Every Voice Deserves To Be Heard. Christina Santos MS CCC-SLP INTEGRIS Jim Thorpe Outpatient Rehabilitation

Transcription

1 Every Voice Deserves To Be Heard Christina Santos MS CCC-SLP INTEGRIS Jim Thorpe Outpatient Rehabilitation

2 Course Objectives O Participants will be able to: 1) Identify symptoms of hypokinetic dysarthria associated with Parkinson s 2) Identify how the model of intention can improve speech and voice deficits associated with hypokinetic dysarthria 3) Identify the 6 components of the SPEAK OUT! Program 4) Identify the importance of both SPEAK OUT! And LOUD Crowd in long-term voice and speech maintenance in the Parkinson s population

3 Statistics about Parkinson s O 1.5 million people in the U.S. have Parkinson s. O 1 in 100 adults over the age of 60 are diagnosed with Parkinson s. O It is estimated that by 2040, there will be four times as many people diagnosed with Parkinson s.

4 Famous People Diagnosed O Mohammed Ali O Michael J. Fox O Billy Graham O Janet Reno O Pope John Paul II With PD O Charles Schulz (Cartoonist, Peanuts) O Linda Ronstadt O Bill Geist O Robin Williams

5 Parkinson s The 4 hallmark symptoms: 1) Tremors of the hands, face and limbs 2) Rigidity (stiffness) 3) Postural instability (reduced balance) 4) Bradykinesia (slow movement)

6 Dopamine O Dopamine helps control muscle movement. O With PD, brain cells that make dopamine slowly die. O Without dopamine, the cells that control movement can t send messages to the muscles. O Slowly over time, this damage gets worse.

7 Dopamine O By the time a patient exhibits symptoms of Parkinson s, the brain has already lost 60-80% of the dopamine. O Dopamine is responsible for making movements smooth and coordinated. O Dopamine loss causes reduced amplitude of movement. O Movements become smaller as the disease progresses.

8 Reduced Amplitude of Movement O Commonly noted with writing (micrographia), shuffling gait, reduced arm swing. O This is also seen with breath control for speech, oral and facial movements, vocal folds.

9 Speech Deficits in PD O Approximately 89% of individuals with Parkinson s will develop speech and swallowing disorders during the course of their illness. O Speech and swallowing disorders have negative effects on communication, health, psychological well-being and quality of life. (Ramig et al, 2008)

10 Speech Deficits in PD O Reduced vocal volume O Inconsistent production of the voice O Hoarse, scratchy, or breathy vocal quality O Reduced clarity or articulation of syllables O Decreased breath support for speech O Speech hesitation O Decreased facial expression O Weakness and fatigue O Monotone voice

11 Swallowing Deficits in PD O Drooling O Difficulty chewing food O Taking more than one hour to eat a meal O Coughing or choking with food or liquid during or soon after eating or drinking O Eyes watering while eating or drinking O Nose running while eating or drinking O Sensation of food/pills getting stuck O Unintentional weight loss O Loss of appetite

12 Main Cause of Death in PD O According to the National Institute of Health, the leading cause is aspiration pneumonia. O Patients are also at risk for asphyxiation or choking to death due to food blocking the airway and stopping breathing.

13 An Essay on the Shaking Palsy By: James Parkinson O His words are now scarcely intelligible; and he is not only no longer able to feed himself, but when the food is conveyed to the mouth, so much are the actions of the muscles of the tongue and pharynx impeded by impaired action and perpetual agitation, that the food is with difficulty retained in the mouth until masticated; and then as difficultly swallowed. Now, also from the same cause, another very unpleasant circumstance occurs: the saliva fails of being directed to the back part of the fauces, and hence is continually draining from the mouth, mixed with the particles of food, which he is no longer able to clear from the inside of the mouth.

14 Interaction Between Speech, Language and Cognition O Scaling problem (force and amplitude) with movement O Internal cueing O Sensory problem O Self-perception of voice O Self-regulation of vocal output (Ramig 2008; Sapir, Ramig, Fox 2006)

15 Speech, Language, Cognition O Pausing and verbal disruptions O Turn-taking O Shorter responses O Finding words O Language not as rich or complex O Expressing emotions

16 PD Dementia O 30% prevalence in Idiopathic PD. O Deficits noted in attention, executive functioning, visuo-spatial skills, as well as memory impairments. O Can become more anxious in challenging situations.

17 Speech Deficits O De Letter and colleagues (2007) found significant respiratory difficulties as possibly contributing to the PD patients voice symptoms. O Ramig & colleagues (1994) found that 35 out of 40 PD subjects had bowed vocal folds.

18 Atypical Parkinsonism O Multiple System Atrophy (MSA) O Progressive Supra-Nuclear Palsy (PSP) O Corticobasilar Degeneration (CBD) O Dementia with Lewy Bodies (DLB) O Drug-induced Parkinsonism

19 Medications and DBS-STN O The majority of studies have failed to find a causal relationship between dopamine and speech, or rigidity and speech, or a positive impact of dopamine therapy on functional speech intelligibility in individuals with PD. (Ramig 2008) O Despite use of Levodopa and other PD medications, voice and speech continue to decline.

20 DBS-STN (continued) O Can cause everything in the vocal mechanism to become tight and sometimes people have difficulty initiating oral movement and have a strained voice quality. O DBS has been shown to impact rate and fluency of speech negatively. O Can be adjusted to optimize for speech production and this can help with voice production.

21 Swallow Treatment O Evaluate as soon as symptoms begin and teach exercises to help them improve and maintain function. O Intensive exercises and a home program. O Focus on re-coordinating breathing and swallowing patterns. (The Coordination of Breathing and Swallowing in Parkinson s Disease. Roxann Diez Gross. Dysphagia Vol 23. Number 2. June 2008)

22 Traditional Speech Therapy O Results disappear on the way to the parking lot. (Ramig) O Commonly includes oral exercises O Usually focuses on respiration, articulation, loudness and rate of speech. O It is difficult to remember to focus on all 4 of these areas every time we speak, therefore strategies aren t carried over outside of the therapy session.

23 Exercise O There is basic science evidence that values exercise in management of Parkinson s. O Principles: Intensity, repetition, salience, complexity. Timing matters. O Exercise is like medicine!!! (Kleim et al)

24 Intention Assisted Therapy O The most effective voice therapy approach is a holistic one. Increasing volume helps improve function in all other components. O When patients speak with intent, their speech is often slower and louder. They also have better voice quality and better articulation. (Dr. Daniel Boone)

25 Daniel R. Boone s Use of Intention O Late 1950 s O Highland View Hospital in Cleveland, Ohio O When counting backwards, noticed near normal rate of speaking, good articulation, and a louder voice. O Automatic coordination of breathing, voice, and speech articulation takes place within the extrapyramidal system. O Speaking with Intent involves bypassing the extrapyramidal system and uses a higher motor tract (Pyramidal system)

26 Daniel R. Boone s Use of Intention Within the therapy session we focused on talking louder, even encouraging her to yell speech responses. When speaking with such deliberate intention (speaking inappropriately louder), her speech was much more normal in rhythm and clarity of articulation. Boone, Daniel R. Damn Shoes And Other Talking Tales. Arizona: Forman Publishing, 2009.

27 Use of Intention Increase the amplitude! O Walk with Intent! O Write with Intent! O Speak with Intent! O Speak with Authority! O Speak with Purpose! O Use your CEO voice! O Use your pyramidal system instead of your extrapyramidal system! O Think about HOW you re saying something instead of just WHAT you re going to say!

28 O Ramig and colleagues (2001) and Spielman and colleagues (2011) have also studied the model of intention in a formal voice and speech program called Lee Silverman Voice Treatment (LSVT LOUD)

29 SPEAK OUT! Voice Treatment O Target: Focus on speaking with intent and increasing vocal volume. O Mode: Intensive treatment with high effort. (3 sessions a week for 4 weeks) O Calibration: Generalize outside of the treatment room. O Developed by Parkinson Voice Project. Founder: Samantha Elandary, MA, CCC/SLP and colleagues.

30 SPEAK OUT! O Part one of a two part program O Program includes 6 components: 1) Vocal warm-up 2) Sustained phonation of ah 3) Vocal glides 4) Automatic sequences 5) Reading 6) Cognitive tasks (think & speak louder)

31 Warm-ups O Engages voice and starts the coordination of respiratory laryngeal sequences.

32 Sustained phonation O Increases awareness of breath support O Vocal loudness drives respiratory and laryngeal systems

33 Glides O Glide pitch up and down the scale O Cricothyroid moves to stretch the vocal folds as pitch is changed O Raising pitch changes tongue position and laryngeal elevation

34 Automatic sequences O Counting, days, months O Begins with fewer syllables and gradually increases number of syllables per breath O Reinforces coordination of breathing and voicing

35 Oral Reading O Begins transfer of skills to conversational speech O It is important that the patient does not focus on content of what they are reading O If the patient has trouble reading, singing or reciting are good alternatives

36 Cognitive Exercise O Focuses on thinking and speaking louder at the same time O It appears that cognitive exercises enable a transfer of their louder intentional voice to meaningful, functional communication.

37 The LOUD Crowd O Part 2 of the program includes groups and a life-long home exercise program O Weekly voice groups at the Parkinson Foundation of Oklahoma at no charge for patients ( 4 current groups) O Led by a Speech-Language Pathologist O Bi-monthly singing groups at the Parkinson Foundation of Oklahoma

38 O Individuals with PD have reported conversational difficulties. O Patients who have completed SPEAK OUT! have reported anecdotally that their confidence in everyday interactions with family and friends has increased.

39 Speech Treatment Although Parkinson s is labeled as progressive and degenerative, it is one of the few neurological disorders that responds favorably to rehabilitation.

40 A Case Study: The Effects of the SPEAK OUT! Voice program for Parkinson s Disease O Dr. June Levitt, Department of Communication Sciences and Disorders, Texas Woman s University O 6 individuals with PD participated, all males O Results suggest that SPEAK OUT! Individual voice therapy is effective in improving vocal functions of individuals with PD. O Improved vocal performance was generally maintained throughout the attendance of the subsequent LOUD Crowd group therapy sessions beyond the 12 sessions of SPEAK OUT! (Measured after 4 and then 8 group sessions)

41 The Effect of SPEAK OUT! Voice Therapy on Speech Intensity in Persons with Parkinson s Disease O O O Eunsun Park, M.A. 1, Christina Santos, M.S. 2, Justin Dvorak, B.A. 1, Jason Gates,M.H.A. 2, Pam Forducey, Ph.D. 2, Frank Boutsen, Ph.D. 1 1 Motor Speech and Prosody Research Lab, Dept. of CSD, College of Allied Health, University of Oklahoma 2 INTEGRIS Jim Thorpe Rehabilitation O Analyzed tape Pre- and Post-treatment recordings of 21 patients with PD reading the Grandfather Passage O O 2 Females, 19 Males RMS Measures derived from acoustic waveforms of recordings.

42 Results O Post-therapy intensity was significantly greater than pre-treatment intensity. O Patients gained an average of 10.4 db intensity which corresponds to an approximate doubling in perception of loudness O Neither patient age nor duration of disease significantly influenced change in intensity O Results suggest SPEAK OUT! Is a viable alternative to LSVT for patients with PD. O Study has recently been expanded to include new patients in SPEAK OUT!

43 SPEAK OUT! Oklahoma protocol O Patient is evaluated at clinic O Attends orientation at the Parkinson Foundation of Oklahoma (PFO) O Begins 4 weeks of individual treatment (does exercises 2x/day for 25 days) O Graduates at end of the 4 weeks O Begins LOUD Crowd groups at PFO O Returns to clinic every 6 months for reevaluation

44 Maintaining therapeutic outcomes O Requires daily vocal exercises for life. O Always speak with intent in a louder voice. O Re-evaluations to assess if patient is maintaining function. O Attend maintenance groups as often as possible: Patients who participate regularly in LOUD Crowd groups have been shown to easily maintain the results of initial voice treatment for 5+ years (Samantha Elandary)

45 Maintaining Function- Barriers O Memory/cognitive deficits. O Usual excuses of no time or too tired. O Reduced motivation/apathy caused by PD. O Reduced awareness that exercises actually help them (sensory deficits)

46 Speech Language Pathology O Question: When to refer for services? O Answer: As soon as someone is experiencing dysphagia or changes with speech and voice function. O *Do NOT wait until the problem is severe to seek treatment!

47 Helping a Person with PD O Encourage them to keep talking and to engage in conversation, even when it s hard. O Remind them often to speak louder rather than saying What did you say? O Encourage them to seek effective treatment when a decline first occurs because very often, they don t realize it.

48 Helping (cont.) O Encourage them to do voice/speech and/or swallow exercises daily because it s difficult to stay motivated for life. O *If they don t do them, they will decline with their ability to communicate and swallow.

49 Empowering O Encourage people with PD to have a team of healthcare providers to help them maintain overall function as long as possible. O Check in with that team on a regular basis. O Join support groups. O Keep positive! You CAN live a productive life with Parkinson s.

50 Summary O 89% of people with PD are at risk of losing the ability to swallow and communicate. O SPEAK OUT! is a viable treatment option for people with PD. O Early treatment is recommended to maintain best function for the long-term. O Maintenance programs are crucial for sustaining therapeutic outcomes.

51 Thank You! Christina Santos MS, CCC-SLP SPEAK OUT! Coordinator or