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