Download Every Voice Deserves To Be Heard

Every Voice Deserves To Be
Heard
Christina Santos MS CCC-SLP
INTEGRIS Jim Thorpe Outpatient
Rehabilitation
[email protected]
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
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.
Famous People Diagnosed
With PD
O Mohammed Ali
O Michael J. Fox
O Billy Graham
O Janet Reno
O Pope John Paul II
O Charles Schulz (Cartoonist, Peanuts)
O Linda Ronstadt
O Bill Geist
O Robin Williams
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)
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.
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.
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.
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)
Speech Deficits in PD
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O
O
O
O
O
O
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Reduced vocal volume
Inconsistent production of the voice
Hoarse, scratchy, or breathy vocal quality
Reduced clarity or articulation of
syllables
Decreased breath support for speech
Speech hesitation
Decreased facial expression
Weakness and fatigue
Monotone voice
Swallowing Deficits in PD
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O
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O
O
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Drooling
Difficulty chewing food
Taking more than one hour to eat a meal
Coughing or choking with food or liquid
during or soon after eating or drinking
Eyes watering while eating or drinking
Nose running while eating or drinking
Sensation of food/pills getting stuck
Unintentional weight loss
Loss of appetite
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.
An Essay on the Shaking Palsy
By: James Parkinson
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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.”
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)
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
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.
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.
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
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.
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.
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)
“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.
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)
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)
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)
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.
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!
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)
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.
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)
Warm-ups
O Engages voice and starts the
coordination of respiratory
laryngeal sequences.
Sustained phonation
O Increases awareness of breath
support
O Vocal loudness drives respiratory
and laryngeal systems
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
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
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
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.
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
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.
Speech Treatment
Although Parkinson’s is labeled as
“progressive and degenerative,”
it is one of the few neurological
disorders that responds favorably
to rehabilitation.
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)
The Effect of SPEAK OUT! Voice Therapy
on Speech Intensity in Persons with
Parkinson’s Disease
O Eunsun Park, M.A.1, Christina Santos, M.S.2, Justin
O
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Dvorak, B.A.1 , Jason Gates,M.H.A.2, Pam Forducey,
Ph.D.2, Frank Boutsen, Ph.D.1
1Motor Speech and Prosody Research Lab, Dept. of CSD,
College of Allied Health, University of Oklahoma
2INTEGRIS Jim Thorpe Rehabilitation
Analyzed tape Pre- and Post-treatment recordings of 21
patients with PD reading the “Grandfather Passage”
2 Females, 19 Males
RMS Measures derived from acoustic waveforms of
recordings.
Results
O Post-therapy intensity was significantly greater
O
O
O
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than pre-treatment intensity.
Patients gained an average of 10.4 dB intensity
which corresponds to an approximate doubling in
perception of loudness
Neither patient age nor duration of disease
significantly influenced change in intensity
Results suggest SPEAK OUT! Is a viable alternative
to LSVT for patients with PD.
Study has recently been expanded to include new
patients in SPEAK OUT!
SPEAK OUT! Oklahoma
protocol
O Patient is evaluated at clinic
O Attends orientation at the Parkinson
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O
Foundation of Oklahoma (PFO)
Begins 4 weeks of individual treatment
(does exercises 2x/day for 25 days)
Graduates at end of the 4 weeks
Begins LOUD Crowd groups at PFO
Returns to clinic every 6 months for reevaluation
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)
Maintaining FunctionBarriers
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)
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!
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.
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.
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.
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.
Thank You!
Christina Santos MS, CCC-SLP
SPEAK OUT! Coordinator
[email protected]
or
[email protected]