Voice Use in Daily Life Studied With a Portable Voice Accumulator in Individuals With Parkinson's Disease and Matched Healthy Controls

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.

Clinical Insights Into the Use of Speech Amplification Devices for Managing Hypophonia: Interviews With Speech-Language Pathologists

PURPOSE

The purpose of this qualitative interview study was to identify themes regarding considerations in the usage of speech amplification device usage for people with Parkinson's disease (PD) and hypophonia from the perspective of speech-language pathologists (SLPs).

METHOD

Eligible participants included SLPs currently practicing in the United States or Canada with experience working with clients with PD for at least 2 years. Ten SLPs participated in 60-min interviews conducted via Zoom. A semistructured interview guide was created prior to the interviews. The interviews were transcribed following their completion, and an iterative coding process was used to identify themes using thematic analysis.

RESULTS

Three main themes were identified from the interviews. The first theme encapsulated how clinicians described amplification devices as a potential treatment tool, which highlighted the nuances that may impact selecting an amplification device as a treatment option such as increased hypophonia or dysarthria severity and cognitive decline. The second theme highlighted how device selection depends on the individual needs of the user. Individual client characteristics (such as disease symptoms and individual needs and preferences) may impact the choice of amplification device. The last theme outlined the importance of involving family members in all stages of device use and involving other health care team members on a case-by-case basis.

CONCLUSIONS

The insights provided by the SLP participants help to understand the clinical decisions that are made when determining device candidacy, selecting a device, and evaluating device success. These insights can be used to improve research studies of augmentative management of hypophonia and guide more personalized management decisions.

Using Portable Voice Accumulators to Study Transfer of Speech Outcomes Following Intervention - A Feasibility Study

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.

Daily Phonatory Activity of Individuals With Parkinson's Disease

PURPOSE

This study evaluated the amount of phonatory activity of Persons with Parkinson disease (PwPD) compared to adults without Parkinson's disease measured over 3 days. The relationship between the amount of phonatory activity and Voice Handicap Index (VHI) total score was assessed as were differences in voicing activity across 3 days of data collection.

METHODS

Fifteen PwPD receiving dopaminergic medication and fifteen age and sex matched adults without Parkinson's disease completed the VHI and then wore a VocaLog vocal monitor (VM) for 3 consecutive days. From the VM data, the number of 1-second windows with dB sound pressure level > 0 were summed as a measure of phonatory activity (PA) and reported relative to the time the VM was worn (%PA).

RESULTS

The percentage of time the VM was worn did not differ between groups or across days. The PwPD had statistically significantly fewer minutes of PA per day than controls (F = 21.782, P < 0.001) by 54 minutes on average. The %PA also differed significantly (F = 31.825, P < 0.001) with a mean of 11.1% for PwPD and 18.6% for controls. Neither PA nor %PA differed across the 3 days of vocal monitoring. VHI total score was significantly correlated with PA (r = -0.436, P = 0.016) and %PA (r = -0.534, P = 0.002) for all participants.

CONCLUSIONS

The results indicate that PwPD engaged in less verbal communication in their daily environment compared to adults without Parkinson's disease. The findings support reports in the literature indicating that PwPD often have reduced communication participation. Measures such as %PA could serve as a quantifiable metric in future studies assessing communication changes in PwPD as a function of disease progression or therapeutic interventions.

Treatment of Hypophonia in Parkinson's Disease Through Biofeedback in Daily Life Administered with A Portable Voice Accumulator

OBJECTIVES

The purpose of this study was to assess the outcome following continuous tactile biofeedback of voice sound level administered, with a portable voice accumulator to individuals with Parkinson's disease (PD).

METHOD

Nine out of 16 participants with PD completed a 4-week intervention program where biofeedback of voice sound level was administered with the portable voice accumulator VoxLog during speech in daily life. The feedback, a tactile vibration signal from the device, was activated when the wearer used a voice sound level below an individually predetermined threshold level, reminding the wearer to increase voice sound level during speech. Voice use was registered in daily life with the VoxLog during the intervention period as well as during one baseline week, one follow-up week post intervention and 1 week 3 months post intervention. Self-to-other ratio (SOR), which is the difference between voice sound level and environmental noise, was studied in multiple noise ranges.

RESULTS

A significant increase in SOR across all noise ranges of 2.28 dB (SD: 0.55) was seen for participants with scores above the cut-off for normal function (>26 points) on the cognitive screening test Montreal Cognitive Assessment (MoCA) (n = 5). No significant increase was seen for the group of participants with MoCA scores below 26 (n = 4). Forty-four percent ended their participation early, all which scored below 26 on MoCA (n = 7).

CONCLUSIONS

Biofeedback administered in daily life regarding voice level may help individuals with PD to increase their voice sound level in relation to environmental noise in daily life, but only for a limited subset. Only participants with normal cognitive function as screened by MoCA improved their voice sound level in relation to environmental noise.

Conversational Vocal Intensity in Parkinson's Disease: Treatment and Environmental Comparisons

BACKGROUND

Vibrotactile Feedback (VF) using wearable devices is an emerging treatment option for hypophonia in Individuals with Parkinson's disease (IwPD). Studies evaluating the effectiveness of VF in improving conversational vocal intensity in real-life environment in IwPD are limited.

OBJECTIVE

To determine the effect of VF on conversational vocal intensity and compare vocal intensity between a) clinic and real-life environment b) VF and Lee Silverman Voice Treatment (LSVT LOUD®)vs. VF alone in IwPD using a portable voice monitor (VocaLog2).

METHODS

Eight individuals with hypophonia secondary to PD were randomly assigned to two treatment groups- VF and LSVT LOUD® (Group 1) and VF (Group 2). VF was provided using VocaLog2 device. Duration of treatment was 4 weeks for both groups. Vocal intensity was measured in the real-life environment at baseline, during treatment, and at one-month follow-up. Vocal intensity in clinic was obtained at baseline and one-month follow-up. Voice Handicap Index (VHI) questionnaire was administered at baseline and one-month follow-up.

RESULTS

There was no significant difference in conversational vocal intensity between a) clinic and real-life environment at any point of time b) baseline and follow up for both treatment groups c) the two treatment groups at baseline, during each of the 4 weeks of treatment and at follow up d) VHI baseline and one month follow up scores.

CONCLUSION

VF, including when combined with LSVT LOUD®, is limited in improving conversational vocal intensity in real-life in IwPD. The effects of frequency and duration of VF on conversational vocal intensity must be systematically investigated using large scale studies in IwPD.

Clinical outcomes of PD Check-In, a model for supported self-managed maintenance of speech in Parkinson's disease: A Phase 1 study

BACKGROUND

For many people with Parkinson's disease (PWPD), the long-term maintenance of speech following intensive treatment remains elusive. PD Check-In, a model for supported self-managed maintenance of speech following LSVT LOUD^® , was developed and evaluated.

AIMS

To evaluate the impact of PD Check-In on vocal intensity and level of satisfaction of PWPD and their communication partners (CPs) over 24 months following LSVT LOUD.

METHODS & PROCEDURES

A repeated-measures study design examined the impact of PD Check-In on the speech of 16 PWPD. Participants received LSVT LOUD followed by PD Check-In at 6 and 12 weeks, and 6, 12 and 24 months after treatment. Outcome measures included acoustic measures of vocal intensity (sound pressure level-SPL) during sustained phonation, functional phrases, reading, and monologue, and satisfaction questionnaires for PWPD and their CPs.

OUTCOMES & RESULTS

A significant treatment effect for time (p < 0.01) was identified for all SPL variables. Planned comparisons showed significant improvements for each variable pre- to post-LSVT LOUD. There was a significant maintenance effect for SPL maximum sustained phonation only, post-LSVT LOUD to 24 months. SPL remained significantly above baseline for functional phrases and maximum sustained phonation at 24 months. Participants' satisfaction with PD Check-In was high, at 93.75% for PWPD and 79.99% for CPs, at 24 months post-treatment. Long intervals between appointments led PWPD to feel less motivated about speech practice but more confident in self-management.

CONCLUSIONS & IMPLICATIONS

For PWPD and CPs, maintenance of speech following LSVT LOUD encompasses more than acoustic outcomes.

WHAT THIS PAPER ADDS

What is already known on this subject? Maintenance of speech following LSVT LOUD has been shown to be variable in individual and group models. For PWPD and their CPs, a model for speech maintenance supports their expectation of sustained treatment effect over time and meets their changing needs for speech and language therapy services. Supported self-management is a model under investigation for long-term maintenance of speech. What this paper adds to existing knowledge? This study presents the impact of five individual PD Check-In interventions on the maintenance of vocal intensity (SPL) of 16 PWPD over 24 months following LSVT LOUD. PWPD and CPs reported a high level of satisfaction with PD Check-In independent of acoustic outcomes. What are the potential or actual clinical implications of this work? Participant satisfaction with PD Check-In is derived from multiple factors and not limited to acoustic outcomes post-LSVT LOUD. Further investigation of the efficacy of PD Check-In to support the perceived maintenance of speech of PWPD and CPs is warranted.

HiCommunication as a novel speech and communication treatment for Parkinson's disease: A feasibility study

INTRODUCTION

Speech and communication problems are common in Parkinson's disease (PD) and can result in social withdrawal and reduced quality of life. Intervention may improve symptoms but transfer and maintenance remain challenging for many. Access to treatment may also be limited. Group intervention incorporating principles for experience-dependent plasticity may address these challenges. The aim of this study was to develop and study feasibility aspects of a new intervention program for group training of speech and communication in people with PD.

MATERIALS & METHODS

Development and content of the program called HiCommunication is described. Core target areas are voice, articulation, word-finding and memory. Five participants with mild-moderate PD completed this feasibility trial. Attendance rate and possible adverse events as well as the participants' experiences were documented. A speech recording and dysarthria testing were completed to study feasibility of the assessment procedure and evaluate possible changes in voice sound level and intelligibility.

RESULTS

Attendance rate was 89%. No adverse events occurred. Participants reported a positive experience and limited fatigue. Assessment was completed in approximately 30 min and was well tolerated. Four of five participants had an increased voice sound level during text-reading postintervention and mean intelligibility improved.

CONCLUSIONS

Results indicate that HiCommunication is feasible for people with mild-moderate PD. The program was appreciated and well tolerated. Positive outcomes regarding voice sound level and intelligibility were observed; however, the number of participants was very limited. The results motivate that effects of HiCommunication are further studied in a randomized controlled trial, which is ongoing.

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.

A Comparison of Speech Amplification and Personal Communication Devices for Hypophonia

Purpose This study compared the performance of three amplification devices hypothesized to improve speech communication in individuals with hypophonia (HP), as well as to identify individuals' device preferences. Method Twenty-two individuals with HP and their primary communication partners participated in a cross-over design study comparing three different speech amplification devices: a wired portable amplifier (Device A), a wireless stationary amplifier (Device B), and a one-way personal communication system (Device C). Participants attended one laboratory visit followed by 1-week trial periods with each device. At the first visit, HP participants completed speech tasks with and without the devices, in quiet and in noise. Following the in-laboratory test period, participants trialed each device at home for approximately 1 week per device. Following completion of the study, participants indicated whether or not they would like to continue using a device. Results Overall, in the presence of noise, all three devices demonstrated significant improvements in speech-to-noise levels and speech intelligibility compared to no device. A clear device hierarchy emerged such that the personal communication device (Device C) was associated with significantly better speech outcomes compared to the other two devices. The majority of participants elected to continue using a device at the completion of the study. Device preferences, however, did not clearly reflect the objective device hierarchy that was found for the objective speech measures. Each of the three devices was selected as a preferred device by at least three participants at the completion of the study. Conclusion Results from this study demonstrated clear differences in device performance in three distinct forms of amplification devices for individuals with HP. Findings suggest that amplification device use may be beneficial for this clinical population and underscore the potential to improve device availability and device selection criteria in future research. Supplemental Material https://doi.org/10.23641/asha.12735875.