Directed Neurological Examination

Speech. The examination of speech includes the assessment of speech volume, rate, articulation, prosody, and initiation. M , y Each component of speech can be affected differently in various disorders. The examiner should assess speech through spontaneous conversation or by having the patient read a standardized passage to elicit a wide range of sounds including labials, linguals, dentals, and gutturals.

Speech volume may be increased with auditory perceptual problems. Reduced volume (hypophonia) is seen in extrapyramidal motor disorders and in peripheral disorders such as vocal cord paresis.

The rate of speech may be increased in Parkinson's disease, in which patients speak rapidly, and in patients with Wernicke's aphasia, who have pressured speech. In general, nonfluent aphasics speak slowly.

Articulation defect is a sign of motor impairment. Dysarthric speech often results in stereotyped speech errors, that is, repeating the same errors when trying to produce certain sounds. This helps distinguish dysarthric speech from paraphasic speech, in which substituted letters occur in a variable pattern.

Prosody evaluation includes assessment of the inflection, prosodic matching of sentence structure (declarative sentence, questions, boundaries between clauses), assessment of affective intent, and assessment of pragmatic intent (humor, declarative, sarcastic, defensive). Speech inflection and prosodic matching of sentence structure are mediated by the left hemisphere, whereas affective intent is mediated by right hemisphere and basal ganglia functions.

Timing of speech initiation is related to supplementary

motor area function and its outflow.y , y Patients with severe latencies do not speak at all (mutism).

Laryngeal phonation, or breathiness, and resonance, or nasality, are two other qualities of speech that aid in localization.

Language. The six main parts of the language examination can be performed at the patient's bedside. These parts include (1) expressive speech, (2) comprehension of spoken language, (3) repetition, (4) naming, (5) reading, and (6) writing. y y y The examiner can classify most aphasic syndromes after evaluating spontaneous speech, repetition, and comprehension (.Fig, 6.-3. ).

Expressive Speech. The evaluation of aphasia traditionally begins by observing the spontaneous or conversational speech of the patient. Aphasic verbal output is either nonfluent or fluent. Normal English output is 100 to 150 words per minute. y Nonfluent aphasic output is sparse (under 50 words per minute), produced with considerable effort, poorly articulated, of short phrase length (often only a single word), and dysprosodic (abnormal rhythm), and features a preferential use of substantive meaningful words with a relative absence of functor words (prepositions, articles, adverbs). Fluent aphasic output is the opposite, featuring many words, easily produced, with normal phrase length and prosodic quality but often omitting semantically significant words. Fluent aphasia, when severe, may sound empty and devoid of content. In addition, paraphasic errors (substitution of phrases or words) are often abundant in fluent aphasic output. Nonfluent aphasic output is associated with pathology involving the anterior left hemisphere, y , y and fluent aphasia results from pathology posterior to the fissure of Rolando.

Comprehension of Spoken Language. Comprehension can be assessed in many waysy ; four examples of clinical evaluations of comprehension include (1) conversation-engaging the patient in ordinary conversation probes the patient's ability to understand questions and commands; (2) commands--a series of single or multistep commands, such as asking the patient to pick up a piece of paper, fold it in two, and place it on a bedside stand; (3) yes and no answers-require only elementary motor function and can be used to assess various comprehension levels (for example, are the lights on in this room?); and (4) pointing-requires a limited motor response (patients can be asked to point to the window, the door, and the ceiling; the patients are asked to point to these places in a specific sequence, and more difficult tasks also can be given [e.g., point to the source of illumination in this room]).

Despite all of these methods, comprehension remains difficult to assess. Patients may derive significant meaning from nonverbal cues (e.g., tone of voice, facial or arm gesture) and may lead the clinician to underestimate the comprehension deficit. Apraxia and other motor disorders may cause a failure to perform, leading to an overestimation of the deficits. Perseverative answers may further complicate comprehension assessment.

Repetition. The examiner tests repetition by requesting that the patient repeat digits, words, and sentences. A phrase like "no ifs, ands, or buts" poses special difficulty.y Aphasics with impaired repetition have pathology that involves the perisylvian region. In contrast, a strong, often mandatory tendency to repeat (echolalia) suggests an extrasylvian locus of pathology, often involving the vascular borderzone areas.

Figure 6-3 Algorithm for demonstration of aphasia syndromes.

Naming. Disturbances in confrontational naming are the least specific language abnormalities. Naming is disturbed in most aphasic patients. Testing should evaluate the patient's ability to name objects (both high and low frequency), body parts, colors, and geometrical figures. If the patient fails, the examiner provides a phonemic cue (such as pronouncing the initial phoneme of the word) or a semantic cue (such as "You write with a_."). Anomia is generally not a reliable localizing abnormality.y

Reading. The examination tests both reading aloud and reading for comprehension.

Writing. Writing is nearly always disturbed in aphasic patients. Writing provides a further sample of expressive language and permits evaluation of spelling, syntax, visuospatial layout, and mechanics. The examiner assesses writing to dictation and to command (e.g., describe your job), as well as copying.

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