Communication – the essence of human connection!

The speech disorder most commonly seen in ALS is clinically known as “Mixed (Spastic+Flaccid) Dysarthria”. This type of speech disorder is mainly caused due to the weakness, slowness, or sometimes paralysis of muscles, that is encountered in Motor Neuron Diseases; especially ALS.

WHAT CAUSES SPEECH PROBLEMS IN MND/ALS?

The tongue, lips, jaw, soft palate and larynx along with their muscles, together help us to speak. When these set of oral muscles are affected (weakened/ paralysed), the range of movement, speed of movement and accuracy with which these muscles move is lost. Thus the overall precision of producing accurate sounds is lost. Hence, the speech produced is considered to be out of the normative range and is unclear/muffled/non-intelligible.

Respiration also gets affected in many cases. Change of breathing pattern often leads to a change in the voice quality, making the voice breathy in quality. Weakness of soft palate also influences the voice quality making it nasal in nature.

All the above changes causes the patient to “sound” completely different, making the patient unrecognisable by voice print.

CLINICAL FEATURES

Features seen in initial stages:

• Loss of precision of certain sounds
• Slurring of speech
• Worsening of speech with long hours of speaking (fatigue) Muffled speech quality
• Breathy/hoarse voice

Features seen in serve stages:

• Inability to speak loudly
• Inability to change pitch of voice
• Slow rate of speaking
• Nasal voice quality
• Breathlessness while speaking

MANAGEMENT

A Speech Language Pathologist will provide exercises of oral muscles. These exercises help in improving speech intelligibility, and also prevent the oral muscles from getting fatigued during speech acts, thus helping effective expression.

They include:

Oro-motor exercises: Strength and rapid mobility of oral muscles is a requisite for clear speech. Oro-motor exercises involve exercises of the lips, tongue, jaw and soft palate in order to build strength and the necessary mobility in these muscles.

The oro-motor exercises include:

• Lip retraction spreading exercises
• Lip pursing, puffing exercises
• Tongue protrusion, retraction, elevation, depression and lateralization exercises
• Tongue rotation exercises
• Blowing and sucking velar exercises

The SLP will make the use of an Oral Motor Kit (as shown below) in order to aid exercises of the oral muscles.

Proprioceptive Neuromuscular Facilitation (PNF): It is a rehabilitative technique used to stimulate the neuromuscular system to excite specific muscles in the effort to bring about desired movements. The SLP will use a Finger Brush, and other assistive materials in order to give taste, temperature and tactile stimulation to the oral muscles to assist the movement of those muscles.

Intelligibility Drills: Once the oral muscles start gaining increasing strength and mobility, these muscles have to be integrated with speech movements. The SLP will bring about this integration by prescribing the patient with intelligibility drills. This will help improve intelligibility in daily conversations, helping patients regain interest and confidence to speak.

Communication Strategies: Communication strategies may be prescribed by the SLP (if required) in order to fill the intelligibility gap that may exist even after speech production strategies are given.

The SLP may also serve the patient with an alternative/ augmentative communication (AAC) aid / device to bring about effective communication, in patients where speech production may not be the best communication option.

Some AAC option are:

1) AAC Board: This board is costume made for each patient and may consist of pictures/ words. The SLP trains the patient to use this board to communicate using either finger or laser pointing.

2) Speech Generating Devices: These devices produce speech either in written or spoken format and hence helps in aiding communication.

3) AAC Apps: There are a number of Android and iOS AAC Applications. The SLP will make the patient avail to these Apps and will also train the patient to use them effectively for quick communication.

ARTICULATION THERAPY

Patient should make conscious effort to produce the below sound several times a day. Take time to make each sound as clearly as possible put emphasis on each letter sound. Say each letter as loudly as possible.

Articulation therapy includes exercises and/or techniques, given in order to increase the clarity of sounds in speech. The SLP targets the improvement of sounds by mainly giving the feedback of how these sounds are actually produced, so that the patient can consciously make an effort to produce them accurately.

The diagram given below shows the various articulators which help to produce speech sounds. Patient should make conscious effort to produce the below sound several times in a day. Take time to make each sound as clearly as possible. Put emphasis on each latter sound.Say each letter as loudly as possible.

Now that we are a little oriented to the clinical names of different oral structures, let us have a loot as to how we produce sounds.

Bilabial sounds: They are the sounds that are produced by bring

ing the two lips together; sounds like /p-u-h/, /b-u-h/, /m-u-h/.

Labio-dental sounds: They are sounds that are produced by touching the the teeth to the lips; sounds like /f-u-h/, /v-u-h/.

Labio-dental sounds: They are sounds that are produced by touching the the teeth to the lips; sounds like /f-u-h/, /v-u-h/.

Lingua-dental sounds: They are sounds that are produced by touching the tongue to the teeth; sounds like /d-u-h/, /t-u-h/.

Alveolar sounds: Sounds that are produced by touching the tongue to the alveolus; like /l-u-h/, /r-u-h/.

Palatal sounds: Sounds that are produced by touching the tongue to the palate; sounds like /t-u-h/, /d-u-h/.

Velar sounds: Sounds that are produced by touching the back of the tongue to the back of the palate; sounds like /k-u-h/, /g-u-h/.