ACQ Vol 12 no 1 2010

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ACQ Volume 12, Number 1 2010 7
Treatment
Treatment for acquired dysarthria aims to effect sustained
improvement in the speech system following brain injury,
utilising principles of neural plasticity.1
Current evidence guiding treatment
approaches
Recently, a Cochrane Collaboration review evaluated the
efficacy of treatments for dysarthria associated with ABI in
children aged three to 16 years (Morgan & Vogel, 2008). The
review systematically identified that there are only 2
empirically driven studies in this field to date: 1) a single case
ABAB study design focused on respiratory-based treatment
for dysarthria (box 2; Murdoch et al., 1999), and 2) a case
series ABA study design focused on an articulatory-based
treatment (box 3; Morgan et al., 2007).
met the operational definition for adequate content validity,
but not for criterion-related or construct validity (McCauley
& Strand, 2008). Hence, using assessment tool selection
criteria based on psychometric properties, it appears that the
VMPAC is the superior option for the assessment of motor
speech impairment in children three to 12 years of age.
Current paediatric motor speech assessment tools
(including those reviewed by McCauley & Strand, 2008)
largely measure impairment. They provide little consideration
of the child’s everyday functional speech performance.
Attempts to capture more functional aspects of speech
performance are largely based on measuring intelligibility.
Two commercially available standardised tools in the broader
developmental speech field (i.e., not specifically designed
for children with motor speech impairment) include the
Children’s Speech Intelligibility Measure (CSIM; (Wilcox &
Morris, 1999) and the recent Test of Children’s Speech
Plus – Sentence Measure (TOCS+ SM; Hodge, 2008). The
CSIM assesses intelligibility at a single word level, whereas
the TOCS+ SM is based on sentences. Unfortunately, to
the author’s knowledge, a more naturalistic standardised
assessment of spontaneous speech is not available.
Non-commercial assessment tools
The McCauley and Strand (2008) study reviewed only
commercial assessment tools still available for purchase in
mid-2006. This criterion is understandable because it would
ensure that the tools of interest were still readily available to
clinicians, and that they were not outdated. It is possible,
however, that useful non-commercial assessment tools may
exist. For example, the non-commercial but standardised
Oral and Speech Motor Control Protocol (OSMCP; Robbins
& Klee, 1987). While the OSMCP was reported in 1987,
references to its use still appear in the clinical-research
literature to date, including in speech genetic studies where
strong phenotyping or behavioural descriptions of children’s
speech performance is required (e.g., Miscimarra et al.,
2007; Stein et al., 2006).
The OSMCP was normed on 90 children, with 10 children
included for each 6 month age band from 2;6 to 6;11 years.
There is overlap in the particular tasks required of the child
in the OSMCP and the VMPAC. One difference between
the two assessments is that the OSMCP is explicit in
associating structure or function with specific cranial nerves.
The OSMCP may be useful for a clinician working on an
acute ward who seeks a systematic tool to document cranial
nerve function in children within this age range. There are
multiple formal or informal non-speech oral motor or cranial
assessments available, however to the author’s knowledge,
none have such extensive psychometric data (i.e., the
OSMCP is standardised, and has examined test reliability,
and inter-rater agreement).
Implications for clinical practice
The preceding review focused on oral motor or motor
speech assessment tools that may be appropriate for use
with children with acquired dysarthria. At a minimum
however, childhood speech disorders call for a differential
diagnosis of three key areas. Specifically, it is critical to
determine whether and to what degree, i) structural
anatomical, ii) developmental and/or iii) neurologically-based
oral motor and motor speech factors are involved in the
presenting speech impairment; see box 1 for an example of
an assessment protocol.
Box 1. Example protocol for assessment of motor
speech (dysarthria) in ABI
1. Oro-facial structural exam (e.g., OSMCP; selected items from
OSMCP or VMPAC)
2. Developmental speech production, i.e., articulation and phonology
(e.g., Goldman Fristoe Test of Articulation – 2, Goldman & Fristoe,
2000; Diagnostic Evaluation of Articulation and Phonology, Dodd,
Hua, Crosbie, Holm, & Ozanne, 2006)
3. Motor speech examination
• Oral motor/non-speech function (e.g., selected non-speech
items in VMPAC Global motor control, Focal motor control,
Sequencing subtests; or selected non-speech items in OSMCP)
• Motor speech production (e.g., selected speech items in
VMPAC or OSMCP)
• Functional speech measure (e.g., CSIM, TOCS+ SM)
Box 2. Treatment example summary A (Murdoch
et al., 1999)
• Participant: 12.5 year old with TBI post MVA
• Time post-injury: 2.5 years
• Speech diagnosis: mixed spastic-ataxic flaccid dysarthria (with
severely impaired respiratory function)
• Study design: single case ABAB design
• Key therapy goals: i) increase control of inhalation and exhalation;
ii) improve co-ordination of phonation and exhalation
• Treatment technique: B1: Traditional therapy (included non-
speech and speech tasks focused on establishing appropriate
sub-glottal air pressure and enhancing the participant’s inhalation
and exhalation control); B2: Visual biofeedback (included using a
Respitrace plethysmograph to provide visual feedback of speech
breathing while performing similar tasks to those in B1)
• Treatment dose: B1: 8 x 30-45 minute sessions of traditional
therapy across 2 weeks followed by a 10 week withdrawal period;
B2: 8 x 30 minute sessions of respitrace (with visual biofeedback)
over 2 weeks
• Post-treatment result: real-time continuous biofeedback treatment
was effective and superior to traditional therapy for modifying
speech breathing patterns in this case
TBI: traumatic brain injury, MVA: motor vehicle accident;
ABAB: A = assessment, B = treatment