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Beata Szewczyk
Gdańsk Industrial Healthcare Centre 0000-0001-9052-
Diagnosis and Therapy of Respiratory
and Phonatory Disorders in Dysarthria –
Case Studies
Abstract: This article presents the exemplary types of dysarthria with its characteristic respiration, phonation, and prosody disorders. The author examined the voice capabilities of three patients, aged 52, 74 and 81, respectively, described them, and composed short session programmes in voice therapy (comprised of three meetings) adapted to their individual needs. The author carried out the part of the therapy and then listed tendencies resurfacing during the exercises performed by the patients. Finally, the expected effects of further exercises (following previously applied methods) were presented. Key words: dysarthria, respiration, phonation, voice modulation, neurologopaedic diagnosis and therapy
Introduction
The human voice is commonly recognized as one of the most perfect wind instruments, generated by the nature. Its three main features – volume, timbre and frequency are unique for every man. It reflects the spectrum of emotions which accompanies our everyday communication. This element of human physi- ology is so obvious, that its sudden change, loss or defect seems unimaginable. However in the process of multiple diseases, its irreversible and even progressive disorders may occur. One of the unquestionable reasons for this process is the occurrence of dysarthria, that is, “the inability to express clearly, a syndrome of bulbous-phonation-articulatory disorders caused by damage to centers and paths that innervate the speech apparatus, occurring despite the correct speech plan” (Gatkowska, 2012, p. 19). Phonetic structure and speech expression of a person with dysarthria are dis- torted, but lexis and grammar are unimpaired. Grazyna Jastrzębowska (2003) rightly remarks that the term ‚dysarthria’ is often used to describe articulation disorders, but she points out that these are
„Logopedia Silesiana”, t. 8, ISSN 2391 - 4297 DOI 10.31261/LOGOPEDIASILESIANA.2019.08.
B. Szewczyk: Diagnosis and Therapy of Respiratory… 401
also disorders of phonation, such as generating of sounds within the larynx and resonance disorders. Urszula Mirecka also draws attention to the problem of mar- ginal regard for respiratory and phonatory dysfunctions (2008, p. 235).
Respiratory and phonatory disorders in particular types of dysarthria
Before analyzing specific voice disorders that may occur in particular types of dysarthria, it is worth recalling the definition of the voice and determining characteristic features of the correct voice (euphonic) and when it is incorrect (dysphonic). Agata Szkiełkowska (2012) defines these terms in the following way: “the healthy voice is resonant and clear, it stays so after the effort, it has no noise components, it is opulent in resonance and created with a soft setting, has a fre- quency appropriate to gender and age, and intensity appropriate to the situation; during the speech, volume and frequency changes smoothly, according to the content of the speech, the articulation is correct and clear”. In dysphonia, on the other hand, “the way the voice is emitted, the nature of the voice, range, average position of the voice and the length of phonation time are changing. Dysphonia is a disorder of the voice organ function as a result of a pathological change within the voice organ (organic dysphonia) or the effect of a disorder of complicated mechanisms in the process of voice emission (functional dysphonia). Dysphonia type voice disorders are always caused by a insufficiency of the voice organ and are very often accompanied by hoarseness” (Szkiełkowska, 2012, p. 186). Frederic L. Darley’s symptomatic classification was used to describe phona- tory and respiratory disorders in different types of dysarthria. In 1975 Darley and co-authors distinguished the following types of this disorder: flaccid dysarthria, spastic dysarthria, atactic dysarthria, hyperkinetic dysarthria, hypokinetic dys- arthria and mixed dysarthria (Mirecka, 2012). Spastic dysarthria is characterized by excessive tension of the vocal folds, which results in difficulties in starting the voice emission. When the tension of the vocal folds increases, uncontrolled changes in the pitch and volume of the voice and disturbances in its modulation may occur. More often, however, the height and volume of the voice are pathologically unchanged, which is the result of prolonged persistence of increased tone of the vocal folds. Increased tension also applies to the soft palate, as a result of which the voice is characterized by nasal staining (Jauer-Niworowska & Kwasiborska, 2015, p. 39, 40). There are breaks in the pitch, the voice is hoarse, low, weak and tense-choked. Breathing difficulties are mainly manifested by shortened phrases and a breath audible in the course of speech (Mirecka, 2012, p. 535).
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Mixed dysarthria can be a combination of the symptoms of two or more types of dysarthria. In clinical practice there are combinations of almost all types. Studies from 1995 show that the most common combinations are flaccid spastic (42%), atactic-spastic (23%), hypokinetic-spastic (7%), atactic-flaccid-spastic (6%) and hyperkinetic-hypokinetic (3%) (Mirecka, 2012, p. 537). To sum up, each type of dysarthria from the classification cited above can be assigned to specific voice disorders. Moreover, they are compatible with general movement disorders that occur with diseases inextricably connected with dysar - thria. The muscles of the voice organ and speech apparatus behave like all other muscles of the body, attacked by a neurological disease.
Goal, material and method
The purpose of this article is to present examples of respiratory-phonation disorders accompanying dysarthria and to answer the question: is voice therapy in the case of dysarthria effective and to what extent? Such studies may encour- age therapists conducting rehabilitation of patients with dysarthria to look more closely at their respiratory and phonative abilities, especially since the article pro- vides a collection of exercises for practical use. The study group included three patients diagnosed with dysarthria with a dif- ferent etiological background, accompanied by respiratory and phonation disor- ders. The research method chosen by the author is the study of individual cases. Following research tools were used for diagnosis of the patients:
- GRBAS scale – the scale most often used by phoniatrists and voice therapists for perceptual (listening) assessment. This scale describes voice disturbance using the following five parameters: G – grade of hoarseness; R – roughness
- due to the irregularity of the vibrations of the vocal folds; B – breathiness – a puffing voice, which is the result of air escaping during phonation by a open epiglottis; A – asthenic; S – strained. These parameters are evaluated according to the following four levels of disorder intensity (according to all parameters): 0 – normal voice; 1 – slight severity; 2 – moderate severity; 3 – severe disor- der. The GRBAS scale is a subjective, auditory rated method of voice testing, taking into account its most important features. It was invented in 1981 by the Japanese doctor Minoru Hirano (Śliwińska-Kowalska & Niebudek-Bogusz, 2009, p. 13).
- Measurement of phonation time – determining the maximum time in which the patient says the vowel [a] during full exhale. The final measurement is the average of three measurements taken (Śliwińska-Kowalska & Niebudek- Bogusz, 2009, p. 13).
404 Part Two: Studies Based on Speech Therapy Activities
- Czermak’s test – a test used to recognize the hypernasality. It involves pro- nouncing vowels or syllables made of explosive consonants and vowels, e.g. “pa-pa”, “ta-ta”, “ba-ba” while unheated mirror is set in front of the patient’s front nostrils. When the water vapor found in the exhaled air coming out of the nose condenses on the mirror, thereby misting its surface, hypernasality is diagnosed (Pruszewicz, 1992, p. 250). The rest of the research is inspired by the publication “Dyzartria Nabyta. Diagnoza logopedyczna i terapia osób dorosłych” by Olga Jauer-Niworowska, who proposed many practical tests of qualitative voice testing in the chapter “Clinical study of respiratory-phonatory possibilities”. The study was conducted in the Neurological Rehabilitation Ward in the Hospital Św. Wincentego a Paulo in Gdynia and the Hospital Outpatient Clinic of the University Clinical Hospital Norberta Barlickiego in Łodzi. All information obtained through observation was immediately recorded and then analyzed.
Characteristics of the subjects
Ryszard, aged 74
The patient was hospitalized for two months in a hospital in Gdynia. He came to the neurological department with a stroke of the subordinate hemi- sphere of the brain. He had problems with the motility of articulatory, phona- tive and respiratory organs, which gave a typical view of dysarthria. The patient did not complain of shortness of breath while speaking, but he felt tension in the larynx. He had difficulty breathing freely through his nose, and breathing in deeply and freely. His breathing was unequal and wheezing. He often drew in air when speaking. The voice was hoarse, rough, asthenic, with shortened expiratory phase (18 s) and phonation phase (12 s). The tone of the voice was changed in relation to the physiological voice, its frequency was unnaturally low and the intensity slightly reduced. The patient did not consciously control the decrease and increase of vol- ume of his voice both in the continuous phonation of the vowel [a] and the imple- mentation of the same vowel staccato. Subglottic pressure was normal, allowing free conversation. Czermak’s test, was positive, because the mirror set in front of the subject’s nose when pronouncing syllables, was fogged up. The test using the GRBAS scale showed: ■ grade of hoarseness: 3; ■ roughness: 3;
406 Part Two: Studies Based on Speech Therapy Activities
was normal. Czermak’s test confirmed the nasal voice in a variable form, which was caused by discoordination of the soft palate muscles. The test using the GRBAS scale showed: ■ grade of hoarseness: 1; ■ roughness: 3; ■ breathiness: 2; ■ asthenic: 2; ■ strained: 2.
Course of therapy
Individual therapy programs for patients are presented below. They include the purpose of the exercises, the duration of therapeutic sessions, recommended forms and methods of work, speech therapy aids and examples of exercises. Three meetings with the therapist are planned for each of the subjects. Of course, this is an insufficient amount of time that should be spent with a person with dys- arthria, because the rehabilitation of neurological diseases accompanied by dys- arthria is usually a permanent condition that is part of the injured person’s life. The presentation of sample therapy programs is only intended to inspire to fur- ther rehabilitation activities thanks to the various exercises and tips they contain. Duration of a single therapeutic session: 20 minutes A form of therapy: individual Work methods: explaining and presenting the proposed exercises and grading the difficulty of the exercises.
Ryszard, aged 74
First therapysession
Aims of therapy: deepening inspiration, extending the exhalation and phona- tion phases.
Speech therapy aids: photocopy of a fragment of the poem.
Sample exercises:
- The patient is lying on his back. He puts one hand on the upper chest, the other between the rib arches. First, he breathes in through his nose several times and breathes out freely with his mouth. He controls the air in his chest by his
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hands. Then he breathes quickly through his mouth and nose simultaneously, trying to bring air to the lowest parts of thoracic cage. The hand lying between the rib arches should rise visibly, while the hand lying in the upper part of the chest should rise much less. Then the patient flexes the abdominal muscles, trying to hold the lungs for a moment, then he exhales very slowly through the slightly parted lips (Śliwińska-Kowalska & Niebudek-Bogusz, 2009, p. 41).
- The patient pronounces the numbers in one exhalation at a moderate rate, gradually increasing the exhalation phase. First, he counts from 1 to 10, then from 1 to 15, from 1 to 20, etc., to get an increasing number.
Recommendations for self-work: the patient gets a four-piece fragment of the epic poem “Pan Tadeusz” by Adam Mickiewicz:
Śród takich pól przed laty, nad brzegiem ruczaju, Na pagórku niewielkim, we brzozowym gaju, Stał dwór szlachecki, z drzewa, lecz podmurowany; Świeciły się z daleka pobielane ściany […]
He begins the exercise by reading one verse on one exhalation. Then he extends the reading into two verses. Finally, he attempts to read all four verses on one exhaust. He reads at a moderate pace, with monotonous intonation.
Second therapysession
Aims of therapy: increasing the diameter of the voice and working on control of the height of the voice.
Speech therapy aids: photocopy of a fragment of the poem, a list of words with a vowel [i] with its syllabic function, ukulele or other small stringed instrument.
Sample exercises:
- Exercise using phonetic features of sounds. The patient repeats the words with the voice [i], prolonging it. Examples of words: „nici”, „zima”, „lis”, „kino”, „piła”, „kiwi”, etc.
- Exercise with the instrument. We ask the patient to do glissando between two tones - the first one should be similar to the current voice capabilities of the patient, and the second one that we want to achieve. We present two sounds on an instrument that also has the option of performing glissando, e.g. on an ukulele. The patient emits a phone [m], then oral vowels: [a], [e], [i], [o], [u], [y].
- The patient reads a poem he received at a previous therapeutic session, extend- ing the vowels. At first, he emits a tone that is comfortable for him, then he tries to speak in a higher voice (e.g. about half a tone, up to a maximum of
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At the initial stage, the exercise helps her realize her own breathing rhythm and inspiration depth. The patient is in a lying position with her knees bent. She gradually increases the depth of inspiration, taking in more and more air (Jauer-Niworowska, 2009, p. 70).
- The patient performs breathing exercises combined with the movements of the arms and legs. When breathing in, she slowly lifts her hands up, and when breathing out, lowers her hands. Then: inhale – hands up sideways, legs straight in the knees, exhale – lower hands, bends her knees to the stomach (Jauer-Niworowska, 2009, p. 70).
- The patient blows on a handkerchief attached to the wall so that it stays on its surface for as long as possible.
- The patient utters the sounds [f] and [w] for as long as possible on one exha- lation.
- The patient counts on one exhalation as long as possible: “jedna wrona bez ogona, druga wrona bez ogona, trzecia wrona bez ogona, czwarta wrona bez ogona, piąta wrona bez ogona…” During the exercise, the patient makes sure that the last word is spoken in the same loud way as the first (Walencik- Topiłko, 2009, p. 43).
Recommendations for self-work: the patient’s task is to read the sentence: “Ależ alabastrowa Ala alarmuje altem alpejskiego albatrosa” on one exhaust. Gradually, she duplicates this sentence by saying it twice, three times, etc. (Wosik-Kawala, 2015, p. 71).
Second therapysession
Aims of therapy: increase of exhalation force and increase of phonation time.
Speech therapy aids: water, cup, straw, stopwatch.
Sample exercises:
- The patient blows through a straw (about 10 mm in diameter) placed on the tongue, immersed in water, so that air bubbles form on the water surface. If necessary, initially compress the wings of the nose so that most of the air does not leak out of the nose.
- The patient blows on her hand dipped in water in such a way as to feel a gust of air on it. When she sees improvement, she blows with more and more force (Jauer-Niworowska, 2009, p. 71).
- The patient emits vowels as long as possible on one exhalation: [a], [e], [i], [o], [u], [y].
- The patient emits all oral vowels on one exhalation, looping them: „a-e-i-o-u- y-a-e-i-o-u-y-a-e…”.
410 Part Two: Studies Based on Speech Therapy Activities
Recommendations for self-work: the patient pronounces the vowel [a] on one exhalation, measuring the time with a stopwatch or a clock hand indicating the seconds. She saves the results and presents them at the next therapy session.
Third therapysession
Aims of therapy: increase of the volume and elimination of nasality.
Speech therapy aids: no aids.
Sample exercises:
- The patient performs mormorando on the phone [m]. Then she starts the voice emission quietly, almost in a whisper, and gradually increases the volume, end- ing with a loud, voiced [m].
- The patient repeatedly articulates the “bu!” syllable in a loud way, as if he would scare someone. One of her hands controls the diaphragm during articulation and the other hand the amount of exhaled air (we strive to minimize it).
- Exercise using plosive velar consonants: [k] ang [g]. The patient repeats the pseudoword: akka, ekke, okko, ukku, ykky, agga, egge, oggo, uggu, yggy.
- The patient emits oral vowels, trying to control the tone of her voice by control- ling the organ of hearing. Then she repeats the exercise with her nose closed. She tries to make the difference between the first and second way of vowel emission almost imperceptible.
Recommendations for self-work: the patient repeat the syllables, extending the vowels: ra, re, ri, ro, ru, ry, in a lying position, with legs slightly raised so that she feels abdominal muscles working.
Konrad, aged 52
First therapysession
Aims of therapy: obtaining a uniform force of exhalation.
Speech therapy aids: paper, candle, lighter, hygienic tissue.
Sample exercises:
- The patient holds a sheet of paper about 30 cm from the face. He blows on its lower end so that it bends 30–40 degrees from the vertical axis. He tries to maintain this bend angle with the force of the exhalation throughout duration of the exercise (Walencik-Topiłko, 2009, p. 44).
412 Part Two: Studies Based on Speech Therapy Activities
Third therapysession
Aims of therapy: pitch control and voice modulation.
Speech therapy aids: fragment of the seventh chapter of the novel “Master and Margarita” by Michaił Bułhakow.
Sample exercises:
- The patient pronounces the vowels in turn for as long as possible and without changing the pitch: [a], [e], [i], [o], [u], [y] (Wosik-Kawala, 2015, p. 86).
- The patient pronounces all oral vowels in one string as if they were one word: “aeiouy”, while extending each of them and trying not to allow the pitch to change.
- The patient listens to a fragment of the text and determines when there is descending and ascending intonation.
- The patient pronounces the combination of the vowel “au” with different intona- tion (as a question, claim, surprise, anger, delight) (Walencik-Topiłko, 2009, p. 50).
- The patient tries to express: surprise, contentment, anger, disgust, indignation, denial, irritability, mockery, doubt and sarcasm, using vowels [a], [e], [i], [o], [u], [y] (Wosik-Kawala, 2015, p. 86).
Recommendations for self-work: the patient tries to name two emotions whose names were not mentioned in exercise 5. He considers how they could be repre- sented by the same vowels and prepares to present them during the next thera- peutic session. He does not tell the therapist what these emotions are before the presentation – they must be expressive enough for the speech therapist to guess them himself.
Effects of therapy
It is not easy to talk about long-term and effective effects of voice therapy with the limit of meetings with patients for research purposes set by the institutions. On their basis, we can limit ourselves to the description of the expected course of therapy. To create such a forecast, several important factors should be taken into account, such as: patient’s involvement in performed exercises, precision of performed exercises, level of auditory control of performed exercises, number and quality of achieved goals set for the needs of each therapeutic session, awareness of problems with the voice apparatus, willingness to follow the therapist’s recom- mendations or to treat homework seriously.
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In the case of Ryszard, we could afford to set a minimum of two goals for each therapeutic session. All instructions to the patient after the presentation of the exercises became understandable. The patient participated in therapy actively, asked questions and performed exercises recommended for self-work. He compared the course of performed exercises with the model presented by the therapist and corrected his mistakes by experiments. A large part of the first therapeutic session was devoted to the first exercise, which implemented the patient in the course of therapy, and also had a relaxing effect. Four days break between the first and the next meeting made him possible to achieve the goal of reading a four-verses poem on one exhaust. This resulted in the introduction of new goals in the second therapeutic session. The use of the instrument turned out to be a great element diversifying the therapy, because the patient retained the basic knowledge of music he had acquired from a music school. Measurable effects were also brought by the use of phonetic fea- tures of the vowel [i], classified as a closed, front, unrounded vowel. Due to its acoustic characteristics (the highest frequency among Polish oral vowels), it was conducive to increasing the diameter of the voice. A little more time was needed to teach the patient to gradually increase and decrease the frequency of voice, necessary for the proper performance of Exercise 2 at the second therapeutic meeting, because he initially only emitted extreme sounds. Such a sudden change may not be conducive to the work of vocal folds. To illustrate glissando, an auxiliary, smooth movement of the hand was added. The third exercise did not cause any problems. The therapist proposed the appropri- ate key with which he uttered the poem, then recited it together with the patient, and finally the patient performed the task himself. The first exercise at the third meeting brought positive results due to the addi- tional work of the visual analyzer. The patient, seeing the handkerchief leaning at the right angle, saw the result of his work, so it was easier for him to control his breathing. However, he had trouble shorting the soft palate to the back of the tongue, which was observed during the second exercise. In the third exercise, the patient noticed the difference between nasality and it’s absence, demonstrated by a speech therapist, while he had trouble seeing this difference in himself. In conclusion, the prognosis for this patient seems to be good, provided that the patient is just as willing to perform exercises as before and if his health does not deteriorate.
Marianna was a patient who had been undergoing therapy for a long time (about two years). Working with such a patient was easier because she had already mastered the approximate scheme of therapy, knew the goals of her exercises, and appeared in the clinic alone and of her own free will. The first two exercises, performed in a lying position, were relaxing. A hand- kerchief was used to exhale strengthening exercise because it is light and it is not
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of control so that the exhalation was even and gentle enough not to put out the fire. With this type of dysarthria it was a real challenge. The second meeting focused on tone volume control. The patient had already developed the skill of gentle gradation of the tone volume, but during the session he had to be reminded about it, so that he would focus his attention – only then the exercises were carried out with the intended effect. The patienthad the least trouble for the fourth exercise, probably due to the fact that it did not require gra- dation of volume, but adjustment of volume and intonation to a specific, imposed manner of expression (whisper, low voice, full voice, shouting). The third meeting began with checking homework. The patient admitted that he did not find time for independent exercise at home, but when asked to do it, he managed the task. Then, shaping of pitch control and voice modulation was undertaken. The first two exercises showed that any momentary deviations from the determined tone are insignificant. The third (auditory) exercise did not cause the patient any problem – he evaluated all sentences correctly in terms of intonation. It was anintroduction to voice modulation therapy. Voice exercises in this area caused the patient some trouble, because on the one hand they were subjective (due to individualized ways of expressing emotions by people), and on the other hand the expressed emotion had to be evident enough for the therapist to decode it in an adequate way. This goal was not fully achieved (although the clue was correct), so the patient was given homework related to the topic along with instructions. The prognosis for Konrad’s voice therapy is good primarily because he is a rela- tively young man, professionally active and regularly attending therapy. However, he should find more time for self exercises at home recommended by the therapist.
Summary
Voice testing on three patients with dysarthria showed some differences and similarities between them. All had nasality, voice modulation disorders, and shortened exhalation and phonation phases. Parameterssuch as intensity or fre- quency varied depending on the etiology of the disorder, i.e. elevated, decreased or variable. Forsome patients with dysarthria unwanted acoustic phenomena in the breath and phonationmay be recognized, such as wheezing or hoarseness, while for others subjective complaints related to the breathing apparatus, such as feeling larynx pressure or shortness of breath when speaking occur. During observation of patients’ work, the patient’s age, mobility and stage of therapy they turned out to be important factors affecting the effects of voice reha- bilitation. The most noticeable effects among the three patients were achieved by
416 Part Two: Studies Based on Speech Therapy Activities
the youngest, although he did not always find time for exercises recommended for independent work at home. The prognosis of further effects of therapy is quite a subjective matter – it can be derived from what we have learned about the patient so far. One day the patient may meet the therapist in a depressed mood, with an infection or with worsening of symptoms. Therapist should not modify hisprediction under the influence of such moments, but only when such a condi- tion begins to persist permanently. The patient’s health safety principles should be employed – include proper dia- phragm operation in therapy not to strain the voice organ, explain the principles of lowering the mandible with vowels, not to damage the temporomandibular joint, and to prevent dizziness or hyperventilation during breathing exercises. It is worth making the patient aware of the huge role of recommendations for self workin the therapy. The maintask of the therapist is to monitor progress and give instructions, and the patient’s goal – to use directions and take exercises every day, several minutes to several dozen minutes a day.
Bibliography
Gatkowska, I. (2012). Diagnoza dyzartrii u dorosłych w neurologii klinicznej. Kraków: Wydaw. Uniwersytetu Jagiellońskiego. Jastrzębowska, G. (2003). Dysartria, anartria. In: T. Gałkowski, & G. Jastrzębowska (Eds.), Logopedia. Pytania i odpowiedzi. Vol. 2 (pp. 772–783). Opole: Wydaw. Uniwersytetu Opolskiego. Jauer-Niworowska, O. (2009). Dyzartria nabyta. Diagnoza logopedyczna i terapia osób dorosłych. Warszawa: Wydaw. Akademii Pedagogiki Specjalnej. Jauer-Niworowska, O., & Kwasiborska, J. (2015). Wskazówki do diagnozy różnicowej poszczegól- nych typów dyzartrii. Gliwice: Wydaw. Komlogo Piotr Gruba. Mirecka, U. (2008). Standard postępowania logopedycznego w przypadku dyzartrii. Logopedia, 37, 235–242. Mirecka, U. (2012). Dyzartria w aspekcie diagnostycznym – typologia zjawisk. In: S. Grabias, & M. Krukowski (Eds.), Logopedia. Teoria zaburzeń mowy (pp. 527–545). Lublin: Wydaw. Uni- wersytetu Marii Curie-Skłodowskiej. Pruszewicz, A. (1992). Foniatria Kliniczna. Warszawa: Wydaw. Lekarskie PZWL. Szkiełkowska, A. (2012). Klasyfikacja zaburzeń głosu. In: S. Grabias, & M. Kurkowski (Eds.), Logopedia. Teoria zaburzeń mowy (pp. 185–193). Lublin: Wydaw. Uniwersytetu Marii Curie- -Skłodowskiej. Śliwińska-Kowalska, M., & Niebudek-Bogusz, E. (2009). Rehabilitacja zawodowych zaburzeń głosu. Poradnik dla nauczycieli. Łódź: Wydaw. Instytutu Medycyny Pracy im. prof. J. Nofera. Walencik-Topiłko, A. (2009). Głos jako narzędzie. Materiały do ćwiczeń emisji głosu dla osób pra- cujących głosem i nad głosem. Gdańsk: Wydaw. Harmonia. Wosik-Kawala, D. (2015). Podstawy emisji głosu. Lublin: Wydaw. Uniwersytetu Marii Curie-Skło- dowskiej.
418 Część druga: Studia z praktyki logopedycznej
Mowa w dyzartrii jest zniekształcona pod względem fonetycznym i ekspre- syjnym, pozostaje natomiast nienaruszona pod względem leksykalnym, grama- tycznym i syntaktycznym. Grażyna Jastrzębowska (2003) słusznie zauważa, że terminem „dyzartria” często określa się zaburzenia artykulacji, ale zaznacza, iż są to także zaburzenia fonacji, czyli generowania dźwięków w obrębie krtani oraz zaburzeń rezonacji – zmian brzmienia dźwięków zachodzących w nasadzie. Na niesłusznie margine- sowe traktowanie dysfunkcji oddechowych i fonacyjnych zwraca uwagę również Urszula Mirecka (2008, s. 235).
Zaburzenia funkcji oddechowych i fonacyjnych w poszczególnych rodzajach dyzartrii
Przed przystąpieniem do analizy konkretnych zaburzeń głosu, jakie mogą wystąpić w poszczególnych rodzajach dyzartrii, warto przypomnieć definicję głosu, określić czym się on charakteryzuje, gdy jest prawidłowy (eufoniczny) oraz gdy jest nieprawidłowy (dysfoniczny). Agata Szkiełkowska (2012) definiuje te pojęcia w następujący sposób: „ Głos prawidłowy jest dźwięczny i czysty, pozo- staje taki również po wysiłku, nie zawiera komponentów szumowych, jest bogaty rezonansowo i tworzony z nastawieniem miękkim, ma wysokość odpowiednią do płci i wieku oraz natężenie odpowiednie do sytuacji; w czasie wypowiedzi zmiany natężenia i wysokości tego głosu występują płynnie, stosownie do treści wypo- wiedzi, artykulacja jest prawidłowa, wyrazista”. W dysfonii natomiast „zmianie ulegają sposób emisji, charakter głosu, zakres, średnie położenie głosu oraz czas fonacji. Dysfonia jest zaburzeniem czynności narządu głosu, jako skutek istnieją- cej w obrębie narządu głosu zmiany patologicznej (dysfonia organiczna) lub efekt zaburzeń czynności skomplikowanych mechanizmów w procesie tworzenia (dys- fonia czynnościowa). Zaburzenia głosu o typie dysfonii zawsze spowodowane są niesprawnością narządu głosu i bardzo często towarzyszy im chrypka” (Szkieł- kowska, 2012, s. 186). W celu opisania zaburzeń fonacji i oddychania w poszczególnych typach dyz- artrii posłużono się klasyfikacją objawową Frederica L. Darleya i współautorów z 1975 roku, która wyróżnia następujące typy tego zaburzenia: dyzartria wiotka, dyzartria spastyczna, dyzartria ataktyczna, dyzartria hiperkinetyczna, dyzartria hipokinetyczna i dyzartria mieszana (Mirecka, 2012). Dyzartria spastyczna charakteryzuje się nadmiernym napięciem fałdów gło - sowych, czego efektem są trudności w rozpoczęciu emisji głosu. Gdy napięcie fałdów głosowych wzrasta, mogą pojawić się niekontrolowane zmiany wysokości i natężenia głosu oraz zakłócenia w jego modulacji. Częściej jednak wysokość
B. Szewczyk: Diagnoza i terapia zaburzeń oddechowo-fonacyjnych w dyzartrii… 419
i natężenie głosu są patologicznie niezmienne, co jest efektem długotrwałego utrzymywania się wzmożonego napięcia fałdów głosowych. Wzmożone napię- cie dotyczy również podniebienia miękkiego, wskutek czego głos charakteryzuje się nosowym zabarwieniem (Jauer-Niworowska & Kwasiborska, 2015, s. 39, 40). Pojawiają się załamania wysokości głosu, głos jest chrapliwy, niski, słaby i napię- to-zdławiony. Trudności oddechowe objawiają się głównie skróceniem fraz oraz słyszalnym w toku mowy przydechem (Mirecka, 2012, s. 535). W dyzartrii wiotkiej zaburzenia rozpoczęcia emisji głosu są spowodowane trudnościami w uzyskaniu zwarcia fałdów głosowych z uwagi na patologicznie obniżone napięcie mięśni aparatu fonacyjnego. Ta sama przyczyna powoduje patologiczną monotonię natężenia i wysokości głosu. Nosowe zabarwienie rów- nież jest tu obserwowane, ale w odróżnieniu od dyzartrii spastycznej, powoduje go obniżenie mięśni podniebienia miękkiego (Jauer-Niworowska & Kwasiborska, 2015, s. 39, 40). Głos jest szorstki, monotonny, o obniżonym natężeniu i osłabio- nej dźwięczności. Niekiedy obserwuje się zjawisko diplofonii. Te trudności fona- cyjne wynikają z porażenia mięśni zaopatrywanych przez X nerw czaszkowy. Zaburzenia oddechu manifestują się jego spłyceniem, osłabieniem kontroli fazy wydechowej i skróconym czasem wydechu. Podczas mówienia występuje męcz- liwość oddechowa, wdech jest głośny (Mirecka, 2012). Dyzartria ataktyczna , w której zaburzenia głosu są kompatybilne z obja- wami uszkodzenia móżdżku, charakteryzuje się dyskoordynacją pracy fałdów głosowych, przez co rozpoczęcie emisji głosu również jest utrudnione. Drżenia zamiarowe i zaburzenia koordynacji fałdów głosowych powodują niekontrolo- wane zmiany wysokości i natężenia głosu, a jego nosowe zabarwienie, obecne również w tym typie dyzartrii, wynika z zaburzeń koordynacji mięśni pod- niebienia miękkiego. Wysokość głosu jest patologicznie niezmienna w wyniku skandowania, a natężenie – w wyniku obniżonego napięcia fałdów głosowych (Jauer-Niworowska & Kwasiborska, 2015, s. 39, 40). Barwa głosu określana jest jako chrapliwa (Mirecka, 2012). W dyzartrii hiperkinetycznej występują takie trudności fonacyjne jak: krót - kie, rytmiczne przerwy w fonacji, nieoczekiwane zamilknięcia, chrapliwy, drżący, napięto-zdławiony głos, nadmierna głośność. Zaburzenia oddechowe występu- ją pod postacią nagłych, mimowolnych wdechów i wydechów, przyspieszonego oddychania, skrócenia frazy oraz mówienia na wdechu (Mirecka, 2012, s. 536). Emisja głosu w dyzartrii hiperkinetycznej pląsawiczej nie zawsze rozpoczyna się z wysiłkiem; zależy to od aktualnego napięcia fałdów głosowych, które charakte- ryzuje się zmiennością. Na skutek mimowolnych ruchów fałd głosowych wystę- pują zaburzenia modulacji głosu w zakresie jego wysokości i natężenia. Ruchy mimowolne mięśni podniebienia miękkiego mogą przyczyniać się do występo- wania nosowania. Dyzartria hiperkinetyczna występuje również w postaci dys- tonicznej i cechuje się emisją rozpoczynaną z wysiłkiem, w skrajnych postaciach afonią, pojawiającą się w czasie dystonicznych skurczów fałdów głosowych –
