Treatment Techniques for the Acquired Dysarthrias Oklahoma Speech-Language-Hearing Assoc. Sept. 30, 2010 Joe Duffy, Ph.D., BC-ANCDS Mayo Clinic Rochester, MN Respiration Tx focus unnecessary if loudness & flexible breath patterning for speech are adequate. Unnecessary if steady subglottal air pressure of 5- 10 cm of water can be generated for 5 secs (“5 for 5”). Respiration (cont.) Increasing respiratory support may be appropriate if patient can‟t produce > 1 word per breath during speech Increasing Respiratory Support Consistent subglottic pressure “5 for 5” tasks with water manometer Maximum vowel duration (& loudness) tasks (3-5 sec) Optimal breath group - # syllables comfortably produced on 1 breath Pushing, pulling, bearing down during speech & nonspeech tasks Controlled exhalation (slow uniform exhalation) Expiratory muscle strength training (EMST) Respiration – Behavioral Compensation Inhaling deeply (50% of capacity) & exerting force when exhaling (inspiratory checking) “let it out slowly” Initiate & terminate phonation @ same point in respiratory cycle Shorten phrase length Remove maladaptive strategies (e.g., too short or long breath groups; speaking on inhalation) Respiration – Compensatory (more examples) Speak at onset of Neck breathing exhalation Glossopharyngeal Increase vocal strain breathing Shorten fricative duration Increasing Respiratory Support (cont.) Postural & prosthetic aids Adjustable beds, wheelchair, chairs Sitting vs. supine positioning Abdominal binders/trussing (corsets) Expiratory board/paddle/pushing with hand Phonation – Medical Weakness/Hypoadduction Medialization laryngoplasty/Type I thyroplasty for vocal fold paralysis/weakness - displaces weak fold medially reversible bilateral medialization possible + benefits reported Phonation – Medical Weakness/hypoadduction (cont.) Collagen/autologous fat injection not used until ~ 1 year p/o gelfoam can be used as temporary tx + effects reported for vocal fold paralysis Phonation - Medical Hyperadduction (cont.) Botulinum toxin injection into thyroarytenoid for adductor SD blocks Ach release + effects (M = 3 months) posterior cricoarytenoid injection for ABD SD Phonation - Prosthetic Portable amplification systems Vocal intensity controller/VU meter Artificial larynges Neck braces/cervical collars Phonation - Behavioral For hypofunction Usual goal is to increase utterance length or loudness Effort closure techniques Initiate phonation @ start of exhalation Head posture adjustments (compensatory only) Manipulation of laryngeal cartilages (compensatory only) Intense, high-level phonatory effort (LSVT) Phonation - Behavioral (cont.) For hyperfunction Increase pitch or rotate head back Breathy onset High lung volumes Resonance - VP Function Crude assessment of effect of VPI on intelligibility – (1) upright vs. supine (2) nares occluded vs. unoccluded Surgical Management pharyngeal flap; sphincter pharyngoplasty Teflon/collagen/fat injection (rarely pursued) VP Management – Prosthetic Palatal lift/obturator Best candidates stable or not declining rapidly less significant/minimal deficits @ other levels adequate dentition no sig. spasticity motivated, patient & good self-care ability Some can eventually discard device Documented success for flaccid, spastic, & mixed flaccid- spastic types VP Management: Behavioral Facilitation techniques - pressure, brushing, icing, stroking, vibratory. Inhibition techniques - prolonged icing, pressure stim., vibration Strengthening exercise (blowing, sucking) “The general consensus…these exercises are disappointing and generally ineffective” (Johns, „85, p. 158) VP Management: Other Behavioral Techniques CPAP Speaking strategy Supine positioning modifications Occlude nares Increase loudness Reduce pressure consonant duration Exaggerate jaw movement Articulation Surgical Neural anastomoses for weakness (XII – VII) Botox injection for hemifacial spasm, spasmodic torticollis, oromandibular dystonia Pharmacologic effects of antispasticity meds on articulation uncertain Prosthetic Bite block mandibular dystonia to force more tongue/lip movement Articulation - Behavioral Strengthening exercises Sensory tricks Stretching (slow, steady, Conservation of strength continuous, prolonged) Biofeedback (e.g., EMA) Articulation: Behavioral Management Traditional watch & listen (integral stimulation) phonetic placement phonetic derivation exaggeration of consonants (“clear speech”) minimal contrasts contrastive stress drills intelligibility drills with referential tasks Rate “Maybe the most powerful behaviorally modifiable variable for improving intelligibility” (Yorkston et al ‘92) Prosthetic/Behavioral Pacing devices (success documented for hypokinetic dysarthria/palilalia) •metronome • pacing board Rate “Maybe the most powerful behaviorally modifiable variable for improving intelligibility” (Yorkston et al ‘92) Prosthetic/Behavioral DAF - success documented for hypokinetic dysarthria Rate “Maybe the most powerful behaviorally modifiable variable for improving intelligibility” (Yorkston et al ‘92) Prosthetic/Behavioral Alphabet supplementation/point to 1st letter of each word Rate (cont.) Nonprosthetic/Behavioral hand/finger tapping visual feedback (computer, oscilloscope) rhythmic cueing modify pauses Prosody & Naturalness Breath group level (increase or learn to chunk) Reduce frequency of inhalation (some inhale more frequently than necessary) Contrastive stress tasks Referential tasks Work on stress to help rate control Flaccid Dysarthria Unique treatments relate to increasing strength or compensating for weakness Respiratory - increase physiologic support Laryngeal - medialization laryngoplasty; teflon/collagen injection; effort closure techniques VP function - surgical VP augmentation; palatal lift/obturator; postural adjustments Articulation strengthening exercises Behavioral/strengthening tx contraindicated in MG Spastic Dysarthria Laryngeal effort closure techniques contraindicated Medialization surgery/teflon injection contraindicated Pharmacologic (e.g. baclofen; Dantrium (Dworkin, „91) - ? effect on strained voice Stretching exercise has face validity - not studied Amitriptyline (Elavil) & behavioral management documented as helpful for pseudobulbar affect Ataxic Dysarthria Efforts to increase strength or reduce tone are probably inappropriate in most cases Laryngeal & palatal surgeries inappropriate Some medications (e.g., Tegretol) effective for paroxysmal ataxic dysarthria Tx is usually behavioral & related to improving motor control/coordination (rate, prosody, naturalness, intelligibility) Hypokinetic Dysarthria Medialization laryngoplasty & teflon/collagen injection may be appropriate. Prime candidates for rate control efforts (when rate is rapid) Anti-parkinsonian drugs that help other PD symptoms may help speech (e.g., L-Dopa, Sinemet, Klonopin), but usually not dramatically. Lee Silverman Voice Treatment (LSVT) (Ramig et al) has documented effectiveness Lee Silverman Voice Treatment (LSVT) - A Model for establishing tx efficacy? Strong theoretical & clinical rationale Well-specified, replicable treatment program for a specific disorder. Programmatic approach to research into its efficacy (multiple data-based refereed publications) Pre-post case studies Group outcomes (pre vs post tx) Group comparisons (e.g., LSVT vs respiration tx) Documented short- & long-term benefits. Tx effects documented in multiple ways (e.g., perceptual, aerodynamic, laryngostroboscopic, acoustic, social validity) Hyperkinetic Dysarthria Pharmacologic– usually not dramatically helpful (examples only) Voice tremor - Inderal, Methazolamide, Mysoline, Tegretol may help some patients, but not often or dramatically. Small amts ETOH may reduce tremor amplitude Laryngeal/respiratory dystonia - Artane Chorea - Lioresal, reserpine, Haldol may help minimally Tics (Tourette‟s) - Haldol Action myoclonus - Clonazepam (Klonopin) Hyperkinetic Dysarthria (cont.) Surgery (thalamotomy, pallidotomy, DBS) may have secondary beneficial or negative effects on speech Botox Preferred tx for: neurogenic adductor SD oromandibular dystonia spasmodic torticollis Hyperkinetic Dysarthria - Behavioral Management Adductor SD Raise pitch Increased breathiness “Performance mode” Abductor SD Hard glottal attack @ phonation onset Voice VL consonants Hyperkinetic Dysarthria - Behavioral Management Mostly anecdotal evidence for efficacy Dystonias Bite block or similar “bite strategy” for mandibular & lingual dystonias Sensory tricks EMG biofeedback for lip dystonia/hypertonia (Hand et al., „79; Netsell & Cleeland, „73; Rubow et al., „84) Action Myoclonus Slow rate Unilateral UMN Dysarthria No formal reports of tx Prosthetic & surgical tx inappropriate Behavioral approaches focus on rate, prosody, & articulation Strengthening exercise may be appropriate if weakness is evident (& if we knew it worked!) Communication-Oriented Treatment Speaker Strategies Alerting signals Convey how communication will take place Set the context Modify content & length Monitor comprehension Alphabet board supplementation Communication-Oriented Treatment (cont.) Listener Strategies Modify physical environment Maximize listener hearing & visual acuity Learn “active” listening (practice listening?) - confirm comprehension Communication-Oriented Treatment (cont.) Interaction Strategies Maintain eye contact Establish methods of feedback (e.g., locus of breakdown, cues for repairs, fail-proof strategies) Clinician uses target strategies during training & conversation (rate, hand tapping, phrasing, etc.) Establish what works best when Managing Dysarthrias: The Bottom Line? “There is both scientific & clinical evidence that individuals with dysarthria benefit from the services of speech-language pathologists. This evidence is documented in experimental research, program evaluation data, & case studies.” Yorkston, KM. Treatment efficacy: dysarthria. JSHR, 39, S46-S57, 1996). Managing MSDs - Some Facts & Needs - Efficacy data for dysarthrias come mostly from individual & aggregated case reports. In general, they support conclusion that management is efficacious. Little known about relative merits of different treatments or the specific disorders & other patient characteristics for which specific approaches are most effective. State of affairs not substantially different from what we understand about effectiveness of medical interventions in general, especially those focused on modifying behavior. Studies of treatment essential if quality & efficiency of management are to improve, & continue to be supported by health care systems. A Complex Issue Demonstrating efficacy of behavioral management is extremely difficult, moreso than for most medical interventions. Change due to behavioral tx takes time. Defining behavioral treatment so it can be replicated is not easy. Change - even when meaningful - may not be dramatic. Perception/intelligibility/communicative effectiveness are gold standards (measurement can be difficult). Management effects interact with natural course & variability of underlying disease. Published Practice Guidelines or Systematic Reviews - Dysarthria & AOS Yorkston KM et al.: Evidence-based practice guidelines for dysarthria: Management of velopharyngeal dysfunction. J Med Speech-Lang Pathol 9:257, 2001. Duffy JR & Yorkston KM: Medical interventions for spasmodic dysphonia and some related conditions: A systematic review. J Med Speech-Lang Pathol 11: ix, 2003. Spencer KA, Yorkston KM & Duffy JR: Behavioral management of respiratory/phonatory dysfunction from dysarthria: A flowchart for guidance in clinical decision-making. J Med Speech-Lang Pathol 11:xxxix, 2003. Yorkston KM, Spencer KA & Duffy JR: Behavioral management of respiratory/phonatory dysfunction from dysarthria: a systematic review of the evidence. J Med Speech-Lang Pathol 11:xiii, 2003. Published Practice Guidelines or Systematic Reviews- Dysarthria & AOS (cont.) Hanson EK, Yorkston KM, & Beukelman DR: Speech supplementation techniques for dysarthria: a systematic review. J Med Speech-Lang Pathol 12:ix, 2004. Baylor CR et al. A systematic review of outcome measurement in unilateral vocal fold paralysis. J Med Speech-Lang Pathol 14:xxvii, 2006. Wamabugh et al.: Treatment guidelines for acquired apraxia of speech: a synthesis and evaluation of the evidence. J Med Speech-Lang Pathol, 14, 15-32, 2006 Wambaugh et al.: Treatment guidelines for acquired apraxia of speech: treatment descriptions and recommendations. J Med Speech-Lang Pathol, 14, 25-67. Yorkston KM et al. Evidence for effectiveness of treatment of loudness, rate, or prosody in dysarthria: a systematic review. J Med Speech-Lang Pathol 15:xi, 2007.