Dysarthria treatment for Parkinson's disease: one-year follow-up of SPEAK OUT!® with the LOUD Crowd®.

INTRODUCTION: SPEAK OUT! with The LOUD Crowd is a standardized speech therapy program typically consisting of 12 one-on-one treatments and ongoing weekly group maintenance sessions for patients with dysarthria due to Parkinson's disease (PD). It is based upon the hypothesis that increased attention to speech, which is a goal-directed motor activity, may compensate for the impairment in automatic sequential motor behaviors often demonstrated in patients with PD. We present results on the 1-year response to treatment. METHODS: Forty individuals with idiopathic PD received SPEAK OUT! delivered in 12 one-on-one 40-min treatment sessions 3 times per week for four consecutive weeks in addition to ongoing group maintenance sessions called The LOUD Crowd. Evaluations occurred 3 times at baseline, within one and six weeks after completion of the SPEAK OUT! sessions (N = 40) and 1-year later (N = 35). Assessments included mean speech intensity and intonation from reading and monolog, the voice quality acoustic measure called cepstral peak prominence (CPP), and scores on the voice-related quality of life questionnaire. RESULTS: The significant improvements achieved in all outcome measures from baseline to completion of SPEAK OUT! were maintained 1-year later. Participation throughout the year in regular group maintenance sessions (The LOUD Crowd) was positively correlated with level of improvement at 1 year for all measures except patient perception of voice. CONCLUSIONS: These long-term data contribute evidence of the effectiveness of this speech therapy program for improving communication for individuals with PD and emphasize the importance of regular and ongoing group sessions to sustain therapeutic gains.

The Effect of SPEAK OUT! and The LOUD Crowd on Dysarthria Due to Parkinson's Disease.

Purpose SPEAK OUT! and The LOUD Crowd is a standardized speech therapy program of 12 individual treatments combined with ongoing weekly group sessions for individuals with dysarthria due to Parkinson's disease (PD). The premise of this program is that individuals with PD must rely on goal-directed basal ganglia-cortical circuits to compensate for deficits in habitual, automatic control. The purpose of this study was to assess the outcome of this therapy program. Method Forty individuals with idiopathic PD received SPEAK OUT! in 12 individual 40-min sessions 3 times per week for 4 consecutive weeks and also participated in The LOUD Crowd. Assessments were conducted 3 times at baseline and then within 1 and 6 weeks after completion of the individual SPEAK OUT! sessions. Twenty-five adults without communication disorders were assessed on the same schedule. Acoustic outcome measures were mean intensity from reading and monologue, the prosody measures of standard deviation of intensity and frequency from reading and monologue, and the voice quality measure of cepstral peak prominence from reading. Patient perception of voice was also assessed with the Voice-Related Quality of Life. Results Posttherapy, mean intensity was greater and variation of frequency was larger in reading and monologue, while variation in intensity was larger in monologue but unchanged in reading. Cepstral peak prominence and Voice-Related Quality of Life scores were significantly higher (improved) after therapy. Conclusion These data contribute to evidence of the effectiveness of this program for hypokinetic dysarthria secondary to idiopathic PD and thus inform clinical practice in the selection among treatment options.

The Effect of Clear Speech on Temporal Metrics of Rhythm in Spanish-Accented Speakers of English.

This paper presents a comparative analysis of temporal rhythm in native American English talkers and Spanish-accented English talkers producing clear (hyperarticulated) speech and typical, conversational-style speech. Five acoustic measures of comparative vocalic and consonantal interval duration ("temporal metrics") were obtained from speech samples of 40 adult men and women (half native and half Spanish-accented talkers). In conversational-style speech, vocalic-based metrics differed significantly between native and Spanish-accented talkers, consistent with phonotactic differences between the two native languages. In clear speech, however, all metric values from the Spanish-accented talkers became more English-like and no longer differed significantly from those observed in the native English talkers. Post-hoc analysis revealed that native English talkers increased the duration of both weak and strong vowels in clear speech, whereas the Spanish-accented talkers increased the duration of strong vowels without changing the duration of weak vowels. Listener ease of understanding, as perceived by monolingual English speakers, was significantly improved in clear- compared with conversational-style speech for all talkers. The acoustic data help to explain the changes that result from use of clear speech in nonnative speakers. Together with the improved listener ease of understanding, these data strongly support the further exploration of clear speech as a clinical tool to improve prosody and hence, interpersonal communication, in nonnative speakers.

A Clear Speech Approach to Accent Management.

PURPOSE: A 5-session twice-weekly clear speech protocol with daily home practice was developed to enable Spanish-accented speakers of English to code-switch for increased listener ease of understanding. This study provides preliminary data to test the hypothesis that this protocol results in increased ease of understanding for native English listeners, not in decreased talker accentedness. METHOD: Using a single-case experimental design, 6 adult native Spanish speakers with English proficiency participated in the protocol. Ease of understanding and accentedness were probed at least 5 times pretraining, at each training session, and once per week for 5 weeks posttraining. Thirty native English-speaking listeners assessed the probes using 7-point scales for each measure. RESULTS: Ease of understanding improved for all participants (mean improvement = 3.5 points; effect size range = 6.98 to 15.33). Accentedness improved for 4 of 6 participants (mean improvement = 2.3 points; effect size range = 4.04 to 10.48). At the outset, most participants expressed concern that this approach would highlight speech errors. Upon follow-up, all participants reported confidence in using the approach and found it helpful in daily communication. CONCLUSIONS: Further research should explore the effects of this protocol on intelligibility and acoustic metrics and their relationship to ease of understanding and accentedness.

The Effect of Loud Voice and Clear Speech on the Use of Vocal Fry in Women.

OBJECTIVE: This study investigated the effects of clear speech and loud voice on the use of vocal fry in women. METHODS: Twenty healthy-voiced young women who used a moderate amount of vocal fry when reading aloud in conversational-style speech (defined as a minimum of three occurrences per sentence) also read the same stimuli in loud voice and clear speech. The occurrence of vocal fry was assessed in the three speaking styles. Intensity and fundamental frequency levels in each condition were obtained to help interpret the findings. RESULTS: A statistically significant reduction in the use of vocal fry was found in loud and clear conditions compared to conversational style. However, a significantly greater reduction in use of vocal fry was obtained in clear speech than in loud voice. The increased intensity and mean F0 in loud and clear speech only partially explain the decrease in use of vocal fry. CONCLUSION: Women who use vocal fry in typical speech may persist in its use when speaking more loudly, although not when speaking more clearly. Apparently, different phonatory strategies are used for the two speaking styles. Further research is needed to clarify the laryngeal dynamics of clear speech.

Segmental and prosodic approaches to accent management.

PURPOSE: This study investigated the relative outcomes of segmental and prosodic training of nonnative speakers of American English. METHOD: The study used a single-subject, alternating treatments, multiple baseline design with replication across participants and counterbalanced for order effect. Participants were 4 adult male native Hindi speakers proficient in English. Two participants received ABABCACA (A = baseline/withdrawal, B = segmental training, C = prosody training), and 2 participants received ACACBABA, with a minimum of 5 sessions per phase. Segmental accuracy and prosodic accuracy were probed at each session, as were perception of accentedness and ease of understanding. RESULTS: Visual assessment of data and effect size calculation demonstrated that segmental and prosody training resulted in increased accuracy of pronunciation and prosody patterns, respectively, and those improvements appeared to be maintained over the short term. Listeners perceived lesser accent and easier understanding as a result of the combination of segmental and prosody training. The findings are uncertain with respect to the relative contribution of segmental and prosody training, and they may be speaker dependent, but the data do suggest that both components are important. CONCLUSION: Accent management, consisting of both segmental and prosody training, yielded positive outcomes. Further research with native language speakers of other languages is important to verify and expand on these findings.

The influence of semantic context on the perception of Spanish-accented American English.

PURPOSE: In this article, the authors examine (a) the effect of semantic context on accentedness, comprehensibility, and intelligibility of Spanish-accented American English (AE) as judged by monolingual AE listeners and (b) the interaction of semantic context and accentedness on comprehensibility and intelligibility. METHOD: Twenty adult native (L1) Spanish speakers proficient in AE and 4 L1 AE speakers (controls) read 48 statements consisting of true-false, semantically meaningful, and semantically anomalous sentences. Eighty monolingual AE listeners assessed accentedness, comprehensibility, and intelligibility of the statements. RESULTS: A significant main effect was found for semantic category on all 3 dependent variables. Accents were perceived to be stronger, and both comprehensibility and intelligibility were worse, in semantically anomalous contexts. Speaker data were grouped into strong, mid-level, and mild accents. The interaction between semantic category and accent was significant for both comprehensibility and intelligibility. The effect of semantic context was strongest for strong accents. Intelligibility was excellent for speakers with mid-level accents in true-false and semantically meaningful contexts, and it was excellent for mild accents in all contexts. CONCLUSIONS: Listeners access semantic information, in addition to phonetic and phonotactic features, in the perception of nonnative speech. Both accent level and semantic context are important in research on foreign-accented speech.

Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma.

PURPOSE: To assess the effectiveness of vocal hygiene education (VHE) and voice production therapy (VP) in altering patient perception of vocal handicap in adult women with benign, bilateral phonotraumatic vocal fold lesions and the role of adherence in that perception. METHOD: Sixty-two women were randomly assigned to 6 weeks of VP (n = 31) or VHE (n = 31), followed by 4 weeks of self-study. The primary outcome measure was the Voice Handicap Index (VHI) score, assessed at baseline, post-therapy, and post-self-study. Patient adherence was assessed as a cofactor. RESULTS: Both groups achieved a decrease in VHI scores from baseline to completion of the study, although the improvement was significantly greater for the VP group. The treatment effect size was large for the VP group and small for the VHE group. More participants adhered to VP than to VHE. Only adherent participants achieved significant improvement. Only adherent participants in the VP group improved with self-study. More than two thirds of the VP group achieved final VHI scores within normal limits, compared with approximately one third of those in the VHE group. CONCLUSIONS: VP therapy may be more effective than VHE in addressing patient perception of vocal handicap in adult women with phonotrauma, and self-study may be an important component of therapy. However, adherence is a critical mediator of outcome.

Facilitating behavioral change in voice therapy: the relevance of motivational interviewing.

PURPOSE: The purpose of this article is to present an exploration of some of the issues surrounding adherence to vocal behavioral change in voice therapy within the context of Motivational Interviewing (MI) and to explore MI's potential for integration into voice therapy (MI-adapted voice therapy). MI is a style of interpersonal communication in which resistance is minimized through the use of skillful listening in a directive, constructive discussion about behavior change. The goal of MI-adapted voice therapy is to enhance patient adherence to vocal behavioral change. METHOD: A narrative review of the literature is presented, together with the experiences of the author with 10 adult patients with voice disorders who participated in MI-adapted voice therapy. RESULTS: It is shown that the principles of MI can be applied throughout the therapy program. Points of resistance to vocal behavioral change that were common across many patients appeared to be addressed appropriately by specific MI dialogue strategies. CONCLUSIONS: It is concluded that MI-adapted voice therapy holds promise as an approach to address patient adherence to vocal behavioral change. However, research is necessary to define the efficacy of this approach and the factors associated with its efficacy.

Common practices of voice therapists in the evaluation of patients.

This study surveys voice therapists regarding common diagnostic practices in patients referred for therapy with the diagnosis of muscle tension dysphonia (broadly defined as the "hyperfunctional" component of the dysphonia). Through postings on the e-mail list of the ASHA special interest division on voice, speech pathologists with at least 3 years' experience in stroboscopy and acoustic instrumentation were invited to complete the survey. Results from 53 completed surveys demonstrated that voice quality and patient self-perception are the sole assessments performed by all therapists. Voice quality, observation of body posture and movement, and probing the patient's ability to alter voice production are each significantly more likely to be performed than the more objective stroboscopic, acoustic, aerodynamic, and EGG assessments. Further, the tasks of defining specific therapy session goals and helping the patient to achieve a particular target skill are considered best served by measures of vocal quality, observation of body position and movement, and judging the patient's ability to alter voice production. For definition of the overall therapy goal, stroboscopy and patient perception scales are added to all of the subjective assessment measures as being important. Acoustic data are considered most important for patient reinforcement and outcomes assessment. Implications of these findings are discussed, and topics for further exploration are identified.

The inspiratory maneuver: a simple method to assess the superficial lamina propria during endoscopy.

We describe a simple means of assessing the condition of the superficial lamina propria during endoscopy, which we use in our practice as an adjunct to careful stroboscopic examination. An intake of breath against partially adducted vocal folds serves to draw the mucosa inferomedially into the glottis, which reveals areas of diminished mobility, the relationship of mucosal lesions to deeper tissues of the vocal folds, and subtle submucosal lesions. This is possible because of the unique geometry of the glottis that renders the vector forces of airflow different at inspiration and expiration. Because the integrity of the superficial lamina propria is essential to healthy phonation, we have found the inspiratory maneuver useful across a wide variety of mucosal pathologic conditions.

Factors predicting patient perception of dysphonia caused by benign vocal fold lesions.

OBJECTIVES/HYPOTHESIS: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score. STUDY DESIGN: : Retrospective review of 100 patients with benign vocal fold lesions. METHODS: Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients. RESULTS: Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score. CONCLUSIONS: Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.

Evidence-based treatment of paralytic dysphonia: making sense of outcomes and efficacy data.

The criteria used to determine the success or failure of a given treatment for vocal fold paralysis are fundamental components of routine clinical practice and treatment outcomes research for the surgeon and voice therapist. The purpose of this article is to offer a guide to the critical interpretation of available measures of out-come and efficacy for this patient population. Such data form the basis for the practice of evidence-based medicine and voice therapy,essential if the standard of care is to evolve to the benefit of the patient. A better understanding of the potentials and limitations of each measure is important for treatment planning and patient counseling and, ultimately, for the conception of future well-designed clinical research. The complex issues regarding outcomes measurement are addressed here within the context of current treatment literature on vocal fold paralysis. Particular emphasis is placed on realistic data gathering within clinical practice.

Voice rest after microlaryngoscopy: current opinion and practice.

OBJECTIVE: Although voice rest is often recommended after excision of benign mucosal vocal fold lesions, no standard of care exists regarding the use, duration, or extent of vocal restrictions. This prospective study is intended to explore current opinions and practices of otolaryngologists regarding the use of complete and relative voice rest. STUDY DESIGN AND METHODS: A 16-item survey was mailed to all active U.S. members of the American Academy of Otolaryngology-Head and Neck Surgery (n = 7,321) regarding use of complete and relative voice rest after surgical excision of vocal fold nodules, polyps, and cysts. Treatment preference questions used a Likert 5-point scale with end anchors of 1 equaling "never" and 5 equaling "always". RESULTS: The response rate was 16.5% (1,208 respondents). Differences by lesion type were not statistically significant, suggesting that surgeons consider the mucosal disruption resulting from the surgery to be similar across lesions. Approximately 51.4% (620) favored complete voice rest. Approximately 62.3% (753) favored relative voice rest. Approximately 18% (213) of the respondents who "always" recommend complete rest also "always" recommend relative rest. The most common duration for both types of rest is 7 days. CONCLUSIONS: There is a clear preference for the use of voice rest, but the specific type (complete or relative) is controversial, and a notable percentage of respondents (15%) do not favor any type of voice rest. It is likely that the lack of uniformity of opinions and practices reflects the absence of empirical data. Prospective clinical trials are needed to guide clinical standards of care.

Management of benign vocal fold lesions: a survey of current opinion and practice.

Empirical data are often not available to guide clinical practices in the treatment of benign mucosal lesions of the vocal folds. The purpose of this report is to describe opinions and practices in order to identify areas of consensus and discrepancy and thus guide future inquiry. A 16-item survey mailed to all active US members of the American Academy of Otolaryngology-Head and Neck Surgery (n = 7,321) included questions on the use of voice therapy; diagnostic testing; perioperative use of steroids, antibiotics, and antireflux medications; and use of lasers. Responses used a Likert 5-point scale with end anchors of 1 equaling "never" and 5 equaling "always" and were stratified according to lesion (nodules, polyps, cysts). A 16.5% response rate (n = 1,208) was obtained. A lack of consensus was most evident in the use of voice therapy for lesions other than nodules; antireflux medication; and intravenous steroids. Disagreement was also noted regarding the use of lasers, oral steroids, and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication. Prospective clinical trials addressing voice therapy, antireflux medications, steroids, and antibiotics are needed to inform clinical practice. Furthermore, treatment practices appear to be largely independent of lesion type. Therefore, traditional diagnostic categories do not seem to be useful guides to treatment, and may need to be reevaluated in light of improvements in diagnostic technology and surgical technique.

Anterior-posterior and medial compression of the supraglottis: signs of nonorganic dysphonia or normal postures?

Two vocal tract postures commonly identified as hallmarks of nonorganic dysphonia are anterior-posterior and medial compression of the supraglottis. However, insufficient data exist to support their diagnostic utility. The purpose of this study was to compare these two postures in patients with nonorganic dysphonia and normal controls using interval data derived from quantitative measures of videostroboscopic images obtained with an oral endoscope. Retrospectively, 40 patients with nonorganic dysphonia and 40 normal controls were selected. Relative anterior-posterior compression (LO(AP)) was calculated as the laryngeal outlet (LO) (the view of the true vocal folds during phonation) normalized to the anterior-posterior dimension in pixels. Relative ventricular fold medial compression (LO(w)) was calculated as the laryngeal outlet normalized to the medial dimension in pixels. Results were as follows: (1) LO(AP) was significantly greater for the dysphonic group, (2) the range of LO(AP) values between the two groups overlapped considerably, (3) no significant difference was found between groups for LO(w), (4) the correlation between LO(AP) and LO(w) within each subject yielded r values of 0.71 and 0.67 for the nonorganic dysphonia and normal control groups, respectively. It is concluded that medial compression of the ventricular folds can be a normal laryngeal posture, and that although anterior-posterior compression is present in greater degree in dysphonics, it is sufficiently common in normals to question its utility as a diagnostic sign of phonatory dysfunction.

The effect of upper airway surgery on voice.

OBJECTIVE: Our goal was to assess patient perception and acoustic characteristics of voice before and after upper airway surgery. STUDY DESIGN AND SETTING: We conducted a prospective assessment of 44 surgical patients preoperatively and postoperatively at a tertiary care, academic hospital. Operations included septoplasty and turbinectomy (n = 28) and septoplasty, turbinectomy, uvulopalatopharyngoplasty, and tonsillectomy (n = 16). Patient opinion measures included Voice Handicap Index score, perception of vocal resonance, and change in voice. Acoustic measures included assessment of the relative amplitude of selected formants (resonances) of the vocal tract. RESULTS: Mean Voice Handicap Index scores were unchanged after surgery. Nine patients (20%) perceived their voice to be improved after surgery. None perceived the voice to be worse. Postoperative changes in relative formant amplitudes were statistically significant. These changes caused the acoustic features to become more representative of normative data than the preoperative values. CONCLUSION: Upper airway oeprations can affect acoustics and perception of voice. SIGNIFICANCE: Patients are unlikely to perceive a change in voice as a result of upper airway surgeries, but in those cases where a difference is perceived, it is likely to be a positive change.