European Journal of Disorders of Communication
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Dysarthria associated with focal unilateral upper motor neuron lesion David E. Hartman & James H. Abbs To cite this article: David E. Hartman & James H. Abbs (1992) Dysarthria associated with focal unilateral upper motor neuron lesion, European Journal of Disorders of Communication, 27:3, 187-196 To link to this article: http://dx.doi.org/10.3109/13682829209029419
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European Journal o Disorders of Communication,27,187-1% (1992) 0 The College of peech and Language Therapists, London
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Dysarthria associated with focal unilateral upper motor neuron lesion David E. Hartman Department of Neurology, Gundersen Clinic Ltd and Gundersen Medical Foundation, La Crosse, WI, USA
James H. Abbs Departments of Neurology and Neuro hysiology, Universiry of Wisconsin-Madisonand Gundersen Medical Foundation, Madison, Wl, &A
ABSTRACTS Speech motor changes in six patients with focal unilateral upper motor neuron (UUMN) lesions were characterised using a variety of techniques including listener judgements, speech acoustic analyses, electromyographic and strength measures. Listener judgements of speech understandability, intelligibility and dysarthric features indicated mild dysarthria. Diadochokinesis. electromyographic and strength measures corroborated these observations. The findings of this study delineate the characteristicsof the dysarthria associated with unilateral upper motor neuron lesions and have important implicationsfor identifring potential upper motor neuron components of other neurogenic disorders of speech and language. Les caractkristiquesdes changements des aspects moteurs de la locution ont kt6 dkfinies chez six malades souffrant de Iksions focales unilatkrales des neurons moteurs supkrieurs, au moyen d'un certain nombre de techniques comprenant des jugements par des auditeurs, des analyses acoustiques du language, des mesures klectromyographiques et de force (articulatoire). Les jugements par les auditeurs de traits de comprkhensibilitk, dintelligibilitk et de dysarthrie ont r&vdlk la prksence de lkg&res dysarthries - jugements corroborks par la diadochokinkse ainsi que par des mesures d'klectromyographieet de force. Les rksubats de cette etude permettent de dkjinir les caractkristiques de la dysarthrie associke aux l&sionsunilatkrales des neurons moteurs supkrieurs; elles devraient se rkvkler riches de renseignements pour I'identification du jeu possible des neurons moteurs supkrieurs dam les autres dksordres neurogkniques du langage et de la locution. Wir haben die sprechmotorischen Anderungen von sechs Patienten mit einer fokalen einseitigen Liision des oberen Motoneurons mit einer Auswahl von Methoden untersucht, einschliesslich Bewertungen durch Zuhorer, sprechakustische Analysen, elektromyographische und Starkemessungen. Die Bewertungen der Zuhorer in Bezug auf die Verstandlichkeit und dysarthrische Merkmale deuteten auf eine leichte Dysarthrie. Diadochokinetische, elektromyographische und Starkemessungen stimmten mit diesen Beobachtungen iiberein. Die Befunde dieser Studie stellen die Merkmale der Dysarthrie dar, die man bei einseitigen Liisionen der oberen Motoneuronen findet und haben wichtige Folgerungen fur die Identifirierung von potentiellen oberen Motoneuronenkomponenten bei anderen neurogenen Sprech- und Sprachstorungen.
Key words: dysarthria, unilateral upper motor neuron lesion.
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INTRODUCTION It has been shown that select lesions of the nervous system produce changes in speech that have localising value (Darley, Aronson & Brown, 1975; Aronson, 1985; Ropper, 1987; Hartman & Abbs, 1988). Focal unilateral pyramidal tract lesions due to stroke are common and may involve the motor cortex, cell bodies and/or axons. Such lesions produce contralateral upper motor neuron signs frequently involving the speech musculature. However, the dysarthria that occurs secondary to unilateral upper motor neuron (UUMN) involvement is incompletely understood. It has been suggested that speech signs that occur as sequelae to UUMN vascular lesions resolve rapidly leaving the patient with minimal deficits (Darley et al., 1975), may be severe and persist for several years, and have characteristics of both flaccid and ataxic dysarthria (Aronson, 1985; Duffy & Folger, 1986; Ropper, 1987), or have no localising value (Melo, Bogousslavsky, Melle & Regli, 1992). Some additional insights concerning UUMN dysarthria have also been provided by Ozaki and colleagues (Ozaki, Baba, Narita, Matsunga & Takebe, 1986) and Spertell and Ransom (1979). Although detailed information was provided in the retrospective studies by Ropper (1987) and Duffy and Folger (1986), their findings may have been affected by a heterogeneous population of patients including those with dysarthria-clumsy hand syndrome (Fisher, 1967, 1982; Glass, Levey & Rothstein, 1990) or more diffuse neuropathology. What is needed are prospective quantitative analyses concerning the dysarthria associated with focal UUMN lesions. Such information would help shed light on underlying neuropathological mechanisms and potentially give rise to improved differential diagnosis and treatment. This study attempted to provide such information.
METHOD Subjects
Patients To ensure that only effects of UUMN lesions were being measured, stringent criteria for patient selection were employed. Six right-handed patients, three female and three male, who were medically and neurologically stable, were found suitable for the study. The age range was 59.7-80.0 years with a mean age of 68.9 years and none of the patients was more than one month poststroke at the time of the study. All had clinical and/or computed tomographic (CT) scan evidence of focal UUMN stroke, i.e. clinical and/or CT scan data indicated that focal lesions were confined to the pyramidal tract (Figure 1). In all patients, signs included central facial and/or tongue weakness and contralateral central arm and/or leg weakness. Although magnetic resonance imaging (MRI) is the neuro-imaging technique of choice for small vascular lesions, the clinical signs and/or CT scan evidence in these patients unequivocally indicated focal UUMN involvement. All patients manifested dysarthria. None of the patients had evidence of dysphasia, dementia, dyspraxia of speechloral dyspraxia, significant confusion, visual perceptual deficits, prior stroke, basal ganglia, cerebellar or other neurological disorders, psychiatric illness, alcoholism or other drug abuse, premorbid craniofacial anomaly
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Figure 1: CT scan showing capsular infarction on the left (amw) for patient no. 1, male, age 59.7years.
and/or ill-fitting dentures. Exclusion of these potentially contaminating problems was felt to be critical for the present study; all patients were evaluated using standardised or accepted descriptive tests, e.g. Token Test (Derenzi & Vignolo, 1962), Porch Index of Communicative Ability (Porch, 1981), Short Test of Mental Status (Kokmen, Nassens & Offord, 1987), Mayo Clinic Battery for Neurogenic Communicative Disorders (unpublished) and/or routine clinical procedures. Three patients had left hemisphere and three had right hemisphere stroke; the patients’ auditory and visual acuities were adequate for examination. A11 patients had a history of hypertension; one patient had a history of atherosclerotic cerebral vascular disease and insulin-dependent diabetes meilitus. One patient had atrial fibrillation.
Normal controls Five females and three males ranging in age from 59.9 to 80.5 years (mean age of 71.9 years) served as control subjects. None had a history of a neurological, communication or psychiatric disorder, alcoholism or drug abuse, craniofacial anomaly or ill-fitting dentures. Both auditory and visual acuities were adequate for participation.
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Listener Judgements and Acoustic Measures To characterise the potential dysarthria due to a UUMN lesion, listener judgements provided measures of understandability, intelligibility (Yorkston & Beukelman, 1980), and feature judgements (Darley et al., 1975). All patients and five female control subjects read a widely used and accepted standard reading passage (the ‘Grandfather Passage’: Darley et al., 1975), described the ‘Cookie Theft Picture’ (Goodglass & Kaplan, 1972)’ and read 50 different randomly obtained words from lists created by Yorkston and Beukelman (1980) for dysarthria intelligibility testing. For samples of oral diadochokinesis (DDK), all subjects were instructed to produce as rapidly and as evenly as possible consonant-vowel sequences, e.g. pah pah pah, tah tah tah, kah kah kah, for at least 2 seconds per sequence. All speech samples were audio-recorded on a high quality recording system.
Understandability Fourteen untrained listeners made free-field judgements of understandability on a seven-point equal appearing interval scale for speech samples from the ‘Grandfather Passage’ and ‘Cookie Theft Picture’ story. Listeners were instructed that a rating of ‘1’ meant not understood and of ‘7’ completely understood. The sample from each patient and control subject was played back only once. Intelligibility For use as an objective measure of intelligibility, the same 14 listeners transcribed the 50 randomlychosen words (open set) produced by each patient and female control subject. As noted by Yorkston and Beukelman (1980), transcription of randomly chosen isolated words provides the most sensitive measure of intelligibility for mildly impaired patients. Each word was presented once free-field. Feature judgements Three speech and language pathologists with expertise in dysarthria made judgements of presence and severity of 14 individual dysarthric features according to the perceptual protocol utilised by Darley et al. (1975). The judges were allowed to listen to the recorded ‘Grandfather Passage’ for each patient as many times as necessary to make judgements. The 14 selected features included those with a mean scale value of 2.0 or greater for flaccid, spastic and ataxic dysarthria (Darley et a]., 1975). The features were selected on the basis that UUMN dysarthria has been reported to have similar clinical and possibly neuropathological characteristics to those of these three dysarthrias (Aronson, 1985; Duffy & Folger, 1986). Diadochokinesis Three trained speech and language pathologists made judgements of DDK rate and regularity from the audio samples of all subjects using equal appearing interval scales. Again, judges were allowed to listen to the samples as many times as necessary to make decisions. The rate of syllable productions was also measured from oscillographic printouts of the root mean square acoustic signal.
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Physiological Measures, Strength, Electromyography (EMG) and Nasal Pressure To augment and confirm the oral manifestations of the UUMN lesions, a select set of electromyographic and strength measures was obtained from all patients and the eight control subjects. Force transducers, described previously (Barlow & Abbs, 1983), were used with established procedures to evaluate maximum lip, tongue and jaw muscle strength (Dworkin, 1980; Dworkin, Aronson & Mulder, 1980; DePaul, Abbs, Caligiuri, Gracco 8i Brooks, 1988). In brief, the protocol requires the subject to exercise maximum effort, i.e. purse-string lip closure against a strategically placed transducer, which in turn provides a signal to a chart recorder or computer for later analysis. Lip-muscle strength was evaluated on the right and left sides and at midline. Surface EMG electrodes (Cole, Konopacki & Abbs, 1983) were placed bilaterally over the masseter, orbicularis oris inferior and frontalis muscles. For lip and jaw muscles, this bilateral EMG was obtained simultaneously with measures of muscle force. EMG was also recorded during a bilabial speech task, e.g. repetition of the word ‘apple’. To evaluate the frontalis muscle, subjects were requested to furrow (raise) their brow. From these EMG and strength measures, oscillographic records of force and EMG signals were examined to identify (1) major asymmetries from one side of the face to the other, (2) major reductions in strength, and (3) patterns of EMG or muscle force irregularities (primarily fluctuations over the course of the maximum force trials). All of these determinations were based upon direct comparisons of signals from the eight control subjects; in no case were abnormalities specified unless the degree of deficit (reduced maximum strength, degree of asymmetry) was absent in all records of the normal subjects. Thus, this procedure was conservative in minimising false positives and avoiding inappropriate identification of unreliable abnormalities. For assessment of velopharyngeal function a nasal bulb connected to a pressure transducer via a catheter was placed in each subject’s most patent nares during five repetitions each of two non-nasal sentences: ‘I saw poppa play taps’ and ‘I packed two salad forks’. The resulting signal provided a general index of air escape through the velopharyngeal port. RESULTS
Listener Judgements and Acoustic Measures The mean understandability, intelligibility and feature judgement ratings for all six patients are given in Table 1. For understandabilify, average ratings of 5.35 (s.d. = 0.818) for dysarthric speakers (vs 6.63, s.d. = 0.270, for normal controls) for both reading and contextual speech tasks represented mild dysarthric severity (P < 0.01; degrees of freedom, d.f. = 9; t = 3.39). For intelligibility, the range of accurate transcription was from 81.3% to 93.3% ( x = 86.7%, s.d. = 5.56) indicating comparable altered intelligibility. Intrajudge reliability for understandability and intelligibility was 84% and 87%, respectively. As shown in Table 2, of the 14 judged dysarthric features utilised in this study, 6 received average ratings above 2.0, and included imprecise
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Table 1: Mean understandability, intelligibility and feature judgement ratings for six patients. Patient
Lesion
Understandability
Intelligibility (%)
Feature values
1 2 3 4 5 6 Mean
Left Left Left Right Right Right
5.36 5.86 5.64 5.71 5.79 3.71 5.35
81.3 84.0 82.1 92.0 93.3 87.4 86.7
2.30 1.96 2.27 1.26 1.88 2.45 2.02
Table 2: Average feature ratings of dysarthric speech from six patients with UUMN lesions. Rank order
7 8 9 10 11
12 13 14
Dysarthric feature
Average rating
Imprecise consonants Monoloud Monopi tch Low pitch Phrases short Slow rate
2.8 2.7 2.7 2.4 2.4 2.2
Breathy voice Vowels distorted Harsh voice Hypernasality Irregular articulatory breakdown Strain-strangle phonation Excess and equal stress Reduced stress
1.9 1.9 1.8 1.5 1.4 1.4 1.2
Table 3: Physiological measures from six patients with
Jawt
Patient
1.1
UUMN lesions.'
Lip*
Frontalis7
Number
Lesion
EMC
Force
EMG
Force
Apple
EMC
1
Left Left Left Right Right Right
L>R L>R L>R L#R L#R/R>L INC
INC IRR IRR IRR IRR IRR
L>R INC INC INC WNL INC
L>R R>L L>R R>L WNL R>L
INC L>R WNL INC R>L NO
W L L>R L#R INC WNL L= R
2 3 4 5 6
= lesser or greater force of EMG magnitude; INC = inconclusive re: laterality; WNL = within normal limits; IRR = irregular force pattern; # different L vs R EMG temporal pattern; N O = data not obtained. t Masseter EMG and jaw force for maximum bite task. t Orbicularis oris EMG and lip force for maximum strength task, and EMG for 'apple' task. 1 Frontalis EMG for brow 'furrow' task.
consonants, monopitch, monoloud, low pitch, phrases short and slow rate. Three others were close to the 2.0 cut-off criteria and included breathy voice, vowels distorted and harsh voice. Features reflecting stress, e.g. reduced stress and excess and .equal stress, averaged near-normal ratings. Of the nine salient features (near, at or above 2.0), seven were the same as those identified by Darley et al. (1975) for pseudobulbar palsy (spastic dysarthria) and included
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Figure 2: Average values of diadodwkinetic(DDK) rate (a) and DDK regularity (b) for normal (open bars) and UUMN (closed bars) subjects. The index of DDK mgularity is the coefficient of variability (standard &viation/mean) of indivdual syllable strings expressed as a pemntage. (a) UUMN: mean = 4.7; normals: mean = 6.3. (b) UUMN: mean = 17.4; normals: mean = 7.6.
imprecise consonants, monoloud, monopitch, low pitch, phrases short, slow rate and harsh voice. Listener judgements revealed no significant differences between the patients and the controls for either DDK rate or regularity. However, as illustrated in Figure 2, based upon direct measures, both rate and regularity were significantly different for patients versus normal controls (P < 0.001, d.f. = 40, f = 7.38; P < 0.01, d.f. = 40, t = 3.11). Specifically, the patients demonstrated slower DDK rate and greater irregularity than the controls. Physiological Measures
Physiological measures revealed abnormal findings for all patients studied. The findings for all physiological measures are summarised in Table 3, with
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the exception of tongue force and nasal pressure data which were inconclusive, i.e. these latter physiological measures did not differentiate patients from normal controls. For the jaw, five of six patients demonstrated right-left EMG differences, with four of those five subjects showing reduced EMG contralateral to the lesion. Irregular jaw force was revealed in five of six patients. Lip EMG and strength measures were also revealing: reduced activity andor strength was demonstrated contralateral to the lesion for five of six patients. Paradoxically, patient number 2, who had a left UUMN lesion, showed ipsilateral reduction in lip strength but the expected contralateral reduction in EMG activity. Frontalis EMG showed diminution of function contralateral to the lesion in only one patient, whereas differences in EMG temporal patterns were demonstrated in two patients. DISCUSSI0N
The patients studied here manifested compromised neural speech mechanisms and, contrary to Darley et al. (1975) and Melo et al. (1992), distinct speech deficits. The data from the present study also substantially extend the brief descriptions by Darley et al. (1975), Spertell and Ransom (1979), Aronson (1985) and Ozaki et a]. (1986) for speech changes associated with UUMN disease. The results, however, are most appropriately interpreted in relation to Duffy and Folger’s (1986) and Ropper’s (1987) investigations. In their description of the dysarthria associated with unilateral central nervous system lesions, the former authors reported imprecise articulation as the most common deviant feature, with speech DDK often mildly slowed and irregular. Ropper noted that along with ‘incomplete pronunciation’, slowed (speaking) rate and monotonic voice were prominent aberrant features for his patients. These results closely parallel those of the present study. Conversely, however, Duffy and Folger’s findings differ from ours in several respects. Notably, for the patients in the present study there was no significant evidence of vocal harshness, faster than normal speaking rate or irregular articulatory breakdown as was reported by Duffy and Folger. Ropper commented similarly that irregular articulatory breakdown was notably absent in his patients. Further, the judged features observed in the present study were not compatible with either flaccid or ataxic dysarthria as reported previously. The reasons for the differences between the present results and those of Duffy and Folger most probably concern patient selection. Duffy and Folger’s patients had a wider variety of lesions, conditions and aetiologies than did the patients in the present report. Although the results of the present study and those of Ropper are consistent, the much greater dysarthric severity in his patients was seemingly due to larger, more diffuse lesions, as reflected in his autopsy data. In this respect, the present investigation is the only detailed report concerning the dysarthria due to focal UUMN lesions. Apart from the differences and similarities between these studies, a longitudinal investigation from one month to one year post-stroke is necessary to determine the permanence of dysarthric features. Beyond allowing for description of UUMN dysarthria, the patients in the
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current study also offered the rare opportunity to evaluate the degree to which focal UUMN lesions produce features of speech or deficits that may be components of diffuse cerebral disease or involvement of the frontal operculum. Notably, there are several neurological disorders of speech that are due, in part, to damage to the pyramidal tract(s) (Darley, Brown & Goldstein, 1972; Berry, Darley, Aronson & Goldstein, 1974; Darley et al., 1975; Fisher, 1982; Jackson, Jankovic & Ford, 1983; Bassich, Ludlow & Polinsky, 1984; Caroscio, Mulvihill, Sterling & Abrams, 1987; Hartman & Abbs, 1988). Further, because of the proximity of Brodmann areas 44 and 45 to the primary motor cortex, and the common blood supply (e.g. middle cerebral artery), it is probable, if not expected, that patients with focal vascular lesions of the dominant inferior frontal gyrus (with resultant dyspraxia of speech) will also have involvement of the adjoining motor strip (Whitty, 1964; Bruyn & Gathier, 1978; Alexander, Naeser & Palumbo, 1990; Square-Storer & Apeldoorn, 1991). To this point, Ropper (1987) stated that his patients with right hemisphere lesions ‘. . . mouthed syllables before beginning to speak or repeated the first sound of a word like a stutter’ (p. 1061). Such descriptions have been used to characterise dyspraxia of speech. In this context our results stress the need for careful interpretation of speech disorders that may be due in part to upper motor neuron lesions. For example, in amyotrophic lateral sclerosis (see DePaul & Abbs, 1987) or dyspraxia of speech (see McNeil, Weismer, Adams & Mulligan, (1990), it may be that the DDK rate and regularity aberrations along with other speech or oral motor signs are due solely to upper motor neuron disturbance. In conclusion, it needs to be stressed that the profile of abnormal speech features identified in this study, although bearing some resemblance to spastic dysarthria, was different. Indeed, one of the cardinal features of spastic dysarthria, e.g. strain-strangle phonation (Darley et al., 1975), was not present and phonation was rated near normal in our patients. Clinical observation several months post-stroke suggests that this phonatory feature does not develop in patients with UUMN lesions. Moreover, contrary to previous reports, the features observed were not those classically associated with ataxic or flaccid types. To determine whether UUMN dysarthria is a distinct entity, a larger study comparing ataxic, flaccid and spastic dysarthric patients to those with focal UUMN lesions is necessary. ACKNOWLEDGEMENTS Portions of this paper were presented at the annual meeting of the American Speech-LanguageHearin Association St Louis, MO, November 1989, and Seattle, WA, November 1990. The authors gratefuf y acknowledge the assistance provided by Susan Bri gs, Nadine Comer, Roxanne DePaul Joseph Duffy, Chauncey Hunker, Jeanne Joyce, Fran Kakusfa and Jeanna Rosten, and Geri Torti: We also extend our thanks to Lisa Ritter for preparation of the manuscript. This research was supported by the Gundersen Medical Foundation and Gundersen Clinic.
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Address correspondence to David E. Hartman, PhD, Head, Speech Pathology, Gundersen Clinic Ltd, 1836 South Avenue, La Crosse, WI 54601, USA.
Received February 1992; revised version accepted April 1992.
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Dysarthria associated with focal unilateral upper motor neuron lesion David E. Hartman & James H. Abbs To cite this article: David E. Hartman & James H. Abbs (1992) Dysarthria associated with focal unilateral upper motor neuron lesion, European Journal of Disorders of Communication, 27:3, 187-196 To link to this article: http://dx.doi.org/10.3109/13682829209029419
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Dysarthria associated with focal unilateral upper motor neuron lesion David E. Hartman Department of Neurology, Gundersen Clinic Ltd and Gundersen Medical Foundation, La Crosse, WI, USA
James H. Abbs Departments of Neurology and Neuro hysiology, Universiry of Wisconsin-Madisonand Gundersen Medical Foundation, Madison, Wl, &A
ABSTRACTS Speech motor changes in six patients with focal unilateral upper motor neuron (UUMN) lesions were characterised using a variety of techniques including listener judgements, speech acoustic analyses, electromyographic and strength measures. Listener judgements of speech understandability, intelligibility and dysarthric features indicated mild dysarthria. Diadochokinesis. electromyographic and strength measures corroborated these observations. The findings of this study delineate the characteristicsof the dysarthria associated with unilateral upper motor neuron lesions and have important implicationsfor identifring potential upper motor neuron components of other neurogenic disorders of speech and language. Les caractkristiquesdes changements des aspects moteurs de la locution ont kt6 dkfinies chez six malades souffrant de Iksions focales unilatkrales des neurons moteurs supkrieurs, au moyen d'un certain nombre de techniques comprenant des jugements par des auditeurs, des analyses acoustiques du language, des mesures klectromyographiques et de force (articulatoire). Les jugements par les auditeurs de traits de comprkhensibilitk, dintelligibilitk et de dysarthrie ont r&vdlk la prksence de lkg&res dysarthries - jugements corroborks par la diadochokinkse ainsi que par des mesures d'klectromyographieet de force. Les rksubats de cette etude permettent de dkjinir les caractkristiques de la dysarthrie associke aux l&sionsunilatkrales des neurons moteurs supkrieurs; elles devraient se rkvkler riches de renseignements pour I'identification du jeu possible des neurons moteurs supkrieurs dam les autres dksordres neurogkniques du langage et de la locution. Wir haben die sprechmotorischen Anderungen von sechs Patienten mit einer fokalen einseitigen Liision des oberen Motoneurons mit einer Auswahl von Methoden untersucht, einschliesslich Bewertungen durch Zuhorer, sprechakustische Analysen, elektromyographische und Starkemessungen. Die Bewertungen der Zuhorer in Bezug auf die Verstandlichkeit und dysarthrische Merkmale deuteten auf eine leichte Dysarthrie. Diadochokinetische, elektromyographische und Starkemessungen stimmten mit diesen Beobachtungen iiberein. Die Befunde dieser Studie stellen die Merkmale der Dysarthrie dar, die man bei einseitigen Liisionen der oberen Motoneuronen findet und haben wichtige Folgerungen fur die Identifirierung von potentiellen oberen Motoneuronenkomponenten bei anderen neurogenen Sprech- und Sprachstorungen.
Key words: dysarthria, unilateral upper motor neuron lesion.
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INTRODUCTION It has been shown that select lesions of the nervous system produce changes in speech that have localising value (Darley, Aronson & Brown, 1975; Aronson, 1985; Ropper, 1987; Hartman & Abbs, 1988). Focal unilateral pyramidal tract lesions due to stroke are common and may involve the motor cortex, cell bodies and/or axons. Such lesions produce contralateral upper motor neuron signs frequently involving the speech musculature. However, the dysarthria that occurs secondary to unilateral upper motor neuron (UUMN) involvement is incompletely understood. It has been suggested that speech signs that occur as sequelae to UUMN vascular lesions resolve rapidly leaving the patient with minimal deficits (Darley et al., 1975), may be severe and persist for several years, and have characteristics of both flaccid and ataxic dysarthria (Aronson, 1985; Duffy & Folger, 1986; Ropper, 1987), or have no localising value (Melo, Bogousslavsky, Melle & Regli, 1992). Some additional insights concerning UUMN dysarthria have also been provided by Ozaki and colleagues (Ozaki, Baba, Narita, Matsunga & Takebe, 1986) and Spertell and Ransom (1979). Although detailed information was provided in the retrospective studies by Ropper (1987) and Duffy and Folger (1986), their findings may have been affected by a heterogeneous population of patients including those with dysarthria-clumsy hand syndrome (Fisher, 1967, 1982; Glass, Levey & Rothstein, 1990) or more diffuse neuropathology. What is needed are prospective quantitative analyses concerning the dysarthria associated with focal UUMN lesions. Such information would help shed light on underlying neuropathological mechanisms and potentially give rise to improved differential diagnosis and treatment. This study attempted to provide such information.
METHOD Subjects
Patients To ensure that only effects of UUMN lesions were being measured, stringent criteria for patient selection were employed. Six right-handed patients, three female and three male, who were medically and neurologically stable, were found suitable for the study. The age range was 59.7-80.0 years with a mean age of 68.9 years and none of the patients was more than one month poststroke at the time of the study. All had clinical and/or computed tomographic (CT) scan evidence of focal UUMN stroke, i.e. clinical and/or CT scan data indicated that focal lesions were confined to the pyramidal tract (Figure 1). In all patients, signs included central facial and/or tongue weakness and contralateral central arm and/or leg weakness. Although magnetic resonance imaging (MRI) is the neuro-imaging technique of choice for small vascular lesions, the clinical signs and/or CT scan evidence in these patients unequivocally indicated focal UUMN involvement. All patients manifested dysarthria. None of the patients had evidence of dysphasia, dementia, dyspraxia of speechloral dyspraxia, significant confusion, visual perceptual deficits, prior stroke, basal ganglia, cerebellar or other neurological disorders, psychiatric illness, alcoholism or other drug abuse, premorbid craniofacial anomaly
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Figure 1: CT scan showing capsular infarction on the left (amw) for patient no. 1, male, age 59.7years.
and/or ill-fitting dentures. Exclusion of these potentially contaminating problems was felt to be critical for the present study; all patients were evaluated using standardised or accepted descriptive tests, e.g. Token Test (Derenzi & Vignolo, 1962), Porch Index of Communicative Ability (Porch, 1981), Short Test of Mental Status (Kokmen, Nassens & Offord, 1987), Mayo Clinic Battery for Neurogenic Communicative Disorders (unpublished) and/or routine clinical procedures. Three patients had left hemisphere and three had right hemisphere stroke; the patients’ auditory and visual acuities were adequate for examination. A11 patients had a history of hypertension; one patient had a history of atherosclerotic cerebral vascular disease and insulin-dependent diabetes meilitus. One patient had atrial fibrillation.
Normal controls Five females and three males ranging in age from 59.9 to 80.5 years (mean age of 71.9 years) served as control subjects. None had a history of a neurological, communication or psychiatric disorder, alcoholism or drug abuse, craniofacial anomaly or ill-fitting dentures. Both auditory and visual acuities were adequate for participation.
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Listener Judgements and Acoustic Measures To characterise the potential dysarthria due to a UUMN lesion, listener judgements provided measures of understandability, intelligibility (Yorkston & Beukelman, 1980), and feature judgements (Darley et al., 1975). All patients and five female control subjects read a widely used and accepted standard reading passage (the ‘Grandfather Passage’: Darley et al., 1975), described the ‘Cookie Theft Picture’ (Goodglass & Kaplan, 1972)’ and read 50 different randomly obtained words from lists created by Yorkston and Beukelman (1980) for dysarthria intelligibility testing. For samples of oral diadochokinesis (DDK), all subjects were instructed to produce as rapidly and as evenly as possible consonant-vowel sequences, e.g. pah pah pah, tah tah tah, kah kah kah, for at least 2 seconds per sequence. All speech samples were audio-recorded on a high quality recording system.
Understandability Fourteen untrained listeners made free-field judgements of understandability on a seven-point equal appearing interval scale for speech samples from the ‘Grandfather Passage’ and ‘Cookie Theft Picture’ story. Listeners were instructed that a rating of ‘1’ meant not understood and of ‘7’ completely understood. The sample from each patient and control subject was played back only once. Intelligibility For use as an objective measure of intelligibility, the same 14 listeners transcribed the 50 randomlychosen words (open set) produced by each patient and female control subject. As noted by Yorkston and Beukelman (1980), transcription of randomly chosen isolated words provides the most sensitive measure of intelligibility for mildly impaired patients. Each word was presented once free-field. Feature judgements Three speech and language pathologists with expertise in dysarthria made judgements of presence and severity of 14 individual dysarthric features according to the perceptual protocol utilised by Darley et al. (1975). The judges were allowed to listen to the recorded ‘Grandfather Passage’ for each patient as many times as necessary to make judgements. The 14 selected features included those with a mean scale value of 2.0 or greater for flaccid, spastic and ataxic dysarthria (Darley et a]., 1975). The features were selected on the basis that UUMN dysarthria has been reported to have similar clinical and possibly neuropathological characteristics to those of these three dysarthrias (Aronson, 1985; Duffy & Folger, 1986). Diadochokinesis Three trained speech and language pathologists made judgements of DDK rate and regularity from the audio samples of all subjects using equal appearing interval scales. Again, judges were allowed to listen to the samples as many times as necessary to make decisions. The rate of syllable productions was also measured from oscillographic printouts of the root mean square acoustic signal.
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Physiological Measures, Strength, Electromyography (EMG) and Nasal Pressure To augment and confirm the oral manifestations of the UUMN lesions, a select set of electromyographic and strength measures was obtained from all patients and the eight control subjects. Force transducers, described previously (Barlow & Abbs, 1983), were used with established procedures to evaluate maximum lip, tongue and jaw muscle strength (Dworkin, 1980; Dworkin, Aronson & Mulder, 1980; DePaul, Abbs, Caligiuri, Gracco 8i Brooks, 1988). In brief, the protocol requires the subject to exercise maximum effort, i.e. purse-string lip closure against a strategically placed transducer, which in turn provides a signal to a chart recorder or computer for later analysis. Lip-muscle strength was evaluated on the right and left sides and at midline. Surface EMG electrodes (Cole, Konopacki & Abbs, 1983) were placed bilaterally over the masseter, orbicularis oris inferior and frontalis muscles. For lip and jaw muscles, this bilateral EMG was obtained simultaneously with measures of muscle force. EMG was also recorded during a bilabial speech task, e.g. repetition of the word ‘apple’. To evaluate the frontalis muscle, subjects were requested to furrow (raise) their brow. From these EMG and strength measures, oscillographic records of force and EMG signals were examined to identify (1) major asymmetries from one side of the face to the other, (2) major reductions in strength, and (3) patterns of EMG or muscle force irregularities (primarily fluctuations over the course of the maximum force trials). All of these determinations were based upon direct comparisons of signals from the eight control subjects; in no case were abnormalities specified unless the degree of deficit (reduced maximum strength, degree of asymmetry) was absent in all records of the normal subjects. Thus, this procedure was conservative in minimising false positives and avoiding inappropriate identification of unreliable abnormalities. For assessment of velopharyngeal function a nasal bulb connected to a pressure transducer via a catheter was placed in each subject’s most patent nares during five repetitions each of two non-nasal sentences: ‘I saw poppa play taps’ and ‘I packed two salad forks’. The resulting signal provided a general index of air escape through the velopharyngeal port. RESULTS
Listener Judgements and Acoustic Measures The mean understandability, intelligibility and feature judgement ratings for all six patients are given in Table 1. For understandabilify, average ratings of 5.35 (s.d. = 0.818) for dysarthric speakers (vs 6.63, s.d. = 0.270, for normal controls) for both reading and contextual speech tasks represented mild dysarthric severity (P < 0.01; degrees of freedom, d.f. = 9; t = 3.39). For intelligibility, the range of accurate transcription was from 81.3% to 93.3% ( x = 86.7%, s.d. = 5.56) indicating comparable altered intelligibility. Intrajudge reliability for understandability and intelligibility was 84% and 87%, respectively. As shown in Table 2, of the 14 judged dysarthric features utilised in this study, 6 received average ratings above 2.0, and included imprecise
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Table 1: Mean understandability, intelligibility and feature judgement ratings for six patients. Patient
Lesion
Understandability
Intelligibility (%)
Feature values
1 2 3 4 5 6 Mean
Left Left Left Right Right Right
5.36 5.86 5.64 5.71 5.79 3.71 5.35
81.3 84.0 82.1 92.0 93.3 87.4 86.7
2.30 1.96 2.27 1.26 1.88 2.45 2.02
Table 2: Average feature ratings of dysarthric speech from six patients with UUMN lesions. Rank order
7 8 9 10 11
12 13 14
Dysarthric feature
Average rating
Imprecise consonants Monoloud Monopi tch Low pitch Phrases short Slow rate
2.8 2.7 2.7 2.4 2.4 2.2
Breathy voice Vowels distorted Harsh voice Hypernasality Irregular articulatory breakdown Strain-strangle phonation Excess and equal stress Reduced stress
1.9 1.9 1.8 1.5 1.4 1.4 1.2
Table 3: Physiological measures from six patients with
Jawt
Patient
1.1
UUMN lesions.'
Lip*
Frontalis7
Number
Lesion
EMC
Force
EMG
Force
Apple
EMC
1
Left Left Left Right Right Right
L>R L>R L>R L#R L#R/R>L INC
INC IRR IRR IRR IRR IRR
L>R INC INC INC WNL INC
L>R R>L L>R R>L WNL R>L
INC L>R WNL INC R>L NO
W L L>R L#R INC WNL L= R
2 3 4 5 6
= lesser or greater force of EMG magnitude; INC = inconclusive re: laterality; WNL = within normal limits; IRR = irregular force pattern; # different L vs R EMG temporal pattern; N O = data not obtained. t Masseter EMG and jaw force for maximum bite task. t Orbicularis oris EMG and lip force for maximum strength task, and EMG for 'apple' task. 1 Frontalis EMG for brow 'furrow' task.
consonants, monopitch, monoloud, low pitch, phrases short and slow rate. Three others were close to the 2.0 cut-off criteria and included breathy voice, vowels distorted and harsh voice. Features reflecting stress, e.g. reduced stress and excess and .equal stress, averaged near-normal ratings. Of the nine salient features (near, at or above 2.0), seven were the same as those identified by Darley et al. (1975) for pseudobulbar palsy (spastic dysarthria) and included
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Figure 2: Average values of diadodwkinetic(DDK) rate (a) and DDK regularity (b) for normal (open bars) and UUMN (closed bars) subjects. The index of DDK mgularity is the coefficient of variability (standard &viation/mean) of indivdual syllable strings expressed as a pemntage. (a) UUMN: mean = 4.7; normals: mean = 6.3. (b) UUMN: mean = 17.4; normals: mean = 7.6.
imprecise consonants, monoloud, monopitch, low pitch, phrases short, slow rate and harsh voice. Listener judgements revealed no significant differences between the patients and the controls for either DDK rate or regularity. However, as illustrated in Figure 2, based upon direct measures, both rate and regularity were significantly different for patients versus normal controls (P < 0.001, d.f. = 40, f = 7.38; P < 0.01, d.f. = 40, t = 3.11). Specifically, the patients demonstrated slower DDK rate and greater irregularity than the controls. Physiological Measures
Physiological measures revealed abnormal findings for all patients studied. The findings for all physiological measures are summarised in Table 3, with
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the exception of tongue force and nasal pressure data which were inconclusive, i.e. these latter physiological measures did not differentiate patients from normal controls. For the jaw, five of six patients demonstrated right-left EMG differences, with four of those five subjects showing reduced EMG contralateral to the lesion. Irregular jaw force was revealed in five of six patients. Lip EMG and strength measures were also revealing: reduced activity andor strength was demonstrated contralateral to the lesion for five of six patients. Paradoxically, patient number 2, who had a left UUMN lesion, showed ipsilateral reduction in lip strength but the expected contralateral reduction in EMG activity. Frontalis EMG showed diminution of function contralateral to the lesion in only one patient, whereas differences in EMG temporal patterns were demonstrated in two patients. DISCUSSI0N
The patients studied here manifested compromised neural speech mechanisms and, contrary to Darley et al. (1975) and Melo et al. (1992), distinct speech deficits. The data from the present study also substantially extend the brief descriptions by Darley et al. (1975), Spertell and Ransom (1979), Aronson (1985) and Ozaki et a]. (1986) for speech changes associated with UUMN disease. The results, however, are most appropriately interpreted in relation to Duffy and Folger’s (1986) and Ropper’s (1987) investigations. In their description of the dysarthria associated with unilateral central nervous system lesions, the former authors reported imprecise articulation as the most common deviant feature, with speech DDK often mildly slowed and irregular. Ropper noted that along with ‘incomplete pronunciation’, slowed (speaking) rate and monotonic voice were prominent aberrant features for his patients. These results closely parallel those of the present study. Conversely, however, Duffy and Folger’s findings differ from ours in several respects. Notably, for the patients in the present study there was no significant evidence of vocal harshness, faster than normal speaking rate or irregular articulatory breakdown as was reported by Duffy and Folger. Ropper commented similarly that irregular articulatory breakdown was notably absent in his patients. Further, the judged features observed in the present study were not compatible with either flaccid or ataxic dysarthria as reported previously. The reasons for the differences between the present results and those of Duffy and Folger most probably concern patient selection. Duffy and Folger’s patients had a wider variety of lesions, conditions and aetiologies than did the patients in the present report. Although the results of the present study and those of Ropper are consistent, the much greater dysarthric severity in his patients was seemingly due to larger, more diffuse lesions, as reflected in his autopsy data. In this respect, the present investigation is the only detailed report concerning the dysarthria due to focal UUMN lesions. Apart from the differences and similarities between these studies, a longitudinal investigation from one month to one year post-stroke is necessary to determine the permanence of dysarthric features. Beyond allowing for description of UUMN dysarthria, the patients in the
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current study also offered the rare opportunity to evaluate the degree to which focal UUMN lesions produce features of speech or deficits that may be components of diffuse cerebral disease or involvement of the frontal operculum. Notably, there are several neurological disorders of speech that are due, in part, to damage to the pyramidal tract(s) (Darley, Brown & Goldstein, 1972; Berry, Darley, Aronson & Goldstein, 1974; Darley et al., 1975; Fisher, 1982; Jackson, Jankovic & Ford, 1983; Bassich, Ludlow & Polinsky, 1984; Caroscio, Mulvihill, Sterling & Abrams, 1987; Hartman & Abbs, 1988). Further, because of the proximity of Brodmann areas 44 and 45 to the primary motor cortex, and the common blood supply (e.g. middle cerebral artery), it is probable, if not expected, that patients with focal vascular lesions of the dominant inferior frontal gyrus (with resultant dyspraxia of speech) will also have involvement of the adjoining motor strip (Whitty, 1964; Bruyn & Gathier, 1978; Alexander, Naeser & Palumbo, 1990; Square-Storer & Apeldoorn, 1991). To this point, Ropper (1987) stated that his patients with right hemisphere lesions ‘. . . mouthed syllables before beginning to speak or repeated the first sound of a word like a stutter’ (p. 1061). Such descriptions have been used to characterise dyspraxia of speech. In this context our results stress the need for careful interpretation of speech disorders that may be due in part to upper motor neuron lesions. For example, in amyotrophic lateral sclerosis (see DePaul & Abbs, 1987) or dyspraxia of speech (see McNeil, Weismer, Adams & Mulligan, (1990), it may be that the DDK rate and regularity aberrations along with other speech or oral motor signs are due solely to upper motor neuron disturbance. In conclusion, it needs to be stressed that the profile of abnormal speech features identified in this study, although bearing some resemblance to spastic dysarthria, was different. Indeed, one of the cardinal features of spastic dysarthria, e.g. strain-strangle phonation (Darley et al., 1975), was not present and phonation was rated near normal in our patients. Clinical observation several months post-stroke suggests that this phonatory feature does not develop in patients with UUMN lesions. Moreover, contrary to previous reports, the features observed were not those classically associated with ataxic or flaccid types. To determine whether UUMN dysarthria is a distinct entity, a larger study comparing ataxic, flaccid and spastic dysarthric patients to those with focal UUMN lesions is necessary. ACKNOWLEDGEMENTS Portions of this paper were presented at the annual meeting of the American Speech-LanguageHearin Association St Louis, MO, November 1989, and Seattle, WA, November 1990. The authors gratefuf y acknowledge the assistance provided by Susan Bri gs, Nadine Comer, Roxanne DePaul Joseph Duffy, Chauncey Hunker, Jeanne Joyce, Fran Kakusfa and Jeanna Rosten, and Geri Torti: We also extend our thanks to Lisa Ritter for preparation of the manuscript. This research was supported by the Gundersen Medical Foundation and Gundersen Clinic.
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Address correspondence to David E. Hartman, PhD, Head, Speech Pathology, Gundersen Clinic Ltd, 1836 South Avenue, La Crosse, WI 54601, USA.
Received February 1992; revised version accepted April 1992.
