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Conducting a Conducting a Comprehensive Voice Comprehensive Voice
Assessment in Assessment in Parkinson’s DiseaseParkinson’s Disease
Voice Disorders – Dr. Brindleat
Western Kentucky UniversitySpring 2005
Voice and Speech Problems in Parkinson'sVoice and Speech Problems in Parkinson's
INCIDENCE
60-80% of PD patients develop speech and voice problems as the disease progresses over time; mild to moderate symptoms occur in the early stages
Parkinson Dysarthria: 1) Hypo kentic Dysarthria – 98% have reduced automatic muscular movements affecting speech control -Symptoms are the same as in the limbs: - Rigidity - Reduced Range of Motion & Coordination - Resting Tremor - early sign in many cases
- Difficulty Initiating Phonation (most frequent symptom ) - Slow Movements (bradykinesia)
Impaired Mechanisms in Parkinson'sImpaired Mechanisms in Parkinson's
Respiratory System - impaired breathing & reduced breath
support
Phonatory System - impaired or reduced larynx mobility due to
rigidity of vocal folds trachea, soft palate, tongue, lips and jaw
Resonation System - reduced mobility of the soft palate
Articulatory System - impairments in tongue, lips, jaw effecting
rate and clarity of speech In the later stages, patient may experience increased frustration because of reduced conversation skills and/or limited social contact
General Voice - Speech Characteristics General Voice - Speech Characteristics Ordered by SeverityOrdered by Severity
Monotone pitch/loudness Reduced Stress Reduced Pitch/loudness Imprecise consonants Short Rapid Rushes of Speech Harshness/Hoarseness Breathiness – caused by bowing of vocal folds Variable Speech Rate Aphonia – In the later stage Difficulty initiating phonation for articulation
because of difficulty adducting folds; may also complain of
hoarseness (Gentil & Pollack, 1995)
VOICE EVALUATION VOICE EVALUATION
Team Approach – may involve:
- Laryngologist - SLP, OT , PT
- General physician - Neurologist
- Orthodontist - Family
- Prosthodontist - Psychologist
SLP - Obtains ENT report before treatment to rule out
laryngeal disease
- Assesses laryngeal function
- Analyzes: - ENT results
- Vidoendoscopic Data/ EGG data
- Obtains initial diagnosis from physician before
treatment to rule out life threatening condition
CASE HISTORYCASE HISTORY
- Establish Rapport - - Listen and observe - Avoid leading questions - Ask questions in different ways - Determine client’s greatest concern Biographical Information - DOB - Marital status - Number of children - Occupation Health/Medical History Allergies - Smoking - Accident - Surgeries Meds - Alcohol - Daily fluid intake - Physical symptoms associated with PD -Med Side effects - Fatigue - Depression – Anxiety - Previous therapy & Testing – relevant to complaint Patient Observation: - posture – breathing pattern - facial expression - eye contact
a) Describe behavior; don’t just label it b) Consider degree of social adequacy
CASE HISTORY Cont’d…….CASE HISTORY Cont’d…….
Patient Description Helps reveal perception in relationship to clinical findings: a) Onset - Slow onset suggests gradual neurological disease as
in Parkinson’s disease (PD) b) Severity rating, duration, cause, progression &
variability of symptoms c) Situations where best & worst voice & how disorder
affects life e) Other Symptoms in PD : (GERD / Vocal Abuse; dysphagia, nasal regurgitation (PD) patient is often unaware of changes because of very gradual
decline in function..
EVALUATION cont’d……EVALUATION cont’d……
Use Voice Rating Scales – helps measure severity of disorder Listening and thinking objectively is an essential skill Compares performance of client to peers of some age/gender in
the Following: 1) Pitch /frequency (phonation) 2) Loudness/Intensity (phonation) 3) Quality/Waveform (respiration) - breathiness/air wastage/airflow rate - hoarseness - thinness - tightness - tremor - strained - strangled 4) Nasal and Oral resonance 5) Speech Rate 6) Variability of Inflection
Self-Rating Scales Provides valid & reliable self- assessment of patient 1) Voice handicap Inventory 2) Voice Related Quality of Life (VRQOL)
Instrumentation vs. perceptual EvaluationInstrumentation vs. perceptual Evaluation
Instrumentation is often not necessary but can be useful in planning voice treatment; documenting and quantifying data
I. Strobovideolaryngoscopy – Within scope of SLP – helps identify subtle changes in vibratory patterns of vocal folds
II. Videoendoscopy -- Assesses in study of vocal tract anatomy and physiology
III. Videostroboscopy -- Helps analyze abnormal mucosal wave
IV. Laryngostroboscope - Precise evaluation of larynx & vocal fold movement
and subtle changes in mucosa function
INSTRUMENTATION…CONT’D INSTRUMENTATION…CONT’D
V. Oral Scope – Solid/rigid glass rod provides excellent picture
VI. Nasal Scope - -- Flexible fiber optic cable - helps identify vocal
pathology during connected speech
VII. Flexible Endoscope -- Reveals velar, pharyngeal & tongue movement
contributing to vocal tremor
VIII. Spectrography -- Measures degree of tremor during phonation
-- Reveals irregular pitch periods -- Vocal Folds may appear normal at rest in PD; --- Identifies incomplete vocal fold closure or “bowing” – can cause breathiness & reduced loudness.
Assessing Respiration - Endurance and Assessing Respiration - Endurance and SupportSupport
DETECT - Shallow & reduced breathing; air supply and/or wastge - Difficulty coordinating breathing and speaking TASK a) Maintain duration of phonation on 1) vowel ‘ah’ & 2) s/z ratio (< 1.4)
- if /s/ is 20% longer than /z/ (>1.4) indicative of vocal pathology
Repeat tasks 3 times – use stop watch - Normal 20 to 25 sec. Sedate Geriatric 14.7 to 19.3 sec. 2) Assess maintenance of sufficient muscular effort over time during
speech TASK Rapidly count to 200 noting changes in phonation, veloPharyngeal closure and articulation of speech
Overall Voice and Speech AssessmentOverall Voice and Speech Assessment
Voice/Speech Sample – reading of: Rainbow Passage/ Grandfather Passage
Listen for: 1) Speech Rate Irregularities (especially rushes of speech)
2) Pitch /loudness (phonation) 3) Intelligibility – unclear & imprecise articulation 4) Respiratory Support - shallow breathing - less frequent breaths Clavicular - Elevated shoulders on inhalation tenses strap muscles – excessive effort for too little breath Diaphragmatic - Expansion of abdomen during inspiration Thoracic - Upper or lower thoracic movement
Identify Breathing PatternsIdentify Breathing Patterns
Instrumentation Aerodynamic Evaluation – determine air pressure and
airflow rates used during speaking tasks; helps in treatment
planning 1) Pneumograph - records thoracic and abdominal
movement 2) Respiratrace - X-ray 3) Spirometer - pressure measuring gauges lung volume
in cc or liters 4) Manometer - measures air pressure 5) Phonatory Function Analyzer 6) Pneumotachometer 7) Aerophone - breathing patterns can been visual
observed (Dr. Brindle, 2005)
Assessing Pitch Assessing Pitch 1) Identify Optimal/Best pitch Range Range at which most pleasing quality is heard without physical effort or excessive expenditure of energy (Brindle, 2005) Use: yawn-sigh - uh, huh (most relaxed
phonation) 2) Identify Habitual Pitch Most typically used; should be appropriate for age and gender Males – Higher pitch males; lower in females Some studies found the reverseCAUSE Limited pitch range and variability and/or tremor in PD caused by reduced tensing of folds or “bowing”
ASSESSING PITCH…CONT’ D….ASSESSING PITCH…CONT’ D…. TASK 1) Begin by singing a sound in the middle vocal range use: pitch pipe - piano /keyboard 2) Go down one tone at a time until reaching lowest range. 3) Afterwards patient goes up scale one tone at a time until
reaching highest note his/her range. Repeat 3 times. 4) Compare pitch range with habitual pitch during paragraph oral
reading 5) Determine if patient is using most efficient pitch; pitch difference should be less than 2 tones.
Instrumentation -Visipitch -Phonatory Function Analyzer -Computerized Speech Lab -Chromatic Tuner
Acoustic Analysis - Helps identify vocal range & fundamental frequency Fo
- Provides objective measures of severity - Usually higher Fo in (PD)
ASSESSING LOUDNESS LEVEL ASSESSING LOUDNESS LEVEL
Monoloudness - lack of variability- can be caused by a vocal tremor and/or rigidity in respiratory and vocal folds muscles
Reduced loudness Aphonia - caused by incomplete closure of vocal fold
often resulting in bowing Loudness *shimmer <2.4% (amplitude) Instrumentation - Sound Pressure level meter - Vispitch - Computerized Speech Lab - Phonatory Function
Analyzer
ASSESSING VOCAL QUALITY ASSESSING VOCAL QUALITY Breathiness & harshness - often manifests in initial stages of (PD) due to muscle rigidity;
inability to tense folds and/or “bowing” Hoarseness / Harshness / Raspy - first thought related to chronic allergies or post nasal Strained Strangled – result from: - changes in control of laryngeal muscles and respiratory system or - use of compensatory techniques to counteract negative changes - often first format shows abrupt onset and heavier concentration of
energ y and reduced Fo Register Variations – fold approximation incompatible with desired pitch level Pitch breaks – in voices pitched too high or low (hyper function) Intonation & Stress Variations - lack of vocal inflection melody or flat uninteresting quality Instrumentation: Spectrogram - records above characteristics as : - represented as aperiodicity or noise; increased when vocal quality
is abnormal.
ASSESSING RESONANCEASSESSING RESONANCE
Hypo nasality
Cause - Talking through the nose due to inadequate closing off nasal cavity - Allowing air to leak in creating nasal quality on all consonants rather than nasal
sounds [ n, m, ng] - Can be result of reduced movement of soft palate/velum
Task 1) Read word list or passage with/m/, /n/, and /ing / words. 2) Compress and release nostrils as patient reads or “hums” 3) Listen for hypo nasality inability clearly indicates hyper nasality.
Hyper nasality - A typical in PD; however when occurring it can be severe TASK 1) Alternate sustained /i/ and /u/. 2) Compress (pinch) and release nostrils. 3) If velopharyngeal closure is adequate, no alterations perceived in vowel quality. 4) If poor velopharyngeal closure, flutter-like sound is heard
ASSESSING RESONANCE…Cont’dASSESSING RESONANCE…Cont’dCul-De-Sac Resonance 1) Phonate on /”ah”/ and observe if tongue is retracted posteriorly. 2) If so, have patient read word lists with tongue-tip sounds to move tongue to forward position: e.g. “did” “sip” “tip” “seed” “pit” “teeth” “maid” “sis” “tizzy” (White, 2001) Excessive Anterior Tongue Carriage 1) Read words with a lot of back vowels and back consonants (k/g) e. g. cook kook go good cog
Note if improvement heard in vocal resonance. Assessing Oral peripheral Structure & Oral Motor Functioning Oral Peripheral Exam – observe structure and function related to
cranial nerve damage - Face - Cheeks - Lips - Mandible - Tongue – occasional resting tremor AMR’s (alternating motion rates) usually slow or may be fast and
irregular
ASSESSING RESONANCE Cont’d ….ASSESSING RESONANCE Cont’d ….
ROM – (range of motion) is restricted or reduced during AMR’s due to
rigidity is most typical in PD with high notes 1) Ability to produce rapid and accurate speech. 2) Deeply inhale & repeat: [/p^/, t^, k^ ] and “Patticake” 3) Repeat syllables for 10 seconds for at least 3 trials; 4) Average the number of Reps 5) Syllables should be equally spaced.
Assessing Hyper function Observe sites of potential hyerfunction /tension 1) muscles of face and neck, mandibular restriction 2) Listen for strained voice quality / hard glottal attacks. 3) Note complaints of laryngeal pain. 4)Laryngeal excursion 5) Thyroid tipping forward – on high note causes stress 6) Tongue placement (Gentil, Pollak, 95’)
Laryngeal problemsLaryngeal problems
Neuromuscular Effects
- May affect esophageal mobility and contribute to 1) swallowing problems (dysphagia) 2) gastroesophageal reflux - Can cause reflexive hypertonicity in the larynx
possibility contributing further to voice impairment ASSESSMENT - Bedside Evaluation Videoendoscope
BibliographyBibliography
Boone, D., Mcfarlane, S. C., Von Berg, S. L. (2005). The Voice and Voice Therapy (7th Ed.) Pearson: Boston, MA. Deem, J.F., Miller, L. (1984). Neurogentic Dyshonias. Manual of Voice Therapy. Pro-Ed. Austin,
TX. Duffy, J.R. (1995). Motor Speech Disorders:substrates, differential diagnosis, and management. Mayo Foundation, MO: Mosby. Hedge, M.N., (1997) Pocket Guide to Treatment in Speech-Language Pathology (3rd ed.). Singular; San Diego, CA. Rammage, L., Morrison, M., (2001). Management of the Voice and Its Disorders ( 2nd ed.). Hamish Nichol Singular; San Diego, CA. White, Patrica F. (200l). Pocket reference of: Diagnosis and Management for the Speech-
Language Pathologist (2nd ed. ). B & H, Woburn, MA. Parkinson’s disease. (2002). Retrived mar. 10, 2003 from medlinepulus Medical Encyclopedia
database. March 2002. www.pdf.org/AboutPD/symptoms.cfmwww.postgradmed.com/issues/2003/12_03vartarian.htmwww.parkinson.org/site/pp.asp?e=9dJFILPwB+b=71354www.burke.org./medservices/outpatient/outpatient.ctm#15www.aafp.org/afp/980600ap/rosen.btml.www.voiceandswallowing.com/newpadiagvis.htm.