Disclosures. Roadmap of Talk 2/5/2018. Treatment Options for Vocal Tremor. Voice Evaluation Tasks of Interest

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Disclosures Zen and art of vocal mechanics: Key Factors That Influence Vocal Tremor Treatment Decisions Financial: I am an affiliate instructor and receive royalties from MedBridge Inc related to my

edu Non Financial: Research focus relevant to the presentation topic Roadmap of Talk Treatment Options for Vocal Tremor Factors impacting treatment decisions Voice evaluation findings of interest

1 Disclosures Zen and art of vocal mechanics: Key Factors That Influence Vocal Tremor Treatment Decisions Financial: I am an affiliate instructor and receive royalties from MedBridge Inc related to my online courses on vocal tremor Julie Barkmeier Kraemer, Ph.D. Professor, Division of Otolaryngology Clinic Director, Voice Disorders Center JulieB.Kraemer@utah.edu Non Financial: Research focus relevant to the presentation topic Roadmap of Talk Treatment Options for Vocal Tremor Factors impacting treatment decisions Voice evaluation findings of interest Vocal Tremor Speech Treatment Principles Vocal tremor is action induced Voicing duration and vocal tremor Speech structure contributions Vocal Tremor Speech Treatment Summary Case Examples Treatment Options for Vocal Tremor Pharmaceutical Systemic Propranolol, primidone, etc. Local Botox to laryngeal muscles Surgical Deep Brain Stimulation (DBS) Thalamic ablative Voice therapy I ve always wanted to be a mover and a shaker! (Adler et al, 2004; Bové et al, 2006; Ludlow, 1995; Moringlane et al, 2004; Sataloff et al, 2002; Sulica & Louis, 2010; Warrick et al, 2000; Barkmeier-Kraemer et al, 2011; Justicz et al, 2016; Nida et al, 2016) Factors Impacting Treatment Decisions The degree to which the tremor is isolated to the larynx or affects other speech structures The severity of impaired intelligibility during conversation Responsiveness to therapy strategies during stimulability testing Motivation to pursue behavioral intervention May desire Botox treatment alone or combined with speech treatment May respond well to systemic medications Ability to attend treatment sessions consistently Voice Evaluation Tasks of Interest Patient Self-Report on quality of life impact Auditory-Perceptual Evaluation Sustained vowel using /a/ and /i/ Evaluate pitch and loudness changes to vocal tremor Sustained phonation vs connected speech sentences varying voiceless and voiced phonemes Acoustic Measures of rate and extent of fo, SPL, and F1 and F2 Laryngeal Imaging to observe structures 1

Voice Evaluation Findings of Interest: Determine the speaking patterns that elicit greater or lesser vocal tremor magnitude 1. Vocal tremor severity by speech context 2.

Changes in vocal tremor severity with pitch and loudness changes Roadmap of Talk Treatment Options for Vocal Tremor Factors impacting treatment decisions Voice evaluation findings of interest Vocal

2 Voice Evaluation Findings of Interest: Determine the speaking patterns that elicit greater or lesser vocal tremor magnitude 1. Vocal tremor severity by speech context 2. Ability of individual to shorten voicing duration 3. Speech structures exhibiting oscillation 4. Acoustic measures (rate and extent of fo, SPL, F1/F2, articulation rate) 5. Changes in vocal tremor severity with pitch and loudness changes Roadmap of Talk Treatment Options for Vocal Tremor Factors impacting treatment decisions Voice evaluation findings of interest Vocal Tremor Speech Treatment Principles Vocal tremor is action-induced Voicing duration and vocal tremor Speech structure contributions Vocal Tremor Speech Treatment Summary Case Examples Vocal tremor and speech strategies The solutions all are simple after you have arrived at them. But they're simple only when you know already what they are. -Robert M Pirsig Vocal Tremor Speech Treatment Principles Vocal tremor is action-induced Reducing upper airway volitional muscle contraction will lessen oscillation amplitude Voice duration determines vocal tremor perception Voicing duration < 500 ms results in mild to no perception of vocal tremor The contribution of specific structures can influence strategies Altered Pitch/loudness intonation patterns may reduce vocal tremor Vocal Tremor is Action-Induced Action-Induced Tremor Worsens with increased activation of affected muscles Magnitude of tremor is inversely related to rate Reflects severity or degree of muscle activation Common patient strategy for speaking with a predictable perturbation (i.e. tremor) Slowed speaking rate with prolonged voicing durations Reduced airflow due to increased throat strain Methods that help restore phonatory-respiratory coordination Accent Method Confidential Voice Flow Phonation Easy Voice Onset 2

Voicing Duration and Vocal Tremor Speech Structure Contributions Shorten duration of voicing during speaking < 500 ms reduces perception of vocal tremor Begin with single syllable productions ( ha he

3 Voicing Duration and Vocal Tremor Speech Structure Contributions Shorten duration of voicing during speaking < 500 ms reduces perception of vocal tremor Begin with single syllable productions ( ha he ) Progress to all-voiced words, phrases, sentences, paragraph reading, and conversation Look for patterns of vocal tremor worsening/ lessening with intonation Worse during lower pitches/sentence endings Worse during higher pitches/questions Insertion of pauses or phrase breaks Treatment Summary THERAPY OBJECTIVE METHODS OUTCOME Accent Method, Flow phonation, Reduce upper airway Increase respiratoryphonatory coordination Confidential Voicing, Easy voice muscle tension and onset, Yawn sigh, Resonant Voicing tremor amplitude Shorten Voicing Duration (< 500 ms) Link specific speech structures exhibiting tremor to contexts that worsen and lessen vocal tremor 1) Easy voice onset using "h" words and build toward all words typically spoken; 2) Practice volitional shortened voicing duration using phrase context (e.g. voiceless loaded speech sounds and then voiceloaded speech sounds); 3) Shape toward sentences, reading paragraphs, conversation Tweak intonation patterns, encourage shorter phrase length, insert pauses for air replenishment, reduce, or increase speaking rate as deemed beneficial Reduce the frequency of detecting vocal tremor during conversation due to reduced voicing duration < 500 ms Further modify individual speaking patterns to lessen speaking patterns that increase vocal tremor amplitude Vocal Tremor Treatment (thus far) Target population = Mild-moderate vocal tremor Critical therapy program elements include: Respiratory-phonatory coordination Shortened voicing duration Secondary therapy program elements include: Insertion of pauses or phrase breaks Increased breathiness Modification of intonation patterns Typical therapy dosage to achieve goals 6-8 sessions: 1 session/week Treatment outcome variables Sustained phonation acoustic measures (fo, SPL, F1, F2) % detection of vocal tremor within connected speech Patient self-report questionnaires Treatment Considerations Severity of tremor, particularly over time Structures affected by tremor Individual speaking patterns that worsen or lessen the perception of tremor Motivation to pursue behavioral intervention Strategies may not automatize Ability to attend treatment sessions consistently Adaptation with disease progression Consider as a supplement to Botox Roadmap of Talk Treatment Options for Vocal Tremor Factors impacting treatment decisions Voice evaluation findings of interest Vocal Tremor Speech Treatment Principles Vocal tremor is action-induced Voicing duration and vocal tremor Speech structure contributions Vocal Tremor Speech Treatment Summary Case Examples 3

Case 1: Vocal Tremor Treatment Program Case Example #2: Pre-treatment Sustained phonation of /a/ We rolled along Long Island Avenue We mow our lawn all year Case Example #2:

4 Case 1: Vocal Tremor Treatment Program Case Example #2: Pre-treatment Sustained phonation of /a/ We rolled along Long Island Avenue We mow our lawn all year Case Example #2: Post-treatment Sustained phonation of /a/ We rolled along Long Island Avenue We mow our lawn all year Case Example #3 Pre-treatment speech recording Post-treatment speech recording 4

Vocal Tremor Treatment Summary Vocal tremor is a neurological voice problem action-induced tremor affecting speech structures The voice evaluation should elucidate the acoustic and

5 Vocal Tremor Treatment Summary Vocal tremor is a neurological voice problem action-induced tremor affecting speech structures The voice evaluation should elucidate the acoustic and auditory-perceptual characteristics across speech tasks Observing or imaging affected structures during systematic testing of pitch and loudness can inform affected musculature Speech treatment offers strategies for reducing vocal tremor perception for those with mild to moderately severe vocal tremor Patterns DISCUSSION You look at where you're going and where you are and it never makes much sense, but then you look back at where you've been and a pattern seems to emerge. And if you project forward from that pattern, then sometimes you can come up with something. -Robert M Pirsig References 1. Ackermann, H. and W. Ziegler, Cerebellar voice tremor: an acoustic analysis. J Neurol Neurosurg Psychiatry, (1): p Adler, C.H., et al., Botulinum toxin type A for treating voice tremor. Arch Neurol, (9): p Barkmeier-Kraemer, J., Lato, A. and Wiley, K. Development of a speech treatment program for a client with essential vocal tremor. Semin Speech Lang, (1): p Barkmeier-Kraemer, J.M., and Story B.S., Conceptual and Clinical Updates on Vocal Tremor. 2010: The ASHA Leader. p Bove, M., et al., Development and validation of the vocal tremor scoring system. Laryngoscope, (9): p Brown, J.R. and J. Simonson, Organic voice tremor. A tremor of phonation. Neurology, : p Crawford, P. and E.E. Zimmerman, Differentiation and diagnosis of tremor. Am Fam Physician, (6): p Critchley, M., Observations on essential (heredofamial) tremor. Brain, (Pt. 2): p Dromey, C., P. Warrick, and J. Irish, The influence of pitch and loudness changes on the acoustics of vocal tremor. J Speech Lang Hear Res, (5): p Elble, R.J., The essential tremor syndromes. Curr Opin Neurol, (4): p Finnegan, E.M., et al., Synchrony of laryngeal muscle activity in persons with vocal tremor. Arch Otolaryngol Head Neck Surg, (3): p Fischer, B., A sing-song way to a cure for speech disorder, in News Releases, C. Basi, Editor. 2010, MU News Bureau. 13. Gamboa, J., et al., Acoustic voice analysis in patients with essential tremor. J Voice, (4): p Gillivan-Murphy, P., P. Carding, and N. Miller, Vocal tract characteristics in Parkinson's disease. Curr Opin Otolaryngol Head Neck Surg, (3): p Gurey, L.E., C.F. Sinclair, and A. Blitzer, A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope, (10): p Hachinski, V.C., I.V. Thomsen, and N.H. Buch, The nature of primary vocal tremor. Can J Neurol Sci, (3): p References 17. Hallett, M., Tremor: pathophysiology. Parkinsonism Relat Disord, Suppl 1: p. S Hilo, J., Inspiratory breathing exercises for vocal tremor: A preliminary study, in Speech and Hearing Science. 2012, University of Southern Florida: scholarcommons.usf.edu/etd. p Ji, A., Story, B., Durbin-Johnson, B., Barkmeier-Kraemer, J., Association of formant modulation with oropharyngeal vocal tract tremor. 2014, Voice Foundation: Voice Foundation's 43rd Annual Symposium: Care of the Professional Voice. 20. Jiang, J., E. Lin, and D.G. Hanson, Acoustic and airflow spectral analysis of voice tremor. J Speech Lang Hear Res, (1): p Julius, A. and K. Longfellow, Movement Disorders: A Brief Guide in Medication Management. Med Clin North Am, 2016, 100(4): Justicz N, Hapner ER, Josephs JS, Boone BC, Jinnah HA, Johns MM 3 rd. Comparative effectiveness of propranolol and botulinum for the treatment of essential voice tremor. 2016, Laryngoscope, 126(1): Kendall, K.A. and R.J. Leonard, Interarytenoid muscle botox injection for treatment of adductor spasmodic dysphonia with vocal tremor. J Voice, (1): p Koda, J. and C.L. Ludlow, An evaluation of laryngeal muscle activation in patients with voice tremor. Otolaryngol Head Neck Surg, (5): p LeBaron, J., Testing a conceptual model of vocal tremor: Respiratory and laryngeal contributions to acoustic modulation, in Communication Sciences and Disorders. 2016, University of Utah. p Lederle, A., J. Barkmeier-Kraemer, and E. Finnegan, Perception of vocal tremor during sustained phonation compared with sentence context. J Voice, (5): p. 668 e Lester, R.A., J. Barkmeier-Kraemer, and B.H. Story, Physiologic and acoustic patterns of essential vocal tremor. J Voice, (4): p Louis, E.D., Essential tremor: evolving clinicopathological concepts in an era of intensive post-mortem enquiry. Lancet Neurol, (6): p Louis, E.D., Re-thinking the biology of essential tremor: from models to morphology. Parkinsonism Relat Disord, Suppl 1: p. S Louis, E.D., Non-motor symptoms in essential tremor: A review of the current data and state of the field. Parkinsonism Relat Disord, Suppl 1: p. S

6 References 31. Lundy, D.S., et al., Spastic/spasmodic vs. tremulous vocal quality: motor speech profile analysis. J Voice, (1): p Massey, E.W. and G.W. Paulson, Essential vocal tremor: clinical characteristics and response to therapy. South Med J, (3): p Nida A, Alston J, Schweinfurth J. Primidone therapy for essential vocal tremor. JAMA Otolaryngol Head Neck Surg, 2016, 142(2): Ondo, W., Essential Tremor: What We Can Learn from Current Pharmacotherapy. Tremor Other Hyperkinet Mov (N Y), : p Panda, A.K., S. Kushwaha, and M. Kaur, Essential palatal tremor with hemifacial and vocal cord tremor. BMJ Case Rep, Raethjen, J. and G. Deuschl, The oscillating central network of Essential tremor. Clin Neurophysiol, (1): p Sulica, L. and E.D. Louis, Clinical characteristics of essential voice tremor: a study of 34 cases. Laryngoscope, (3): p Tomoda, H., et al., Voice tremor: dysregulation of voluntary expiratory muscles. Neurology, (1): p Twohig, A., Finnegan, E., The effect of vowel duration on tremor severity for patients with vocal tremor., in Communication Sciences and Disorders. 2008, University of Iowa. 40. Warrick, P., et al., The treatment of essential voice tremor with botulinum toxin A: a longitudinal case report. J Voice, (3): p Weiss, H.D., Clinical Pearls in Tremor and Other Hyperkinetic Movement Disorders. Semin Neurol, (4): p Wolraich, D., et al., Laryngeal tremor: co-occurrence with other movement disorders. ORL J Otorhinolaryngol Relat Spec, (5): p

Disclosures. Roadmap of Talk. Tremor Classification 2/4/2018. Are tremor disorders diagnosed in the limbs the same as those affecting speech?

Disclosures. Roadmap of Talk. Tremor Classification 2/4/2018. Are tremor disorders diagnosed in the limbs the same as those affecting speech? Disclosures Zen and art of vocal mechanics: Vocal Tremor Financial: I am an affiliate instructor and receive royalties from MedBridge Inc related to my online courses on vocal tremor Julie Barkmeier Kraemer,