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

1
The Effects of Specific Respiratory Muscle
Training on the Speech Intelligibility of a
Patient with Parkinsons Disease

• Vaneysa Hansen, M.A., SLP (C)
• Barbara Mathers-Schmidt, PhD, SLP-CCC
• Western Washington University
• ASHA Conference Chicago
• November 22, 2008

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Agenda

• Purpose
• Background information
• Outcome Measures
• Method
• Results
• Discussion
• Summary

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Learning Objectives

• Possible new therapy option for SLPs 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

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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)

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Respiration PD

• Chest wall rigidity contributes to muscle
  weakness (Tamaki, Matsuo, Yanagihara, Abe,
  2000)
• limits the lungs 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

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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.).

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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

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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)

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IMT COPD

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

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EMT MS

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

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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

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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)

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Hypotheses

• MEP/MIP and dB SPL will increase with tx because
  of improved strength, resulting in increased
  speech intelligibility.

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

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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

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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

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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
  off-state in the afternoon and evening

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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 H2O for 5 sec. and 10 cm of H2O for 10
  sec.

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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)

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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
  Parkinsons disease (Ramig, 1992)

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Outcome Measures

• Intelligibility
• Sentence Intelligibility Test (SIT) (Yorkston,
  Beukelman, Tice, 1996)
• Percentage of speech intelligible
• speaking rate and intelligibility rate
• communication efficiency ratio
• McHenry Parles Unpredictable Sentences
• Kent Phonetic Contrast Word List

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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 persons speech intelligibility of
  words in sentences

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Why use other Intelligibility Tests?

• McHenry Parles 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

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SIT Demonstration
Instructions and sentence stimuli
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MEP/MIP
MEP/MIP Instructions
MEP/MIP Demo
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Reliability

• Protocols provided
• Interjudge 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).

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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
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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).

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Training Demonstration
PowerLung Demo
9th 10th Breath
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Training

• Weekly or biweekly phone calls or emails 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 subjects ideal
  settings as strength increased.
• To provide feedback on technique.

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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

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Figure 1 Percentages of intelligible speech on
the SIT

• increase of 6.88 - baseline ? 5th week of
  training
• increase of 15.22 - end of withdrawal ? 8th
  week of training

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Intelligibility Tests

• Single words
• improved intelligibility
• 4 increase overall
• Unpredictable Sentences
• improvement overall
• 8.59 increase

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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
• No change in intensity levels

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Spirometry

• FVC
• Increased with respiratory training
• improved by 1.5 L (from 3.04-4.54 L).
• Predicted FVC
• Increased with respiratory training
• gain of 29.15 (from 58-87.10)

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Communicative Effectiveness

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

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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

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Discussion

• MEP/MIP below Black Hyatts 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

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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

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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

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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)

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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

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Theoretical Speculations

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

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Implications for clinical practice

• Suggests that focusing on respiratory training
  may improve speech intelligibility and lung
  volume in an individual with PD

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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

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• For more informationEmail Vaneysa.Hansen_at_viha.c
  a
• For references
• ASHA online handouts
• Thank Yous
• Dr. Mathers-Schmidt, my subject, fellow graduate
  students, undergraduate student judge, my audience