What is the management approach for a patient with a history of cerebrovascular accident (CVA) presenting with progressive dysarthria?

Management of Progressive Dysarthria in a Patient with History of CVA

Early referral to a speech-language pathologist (SLP) is essential for comprehensive evaluation and treatment of progressive dysarthria in post-stroke patients to maximize communication recovery and prevent functional decline.

Initial Assessment

• A comprehensive evaluation by a certified SLP should identify the presence, type, and severity of dysarthria by assessing all components of the motor speech system: respiration, phonation, resonance, articulation, prosody, and overall intelligibility 1
• The Frenchay Dysarthria Assessment is recommended to quantitatively evaluate respiration, phonation, resonation, articulation, and prosody 1
• Neuroimaging (CT or MRI) should be performed to identify new lesions or progression of existing damage, as dysarthria can result from lesions along the pyramidal tract or in the cerebellum 2, 3
• Evaluation should occur as early as possible, as treatment outcomes are superior when begun in the acute stage of recovery 4

Treatment Approach

Speech and Language Therapy

• Individualized speech therapy should target the specific physiological support systems affected, including respiration, phonation, articulation, and resonance 1

• Treatment should focus on:

  • Improving articulation precision (most common deficit in post-stroke dysarthria) 5
  • Addressing harsh voice quality and respiratory control 5
  • Optimizing speaking rate 6
  • Developing compensatory strategies for communication 4

• Specific therapeutic techniques include:

  • Direct intervention targeting affected subsystems (articulation, resonance, phonation, respiration, or prosody) 4
  • Development of compensatory behaviors 4
  • Training in the use of augmentative/alternative communication devices for severely affected patients 1

Patient-Centered Strategies

• Self-led speech rehabilitation activities that are functionally based should be encouraged, including:
  • Careful articulation and vocal projection exercises 7
  • Pre-planning interactions 7
  • Focused, effortful speech practice 7
  • Word substitution techniques 7
  • Reading-aloud and speaking-aloud activities 7

Communication Partner Training

• The SLP should educate rehabilitation staff and family/caregivers in techniques to enhance communication with patients who have dysarthria 4
• Environmental modifications should be implemented to improve communication effectiveness 1
• Communication partner training has been shown to be effective in improving communication activities and participation 1

Monitoring and Follow-up

• Regular reassessment of communication abilities should document resolution, improvement, or worsening of symptoms after treatment 1
• Monitoring is crucial as dysarthria may be a symptom of recurrent stroke, particularly when progressive 4
• Patients with progressive symptoms within 48 hours of onset should be immediately sent to an emergency department with capacity for advanced stroke care 4

Special Considerations

• Dysarthria is more prevalent in left than right hemisphere lesions 6
• The most common type of dysarthria following stroke is Unilateral Upper Motor Neuron (UUMN), present in approximately 52% of patients 5
• The psychosocial impact of dysarthria is often disproportionate to the severity of the physiological impairment 1
• Activities to facilitate social participation and promote psychosocial well-being should be incorporated into the treatment plan 1

Prognosis

• Approximately half of patients with post-stroke dysarthria show complete recovery within one week following symptom onset 5
• Early treatment is key to maximizing recovery, as outcomes are superior when treatment begins in the acute stage 4
• The recovery of treated individuals is nearly twice that of untreated individuals when treatment is begun in the acute stage (less than 4 months from insult) 4

By implementing this comprehensive management approach, patients with progressive dysarthria following CVA can achieve optimal communication outcomes and improved quality of life.