1. The Clinical History

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

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

4. 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?

5. 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?

6. 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

7. 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.

8. 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

9. Equipment needed Flashlight Tongue depressors Small mirror
Examination gloves

10. 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

11. 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)

12. 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.

13. 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.

14. 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

15. 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

16. Examination Procedures

17. The Face

18. 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

19. 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

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

21. 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

22. 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

23. 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

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

25. 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.

26. Teeth

27. 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

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

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

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

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

32. 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

33. 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

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

35. 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

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

37. Obturators

38. Prosthesis and dentures

39. 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

40. 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.

41. 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.

42. 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 ( ) = 10 reps in 3-5 seconds or average of excursions per second.

43. 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

44. 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

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

46. 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

47. 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.

48. 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

49. 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

50. 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)

51. Hard Palate Structure

52. Fistula

53. Fistula

54. Velopharyngeal mechanism structure

55. 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

56. 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)

57. 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

58. Trauma to uvula
Note any indications of trauma

59. Velopharyngeal Mechanism
Observations
Tonsils – note if infected

60. Velopharyngeal Mechanism
Adenoids – note if infected

61. 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

62. 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

63. 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.

64. 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

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