Voice Disorders

Parkinsons Disease

Introduction
According to the Parkinsons Disease foundation:

In the US 50,000-60,000 new cases are diagnosed each year Estimated that 4-6 million people suffer from the condition worldwide More common in men (3:2 men to women ratio) Age of onset is usually above the age of 50

Introduction According to a study by Fox, Morrison, Ramig and Sapir (2002), only 3-4% of those with ideopathic parkinsons disease (IDP), seek out speech therapy.

What is Parkinsons disease?

A neurodegenerative brain disorder that slowly progresses (i.e. most people with PD will live with PD for twenty years or more from the time of diagnosis) Motor symptoms of Parkinsons disease appear when 60-80% of the dopamine producing cells are damaged and do not produce enough dopamine

Braaks Hypothesis
The earliest signs of Parkinsons are found in the nervous system and progress to the substantia nigra and cortex over the years This theory suggests that non-motor symptoms (i.e. loss of sense of smell, hyposmia, sleep disorders, constipation) precede the motor features by several years This theory is used in early detection

10 Early Warning Signs

Tremor or shaking Small handwriting Loss of smell Trouble sleeping Trouble walking or moving Constipation A soft or low voice Masked face Dizziness and fainting Stooping or hunching over

Diagnosis of PD
In diagnosing PD, two of the four main symptoms must be present over a period of time

Shaking or tremor Slowness of movement (bradykinesia) Stiffness or rigidity of the arms, legs or trunk Trouble with balance and possible falls (postural instability)

TRAP
According to Jankovic (2007), the cardinal features of PD can be grouped under the acronym TRAP:

T: Tremor at rest R: Rigidity A: Akinesia (or bradykinesia) P: Postural instability

Voice and Parkinsons Disease

Low volume voice Monotone quality Speech pattern of short bursts with inappropriate silences Long pauses Speech may be slurred 15% may have a tremulous voice

Voice and PD
According to Huber and Darling (2010):

PD creates both respiratory physiologic and cognitive-linguistic issues in speech production by individuals with PD. Individuals with PD have difficulty regarding their ability to plan or coordinate language and respiratory support, particularly during extemporaneous speech.

Voice symptoms of PD
According to Plowman-Prine, Okun, Sapienza, et. al (2009), the perceptual dimensions most severely affected include:

Sound imprecision Mono-loudness Mono-pitch Reduced stress Harsh voice

Treatment of PD

Team approach: Neurologist Speech pathologist Otolaryngologist

Treatment of PD
Medication (levadopa) commonly used for the motor manifestations Communication problems are treated using a specialized voice therapy treatment method called Lee Silverman Voice Treatment

Medical Treatment
Levadopa, which is used to treat motor symptoms of PD, has also been used to treat the voice symptoms of PD. According to a study by Plowman-Prine, Okun, Sapienza, et.al (2009), there is no significant difference in the vocal quality of those with PD when medicated compared to no medication.

Lee Silverman Voice Treatment (LSVT)

Prior to this method, very little success in speech therapy for PD Treatment is conducted over a 4 week period with therapy being given four times a week for 50-60 minutes per session.

LSVT
During each therapy session, patients practiced three daily exercises:

Maximum duration of sustained vowel phonation Maximum fundamental frequency range Maximum functional speech loudness drill

LSVT
There are five essential concepts in LSVT: Exclusive focus on voice (vocal loudness) Stimulation of high-effort productions with multiple repetitions Intensive delivery of treatment Enhancing sensory awareness of increased vocal loudness and effort Quantification of behaviors

Fox, Morrison, Ramig and Sapir (2002)

LSVT
Patients were also trained to:

Use a louder voice while speaking To accurately judge their loudness And to feel the effort and the loudness

All patients did daily homework & carry over exercises focusing on thinking loud

Effects of LSVT
A study by El Sharkawai, Ramig, Logemann (2002), et al found a significant increase in vocal intensity following completion of the LSVT. Other results also included an increase in the average fundamental frequency and improvement in the perception of speech indicating better intelligibility.