REVIEW SERIES: Chronic cough: Behaviour modification therapies for chronic cough

Chronic cough (CC) can be refractory to medical treatment and newer strategies are required for these patients. Behaviour modification therapies are a potential approach for management of cough that does not respond to medical management. Behaviour modification therapy for CC involves an individually tailored programme teaching individuals to increase control over cough symptoms and includes education, specific strategies to suppress the cough, vocal hygiene training and psychoeducational counselling. Several case series have described speech pathology treatment for CC and a recent randomized control trial has demonstrated a significant improvement in symptoms. Possible mechanisms for this improvement include reduced cough reflex sensitivity, increased voluntary control of the cough and reduced stimulation of cough receptors. Respiratory retraining used by physiotherapists may also have potential for use in CC. The validity of psychological therapeutic approaches to CC rests on concepts of CC as a disorder with a psychogenic component, and the ability of cognitive therapies to modify the cough pathway. This work outlines current literature into behavioural management of CC and suggests new directions for practice and research in adults with this condition. Chronic Respiratory Disease 2007; 4: 89—97

Using videotelephony to support paediatric oncology-related palliative care in the home: from abandoned RCT to acceptability study

Videotelephony (real-time audio-visual communication) has been used successfully in adult palliative home care. This paper describes two attempts to complete an RCT (both of which were abandoned following difficulties with family recruitment), designed to investigate the use of videotelephony with families receiving palliative care from a tertiary paediatric oncology service in Brisbane, Australia. To investigate whether providing videotelephone-based support was acceptable to these families, a 12-month non-randomised acceptability trial was completed. Seventeen palliative care families were offered access to a videotelephone support service in addition to the 24 hours 'on-call' service already offered. A 92% participation rate in this study provided some reassurance that the use of videotelephones themselves was not a factor in poor RCT participation rates. The next phase of research is to investigate the integration of videotelephone-based support from the time of diagnosis, through outpatient care and support, and for palliative care rather than for palliative care in isolation. Trial registration ACTRN 12606000311550.

Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy

BACKGROUND

Chronic cough that persists despite medical treatment may respond to speech pathology intervention, but the efficacy of such treatment has not been investigated in prospective randomised trials. The aim of this study was to determine the efficacy of a speech pathology intervention programme for chronic cough.

METHODS

A single blind, randomised, placebo controlled trial was conducted in 87 patients with chronic cough that persisted despite medical treatment. Patients were randomly allocated to receive either a specifically designed speech pathology intervention or a placebo intervention. Participants in both groups attended four intervention sessions with a qualified speech pathologist.

RESULTS

Participants in the treatment group had a significant reduction in cough (8.9 to 4.6, p<0.001), breathing (7.9 to 4.7, p<0.001), voice (7.3 to 4.6, p<0.001) upper airway (8.9 to 5.9, p<0.001) symptom scores and limitation (2.3 to 1.6, p<0.001) ratings following intervention. There was also a significant reduction in breathing (6.8 to 5.6, p = 0.047), cough (7.6 to 6.3, p = 0.014), and limitation (2.3 to 2.0, p = 0.038) scores in the placebo group, but the degree of improvement was significantly less than in the treatment group (p<0.01). Clinical judgement of outcome indicated successful ratings in 88% of participants in the treatment group compared with 14% in the placebo group (p<0.001).

CONCLUSION

Speech pathology is an effective management intervention for chronic cough which may be a viable alternative for patients who do not respond to medical treatment.

Defining a role for the subthalamic nucleus within operative theoretical models of subcortical participation in language

OBJECTIVE

To investigate the effects of bilateral, surgically induced functional inhibition of the subthalamic nucleus (STN) on general language, high level linguistic abilities, and semantic processing skills in a group of patients with Parkinson's disease.

METHODS

Comprehensive linguistic profiles were obtained up to one month before and three months after bilateral implantation of electrodes in the STN during active deep brain stimulation (DBS) in five subjects with Parkinson's disease (mean age, 63.2 years). Equivalent linguistic profiles were generated over a three month period for a non-surgical control cohort of 16 subjects with Parkinson's disease (NSPD) (mean age, 64.4 years). Education and disease duration were similar in the two groups. Initial assessment and three month follow up performance profiles were compared within subjects by paired t tests. Reliability change indices (RCI), representing clinically significant alterations in performance over time, were calculated for each of the assessment scores achieved by the five STN-DBS cases and the 16 NSPD controls, relative to performance variability within a group of 16 non-neurologically impaired adults (mean age, 61.9 years). Proportions of reliable change were then compared between the STN-DBS and NSPD groups.

RESULTS

Paired comparisons within the STN-DBS group showed prolonged postoperative semantic processing reaction times for a range of word types coded for meanings and meaning relatedness. Case by case analyses of reliable change across language assessments and groups revealed differences in proportions of change over time within the STN-DBS and NSPD groups in the domains of high level linguistics and semantic processing. Specifically, when compared with the NSPD group, the STN-DBS group showed a proportionally significant (p<0.05) reliable improvement in postoperative scores achieved on the word test-revised (TWT-R), as well as a reliable decline (p<0.01) in the accuracy of lexical decisions about words with many meanings and a high degree of relatedness between meanings.

CONCLUSIONS

Bilateral STN-DBS affects certain aspects of linguistic functioning, supporting a potential role for the STN in the mediation of language processes.

Physiological assessment of tongue function in dysarthria following traumatic brain injury

A tongue pressure transducer system was used to assess tongue strength, endurance, fine pressure control and rate of repetitive movement in a group of 20 individuals, aged 17 to 60 years, with dysarthria following severe traumatic brain injury (TBI). Comparison of the TBI group's results against data obtained from a group of 20 age and sex matched control subjects revealed reductions in tongue endurance and rate of repetitive movement. Tongue strength and fine pressure control, however, were found not to differ significantly from the control group. Pearson's product-moment correlations indicated there to be only weak correlations between the physiological nonspeech tongue parameters and the deviant perceptual articulatory features exhibited by the TBI group. Further analysis of the results on an individual subject basis revealed no clear relationships between the physiological and perceptual parameters suggesting that the TBI subjects may have been compensating in different ways for the physiological impairments.

Kinematic analysis of tongue movements in dysarthria following traumatic brain injury using electromagnetic articulography

Electromagnetic articulography (EMA), a technique that uses alternating magnetic fields to track the movement of miniature receiver coils affixed to the articulators, was used to assess the speed and accuracy of tongue movements exhibited by an individual with dysarthria following severe traumatic brain injury (TBI). Three receiver coils were attached to the TBI subject's tongue and the movements of these coils were recorded during five productions of three single syllable real words consisting of the lingual consonants /t, s, k/ in the word-initial position. A non-neurologically impaired adult male served as a control subject. A range of kinematic parameters was analysed from the consonant productions including the movement trajectories, velocity, acceleration, distance, and duration of tongue movements. Examination of the complex interactions between the kinematic parameters recorded for the TBI subject revealed a disturbance in the 'control' of tongue speed rather than a disturbance in speed per se, as it was found that the TBI subject exhibited difficulty in decelerating his tongue movements appropriately on the approach up to the palate during consonant production. The difficulty noted in deceleration resulted in inaccurate tongue movements that overshot the point of intent (in the case of /t/) and may have been instrumental in reducing the length of time that the tongue remained at the palate (in the case of /s/ and /k/) in comparison to the control subject. The disturbances identified in the kinematic parameters recorded provided objective insights into the nature of the articulatory disturbances responsible for the deviant speech feature, consonant imprecision, perceived in the TBI subject's speech. The study stresses the importance of examining a range of kinematic parameters and the interactions between these parameters in attempting to determine the nature of articulatory disturbances exhibited by individuals with dysarthria following TBI.

Real-time continuous visual biofeedback in the treatment of speech breathing disorders following childhood traumatic brain injury: report of one case

The efficacy of traditional and physiological biofeedback methods for modifying abnormal speech breathing patterns was investigated in a child with persistent dysarthria following severe traumatic brain injury (TBI). An A-B-A-B single-subject experimental research design was utilized to provide the subject with two exclusive periods of therapy for speech breathing, based on traditional therapy techniques and physiological biofeedback methods, respectively. Traditional therapy techniques included establishing optimal posture for speech breathing, explanation of the movement of the respiratory muscles, and a hierarchy of non-speech and speech tasks focusing on establishing an appropriate level of sub-glottal air pressure, and improving the subject's control of inhalation and exhalation. The biofeedback phase of therapy utilized variable inductance plethysmography (or Respitrace) to provide real-time, continuous visual biofeedback of ribcage circumference during breathing. As in traditional therapy, a hierarchy of non-speech and speech tasks were devised to improve the subject's control of his respiratory pattern. Throughout the project, the subject's respiratory support for speech was assessed both instrumentally and perceptually. Instrumental assessment included kinematic and spirometric measures, and perceptual assessment included the Frenchay Dysarthria Assessment, Assessment of Intelligibility of Dysarthric Speech, and analysis of a speech sample. The results of the study demonstrated that real-time continuous visual biofeedback techniques for modifying speech breathing patterns were not only effective, but superior to the traditional therapy techniques for modifying abnormal speech breathing patterns in a child with persistent dysarthria following severe TBI. These results show that physiological biofeedback techniques are potentially useful clinical tools for the remediation of speech breathing impairment in the paediatric dysarthric population.

Motor speech impairment following traumatic brain injury in childhood: a physiological and perceptual analysis of one case

The physiological and perceptual characteristics of persistent dysarthria exhibited by a 14 year-old boy, following a severe traumatic brain injury (TBI) were investigated. The subject's speech and motor speech mechanism were comprehensively evaluated both perceptually and physiologically, and the findings were compared with those of a non-neurologically impaired control subject, matched for age and sex, and a number of control groups from previous studies. Overall, the assessments indicated that the major motor speech deficits demonstrated by the subject included severely reduced tongue function, and moderately impaired lip, laryngeal, and velopharyngeal function. Respiratory function was found to be mildly impaired. Perceptual assessments indicated that the subject's speech was severely impaired in relation to rate, pitch variation, and consonant precision, with a moderate impairment in overall intelligibility. The effects of a severe TBI on the functioning of the child's motor speech mechanism were discussed. The clinical implications for the assessment and treatment of dysarthria in childhood following severe TBI were highlighted.

The effects of age and gender on laryngeal aerodynamics

A computerized airflow/air pressure analysis system, the Aerophone II Model 6800 (Kay Elemetrics Corp.), was used to assess the effects of age and gender on laryngeal aerodynamics. A sample of 56 male and 53 female normal speaking subjects was divided into six age groups (20-30; 31-40; 41-50; 51-60; 61-70 and 71-80 years). The laryngeal aerodynamic parameters measured included phonatory (mean) flow rate, estimated subglottal pressure, laryngeal airway resistance, phonatory sound pressure level, phonatory power, and phonatory efficiency. Most comfortable phonation, vocal efficiency, and running speech tasks were used to collect the aerodynamic data. Comfortable pitch and loudness levels were used for each of these tasks. Age and gender effects were found for a number of the phonatory (mean) flow rate and phonatory sound pressure level values. Results failed, however, to indicate age or gender effects for the estimated subglottal pressure, laryngeal airway resistance, phonatory power and phonatory efficiency parameters. High intersubject variability was found for the phonatory flow rate, laryngeal airway resistance, phonatory power and phonatory efficiency values. Estimated subglottal pressure values, however, appeared to vary the least among subjects. The results are discussed with respect to factors that might influence laryngeal aerodynamics, such as underlying laryngeal anatomical and physiological age-related changes and gender-related differences. The clinical implications of the findings for the assessment and treatment of individuals with voice disorders using the Aerophone II are also discussed.

Lip and tongue function in multiple sclerosis: A physiological analysis

A physiological analysis of the articulatory function of 16 adults with multiple sclerosis (MS) was performed using lip and tongue transduction systems. Sixteen nonneurologically impaired adults, matched for age, gender, and education, served as controls. The MS speakers demonstrated patterns of tongue function that were significantly different from those of the control speakers. Specifically, the MS speakers were found to have significantly reduced tongue strength, endurance, and rate of repetitive movements. In addition, preclinical signs of lingual dysfunction were evident in nondysarthric MS speakers on endurance and rate tasks when compared to control subjects. These physiological findings could account for the perceptual findings of impaired articulation and reduced intelligibility. No lip dysfunction was found on either the physiological or perceptual assessments.

Effect of oral levodopa treatment on articulatory function in Parkinson's disease: preliminary results

To quantify lip function in 16 patients with Parkinson's disease, a computerized semiconductor lip pressure transducer system was used prior to subjects being administered oral levodopa and at approximately 0.5 hr, 1.5 hr, and 3.0 hr postmedication. Two blood samples were taken from each subject at varying times during the levodopa dosage interval, and the exact time and dosage of levodopa were noted. Lip function measurements were expressed as percentage changes from baseline and were plotted for each subject against time and levodopa concentrations to determine the effects of levodopa therapy on articulatory function. The results supported the effectiveness of levodopa therapy in improving lip function. In particular, lip pressures recorded during both speech and nonspeech tasks tended to improve after levodopa administration, the lip measures improving somewhat in parallel with the rise and fall of blood plasma levodopa concentrations. Evidence of a hysteresis effect was noted.

Motor speech impairment in a case of childhood basilar artery stroke: treatment directions derived from physiological and perceptual assessment

The perceptual and physiological characteristics of the speech of a nine year old child who suffered a basilar artery stroke at the age of five years were investigated using a battery of perceptual and physiological instrumental measures. Perceptual tests administered included the Frenchay Dysarthria Assessment, a perceptual analysis of a speech sample based on a reading of the Grandfather Passage and a phonetic intelligibility test. Instrumental procedures included: spirometric and kinematic analysis of speech breathing; electroglottographic evaluation of laryngeal function, nasometric assessment of velopharyngeal function and evaluation of lip and tongue function using pressure transducers. Physiological assessment indicated the most severe deficits to be in the respiratory and velopharyngeal sub-systems with significant deficits in the articulatory sub-system, all of which resulted in severely reduced intelligibility. These results were compared and contrasted with the subject's performance on the perceptual assessment battery. In a number of instances the physiological assessments were able to identify deficits in the functioning of components of the speech production apparatus either not evidenced by the perceptual assessments or where the findings of the various perceptual assessments were contradictory. The resulting comprehensive profile of the child's dysarthria demonstrated the value of using an assessment battery comprised of both physiological and perceptual methods. In particular, the need to include instrumental analysis of the functioning of the various subcomponents of the speech production apparatus in the assessment battery when defining the treatment priorities for children with acquired dysarthria is highlighted. Treatment priorities determined on the basis of both the perceptual and physiological assessments for the present CVA case are discussed.

Physiological and perceptual features of dysarthria in Moebius syndrome: directions for treatment

The functioning of the major subsystems of the speech production apparatus of a 12 year old female with Moebius syndrome was investigated using a battery of perceptual and physiological instrumental measures. Perceptual tests administered included: The Assessment of Intelligibility of Dysarthric Speech; the Frenchay Dysarthria Assessment; and a perceptual analysis of a speech sample based on a reading of the Grandfather Passage. Instrumental procedures included: spirometric and kinematic analysis of speech breathing; electroglottographic and aerodynamic evaluation of laryngeal function; nasometric assessment of velopharyngeal function; and evaluation of lip and tongue function using a variety of strain-gauge and pressure transducers. Consistent with the pathophysiological basis of Moebius syndrome, the major dysfunctions of the speech production mechanism were found at the level of the articulatory valve. Somewhat unexpectedly, however, impaired function was also identified at the level of the velopharyngeal and laryngeal valves by both the perceptual and instrumental assessments and at the level of the respiratory system by the physiological analysis alone. The results are discussed with reference to the neurological basis and clinical features of Moebius syndrome. The implications of the findings for the treatment of congenital dysarthria associated with Moebius syndrome are also discussed. The advantage of instrumental analysis over perceptual assessments in defining treatment goals for children with congenital dysarthria is highlighted.

Variability in upper motor neurone-type dysarthria: an examination of five cases with dysarthria following cerebrovascular accident

The degree of diversity in the nature and extent of the physiological deficits which occur in subjects with dysarthria with similar neurological damage is demonstrated through the individual assessment profiles of five subjects with dysarthria following upper motor neurone (UMN) damage. The perceptual profiles of each subject were compiled using perceptual ratings of deviant speech parameters, intelligibility ratings from the Assessment of Intelligibility of Dysarthric Speech (ASSIDS), and perceptual judgements of subsystem function determined from the Frenchay Dysarthria Assessment (FDA). For each individual, the perceptual profile of their speech impairments was compared and contrasted with the objective results of spirometric and kinematic assessments of respiratory function aerodynamic and electroglottographic evaluations of laryngeal function, pressure and strain gauge evaluations of articulatory function, and nasal accelerometric assessments of nasality. The outcomes of the individual perceptual and physiological profiles are discussed with respect to the presence of differential subsystem impairments both within each subject and between subjects with similar underlying pathophysiological deficits. The importance of interpreting the instrumental findings with respect to the interdependency of each of the motor speech subsystems, the limitations of perceptual assessments, and the advantages of utilising both perceptual and physiological analyses in the process of identifying treatment goals is discussed.

Variability in the perceptual and physiological features of dysarthria following severe closed head injury: an examination of five cases

The perceptual and physiological features of the dysarthric speech of five severely closed-head-injured (CHI) subjects were examined in a case-by-case analysis. The five male CHI subjects included in the study were selected to reflect the range of severity and types of dysarthria evident in the CHI population. The perceptual profiles of each subject consisted of the findings of a perceptual speech analysis, the Frenchay Dysarthria Assessment (FDA) and the Assessment of the Intelligibility of Dysarthric Speakers (ASSIDS). The subjects' physiological profiles included the results of instrumental assessments of the respiratory, laryngeal, velopharyngeal and articulatory subsystems of the speech-production mechanism. The case studies highlighted the variability among the individual subjects with respect to the location, physiological nature, and severity of impairment in their speech-production mechanisms. In addition, the interdependence of the various speech subsystems in determining speech outcome, the presence of differential subsystem impairment in dysarthria following CHI, and the varied therapeutic requirements of the individual subjects were identified. Clinically, the case studies highlighted the importance of developing individual treatment programmes based on comprehensive perceptual and physiological evaluations of the speech mechanism in each CHI subject with dysarthric speech.

A physiological analysis of articulatory dysfunction in dysarthric speakers following severe closed-head injury

A physiological analysis of the lip and tongue function of a group of 18 severely closed-head injured (CHI) subjects was performed using lip and tongue force transduction systems. Lip and tongue strength, endurance and rate of repetitive movements were assessed on four non-speech tasks: maximum strength, sustained maximum strength, repetition of 10 maximum strength compressions, and maximum repetition rate. The values recorded were compared to those achieved by a group of 18 non-neurologically impaired subjects, matched for age and sex, who served as the controls. The results of the study indicated that the CHI subjects demonstrated a significant impairment of lip and tongue function based on strength, endurance and rate of repetitive movements, compared to the controls. While lip function was found to be significantly impaired on several measures of strength and endurance, tongue function was noted to be more severely compromised. The CHI subjects were found to exhibit a significantly reduced rate of repetitive movements of the lips and tongue. The results are discussed in relation to the effects of CHI on neuromuscular function and differential subsystem impairment in dysarthria. The clinical implications of these findings are also discussed in relation to the treatment of articulatory disturbances following severe CHI.

Laryngeal dysfunction in dysarthric speakers following severe closed-head injury

The laryngeal function of 19 severely closed head-injured subjects with a perceptible dysarthria was assessed using electrolaryngography and a computerized airflow/air pressure analysis system (Aerophone II). Variables measured included parameters of the Lx waveform (Fo, duty cycle and closing time) as well as aerodynamic parameters such as subglottal pressure, glottal resistance, average phonatory sound pressure level, phonatory flow rate and ad/abduction rate. Values were compared to those recorded from a non-neurologically impaired control group matched for age and sex, and correlated with the findings of a perceptual speech analysis. The findings are discussed in relation to the effects of a severe closed-head injury on laryngeal function. The clinical implications of the findings for the assessment and treatment of vocal dysfunction in head-injured subjects are also discussed.

Perceptual speech characteristics of dysarthric speakers following severe closed head injury

The perceptual speech characteristics of a group of 20 severely closed head-injured (CHI) subjects were compared with those of a normal non-neurologically impaired control group matched for age and sex. The CHI subjects were found to be significantly less intelligible than the controls, and exhibited deficits in the prosodic, resonatory, articulatory, respiratory and phonatory aspects of speech production. The most frequently occurring deviant speech dimensions related to disturbances of prosody, resonance, articulation and respiration, with those deviant speech dimensions pertaining to phonation being less apparent in the speech of the CHI subjects. The findings are discussed in relation to the heterogeneity of the CHI population and the effects of CHI on neuromuscular function. The study highlights the need for accurate, instrumental physiological evaluation of the motor subsystems involved in speech production.

Abnormal patterns of speech breathing in dysarthric speakers following severe closed head injury

The respiratory abilities of a group of 20 subjects with a speech disorder resulting from severe closed head injury (CHI) were assessed using both spirometric and kinematic techniques and compared with those of a group of 20 non-neurologically impaired controls matched for age and gender. Results of the spirometric assessment showed that the CHI subjects as a group had lower vital capacities and lower forced expiratory volumes 1 second than the controls. Kinematic assessment also showed that the CHI subjects had problems co-ordinating the action of the rib-cage and abdomen when carrying out speech tasks such as vowel prolongations, syllable repetitions and reading. Results are discussed in terms of the effects of CHI on neuromuscular function.