The Clinical History

Definition Refers to background information about the communication disorder so we can better understand its nature and can assist in treatment.

Effective Interviews Attention must be placed at What you want to ask How we talk to our clients

Answer the following questions about the interview process What is “friendly manner”? What is professional manner? How do we use technical language in the interview? What if we have a limited amount of time to interview? How can we be sensitive to cultural differences? How do we deal with confidentiality?

Answer the following questions about the interview process What if the client does not have the information we need? How can we tell if the information given is dependable?

Oral Mechanism Structural Adequacy deals with normalcy of the structures and their normalcy in relation to each other Looking at physical structures Functional Adequacy deals with how well these structures, regardless of intactness and relationships to each other, move and perform during speech production. Is more difficult than arriving at structural decisions Judgments depend on rate of movements and accuracy of production

Problems with measurements Few direct measurements may be made (cleft palate, dental occlusions, dental relationships) Relationships between measurements and production of speech are unclear. Equipment to perform measurements not readily available.

Norm-references Compare the client’s performance of a specific task to the performance of a groups of persons with “normal” speech doing the task. Diadochokinetic rates Help with the functional adequacy testing Help to evaluate change over time

Equipment needed Flashlight Tongue depressors Small mirror Examination gloves

The examination Test forms Go to your guide and review it Are available in many resources. Should be thought as guides Go to your guide and review it

Diadochokinetic Tasks Evaluate functional adequacy Call for rapid repetition of either a speech or nonspeech task. Assess the following of repeated movements Consistency Accuracy Rate (speech)

Diadochokinetic Tasks Method 1 Client produces speech or non-speech task for a specified period, often 5 seconds, which is then repeated for a total of three more trials. The average number of productions per second is then calculated.

Diadochokinetic Tasks Method 2 Patient produces a specified number of productions or movements, with the speech-language pathologist timing the trial to determine how much time the client needs to complete the entire task.

Diadochokinetic Tasks Norms should be used with caution. /p/ Children 3-6 per second Adults 6-7 per second Rate increase developmentally but are not reflected in norms Samples for these norms are small

Use of non-speech tasks Controversial Help with looking at Range of movement – how far a structure is able to move Duration of movement – how long a single or repeated movement can be maintained or sustained Strength of movement – how well a structure can achieve and maintain a position when an external force is applied

Examination Procedures

The Face

The Face Gives clues about muscle weakness and possible problems of innervation of the mouth and face which are associated with speech production and facial expression. Observe during interview conversation

The Face Observe external features Observe symmetry of face at rest Forehead Nose Lips Jaw Observe symmetry of face at rest Observe symmetry of face through tasks Open mouth as far as possible Raise both eyebrows Close both eyes tightly

Lip Structure Important for speech production Abilities to Restrict air by sealing Swallow by sealing

Lip Structure Observe Summary of procedures Symmetry General contour Shape of mucocutaneous ridge Condition of lips Summary of procedures Observe lips at rest for above Observe for presence of scar tissue

Lip Function Nonspeech movements Static movements – are made and then “held in place” (unilateral retraction of lips) Diadochokinetic tasks - Non-static movement – Alternate between protruding and retracting (reciprocal movement task) “pucker, then smile, pucker, then smile” Open and close the upper and lower lips without making a speech sound Observe symmetry of movement, ease and how long they can continue to make movement series

Lip function Summary of Procedures Unilateral retraction of the lips to each side of the face Bilateral retraction of the lips Series of “pucker, smile” Series of upper and lower lip approximations. Open and close lips for adults = 5-6 times per second

Lip function Speech movements Diadochokinetic Summary of procedures Repetitions of /uiuiuiui/ Repetitions of /p/

Lip strength Summary of procedures Request that the patient puff out the cheeks, then pushing against each cheek, and both cheeks. Check for air coming out with your hand.

Teeth

Teeth We are able to compensate for dental deviations See page 102 for eruption of dentition table Must assess dental “occlusion”=the relationship of the upper and lower dental arches and the alignment of the teeth when the jaw is closed. Ask the client to “bite down” on the back teeth and then to spread the lips to “show the gums” You must look at the upper and lower molars to determine any malocclussion

Types of Occlusion Normal occlusion – first upper molar should fit into the “groove” between the two anterior and posterior cusps of the lower molar.

Types of Occlusion Neutroclusion (Angle’s Class I) – Upper and lower dental arches are in correct occlusion but individual teeth are misaligned.

Types of Oclusion Distoclusion (Angle’s Class II) – Lower dental arch, or mandible, is “too far back”.

Types of Occlusion Mesioclusion (Angle’s Class III) – mandible is “too far forward” in relation to maxilla

Types of Occlusion Openbite –lack of contact between upper and lower anterior teeth Overbite or closebite – excessive vertical overlapping of the lower anterior teeth the upper anterior teeth overbite openbite

Types of Occlusion Crossbite – lateral, rather than parallel, overlapping of the upper and lower dental arches Overjet – excessive horizontal distance between the surfaces of the incisors (thumbsucking) overjet crossbite

Types of Occlusion Underjet – lack of normal horizontal distances Underbite undergirte

Other terms Labioversion – tooth tilting toward lip Bucoversion – tooth tilting toward cheek Linguaversion - tooth tilting toward tongue Edentulous spaces – missing tooth supernumery/extraneous teeth – extra teeth

Other observations Teeth condition Appliances or prosthesis Dentures Orthodontic appliances (braces) Obturators and palatal lift appliances

Obturators

Prosthesis and dentures

Teeth Summary of Procedures Noting dental development and condition of teeth Observing the occlusion Observing any deviations in the positions of the anterior teeth Observing any deviations in the position of other individual teeth Noting dental appliances or prosthesis

Tongue Structure Crucial for production of speech sounds and swallowing. Vary in size and shape. Size and shape of mouth and tongue must be related.

Tongue Function Nonspeech Tasks – Task 1 Request cl. to open mouth slightly and make repeated elevations of the tongue tip to the alveolar ridge without making sound Use stopwatch and count number of times Average diadochokinetic rate for elevating the tongue to alveolar ridge with no sound is 4.5 to 5.0 per second. Use of mandibular assist may be necessary, espcially clients below the age of 7 -8 years Client or you stabilize the jaw by holding it during trials.

Tongue Function Nonspeech Tasks – Task 2 Tongue wiggle Consists of alternate lateral touching of the corners of the mouth during several trials. One unit is the full movement in both sides. Note rate, accuracy, and smoothness of movements. Rate for children and adolescents (4.5-14.5) = 10 reps in 3-5 seconds or average of 4.5-5.0 excursions per second.

Tongue Function Nonspeech Tasks – Task 3 Tongue circle Cl. Opens mouth slightly and attempts to move tongue around mouth opening. Rate smoothness, accurateness, and coordination

Tongue Function Summary of Procedures for nonspeech tasks Repeated elevation of the tip of tongue to the alveolar ridge without sound The tongue wiggle The tongue circle

Tongue Function Speech Tasks Diadochokinetic /t/ =tip tongue function Rates = 3.5-5.5/sec children(2.5-5 yrs) 5.5-6.5/sec adults /k/ =posterior tongue function Rates = 3.5-5.5/sec children (2.5-15 yrs) 4-6/sec adults /p t k/ =tongue and lip function “Pattycake, buttercup” Rates = 1.0-1.5/sec 8 yr olds

Tongue Function Production of Multisyllabic words Check for accuracy of sequences Restricted lingual frenum (Ankyloglossia ) Incorporate /l,n,t,d/ sounds in assessment Rarely impacts production

Tongue Function Summary of Procedures Diadochokinetic production of /t/ Diadochokinetic production of /k / Diadochokinetic production of /p t k / or real multisyllabic words If suspect of restricted frenum, speech tasks that include /l,n,t,d/ sounds.

Tongue Strength Use tongue depressor Task 1- Task 2- Cl protrudes tongue and then resists efforts to force the tongue to the Right Left Back into mouth Task 2- Ask Cl to place tongue tip against the inside of the cheek and to resist your efforts to move the tongue toward the midline of the mouth with the flat of your fingers placed on outside of cheek Easier to force the tongue inward on the side which is opposite the weakness

Tongue Strength Summary of Procedures Cl protrudes and resists tongue depressor force on left, right and center of tongue. Cl places tongue against inside cheek and resist force you apply

Hard Palate Structure Provides barrier between nasal and oral cavities. Check for structural intactness or adequacy Bony structure Check structure and color of the center or midline Check height and width of vault Check ease in producing /l,n,t,d/ Check for submucous cleft palate Has not ill effect on speech Check for fistulas (small openings)

Hard Palate Structure

Fistula

Fistula http://www.emedicine.com/plastic/topic519.htm#target2

Velopharyngeal mechanism structure

Velopharyngeal Mechanism Known as VP Port or Palatopharyngeal mechanism Includes velum (soft palate), pharynx (back wall) and side walls of the throat. Look at Figure 5.5 The port opens and closes the area at the back of the throat that separates the oral and nasal passages for safe swallowing and speech. Don’t tilt the head when examining. Clinicians eye should be at mouth level. Patient’s mouth only opened ¾

Velopharyngeal Mechanism Observations Intactness of soft palate and uvula Symmetry (ask to produce /a/ to see if symmetry changes) Note height and width (if there is bluish color suspect a submucous cleft) Bifid uvula (split)

Oropharynx Depth and width of the oropharynx must be shallow allowing the soft palate to extend back and elevate slightly for achievment of closure with the back wall or throat or pharynx

Trauma to uvula Note any indications of trauma

Velopharyngeal Mechanism Observations Tonsils – note if infected

Velopharyngeal Mechanism Adenoids – note if infected

Velopharyngeal Mechanism Summary of Procedures Observe soft palate for intactness and symmetry at rest and during productions of prolonged and repeated /a/. Evaluating width and depth of oropharynx

Velopharyngeal Function There are instrumental techniques for this Radiological and aerodynamic techniques Oral endoscopy Nasal endoscopy Speech Tasks Look for how air escapes (hypernasality, etc.) and sounds produced sound Nasal mirror exam to check for nasal emissions

Velopharyngeal Function 3. Cl. Opens mouth ¾ and observe soft palate moving up and down and wall move inward Prolongation of /a/ Production of short repeated /a/s You can use tongue depressor 4. Pataka with nostrils open and closed . Nares occluded with help if there is a leak of air in the velopharyngeal mechanism.

Velopharyngeal Function Summary of Procedures Observation of conversational speech Use of the nasal mirror during simplified speech tasks Observing prolonged /a/ Observing repeated /a/ Measuring diadochokinetic rates for /pataka/ with the nares open and colsed

Velopharyngeal Function Non-speech tasks Blowing out candle – check for air coming out of the nose Eliciting gag reflex