5/30/2016

FOLLOWING
THEIR PATHWAY
CASE STUDIES OF PATIENTS
WITH PARKINSONISM
Marta DeLuca, SLP
Voice Disorders Clinic
St. Michaels Hospital

WHAT WE KNOW
PARKINSONS FEATURES

Bradykinesia
Rigidity/Hypokinesia
Reduced facial
expression
Micrographia
Reduced gait
Hypophonia

Resting tremor
Postural instability

SPEECH AND VOICE

CHARACTERISTICS OF IPD

Reduced loudness
Breathy quality
Sometimes harsh
Consonant imprecision
Short rushes of speech
and palilalia
Masked facial
expression

OBJECTIVES
1. Features of Parkinsonism
2. Current Treatments
medical/non-medical
3. Clinical cases
4. Conclusions

PARKINSONISM

(AKA: PARKINSON-PLUS/ATYPICAL PARKINSONS)

Progress more
A group of disorders that
rapidly
causes Parkinsons-like

Dont respond or
features (bradykinesia,
respond only for a
sometimes tremor & rigidity):
short time to
levodopa therapy.
MSA (Multisystem Atrophy)
severe
PSP (Progressive Supranuclear additional
symptoms
Palsy)
Therapy focuses
CBD (Corticobasal degeneration)
on the variable and
changing
DLB (Dementia with Lewy
communication
bodies)
needs of patient
http://www.parkinson.ca

MEDICAL
MANAGEMENT OF PD
Medications:
Levodopa, Cardopa
Amantidine, Entacapone
Surgeries:
Pallidotomy (dyskinesia tx)
DBS bilateral subthalamic stimulation (for
tx of bradykinesia, tremor and rigidity)
Voice Surgery: Medialization/augmentation
of vocal folds (Berke, Gerratt, Kreiman & Jackson, 1999)

(A review of Parkinsons Disease, C.A. Davie, 2008)

5/30/2016

LEE SILVERMAN VOICE TREATMENT

1. LSVT/Loud has been shown to have both short
term and long term benefit on voice and speech.
(Ramig and Countryman, 1996).
2. Trains the single motor control parameter of
loudness in an intensive way across speech
tasks =>neuroplastic effect. (Fox, Ramig et al 2006)
3. Research shows a cross-system improvement in
articulation, facial expression and swallowing.
4. Researchers are now looking at the intensive
practice of amplitude across all disciplines
(SLP,OT, PT) as a means of disease modification.
(Farly, Fox, Ramig, and McFarlane, 2008)

CASE 1

Pre therapy reading

AGE: 73
Onset: 2 years
Severity: mild to moderate
Complicating Factors:
chronic pain from OA
Medications: amitryptiline,
percocet, Prodopa
Supports:
living in a community,
motivated to continue
ministry.

1. Telemedicine delivery of LSVT

(Theodoros & Ramig, 2011)

2. LSVT-X

(Spielman, Ramig et al, 2007)

3. EchoWear: Smartwatch technology (Dubey,

Goldberg et al, 2015)

4. Music Therapy effect on speech, voice

intensity and mood (Haneishi, E 2016 & Pacchetti, Mancini et
al, 2000)

5. Training slow rate and intonation/prosody

(Martens, Van Nufflelen, Dekens et al, 2015)

CASE 1
Frequency:
Seen for 5 sessions over two
months

Post Therapy

Mode: 1:1 visits with recording of

sessions to facilitate home practice
Outcome:
Voice quality improved in clarity
and volume. Patient returned to
preaching.

CASE 2
AGE: 81
Onset: IPD for 20 years
Severity: moderate-severe
(fluctuation aphonia)
Challenges:
Dyskinesia, mild cognitive
impairment
Supports: Daughter very
involved in care of father.

OTHER THERAPY
APPROACHES?

CASE 2
STROBE

Pre therapy

Frequency: 4 sessions over 3 months

Twice daily home practice with
daughter.

1 month post therapy

Outcome:
-Maximum intensity increased from 84
to 102 dBSPL
-clearer but still variable output

3 months post therapy

-now able to be heard on the phone

Plan: Recommend medialization
followed by further therapy.

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CASE 3

CASE 3
Challenges:
mild cognitive impairment
?depressed
clinicians caseload
Unable to use telemedicine
Patient introversion
Supports:
Limited family involvement
Difficulty with transportation to clinic

AGE: 68
Onset: PD diagnosed age 64
Severity: severe - aphonic

Referred after bilateral

medialization thyroplasty

Clinical Course:

seen for 4 sessions over 4 months

voice improved but still significant
glottic gap (MPT = 4 seconds)

referred back to ENT no sx

2 years later aphonic. Wishes to

retry therapy with intensive
approach.

CASE 4:

CASE 4

Referred in 2005 for MTD (age 42)

PATIENT HISTORY

Respiratory failure 2007

Esophagus dilated due to severe achalasia 2008
Vocal fold paralysis treated in 2008. (age 45)
2005
Before
Therapy

2006
After
Therapy

2008
After Surgery

Poor balance

Atonic bladder

Autonomic dysfunction

Respiratory failure

Bradykinesia

Rigidity
Moderate to severe
dysphagia (VFSS, age 52) Incoordination

Right eye strabismus

Unilateral vocal fold
paralysis
Mild lingual weakness

CASE 4
Patient called again in
2016 with concerns about
possible voice change.

MSA FEATURES

Poor balance

Patients respond poorly

to PD medications
Symptoms can progress
more rapidly

CASE 4: ROLE OF SLP

STROBOSCOPIC VIEW

INDIRECT

DIRECT

Communication and
Counseling and
swallowing strategies
case management
Managing
referral back to
hyperfunction
specialists (GI,
(massage, yawn-sigh)
respirology, ENT)

voice amplifier
reassurance

Optimize respiratory
phonatory balance
(breath pacing,
humming)

5/30/2016

CONCLUSIONS

CONCLUSIONS

Global benefit with LSVT seen across

subsystems of voice from increasing
intensity of phonation.

Intensive program: seems to be required

especially in more severe cases, to
achieve better compliance and better
generalization.

Changing one subsystem is not enough

example: Vocal fold medialization in the
absence of voice therapy does not
improve intelligibility.
Communication demand (support
system) and patient mood may
help/hinder outcome.

Technology may assist in increasing

accessibility of SLP therapy at the dosing
level needed to see change.
Long term degeneration requires long
term follow-up.

THANK YOU!