Transcription

1

2 What may happen to breathing, voice and swallow in PD? Muscles of breathing, voice and speech can be subject to the same disease processes as other muscle groups in PD Slowness, stiffness, Freezing, tremor, smaller/faster movements BUT may have a unique response to current surgical interventions for motor symptoms in PD

3 Motor changes -weak, slow or rigid palate -Weak slow or rigid tongue -Reduced amplitude of jaw movement -Reduced strength of laryngeal closure -Reduced and incoordinate respiratory support

4 Impact of PD on Speech? Typical Hypokinetic Dysarthria (incidence in PD patients70-90%) Characteristics of hypokinetic dysarthria include: monotonous and reduced pitch and loudness, variable rate of speech, short rushes of speech, imprecise consonants, and a breathy and harsh voice (Boshes, 1966; Canter, 1963, 1965a, 1965b; Sapir, 2001). In other words, the speech impairments can show themselves in PD through impacting vocal sounds, overall expression of words, breath control during speech, speech volume (softening speech volume), and/or prosody changes (i.e., changes in intonation or rhythm) of speech that reflect emotional expression (Pell & Leonard, 2003; Schulz & Grant, 2000).

5 DBS AND SPEECH - A METHODOLOGICAL MINEFIELD Stage One Is there a problem? Overview of STN Stimulation Effects on Speech: Methodological Issues. Disagreement concerning the effects of bilateral STN stimulation on speech depending on: Selection and number of patients Severity of the disease and dysarthria Speech measurement tools vs. UPDRS Aspect of speech measured Time post surgery Availability of data before surgery and medication status Consideration for the disease vs. treatment (pharmacological and surgical) effects on speech over time

6 DBS AND SPEECH - A METHODOLOGICAL MINEFIELD Overview of STN Stimulation Effects on Speech (A): Studies Using the UPDRS-III Speech is less responsive to STN stimulation than limb movements Limousin et al., 1995, 1998 Bejjani et al., 2000 Krack et al., 2001, 2003 Kleiner-Fishman et al., 2003, 2006

7 DBS AND SPEECH - A METHODOLOGICAL MINEFIELD Overview of STN Stimulation Effects on Speech (B): Studies on Non Speech Oro-Motor Tasks Gentil et al., 1999, JNNP Improvement with STN stim in oral force control Gentil et al., 2000, Eur Neurol Improvement with STN stim compared with Vim Gentil et al., 2001, Brain Lang Improvement in acoustic parameters Pinto et al., 2003, J Neurol Gentil et al., 2003, Brain Lang Improvement in oral force control Pinto et al., Mov Disord Both improvement and worsening possibly induced by STN stimulation, depending on electrode location and stimulation parameters

8 Speech Post DBS-STN The Parkinson Alliance/DBS-STN Research Team June 2004 Although some research has found speech to be improved by bilateral DBS-STN (Gentil et al. 2003; Hoffman-Ruddy et al, 2001), the majority has suggested that the increase of impaired speech might be an underestimated problem in this population (Cabrejo et al., 2003; Dromey et al., 2000; Gentil, 1999; Santens et. al., 2003; Wang et al., 2002). There is convincing evidence that STN stimulation can have either no impact on the natural progression of speech problems in PD, or it may have a deleterious effect on speech

9 And then along came U-Fun Universtiy of Functional Neurosurgery, Queens Suare London Dr. Elina Tripoliti, PhD is an employee of the National Hospital for Neurology and Neurosurgery, UCLH, NHS Trust, Unit of Functional Neurosurgery. The Unit is supported by the Sainsbury Monument Trust and Parkinson's Appeal for Deep Brain Stimulation. In addition, part of the research was funded by Parkinson's UK and UCLH Foundation NHS Trust.

10 Larger cohort, longitudinal U-FUN Longitudinal Study in Consecutive Patients: Methods-Tasks and Equipment Speech protocol: Sustained phonation Assessment of Intelligibility of Dysarthric Speech 60 second monologue about a topic of their choice Aerodynamics Aerophone II UPDRS-III Methods: Time Scale DBS 1 year before surgery on/off meds 1 year after on/off meds and ON/OFF stim 2 weeks before on/off meds 2 weeks after on/off meds and ON/OFF stim 6 months after on/off meds and ON/OFF stim Longitudinal Study in Consecutive Patients: Results 1 Year Post, N=54 Motor score: 53.5% improvement Speech intelligibility: 13.3% decline

11 STN Variability Speech Shows Great Variability Post STN-DBS: Why? Surgical factors: Electrode positioning Parameters of stimulation: amplitude (Volts), frequency (Hertz) and pulse width (milliseconds) Clinical factors: disease duration, age at surgery, motor scores, response to medication, speech before surgery Predictive Factors for Speech Deterioration (Tripoliti et al., Mov Dis) Surgical: Contact localisation and high voltage on the LEFT Clinical: Low speech intelligibility before the operation and disease duration (as in Buck and Cooper, 1956 and Parkinson Alliance survey) Medially Placed LEFT Active Contacts Worse for Speech than Contacts Inside the STN (Tripoliti et al., 2011) Is it Location or Voltage that Affects Speech? (Tripoliti et al., 2008)

12 For clinicians? What to Do to Prevent and Treat Speech Problems? Surgical: Contact localization Adjust electrical parameters keep them low, especially on the LEFT Treatment-Behavioral: Summary Work in a team Follow all changes in batteries, possibilities of stimulations, adjustments and effects on speech, etc. Don t be afraid to say when speech is worse Don t give up with the behavioral treatments Acknowledging the FATIGUE factor is relieving to patients and family Inform before surgery: take a pre-op recording

13 Our OSP Motor Speech Protocol Motor Speech Evaluation Robertson/Frenchay Video conversation/reading/harvard Sentences Operavox Voice/LSVT Screen SWALQOL VHI Timed Water Swallow Test Timed Biscuit Swallow Test?Intelligibility Measure? Verbal Fluency

14 Option 1: Gold Standard Treatment: Lee Silverman Voice Treatment Lee Silverman Center for Parkinson s -LSVT Global 5000 certified clinicians in 40 countries -First speech treatment to achieve Level 1 Evidence and established efficacy for treating voice and speech disorders in individuals with Parkinson s Disease -Improve both speech and loudness by treating the underlying physical pathology. -Treats loudness with immediate carryover into daily communication -Intensive regime (16 x 1 hr in 1 month) -90% improved loudness; 80% maintain for mths -St Josephs Auburn, St Vincents, Nepean, Hornsby, War Memorial Optimal SP m

15 Option 2. Some of your treatment at home....lsvt Companion Optimal SP m

16 Option 3 Telerehabilitation (Deborah Theodoros UQ 2011, SVH ) Option 3: LSVT by Skype- Telehealth Deborah Theodoros UQ

17 Option 4 Expiratory Muscle Strength Training (Sapienza et al 2007 onwards) - Our breath drives our voice and cough - So push it!! - Grounded in Muscle Training theory - Expiratory Muscle Strength Training in PD

18

19 Option 5 iparkinsons, DAF, Altered Auditory Feedback (Emily Wang, Rush University, Chicago)

20 But who benefits, what severity, what settings???

21 Option 6 Ronnie Gardiner Rhythm and Music Method Singing has great QOL impact but not necessarily transfer to speech changes - however 2013 feasability study into movement plus music holds promise (Pohl et al Sweden)

22 Option 7 Technology - news tab

23 What works? A Consensus Meeting to Discuss Deep Brain Stimulation for Parkinson s Disease New York City: 4/01/09 through 4/03/09 Hosted by The Parkinson Alliance LSVT has been reported to be effective for many patients after DBS. However, it is important to note, that in some cases, the speech disturbance following DBS may require more LSVT (than the efficacious 16 hours in one month dosage) or more frequent follow-ups. In addition, sometimes the speech disturbance following DBS may be difficult to treat with speech therapy.

24 DBS and LSVT

25 And so - the challenge continues. Following LSVT LOUD, both the LSVT and LSVT-DBS groups significantly increased SPL from PRE to POST and FU. SPL changes were comparable to previously published outcomes (Ramig et al., 2001b) and indicate that individuals may successfully learn to speak with increased loudness following STN-DBS surgery Finally, future research should also evaluate the effectiveness of administering treatment before or after surgical intervention to determine whether this can significantly affect communication following surgery Elina wants to do this study and her clinical instinct is that yes, LSVT LOUD before DBS helps the outcome. It would be a great study to do! Maybe you can do it?!!

26 Optimal Speech Pathology Ph