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Steurer H, Körner Gustafsson J, Franzén E, Schalling E. Using Portable Voice Accumulators to Study Transfer of Speech Outcomes Following Intervention - A Feasibility Study. J Voice 2024; 38:965.e1-965.e13. [PMID: 34852954 DOI: 10.1016/j.jvoice.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the process and scientific feasibility of using a portable voice accumulator (PVA) to study carry-over of treatment effects on speech and voice in people with mild-moderate Parkinson's disease. METHODS The study was guided by the checklist in Consolidated Standards of Reporting Trials (CONSORT) 2010 statement: extension to randomized pilot and feasibility trials. Participants with Parkinson's disease were recruited within the context of a randomized controlled trial with random allocation to intervention with either HiCommunication, a program targeting speech and communication, or HiBalance, a program targeting balance and strength. Before and after intervention data was collected from standardized studio recordings of speech and registrations of voice use in daily life with the PVA VoxLog. RESULTS Fifteen participants were included in the study and sufficient data was yielded from six of them. Reasons for insufficient data included technical issues and difficulties handling the PVA. Changes in voice sound level from pre to post intervention differed at an individual level when assessed in daily life compared to studio recordings. Registrations in daily life provided information on phonation ratio and ability to adapt voice sound level to environmental noise. CONCLUSION This study highlights the challenges of studying intervention effects on voice use in daily life using a PVA. Improvements of test protocols in future studies are suggested. We exemplify how PVA data may generate a more detailed and ecologically valid picture of voice use complementing studio recordings of speech. Finally, we encourage technical development of more user-friendly PVAs.
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Affiliation(s)
- Hanna Steurer
- Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Division of Speech and Language Pathology, Stockholm, Sweden; Stockholms Sjukhem, R&D unit, Stockholm, Sweden.
| | - Joakim Körner Gustafsson
- Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Division of Speech and Language Pathology, Stockholm, Sweden; Karolinska University Hospital, Theme Women's Health and Allied Health Professionals, Medical unit Speech & Language Pathology, Stockholm, Sweden
| | - Erika Franzén
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Physical Therapy, Stockholm, Sweden; Karolinska University Hospital, Women's Health and Allied Health Professionals Theme, Medical unit Occupational Therapy & Physiotherapy, Stockholm, Sweden; Stockholms Sjukhem, R&D unit, Stockholm, Sweden
| | - Ellika Schalling
- Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Division of Speech and Language Pathology, Stockholm, Sweden; Karolinska University Hospital, Theme Women's Health and Allied Health Professionals, Medical unit Speech & Language Pathology, Stockholm, Sweden; Uppsala University, Department of Neuroscience, Speech-Language Pathology, Uppsala, Sweden
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2
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Contreras-Ruston F, Castillo-Allendes A, Saavedra-Garrido J, Ochoa-Muñoz AF, Hunter EJ, Kotz SA, Navarra J. Voice self-assessment in individuals with Parkinson's Disease as compared to general voice disorders. Parkinsonism Relat Disord 2024; 123:106944. [PMID: 38552350 DOI: 10.1016/j.parkreldis.2024.106944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Individuals with Parkinson's Disease (IwPD) often fail to adjust their voice in different situations, without awareness of this limitation. Clinicians use self-report questionnaires that are typically designed for individuals with General Voice Disorders (GVD) in the vocal assessment of IwPD. However, these instruments may not consider that IwPD have a reduced self-perception of their vocal deficits. This study aimed to compare self-reported vocal symptoms and voice loudness between IwPD and GVD. METHODS 28 IwPD and 26 with GVD completed the Voice Symptom Scale (VoiSS) questionnaire to evaluate their voice self-perception. Vocal loudness (dB) was also assessed. Univariate and multivariate analyses were used to compare the outcomes from these measures between the two groups. Principal Component Analysis and Hierarchical Clustering Analysis were applied to explore data patterns related to voice symptoms. RESULTS IwPD reported significantly fewer vocal symptoms than those with GVD in all VoiSS questionnaire domains. Multivariate principal component analysis found no significant correlations between VoiSS scores and participant similarities in voice measures. Despite experiencing hypophonia, IwPD scored lower in all VoiSS domains but still fell in the healthy voice range. Hierarchical Clustering Analysis grouped participants into three distinct categories, primarily based on age, vocal loudness, and VoiSS domain scores, distinguishing between PD and GVD individuals. CONCLUSIONS IwPD reported fewer vocal symptoms than GVD. The voice self-assessment seems to be unreliable to assess vocal symptoms in IwPD, at least regarding loudness. New self-report instruments tailored to PD individuals are needed due to their particular voice characteristics.
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Affiliation(s)
- Francisco Contreras-Ruston
- Department of Cognition, Development and Educational Psychology, University of Barcelona, Barcelona, Spain; Faculty of Psychology and Neuroscience, Department of Neuropsychology & Psychopharmacology, Maastricht University, 6229 ER, Maastricht, the Netherlands; Speech-Language Pathology and Audiology Department - Universidad de Valparaíso, San Felipe, Chile.
| | - Adrián Castillo-Allendes
- Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, MI, USA; Department of Communication Sciences and Disorders, University of Iowa, Iowa City, IA, USA
| | - Jorge Saavedra-Garrido
- Institute of Statistics, University of Valparaíso, Faculty of Science, Valparaíso, Chile; Department of Meteorology, University of Valparaíso, Valparaíso, Chile
| | - Andrés Felipe Ochoa-Muñoz
- Institute of Statistics, University of Valparaíso, Faculty of Science, Valparaíso, Chile; School of Statistics, Universidad del Valle, Cali, Colombia
| | - Eric J Hunter
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, IA, USA
| | - Sonja A Kotz
- Faculty of Psychology and Neuroscience, Department of Neuropsychology & Psychopharmacology, Maastricht University, 6229 ER, Maastricht, the Netherlands
| | - Jordi Navarra
- Department of Cognition, Development and Educational Psychology, University of Barcelona, Barcelona, Spain
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3
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Ramage AE, Greenslade KJ, Cote K, Lee JN, Fox CM, Halpern A, Ramig LO. Narrative analysis in individuals with Parkinson's disease following intensive voice treatment: secondary outcome variables from a randomized controlled trial. Front Hum Neurosci 2024; 18:1394948. [PMID: 38841124 PMCID: PMC11150807 DOI: 10.3389/fnhum.2024.1394948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/18/2024] [Indexed: 06/07/2024] Open
Abstract
Communication is often impaired in individuals with Parkinson's disease (PD), typically secondary to sensorimotor deficits impacting voice and speech. Language may also be diminished in PD, particularly for production and comprehension of verbs. Evidence exists that verb processing is influenced by motor system modulation suggesting that verb deficits in PD are underpinned by similarities in the neural representations of actions that span motor and semantic systems. Conversely, subtle differences in cognition in PD may explain difficulty in processing of complex syntactic forms, which increases cognitive demand and is linked to verb use. Here we investigated whether optimizing motor system support for vocal function (improving loudness) affects change in lexical semantic, syntactic, or informativeness aspects of spoken discourse. Picture description narratives were compared for 20 Control participants and 39 with PD, 19 of whom underwent Lee Silverman Voice Treatment (LSVT LOUD®). Treated PD narratives were also contrasted with those of untreated PD and Control participants at Baseline and after treatment. Controls differed significantly from the 39 PD participants for verbs per utterance, but this difference was largely driven by untreated PD participants who produced few utterances but with verbs, inflating their verbs per utterance. Given intervention, there was a significant increase in vocal loudness but no significant changes in language performance. These data do not support the hypothesis that targeting this speech motor system results in improved language production. Instead, the data provide evidence of considerable variability in measures of language production across groups, particularly in verbs per utterance.
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Affiliation(s)
- Amy E. Ramage
- Department of Communication Sciences and Disorders, Durham, NH, United States
- Interdisciplinary Program in Neuroscience and Behavior, University of New Hampshire, Durham, NH, United States
| | | | - Kaila Cote
- Department of Communication Sciences and Disorders, Durham, NH, United States
| | - Jessica N. Lee
- Department of Communication Sciences and Disorders, Durham, NH, United States
| | | | | | - Lorraine O. Ramig
- LSVT Global, Inc., Tucson, AZ, United States
- Teachers College, Columbia University, Communication Sciences and Disorders, New York, NY, United States
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4
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Roßkopf S, Wechsler TF, Tucha S, Mühlberger A. Effects of facial biofeedback on hypomimia, emotion recognition, and affect in Parkinson's disease. J Int Neuropsychol Soc 2024; 30:360-369. [PMID: 38017615 DOI: 10.1017/s1355617723000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVES Facial expressions are a core component of emotions and nonverbal social communication. Therefore, hypomimia as secondary symptom of Parkinson's disease (PD) has adverse effects like social impairment, stigmatization, under-diagnosis and under-treatment of depression, and a generally lower quality of life. Beside unspecific dopaminergic treatment, specific treatment options for hypomimia in PD are rarely investigated. This quasi-randomized controlled trial evaluated the short-term effects of facial electromyogram (EMG) based biofeedback to enhance facial expression and emotion recognition as nonverbal social communication skills in PD patients. Furthermore effects on affect are examined. METHOD A sample of 34 in-patients with PD were allocated either to facial EMG-biofeedback as experimental group or non-facial exercises as control group. Facial expression during posing of emotions (measured via EMG), facial emotion recognition, and positive and negative affect were assessed before and after treatment. Stronger improvements were expected in the EMG-biofeedback in comparison to the control group. RESULTS The facial EMG-biofeedback group showed significantly greater improvements in overall facial expression, and especially for happiness and disgust. Also, overall facial emotion recognition abilities improved significantly stronger in the experimental group. Positive affect was significantly increased in both groups with no significant differences between them, while negative affect did not change within both groups. CONCLUSIONS The study provides promising evidence for facial EMG-biofeedback as a tool to improve facial expression and emotion recognition in PD. Embodiment theories are discussed as working mechanism.
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Affiliation(s)
- Sarah Roßkopf
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Regensburg, Regensburg, Germany
| | - Theresa Friederike Wechsler
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Regensburg, Regensburg, Germany
| | - Stefanie Tucha
- Schön Klinik München Schwabing - Neurologie München, München, Germany
- Schön Klinik MVZ, München, Germany
| | - Andreas Mühlberger
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Regensburg, Regensburg, Germany
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Bianchini E, Rinaldi D, Alborghetti M, Simonelli M, D’Audino F, Onelli C, Pegolo E, Pontieri FE. The Story behind the Mask: A Narrative Review on Hypomimia in Parkinson's Disease. Brain Sci 2024; 14:109. [PMID: 38275529 PMCID: PMC10814039 DOI: 10.3390/brainsci14010109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Facial movements are crucial for social and emotional interaction and well-being. Reduced facial expressions (i.e., hypomimia) is a common feature in patients with Parkinson's disease (PD) and previous studies linked this manifestation to both motor symptoms of the disease and altered emotion recognition and processing. Nevertheless, research on facial motor impairment in PD has been rather scarce and only a limited number of clinical evaluation tools are available, often suffering from poor validation processes and high inter- and intra-rater variability. In recent years, the availability of technology-enhanced quantification methods of facial movements, such as automated video analysis and machine learning application, led to increasing interest in studying hypomimia in PD. In this narrative review, we summarize the current knowledge on pathophysiological hypotheses at the basis of hypomimia in PD, with particular focus on the association between reduced facial expressions and emotional processing and analyze the current evaluation tools and management strategies for this symptom, as well as future research perspectives.
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Affiliation(s)
- Edoardo Bianchini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (E.B.); (D.R.); (M.A.); (M.S.)
- AGEIS, Université Grenoble Alpes, 38000 Grenoble, France
- Sant’Andrea University Hospital, 00189 Rome, Italy;
| | - Domiziana Rinaldi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (E.B.); (D.R.); (M.A.); (M.S.)
- Sant’Andrea University Hospital, 00189 Rome, Italy;
| | - Marika Alborghetti
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (E.B.); (D.R.); (M.A.); (M.S.)
- Sant’Andrea University Hospital, 00189 Rome, Italy;
| | - Marta Simonelli
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (E.B.); (D.R.); (M.A.); (M.S.)
- Ospedale dei Castelli, ASL Rome 6, 00040 Ariccia, Italy
| | | | - Camilla Onelli
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy;
| | - Elena Pegolo
- Department of Information Engineering, University of Padova, 35131 Padova, Italy;
| | - Francesco E. Pontieri
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (E.B.); (D.R.); (M.A.); (M.S.)
- Sant’Andrea University Hospital, 00189 Rome, Italy;
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy
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Rasing NB, van de Geest-Buit WA, Chan OYA, Mul K, Lanser A, van Engelen BG, Erasmus CE, Fischer AH, Ingels KJ, Post B, Siemann I, Groothuis JT, Voermans NC. Treatment Approaches for Altered Facial Expression: A Systematic Review in Facioscapulohumeral Muscular Dystrophy and Other Neurological Diseases. J Neuromuscul Dis 2024; 11:535-565. [PMID: 38517799 PMCID: PMC11091602 DOI: 10.3233/jnd-230213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 03/24/2024]
Abstract
Background Facial weakness is a key feature of facioscapulohumeral muscular dystrophy (FSHD) and may lead to altered facial expression and subsequent psychosocial impairment. There is no cure and supportive treatments focus on optimizing physical fitness and compensation of functional disabilities. Objective We hypothesize that symptomatic treatment options and psychosocial interventions for other neurological diseases with altered facial expression could be applicable to FSHD. Therefore, the aim of this review is to collect symptomatic treatment approaches that target facial muscle function and psychosocial interventions in various neurological diseases with altered facial expression in order to discuss the applicability to FSHD. Methods A systematic search was performed. Selected studies had to include FSHD, Bell's palsy, Moebius syndrome, myotonic dystrophy type 1, or Parkinson's disease and treatment options which target altered facial expression. Data was extracted for study and patients' characteristics, outcome assessment tools, treatment, outcome of facial expression and or psychosocial functioning. Results Forty studies met the inclusion criteria, of which only three studies included FSHD patients exclusively. Most, twenty-one, studies were performed in patients with Bell's palsy. Studies included twelve different therapy categories and results were assessed with different outcomes measures. Conclusions Five therapy categories were considered applicable to FSHD: training of (non-verbal) communication compensation strategies, speech training, physical therapy, conference attendance, and smile restoration surgery. Further research is needed to establish the effect of these therapies in FSHD. We recommend to include outcome measures in these studies that cover at least cosmetic, functional, communication, and quality of life domains.
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Affiliation(s)
- Nathaniël B. Rasing
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willianne A. van de Geest-Buit
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - On Ying A. Chan
- Information Specialist, Medical Library, Radboud University, Nijmegen, The Netherlands
| | - Karlien Mul
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anke Lanser
- Patient Representative and Chairman FSHD Advocacy Group, Patient Organization for Muscular Disease Spierziekten Nederland, Baarn, The Netherlands
| | - Baziel G.M. van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Corrie E. Erasmus
- Department of Paediatric Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Amalia Children’s Hospital, Nijmegen, The Netherlands
| | - Agneta H. Fischer
- Department of Psychology, Social Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Koen J.A.O. Ingels
- Department of Otorhinolaryngology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Post
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ietske Siemann
- Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan T. Groothuis
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Halpern A, Fox C, Ramig L, Tripoliti E. Evidenzbasierte Sprachtherapie bei Morbus Parkinson: LSVT LOUD. SPRACHE · STIMME · GEHÖR 2022. [DOI: 10.1055/a-1941-3605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Why cognitive training is important for the health status in Parkinson's disease: preliminary evidence from a clinical three-weeks multidisciplinary intervention. Neurol Res Pract 2022; 4:47. [PMID: 36184630 PMCID: PMC9528077 DOI: 10.1186/s42466-022-00210-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/02/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Several non-motor symptoms are present in Parkinson's disease (PD), including increasing prevalence rates of cognitive impairment during disease progression. Due to its multifaceted nature, PD management involves pharmacotherapy and non-pharmacotherapies, ideally in a multidisciplinary manner. Evidence regarding the impact of multidisciplinary interventions on motor and non-motor symptoms, as well as its impact on quality of life and daily activities of living, is limited. METHODS The aim of this real-life exploratory study was to investigate the effectiveness of a three-week clinical multidisciplinary Parkinson complex therapy (Parkinson-Komplexbehandlung, PKB), which is available as standard care for PD in the German health care system. Especially, the effect of neuropsychological attention training of 40 patients with PD was analyzed concerning their impact on motor abilities (UPDRS-III ON state), cognitive profiles and reported depressive symptoms and psychosocial function. RESULTS Neuropsychological data showed an improvement in response inhibition after intervention (z = - 2.611, p = 0.009). Additionally, improvements in verbal memory (z = - 2.318, p = 0.020), motor functions (UPDRS-III-score; z = - 5.163, p < 0.001) and reduction in depression symptoms (BDI-II) (z = - 2.944, p = 0.003) were also present. CONCLUSIONS Patients with PD benefited from this multidisciplinary Parkinson complex therapy in terms of improved cognitive functioning, including attention and verbal learning, motor symptoms and emotional well-being.
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van de Geest-Buit WA, Rasing NB, Mul K, Deenen JCW, Vincenten SCC, Siemann I, Lanser A, Groothuis JT, van Engelen BG, Custers JAE, Voermans NC. Facing facial weakness: psychosocial outcomes of facial weakness and reduced facial function in facioscapulohumeral muscular dystrophy. Disabil Rehabil 2022:1-10. [DOI: 10.1080/09638288.2022.2092779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- W. A. van de Geest-Buit
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N. B. Rasing
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K. Mul
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J. C. W. Deenen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S. C. C. Vincenten
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - I. Siemann
- Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A. Lanser
- Patient Representative and Chairman FSHD Advocacy Group, Patient Organization for Muscular Diseases Spierziekten Nederland, Baarn, The Netherlands
| | - J. T. Groothuis
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B. G. van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J. A. E. Custers
- Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N. C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Fröhlich H, Bontridder N, Petrovska-Delacréta D, Glaab E, Kluge F, Yacoubi ME, Marín Valero M, Corvol JC, Eskofier B, Van Gyseghem JM, Lehericy S, Winkler J, Klucken J. Leveraging the Potential of Digital Technology for Better Individualized Treatment of Parkinson's Disease. Front Neurol 2022; 13:788427. [PMID: 35295840 PMCID: PMC8918525 DOI: 10.3389/fneur.2022.788427] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 01/31/2022] [Indexed: 12/18/2022] Open
Abstract
Recent years have witnessed a strongly increasing interest in digital technology within medicine (sensor devices, specific smartphone apps) and specifically also neurology. Quantitative measures derived from digital technology could provide Digital Biomarkers (DMs) enabling a quantitative and continuous monitoring of disease symptoms, also outside clinics. This includes the possibility to continuously and sensitively monitor the response to treatment, hence opening the opportunity to adapt medication pathways quickly. In addition, DMs may in the future allow early diagnosis, stratification of patient subgroups and prediction of clinical outcomes. Thus, DMs could complement or in certain cases even replace classical examiner-based outcome measures and molecular biomarkers measured in cerebral spinal fluid, blood, urine, saliva, or other body liquids. Altogether, DMs could play a prominent role in the emerging field of precision medicine. However, realizing this vision requires dedicated research. First, advanced data analytical methods need to be developed and applied, which extract candidate DMs from raw signals. Second, these candidate DMs need to be validated by (a) showing their correlation to established clinical outcome measures, and (b) demonstrating their diagnostic and/or prognostic value compared to established biomarkers. These points again require the use of advanced data analytical methods, including machine learning. In addition, the arising ethical, legal and social questions associated with the collection and processing of sensitive patient data and the use of machine learning methods to analyze these data for better individualized treatment of the disease, must be considered thoroughly. Using Parkinson's Disease (PD) as a prime example of a complex multifactorial disorder, the purpose of this article is to critically review the current state of research regarding the use of DMs, discuss open challenges and highlight emerging new directions.
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Affiliation(s)
- Holger Fröhlich
- Department of Bioinformatics, Fraunhofer Institute for Algorithms and Scientific Computing, Sankt Augustin, Germany
- Bonn-Aachen International Center for IT (b-it), University of Bonn, Bonn, Germany
| | - Noémi Bontridder
- Centre de Recherches Information, Droit et Societe, University of Namur, Namur, Belgium
| | | | - Enrico Glaab
- Luxembourg Center for Systems Medicine, University of Luxembourg, Esch, Luxembourg
| | - Felix Kluge
- Department of Artificial Intelligence in Biomedical Engineering, University of Erlangen Nuremberg, Erlangen, Germany
| | | | | | | | - Bjoern Eskofier
- Department of Artificial Intelligence in Biomedical Engineering, University of Erlangen Nuremberg, Erlangen, Germany
| | | | | | - Jürgen Winkler
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Jochen Klucken
- Luxembourg Center for Systems Medicine, University of Luxembourg, Esch, Luxembourg
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11
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Narayana S, Franklin C, Peterson E, Hunter EJ, Robin DA, Halpern A, Spielman J, Fox PT, Ramig LO. Immediate and long-term effects of speech treatment targets and intensive dosage on Parkinson's disease dysphonia and the speech motor network: Randomized controlled trial. Hum Brain Mapp 2022; 43:2328-2347. [PMID: 35141971 PMCID: PMC8996348 DOI: 10.1002/hbm.25790] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/16/2021] [Accepted: 01/07/2022] [Indexed: 11/07/2022] Open
Abstract
This study compared acoustic and neural changes accompanying two treatments matched for intensive dosage but having two different treatment targets (voice or articulation) to dissociate the effects of treatment target and intensive dosage in speech therapies. Nineteen participants with Parkinsonian dysphonia (11 F) were randomized to three groups: intensive treatment targeting voice (voice group, n = 6), targeting articulation (articulation group, n = 7), or an untreated group (no treatment, n = 6). The severity of dysphonia was assessed by the smoothed cepstral peak prominence (CPPS) and neuronal changes were evaluated by cerebral blood flow (CBF) recorded at baseline, posttreatment, and 7-month follow-up. Only the voice treatment resulted in significant posttreatment improvement in CPPS, which was maintained at 7 months. Following voice treatment, increased activity in left premotor and bilateral auditory cortices was observed at posttreatment, and in the left motor and auditory cortices at 7-month follow-up. Articulation treatment resulted in increased activity in bilateral premotor and left insular cortices that were sustained at a 7-month follow-up. Activation in the auditory cortices and a significant correlation between the CPPS and CBF in motor and auditory cortices was observed only in the voice group. The intensive dosage resulted in long-lasting behavioral and neural effects as the no-treatment group showed a progressive decrease in activity in areas of the speech motor network out to a 7-month follow-up. These results indicate that dysphonia and the speech motor network can be differentially modified by treatment targets, while intensive dosage contributes to long-lasting effects of speech treatments.
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Affiliation(s)
- Shalini Narayana
- Department of Pediatrics, Division of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Crystal Franklin
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Eric J Hunter
- Department of Communicative Sciences and Disorders, Michigan State University, Lansing, Michigan, USA
| | - Donald A Robin
- Department of Communication Sciences and Disorders, University of New Hampshire, Durham, New Hampshire, USA
| | - Angela Halpern
- LSVT Global Inc, Tucson, Arizona, USA.,National Center for Voice and Speech and Department of Speech-Language and Hearing Sciences, University of Colorado-Boulder, Boulder, Colorado, USA
| | - Jennifer Spielman
- National Center for Voice and Speech and Department of Speech-Language and Hearing Sciences, University of Colorado-Boulder, Boulder, Colorado, USA.,Front Range Voice Care, Denver, Colorado, USA
| | - Peter T Fox
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, Texas, USA.,Audie L. Murphy South Texas Veterans Administration Medical Center, San Antonio, Texas, USA
| | - Lorraine O Ramig
- LSVT Global Inc, Tucson, Arizona, USA.,National Center for Voice and Speech and Department of Speech-Language and Hearing Sciences, University of Colorado-Boulder, Boulder, Colorado, USA.,Columbia University, New York, New York, USA
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12
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Ali R, Hoque E, Duberstein P, Schubert L, Razavi SZ, Kane B, Silva C, Daks JS, Huang M, Van Orden K. Aging and Engaging: A Pilot Randomized Controlled Trial of an Online Conversational Skills Coach for Older Adults. Am J Geriatr Psychiatry 2021; 29:804-815. [PMID: 33308893 PMCID: PMC8140061 DOI: 10.1016/j.jagp.2020.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/29/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Communication difficulties negatively impact relationship quality and are associated with social isolation and loneliness in later life. There is a need for accessible communication interventions offered outside specialty mental health settings. DESIGN Pilot randomized controlled trial. SETTING Assessments in the laboratory and intervention completed in-home. PARTICIPANTS Twenty adults age 60 and older from the community and a geriatric psychiatry clinic. INTERVENTION A web-based communication coach that provides automated feedback on eye contact, facial expressivity, speaking volume, and negative content (Aging and Engaging Program, AEP), delivered with minimal assistance in the home (eight brief sessions over 4-6 weeks) or control (education and videos on communication). MEASUREMENTS System Usability Scale and Social Skills Performance Assessment, an observer-rated assessment of social communication elicited through standardized role-plays. RESULTS Ninety percent of participants completed all AEP sessions and the System Usability Scale score of 68 was above the cut-off for acceptable usability. Participants randomized to AEP demonstrated statistically and clinically significant improvement in eye contact and facial expressivity. CONCLUSION The AEP is acceptable and feasible for older adults with communication difficulties to complete at home and may improve eye contact and facial expressivity, warranting a larger RCT to confirm efficacy and explore potential applications to other populations, including individuals with autism and social anxiety.
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Affiliation(s)
- Rafayet Ali
- Department of Computer Science, University of Rochester
| | - Ehsan Hoque
- Department of Computer Science, University of Rochester
| | - Paul Duberstein
- Department of Health Behavior, Society & Policy, Rutgers University School of Public Health
| | | | | | - Benjamin Kane
- Department of Computer Science, University of Rochester
| | - Caroline Silva
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry
| | | | - Meghan Huang
- Department of Psychology, University of Rochester
| | - Kim Van Orden
- Department of Psychiatry (CS, KVO), University of Rochester School of Medicine & Dentistry, Rochester, NY.
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13
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Single Word Intelligibility of Individuals with Parkinson's Disease in Noise: Pre-Specified Secondary Outcome Variables from a Randomized Control Trial (RCT) Comparing Two Intensive Speech Treatments (LSVT LOUD vs. LSVT ARTIC). Brain Sci 2021; 11:brainsci11070857. [PMID: 34199093 PMCID: PMC8301858 DOI: 10.3390/brainsci11070857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
The majority of people with Parkinson's disease (PD) experience both prosodic changes (reduced vocal volume, reduced pitch range) and articulatory changes (imprecise articulation) that often limit speech intelligibility and may contribute to significant declines in quality of life. We conducted a randomized control trial comparing two intensive treatments, voice (LSVT LOUD) or articulation (LSVT ARTIC) to assess single word intelligibility in the presence of background noise (babble and mall). Participants (64 PD and 20 Healthy) read words from the diagnostic rhyme test (DRT), an ANSI Standard for measuring intelligibility of speech, before and after one month (treatment or no treatment). Teams of trained listeners blindly rated the data. Speech intelligibility of words in the presence of both noise conditions improved in PD participants who had LSVT LOUD compared to the groups that had LSVT ARTIC or no treatment. Intensive speech treatment targeting prominent prosodic variables in LSVT LOUD had a positive effect on speech intelligibility at the single word level in PD.
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14
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Mood and emotional disorders associated with parkinsonism, Huntington disease, and other movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:175-196. [PMID: 34389117 DOI: 10.1016/b978-0-12-822290-4.00015-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This chapter provides a review of mood, emotional disorders, and emotion processing deficits associated with diseases that cause movement disorders, including Parkinson's disease, Lewy body dementia, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, frontotemporal dementia with parkinsonism, Huntington's disease, essential tremor, dystonia, and tardive dyskinesia. For each disorder, a clinical description of the common signs and symptoms, disease progression, and epidemiology is provided. Then the mood and emotional disorders associated with each of these diseases are described and discussed in terms of clinical presentation, incidence, prevalence, and alterations in quality of life. Alterations of emotion communication, such as affective speech prosody and facial emotional expression, associated with these disorders are also discussed. In addition, if applicable, deficits in gestural and lexical/verbal emotion are reviewed. Throughout the chapter, the relationships among mood and emotional disorders, alterations of emotional experiences, social communication, and quality of life, as well as treatment, are emphasized.
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15
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Social Symptoms of Parkinson's Disease. PARKINSONS DISEASE 2020; 2020:8846544. [PMID: 33489081 PMCID: PMC7790585 DOI: 10.1155/2020/8846544] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/05/2020] [Accepted: 12/03/2020] [Indexed: 12/28/2022]
Abstract
Parkinson's disease (PD) is typically well recognized by its characteristic motor symptoms (e.g., bradykinesia, rigidity, and tremor). The cognitive symptoms of PD are increasingly being acknowledged by clinicians and researchers alike. However, PD also involves a host of emotional and communicative changes which can cause major disruptions to social functioning. These incude problems producing emotional facial expressions (i.e., facial masking) and emotional speech (i.e., dysarthria), as well as difficulties recognizing the verbal and nonverbal emotional cues of others. These social symptoms of PD can result in severe negative social consequences, including stigma, dehumanization, and loneliness, which might affect quality of life to an even greater extent than more well-recognized motor or cognitive symptoms. It is, therefore, imperative that researchers and clinicans become aware of these potential social symptoms and their negative effects, in order to properly investigate and manage the socioemotional aspects of PD. This narrative review provides an examination of the current research surrounding some of the most common social symptoms of PD and their related social consequences and argues that proactively and adequately addressing these issues might improve disease outcomes.
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16
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Muñoz-Vigueras N, Prados-Román E, Valenza MC, Granados-Santiago M, Cabrera-Martos I, Rodríguez-Torres J, Torres-Sánchez I. Speech and language therapy treatment on hypokinetic dysarthria in Parkinson disease: Systematic review and meta-analysis. Clin Rehabil 2020; 35:639-655. [PMID: 33233932 DOI: 10.1177/0269215520976267] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the effect of speech and language therapy (SLT) on Hypokinetic dysarthria (HD) in Parkinson's disease. DESIGN Systematic review and meta-analysis of randomized controlled trials. METHODS We performed a literature search of randomized controlled trials using PubMed, Web of Science, Science Direct and Cochrane database (last search October 2020). Quality assessment and risk of bias were assessed using the Downs and Black scale and the Cochrane tool. The data were pooled and a meta-analysis was completed for sound pressure levels, perceptual intelligibility and inflection of voice fundamental frequency. RESULTS We selected 15 high to moderate quality studies, which included 619 patients with Parkinson's disease. After pooling the data, 7 studies, which compared different speech language therapies to no treatment, control groups and 3 of their variables, (sound pressure level, semitone standard deviation and perceptual intelligibility) were included in the analysis.Results showed significant differences in favor of SLT for sound pressure level sustained phonation tasks (standard mean difference = 1.79; 95% confidence interval = 0.86, 2.72; p ⩽ 0.0001). Significant results were also observed for sound pressure level and semitone standard deviation in reading tasks (standard mean difference = 1.32; 95% confidence interval = 1.03, 1.61; p ⩽ 0.0001). Additionally, sound pressure levels in monologue tasks showed similar results when SLT was compared to other treatments (standard mean difference = 0.87; 95% confidence interval = 0.46, 1.28; p ⩽ 0.0001). CONCLUSION This meta-analysis suggests a beneficial effect of SLT for reducing Hypokinetic Dysarthria in Parkinson's disease, improving perceptual intelligibility, sound pressure level and semitone standard deviation.
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Affiliation(s)
- Natalia Muñoz-Vigueras
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Esther Prados-Román
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Marie Carmen Valenza
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Maria Granados-Santiago
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Irene Cabrera-Martos
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Janet Rodríguez-Torres
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Irene Torres-Sánchez
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, Granada, Spain
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17
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Yuan F, Guo X, Wei X, Xie F, Zheng J, Huang Y, Huang Z, Chang Z, Li H, Guo Y, Chen J, Guo J, Tang B, Deng B, Wang Q. Lee Silverman Voice Treatment for dysarthria in patients with Parkinson's disease: a systematic review and meta-analysis. Eur J Neurol 2020; 27:1957-1970. [PMID: 32539227 DOI: 10.1111/ene.14399] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Approximately 89% of patients with Parkinson's disease (PD) suffer from dysarthria. Lee Silverman Voice Treatment (LSVT), a behavioral therapy, aims to improve speech and voice functions. The objective was to assess the effectiveness of LSVT compared with other/no speech interventions for dysarthria in patients with PD. Electronic databases, including PubMed, Embase and the Cochrane Library, were searched. The publication date of all included studies was before 6 March 2020. Only randomized controlled trials (RCTs) that evaluated the LSVT intervention compared with other/no speech intervention were considered. The data obtained from the included studies were described and the mean differences were calculated. Eight RCTs were included in this meta-analysis comparing LSVT with other/no speech interventions. In the comparison of LSVT versus no intervention, vocal intensity for sustained 'Ah' phonation, reading the 'Rainbow passage', monologue and describing a picture increased by 8.87, 4.34, 3.25 and 3.31 dB, respectively, after 1 month of therapy. Compared with the respiratory therapy group, the LSVT group also showed significant improvement in vocal intensity for sustained 'Ah' phonation, reading the 'Rainbow passage' and monologue immediately after treatment (13.39, 6.66 and 3.19 dB). Positive improvement still existed after 24 months. There was no difference in the therapeutic effect between face-to-face and online LSVT. The effectiveness of LSVT for dysarthria in patients with PD was verified in these trials. However, future RCTs with sufficient participants are essential to evaluate the effectiveness of LSVT for dysarthria.
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Affiliation(s)
- F Yuan
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - X Guo
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - X Wei
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - F Xie
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - J Zheng
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Y Huang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Z Huang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Z Chang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - H Li
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Y Guo
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - J Chen
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - J Guo
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, China
| | - B Tang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, China
| | - B Deng
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Q Wang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
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18
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Levy ES, Moya-Galé G, Chang YHM, Freeman K, Forrest K, Brin MF, Ramig LA. The effects of intensive speech treatment on intelligibility in Parkinson's disease: A randomised controlled trial. EClinicalMedicine 2020; 24:100429. [PMID: 32639484 PMCID: PMC7327886 DOI: 10.1016/j.eclinm.2020.100429] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND More than 6,000,000 individuals worldwide are diagnosed with Parkinson's disease (PD). Nearly 90% develop speech signs that may substantially impair their speech intelligibility, resulting in losses in their communication and quality of life. Benefits of intensive speech treatment have been documented for a range of speech signs. However, the critical question of whether speech is more intelligible after treatment has not been investigated in a randomised controlled trial (RCT). We hypothesised that intensive speech treatment would improve speech intelligibility in PD. METHOD Sixty-four patients with hypokinetic dysarthria secondary to PD participated in this single-centre, parallel arm, statistically-powered RCT. Reporting follows CONSORT guidelines for non-pharmacological treatment. Patients were recruited from US clinics and randomised using a statistician-derived minimisation algorithm, to intensive speech treatment (16 1-hour sessions/1 month) targeting voice (voice group) or targeting articulation (articulation group) or to an untreated group (no treatment group). Speech treatments were delivered by speech clinicians who specialised in treating patients with PD. Trial design minimised bias and supported equipoise. For intelligibility assessment, blinded listeners (n = 117) orthographically transcribed 57 patients' recorded, self-generated narrative speech samples, randomly presented in multi-talker babble noise. Listeners were American-English speakers, ages 18-35 years, with normal hearing. The primary outcome was baseline (pre-treatment) to post-treatment change in transcription accuracy (TA), recognised as the most objective measure of intelligibility. TA was defined as the percentage of words transcribed correctly. Listeners, data collectors, and data managers were blinded to treatment conditions and groups. Reliability was evaluated using intraclass correlation coefficients and differences amongst groups were evaluated by mixed-effects models, in accordance with the intention-to-treat approach.This trial was registered with ClinicalTrials.gov Identifier: NCT00123084. FINDINGS Between June 23, 2016 and August 14, 2017, blinded listeners transcribed baseline and post-treatment speech samples for intelligibility assessment of 57 patients in the voice (n = 19), articulation (n = 19) and no treatment (n = 19) groups. Between-group differences (d) in changes from baseline to post-treatment in TA indicated significantly greater increases following treatment targeting voice than treatment targeting articulation (d = 26·2%, 95% CI 1·5 - 51·0; p = 0·04; ES=1·0). Differences between TA changes in the treatment targeting voice and in the no treatment group were significant (d = 42·8%, 95% CI 22·4 - 63·2; p = 0·0002; ES=1·8). Differences between TA changes in the treatment targeting articulation and in the no treatment group were not significant (d = 16·5%, 95% CI -6·1 - 39·2; p = 0·147; ES=0·9). INTERPRETATION These findings provide the first RCT evidence that intensive speech treatment targeting voice improves speech intelligibility in PD. Thus, this evidence-based treatment may positively impact health-related quality of life for patients with PD globally when it is included in patient management. FUNDING
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Affiliation(s)
- Erika S. Levy
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States
| | - Gemma Moya-Galé
- Department of Communication Sciences and Disorders, Long Island University, Brooklyn, NY, United States
| | - Young Hwa M. Chang
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States
| | - Katherine Freeman
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Karen Forrest
- Department of Speech and Hearing Sciences, Indiana University, Bloomington, IN, United States
| | - Mitchell F. Brin
- Department of Neurology, University of California, Irvine, Allergan LLC, Irvine, CA, United States
- Research and Development, Allergan, an AbbVie Company, Irvine, CA, United States
| | - Lorraine A. Ramig
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States
- National Center for Voice and Speech, Denver, CO, United States
- Department of Speech-Language and Hearing Sciences, University of Colorado, Boulder, CO, United States
- LSVT Global, Inc., Tucson, AZ, United States
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19
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Okamoto R, Adachi K, Mizukami K. [Effects of facial rehabilitation exercise on the mood, facial expressions, and facial muscle activities in patients with Parkinson's disease]. Nihon Ronen Igakkai Zasshi 2019; 56:478-486. [PMID: 31761854 DOI: 10.3143/geriatrics.56.478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Facial expressions are often impaired in patients with Parkinson's disease (PD). Few studies have examined the effects of head and neck rehabilitation in patients with PD using a facial expression analysis. In the present study, to further elucidate the effects of facial rehabilitation exercise in patients with PD, a three-dimensional facial expression analysis with FaceReader™ and surface electromyography (EMG) were performed in order to assess the facial expressions and muscle activities, respectively. The effects of such exercises on the mood and mental health were also evaluated. METHOD Twenty-one patients with PD (63.3±12.1 years) participated in the present study and were randomly assigned to an intervention group and non-intervention group. Facial rehabilitation exercise was performed for 60 minutes once a week for 12 weeks in the intervention group. GHQ-12, the facial expression analysis with FaceReader™, surface EMG, and the VAS scale for mood changes were used to evaluate the effects of the program. The results from both groups were compared. RESULTS The results from eight patients in the intervention group and five in the non-intervention group were analyzed. FaceReader™ revealed a higher "Happy" index and lower "Sad" index in the intervention group than in the non-intervention group, and a significant interaction "Happy" index by an analysis of variance was noted between the two groups. EMG also showed increases in the activity of facial muscles in the intervention group. The subjects' mood improved after each facial rehabilitation exercise session. CONCLUSION The results of the present study suggest that the facial rehabilitation exercise affected the mood, facial expression, and facial muscle activities in patients with PD and indicate that the expression analysis with the FaceReader™ and surface EMG are useful for evaluating the effects of facial rehabilitation exercise.
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Affiliation(s)
- Rumiko Okamoto
- Graduate School of Comprehensive Human Science, Department of Social Health and Stress Management, University of Tsukuba
| | | | - Katsuyoshi Mizukami
- Graduate School of Comprehensive Human Science, Department of Social Health and Stress Management, University of Tsukuba.,Faculty of Health and Sport Sciences, University of Tsukuba
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20
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Ma HI, Gunnery SD, Stevenson MT, Saint-Hilaire M, Thomas CA, Tickle-Degnen L. Experienced facial masking indirectly compromises quality of life through stigmatization of women and men with Parkinson's disease. STIGMA AND HEALTH 2019; 4:462-472. [PMID: 33225063 PMCID: PMC7678084 DOI: 10.1037/sah0000168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2023]
Abstract
This study examined the relationship between self-reported facial masking and quality of life (QoL) in people with Parkinson's disease (PD), and tested experienced stigma as a mediator and gender as a moderator of this relationship. The strength of stigma as a mediator was compared against an alternative mediator, depression. Ninety people with PD (34 women) rated difficulty showing facial expression (masking), and completed the Stigma Scale for Chronic Illness, Geriatric Depression Scale (15-item), and Parkinson's Disease Questionnaire-39. A conditional process model tested the indirect effect of facial masking on QoL through stigma, separately for women and men. A parallel indirect model included both stigma and depression to compare their statistical and clinical significance as mediators. Gender-moderated mediation of stigma reduced the association between facial masking and QoL to non-significance, suggesting stigma explained the association between facial masking and QoL. While facial masking was more stigmatizing for women than for men, stigma mediated the facial masking-QoL association for both women and men. Stigma (controlling for depression) reached a statistically and clinically significant level of mediation, whereas depression (controlling for stigma) reached a statistically yet not clinically significant level of mediation. People with PD who experience more severe facial masking feel more stigmatized, especially women. Regardless of gender, an increase in stigma from facial masking increases the likelihood of compromised QoL that reaches both statistical and clinical levels of significance.
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Affiliation(s)
- Hui-Ing Ma
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan 701, Taiwan
| | - Sarah D. Gunnery
- Department of Psychology, New England College, 98 Bridge St., Henniker, NH, 03242
| | - Michael T. Stevenson
- Department of Occupational Therapy, Tufts University, 574 Boston Ave., Medford, MA 02155, USA
| | - Marie Saint-Hilaire
- Department of Neurology, Boston University Medical Center, 725 Albany St., Boston, MA, 02118, USA
| | - Cathi A. Thomas
- Department of Neurology, Boston University Medical Center, 725 Albany St., Boston, MA, 02118, USA
| | - Linda Tickle-Degnen
- Department of Occupational Therapy, Tufts University, 574 Boston Ave., Medford, MA 02155, USA
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21
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Ramig L, Halpern A, Spielman J, Fox C, Freeman K. Speech treatment in Parkinson's disease: Randomized controlled trial (RCT). Mov Disord 2018; 33:1777-1791. [PMID: 30264896 PMCID: PMC6261685 DOI: 10.1002/mds.27460] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/07/2018] [Accepted: 05/22/2018] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Lorraine Ramig
- University of Colorado‐BoulderBoulderColoradoUSA
- National Center for Voice and Speech‐DenverDenverColoradoUSA
- Columbia University‐New York CityNew YorkNew YorkUSA
- LSVT Global, Inc.‐TucsonTucsonArizonaUSA
| | - Angela Halpern
- University of Colorado‐BoulderBoulderColoradoUSA
- National Center for Voice and Speech‐DenverDenverColoradoUSA
- LSVT Global, Inc.‐TucsonTucsonArizonaUSA
| | - Jennifer Spielman
- University of Colorado‐BoulderBoulderColoradoUSA
- National Center for Voice and Speech‐DenverDenverColoradoUSA
| | - Cynthia Fox
- National Center for Voice and Speech‐DenverDenverColoradoUSA
- LSVT Global, Inc.‐TucsonTucsonArizonaUSA
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Wootton A, Starkey NJ, Barber CC. Unmoving and unmoved: experiences and consequences of impaired non-verbal expressivity in Parkinson’s patients and their spouses. Disabil Rehabil 2018; 41:2516-2527. [DOI: 10.1080/09638288.2018.1471166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Adrienne Wootton
- School of Psychology, Faculty of Arts and Social Sciences, The University of Waikato, Hamilton, New Zealand
| | - Nicola J. Starkey
- School of Psychology, Faculty of Arts and Social Sciences, The University of Waikato, Hamilton, New Zealand
| | - Carol C. Barber
- School of Psychology, Faculty of Arts and Social Sciences, The University of Waikato, Hamilton, New Zealand
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Schalling E, Johansson K, Hartelius L. Speech and Communication Changes Reported by People with Parkinson’s Disease. Folia Phoniatr Logop 2018; 69:131-141. [DOI: 10.1159/000479927] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 08/01/2017] [Indexed: 11/19/2022] Open
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Gunnery SD, Habermann B, Saint-Hilaire M, Thomas CA, Tickle-Degnen L. The Relationship between the Experience of Hypomimia and Social Wellbeing in People with Parkinson's Disease and their Care Partners. JOURNAL OF PARKINSONS DISEASE 2017; 6:625-30. [PMID: 27285568 DOI: 10.3233/jpd-160782] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Though hypomimia, also called facial masking, is experienced by many people with Parkinson's disease (PD), little is known about how the experience of this motor impairment relates to their own and their care partners' (CP) social life and relationship quality. OBJECTIVE To test if the experience of facial masking relates to social wellbeing in people with PD and their CPs. METHOD Forty individuals with PD and their CPs rated PD's difficulty showing facial expression (facial masking), and completed questionnaires about their own social wellbeing and depression. RESULTS PD-reported and CP-reported facial masking of PD were positively correlated with experience of social rejection in both partners, though this relationship was diminished when controlling for depression. CPs' rating of their partner's facial masking was negatively associated with enjoyment interacting with their partner. This relationship remained when controlling for CP and PD depression. CONCLUSIONS The findings suggest that the experience of facial masking is negatively associated with social wellbeing particularly for the CPs, and especially so for the quality of CPs interpersonal relationship with their partner with PD.
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Affiliation(s)
- Sarah D Gunnery
- Department of Occupational Therapy, Tufts University, Medford, MA, USA
| | | | | | - Cathi A Thomas
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
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McDonnell MN, Rischbieth B, Schammer TT, Seaforth C, Shaw AJ, Phillips AC. Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil 2017; 32:607-618. [PMID: 28980476 DOI: 10.1177/0269215517734385] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The technique called Lee Silverman Voice Treatment (LSVT)-LOUD has previously been used to improve voice quality in people with Parkinson's disease. The objective of this study was to assess the effectiveness of an alternate intervention, LSVT-BIG (signifying big movements), to improve functional mobility. DESIGN Systematic review with meta-analysis of randomized trials. DATA SOURCES Medline, Embase, CINAHL, AgeLine, Scopus and Cochrane Library were searched from inception to September 2017 using multiple search terms related to Parkinson's disease and LSVT-BIG. REVIEW METHOD Two researchers searched the literature for studies of the LSVT-BIG intervention of 16 sessions, delivered by a certified instructor over four weeks, to any other intervention. Outcomes related to functional ability were included. Study quality was appraised using the Cochrane Risk of Bias tool. RESULTS Four studies were included, reporting on three randomized trials of 84 participants with mild Parkinson's disease. Compared to physiotherapy exercises, or a shorter training protocol, there was a significant improvement in motor function assessed with the Unified Parkinson's Disease Rating Scale part III (mean difference = -3.20, 95% confidence interval = -5.18 to -1.23) and a trend towards faster Timed Up and Go performance (mean difference = -0.47, 95% confidence interval = -0.99 to 0.06) and 10-metre walk test (mean difference = -0.53, 95% confidence interval = -1.07 to 0.01). CONCLUSION Compared to shorter format LSVT-BIG or general exercise, LSVT-BIG was more effective at improving motor function. This provides preliminary, moderate quality evidence that amplitude-oriented training is effective in reducing motor impairments for people with mild Parkinson's disease.
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Affiliation(s)
- Michelle N McDonnell
- 1 School of Health Sciences, University of South Australia, Adelaide, SA, Australia.,2 Stroke and Rehabilitation Research Group, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia.,3 Alliance for Research in Exercise, Nutrition and Activity, University of South Australia, Adelaide, SA, Australia
| | - Briony Rischbieth
- 1 School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Tenille T Schammer
- 1 School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Chantel Seaforth
- 1 School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Alex J Shaw
- 1 School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Anna C Phillips
- 1 School of Health Sciences, University of South Australia, Adelaide, SA, Australia
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Gunnery SD, Naumova EN, Saint-Hilaire M, Tickle-Degnen L. Mapping spontaneous facial expression in people with Parkinson's disease: A multiple case study design. COGENT PSYCHOLOGY 2017; 4. [PMID: 29607351 PMCID: PMC5875435 DOI: 10.1080/23311908.2017.1376425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
People with Parkinson’s disease (PD) often experience a decrease in their facial expressivity, but little is known about how the coordinated movements across regions of the face are impaired in PD. The face has neurologically independent regions that coordinate to articulate distinct social meanings that others perceive as gestalt expressions, and so understanding how different regions of the face are affected is important. Using the Facial Action Coding System, this study comprehensively measured spontaneous facial expression across 600 frames for a multiple case study of people with PD who were rated as having varying degrees of facial expression deficits, and created correlation matrices for frequency and intensity of produced muscle activations across different areas of the face. Data visualization techniques were used to create temporal and correlational mappings of muscle action in the face at different degrees of facial expressivity. Results showed that as severity of facial expression deficit increased, there was a decrease in number, duration, intensity, and coactivation of facial muscle action. This understanding of how regions of the parkinsonian face move independently and in conjunction with other regions will provide a new focus for future research aiming to model how facial expression in PD relates to disease progression, stigma, and quality of life.
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Affiliation(s)
- Sarah D Gunnery
- Department of Occupational Therapy, Tufts University, 574 Boston Ave, Medford, MA 02155, USA
| | - Elena N Naumova
- The Gerald J. and Dorothy H Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Ave, Boston, MA 02111, USA
| | - Marie Saint-Hilaire
- Department of Neurology, Parkinson's Disease and Movement Disorders Center, Boston University Medical Center, 725 Albany St, Boston, MA 02118, USA
| | - Linda Tickle-Degnen
- Department of Occupational Therapy, Tufts University, 574 Boston Ave, Medford, MA 02155, USA
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Mace CZ. The complexities of advance care planning in patients with idiopathic Parkinson's disease. ACTA ACUST UNITED AC 2017. [DOI: 10.12968/bjnn.2017.13.4.178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Clair Zoe Mace
- Parkinson's disease nurse specialist, Nottingham University NHS Trust
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28
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Schwartz R, Pell MD. When emotion and expression diverge: The social costs of Parkinson’s disease. J Clin Exp Neuropsychol 2016; 39:211-230. [DOI: 10.1080/13803395.2016.1216090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Theodoros DG, Hill AJ, Russell TG. Clinical and Quality of Life Outcomes of Speech Treatment for Parkinson's Disease Delivered to the Home Via Telerehabilitation: A Noninferiority Randomized Controlled Trial. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2016; 25:214-232. [PMID: 27145396 DOI: 10.1044/2015_ajslp-15-0005] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 11/30/2015] [Indexed: 06/05/2023]
Abstract
PURPOSE This study investigated the noninferiority and validity of an intensive speech treatment for people with Parkinson's disease (PD) delivered via telerehabilitation to the home. The effect of location on online delivery was also investigated. METHOD In this single-blinded, randomized controlled noninferiority trial, 31 participants with dysarthria associated with PD from a metropolitan area were randomly assigned to either face-to-face or online Lee Silverman Voice Treatment (LSVT LOUD). A cohort of 21 participants from nonmetropolitan areas was also recruited and treated online. Outcomes were assessed using acoustic, perceptual, and quality of life measures. RESULTS Noninferiority of online treatment was confirmed through comparable clinical and quality of life outcomes for the metropolitan online and face-to-face treatment groups. Significant improvements posttreatment were achieved for several acoustic, perceptual, and quality of life measures across the groups. No significant effect of online treatment location was identified. CONCLUSIONS Clinical and quality of life outcomes supported the noninferiority and validity of online delivery of intensive speech treatment to people with PD in the home. Future research should address the implementation of online treatment in a clinical service, cost analyses, and potentially technology-enabled clinical pathways for people with PD in order to maintain optimal communication and quality of life.
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Zhi N, Jaeger BK, Gouldstone A, Sipahi R, Frank S. Toward Monitoring Parkinson's Through Analysis of Static Handwriting Samples: A Quantitative Analytical Framework. IEEE J Biomed Health Inform 2016; 21:488-495. [PMID: 26800555 DOI: 10.1109/jbhi.2016.2518858] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Detection of changes in micrographia as a manifestation of symptomatic progression or therapeutic response in Parkinson's disease (PD) is challenging as such changes can be subtle. A computerized toolkit based on quantitative analysis of handwriting samples would be valuable as it could supplement and support clinical assessments, help monitor micrographia, and link it to PD. Such a toolkit would be especially useful if it could detect subtle yet relevant changes in handwriting morphology, thus enhancing resolution of the detection procedure. This would be made possible by developing a set of metrics sensitive enough to detect and discern micrographia with specificity. Several metrics that are sensitive to the characteristics of micrographia were developed, with minimal sensitivity to confounding handwriting artifacts. These metrics capture character size-reduction, ink utilization, and pixel density within a writing sample from left to right. They are used here to "score" handwritten signatures of 12 different individuals corresponding to healthy and symptomatic PD conditions, and sample control signatures that had been artificially reduced in size for comparison purposes. Moreover, metric analyses of samples from ten of the 12 individuals for which clinical diagnosis time is known show considerable informative variations when applied to static signature samples obtained before and after diagnosis. In particular, a measure called pixel density variation showed statistically significant differences ( ) between two comparison groups of remote signature recordings: earlier versus recent, based on independent and paired t-test analyses on a total of 40 signature samples. The quantitative framework developed here has the potential to be used in future controlled experiments to study micrographia and links to PD from various aspects, including monitoring and assessment of applied interventions and treatments. The inherent value in this methodology is further enhanced by its reliance solely on static signatures, not requiring dynamic sampling with specialized equipment.
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Rochester L, Espay AJ. Multidisciplinary rehabilitation in Parkinson's disease: A milestone with future challenges. Mov Disord 2015; 30:1011-3. [DOI: 10.1002/mds.26277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 04/29/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Lynn Rochester
- Institute of Neuroscience, Newcastle University, Clinical Ageing Research Unit, Campus for Ageing and Vitality; Newcastle upon Tyne UK
| | - Alberto J. Espay
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati; Cincinnati Ohio USA
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Evidence-based treatment of voice and speech disorders in Parkinson disease. Curr Opin Otolaryngol Head Neck Surg 2015; 23:209-15. [DOI: 10.1097/moo.0000000000000151] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ikui Y, Nakamura H, Sano D, Hyakusoku H, Kishida H, Kudo Y, Joki H, Koyano S, Yamauchi A, Takano S, Tayama N, Hirose H, Oridate N, Tanaka F. An Aerodynamic Study of Phonations in Patients With Parkinson Disease (PD). J Voice 2015; 29:273-80. [DOI: 10.1016/j.jvoice.2014.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 08/14/2014] [Indexed: 11/30/2022]
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