Clinical Examination of Voice and Motor Speech Disorders

Part I Confidential Questionnaire Date of evaluation: ____________________

Patient name: _______________________ Date of Birth: _____________Age________

Address: _______________________ Phone: (w) ________________________

____________________________________ (h) ________________________

Occupation: ____________________________________________________________

School (last grade attended):_________________________________________________

Living situation (lives alone, assisted living, etc):________________________________________________________________________

Referred by: ____________________________________________________________

Physician: ___________________________________________________________

Please attach physician report to this questionnaire

Medicare #: ____________________ Medicaid #: ____________________________

Copies of the reports to be sent to: ____________________________________________

Section II: Patient Impressions

Briefly describe the problems that you are having with breathing, speech, voice or swallow. What do you think caused these problems?

How did your physician(s) describe the problem that you are having?

When did the changes begin? Did the problem come on suddenly, or over a period of time?

Assessment II

Are there specific times when your speech and voice are better or worse? Morning? Afternoon?

What are your communication demands throughout the day? How many people do you speak with?

Do you speak over the telephone? If not, why not?

What percentage of the time would you say that you are understood by others?

Are you right or left handed?

Part III: Please complete the following:

Do you smoke now? ___________. Have you smoked in the past? _____________ Do you drink alcohol and/or caffeine? ___________ How much? _______________

How many glasses of water do you drink per day? ___________________________

Do you ever notice heartburn or a sour taste in your mouth? ____________________

Assessment III

Part IV: Medical History: Are you now, or have you been, seen by a physician or other health professional for the change in speech/voice or swallow? Explain.

List all of the medications (prescription and over the counter) that you are taking or have taken in the past.

Medical history: Please write “yes” next to the items that you are experiencing now or have experienced in the past.

Measles AllergiesDiphtheria SinusitisChicken pox TonsillitisMumps Ear diseaseFlu Jaw/tooth painMeningitis Acid indigestionCleft palate Swallowing problemsStroke BronchitisHeart Disease AsthmaSeizures Tender glandsInsomnia ArthritisParalysis Neurological diseaseInvoluntary movements Hypernasality/hyponasalityHead/bodily injury Endotracheal intubationSurgeries Trouble walkingCancer Trouble talking

What is your diet status? Do you have any eating restrictions?

Have you ever received an endoscopy, barium swallow or modified barium swallow examination? If so, what was the date and what were the results?

Is there any other information that you would like us to know about the changes in your speech and voice?

Do you wear hearing aids? Glasses? Dentures? Explain.

Assessment IV

Motor Speech/Voice Evaluation

Respiration:

Non-Instrumental

Watch patient during quiet breathing. Observe and record posture. Chart breaths per minute: average adults = 16/18 per minute (Duffy, 1995), 20-25 per minute for children and 50 for infants. Is breathing smooth/labored/shallow? Are there any involuntary movements involving the thoracic area? Explain.

Investigate dentition: Missing front teeth have the most direct effect on speech, especially /s/ and /z/. Check for tooth and bite irregularities.

Is patient a mouth breather? If so, investigate.

Listen for wheezing, stridor, “wet” quality of breathing:

Manometer test: Can patient maintain a stream of bubbles for 5 seconds with straw at a depth of 5 centimeters? (Hixon, Hawley and Wilson, 1982)

Pulmonary and Laryngeal Function and Coordination

Non-Instrumental

MPT: Instruct client to take a deep breath and sustain an /a/. Repeat 2 more times. Record maximum phonation time (MPT). Mean in seconds for children (4 yo) (9.5); (6 yo) (10.5); young males (28.5); young females (22.7), elderly males (13.8), elderly females (14.4). (Darley, Aronson & Brown, 1975; Harden & Looney, 1984; Kent, Kent and Rosenbek, 1987). Describe vocal quality. Normal? Rough? Hoarse? Breathy? Strained? Strangled? Pitch breaks? Phonation breaks?

Pitch for sustained vowel: Using a keyboard, record pitch for sustained /a/. Compare with note-frequency keyboard chart. Avg. pitch for adult males is 128 Hz (C3) , adult women 213 Hz (A3) and prepubertal children 256 Hz (C4). (Boone & McFarlane, 2000).

Habitual pitch: Using standard keyboard, record a two to three minute speech sample. Select 7-8 samples and match with note on keyboard. Find mean of 8 notes = modal or speaking pitch.

Pitch range: Use standard keyboard. See attached keyboard frequency sheet. Model and then instruct client to “sing” up a scale from his or her lowest note. Can client patient produce 1.5 octave pitch range? (Hirano & Bless, 1993). Is vocal quality steady or tremorous? Is volume normal?

Assessment V

Pulmonary and Laryngeal Function and Coordination (cont)

Non-instrumental

s/z ratio (Boone and McFarlane, 2000). Instruct the client to sustain an /s/ as long as possible, followed by a /z/ as long as possible. Record in seconds for both. The /s/ should closely match the /z/.

Oral reading assessment: Instruct client to read the Grandfather Passage (Darley et al. 1975). Record speech sample. Transcribe sample to determine number of words per minute. Measure duration of selected sample; compute speakingrate. Normal paragraph reading rates for adults range from 160-170 wpm, (Fairbanks, 1960). Record respiratory-phonatory coordination, reading rate, vocal quality and articulation.

Automatic speech: Instruct client to count to 20 and to name the days of the week. Record respiratory-phonatory coordination, ease of production, articulatory accuracy and rhythm.

Spontaneous speech: Engage client in spontaneous speech. Perform identical calculations as in Reading assessment above. Normal range of conversational speaking rate for adults varies from 150 wpm to 250 wpm, or about 3 words per second (Goldman-Eisler, 1968; Kent & Forner, 1980). For children 4-5 it is 2.5 wps = 150 wpm; for children 2;0 it is 1.6 wps = 96 wpm). Average number of words per spoken phrase (for adults) is eight (Goldman-Eisler, 1968). Assess for respiratory-phonatory coordination; ease of production, rate, vocal quality and articulatory accuracy.

Instrumental

Phonatory function analysis: Normal transglottal airflow is 80-200 ml/s (Boone, McFarlane & Von Berg, 2005)

Acoustic instrumentation: Record fundamental frequency, relative average perturbation (RAP), and shimmer. Normative measures for RAP: .80% or below; shimmer 3.80% or below (Boone, & Von Berg, 2005).

Endoscopy: Rigid or fiberoptic: Observe anatomy of structures and record glottic closure, phase closure, amplitude, status of mucosal wave, vibratory behavior, phase symmetry, periodicity. Note any hyperfunctional behaviors (Hirano and Bless, 1993)

Assessment VI

Resonance

Non-instrumental

Velum at rest: With tongue blade and flashlight, observe status of palate; is it symmetric? Does it rest low on tongue? Any signs of bifid? Any tremors? Check for redness or fullness that might indicate infection.

Velum during sustained posture: Instruct client to sustain an /ah/. Observe for superior and posterior movement.

Velum during movement: Intraoral: (record strength, speed, range of movement, accuracy, steadiness and tone). Produce several sharp /ah/s.

Velopharyngeal observation :Extra-oral: Modified tongue anchor test; octopus tubing*; straw from naris to ear; nares test closure test for /i/ and /s/. Record any fogging and air turbulence and record the stimuli on which they occur.

Instrumental

Nasometer: Zoo Passage ranges = 2 SD from mean (15.5% nasalance) (Fletcher 1978)

Nasovideoendoscopy: Instruct client to engage in various speech and non-speech tasks: Record velopharyngeal strength, speed, range of movement, accuracy, steadiness and tone.

Videofluoroscopic evaluation: Instruct client to engage in various speech and non-speech tasks. Record velopharyngeal strength, speed, range of movement. Accuracy, steadiness and tone.

Assessment VII

Oral Motor Evaluation:

Inspect oral cavity. Observe mucosa, dentition, record any abnormalities.

Face at rest: Observe facial symmetry, observe overall expression, any involuntary movements?

Face during sustained postures: Instruct client to retract, round and puff lips and cheeks. Can client retain posture for several seconds? Can patient maintain lip closure with examiner manipulation (pulling down or up on closed lips)?

Face during movement (Record strength, speed, range of movement, accuracy, steadiness, and tone.) Lips: Retraction, rounding as rapidly and as steadily as possible; attempt to elicit a spontaneous smile. Record any signs of emotional lability.

Jaw at rest: Is the mandible closed or slightly open at rest? Does the jaw hang open? Record any involuntary movements.

Jaw during sustained postures: Instruct client to open mouth. Does jaw deviate from one side to another? Is excursion limited? Can client resist opening and closing of the jaw by examiner? Instruct client to close jaws. Is muscle bulk symmetric?

Jaw during movement. Instruct client to open and close mouth and to ‘pretent” chew. (record strength, speed, range of movement, accuracy, steadiness and tone)

Tongue at rest: Observe tongue bulk and symmetry. Does tongue remain at floor of mouth with no twitching or movement. If tongue does move, is that an artifact?

Tongue during sustained postures: Instruct client to protrude tongue several times and hold position. Does tongue regularly deviate to one side? Can tongue resist examiner’s pressure with a tongue blade? Can client resist examiner’s pressure against tongue pushing against the inside of the cheek?

Tongue during movement (record strength, speed, range of movement, accuracy, steadiness and tone). Observe tongue during protrusion /retraction and lateralization exercises.

Assessment VIII

Instruct client to produce AMRs and SMRs for at least 3-5 seconds. Count each repetition per second. Means and ranges vary for production per second. Young adult means = SMRs 4.5, AMRS: puh 6.3, tuh 6.1, kuh 5.8; Female adult means = SMRs 6.3, AMRs: puh 6.2, tuh, 6.2, kuh, 5.6; Male adult means = SMRs 6.4, AMRs: puh 6.3, tuh 6.1, kuh 5.8. Six-year-old child: SMR = 1.0; AMRs: puh 4.2, tuh 4.1, kuh 3.6 (Fletcher, 1972; Lass and Sandusky, 1971) (Monitor for vocal quality, articulatory precision, rate and steadiness.

AMRs: puh-puh-puh/tuh-tuh-tuh/kuh-kuh-kuh

SMRs: puhtuhkuh-puhtuhkuh

Fatigue testing: Count as precisely as possible for 2 minutes. Record strength, speed, range of movement, accuracy, steadiness and tone. Also transcribe for articulatory accuracy.

Assessment of IntelligibilityAdminister

Assessment of Intelligibility in Dysarthric Speakers (Yorkston and Beukelman, 1981a)AIDS measures intelligibility and rate of speech for single words and sentences.

Phoneme identification task. (Yorkston, Beukelman and Traynor, 1988)PIT measures phoneme intelligibility in non-contextual sentences.

Frenchay Dysarthria Assessment (Enderby, 1983)

Dworkin-Culatta Oral Mechanism Evaluation (1980).

Assessment of Intelligibility in Connected SpeechAsk the client to describe his favorite vacation or pet or job. Tape record. Ask a naïve listener to transcribe the sample. Quantify using the same method as the AIDS. Analyze for sound errors, hesitations, fillers, iterations.

Assessment of Prosody

Non-Instrumental

Reading:

Instruct client to read a sentence ranging from 5-8 words. Record. Then, instruct client to reread the sentence and inflect a single target word in the sentence. Record accuracy of target inflection with a +/- in a series of 10 opportunities. Perform the identical procedure and instruct the client to inflect two target words. Compare according to procedure above.

Assessment IX

Assessment of ProsodyNon-Instrumental

Connected speech:

Contrastive stress: Engage the client in contrastive stress drills (eg Sue bit Molly. Who bit Molly? Sue bit Molly). Record accuracy of target inflection with a +/- in a series of 10 opportunities.

Heteronyms: Instruct client to generate a sentence using heteronyms. Record accuracy of target inflection with a +/- in a series of 10 opportunities. (content/content; conduct/conduct; contest, contest, desert, desert, escort, escort)

Instrumental

Perform the activities above, however record results acoustically, measuring Fo, duration, and intensity.

Apraxia of SpeechSee selected assessments of apraxia featured in the Western Aphasia Battery (Kertesz, 1982); Boston Diagnostic Examination of Aphasia (Goodglass & Kaplan, 1983); Motor Speech Disorders (Duffy, 1995), Oral and speech motor control protocol for young children (Robbins & Klee); Tests for apraxia of speech and oral apraxia: Children’s battery (Darley, Aronson and Brown, 1975).References for reported values and for InstrumentsBoone, DR, & McFarlane, SC (2000). The Voice and voice therapy, 6th ed. Boston, Allyn and BaconDarley, FL, Aronson, AE, and Brown, JR (1975). Motor speech disorders, WB Saunders.Duffy, J (1995). Motor speech disorders. St. Louis, Mosby.Dworkin, J, and Culatta, R (1980). Dworkin-Culatta Oral Mechanism Examination. Nicholasville, KY: Edgewood Press.Enderby, PA (1983) Frenchay Dysarthria Assessment, San Diego, College-Hill.Fairbanks, G (1960). Voice and Articulation Drillbook. New York, Harper & Brothers.Fletcher, SG (1976). Nasalance vs. Listner (sic) judgements of nasality. Cleft Palate Journal,13, 31-44. Fletcher, S (1972). Time-by-count measurement of diadochokinetic syllable rate. Journal of Speech and Hearing Research, 15, 763-770. Goldman-Eisler , F (1968). Psycholinguistics: Experiments in spontaneous speech. New York: Academic Press.Goodglass, H and Kaplan, E (1983). Boston Diagnostic Aphasia Examination. Media, PA, Williams & Wilkins. Harden, JR and Looney, NA (1984). Duration of sustained phonation in kindergarten children. International Journal of Pediatric otolaryngology, 7, 11-19. Hirano, M and Bless, DM (1993). Videostroboscopic examination of the larynx. San Diego, Singular Publishing Group. Hixon, TJ, Hawley, JL, and Wilson, KJ (1982). An around the house device for the clinical determination of respiratory driving pressure: a note on making the simple even simpler. J Speech and Hearing Disorders, 47:413, 1982.Kent, RD, Kent JF, and Rosenbek, JC. (1987). Maximum performance tests of speech production. J Speech Hearing Disorders 52: 367-387. Kertesz, A (1982). Western Aphasia Battery. New York, Grune & Stratton, Inc.Lass, N and Sandusky J (1971). A study of the relationship of diadochokinetic rate, speaking rate and reading rate. Today’s Speech, 19, 49-54.Robbins, J, and Klee, T (1987). Clinical assessment of oropharyngeal motor development in young children. Journal of Speech and Hearing Disorders, 52, 271-277. Yorkston, KM, and Beukelman DR (1984). Assessment of Intelligibility of Dysarthric Speech. Austin, TX, Pro-Ed. Yorkston, KM, Beukelman, DR, and Traynor, CD (1988). Articulatory adequacy in dysarthric speakers: A comparison of judging formats, J. Communication Disorders, 21, 351-361.Yorkston, KM, Beukelman, DR, Strand, EA, and Bell, KR (1999). Management of Motor speech Disorders in Children and Adults, 2nd ed. Austin, Pro-Ed.

My Grandfather passage

You wish to know all about my grandfather. Well, he is nearly

ninety three years old; he dresses himself in an ancient black frock

coat, usually minus several buttons, yet he still thinks as swiftly as

ever. A long, flowing beard clings to his chin, giving those who

observe him a pronounced feeling of the utmost respect. When he

speaks, his voice is just a bit cracked and quivers a trifle. Twice

each day he plays skillfully and with zest upon our small organ.

Except in the winter when the ooze of snow or ice presents, he

slowly takes short walk in the open air each day. We have often

urged him to walk more and smoke less, but he always answers

banana oil! Grandfather likes to be modern in his language.

Extracted from Speech Correction: Principles and Methods, Van Riper, Charles, 1963. P.

484

Musical note to frequency chart

Note Freq (Hz) Note Freq. (Hz) Note Freq. (Hz)A1 55 A3 220 A5 880B1 62 B3 245 B5 988C2 65 C4 262 C6 1046D2 73 D4 294 D6 1175E2 82 E4 330 E6 1318F2 87 F4 349 F6 1397G2 98 G4 392 G6 1568A2 110 A4 440 A6 1760B2 123 B4 494 B6 1975C3 131 C5 523 C7 2093D3 147 D5 587 D7 2349E3 164 E5 659 E7 2637F3 175 F5 698 F7 2794G3 196 G5 784 G7 3136

Phoneme Identification Task (Adapted from Yorkston, Beukelman and Traynor, 1988)

Client stimulus sheet

1. Madge is between loan and thought.

2. Moth and rung are first and man is last.

3. He said mum; she said love or who’ll.

4. Mash and ham come before bake.

5. I thought it was neat or bathe; you thought rain.

6. Spell the words showed, Tom and vat.

7. Spell pan then say fuel and should.

8. Heal is before taught or loaf.

9. There and howl were correct; fan was spelled wrong.

10.Remember the words gain, Ian and main.

11.First comes moss and lug; later comes lob.

12.I said year and men not map.

13.Write the words zone, seat and lot.

14.Lowell, win and Dane are the words he spelled.

15.Say boy and match, then say male.

16.Ban is after Hal and will.

17.You said mall; I said lean and mod.

18.Read the words sham and maze; say the word mom.

19.He spelled chin; I spelled cane and by.

Phoneme Identification Task (Adapted from Yorkston, Beukelman and Traynor, 1988)

Listener Response sheet

1. Ma___ is between ___oan and ___ought. __/3

2. Mo___ and ru___ are first and ___an is last. __/3

3. He said mu___; she said lo___ or wh___ll. __/3

4. Ma___ and ___am come before ba___. __/3

5. I thought it was ___at or ba___; you thought ___ain. __/3

6. Spell the words sh___ed, T___m and ___at. __/3

7. Spell ___an then say f___l and sh___ld. __/3

8. H___l is before ___aught or loa___. __/3

9. ___ere and h___l were correct; ___an was spelled wrong. __/3

10.Remember the words ___ain, ___an and mai___. __/3

11.First comes mo___ and lu___; later comes lo___. __/3

12.I said ___ear and m___n not ma___. __/3

13.Write the words ___one, ___eat and lo___. __/3

14.Low___, ___in and ___ane are the words he spelled. __/3

15.Say b___ and ma___, then say m___le. __/3

16.___an is after H___l and w___ll. __/3

17.You said m___ll; I said l___n and mo___. __/3

18.Read the words ___am and ma___e; say the word mo___. __/3

19.He spelled __in; I spelled cane and b___. __/3

Total =

Add the total phonemes accurately perceived, and divide by 57

Example: 42 words accurately transcribed / 57 = 73% accuracy