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However, inasmuch as the bene t is also psychologic, an interested family member or schoolteacher can be of help if a speech therapist is not available in the community Frustration, depression, and paranoia, which complicate some aphasias, may require psychiatric evaluation and treatment The developmental language disorders of children pose special problems and are considered in Chap 28 Prognosis and Patterns of Recovery Some aspects of prognosis have been discussed above In general, recovery from aphasia due to cerebral trauma is usually faster and more complete than that from aphasia due to stroke The type of aphasia and particularly its initial severity (extent of the lesion) clearly in uence recovery: global aphasia usually improves very little, and the same is true of severe Broca s and Wernicke s aphasias (Kertesz and McCabe) The various dissociative speech syndromes and pure word mutism tend to improve rapidly and often completely Also, in general, the outlook for recovery from any particular aphasia is more favorable in a left-handed person than in a right-handed one Characteristically, in the course of recovery, a severe aphasia of one type may evolve into another type (global into severe Broca s; Wernicke s, transcortical, and conduction into anomic) patterns of recovery that may mistakenly be attributed to the effects of therapy It is in part because so many factors may in uence the mode of recovery from aphasia that the effectiveness of formal speech therapy has never been fully evaluated
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sonants (eg, la-la-la-la, me-me-me-me, or k-k-k-k) bring out the particular abnormality Disorders of phonation call for a precise analysis of the voice and its apparatus during speech and singing If necessary, the movements of the vocal cords should be inspected with a laryngoscope and those of the tongue, palate, and pharynx by direct observation
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In pure dysarthria or anarthria, there is no abnormality of the cortical language mechanisms The dysarthric patient is able to understand perfectly what is heard and, if literate, has no dif culty in reading and writing, although he may be unable to utter a single intelligible word This is the strict meaning of being inarticulate Defects in articulation may be subdivided into several types: lower motor neuron (neuromuscular); spastic (pseudobulbar); rigid (extrapyramidal); cerebellar-ataxic; and hypo- and hyperkinetic dysarthrias Lower Motor Neuron (Neuromuscular) Dysarthria, Atrophic Bulbar Paralysis This is due to weakness or paralysis of the articulatory muscles, the result of disease of the motor nuclei of the medulla and lower pons or their intramedullary or peripheral extensions (lower motor neuron paralysis) In advanced forms of this disorder, the shriveled tongue lies inert and fasciculating on the oor of the mouth, and the lips are lax and tremulous Saliva constantly collects in the mouth because of dysphagia, and drooling is troublesome Dysphonia alteration of the voice to a rasping monotone due to vocal cord paralysis is often added As this condition evolves, speech becomes slurred and progressively less distinct There is special dif culty in the enunciation of vibratives, such as r, and as the paralysis becomes more complete, lingual and labial consonants are nally not pronounced at all In the past, bilateral paralysis of the palate, causing nasality of speech, often occurred with diphtheria and poliomyelitis, but now it occurs most often with progressive bulbar palsy, a form of motor neuron disease (page 940), and with certain other neuromuscular disorders, particularly myasthenia gravis Bilateral paralysis of the lips as in the facial diplegia of the Guillain-Barre syndrome or of Lyme dis ease interferes with enunciation of labial consonants; p and b are slurred and sound more like f and v Degrees of both of these abnormalities are also observed in myasthenia gravis Spastic (Pseudobulbar) Dysarthria Diseases that involve the corticobulbar tracts bilaterally usually due to vascular, demyelinative, or motor system disease (amyotrophic lateral sclerosis) result in the syndrome of spastic bulbar (pseudobulbar) palsy The patient may have had a clinically inevident vascular lesion at some time in the past, affecting the corticobulbar bers on one side; however, since the bulbar muscles on each side are innervated by both motor cortices, there may be little or no impairment in speech or swallowing from a unilateral corticobulbar lesion Should another stroke then occur, involving the other corticobulbar tract at the pontine, midbrain, or capsular level, the patient immediately becomes dysphagic, dysphonic, and anarthric or dysarthric, often with paresis of the tongue and facial muscles This condition, unlike bulbar paralysis due to lower motor neuron involvement, entails no atrophy or fasciculations of the paralyzed muscles; the jaw jerk and other facial re exes usually become exaggerated, the palatal re exes are retained or increased, emotional control is impaired (spasmodic crying and laughing the pseudobulbar affective state
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