L13: Treatment of Hypokinetic D Flashcards
What did the 7 early studies in the 1970s report on the effects of levodopa?
at least 7 studies in the early 1970’s reported that levodopa had a beneficial effect on speech when first provided to PDs at various levels of severity (improved intelligibility, intensity articulation, voice quality, and pitch variation)
Subsequent (after 1970s) ON-OFF studies of PDS who were taken off their regular levodopa mediation for a short time failed to show…
consistent changes in speech/voice across all patients (may be beneficial in isolated cases)
several studies have also noted that levodopa may be associated w …
worsening of speech symptoms in isolated cases
speech is often considered to be one of the ____ levodopa improved PD symptoms when measured w general PD severity scales
least
it has been suggested that after 10+ years, levodopa may have relatively limited effects on
speech
hypothesis that speech becomes resistant to levodopa after +10 years
what is the alternative hypothesis to why there is a lack of response to levodopa after +10 years?
speech symptom severity responsiveness hypothesis
describe speech symptom severity responsiveness hypothesis
The more severe the speech symptom the greater the response to levodopa medication.
more severe voice quality, dysfluency, vowel intensity & imprecise articulation may show greater response to levodopa than less severe (Adams 2022; Cushnie-Sparrow et al., 2018; Im et al, 2018)
recent work in Adams lab (2025) continues to support the hypothesis in 6 speech/voice domains and 17/19 speech measures.
What are the 2 surgical procedures often used for hypokinetic dys?
lesions of the globus pallidus
deep brain stimulation (usually implanted in subthalamic n or globus pallidus)
lesions of the globus pallidus stop…
abnormal inhibitory activity of globus pallidus
deep brain stimulation surgery is often offered to …
speech effects have been…
to a small percentage of PDs who are having difficulty with levodopa medications and dyskinesia (extraneous movements from meds – can be debilitating)
effects on speech have been very inconsistent across individual patients and across studies (speech improvements should not be expected; sometimes worse
w deep brain stimulation it may be possible to adjust…
it may be possible to adjust stimulation settings to optimize speech
lower frequency (60Hz instead of standard 90-120Hz) and lower voltage may be better for intelligibility, vowel acoustics (Knowles, et al. 2018), voice quality & intensity
prosodic therapy is aimed at…
increasing the patient’s awareness of the abnormal prosodic features in his/her own speech and extensive practice with various prosodic patterns of conversational speech. (these authors believe that PDs have difficulty in both the perception and production of prosody)
how does prosodic therapy work?
stressing underlined words in sentences, contrastive stress drills, practice emphasizing various intonation patterns and intended emotions (assisted by clinician’s modelling)
patients were continuously encouraged to over emphasize prosodic aspects and emotional content
facial expressiveness also emphasized in exercises
practice recognizing a variety of stress locations, intonation patterns and intended emotions
use of a visual feedback system (vocalite) for pitch and intensity was recommended during prosodic exercises
how effective is prosodic therapy?
26 PDs; 10-15 hrs of prosodic therapy
Outcome measure: prosodic abnormality score based on perceptual ratings of 7 prosodic dimensions
improved prosodic abnormality scores following therapy
PDs who used visual feedback system slightly more improvement
what are 9 treatment methods for reduced speech intensity?
LSVT
Multidimensional therapies for reduced intensity
speech in noise treatment program
speak out and the loud crowd programs
portable intensity feedback devices
voice amplifier
speechVive device
MP3 player/smartphone w multitasker noise audio file
vocal fold augmentation
describe the Lee Silverman voice therapy program (LSVT)
Increase speech intensity by increasing phonatory effort and laryngeal adduction. Also to recalibrate the sense of effort required to achieve appropriate levels of speech intensity (Ramig et al., 2004)
intensive program, 16 sessions over 4 weeks
emphasis on increasing loudness “think loud” and focus on increasing level of phonatory effort
vocal pushing techniques
increasing maximum phonation time & pitch range
louder speech in progressively more complex speech tasks
detailed manual and workshops that are available for clinician training and certification
how effective was LSVT on perceptual ratings?
improvements in loudness (31%), monotony (30%) & intelligibility (20%)
how effective was LSVT on acoustic ratings?
improvements in max. phonation time (26%), max. F0 range (14%), and F0 variation in speech (12%)
more recent LSVT studies have used randomized untreated controls, randomized comparison treatment groups, placebo controls, blinded evaluation procedures, and long-term (12 and 24 month) outcome measures
what are the 3 concerns w LSVT?
1 - the primary laryngeal/intensity focus of treatment may be regarded as too narrow to be applicable to most hypokinetic dysarthrics (often only one of the symps they face is low speech intesity)
2- Low intensity may be related to laryngeal and additional non-laryngeal processes (i.e. respiratory, oral opening, posture, rate, etc.)
3 - all of the efficacy evidence for LSVT has been obtained from measures obtained in the speech clinic
describe multi-dimensional therapies for reduced speech intensity
use of Visipitch (or similar system) to provide visual targets for increased speech intensity
speech intensity instruction related to multiple systems (laryngeal, respiratory, oral, posture, etc.)
**I.e. may be better to combine LSVT methods w other methods
describe speech-in-noise (SIN) treatment program
focuses on teaching individuals with PD to use appropriate speech-to-noise levels in background noise situations
involves extensive and systematic instruction, practice and feedback while speaking in a wide range of background noise conditions
successful communication in background noise a major goal of treatment
multi-talker noise (65-75dB) used (90%) in 12 tx sessions
second half of each session (30 minutes) involves transfer to talking outside clinic room
speech intensity instruction/procedures related to multiple systems (laryngeal, respiratory, oral, posture, rate reduction, etc.)
Outcomes: increased intensity (4dB), SNR, intelligibility (35-40%), CETI scores
describe speak out and the loud crowd program(s)
aims at increasing vocal intensity, clarity, and thinking processes by applying intention in verbal communication to compensate for the weakened automatic approximation of the movement amplitude of the structures for voice/speech production due to PD, with its catchphrase of “Speak with Intent”
12 sessions (1 to 1) over 4 weeks; follow-up with group sessions
Outcomes: improved intensity, voice quality and pitch variation
what is a major concern in the treatment of PD?
transfer of treatment prob may be a major concern in the treatment of PD
may relate to sensorimotor deficits or procedural memory deficits in PD
what are some solutions to the transfer of treatment problem? (6)
conduct out of clinic sessions
design treatments that incorporate eco valid contexts
portable intensity feedback devices
voice amplified
speechvive device
MP3 player or smartphone w multitasker noise audio file
how could you design treatments that incorporate ecologically valid contexts?
variable levels of background noise, various interlocutor distances, variable speech tasks (esp. conversations), variable levels of cognitive/attentional load, parallel tasks (manual activities , walking, etc.)
what are the two portable intensity feedback devices - describe them
voxlog –>
records 14 hours x 30 recordings, 5sec to 1min periods, 30hour battery
neck collar worn – a throat and a speech microphone – intensity, noise, f0, talk time
specific target intensity can be set, feedback given via tactile vibration
vocalog –>
records 3 weeks; neck collar worn – a throat and a speech microphone
monitor intensity, specific target intensity can be set, feedback given via auditory signal to earphone
Note: VoxLog & LSVT; no significant improvement in real-life conversational intensity following LSVT! (only 8 PDs)
why would a voice amplifier be used?
if pt has too much difficulty with transfer or if pt can’t increase intensity in therapy an amplifier should be considered
could be used only in demanding situations or continuously
what are the 4 voice amplifiers?
chattervox
minibuddy
boomvox
personal FM system: easy listener or oticon amigo
speechvive device works by
use of voice activated noise to produce the lombard effect
MP3 aplyer or smartphone w multitasker noise audio file may be useful for…
evaluating (2 week trial period) person’s acceptance of a long-term Lombard response device such as the more expensive SpeechVive ($3000)
describe vocal fold augmentation
inject about .3 to 2.0 ml of bovine dermal collagen into the medial thyroarytenoid muscle
three studies (involving a total of 65 PDs) suggest that 61-75% of patients perceived an improvement in their dysphonia that lasted about 2 months; results of all 3 studies are based on patient questionnaires, need for objective measures of vocal function (Berke et al., 1999; Hill et al., 2003; Kim et al., 2002)
what are the 6 ways to treat fast speech rate?
pacing board
alphabet board
metronome and apps
computerized rhythmic cueing
pacesetter and other pacing apps
delayed auditory feedback
pacing board
can be effective at reducing speech rate in PDs
many PDs fail to use consistently outside of clinic
pts with rapid hand movements may not be able to use their limbs to pace their speech
alphabet board may provide…
good pacing of speech even in pts with rapid hand movements
consistent use outside of clinic may be a problem
computerized rhythmic cueing can be effective…
can be effective in the clinic setting - no data on transfer to out-of-clinic setting
delayed auditory feedback is very ….
effective at reducing rate of speech in PDs, can produce dramatic improvements in intelligibility, effective whenever person is wearing the DAF so also addresses the transfer of treatment problem in PD, shows long-term effects
recommend: 50-150 msec delays (try 80 msec 1st), make sure volume is relatively high during initial assessment phase(gradually reduce volume to balance DAF effect with minimum discomfort)
