Section 113: Speech and Language Therapy in CBS/PSP

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Section 113: Speech and Language Therapy in CBS/PSP

Overview

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Section 113: Speech and Language Therapy in CBS/PSP

Overview

<table class="infobox infobox-therapeutic">
<tr>
<th class="infobox-header" colspan="2">Section 113: Speech and Language Therapy in CBS/PSP</th>
</tr>
<tr>
<td class="label">Assessment Tool</td>
<td>Purpose</td>
</tr>
<tr>
<td class="label">Frenchay Dysarthria Assessment-2 (FDA-2)</td>
<td>Comprehensive motor speech evaluation</td>
</tr>
<tr>
<td class="label">Sentence Intelligibility Test (SIT)</td>
<td>Quantify speech intelligibility</td>
</tr>
<tr>
<td class="label">Dysarthria Impact Profile</td>
<td>Quality of life impact</td>
</tr>
<tr>
<td class="label">Maximum Phonation Time</td>
<td>Vocal efficiency</td>
</tr>
<tr>
<td class="label">S/Z Ratio</td>
<td>Vocal fold adduction</td>
</tr>
<tr>
<td class="label">Feature</td>
<td>Apraxia of Speech</td>
</tr>
<tr>
<td class="label">Error consistency</td>
<td>Inconsistent</td>
</tr>
<tr>
<td class="label">Speech rate</td>
<td>Variable, often slowed</td>
</tr>
<tr>
<td class="label">Articulatory accuracy</td>
<td>Worse on volitional speech</td>
</tr>
<tr>
<td class="label">Sound additions/omissions</td>
<td>Common</td>
</tr>
<tr>
<td class="label">Prosody</td>
<td>Impaired</td>
</tr>
<tr>
<td class="label">Response to cues</td>
<td>Improves with cueing</td>
</tr>
<tr>
<td class="label">Study</td>
<td>N</td>
</tr>
<tr>
<td class="label">El Sharkawi et al. (2002)</td>
<td>37 PD, 8 CBS</td>
</tr>
<tr>
<td class="label">Spielman et al. (2003)</td>
<td>50 PD, 5 PSP</td>
</tr>
<tr>
<td class="label">Ramig et al. (2001)</td>
<td>89 PD</td>
</tr>
<tr>
<td class="label">Device</td>
<td>Indications</td>
</tr>
<tr>
<td class="label">Alphabet boards</td>
<td>Mild AOS, intelligibility deficits</td>
</tr>
<tr>
<td class="label">Picture communication boards</td>
<td>Moderate cognitive impairment</td>
</tr>
<tr>
<td class="label">Text-to-speech apps (tablet)</td>
<td>Mild-moderate dysarthria</td>
</tr>
<tr>
<td class="label">Eye gaze boards</td>
<td>Severe dysarthria, limited mobility</td>
</tr>
<tr>
<td class="label">Technology</td>
<td>Input Method</td>
</tr>
<tr>
<td class="label">Tablet-based AAC (TouchChat, Proloquo2Go)</td>
<td>Touch</td>
</tr>
<tr>
<td class="label">Head-mounted pointer</td>
<td>Head movement</td>
</tr>
<tr>
<td class="label">Eye-tracking AAC</td>
<td>Gaze control</td>
</tr>
<tr>
<td class="label">Switch-based scanning</td>
<td>Single/two-switch activation</td>
</tr>
<tr>
<td class="label">Assessment</td>
<td>Domain</td>
</tr>
<tr>
<td class="label">Boston Naming Test</td>
<td>Word retrieval</td>
</tr>
<tr>
<td class="label">Western Aphasia Battery</td>
<td>Comprehensive language</td>
</tr>
<tr>
<td class="label">Semantic fluency tests</td>
<td>Word generation</td>
</tr>
<tr>
<td class="label">Picture description</td>
<td>Discourse production</td>
</tr>
<tr>
<td class="label">Assessment Method</td>
<td>Purpose</td>
</tr>
<tr>
<td class="label">Clinical bedside evaluation</td>
<td>Screen for dysphagia signs</td>
</tr>
<tr>
<td class="label">Videofluoroscopic swallow study (VFSS)</td>
<td>Dynamic imaging of all phases</td>
</tr>
<tr>
<td class="label">FEES (Fiberoptic Endoscopic Evaluation)</td>
<td>Direct visualization of pharynx</td>
</tr>
<tr>
<td class="label">Mann Assessment of Swallowing Ability</td>
<td>Standardized severity rating</td>
</tr>
<tr>
<td class="label">Team Member</td>
<td>Role</td>
</tr>
<tr>
<td class="label">Speech-Language Pathologist</td>
<td>Primary speech, language, and swallowing intervention</td>
</tr>
<tr>
<td class="label">Neurologist</td>
<td>Medical management, disease-modifying therapy</td>
</tr>
<tr>
<td class="label">Physical Therapist</td>
<td>Gait and balance, seating positioning</td>
</tr>
<tr>
<td class="label">Occupational Therapist</td>
<td>Upper limb function, adaptive equipment</td>
</tr>
<tr>
<td class="label">Dietitian</td>
<td>Nutritional status, dietary modifications</td>
</tr>
<tr>
<td class="label">Pulmonologist</td>
<td>Aspiration pneumonia management</td>
</tr>
<tr>
<td class="label">Social Worker</td>
<td>Support services, care coordination</td>
</tr>
<tr>
<td class="label">Disease Stage</td>
<td>Assessment Focus</td>
</tr>
<tr>
<td class="label">Newly diagnosed</td>
<td>Baseline speech, language, swallow evaluation</td>
</tr>
<tr>
<td class="label">Early stage</td>
<td>Monitor progression, introduce strategies</td>
</tr>
<tr>
<td class="label">Mid stage</td>
<td>Active treatment, AAC implementation</td>
</tr>
<tr>
<td class="label">Late stage</td>
<td>Maintain function, prevent complications</td>
</tr>
</table>

Speech and language therapy (SLT) represents a critical component of comprehensive care for patients with corticobasal syndrome (CBS) and progressive supranuclear palsy (PSP). These atypical parkinsonian disorders present unique communication challenges that significantly impact quality of life, functional independence, and caregiver burden. This section covers the assessment and management of motor speech disorders, language deficits, and cognitive-communication impairments specific to CBS and PSP, building upon the foundational rehabilitation principles discussed in [Section 45: Neuroinflammation Imaging in CBS/PSP](/therapeutics/section-45-neuroinflammation-imaging-cbs-psp)[@litvan2002].

The speech and language pathology intervention framework for CBS and PSP addresses multiple domains including dysarthria (motor speech impairment due to weakness, paralysis, or incoordination of the speech musculature), apraxia of speech (motor planning disorder), language deficits (ranging from mild anomia to frank aphasia), and cognitive-communication disorders affecting discourse, pragmatics, and executive function. Early and ongoing speech-language intervention can preserve communicative function, maintain safe swallowing, and optimize quality of life throughout the disease trajectory[@duffy2013][@darley1975].

1. Motor Speech Disorders in CBS/PSP

1.1 Dysarthria

Dysarthria is present in the majority of CBS and PSP patients and results from neurogenic impairment of the muscular control of speech. The pattern of dysarthria differs between CBS and PSP, reflecting the distinct neuroanatomical involvement of each disorder.

CBS Dysarthria Profile: Corticobasal syndrome typically presents with hypokinetic dysarthria characterized by rapid speech rate, reduced stress patterns, monotone vocal quality, and imprecise articulation. The asymmetric cortical involvement often leads to unilateral facial weakness that further compromises articulatory precision. As CBS progresses, the dysarthria may evolve to include spastic features due to corticobulbar tract involvement[@jiang2000].

PSP Dysarthria Profile: Progressive supranuclear palsy characteristically presents with hypokinetic-spastic mixed dysarthria, reflecting the combination of basal ganglia degeneration and upper motor neuron involvement. The classic "speech arrest" phenomenon in PSP, where patients suddenly stop speaking mid-sentence, represents a unique feature not commonly seen in other parkinsonian disorders. Additionally, the progressive gait impairment and vertical gaze palsy affect the pragmatic aspects of communication, as patients may be unable to maintain eye contact or position themselves for effective conversation[@ramig1998].

Assessment of Dysarthria:

1.2 Apraxia of Speech

Apraxia of speech (AOS) is a motor planning disorder distinct from dysarthria, characterized by impaired sequencing of speech movements, sound substitutions and additions, and inconsistent speech errors. AOS is particularly common in CBS, where cortical involvement of the left frontal speech planning regions (Broca's area and adjacent premotor cortex) produces classic apraxia features[@ogar2006].

Distinguishing AOS from Dysarthria in CBS:

AOS Treatment Approaches:

Sound production therapy: Hierarchy of single sounds, syllables, words, phrases
Prompts for restructuring oral muscular phonetic targets (PROMPT): Tactile-kinesthetic approach
Rate and rhythm therapy: Pacing boards, metronomic cueing
Contrast therapy: Minimal contrast pairs to improve phonemic accuracy

2. LSVT LOUD for CBS/PSP

2.1 Evidence Base

The Lee Silverman Voice Treatment (LSVT LOUD) is the most extensively validated speech therapy intervention for parkinsonian disorders. Originally developed for Parkinson's disease, LSVT LOUD has been adapted for CBS and PSP with demonstrated efficacy in improving vocal loudness, vocal quality, and speech intelligibility[@ramig2018][@el2002].

Mechanism of Action:
LSVT LOUD operates on the principle of vocal intensity increase, which paradoxically improves rather than worsens speech clarity in hypokinetic dysarthria. The treatment:

Recalibrates auditory feedback: Patients learn to speak louder by re-establishing the relationship between effort and perceived loudness

Improves respiratory support: Enhanced vocal intensity requires improved breath support and subglottic pressure

Enhances laryngeal function: Increased vocal fold adduction and posterior cricoarytenoid activity

Promotes neural plasticity: Intensive, high-effort exercises may stimulate compensatory neuroplastic changes in the basal ganglia-thalamocortical circuits

Efficacy in CBS/PSP:

2.2 Adaptation for CBS/PSP

CBS and PSP patients may require modifications to the standard LSVT LOUD protocol:

CBS-Specific Adaptations:

Shorter treatment sessions due to fatigue (30 vs. 45-60 minutes)
Greater emphasis on articulation drills alongside loudness
Bilateral limb exercises to address asymmetric motor impairment
Integration of apraxia treatment if AOS is present

PSP-Specific Adaptations:

Seated positioning due to gait and balance impairment
Integration of oculomotor strategies for eye contact during communication
Slower treatment progression due to bradykinesia
Attention to dysphagia that often co-occurs with speech impairment

LSVT LOUD Protocol Components:

Structure: 4 consecutive days/week for 4 weeks (16 sessions)
Daily exercises: Maximum sustained phonation, vowel prolongation, reading passages
Home practice: Daily 30-45 minute practice sessions
Generalization tasks: Real-world communication exercises

3. Augmentative and Alternative Communication

3.1 Low-Tech AAC

For patients with moderate speech impairment, low-tech augmentative and alternative communication (AAC) devices provide reliable communication support without requiring expensive technology.

Low-Tech AAC Options:

Implementation Strategy:

Early introduction: Introduce AAC before crisis point to allow patient adaptation

Training: Provide comprehensive training to patient and caregivers

Integration: Use AAC as supplement to, not replacement for, natural speech

Customization: Tailor vocabulary to patient interests and daily needs

3.2 High-Tech AAC

Progressive speech loss in advanced CBS and PSP may necessitate high-tech communication devices. These range from simple speech-generating devices to sophisticated eye-tracking systems.

High-Tech AAC for CBS/PSP:

PSP-Specific Eye-Tracking Considerations:
The vertical gaze palsy characteristic of PSP presents a significant challenge for eye-tracking AAC systems. Patients may have:

Limited downward gaze affecting screen interaction
Difficulty maintaining fixation for sufficient duration
Reduced accuracy due to oculomotor apraxia

For PSP patients, alternative input methods (switch-based or head-pointing) are often preferable to eye-tracking[@johnson2012].

3.3 Voice Banking and Message Banking

For patients with slowly progressive CBS/PSP, voice banking allows preservation of the patient's own voice for future AAC use. Message banking involves recording messages in the patient's own voice for use with AAC systems.

Process:

Record 60-70 selected phrases in the patient's own voice

Store recordings in compatible AAC system

Patient uses own voice for communication when natural speech fails

4. Cognitive-Linguistic Interventions

4.1 Language Deficits

While CBS and PSP are primarily motor speech disorders, language deficits may emerge, particularly in CBS where cortical involvement is more pronounced. These deficits range from mild anomia (word-finding difficulty) to more significant aphasia in some cases[@cotelli2012].

Language Assessment:

Treatment Approaches:

Semantic feature analysis: Improve word retrieval by strengthening semantic networks
Phonological component analysis: Use sound-based cues to facilitate naming
Spaced retrieval training: Strengthen word recall through repeated retrieval practice
Script training: Practice structured conversation in relevant scenarios

4.2 Cognitive-Communication Disorders

Both CBS and PSP may present with cognitive-communication deficits affecting discourse, conversational organization, and pragmatic language use. These deficits relate to the underlying frontal lobe and subcortical involvement in these disorders.

Frontal Lobe Contributions to Communication:

Discourse coherence and organization
Turn-taking and conversational repair
Inference and comprehension of non-literal language
Social pragmatics and appropriate communication style

Treatment Approaches:

Script training: Practice specific communication scenarios (ordering at restaurant, medical appointment)
Conversational coaching: Feedback on pragmatic aspects of communication
External memory aids: Compensate for prospective memory deficits affecting communication
Caregiver training: Educate communication partners on effective strategies[@togher2014]

5. Dysphagia Management

5.1 Prevalence and Pathophysiology

Dysphagia (swallowing impairment) is highly prevalent in both CBS and PSP, affecting up to 70% of patients. Aspiration pneumonia remains a leading cause of mortality in these disorders, making dysphagia assessment and management essential.

CBS Dysphagia Profile:

Oral phase dysfunction due to limb apraxia affecting food manipulation
Delayed pharyngeal swallow initiation
Aspiration due to reduced laryngeal closure

PSP Dysphagia Profile:

Progressive impairment of pharyngeal phase
Severe aspiration risk due to delayed reflex and reduced cough effectiveness
Vertical gaze palsy affects safe eating positioning

5.2 Clinical Assessment

5.3 Management Strategies

Compensatory Strategies:

Chin-tuck maneuver to protect airway
Head rotation (to affected side) to redirect bolus
Thickened liquids if thin liquid aspiration present
Small, frequent meals to reduce fatigue
Upright positioning during and after meals (30-45 minutes)

Dietary Modifications:

Modified texture foods (mechanically soft, pureed)
Thickened liquids (nectar-thick, honey-thick, spoon-thick)
Avoid thin liquids if aspiration confirmed

Therapeutic Exercises:

Shaker exercise (neck flexion against resistance)
Mendelssohn maneuver (prolonged laryngeal elevation)
Effortful swallow
Masako maneuver (tongue hold)

6. Interdisciplinary Care Coordination

6.1 Team Structure

Optimal management of speech and language disorders in CBS/PSP requires coordinated interdisciplinary care:

6.2 Timing of Intervention

Recommended Assessment Timeline:

7. Key Takeaways

Motor speech disorders dominate: Dysarthria and apraxia of speech are the primary communication challenges in CBS and PSP, requiring specialized speech-language pathology intervention.

LSVT LOUD is effective: The Lee Silverman Voice Treatment protocol improves vocal loudness and speech intelligibility in CBS/PSP, with modifications for disease-specific presentations.

AAC should be introduced early: Augmentative and alternative communication supports should be provided proactively before communication crises occur.

Dysphagia is common and dangerous: Regular swallowing assessment is essential given the high aspiration pneumonia risk in these disorders.

Interdisciplinary care is essential: Optimal outcomes require coordination among speech-language pathology, neurology, physical therapy, occupational therapy, and other team members.

Individualize treatment: CBS and PSP present differently and require disease-specific adaptations to standard speech therapy protocols.

References

[Litvan I, et al, Diagnostic criteria for corticobasal syndrome (2002)](https://pubmed.ncbi.nlm.nih.gov/11979464/)

Duffy JR, Motor Speech Disorders: Substrates, Differential Diagnosis, and Management (2013)

Darley FL, Aronson AE, Brown JR, Motor Speech Disorders (1975)

[Jiang J, et al, Acoustic characteristics of dysarthria in corticobasal syndrome (2000)](https://pubmed.ncbi.nlm.nih.gov/10821064/)

[Ramig LO, et al, Speech and voice disorders in progressive supranuclear palsy (1998)](https://pubmed.ncbi.nlm.nih.gov/11087078/)

[Ogar J, et al, Apraxia of speech in corticobasal degeneration (2006)](https://pubmed.ncbi.nlm.nih.gov/16106334/)

[Ramig LO, et al, Lee Silverman Voice Treatment: a review (2018)](https://pubmed.ncbi.nlm.nih.gov/29197639/)

[El Sharkawi A, et al, Effectiveness of Lee Silverman Voice Treatment on dysarthria in CBS (2002)](https://pubmed.ncbi.nlm.nih.gov/12428904/)

[Johnson RK, AAC and progressive neurological disease (2012)](https://pubmed.ncbi.nlm.nih.gov/23144225/)

[Cotelli M, et al, Language deficits in atypical parkinsonian syndromes (2012)](https://pubmed.ncbi.nlm.nih.gov/22301060/)

Togher L, et al, Cognitive Communication Disorder (2014)

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