Towards a core outcome set for dysarthria after stroke: What should we measure?

OBJECTIVE

To identify and agree on what outcome domains should be measured in research and clinical practice when working with stroke survivors who have dysarthria.

DESIGN

Delphi process, two rounds of an online survey followed by two online consensus meetings.

SETTING

UK and Australia.

PARTICIPANTS

Stroke survivors with experience of dysarthria, speech and language therapists/pathologists working in stroke and communication researchers.

METHODS

Initial list of outcome domains generated from existing literature and with our patient and public involvement group to develop the survey. Participants completed two rounds of this survey to rate importance. Outcomes were identified as 'in', 'unclear' or 'out' from the second survey. All participants were invited to two consensus meetings to discuss these results followed by voting to identify critically important outcome domains for a future Core Outcome Set. All outcomes were voted on in the consensus meetings and included if 70% of meeting participants voted 'yes' for critically important.

RESULTS

In total, 148 surveys were fully completed, and 28 participants attended the consensus meetings. A core outcome set for dysarthria after stroke should include four outcome domains: (a) intelligibility of speech, (b) ability to participate in conversations, (c) living well with dysarthria, (d) skills and knowledge of communication partners (where relevant).

CONCLUSIONS

We describe the consensus of 'what' speech outcomes after stroke are valued by all stakeholders including those with lived experience. We share these findings to encourage the measurement of these domains in clinical practice and research and for future research to identify 'how' best to measure these outcomes.

Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

Background

Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients’ quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies.

Methods

Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes.

Results

4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures.

Conclusions

Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Neuroprosthesis for Decoding Speech in a Paralyzed Person with Anarthria

BACKGROUND

Technology to restore the ability to communicate in paralyzed persons who cannot speak has the potential to improve autonomy and quality of life. An approach that decodes words and sentences directly from the cerebral cortical activity of such patients may represent an advancement over existing methods for assisted communication.

METHODS

We implanted a subdural, high-density, multielectrode array over the area of the sensorimotor cortex that controls speech in a person with anarthria (the loss of the ability to articulate speech) and spastic quadriparesis caused by a brain-stem stroke. Over the course of 48 sessions, we recorded 22 hours of cortical activity while the participant attempted to say individual words from a vocabulary set of 50 words. We used deep-learning algorithms to create computational models for the detection and classification of words from patterns in the recorded cortical activity. We applied these computational models, as well as a natural-language model that yielded next-word probabilities given the preceding words in a sequence, to decode full sentences as the participant attempted to say them.

RESULTS

We decoded sentences from the participant's cortical activity in real time at a median rate of 15.2 words per minute, with a median word error rate of 25.6%. In post hoc analyses, we detected 98% of the attempts by the participant to produce individual words, and we classified words with 47.1% accuracy using cortical signals that were stable throughout the 81-week study period.

CONCLUSIONS

In a person with anarthria and spastic quadriparesis caused by a brain-stem stroke, words and sentences were decoded directly from cortical activity during attempted speech with the use of deep-learning models and a natural-language model. (Funded by Facebook and others; ClinicalTrials.gov number, NCT03698149.).

Speech rehabilitation in dysarthria after stroke: a systematic review of the studies

INTRODUCTION

Speech difficulties such as dysarthria or aphasia are frequently seen, in addition to motor impairments, in subjects after stroke.

EVIDENCE ACQUISITION

Literature searches with the keywords: "stroke" AND "dysarthria" AND "speech therapy" OR "language therapy" were conducted in PubMed, EMBASE, Cochrane Library and Web of Science to perform the systematic review about the several strategies used to treat dysarthria in subjects after stroke. The search was performed independently by two authors (CR and VM) from December 15th 2019 to January 15th 2020, using the PICOS criteria: participants were aging adults (>18 years old) affected by stroke; intervention was based on rehabilitation speech therapy; comparator was any comparator (all logopedic and speech rehabilitation tools); outcomes included clinical assessments, diagnostic scales and acoustic analysis of voice; and study design was RCTs, case series and case report, observational studies. The research identified a total of 94 articles for the first search and 56 for the second search. Sixty selected articles were analyzed by the reviewers. Twenty-five publications met the inclusion criteria and were included in the systematic review. Thirty-three articles were excluded for the following reasons: 12 involved individuals with aphasia or other speech problems different from dysarthria, 10 examined the clinical features of dysarthria, 3 treated on the impact of dysarthria on social participation following stroke, 8 did not include cases after stroke.

EVIDENCE SYNTHESIS

A systematic review was performed to identify the main used speech rehabilitation treatments for dysarthria after stroke. We defined the several techniques to better guide the physician to delineate a speech rehabilitation protocol adopting the better strategies described in the current literature.

CONCLUSIONS

This systematic review tried to provide to the reader a complete overview of the literature of all possible different speech treatments for dysarthria after stroke. A correct protocol could permit to improve the communication and the quality of life of these subjects.

"Ode to confidence": Poetry groups for dysarthria in multiple sclerosis

Purpose: Approximately 40-50% of people with multiple sclerosis (MS) have dysarthria impacting confidence in communication. This study explored how people with MS experienced a novel therapeutic approach combining dysarthria therapy with poetry in a group format.Method: Participants were recruited through MSWA (formerly known as the Multiple Sclerosis Society of Western Australia), a leading service provider for people living with all neurological conditions in Western Australia. They attended eight weekly sessions led by a speech pathologist and a professional poet. The study was co-designed and qualitative, using observational field notes recorded during sessions and semi-structured in-depth interviews with participants after programme completion. The results from an informal, unstandardised rating scale of communication confidence, along with standardised voice and speech measures, were used to facilitate discussion about confidence in the interviews.Result: Nine participants with MS completed the group programme. Analysis of the qualitative data revealed participants' positive views regarding the pairing of speech pathology and poetry. Thematic analysis identified four core themes: living with MS and its "series of griefs"; belonging to a group - "meeting with a purpose"; the power of poetry; and poetry as a medium for speech pathology.Conclusion: Poetry in combination with dysarthria therapy represents a novel, interprofessional approach for improving communication confidence in individuals with MS.

A new training method for velopharyngeal dysfunction: Self-inhalation for hypernasality

OBJECTIVE

There are various methods to treat velopharyngeal dysfunction including　surgery and rehabilitation therapy. Even if a rehabilitation program is effective, the evaluation of its efficacy remains subjective. In this paper, we propose a new method of rehabilitation training for velopharyngeal dysfunction focusing on the objective peak inspiratory flow (PIF) rate.

METHODS

Four patients, who were diagnosed with velopharyngeal dysfunction without cleft palate at ENT clinic of the National Hospital Organization, Tokyo Medical Center, participated in this study. All patients underwent our original rehabilitation program for velopharyngeal dysfunction, a method using the In-Check Dial, Turbohaler model. As a self-training rehabilitation program, we asked them to inhale forcefully 10 times daily at home using the In-Check Dial to increase the value of PIF rate for 3 months. We measured the patients' PIF rates with the In-Check Dial at the ENT clinic at the initial visit and after the 3-month training.

RESULTS

The PIF rates of the four patients without nasal clips were higher than the rates with nasal clips at the initial visit. After the training, PIF rate without a nasal clip of all patients increased than the rate at the initial visit, which represented significant difference (P < 0.05). Also, after 3 months, PIF rate without a nasal clip was higher or equal than the rates with a nasal clip at the initial visit except one case. Naso-pharyngo-laryngeal fiberscopy did not detect salivary pooling around larynx and mirror fogging test did not show nasal escape in the three of four patients after 3 months of training. All reported improvement in dysphagia and dysarthria.

CONCLUSION

This new method can be used not only to evaluate velopharyngeal function but also as an effective self-training treatment.

Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study

Purpose: This study aimed to determine the feasibility of delivering a group speech maintenance programme (eLoud and Proud) to people with Parkinson's disease via telerehabilitation. Method: Treatment was delivered to eight participants who had previously received LSVT LOUD®. The programme focussed on using a "loud" voice within conversational and cognitively loaded tasks, and was delivered in two 90-minute sessions per week for four weeks. Data pertaining to sound pressure level (SPL) (for sustained phonation, reading and monologue tasks), maximum frequency range, maximum phonation duration and impact of dysarthria on quality of life were collected at three time points: (1) pre-treatment (PRE); (2) immediately post-treatment (POST); and (3) three months post-treatment (FU). Participant satisfaction with telerehabilitation was also obtained at POST. Result: Significant improvements were identified for all SPL measures PRE-POST and maintained for sustained phonation and reading tasks at FU. No significant differences were identified for the remaining outcome measures. Participants were overall highly satisfied with telerehabilitation and considered it to be an acceptable alternative to traditional service delivery. Conclusion: This study demonstrated the feasibility of delivering group speech maintenance therapy via telerehabilitation, and the potential for eLoud and Proud to improve and maintain vocal loudness in people with PD.

The emergence of clause construction in children who use speech generating devices

This study aimed to detect patterns in clause construction structural changes produced by four participants aged 9;5-13;7 (years;months) with motor speech disorders who used speech-generating devices. Sequences of adult-child interactions, drawn from the data of a larger study focused on enhancing vocabulary and grammar skills, were examined. This current study comprises a secondary analysis of a corpus of 29 conversations totalling 808.36 min, analysing clause structures by type, linguistic complexity, and intensity of adult prompts (number of turns). Results show that, over time, the participants' clause structure complexity increased through addition of phrase-internal elements such as inflections, articles, and prepositions. Use of specific grammatical elements followed the developmental stages observed in children with typical development. For all participants, the personal pronoun I (first-person singular) emerged before she, he (third-person singular), and we or they (plural). Participants with the highest number of adult-child co-constructed clauses also had the highest number of well-formed clauses. The intensity of adult prompts increased as clause structures became more complex and as participants needed more support. Implications for practice and theory are discussed.

Internet delivery of intensive speech and language therapy for children with cerebral palsy: a pilot randomised controlled trial

OBJECTIVES

To test the feasibility of recruitment, retention, outcome measures and internet delivery of dysarthria therapy for young people with cerebral palsy in a randomised controlled trial.

DESIGN

Mixed methods. Single blind pilot randomised controlled trial, with control offered Skype therapy at end of study. Qualitative study of the acceptability of therapy delivery via Skype.

SETTING

Nine speech and language therapy departments in northern England recruited participants to the study. Skype therapy was provided in a university setting.

PARTICIPANTS

Twenty-two children (14 M, 8 F) with dysarthria and cerebral palsy (mean age 8.8 years (SD 3.2)) agreed to take part. Participants were randomised to dysarthria therapy via Skype (n=11) or treatment as usual (n=11).

INTERVENTIONS

Children received either usual speech therapy from their local therapist for 6 weeks or dysarthria therapy via Skype from a research therapist. Usual therapy sessions varied in frequency, duration and content. Skype dysarthria therapy focused on breath control and phonation to produce clear speech at a steady rate, and comprised three 40 min sessions per week for 6 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility and acceptability of the trial design, intervention and outcome measures.

RESULTS

Departments recruited two to three participants. All participants agreed to random allocation. None withdrew from the study. Recordings of children's speech were made at all time points and rated by listeners. Families allocated to Skype dysarthria therapy judged internet delivery of the therapy to be acceptable. All families reported that the study design was acceptable. Treatment integrity checks suggested that the phrases practised in one therapy exercise should be reduced in length.

CONCLUSIONS

A delayed treatment design, in which dysarthria therapy is offered at the end of the study to families allocated to treatment as usual, is acceptable. A randomised controlled trial of internet delivered dysarthria therapy is feasible.

A Weighted Speaker-Specific Confusion Transducer-Based Augmentative and Alternative Speech Communication Aid for Dysarthric Speakers

An augmentative and alternative speech communication (AASC) aid comprises a speech recognition system and a speech synthesis system. The main challenge in developing such an aid for dysarthric speakers lies in handling errors in the text derived from the recognition system. These errors (substitution, deletion, and insertion) may be due to inability of a dysarthric speaker to utter certain phones (articulatory error) or due to inaccuracy of the models trained (modeling error). Most existing AASC approaches only focus on the articulatory errors and the ones that do address both errors, and do not differentiate between them. However, this paper performs a three-level cascaded analysis to identify and distinguish between these errors, as differentiating these errors will aid in appropriately handling them. Furthermore, analyses in the paper are independent of the syntax of utterances. Based on these analyses, weighted phone confusion transducers are formulated and used to correct erroneous text from the recognition system. The corrected text is finally synthesized by a text-to-speech synthesis system. The proposed AASC is observed to significantly reduce a word error rate of severe dysarthric speakers from 100% to 41.52%, moderate from 61.85% to 18.08%, and mild from 12.23% to 8.55%.

Effects of Familiarization on Intelligibility of Dysarthric Speech in Older Adults With and Without Hearing Loss

PURPOSE

Familiarization tasks offer a promising platform for listener-targeted remediation of intelligibility disorders associated with dysarthria. To date, the body of work demonstrating improved understanding of dysarthric speech following a familiarization experience has been carried out on younger adults. The primary purpose of the present study was to examine the intelligibility effects of familiarization in older adults.

METHOD

Nineteen older adults, with and without hearing loss, completed a familiarization protocol consisting of three phases: pretest, familiarization, and posttest. The older adults' initial intelligibility and intelligibility improvement scores were compared with previously reported data collected from 50 younger adults (Borrie, Lansford, & Barrett, 2017a).

RESULTS

Relative to younger adults, initial intelligibility scores were significantly lower for older adults, although additional analysis revealed that the difference was limited to older adults with hearing loss. Key, however, is that irrespective of hearing status, the older and younger adults achieved comparable intelligibility improvement following familiarization (gain of roughly 20 percentage points).

CONCLUSION

This study extends previous findings of improved intelligibility of dysarthria following familiarization to a group of listeners who are critical to consider in listener-targeted remediation, namely, aging caregivers and/or spouses of individuals with dysarthria.

Effects of Lexical and Somatosensory Feedback on Long-Term Improvements in Intelligibility of Dysarthric Speech

PURPOSE

Intelligibility improvements immediately following perceptual training with dysarthric speech using lexical feedback are comparable to those observed when training uses somatosensory feedback (Borrie & Schäfer, 2015). In this study, we investigated if these lexical and somatosensory guided improvements in listener intelligibility of dysarthric speech remain comparable and stable over the course of 1 month.

METHOD

Following an intelligibility pretest, 60 participants were trained with dysarthric speech stimuli under one of three conditions: lexical feedback, somatosensory feedback, or no training (control). Participants then completed a series of intelligibility posttests, which took place immediately (immediate posttest), 1 week (1-week posttest) following training, and 1 month (1-month posttest) following training.

RESULTS

As per our previous study, intelligibility improvements at immediate posttest were equivalent between lexical and somatosensory feedback conditions. Condition differences, however, emerged over time. Improvements guided by lexical feedback deteriorated over the month whereas those guided by somatosensory feedback remained robust.

CONCLUSIONS

Somatosensory feedback, internally generated by vocal imitation, may be required to affect long-term perceptual gain in processing dysarthric speech. Findings are discussed in relation to underlying learning mechanisms and offer insight into how externally and internally generated feedback may differentially affect perceptual learning of disordered speech.

Game-Based Augmented Visual Feedback for Enlarging Speech Movements in Parkinson's Disease

PURPOSE

The purpose of this pilot study was to demonstrate the effect of augmented visual feedback on acquisition and short-term retention of a relatively simple instruction to increase movement amplitude during speaking tasks in patients with dysarthria due to Parkinson's disease (PD).

METHOD

Nine patients diagnosed with PD, hypokinetic dysarthria, and impaired speech intelligibility participated in a training program aimed at increasing the size of their articulatory (tongue) movements during sentences. Two sessions were conducted: a baseline and training session, followed by a retention session 48 hr later. At baseline, sentences were produced at normal, loud, and clear speaking conditions. Game-based visual feedback regarding the size of the articulatory working space (AWS) was presented during training.

RESULTS

Eight of nine participants benefited from training, increasing their sentence AWS to a greater degree following feedback as compared with the baseline loud and clear conditions. The majority of participants were able to demonstrate the learned skill at the retention session.

CONCLUSIONS

This study demonstrated the feasibility of augmented visual feedback via articulatory kinematics for training movement enlargement in patients with hypokinesia due to PD.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5116840.

Regularized Speaker Adaptation of KL-HMM for Dysarthric Speech Recognition

This paper addresses the problem of recognizing the speech uttered by patients with dysarthria, which is a motor speech disorder impeding the physical production of speech. Patients with dysarthria have articulatory limitation, and therefore, they often have trouble in pronouncing certain sounds, resulting in undesirable phonetic variation. Modern automatic speech recognition systems designed for regular speakers are ineffective for dysarthric sufferers due to the phonetic variation. To capture the phonetic variation, Kullback-Leibler divergence-based hidden Markov model (KL-HMM) is adopted, where the emission probability of state is parameterized by a categorical distribution using phoneme posterior probabilities obtained from a deep neural network-based acoustic model. To further reflect speaker-specific phonetic variation patterns, a speaker adaptation method based on a combination of L2 regularization and confusion-reducing regularization, which can enhance discriminability between categorical distributions of the KL-HMM states while preserving speaker-specific information is proposed. Evaluation of the proposed speaker adaptation method on a database of several hundred words for 30 speakers consisting of 12 mildly dysarthric, 8 moderately dysarthric, and 10 non-dysarthric control speakers showed that the proposed approach significantly outperformed the conventional deep neural network-based speaker adapted system on dysarthric as well as non-dysarthric speech.

Effect of Dysarthria Type, Speaking Condition, and Listener Age on Speech Intelligibility

PURPOSE

The aim of this study was to examine the effect of loud and slow speech cues on younger and older listeners' comprehension of dysarthric speech, specifically, (a) whether one strategy, as opposed to the other, promoted greater intelligibility gains for different speaker groups; (b) whether older and younger listeners' understandings were differentially affected by these strategies; and (c) which acoustic changes best predicted intelligibility gain in individual speakers.

METHOD

Twenty younger and 40 older listeners completed a perceptual task. Six individuals with dysarthria produced phrases across habitual, loud, and slow conditions. The primary dependent variable was proportion of words correct; follow-up acoustic analyses linked perceptual outcomes to changes in acoustic speech features.

RESULTS

Regardless of dysarthria type, the loud condition produced significant intelligibility gains. Overall, older listeners' comprehension was reduced relative to younger listeners. Follow-up analysis revealed considerable interspeaker differences in intelligibility outcomes across conditions. Although the most successful speaking mode varied, intelligibility gains were strongly associated with the degree of change participants made to their vowel formants.

CONCLUSIONS

Perceptual outcomes vary across speaking modes, even when speakers with dysarthria are grouped according to similar perceptual profiles. Further investigation of interspeaker differences is needed to inform individually tailored intervention approaches.

Progressive dysarthria and augmentative and alternative communication in conversation: establishing the reliability of the Dysarthria-in-Interaction Profile

BACKGROUND

The Dysarthria-in-Interaction Profile's potential contribution to the clinical assessment of dysarthria-in-conversation has been outlined in the literature, but its consistency of use across different users has yet to be reported.

AIMS

To establish the level of consistency across raters on four different interaction categories. That is, how reliable clinicians are when rating a series of videos. A secondary aim was to investigate the relationship between raters' estimates of dysarthric speech intelligibility and their rating of each dyad's overall interaction.

METHODS & PROCEDURES

Ten UK speech and language therapists rated independently a series of 40 video samples featuring people with progressive dysarthria in conversation with family members. An equal number of video samples was selected from a collection of recordings featuring four different types of interactional relationship.

OUTCOMES & RESULTS

The results show that practising speech and language therapists can rate consistently, and with a high degree of agreement, a series of everyday conversation videos featuring dyads with progressive dysarthria and presenting at different interaction levels. The results also indicate that speech intelligibility does not predict the level of impairment in the interaction in a systematic way suggesting that conversation contains elements that are not directly related to speech intelligibility.

CONCLUSIONS & IMPLICATIONS

Further work is required to establish the clinical functionality of this tool, but the results presented here support the development of this conversation profiling system, particularly for people experiencing significant intelligibility problems but remaining highly interactive/communicative.

Intrathecal baclofen therapy improves functional intelligibility of speech in cerebral palsy

Objective: To assess the effect of intrathecal baclofen on spastic dysarthia in cerebral palsy.

Design: Single case study.

Methods: Functional outcome measures, including the Assessment of Intelligibility of Dysarthric Speech, were performed before and after a trial of intrathecal baclofen in an adult patient with spastic dysarthria due to cerebral palsy. The patient proceeded to intrathecal baclofen pump implantation and was reassessed after six months of continuous intrathecal baclofen therapy.

Results: Improvement in function including speech intelligibility was seen following the intrathecal baclofen trial. The improvement was sustained at six months post pump implantation.

Conclusions: Intrathecal baclofen improved functional intelligibility of speech in a carefully selected subject. The Assessment of Intelligibility of Dysarthric Speech was found to be a useful quantitative tool to assess the effect of intrathecal baclofen on spastic dysarthria.

[Neurologopedic treatment in dysarthria cases. Diagnosis and therapy]

INTRODUCTION

The article is devoted to the problems of diagnosis and neurologopedic therapy of hospitalized persons suffering from dysarthria.

MATERIAL AND METHODS

The research presented in the article was conducted on a group of 49 patients (people aged 18-95, including 26 men and 23 women) who were diagnosed and underwent logopedic therapy in the department of Neurological Rehabilitation in the Independent Public Teaching Hospital no 4 in lublin in 2014. In the neurologopedic diagnostics the following methods were used: the analysis of the medical record (information cards containing medical diagnosis, mriri, ct head scanning, eeg ), clinical interview and clinical observations, The Robertson Dysarthria Profile, Dysarthria Scale by mirecka and gustaw, scale of deficiency depth, w. Łucki's package of tests to examine cognitive processes in the patients with brain damages, tests to examine aphasia by j. Szumska, tests to examine aphasia by m. Szepietowska and h. Misztal, author's questionnaire to examine dysarthria and aphasia, experimental tests to examine pragnosia and dysphagia.

RESULTS

In the group of 49 patients dysarthria was diagnosed among 22 persons as the only speech disorder and in the group of 27 patients other speech disorders (aphasia, pragnosia, interpersonal communication disorders) co-occurred with dysarthria. Dysphagia was diagnosed among 21 patients.

CONCLUSIONS

Neurologopedic diagnostics and therapy of the dysarthric patients should constitute an integral part of the complex improving treatment (in addition to medical, rehabilitation and psychological procedures).

The Lee Silverman Voice Treatment (LSVT®) speech therapy in progressive supranuclear palsy

BACKGROUND

The Lee Silverman Voice Treatment (LSVT®) was specifically created and tested to comply with the needs of individuals with Parkinson's disease (PD) and other neurological problems. This is a high effort intensive treatment that aims at increasing vocal intensity through the increase of subglottal air pressure, i.e. respiratory effort, for a better cordal adduction and vibration, following the motto "think loud".

AIM

The main goal of this study is to inspect the efficacy of LSVT® treatment in progressive supranuclear palsy (PSP) patients.

DESIGN

Longitudinal study.

SETTING

Rehabilitative inpatient unit.

POPULATION

Sixteen patients with PSP and 23 patients with idiopathic PD as control were enrolled in the study.

METHODS

All patients underwent a training consisting in16 sessions of speech therapy following the LSVT® protocol. Initially the two groups of patients had similar voice problems, i.e. low volume and bad articulation of speech.

RESULTS

A statistically significant improvement was found among the data collected before and after treatment in the PSP and Parkinson groups. Increase in maximum phonation duration and volume of voice in reading were similar in the two groups. Improvement in quality of voice and articulation were more significant in the PD group as compared to the PSP group.

CONCLUSION

These results, along with previous findings, add further support to the generalized therapeutic impact of intensive voice treatment on respiratory and laryngeal functions in individuals with PSP.

CLINICAL REHABILITATION IMPACT

The positive results, the absence of dropout and collateral effect following this clinical treatments with LSVT technique encouraged to use this technique in PSP patients.

Multiple ANN Recognizers for Adaptive Recognition of the Speech of Dysarthric Patients in AAL Systems

People suffering from neuromuscular disorders are one of the main target groups of speech-controlled Ambient Assisted Living systems. However, the speech of these patients is often distorted because of the dysarthric symptoms of the disease. The dysarthria is known to become worse as the disease progresses. We propose a framework for an adaptive speech recognition system that may be able to follow the slow deterioration of speech quality without risking the accuracy of the system from incorrect data.

Non-speech oro-motor exercises in post-stroke dysarthria intervention: a randomized feasibility trial

BACKGROUND

There has been little robust evaluation of the outcome of speech and language therapy (SLT) intervention for post-stroke dysarthria. Non-speech oro-motor exercises (NSOMExs) are a common component of dysarthria intervention. A feasibility study was designed and executed, with participants randomized into two groups, in one of which NSOMExs were a component of the intervention programme.

AIMS

To examine (1) operational feasibility of the programme; (2) participants' views of the programme; and (3) speech intelligibility, communication effectiveness and tongue and lip movement at four points (A1 and A2 before, and A3 and A4 after intervention).

METHODS & PROCEDURES

Thirty-nine participants were randomized into Group A (n=20) and Group B (n=19). Groups were equivalent at enrolment in demographic variables and A1 measures. Intervention was behavioural, delivered in eight home-based SLT sessions, and included practise of individually appropriate words, sentences and conversation, and for Group B also NSOMExs. Between-session practice was recorded in a diary. Data on speech intelligibility, effectiveness of communication in conversation, self-rated situational communication effectiveness, and tongue and lip movement were collected at 8-week intervals, twice before and twice after intervention. Anonymous evaluation (AE) questionnaires were completed.

OUTCOME & RESULTS

The recruited number was 20% below the target of 50. Thirty-six participants completed the intervention and 32 were followed through to A4. The programme was delivered to protocol and fidelity was verified. Thirty-four AEs were returned. These showed high satisfaction with the programme and its outcome. According to diary records from 32 participants, 59% carried out at least the recommended practice amount. Outcome measure performance across the four assessment points did not indicate any group effect. For the whole sample both externally rated and self-rated communication effectiveness measures showed statistically significant gains across the intervention period (A2/A3), which were maintained for 2 months after intervention (A2/A4). Non-intervention period changes (A1/A2 and A3/A4) were not present. There were no intervention-related gains in tongue and lip movement or speech intelligibility, but the latter is likely to be attributable to a ceiling effect on scores.

CONCLUSIONS & IMPLICATIONS

The results indicate positive outcomes associated with a short period of behavioural SLT intervention in the post-stroke dysarthria population. The inclusion of NSOMExs, delivered in accordance with standard clinical practice, did not appear to influence outcomes. The results must be viewed in relation to the nature of feasibility study and provide a foundation for suitably powered trials.

[The curative effect of task-oriented approach in combination with articulation approach on spastic dysarthria]

OBJECTIVE

To assess the effectiveness of task-oriented approach in treating patients with spastic dysarthria.

METHODS

A randomized control trial was undertaken in 44 inpatients diagnosed with spastic dysarthria at the Department of Rehabilitation Medicine in West China Hospital. All of the participants received basic medical therapy, occupational therapy, physical therapy, and an articulation approach for speech therapy by a professional speech therapist over a one month period. A task-oriented approach was added to the speech therapy regime of the test group of participants by another professional speech therapist over the same period of time. The outcomes of speech therapy were measured by the Frenchay dysarthria assessment (FDA).

RESULTS

Significant improvements were found in the test group in relation to 15 FDA items, such as dribbling, lips spread, and palate maintenance (P<0. 05). The performance of the participants in the test group on the rest of FDA items also demonstrated an improvement trend compared with that of the controls (P>0. 05) except for the three items in relation to cough, lips at rest and jaw in speech.

CONCLUSION

Task-oriented approach for speech therapy is effective in treating patients with spastic dysarthria. A task-oriented approach in combination with an articulation approach can produce better patient outcomes compared with the articulation approach alone. Further studies are warranted.

The Living with Dysarthria group for post-stroke dysarthria: the participant voice

BACKGROUND

The Living with Dysarthria group programme, devised for people with post-stroke dysarthia and family members, was piloted twice. Feedback from those who experience an intervention contributes to the evaluation of speech and language therapy programmes, giving the participant view of the intervention's value and guiding further developments.

RESEARCH QUESTION

What feedback do participants in the Living with Dysarthria programme provide, informing on its perceived usefulness and guiding its future development?

METHODS & PROCEDURES

Nine people with chronic dysarthria following stroke and four family members who completed the Living with Dysarthria programme all contributed to Focus Group (FG) discussion, transcribed and thematically analysed, and completed an Anonymous Questionnaire Evaluation (AQE), comprising closed statements and open questions. An anonymous descriptive adjective selection task (ADAST) was also used.

OUTCOMES & RESULTS

The varied forms of feedback provided complementary information. Thematic analysis of FG data and AQE open question responses were configured around programme benefits, programme structure and content, and programme practicalities. Benefits associated with participation included learning and insight, being supported by peers and professionals, and improved speech and confidence. These are consistent with the main programme elements of education, support and speech practice. All activities were seen as relevant and positively received. Flexibility, recognition of and catering to individual needs were valued characteristics. The community location was approved by all. Most participants thought the format of eight weekly sessions of 2 h was appropriate. Responses to AQE closed statements provided almost unanimous confirmation of the very positive feedback conveyed in FG discussions. The main response to suggested improvements in AQEs was that the number of sessions should be increased. Feedback indicated that for a few individuals there was negative reaction to some facts about stroke, home practice tasks were difficult to complete, the person with dysarthria/family member pair may not be the optimum combination for paired practice activities and pre-programme information should be extended. The ADAST showed that the programme was enjoyable, interesting, stimulating and useful.

CONCLUSIONS & IMPLICATIONS

Participant feedback indicates that group therapy, with family member participation, is a valid form of management for chronic post-stroke dysarthria. Education, peer and professional support, and speech practice are confirmed as relevant programme components. Consistent majority opinions were communicated in different situations and via varied mediums. Some individuals expressed views relevant to their own needs, and these responses also inform future implementation of the Living with Dysarthria programme.

Acoustics of clear speech: effect of instruction

PURPOSE

This study investigated how different instructions for eliciting clear speech affected selected acoustic measures of speech.

METHOD

Twelve speakers were audio-recorded reading 18 different sentences from the Assessment of Intelligibility of Dysarthric Speech ( Yorkston & Beukelman, 1984). Sentences were produced in habitual, clear, hearing impaired, and overenunciate conditions. A variety of acoustic measures were obtained.

RESULTS

Relative to habitual, the clear, hearing impaired, and overenunciate conditions were associated with different magnitudes of acoustic change for measures of vowel production, speech timing, and vocal intensity. The overenunciate condition tended to yield the greatest magnitude of change in vowel spectral measures and speech timing, followed by the hearing impaired and clear conditions. SPL tended to be the greatest in the hearing impaired condition for half of the speakers studied.

CONCLUSIONS

Different instructions for eliciting clear speech yielded acoustic adjustments of varying magnitude. Results have implications for direct comparison of studies using different instructions for eliciting clear speech. Results also have implications for optimizing clear speech training programs.

Innovative technology for the assisted delivery of intensive voice treatment (LSVT®LOUD) for Parkinson disease

PURPOSE

To assess the feasibility and effectiveness of a newly developed assistive technology system, Lee Silverman Voice Treatment Companion (LSVT(®) Companion™, hereafter referred to as "Companion"), to support the delivery of LSVT(®)LOUD, an efficacious speech intervention for individuals with Parkinson disease (PD).

METHOD

Sixteen individuals with PD were randomized to an immediate (n = 8) or a delayed (n = 8) treatment group. They participated in 9 LSVT LOUD sessions and 7 Companion sessions, independently administered at home. Acoustic, listener perception, and voice and speech rating data were obtained immediately before (pre), immediately after (post), and at 6 months post treatment (follow-up). System usability ratings were collected immediately post treatment. Changes in vocal sound pressure level were compared to data from a historical treatment group of individuals with PD treated with standard, in-person LSVT LOUD.

RESULTS

All 16 participants were able to independently use the Companion. These individuals had therapeutic gains in sound pressure level, pre to post and pre to follow-up, similar to those of the historical treatment group.

CONCLUSIONS

This study supports the use of the Companion as an aid in treatment of hypokinetic dysarthria in individuals with PD. Advantages and disadvantages of the Companion, as well as limitations of the present study and directions for future studies, are discussed.

The living with dysarthria group: implementation and feasibility of a group intervention for people with dysarthria following stroke and family members

BACKGROUND

The broad life implications of acquired dysarthria are recognized, but they have received little attention in stroke management. Reports of group therapy, which may be a suitable approach to intervention, are not available for stroke-related dysarthria.

AIMS

To examine the operational feasibility of and response to a new eight-session weekly group intervention programme, Living with Dysarthria, designed for people with chronic dysarthria following stroke and their main communication partners.

METHODS & PROCEDURES

The target participation was for programme completion by two groups of eight people with dysarthria (PWD) and available family members (FMs) or carers. An active recruitment strategy was undertaken from the speech and language therapy case records for the previous 6 years in two hospitals with combined annual stroke admissions of over 500 people. Twelve PWD and seven FMs were recruited (group 1: seven PWD and four FMs; group 2: five PWD and three FMs). Speech intelligibility, communication effectiveness, general well-being, quality of communication life, and knowledge of stroke and dysarthria were assessed pre- and post-programme. Each PWD and FM also set an individual goal and rated their achievement of this on a 0-10 scale.

OUTCOMES & RESULTS

Recruitment to the programme was lower than anticipated and below target. The 12 PWD were recruited from 62 initial contacts, which was the total number who according to available information met the criteria. The programme was viable: it ran to plan, with only minor content alterations, in community accommodation, and with good participant engagement. Group median score changes were in a positive direction for all measures and effect sizes ranged from 0.17 (quality of communication life) to 0.46 (intelligibility). Significant post-programme changes were present for intelligibility and knowledge of stroke and dysarthria (p= 0.05). Participants' ratings of goal achievements ranged from 6 (some change) to 10 (a lot of change).

CONCLUSIONS & IMPLICATIONS

The recruitment experience revealed a take-up rate of around 20% from PWD following stroke, informing future planning. The participant engagement and performance results from the piloting of the programme indicate that the Living with Dysarthria programme is viable and has potential for effecting positive change. Further testing is justified.

Lingual kinematics during rapid syllable repetition in Parkinson's disease

BACKGROUND

Rapid syllable repetition tasks are commonly used in the assessment of motor speech disorders. However, little is known about the articulatory kinematics during rapid syllable repetition in individuals with Parkinson's disease (PD).

AIMS

To investigate and compare lingual kinematics during rapid syllable repetition in dysarthric speakers with PD (DPD), non-dysarthric speakers with PD (NDPD) and a group of healthy controls.

METHODS & PROCEDURES

Electromagnetic articulography was used to record tongue-tip and tongue-back movement in five DPD and five NDPD participants during rapid repetition of /ta/and /ka/syllables, and matched with six healthy controls.

OUTCOMES & RESULTS

Results revealed significant between-group differences for most of the kinematic parameters measured but comparable rapid syllable repetition rates. Post-hoc analyses indicated that the DPD participants, when compared with the NDPD participants, had similar range but prolonged duration of lingual movement. The DPD and NDPD participants had primarily increased range and prolonged duration of lingual movement accompanied by increased speed parameters, when compared with healthy controls.

CONCLUSIONS & IMPLICATIONS

The findings of the present study contradict theories that suggest that the clinical features of hypokinetic dysarthria, including articulatory imprecision, are the outcome of restrictions in the range of movement of the muscles of the articulators. The observed prolonged duration of lingual movement in PD may plausibly be due to the observed increased range of lingual movement rather than slowness of lingual movement.

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial

OBJECTIVE

To assess the effectiveness of enhanced communication therapy in the first four months after stroke compared with an attention control (unstructured social contact).

DESIGN

Externally randomised, pragmatic, parallel, superiority trial with blinded outcome assessment.

SETTING

Twelve UK hospital and community stroke services.

PARTICIPANTS

170 adults (mean age 70 years) randomised within two weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers.

INTERVENTIONS

Enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants' needs for up to four months, with continuity from hospital to community. Comparison was with similarly resourced social contact (without communication therapy) from employed visitors.

OUTCOME MEASURES

Primary outcome was blinded, functional communicative ability at six months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (unblinded, six months): participants' perceptions on the Communication Outcomes After Stroke scale (COAST); carers' perceptions of participants from part of the Carer COAST; carers' wellbeing on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events.

RESULTS

Therapist and visitor contact both had good uptake from service users. An average 22 contacts (intervention or control) over 13 weeks were accepted by users. Impairment focused therapy was the approach most often used by the speech and language therapists. Visitors most often provided general conversation. In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure. Both groups improved on the TOM activity subscale. The estimated six months group difference was not statistically significant, with 0.25 (95% CI -0.19 to 0.69) points in favour of therapy. Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference. Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care. There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95% CI 0.16 to 1.1)).

CONCLUSIONS

Communication therapy had no added benefit beyond that from everyday communication in the first four months after stroke. Future research should evaluate reorganised services that support functional communication practice early in the stroke pathway. This project was funded by the NIHR Health Technology Assessment programme (project No 02/11/04) and is published in full in Health Technology Assessment 2012;16(26):1-160.

TRIAL REGISTRATION

ISRCTN78617680.

Assessing the treatment effects in apraxia of speech: introduction and evaluation of the Modified Diadochokinesis Test

BACKGROUND

The number of reliable and valid instruments to measure the effects of therapy in apraxia of speech (AoS) is limited.

AIMS

To evaluate the newly developed Modified Diadochokinesis Test (MDT), which is a task to assess the effects of rate and rhythm therapies for AoS in a multiple baseline across behaviours design.

METHODS

The consistency, accuracy and fluency of speech of 24 adults with AoS and 12 unaffected speakers matched for age, gender and educational level were assessed using the MDT. The reliability and validity of the instrument were considered and outcomes compared with those obtained with existing tests.

RESULTS

The results revealed that MDT had a strong internal consistency. Scores were influenced by syllable structure complexity, while distinctive features of articulation had no measurable effect. The test-retest and intra- and inter-rater reliabilities were shown to be adequate, and the discriminant validity was good. For convergent validity different outcomes were found: apart from one correlation, the scores on tests assessing functional communication and AoS correlated significantly with the MDT outcome measures. The spontaneous speech phonology measure of the Aachen Aphasia Test (AAT) correlated significantly with the MDT outcome measures, but no correlations were found for the repetition subtest and the spontaneous speech articulation/prosody measure of the AAT.

CONCLUSIONS & IMPLICATIONS

The study shows that the MDT has adequate psychometric properties, implying that it can be used to measure changes in speech motor control during treatment for apraxia of speech. The results demonstrate the validity and utility of the instrument as a supplement to speech tasks in assessing speech improvement aimed at the level of planning and programming of speech.

The Levels of Speech Usage rating scale: comparison of client self-ratings with speech pathologist ratings

BACKGROUND

The term 'speech usage' refers to what people want or need to do with their speech to fulfil the communication demands in their life roles. Speech-language pathologists (SLPs) need to know about clients' speech usage to plan appropriate interventions to meet their life participation goals. The Levels of Speech Usage is a categorical scale intended for client self-report of speech usage, but SLPs may want the option to use it as a proxy-report tool. The relationship between self-report and clinician ratings should be examined before the instrument is used in a proxy format.

AIMS

The primary purpose of this study was to compare client self-ratings with SLP ratings on the Levels of Speech Usage scale. The secondary purpose was to determine if the SLP ratings differed depending on whether or not the SLPs knew about the clients' medical condition.

METHODS & PROCEDURES

Self-ratings of adults with communication disorders on the Levels of Speech Usage scale were available from prior research. Vignettes about these individuals were created from existing data. Two sets of vignettes were created. One set contained information about demographic information, living situation, occupational status and hobbies or social activities. The second set was identical to the first with the addition of information about the clients' medical conditions and communication disorders. Various communication disorders were represented including dysarthria, voice disorders, laryngectomy, and mild cognitive and language disorders. Sixty SLPs were randomly divided into two groups with each group rating one set of vignettes. The task was completed online. While this does not replicate typical in-person clinical interactions, it was a feasible method for this study. For data analysis, the client self-ratings were considered fixed points and the percentage of SLP ratings in agreement with the self-ratings was calculated.

OUTCOMES & RESULTS

The percentage of SLP ratings in exact agreement with client self-ratings was 44.9%. Agreement was lowest for the less-demanding speech usage categories and highest for the most demanding usage category. There was no significant difference between the two groups of SLPs based on knowledge of medical condition.

CONCLUSIONS & IMPLICATIONS

SLPs often need to document the speech usage levels of clients. This study suggests the potential for SLPs to misjudge how clients see their own speech demands. Further research is needed to determine if similar results would be found in actual clinical interactions. Until then, SLPs should seek the input of their clients when using this instrument.

Acoustic characteristics of ataxic speech in Japanese patients with spinocerebellar degeneration (SCD)

BACKGROUND

In English- and German-speaking countries, ataxic speech is often described as showing scanning based on acoustic impressions. Although the term 'scanning' is generally considered to represent abnormal speech features including prosodic excess or insufficiency, any precise acoustic analysis of ataxic speech has not been performed in Japanese-speaking patients. This raises the question of what is the most dominant acoustic characteristic of ataxic speech in Japanese subjects, particularly related to the perceptual impression of 'scanning'.

AIMS

The study was designed to investigate the nature of speech characteristics of Japanese ataxic subjects, particularly 'scanning', by means of acoustic analysis.

METHODS & PROCEDURES

The study comprised 20 Japanese cases with spinocerebellar degeneration diagnosed to have a perceptual impression of scanning by neurologists (ataxic group) and 20 age-matched normal healthy subjects (control group). Recordings of speech samples of Japanese test sentences were obtained from each subject. The recorded and digitized acoustic samples were analysed using 'Acoustic Core-8' (Arcadia Inc.).

OUTCOMES & RESULTS

Sentence duration was significantly longer in the ataxic group as compared with the control group, indicating that the speaking rate was slower in the ataxic subjects. Segment duration remained consistent in both vowels and consonants in the control group as compared with the ataxic group. In particular, the duration of vowel segments, i.e. the nucleus of Japanese mora, was significantly invariable in the control group regardless of differences between subjects as well as in segments compared with the ataxic group. In addition, the duration of phonemically long Japanese vowels was significantly shorter in the ataxic group.

CONCLUSIONS & IMPLICATIONS

The results indicate that the perceptual impression of 'scanning' in Japanese ataxic cases derives mainly from the breakdown of isochrony in terms of difficulty in keeping the length of vowel segments of Japanese invariable during speech production. In addition, the tendency toward irregular shortening of the length of phonemically long Japanese vowels is thought to reinforce the impression of 'scanning' in ataxic speech in Japanese cases.

Acquired dysarthria in conversation: methods of resolving understandability problems

BACKGROUND

People with acquired progressive dysarthria typically experience increased problems with intelligibility in everyday conversation as their disease progresses. Such problems are likely to impact on both the person with dysarthria and those with whom they interact. If this is the case then we may ask questions not just about the nature of these problems but how it is that such problems are dealt with by participants when they occur.

AIMS

To investigate ways through which problems resulting from dysarthria in everyday conversation are resolved by participants. Further, to examine some of the features of repair resolution, particularly where understanding of self-repair attempts themselves prove difficult.

METHODS & PROCEDURES

Video data of natural conversation from two dyads were selected for this paper. One dyad features a 58 year-old man with multiple sclerosis and moderate intelligibility problems, the other a 79 year-old woman with motor neurone disease with mild to moderate intelligibility problems. Both elected to be recorded in conversation with their spouses. The dyads were video-recorded at home with no researcher present. Using the methods of Conversation Analysis (CA) a collection of sequences was identified and transcribed. The sequences were analysed with reference to how the participants resolve problems in the understanding of dysarthric speech.

OUTCOMES & RESULTS

It is shown how some problems resulting from dysarthria in conversation can be resolved relatively quickly, particularly where a specific element of a prior turn is highlighted by the recipient as problematic. In other instances, the recipient's understanding problem may be more global. These result in longer repair sequences in which problematic elements are addressed individually. Such a resolution method is ultimately successful but may also be characterised by additional understanding problems. These findings draw attention to an important distinction between intelligibility and understandability.

CONCLUSIONS & IMPLICATIONS

It is concluded that problems resulting from dysarthria in conversation can require extensive repair work involving both parties. This has implications for the assessment of dysarthria in everyday conversation and also the promotion of intervention strategies that encompass the activities of both participants when dealing with dysarthria in interaction. These findings may be usefully employed in informing both direct clinical work and through training those who work with this client group and their significant others.

Articulatory kinematics in the dysarthria associated with Friedreich's ataxia

Electromagnetic articulography (EMA) was used to investigate the tongue kinematics in the dysarthria associated with Friedreich's ataxia (FRDA). The subject group consisted of four individuals diagnosed with FRDA. Five nonneurologically impaired individuals, matched for age and gender, served as controls. Each participant was assessed using the AG-200 EMA system during six repetitions of the tongue tip sentence Tess told Dan to stay fit and the tongue back sentence Karl got a croaking frog. Results revealed reduced speed measures (i.e., maximum acceleration / deceleration / velocity), greater movement durations and increased articulatory distances for the approach phases of consonant productions. The approach phase, involving movement up to the palate, was more affected than the release phase. It is suggested that deviant lingual kinematics could be the outcome of disturbances to cerebellar function, or possibly in combination with disturbances to upper motor neuron systems.

Applying the WHO ICF framework to communication assessment and goal setting in Huntington's disease: a case discussion

PURPOSE

Huntington's Disease (HD) is a fatal, hereditary neurodegenerative disorder that is characterized by a triad of motor, cognitive and psychiatric symptoms that impact on both communicative effectiveness and the treatment techniques used to maximize communicative participation. The purpose of this article is to describe the application of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to communication assessment and goal setting for a 37 year old man with HD.

METHOD

Communication assessment consisted of qualitative interviews based on the ICF framework with the client and his mother, supplemented with quantitative communication assessments. Analysis and conceptualization of assessment information was completed with a modified version of the Rehabilitation Problem Solving Form (RPS-Form) (Steiner et al., 2002).

RESULTS

While impairments in body structures and functions were evident, analysis revealed that environmental factors such as family support were both key barriers and facilitators to communicative participation.

CONCLUSIONS

This case illustrates the potential of using the ICF to conceptualize communicative functioning and disability in HD and particularly highlights the importance of consideration of personal and environmental factors in revealing contributions to activity limitations and participation restrictions. Further investigation of applications of ICF for individuals with HD is suggested.

LEARNING OUTCOMES

As a result of this activity, readers will recognize the application of the WHO ICF to assessment and goal setting in a complex hereditary condition, Huntington Disease. As a result of this activity, readers will describe the use of the Rehabilitation Problem Solving Form (RPS-Form) for communication disorders. As a result of this activity, readers will identify relevant issues in comprehensive communication assessment of a fatal, degenerative neurological condition such as the advantages and challenges of clinical use of the ICF and its coding. As a result of this activity, readers will introduce life storybooks as a potential legacy item in degenerative diseases.

Treating disordered speech and voice in Parkinson's disease online: a randomized controlled non-inferiority trial

BACKGROUND

Telerehabilitation may be a feasible solution to the current problems faced by people with Parkinson's disease in accessing speech pathology services.

AIM

To investigate the validity and reliability of online delivery of the Lee Silverman Voice Treatment (LSVT®) for the speech and voice disorder associated with Parkinson's disease.

METHOD & PROCEDURES

Thirty-four participants with Parkinson's disease and mild-to-moderate hypokinetic dysarthria took part in the randomized controlled non-inferiority laboratory trial and received the LSVT® in either the online or the face-to-face environment. Online sessions were conducted via two personal computer-based videoconferencing systems with real-time and store-and-forward capabilities operating on a 128 kbit/s Internet connection. Participants were assessed pre- and post-treatment on acoustic measures of mean vocal sound pressure level, phonation time, maximum fundamental frequency range, and perceptual measures of voice, articulatory precision and speech intelligibility.

OUTCOMES & RESULTS

Non-inferiority of the online LSVT® modality was confirmed for the primary outcome measure of mean change in sound pressure level on a monologue task. Additionally, non-significant main effects for the LSVT® environment, dysarthria severity, and interaction effects were obtained for all outcomes measures. Significant improvements following the LSVT® were also noted on the majority of measures. The LSVT® was successfully delivered online, although some networking difficulties were encountered on a few occasions. High participant satisfaction was reported overall.

CONCLUSIONS & IMPLICATIONS

Online treatment for hypokinetic dysarthria associated with Parkinson's disease appears to be clinically valid and reliable. Suggestions for future research are outlined.

Non-speech oro-motor exercise use in acquired dysarthria management: regimes and rationales

BACKGROUND

Non-speech oro-motor exercises (NSOMExs) are described in speech and language therapy manuals and are thought to be much used in acquired dysarthria intervention, though there is no robust evidence of an influence on speech outcome. Opinions differ as to whether, and for which dysarthria presentations, NSOMExs are appropriate.

AIMS

The investigation sought to collect development-phase data, in accordance with the Medical Research Council (MRC) evaluation of complex interventions. The aims were to establish the extent of use of NSOMExs in acquired disorders, the exercise regimes in use for dysarthria, with which dysarthric populations, and the anticipated clinical outcomes. A further aim was to determine the influencing rationales where NSOMExs were or were not used in dysarthria intervention.

METHODS & PROCEDURES

Speech and language therapists throughout Scotland, Wales, and Northern Ireland, working with adult-acquired dysarthria, were identified by their service heads. They received postal questionnaires comprising 21 closed and two open questions, covering respondent biographics, use of NSOMExs, anticipated clinical outcomes, and practice influencing rationales.

OUTCOME & RESULTS

One hundred and ninety-one (56% response) completed questionnaires were returned. Eighty-one per cent of respondents used NSOMExs in dysarthria. There was no association with years of speech and language therapy experience. Those who used and those who did not use NSOMExs provided similar influencing rationales, including evidence from their own practice, and Higher Education Institute teaching. More experienced speech and language therapists were more likely than those more recently qualified to be guided by results from their own practice. Input from the attended Higher Education Institute was more influential for those less experienced than for those more experienced. Clinical outcome aims were not confined to speech, but also included improvements in movement, sensory awareness, appearance, emotional status, dysphagia and drooling. NSOMExs were used with many neurological disorders, especially stroke, all dysarthria classes, especially flaccid, and all severity levels. Tongue and lip exercises were more frequent than face, jaw and soft palate. The most common regimes were four to six repetitions of each exercise, during three practice periods daily, each of 6–10 min.

CONCLUSIONS & IMPLICATIONS

NSOMExs are a frequent component of dysarthria management in the UK-devolved government countries. This confirmation, along with the details of speech and language therapy practice, provides a foundation for clinical research which will compare outcomes for people with dysarthria, whose management includes and does not include NSOMExs. Speech and language therapy practice may be guided by evidence that speech outcome is or is not affected by NSOMExs.

The impact of stroke-related dysarthria on social participation and implications for rehabilitation

INTRODUCTION

Each year an estimated 30,000-45,000 UK individuals experience stroke-related dysarthria (impairment of movements required to produce speech). Many will experience persistent dysarthria long after discharge from stroke services. Although we have some insight into the impact of other communication impairments, we have very limited information on the impact of dysarthria on social participation.

PURPOSE

To explore the impact of dysarthria on social participation following stroke.

METHODS

We report data from in-depth semi-structured interviews with 24 individuals with stroke-related dysarthria.

RESULTS

Our findings suggest a complex association between the severity of an individual's dysarthria and the impact on their social participation. Participants' descriptions highlighted their experiences of social participation and isolation. We further suggest that, in some cases, the coping strategies adopted by the participants could be seen to further exacerbate this isolation. These results have important implications for the prioritisation, planning and delivery of therapeutic interventions for people with dysarthria.

CONCLUSIONS

The impact of stroke-related dysarthria transcends the physiological impairment to impact upon individuals' social participation, which is key to the process of rehabilitation. The development and evaluation of the effectiveness of an intervention that addresses these impacts is the next challenge for therapists and researchers working in this area.

The cognitive competence of speakers with acquired dysarthria: Judgements by doctors and speech and language therapists

BACKGROUND

Studies have shown that listeners make negative attributions towards people with communication impairments. This appears to be the case for health care professionals as well as non-professional listeners.

AIMS

This study extends this line of research to speakers with acquired dysarthria. These clients often complain that listeners treat them differently after the onset of their speech impairment. The study examines judgements of the cognitive status of speakers with acquired dysarthria made by health care professionals.

METHODS AND PROCEDURES

Doctors, speech and language therapists and speech and language therapy students viewed videos of speakers with acquired dysarthria and of controls matched for age and gender who had acquired neurological deficits that did not affect their speech. Listeners judged whether speakers could carry out a number of everyday tasks. All the tasks were known to be within the speakers' competence.

OUTCOMES AND RESULTS

Doctors were significantly less confident of the competence of speakers with dysarthria than of the controls. No difference was found for speech and language therapists or speech and language therapy students.

CONCLUSIONS

Although caution is required in generalizing these results to other speakers, the results lend some support to the complaints of clients with acquired dysarthria that their speech leads others, in this case doctors, to misjudge their cognitive competence.

Dysarthria impact profile: development of a scale to measure psychosocial effects

BACKGROUND

The psychosocial impact of acquired dysarthria on the speaker is well recognized. To date, speech-and-language therapists have no instrument available to measure this construct. This has implications for outcome measurement and for planning intervention. This paper describes the Dysarthria Impact Profile (DIP), an instrument that has the potential to meet this need in clinical practice.

AIMS

To describe the development of the DIP, which was devised as part of a larger study to measure psychosocial impact of acquired dysarthria from the speaker's perspective.

METHODS & PROCEDURES

The current psychometric properties of the DIP are examined. The scale was administered to 31 participants with acquired dysarthria. The internal consistency of the scale items and their intra-rater reliability were investigated. Concurrent validity was assessed for the portion of the scale (Section A) assessing impact of acquired dysarthria on self-perception, self-concept and self-esteem by comparing the results with changes in self-concept as determined by the Head Injury Semantic Differential Scale (HISD II).

OUTCOMES & RESULTS

The DIP shows good internal consistency and strong intra-rater reliability overall. There was a strong, statistically significant, correlation between results on Section A of the DIP and the results of the HISD II suggesting convergent validity for this portion of the scale. There are some limitations to the scale in its current format and these are highlighted.

CONCLUSIONS & IMPLICATIONS

The scale is now ready for further refinement and development. Once validated, it should act as a robust outcome measure for clinicians.

Speech recognition and dysarthria: a single subject study of two individuals with profound impairment of speech and motor control

This study investigated the use of the speech recognition system Dragon Dictate as an augmentative method of computer access for two individuals with cerebral palsy, including severe motor dysfunction and dysarthria. Single subject design was used and measures of computer access system effectiveness and speech production were used before, during and after intervention. The users' original switch access system was compared to a combination of their switch access system and speech recognition, by counting the number of correct entries. Adding speech recognition increased the number of correct entries by 40% for one of the participants. The other participant did not complete the intervention protocol. An independent judge rated speech production. No changes in speech were observed. Dragon Dictate is time-consuming to learn and demands a high level of motivation, but can be beneficial to a person who has profound dysarthria and great difficulties in accessing the computer.

A Cochrane review of treatment for dysarthria following acquired brain injury in children and adolescents

BACKGROUND

The expression ''acquired brain injury'' (ABI) incorporates a range of etiologies including cerebrovascular accident, brain tumour and traumatic brain injury. ABI is a common cause of disability in the pediatric population, and dysarthria is a common and often persistent sequelae associated with ABI in children.

OBJECTIVES

The aim of this study was to assess the efficacy of intervention delivered by Speech and Language Pathologists/Therapists targeting dysarthric speech in children resulting from acquired brain injury.

METHODS

Several electronic databases were searched up to January 2007. The review considered randomised controlled trials (RCTs) and quasi-randomised studies of children aged 3 to 16 years with acquired dysarthria grouped by aetiology (e.g., brain tumour, traumatic brain injury, cerebrovascular accident). Both authors independently assessed the titles and abstracts for relevance (100% inter-rater reliability) and the full text version of all potentially relevant articles was obtained. No studies met inclusion criteria.

RESULTS

Of 2091 titles and abstracts identified, full text versions of only three were obtained. The remaining 2 088 were excluded, largely on the basis of not including dysarthria, being diagnostic or descriptive papers, and for concerning adults rather than children. All obtained articles were excluded due to including populations without ABI, adults with dysarthria, or inappropriate design. Thus, no studies met inclusion criteria.

CONCLUSIONS

The review demonstrates a critical lack of studies, let alone RCTs, addressing treatment efficacy for dysarthria in children with ABI. Possible reasons to explain this lack of data include 1) a lack of understanding of the characteristics or natural history of dysarthria associated with this population; 2) the lack of a diagnostic classification system for children precluding the development of well targeted intervention programs; and 3) the heterogeneity of both the etiologies and resultant possible dysarthria types of pediatric ABI. Efforts should first be directed at modest well-controlled studies to identify likely efficacious treatments that may then be trialled in multicentre collaborations using quasi-randomised or RCT methodology.

Delivering the Lee Silverman Voice Treatment (LSVT) by web camera: a feasibility study

BACKGROUND

Speech disorders are a feature of Parkinson's disease, typically worsening as the disease progresses. The Lee Silverman Voice Treatment (LSVT) was developed to address these difficulties. It targets vocal loudness as a means of increasing vocal effort and improving coordination across the subsystems of speech.

AIMS

Currently LSVT is not widely available, and there are practical difficulties associated with the delivery of an intensive treatment in an environment of resource constraints in the National Health Service (NHS). Delivery of LSVT over the World-Wide Web may address some of these difficulties.

METHODS & PROCEDURES

A feasibility study is reported in which three individuals with speech disorders resulting from Parkinson's disease received LSVT over the Internet, using broadband connection and a web camera. Participants were seen face to face for every fourth session in order to build a personal relationship, measure vocal sound pressure level (SPL) during treatment, and to review and prepare homework tasks. All other sessions were delivered over the Internet.

OUTCOMES & RESULTS

Broadly similar treatment gains were found between individuals treated over the Internet and those treated face to face. Gains were maintained or improved at an assessment two months after the treatment.

CONCLUSIONS & IMPLICATIONS

This study demonstrates that delivery of LSVT over the Internet is feasible, and that a larger trial would be appropriate to establish cost and treatment effectiveness.

Patients' experiences of disruptions associated with post-stroke dysarthria

BACKGROUND

Post-stroke dysarthria rehabilitation should consider social participation for people with dysarthria, but before this approach can be adopted, an understanding of the psychosocial impact of dysarthria is required. Despite the prevalence of dysarthria as a result of stroke, there is a paucity of research into this communication disorder, particularly studies that address the experiences of individuals. The available literature focuses mainly on the perceptions of others or includes groups of mixed aetiologies.

AIMS

To investigate the beliefs and experiences of people with dysarthria as a result of stroke in relation to their speech disorder, and to explore the perceived physical, personal and psychosocial impacts of living with dysarthria.

METHODS & PROCEDURES

Participants for this qualitative study were recruited from twelve hospitals in Scotland that served both rural and urban populations and afforded opportunity for comparison. Semi-structured, in-depth interviews were carried out over a 12-month period with 24 individuals with varying severity of dysarthria following stroke. The interviews were orthographically transcribed and coded using the NVivo package, which also facilitated identification of patterns using the constant comparative method.

OUTCOMES & RESULTS

The results of the study indicate that the effects of dysarthria following stroke extend beyond the physiological characteristics of the impairment. In turn, the resulting communication difficulties lead to changes in self-identity, relationships, social and emotional disruptions, and feelings of stigmatization or perceived stigmatization. The impact of dysarthria was found to be disproportionate to the physiological severity, with participants continually striving to get their speech back to 'normal'.

CONCLUSIONS & IMPLICATIONS

The findings provide insight into the psychosocial impact of dysarthria following stroke. Speech and language therapy interventions need to go beyond the speech impairment to address and promote psychosocial well being, reduce the likelihood of feelings of stigmatization and changes in self-identity, irrespective of the severity of dysarthria.

[Foix-Chavany-Marie syndrome: anarthria and severe dyphagia after sequential bilateral infarction of the middle cerebral artery]

Bilateral lesions of the opercula frontoparietalia are uncommon and cause a symptom cluster including anarthria, severe dysphagia, inability to chew and sometimes facial paresis. At the same time there is an automatic-voluntary dissociation, meaning that the affected muscles are functional within the scope of involuntary movements. This syndrome is known as Foix-Chavany-Marie syndrome (FCMS), (bilateral) anterior operculum syndrome or facio-pharyngo-glosso-masticatory diplegia. We report the case of a patient who suffered from FCMS after having infarctions in the territory of the middle cerebral artery on each side 4 years apart.