Conducting a Comprehensive Voice Assessment in Parkinson’s Disease

1. Conducting a Comprehensive Voice Assessment in Parkinson’s Disease Voice Disorders – Dr. Brindle at Western Kentucky University Spring 2005

2. Voice 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)

3. Impaired 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

4. General Voice - Speech Characteristics Ordered 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)

5. 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

6. CASE 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

7. 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..

8. 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)

9. Instrumentation 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

10. 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 causebreathiness & reduced loudness.

11. Assessing Respiration - Endurance and Support 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

12. Overall Voice and Speech Assessment Voice/Speech Sample– reading of: Rainbow Passage/ Grandfather PassageListen 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

13. Identify 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)

14. 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 reverse CAUSE Limited pitch range and variability and/or tremor in PD caused by reduced tensing of folds or “bowing”

15. 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)

16. 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

17. 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.

18. ASSESSING 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

19. ASSESSING RESONANCE…Cont’d Cul-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

20. 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’)

21. Laryngeal 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

22. Bibliography 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.cfm www.postgradmed.com/issues/2003/12_03vartarian.htm www.parkinson.org/site/pp.asp?e=9dJFILPwB+b=71354 www.burke.org./medservices/outpatient/outpatient.ctm#15 www.aafp.org/afp/980600ap/rosen.btml. www.voiceandswallowing.com/newpadiagvis.htm.