Summary. This paper describes the necessity for, and the development of an assessment for dysarthria. The short easy assessment described has been found to ...
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Frenchay D ysarthria Assessment P. ENDERBY Department of Speech Therapy, Frenchay Hospital, Bristol.
Summary This paper describes the necessity for, and the development of an assessment for dysarthria. The short easy assessment described has been found to have acceptable inter-rater reliability, even between Speech Therapists who have not been trained to use the test. The clinical value of the test has been proven with its use with more than a hundred patients. However, there are several areas that point to the necessity of further research,
Introduction The term “dysarthria” is used in the restricted sense to describe faulty pronunciation or speech deviation due to neuromuscular disorders. (Espir and Rose 1976). Despite this restriction, we are still discussing the most commonly acquired speech disorder. It is surprising that, considering the frequency of occurrence of dysarthria, it has attracted little interest as is reflected in research or literature. This lack of initiative coupled with the dearth of treatise on the treatment of dysarthria is possibly associated with the absence of any standardised validated and reliable assessment. Universally, the conventional method of assessment is one of description. This method can have little reliability or sensitivity as the adjectives used to describe the behaviour are not consistent between the pathologists. The descriptions of speech produced by patients with multiple sclerosis by different authors (Ivers and Goldstein 1963, Merritt 1967, Darley et a1 1972) illustrates the problems of the different emphasis on varying characteristics of the speech produced. Other methods of assessment currently used are Electromyographic studies (Dworkin 1979) Spectroanalysis and Panel Judgement. All of these are rendered impractical in a normal clinical situation by cost, equipment and time.
Present Study The aims of the current work were to establish a reliable assessment for dysarthria. This will, it is hoped, promote greater interest in developing and evaluating treatment methods for this population. It could also ease the present difficulty of communicating case studies. The problems are obvious and make it difficult for therapists to recognize the pertinence of recommendations as the populations are poorly described. (Hartman et a1 1979) BJDC 1980.15.3. Enderby. Dysarthria Assessment. 165-173.
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To be of maximum value, it was felt that: 1 . The test results should be easily applicable to therapy. There is a great deal of guidance to therapists on how to distinguish between the primary disorders of the muscles (myopathies) (Darley, Aronson & Brown 1975). This is a guide to the general principles of treatment. But every dysarthria has a predilection for certain groups of muscles and therapy can only be specific if the relative patterns and distribution of the muscles affected can be mapped. The principles of proprioceptive neuromuscular facilitation depend upon accuracy which is “essential if these procedures are to be of optimum benefit to the patient.” (Kabat & Knott 1953) It is difficult to comply with, or to contest the principle if there is lack of certainty about accuracy.
2 . The test should be sensitive to change. Therapists need to be able to identify the value of treatment by analysing change in the pattern of behaviour. This can indicate when it is necessary to change the emphasis of treatment or when discharge would be appropriate. It may be argued that tape recordings will give this information to the therapist. However, a recording alone will not identify whether a patient’s intelligibility has improved because of improvement in the overall status or by compensation of particular muscle groups. 3 . The test should be short and easy to use. If a test is to be used in the specified way, it is essential that it is practical. Consideration must be given to the number of patients with dysarthria having poor stamina and to the pressure of time of the therapist, rendering administration of lengthy procedures undesirable. 4 . Little training should be required to achieve test reliability. If the test procedure and the scoring system are clearly defined, it is hoped that the assessment will be useful to therapists who are unable to attend workshops. A test is the tool of the assessor. If lengthy and expensive training is required, it is possible that there is a fault in the basic design of the tool.
5. The test results should be easy to communicate. If the Speech Therapist sees herself as part of the team in treating the dysarthric patient, she must endeavour to make her findings understandable to others. Furthermore, the findings showing changes in the dysarthric pattern may be useful to Medical Officers in identifying or confirming a diagnosis. It is necessary that the results of an assessment should be presented in a manner which will be inclusive of other professions rather than exclusive.
Development of the Frenchay Dysarthria Assessment Initially, the traditional procedures used by many Speech Therapists, were reviewed. As previously stated, the most common method of assessing dysarthria is for the therapist to follow a check list, frequently based on that developed by Butfield. The ensuing report is often lengthy and describes the various features of the patient’s speech. The value of these reports is unclear, as many of the Medical Officers interviewed by the author reported that they found them difficult to follow and frequently that the summary alone was of interest. It is also apparent that Speech Therapists have difficulty in analysing the change of the patient’s behaviour by comparing reports. Not surprisingly, there was a great
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deal of similarity between the main areas which were investigated by Speech Therapists and reported upon, although the adjectives describing the behaviour varied greatly. Furthermore, a descriptive report undertaken by two Speech Therapists on the same patient, bore different weighting to differing features, so that one therapist might stress a particular area of speech difficulty or concentrate on describing accurately one behaviour, whereas another might dwell more particularly on some other feature. Dysarthria reports of nine therapists showed that the main headings of their examination included reflexes, respiration, lips, jaw, palate, vocal cords, tongue and intelligibility. These main headings were broken down into finer groups so that appearance, activity and function of each might be described. However, there was less similarity between these sub-headings. The procedures which these therapists followed required different tasks to be performed by the patient. Again, there was a certain similarity about the tasks but the length of time during which they had to be undertaken and the degree of skill to be achieved, varied. The descriptions by the therapists of the results showed some common elements, but there was variability of emphasis. In considering the type and degree of dysarthria associated with certain neurological disorders it is necessary to include a study of the relevant anatomical, physiological, and perceptual features to achieve an eclectic view of this complicated disorder instead of adhering rigidly to an individual isolated framework. The term “features” will follow this inclusive definition in this paper. It is interesting to note that Speech Therapists and Neurologists over several decades have described dysarthria in this multi-factorial fashion, therefore indicating the value of a comprehensive approach. At this stage (1976) a set procedure for the examination of the dysarthria was described by the author, e.g. “Ask the patient to round and spread the lips seven times - Note and time the second attempt.” This procedure was followed by seven Speech Therapists in two Hospitals. Meetings were held between therapists on several occasions which led to amendments and expansion of the procedure. Certain tasks were added when features were not fully described and other tasks were omitted if, after a period of time, they were shown to be redundant. Tasks that were difficult for either the majority of patients or the therapist to conduct, were also modified. In 1977 the descriptions used by the therapists to describe the behaviour of the patient while he was involved in the tasks were examined. These descriptions showed similarities in grouping and obviously were used by each therapist to differentiate the behaviour she was observing in individual patients. For example, a therapist may describe a patient’s attempt to drink a glass of water as being “normal”, “slow”, “intermittant”, “showing occasional difficulty” etc. But without further specification difficulties arise in discriminating clearly between these terms. For accuracy of recording, some agreement has to be made so that therapists realise what constitutes a “slow” movement or what a “normal” response on certain tasks. Therefore, each description or group of descriptions was simplified and rating scales were produced, with the result that on certain tasks, if the patient is able to produce the behaviour within a given time span he is ascribed a certain score. If the behaviour is incomplete or inaccurate he is ascribed another score. Thus, a rating was given to each possible result of a demanded activity. These descriptions were continually amended until the seven therapists felt that the activity was described accurately . Figure I.
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Alternating Movements
Ask the patient to repeat “00 ee” ten times. Demonstrate by producing ten segments in ten seconds. Ask patient to exaggerate movement and to try to copy the speed demonstrated. Note his second attempt. Do not say in unison. It is not necessary for the patient to use voice. (a) Able to articulate both movements in 10 secs rhythmically. Shows good rounding and spread of lips.
(b) Able to articulate both movements in 15 secs. May have faltering rhythm, or variability in rounding and spreading of lips.
(c) Attempts both movements, but laboured. O n e movement may be within normal limits, but other movement severely distorted.
(d) Shapes recognisable as being different. Or one shape managed three times.
(e) Unable to make any movement recognisable as representing either shape.
Figure I Example of Rating Scale.
Result Form Instead of marking a score sheet and then transferring the result to a report form, a report form was designed to act as the score sheet. This is not only economical of time but also prompts the therapist to score all areas and draws attention to any omissions. The result form is similar to a bar graph. The vertical axis is divided into the rating scale and the horizontal axis is divided into the main features. These features are subdivided into the various tasks. A line is drawn at the appropriate point as a reflection of the rating achieved by the patient on a certain task. Figure ZZ. After this form had been used with 37 patients over a period of six months, it was felt that the assessment was not always sufficiently sensitive to change and that sometimes it did not parallel the clinical opinion of the therapist. To remedy this, intermediate gradings were added so that if a patient’s activity did not fit precisely into a rating, the tester could add or subtract one Y2 point. Further amendments to the presentation of the report form were made on the suggestion of Medical staff, thereby ensuring that information was more meaningful to them. Figure ZZZ.
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Figure I1 Initial Dysarthria Score Sheet, showing example of scoring.
Therapeutic Applicability The bar graph form of presentation of results was found to be extremely useful from the Speech Therapist’s point of view. It is easy to see the relative strengths and weaknesses of a patient’s speech and therefore to structure the therapy accordingly. Very often, the nature of dysarthria can produce ill-defined, slurred, poorly articulated unclear speech and it is hard for the therapist to know which features of the speech are disproportionately affected. The graph easily and clearly identifies these features. Figures ZV, V , VZ.
Norms The test procedure was carried out on 46 normal healthy adults ranging between 23 and 64 years old, with a mean age of 42 years. Following this it was apparent that some of the rating scales required minor adjustments particularly with regard to the amount of time allocated for certain tasks to be achieved. It appeared that, because this assessment had been born from investigating the abnormal adult that we had been underestimating the ability necessary for a patient to achieve a normal grading upon the graph. Further testing with an older and younger sample is necessary and this is currently being carried out.
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I
REFLEX
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RESP.
I
LIPS
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JAW
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Figure I11 Amended Score Sheet.
Interscorer Reliability Trials Two Interscorer Reliability Trials have been conducted. The first was with seven therapists who were untrained in the test procedure. They simultaneously assessed 15 patients who represented a broad spectrum of ability. The therapists used only the test manual as their guide and each one conducted the assessment at least twice, while the others filled in the score sheets. The correlations were very encouraging. Figure VZZ. The therapists had some difficulty in understanding some of the procedures in the test manual and this necessitated some modification. It is now felt that the test is reliable enough for untrained therapists to use it in a way that is clinically useful. Further interscorer reliability trials were conducted in 1979 when three therapists unfamiliar with adult dysarthric patients, were first trained to use the assessment by watching videotapes. They then assessed seven individual patients. The results showed an expected improvement in the reliability. Figure VZZZ. h t u r e Developments More than 100 patients have been assessed using this procedure. It has been proven to be short, easy to use and clinically useful. However, the experience gained by using this assessment has highlighted the necessity for further work in this area. It is essential that there should be an improvement in the sensitivity of some of the rating scales. Work is also being conducted to extend and clarify the rating scales
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for the areas of intelligibility which are causing some difficulty in reflecting the true picture of some dysarthrias. Preliminary studies into a measure of kinesis to be included as part of the Dysarthria assessment, is underway. It is necessary to determine whether a measure of kinesis would be useful from a differential or a therapeutic point of view as well as whether it can be assessed in a practical and accurate fashion. Further planned work includes the examination of the aspects of the differential speech patterns shown by various groups of dysarthric patients to establish whether this assessment has any diagnostic or prognostic value.
Figure IV Dysarthria Assessment of Parkinsonian patient showing difficulty in all repeated movements and severe dysphonia.
Figure V Mild spastic dysarthria.
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Dysarthna related to Acute Facial Palsy.
Figure VII Correlation of interscore reliability trials ( 1 ) 7 untrained therapists rating 15 patients.
raiing 7 patients.
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Bibliography
and GOLDSTEIN, N. (1972) Dysarthria in Multiple Sclerosis. Journal Speech & Hearing. Res. 1972. Vol. 15. No. 2. Pages 229-245. DARLEY, F. L., ARONSON, A . E. and BROWN, J. R. (1975) Motor Speech Disorders. W . B. Saunders. DWORKIN,J. (1979) The influence of lingual muscular strength on articulatory proficiency. Clinical Otolaryngology & Allied Sciences. Pages 4 13-420. ESPIR, M. and ROSE, c. (1976) The Basic Neurology of Speech. Blackwell Scientific Publications. HARTMAN, D., DAY, M. and PECORA, R. (1979) Treatment Of Dysarthria. A Case Report. Journal of Communication Disorders. 12. Pages 167-173. IVERS, R. R. and GOLDSTEIN, N. P. (1963) Multiple Sclerosis: A Current Appraisal of Symptoms and Signs. Proc. staff meeting. Mayo Clinic. No. 3 8 . Pages 457-466. KABAT, H. and KNOTT, M. (1953) Proprioceptive Facilitation Techniques for Treatment of Paralysis. Physical Therapy Review. 33. No. 2. MERRITT, H. H. (1967) A Textbook of Neurology. Lee & Febiger. DARLEY, F. L., BROWN, J.
Further enquiries to Miss P. Enderby MSc, Dept of Speech therapy at Frenchay Hospital, Bristol, UK.
