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15-Day Speech Therapy Plan: Spastic Dysarthria + Broca's Aphasia

Understanding the Combined Presentation

• Bradley and Daroff's Neurology in Clinical Practice, p. 1211: "Spastic dysarthria occurs in patients with bilateral lesions of the motor cortex or corticobulbar tracts... harsh or strain-strangle vocal quality, reduced rate, low pitch, consonant errors."
• Adams and Victor's Principles of Neurology, 12e, p. 507: Broca aphasia = "primary deficit in language output and speech production with relative preservation of comprehension... words uttered slowly and laboriously, enunciated poorly, missing normal inflection, intonation, phrasing."

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Pre-Therapy Baseline Assessment (Day 1)

• Speech intelligibility (word, sentence level - % intelligible)
• Oral motor function: lip/tongue strength, range of motion, diadochokinesis (puh-tuh-kuh)
• Voice quality: pitch, loudness, strain-strangle quality (GRBAS scale)
• Respiratory support: breath support for speech
• Language: confrontation naming, repetition, spontaneous speech, auditory comprehension (WAB-R or BDAE)
• Functional communication: ASHA FACS or CADL-2

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Overall Goals (15 Days)

1. Motor speech: Reduce vocal strain, improve breath support, increase articulatory precision and speech rate control
2. Language (expressive): Increase mean length of utterance, improve word retrieval, reduce agrammatism
3. Functional communication: Establish reliable AAC strategies and supported communication strategies

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Phase 1: Foundation (Days 1-5)

Day 1 - Baseline + Orientation

• Assessment: Full baseline as above
• Patient/family education: Explain both disorders, set expectations, introduce home practice
• Relaxation exercises: Gentle jaw, neck, and shoulder relaxation to reduce hypertonia

Day 2 - Respiratory Foundation

Day 3 - Oral Motor + Phonation

Day 4 - Articulation Basics

Day 5 - Review + Respiratory-Phonatory Integration

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Phase 2: Building (Days 6-10)

Day 6 - Articulation - Fricatives & Stops

Day 7 - Rate Control + Intonation

Day 8 - Phonation + Voice Quality

Day 9 - Sentence Level + Functional

Day 10 - Mid-Point Review

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Phase 3: Generalization & Functional Communication (Days 11-15)

Day 11 - Conversational Speech

Day 12 - Literacy and Reading Aloud

Day 13 - AAC and Self-Monitoring Strategies

Day 14 - Home Program Design + Intensive Practice

Day 15 - Final Assessment + Discharge Planning

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Summary of Key Techniques Used

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Important Clinical Notes

1. Session length: 45-60 minutes/day is appropriate; fatigue is common - monitor closely, especially with bilateral motor lesions.
2. Co-occurrence complexity: Broca's aphasia impairs word retrieval AND motor programming simultaneously - always distinguish an articulatory error (dysarthria) from a phonemic/word-level error (aphasia) when analyzing errors.
3. Apraxia of speech often co-occurs with Broca's aphasia (insular/premotor involvement per Adams & Victor) - if sound sequencing errors predominate, add specific AOS tasks (articulatory kinematic treatment).
4. Spasticity warning: Oral motor exercises against resistance should be introduced cautiously - strengthening exercises alone do not improve speech in UMN dysarthria; the focus is on movement coordination and respiratory-phonatory efficiency.
5. Theta burst TMS: Emerging evidence (PMID: 41401734, 2026 meta-analysis) supports inhibitory TBS over right hemisphere homologs to improve post-stroke aphasia - may be considered as adjunct if available.
6. Reassess at Day 10 and adjust the remaining plan based on progress - the most responsive patients may accelerate to conversational/functional goals earlier.

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15-Day Individualized Speech Therapy Plan

Patient Profile (from Medicover Hospital Document)

Clinical Examination Findings

• Right UMN facial palsy +
• Severe dysarthria (spastic type - bilateral corticobulbar involvement)
• Broca's aphasia +
• Comprehension intact
• Right UL/LL power: 4/5
• Right pronator drift +
• HSS: 5
• Out of thrombolysis window; underwent 4-vessel DSA + intra-arterial thrombolysis; ICU stay

Imaging (MRI + CT Brain)

• Acute non-hemorrhagic infarcts: Left frontal lobe + left centrum semiovale (explains Broca's aphasia + dysarthria)
• Chronic lacunar infarcts: Right frontal lobe (explains bilateral UMN picture = spastic dysarthria)
• Bilateral cerebellar hemispheres + right superior cerebellar peduncle involvement
• Possible NPH (Evan's index 0.41 on MRI; 0.40 on CT)
• Moderate generalized cerebral atrophy + mild cerebellar atrophy
• Hypoplastic left vertebral artery + left posterior communicating artery
• Fetal origin of right PCA

Discharge Status

• Conscious, alert
• Persistent dysarthria (spastic)
• Right-sided weakness improved
• Broca's aphasia persisting (comprehension intact, expression impaired)

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Clinical Reasoning for Therapy Design

• Spastic dysarthria - from bilateral corticobulbar tract damage (left acute infarct + right chronic lacunar infarcts). Features: harsh/strain-strangle voice, slow rate, consonant distortion, reduced loudness. (Bradley & Daroff's Neurology, p. 1211)
• Broca's aphasia - from left frontal lobe + centrum semiovale infarct. Features: non-fluent telegraphic output, effortful articulation, agrammatism, word-finding difficulty, comprehension relatively intact. (Adams & Victor, p. 507)
• Additional consideration: possible cerebellar component (bilateral cerebellar hemisphere involvement) may add mild ataxic features to speech
• Right hemiparesis (4/5) means right-hand writing is compromised - AAC must use left hand/gesture
• NPH risk - monitor for gait and cognitive changes that may affect therapy compliance
• Age 61, post-acute phase (therapy starting ~Day 12 post-stroke): in the window of maximum neuroplasticity

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Baseline Assessment (To be done before Day 1)

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PHASE 1: STABILIZATION & FOUNDATION (Days 1-5)

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DAY 1 - Orientation, Relaxation & Baseline Confirmation

Dysarthria Component (20 min)

Aphasia Component (20 min)

Home Task

• Family to practice: ask yes/no questions and allow patient to nod/gesture without rushing

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DAY 2 - Respiratory Foundation & Auditory Stimulation

Dysarthria Component (22 min)

Aphasia Component (20 min)

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DAY 3 - Oral Motor Activation & Word Retrieval Initiation

Dysarthria Component (22 min)

Aphasia Component (20 min)

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DAY 4 - Consonant Articulation & Phrase Facilitation

Dysarthria Component (22 min)

Aphasia Component (20 min)

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DAY 5 - Breath-Voice Integration & Automatic Speech Expansion

Dysarthria Component (22 min)

Aphasia Component (20 min)

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PHASE 2: BUILDING ARTICULATORY PRECISION & PHRASE OUTPUT (Days 6-10)

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DAY 6 - Fricatives & Minimal Pairs

Dysarthria Component (25 min)

Aphasia Component (18 min)

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DAY 7 - Rate Control & Prosody

Dysarthria Component (25 min)

Aphasia Component (18 min)

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DAY 8 - Voice Quality & Connected Speech

Dysarthria Component (25 min)

Aphasia Component (18 min)

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DAY 9 - Sentence-Level Speech & Functional Communication

Dysarthria Component (22 min)

Aphasia Component (20 min)

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DAY 10 - Mid-Program Reassessment & Consolidation

Formal Reassessment (25 min)

Consolidation Practice (18 min)

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PHASE 3: GENERALIZATION, FUNCTIONAL COMMUNICATION & DISCHARGE PREP (Days 11-15)

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DAY 11 - Conversational Speech & Role-Play Contexts

Dysarthria Component (22 min)

Aphasia Component (20 min)

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DAY 12 - Oral Reading & Writing (Compensatory)

Dysarthria Component (22 min)

Aphasia Component (20 min)

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DAY 13 - AAC Independence & Family/Caregiver Training Session

AAC & Caregiver Session (25 min)

Carry-Over Speech Practice (18 min)

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DAY 14 - Home Program Design & Intensive Pre-Discharge Practice

Intensive Practice (25 min)

Home Program Construction (18 min)

• Provide written + illustrated home program
• Family demonstrates program back to SLP (teach-back method)
• Review red flags: sudden new speech regression, new swallowing difficulty, increased confusion (signs of NPH progression or new infarct)

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DAY 15 - Final Assessment & Discharge Planning

Formal Final Assessment (25 min)

Discharge Planning (18 min)

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Summary Matrix: All 15 Days

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Special Considerations for This Patient

1. Bilateral cerebellar infarcts: Monitor for ataxic overlay on speech (irregular articulatory breakdown). If present, add cerebellar dysarthria techniques (syllable-by-syllable pacing, reduced rate targets).
2. NPH watch (Evan's index 0.41): If gait deteriorates, urinary incontinence appears, or cognition declines during therapy - alert neurology immediately. Cognitive decline will directly impair therapy participation.
3. Right hemiparesis (4/5): All writing tasks default to left hand. AAC designed for left-hand operation. Coordinate with OT for right hand functional recovery.
4. Post-ICU fatigue: Days 1-3 sessions may need to be shortened to 30 min if fatigue is significant. Never push through marked fatigue - neuroplasticity requires adequate rest.
5. Intra-arterial thrombolysis + DSA history: No contraindications to SLP intervention, but coordinate with neurology before any form of oromotor strengthening resistance exercises.
6. High-intensity therapy is cost-effective and minimally fatiguing: Per COMPARE trial (PMID 38328930, Stroke 2024) - high-intensity aphasia therapy post-stroke is cost-effective and not excessively fatiguing even in older patients. This supports 45 min/day intensity for this patient.

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✅ Printable Patient Home Exercise Program – Ready!

• 📄
  speech hep

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  (565 KB – print-ready, 3 pages A4)
• 🌐
  speech hep

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What's included across the 3 pages:

• Patient identity card (61M, Medicover Hospital, 17 May 2026, Dr. Ojha & Dr. Basak)
• Diaphragmatic breathing with SVG illustration (sitting figure + breath arrows)
• Sustained vowel /aaa/ drill with timer arc
• LSVT LOUD voice drill box

• Bilabial /p/ /b/ /m/ drill with 3-face SVG illustration
• Alveolar /t/ /d/ /n/ /l/ with mouth cross-section SVG
• Metronomic pacing with metronome SVG
• Clear speech strategy card with "casual vs. clear" speech bubble diagram
• Contrastive stress with pitch contour line SVG
• Breath group phrase practice with visual boxes

• Melodic Intonation Therapy (MIT) with musical notes + hand tapping SVG
• 5 functional MIT phrases listed
• Picture naming, automatic sequences, sentence completion
• Full daily schedule table (Morning / Afternoon / Evening)
• 15-day progress tracker with 3 checkboxes per day (tick-off format)
• Family/caregiver rules box
• Red emergency warning box (when to call doctor)

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🎬 Video Demonstration Script — Ready!

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  video script

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• 🌐
  video script

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What's inside — 12 complete video scripts across 8 pages:

Each script includes:

• Timecode — exact second-by-second breakdown
• Shot — Camera 1 (wide/medium) or Camera 2 (close-up mouth)
• [SAYS] — verbatim therapist narration in full
• [DEMO] — exact physical actions to perform on camera
• [TEXT] — word-for-word on-screen text overlays
• Correct vs. common mistake split-screen moments (V1, V6, V7, V8, V9, V11, V12)
• Clinical rationale narrated in patient-friendly language (especially V2 LSVT, V10 MIT)
• Production setup notes for each video (camera position, props, lighting)
• Full pre-shoot production checklist on the final page

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✅ Word Document Ready!

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What's inside — 5 pages, fully formatted:

• Patient identity table (name, diagnosis, hospital, neurologists, NIHSS, date)
• Two side-by-side shaded boxes: Spastic Dysarthria vs. Broca's Aphasia — plain language explanation of each
• Neuroplasticity explanation box in green — why daily practice works

• Full daily schedule table (Morning / Afternoon / Evening, who helps, duration)
• Colour-coded timing tips box
• 4-step cueing hierarchy table (Step 1: wait 10 sec → Step 2: first sound → Step 3: syllable → Step 4: full word)
• "Wait fully" warning box

• Science of MIT explained in plain language (right brain bypass)
• 5 numbered steps for how to do MIT together
• MIT phrase table with singing guide (syllables + pitch notes) for all 5 daily phrases

• Two-column DO / DON'T table (10 items each, green/red shading)
• 6-step conversation guide
• Yes/No question bank for tired days
• 4-point clear speech checklist as a coloured 4-box table

• 15-day tracker (3 checkboxes per day: Morning / Afternoon / Evening)
• Weekly progress notes lines (fill-in)
• Emergency warning box in red (when to call immediately)
• NPH watch box (Evan's index 0.41 — specific to this patient)
• Contacts table (Medicover helpline, neurology, SLP, 112)
• Warm closing message to family

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Speech Discrimination Score (SDS) — Audiometry: Protocol & Reporting

1. Terminology Clarification

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2. What SDS Actually Tests

• SRT/SDT — measures the threshold at which speech is first detected or recognised
• Pure tone audiometry — measures threshold sensitivity to tones, not speech comprehension

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3. Pre-Test Requirements

Equipment

• Calibrated audiometer with speech channel (TDH-39 or insert earphones; Etymotic ER-3A inserts preferred for masking)
• Recorded PB word lists (preferred over monitored live voice — MLV)
• Sound-treated booth (ambient noise levels per ANSI S3.1)
• VU meter for speech level calibration

Patient Preparation

• Otoscopy first: clear cerumen, confirm no active discharge or TM perforation that would affect placement
• Establish pure tone average (PTA) and SRT before SDS testing
• Explain the task: "You will hear single words. Repeat each word exactly as you hear it. If you are not sure, guess."
• Confirm the patient understands the language of the word list being used

Calibration

• Set the VU meter so the calibration tone reads 0 VU
• Recorded speech materials include a calibration signal — use it every session
• In sound-field testing: calibrate using a sound level meter; calibration signal is typically a 1000 Hz FM tone or narrow-band noise per ISO 8253-3:2012 (Scott-Brown's Otorhinolaryngology, p. 7107)

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4. Test Protocol — Step by Step

Step 1: Determine the Presentation Level (PL)

• Mild HL (SRT ~25 dB): Present at 50–60 dB HL
• Moderate HL (SRT ~50 dB): Present at 75–85 dB HL
• Severe HL: Present at MCL (most comfortable loudness) if 40 dB SL exceeds UCL

Step 2: Select the Word List

• Phonetically Balanced (PB) = phonemes in the list occur at the same proportion as in natural spoken discourse (K.J. Lee, p. 3180)
• Use recorded material, not monitored live voice (MLV). MLV reduces repeatability and inter-tester reliability.
• Standard test = 50-word list (occasionally 25-word half-lists used for screening — multiply % by 2)

Step 3: Masking the Non-Test Ear

• Presentation level to the test ear exceeds bone-conduction threshold of the better ear by 40 dB or more at two frequencies
• Masking noise = speech-shaped noise (white noise filtered to match long-term average speech spectrum) (Scott-Brown's, p. 7093)
• Set masking level: SRT of non-test ear + 20 dB (adjust as needed using plateau method)

Step 4: Administer the Test

1. Present each word at the chosen level through earphones (or insert phones)
2. Patient responds by repeating the word aloud (open-set, no word choices shown)
3. Scorer marks each word as correct or incorrect
4. No partial credit for similar-sounding words in whole-word scoring
5. If using phoneme scoring (Boothroyd): score each phoneme separately (3 phonemes/word × 10 words = 30 phonemes total → multiply correct phonemes × 3.33 for percentage)

Step 5: Calculate the Score

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5. Interpretation — SDS Score Classification

Standard Classification (K.J. Lee's Essential Otolaryngology, p. 3188)

Critical Clinical Interpretation: Presentation Level Context

• Average conversational speech = 50–60 dB HL
• A patient with SRT 25 dB, tested at 30 dB SL (= 55 dB HL) and scoring 80%: words were at conversational level → clinically relevant result
• A patient with SRT 45 dB, tested at 30 dB SL (= 75 dB HL) and scoring 80%: words were presented louder than normal conversation → real-world understanding will be worse than the score suggests (K.J. Lee, p. 3198)

Retrocochlear Red Flags in SDS

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6. PI-PB Function (Rollover) — Advanced SDS Protocol

Procedure

1. Measure SDS at 5–6 different presentation levels (e.g., SRT+10, +20, +30, +40, +50, +60 dB SL)
2. Plot SDS% on Y-axis vs. presentation level (dB HL) on X-axis
3. Identify the PB-max (highest score) and note if score decreases at higher levels

Rollover Index (RI)

Normal vs. Abnormal PI-PB Function

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7. Masking in Speech Audiometry — Rules

• Masking noise type: speech-shaped noise (not narrow-band, not white noise)
• Over-masking: if masking level becomes too high, it crosses to the test ear and artificially reduces the score — use plateau method to avoid this

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8. SDS Reporting — Standard Format

Minimum Required Elements

SPEECH AUDIOMETRY REPORT

Patient:          _______________    Date: ___________
Audiologist:      _______________    Equipment: ___________

                        RIGHT EAR        LEFT EAR
──────────────────────────────────────────────────────
SRT (dB HL)              ___              ___
SRT-PTA agreement        ±___ dB          ±___ dB
SDS Presentation Level   ___ dB HL        ___ dB HL
  (Sensation Level)      ___ dB SL        ___ dB SL
SDS %                    ___%             ___%
Word List Used           NU-6 / CID-W22 / Other: ___
Masking used?            Yes / No         Yes / No
  Masking level          ___ dB           ___ dB
Method                   Recorded / MLV

Interpretation Section (mandatory in clinical reports)

1. SRT-PTA agreement: should be within ±10 dB. If not — note discrepancy and possible cause (non-organic HL, steeply sloping audiogram, etc.)
2. SDS performance category: use the 5-tier classification above
3. Functional communication implications: estimate real-world conversational ability based on absolute HL + SDS
4. Symmetry: compare right vs. left SDS — note if >15% asymmetry
5. Retrocochlear flags: note if SDS is disproportionately reduced for PTA, if rollover was present, or if asymmetry is present
6. Recommendations: hearing aid evaluation, further testing (ABR, MRI IAM), review interval

Sample Report Language

"Right ear SDS: 52% at 75 dB HL (SRT+30 dB SL). Left ear SDS: 94% at 60 dB HL (SRT+30 dB SL). The right ear demonstrates a marked asymmetry in word recognition ability (42% interaural difference). Right ear SDS is disproportionately reduced relative to the PTA of 45 dB. Rollover testing was performed; RI = 0.48 (significant). These findings are suspicious for a retrocochlear lesion on the right. Recommendation: MRI internal auditory meatus with gadolinium contrast to rule out vestibular schwannoma. Acoustic reflex testing and ABR also recommended."

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9. SDS in Specific Clinical Contexts

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10. Quality Assurance & Common Errors

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Summary Table: SDS Protocol at a Glance

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SRT Audiometry — Frequencies, Protocol & Report Writing with Example

1. What SRT Is and Why It Matters

1. Confirm and validate the pure tone audiogram (the SRT should match the PTA)
2. Serve as the reference level from which to set the presentation level for SDS/WRS testing (SRT + 25–35 dB SL)

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2. Which Frequencies Are Involved in SRT?

SRT does NOT use pure tone frequencies — it uses SPEECH (spondees)

SRT is validated against the Pure Tone Average (PTA) at:

SRT–PTA Agreement Rule:

• SRT must be within ±10 dB of the PTA (K.J. Lee, p. 3174)
• Shambaugh Surgery of the Ear is stricter: SRT should differ by no more than ±6 dB from the 500/1000/2000 Hz PTA (p. 4617)
• If discrepancy is >10 dB → pure tone thresholds are suspect → re-test, consider non-organic hearing loss (NOHL/functional hearing loss)

When to use a Best Two-Frequency PTA instead:

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3. What Are Spondees?

• Why spondees? Because both syllables are equally stressed, the word is audible as a whole at threshold — unlike monosyllables where threshold is smeared, or trochees (RAIN-bow) where the stressed syllable masks the weaker one.
• Spondees have a narrow intensity range between audibility and recognition — this makes them ideal threshold markers.

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4. Step-by-Step SRT Test Protocol

Pre-test

1. Otoscopy — clear canal, no active infection
2. Complete pure tone audiometry first (obtain PTA at 500, 1000, 2000 Hz)
3. Calculate PTA — this gives you the predicted SRT starting level
4. Familiarise the patient with the spondee word list: read the full list to the patient at a comfortable level before starting so they know what words to expect

Starting Level

• Begin 20–30 dB ABOVE the estimated SRT (i.e., above the PTA)
• This ensures the patient hears the first few words easily (no false starts)

Ascending Method (Standard — ASHA 1988 Guidelines)

Masking

• Speech presentation level to test ear exceeds bone conduction thresholds of the better ear by 40 dB or more at two frequencies
• This is the same crossover rule as for pure tones — interaural attenuation for air-conduction earphones = ~40–60 dB (K.J. Lee, p. 5783)

Record

• SRT in dB HL for each ear
• Note whether masking was used
• Compare SRT to PTA (500 + 1000 + 2000 Hz ÷ 3)

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5. SRT–PTA Agreement Interpretation

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6. How to Write the SRT Audiometry Report

What Every SRT Report Must Include:

1. Patient demographics (name, age, sex, date, referring doctor)
2. Equipment used (audiometer model, calibration date)
3. Pure tone thresholds at 500, 1000, 2000 Hz (basis for PTA)
4. PTA calculation for each ear
5. SRT in dB HL for each ear
6. SRT–PTA agreement (in dB, and whether within acceptable range)
7. Masking — used or not, masking level if applied
8. SDS/WRS (presentation level and % score) — routinely included in same session
9. Interpretation — type of hearing loss, degree, site-of-lesion comments
10. Recommendations

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7. Complete Example Report

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🏥 AUDIOLOGY REPORT — SPEECH AUDIOMETRY

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SECTION A: PURE TONE AUDIOMETRY SUMMARY

• Right ear PTA: (35 + 45 + 55) ÷ 3 = 45 dB HL → Moderate SNHL
• Left ear PTA: (20 + 25 + 30) ÷ 3 = 25 dB HL → Mild SNHL

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SECTION B: SPEECH RECOGNITION THRESHOLD (SRT)

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SECTION C: SPEECH DISCRIMINATION SCORE / WORD RECOGNITION SCORE (SDS/WRS)

• Right ear 68%: Moderate difficulty (60–74% range)
• Left ear 92%: Normal word recognition (90–100% range)
• Interaural SDS asymmetry: 24% — this exceeds the 15–20% alert threshold

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SECTION D: OVERALL INTERPRETATION

• Right ear: Moderate sensorineural hearing loss with a gently sloping configuration (35 dB at 500 Hz to 70 dB at 6000 Hz). Air-bone gap ≤5 dB — consistent with cochlear/sensorineural pathology.
• Left ear: Mild sensorineural hearing loss, flat-to-gently-sloping configuration (20–45 dB). Cochlear pattern.

• Bilateral SRT–PTA agreement is excellent, confirming audiometric reliability.
• Left ear SDS (92%) is within normal limits for a mild SNHL — consistent with cochlear hearing loss.
• Right ear SDS (68%) shows moderate difficulty. However, there is a clinically significant interaural SDS asymmetry of 24% — the right ear word recognition is disproportionately poorer than predicted by its PTA of 45 dB.
• This disproportionate reduction in right SDS, combined with right > left asymmetric hearing loss, raises suspicion for a possible retrocochlear etiology on the right side.

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SECTION E: RECOMMENDATIONS

1. MRI internal auditory meatus (IAM) with gadolinium contrast — to rule out right vestibular schwannoma or other retrocochlear pathology, given the asymmetric SNHL and disproportionate right SDS reduction.
2. Acoustic reflex testing and reflex decay — add to this test battery at earliest convenience.
3. ABR (Auditory Brainstem Response) — electrophysiological evaluation of right auditory pathway; interaural wave V latency comparison.
4. PI-PB function (rollover testing) — right ear at multiple intensity levels to calculate Rollover Index.
5. Hearing aid evaluation — bilateral SNHL warrants amplification, especially right ear; however, defer formal fitting until retrocochlear evaluation is complete.
6. Repeat audiogram in 3 months to monitor for any progression of SNHL bilaterally.

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8. Quick Reference Summary

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