Title: The Effects of Specific Respiratory Muscle Training on the Speech Intelligibility of a Patient with
1The 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
2Agenda
- Purpose
- Background information
- Outcome Measures
- Method
- Results
- Discussion
- Summary
3Learning Objectives
- Possible new therapy option for SLPs working
with PD patients - Potential value of IMT/EMT approach
- Implications for future research
4Purpose
- 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
5Respiration 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)
6Respiration 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
7Why 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.).
8Inspiratory 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
9Expiratory 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)
10IMT COPD
- Successfully strengthened the respiratory muscles
and eliminated dyspnea and fatigue in pts with
COPD. (Hill et al, 2006)
11EMT MS
- Increased muscle strength in pts with MS
- Increased cough efficacy
- Did not change vocal quality
- (Chiara, Martin, Sapienza, 2007)
12Rationale 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
13Combining 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)
14Hypotheses
- MEP/MIP and dB SPL will increase with tx because
of improved strength, resulting in increased
speech intelligibility.
15- Lung volume will increase with tx due to an
expanded range of motion of respiratory muscles,
leading to improved speech intelligibility.
16Subject
- 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
17Pre-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
18Interview 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
19Subject 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.
20Method
- 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)
21Outcome 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)
22Outcome 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
23Why 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
24Why 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
25SIT Demonstration
Instructions and sentence stimuli
26MEP/MIP
MEP/MIP Instructions
MEP/MIP Demo
27Reliability
- 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).
28Training- 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
29Training 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).
30Training Demonstration
PowerLung Demo
9th 10th Breath
31Training
- 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.
32Results-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
33Figure 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
34Intelligibility Tests
- Single words
- improved intelligibility
- 4 increase overall
- Unpredictable Sentences
- improvement overall
- 8.59 increase
35Figure 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
36 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)
37Communicative 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.
38Discussion
- 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
39Discussion
- 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
40Limitations
- 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
41Limitations
- 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
42Previous 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)
43Theoretical 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
44Theoretical Speculations
- Overflow of neural drive from respiratory
muscles to voice and articulatory muscles
increases intelligibility (Saleem, et al., 2005).
45Implications for clinical practice
-
- Suggests that focusing on respiratory training
may improve speech intelligibility and lung
volume in an individual with PD
46Suggestions 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
47- 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