8/17/11 IMPROVING RESPIRATORY SUPPORT: NONSPEECH TASKS. DYSARTHRIA TREATMENT: PRACTICE GUIDELINES AND OPTIONS PART 1 KSHA September 2011

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1 NONSPEECH TASKS DYSARTHRIA TREATMENT: PRACTICE GUIDELINES AND OPTIONS PART 1 KSHA September 2011 Use these strategies if speaker can t generate enough subglottic air pressure to support phonation These strategies may be limited to people with isolated respiratory impairments These strategies should be cleared by a physician knowledgeable about pulmonary function Difficulty generalizing from nonspeech to speech tasks No support in the literature for many nonspeech tasks (blowing balloons, bubbles, pinwheels, etc ; applying pressure/vibration to diaphragm, ribs, etc ; applying ice to diaphragm, electrical stimulation) NONSPEECH TASKS Evidence-based support for some nonspeech techniques (breathing against resistance using a mask, pushing and pulling techniques, biofeedback of chest wall movement) Use of some nonspeech techniques are supported by expert opinion (max. inhalation and exhalation tasks, controlled exhalation tasks, breathing against resistance through pursed lips, using an air pressure transducer w/ feedback from an oscilloscope or computer screen, sustaining phonation w/ feedback from VisiPitch or the VU meter or a tape recorder) POSTURAL ADJUSTMENTS Can have a major influence on respiratory support for speech Most of the postural adjustment techniques are supported by expert opinion only Upright posture for people with inspiratory problems (ALS, PD); gravity can assist with lowering the diaphragm into the abdomen on inspiration POSTURAL ADJUSTMENTS Supine posture for people with expiratory problems (TBI, MS, spinal cord injury, spastic CP); gravity and abdominal contents help push the diaphragm into the thoracic cavity on expiration Adaptive seating systems for people with expiratory difficulty (beds, chairs, wheelchairs w/ adjustable backs) Caveats for supine positioning: inspiratory ability will be diminished, may be difficult to generalize from supine to upright position There is no support Neurodevelopmental Treatment (NDT) PROSTHETIC ASSISTANCE Prosthetic devices are often evaluated in consultation with a physical therapist A physician should approve these devices Expiratory boards/paddles person leans into the object while speaking assists w/ expiration use supported by expert opinion only person may lack trunk strength or balance to use the paddle Push in abdomen with one hand during expiration if person has enough arm strength use supported by expert opinion only 1

2 PROSTHETIC ASSISTANCE Abdominal trussing trussing might involve the use of abdominal binders (corsets), abdominal wraps, and pneumobelts assists with expiration contraindicated for those w/ inspiratory problems may cause pneumonia use if person doesn t have enough trunk control to use an expiratory board there is evidence-based support for this technique medical approval and supervision are essential SPEECH TASKS It s ideal to target improvements in respiratory support for speech during actual speech tasks Manipulations of breathing patterns expert opinion support Inhale more deeply When you do this, there are more forceful elastic recoil of the lungs, which may result in excessive loudness bursts or air wastage if the higher expiratory forces are not checked during exhalation Inspiratory checking Designed to produce stable subglottic air pressure Person is asked to inhale to 50% of maximum capacity and then let the air out slowly when talking; could also practice sustaining an isolated sound for 5 secs while keeping intensity and quality constant Abdominal or diaphragmatic breathing Affords the greatest lung volumes, increases abdominal contributions during speech Use more force when exhaling SPEECH TASKS Various forms of biofeedback Output from air pressure transducers can be displayed on an oscilloscope person works toward targeted air pressure levels Could use a VisiPitch, VU meter, or tape recorder to give feedback about loudness level Evidence-based support for the use of biofeedback to improve respiratory support for speech Best candidates are those with low to midlevel stimulability (relatively poor response to initial training) CONTROL: NONSPEECH TASKS These techniques are used with those who have difficulty coordinating their respiratory and phonatory systems during speech (those with ataxic or involuntary movements those with ataxic or hyperkinetic dysarthria) Level of support is mainly expert opinion Matching the rate of respiration to the ticking of a metronome Biofeedback therapy to increase control of inhalation and exhalation evidence-based support Inspiratory checking without accompanying speech Facilitating inspiratory coordination/speed through sniffing or exhalatory coordination through blowing Practicing an effective breathing pattern (quick inspirations and slow, controlled exhalations) Practicing switching between inspiration and expiration the speed of the task can eventually be increased to resemble panting CONTROL: SPEECH TASKS Supported mainly by expert opinion Speech stimuli could range from syllables or simple words to sentences you want to encourage respiratory/phonatory control over longer and longer utterances Feedback on chest wall movement and phonation Improved awareness of speech breathing pattern (quick inhalation followed by prolonged exhalation during speech) may use Respitrace Learning to evaluate and monitor loudness levels during speech Combining pressing movements on the speaker s abdomen with instruction about getting to the right size during inhalation/exhalation for speech CONTROL: SPEECH TASKS Use of optimal breath groups an optimal breath group is the number of syllables that can be comfortably placed on one breath Inspiratory checking during speech for people who release excessive amounts of air through the larynx before speaking or when they speak Training respiratory flexibility training the ability to vary the depth of inhalation depending on the length and volume of the intended utterance; could practice reading passages that the clinician has marked re: when to take a breath 2

3 CONTROL: SPEECH TASKS Candidates for these treatment strategies are persons who: Initiate speech at variable points in the respiratory cycle and need more consistent inspiratory control Initiate speech at inappropriate lung volume levels and need to vary the depth of consecutive inhalations Terminate speech late in the expiratory cycle with resultant diminished loudness and vocal fry Exhibit abnormal or maladaptive respiratory patterns, such as speaking on inhalation and forced exhalation, often seen in persons with hyperkinetic dysarthria or those with a concomitant cognitive impairment Adopt a fatiguing pattern of breathing, such as excessive shoulder elevation SPEAKING WHILE ON A VENTILATOR OR WITH THE USE OF A TRACHEOSTOMY We won t cover this content today The Passy-Muir company provides some information about speaking and swallowing while using a tracheostomy or ventilator, and CEUs may be earned by reviewing this information S FOR HYPOADDUCTION Physical strategies to enhance adduction Effort closure techniques (e.g., pulling upward on chair seat, pushing against arms of wheelchair) Hard glottal attack (forceful, abrupt phonatory efforts) Postural adjustments (turn head away from paralyzed vocal fold may increase tension of paralyzed fold) Physical manipulations of the thyroid cartilage push on the larynx while the speaker phonates Trigger better speech with increased loudness LSVT program training improved articulation as well as loudness; most effective for those with mildmoderate PD LEE SILVERMAN VOICE TREATMENT (LSVT) PROGRAM Designed for those with hypokinetic dysarthria associated with PD. Goals are to increase phonatory effort, vocal fold adduction, and respiratory support High-intensity 4 days/week for 4 weeks Speakers learn to produce loud speech Client is taught to recalibrate speech effort that s/he needs to increase effort Good candidate mild-mod PD, reduced loudness as a result of hypoadduction of vf s, poor respiratory support/effort, good stimulability, high motivation PROSTHETIC INTERVENTIONS (DEVICES) FOR HYPOADDUCTION Delayed Auditory Feedback (DAF) To slow the rate of speech Portable biofeedback device Voice amplifier Masking noise Speech Enhancer and clarify speech signal Artificial larynx To provide a vibratory source (aphonia, severe breathiness) SURGICAL INTERVENTIONS FOR HYPOADDUCTION (UNILATERAL VOCAL FOLD PARALYSIS) Laryngeal framework surgery Type I thyroplasty insert a shim of silastic through a surgically created window in the thyroid lamina (pushes the paralyzed fold toward midline). Done when there is a large glottic gap. procedures/laryngoplasty.html Arytenoid adduction rotate the arytenoid cartilage to stimulate its position during normal adduction, secured by a suture. Done when there is a large posterior glottic gap and when adjustment of the vertical position of the fold is desired. 3

4 SURGICAL INTERVENTIONS FOR HYPOADDUCTION (UNILATERAL VOCAL FOLD PARALYSIS) Injection medialization Inject a substance (e.g., collagen, autologous fat) into the paralyzed fold to increase its bulk. Done when there is a small glottic gap. procedures/injection.html Reinnervation Donor nerves (e.g., ansa cervicalis) from self supply alternate innervation to the paralyzed fold. Done to reduce atrophy, maintain or improve muscle tone and bulk, stabilize arytenoid cartilage positioning, enable tensing functions %20PARALYSIS.html IMPROVING PHONATORY FUNCTION IN ABDUCTOR SPASMODIC DYSPHONIA breathy voice, abrupt terminations in voicing resulting in whispered segments of speech; treat with Botox injections to muscles that are responsible for opening the vocal folds (posterior cricoarytenoids) S FOR HYPERADDUCTION Nonspeech techniques Relaxation strategies (relaxation exercises, massage of larynx) Biofeedback of airflow or the laryngeal muscles (e.g., maintain a steady and controlled stream of air - use VisiPitch; EMG feedback) Speech tasks Reduce laryngeal tension by using strategies for easy onset of phonation ( yawn-sigh, chewing, or chanting techniques, confidential voice) Biofeedback during speech (EMG, videoendoscopic, or aerodynamic feedback) Increase pitch, rotate head back, initiate utterances at a high lung volume level (all associated w/decreased airway resistance) SURGICAL INTERVENTIONS FOR HYPERADDUCTION Botox injections to vocal folds in spastic dysarthria and hyperkinetic dysarthria (usually as a result of adductor spasmodic dysphonia (SD)). Effect lasts 2-6 months. Voice therapy alone is not effective in SD One study (Murry & Woodson, 1995) found that Botox plus voice therapy was more effective than Botox alone in subjects with SD Section the recurrent laryngeal nerve on one side and then do laryngeal reinnervation surgery Type II thyroplasty brings the vocal folds apart TREATMENT FOR VELOPHARYNGEAL IMPAIRMENT Three categories of intervention studies Prosthetic, surgical, exercise There is evidence in the literature of effectiveness of prosthetic intervention There is not sufficient evidence to assess the effectiveness of surgical management for velopharyngeal impairment in dysarthria (evidence is insufficient to make recommendations) There is not sufficient evidence to assess the effectiveness of exercise for velopharyngeal impairment in dysarthria (only 2 case reports have been published) EVIDENCE FOR THE EFFECTIVENESS OF PROSTHETIC INTERVENTION Who is a good candidate for prosthetic intervention? Speech characteristics of hypernasality, nasal emission, and severe reduction of intelligibility Physiological factors such as VPI, palatopharyngeal paralysis, inconsistent soft palate contact with the pharyngeal wall, inability to achieve adequate oral pressure, and poor respiratory support for speech Rationale: resolution of VPI would lead to speech improvement Behavioral speech tx had been unsuccessful or progress had plateaued Far enough time post-onset that no further recovery was likely 4

5 EVIDENCE FOR THE EFFECTIVENESS OF PROSTHETIC INTERVENTION What Risks or complications of palatal lifts were identified? Tooth movement or injury to the soft tissue Initial discomfort Inability to inhibit a gag Prosthesis retention difficulty (edentulous) Difficulty with articulation in some persons with severe spasticity Increased swallowing difficulty Hypersalivation Lack of acceptance of the device Unrealistic expectations EVIDENCE FOR THE EFFECTIVENESS OF PROSTHETIC INTERVENTION What were the outcomes of the intervention studies? Generally, positive outcomes were reported Improved articulation Decreased hypernasality Improved speech intelligibility More efficient use of respiratory support for speech Palatal lift fitting was more difficult in those who were edentulous or had a spastic palate Best results when the soft palate was flaccid and good pharyngeal wall movement was present Most improvement in those who wore their palatal lifts the longest PROSTHETIC INTERVENTION: NASAL OBTURATOR A plastic frame with a oneway valve The frame fits into the nares The one-way valve allows the person to inhale, but prevents air from escaping through the nares on exhalation Case study evidence of increased oral pressures and decreased nasal flows and/or better phoneme intelligibility research_institute/ communication_center/ research/ current_research.html An appropriate candidate for behavioral intervention is someone who has velopharyngeal impairment and can compensate for the velopharyngeal impairment The questions of whether speakers can compensate can be addressed by evaluating stimulability Use the following techniques to assess stimulability: Changing speaking rate (e.g., slowing the rate) Changing the effort level (e.g., increase the effort for those with mild velopharyngeal weakness or decrease the effort for those with ataxia who have excess effort) Additional techniques to assess stimulability: Monitoring excess nasal airflow and resonance features Increase the precision of speech by exaggerating articulatory movements ( clear speech ) The timing of palatal lift intervention in those with moderate impairment expert opinion varies Some argue for VP management before phonation, articulation, and prosody exercises for those who are recovering function Others argue for VP management only after the speaker can phonate voluntarily Re: the timing of palatal lift intervention the clinician needs to consider several factors, including the relative severity of involvement in other functional components, to determine whether treatment of the velopharynx would enhance function in other areas (e.g., tax respiration less), and whether velopharyngeal function would benefit from treating other components first or from modifying the patient s speaking rate or effort 5

6 Techniques Focusing on Speech Production Modifying the pattern of speaking Resistance treatment during speech Feedback Expert opinion supports How long should the intervention be applied? Techniques Focusing on Nonspeech Movements Pushing techniques Strengthening exercises, such as blowing and sucking Tasks that encourage the person to control and modify the airstream using balls, whistles, candles, etc... Inhibition techniques (prolonged icing, pressure to muscle insertion points, desensitization) NOT EFFECTIVE TECHNIQUES FOCUSING ON SPEECH PRODUCTION Modifying the Pattern of Speaking Producing speech with increased effort Using a slower rate of speech Use of overarticulated speech prompt with comments like, Open your mouth more, Speak more clearly, Overarticulate, and Talk slowly Resistance Treatment During Speech Use of CPAP (continuous positive airway pressure) to exercise the soft palate during speech The muscles of the velopharyngeal closure must work against resistance Used with 2 persons with TBI We have CPAP therapy materials in our clinic CPAP NASAL MASKS TECHNIQUES FOCUSING ON SPEECH PRODUCTION Feedback The person with dysarthria may benefit from feedback from a mirror, nasal flow transducer, or nasoendoscope during efforts to decrease nasal airflow and hypernasality PROSTHETIC INTERVENTION: CANDIDACY FOR PALATAL LIFT FITTING The speaker is not able to compensate for the velopharyngeal impairment Progressive dysarthria better candidates: slower rate of disease progression intact cognition, memory, judgment, swallowing, and manual dexterity respiratory/phonatory and oral articulatory aspects of speech are adequate the soft palate is weak from flaccidity rather than spasticity speech is characterized by disproportionately reduced ability to produce pressure consonants maintaining functional speech is critical to the speaker PROSTHETIC INTERVENTION: CANDIDACY FOR PALATAL LIFT FITTING Stable or recovering dysarthria better candidates: stable or slow rate of change intact cognition, memory, judgment, swallowing, and manual dexterity good oral articulation is not as critical as in progressive dysarthria articulation and respiratory function should improve once the lift is fitted the soft palate is weak from flaccidity rather than spasticity speech is characterized by disproportionately reduced ability to produce pressure consonants Improved speech is critical to the speaker 6

7 SURGICAL INTERVENTION FOR VELOPHARYNGEAL IMPAIRMENT Less beneficial than prosthetic management and contraindicated for children with CP Pharyngeal flap is one type of surgery File:Pharyngeal_flap_procedures1.svg File:Pharyngeal_flap_procedures2.svg Pharyngeal implants is a second type of surgery Teflon injections into the pharynx is a third type of surgery 7