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1.
Medicine (Baltimore) ; 99(10): e19337, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32150072

RESUMO

OBJECTIVE: To examine the efficacy of combined inspiratory and expiratory respiratory muscle training (RMT) with respect to the swallowing function, pulmonary function, functional performance, and dysarthria in patients with stroke. DESIGN: Prospective, randomized controlled trial. SETTING: Tertiary hospital. PARTICIPANTS: The trial included 21 subjects (12 men, 9 women) aged 35 to 80 years presenting with 6 months history of unilateral stroke, respiratory muscle weakness (≥70% predicted maximal inspiratory pressure (MIP) and/or ≤70% maximal expiratory pressure (MEP)), dysphagia, or dysarthria. These subjects were randomly assigned to the control (n = 10, rehabilitation) and experimental (n = 11, rehabilitation with RMT) groups. INTERVENTION: Inspiratory RMT starting from 30% to 60% of MIP and expiratory RMT starting from 15% to 75% of MEP for 5 days/week for 6 weeks. MAIN OUTCOME MEASURES: MIP, MEP, pulmonary function, peak cough flow, perception of dyspnea, Fatigue Assessment Scale, Modified Rankin Scale, Brunnstrom stage, Barthel index, Functional Oral Intake Scale (FOIS), and parameters of voice analysis. RESULTS: Significant differences were observed between both groups in terms of MIP, forced vital capacity (FVC), and forced expiratory volume per second (FEV1) of the percentage predicted. Significant difference was found with respect to the change in fatigue, shimmer percent, amplitude perturbation quotient, and voice turbulence index (VTI) according to the acoustic analysis in the RMT group. The FEV1/FVC ratio was negatively correlated with jitter percent, relative average perturbation, pitch perturbation quotient, and VTI; the maximum mid-expiratory flow (MMEF) and MMEF% were also negatively correlated with VTI. Significant differences among participants of the same group were observed while comparing the Brunnstrom stage before and after training of the affected limbs and the Barthel scale and FOIS scores in both the groups. CONCLUSIONS: Altogether, 6-week combined inspiratory and expiratory RMT is feasible as adjuvant therapy for stroke patients to improve fatigue level, respiratory muscle strength, lung volume, respiratory flow, and dysarthria.Clinical trial registration number (Clinical Trial Identifier): NCT03491111.


Assuntos
Exercícios Respiratórios/métodos , Transtornos de Deglutição/terapia , Disartria/terapia , Debilidade Muscular/terapia , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Exercícios Respiratórios/normas , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/fisiopatologia , Disartria/etiologia , Disartria/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Debilidade Muscular/etiologia , Debilidade Muscular/fisiopatologia , Estudos Prospectivos , Músculos Respiratórios/fisiopatologia , Estatísticas não Paramétricas , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/terapia
2.
Codas ; 31(5): e20180230, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31691746

RESUMO

PURPOSE: To develop a protocol for the evaluation of acquired speech disorders in individuals with Parkinson's disease (PADAF) and to validate its content and determine its inter-judge reliability. METHODS: The study was carried out in three stages: in the first one, the protocol was prepared and its content validated through the analysis of seven specialists; in the second, the instrument was applied to 25 individuals with idiopathic Parkinson's disease (PD); in the third and last stage, the inter-judge reliability was determined. RESULTS: The final version of PADAF consisted of 32 items that evaluated breathing, phonation, resonance, articulation, and prosody. It was shown to be valid, with a content validity index (CVI) much higher than that established in the literature, and with perfect agreement in the determination of inter-judge reliability. CONCLUSION: PADAF for PD individuals was developed and its content was validated, showing perfect instrument reliability.


Assuntos
Disartria/diagnóstico , Doença de Parkinson/complicações , Inquéritos e Questionários , Idoso , Protocolos Clínicos , Disartria/etiologia , Escolaridade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fonação , Reprodutibilidade dos Testes
6.
J Clin Neurosci ; 66: 77-82, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31164264

RESUMO

OBJECTIVE: The present study aimed to identify certain acoustic parameters for speech evaluation in cerebral palsy children with dysarthria. METHODS: The subject included 30 native Mandarin-Speaking children with cerebral palsy, who were 5-15 years old, and 13 healthy children in a similar age range. Each subject was recorded while producing a list of 12 Mandarin words, which included three syllables ('ba', 'bi' and 'du'), in all four Mandarin tones. The formants (F1 and F2) of monophthong vowels /a, i, u/ were extracted from each vowel token. Based on F1 and F2, the vowel acoustic indexes VSA, VAI and FCR were calculated and analyzed. RESULTS: Compared with the control group, the cerebral palsy group had significantly low F1 and F2 in vowel /a/ (P < 0.05), and F2 in vowel /i/ (P < 0.05), while F1 and F2 in vowel /u/ and F1 in vowel /i/ had no significant difference. Between the healthy group and cerebral palsy group, the differences in VSA, VAI and FCR were all statistically significant. CONCLUSION: Children with cerebral palsy have reduced vowel space and speech articulation. The significant difference in vowel acoustic indexes (VSA, VAI and FCR) among the two groups revealed that the three indexes were sensitive to the variation of the vowels production in children with cerebral palsy, and that these may be used as an evaluation method of speech intelligibility caused by impaired vowel pronunciation in children with cerebral palsy, and the effect of rehabilitation therapy.


Assuntos
Paralisia Cerebral/complicações , Disartria/fisiopatologia , Acústica da Fala , Adolescente , Criança , Disartria/etiologia , Feminino , Humanos , Masculino , Fonética , Inteligibilidade da Fala
10.
J Clin Neurosci ; 65: 28-33, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31072740

RESUMO

BACKGROUND: Impairment of cognition and speech are common in multiple sclerosis (MS) patients, but their relationship is not well understood. OBJECTIVE: To describe the relationship between articulation rate characteristics and processing speed and to investigate the potential role of objective speech analysis for the detection of cognitive decline in MS. METHODS: A total of 122 patients with clinically definite MS were included in this cross-sectional pilot study. Patients underwent three speaking tasks (oral diadochokinesis, reading text and monologue) and assessment of processing speed (Symbol Digit Modalities Test [SDMT], Paced Auditory Serial Addition Test-3 s [PASAT-3]). Association between articulation rate and cognition was analyzed using linear regression analysis. We estimated the area under the receiver operating characteristics curves (AUC) to evaluate the predictive accuracy of articulation rate measures for the detection of abnormal processing speed. RESULTS: We observed an association between articulation rate and cognitive measures (rho = 0.45-0.58; p < 0.001). Faster reading speed by one word per second was associated with an 18.7 point (95% confidence interval [CI] 14.9-22.5) increase of the SDMT score and 14.7 (95% CI 8.9-20.4) point increase of PASAT-3 score (both p < 0.001). AUC values of articulation rate characteristics for the identification of processing speed impairment ranged between 0.67 and 0.79. Using a cutoff of 3.10 in reading speed, we were able to identify impairment in both the SDMT and PASAT-3 with 91% sensitivity and 54% specificity. CONCLUSION: Slowed articulation rate is strongly associated with processing speed decline. Objective quantitative speech analysis identified patients with abnormal cognitive performance.


Assuntos
Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etiologia , Disartria/etiologia , Esclerose Múltipla/complicações , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Curva ROC , Análise de Regressão
12.
Rinsho Shinkeigaku ; 59(6): 356-359, 2019 Jun 22.
Artigo em Japonês | MEDLINE | ID: mdl-31142710

RESUMO

An 85-year-old woman was transported to our emergency room by ambulance with a complaint of slurred speech. Neurological examination revealed dysarthria only. We considered that lingual edema identified on physical examination might have influenced dysarthria. However, we were unable to perform sufficient evaluation, since she could not open her mouth widely or push the tongue out beyond the lips. We considered the incidence of acute cerebrovascular disease because of the acute onset, and performed emergency brain MRI. Imaging revealed that although no abnormality was present in the brain parenchyma, edema of the tongue and soft palate was evident on T2-weighted sagittal imaging. We confirmed the dysarthria was caused by tongue edema due to angioedema. In addition, we diagnosed angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema, because ACEI had been started 2 months earlier as pharmacotherapy for hypertension. Tongue swelling due to angioedema should be considered when examining patients with dysarthria.


Assuntos
Angioedema/induzido quimicamente , Angioedema/complicações , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Disartria/etiologia , Doenças da Língua/induzido quimicamente , Doenças da Língua/complicações , Idoso de 80 Anos ou mais , Angioedema/diagnóstico por imagem , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Diagnóstico Diferencial , Imagem de Tensor de Difusão , Feminino , Humanos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Ataque Isquêmico Transitório , Doenças da Língua/diagnóstico por imagem
13.
Medicine (Baltimore) ; 98(20): e15706, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096519

RESUMO

RATIONALE: Anti-IgLON5 disease is a complex neurological illness which is characterized by progressive sleep and movement disorders and defined by specific autoantibodies to IgLON5. We here describe the first case of a patient with coexisting anti-IgLON5 as well as anti-γ-aminobutyric acid B (GABAB)-receptor antibodies and predominant clinical features of anti-IgLON5 disease. PATIENT CONCERNS: The patient initially presented with subacute symptoms of severe sleep disorder, gait stability, dysarthria, cognitive impairment, depressive episode and hallucinations. DIAGNOSES: The patient was diagnosed with autoimmune encephalitis, based on clinical features and positive anti-IgLON5 antibodies in serum as well as in cerebrospinal fluid and anti-GABAB-receptor antibodies in serum only. INTERVENTIONS: Initially, the patient was treated with high dosages of methylprednisolone and subsequently with plasmapheresis. Due to the lack of clinical improvement immunosuppressive treatment with intravenous cyclophosphamide was initiated. OUTCOMES: Following the first year of cyclophosphamide treatment, neurological examination revealed an improvement in gait instability, visual and acoustic hallucinations and sleep disorder. LESSONS: The case report demonstrates that anti-IgLON5 and anti-GABAB-receptor antibodies can coexist in the same patient whereas clinical leading symptoms are determined by those antibodies that were tested positive in cerebrospinal fluid.


Assuntos
Moléculas de Adesão Celular Neuronais/sangue , Moléculas de Adesão Celular Neuronais/líquido cefalorraquidiano , Encefalite/imunologia , Antagonistas de Receptores de GABA-B/sangue , Doença de Hashimoto/imunologia , Administração Intravenosa , Autoanticorpos/sangue , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Ciclofosfamida/administração & dosagem , Ciclofosfamida/uso terapêutico , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/etiologia , Disartria/diagnóstico , Disartria/etiologia , Encefalite/diagnóstico , Encefalite/tratamento farmacológico , Transtornos Neurológicos da Marcha/diagnóstico , Transtornos Neurológicos da Marcha/etiologia , Glucocorticoides/uso terapêutico , Alucinações/diagnóstico , Alucinações/etiologia , Doença de Hashimoto/diagnóstico , Doença de Hashimoto/tratamento farmacológico , Humanos , Imunossupressores/uso terapêutico , Masculino , Metilprednisolona/administração & dosagem , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Plasmaferese/métodos , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/etiologia , Resultado do Tratamento
14.
World Neurosurg ; 128: 248-253, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31048052

RESUMO

BACKGROUND: An intraoperative technique for foramen magnum decompression of Chiari malformation is presented. The technique uses minimal exposure tubular retractors attached to a flexible arm to keep the retractor in a fixed position, while allowing flexible angulation under fluoroscopic guidance. METHODS: Operations were performed between 2009 and 2018 on 22 patients with cerebellar tonsillar descent below the foramen magnum and a diagnosis of type I Chiari malformation. A linear durotomy was necessary, but only the outer layer of the dura was opened for some patients, which is less invasive than the traditional procedure where a durotomy is performed for both the inner and outer layers, and then a duraplasty is performed. RESULTS: The approach allowed access to a wide working area, minimized soft tissue exposure, and optimized extent of decompression. The postoperative imaging demonstrated satisfactory bony removal, and magnetic resonance imaging of the area with cerebrospinal (CSF) flow study showed good CSF flow across the foramen magnum. There was a low incidence of postoperative complications, and the average length of hospital stay was 1 day. For 19 of 22 cases, the symptoms completely resolved or markedly improved, and each of the patients who attended the last follow-up demonstrated syrinx resolution. CONCLUSIONS: Based on our experience with this technique, when used to assist in foramen magnum decompression of Chiari malformation I, the minimally invasive tubular retractor is a useful tool, providing the surgeon with enhanced visualization of the operative field, while reducing potential damage to tissue and optimizing surgical outcomes.


Assuntos
Malformação de Arnold-Chiari/cirurgia , Descompressão Cirúrgica/métodos , Forame Magno/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Malformação de Arnold-Chiari/complicações , Malformação de Arnold-Chiari/diagnóstico por imagem , Ataxia/etiologia , Tontura/etiologia , Dura-Máter/cirurgia , Disartria/etiologia , Dor Facial/etiologia , Feminino , Forame Magno/diagnóstico por imagem , Cefaleia/etiologia , Humanos , Tempo de Internação , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Neurocirúrgicos/instrumentação , Reflexo Anormal , Tração/instrumentação , Adulto Jovem
15.
Brain Lang ; 194: 58-64, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31102976

RESUMO

Although dysarthria is a common pattern in multiple sclerosis (MS), the contribution of specific brain areas to key factors of dysarthria remains unknown. Speech data were acquired from 123 MS patients with Expanded Disability Status Scale (EDSS) ranging from 1 to 6.5 and 60 matched healthy controls. Results of computerized acoustic analyses of subtests on spastic and ataxic aspects of dysarthria were correlated with MRI-based brain volume measurements. Slow articulation rate during reading was associated with bilateral white and grey matter loss whereas reduced maximum speed during oral diadochokinesis was related to greater cerebellar involvement. Articulation rate showed similar correlation to whole brain atrophy (r = 0.46, p < 0.001) as the standard clinical scales such as EDSS (r = -0.45, p < 0.001). Our results support the critical role of the pyramidal tract and cerebellum in the modification of motor speech timing in MS.


Assuntos
Encéfalo/diagnóstico por imagem , Disartria/diagnóstico por imagem , Esclerose Múltipla/diagnóstico por imagem , Adulto , Atrofia/diagnóstico por imagem , Encéfalo/patologia , Disartria/etiologia , Feminino , Substância Cinzenta/diagnóstico por imagem , Substância Cinzenta/patologia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/complicações , Leitura
16.
J Korean Med Sci ; 34(13): e108, 2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-30950253

RESUMO

BACKGROUND: The gold standard in dysarthria assessment involves subjective analysis by a speech-language pathologist (SLP). We aimed to investigate the feasibility of dysarthria assessment using automatic speech recognition. METHODS: We developed an automatic speech recognition based software to assess dysarthria severity using hidden Markov models (HMMs). Word-specific HMMs were trained using the utterances from one hundred healthy individuals. Twenty-eight patients with dysarthria caused by neurological disorders, including stroke, traumatic brain injury, and Parkinson's disease were participated and their utterances were recorded. The utterances of 37 words from the Assessment of Phonology and Articulation for Children test were recorded in a quiet control booth in both groups. Patients were asked to repeat the recordings for evaluating the test-retest reliability. Patients' utterances were evaluated by two experienced SLPs, and the consonant production accuracy was calculated as a measure of dysarthria severity. The trained HMMs were also employed to evaluate the patients' utterances by calculating the averaged log likelihood (aLL) as the fitness of the spoken word to the word-specific HMM. RESULTS: The consonant production accuracy reported by the SLPs strongly correlated (r = 0.808) with the aLL, and the aLL showed excellent test-retest reliability (intraclass correlation coefficient, 0.964). CONCLUSION: This leads to the conclusion that dysarthria assessment using a one-word speech recognition system based on word-specific HMMs is feasible in neurological disorders.


Assuntos
Disartria/diagnóstico , Cadeias de Markov , Fala , Adulto , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico , Estudos de Casos e Controles , Disartria/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/complicações , Doença de Parkinson/diagnóstico , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico
17.
BMC Neurol ; 19(1): 49, 2019 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-30927916

RESUMO

BACKGROUND: Metronidazole, a common antimicrobial agent, can induce encephalopathy in rare cases. After discontinuing metronidazole, most patients show clinical improvement. However, in the face of deteriorating conditions, there have done not to have reports of effective drug treatment. CASE PRESENTATION: A 57-year-old man was admitted to our hospital due to dysarthria and ataxic gait after taking metronidazole at the dose of about 32 g for 20 days. Neurological examination showed that his upward and outward movements of bilateral eyeballs were limited, and horizontal and vertical nystagmus were noted. The brain magnetic resonance imaging showed hyper-intensities in the bilateral cerebellar dentate nuclei, medulla oblongata, midbrain and red nuclei in T2W and FLAIR images. However, the patient's clinical symptoms worsened after drug cessation. High-dose intravenous methylprednisolone pulse therapy was applied, and this led to a drastic improvement of his symptoms and signs. CONCLUSIONS: In our case, we suggest that early methylprednisolone intervention can prevent the progression of metronidazole-induced encephalopathy and accelerate neurological recovery. We infer that the progression of encephalopathy is related to the delayed toxicity caused by high dose or concentration of metronidazole.


Assuntos
Encefalopatias/induzido quimicamente , Metilprednisolona/uso terapêutico , Metronidazol/efeitos adversos , Disartria/etiologia , Marcha Atáxica/etiologia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
18.
J Neurol ; 266(5): 1260-1266, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30840144

RESUMO

We aimed to provide proof-of-principle evidence that intensive home-based speech treatment can improve dysarthria in complex multisystemic degenerative ataxias, exemplified by autosomal recessive spastic ataxia Charlevoix-Saguenay (ARSACS). Feasibility and piloting efficacy of speech training specifically tailored to cerebellar dysarthria was examined through a 4-week program in seven patients with rater-blinded assessment of intelligibility (primary outcome) and naturalness and acoustic measures of speech (secondary outcomes) performed 4 weeks before, immediately prior to, and directly after training (intraindividual control design). Speech intelligibility and naturalness improved post treatment. This provides piloting evidence that ataxia-tailored speech treatment might be effective in degenerative cerebellar disease.


Assuntos
Disartria/etiologia , Disartria/reabilitação , Espasticidade Muscular/complicações , Fonoterapia/métodos , Ataxias Espinocerebelares/congênito , Retroalimentação Sensorial/fisiologia , Feminino , Humanos , Masculino , Projetos Piloto , Ataxias Espinocerebelares/complicações , Estatísticas não Paramétricas
19.
Rinsho Shinkeigaku ; 59(3): 139-143, 2019 Mar 28.
Artigo em Japonês | MEDLINE | ID: mdl-30814445

RESUMO

A 52-year old woman first noted dysphagia four months before admission followed by dysarthria two months later. She then developed weakness of all limbs and became unable to walk. All these symptoms, associated with tongue atrophy, slowly progressed, leading to the initial clinical impression of a motor neuron disease, although her nerve conduction study and electromyography showed no abnormalities. Her brain MRI with T2 weighted/diffusion weighted image (DWI)/fluid attenuated inversion recovery (FLAIR) revealed a high signal lesion located at dorsal medulla oblongata. She proved positive for anti-aquaporin 4 antibody, which confirmed the diagnosis of neuromyelitis optica spectrum disorders (NMOSD). We conclude that NMOSD may initially present with progressive bulbar palsy and pyramidal tract disorder over a few months, mimicking a motor neuron disease. Awareness of this atypical presentation helps establish an early diagnosis of this treatable entity.


Assuntos
Paralisia Bulbar Progressiva/diagnóstico , Paralisia Bulbar Progressiva/etiologia , Doença dos Neurônios Motores , Neuromielite Óptica/complicações , Neuromielite Óptica/diagnóstico , Aquaporina 4/imunologia , Atrofia/etiologia , Autoanticorpos/sangue , Biomarcadores/sangue , Encéfalo/diagnóstico por imagem , Diagnóstico Diferencial , Progressão da Doença , Disartria/etiologia , Feminino , Humanos , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Fatores de Tempo , Língua/patologia
20.
J Neurol ; 266(6): 1394-1404, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30859316

RESUMO

Although motor speech disorders represent an early and prominent clinical feature of multiple system atrophy (MSA), the potential usefulness of speech assessment as a diagnostic tool has not yet been explored. This cross-sectional study aimed to provide a comprehensive, objective description of motor speech function in the parkinsonian (MSA-P) and cerebellar (MSA-C) variants of MSA. Speech samples were acquired from 80 participants including 18 MSA-P, 22 MSA-C, 20 Parkinson's disease (PD), and 20 healthy controls. The accurate differential diagnosis of dysarthria subtypes was based on quantitative acoustic analysis of 14 speech dimensions. A mixed type of dysarthria involving hypokinetic, ataxic and spastic components was found in the majority of MSA patients independent of phenotype. MSA-P showed significantly greater speech impairment than PD, and predominantly exhibited harsh voice, imprecise consonants, articulatory decay, monopitch, excess pitch fluctuation and pitch breaks. MSA-C was dominated by prolonged phonemes, audible inspirations and voice stoppages. Inappropriate silences, irregular motion rates and overall slowness of speech were present in both MSA phenotypes. Speech features allowed discrimination between MSA-P and PD as well as between both MSA phenotypes with an area under curve up to 0.86. Hypokinetic, ataxic and spastic dysarthria components in MSA were correlated to the clinical evaluation of rigidity, cerebellar and bulbar/pseudobulbar manifestations, respectively. Distinctive speech alterations reflect underlying pathophysiology in MSA. Objective speech assessment may provide an inexpensive and widely applicable screening instrument for differentiation of MSA and PD from controls and among subtypes of MSA.


Assuntos
Doenças Cerebelares/fisiopatologia , Disartria/diagnóstico , Disartria/fisiopatologia , Atrofia de Múltiplos Sistemas/fisiopatologia , Transtornos Parkinsonianos/fisiopatologia , Idoso , Doenças Cerebelares/complicações , Estudos de Coortes , Estudos Transversais , Disartria/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atrofia de Múltiplos Sistemas/complicações , Transtornos Parkinsonianos/complicações , Acústica da Fala
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