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DYSPHASIA/DYSARTHRIA
LEARNING OBJECTIVES:

At the end of this tutorial you should be able to:

1. Define dysphasia and dysarthria
2. Form a differential diagnosis for each.
3. Differentiate between the different types of dysphasia, based on clinical
features and anatomical location.
4. Examine patients with dysarthria, including examining for clinical
features suggestive of underlying aetiology.
5. Examine patients with dysphasia to determine type of dysphasia, and to
elicit features suggestive of underlying aetiology.
6. Choosing and justifying appropriate investigations of the patient with
dysarthria and dysphasia.

DEFINITION:
Dysarthria is a disorder of speech. 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.

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.

PATHOPHYSIOLOGY:
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, visuospatial and cognitive problems

DIFFERENTIAL DIAGNOSIS:

Dysarthria Dyphasia
Cerebrovascular Disease /CVA Cerebrovascular Disease /CVA
Multiple Sclerosis Dementia
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Motor Neuron Disease Space occupying lesion

Cerebellar Disease Head injury
Parkinsons Disease

HISTORY:

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 .
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
extra-pyramidal 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.

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.

Specific types of aphasia are associated with damage to particular cortical

regions but in practice distinctions are not always clear. Generally, expressive
dysphasia suggests an anterior lesion while receptive dysphasia suggests a
posterior lesion. There are a number of sub types. They are:

1. 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. The
consequence is a fluent or receptive aphasia in which speech is fluent but
lacking in content. Patients lack awareness of their speech difficulties.
2. 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.
3. 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.
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4. 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.

EXAMINATION:

Dysarthria
As this is difficulty with articulation, ask the patient to say British Constitution
or Peter Piper picked a peck of pickled peppers.
Look for signs of common causes for dysarthria including
1. Alcohol intoxication.

2. Pass pointing, dysdiadokinesis, intention tremor, ataxia and nystagmus

may indicate cerebellar disease.
3. If speech is typical of pseudobulbar palsy (speech sounds like patient is
trying to squeeze words out form tight lips) look for signs of multiple
sclerosis, motor neurone disease or bilateral cerebrovascular disease.

4. Slow monotonous dysarthric speech may indicate Parkinsons disease so

signs of this including tremor, rigidity and bradykinesia should be looked
for.

Dyphasia
Examining patients with receptive dysphasia

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.
1. Ask patients to name objects (often will be unable or will name them
poorly)
2. Repetition-often will be unable to repeat words
3. Ask patients to read a sentence such as Close your eyes and ask
them to do what it says-patients who have receptive dysphasia often
have difficulty following commands and reading.
4. Ask patients to write a sentence- patients will often include
abnormal content.

Examining patients with expressive dysphasia

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.

1. Ask patient to name an object-they will usually be unable to do so.

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2. Ask them to repeat No ifs, ands or buts .This is usually very poor.

3. Can the patient talk spontaneously on a familiar topic? "Tell me about

your family." "Tell me about the work you used to do".
4. Ask patients to read a sentence such as Close your eyes and ask them
to do what it says. Comprehension may be mildly impaired but patients
will often be able to follow written and verbal commands.

5. Dysgraphia is often present if patients are asked to write a sentence. Also

observe for hemiparesis.

6. Patients can often be frustrated and depressed as they are very aware of
their deficits.

INVESTIGATIONS:

1. Laboratory investigation: Full blood count (Thrombocytosis/

polycythaemia are risks for stroke) , urea and electrolytes (sever
electrolyte imbalance can cause neurological deficit, as can renal
encephalopathy), liver function tests (hepatic encephalopathy),
coagulation studies (?thrombophilia), and cardiac enzymes (Acute
coronary syndrome can precipitate stroke) should be obtained in most
patients.
2. Neuroimaging: Computerized tomography (CT) scan or magnetic
resonance imaging (MRI) for investigation of cerebrovascular disease,
multiple sclerosis or to exclude head injury..
3. Nerve studies: An electromyogram (EMG) is indicated if Motor Neurone
Disease is suspected.
4. Lumbar puncture: This test is necessary to investigate for multiple
sclerosis.
5. Neuropsychological tests: This group of tests further evaluates
cognitive function and assesses intellectual, language and spatial skills,
as well as memory, reasoning and judgment.