SLT ASSESSMENT: WHY DOES IT MATTER
Knowledge Is Power
WELCOME
We are here today to tell you about the importance of Speech and Language Therapy Assessments, in response to your request for training after the case referral of *Rose. We have created this website with many resources and information that will benefit you in your professional career.
TRAINING OVERVIEW
Dysarthria and Dysphagia
Case History
Oro-facial Examination
Perceptual (Informal) Assessments
Formal Assessment
Assessment of Intelligibility and Comprehensibility
Assessment of Activities and Participation Restrictions
DYSARTHRIA AND NEUROLOGY
Dysarthria is a speech disorder which is caused by neurologic difficulties affecting the muscles needed for speech.
MSDs for example dysarthria can often be the first and possibly only sign of a neurological disease.
Types of Dysarthria and links to Neurological Disorders
1. Flaccid — associated with disorders of the lower motor neuron system and/or muscle eg. Stroke and Tumour (brainstem), Motor Neuron Disease, Myasthenia Gravis, TBI.
2. Spastic — associated with bilateral disorders of the upper motor neuron system eg. Stroke, Tumour, Cerebral Anoxia, Viral/bacterial infection, Motor Neuron Disease.
3. Ataxic — associated with disorders of the cerebellar control circuit eg. Cerebellar Stroke, MS, Friedrichs Ataxia, Toxicity, TBI, Tumour.
4. Hypokinetic — associated with disorders of the basal ganglia control circuit eg. Parkinson’s Disease.
5. Hyperkinetic — associated with disorders of the basal ganglia control circuit eg. Huntingtons Disease, Syndenham Chorea.
6. Unilateral upper motor neuron — associated with unilateral disorders of the upper motor neuron system eg. Stroke (most common), Tumour, Surgical Trauma.
7. Mixed — various combinations of dysarthria types (e.g., spasticataxic; flaccid-spastic) 8.
8. Undetermined — perceptual features are consistent with a dysarthria but do not clearly fit into any of the identified dysarthria types
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DYSPHAGIA AND NEUROLOGY
Dysphagia refers to a difficulty in swallowing. Dysphagia often occurs in patients with neurological diseases. A stroke is the most common neurological condition that causes dysphagia. Examples of other neurological conditions that can cause swallowing difficulties are cerebral palsy, Parkinsons disease, multiple sclerosis and traumatic brain injury.
CASE HISTORY
What is it & why is it important for SLTs and other members of the MDT (e.g. The Neurology Team) ?
The Case History identifies any red flags that may be a factor or a contributing factor, to any speech, voice, fluency, swallowing, or language difficulties.
The more information the client provides the SLT during this session, the better the diagnosis will be, as Case History can lead to the final diagnosis in 76% of cases.
The Case History gives the SLT a full picture of their client and his/her background, as well as their perspectives and priorities.
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During the client interview SLTs :
use open-ended questions which provide the SLT with richer information.
avoid their own information bias.
avoid overloading the client with questions.
avoid leading questions.
avoid 'Why?' questions, because these can sound judgmental.
may emphasise key words, or use pen and paper, pictures, and gestures.
summarize the client's information for them afterwards, as this gives the client an opportunity to correct any misinterpretations made by the SLT.
adopt a solution-focused approach.
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The importance of Case History taking in terms of assessing if a patient has Dysarthria :
To describe the perceptual characteristics of the individual's speech and relevant physiologic findings.
To describe speech subsystems affected (i.e. articulation, phonation, respiration, resonance, and prosody) and the severity of impairment for each.
To identify other systems and processes that may be affected (e.g. swallowing, language, cognition).
To assess the impact of the dysarthria on speech intelligibility and naturalness, communication efficiency and effectiveness, and participation.
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Here are a few examples of the types of questions that a SLT might ask a patient presenting with speech, voice, fluency, language, communication or swallowing difficulties :
Are you taking any medications that affect your speech in a positive or negative way?
Are there any other factors that predictably affect your speech (e.g. time of day, stress, fatigue, environment)?
Have you had any difficulty with chewing or saliva control?
Do you have trouble swallowing food or liquid?
Do you have trouble getting a swallow started?
Do you lose food or liquid out of your mouth.
Do people have trouble understanding you?
Describe your current speech difficulty - how does it sound to you?
Have you altered any of your work or social activities because of your speech? How?
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ORO-FACIAL EXAMINATION
This is a brief look at the oro-facial examination carried out by SLT. We discuss why the oro-facial is important for assessment
PERCEPTUAL SPEECH EVALUATION
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What is it and why it's important?
A perceptual assessment is essentially describing and evaluating a client’s voice based on auditory perception alone.
There are various tasks that can be used clinically to diagnose a motor speech disorder such as dysarthria
In terms of motor speech production diadochokinesis (DDK) tasks are proven to be very useful in speech assessments to assist in ‘’underlying neuromuscular dysfunction and speech subsystem impairment’’
There are two traditional tests involved in DDK:
AMR involves ‘’single syllable repeating at maximum rate’’ for example repeating the symbols /pa/, /ta/ and /ka/ Ideally 5-7 reps per sec would be the key values required.
SMR involves ‘’sequence of syllables repeated at maximum rate’’ for example the sequence /pataka/ is commonly used Ideally 3-7 reps per sec would be the key values required.
‘’Quantitative aspects of DDK rate have been shown to provide a sensitive indicator of the presence and severity of neurological impairment and evolution of changes over time in both developmental and acquired disorders
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These tests are vital to SLT’s as they have both ‘’been found to be sensitive for the measurement and diagnosis of speech disorders arising from progressive neurological disorders’’
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There are various additional informal assessments which can be used alongside DDK to assist in the overall assessment and diagnosis of speech and swallowing difficulties, including obtaining a connected speech sample in order to check for dysprosody, monotonous speech, uneven and equal stress patterns in speech or placing a small mirror under the nose and ask person to say /u/ for as long as possible- this can check for either hyponasal or hypernasal speech.
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Here is a brief outline of DDK (perceptual assessment) to aid your understanding
FORMAL ASSESSMENT
Formal assessments are important in the accurate diagnosis of the different types of dysarthria. This is important because, in order to develop an effective treatment plan and advise other professionals on their treatment plans, we must be able to gather the information about the characteristics and severity of one's dysarthria and it is these formal assessments (alongside the informal assessments) that allow us to do so.
There are multiple formal assessments available to SLTs which aid in the diagnosis of dyarthria, such as AIDS, Dysarthria Profile, Dysarthric Speech, and Voice Handicap Index, but the most common one would be the Frenchay Dysarthria Assessment.
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Frenchay Dysarthria Assessment
the FDA-2 provides new and important information/knowledge about motor speech disorders and how they contribute to neurological diagnosis. This second edition is a well established test for the measurement of, as well as the differential description and diagnosis of dysarthria.
this test is quick and simple to carry out and is reliable, accurate and cost-efficient. In it the client is required to carry out a series of tasks that relate to speech function across the following eight sections:
Reflexes
Respiration
Lips
Palate
Laryngeal
Tongue
Intelligibility
Influencing Factors
The test results indicate both the client's strengths and weaknesses. The Rating Form also allows the clinician to compare the patient's performance across all sections. Separate tables allow SLTs to compare individual results with those of known dysarthric groups. The results are easily communicated to other professionals via the three-part carbonized record form.
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ASSESSMENT OF INTELLIGIBILITY AND COMPREHENSIBILITY
Assessment of intelligibility, comprehensibility, and efficiency of speech allows us to see how Dysarthria impacts communication. Each factor has its own impact on communication. Intelligibility and efficiency reflect the functional impact of Dysarthria, on spoken communication, whereas comprehensibility reflects the degree of disability imposed by Dysarthria also taking into account the contribution of non-verbal communication.
Intelligibility
· Intelligibility: How accurately speech is conveyed by the speaker and recovered by the listener. A limitation to intelligibility is the pressure on the speaker, it is typically reported as percentage of words correctly identified by the listener.
· When assessing speech intelligibility, it should be assessed at word level, sentence level and connected speech. There are many different assessments, it is important to choose the assessment best suited to the patient.
· Assessments of intelligibility: Sentence Intelligibility Test (SIT) , Frenchay Dysarthria Assessment (FDA-2), A Word Intelligibility Test, Munich Intelligibility Profile, Assessment of Intelligibility in Dysarthric Speakers (AIDS).
· Assessment of Intelligibility of Dysarthric Speech is especially useful as it assesses both word level and sentence level. It is the most widely used standardized test for measuring intelligibility, speaking rate and efficiency. It measures these factors by examining the rate of intelligible words per minute. The AIDS provides an index of severity of impairment, an estimate of the patient’s deviation from normal, and a standard for monitoring change over time. Recommendations for assessing intelligibility from ASHA: Use material unknown to the listener and with low semantic predictability.
· Assessment of intelligibility is important because it gives an index of severity, the standardized assessments can be repeated and measured over time to see if there is any change in intelligibility. However, there are limitations, the measure of the speaker’s intelligibility does help us discover the nature or cause of the problem and intelligibility but it can be influenced by factors such as environment etc.
Comprehensibility
· Comprehensibility is the degree to which the listener understands the spoken message. This differs from intelligibility as it considers other information and cues such as semantic context and gestures.
· Comprehensibility is important as it is dyadic, both the speaker and listener have roles of equal importance. It takes into account the communication context which would be important for Rose, her interests in socialising and career as a hairdresser.
· Assessing comprehensibility indicates the impact of dysarthria has in conversational speech.
· Comprehensibility is assessed by observing how the speaker communicates, both verbally and nonverbally, and what strategies the speaker uses. We should also consider how the listener facilitates conversation.
Efficiency
· Efficiency refers to the rate at which intelligible or comprehensible speech is communicated and It is typically reported as the number of intelligible and comprehensible words produced per minute.
· Importance: Assessing the effectiveness of communication from the perspective of affected speakers and their significant others is highly relevant to estimates of dysarthria severity, intervention planning, and functional outcome measurement.
· The Communicative Effectiveness Survey (CES): The CES is a questionnaire with eight items that address the effectiveness of communication under several conditions
· Efficiency is important to consider when looking at the patient’s lifestyle and their communication environments. Is there a demand for high-efficiency speech for their job etc.
ASSESSMENT OF ACTIVITIES AND PARTICIPATION RESTRICTIONS
SLT assessment considers all the features of the International Classification of Functioning, Disability and Health (ICF). SLT take a holistic approach to assessment. They must consider not only the physical aspects but the impact of the impairment on the person’s daily life and relationships and factors that might limit or facilitate their communication, socialisation and participation in society.
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It is important to highlight that regardless of how severe the impairment is a Speech and Language Therapist cannot assume what the psychosocial impacts will be for a person and whether it will have an effect on various different aspects of their life. This is the case for *Rose.
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People with an impairment can often feel isolated and misunderstood. This can cause a reduction in socialisation and communication due to the fear of being judged or lack of confidence. This can have a significant impact on their career, relationships and participation in social events.
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There is often a lot of stigmatism and negativity about people with speech and/or swallowing difficulties. It can lead to cruel labelling and misinterpretations about the person's intelligence. This is why it is extremely important for SLT to be aware of local support groups and resources that may help the person. This can potentially help reduce social isolation and increase participation.
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Assessments
These assessments are often included alongside formal and informal assessments to help assess the clients experiences with the impairment.
Communication Effectiveness Survey.
Dysarthria Impact Profile is used to examine the psychosocial impact and experiences of acquired dysarthria from the individual’s perspective. The psychosocial impact can have a direct affect on participation.
Communicative Participation Item Bank is a short form which allows the client to mark how much their condition interferes with their participation in society.
BLOG
By Rose
Hi my name is Rose and I am 26 years old. I was referred onto Speech and language therapy while I was in hospital, because I finally expressed my concerns about some changes I noticed in my speech and swallowing. It was worrying me for many reasons. Some people didn't notice any difference at all but I felt that something wasn't right and that if I didn't get it checked soon, it would only get worse.
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I work as a hairdresser and a huge part of my job is socialising with the customers, so, when my voice began to change I would feel so anxious about going into work because I thought that people would judge my voice and then, when I felt it getting worse, this worry deepened and I almost did not want to go into work at all. I am definitely an outgoing person, I love to sing and socialise with my friends, but when my voice started to change my confidence plummeted and I felt like a completely different person, quieter and withdrawn because I was embarrassed and very worried about what everyone would think. However, when I was given a referral I was filled with hope.
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When I met with the Speech and Language therapist in the hospital I have to say, I was a mess. The changes I was experiencing were really worrying me for all of these reasons, I was upset, confused, and incredibly stressed because I did not understand what was happening. However, the SLT who I worked with helped me a lot by validating my thoughts and feelings as well as helping me understand the situation. I was so happy to be seen because I could not go on with the way it was affecting me and my life. I am getting married next year and I am determined not to let this affect that. I want to be confident enough to say my vows without worrying what people will think and I think with the help of Speech and language therapy, I will get there.
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Quotes from Rose
"It wasn't my voice..."
"I feel frustrated"
"It's not what I normally sound like"
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