exploit and develop all available residual motor skills in persons with dysarthria. What are the potential or actual clinical implications of this work? The improvements in intelligibility demonstrate the effectiveness of a BArT at the segmental level of speech. This makes it to be considered a suitable approach in the treatment of patients with chronic or progressive dysarthria.

The Impact of Dysarthria on Laypersons' Attitudes towards Adults with Cerebral Palsy

OBJECTIVE

This study investigated laypersons' attitudes towards adults with dysarthria due to cerebral palsy (CP). We aimed to explore the impact of the overall severity and of specific symptoms of dysarthria on laypersons' evaluations.

PATIENTS AND METHODS

Eighteen adults with dysarthria due to CP and 6 nondysarthric controls participated as speakers. The individuals with CP underwent dysarthria assessment based on a standardized tool. The results were compared to those of a listening experiment with 20 laypersons. A text passage spoken by all speakers was presented to the listeners, who provided their evaluations using rating scales specifically developed for this study. The tool addressed 3 dimensions of attitudes: (1) estimation of a speaker's cognitive-linguistic abilities; (2) attribution of personality and social characteristics, and (3) listeners' emotions and behavioral tendencies towards the speaker.

RESULTS

Severity of dysarthria was strongly correlated with the overall attitudes. Regression analyses identified different symptoms as predictors of the listeners' judgements.

CONCLUSION

Severity of dysarthria seems to have a major impact on laypersons' attitudes. Results suggest that speech symptoms may have a very specific influence on laypersons' evaluations. This may be important for clinical care, since symptoms with the most negative impact should be focused on in treatment.

Therapeutic effects of intensive voice treatment (LSVT LOUD®) for children with spastic cerebral palsy and dysarthria: A phase I treatment validation study

PURPOSE

The aim of the present study was to validate and extend the evaluation of treatment outcomes following LSVT LOUD® in children with dysarthria secondary to cerebral palsy (CP).

METHOD

Seven children (5 females, 6-10 years) with spastic quadriplegia and dysarthria received LSVT LOUD. Outcomes included: (a) quantitative and qualitative indices of communication and social functioning representing therapeutic effects and (b) features of the acoustic signal representing physiological effects on the speech mechanism. A matched group of typically developing children served as controls. Testing occurred just prior to (PRE), immediately following (POST), and at 12 weeks post-treatment (FUP).

RESULT

Expert listeners preferred voice quality and articulatory precision of children with CP at FUP as compared to PRE. Acoustic data indicated improvements on select measures of vocal functioning at POST with some maintenance at FUP. Single word intelligibility improved immediately POST, but was not maintained at FUP. Parents rated positive changes in characteristics of voice and speech and qualitative changes in communication at both POST and FUP.

CONCLUSION

The present study validated some of the previous LSVT LOUD outcomes in children with dysarthria and CP and extended our understanding of therapeutic effects through qualitative data obtained from extensive parent interviews.

Speech therapy for children with dysarthria acquired before three years of age

BACKGROUND

Children with motor impairments often have the motor speech disorder dysarthria, a condition which effects the tone, strength and co-ordination of any or all of the muscles used for speech. Resulting speech difficulties can range from mild, with slightly slurred articulation and breathy voice, to profound, with an inability to produce any recognisable words. Children with dysarthria are often prescribed communication aids to supplement their natural forms of communication. However, there is variation in practice regarding the provision of therapy focusing on voice and speech production. Descriptive studies have suggested that therapy may improve speech, but its effectiveness has not been evaluated.

OBJECTIVES

To assess whether any speech and language therapy intervention aimed at improving the speech of children with dysarthria is more effective in increasing children's speech intelligibility or communicative participation than no intervention at all , and to compare the efficacy of individual types of speech language therapy in improving the speech intelligibility or communicative participation of children with dysarthria.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 , Issue 7 ), MEDLINE, EMBASE, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to July 2015, handsearched relevant journals published between 1980 and July 2015, and searched proceedings of relevant conferences between 1996 to 2015. We placed no restrictions on the language or setting of the studies. A previous version of this review considered studies published up to April 2009. In this update we searched for studies published from April 2009 to July 2015.

SELECTION CRITERIA

We considered randomised controlled trials and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.

DATA COLLECTION AND ANALYSIS

One author (LP) conducted searches of all databases, journals and conference reports. All searches included a reliability check in which a second review author independently checked a random sample comprising 15% of all identified reports. We planned that two review authors would independently assess the quality and extract data from eligible studies.

MAIN RESULTS

No randomised controlled trials or group studies were identified.

AUTHORS' CONCLUSIONS

This review found no evidence from randomised trials of the effectiveness of speech and language therapy interventions to improve the speech of children with early acquired dysarthria. Rigorous, fully powered randomised controlled trials are needed to investigate if the positive changes in children's speech observed in phase I and phase II studies are generalisable to the population of children with early acquired dysarthria served by speech and language therapy services. Research should examine change in children's speech production and intelligibility. It must also investigate children's participation in social and educational activities, and their quality of life, as well as the cost and acceptability of interventions.

Biofeedback eletromiográfico no tratamento das disfunções orofaciais neurogênicas: revisão sistemática de literatura

RESUMO Objetivo Investigar se o uso do biofeedback eletromiográfico na terapia voltada às funções orofaciais (expressão facial, mastigação, deglutição, fonação e fala) produz efeitos benéficos para os indivíduos com doenças neurológicas. Estratégia de pesquisa Foi realizada busca nas bases de dados MEDLINE, LILACS e SciELO, por meio dos descritores “electromyographic biofeedback”, “swallowing”, “speech” “chewing”, “phonation”, e “facial expression”. A busca nas bases de dados e a seleção dos artigos foram realizadas independentemente, por duas pesquisadoras e, nos casos de não concordância, houve discussão fundamentada nos critérios de inclusão e exclusão para que chegassem a um consenso. Critérios de seleção Foram incluídos estudos experimentais em seres humanos, em inglês e português, que descreveram e discutiram a utilização do biofeedback eletromiográfico no tratamento das alterações das funções orofaciais provenientes de doenças neurológicas. Resultados Foram encontrados 175 artigos, sendo que somente 10 se adequaram aos critérios de inclusão. A maioria dos trabalhos relacionou-se a estudo de caso, seguido por estudos de série de casos, caso controle e ensaio clínico randomizado. A maior parte dos artigos abordou a aplicação da terapia com biofeedback eletromiográfico na função da deglutição, seguida da função da fala e apenas um artigo utilizou esta modalidade de tratamento na terapia para melhora da expressão facial. Não foram encontrados estudos que abordassem o tratamento fonoaudiológico utilizando o biofeedback eletromiográfico em pacientes com doenças neurológicas, nas funções de fonação e mastigação. Conclusão O uso do biofeedback eletromiográfico na terapia voltada às funções orofaciais pode produzir efeitos benéficos para os indivíduos com doenças neurológicas, nas funções de deglutição, fala e expressão facial.

Socialization and nonverbal communication in atypically developing infants and toddlers

Emphasis on early identification of atypical development has increased as evidence supporting the efficacy of intervention has grown. These increases have also directly affected the availability of funding and providers of early intervention services. A majority of research has focused on interventions specific to an individual's primary diagnoses. For example, interventions for those with cerebral palsy (CP) have traditionally focused on physiological symptoms, while intervention for individuals with Autism Spectrum Disorder (ASD) focus on socialization, communication, and restricted interests and repetitive behaviors. However deficits in areas other than those related to their primary diagnoses (e.g., communication, adaptive behaviors, and social skills) are prevalent in atypically developing populations and are significant predictors of quality of life. Therefore, the purpose of the current study was to examine impairments in socialization and nonverbal communication in individuals with Down's syndrome (DS), CP, and those with CP and comorbid ASD. Individuals with comorbid CP and ASD exhibited significantly greater impairments than any diagnostic group alone. However, individuals with CP also exhibited significantly greater impairments than those with DS. The implications of these results are discussed.

Long-term neurodevelopmental outcomes after preterm birth

CONTEXT

All over the the world, preterm birth is a major cause of death and important neurodevelopmental disorders. Approximately 9.6% (12.9 million) births worldwide are preterm.

EVIDENCE ACQUISITION

In this review, databases such as PubMed, EMBASE, ISI, Scopus, Google Scholar and Iranian databases including Iranmedex, and SID were researched to review relevant literature. A comprehensive search was performed using combinations of various keywords.

RESULTS

Cerebral palsy especially spastic diplegia, intellectual disability, visual (retinopathy of prematurity) and hearing impairments are the main neurodevelopmental disorders associated with prematurity.

CONCLUSIONS

The increased survival of preterm infants was not associated with lower complications. There is now increasing evidence of sustained adverse outcomes into school age and adolescence, for preterm infants.

Speech-associated labiomandibular movement in Mandarin-speaking children with quadriplegic cerebral palsy: a kinematic study

The purpose of this study was to investigate the speech-associated labiomandibular movement during articulation production in Mandarin-speaking children with spastic quadriplegic (SQ) cerebral palsy (CP). Twelve children with SQ CP (aged 7-11 years) and 12 age-matched healthy children as controls were enrolled for the study. All children underwent analysis of percentage of consonants correct (PCC) and kinematic analysis of speech tasks using the Vicon Motion 370 system. Kinematic parameters included utterance duration, displacement and velocity of the lip and jaw, coefficient of variation (CV) of lip utterance duration, and spatial and temporal coupling of labiomandibular movement of speech produced in mono-syllable (MS) and poly-syllable (PS) tasks. Children with CP showed lower temporal coupling (MS, p = 0.015; PS, p = 0.007), but not spatial coupling, of labiomandibular movement than healthy children. Children with CP had greater CVs (MS, p = 0.003; PS, p = 0.010) and the peak opening displacement and velocity of lower lip and jaw (p < 0.05) and lower PCC (p < 0.001) than healthy children. Children with SQ CP displayed labiomandibular coupling movement impairment, especially in the aspect of temporal coupling. These children also had high temporal oromotor variability and needed to make more effort to coordinate the labiomandibular movement for speech production.

Electropalatography in the description and treatment of speech disorders in five children with cerebral palsy

Some children with cerebral palsy have articulation disorders that are resistant to conventional speech therapy. The aim of this study was to investigate whether the visual feedback method of electropalatography (EPG) could be an effective tool for treating five children (mean age of 9.4 years) with dysarthria and cerebral palsy and to explore whether training improved the posteriorly placed articulation of the Swedish dental/alveolar target consonants /t/, /d/, /n/ and /s/ produced in different positions. An EPG analysis was conducted and some of the data were combined with a perceptual analysis. A more anterior placement was seen after treatment for the target sounds. Features of diagnostic importance revealed were unusual tongue-palate contacts, such as double articulation and abnormally retracted articulation. A possible change in stop closure duration was indicated. The results suggest that EPG could be of potential benefit for diagnosing, treating and describing articulation errors associated with cerebral palsy.

Oromotor variability in children with mild spastic cerebral palsy: a kinematic study of speech motor control

Background

Treating motor speech dysfunction in children with CP requires an understanding of the mechanism underlying speech motor control. However, there is a lack of literature in quantitative measures of motor control, which may potentially characterize the nature of the speech impairments in these children. This study investigated speech motor control in children with cerebral palsy (CP) using kinematic analysis.

Methods

We collected 10 children with mild spastic CP, aged 4.8 to 7.5 years, and 10 age-matched children with typical development (TD) from rehabilitation department at a tertiary hospital. All children underwent analysis of percentage of consonants correct (PCC) and kinematic analysis of speech tasks: poly-syllable (PS) and mono-syllable (MS) tasks using the Vicon Motion 370 system integrated with a digital camcorder. Kinematic parameters included spatiotemporal indexes (STIs), and average values and coefficients of variation (CVs) of utterance duration, peak oral opening displacement and velocity. An ANOVA was conducted to determine whether PCC and kinematic data significantly differed between groups.

Results

CP group had relatively lower PCCs (80.0-99.0%) than TD group (p = 0.039). CP group had higher STIs in PS speech tasks, but not in MS tasks, than TD group did (p = 0.001). The CVs of utterance duration for MS and PS tasks of children with CP were at least three times as large as those of TD children (p < 0.01). However, average values of utterance duration, peak oral opening displacement and velocity and CVs of other kinematic data for both tasks did not significantly differ between two groups.

Conclusion

High STI values and high variability on utterance durations in children with CP reflect deficits in relative spatial and/or especially temporal control for speech in the CP participants compared to the TD participants. Children with mild spastic CP may have more difficulty in processing increased articulatory demands and resulted in greater oromotor variability than normal children. The kinematic data such as STIs can be used as indices for detection of speech motor control impairments in children with mild CP and assessment of the effectiveness in the treatment.

Speech therapy for children with dysarthria acquired before three years of age

BACKGROUND

Children with motor impairments often have the motor speech disorder dysarthria, a condition which effects the tone, power and coordination of any or all of the muscles used for speech. Resulting speech difficulties can range from mild, with slightly slurred articulation and low-pitched voice, to profound, with an inability to produce any recognisable words. Children with dysarthria are often prescribed communication aids to supplement their natural forms of communication. However, there is variation in practice regarding the provision of therapy focusing on voice and speech production. Descriptive studies have suggested that therapy may improve speech, but its effectiveness has not been evaluated.

OBJECTIVES

To assess whether direct intervention aimed at improving the speech of children with dysarthria is more effective than no intervention at all. To assess whether individual types of intervention are more effective than others in improving the speech intelligibility of children with dysarthria.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to April 2009, handsearched relevant journals published between 1980 and April 2009, and searched proceedings of relevant conferences between 1996-2009.

SELECTION CRITERIA

We considered randomised controlled trials and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.

DATA COLLECTION AND ANALYSIS

L Pennington conducted searches of all databases and conference reports. L Pennington, N Miller and S Robson handsearched journals. All searches included a reliability check in which a second review author independently checked a random sample comprising 15% of all identified reports. We planned that two review authors would independently assess the quality and extract data from eligible studies.

MAIN RESULTS

No randomised controlled trials or group studies were identified.

AUTHORS' CONCLUSIONS

We found no firm evidence of the effectiveness of speech and language therapy to improve the speech of children with early acquired dysarthria. No change in practice is warranted at the present time. Rigorous research is needed to investigate if the positive changes in children's speech observed in small descriptive studies are shown in randomised controlled trials. Research should examine change in children's speech production and intelligibility. It should also investigate the secondary education, health and social care outcomes of intervention, including children's interaction with family, friends and teachers, their participation in social and educational activities, and their quality of life. Cost and acceptability of interventions must also be investigated.