Treatment section of the Dysarthria Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
Treatment is individualized to address the specific areas of need identified during assessment. It is provided in the language(s) used by the person with dysarthria—either by a bilingual SLP or with the use of trained interpreters, when necessary. See ASHA's Practice portal page on
Collaborating With Interpreters, Transliterators, and Translators.
Consistent with the WHO's ICF framework (WHO, 2001), the goal of intervention is to help the individual achieve the highest level of independent function for participation in daily living.
Intervention is designed to
- capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication across partners, activities, and settings;
- optimize retention of new motor skills by implementing principles of motor learning (Maas et al., 2008);
- facilitate the individual's activities and participation by (a) teaching new skills and compensatory strategies to the individual with dysarthria and his or her partner(s) and (b) incorporating AAC strategies if appropriate; and
- modify contextual factors that serve as barriers and enhance those that facilitate successful communication and participation, including development and use of appropriate accommodations.
For individuals with dysarthria, treatment focuses on facilitating the efficiency, effectiveness, and naturalness of communication (Rosenbek & LaPointe, 1985; Yorkston et al., 2010).
Person-Centered Focus on Function: Dysarthria [PDF] for an example of functional goals consistent with ICF.
Treatment can be restorative (i.e., aimed at improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for deficits not amenable to retraining).
Restorative approaches focus on improving
- speech intelligibility,
- prosody and naturalness, and
Compensatory approaches focus on
- improving comprehensibility by
- increasing the speaker's use of communication strategies,
- improving listener skills and capacity, and
- altering the communication environment;
- increasing effective use of AAC options; and
- increasing use of non-AAC devices.
Treatment is not always restorative or compensatory. Sometimes, it is directed at preserving or maintaining function, such as when an individual has a slowly progressing degenerative disease.
Below are brief descriptions of treatment options for addressing dysarthria. This list is not exhaustive, and the inclusion of any specific treatment does not imply endorsement from ASHA.
Treatments are grouped into (a) those that directly target the speech-production subsystems and (b) other treatment options, including communication strategies, environmental modifications, AAC, and medical/surgical interventions by other specialists.
Treatment selection depends on a number of factors, including the severity of the disorder, natural history and prognosis of the underlying neurologic disorder, the perceptual characteristics of the individual's speech and his or her communication needs, patient and family preference and engagement, and the presence and severity of co-occurring conditions (e.g., aphasia, cognitive impairment, or apraxia of speech). One or more of these co-occurring conditions might affect the individual's insight into communication limitations, ability to implement compensatory strategies such as conversational repair, or ability to benefit from some treatment approaches.
It can be important to sequence treatments. For example, respiration and phonation are usually targeted initially, but prosthetic management of velopharyngeal dysfunction may be needed first in order to achieve efficient and effective breathing and phonation for speech (Duffy, 2013; Yorkston et al., 2010).
Some treatments have benefits that extend to subsystems other than the one being targeted. For example, improving prosody can benefit naturalness and intelligibility (Patel, 2002; Yorkston et al., 2010), and increased loudness (vocal effort) may induce changes in articulation and resonance (Neel, 2009).
Treatments That Target Speech-Production Subsystems
- Making postural adjustments (e.g., sitting upright to improve breath support for speech)
- Inhaling deeply before onset of speech utterance (known as preparatory inhalation)
- Using optimal breath groups when speaking (i.e., for each breath, speak only the number of syllables that can be comfortably produced)
- Using expiratory muscle strength training to improve strength of the expiratory muscles (the individual blows into a pressure threshold device with enough effort to overcome a preset threshold)
- Using inspiratory muscle strength training to improve strength of the inspiratory muscles to permit better sustained or repeated inspirations (the individual uses a handheld device that is set to require a minimum inspiratory pressure for inspiration to continue)
- Using maximum vowel prolongation tasks to improve duration and loudness of speech
- Using controlled exhalation tasks (air is exhaled slowly over time) to improve control of exhalation for speech
- Using nonspeech tasks to improve subglottal air pressure and respiratory support (e.g., blowing into a water glass manometer)
- Lee Silverman Voice Treatment (LSVT®; Ramig, Bonitati, Lemke, & Horii, 1994)—an intensive program that targets high phonatory effort to improve loudness and intelligibility
- Pitch Limiting Voice Treatment (PLVT; De Swart, Willemse, Maassen, & Horstink, 2003)—a program for increasing vocal loudness without increasing pitch
- Effort closure techniques to increase adductory forces of vocal folds (e.g., pulling upward on chair seat; squeezing palms of hands together)
- Improved timing of phonation (e.g., initiating phonation at beginning of expiration)
- Phonetic placement techniques (e.g., hands-on, descriptive, pictures) to work on positioning of the mouth, tongue, lips, or jaw during speech.
- Phonetic derivation techniques (nonspeech to speech tasks such as "blowing" to /u/).
- Exaggerated articulation (overarticulation) to emphasize phonetic placement and increase precision, sometimes called "clear speech."
- Minimal contrasts to emphasize sound contrasts necessary to differentiate one phoneme from another.
- Intelligibility drills in which the individual reads words, phrases, or sentences and attempts to repair content not understood by the listener.
- Rate modification to facilitate articulatory precision—strategies include
- pausing at natural linguistic boundaries (e.g., using printed script marked at natural pauses);
- using external pacing methods such as pacing boards, hand/finger tapping, and alphabet boards;
- using auditory feedback (e.g., delayed auditory feedback or metronome);
- using visual feedback (e.g., using computerized voice programs); and
- using approaches that reduce speech rate without directly targeting it (e.g., increasing loudness, altering pitch variation, altering phrasing or breath patterns).
- Prosthetic management in collaboration with other disciplines (e.g., dentists, prosthodontists)—examples include
- palatal lift prosthesis and
- nasal obturator to occlude nasal airflow.
- Resistance training during speech using continuous positive air pressure (Kuehn, 1997).
- Increasing awareness and ability to control respiration, rate, and pitch to vary emphasis within multisyllabic words and in connected utterances (e.g., using scripts, marked and unmarked passages)
- Improving intonation by signaling stress with loudness, pitch, or duration
- Extending breath groups to better align with syntactic boundaries
- Using contrastive stress tasks to improve prosody and naturalness (e.g., repeating sentence with stress on different word[s])
Other Treatment Options
A variety of communication strategies can be used by the individual with dysarthria (speaker) and his or her communication partner to enhance communication when speech intelligibility or efficiency is reduced. These strategies can be used before, during, or after other treatment approaches are implemented to improve or compensate for speech deficits (see, e.g., Duffy, 2013).
Speaker strategies include
- maintaining eye contact with the communication partner;
- preparing the communication partner by gaining his or her attention and introducing the topic of conversation before speaking;
- pointing and gesturing to help convey meaning;
- looking for signs that the communication partner has or has not understood the message; and
- effectively using conversational repair strategies (e.g., restating message in different words; using gestures to help clarify message).
Communication-partner strategies include
- maintaining eye contact with the speaker;
- being an active listener and making every effort to understand the speaker's message;
- asking for clarification by asking specific questions;
- providing feedback and encouragement; and
- optimizing the ability to hear the speaker and to see the speaker's visual communication cues (e.g., by wearing prescribed hearing aids and glasses during conversations).
Environmental modification involves identifying optimal parameters to enhance comprehensibility.
These parameters include
- reducing background noise (e.g., choose a quiet setting for conversations; turn off TV, radio, and fans);
- ensuring that the environment has good lighting;
- improving proximity between the speaker and his or her communication partner; and
- using face-to-face seating for conversations.
Augmentative and Alternative Communication (AAC)
AAC involves supplementing or replacing natural speech and/or writing.
The two forms of AAC are
- unaided (e.g., manual signs, gestures, and finger spelling) and
- aided (e.g., line drawings, pictures, communication boards, tangible objects, speech-generating devices).
Other augmentative supports include voice amplifiers, artificial phonation devices (e.g., electrolarynx devices and intraoral devices), and oral prosthetics to reduce hypernasality.
See ASHA's Practice Portal page on
Augmentative and Alternative Communication.
SLPs may refer the individual to a medical specialist to assess the appropriateness of, or need for, medical interventions.
These interventions can include, for example,
- pharyngeal augmentation, pharyngeal flap, or palatal flap to treat velopharyngeal incompetency and improve resonance;
- laryngeal (vocal fold) augmentation (e.g., autologous fat or collagen), laryngoplasty, or recurrent laryngeal nerve sectioning to improve phonation; and
- pharmacological management to relieve symptoms of the underlying neurologic condition (e.g., spasticity, tremor) associated with underlying neurologic disease.
Not all individuals with dysarthria are candidates for treatment. Factors influencing decisions about treatment include the individual's communication needs, his or her motivation, and the presence of other deficits or conditions that can affect communication.
In neurodegenerative disease, treatment is often appropriate. The goal of treatment is to maximize communication at each stage of the disease, not to reverse decline (Duffy, 2013). This may include strategies to conserve energy and minimize fatigue.
Individuals with neurodegenerative diseases will need compassionate counseling to anticipate
- the potential progression of dysarthria;
- the corresponding changes in communication; and
- the types of intervention that might be appropriate at different stages (e.g., AAC, voice banking).
Views of the natural aging process and acceptance of disability vary by culture. Cultural views and preferences may not be consistent with medical approaches typically used in the U.S. health care system. It is essential that the clinician demonstrate sensitivity to family wishes when sharing potential treatment recommendations and outcomes. Clinical interactions should be approached with cultural humility.
See the Service Delivery section of the Dysarthria Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the optimal treatment approach for an individual with dysarthria, the clinician considers service delivery variables—such as format, provider, dosage, timing, and setting—which may have an impact on treatment outcomes.
Format—refers to the structure of the treatment session (e.g., group and/or individual). Individual treatment may be most appropriate for learning new techniques and strategies. Group treatment provides opportunities to practice techniques and strategies in a naturalistic setting and receive feedback about their effectiveness in improving comprehensibility and overall communication.
Provider—refers to the person providing the treatment (e.g., SLP, trained volunteer, family member, caregiver). In addition to skilled treatment provided by the SLP, family members and other communication partners can be trained by the SLP to provide opportunities for practice, encourage the use of strategies like AAC, and give feedback about performance in functional settings.
Dosage—refers to the frequency, intensity, and duration of service. Dosage may vary depending on individual's type and severity of disease, energy level, motivation, and degree of community support. Individuals with dysarthria may benefit from frequent and intense practice consistent with the principles of motor learning to enhance retention of speech skills (Bislick, Weir, Spencer, Kendall, & Yorkston, 2012; Kleim & Jones, 2008; Maas et al., 2008).
Timing—refers to when intervention is initiated relative to the diagnosis. Early initiation of treatment may be beneficial for learning or relearning motor patterns; however, improvements in comprehensibility using communication strategies are possible at any point. Timing for introducing prosthetic management and/or AAC may vary with the setting, the individual's preferences, and the severity and stage of disease.
Setting—refers to the location of treatment (e.g., home, community-based). Individuals may benefit from a naturalistic treatment environment that incorporates a variety of communication partners to facilitate generalization and carryover of skills.