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.

Communicative participation outcomes in individuals with Parkinson's disease receiving standard care speech-language therapy services in community settings.

BACKGROUND: The Communicative Participation Item Bank (CPIB) is a patient-reported outcome measure (PROM) designed to measure the extent of interference, or difficulty, experienced by adults with communication disorders participating in their day-to-day communication activities. To date, there is limited evidence regarding sensitivity of the CPIB for capturing change with intervention in people with Parkinson's disease (PwPD). AIMS: The purpose of this study was to examine the following measurement properties of the CPIB in PwPD who received community-based, standard care, speech-language therapy focusing on motor speech concerns: Change over time between treatment and observation groups, comparison to patient-defined ideal and satisfactory targets, comparison of static short form to computerised adaptive testing (CAT), comparison of self to proxy-rated scores, and comparison to other common PROMs. METHODS AND PROCEDURES: Forty-six PwPD (20 treatment/26 observation) completed data collection upon enrolment (pre-treatment) and 6 months later. In addition to the CPIB, PROMs included the Voice Handicap Index 10-item short form (VHI-10), PROMIS Global Health-Related Quality of Life, Levels of Speech Usage, self-rated speech severity, and Patient Health Questionnaire-9 (PHQ-9). Participants also engaged in qualitative interviews. Forty-four family members completed proxy CPIB ratings. OUTCOMES AND RESULTS: There were no significant differences between treatment and observation groups on the CPIB pre-treatment, but there were significant differences post-treatment. The differences appeared to be largely due to significant gains in the treatment group. No participants reached their ideal CPIB target, and few reached their satisfactory target. Static CPIB short form and CAT scores were not significantly different, with an average of five CAT items administered per participant. Overall group similarities between patient and proxy scores may have obscured wide variability across individual patient-proxy pairs. Associations between CPIB and VHI-10, health-related quality of life, self-reported speech severity, and depression ranged from weak to moderate. CONCLUSIONS AND IMPLICATIONS: The CPIB appears to be sensitive to capturing change with intervention, and similar results are obtained with the static short form and CAT formats. One clinical caution is that even with gains observed in the treatment group, no participants obtained their ideal communicative participation goals, and few obtained a satisfactory level of communicative participation. Thus, while current interventions are beneficial, they may not meet the full range of clients' communication needs. While responding to the CPIB through a proxy rater may be feasible, caution is warranted due to concerns about maintaining the autonomy of PwPD. WHAT THIS PAPER ADDS: What is already known on this subject The communication disorders associated with Parkinson's disease (PD) can have a negative impact on quality of life and life participation as measured by patient (or person)-reported outcome measures (PROMs). The Communicative Participation Item Bank (CPIB) is one PROM available to use with adults with communication disorders. However, little is known about whether the CPIB captures changes in communicative participation as a result of standard care treatment for people with Parkinson's disease (PwPD). Use of computerised adaptive testing (CAT), proxy report and comparison to targeted participation outcomes have not been explored. What this study adds to existing knowledge As a result of this study, we know that the CPIB captured differences between treatment and observation groups after community-based, standard care speech therapy intervention focusing on motor speech production in PwPD. Static short form and CAT scores did not differ significantly, so the CAT option provides better efficiency requiring, on average, five items to administer compared to the 10-item short form. Proxy and PwPD scores did not differ as a group, but wide variability was noted. What are the potential or actual clinical implications of this work? The CPIB may be a clinically sensitive instrument for capturing changes in communicative participation after treatment. No participants met their ideal CPIB target, and few reached their satisfactory target, suggesting that while current interventions contribute to gains in communicative participation, there are still unmet needs that may call for support and interventions addressing the more complex array of factors affecting communicative participation outcomes for PwPD.

Extreme Sawtooth-Sign in Motor Neuron Disease (MND) suggests Laryngeal Resistance to Forced Expiratory Airflow.

OBJECTIVE: The impact of laryngeal dysfunction on airflow has not been well characterized in motor neuron disease (MND). This study aimed to detect and characterize extreme airflow oscillations informally observed during volitional cough and forced vital capacity (FVC) tasks in individuals with MND who demonstrated neurolaryngeal impairments including reduced speed and extent of vocal fold abduction compared to healthy controls during volitional cough expulsion. The extreme airflow oscillations in the MND group, when viewed as a flow-volume loop, appeared similar to the "sawtooth-sign." If the airflow oscillations are periodic in a range similar to phonation, they may reflect reduced laryngeal patency. METHODS: Volitional cough and FVC airflow data (3 trials each) from 12 participants with MND with bulbar/laryngeal involvement (3 F; ages 45-76) and 12 healthy controls (6 F; ages 41-68) were analyzed for periodicity. Percent and absolute durations of periodicity of the flow oscillations were calculated by an algorithm applied to the airflow signals. In addition, the frequency, magnitude, and kurtosis of the periodic airflow oscillations were described and compared between groups. RESULTS: In both volitional cough and FVC trials, the percent of airflow periodicity during forced expiration was significantly higher (z = 3.54) in individuals with MND, adjusted for age and sex. Periodic airflow accounted for on average 28% of the total time in participants with MND and was within a frequency range similar to phonation. Magnitude of the airflow oscillations was also larger for participants with MND (z = 3.46), and kurtosis of airflow was smaller (z = -4.70) during forced expiration, indicating persistent airflow oscillations throughout exhalation. CONCLUSIONS: The significantly larger-magnitude, lower-kurtosis, and more prominent presence of sawtooth-like airflow periodicity within a frequency range similar to phonation observed in individuals with MND with neurolaryngeal impairments suggests glottic airflow resistance during forced expiration.

Sensitivity of the Communicative Participation Item Bank for Measuring Patient-Reported Outcomes After Treatment of Unilateral Vocal Fold Immobility.

Importance: The Communicative Participation Item Bank (CPIB) is a patient-reported outcome measure assessing the association between communication disorders and participation in daily communication. To our knowledge, no prior research has examined whether CPIB scores change after treatment of unilateral vocal fold immobility (UVFI). Objective: To compare CPIB scores before and after treatment of UVFI and with patient-defined target treatment outcomes and other common clinical outcomes after UVFI intervention. Design, Setting, and Participants: This single-group case series recruited a convenience sample of community-dwelling patients aged 18 years or older from an urban academic medical center who had a diagnosis of UVFI and planned to receive intervention for UVFI. The study was conducted from March 2014 to March 2019. Exposures: Intervention for UVFI according to clinicians' recommendations. The treatment type was not controlled for this study. Main Outcomes and Measures: Patients' self-reported communicative participation was assessed by obtaining CPIB scores before and after treatment of UVFI, with scores calibrated to the standardized T scale. Pearson correlations between the CPIB general short form and computerized adaptive format, the Voice Handicap Index-10 (VHI-10), and self-rated and clinician-rated voice severity were also evaluated. Results: The sample included 25 participants, of whom 17 (68%) were male, 8 (32%) were female, and the mean (SD) age was 54.9 (17.0) years. Significant changes after treatment were observed in all quantitative outcomes including the primary outcome of the CPIB; the mean T score before treatment was 40.95 (95% CI, 37.49-44.41) and after treatment was 53.23 (95% CI, 48.41-58.04) (mean difference, -13.04 [95% CI, -7.30 to -18.79]; Cohen d, 0.96). The Pearson correlation between the CPIB general short form and computerized adaptive testing scores at pretreatment was r = 0.93 and at posttreatment, r = 0.95. Computerized adaptive testing showed efficiency advantages, with typically 5 to 6 items required for administration compared with 10 items for the short form. The correlation between the CPIB and VHI-10 was moderate before treatment (r = -0.70) and strong after treatment (r = -0.91). Moderate correlations were observed between the CPIB and clinician-rated voice quality before (r = -0.52) and after (r = -0.46) treatment and between CPIB and self-rated voice quality before (r = -0.56) and after (r = -0.62) treatment. Conclusions and Relevance: The results of this case series suggest that the CPIB is relevant for clinical use to assess changes in communicative participation among patients with UVFI before and after they receive treatment.

Effects of Mouthpiece Noninvasive Ventilation on Speech in Men With Muscular Dystrophy: A Pilot Study.

Purpose The use of noninvasive ventilation (NIV) is on the rise as an alternative to tracheostomy for individuals with neuromuscular disorders with life-prolonging and quality-of-life benefits. This pilot study was designed to determine if mouthpiece NIV (M-NIV) alters speech in individuals with muscular dystrophy (MD). Method Eight men (23-44 years), seven with Duchenne MD and one with Becker MD, who used daytime M-NIV, were asked to sustain phonation, count, and read under three conditions: (a) Uncued (no instructions), (b) With M-NIV (cued to use M-NIV with all speaking breaths), and (c) Without M-NIV (as tolerated). Breath group and inspiratory durations, syllables/breath group, and relative sound pressure level were determined from audio and video recordings. Results Uncued condition: Participants used the ventilator for all inspirations that preceded sustained phonation and counting. During reading, four participants used M-NIV for all inspirations, one never used it, and three used it for some (19%-41%) inspirations. With- versus Without-M-NIV conditions: Breath group duration was significantly longer across all tasks, syllables per breath group were significantly greater during reading, and inspiratory pause duration during reading was significantly longer with M-NIV than without. Sound pressure level was significantly higher during the first second of sustained phonation with M-NIV (though not for counting and reading). Two participants were unable to complete the reading task audibly without using their M-NIV. Conclusions Speech may be better with M-NIV than without because it is possible to produce longer breath groups and some people with severe respiratory muscle weakness may not be able to speak at all without ventilator-supplied air. Nevertheless, the longer inspiratory pauses that accompany M-NIV may interrupt the flow of speech. Future research is needed to determine the most effective way to use M-NIV for speaking and whether training participants in its use can bring even greater speech benefits.

Dysphagia in Parkinson's disease patients prior to deep brain stimulation: Is screening accurate?

BACKGROUND: Swallowing problems are common in Parkinson's Disease (PD) and aspiration pneumonia is the leading cause of death. Deep brain stimulation (DBS) surgery can successfully manage the motor symptoms of PD when pharmacological management begins to fail. Before DBS it is important to identify baseline dysfunction, but no consensus regarding swallowing screening exists. OBJECTIVES: This study was undertaken to: 1) identify the prevalence of dysphagia prior to DBS; and 2) determine if screening measures or other characteristics were predictive for reduced airway protection. METHODS: A standardized protocol was performed for 137 consecutive patients with idiopathic PD and no confounding medical conditions, including those referred for work-up of dysphagia (n = 57) and those prior to DBS (n = 80). Three validated screening measures were completed before videofluoroscopic evaluation. RESULTS: On videofluoroscopy, there were significant differences in reduced airway protection by group (dysphagia group: 44 %; pre-DBS group: 21 %). Aspiration also differed by group (dysphagia group: 18 %; pre-DBS group: 8 %) although not significantly. Although there were significant between-group differences, none of the screening measures was predictive of reduced airway protection or aspiration in the sample overall. Male gender, previous videofluoroscopic evaluation, history of pneumonia, and previous DBS surgery were associated with increased aspiration-risk. Age also showed a modest correlation. CONCLUSIONS: Dysphagia is not uncommon prior to DBS. No screening measure accurately predicted reduced airway protection on videofluoroscopy. Abnormal findings on clinical assessment prior to DBS, particularly in patients that are older, male, or have a history of pneumonia, may identify individuals requiring an objective dysphagia evaluation.

Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis.

The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22-42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne's; 1 with Becker's) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3-22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing-swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing-swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.

Experiences of Speaking With Noninvasive Positive Pressure Ventilation: A Qualitative Investigation.

Purpose The aim of this study was to describe experiences of speaking with 2 forms of noninvasive positive pressure ventilation (NPPV)-mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP)-in people with neuromuscular disorders who depend on NPPV for survival. Method Twelve participants (ages 22-68 years; 10 men, 2 women) with neuromuscular disorders (9 Duchenne muscular dystrophy, 1 Becker muscular dystrophy, 1 postpolio syndrome, and 1 spinal cord injury) took part in semistructured interviews about their speech. All subjects used M-NPPV during the day, and all but 1 used BPAP at night for their ventilation needs. Interviews were audio-recorded, transcribed, and verified. A qualitative descriptive phenomenological approach was used to code and develop themes. Results Three major themes emerged from the interview data: (a) M-NPPV aids speaking (by increasing loudness, utterance duration, clarity, and speaking endurance), (b) M-NPPV interferes with the flow of speaking (due to the need to pause to take a breath, problems with mouthpiece placement, and difficulty in using speech recognition software), and (c) nasal BPAP interferes with speaking (by causing abnormal nasal resonance, muffled speech, mask discomfort, and difficulty in coordinating speaking with ventilator-delivered inspirations). Conclusion These qualitative data from chronic NPPV users suggest that both M-NPPV and nasal BPAP may interfere with speaking but that speech is usually better and speaking is usually easier with M-NPPV. These findings can be explained primarily by the nature of the 2 ventilator delivery systems and their interfaces.

The Safety and Efficacy of Expiratory Muscle Strength Training for Rehabilitation After Supracricoid Partial Laryngectomy: A Pilot Investigation.

OBJECTIVES: Expiratory muscle strength training (EMST) is a safe, effective intervention that can be performed at home and may be beneficial for individuals with voice and swallowing disorders. To date there have been few studies of EMST in the head and neck cancer population, and there are no previous reports of its use after supracricoid partial laryngectomy (SCPL). The current prospective clinical pilot study was undertaken to determine the safety and efficacy of a 4-week treatment program. METHODS: Six participants were recruited who had previously undergone SCPL, were medically stable, and had no contraindications for use of the device. At baseline, objective respiratory measurements were collected, dietary status was recorded, and participants were asked to complete a series of validated self-report instruments relating to voice, swallowing, breathing, and cough. Following the completion of treatment, baseline measures were repeated, and participant feedback was solicited. RESULTS: The majority of individuals found the device easy to use (83%) and beneficial (83%). The side effects of treatment were relatively minor and included dizziness, muscle inflammation, and vocal fatigue. There were improvements in 2 measures from before to after treatment, namely, an average 21% increase in peak cough flow (from 371.67 to 451.33 L/min) and a 38% decrease on the Dyspnea Index (from 6.17 to 3.83). Other measures showed inconsistent changes. CONCLUSIONS: EMST appeared to improve cough strength and reduce dyspnea symptoms after SCPL. Further study of the relative efficacy of EMST compared to other rehabilitation protocols after SCPL is needed.

Swallowing and Secretion Management in Neuromuscular Disease.

Neuromuscular disease frequently leads to dysphagia and difficulty managing secretions. Dysphagia may lead to medical complications, such as malnutrition, dehydration, aspiration pneumonia, and other pulmonary complications, as well as social isolation and reduced overall quality of life. This review provides an overview of dysphagia associated with neuromuscular disease in adults, along with a concise review of swallowing assessment and intervention options.

Utility of Pulse Oximetry to Detect Aspiration: An Evidence-Based Systematic Review.

Pulse oximetry is a commonly used means to measure peripheral capillary oxyhemoglobin saturation (SpO2). Potential use of pulse oximetry to detect aspiration is attractive to clinicians, as it is readily available, quick, and noninvasive. However, research regarding validity has been mixed. This systematic review examining evidence on the use of pulse oximetry to detect a decrease in SpO2 indicating aspiration during swallowing is undertaken to further inform clinical practice in dysphagia assessment. A multi-engine electronic search was conducted on 8/25/16 and updated on 4/8/17 in accordance with standards published by the Preferred Reporting for Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA). Inclusion criteria included use of pulse oximetry to detect aspiration with simultaneous confirmation of aspiration via a gold standard instrumental study. Keywords included dysphagia or aspiration AND pulse oximetry. Articles meeting criteria were reviewed by two blinded co-investigators. The search yielded 294 articles, from which 19 were judged pertinent and reviewed in full. Ten met the inclusion criteria and all were rated at Level III-2 on the Australian Diagnostic Levels of Evidence. Study findings were mixed with sensitivity ranging from 10 to 87%. Potentially confounding variables were observed in all studies reviewed, and commonly involved defining "desaturation" within a standard measurement error range (~ 2%), mixed populations, mixed viscosities/textures observed during swallowing, and lack of comparison group. The majority of studies failed to demonstrate an association between observed aspiration and oxygen desaturation. Current evidence does not support the use of pulse oximetry to detect aspiration.

Speech Versus Speaking: The Experiences of People With Parkinson's Disease and Implications for Intervention.

PURPOSE: In this project, we explore the experiences of people who report speech changes associated with Parkinson's disease as they describe taking part in everyday communication situations and report impressions related to speech treatment. METHOD: Twenty-four community-dwelling adults with Parkinson's disease took part in face-to-face, semistructured interviews. Qualitative research methods were used to code and develop themes related to the interviews. RESULTS: Two major themes emerged. The first, called "speaking," included several subthemes: thinking about speaking, weighing value versus effort, feelings associated with speaking, the environmental context of speaking, and the impact of Parkinson's disease on speaking. The second theme involved "treatment experiences" and included subthemes: choosing not to have treatment, the clinician, drills and exercise, and suggestions for change. CONCLUSIONS: From the perspective of participants with Parkinson's disease, speaking is an activity requiring both physical and cognitive effort that takes place in a social context. Although many report positive experiences with speech treatment, some reported dissatisfaction with speech drills and exercises and a lack of focus on the social aspects of communication. Suggestions for improvement include increased focus on the cognitive demands of speaking and on the psychosocial aspects of communication.

Beyond Tracheostomy: Noninvasive Ventilation and Potential Positive Implications for Speaking and Swallowing.

For more than a decade, there has been a trend toward increased use of noninvasive positive pressure ventilation (NPPV) via mask or mouthpiece as a means to provide ventilatory support without the need for tracheostomy. All indications are that use of NPPV will continue to increase over the next decade and beyond. In this article, we review NPPV, describe two common forms of NPPV, and discuss the potential benefits and challenges of NPPV for speaking and swallowing based on the available literature, our collective clinical experience, and interviews with NPPV users. We also speculate on how future research may inform clinical practice on how to best maximize speaking and swallowing abilities in NPPV users over the next decade.

Associations between laryngeal and cough dysfunction in motor neuron disease with bulbar involvement.

True vocal fold (TVF) dysfunction may lead to cough ineffectiveness. In individuals with motor neuron disease (MND), cough impairment in the context of dysphagia increases risk for aspiration and respiratory failure. This study characterizes differences and associations between TVF kinematics and airflow during cough in individuals with bulbar MND. Sequential glottal angles associated with TVF movements during volitional cough were analyzed from laryngeal video endoscopy examinations of adults with bulbar MND (n = 12) and healthy controls (n = 12) and compared with simultaneously collected cough-related airflow measures. Significant group differences were observed with airflow and TVF measures: volume acceleration (p ≤ 0.001) and post-compression abduction TVF angle average velocity (p = 0.002) were lower and expiratory phase rise time (p = 0.001) was higher in the MND group. Reductions in maximum TVF angle during post-compression abduction in the MND group approached significance (p = 0.09). All subjects demonstrated complete TVF and supraglottic closure during the compression phase of cough, except for incomplete supraglottic closure in 2/12 MND participants. A strong positive relationship between post-compression maximum TVF abduction angle and peak expiratory cough flow was observed in the MND group, though it was not statistically significant (r = 0.55; p = 0.098). Reductions in the speed and extent of TVF abduction are seen during the expulsion phase of cough in individuals with MND. This may contribute to cough impairment and morbidity.

Endoscopic assessment of vocal fold movements during cough.

OBJECTIVES: Little is known about the function of the true vocal folds (TVFs) during cough. The objective of this study was to determine the reliability of measuring TVF movements during cough and to obtain preliminary normative data for these measures. METHODS: Sequential glottal angles associated with TVF adduction and abduction across the phases of cough were analyzed from laryngeal videoendoscopy records of 38 young healthy individuals. RESULTS: The intraobserver and interobserver reliability of 3 experienced measurers was high (intraclass correlation of at least 0.97) for measuring sequential and maximum glottal angles. The TVF abduction velocity during expulsion was significantly higher than the precompression adduction velocity (p = 0.002), but there were no significant differences in maximum angle. No statistically significant differences were seen in maximum TVF angle and velocity when they were compared between the sexes and between the levels of cough strength. True vocal fold closure following expulsion occurred in 42% of soft coughs and in 57% of moderate to hard coughs. CONCLUSIONS: The TVF abduction angles during cough can be reliably measured from laryngeal videoendoscopy in young healthy individuals. The TVF movements are faster for expulsion abduction than for precompression adduction, but the extents of abduction are similar. To validly determine the cough phase duration, simultaneous measures of airflow are needed.

A qualitative study of interference with communicative participation across communication disorders in adults.

PURPOSE: To explore the similarities and differences in self-reported restrictions in communicative participation across different communication disorders in community-dwelling adults. METHOD: Interviews were conducted with 44 adults representing 7 different medical conditions: spasmodic dysphonia, multiple sclerosis, stroke, stuttering, Parkinson's disease, amyotrophic lateral sclerosis, and laryngectomy. This article represents a secondary analysis of qualitative data collected in cognitive interviews during development of the Communicative Participation Item Bank. The data were analyzed to identify themes in participants' experiences related to communicative participation. RESULTS: Participants described many situations in which they experienced interference in communicative participation. Two themes emerged from the data. The first theme was Interference is both "functional" and "emotional," in which participants defined interference as limitations in accomplishing tasks and emotional consequences. The second theme was "It depends"-sources of interference, in which participants described many variables that contribute to interference in participation. Participants had limited control of some variables such as symptoms and environmental contexts, but personal decisions and priorities also influenced participation. CONCLUSIONS: Despite different impairments and activity limitations, participants described similar communicative participation restrictions. These similarities may have theoretical and clinical implications in terms of how we assess, treat, and study the participation restrictions associated with communication disorders.

Variables associated with communicative participation in people with multiple sclerosis: a regression analysis.

PURPOSE: To explore variables associated with self-reported communicative participation in a sample (n = 498) of community-dwelling adults with multiple sclerosis (MS). METHOD: A battery of questionnaires was administered online or on paper per participant preference. Data were analyzed using multiple linear backward stepwise regression. The dependent variable was an item response theory score of communicative participation measured by a subset of items from the Communicative Participation Item Bank asking respondents to rate how much their health condition interfered with participation in real-life speech communication situations. Thirteen independent variables were included in the model as self-reported symptoms: problems thinking, slurred speech, vision loss, pain, mobility, depression, fatigue, perceived social support, age, education level, employment status, gender, and MS duration. RESULTS: Fatigue, slurred speech, depression, problems thinking, employment status, and social support were significantly associated with communicative participation, accounting for 48.7% of the variance. CONCLUSIONS: Communicative participation is significantly associated with multiple variables, only some of which reflect communication disorders. If the goal of intervention is to improve communicative participation, intervention may need to extend beyond traditional speech-language pathology boundaries to include other health symptoms as well as personal, social, and physical environments.

Baclofen pump intervention for spasticity affecting pulmonary function.

INTRODUCTION: Muscle spasticity may adversely affect pulmonary function after spinal cord injury (SCI). However, there is limited information regarding the treatment of spasticity as a determinant of pulmonary function. This study presents the case of a man with C4 tetraplegia who had severe spasticity and difficulty weaning from ventilatory support. METHODS: Case presentation. RESULTS: Severe spasticity likely contributed to respiratory compromise in this patient. Successful and rapid weaning from the ventilator occurred within 3 weeks of baclofen pump placement. CONCLUSIONS: Randomized clinical trials among SCI patients with significant spasticity are needed to determine whether intervention with a baclofen pump facilitates earlier ventilatory weaning.