Behavioral Management of Respiratory/Phonatory Dysfunction for Dysarthria Associated With Neurodegenerative Disease: A Systematic Review.

PURPOSE: This systematic review represents an update to previous reviews of the literature addressing behavioral management of respiratory/phonatory dysfunction in individuals with dysarthria due to neurodegenerative disease. METHOD: Multiple electronic database searches and hand searches of prominent speech-language pathology journals were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. RESULTS: The search yielded 1,525 articles, from which 88 met inclusion criteria and were reviewed by two blinded co-investigators. A large range of therapeutic approaches have been added to the evidence base since the last review, including expiratory muscle strength training, singing, and computer- and device-driven programs, as well as a variety of treatment modalities, including teletherapy. Evidence for treatment in several different population groups-including cerebellar ataxia, myotonic dystrophy, autosomal recessive spastic ataxia of Charlevoix-Saguenay, Huntington's disease, multiple system atrophy, and Lewy body dementia-were added to the current review. Synthesis of evidence quality provided strong evidence in support of only one behavioral intervention: Lee Silverman Voice Treatment Program (LSVT LOUD) in people with Parkinson's disease. No other treatment approach or population included in this review demonstrated more than limited evidence, reflecting that these approaches/populations require urgent further examination. CONCLUSION: Suggestions about where future research efforts could be significantly strengthened and how clinicians can apply research findings to their practice are provided. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24964473.

Rehabilitation of Airway Protection in Individuals With Movement Disorders: A Telehealth Feasibility Study.

PURPOSE: Airway protective deficits (swallowing and cough) greatly reduce health and quality of life and are a pervasive consequence of neurodegenerative movement disorders. Expiratory muscle strength training (EMST) and cough skill training (CST) are two treatment approaches to improve airway protection; however, many patients are unable to access these treatments. Telehealth may improve access to care, but it remains unknown whether these treatments are feasible and efficacious via telehealth. This study aimed to determine the practical feasibility and preliminary treatment effect of EMST and CST via telehealth. METHOD: Twenty participants with movement disorders completed 4 weeks of EMST and 2 weeks of CST, including two clinician-directed treatment sessions via telehealth and 3 days of home practice per week. Feasibility was calculated for each treatment. Practical feasibility was defined as completing treatment (EMST or CST) and obtaining the relevant outcome measures-a proxy of maximum expiratory pressure (pMEP) for EMST and peak expiratory flow rate (PEFR) for CST-within a 30-min session/period. Session factors that may have influenced feasibility were examined. Preliminary treatment effect was defined as changes in pMEP and PEFR. RESULTS: Time taken to obtain pMEP and complete EMST was 17.48 min, and time taken to obtain PEFR and complete CST was 17.69 min. pMEP, single voluntary cough PEFR, and sequential voluntary cough PEFR increased from pre- to posttreatment. CONCLUSIONS: Findings suggest that the delivery of EMST and CST is feasible via telehealth and yield improvements to pMEP and PEFR. This has important implications for expanding service delivery of airway protective interventions and reducing health care disparities in people with neurodegenerative movement disorders. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21357669.

Respiratory Responses to Two Voice Interventions for Parkinson's Disease.

PURPOSE: The purpose of this study was to examine the respiratory strategies used by persons with Parkinson's disease (PD) to support louder speech in response to two voice interventions. Contrasting interventions were selected to investigate the role of internal and external cue strategies on treatment outcomes. LSVT LOUD, which uses an internal cueing framework, and the SpeechVive prosthesis, which employs an external noise cue to elicit louder speech, were studied. METHOD: Thirty-four persons with hypophonia secondary to idiopathic PD were assigned to one of three groups: LSVT LOUD (n = 12), SpeechVive (n = 12), or a nontreatment clinical control (n = 10). The LSVT LOUD and SpeechVive participants received 8 weeks of voice intervention. Acoustic and respiratory kinematic data were simultaneously collected at pre-, mid- and posttreatment during a monologue speech sample. Intervention outcomes included sound pressure level (SPL), utterance length, lung volume initiation, lung volume termination, and lung volume excursion. RESULTS: As compared to controls, the LSVT LOUD and SpeechVive participants significantly increased SPL at mid- and posttreatment, thus confirming a positive intervention effect. Treatment-related changes in speech breathing were further identified, including significantly longer utterance lengths (syllables per breath group) at mid- and posttreatment, as compared to pretreatment. The respiratory strategies used to support louder speech varied by group. The LSVT LOUD participants terminated lung volume at significantly lower levels at mid- and posttreatment, as compared to pretreatment. This finding suggests the use of greater expiratory muscle effort by the LSVT LOUD participants to support louder speech. Participants in the SpeechVive group did not significantly alter their respiratory strategies across the intervention period. Single-subject effect sizes highlight the variability in respiratory strategies used across speakers to support louder speech. CONCLUSIONS: This study provides emerging evidence to suggest that the LSVT LOUD and SpeechVive therapies elicit different respiratory adjustments in persons with PD. The study highlights the need to consider respiratory function when addressing voice targets in persons with PD.

Perception of Physical Demand, Mental Demand, and Performance: A Comparison of Two Voice Interventions for Parkinson's Disease.

PURPOSE: The purpose of the study was to examine the effect of two voice intervention approaches for hypophonia secondary to Parkinson's disease (PD) on self-reported measures of physical demand, mental demand, and vocal performance. METHOD: Thirty-four persons with hypophonia secondary to PD were assigned to one of three groups: Lee Silverman Voice Treatment (LSVT) LOUD (n = 12), SpeechVive (n = 12), and nontreatment clinical control (n = 10). The LSVT LOUD and the SpeechVive participants received 8 weeks of voice intervention following the standardized protocol previously described for each approach. To confirm the effectiveness of each voice intervention, sound pressure level (dB SPL) data were analyzed for the experimental and control participants for a monologue sample obtained pretreatment, midtreatment, and posttreatment. During the voice intervention period, the LSVT LOUD and the SpeechVive participants were instructed to complete a modified version of the National Aeronautics and Space Administration Task Load Index rating scale to indicate the mental and physical demand required to complete the intervention activities, and to indicate how well they performed in completing the assigned vocal tasks. RESULTS: The LSVT LOUD and the SpeechVive participants demonstrated a significant posttreatment increase in SPL (dB), in comparison to the clinical controls, thus confirming a positive intervention effect. The LSVT LOUD participants reported significantly higher ratings of physical and mental demand over the course of treatment, in comparison to the SpeechVive participants. CONCLUSION: Consideration of the mental and physical demand associated with two voice intervention approaches, commonly used for PD, may help to foster improved therapeutic compliance and treatment outcomes.

Obtaining Objective Clinical Measures During Telehealth Evaluations of Dysarthria.

Purpose COVID-19 has shifted models of health care delivery, requiring the rapid adoption of telehealth, despite limited evidence and few resources to guide speech-language pathologists. Management of dysarthria presents specific challenges in the telehealth modality. Evaluations of dysarthria typically rely heavily on perceptual judgments, which are difficult to obtain via telehealth given a variety of technological factors such as inconsistencies in mouth-to-microphone distance, changes to acoustic properties based on device settings, and possible interruptions in connection that may cause video freezing. These factors limit the validity, reliability, and clinicians' certainty of perceptual speech ratings via telehealth. Thus, objective measures to supplement the assessment of dysarthria are essential. Method This tutorial outlines how to obtain objective measures in real time and from recordings of motor speech evaluations to support traditional perceptual ratings in telehealth evaluations of dysarthria. Objective measures include pause patterns, utterance length, speech rate, diadochokinetic rates, and overall speech severity. We demonstrate, through clinical case vignettes, how these measures were completed following three clinical telehealth evaluations of dysarthria conducted via Zoom during the COVID-19 pandemic. This tutorial describes how each of these objective measures were utilized, in combination with subjective perceptual analysis, to determine deviant speech characteristics and their etiology, develop a patient-specific treatment plan, and track change over time. Conclusion Utilizing objective measures as an adjunct to perceptual ratings for telehealth dysarthria evaluations is feasible under real-world pandemic conditions and can be used to enhance the quality and utility of these evaluations.