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J Med Speech Lang Pathol. Author manuscript; available in PMC 2013 August 12.
Published in final edited form as: J Med Speech Lang Pathol. 2004 December ; 12(4): 213219.

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Speech-Breathing Treatment and LSVT for a Patient With Hypokinetic-Spastic Dysarthria After TBI
Nancy Pearl Solomon, Ph.D., Walter Reed Army Medical Center, Washington, DC Matthew J. Makashay, Ph.D., Walter Reed Army Medical Center, Washington, DC Leslie S. Kessler, M.A., and The Language Experience, Rockville, Maryland Katherine W. Sullivan, M.A. Walter Reed Army Medical Center, Washington, DC

Abstract
Previously, we reported improved speech breathing and intelligibility after behavioral treatment for a man with hypokinetic-spastic dysarthria following traumatic brain injury (TBI) (Solomon, McKee, & Garcia-Barry, 2001). Treatment included the Lee Silverman Voice Treatment (LSVT) program followed by 6 weeks of speech-breathing training, physical therapy, and LSVT-type tasks. In this article, we report a new patient with similar speech characteristics post-TBI. Breathing-for-Speech Treatment (BST), custom designed to improve nonspeech- and speechbreathing coordination, was followed by LSVT. After BST, speech breathing approached normal levels; after LSVT, speech breathing improved further and intelligibility improved markedly. Gains generally were maintained up to 4 months, but were limited by the spastic characteristics of his dysarthria and sporadic medical complications. The Lee Silverman Voice Treatment (LSVT) program was developed to improve speech in persons with hypokinetic dysarthria associated with Parkinson disease (PD) (Ramig, 1995). It has been tested in a relatively large number of people with PD, and available evidence supports its effectiveness for up to 2 years (Ramig et al., 2001). Less often, LSVT has been used with patients who have other etiologies, including Parkinson-plus syndromes (Countryman, Ramig, & Pawlas, 1994) and multiple sclerosis (Sapir et al., 2001). Results from these cases are guarded by the apparent need to supplement or extend the standard 4week program and evidence of decreased effectiveness over subsequent months. Previously, we published a case study of a young man who presented with mixed hypokinetic-spastic dysarthria 20 months post-TBI (Solomon et al., 2001). He participated in LSVT followed by 6 weeks of Combination Treatment that included speech-breathing training, physical therapy, and LSVT-type tasks. The additional treatment was deemed necessary because of minimal improvement in speech breathing and speech intelligibility following LSVT alone. Marked improvements resulted after the full 10-week program, and

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Address correspondence to Nancy Pearl Solomon, Ph.D., CCC-SLP, Army Audiology & Speech Center, Walter Reed Army Medical Center, 6900 Georgia Ave. NW, Washington, DC 20307 USA. Nancy.P.Solomon@us.army.inil. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

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these gains were maintained for several months. To further examine the viability of LSVT as a treatment strategy for patients with mixed hypokinetic-spastic dysarthria, we replicated the study in a similar patient. In contrast to the previous study, we simplified the Combination Treatment to focus only on nonspeech and speech breathing, conducted treatments in reverse order, and included multiple baseline assessments. Data also were collected after 6 weeks of Breathing-for-Speech Treatment (BST), after the 4-week LSVT program, and 1- and 4months posttreatment.

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CASE DESCRIPTION
CM (fictitious initials), a 58-year-old highly educated man, sustained a traumatic closedhead injury following a suspected assault and fall. CT imaging revealed subarachnoid hemorrhage (left > right), including contusions of the left frontal and both temporal lobes. His 1.5-month hospital course was significant for a 15-day coma, intubation, and a percutaneous gastrostomy tube. After discharge, CM participated in a 2-month rehabilitation day program. At 8-months postinjury, he was re-admitted briefly for suicidal ideations, disinhibition, and general functional decline. At that time, speech-language assessments revealed global cognitive-linguistic deficits and mild-moderate dysarthria, with 71% sentence intelligibility (Sentence Intelligibility Test [SIT]) (Yorkston, Beukelman, & Tice, 1996) to an unfamiliar listener. At 10 months postinjury, CM was seen in our outpatient speech clinic. His primary complaint was poor speech intelligibility that prevented functional independence and socialization. Motor-Speech Evaluation Clinical evaluation 10 months post-TBI revealed moderate hypokinetic dysarthria with milder spastic features. Speech was characterized by low loudness, short breath groups, rushes of speech, imprecise consonants, monopitch, harsh voice, and hypernasality. Intelligibility (SIT) was 79.5% to an unfamiliar listener. Speech alternating motion rates (AMRs) were rapid and blurred. Nonverbal oral apraxia and volitional-breathing dyscoordination were notable. The lower face (L > R) and tongue evidenced spastic paresis. Rigid videostroboscopy revealed normal laryngeal structure and function bilaterally. Vital capacity was 4.32 L (97% predicted). To assess CMs candidacy for LSVT, we conducted two sessions of trial therapy 3 weeks apart. Volitional control of breathing was markedly uncoordinated, but performance improved in the supine position and with tactile feedback. CMs initial attempts at loud phonation resulted in a strained, harsh voice. He was inconsistently stimulable for loud, clear phonation during vowels. Positive prognostic indicators included high motivation, good comprehension of tasks, and dysarthria type. Negative indicators were impaired cognition, history of depression, and limited stimulability. We explained LSVT to CM and prescribed daily breathing-coordination exercises. Treatments An experienced LSVT-certified speech-language pathologist (SLP) conducted all treatment sessions. The first treatment phase, BST, took 11 hour-long sessions over 6 weeks (from 04 sessions/week, constrained by vacations and illnesses). The goals of BST were to achieve relaxed, coordinated breathing for nonspeech and speech activities. Nonspeech breathing targeted slow-to-moderately paced abdominal and rib cage expansion during inspiration, and relaxed expiration. Breathing was produced without motor overflow or excessive muscle tension, especially in the tongue or neck. Body position progressed from supine to seated to standing. Movements then progressed from walking in place, treadmill walking, and free walking. At each level, tactile cues were used and quickly faded, and 90% accuracy was

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required. Speech-breathing tasks required the same essential target behaviors with the additional goal of rapid inspiration followed by controlled expiration with vocalization. Tasks progressed from sustained phonation to words to short phrases to simple sentences to complex speech tasks including complex sentences, poetry, paragraph reading, questionanswer responses, and conversation. The second treatment phase was LSVT, which, in brief, consisted of four hourly sessions per week for 4 weeks. Goals were to maximize (1) loudness and duration of sustained vowels; (2) pitch range; and (3) loudness during short phrases, paragraph reading, and conversation. Full calibration (habituation of effort level) at each level was required.

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DATA COLLECTION
Data were collected twice before initiating intervention (BL1 & BL2, 2 months apart), twice 1 month later, immediately following trial therapy (BL3 & BL4, 1 week apart), once the day after completing BST, once the day after completing LSVT, and 1 month and 4 months following discharge from treatment. CM continued LSVT exercises daily after discharge. Unfortunately, between the 1-month and 4-month follow-up sessions, CM experienced seizure activity and transient functional decline. Details regarding laboratory data-collection procedures were published previously (Solomon et al., 2001) and are summarized briefly here. Self-Rating of Speech Disability The Voice Handicap Index (VHI) (Jacobson et al., 1997), was self-administered. To improve its relevance, we instructed CM to substitute speech for voice. Intelligibility CM was instructed to read sentences clearly that were randomly selected from the SIT inventory, according to standard instructions in the manual (Yorkston et al., 1996). The sentences were played later over headphones to three normal listeners, who followed standard scoring procedures. Median scores (percent of words identified correctly) were used. Breathing Assessment Chest-wall kinematic signals, using respiratory inductive plethysmography (RIP, Ambulatory Monitoring), provided data for breathing-task assessments. CM was seated in a sound-treated booth for all tasks. Rib cage and abdomen signals were calibrated for lung volume by multiple isovolume maneuvers at resting expiratory level (REL), and specificvolume maneuvers (~1 L above and ~0.5 L below REL, MedGraphics CPFS/D). Kinematic and acoustic data (AKG C420 head-mounted microphone) were digitized simultaneously at 6 kHz (DATAQ DI-720) onto a laboratory computer. Breathing data were taken from resting tidal breathing (RTB, 1015 cycles), two oral readings of the Rainbow Passage (sentences 26; total = 2432 breath groups), and two extemporaneous monologues (15 breath groups from each, excluding the first). Perceptual studies and orthographic transcriptions of the reading and monologue (and SIT) tasks relied on acoustic signals also recorded on a digital workstation (Boss BR-1180) at 44.1 kHz. Measurement variables were lung-volume initiation, termination, and excursion (LVI, LVT, LVE), number of syllables, and duration of each breath group (expiratory phase). Expiratory speech rate (ESRate) was calculated as syllables per speech-expiration duration. Summary data from the baseline sessions were averaged and used for comparison to the posttreatment

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sessions according to the criteria established by Schulz, Peterson, Sapienza, Greer, and Friedman (1999) and as used by Solomon et al. (2001).

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Other Perceptual Measures Sentences 26 (~30 second) of one reading trial and a 2832-second excerpt from a monologue from each session were rated by five SLPs (833 years experience) for articulatory precision, breathiness, and overall severity along separate 7-point scales (1 = normal; 7 = severe). A 30-minute training session included listening to seven nontest speech samples by CM, rating three additional speech samples, and consensus discussions. The SLPs then independently listened over headphones to the test samples from each session, which were randomized within task and across listeners. Median ratings were used.

RESULTS
Voice Handicap Index CMs score on the VHI indicated a substantial handicap during the initial assessment (10months post-TBI). After LSVT, his ratings indicated minimal disability (Table 1), but the score returned to the severe range 4 months after discharge from treatment. Sentence Intelligibility SIT scores varied from 62 to 91% across three sessions in the 5 weeks before treatments (Table 1). Scores appeared to be related to loudness level; during Session BL3, which immediately followed trial therapy, CM spontaneously read quite loudly (because we had told him about LSVT, and he was trying to impress us) and attained a SIT score of 91%. When asked to read typically, intelligibility dropped to 62%. Because of this discrepancy, we repeated the SIT 1 week later (Session BL4), first instructing him to read typically and then to read loud and clear. Both productions resulted in similarly low scores, revealing that improved intelligibility was not under consistent volitional control. Moreover, scores from BL3 provided clear evidence that CM was able to improve intelligibility, and hence, was a good candidate for treatment. After BST, sentence intelligibility was essentially unchanged. After LSVT, SIT improved to 96%, a level that was maintained 1 month after discharge whether he was instructed to speak loudly or typically. Four months after treatment, SIT scores decreased slightly (8791%). Speech Breathing Speech breathing was markedly abnormal before treatment (Figure 1). Most notably, speech typically was initiated at approximately the same lung-volume level as RTB rather than at the expected level of twice RTB. Speech breath groups were short in terms of number of syllables and duration (Table 1). After BST, lung-volume levels tended to improve towards normal values, and reading rate tended to decrease. After LSVT, LVI and LVE increased reliably from baseline, and more syllables tended to be produced per breath group for both tasks. Phrasing and breath-group length were abnormally low at each assessment session. Syllables per breath group increased after trial therapy (BL3), but CM accomplished this by increasing ESRate. After LSVT, syllables per breath group during monologue tended to increase without a concomitant increase in ESRate. Four months after treatment, lungvolume levels generally were maintained, and reading rate continued to decrease. Perceptual Ratings of Speech Experienced SLPs rated CMs speech as mildly to moderately impaired for breathiness, articulation, and overall dysarthria for all sessions. Mild improvements in articulatory

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precision and breathiness were perceived after treatments. However, there was no systematic difference in overall severty of dysarthria. Articulatory precision and overall severity were affected by apparent spasticity of the tongue and lips, as well as persistent hypernasality.

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DISCUSSION
One year after a severe TBI, CMs primary residual complaint was dysarthria. He successfully completed two phases of treatment, BST and LSVT, by meeting all treatment goals. CM expressed extreme satisfaction with his treatments, as indicated by a drastic reduction in his VHI scores. However, several months later, his VHI score returned to the severe range, indicating his continuing awareness of deficits, frustration from new seizure activeity, and perhaps reflecting his cognitive difficulties responding to a graded rating scale. Despite this score, CM claimed that he was more confident, better able, and more willing to engage in communication. His wifes appraisal of his handicap, a structured interview, confidence ratings, or some other psychosocial measure might have better captured CMs functional and social abilities. Speech breathing before treatment was characterized by lower than normal lung volume initiations and short phrases. BST alone improved speech breathing, but there was no corresponding increase in intelligibility. Despite variable SIT scores before treatment, we were able to demonstrate a consistent improvement in sentence intelligibility after the full course of treatment (BST followed by LSVT). Four months later, speech-breathing gains remained, and sentence intelligibility only declined slightly. Perceptual characteristics of speech improved subtly after treatment, and these changes were not maintained after 4 months. Our clinical impression is that persisting features of spastic dysarthria had an overriding effect on listeners perceptions. Contributing instead to increased intelligibility may have been the improvements in phrasing and rate. These measures may have been more sensitive to functional improvements in speech than the perceptual judgments. Including multiple measures was beneficial because each appeared to address different aspects of dysarthria. Caution must be exercised, however, when comparing the SIT scores to the speech ratings from the reading and monologue samples because of task differences. The two cases of hypokinetic-spastic dysarthria secondary to TBI that we have reported thus far demonstrated improved speech breathing and consistently improved speech intelligibility after treatment, and to some extent for at least several months after discharge. Other functional gains included sustained employment by the previously published patient (Solomon et al., 2001) and decreased self-perceived disability by this patient. Both the BST and LSVT treatment phases appeared necessary to effect positive outcomesdespite providing the treatments in opposite order, neither patient demonstrated improvements in intelligibility after the first phase. Furthermore, progress for both patients was limited by the spastic features of their dysarthria. Careful manipulation of treatments in additional patients and continued follow-up are needed to more completely address treatment effectiveness for hypokineticspastic dysarthria after TBI.

Acknowledgments
This research was supported in part by NIDCD Grant R03-DC06096. A portion of the clinical services was donated by The Language Experience, a speech-language pathology private practice in Rockville, MD. We appreciate the assistance of Laura Battiata, Joyce Gurevich, JoAnn Lamm, Sandra Martin, and Lisa Newman.

REFERENCES
Countryman S, Ramig LO, Pawlas AA. Speech and voice deficits in parkinsonian plus syndromes: Can they be treated? Journal of Medical Speech-Language Pathology. 1994; 2:211225.

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Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, Newman CW. The Voice Handicap Index (VHI): Development and validation. American Journal of Speech-Language Pathology. 1997; 6:6670. Ramig, LO. Speech therapy for patients with Parkinsons disease. In: Roller, WC.; Paulson, G., editors. Therapy of Parkinsons disease. New York: Marcel Dekker; 1995. p. 539-548. Ramig LO, Sapir S, Countryman S, Pawlas AA, OBrien C, Hoehn M, Thompson LL. Intensive voice treatment (LSVT) for patients with Parkinsons disease: A 2 year follow up. Journal of Neurology, Neurosurgery, & Psychiatry. 2001; 71:493498. Sapir S, Pawlas A, Ramig L, Seeley E, Fox C, Corboy J. Effects of intensive phonatory-respiratory treatment (LSVT) on voice in two individuals with multiple sclerosis. Journal of Medical SpeechLanguage Pathology. 2001; 9:3545. Schulz GM, Peterson T, Sapienza CM, Greer M, Friedman W. Voice and speech characteristics of persons with Parkinsons disease pre- and post-pallidotomy surgery: Preliminary findings. Journal of Speech, Language, and Hearing Research. 1999; 42:11761194. Solomon NP, McKee AS, Garcia-Barry S. Intensive voice treatment and respiration treatment for hypokinetic-spastic dysarthria after traumatic brain injury. American Journal of Speech-Language Pathology. 2001; 10:5164. Yorkston, K.; Beukelman, D.; Tice, R. Sentence Intelligibility Test. Lincoln, NE: Institute for Rehabilitation Science and Engineering, Madonna Rehabilitation Hospital; 1996.

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Figure 1.

Lung-volume data for resting tidal breathing (RTB), oral reading, and monologue production before treatments (BLl3), after BST, after LSVT, and 4-months after discharge from treatments. The dashed horizontal line at LV = 0 L represents resting expiratory level (REL). Each bar represents mean lung-volume initiation (LVI) at the top, and mean lungvolume termination (LVT) at the bottom. Consequently, the length of the bar represents mean lung-volume excursion (LVE). Error bars at the top and bottom of each bar are standard deviations of LVI and LVT, respectively. Typically, normal speech is initiated at about twice LVI for RTB (~0.8 L) and terminated near REL (~0 L).

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TABLE 1

Results for auditory-perceptual ratings, speech phrasing, SIT, and VHI across sessions.
BL1 BL2 BL3 BL4 Post-BST Post-LSVT 1Month Posttreatment 4-Months osttreatment

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Measure

Reading *
3 4 2 6.17 1.29 4.53 5.53 1.68 9.16 3 4 4 3 3 2 8.70 1.96 4.41 4.11 1.97 7.89 2 3 3 4 4 2 7.89 2.13 3.60

Overall

Imprecise

* *
7.01 1.37 5.11

Breathy

Syl/breath

Duration

ESRate

Monologue *
2 3 2 5.73 1.20 4.92 87.7 90.5; 61.8 62.7; 67.3 70.0 95.5 95.9; 97.3 13 5.32 1.16 6.13 3 4 4 5 5 3 6.53 1.24 5.27 5.06 1.51 7.80 2 3 3 4 4 2 6.27 1.29 4.99 86.8; 91.4 94

Overall

Imprecise

* *
5.77 1.16 5.20

Breathy

Syl/breath

Duration

ESRate

SIT (loud; typical) 103

VHI

Missing data due to acoustic distortion

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Did not test

VHI: Voice Handicap Index (scores range from 0120 where 030 is minimal; 3160 is moderate, and 61120 is substantial); SIT: Sentence Intelligibility Test (in percentage of words understood; median of 3 unfamiliar listeners); typical or loud and typical productions; Overall, Imprecise, and Breathy: rated from 1 (normal) to 7 (severe); median scores of 5 experienced SLPs; Syl/breath: Number of syllables produced per speech expiration (normal = ~18); Duration: Duration (in s) of expiratory phase of speech breath groups (normal = ~3.5 s); ESRate: Expiratory Speech Rate = syllables produced per duration (in s) of speech expiration (normal = ~4.8).

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