L15: Hyperkinetic D Treatment Flashcards
for hyperkinetic D, medication is only …
infrequently helpful in the management of hyperkinetic dysarthrias, and positive effects, at best, are usually only modest
for huntington’s chorea, there is limited research on…
the effectiveness of behavioural speech treatment
what are the two treatment options for huntington’s chorea?
verbal interaction strategies
augmentative or assistive approaches
during verbal interaction strategies for hungtington’s chorea, pts are instructed to…
Maintain eye contact with listener when postural position permits.
Inform the listener that they wish to know immediately when they have not been understood.
Reiterate an utterance or word when an abnormal movement pattern has potentially interfered with communication.
Carefully introduce the topic of discussion rather than jump from one topic to another.
describe augmentative or assistive approaches for huntington’s chorea
alphabet board, speech synthesizer, talking mats, etc.
Ferm et al (2010) Talking mats in 5 Huntingtons; improved communication effectiveness and increased communication time
Klasner et al., (1994)
focuses on improving the coordination between respiration and phonation
teach patients to avoid speaking during inhalation
reported improved/maintained intelligibility (CAIDS) in 5 patients following 18 months of tx (twice per week)
Possible associated effects of reduced speaking rate?
what are the 8 treatment options for oromandibular dystonia?
verbal interaction strategies
augmentative comm systems
EMG biofeedback (provide feedback on hyperactivity aka dystonia)
bite block
rate reduction
medications
deep brain stimulators (globus pallidus)
botulinum toxin injections
4 ways to treat essential voice tremor
medications (propranolol, primidone, gabapentin, topiramate)
deep brain stimulators (thalamus)
Botulinum toxin injections (Thyroarytenoid and interarytenoid)
rate reduction procedures
what are the 5 behavioural approaches for spasmodic dysphonia?
Changing the place of the voice
Changing pitch, breath support, and increased airflow (Cooper, 1977)
Breathy phonation (Fox, 1969)
Elevation of pitch & easy voice onset (Stoicheff, 1986)
Inhalation phonation (Freeman, 1988)
what are the two medical/surgical approaches for spasmodic dysphonia?
recurrent laryngeal nerve section
- incision just below thyroid cart on L side - recurrent L nerve cut and 2cm section removed - initial improvement good but not longterm
botulinum toxin injections for SD
how does botox help spasmodic dysphonia? mechanism of action?
reduces or eliminates dystonic contractions by causing a partial paralysis in the target muscle
Botox blocks the release of Ach from the presynaptic terminal on the neuromuscular junction
clinical dose for SD is 2 to 15 units
usually remains in the target muscle
process takes about 2-4 days to cause nerve block
lasts for 3-4 months
return of symptoms relates to the nerves sprouting collaterals that reinnervate the muscle
patient must return for re-injection every 3-4 months
describe how botox is injected in SD
needle inserted through the cricothyroid membrane (just below the thyroid cartilage)
directed upwards into the thyroarytenoid (vocalis) muscle
tip of the needle records EMG activity
patient asked to alternate between phonation and inhalation
look for EMG activity during phonation (adduction) and quiet EMG during inhalation (abduction)
inject BT into muscle
1) Unilateral injection: 5 - 15 units 2) Bilateral injection: 1- 3 units in each side
how effective is botox in SD? side effects?
85-100% success rates reported across centres
reduction in vocal spasms & less vocal effort
response duration 3-4 months
side effects
a) mild breathy phonation
· 23-50% of pts & lasts about 7-14 days
b) mild swallowing problems
· 10-35% of pts & lasts about 1-7 days
what two ways can botox treatment be enhanced in SD?
continuous vocalization vs vocal rest
botox + voice therapy
how does continuous vocalization vs vocal rest work for enhancing botox treatment in SD?
10 patients vocal rest (30min) versus 10 vocalization (30min)
hypothesized that vocalization may enhance BT uptake and response
patients who had vocal rest (30 min) showed superior results to those who vocalized (30 min)
at 10 weeks post injection the vocal rest pts had lower spasm severity ratings and lower voice break frequencies than the vocalization patients
what are the two explanations for the benefits of vocal rest on botox treatment in SD?
- The increased blood circulation and tissue movement associated with vocalization may cause BT to flow out of the thyroarytenoid muscle more rapidly than during vocal rest (i.e., less BT diffusion and greater BT uptake during vocal rest)
- The increase in tissue vibration and temperature that are associated with phonation may accelerate the denaturation and breakdown of BT
describe botox + voice therapy as a way to enhance botox treatment for SD
One study with a small number of subjects found that speakers with ADSD who received Botox treatment plus voice therapy improved phonation and had a longer benefit (Murry & Woodson, 1995).
A case study of ABSD showed improvement when Botox tx combined with LSVT (Schnell & Slavin 2024)
