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1、Dysarthria in stroke: A narrative review of its description and the outcome of interventionCatherine MackenzieUniversity of Strathclyde, Glasgow, UK Correspondence: Professor Catherine Mackenzie, School of Psychological Sciences and Health, University of Strathclyde, Southbrae Drive, Glasgow G13 1PP
2、, UK. c.mackenziestrath.ac.ukKey words: dysarthria; stroke; managementRunning head: dysarthria in strokeAbstractDysarthria is a frequent and persisting sequel to stroke and arises from varied lesion locations. Although the presence of dysarthria is well documented, for stroke there are scant data on
3、 presentation and intervention outcome. A literature search was undertaken to evaluate a) the features of dysarthria in adult stroke populations relative to the conventional Mayo system for classification, which was developed from diverse pathological groups, and b) the current status of evidence fo
4、r the effectiveness of intervention in dysarthria caused by stroke. A narrative review of results is presented.The limited data available indicate that regardless of stroke location, imprecise articulation and slow speaking rate are consistent features, and voice disturbances, especially harshness,
5、and reduced prosodic variation are also common. Dysarthria is more prevalent in left than in right hemisphere lesions. There is a need for comprehensive, thorough analysis of dysarthria features, involving larger populations, with stroke and other variables controlled and with appropriate age-refere
6、nced control data. There is low level evidence for benefits arising from intervention in stroke related dysarthria. Because studies involve few participants, without external control, and sometimes include stroke with other aetiologies, their results lack the required weight for confident evidence-b
7、ased practice. IntroductionDysarthria is a neuro-motor disorder which results from abnormalities in speed, strength, steadiness, range, tone, or accuracy of movements required for the control of speech (Duffy, 2005). The speech impairments of dysarthria relate to articulation, phonation, respiration
8、, nasality and prosody, and affect intelligibility, audibility, naturalness, and efficiency of spoken communication. Severity ranges from absence of speech (anarthria) or complete unintelligibility to mild changes which may be evident only to the speaker or by detailed speech evaluation. In contempo
9、rary usage dysarthria does not encompass speech disorders which are caused by structural abnormalities, such as cleft palate or glossectomy. It is also distinguished from apraxia of speech, which though of neurological origin, is conceptualised as a disorder of speech motor planning or programming (
10、Duffy, 2005). Dysarthria is reported to be the most frequently acquired speech and language disorder (Enderby & Emerson, 1995). The significance of stroke as a cause of dysarthria is evident by 22% of a 1276 speech-language pathology (SLP) dysarthria case audit series having stroke aetiology (Duffy,
11、 2005). While there has been a fair volume of research into dysarthria in progressive disease and its treatment, notably Parkinsons disease, dysarthria in stroke tends not to receive specific attention in published texts and reports, despite its frequency. In the SLP literature, dysarthria is normal
12、ly described with reference to a set of diagnostic categories (the Mayo system, Darley, Aronson & Brown, 1975), within which stroke is combined with other aetiologies. Also there has been little controlled evaluation of any intervention approach in the dysarthric stroke population. No randomised con
13、trolled trials have been identified for stroke or other non-progressive dysarthria (Sellars, Hughes & Langhorne, 2005). As with diagnostic descriptions, in treatment studies stroke has often been included with other aetiological groups, such as traumatic brain injury and progressive disorders, and e
14、ven participants with communication disorders other than dysarthria. Speech-language pathologists (SLPs) who work with adults will often encounter dysarthria in the context of stroke. A synthesis of the literature on the presentation of dysarthria in adult stroke and the current evidence base for in
15、tervention is thus relevant. In view of the lack of focus on stroke dysarthia in the SLP literature, some background context is first provided, regarding the prevalence of dysarthria in stroke, variables affecting diagnosis and description, and the course of dysarthria in stroke. The prevalence of d
16、ysarthria in stroke populationsDysarthria results from varied stroke lesion locations and its presence may have no localizing value (Kumral & Bayulkem, 2003; Melo, Bogousslavsky, van Melle & Regli, 1992). In prospective studies of large first stroke series, lesions were supratentorial in over 60% of
17、 cases (Kumral, Celebisoy, Celebisoy, Canbaz & Calli, 2007; Urban et al., 2006). Infratentorial lesions producing dysarthria were largely pontine and cerebellar. Rarely, and usually associated with lacunar stroke, dysarthria may be an isolated sign (Urban et al., 2006) or present within the dysarthr
18、ia-clumsy hand syndrome (Arboix et al., 2004). However for the majority of patients, dysarthria occurs in the context of other impairments, and resultant limitations in activity and participation, relating to physical, sensory, psychological and cognitive domains. Dysphagia commonly co-exists with d
19、ysarthria, especially where severe (Ropper, 1987). Natural aging or concomitant diseases, including dementia, may further compromise the speech status of the dysarthric stroke population.Dysarthria in acute first stroke populations is reported as: 53% (Mann, Hankey, & Cameron, 1999) and 41.5% (Lawre
20、nce et al., 2001) for general series; 49% for brain stem lesions (Teasell, Foley, Doherty & Finestone, 2002); 48% in middle cerebral artery occlusive disease (Yoo, Shin, Chang & Caplan, 1998); 30% for internal capsule lesions (Fries, Danek, Scheidtmann & Hamburger, 1993); 29% for an isolated hemipar
21、esis group (Melo et al., 1992) and 25% for lacunar infarcts (Arboix, Marti-Vilalta & Garcia, 1990). Examining stroke subsets, Lawrence et al. (2001) found prevalence ranging from 85% in total anterior circulation infarcts to 5% in subarachnoid haemorrhage. Variables affecting dysarthria diagnosis an
22、d descriptionMany research design factors may influence the diagnosis and description of dysarthria, relating to participant sample and the nature of assessment. Relevant participant variables include time since stroke, lesion site and extent, exclusion criteria, such as previous stroke, recruitment
23、 method, and in smaller series, the extent to which cases are representative of the population. Given the older age group in which stroke most often occurs, suitable comparative speech data from healthy populations should be used in dysarthria diagnosis and description. Amerman and Parnell (1990) re
24、ported resemblance between the speech of non-brain-damaged elderly people and those with dysarthria in an auditory-perceptual speech rating task, with resultant misclassification of normal elderly speakers. Similarly Wang, Kent, Kent, Duffy and Thomas (2009), using instrumental examination, found vo
25、ice characteristics in a dysarthric stroke series to be similar to those of healthy ageing speakers.Assessment variables which may affect dysarthria statistics and descriptions include the nature, sensitivity and comprehensiveness of evaluation, and instrument psychometrics, such as reliability and
26、validity. Also important is the experience and acumen of the person who makes the dysarthria diagnosis, in particular whether this is an SLP. Where the full range of dysarthria speech features are not evaluated, description may be incomplete and milder cases may be excluded. Conflicting results may
27、be partly attributable to poor definition of parameters (Urban et al., 2006). Patient and carer evaluations of speech status have been included informally in some investigations of speech features of dysarthria in stroke (Urban et al., 2006). While such reports may not be unbiased and the extent of
28、self awareness will vary, a unique perspective on change, speech difficulties and their effects is available from the individual and people familiar with his/her speech before stroke.The course of dysarthria in strokeDysarthria has been shown to have some negative effect on level of outcome after st
29、roke (Tilling et al., 2001), but methodical, longitudinal investigation of its natural course has not been undertaken. Urban, Wicht, Hopf, Fleischer and Nickel (1999) recorded dysarthria as clearing within two weeks to six months in all of a group of seven patients who presented with isolated mild-m
30、oderate dysarthia subsequent to unilateral lacunar infarct. Ropper (1987) noted that dysarthria, which was initially severe, improved slowly over one to three weeks, in seven of ten patients with right hemisphere stroke, even if other aspects of stroke showed no change. Urban et al. (2006) provide s
31、ome follow up data on 38 patients with dysarthria following unilateral lesions, a minimum of six months from initial speech examination. Most speech characteristics were significantly improved. 61% were diagnosed as still having mild dysarthria. Interpretation of these data is however confounded by
32、all patients having received SLP in the first two to four weeks after stroke. Despite such documented improvements, it is evident from the long time after stroke at which assessment has been conducted in some descriptive studies that even unilateral lesions can result in persistent dysarthria. Inter
33、vention studies similarly typically report on stroke patients many months or years following onset.Search questionsTo provide a current view of the characteristics of dysarthria in stroke and its management, two questions were addressed by a literature search:a) What are the features of dysarthria i
34、n adult stroke populations and is presentation consistent with the conventional Mayo system for classification?b) What evidence exists for the effectiveness of intervention in dysarthria caused by stroke? Search strategyThe search and review of sourced material was carried out by the author. The sea
35、rch was confined to publications in English between 1985 and May 2010 for question a) and between January 2007 and May 2010 for question b). This shorter time period for the latter was selected because of the existence of two comprehensive intervention reviews on non-progressive dysarthria which enc
36、ompass, but are not confined to stroke (Sellars et al., 2005; Palmer & Enderby, 2007). An initial search was conducted using MEDLINE. To address question a) stroke was used in combination with dysarthria. To address question b) therapy was added as a search term. MEDLINE applies additional related t
37、erms: stroke (apoplexy; apoplexies; cerebral stroke; cerebrovascular accident; cerebrovascular apoplexy; cerebrovascular stroke; strokes; vascular accident brain; cva); dysarthria (dysarthrias; dysarthosis); therapy (therapeutic; management; treatment; intervention; remedy; relief; amelioration; all
38、eviation). For question a) 30290 references were raised, of which 586 were classified as 5*, having all search terms, or their applied related terms, present and complete. For question b) 5298 references were raised of which 86 were classified as having all search terms present and complete. Abstrac
39、ts of all 5* references were evaluated to determine their relevance to the questions, according to the following inclusion criteria:o Tree1) data confined to participants with stroke or from which stroke specific data could be clearly distinguished; 2) adult population;3) dysarthria diagnosis withou
40、t accompanying apraxia of speech or aphemia and clearly differentiated from any co-existing aphasia.Additionally for question a):4) description of a range of speech parameters derived from specified tasks, including connected speech: data confined to one parameter such as articulation or phonation,
41、or obtained from a single task, such as vowel prolongation or rapid syllable repetition provides a narrow focus without necessarily identifying the dimensions most commonly associated with stroke;5) data from a minimum of 10 stroke participants, as the representativeness of single case and small gro
42、up descriptions cannot be determined. No lower limit as to the number of participants was set for question b) because of the small amount of outcome research.Where more than one publication reported on the same participant group or a subset thereof, the publication with the most complete and compreh
43、ensive data was used. From the MEDLINE search, six discrete studies met the criteria for question a) and six for question b). Applying the same inclusion criteria and timeframe, Ingentaconnect, PsycINFO, LLBA and ANCDS databases were examined with a view to sourcing any additional publications not i
44、ndexed in MEDLINE. Additional search terms of vascular, CVA, infarction, intervention, speech, treatment and rehabilitation were applied. Reference lists for all qualifying material were also scanned and electronic and hand searches were undertaken of relevant communication disorders journals which
45、may not be fully referenced in the databases through the time period. Beyond the material sourced from MEDLINE these further searches provided one additional source for question a) and one for question b), thus totalling seven sources for questions a) and seven for b). Suitable to the heterogeneous
46、nature of the available data, the findings are presented in the form of a narrative review, with associated discussion of key issues arising from the data. Such overviews of the literature are defined as “comprehensive narrative syntheses of previously published information” (Green, Johnson & Adams,
47、 2006, p. 103).Search results 1Question a): Dysarthria presentation in stroke populationsInvestigations of the features of dysarthria in large stroke populations are few and methodologically diverse, as regards dysarthria severity, lesions locations and extents, and the point after stroke at which s
48、peech assessment was carried out. For the seven discrete studies involving at least 10 participants with dysarthria which were identified, table 1 gives the participant details and table 2 a synthesis of the main dysarthria presenting features. Participant numbers ranged from 10 to 101. In some earl
49、y studies diagnosis of stroke did not include neuroimaging. Some studies included participants with varied lesion locations and others were restricted to one site, usually upper motor neurone, or cerebellar. Lesions were exclusively unilateral or bilateral in some studies and in other populations both unilateral and bilateral lesions were included. The professional background of the speech assessor is not given in Ropper (1987) and Kumral et al. (2007), but in t
