Speech Amplification Device Usage for the Management of Hypophonia: A Survey of Speech-Language Pathologists.

PURPOSE: The purpose of this study was to survey speech-language pathologists (SLPs) who assess and treat people with Parkinson's disease (PD) to gather insights into their decision making regarding their use or potential use of speech amplification technology for the management of hypophonia. METHOD: A total of 111 SLPs who were currently practicing in the United States or Canada and had experience working with clients with PD for at least 2 years completed an anonymous Qualtrics survey. Questions were designed to probe the following areas: (a) degree of familiarity with amplification devices as a form of treatment for PD, (b) attitudes and perceptions of the implementation of these devices for PD, and (c) factors that influence the clinical decision to prescribe such devices. RESULTS: Most participants (75; 71%) reported they had considered prescribing a device to at least one client with PD. When asked at which stages of speech or voice impairment they would consider the use of an amplification device for clients with PD, the most common response was for clients with moderate or severe hypophonia who were not stimulable for louder speech. However, 36 (32%) respondents indicated they would also consider an amplification device for clients who were stimulable for louder speech with severe hypophonia. When asked to rank the most important factors they would weigh when considering the prescription of an amplification device, they ranked the client's preference and comfort level as the most important consideration. CONCLUSION: This study provides valuable clinical insights regarding how SLPs can approach utilizing speech amplification devices in the therapy environment.

Clinical Insights Into the Use of Speech Amplification Devices for Managing Hypophonia: Interviews With Speech-Language Pathologists.

PURPOSE: The purpose of this qualitative interview study was to identify themes regarding considerations in the usage of speech amplification device usage for people with Parkinson's disease (PD) and hypophonia from the perspective of speech-language pathologists (SLPs). METHOD: Eligible participants included SLPs currently practicing in the United States or Canada with experience working with clients with PD for at least 2 years. Ten SLPs participated in 60-min interviews conducted via Zoom. A semistructured interview guide was created prior to the interviews. The interviews were transcribed following their completion, and an iterative coding process was used to identify themes using thematic analysis. RESULTS: Three main themes were identified from the interviews. The first theme encapsulated how clinicians described amplification devices as a potential treatment tool, which highlighted the nuances that may impact selecting an amplification device as a treatment option such as increased hypophonia or dysarthria severity and cognitive decline. The second theme highlighted how device selection depends on the individual needs of the user. Individual client characteristics (such as disease symptoms and individual needs and preferences) may impact the choice of amplification device. The last theme outlined the importance of involving family members in all stages of device use and involving other health care team members on a case-by-case basis. CONCLUSIONS: The insights provided by the SLP participants help to understand the clinical decisions that are made when determining device candidacy, selecting a device, and evaluating device success. These insights can be used to improve research studies of augmentative management of hypophonia and guide more personalized management decisions.

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.

Training students from rehabilitation professions on communicating with patients with communication disorders.

BACKGROUND: FRAME, a mnemonic referring to a program for helping health care providers adapt patient-provider communication when working with patients with communication disorders, improves the knowledge, confidence, and communication skills of medical students for working with this population. However, the impact of the FRAME program for preparing students from the rehabilitation disciplines to work with patients with communication disorders is unknown. OBJECTIVE: To examine the effects of the FRAME program on the knowledge, confidence, and communication skills of students in physical therapy (PT), occupational therapy (OT), and prosthetics and orthotics (P&O) in terms of how to communicate effectively with patients with communication disorders. DESIGN: An exploratory, quasi-experimental pretest-posttest design. SETTING: PT, OT, and P&O clinical education programs at the University of Washington's Department of Rehabilitation Medicine. PARTICIPANTS: Twenty rehabilitation students (PT = 12; OT = 7; and P&O = 1) participated in the FRAME training. INTERVENTIONS: The FRAME program, delivered in a single, 2-hour session teaches students communication skills to use with patients with various types of communication disorders. MAIN OUTCOME MEASURES: A quiz of students' knowledge about communication disorders and a self-rating of confidence for interacting with this patient population were used. Speech-language pathology graduate clinicians rated students' use of communication strategies from each area of the FRAME training during interactions with standardized patients portraying aphasia and dysarthria. Student qualitative feedback were also collected. RESULTS: Students' knowledge, confidence, and use of communication strategies improved significantly following training. Greatest gains were observed in students' ability to familiarize themselves with how a patient communicates and establish a method of communication before proceeding with the interview. Qualitative feedback aligned with these findings. CONCLUSIONS: The FRAME program increases the knowledge, confidence, and use of communication strategies in rehabilitation students in order to communicate more effectively with patients with communication disorders in their future careers.

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.

Beyond the Patient: A Mixed-Methods Inquiry Into Family Members' Involvement in the Treatment of Parkinson's Disease to Target Third-Party Disability.

Purpose Family members of people with Parkinson's disease (PD) may experience third-party disability, manifesting as difficulty managing communication breakdowns and changed relationships influenced by communication disorders. This study examined family involvement in therapy to address third-party disability from the perspective of family members of people with PD and speech-language pathologists (SLPs). Method A mixed-methods design was used with two phases of data collection. In Phase 1 qualitative interviews, nine family members shared their perspectives about their involvement in therapy. In Phase 2, a survey was developed from Phase 1 data to gather data from SLPs (N = 110) on their clinical practices involving family members. Results Family members and SLPs agreed that when family were involved in therapy, it was primarily to support therapy exercises for the person with PD. Many SLPs reported providing supportive activities for family members. However, qualitative data from family members suggested that the limited involvement they had in therapy did not sufficiently meet their unique needs resulting from communication changes with the person with PD and other related challenges. Constraints influencing family member involvement included insurance billing regulations, privacy laws for patients, and family members' availability. Conclusions While some families and SLPs reported efforts to specifically include families and address their needs in therapy, these practices were inconsistent and, from families' perspectives, insufficient to meet their own needs. Future research should consider family-centered approaches that involve family members in speech-language therapy to enhance their daily lives, along with persons with PD.

Teaching Medical Students Skills for Effective Communication With Patients Who Have Communication Disorders.

Purpose Patients with communication impairments including speech, language, cognition, or hearing disorders face many barriers to communication in health care settings. These patients report loss of autonomy in health care decision making, are at increased risk for medical errors, and are less satisfied with health care than patients without communication disorders. Although medical students receive training in effective patient-provider communication, most of this training assumes patients have intact communication abilities. Medical students and other health care providers are often unprepared to meet the communication needs of patients with communication disorders in health care encounters. The purpose of this study was to assess the impact of a curriculum for training medical students to communicate effectively with patients who have a range of communication disorders. Method Twenty-six 2nd-year medical students volunteered for assessments before and after a required workshop in a class. This workshop included instruction about different types of communication disorders and communication strategies, followed by practice with standardized patients portraying different communication disorders. Outcome measures included a knowledge test, ratings of self-efficacy, and evaluation of students' skills when interviewing standardized patients portraying aphasia and dysarthria. Results Medical students demonstrated significant improvements in knowledge, self-efficacy, and use of recommended communication techniques. Conclusions The curriculum appeared effective in changing medical students' knowledge and skills for working with patients with communication disorders. Equipping medical students to meet the needs of patients with communication disorders is 1 key element for improving the quality of health care for this patient population.

Assessing the Believability of Standardized Patients Trained to Portray Communication Disorders.

PURPOSE: The purpose of this study was to evaluate the believability of standardized patients portraying individuals with communication disorders as part of a larger study in which standardized patients help train medical and allied health students about communication disorders. METHOD: Two women portrayed persons with aphasia, and 2 men depicted persons with dysarthria associated with Parkinson's disease. Two stakeholder groups rated believability. Speech-language pathologists rated believability of videos online. Persons with aphasia rated aphasia videos during in-person sessions with the researchers. RESULTS: Targeted believability was 80 or higher (0-100 scale; 0 = not at all believable, 100 = very believable). For speech-language pathologist raters, average ratings met the target for the portrayals of the aphasia characteristics of word-finding problems, agrammaticism, nonverbal communication, and overall portrayal but not for auditory comprehension problems. Targets for the portrayals were met for the dysarthria characteristics of reduced speech movements, reduced loudness, reduced intonation, flat affect, and overall portrayal but not for speech rate. Ratings for different standardized patients portraying the same case were not significantly different from each other on most characteristics. Ratings from persons with aphasia were highly variable. CONCLUSION: Standardized patients who do not have communication disorders can portray disorder characteristics in a believable manner.

Factors Associated With Communicative Participation in Amyotrophic Lateral Sclerosis.

Purpose: People with amyotrophic lateral sclerosis frequently experience bulbar impairment and dysarthria that may restrict their ability to take part in everyday communication situations. The aim of this study is to examine selected variables that may contribute to restrictions in communicative participation. Method: Community-dwelling participants with amyotrophic lateral sclerosis (N = 70) who reported communication changes but continued to use natural speech completed a survey, including the Communicative Participation Item Bank, demographics (age, sex, living situation, employment status, education, and time since diagnosis), and self- reported symptom-related variables (physical activity, emotional problems, fatigue, pain, speech severity, speech usage, and cognitive and communication skills). To identify predictors of restrictions in communicative participation, these variables were entered into a backward stepwise multiple linear regression analysis. Results: Three variables (speech severity, swallowing severity, and speech usage) were included in the final model and accounted for 55% of the variability. Conclusions: Better speech and swallowing skills and higher speech usage are associated with better communicative participation in this sample. Thus, when making clinical decisions regarding intervention, clinicians should continue their efforts to target speech and swallow abilities, while recognizing other variables that have the potential of restricting communicative participation.