JOURNAL OF COMMUNICATIONS DISORDERS 12 (1979), 167- 173 167

TREATMENT OF DYSARTHRIA: A CASE REPORT

DAVID E. HARTMAN
Department ofCommunicative Disorders, College of Saint Teresa. Winona, Minnesota 55987

MARY DAY
Department of Communicative Disorders, University of Wisconsin, Madison, Wisconsin 53706

ROBERTA PECORA
Department of Communicative Disorders, College of Saint Teresa, Winonn, Minnesota 55987

There is little information available to the speech clinician on management of dysarthria. This article
presents the rationale, procedural outline, and results of an approach to communication training for
one dysarthric subject in view of suggestions made by Darley et al. (1975).

Introduction

A review of the literature concerned with management of neurophysiological

speech disorders reveals a dearth of information for treatment of dysarthria.
Darley et al. (1975) suggested five general principles which should be considered
in the treatment of this articulation disorder. These included:

1. compensation, whereby the patient learns to maximize remaining potential;

2. purposeful activity, in which skills which were previously automatic must
now be made purposeful;
3. monitoring, whereby feedback modalities are actively used for self-judgments
of accuracy;
4. an early start, whereby the sooner the patient learns to take responsibility for
his speaking behavior, the better;
5. motivation, which through the help of the clinician, reassures the patient that
his efforts are worthwhile.

These principles were utilized as a frame of reference for a specific total

communication approach to speech management for one dysarthric subject.
The following is an account of the intervention strategies used with this indi-
vidual and their effectiveness.

Address correspondence to: David E. Hartman, Section of Speech Pathology, Mayo Clinic,
Rochester. Minnesota 55901.

0 Elsevier North Holland Publishing Company, Inc., 1979 0021-9924/79/020167-07$01.75

168 DAVID E. HARTMAN, et al

Case History

In 1951, at the age of 5 yr, L.B. was struck by an automobile. The accident
resulted in multiple broken bones and suspected brain damage. The patient was
unconscious for approximately 13 wk. Speech was defective upon regaining
consciousness. Prior to the accident, the patient was a normal and active 5-
yr-old.
In 1968, L.B. was first seen for a neurological evaluation at the Mayo Clinic.
The results revealed predominantly left hyperactive deep and superficial reflexes,
a scissor gait, scoliosis, and dysarthria. A second evaluation in 1976 revealed no
further deterioration in gait or speech, although both were judged to be major
problems.
Because of the effects of the accident, L.B. did not receive a formal education.
Reading, writing, and arithmetic skills were learned in the home.
Since 1970, the subject has been employed as a bartender and purchaser of
liquor. According to his employer, L.B. performs his job admirably. He was
described as gregarious and sociable.

Language, Speech, and Hearing Assessment

L.B. was brought to the Speech and Hearing Center in March 1977, at the age
of 30 yr 10 mo. He was ambulatory, although left hemiparesis and a scissor gait
interferred with movement. Both formal and informal procedures were used to
assess communicative skills. The following is a summary of the initial evalua-
tion.

No formal language tests were administered. Informally, receptive knowledge

of language was assessed by asking L.B. to follow a series of commands of
graduated difficulty. In all instances, the subject accurately performed the re-
quired tasks. Expressive language was occasionally telegraphic as noted through
shortened and modified sentences during repetition.

Numerous articulation errors were noted from administration of Thr

Trtnplin-Durlq Tests qf Articulcrtion (1969) in the single word and modified
sentence forms. Of the 50 articulation errors, only 5 were found to be stimulable.

Personal communication with Arnold E. Aronson, Speech Consultant. Mayo Clinic, Rochester,
Minnesota.
 TREATMENT OF DYSARTHRIA 169

Articulation was generally impaired due to faulty place and manner of articula-
tion in which lingua-dental or lingua-alveolar sounds were substituted for most
phonemes. Overall intelligibility was affected by labored articulatory move-
ments, scanning, and a slow rate of speech. Limited lingual mobility also ad-
versely influenced articulation.

Hearing

The subject acknowledged a tone of 15 dB (ANSI, 1969) binaurally for the

frequencies 500, 1000, 2000, and 4000 Hz during a pure-tone air conduction
screening test. His hearing was therefore judged to be adequate for monitoring
speech.

Management

Design

Since the subject displayed numerous articulation errors which made much of
his verbal communication unintelligible, management was initially designed to
enhance articulatory skills. However because of his age, and limited removabil-
ity of causual/maintaining factors, a program of sign was incorporated into
management to serve as an adjunct to speech.
Because it provided methodological structure, each task to be trained was
incorporated into an individual Base 10 Programmed Speech-Language Stimula-
tion Format (LaPointe, 1977).

Articulation Training

A distinctive feature analysis (Chomsky and Halle, 1968) showed the conti-
nuancy, strident, anterior and coronal features to be most frequently in error. The
is/ and /v/ phonemes were selected for training since they were representative of
these features.
Baserates taken for Is/ and Iv/ in isolation and in the initial word position
showed 0% accuracy for the former, and 20% accuracy for the latter. Because of
the low baserate scores, training was initiated at a minimal level of behavior. The
hierarchy of training for the phonemes is presented in Table 1.
The criterion for each of the 10 activities was 90% accuracy for three consecu-
tive trials in two consecutive sessions. Each trial was repeated three times for a
total of 30 items per activity, per target phoneme, per session, For example, for
production in isolation, there were 30 stimulus items for Is/ and 30 for Iv/.
Accuracy was defined in terms of designated place and manner articulation.
Each management session involved training of the Is/ and Iv/ in one of the 10
170 DAVID E. HARTMAN, et al.

treatment contexts indicated in Table 1. Because of the different rates at which

criterion was achieved, the phonemes were not necessarily trained at the same
level.
For production of the is/ and iv/, the clinician verbally modeled the phonemes
in their specified contexts. The subject was required to imitate the stimulus using
a mirror for visual feedback of place and manner of articulation. Although the
clinician ultimately made the final judgment of accuracy of production for the
target sounds, the subject was required to make self-judgments after each re-
sponse.
For training the lsi phoneme in isolation, the clinician placed an appliance
similar to a toothpick between the subjects upper and lower central incisors to
direct the airstream. Following presentation of the stimulus the subject was
required to respond with the instrument in place. Eventually, the appliance was
gradually removed while the subject maintained accurate place and manner of
articulation for the phoneme.
For training the iv/ in isolation and monosyllabic words, the clinician occa-
sionally manipulated the subjects articulators in order to elicit the desired re-
sponse. To ensure voicing of the phoneme, the subject placed his hand on the
clinicians larynx during modeled production, and on his own larynx during
imitation.
At the end of each session L.B. was given a copy of the stimuli for each target
phoneme to practice at home. He had set aside specific periods of the day for
home practice.
TABLE I
Hierarchy of Training for is/ and /vi in Treatment of Dysarthria

Sequence
Activity Level

Production in isolation 1

Production in initial position of monosyllables or monosyllabic words 2

Production in initial position of dysyllables or two-word phrases 3

Production in initial word position of four-word phrases 4

Production in final word position of monosyllabic words 5

Production in final position of dysyllables or two-word phrases 6

Production in final word position of four-word phrases 7

Production in medial word position of dysyllabic words or two-word phrases 8

Production in medial word position of four-word phrases 9

Spontaneous production in context IO

*Refers to accurate articulation of target phonemes in reading or conversation

 TREATMENT OF DYSARTHRIA 171

Sign Training

In order to enhance the subjects verbal communication, a portion of each

session was devoted to sign training. The concept for this procedure was based
upon the work of Skelly et al. (1974) with American Indian sign for oral verbal
apraxic subjects. A sign was defined as a gesture, that by itself could
convey the content of a verbal message. The signs did not represent sounds,
letters, or parts of speech as might a system for the deaf, but rather depicted the
total meaning of the message.
Initially, 10 concepts were selected for baserating which were judged to be
appropriate for the subjects needs and natural environment. Since the sign
program was designed to teach the subject a system which could be used with,
rather than in place of verbal communication, an accurate response was
defined as a sign which was produced with a verbal message, but which was
explicit enough to convey that message to two or more untrained judges in the
absence of verbalization.
Once performance at a 90% accuracy level for a group of 10 items had been
demonstrated for three consecutive trials in two consecutive sessions, an au-
diovisual tape recording was made of the subjects sign/verbal responses. This
was played back without the audio portion to two or more judges who were asked
to interpret the signs as an informal check of reliability.
As a group of 10 signs met criterion, combinations were made of those which
were logical. For example, when the signs for hot and drink reached
criterion, they were trained as hot plus drink or hot drink. Additional
individual signs supplemented those which were combined, for a total of ten
items per task.
For training of individual signs, the clinician provided the carrier phrase
What would you do and say if . . , and asked a question designed to elicit
the desired response. The subject was required to provide a sign and verbal
response which fulfilled the request. If unacceptable responses were elicited,
they were trained according to the clinicians concept of appropriateness.
For training two signs in combination, an add gesture (crossed index
fingers) was taught for inclusion between them. Initially the clinician asked three
separate stimulus questions; one which was designed to elicit the first sign and
verbal message of the combination, one to elicit the sign for add, and one
which was to elicit the second sign and verbal message. The subject was required
to respond singularly to each question. For the add component of the items,
the subject responded only with the designated sign. After responding to the third
stimulus question of each item, he was instructed to produce a unified response
by combining the three component responses. It was this unified response which
was judged for accuracy.
172 DAVID E. HARTMAN. et al

Results

L.B. was seen for 33 consecutive I-hr sessions. All responses were recorded,
and converted to percentages relative to the number of stimulus items presented.
For production of the is/, criterion had been achieved for utilization of the
phoneme in the initial position of monosyllables, or level 2 in the training
sequence. He had achieved an accuracy level of 90% for one session for produc-
tion of the phoneme in monosyllabic words. Some generalization was noted to
untrained words containing lsl.
For production of /vi, training followed the proposed sequence through level 4
of the training hierarchy. At this point, the subject showed greater instances of
accuracy for production of the phoneme in the medial rather than final word
position. Training was therefore directed toward production in the former context
of words and phrases (level 8) first. Once the subject achieved criterion at this
level, training was directed toward level 5, or production of the phonemes in the
final word position of monosyllabic words. Criterion was also achieved for this
level. Generalization occurred for untrained words containing /vi in all word
positions.
The criterion level of performance had been achieved for 50 single and com-
bined signs in conjunction with their verbal counterpart. The subject occasionally
incorporated both trained and self-generated signs into his verbal communication
away from the Center. Independent interpretation of signs by judges showed
between 79% and 88% accuracy. All judgmental errors were limited to as-
sociated words or concepts, i.e., cigarette for smoke, car for drive.

Discussion

It is interesting to analyze the changes in L.B.s communication behavior in

light of the five requisites set forth by Darley et al. (1975) for management of
dysarthria. Regarding compensation, we believe that L.B. has, and will continue
to utilize, all available residual skills. Although progress may be considered
minimal to date, application of these skills is apparent in the fine articulatory
adjustments necessary for the production of lsi. The fact that he can produce
phonemes that were previously misarticulated and voluntarily use signs to en-
hance his verbal communication suggests that he has been successful in making
his behavior purposeful. All of the training procedures used with L.B. have
required self-monitoring in some fashion. Improvement in all areas treated is
indicative of application of this principle by the subject. The fact that he has
generalized formal training to items and concepts not trained, is supportive of an
early start to becoming communicatively self-sufficient and responsible. Finally,
the subjects attendance record, enthusiasm for participation in training ac-
tivities, and utilization of guidelines for practice within the Center and in his own
 TREATMENT OF DYSARTHRIA 173

environment are suggestive of motivation for betterment of communication

skills.
The procedures discussed in this report are not conclusive, and served only as
a guide for working with one dysarthric subject. Changes have been made in
L.B. s training program as deemed necessary. His communication abilities con-
tinue to improve in gradual succinct steps. Considering the nature and duration of
the disorder, we are enthusiastic about the potential for developing functional
communication skills.

References

Chomsky, N., and Halle, M. (1968). The Sound Patfern of English. New York: Harper.
Darley, F. L., Aronson, A. E., and Brown, J. R. (1975). Motor Speech Disorders. Philadelphia:
W.B. Saunders.
LaPointe, L. (1977). Base 10 programmed stimulation: Task specification, scoring and plotting
performance in aphasia therapy. J. Speech Hear. Dis., 42: 9C- 105.
Skelly, M., Schinsky, C., Smith, R., and Fust, K. (1974). American Indian sign (AMERIND) as a
facilitator of verbalization for the oral verbal apraxic. J. Speech Hear. Dis., 39: 445-456.
Templin, M., and Darley, F. L. (1969). Templin-Darley Tests of Articulation. Iowa City: The
University of Iowa, 1969.