Treatment Techniques for the Acquired Dysarthrias

1. Treatment Techniques for the Acquired Dysarthrias Oklahoma Speech-Language-Hearing Assoc. Sept. 30, 2010 Joe Duffy, Ph.D., BC-ANCDS Mayo Clinic Rochester, MN

2. 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�).

4. Respiration (cont.) Increasing respiratory support may be appropriate if patient can�t produce > 1 word per breath during speech

5. 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)

6. 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)

7. Respiration � Compensatory(more examples) Speak at onset of exhalation Increase vocal strain Shorten fricative duration Neck breathing Glossopharyngeal breathing Now, I am going to show again most of the slides we just looked at, but indicate those techniques or approaches for which there is some clinical evidence for effectiveness. I�ve been very generous in my definition of evidence. The techniques that remain in white are those for which there do not seem to be any data to support their effectiveness. They include techniques that have been listed or recommended in texts or papers as having face validity or the opinion of authors that they are effective or may be effective. Such anecdotal evidence and opinion may identify an approach worthy of investigation but cannot be considered scientific evidence. The techniques in yellow are those for which some data have been presented to document treatment efficacy or effectiveness. The vast majority of these derive from single case studies or relatively small case series, although there are a few important exceptions in which large case series, group studies, or group comparison data are available. For behavioral approaches to managing respiratory difficulties, you can see here that there are only a few tasks for which there are any data, & the data that are available are mostly derived from case reports. Now, I am going to show again most of the slides we just looked at, but indicate those techniques or approaches for which there is some clinical evidence for effectiveness. I�ve been very generous in my definition of evidence. The techniques that remain in white are those for which there do not seem to be any data to support their effectiveness. They include techniques that have been listed or recommended in texts or papers as having face validity or the opinion of authors that they are effective or may be effective. Such anecdotal evidence and opinion may identify an approach worthy of investigation but cannot be considered scientific evidence. The techniques in yellow are those for which some data have been presented to document treatment efficacy or effectiveness. The vast majority of these derive from single case studies or relatively small case series, although there are a few important exceptions in which large case series, group studies, or group comparison data are available. For behavioral approaches to managing respiratory difficulties, you can see here that there are only a few tasks for which there are any data, & the data that are available are mostly derived from case reports.

8. 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

9. Phonation � MedicalWeakness/Hypoadduction Medialization laryngoplasty/Type I thyroplasty for vocal fold paralysis/weakness - displaces weak fold medially reversible bilateral medialization possible + benefits reported

10. Phonation � MedicalWeakness/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

11. 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

12. Phonation - Prosthetic Portable amplification systems Vocal intensity controller/VU meter Artificial larynges Neck braces/cervical collars

13. 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)

14. Phonation - Behavioral (cont.) For hyperfunction Increase pitch or rotate head back Breathy onset High lung volumes

15. 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)

16. 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

17. 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)

18. VP Management:Other Behavioral Techniques CPAP Supine positioning Occlude nares Speaking strategy modifications Increase loudness Reduce pressure consonant duration Exaggerate jaw movement Behavioral management of velopharyngeal impairment is largely lacking in data, & Johns� conclusion in 1985 that �the general consensus seems to be that these exercises are disappointing & generally ineffective� still seems to hold. There is some recent but as yet limited evidence that the use of continuous positive airway pressure (CPAP) may be an effective technique for modifying velopharyngeal impairment in people with weakness at that level. Behavioral management of velopharyngeal impairment is largely lacking in data, & Johns� conclusion in 1985 that �the general consensus seems to be that these exercises are disappointing & generally ineffective� still seems to hold. There is some recent but as yet limited evidence that the use of continuous positive airway pressure (CPAP) may be an effective technique for modifying velopharyngeal impairment in people with weakness at that level.

19. 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

20. Articulation - Behavioral Strengthening exercises Stretching (slow, steady, continuous, prolonged) Biofeedback (e.g., EMA) Sensory tricks Conservation of strength Data regarding the effective behavioral intervention for articulation difficulties is strikingly missing. It is particularly noteworthy that data regarding the effectiveness of strengthening exercises seems largely unavailable, in spite of the fact that many clinicians recommend such exercises for many dysarthric patients. I don�t have any data, but I do have a sense from many experienced clinicians that strengthening exercises are controversial at best & probably not appropriate for most patients. But, to be fair, the issue hasn�t really been investigated & probably deserves investigation in patients for whom weakness clearly underlies speech impairment & disability. Data regarding the effective behavioral intervention for articulation difficulties is strikingly missing. It is particularly noteworthy that data regarding the effectiveness of strengthening exercises seems largely unavailable, in spite of the fact that many clinicians recommend such exercises for many dysarthric patients. I don�t have any data, but I do have a sense from many experienced clinicians that strengthening exercises are controversial at best & probably not appropriate for most patients. But, to be fair, the issue hasn�t really been investigated & probably deserves investigation in patients for whom weakness clearly underlies speech impairment & disability.

21. 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

22. Rate�Maybe the most powerful behaviorally modifiable variable for improving intelligibility� (Yorkston et al �92) Prosthetic/Behavioral

23. Rate�Maybe the most powerful behaviorally modifiable variable for improving intelligibility� (Yorkston et al �92) Prosthetic/Behavioral DAF - success documented for hypokinetic dysarthria

24. Rate�Maybe the most powerful behaviorally modifiable variable for improving intelligibility� (Yorkston et al �92) Prosthetic/Behavioral

25. Rate (cont.) Nonprosthetic/Behavioral hand/finger tapping visual feedback (computer, oscilloscope) rhythmic cueing modify pauses

26. 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

27. 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

28. 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

29. 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)

30. 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

31. 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) There are clearly efforts being made that indicate that it is possible to develop efficacy data that are convincing. In this regard, I think the Lee Silverman Voice Therapy treatment approach is a good example. I�m not singling out LSVT to endorse it as an effective treatment but rather to identify the characteristics of the research that has been associated with it as a model for investigating other treatment packages. The LSVT approach has a strong theoretical & clinical rational. It is well specified & replicable as a treatment program for a specific disorder, the dysarthria associated with Parkinson�s disease. The research into the efficacy of LSVT has been very programmatic. There are a number of data based refereed publications reporting the results of the treatment, including pre/post case studies, pre versus post treatment group outcome studies, & even a group comparison study in which it was compared to the effects of a treatment program focused only on respiration rather than respiration & voice. The data have documented both short- & long-term benefits, & the positive treatment effects have been documented in multiple ways - perceptually, aerodynamically, laryngostroboscopically, acoustically, & social validity. I am sure that Ramig & colleagues can testify to the painstaking nature of this kind of work, but it does represent a model to follow for acquiring convincing data about treatment packages that may be effective for fairly large numbers of appropriately selected patients. There are clearly efforts being made that indicate that it is possible to develop efficacy data that are convincing. In this regard, I think the Lee Silverman Voice Therapy treatment approach is a good example. I�m not singling out LSVT to endorse it as an effective treatment but rather to identify the characteristics of the research that has been associated with it as a model for investigating other treatment packages. The LSVT approach has a strong theoretical & clinical rational. It is well specified & replicable as a treatment program for a specific disorder, the dysarthria associated with Parkinson�s disease. The research into the efficacy of LSVT has been very programmatic. There are a number of data based refereed publications reporting the results of the treatment, including pre/post case studies, pre versus post treatment group outcome studies, & even a group comparison study in which it was compared to the effects of a treatment program focused only on respiration rather than respiration & voice. The data have documented both short- & long-term benefits, & the positive treatment effects have been documented in multiple ways - perceptually, aerodynamically, laryngostroboscopically, acoustically, & social validity. I am sure that Ramig & colleagues can testify to the painstaking nature of this kind of work, but it does represent a model to follow for acquiring convincing data about treatment packages that may be effective for fairly large numbers of appropriately selected patients.

32. 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)

33. 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

34. Hyperkinetic Dysarthria -Behavioral Management Adductor SD Raise pitch Increased breathiness �Performance mode� Abductor SD Hard glottal attack @ phonation onset Voice VL consonants

35. 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

36. 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!)

37. Communication-Oriented Treatment Speaker Strategies Alerting signals Convey how communication will take place Set the context Modify content & length Monitor comprehension Alphabet board supplementation

38. Communication-Oriented Treatment (cont.) Listener Strategies Modify physical environment Maximize listener hearing & visual acuity Learn �active� listening (practice listening?) - confirm comprehension

39. 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

40. 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). Let�s focus now on management of the dysarthrias. The bottom line first because it gives us good reason to be optimistic. In a review of treatment efficacy for dysarthria in 1996, Yorkston said (SEE SLIDE) But she also went on to say that (SEE SLIDE) So, we have reason to be pleased but also see work ahead.Let�s focus now on management of the dysarthrias. The bottom line first because it gives us good reason to be optimistic. In a review of treatment efficacy for dysarthria in 1996, Yorkston said (SEE SLIDE) But she also went on to say that (SEE SLIDE) So, we have reason to be pleased but also see work ahead.

41. 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. Let me briefly summarize this. Efficacy data for motor speech disorders come mostly from individual & aggregated case reports. In general, they support a conclusion that management is efficacious. But, we know little about the relative merits of different treatments or the specific disorders & other patient characteristics for which specific approaches are most effective. What we don�t know is more impressive than what we do know, but I also think it is important to recognize that this state of affairs may not be substantially different from what is understood about the effectiveness of medical interventions in general, especially those that focus on the modification of behavior. So we have company. But this is not reason for complacency. We need to recognize that studies of treatment are essential if quality & efficiency of management for people with motor speech disorders is to improve & if those efforts are to be supported by the health care system. Let me briefly summarize this. Efficacy data for motor speech disorders come mostly from individual & aggregated case reports. In general, they support a conclusion that management is efficacious. But, we know little about the relative merits of different treatments or the specific disorders & other patient characteristics for which specific approaches are most effective. What we don�t know is more impressive than what we do know, but I also think it is important to recognize that this state of affairs may not be substantially different from what is understood about the effectiveness of medical interventions in general, especially those that focus on the modification of behavior. So we have company. But this is not reason for complacency. We need to recognize that studies of treatment are essential if quality & efficiency of management for people with motor speech disorders is to improve & if those efforts are to be supported by the health care system.

42. 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. In addition to management, an even more daunting challenge arises when we try to demonstrate their efficacy, especially for behavioral management. This is almost certainly more difficult than for most medical interventions. There are a number of reasons for this, & a few are listed on this slide. First, change due to behavioral treatment takes time. Even when a treatment effect is apparent immediately, it still takes time to obtain maximum effects & for results to carry over & be maintained without regression. Behavioral treatment is very difficult to define in a way that it can be replicated by others. If it is not replicable, it cannot be studied by more than one clinician in more than one patient. Another challenge is that change, even when it is quite meaningful, may not be dramatic; when combined with the fact that change takes place over time, detecting it in valid & reliable ways can be difficult. The gold standards for management of motor speech disorders are perception, intelligibility, & communicative effectiveness, & those are things that can be very difficult to measure in valid & reliable ways. Finally, the effects of management interact with the natural course & variability of underlying disease, which can make it very difficult to sort out in conditions in which natural spontaneous recovery or degeneration are the expectation. In addition to management, an even more daunting challenge arises when we try to demonstrate their efficacy, especially for behavioral management. This is almost certainly more difficult than for most medical interventions. There are a number of reasons for this, & a few are listed on this slide. First, change due to behavioral treatment takes time. Even when a treatment effect is apparent immediately, it still takes time to obtain maximum effects & for results to carry over & be maintained without regression. Behavioral treatment is very difficult to define in a way that it can be replicated by others. If it is not replicable, it cannot be studied by more than one clinician in more than one patient. Another challenge is that change, even when it is quite meaningful, may not be dramatic; when combined with the fact that change takes place over time, detecting it in valid & reliable ways can be difficult. The gold standards for management of motor speech disorders are perception, intelligibility, & communicative effectiveness, & those are things that can be very difficult to measure in valid & reliable ways. Finally, the effects of management interact with the natural course & variability of underlying disease, which can make it very difficult to sort out in conditions in which natural spontaneous recovery or degeneration are the expectation.

43. 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. What we are engaged in right now is very extensive literature search to examine the quality of the evidence. As that is completed, the committee will then seek expert opinion about the data & the conclusions drawn about it. Then recommendations will be drafted, reviewed, & revised. We hope that these guidelines will summarize the data that are available, ranging from expert opinion to controlled case studies & group studies, & that they then can be revised over time as better evidence accumulates. What we are engaged in right now is very extensive literature search to examine the quality of the evidence. As that is completed, the committee will then seek expert opinion about the data & the conclusions drawn about it. Then recommendations will be drafted, reviewed, & revised. We hope that these guidelines will summarize the data that are available, ranging from expert opinion to controlled case studies & group studies, & that they then can be revised over time as better evidence accumulates.

44. 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. What we are engaged in right now is very extensive literature search to examine the quality of the evidence. As that is completed, the committee will then seek expert opinion about the data & the conclusions drawn about it. Then recommendations will be drafted, reviewed, & revised. We hope that these guidelines will summarize the data that are available, ranging from expert opinion to controlled case studies & group studies, & that they then can be revised over time as better evidence accumulates. What we are engaged in right now is very extensive literature search to examine the quality of the evidence. As that is completed, the committee will then seek expert opinion about the data & the conclusions drawn about it. Then recommendations will be drafted, reviewed, & revised. We hope that these guidelines will summarize the data that are available, ranging from expert opinion to controlled case studies & group studies, & that they then can be revised over time as better evidence accumulates.