ࡱ>   {bjbj>> :zpTpTXrhh8 lF$$$$$$$$l%l%l%_FaFaFaFaFaFaF$I`L>F +l%l% + +F$$$$HF555 +$$$$_F5 +_F55:8 D$$ n.2sD KFF0F}D.M(1bMDMDl%$':5^(Z)l%l%l%FF3Jl%l%l%F + + + +Ml%l%l%l%l%l%l%l%l%h : ICCD 2016Iowa Conference on Communicative Disorders Cedar Falls, Iowa [differential diagnosis of Motor Speech Disorders] Motor Speech Disorders The evolution of a classification system Prior to the classification system first introduced by Darley, Aronson, & Brown (1969), the dysarthrias were considered a single diagnosis. The implication was that this diagnosis had homogeneous features. Distinctions were made between dysarthria and aphasia, even dysarthria and apraxia of speech. Parallels Autism No longer really considered a unitary diagnosis Autism spectrum Further definition Asbergers Syndrome Differential diagnosis Evolution of a discipline A need to better understand and define clinical populations. Evaluation More accurate diagnosis Treatment Guide our treatment decisions Darley, Aronson, & Brown Pivotal articles (1969) Motor Speech Disorders text (1975) Defined and identified the dysarthrias Initial sample = 212 patients Lesion site Perceptual characteristics Motor characteristics Benefits & Drawbacks Assists with confirmation of lesion site Can rule out other potential diagnoses Clinical shorthand Similar to aphasia syndromes Guides treatment decisions Understanding the underlying pathology results in selecting the appropriate treatment Reliability has been questioned Corresponding lesion data Clinical knowledge Not confirmed empirically Take home message Clinically useful Evolution continues Our understanding of neuropathology will never be static New discoveries New procedures For now, the system is a useful one that will continue to be refined Hyperkinetic Myriad of movement disorders The Dysarthrias A collective name for a group of neurologic speech disorders resulting from abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for control of the respiratory, phonatory, resonatory, articulatory, and prosodic aspects of speech production. The responsible pathophysiologic disturbances are due to central or peripheral nervous system abnormalities and most often reflect weakness; spasticity; incoordination; involuntary movements; or excessive, reduced or variable muscle tone. (Duffy, 2013 p. 4) Prevalence of MSD Based on a sample > 14, 000 people referred for a speech/language evaluation at Mayo Clinic from 1993-2008 Other neurologic speech disorders - 0.4% Apraxia of Speech 3.9% Nonaphasic cognitive-communication disorders 16.8 % Aphasia 25.8% Dysarthria 53% Definition revisited: Key features of the dysarthrias Neurologic basis Disorder of movement Categorized based on Lesion Physical characteristics (OME findings) Speech characteristics DYSARTHRIA Lesion Physical signs Speech  FLACCID  SPASTIC  ATAXIC HYPOKINETIC HYPERKINETIC MIXED  Flaccid Dysarthria Results from injury/damage to cranial and/or spinal nerves Final common pathway Lower motor neuron Reflexive, automatic, and voluntary activities are ALL affected when the lesion resides in the FCP. Can impact all subsystems of speech Primary characteristics can be traced to weakness Which of the Cranial and/or spinal nerves might be implicated? Etiologies Surgical Nonsurgical Neuropathies Tumor/Neoplasm Myasthenia gravis Degenerative Vascular Anatomic malformation Demyelinating Other Lesion analysis Trigeminal Innervation properties Three branches (sensory) Motor component Signs Sensory loss Jaw deviation (unilateral) Jaw may hang open (bilateral) How do you test? Speech signs Imprecision in connected speech Most affected with bilateral lesions Facial Innervation properties Sensory Motor Which would be most devastating to speech? Signs Facial droop Drooling (possibly) Pocketing Testing Speech signs Imprecision in connected speech Related to facial weakness What sounds would be most affected? Glossopharyngeal Innervation properties Sensory Motor Signs Testing Speech signs Vagus Innervation properties Sensory Motor Signs Velar signs Testing Speech signs Phonation Respiration Resonance Spinal Accessory Innervation properties Motor Signs Shoulder weakness Testing Speech signs Hypoglossal Innervation properties Motor Signs Tongue deviation Atrophy Testing Speech signs Imprecision with articulation Compensation with the mandible Spinal nerve lesions Damage to spinal nerves C-1 through C-5 Primary damage to respiration How does that interfere with speech? Signs Rapid/shallow breathing Exaggerated thoracic expansion Flaccid dysarthria related to isolated damage to spinal nerve lesions is rare Primary Characteristics Weakness Hypotonia and reduced reflexes Fasciculations and fibrillations Darley, Aronson & Brown (1969) Hypernasality Articulatory Imprecision Breathiness Monopitch VPI Audible inspiration Harsh vocal quality Short phrases Monoloudness *********************************************************************************** Spastic Dysarthria Secondary to damage of the direct and indirect pathways of the CNS (UMN system) Direct pathway Pyramidal tract Corticobulbar tracts Interacts with cranial nerves Corticospinal tracts Interacts with spinal nerves Facilitatory action Leads to skilled discrete movements Indirect pathway Extramyramidal Regulates reflexes, maintains posture, tone Inhibatory nature Clinical Characteristics Difficulty with fine, discrete movements Initially decreased tone Weakness Develops into increased tone, spasticity Those muscles utilized in fine movements most affected Decreased reflexes initially, then more pronounced Babinski sign Oral motor reflexes Suck Snout Jaw jerk Etiologies Vascular Brainstem stroke Bilateral effects Cerebral stroke cant have the same impact, unless there is previous damage, or perhaps midline shift/compression from a hemorrhagic stroke Lacunar infarcts Multi-infarct dementia Not a common problem with DAT Inflammatory Leukoencephalitis Degenerative disease Primary lateral sclerosis Traumatic Brain Injury Multiple Sclerosis Neoplasm Oral Mechanism Dysphagia Drooling Pseudobulbar affect Normal jaw strength Facial movements may be slow then move into excess/extreme Hyperactive reflexes Speech Characteristics Impairments noticed most by looking at muscle movement rather than isolated muscles speed range force muscle tone Darley, Aronson, & Brown (1969a) Imprecise artic Monopitch stress Harshness Monoloudness Low pitch Slow rate Hypernasality Strained-strangled quality Short phrases Distorted vowels Pitch breaks Breathy quality Excess and equal stress *********************************************************************************** Ataxic Dysarthria Cerebellum Two cerebellar hemispheres Vermis Ipsilateral contribution Unlike the cerebral hemispheres which have contralateral contributions With median lesions, effects may be bilateral How does the circuit function? The circuit Notice of movement-cerebral hemispheres Monitors the movement via feedback from the muscles/joints that conduct the movement. Regulates movement in an ongoing fashion based on both ends of this circuit. Clinical Characteristics Ataxic dysarthria typically manifests with diffuse cerebellar damage Any signs/symptoms from unilateral lesions tend to improve rapidly Disordered gait Truncal instability, titubation Rotated head postures Occular motor abnormalities Ataxic dysarthria Etiologies Degenerative Diseases Hereditary Ataxias Multiple Sclerosis Paroxysmal Ataxic Dysarthria Vascular Disorders Aneurysms AVMs Occlusion in the vertebrobasilar system Neoplasm Trauma Toxic/metabolic conditions Alcoholic cerebellar degeneration Severe malnutrition Vitamin deficiencies Pharmacological Antiseizure drugs Lithium Valium Hypothyroidism Normal Pressure Hydrocephalus Oral Mechanism Most aspects of the OME can be entirely normal Size Strength Symmetry Face, jaw, tongue, palate Rest, and during sustained postures Gag Reflexive swallow OME abnormalities Irregular AMRs Observe the regularity of movement of the tongue, lips, and jaw AMRs and connected speech Systemic problem Affects the entire system rather than isolated impairment from muscles/muscle groups Speech Imprecision with artic Irregular artic breakdown Distorted vowels Excess and/or equal stress Prolonged phonemes/pauses Slow rate Harshness Monopitch Monoloudness Reduced/irregular breathgroups Darley, Aronson, & Brown 1969 Artic imprecision Excess/equal stress Irregular artic breakdowns Distorted vowels Harsh quality Prolonged phonemes Prolonged intervals Monopitch Monoloudness Slow rate Loudness variations Voice tremor *********************************************************************************** Hypokinetic Dysarthria Pathology of the basal ganglia control circuit Rigidity Reduced force/range Decreased mobility a/o range lead to the name hypokinetic The only dysarthria which has rapid speech rate as one of the perceptual characteristics. Depletion or reduction of the neurotransmitter, dopamine. Parkinsons disease that best reflects hypokinetic dysarthria. Basal Ganglia Control Circuit Functions Regulate muscle tone Movements that support goal directed activity Postural adjustments Adjust movements to the environment Assists in learning new movements Damage results in reduced movement a/o a failure to inhibit involuntary movement Hypokinetic dysarthria most reflects reduced movement Clinical Characteristics Resting tremor 4-7 Hz Limbs Pill-rolling Jaw, lips, and tongue Rigidity Resistance to passive stretch Decreased movement Bradykinesia/Akinesia Slow movement Freezing Shuffling gait Micrographia Masked facies Reduction in: Arm movement while walking Gestures Blinking Head movement Swallowing frequency Loss of postural reflexes Reduced righting response Stooped posture Difficulty initiating movment While lying down Sitting to standing Etiologies Damage to the basal ganglia Degenerative Vascular Traumatic Inflammatory Neoplastic Toxic Metabolic diseases Oral Mechanism Immediate revealing features Masked facies Flat affect Respiratory signs Infrequent swallowing May result in drooling Size, strength, and symmetry may be normal AMRs may be slowly initiated a/o rapid and restricted in range Speech Characteristics Monopitch Monoloudness Reduced intensity Breathy quality Reduced stress Short phrases Variable rate Short rushes of speech Imprecise consonants *********************************************************************************** Hyperkinetic Dysarthria Another dysarthria type that manifests secondary to damage to the basal ganglia control circuit May effect all or isolated speech subsystems. Involuntary movement is the hallmark feature Rhythmic Irregular Fast slow Abnormal What constitutes abnormal? Involuntary movements when steadiness is expected Hyper-in this case does not mean fast Excessive, extra Many forms Classified based on speed and periodicity Classification Dyskinesia Myoclonus Tics Chorea Ballism Athetosis Dystonia Spasm Tremor Etiologies Degenerative Vascular Traumatic Inflammatory Toxic Metabolic disease *********************************************************************************** Mixed Dysarthrias Mixed dysarthrias Combination of dysarthrias Two or more Diffuse damage Etiologies Degenerative ALS MS PSP Toxic metabolic Wilsons disease Hepatocerebral degeneration Hypoxic encephalopathy Vascular Disorders Trauma Neoplasm Infectious diseases *********************************************************************************** Apraxia of Speech A neurologic speech disorder that reflexts an impaired capacity to plan or program sensori-motor commands necessary for directing movements that result in honetically and prosodically normal speech. It can occur in the absence of physiologic disturbances associated with the dysarthrias and in the agsence of disturbance in any component of language. (Duffy, 2013, p. 4) Apraxia of speech is secondary to a disturbance of the motor programming system. Central impairment Can occur without muscle impairment Normal function is apparent High variability The motor speech programmer executes the motor movements/sequences necessary to convey language Speech vs Language Primarily left hemisphere lesions Motor speech area Broccas area Supplementary motor cortex Insula Variability in lesion locations Dronkers, 1993 Etiologies AOS is secondary to primarily focal lesions vascular Tumors Focal/discrete trauma Surgical Other Degenerative conditions Occasionally have focal effects Clinical Characteristics May exhibit right sided weakness May also have sensory deficits Hyperactive reflexes Limb apraxia Concomitant aphasia Broccas type Can exist in a pure form Few documented cases Assessment findings Oral mechanism May have rt. weakness May result in dysarthria that is not the same as AOS Nonverbal oral motor apraxia Difficulty performing oral tasks. Sequential AMRs Most sensitive task to the effects of AOS. Specific Speech Characteristics Slow rate Prolonged consonants/vowels Many pauses Inter/intrasegmental Disruptions in prosody Equal stress Decreased pitch/intonation contours False starts Effortful/laborious speech Repetitions *********************************************************************************** Factors that influence speech production Walking Injurious Falls One-third of Americans aged 65+ fall each year. Every 14 seconds, an older adult is treated in the E.R. for a fall, every 29 minutes an older adult dies after a fall. Annually, falls result in more than 2.4 million injuries in emergency departments, resulting in over 772,000 hospitalizations and over 21,700 deaths. In 2012, the costs related to falls was over $36 billion, with an expectation to reach over 59 billion annually by 2020. Aging Affects gait patterns Change in skeletal structure Reduced muscle mass/strength Results in a higher incidence of neuropathology. Often with deleterious cognitive and motor effects. Increasing incidence of falls Fear of falling Multitasking Bombarded today by competing stimuli Cell phones Talking or texting Music Environment Walking while talking Sharing tasks may become more difficult when systems become compromised. Statement of the Problem Injurious falls are a major medical concern. Individuals with neurologic compromise may be at a greater risk. There are known factors that contribute to fall risk. Physical decline Cognitive decline Pharmacological effects Environmental factors What other factors may be influential? Cognitive load GAITRite System Analysis of gait conducted using the GAITRite System 14 portable carpet 16,128 embedded sensors to capture footfalls instantly Measures include temporal and spatial parameters Procedures Each of the groups completed the following: Montreal Cognitive Assessment Beck Depression Index Gait Measures Baseline (walking, no talking) Low load (counting by ones) Medium load (subtracting by 3s) Originating number varied/attempt High load (alpha-numeric sequence) D-7, E-8, F-9 Gait conditions were counterbalanced to account for order effect. Each walk was completed twice to control for learning The average was used for analysis. Dependent measures Functional ambulation profile (FAP) Ratio of step length to leg length to step time; FAP score is derived from a formula that includes several critical gait parameters found to be highly related to fall risk. (Nelson et. al, 1999) Velocity Centimeters/second Stride length Centimeters Double support time The percentage of time per ambulation cycle with both feet on the ground. Parkinson and Healthy Elderly Twenty six participants with Parkinson Disease: Peak medication time Age: Mean = 67.44 (41-91) Hoehn & Yahr Stage: 22-Stage 2, 3-Stage 3, 1-Stage 4 Thirteen healthy elderly participants Age: Mean 68.07 Matched for education level No significant differences across groups Stride length or Velocity Data were collapsed and a condition effect was revealed Baseline > High load A significant difference and interaction was revealed for Double Support The healthy adult group significantly increased their Double Support time The group with PD did not High vs. Low Medication State We recruited the same twenty six participants several months later. We asked that they be within 30 minutes of their next medication administration. The same procedures were followed, and we added the Functional Ambulation Profile (FAP) score as a predictor of fall risk. No differences between conditions or High/Low medication states Step velocity Step length Double support FAP Dopaminergic replacement medication did not alleviate the effect of cognitive load. These results were shared at the World Congress on Parkinson Disease in Paris 2009 Current Study A double blind, randomized control study to investigate the effects of cognitive enhancing medication on performance in individuals with Parkinson disease. Participants were randomly assigned to a drug (Rasagiline vs. Placebo). Prior to taking the drug, baseline measures were collected on all experimental tasks (Pre-treatment). Gait Additional measures After 30 days, participants received an increased dose Participants receiving Rasagiline were given a higher dosage for the next 30 days. Participants receiving the placebo received additional placebo tablets. After 60 days, final data collection occurred (Post-treatment). Gait Additional measures Walking while talking Individuals with neurological compromise are at an increased risk for falls during the multitask of talking while walking. Automatic speech doesnt carry as great a risk. Increased cognitive load will have deleterious effects especially in high fall risk conditions Low light Descending stairs Giving directions Mental calculations Tracking conditions Obstacles Environmental variations Cranial Nerve Information Sheet Cranial NerveTypeFunctionI OlfactorySensorySmellII OpticSensoryVisionIII - OculomotorMotorEye movementIV - TrochlearMotorEye movement (superior oblique)V - TrigeminalSensoryFacial sensation 3 branches Opthalamic Maxillary Mandibular Anterior tongue sensationMotorMuscles of masticationVI - AbducensMotorEye Movement - lateral rectusVII - FacialSensoryTaste - anterior 2/3 tongueMotorFacial expressionVIII - VestibulocochlearSensoryHearing BalanceIX - GlossopharyngealSensoryPharyngeal sensationMotorPharyngeal musclesX - VagusSensoryPharynx, larynx, esophagusMotorMuscles of palate, pharynx, and larynxXI- Spinal AccessoryMotorShoulder, head movementXII - HypoglossalMotorTongue movement For the purpose of screening, the functions listed above are the primary functions of the cranial nerves. This is not meant to serve as an exhaustive list of cranial nerve functions. Stierwalt, J.A.G., (2003) Cranial Nerve Information Sheet Cranial Nerve Screening Cranial NerveFunctionScreening TaskI OlfactorySensory - SmellodorsII OpticSensory - Visionvision chart/acuityIII- OculomotorMotor Eye movement"follow the moving finger"IV - TrochlearMotor Eye movement (superior oblique)look at the noseV - TrigeminalSensory - facial sensation/anterior tongueHave the individual close their eyes: touch the faceMotor - muscles of masticationPalpate muscles that clench the teethVI - AbducensMotor - lateral rectuslook to the sideVII - FacialSensory - tastesweet, sour, bitter, saltMotor - facial expressionsmile, raise the eyebrowsVIII - VestibulocochlearSensory - hearinga tuning forkbalancelook for vertigoIX - GlossopharyngealSensory - pharynx sensationgag reflexMotor pharyngeal musclesgag reflexX - VagusSensory pharynx, larynx, esophagus Motor - muscles of palate, pharynx, and larynxCheck phonation Assess vocal qualityXI- Spinal AccessoryMotor Shoulder, head movementshoulder shrug and/or turning the head to resistanceXII - HypoglossalMotor - tongue movementAssess tongue movement 2003 Julie A.G. Stierwalt, Ph.D. Bibliography Ball, L. J., Bernthal, J. E., & Beukelman, D. R. (2002). Profiling communication characteristics of children with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 10, 221-230.Ball, L. J., Beukelman, D. R., & Pattee, G. L. (2002). Timing of speech deterioration in people with amyotrophic lateral sclerosis. Journal of Medical Speech-Language Pathology, 10, 231-236.Barkmeier, J., Jordan, L. S., Robin, D. A., & Schum, R. L. (1991). Inexperienced Listener Ratings of Dysarthric Speaker intelligibility and Physical Appearance. In C. A. Moore (Ed.), Dysarthria and apraxia of speech: Perspectives on management (pp. 65-75). Baltimore: MD, Paul H. Brookes Publishing Co., Inc. Beukelman, D. R., Fager, S., Ullman, C., Hanson, E., & Logemann, J. (2002). The impact of speech supplementation and clear speech on the intelligibility and speaking rate of people with traumatic brain injury. Journal of Medical Speech-Language Pathology, 10, 237-242.Burkhead, L.M., Sapienza, C.M., & Rosenbek, J.C., (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures, and directions for future research. Dysphagia, 22, 251-265.Clark, H.M. (2003), Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech Language Pathology, 12, 400-415.Daniel, B. (1982). A soft palate desensitization procedure for patients requiring palatal lift prostheses. The Journal of Prosthetic Dentistry, 48(5), 565-566.Dromey, C. (2003). Spectral measures and perceptual ratings of hypokinetic dysarthria. Journal of Medical Speech-Language Pathology, 11(2), 85-94.Dronkers, N. F. (1996). A new brain region for coordinating speech articulation. Nature, 384(14), 159-161.Freed, D. (2000). Motor Speech Disorders: Diagnosis and Treatment. San Diego, CA: Singular Thompson Learning.Hageman, C. F., Simon, P., Backer, B., & Burda, A. N. (2002, November). Comparing MIT and motor learning therapy in a nonfluent aphasic speaker. Symposium conducted at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA.Hanson, E. K., Yorkston, K. M., & Beukelman, D. R. (2004). Speech supplementation techniques for dysarthria: A systematic review. Journal of Medical Speech-Language Pathology, 12(2), ix-xxix.Hartelius, L., Carlstedt, A., Ytterberg, M., Lillvik, M., & Laakso, K. (2003). Speech disorders in mild and moderate Huntington disease: Results of dysarthria assessments of 19 individuals. Journal of Medical Speech-Language Pathology, 11(1), 1-14.Hixon, T.J., Weismer, G., & Hoit, J.D., (2008). Preclinical Speech Science: Anatomy, Physiology, Acoustics, Perception. PluralHoriuchi, M., Maki,F., Yanagisawa, T., Sugihara, H., Takahashi, Y., Ohashi, K. (2002). Therapeutic efficacy of transcranial magnetic stimulation for ALS and spinocerebellar degeneration, International Congress Series, 1235, 525-532.Hustad, K. C., & Garcia, J. M. (2002). The influences of alphabet supplementation, iconic gestures, and predictive messages on intelligibility of a speaker with cerebral palsy. Journal of Medical Speech-Language Pathology, 10, 279-286.Hustad, K. C., & Sassano, K. (2002). Effects of rate reduction on severe spastic dysarthria in cerebral palsy. Journal of Medical Speech-Language Pathology, 10, 287-292.Kent, R.D., Duffy, J.R., Weismer, G.,& Stuntebeck, S. (2000) Ataxic Dysarthria. Journal of Speech Language Hearing Research, 143, 1275-1289.Kent, R. D., Kent, J. F., & Rosenbeck, J. C. (1987). Maximum performance tests of speech production. Journal of Speech and Hearing Disorders, 52, 367-387.Klasner, E. R., Yorkson, K. M., & Lillvik, M. (2002). Everyday listeners perspective on amyotrophic lateral sclerosis and Huntington disease dysarthria: Barriers and strategies in understanding distorted speech samples. Journal of Medical Speech-Language Pathology, 10, 293-298.Klockgether, T. (2000). Handbook of Ataxia Disorders: Neurological Disease and Therapy. New York: Marcel Dekker. LaPointe L.L., Stierwalt J.A.G., Maitland C.G. (2010). Cognitive loading and injurious falls in Parkinson disease. International Journal of Speech, Language Pathology Lasker, J.P., Stierwalt, J.A.G., & Hageman, C. F.(2005, November) Enhancing conversation skills in aphasia/apraxia using a multimodal approach.Technical session at American Speech Language Hearing Association, San Diego, CA.Lefkowitz, K, & Netsell, R. (1994). Correlation of clinical deficits with anatomical lesions: Post-traumatic speech disorders and MRI. Journal of Medical Speech-Language Pathology, 2(1), 1-15.Liss, J. M., Kuehn, D. P., & Hinkle, K. P. (1994). Direct training of velopharyngeal musculature. Journal of Medical Speech-Language Pathology, 2(3), 243-251.Ludlow, C., Hoit, J., Kent, R., Ramig, L., Shrivastav, R., Strand, E., et al. (2008). Translating principles of neural plasticity into research on speech motor control recovery and rehabilitation. Journal of Speech, Language and Hearing Research, 51, 240-258.McHenry, M. A. (2002). A comparison of nasalance and velopharyngeal orifice area in dysarthria. Journal of Medical Speech-Language Pathology, 10, 299-306.McKeever, S. L., & Miller, R. M. (2002). Glossopharyngeal breathing to improve functional vital capacity and speech production in a patient with flaccid dysarthria. Journal of Medical Speech-Language Pathology, 10, 307-312.McNeil, M., Rosenbek, J., & Arorison, A. (Eds.) (1984). A Neurobiologic View of the Dysarthrias. The dysarthrias: Physiology, acoustics, perception, management. 53-88.Mitsumoto, H., Chad, D. A., & Pioro, E. P. (1998). Amyotrophic lateral sclerosis. Philadelphia, PA: F. A. Davis Company.Netsell, R. W. (1994). Instrumentation and special procedures for individuals with dysarthria. American Journal of Speech-Language Pathology, (p. 9-11).Netsell, R., & Daniel, B. (1979). Dysarthria in adults: Physiologic approach to rehabilitation. Archives of Physical Medicine and Rehabilitation, 60, 502-507.Raymer, A. M., Haley, M. A., & Kendall, K. L. (2002). Overgeneralization in treatment for severe apraxia of speech: A case study. Journal of Medical Speech-Language Pathology, 10, 313-318.Schmidt, R.A., & Bjork, R.A. (1992). New conceptualizations of practice: Common principles in three paradigms suggest new concepts for training. Psychological Science, 3, 207-217. Schulz, G.M., Dingwall, W.O., & Ludlow, C.L. (1999). Speech and oral motor learning in individuals with cerebellar atrophy. Journal of Speech Language Hearing Research, 42, 1157-1175.Solomon, N. P., Lorell, D. M., Robin, D. A., Rodnitzky, R. L., & Luschei, E. S. (1995). Tongue strength and endurance in mild to moderate Parkinsons disease. Journal of Medical Speech-Language Pathology, 3(1), 15-26.Spencer, K. A., Yorkston, K. M., & Duffy, J. R. (2003). Behavioral management of respiratory/phonatory dysfunction from dysarthria: A flowchart for guidance in clinical decision making. Journal of Medical Speech-Language Pathology, 11(2) xxxix-lxi. Stierwalt, J., Hageman, C. F., & LaPointe, L. L. (2004, August-September). The motor learning guided approach to apraxia of speech. Symposium conducted at the meeting of the World Congress of the International Association of Logopedics and Phoniatrics, Brisbane, Australia.Stierwalt, J.A.G., LaPointe, L. L., Maitland, C.G., & Toole, T. (2008). Effects of cognitive-linguistic load on parameters of gait in Parkinson disease. Journal of Medical Speech-Language Pathology, 16, 4, 259-266.Stierwalt, J.A.G., & Youmans, S.R. (2007). Tongue measures in individuals with normal and impaired swallowing. American Journal of Speech Language Pathology, 16(2), 148-156.Strand, E. (1997). Amyotrophic lateral sclerosis: Diagnosis and management for the clinician. Journal of Medical Speech Language Pathology, 5(2) 153-154. Strand, E., & Sullivan, M. (2001). Evidence-based practice guidelines for dysarthria. Journal of Medical Speech-Language Pathology, 9(4), 258-274.Thompson, E. C., Murdoch, B. E., & Stokes, P. D. (1996). Tongue function in subjects with upper motor neuron type dysarthria following cerebrovascular accident. Journal of Medical Speech-Language Pathology, 3(1), 27-40.Thompson-Ward, E. C., Murdoch, B. E., & Stokes, P. D. (1997). Biofeedback rehabilitation of speech breathing for an individual with dysarthria. Journal of Medical Speech-Language Pathology, 5(4), 277-288.Vogel, D., & Cannito, M.P. (Eds.). (2001). Treating disordered speech motor control. Austin, TX: ProEd.Warlow, C. (1991). Handbook of neurology. Oxford: Blackwell Scientific Publications.Webster, D. B. (1999). Neuroscience of Communication (2nd ed.). San Diego, CA: Singular Thompson Learning.Yorkston, K. M., Klasner, E. R., Bowen, J., Ehde, D. M., Gibbons, L. E., Johnson, K. et al. (2003). Characteristics of multiple sclerosis as a function of the severity of speech disorders. Journal of Medical Speech-Language Pathology, 11(2), 73-84.Yorkston, K. M., Spencer, K. A., & Duffy, J. R. (2003). Behavioral management of respiratory/phonatory dysfunction from dysarthria: A systematic review of the evidence. Journal of Medical Speech-Language Pathology, 11(2), xiii-xxxviii.      Stierwalt: Differential Diagnosis of Motor Speech Disorders April 8, 2016 Julie A.G. 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Stierwalt, Ph.D. Florida State UniversityJulie A G Stierwalt  Oh+'0x   <H h t DMeasures of Tongue Function: Normative Data & Clinical Implications8Julie A.G. Stierwalt, Ph.D. Florida State University Normal.dotmJulie A G Stierwalt3Microsoft Office Word@G@A @\PHa՜.+,0H hp  ( The 4th World Voice Congress:r DMeasures of Tongue Function: Normative Data & Clinical Implications Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~     Root Entry F nData S41TableMWordDocument:zSummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q