... Cerebral Palsy ...

 Cerebral Palsy

Definition

The words Cerebral Palsy are used to describe a medical condition that affects control of the muscles. The movement problems vary from barely noticeable to extremely severe. Cerebral means anything in the head and palsy refers to anything wrong with control of the muscles or joints in the body. If someone has cerebral palsy it means that because of an injury to their brain (that's the cerebral part) they are not able to use some of the muscles in their body in the normal way (that's the palsy part). Thus Cerebral Palsy is not a disease or an illness. Children with cerebral palsy have many problems, but not all of them are related to the brain injury. Most of these complications are nevertheless neurological. They include epilepsy, mental retardation, learning disabilities, and attention deficit-hyperactivity disorder. Problems that occur less commonly, are swallowing problems in children with spastic quadriplegia. Children with cerebral palsy may also develop hip subluxation or have problems with the gait. No two people with cp are the same; it is as individual as people themselves.

Depending on which areas of the brain have been damaged, one or more of the following may occur:

• Muscle tightness or spasm
• Involuntary movement
• Difficulty with gross motor skills such as walking or running
• Difficulty with fine motor skills such as writing and speaking
• Abnormal perception and sensation

These effects may cause associated problems such as difficulties in feeding, poor bladder and bowel control, breathing problems and pressure sores.
 

The brain damage, which caused CP, may also lead to other conditions such as:      

• Seizures
• Learning disabilities
• Developmental delay

It is important to remember that limbs affected by CP are not paralyzed and can feel pain, heat, cold and pressure. It is also important to remember that, just because someone with CP may not be able to speak, it does not mean he has nothing to say. The degree of physical disability experienced by a person with CP is not an indication of his level of intelligence.

Children with CP have damage to the area of their brain that controls muscle tone. Depending on where their brain injury is and how big it is, their muscle tone may be too tight, too loose, or a combination of too tight and loose. Muscle tone is what lets us keep our bodies in a certain position, like sitting with our heads up to look at the teacher in class. Changes in muscle tone let us move.

Cerebral palsy may be classified by the type of movement problem (such as spastic or athetoid cerebral palsy) or by the body parts involved (hemiplegia, diplegia, and quadriplegia).

 

Spastic Cerebral Palsy

If muscle tone is too high or too tight, the term spastic is used to describe the type of cerebral palsy. Children with spastic CP have stiff and jerky movements because their muscles are too tight. They often have a hard time moving from one position to another or letting go of something in their hand. This is the most common type of CP. About half of all people with CP have spastic CP.

Ataxic Cerebral Palsy

Low muscle tone and poor coordination of movements is described as ataxic (a-tax-ick) CP. Kids with ataxic CP look very unsteady and shaky. They have a lot of shakiness, like a tremor you might have seen in a very old person, especially when they are trying to do something like write or turn a page or cut with scissors. They also often have very poor balance and may be very unsteady when they walk. Because of the shaky movements and problems coordinating their muscles, kids with ataxic CP may take longer to finish writing or art projects.  

 

Athetoid Cerebral Palsy

The term athetoid is used to describe the type of cerebral palsy when muscle tone is mixed - sometimes too high and sometimes too low. Children with athetoid CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show lots of movements of their face, arms and upper body that they don't mean to make (random, involuntary movements). These movements are usually big. For some kids with athetoid CP, it takes a lot of work and concentration to get their hand to a certain spot (like to scratch their nose or reach for a cup). Because of their mixed tone and trouble keeping a position, they may not be able to hold onto things (like a toothbrush or fork or pencil).

Mixed Cerebral Palsy

When muscle tone is too low in some muscles and too high in other muscles, the type of cerebral palsy is called mixed. Besides different kinds of muscle tone, kids with CP also show different parts of their bodies that are affected by the CP. This is also due to what part of their brain was hurt and how big the injury was.
 

Quadriplegia

When a child shows CP in all four of their limbs--both arms and both legs, it is called quadriplegia. Quad means four. Usually kids with quadriplegia have trouble moving all the parts of their bodies, their face and trunk as well as their arms and legs, and may need a wheelchair to get around. Because of the problems controlling the muscles in their face and upper body, they also have trouble talking and eating.

 

Hemiplegia

Hemiplegia means that the CP affect one side of the child's body. Hemi means half, so the right arm and leg or the left arm and leg are affected. The other side of the child's body works just fine. Many kids with hemiplegia are able to walk and run, although they may look a little awkward or have a limp.
 

Diplegia

Some children have CP just in their legs or much more severe in their legs than in their arms. This is called diplegia. Di means two, so in diplegia only the two lower limbs are affected. As you probably can guess, the difficulty for children with diplegia is using their legs, so walking and running may be hard for them. Because their upper bodies are usually not affected they have good ability to hold themselves upright and good use of their arms and hands. You may wonder whether anyone ever has CP in their arms but not their legs. This happens sometimes, but it is very, very rare.

This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical, however some people find that they add depth to the patient information leaflets. You may find the abbreviations record helpful.

Dysarthria and Dysphasia

Dysarthria is a disorder of speech whilst dysphasia is a disorder of language.

• Speech is the process of articulation and pronunciation. It involves the bulbar muscles and the physical ability to form words.
• Language is the process in which thoughts and ideas become spoken. It involves the selection of words to be spoken, called semantics, and the formulation of appropriate sentences or phrases, called syntax.

Strictly speaking, the words anarthria and aphasia mean a total absence of ability to form speech or language but they are often used when dysarthria and dysphasia would be more correct.

Dysphasia can be receptive or expressive. Receptive dysphasia is difficulty in comprehension, whilst expressive dysphasia is difficulty in putting words together to make meaning. In reality there is usually considerable overlap of these conditions but a person who has pure dysarthria without dysphasia would be able to read and write as normal and to make meaningful gestures, provided that the necessary motor pathways are intact.

Inability to write is agraphia or dysgraphia if incomplete. Inability to manipulate numbers is acalculia or dyscalculia if incomplete. Difficulty reading is dyslexia.

Dominant hemisphere The speech area is in the left, dominant side of the brain in about 99% of right-handed people. The remaining 1% may represent inherent left-handers who have been forced to write with their right. In left-handed people, the right hemisphere is the dominant side in only 30%. Thus impairment of the speech area with a stroke, causing left-sided weakness, is rare. It will occur in virtually no right-handers and in only 30% of left-handers. As a general rule, a lesion of the left hemisphere will cause dysphasia whilst, in the right hemisphere, it will cause neglect, visuo-spatial and cognitive problems.1

Epidemiology The aetiology is damage or disease of the brain and so it is most common in old people. Disease is usually vascular, neoplastic or degenerative. Around 85% of cases arise from strokes and around 1 person in 3, who has a stroke, will have dysphasia. In younger people it is usually a result of head injury.

Dysarthria

Causes of dysarthria

Dysarthria is caused by upper motor neurone lesions of the cerebral hemispheres or lower motor neurone lesions of the brain stem. It also results from disruption to the integrated action of upper motor neurones, basal ganglia and cerebellum.

Features of dysarthria

There may be some variation depending upon the site of the lesion

• Slurred and weak articulation with a weak voice is typical of pseudobulbar palsy from a stroke. Other neurological signs are usually unilateral with a right-sided hemiplegia (left side of brain). It may be on the left in a minority of left-handers. Brain stem stroke may lead to bilateral signs with dysarthria or anarthria.
• Slurred, scanning and staccato speech caused by cerebellar lesions is typical of multiple sclerosis.
• A dysrhythmic, dysphonic and monotonous voice is caused by disease of the extrapyramidal system in Parkinson's disease. Movement is rigid and stiff in Parkinson's disease and that includes phonation.
• Indistinct articulation, hypernasality and bilateral weakness caused by lower motor neurone disorders can occur with motor neurone disease.

Management of dysarthria

Speech and language therapy is required to assess and treat the bulbar and facial muscles. A programme of exercises is developed to improve muscle tone and movement to match the individual's needs.² Be patient with a dysarthric person and try to make out what is being said. This encourages effort rather than opting out. If this fails they may write or use an electronic communicator if they have one.

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Dysphasia

Causes of dysphasia

Dysphasia is impaired ability to understand or use the spoken word. It is due to a lesion of the dominant hemisphere and may include impaired ability to read, write and use gestures. The commonest cause is cerebrovascular disease but it can arise from a space occupying lesion, head injury or dementia.

Features of dysphasia

Dysphasia can be seen as a disruption in the links between thought and language. The diagnosis is made only after excluding sensory impairment of vision or hearing, perceptual impairment (agnosia), cognitive impairment (memory), impaired movement (apraxia) or thought disturbance, as in dementia or schizophrenia. When testing for dysarthria and dysphasia, the patient's ability to repeat or produce difficult phrases or tongue twisters can be indicative.

• People with receptive dysphasia often have language that is fluent with a normal rhythm and articulation but it is meaningless as they fail to comprehend what they are saying.
• People with expressive dysphasia are not fluent and have difficulty forming words and sentences. There are grammatical errors and difficulty finding the right word. In severe cases they do not speak spontaneously but they usually understand what is said to them.

Specific types of aphasia are associated with damage to particular cortical regions but in practice distinctions are not always clear. Language is a complex activity involving many cortical and sub-cortical areas and lesions do not dissect clearly-demarcated anatomical areas. Generally, expressive dysphasia suggests an anterior lesion while receptive dysphasia suggests a posterior lesion. There are a number of sub types. They are:

• Sensory (Wernicke's) aphasia - lesions are located in the left posterior perisylvian region and primary symptoms are general comprehension deficits, word retrieval deficits and semantic paraphasias. Lesions in this area damage the semantic content of language while leaving the language production function intact. The consequence is a fluent or receptive aphasia in which speech is fluent but lacking in content. Patients lack awareness of their speech difficulties. Semantics is the meaning of words. Semantic paraphrasia is the substitution of a semantically related but incorrect word.
• Production (Broca's) aphasia - lesions are located in the left pre-central areas. This is a non-fluent or expressive aphasia since there are deficits in speech production, prosody and syntactic comprehension. Patients will typically exhibit slow and halting speech but with good semantic content. Comprehension is usually good. Unlike Wernicke's aphasia, Broca's patients are aware of their language difficulties. Prosody is the study of the meter of verse. Here it means the rhythm of speech.
• Conduction aphasia - lesions are around the arcuate fasciculus, posterior parietal and temporal regions. Symptoms are naming deficits, inability to repeat non-meaningful words and word strings, although there is apparently normal speech comprehension and production. Patients are aware of their difficulties.
• Deep dysphasia - lesions are in the temporal lobe especially those mediating phonological processing. Symptoms are word repetition problems and semantic paraphasia (semantically related word substituted when asked to repeat a target word).
• Transcortical sensory aphasia - lesions are in the junction areas of the temporal, parietal and occipital areas of left hemisphere. Symptoms are impaired comprehension, naming, reading, writing and semantic irrelevancies in speech.
• Transcortical motor aphasia - lesions are located between Broca's area and supplementary motor area. Symptoms are transient mutism, telegrammatic, and dysprosodic speech. Telegrammatic means omitting unimportant words, as was done when sending a telegram. Dysprosodic speech is monotone.
• Global aphasia - occurs with extensive damage to the left perisylvian region, white matter, basal ganglia and thalamus. Symptoms are extensive and generalised deficits in comprehension, repetition, naming and speech production.

Examining patients with dysphasia

Tests for receptive dysphasia may include asking patients to read words or a passage and then asking them to explain it. Comprehension of spoken material is assessed by asking the patient to listen to a passage and explain it or, alternatively, by asking them to follow certain instructions such as, "point to the door".

Tests for expressive dysphasia include:

• Asking the patient to name a series of objects and some of their parts. For example, ask the patient, "What is this?", pointing to a pen, your tie and watch in turn. Then ask, "What part of the watch is this?", pointing to the strap and then the face or hands.
• If language is limited then dysphasia may be tested by holding up a pen and asking, "Is this a pen?" If the patient says, "Yes", then point to your watch and ask, "Is this a pen?" This demands a different reply. Look out for difficulty in finding the right word and perseveration. This is inappropriate repetition of the same word or phrase.
• Can the patient talk spontaneously on a familiar topic? "Tell me about your family." "Tell me about the work you used to do".
• Can the patient count numbers or recite days of the week?
• Write a brief dictated passage?
• Write a brief spontaneous passage?
• Copy a short passage?

All tests of literacy and numeracy must be interpreted in the light of pre-morbid function For example, impairment in numeracy in a former accountant probably represents a substantial decline.

Management of dysphasia

Referral to speech and language therapy is the usual practice for dysphasia where a thorough assessment of the nature of the problem is followed by exercises to encourage the recovery of fluent speech and understanding. Therapy tends to be tailored to the needs of the individual patient. The value of these interventions has been assessed by a Cochrane review³ that concluded that, whilst there was no good evidence to support such management, there was none to refute it either. The problem is a shortage of good-quality research to assess the value of speech and language therapy.

Prognosis

Aphasia may have a severe, debilitating effect on the everyday life of the patient. Severe aphasias are likely to show little improvement but other forms can show rapid improvement. The probability of recovery following trauma is higher than following stroke. Around one third of aphasics recover fully within three months but complete recovery is unlikely after six months. When language returns in a person who was an immigrant but has spoken English for many years, it tends to return in the native language. There is a possibility that some drugs may enhance the ability to learn and hence to recover language after a stroke but this is still very much in the experimental stage.^4,5

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Document references

1. Jordan LC, Hillis AE; Aphasia and right hemisphere syndromes in stroke. Curr Neurol Neurosci Rep. 2005 Nov;5(6):458-64. [abstract]
2. Hovard L; Causes and management of dysphasia. Br J Hosp Med. 1992 Sep 16-Oct 6;48(6):320-4. [abstract]
3. Greener J, Enderby P, Whurr R; Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2000;(2):CD000425. [abstract]
4. Bakheit AM; Drug treatment of poststroke aphasia. Expert Rev Neurother. 2004 Mar;4(2):211-7. [abstract]
5. Berthier ML; Poststroke aphasia : epidemiology, pathophysiology and treatment. Drugs Aging. 2005;22(2):163-82. [abstract]

؛ ... صعوبات القراءة ... الديسليكسيا Dyslexia ... ؛

صعوبات القراءة أو الديسليكسيا Dyslexia

هي الفشل في تعلم القراءة خلال النمو، حيث يعاني الطفل المصاب بالديسليكسيا بصعوبة واضحة في التعرف على الكلمات وقراءتها، وبالتالي يعاني من صعوبة في الكتابة والتهجئة، ينطق بعض الأطفال المصابين بهذا الاضطراب الكلمات بصورة مشوهه كأن يزيلوا منها أحرفاً أو يضيفوا أحرفاً غير موجودة أصلاً في الكلمة المنطوقة، كذلك يقوم بعض الأطفال بكتابة الكلمة بشكل معكوس، أو كما يطلق عليها " خيال المرآة mirror image" حيث يكتب كلمة rac بدلاً من car.

أما الديسليكسيا المكتسبة acquired dyslexias فهي قصور في القراءة نتيجة لتلف في المخ، وهي تنقسم إلى قسمين هما الديسليكسيا الطرفية peripheral dyslexia والديسليكسيا المركزية central dyslexia، وينقسم كلاً منهما إلى أنواع أخرى:


1. الديسليكسيا الطرفية Peripheral Dyslexias
هي حالات تتصف بقصور في معالجة النواحي البصرية للمثير حيث يكون الفشل في مطابقة الكلمات المألوفة بممثلاتها من الأشكال الصورية للكلمات visual word form، ومن أهم أنواعها ما يلي:

أ. ديسليكسيا العمى القرائي alexia without agraphia (pure alexia): وتعتبر النموذج النمطي للديسليكسيا الطرفية، ويرجع في الغالب سببها إلى عرض " انفصال disconnection " المعلومات البصرية والتي تقع في النصف الكروي الأيمن من نظام التعرف على الكلمات الذي يقع في النصف الكروي الأيسر، يجد المريض صعوبة هنا في قراءة الكلمات الطويلة مقارنة بالكلمات القصيرة، قد لا يتمكن المريض هنا من القراءة بسهولة وآلية، ولكنه يتمكن من إيجاد استراتجيات تعويضية تساعدة على القراءة ( بواسطة حرفاً بحرف ).

ب. ديسليكسيا الإهمال neglect dyslexia: ويعاني منها عادة المرضى المصابون بعرض الإهمال الحسي وهو تلف الفص الجداري الأيمن أو الأيسر ( وخاصة الأيمن )، من الممكن هنا أن لا يتمكن المريض من قراءة النصف الأول من الكلمة بشكل صحيح ولكن يقرأ النصف الأخير بشكل صحيح، أو العكس ( لا يقرأ النصف الأخير بشكل صحيح )، لم تجرى أبحاثاً كافية على هذا النوع من الديسليكسيا.



المراجــــــع:
Feinberg, T.E., & Farah, M.J. ((2003). Behavioral Neurology & Nduropsychology. (2nd ed.). N.Y.: McGraw-Hill Medical Publishing Division
Kalat, J.W. (2004). Biological Psychology. (8th ed). Canada: Thomson Wadsworth
Kolb, B. & Whishaw, Q. (2003). Fundamentals of Human Neuropsychology. (5th ed.). N.Y.: Worth Publishers
Nolte, J. (2002). The Human Brain. (5th ed.). St. Louis: Mosby, Inc.

Extensive damage to the right hemisphere often leads to the condition known as unilateral neglect. The patient will fail to pay attention to the left side of space, so may engage in conversation only when the speaker is in the right side of space, may eat only the food on the right side of the plate, may dress only the right side of his or her body, and may deny ownership of his or her left arm and leg. Reading may also be affected in the same way, i.e. the right side of the page will be neglected, and in single word reading the right side of the word may be neglected.

However, neglect dyslexia itself is a separate disorder, because recent research (e.g. Patterson and Wilson, 1990; Haywood, 1996) has shown that a number of the patients with this form of acquired dyslexia do not show unilateral neglect outside the domain of reading . In these patients, processing in the left half of space is impaired only when what is being processed is a letter-string.
The symptoms of neglect dyslexia.
In neglect dyslexia, reading errors arise because letters in a particular position in a word or nonword are neglected. Almost all cases are cases of left neglect dyslexia i.e. letters at the left of the stimulus are omitted or misidentified. Hence in left neglect dyslexia, one sees such errors as river read as "liver", cabin read as "robin", or liquid read as "squid".
However, cases of right neglect dyslexia, where errors arise with the rightmost letters of the letter-string, have also been reported.
The theoretical interpretation of neglect dyslexia.

Caramazza. and Hillis (1990) have proposed a model of early visual processing in reading and used that model to offer an interpretation of various forms of neglect dyslexia. In their model, letter strings go through three stages of processing prior to word recognition, as follows:

Retinocentric level: here each letter is represented as a bundle of visual features associated with a specific location on the retina. When neglect dyslexia is occurring at this level, it is because stimuli to the left of the fovea (the fixation point) are being neglected. Therefore a patient with neglect dyslexia at this processing level will show no neglect dyslexia if all the letters of a word are presented in the right visual field (i.e. if the patient fixates to the left of a word that is being read).

 

Stimulus-relative level: here the feature bundles of the retinocentric level have been integrated so each bundle is seen as a particular whole object; and a string of, say, 5 letters is seen as a string of 5 objects. Neglect at this level is relative to such a string: the leftmost object in such a string will be neglected regardless of where that string is on the retina. So if a patient's neglect is at this level, the neglect will occur even for words presented entirely in the right visual field.

Graphemic level: The input from the stimulus-relative level is used to identify each object at that level as a letter. At the graphemic level letters are represented abstractly, not in terms of their specific cases, so the uppercase, lowercase and handwritten forms of a particular letter are represented identically. Moreover, if the letter string is presented in a distorted way such as: 

or even mirror-imaged such as:

these distortions will be eliminated and the string will be represented as [c] [a] [p] at the graphemic level. Information about where exactly the letters were in space or whether they were mirror-imaged or not is discarded. If it is at this level that the left neglect dyslexia is present, this means that with mirror-imaged presentation, the [c] of will be the one that is neglected, even though it is the rightmost letter on the page - because it is the leftmost letter in the graphemic representation. Caramazza and Hillis (1990) described a patient who showed exactly this pattern of performance.

References.

Caramazza, A. and Hillis, A. (1990). Levels of representation, coordinate frames and unilateral neglect. Cognitive Neuropsychology, 7, 391-445.
Haywood, M. (1996) Neglect dyslexia without visuospatial neglect. Unpublished PhD thesis, Macquarie University.
Patterson, K., and Wilson, B. A (1990). A rose is a rose or a nose: A deficit in initial letter recognition. Cognitive Neuropsychology, 7, 447-477.

ج. الديسليكسيا الإنتباهية attentional dyslexia: حيث يستطيع المريض تسمية الحرف إذا كان موجودا لوحده، في حين يجد صعوبة في تسميته إذا كان هناك أكثر من حرف، حتى لو تم تمييز الحرف بلون مختلف أو بسهم أو قام الفاحص بالإشارة إليه، نفس الظاهرة تنطبق على الكلمات، حيث يستطيع المريض التعرف على كلمة مستقلة ولكن ليست ضمن كلمات أخرى، كذلك قد يتمكن المريض هنا من قراءة الكلمة ولكنه يجد صعوبة في تمييز الحروف فيها.

2. الديسليكسيا المركزية Central Dyslexias
وهي قصور في آليات القراءة العليا أو العميقة حيث تجد الكلمات في أشكالها البصرية مدخلاً إلى آليات المعنى أو آليات إنتاج الكلام حيث يحدث القصور، من أهم أنواعها ما يلي:

أ. ديسليكسيا القراءة حرفا بحرف letter-by-letter reading: حيث يتمكن المريض من قراءة الكلمات بعد تهجئتها حرفا بحرف (علانية أو في سره) لذلك يأخذ وقتا في القراءة، يتمكن المريض هنا من الكتابة، ولكنه يأخذ وقتاً ليقرأ ما تمت كتابته.

ب. الديسليكسيا العميقة deep dyslexia: وهي من أكثر أنواع الديسليكسيا دراسة، العلامة المميزة هنا هي وجود أخطاء في المعنى، حيث يضع كلمات شبيهة في المعنى محل الكلمات التي يحاول قراءتها ( كأن يقول سعيد بدلاً من كلمة عيد، وفارس بدلا من قلعة )، ورغم أن أخطاء المعنى من أكثر الصفات شيوعاً في هذا النوع إلاّ أن هناك فروقاً فردية كبيرة بين المرضى في هذه الصفة، بعض المرضى يُظهر أخطاء بصرية أكثر مثل أن يضع كلمة شبيهة كتابياً بدلاً من الكلمة المراد قراءتها ( كأن يقول حكيم بدلاً من حليم ) أو أن تكون الأخطاء في بعض الإضافات أو الأحرف الزائدة في الكلمة كأن يقرأ حكومة بدلاً من حكم أو حاكم.

تكون الأسماء أسهل في القراءة من الصفات، تليها الأفعال في مستوى الصعوبة، وتشكل الكلمات الوظيفية أصعب الأشياء، يجد المريض هنا أن الكلمات الغير مجردة ( التي من الممكن تخيل معناها مثل طاولة) أسهل من المجردة ( مثل لغز، أمل )، ولا يتمكن من قراءة الكلمات التي لا تحمل معنى، كذلك يعاني المريض هنا من قصور في الكتابة وفي الذاكرة قصيرة المدى اللفظية.

ج. الديسليكسيا الشكلية phonological dyslexia: وهي عدم القدرة على قراءة الأشياء الغير مكتوبة بصوت مرتفع ( لا يستطيع أن يقول بأن الرسم أو الشكل الذي يمثل منزل أنه منزل بصوت مرتفع)، فيما عدا ذلك لا تتأثر القراءة العادية إلاّ بشكل بسيط، ويبدو أن أخطاء القراءة هنا لها أساس بصري حيث إنها غالباً ما تتضمن وضع كلمات شبيهة مرئياً كأن يقرأ المريض ساحر بدلاً من ساهر.

د. الديسليكسيا السطحية surface dyslexia: يتميز هذا النوع بعدم قدرة المريض على قراءة الكلمات الغير منتظمة ( الكتابة لا تناسب اللفظ مثل island, have, through )، في حين لا يجد المريض صعوبة في قراءة الكلمات المنتظمة التي تناسب كتابتها لفظها أو نطقها ( تكتب مثلما تلفظ ) مثل state, hand, mint. ويبدو أن الديسليكسيا السطحية هي في الأصح ديسليكسيا صوتية، وهي عرض منتشر بين الأطفال الذين يعانون صعوبة في تعلم القراءة.

وهذا رسم توضيحي يمثل جميع الأنواع والتشخيص الدقيق ...



دمتــــــــــــم بود...

?What Happens During a Therapy Session

?What Happens During a Therapy Session

 

Many individuals who will be attending speech therapy know that the purpose of the therapy will be to help them overcome speech difficulties or disorders but some are less confident that they know exactly what will happen during the therapy sessions. This is a normal concern, given that no two therapy sessions will be absolutely alike.

What happens during a therapy session will depend up on the length of the therapy session, the location of the therapy session, the age of the individual involved, whether the therapy session is private or involves a group and the type of speech difficulty or disorder that is being treated, among other variables.

Length of a Speech Therapy Session
In general, most private speech therapy sessions last for one hour. Of course this is not true of all sessions and some may last for longer or some may be even shorter. This also does not mean that the therapist will be engaging the individual in therapeutic activities for the whole hour.

For the first five or ten minutes the therapist and client will get settled, perhaps speaking about what will happen in the session and what has happened since the last time they saw each other. For the last ten minutes the therapist and client will likely discuss what needs to be practiced for the next session and what “homework” activities are being assigned. This means that there is only about 40 minutes that will be devoted to therapeutic activities during an hour long appointment

Location of a Speech Therapy Session
Many speech therapy sessions are carried out in private offices, though some may be carried out at schools, homes, public halls (for group sessions) and/or hospitals, among other locations. Where a speech therapy session takes place will likely impact what happens during the session as it will determine what type of props (including books and toys) are on hand, where the therapist and client will sit (at desks, around a table, on the floor) and how much room they have to engage in activities. All of these variables will impact what ultimately occurs during the session.

Age of the Individual Receiving Speech Therapy
The age of the individual receiving speech therapy will have great bearing on what happens during the session. To begin with, age appropriate activities will need to be designed or else the session will be wasted if the client can not understand the vocabulary used, the activities are too complex or even the directions given are too confusing. For young children, this means that the therapeutic activities are often more like play activities. For older children, this means that schoolwork will often become the basis of the session.

Individual or Group Therapy Sessions
Most therapy sessions will either be conducted individually, where the therapist and client (and possibly a child’s parents) are the only individuals involved, or as a group session in which multiple individuals suffering from the same types of speech difficulties or disorders receive therapy at the same time.

Obviously a group session will mean less time for each individual to personally interact with the therapist, but it also means that there may be the possibility for different types of activities such as role playing and/or group singing. For some particularly shy individuals, being a part of a larger group may actually seem less threatening than individual sessions.

Type of Speech Difficulty or Disorder Being Treated
It seems obvious, but most of what happens during a speech therapy session will depend upon the type of speech difficulty or disorder being treated. For example, a client who has trouble following plot lines or the meaning of paragraphs and stories will work on his or her comprehension skills. But a client who has a lisp will engage in activities designed to practice the way he or she pronounces certain sounds.

In general, activities such as flash cards, working on handout sheets, clapping games, practicing vocal sounds and even simple story telling or conversation may be the focus of a therapy session. Depending on the age of the client, play time activities and school work may also be the basis of a session. If a client does not enjoy the activities, the therapist may be able to change them slightly to make them more interesting to the individual receiving treatment.

http://www.speechdisorder.co.uk/What...y-Session.html

 

... Childhood Apraxia of Speech ...

Childhood Apraxia of Speech

General Information for Parents

Childhood apraxia of speech (CAS, also known as DVD -- developmental verbal dyspraxia, and DAS -- developmental apraxia of speech) is a disorder that is more easily defined by what it is not. It is not a muscle disorder. It is not a cognitive disorder (although it may have some impact on language as well as speech). The problem occurs when the brain tries to tell the muscles what to do -- somehow that message gets scrambled. It's like trying to watch cable t.v. stations without the right descrambler. There is nothing wrong with the t.v. station, and nothing wrong with your set. It's just that your set can't read the signal that the station is sending out. The child's language-learning task is to figure out how to somehow unscramble the mixed message her/his brain is sending to her/his muscles.

The visible results (symptoms) of CAS are

• little or no babbling in infancy; few consonants
• understanding of language much better than production of language
• slow, effortful, or halting speech; sometimes seems to struggle
• very hard to understand
• may make slow progress in therapy

CAS has much more effect on volitional (voluntary, creative) speech than on automatic speech. This means that the more your child wants to communicate a particular message, the harder it will be! So, if you happen to hear her/him say something once when there is no pressure, and you say, "Say it again!", you are guaranteeing that she/he won't be able to. It is vital to put a minimum of communication pressure on the child. (NOTE: Your child's speech- language pathologist will need to put communication pressure on the child.) Low-pressure verbal activities are the most important thing a parent can do to help. These include: songs (especially repetitive songs, like Old MacDonald and finger-plays), poems, verbal routines (pat-a-cake, Willoughby Walloby Woo, etc.), repetitive books (such as some of the Mercer-Mayer books, Little Bear, etc.) and daily routines (prayers, social greetings, salute to the flag, etc.). You can make other activities into verbal routines: make up little sayings or poems that you say every time you do the same thing, label instead of counting objects in counting books ("Three dogs: dog, dog, dog"), verbalize repetitive activities (e.g., setting the table: "Plate, plate, plate, plate; fork, fork, fork, fork.."), and so on. Don't make a big fuss about whether or not your child is talking or singing along; just provide a supportive environment for her/him to do so. Don't ever say "You can't have it unless you say it first" -- that's sheer torture for a child with CAS. If your child is unable to communicate effectively right now, the use of sign language or a communication board to supplement speech temporarily not only decreases the frustration but also even seems to help with speech development. Don't be afraid to try it! Dyspraxia may affect other motor functions (e.g., fine motor control, gross motor planning) and other language functions (e.g., learning grammatical function words like "the, "is", "or", etc.; learning more complex grammatical forms like passive; spelling; putting words together into a sentence or sentences together into a paragraph, etc.). Occupational therapy, physical therapy, and learning disabilities assistance are often helpful for children who have these difficulties. CAS can be a very frustrating disorder at times. It is common for children to make progress in "fits and starts" -- good progress for a little while, then none, then more, etc. Don't get discouraged! The therapy is helping, even if you don't see the effects immediately.

An Internet Parent Support Group

Sharon Gretz, a parent of a child with dyspraxia, founded an Internet e-mail list for parents (and therapists) about this disorder which has grown into an international organization, the Childhood Apraxia of Speech Association, CASANA. There is a great deal of information for parents of children with CAS on their childhood apraxia web site

An Article for Parents

Stackhouse, J. (1992). Developmental verbal dyspraxia: A longitudinal case study. In R. Campbell (Eds.), Mental Lives (pp. 84-98). Cambridge, MA: Blackwell Publishers

Some Key References for Professionals

• Caruso, A. & Strand, E. (1999). Clinical management of motor speech disorders in children. New York: Thieme.
• Crary, M. (1993). Developmental motor speech disorders. San Diego: Singular.
• Hall, P., Jordan, J., & Robin, D. (1993). Developmental apraxia of speech. Austin, TX: Pro-Ed.
• Velleman, S.L. & Strand, K. (1994). Developmental verbal dyspraxia. In J. E. Bernthal & N. W. Bankson (Eds.), Child phonology: Characteristics, assessment, and intervention with special populations (pp. 110-139). New York: Thieme.
• Velleman, S. L. (1994). The interaction of phonetics and phonology in developmental verbal dyspraxia: Two case studies. Clinics in Communication Disorders, 4(1), 67-78.
• Velleman, S. L. (2002). Childhood apraxia of speech resource guide. San Diego: Singular.

Return to Shelley Velleman's home page

Brodmann Areas in the Human Brain with an Emphasis on Vision and Language

Original Brodmann Map - Colorized 

Outlines - with Functional Attribution

Neuroanatomy of Unilateral Neglect ... ؛

Neuroanatomy of Unilateral Neglect

There is considerable evidence that damage to the inferior parietal lobule (IPL), more than any other brain region, produces the classic symptoms of unilateral neglect (Vallar & Perani, 1986). This region of the associative cortex, initially defined on the basis of late myelination during development, appears to be at the apex of a multistage cortical processing stream, and receives inputs from subcortical structures that carry occulomotor and attentional signals (Vallar & Perani, 1986). In fact, this region appears to be the primary cortical region governing attention and is known to integrate somatic and visual information as well as movement (Vallar & Perani, 1986). It is particularly important for localizing points in space and perceiving depth and motion (Vallar & Perani, 1986).

The IPL is part of the ventral perceptual stream, but incorporates some new capacities, such as the ability to manipulate viewer-centered representations for tasks like mental rotation and map reading (Mattingley, 1999). Such abilities are thought to have been drafted from mechanisms evolving originally in the dorsal stream for the visual guidance of movement (Mattingley, 1999). Milner and Goodale hypothesize that neglect after inferior parietal damage is a purely perceptual disorder, and that visuomotor deficits (such as optic ataxia) arise only after dorsal stream damage to the superior parietal lobule (Mattingley, 1999).

The neuronal connections of the IPL have been documented in studies by Mesulam et al. (1981) and Robinson et al. (1986) through injection of anterograde or retrograde transport substances and determination of resulting visible projection patterns. Two types of cortico – cortico connections were seen (Robinson et al., 1986). Asanuma et al. (1985) also notes connections between the IPL and the medial pulvinar thought by Robinson et al. (1986) to play a role in attentional modulation. Overall, the IPL is well placed to integrate multiple sources of information needed to represent space and send the result of its constructions to other cortical areas (Asanuma et al., 1985).

Portions of the IPL, namely Brodmann’s area 40, exhibit right lateralized activation during both innocuous and painful stimulation, regardless of the side stimulated (Coghill et al., 2001). It can thus be inferred that components of information are processed, in part, by right lateralized systems ana logous to those that process visual spatial information arising from extrapersonal space (Coghill et al., 2001). Such right lateralized processing can account for the left sided neglect seen with injury to brain regions within the right cerebral hemisphere (Coghill et al., 2001).
The right parietal cortex mediates attention to both left and right halves of the body and extrapersonal space (Simon Frasier University). The right posterior parietal cortex is known to be involved in the manipulation of mental images (Brain Injury Resource Centre). Damage to the right parietal cortex has the most dramatic effect on drawing, resulting in images that are fragmented and characterized by the loss of spatial dimensions and the addition of extraneous lines (Brain Injury Resource Centre). Patients with parietal-lobe lesions to the rostral inferior parietal lobe of the right hemisphere demonstrate difficulties maintaining attention at a contralesional location (Maguire, 2002).

The left parietal hemisphere mediates attention only to the right side of the body and extrapersonal space (Simon Frasier University). The left posterior parietal cortex is involved in the production of mental images (Brain Injury Resource Centre). Drawing is affected to a lesser extent with left sided parietal damage. The act of drawing becomes slow and laborious, leading to a product that is coherent, albeit simple, exhibiting a gross lack of detail (Brain Injury Resource Centre). Lesions to the left parietal cortex tend to be compensated by the intact right parietal cortex, resulting in the association of disorders of spatial cognition to lesions of the right parietal lobe (Simon Frasier University).

What makes one consonant different from another?

Consonant parameters

What makes one consonant different from another?

Consonants involve constrictions, or gestures that narrow the vocal tract at a particular point. Most consonants use only one constriction, but some have more than one. In order to fully describe a consonant sound, we need to describe each constriction as well as some other properties of the vocal tract.
Parameters of a constriction gesture

1. active articulator: What articulator moves to make the constriction?
2. passive articulator: What articulator does the active articulator touch or approach?
3. degree of constriction: How close do the active and passive articulators get to each other?
4. (laterality)

These should be specified for every constriction involved in a consonant. The following properties don't apply to any particular constriction, but to the consonant as a whole:
Other parameters

1. state of the glottis: What are the vocal cords doing?
2. nasality: Is air escaping through the nose?
3. airstream mechanism: How is the flow of air being produced?

Answering each of these questions about the state of the vocal tract is enough to uniquely identify any consonant. If two consonants are different, they must differ in their answers for at least one of these questions.

Together, the active and passive articulator are often referred to as the place of articulation (POA). The other parameters are often lumped together and referred to as manner of articulation.

Manners of articulation

Consonant parameters

Manners of articulation

Constriction degree

Place of articulation refers to where the narrowing occurs -- which active articulator gets close to which passive articulator. Constriction degree refers to how close they get. The main constriction degrees are:

• stop: the active articulator touches the passive articulator and completely cuts off the airflow through the mouth. English stops include: [p], [d], [k], [m].
• fricative: the active articulator doesn't touch the passive articulator, but gets close enough that the airflow through the opening becomes turbulent. English fricatives include [f], [], [z].
• approximant: the active articulator approaches the passive articulator, but doesn't even get close enough for the airflow to become turbulent. English approximants include [j], [w], [], and [l].
• affricate: Affricates can be seen as a sequence of a stop and a fricative which have the same or similar places of articulation. They are transcribed using the symbols for the stop and the fricative. If one wants to emphasize the affricate as a "single" sound, a tie symbol can be used to join the stop and the fricative (sometimes the fricative is written as a superscript).

Notes:

• A stop cuts off airflow through the mouth. Airflow through the nose does not matter -- you can have both oral and nasal stops. Oral stops are often called plosives, including in the IPA chart. Nasal stops are usually just call ed nasals.
• Approximants that are apical or laminal are often called liquids (e.g., [], [l]). Approximants that correspond to vowels are often called glides (e.g., [j] corresponds to [i], [w] to [u]).
• English has the affricates [t] and [d]. The stop and the fricative halves of these affricates are at the same place of articulation: the stop is in fact postalveolar rather than alveolar. We could be explicit about this and underline the [t] and [d] (in IPA, a minus sign under a symbol is a diacritic meaning "pronounced further back in the mouth"), but most phoneticians believe this difference in the place of articulation is so predictable that it doesn't have to be marked.

State of the glottis

For now, we can simply use the terms "voiced" and "voiceless" to answer the question of what the vocal cords are doing:

• In voiced sounds, the vocal cords are vibrating.
• In voiceless sounds, the vocal cords are not vibrating.

Ultimately, we will see there are different ways of being voiced or voiceless. The vocal cords can do a number of things. They can:

• be held so wide apart that the air makes no sound passing through them. (This is nice when you have to breathe 24 hours a day, but not as useful for speaking.)
• be held closer together, so that the air passing through them becomes turbulent. This quality of sound is called breathiness. It is what is happening in apsiration and in the sound [h].
• be held together so that the air passing through them causes them to vibrate. This is called voicing.
• be held together so tightly that no air can pass through at all, as in a glottal stop.

(By varying their tension and position, the vocal cords can also produce many other effects like breathy voicing, creaky voicing, and falsetto.)
What the vocal cords are doing is independent of what the higher parts of the vocal tract are doing. For any place of articulation and any degree of stricture, you can get two different sounds: voiced and voiceless. For example, [t] and [d] are formed identically in the mouth; the difference is that the vocal cords vibrate during a [d] but not during a [t]. (The obvious exception is the glottal place of articulation -- you can't vibrate your vocal cords while making a glottal stop.)
In each cell of the IPA chart, the symbol for the voiceless sound is shown to the left and that for the voiced sound to the right. Some rows only have voiced symbols (e.g., nasals and approximants). You can write the corresponding voiceless sound using the voiceless diacritic (a circle under the voiced symbol).

Nasality

The soft palate can be lowered, allowing air to flow out through the nose, or it can be raised to block nasal airflow. As was the case with the vocal cords, what the soft palate is doing is independent the other articulators. For almost any place of articulation, there are pairs of stops that differ only in whether the soft palate is raised, as in the oral stop [d], or lowered, as in the nasal stop [n].

Laterality

When you form an [l], your tongue tip touches your alveolar ridge (or maybe your upper teeth) but it doesn't create a stop because one or both sides of the tongue are lowered so that air can flow out along the side. Sounds like this with airflow along the sides of the tongue are called lateral, all others are called central (though we usually just assume that a sound is central unless we explicitly say it's lateral).
The side of the tongue can lower to different degrees. It can lower so little that the air passing through becomes turbulent (giving a lateral fricative like [] or []) or it can lower enough for there to be no turbulence (a lateral approximant). The [l] of English is a lateral approximant.

Airstream mechanism

Speech sounds need air to move. Most sounds (including all the sounds of English) are created by modifying a stream of air that is pushed outward from the lungs. But it's possible for the air to be set in motion in other ways. Sounds which use one of the other three most common airstream mechanisms are called ejectives, implosives, and clicks. We'll discuss these possibilities later in the course.

Describing consonant segments

A consonant sound can be described completely by specifying each of the parameters for place and manner of articulation. For example, [k] has the following properties:

active articulator	tongue body (dorsum)
passive articulator	soft palate (velum)
constriction degree	stop
state of glottis	voiceless
nasal	no
lateral	no
airstream mechanism	normal

So [k] is a voiceless oral central dorso-velar stop.

Place of articulation

Place of articulation

The active articulator usually moves in order to make the constriction. The passive articulator usually just sits there and gets approached. A sound's place of articulation is usually named by using the Latin ajective for the active articulator (ending with an "o") followed by the Latin adjective for the passive articulator. For example, a sound where the tongue tip (the "apex") approaches or touches the upper teeth is called an "apico-dental". Most of the common combinations of active and passive articulator have abbreviated names (usually leaving out the active half).
These are the abbreviated names for the places of articulation used in English:

bilabial

The articulators are the two lips. (We could say that the lower lip is the active articulator and the upper lip the passive articulator, though the upper lip usually moves too, at least a little.) English bilabial sounds include [p], [b], and [m].

labio-dental

The lower lip is the active articulator and the upper teeth are the passive articulator. English labio-dental sounds include [f] and [v].

dental

Dental sounds involve the upper teeth as the passive articulator. The active articulator may be either the tongue tip or (usually) the tongue blade -- diacritic symbols can be used if it matters which. Extreme lamino-dental sounds are often called interdental. English interdental sounds include [] and [].

alveolar

Alveolar sounds involve the alveolar ridge as the passive articulator. The active articulator may be either the tongue blade or (usually) the tongue tip -- diacritic symbols can be used if it matters which. English alveolar sounds include [t], [d], [n], [s], [z], [l].

postalveolar

Postalveolar sounds involve the area just behind the alveolar ridge as the passive articulator. The active articulator may be either the tongue tip or (usually) the tongue blade -- diacritic symbols can be used if it matters which. English postalveolars include [] and []. Linguists have traditionally used very inconsistent terminology in referring to the postalveolar POA. Some of the terms you may encounter for it include: palato-alveolar, alveo-palatal, alveolo-palatal, and even (especially among English-speakers) palatal. Many insist that palato-alveolar and alveo(lo)-palatal are two different things -- though they don't agree which is which. "Postalveolar", the official term used by the International Phonetic Association, is unambiguous, not to mention easier to spell.

retroflex

In retroflex sounds, the tongue tip is curled up and back. Retroflexes can be classed as apico-postalveolar, though not all apico-postalveolars need to be curled backward enough to count as retroflex. The closest sound to a retroflex that English has is []. For most North Americans, the tongue tip is curled back in [], though not as much as it is in languages that have true retroflexes. Many other North Americans use what is called a "bunched r" -- instead of curling their tongues back, they bunch the front up and push it forward to form an approximant behind the alveolar ridge.

palatal

The active articulator is the tongue body and the passive articulator is the hard palate. The English glide [j] is a palatal.

velar

The active articulator is the tongue body and the passive articulator is the soft palate. English velars include [k], [g], and [].

glottal

This isn't strictly a place of articulation, but they had to put it in the chart somewhere. Glottal sounds are made in the larynx. For the glottal stop, the vocal cords close momentarily and cut off all airflow through the vocal tract. English uses the glottal stop in the interjection uh-uh (meaning 'no'). In [h], the vocal cords are open, but close enough together that air passing between them creates friction noise.

---

Note:

[w] is often called a "labio-velar". This doesn't follow the POA naming convention -- it does not mean that the active articulator is the lower lip and you try to touch your soft palate with it! A [w] is made up of two different approximants: a bilabial approximant and a (dorso-)velar approximant pronounced simultaneously.