The Effects of Specific Respiratory Muscle Training on the Speech Intelligibility of a Patient with Parkinson s Disease

Size: px

Start display at page:

Download "The Effects of Specific Respiratory Muscle Training on the Speech Intelligibility of a Patient with Parkinson s Disease"

Stewart Perkins
5 years ago
Views:

1 The Effects of Specific Respiratory Muscle Training on the Speech Intelligibility of a Patient with Parkinson s Disease Vaneysa Hansen, M.A., SLP (C) & Barbara Mathers-Schmidt, PhD, SLP-CCC Western Washington University ASHA Conference Chicago November 22, 2008

2 Agenda Purpose Background information Outcome Measures Method Results Discussion Summary

3 Learning Objectives Possible new therapy option for SLP s working with PD patients Potential value of IMT/EMT approach Implications for future research

4 Purpose A pilot study to determine if specific inspiratory (IMT) and expiratory muscle training (EMT) resulted in: increased speech intelligibility increased intensity levels improved maximal inspiratory and expiratory pressures self-rating of communication success

Reduced MEP/MIP, abnormal flow volume loops, reduced peak expiratory airflow

5 Respiration Function and PD Lower airway restriction and/or muscle weakness (Silverman et al., 2006; Yorkston et al., 2003). Reduced MEP/MIP, abnormal flow volume loops, reduced peak expiratory airflow rates, and decreased vital capacities. (Hovestadt et al., 1989; Obenour et al.,1972; Tzelepis et al.,1988)

volume on inhalation Limiting the available passive recoil pressure on exhalation that is

6 Respiration & PD Chest wall rigidity contributes to muscle weakness (Tamaki, Matsuo, Yanagihara, & Abe, 2000) limits the lung s ability to fully inflate Restricting lung volume on inhalation Limiting the available passive recoil pressure on exhalation that is required for speech. Recruiting active expiratory muscles when subglottal pressure demands are not met

the diaphragm, requiring specific training of weakened muscles Does not allow

7 Why Specific Respiratory Training? Speech requires rapid initiation and coordination of chest wall musculature and the diaphragm, requiring specific training of weakened muscles Does not allow airflow mechanics to be modified a steady airflow must be maintained throughout the task, as seen in normal speech (Silverman et al.).

influence the PCA: Positive effect on speech production and voice

8 Inspiratory Training & Speech Control of diaphragm and posterior cricoarytenoid muscle (PCA) are linked in the brainstem IMT can influence the PCA: Positive effect on speech production and voice quality (Ruddy et al., 2004). increase in activation may increase lung volume

affected by weakness and rigidity may enhance vocal intensity and quality (M.H.

9 Expiratory Training & Speech Increased respiratory pressures contribute to improvements in sound quality duration intensity strengthening expiratory muscles affected by weakness and rigidity may enhance vocal intensity and quality (M.H. Draper, P. Ladefoged, D. Whitteridge, 1959; E.M. Finnegan, E.S. Luschei, H.T. Hoffman, 2000; N. Isshiki, 1964)

10 IMT & COPD Successfully strengthened the respiratory muscles and eliminated dyspnea and fatigue in pts with COPD. (Hill et al, 2006)

11 EMT & MS Increased muscle strength in pts with MS Increased cough efficacy Did not change vocal quality (Chiara, Martin, & Sapienza, 2007)

IMT increased MIP and MEP for pt with PD and decreases the

12 Rationale for IMT/EMT with PD EMT improved expiratory muscle strength for PD pts (Saleem, Sapienza & Okun, 2005). IMT increased MIP and MEP for pt with PD and decreases the perception of dyspnea (Inzelberg, 2005). Used device similar to PowerLung

control of the respiratory system to benefit speech.

13 Combining IMT/EMT Could resynchronize the ventilatory system improving lung volume decreasing the workload of the expiratory muscles increasing control of the respiratory system to benefit speech. Increase muscle strength and endurance (Weiner, Magadle, Beckerman, Weiner & Berar-Yanay, 2003)

14 Hypotheses 1. MEP/MIP and db SPL will increase with tx because of improved strength, resulting in increased speech intelligibility.

15 2. Lung volume will increase with tx due to an expanded range of motion of respiratory muscles, leading to improved speech intelligibility.

16 Subject 52 year old male PD since 1990 L-dopa/ Carbidopa, Comtan and Welbutrin Advanced PD Bilateral pallidotomy in 1997 Smoker for 30 years Previously participated in speech therapy

Exhibited palalalia Hypokinetic dysarthria: slurred articulation of

17 Pre-intervention Speech Assessment Rigidity in the muscles of the face and mandible Shown by slow movement and a reduced range of motion Exhibited palalalia Hypokinetic dysarthria: slurred articulation of words, delayed initiation of words, rushed bursts of speech, and decreased intensity

medication dosages Difficulty being understood over the phone Most

18 Interview with Subject His speech improved and his dysfluencies decreased 3 months prior to the study due to more efficient medication dosages Difficulty being understood over the phone Most difficult to talk during his medication offstate in the afternoon and evening

Medication intake scheduled for 8am to ensure consistent on-off states Sustain a

19 Subject Criteria No unrelated speech or respiratory health problems Native speaker of English No other speech therapy while completing the training Medication intake scheduled for 8am to ensure consistent on-off states Sustain a steady respiratory driving pressure of 5 cm of H 2 O for 5 sec. and 10 cm of H 2 O for 10 sec.

B1 = first respiratory training (5 weeks) A2 = withdrawal

20 Method Experimental Design: ABAB single subject design 4 phases over a 19-week period A1 = baseline testing (2 days) B1 = first respiratory training (5 weeks) A2 = withdrawal stage (4 weeks) B2 = second respiratory training stage (8 weeks)

Survey (Sullivan, Beukelman & Gaebler, 1997) The Rating

21 Outcome Measures MEP and MIP FVC and predicted FVC% Intensity levels (db) The Communicative Effectiveness Survey (Sullivan, Beukelman & Gaebler, 1997) The Rating Scale for Speech Characteristics in Parkinson s disease (Ramig, 1992)

speaking rate and intelligibility rate communication efficiency ratio

22 Intelligibility Outcome Measures Sentence Intelligibility Test (SIT) (Yorkston, Beukelman, & Tice, 1996) Percentage of speech intelligible speaking rate and intelligibility rate communication efficiency ratio McHenry & Parle s Unpredictable Sentences Kent Phonetic Contrast Word List

23 Why use this Intelligibility Test? SIT program: A commonly used test to measure speech intelligibility in pts with dysarthria (McHenry & Parle, 2006; Yorkston et al., 2003). Measures a person s speech intelligibility of words in sentences

more sensitive to changes in speech intelligibility (Kent et al., 1989; McHenry & Parle, 2006).

24 Why use other Intelligibility Tests? McHenry & Parle s Unpredictable Sentences (2005) Eliminates predictable words Considered to be more sensitive to changes in speech intelligibility (Kent et al., 1989; McHenry & Parle, 2006). Kent Phonetic Contrast List (Kent, Weismer, Kent, & Rosenbeck, 1989) Single word intelligibility correlates highly with sentence and narrative scores

25 SIT Demonstration Instructions and sentence stimuli

26 MEP/MIP MEP/MIP Instructions MEP/MIP Demo

more experienced judges, with more than ½ of scores within 5%.

27 Protocols provided Interjudge reliability: Reliability within 5% for all but the 1st baseline (A1-baseline 1) within 15% of the more experienced judges, with more than ½ of scores within 5%. Intrajudge reliability: within 5% for all but 1 score (A1-baseline 2).

mouth over the lip shield and breathe in and out.

28 Training- PowerLung Spring-loaded resistance training device Inhalation control dial (1 6) Exhalation control dial (1 3) Place mouth over the lip shield and breathe in and out. Settings on dials adjust level of effort needed to open valve inside PowerLung: Trainer-Active Series

29 Training Protocol Review mechanics of inhalation and exhalation Focus on use of diaphragm and ribcage muscles to increase size of thoracic cavity, keep facial and throat muscles relaxed Secure nose clip 2 sets of 10 reps twice daily (1 set in morning, 1 set in afternoon/evening). 1 set = 10 reps inhalation & 10 reps exhalation 1st 8 reps, breathe in/out for 3 seconds 9th and 10th repetitions, breathe in/out in 1 second Increase settings on PowerLung to 1/8 of a turn when reps become less effortful (i.e. no longer using ideal setting).

30 Training Demonstration PowerLung Demo 9 th & 10 th Breath

Training Weekly or biweekly phone calls or emails were used to ensure

31 Training Weekly or biweekly phone calls or s were used to ensure compliance with training protocol and to answer questions 1 per week, trained with researcher in WWU clinic. To adjust settings and maintain subject s ideal settings as strength increased. To provide feedback on technique.

general increased rate (characteristic of hypokinetic dysarthria) No change during

32 Results-Measured Outcomes Percentage of Intelligible Speech on the SIT Results- improved subject performance Speaking rate and intelligibility rate- Results- general increased rate (characteristic of hypokinetic dysarthria) No change during training Communication coefficient- no significant change Slight increase during training

Figure 1: Percentages of intelligible speech on the SIT 100.00% 95.

00% Judge 1 60.00% A1 A1 B1 B1 B1 Training Phases increase of 6.

33 Figure 1: Percentages of intelligible speech on the SIT % 95.00% Percentage of Intelligible Speech 90.00% 85.00% 80.00% 75.00% 70.00% 65.00% Judge % A1 A1 B1 B1 B1 Training Phases increase of 6.88% - baseline 5 th week of training increase of 15.22% - end of withdrawal 8 th week of training A2 A2 B2 B2 B2 B2

Intelligibility Tests Single words improved intelligibility

intelligibility percentage Speech intelligibility scores for

85% 80% 105 100 95 90 85 80 A2 A2 B2 B2 B2 Training Phase

34 Intelligibility Tests Single words improved intelligibility 4% increase overall Unpredictable Sentences improvement overall 8.59% increase Percentage of Intelligible words Speech intelligibility percentage Speech intelligibility scores for single words on the Kent Phonetic Contrast Test 100% 95% 90% 85% 80% A2 A2 B2 B2 B2 Training Phase Speech intelligibility scores for unpredictable sentences A2 B2 B2 B2 Training phases Judge1 Judge2 Judge3 Judge 1 Linear (Judge3)

35 Figure 4: The best of three measurements for Maximum Expiratory Pressure (MEP) and Maximum Inspiratory Pressure (MIP) Measurements within 5% No significant change in MEP or MIP MEP & MIP (cm of H2O) A1 A1 B1 B1 B1 A2 A2 B2 B2 B2 B2 Best MEP Best MIP Training Phases No change in intensity levels

(Liters) 4 3.5 3 2.5 2 FEV improved by 1.

5 0 A1 A1 B1 A2 A2 B2 B2 B2 Training phases

36 Spirometry FVC Increased with respiratory training FCV (Liters) FEV improved by 1.5 L (from L) A1 A1 B1 A2 A2 B2 B2 B2 Training phases Predicted FVC% 100% Increased with respiratory training gain of 29.15% (from 58%-87.10%) FCV% Predicted (percentage) 90% 80% 70% 60% 50% 40% 30% 20% A1 A1 B1 A2 A2 B2 B2 B2 FEV% Training phases

37 Communicative Effectiveness Survey & Rating Scale Completed 3 times by subject and wife during baseline, after 1 st training phase, again after 2 nd training phase Overall, results indicated no awareness of improved speech by the subject and some awareness by his wife.

increasing lung volume Measures of MEP, MIP, communication efficiency, and intensity did not improve Indicating no increase in

38 Discussion Speech intelligibility improved in response to EMT/IMT training FVC and FVC% indicate increased lung capacity and increased control of that power for speech Increased range of motion of respiratory muscles = greater expansion of rib cage, increasing lung volume Measures of MEP, MIP, communication efficiency, and intensity did not improve Indicating no increase in muscle strength Small improvement due to high level of intelligibility at baseline required only a small improvement to reach 100%

delayed initiation of movement L-dopa on-off state Plateau at 4

39 Discussion MEP/MIP below Black & Hyatt s normative ranges at baseline Due to fatigue and poor effort inferior lip seal or delayed initiation of movement L-dopa on-off state Plateau at 4 weeks suggests 8 weeks of Tx might not be needed to reach maximum benefit

40 Limitations Small N Medication Fluctuations in function due to L-dopa Less increase in intelligibility due to management of meds Difficult to generalize due to subject traits Palalalia Advanced PD Early onset

load on PowerLung Listeners judgement of sentences influenced by repeated

41 Limitations Researcher could not monitor training on a daily basis to ensure proper form and ideal settings No method to accurately measure load on PowerLung Listeners judgement of sentences influenced by repeated listening, time restraints, and personal experience Placebo effect Learned effect

Previous Research Not consistent- increased muscle strength

, 2006) Not consistent- short duration high intensity

42 Previous Research Not consistent- increased muscle strength after respiratory muscle training in people with PD (Saleem, Sapienza, & Okun, 2005). Consistent- similar to studies of limb strength in respiratory training (Griffiths, A. E., & McConnell, 2007; Guenette et al., 2006) Not consistent- short duration high intensity exercise successfully strengthened respiratory muscles of others with compromised respiratory systems (Chiara, Martin, & Sapienza, 2007; Silverman et al., 2006)

increased control over airway Compensation for lack of initiation of

43 Theoretical Explanations IMT/EMT decreased rigidity and increased range of motion- Shown by increased lung volume Diaphragm and PCA connection- increased control over airway Compensation for lack of initiation of movement- increased control and lung volume give patient more time to hit articulation targets

44 Theoretical Speculations Overflow of neural drive from respiratory muscles to voice and articulatory muscles increases intelligibility (Saleem, et al., 2005).

45 Implications for clinical practice Suggests that focusing on respiratory training may improve speech intelligibility and lung volume in an individual with PD

Effects of combining this treatment with another treatment (ex.

46 Suggestions for Future Research Increased N, with control group Vary length of treatment phase, frequency of treatment given, age, or severity of PD. Effects of combining this treatment with another treatment (ex. laryngeal muscle training or rate reduction) Brain imaging studies to confirm neural adaptation Measuring VOT pre- and post-treatment Maintenance of increased intelligibility

47 For more information: For references: ASHA online handouts Thank Yous: Dr. Mathers-Schmidt, my subject, fellow graduate students, undergraduate student judge, my audience

COMPREHENSIVE RESPIROMETRY

COMPREHENSIVE RESPIROMETRY INTRODUCTION Respiratory System Structure Complex pathway for respiration 1. Specialized tissues for: a. Conduction b. Gas exchange 2. Position in respiratory pathway determines cell type Two parts Upper