The impact of intensive treatment The impact of intensive treatment on non-progressive dysarthric on non-progressive dysarthric

speakers: A pilot studyspeakers: A pilot study

Deborah Theodoros PhDDeborah Theodoros PhDRachel Wenke PhD CandidateRachel Wenke PhD Candidate

Petrea Cornwell PhDPetrea Cornwell PhDThe University of QueenslandThe University of Queensland

BrisbaneBrisbaneAustraliaAustralia

IntroductionIntroduction

Treatment for non-progressive dysarthria Treatment for non-progressive dysarthria • Most commonly behaviouralMost commonly behavioural• Multi-facetedMulti-faceted• Restoring/normalizing function across motor Restoring/normalizing function across motor

speech subsystemsspeech subsystems• Maximising intelligibility & communication Maximising intelligibility & communication

efficiencyefficiency• Facilitating compensatory communication Facilitating compensatory communication

strategies strategies Limited evidence of efficacy Limited evidence of efficacy (Sellars et al 2002)(Sellars et al 2002)

IntroductionIntroduction evidence to support intensive evidence to support intensive

training/exercise for motor skill learningtraining/exercise for motor skill learning• Facilitates Facilitates neuroplasticityneuroplasticity (adaptive capacity of (adaptive capacity of

CNS) CNS) (Cotman & Berchtold 2002)(Cotman & Berchtold 2002)

• Long-term structural changes Long-term structural changes (cortical (cortical

synaptogenesis & motor map reorganisation)synaptogenesis & motor map reorganisation) in neural in neural functioning occur following continued practice functioning occur following continued practice (Kleim et al 2004)(Kleim et al 2004)

expression neurotrophic factors expression neurotrophic factors cell cell survival survival (Ying et al 2005)(Ying et al 2005)

IntroductionIntroduction

Intensity achieved by:Intensity achieved by:• Freq of treatment (e.g. days per week)Freq of treatment (e.g. days per week)• Repetitions within sessionRepetitions within session• Req. Req. effort, resistance & accuracy during effort, resistance & accuracy during

motor speech tasksmotor speech tasks

LSVTLSVT®® – intensive treatment for PD – intensive treatment for PD

Limited investigation of intensive Limited investigation of intensive treatment for non-progressive dysarthria treatment for non-progressive dysarthria

AimAim

To investigate the immediate & long-To investigate the immediate & long-term effects of intensive dysarthria term effects of intensive dysarthria treatment on speech, voice & treatment on speech, voice & everyday communication in non-everyday communication in non-progressive dysarthric speakersprogressive dysarthric speakers

ParticipantsParticipants

10 participants10 participants

M age= 54.8 yrs; Ra=22-86yrsM age= 54.8 yrs; Ra=22-86yrs

7 males; 3 females7 males; 3 females

CVA = 7; TBI = 3CVA = 7; TBI = 3

Time post-onset: Ra=0.5–21yrsTime post-onset: Ra=0.5–21yrs

ParticipantsParticipants

Non-progressive dysarthria Non-progressive dysarthria (with resp-phonatory (with resp-phonatory impairment)impairment)

• Spastic = 7Spastic = 7• Spastic-Flaccid = 2Spastic-Flaccid = 2• Spastic-hypokinetic = 1Spastic-hypokinetic = 1

SeveritySeverity• Mild = 2Mild = 2• Mild-mod = 2Mild-mod = 2• Mod = 5Mod = 5• Mod-sev = 1Mod-sev = 1

ProcedureProcedurePre treatment Assmt 1Pre treatment Ax 1

Pre treatment Ax 2

Dysarthria Treatment

Post treatment Ax 1

Post treatment Ax 2

6 month Follow up Ax 1

6 month Follow up Ax 2

AssessmentAssessment

Speech sampleSpeech sample – “Rainbow Passage” – “Rainbow Passage”• Perceptual evaluations – direct Perceptual evaluations – direct

magnitude estimation (DME)magnitude estimation (DME)• 2 independent SLPs - randomised 2 independent SLPs - randomised

speech samples scored against standard speech samples scored against standard (moderate dysarthric speaker)(moderate dysarthric speaker) – Standard = – Standard = 100100

• Loudness, roughness, breathiness, Loudness, roughness, breathiness, articulatory precision, rate, stress, articulatory precision, rate, stress, breath support, intelligibilitybreath support, intelligibility

AssessmentAssessment

Assessment of Intelligibility of Assessment of Intelligibility of Dysarthric Speech (AssIDS)Dysarthric Speech (AssIDS)• % Word intell, % Sentence intell, CER% Word intell, % Sentence intell, CER

Acoustic Acoustic • SPL sustained /ah/ (dB)SPL sustained /ah/ (dB)• Duration phonation (secs)Duration phonation (secs)• SPL conversation (dB)SPL conversation (dB)• SPL reading (dB)SPL reading (dB)

Assessment Assessment – Outcome Measures– Outcome Measures

AusTOMS (Speech)AusTOMS (Speech)• 5-point scale (1=complete difficulty; 5=no 5-point scale (1=complete difficulty; 5=no

difficulty)difficulty)• 4 domains - Impairment, Activity Limitation, 4 domains - Impairment, Activity Limitation,

Participation, Wellbeing/DistressParticipation, Wellbeing/Distress Participant QuesParticipant Ques

• 5-point scale (1=normal; 5=Severe)5-point scale (1=normal; 5=Severe) Slurred speechSlurred speech Hoarse voiceHoarse voice How well understoodHow well understood Participate in conversations with unfamiliar peopleParticipate in conversations with unfamiliar people Initiate conversation Initiate conversation

Assessment Assessment – Outcome Measures– Outcome Measures

Communication Partner QuesCommunication Partner Ques• 7-point VAS7-point VAS• 1=very difficult; 4=sometimes difficult; 7=very 1=very difficult; 4=sometimes difficult; 7=very

easyeasy• How easy to understand speakerHow easy to understand speaker• How often request repeatHow often request repeat• How often initiate conversation with youHow often initiate conversation with you• How often initiate conversation with strangerHow often initiate conversation with stranger• Overall, how rate speaker’s speech and voiceOverall, how rate speaker’s speech and voice

TreatmentTreatment

1hr per day, 4 days per week for 4 1hr per day, 4 days per week for 4 weeksweeks

Individualised intervention – multi-Individualised intervention – multi-facetedfaceted

Common behavioural treatmentsCommon behavioural treatments (Literature & SLP focus group)(Literature & SLP focus group)

One SLP administered all treatmentsOne SLP administered all treatments Homework each dayHomework each day Maintenance programMaintenance program

ResultsResultsStatistical analysesStatistical analyses

Repeated measures ANOVA & Repeated measures ANOVA & contrastscontrasts• DMEDME• Acoustic dataAcoustic data

Paired t-tests Paired t-tests (pre/post data only)(pre/post data only)

• AssIDSAssIDS Friedman & Wilcoxin signed ranksFriedman & Wilcoxin signed ranks

• AusTOMSAusTOMS• Participant & Communication partner Participant & Communication partner

QuesQues

Results - Results - Perceptual AnalysisPerceptual AnalysisGeometric meansGeometric means

ParameterParameter PrePre PostPost FUFU

LoudnessLoudness 90.0990.09 121.59 121.59 99.47 99.47

Artic. PrecArtic. Prec 92.2592.25 106.95 106.95 135.52 135.52 RateRate 72.3472.34 68.6268.62 67.9067.90

Stress Stress 127.82127.82 113.63113.63 82.20 82.20 BreathinessBreathiness 75.9275.92 64.9564.95 62.5962.59

Breath SuppBreath Supp 63.0963.09 77.9877.98 83.98 83.98 Intelligibility Intelligibility 80.9480.94 101.11 101.11 124.51 124.51

Significant Pre/Post p<.05 Significant Pre/FU p<.05

Results - Results - AssIDSAssIDS

0

10

20

30

40

50

60

70

80

90

% Word % Sent

Pre

Post

Significant Pre/Post p<.05

12.5% 9.4%

Results - Results - AcousticAcoustic

60

62

64

66

68

70

72

74

76

78

AH Reading Convers

Pre

Post

FU

Mean S

PL

(dB

)

Significant Pre/Post p<.05 Significant Pre/FU p<.05

Duration phonation = NS

Results Results - AusTOMS- AusTOMS

0

0.5

1

1.5

2

2.5

3

3.5

4

Impairment Activity Participation Well-being

Pre

Post

FU

Imp

rove

men

t

Significant Pre/Post p<.05 Significant Pre/FU p<.05

Results Results – Participant Ques– Participant Ques

0

0.5

1

1.5

2

2.5

3

3.5

4

Slurring Voice How wellunderstood

Convopartic

InitiateConvo

Pre

Post

FU

Significant Pre/Post p<.05 Significant Pre/FU p<.05

Imp

rovem

en

t

Results – Results – Communication Partner QuesCommunication Partner Ques

0

1

2

3

4

5

6

Ability tounderstand

Freq of Rep ConvoInitiat

Convo withunfam

Ov Rating

Pre

Post

FU

Imp

rovem

en

t

Significant Pre/Post p<.05

DiscussionDiscussion Positive Positive shortshort & & long-termlong-term effects of effects of

intensive dysarthria treatmentintensive dysarthria treatment• Articulatory precisionArticulatory precision• Speech intelligibilitySpeech intelligibility• Loudness during readingLoudness during reading• Activity limitation Activity limitation (AusTOMS)(AusTOMS)• Slurring Slurring (Part. Ques)(Part. Ques)• How well understood How well understood (Part. Ques)(Part. Ques)• Initiate conversation Initiate conversation (Part. Ques)(Part. Ques)

Intensive treatment led to greater Intensive treatment led to greater acquisition & learning of motor speech acquisition & learning of motor speech behaviours behaviours

DiscussionDiscussion

Short-term effects only Short-term effects only for some for some parametersparameters

Maintenance remains important issueMaintenance remains important issue

Effects achieved in participants Effects achieved in participants several years post-impairmentseveral years post-impairment• 60% > than 1yr post-BI60% > than 1yr post-BI• Ongoing potential for rehabOngoing potential for rehab

Conclusion & Future DirectionsConclusion & Future DirectionsIntensive treatment has positive Intensive treatment has positive

impact on non-progressive dysarthriaimpact on non-progressive dysarthria

Treatment parametersTreatment parameters::• Frequency & durationFrequency & duration• Intensity within session – no. of repsIntensity within session – no. of reps• Saliency of tasks – relevance to PSaliency of tasks – relevance to P

Maintenance of effectsMaintenance of effects• Alt. treatment protocol / service deliveryAlt. treatment protocol / service delivery

Computer-based self-directed activities Computer-based self-directed activities TelerehabilitationTelerehabilitation