Evidence-Based Practice Guidelines for Dysarthria: Management of Velopharyngeal Function

Journal of Medical Speech-Language Pathology

Yorkston, K. M., Spencer, K. A., et al. (2001).

Journal of Medical Speech-Language Pathology, 9(4), 257-274.

<div>This guideline provides recommendations for the management of velopharyngeal dysfunction for individuals with dysarthria.&nbsp;Etiologies associated with dysarthria&nbsp;included but were not limited to&nbsp;traumatic brain injury, stroke, cerebral palsy, or amyotrophic lateral sclerosis. The target audience of this guideline is speech-language pathologists.</div>

Academy of Neurologic Communication Disorders and Sciences

<div>The following is recommended for the assessment of VP function in individuals with dysarthria:</div> <div> <ul> <li><strong>History taking:&nbsp;</strong>Information should be gathered on areas such as the onset of symptoms, medical and dental history, the nature/duration/course of VP impairment, history of prior treatments, and the patient's level of concern about the VP impairment and their motivation for treatment.&nbsp;</li> <li><strong>Speech evaluation:&nbsp;</strong>Perceptual assessment should include testing of: <ul> <li>&nbsp;stimulability for improved speech;</li> <li>determination of the presence and/or severity of hypernasality, nasal emission, diminished loudness, and reduced "strength" or precision of pressure consonants;</li> <li>connected speech with ratings from multiple audiences (e.g., self, clinician, untrained listeners);</li> <li>phonation;</li> <li>articulation, noting any differences in performance for nasal and pressure consonants; and</li> <li>differences in intelligibility, pressure consonants, speaking effort, syllables per breath group, and resonance with nares occluded versus not occluded.&nbsp;&nbsp;</li> </ul> </li> <li><strong>Physical examination: </strong>This should include the assessment of the structure and function of the velopharynx at rest and during movement, the modified tongue-anchor test (i.e., sticking tongue out and puffing out cheeks to note any nasal emission), dental occlusion, gag reflex, swallowing ability and saliva management, and any signs of submucous cleft.&nbsp;</li> <li><strong>Instrumental assessment:&nbsp;</strong>Instrumental assessment may include videofluoroscopy, nasoendoscopy, aerodynamic assessments, and acoustic assessments. These should be used to assess intraoral air pressure and nasal air flow for pressure consonants and for speech in general, palatal and lateral pharyngeal wall movement, sphincteric activity during speech, and the timing of velopharyngeal movements.&nbsp;</li> </ul> </div>

<div>The following techniques may be used to assess for stimulability for compensatory techniques in individuals with velopharyngeal dysfunction secondary to dysarthria:</div> <div> <ul> <li>altering/slowing speech rate;</li> <li>altering the level of speaking effort;</li> <li>self-monitoring for abnormal airflow or resonance; and</li> <li>exaggerating articulatory movements.</li> </ul> </div>

<div>The following behavioral interventions may be considered for use with individuals with VP dysfunction in the setting of dysarthria per expert opinion:</div> <div> <ul> <li><strong>Modifying speaking patterns:&nbsp;</strong>Clinicians may focus on modifying speech effort, slowing speech rate, or prompting for overarticulated speech. Speech modeling may be provided.&nbsp;</li> <li><strong>Resistance training during speech: </strong>Continuous positive airway pressure may be an effective means of strengthening the soft palate during speech. However, evidence for this technique was limited at the time of this guideline.</li> <li><strong>Feedback:</strong> The use of biofeedback such as mirrors, nasal flow transducers, or endoscopy may be helpful in increasing individual's insight into performance.</li> </ul> </div>

<div>Outcome measures for people with velopharyngeal dysfunction in the setting of dysarthria should include measures of:</div> <div> <ul> <li><strong>Impairment:&nbsp;</strong>This may include radiographic or aerodynamic measures, results of physical examination, phonation time, severity ratings by speech subsystem, and pulmonary function tests.&nbsp;</li> <li><strong>Activity Limitation:&nbsp;</strong>This may include the measurement of changes to speech effort or perceptual changes in hypernasality, articulation, voice, or intelligibility.</li> <li><strong>Participation Restriction: </strong>This may include reports of return to work, speaking without fatigue, self-confidence, self-esteem, or quality of life.&nbsp;</li> </ul> </div>

<div>Interventions that utilize nonspeech movements to treat velopharynegal dysfunction in the context of dysarthria have generally not been endorsed by experts for the following reasons:</div> <div> <ul> <li>There was different underlying mechanisms for speech and nonspeech velopharyngeal closure.</li> <li>There is no evidence to support that improving soft palate strength increases speech accuracy.&nbsp;</li> <li>Most nonspeech motor methods do not provide individuals with information regarding speech motor timing.</li> </ul> <div>Evidence suggests that pushing techniques, strengthening exercises such as blowing or sucking, tasks encouraging airstream control/modification (e.g., tasks with items such as whistles, candles, or bubbles), and inhibition techniques (e.g., icing, stroking/brushing, or applying pressure to muscles) are not effective.&nbsp;</div> </div>

<div>The following behavioral interventions may be considered in individuals with velopharyngeal dysfunction in the setting of dysarthria who are poor candidates for palatal lifts:</div> <div> <ul> <li><strong>Alphabet supplementation: </strong>Clinicians can consider alphabet supplementation, a form of augmentative and alternative communication used to supplement speech.&nbsp;</li> <li><strong>Communication partner techniques:&nbsp;</strong>These may include clarifying the topic of conversation, ensuring full attention to the speaker, and piecing together any cues used by the speaker.</li> <li><strong>Speaker techniques:&nbsp;</strong>These may include the use of supplemental gestures, selecting an environment conducive to communication, and the use of turn maintenance signals.&nbsp;</li> <li><strong>Augmentative and alternative communication:&nbsp;</strong>This may involve the use of devices to supplement or replace verbal communication.&nbsp;</li> </ul> </div>

<div>"Exercise as a treatment of velopharyngeal impairment in dysarthria has been reported in a small number of cases, but evidence is so preliminary that recommendations for its use cannot be made at this time" (p. 271).&nbsp;</div>

<div>The following is recommended for individuals with VP impairment secondary to dysarthria for whom communication function is a fundamental target of intervention:</div> <div> <ul> <li>These individuals should receive assessment and treatment from a competent speech-language pathologist (SLP). The SLP should make any appropriate referrals to other disciplines.</li> <li>Assessment of VP function should include history taking, physical examination, speech evaluation, and examination of the VP mechanism. Due to individual variability, the pattern and severity of errors must be assessed based on an individual's impairment profile.&nbsp;</li> <li>Follow-up assessment should occur for individuals with progressive disorders, even if they initially have adequate VP function.</li> <li>Individuals with VP impairments should be assessed for stimulability for behavioral compensations. Those who can compensate should receive behavioral intervention.</li> <li>Individuals with VP impairments that cannot compensate should be assessed for palatal lift candidacy. Individuals with poor candidacy, whether or not they have a progressive disease, should receive behavioral intervention. Individuals with good candidacy should be fit with a palatal lift prior to initiation of behavioral intervention.</li> <li>In any person who receives behavioral intervention, therapy outcomes should be measured. Intervention plan should be individually developed with consideration for the type and severity of dysarthria and any co-existing factors.</li> <li>Staging of interventions must take into account any physiological changes children with developmental dysarthria experience as they grow. For adults, clinicians must consider the impact of recovery or degeneration on treatment selection and timing.&nbsp;</li> <li>Clinicians should communicate the benefits and risks of any treatment.</li> </ul> </div>