Intensive voice treatment (LSVT®LOUD) for Parkinson's disease following deep brain stimulation of the subthalamic nucleus

A comparative study of automatic vowel articulation index and auditory-perceptual assessments of speech intelligibility in Parkinson's disease

PURPOSE

The purpose of this study was to analyse the relationship between automatic vowel articulation index (aVAI) and direct magnitude estimation (DME) among speakers with Parkinson's disease (PD) and healthy controls. We further analysed the potential of aVAI to serve as an objective measure of speech impairment in the clinical setting.

METHOD

Speech samples from native Finnish speakers were utilised. Expert raters utilised DME to scale the intelligibility of speech samples. aVAI scores for PD speakers and healthy control speakers were analysed in relationship to DME speech intelligibility ratings and, among PD speakers, disease stage utilising nonparametric statistical analysis.

RESULT

Mean DME intelligibility ratings were lower among PD speakers compared to healthy controls. Mean aVAI scores were nearly the same between speaker groups. DME intelligibility ratings and aVAI were strongly correlated within the PD speaker group. aVAI and DME intelligibility ratings were moderately correlated with disease stage as measured by the Hoehn and Yahr scale.

CONCLUSION

aVAI was observed to be a promising tool for analysing vowel articulation in PD speakers. Further research is warranted on the application of aVAI as an objective measure of severity of speech impairment in the clinical setting, with varying patient populations and speech samples.

Speech Amplification Device Usage for the Management of Hypophonia: A Survey of Speech-Language Pathologists

PURPOSE

The purpose of this study was to survey speech-language pathologists (SLPs) who assess and treat people with Parkinson's disease (PD) to gather insights into their decision making regarding their use or potential use of speech amplification technology for the management of hypophonia.

METHOD

A total of 111 SLPs who were currently practicing in the United States or Canada and had experience working with clients with PD for at least 2 years completed an anonymous Qualtrics survey. Questions were designed to probe the following areas: (a) degree of familiarity with amplification devices as a form of treatment for PD, (b) attitudes and perceptions of the implementation of these devices for PD, and (c) factors that influence the clinical decision to prescribe such devices.

RESULTS

Most participants (75; 71%) reported they had considered prescribing a device to at least one client with PD. When asked at which stages of speech or voice impairment they would consider the use of an amplification device for clients with PD, the most common response was for clients with moderate or severe hypophonia who were not stimulable for louder speech. However, 36 (32%) respondents indicated they would also consider an amplification device for clients who were stimulable for louder speech with severe hypophonia. When asked to rank the most important factors they would weigh when considering the prescription of an amplification device, they ranked the client's preference and comfort level as the most important consideration.

CONCLUSION

This study provides valuable clinical insights regarding how SLPs can approach utilizing speech amplification devices in the therapy environment.

A neurocomputational view of the effects of Parkinson's disease on speech production

The purpose of this article is to review the scientific literature concerning speech in Parkinson's disease (PD) with reference to the DIVA/GODIVA neurocomputational modeling framework. Within this theoretical view, the basal ganglia (BG) contribute to several different aspects of speech motor learning and execution. First, the BG are posited to play a role in the initiation and scaling of speech movements. Within the DIVA/GODIVA framework, initiation and scaling are carried out by initiation map nodes in the supplementary motor area acting in concert with the BG. Reduced support of the initiation map from the BG in PD would result in reduced movement intensity as well as susceptibility to early termination of movement. A second proposed role concerns the learning of common speech sequences, such as phoneme sequences comprising words; this view receives support from the animal literature as well as studies identifying speech sequence learning deficits in PD. Third, the BG may play a role in the temporary buffering and sequencing of longer speech utterances such as phrases during conversational speech. Although the literature does not support a critical role for the BG in representing sequence order (since incorrectly ordered speech is not characteristic of PD), the BG are posited to contribute to the scaling of individual movements in the sequence, including increasing movement intensity for emphatic stress on key words. Therapeutic interventions for PD have inconsistent effects on speech. In contrast to dopaminergic treatments, which typically either leave speech unchanged or lead to minor improvements, deep brain stimulation (DBS) can degrade speech in some cases and improve it in others. However, cases of degradation may be due to unintended stimulation of efferent motor projections to the speech articulators. Findings of spared speech after bilateral pallidotomy appear to indicate that any role played by the BG in adult speech must be supplementary rather than mandatory, with the sequential order of well-learned sequences apparently represented elsewhere (e.g., in cortico-cortical projections).

Behavioral Management of Respiratory/Phonatory Dysfunction for Dysarthria Associated With Neurodegenerative Disease: A Systematic Review

PURPOSE

This systematic review represents an update to previous reviews of the literature addressing behavioral management of respiratory/phonatory dysfunction in individuals with dysarthria due to neurodegenerative disease.

METHOD

Multiple electronic database searches and hand searches of prominent speech-language pathology journals were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.

RESULTS

The search yielded 1,525 articles, from which 88 met inclusion criteria and were reviewed by two blinded co-investigators. A large range of therapeutic approaches have been added to the evidence base since the last review, including expiratory muscle strength training, singing, and computer- and device-driven programs, as well as a variety of treatment modalities, including teletherapy. Evidence for treatment in several different population groups-including cerebellar ataxia, myotonic dystrophy, autosomal recessive spastic ataxia of Charlevoix-Saguenay, Huntington's disease, multiple system atrophy, and Lewy body dementia-were added to the current review. Synthesis of evidence quality provided strong evidence in support of only one behavioral intervention: Lee Silverman Voice Treatment Program (LSVT LOUD) in people with Parkinson's disease. No other treatment approach or population included in this review demonstrated more than limited evidence, reflecting that these approaches/populations require urgent further examination.

CONCLUSION

Suggestions about where future research efforts could be significantly strengthened and how clinicians can apply research findings to their practice are provided.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24964473.

Functional data analysis of prosodic prominence in Parkinson's disease: a pilot study

This study aims to reveal dynamic changes in prosodic prominence patterns associated with Parkinson's disease (PD). To fulfill this purpose, the study proposes an exploratory methodology involving measuring a novel syllable-based prosody index (SPI) and performing functional principal component analyses (fPCAs) in a semi-automatic manner. First, SPI trajectories were collected from 31 speakers with PD before and after speech therapy and from 36 healthy controls. Then, the SPI trajectories were converted to continuous functions using B-splines. Finally, the functional SPIs were examined using fPCAs. The results showed that PD was associated with an increase of overall prominence for male speakers. The findings regarding higher prominence patterns in PD were supported by traditional phonetic measurements. For female speakers, however, there were no significant differences in prosodic prominence between speakers with PD and healthy controls. The results encourage to explore the proposed methodology also in analyses of other forms of atypical speech.

Communicative participation outcomes in individuals with Parkinson's disease receiving standard care speech-language therapy services in community settings

BACKGROUND

The Communicative Participation Item Bank (CPIB) is a patient-reported outcome measure (PROM) designed to measure the extent of interference, or difficulty, experienced by adults with communication disorders participating in their day-to-day communication activities. To date, there is limited evidence regarding sensitivity of the CPIB for capturing change with intervention in people with Parkinson's disease (PwPD).

AIMS

The purpose of this study was to examine the following measurement properties of the CPIB in PwPD who received community-based, standard care, speech-language therapy focusing on motor speech concerns: Change over time between treatment and observation groups, comparison to patient-defined ideal and satisfactory targets, comparison of static short form to computerised adaptive testing (CAT), comparison of self to proxy-rated scores, and comparison to other common PROMs.

METHODS AND PROCEDURES

Forty-six PwPD (20 treatment/26 observation) completed data collection upon enrolment (pre-treatment) and 6 months later. In addition to the CPIB, PROMs included the Voice Handicap Index 10-item short form (VHI-10), PROMIS Global Health-Related Quality of Life, Levels of Speech Usage, self-rated speech severity, and Patient Health Questionnaire-9 (PHQ-9). Participants also engaged in qualitative interviews. Forty-four family members completed proxy CPIB ratings.

OUTCOMES AND RESULTS

There were no significant differences between treatment and observation groups on the CPIB pre-treatment, but there were significant differences post-treatment. The differences appeared to be largely due to significant gains in the treatment group. No participants reached their ideal CPIB target, and few reached their satisfactory target. Static CPIB short form and CAT scores were not significantly different, with an average of five CAT items administered per participant. Overall group similarities between patient and proxy scores may have obscured wide variability across individual patient-proxy pairs. Associations between CPIB and VHI-10, health-related quality of life, self-reported speech severity, and depression ranged from weak to moderate.

CONCLUSIONS AND IMPLICATIONS

The CPIB appears to be sensitive to capturing change with intervention, and similar results are obtained with the static short form and CAT formats. One clinical caution is that even with gains observed in the treatment group, no participants obtained their ideal communicative participation goals, and few obtained a satisfactory level of communicative participation. Thus, while current interventions are beneficial, they may not meet the full range of clients' communication needs. While responding to the CPIB through a proxy rater may be feasible, caution is warranted due to concerns about maintaining the autonomy of PwPD.

WHAT THIS PAPER ADDS

What is already known on this subject The communication disorders associated with Parkinson's disease (PD) can have a negative impact on quality of life and life participation as measured by patient (or person)-reported outcome measures (PROMs). The Communicative Participation Item Bank (CPIB) is one PROM available to use with adults with communication disorders. However, little is known about whether the CPIB captures changes in communicative participation as a result of standard care treatment for people with Parkinson's disease (PwPD). Use of computerised adaptive testing (CAT), proxy report and comparison to targeted participation outcomes have not been explored. What this study adds to existing knowledge As a result of this study, we know that the CPIB captured differences between treatment and observation groups after community-based, standard care speech therapy intervention focusing on motor speech production in PwPD. Static short form and CAT scores did not differ significantly, so the CAT option provides better efficiency requiring, on average, five items to administer compared to the 10-item short form. Proxy and PwPD scores did not differ as a group, but wide variability was noted. What are the potential or actual clinical implications of this work? The CPIB may be a clinically sensitive instrument for capturing changes in communicative participation after treatment. No participants met their ideal CPIB target, and few reached their satisfactory target, suggesting that while current interventions contribute to gains in communicative participation, there are still unmet needs that may call for support and interventions addressing the more complex array of factors affecting communicative participation outcomes for PwPD.

Volitional and Non-volitional Devices Used in Voice Therapy and Training: A Scoping Review-Part A

OBJECTIVE

To map the volitional and non-volitional devices used by speech and language pathologists (SLPs) in voice training and therapy and characterize their use in research on voice interventions.

METHODS

This scoping review is the first part of a larger study. The electronic search was carried out by mapping the references in PubMed/Medline, LILACS/BVS, Scopus, Web of Science, EMBASE, and the Cochrane Library, and the manual search was carried out in the grey literature. Two blind independent reviewers selected and extracted data; divergences were solved by consensus. The data extracted in this part of the study were the authorship and year of publication, country, study design, sample characteristics, intervention modality, ingredient, target, mechanism of action, dosage, and outcome measures. They were addressed with descriptive analysis.

RESULTS

Publications that use devices as ingredients are mostly from the last two decades, mainly carried out in the United States of America and Brazil, in adults of both sexes with behavioral dysphonia. Forty-two types of devices were used, many of them with similar approaches but different nomenclatures. Most devices were used voluntarily, focusing on vocal function, and aiming to increase source and filter interaction. Most studies used silicone tubes. The most reported technical specification to apply the ingredient was surface electrodes on the neck. Device dosage was time-controlled, and the most used outcomes were self-assessment and acoustic analysis.

CONCLUSION

Devices are currently used as ingredients in vocal interventions, with a greater focus on increasing the source and filter interaction, associated with silicone tubes (the most used devices in these studies), which have been dosed with performance time. Outcomes were measured with self-assessment instruments.

Bridging the Gap: Association between Objective and Subjective Outcomes of Communication Performance in People with Parkinson's Disease Evaluated for Deep Brain Stimulation

Background

Decrements in verbal fluency following deep brain stimulation (DBS) in people with Parkinson's disease (PwP) are common. As such, verbal fluency tasks are used in assessing DBS candidacy and target selection. However, the correspondence between testing performance and the patient's perception of communication abilities is not well-established.

Methods

The Communication Participation Item Bank (CPIB) was administered to 85 PwP during pre-DBS neuropsychological evaluations. Central tendencies for CPIB responses and correlations between CPIB total scores, clinical and demographic factors, and language-based tasks were examined.

Results

Most PwP indicated some degree of communication interference on the CPIB. Worse scores on semantic fluency and greater motor impairment were associated with more communication interference.

Conclusions

Our findings suggest an incomplete correspondence between commonly used language-based tests and patient-reported outcomes of communication abilities. The need for a functional communication instrument that reflects the different aspects of communication abilities in functional contexts is emphasized.

Deep Brain Stimulation Impact on Voice and Speech Quality in Parkinson's Disease: A Systematic Review

OBJECTIVE

Deep brain stimulation (DBS) has considerable efficacy for the motor dysfunction of idiopathic Parkinson's disease (PD) on patient quality of life. However, the benefit of DBS on voice and speech quality remains controversial. We carried out a systematic review to understand the influence of DBS on parkinsonian dysphonia and dysarthria.

DATA SOURCES

A PubMed/MEDLINE and Cochrane systematic review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Population, Intervention, Comparison, Outcome, Timing, and Setting (PICOTS) statements.

REVIEW METHODS

Three investigators screened studies published in the literature from inception to May 2022. The following data were retrieved: age, demographic, sex, disease duration, DBS duration, DBS location, speech, and voice quality measurements.

RESULTS

From the 180 studies identified, 44 publications met the inclusion criteria, accounting for 866 patients. Twenty-nine studies focused on voice/speech quality in subthalamic DBS patients, and 6 included patients with stimulation of pallidal, thalamic, and zona incerta regions. Most studies (4/6) reported a deterioration of the vocal parameters on subjective voice quality evaluation. For speech, the findings were more contrasted. There was an important heterogeneity between studies regarding the voice and speech quality outcomes used to evaluate the impact of DBS on voice/speech quality.

CONCLUSION

The impact of DBS on voice and speech quality significantly varies between studies. The stimulated anatomical region may have a significant role since the stimulation of the pallidal area was mainly associated with voice quality improvement, in contrast with other regions. Future controlled studies comparing all region stimulation are needed to get reliable findings.

LEVEL OF EVIDENCE

Level III: evidence from evidence summaries developed from systematic reviews.

Voice handicap Index in Parkinson's patients: Subthalamic versus globus pallidus deep brain stimulation

PURPOSE

Subthalamic nucleus (STN) and globus pallidus interna (GPI) are the two most common sites for deep brain stimulation (DBS) in people with Parkinson's disease (PWP). Voice impairments are a common symptom of Parkinson's disease and information about voice outcomes with DBS is limited. Most studies in speech-language pathology have focused on STN-DBS and few have examined the effects of GPI-DBS. This was an initial effort to examine the impact of DBS location on Vocal Handicap Index (VHI) scores, which assess the impact of a voice disorder on an individual.

METHOD

Twenty-four gender-matched PWP (12 STN-DBS and 12 GPI-DBS) completed the VHI post-DBS implantation. Two-tailed independent samples t-tests were used to compare each VHI scale score (physical, functional, emotional, total) and patient factors between the two groups.

RESULTS

No significant differences in total or subscale VHI scores were identified between the two DBS groups. A trend toward greater impairment in PWP with GPI-DBS was noted. An association between higher VHI scores and DBS settings was found.

CONCLUSIONS

Studies directly comparing speech outcomes for different DBS targets are lacking. The current findings provide new insights concerning voice outcomes following DBS by adding to the limited literature directly comparing speech outcomes in multiple DBS targets. Limitations and directions for future research are discussed.

Lee Silverman Voice Treatment to Improve Speech in Parkinson's Disease: A Systemic Review and Meta-Analysis

BACKGROUND

Speech changes occur in the early stages of Parkinson's disease (PD) and cause communication difficulties, leading to social isolation. Lee Silverman voice treatment (LSVT) is a speech therapy approach designed to improve patients' language and voice capabilities.

OBJECTIVE

The effectiveness of the LSVT was compared with that of other speech interventions or no treatment to evaluate PD patients with dysarthria.

DESIGN

Systematic review with meta-analysis of randomized trials. Data Sources: PubMed, Embase, Cochrane Library, CNKI, and SinoMed library were searched from inception to December 2021 related to PD and LSVT.

METHOD

Abstracts were screened and reviewed against the eligibility criteria (intervention group participants were PD assessed based on LSVT (LSVT Loud) and randomized control).

RESULT

Ten randomized controlled trials were identified on speech symptoms in patients with PD. Compared with the respiratory therapy (RET) exercise, or no training group, a significant improvement was detected in the sound press level (SPL) after immediate treatment during the reading of vowel and rainbow passages and an increase in semitone standard deviation (STSD). Furthermore, the LSVT training significantly increased the participants' scores on unified Parkinson's disease rating scale (UPDRS-III) and speech intelligibility.

CONCLUSION

This meta-analysis demonstrated the efficacy of LSVT in increasing vocal loudness and functional communication among individuals with PD. However, most studies included participants with mild-moderate PD. Thus, additional randomized controlled trials (RCTs) with large sample sizes are needed to validate the efficacy of LSVT in patients with different progressions of PD, including severe PD.

Intensive voice treatment (the Lee Silverman Voice Treatment [LSVT®LOUD]) for individuals with Wilson's disease and adult cerebral palsy: two case reports

Objective: In this case report, we aimed to examine the effects of an intensive voice treatment (the Lee Silverman Voice Treatment [LSVT^®LOUD]) for Wilson's disease (WD), and adult cerebral palsy (CP), and dysarthria.Method: The participants received LSVT^®LOUD four times a week for 4 weeks. Acoustic, perceptual (GRBAS) analyses were performed and data from the Voice Handicap Index (VHI) were obtained before and after treatment.Results: Besides the Harmonics-to Noise Ratio (HNR) value (dB) of the participant with WD, for both participants' fundamental frequencies (Hz), jitter (%), and shimmer (%) values showed significant differences (p < .05) after therapy. Both participants showed significant improvements (p < .05) in the duration (s) and the sound pressure level (dB, SPL) of sustained vowel phonation (/a/), in SPL (dB) of pitch range (high and low /a/) and reading and conversation (p < .01). There was a positive improvement in the high-frequency values (Hz) of both participants but not in the low-frequency values (Hz) in the participant with WD. Perceptual analysis with GRBAS judgements of sustained vowel (/a/) and paragraph reading of two participants also showed improvement. After therapy, perceived loudness of the participants' voice increased.Conclusions: The findings provide some preliminary observations that the individuals with WD and the adult individuals with CP can respond positively to intensive speech treatment such as LSVT^®LOUD. Further studies are needed to investigate speech treatments specific to WD and adult CP.

The impact of Lee Silverman Voice Treatment (LSVT LOUD®) on voice, communication, and participation: Findings from a prospective, longitudinal study

BACKGROUND

Lee Silverman Voice Treatment (LSVT LOUD®), an intensive 4-week program of voice therapy, is regarded as the most well-researched, efficacious treatment for hypokinetic dysarthria in individuals with Parkinson's disease (PD). Although numerous studies have published acoustic and perceptual findings, there is comparatively little information about the impact of LSVT LOUD® on functional communication outcomes.

METHODS

This prospective, longitudinal study investigated the impact of treatment on daily communication in 25 individuals with PD. Three validated communication measures (the Voice Handicap Index, the Communicative Effectiveness Scale, and the Communicative Participation Item Bank) were given before and after treatment and again 4-8 weeks and 3-6 months following treatment. Communication partners were also asked to rate communication effectiveness at all four timepoints.

RESULTS

Significant improvements were found for all three self-reported scales which remained above baseline across all post-treatment timepoints. In addition, self-reported communicative effectiveness was significantly correlated with the assessments of communication partners. Particular benefits were reported for more complex communicative activities such as asking questions, giving detailed information, communicating in noisy situations, and speaking in groups.

CONCLUSIONS

Overall, the findings suggested that LSVT LOUD® promotes an increased sense of personal control over the communication difficulties resulting from PD by decreasing voice handicap and improving communication effectiveness and communicative participation. For individuals with PD, LSVT LOUD® may reduce the risk of social isolation by improving communication and facilitating social participation.

LEARNING OUTCOMES

As a result of this activity, the participant will be able to (1) describe the impact of PD on voice and communication, (2) discuss how these characteristics may be associated with more global measures of functional communication and particularly communicative participation, (3) explain which aspects of functional communication were affected by LSVT LOUD® as assessed by study participants and their communication partners.

Interventions Involving Biofeedback to Improve Swallowing in People With Parkinson Disease and Dysphagia: A Systematic Review

OBJECTIVES

To examine the effectiveness of biofeedback used in the treatment of adults with Parkinson disease (PD) and dysphagia, define the factors associated with biofeedback treatment outcomes, and inform a theory to guide the implementation of biofeedback in future dysphagia interventions.

DATA SOURCES

A systematic review using a narrative synthesis approach of all published and unpublished studies were sought with no date or language restrictions. Ten electronic databases (EMBASE, PubMed, CINAHL, Web of Science, Scopus, Science Direct, AMED, The Cochrane Database of Systematic Reviews, ProQuest Dissertations and Theses A & I, Google Scholar) were searched from inception to April 2019. This search was updated in January 2020. The methodological quality of included studies was assessed using Downs and Black checklist.

STUDY SELECTION

Four studies were included. The methodological quality of the included studies was low with a high risk of bias. Data were analyzed narratively and descriptively. Despite the heterogeneity of the included studies, the findings suggest that interventions incorporating visual biofeedback may have positive effects on swallowing-related quality of life.

CONCLUSIONS

Based on these preliminary findings, we provide directions for further research and clinical interventions that incorporate an augmentative biofeedback component of swallowing interventions in people with PD. Future studies should be rigorously designed and set appropriate biofeedback treatment in terms of types, schedules, and timing.

Analysis of oral-nasal balance after intensive speech therapy combined with speech bulb in speakers with cleft palate and hypernasality

OBJECTIVE

To evaluate the efficacy of the combination of a speech bulb with an intensive speech therapy program in hypernasal participants with cleft palate.

METHODS

Twenty hypernasal speakers with cleft palate (12 females and 8 males, median age 28.45 years), who were wearing speech bulbs underwent an intensive speech therapy program of 45 sessions over 3 weeks. Three experienced speech-language pathologists rated the participants' speech recordings before and after intensive speech therapy, with and without the speech bulb. Nasometric recordings and long-term averaged spectra were also analyzed using repeated-measures ANOVAs.

RESULTS

The ANOVA of the hypernasality ratings showed significant effects of therapy [F (1,19) = 15.97; p < .001], speech bulb [F(1,190 = 28.54, p < .001] and a therapy -speech bulb interaction effect [F(1.19) = 22.30, p < 0.001]. The most favorable listener ratings of hypernasality were obtained post-therapy when participants were wearing their speech bulbs. Without the speech bulb, intensive speech therapy by itself did not result in a significant improvement. With speech bulb, nasalance scores for high [F (1,19) = 14.07, p < .001] and low pressure [F (1,19) = 14.84, p < .001] sentences were significantly lower post-therapy, providing preliminary evidence that an intensive speech therapy program may enhance the effect of a speech bulb. Before and after comparisons of individual nasalance profiles demonstrated variable improvement in 15 participants, no progress in 2 participants and more severe hypernasality after therapy in 3 participants. Long-term averaged spectra corroborated the findings of the perceptual analysis. Based on a frequency bin from 201 to 300 Hz, there was a significant within-subject effect for with and without speech bulb [F(1, 18) = 4.54, p = .047] as well as for before vs. after session [F (1,18) = 7.14, p = .015].

CONCLUSION

The speech bulb in combination with intensive speech therapy resulted in improved oral-nasal balance for the majority of participants. More research is needed to investigate long-term outcomes as well as individual factors contributing to therapy success.

Technology-enabled management of communication and swallowing disorders in Parkinson's disease: a systematic scoping review

BACKGROUND

Communication and swallowing disorders are highly prevalent in people with Parkinson's disease (PD). Maintenance of functional communication and swallowing over time is challenging for the person with PD and their families and may lead to social isolation and reduced quality of life if not addressed. Speech and language therapists (SLTs) face the conundrum of providing sustainable and flexible services to meet the changing needs of people with PD. Motor, cognitive and psychological issues associated with PD, medication regimens and dependency on others often impede attendance at a centre-based service. The access difficulties experienced by people with PD require a disruptive service approach to meet their needs. Technology-enabled management using information and telecommunications technologies to provide services at a distance has the potential to improve access, and enhance the quality of SLT services to people with PD.

AIMS

To report the status and scope of the evidence for the use of technology in the management of the communication and swallowing disorders associated with PD.

METHODS & PROCEDURES

Studies were retrieved from four major databases (PubMed, CINAHL, EMBASE and Medline via Web of Science). Data relating to the types of studies, level of evidence, context, nature of the management undertaken, participant perspectives and the types of technologies involved were extracted for the review.

MAIN CONTRIBUTION

A total of 17 studies were included in the review, 15 of which related to the management of communication and swallowing disorders in PD with two studies devoted to participant perspectives. The majority of the studies reported on the treatment of the speech disorder in PD using Lee Silverman Voice Treatment (LSVT LOUD^® ). Synchronous and asynchronous technologies were used in the studies with a predominance of the former. There was a paucity of research in the management of cognitive-communication and swallowing disorders.

CONCLUSIONS & IMPLICATIONS

Research evidence supporting technology-enabled management of the communication and swallowing disorders in PD is limited and predominantly low in quality. The treatment of the speech disorder online is the most developed aspect of the technology-enabled management pathway. Future research needs to address technology-enabled management of cognitive-communication and swallowing disorders and the use of a more diverse range of technologies and management approaches to optimize SLT service delivery to people with PD.

Lee Silverman voice treatment (LSVT) mitigates voice difficulties in mild Parkinson's disease

Background: Parkinson's disease (PD) is a progressive neurological disorder and many PD patients experience some type of voice and speech disorders during the course of illness. In this study, the aim was to investigate the effect of Lee Silverman voice treatment (LSVT) on improving voice difficulties in patients with mild PD using voice handicap index (VHI). Methods: This interventional study was conducted on 23 PD patients who were randomly divided into 2 groups: a treatment group (PD-T) (n=13) and a no-treatment group (PD-NT) (n=10). Neurologically healthy control (NNC) group consisted of 13 healthy participants who did not suffer from voice and speech problems and were matched with PD group by age (50-65 years), sex, and education. VHI questionnaire was completed a day before the start of LSVT and a day after the treatment fulfillment for the PD-T group; the same time spots were applied for the PD-NT and NNC groups. Statistical analyses were performed using SPSS Statistics 22.0 and significance level was set at 0.05. The multivariate analysis of variance and repeated measure analysis of variance were used for data analysis. Results: PD groups showed a significant weakness in VHI scores before treatment compared to NNC group (p≤ 0.001). The mean of VHI scores for PD-T, PD-NT, and NNC groups before treatment was 44.31±11.23, 43.54±6.10, and 8.15±4.27, respectively. LSVT was successful in improving VHI scores in PD-T group (17.23±5.35, p≤ 0.001). However, no improvement was observed in PD-NT group (44.00±5.88). Conclusion: Improvement in VHI score could be the result of ameliorated self-monitoring and self-regulation created by LSVT.

Speech treatment in Parkinson's disease: Randomized controlled trial (RCT)

BACKGROUND

As many as 89% of people with Parkinson's disease (PD) develop speech disorders.

OBJECTIVES

This randomized controlled trial evaluated two speech treatments for PD matched in intensive dosage and high-effort mode of delivery, differing in subsystem target: voice (respiratory-laryngeal) versus articulation (orofacial-articulatory).

METHODS

PD participants were randomized to 1-month LSVT LOUD (voice), LSVT ARTIC (articulation), or UNTXPD (untreated) groups. Speech clinicians specializing in PD delivered treatment. Primary outcome was sound pressure level (SPL) in reading and spontaneous speech, and secondary outcome was participant-reported Modified Communication Effectiveness Index (CETI-M), evaluated at baseline, 1, and 7 months. Healthy controls were matched by age and sex.

RESULTS

At baseline, the combined PD group (n = 64) was significantly worse than healthy controls (n = 20) for SPL (P < 0.05) and CETI-M (P = 0.0001). At 1 and 7 months, SPL between-group comparisons showed greater improvements for LSVT LOUD (n = 22) than LSVT ARTIC (n = 20; P < 0.05) and UNTXPD (n = 22; P < 0.05). Sound pressure level differences between LSVT ARTIC and UNTXPD at 1 and 7 months were not significant (P > 0.05). For CETI-M, between-group comparisons showed greater improvements for LSVT LOUD and LSVT ARTIC than UNTXPD at 1 month (P = 0.02; P = 0.02). At 7 months, CETI-M between-group differences were not significant (P = 0.08). Within-group CETI-M improvements for LSVT LOUD were maintained through 7 months (P = 0.0011).

CONCLUSIONS

LSVT LOUD showed greater improvements than both LSVT ARTIC and UNTXPD for SPL at 1 and 7 months. For CETI-M, both LSVT LOUD and LSVT ARTIC improved at 1 month relative to UNTXPD. Only LSVT LOUD maintained CETI-M improvements at 7 months. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Challenges in PD Patient Management After DBS: A Pragmatic Review

BACKGROUND

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) or internal globus pallidus (GPi) represents an effective and universally applied therapy for Parkinson's disease (PD) motor complications. However, certain procedure-related problems and unrealistic patient expectations may detract specialists from indicating DBS more widely despite significant clinical effects.

METHODS

This review provides a pragmatic educational summary of the most conflicting postoperative management issues in patients undergoing DBS for PD.

RESULTS

DBS in PD has been associated with certain complications and post-procedural management issues, which can complicate surgical outcome interpretation. Many PD patients consider DBS outcomes negative due to unfulfilled expectations, even when significant motor symptom improvement is achieved. Speech, gait, postural stability, and cognition may worsen after DBS and body weight may increase. Although DBS may induce impulse control disorders in some cases, in others, it may actually improve them when dopamine agonist dosage is reduced after surgery. However, apathy may also arise, especially when dopaminergic medication tapering is rapid. Gradual loss of response with time suggests disease progression, rather than the wearing off of DBS effects. Furthermore, implantable pulse generator expiration is considered a movement disorder emergency, as it may worsen parkinsonian symptoms or cause life-threatening akinetic crises due to malignant DBS withdrawal syndrome.

CONCLUSION

Major unsolved issues occurring after DBS therapy preclude complete patient satisfaction. Multidisciplinary management at experienced centers, as well as careful and comprehensive delivery of information to patients, should contribute to make DBS outcome expectations more realistic and allow post procedural complications to be better accepted.

The effect of bilateral subthalamic nucleus deep brain stimulation (STN-DBS) on the acoustic and prosodic features in patients with Parkinson's disease: A study protocol for the first trial on Iranian patients

Background: The effect of subthalamic nucleus deep brain stimulation (STN-DBS) on the voice features in Parkinson's disease (PD) is controversial. No study has evaluated the voice features of PD underwent STN-DBS by the acoustic, perceptual, and patientbased assessments comprehensively. Furthermore, there is no study to investigate prosodic features before and after DBS in PD. The current study aimed to assess the efficacy of STN-DBS on the voice and prosodic features by acoustic, perceptual and self-reported evaluations in PD. Methods and Analysis: An experimental prospective cohort pretest-posttest group has been designed to survey patients with PD candidates for STN-DBS surgery. All participants will be evaluated by a speech and language pathologist before and after surgery in four different conditions as follow: pre-surgery: Medication On/ Medication Off; post-surgery: Stimulation On/ Stimulation Off. To compare pre-surgery and post-surgery conditions paired- samples T Test or Wilcoxon signed-rank test will be used. A 95% confidence interval (p value of <0.05) will be considered to be statistically significant. This study protocol is approved by the Ethical Committee of Teheran University of Medical Sciences, and the results of the study will be published in a peer-reviewed journal and presented at national congresses.

Variables associated with communicative participation in Parkinson's disease and its relationship to measures of health-related quality-of-life

PURPOSE

Communication disorders associated with Parkinson's disease (PD) often lead to restricted participation in life roles, yet there is a limited understanding of influencing factors and few quantitative measurement tools available. This study aimed to identify variables associated with communicative participation in PD and to examine the relationship between the Communicative Participation Item Bank (CPIB) and existing health-related quality-of-life (HRQoL) measures.

METHOD

Self-report data from 378 participants with PD from the US and New Zealand were analysed. Data included responses to the CPIB, PD Questionnaire-8, sub-scales of the Global Health instrument from the Patient Reported Outcomes Measurement Information System (PROMIS) and additional self-report instruments.

RESULT

Greater perceived speech disorder, lower levels of speech usage, fatigue, cognitive and emotional problems and swallowing difficulties were associated with lower levels of communicative participation. Participants' age significantly influenced findings, interacting with country of residence, sex and speech usage. Scores on the CPIB were moderately correlated with HRQoL measures.

CONCLUSION

Communicative participation in PD is complex and influenced by both demographic and disease-based variables, necessitating a broader view of the communicative experiences of those with PD. Measurement of communicative participation as a separate construct to existing HRQoL measures is recommended.

Videos Influence Behavior Change Measures for Voice and Speech in Individuals with Parkinson's Disease

The majority of individuals with Parkinson's disease (PD) experience voice and speech difficulties at some point over the course of the disease. Voice therapy has been found to help improve voice and speech in individuals with PD, but the majority of these individuals do not enroll in voice therapy. The purpose of this study was to determine whether watching short videos about voice symptoms and treatment in Parkinson's disease influences readiness to change, stages of change, and self-efficacy in individuals with PD. Eight individuals with PD participated in the study. Fifteen videos were chosen, three representing each of the five stages of change. We chose videos from YouTube that represented variety in speakers, content, and genre. We found that readiness to change significantly increased after watching videos, suggesting that watching videos helped these individuals move closer to actively improving their voice and speech. In addition, five of the eight participants showed forward movement in stages of change. Finally, self-efficacy demonstrated a positive trend following video watching. Overall, our results demonstrate that watching videos available on the internet can influence individuals with Parkinson's disease in changing vocal behavior. Implications for future wireless health applications are described.

Behavioral treatments for speech in Parkinson's disease: meta-analyses and review of the literature

SUMMARY 

Parkinson's disease (PD) results from neurodegenerative processes leading to alteration of motor functions. Most motor symptoms respond well to pharmacological and neurosurgical treatments, except some axial symptoms such as speech impairment, so-called dysarthria. However, speech therapy is rarely proposed to PD patients. This review aims at evaluating previous research on the effects of speech behavioral therapies in patients with PD. We also performed two meta-analyses focusing on speech loudness and voice pitch. We showed that intensive therapies in PD are the most effective for hypophonia and can lead to some improvement of voice pitch. Although speech therapy is effective in handling PD dysarthria, behavioral speech rehabilitation in PD still needs further validation.

Effects of the Lee Silverman Voice Treatment (LSVT® LOUD) on hypomimia in Parkinson's disease

Given associations between facial movement and voice, the potential of the Lee Silverman Voice Treatment (LSVT) to alleviate decreased facial expressivity, termed hypomimia, in Parkinson's disease (PD) was examined. Fifty-six participants--16 PD participants who underwent LSVT, 12 PD participants who underwent articulation treatment (ARTIC), 17 untreated PD participants, and 11 controls without PD--produced monologues about happy emotional experiences at pre- and post-treatment timepoints ("T1" and "T2," respectively), 1 month apart. The groups of LSVT, ARTIC, and untreated PD participants were matched on demographic and health status variables. The frequency and variability of facial expressions (Frequency and Variability) observable on 1-min monologue videorecordings were measured using the Facial Action Coding System (FACS). At T1, the Frequency and Variability of participants with PD were significantly lower than those of controls. Frequency and Variability increases of LSVT participants from T1 to T2 were significantly greater than those of ARTIC or untreated participants. Whereas the Frequency and Variability of ARTIC participants at T2 were significantly lower than those of controls, LSVT participants did not significantly differ from controls on these variables at T2. The implications of these findings, which suggest that LSVT reduces parkinsonian hypomimia, for PD-related psychosocial problems are considered.

Effect of deep brain stimulation on speech performance in Parkinson's disease

Deep brain stimulation (DBS) has been reported to be successful in relieving the core motor symptoms of Parkinson's disease (PD) and motor fluctuations in the more advanced stages of the disease. However, data on the effects of DBS on speech performance are inconsistent. While there are some series of patients documenting that speech function was relatively unaffected by DBS of the nucleus subthalamicus (STN), other investigators reported on improvements of distinct parameters of oral control and voice. Though, these ameliorations of single speech modalities were not always accompanied by an improvement of overall speech intelligibility. On the other hand, there are also indications for an induction of dysarthria as an adverse effect of STN-DBS occurring at least in some patients with PD. Since a deterioration of speech function has more often been observed under high stimulation amplitudes, this phenomenon has been ascribed to a spread of current-to-adjacent pathways which might also be the reason for the sporadic observation of an onset of dysarthria under DBS of other basal ganglia targets (e.g., globus pallidus internus/GPi or thalamus/Vim). The aim of this paper is to review and evaluate reports in the literature on the effects of DBS on speech function in PD.

Speech, voice and language in Parkinson’s disease: changes and interventions

SUMMARY This article covers recent developments in the understanding of communication changes in idiopathic Parkinson’s disease and selected issues in intervention. By contrast to earlier narrow considerations of voice and speech, the effects on communication of cognitive–linguistic and prosody perception and production are also highlighted. Decline can occur from the earliest stages, even when listeners perceive no frank changes. Communication may be relatively trouble-free in one-to-one quiet clinical situations but declines in multi-talker, dual/competing task situations. Assessment should reflect this to gain more accurate insights into daily living performance. Currently, therapies focusing on attention-to-effort in voice production and on monitoring the sense of effort and loudness production appear to be most successful. Medical and surgical treatments have little effect on intelligibility and communication and may even exacerbate the situation.

LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease

Recent advances in neuroscience have suggested that exercise-based behavioral treatments may improve function and possibly slow progression of motor symptoms in individuals with Parkinson disease (PD). The LSVT (Lee Silverman Voice Treatment) Programs for individuals with PD have been developed and researched over the past 20 years beginning with a focus on the speech motor system (LSVT LOUD) and more recently have been extended to address limb motor systems (LSVT BIG). The unique aspects of the LSVT Programs include the combination of (a) an exclusive target on increasing amplitude (loudness in the speech motor system; bigger movements in the limb motor system), (b) a focus on sensory recalibration to help patients recognize that movements with increased amplitude are within normal limits, even if they feel "too loud" or "too big," and (c) training self-cueing and attention to action to facilitate long-term maintenance of treatment outcomes. In addition, the intensive mode of delivery is consistent with principles that drive activity-dependent neuroplasticity and motor learning. The purpose of this paper is to provide an integrative discussion of the LSVT Programs including the rationale for their fundamentals, a summary of efficacy data, and a discussion of limitations and future directions for research.