Post on 08-Jan-2022
Speech & Swallowing assessmentin Parkinson’s Disease
Isabel Guimarães, SLP, PhD
PORTUGAL
Signs & Symptoms of Parkinson’s Disease
Primary motor
Tremor at rest
Rigidity
Bradykinesia
Postural instability
NonmotorDepression
Anxiety
Apathy
Hallucinations
Obsessive-compulsive behaviorsImpulsive behaviors
Secondary motor
Dysphonia
Dysarthria
Dysphagia
Sialorrhea
Dystonia
Freezing
Micrographia
Mask-like expression
Unwanted accelerations
90% of PD patients
Holmes et al. (2000); Skodda (2011)
Characteristics deteriorate with progression of the
disease
The first signs and symptoms are often subtle and vague
Differing magnitudes of impairment
Dysphonia
Hypophonia
Dysphonia
Low voice volume (soft voice)
Vocal decay
Breathy; Hoarse or Harsh voice
DysarthriaHypokinetic articulation
Reduced speech intelligibility
Dysprosody
Imprecise consonants and vowels
Difficulty initiating speech
Inappropriate silences (Freezing)
Reduced voice pitch inflexions
Decay in loudness and articulation
toward end of phrase
Dysphagia
Swallowing imparment
Sialorrhea
Silent aspiration without complain ofdysphagia (15% of PwP)
Pills and liquids (PD early stages)
All food consistences (late stages)
Ali et al. (1996); Darley et al. (1969); Duffy (2005); Skodda (2011)
Signs & Symptoms (examples)
Speech & Swallowing assessment in Parkinson’s DiseaseSc
reen
ing
To identify signs & symtoms:
Risk of susceptibility
Preclinical stagesAs
sess Clinician-based assessment:
Clinical history; Instrumental assessment; Perceptual analysis;
Acoustic analysis;
Functional analysis
Patient or Proxy-based report:
Patient reported outcome measure(PROM)
Deci
sion
mak
ing
Guidance for otherprofessionals
or/and
Adoption of
safety measures
or/and
Rehabilitation
Multidimensional process of clinical reasoning for the purpose of
- It is worst during spontaneous speech or rapid syllable repetition
than during sustained vowel phonation or reading aloud
- It is worst when performed with a competing task
Challenges given the fact
- That there is considerable intraspeaker variability
- Subtle markers in the early stages (disease duration of 5 years of less)
Diagnostic error rate can be high as 25% among inexperienced praticioners
Criteria for classification of scales
International Parkinson & Movement Disoders Society (MDS)
MDS- Task Force – Guidelines for Scales clinical utility
Recommended Suggested ListedUsed in PD patients Used in PD patients Used in PD patients
AND
Used by researchers beyond original
developers
AND
Used by researchers beyond original
developers
BUT
Not used by researchers beyond original
developers
AND
Successful clinimetric testing
(Reliability; Validity & Responsivenes)
OR
Successful clinimetric testing
AND
No successful clinimetric testing
Challenges given the fact
- The scales validity limitations
NeuralMotor planning and execution
Data derived from physical and metabolic imaging
Structural & MuscularApparatus: Displacements, velocities, accelerations/decelerations; time…
Data derived from observation (naked eye or instrumental monitoring)
AeromechanicalAir: volume; flow; pressures
Data derived from observation and aerodynamic measures
AcousticalSound: filtered, condtinioted by the passage through the apparatus
Data derived from acoustics
PerceptualAuditory events: kinesthesia, proprioception, hearing sensation, visual sensation…
Data derived from perceptual analysis
Speech and swallowing are processes with multiple levels of observation
Instrumental assessmentExamples
Larynx endoscopy & stroboscopy
Laryngeal impairments
PD patients versus Healthy speakers
52
87 81
2917
70
2938 45
Incomplete
glottal
closure
Vocal fold
bowing
Mucosal wave
irregularity
Laryngeal
tremor
Supraglottic
constriction
Abnormal
findings
PD Healthy%
Baeur et al. (2011); Blumin, Pcolinsky & Atkins (2004); Yucerk et al. (2002); Smith et al. (1995)
Incomplete glotal closure
Absent Mild Moderate Severe
Vocal folds Contact Quocient (CQ)CQ=(OP/Tx *100) %OP-Time in each cycle vocal folds are apart
Tx-Fundamental period
Healthy adults
American1 CQ=44%-46%
Portuguese2 CQ=40 a 60%
1Orlikoff (1998); 2Guimarães (2002)
EGG (Eletroglottography)
Time domain measures
Fx | SD Fx | Fx range
Jitter | Shimmer | HNR
Peak expiratory flow rate
Maximum flow declination rate (MFDR)
MIR Homecare Spirometer Smartphone
Spirometry
Young Elderly
Mean Peak
Flow (mL/s)
Soft 199.8 179.3
p<0.01Loud 596.9 489.6
MFDR
(L/s)
Soft 166 124.2 p>0.05
Loud 934 792
Mean open
quotient
Soft 0.56 0.59 p<0.05
Loud 0.41 0.46
MIR (Medical International Research)
Hodge, Colton & Kelly (2001)
Equipment: Pressure transducer that senses pressure exerted on an air filled bulb
displayed digitally on the IOPI (Iowa Oral Performance Instrument)
Unit: Kilopascal (KPa)
(Iowa Oral Performance Instrument) 1 Solomon, Robin & Lushe (2000)
IOPI (Iowa Oral Performance Instrument)
Analysis: Tongue function – pressure exerted on the air-filled bulb
Tongue strength – ‘squeeze as hard as the person can’ with the anterior
dorsum of the tongue against the IOPI bulb place against the palate
Tongue endurance – maintaining 50% of maximal pressure as long as possible
Data: Tongue strength mean1 =63KPa people between 40-60 yrs old
56 kPa people >60 yrs old
1Solomon, Robin & Lushe (2000); 2 Nascimento(2017)
01020304050607080
PD Healthy PD Healthy PD Healthy
Labial strength Tongue strengthTongue endurance Saliva swallowHoney texture swallow
Preliminary portuguese data2
p>0.05PD versus Healthy subjects1
Mean
Tongue endurance was lower
Tongue strenght was not
Lip & Tongue function; strength and endurance
Min
Max
Mean
Perceptual assessmentExamples
65 itens
Part I: Evaluation of mental well-being, behavior, and mood
Part II: Self-evaluation of the activities of daily life (ADLs)
Part III: Clinician-scored monitored motor evaluation
Part IV: Complications of therapy
Part V: Hoehn and Yahr staging of severity of Parkinson's disease
Part VI: Schwab and England ADL scale
Maximum score 260 (higher severity)
Speech & SwallowingPart II: 2.1-Speech
2.2- Saliva & Drooling
2.3- Chewing & Swallowing
Part III: 3.1.-Speech
MDS-UPDRS (Movement Disorders Society-Unified Parkinson’s Disease Rating Scale)
GRBAS (Japonese Society of Logopedy and Phoniatrics, 1969) 1
Normal-0 Slight-1 Mild-2 Severe-3
Grade (Severity)
Roughness
Breathiness
Asthenia
Strain
Men with PD significantly higher
Roughness>Breathiness>Asthenia
than healthy matched controls2
Women with PD significantly higher
Breathiness>Astheniathan healthy matched controls2
1 Hirano (1981); 2Midi et al. (2008)
Perceptual voice analysis
Reflexes: Cough, swallow, dribble/drool
Respiration: At rest, in speech
Lips: At rest, spread, seal, alternate, in speech
Palate: Fluids, maintenance, in speech
Laryngeal: Time, pitch, volume, in speech
Tongue: At rest, protrusion, elevation, lateral, alternate, in speech
Intelligibility: Words, sentences, conversation
Possible overall score 104 indicating the best performance
Nature and patterns of oromotor movements
Enderby (1983); Enderby & Palmer (2008)
FDA (Frenchay Dysarthria Assessment)
FDA-2 Portuguese data
Hoehn and Yahr stages
80 PwP
44 males, 36 females
aged 66.7 ± 10.9
80,9
83,9
Gender p>0.05
Females Males
Total score mean
FDA-2 Portuguese data
Healthy speakers > PD2 and PD3 p<0.05
PD3 ON > PD3 OFF p<0.05
Healthy speakers versus PD
diasease duration(yrs) and medication state
95,792,6
86,5
9593,2
89,2
81,2
Healthy speakers PD1 [0-3yrs] PD2 [4-9yrs] PD3 [≥10yrs]
ON OFF
FraLusoPark project
(FCT-ANR/NEU-SCC/0005/2013)
Portuguese
60 Patients with PD (early to late stages)
60 Healthy subjects
Rationale: Sensitive index to motor speech impairments because it requires maximum performance
(rapid repetitive motion of oral articulators)
Tasks: e.g. /pa-pa-pa-pa-pa-pa-pa…./ syllable alternate motion rate (AMR)
e.g. /pataka-pataka-pataka…./ syllable sequential motion rate (SMR)
Significantly correlates to: ‘clarity of articulation’
56.4
4.9 5.4
PD Healthy PD Healthy
Male Female
SMR2
Healthy adults 5-7 syllables/seconds
1Wang et al. (2009); 2Midi et al. (2008)
Oral diadochokinesis (DDK)
AMR1
4,5
8,8
4,1
3,1
5,34,7
4,3
5,4
4,23,5
5,75,3
Skodda
&Schlegel
(2008)
Tjaden & Wilding
(2011)
Walsh & Smith
(2012)
Martinez et al.
(2015)
Antunes et al.
(2015)
Lowit et al.
(2018)
PD Healthy
Syllables per second
Portuguese
data
Speech rate
Variable timing of speech rate
Healthy subjects – 3 to 6 syllables per second1
Number os syllables produced over a given
amount of time rate changes
Are accomplished by modifying the
duration of segments (duration),
inserting pauses (pause), and
modifying segmentals (phonemic change)
1 Hargrove & McGarr (1994)
Rationale: How well a speaker’s acoustic signal can be accurately recovered/understood by a listener
Task: Having Portuguese listeners orthographically transcribe words or sentences that the speaker had read
60,2 60,656,2
70,4 66,867,8 66,461,2
75 73
General
population
PD relatives PD patients Neurologists SLTs
Words Sentences
Speech intelligibility
Logopedics Phoniatrics Vocology, DOI: https://doi.org/10.1080/14015439.2020.1785546
Speech intelligibility (%) according to dysarthria severity
98 98 93,3 98 93,3
64 68,757,8
68,757,8
72,7 75,3 71,1 75,3 71,1
30,7 26,7 27,2 26,7 27,2
General population PD relatives PD patients Neurologists SLTs
Words %
Without dysarthria Mild Moderate Severe Dysarthria
Task: FDA-2 European Portuguese Words
Hit %
PD patients < General population < Relatives < SLTS < Neurologists
Neurologists & SLTs > General population p<0.05
Neurologists >Relatives >PD patients p<0.05
Speech intelligibility (%) according to dysarthria severity
Task: FDA-2 European Portuguese sentences
8274
81,792
8476 73,3 71,7
82 8479,3 7868,3
81,3 82,7
43,3 45,337,2
5648,7
General population PD relatives PD patients Neurologists SLTs
Sentences %
Without dysarthria Mild Moderate Severe Dysarthria
Hit%
Neurologists >Relatives >PD patients p<0.05
SLTs > PD patients p<0.05
Acoustic analysisExamples
Maximum phonation time (MPT)
Rationale: An efficient indicator of voice function,
specifically the glottal competence to utilize air to sustain vocal fold oscillation
Elicitation: Take a deep breath and produce (e.g. demonstration with a different vowel than the elicited one) as long as
possible at a comfortable pitch and loudness
Advantages: noninvasive, fast, easy, low-budget measurement, and a single rater is sufficient to provide highly reliable
measurements (Hirano, Koike, Lieden, 1968; Speyer et al., 2010; Karlsen et al., 2018)
Maximum phonation time (MPT)
14,6 15
18 17,315,9
21,7
25,5
20,3
11,2
14,1 13,4
17
11
14,1
19,7
16,9
Gamboa et al. (1997) Midi et al. (2008) Baeur et al. (2011) Ikue et al. (2015)
Male PD Male Healthy Female PD Female Healthy
Acoustic analysis
Time domain
PraatVoice report
Vocal pitch and intensity
Transient attack
change from silence to sound
Transient of extinction
period of decay and in
which the sound is extinguished
Period of stabilityperiod between the
previous two
Pitch and
are fixed in the period of stability
Olszevvski, Shen & Jiang (2011)
Acoustic analysis
Acoustic analysis - Pitch perturbationRationale: Ability to maintain periodic vibration (allows detection of changes in mass, biochemistry and neuromuscular
vocal fold control)
Task: Sustained vowel /a/ or /i/ or /u/ produced at comfortable pitch & loudness
0,9
0,56
1,1
0,70,58
0,29
0,76
0,2
1,5
0,59
1,99
0,7
PD Healthy PD Healthy
Male Female
JitterGamboa et al. (1997) Rahner et al. (2007) Midi e al. (2011)
0,56 0,450,43 0,36
0,58
0,29
0,76
0,2
3,2
2,1
2,99
1,68
PD Healthy PD Healthy
Male Female
ShimmerGamboa et al. (1997) Rahner et al. (2007) Midi e al. (2011)
Rationale: Loudness is context dependent;
Subglotal air pressure needed – 5 to 10 cm H20
Loud >80 dB| Conversational 40-80 dB| Soft < 40dB
Task: Steady sustained vowel produced at comfortable pitch & loudness at different distances
Acoustic analysis - Vocal intensity
78.9dB 50.9dB67.6dB
Male with PD
72.8dB 76.9dB77.5dB
Healthy Male
PROMs (patient reported outcome measures)
Examples
Original: EUA
Type: Patient Reported Outcome Measure (PROM)
Domains: Functional (F); Emotional (E) & Physical (P)
Items: 30
Scale: Likert type scale-5 points
Total score: 0 a 120 (Higher negative psychosocial impact)
Reference standard tool
Agency for Healthcare, Research Quality (AHRQ), USA
VHI (Voice Handicap Index) Content Examples
F1. My voice makes it difficult for people to hear
me
P2. I run out of air when I talk
F6. I use the phone less often than I would like
E9. People seem irritated with my voice
F12. People ask me to repeat myself when
speaking face-to-face
P13. My voice sounds creaky and dry
P20. I use a great deal of effort to speak
P21. My voice is worse in the evening
E23. My voice problem upsets me
E29. My voice makes me feel incompetent
E30. I'm ashamed of my voice problem
2016
90 patients with Parkinson’s disease
51 males & 39 females
Men age= 67 (ranging from 42 to 87 years old)
61 Healthy speakers - 28 males & 33 females
Men age= 64 (ranging from 42 to 87 years old)
30,9
25,628,6
2,2 2 2,1
0
5
10
15
20
25
30
35
Male Female Total Male Female Total
PD Healthy
Total Functional Physical Emotional
VHI Portuguese data
24,2
8,1 9,46,7
53,9
17,621
15,8
0
10
20
30
40
50
60
Total Functional Physical Emotional
PD without to mild voice complaints
PD with moderate to severe voice complaints
VHI Portuguese data
24,2
53,9
64
50,6
41,735
2,1
PD without to
mild voice
complaints
PD with
moderate to
severe voice
complaints
Neoplasm Unilateral vocal
folds paralysis
Vocal noduls Functional
dysphonia
Healthy
subjects
Total Functional Physical Emotional
Total value< 18–without handicap
[18-30]–low handicap
[31-60]-moderate
[61-120]–severe handicap
Guimarães & Abberton (2004); Guimarães et al. (2016)
VHI Portuguese data
Dysarthria Impact Profile (DIP)
Original: United Kingdom
Type: Patient Reported Outcome Measure (PROM)
Domains: 5
Items: 49
Scale: Likert type scale-5 points
Total score: 49 a 225 (the least dysarthria impact)
DIP- Portuguese data
0
50
100
150
200
25080 PD
p<0.05
Pharyngeal phase
15 statements
Oral phase5 statements
SDQ-PD (Swallowing Disturbance Questionnaire for PD)
Purpose: To screen and monitor dysphagia by covering symptoms that appear in the oral and pharyngeal phases
4-point scale(0-no disability;3-severe disability)
Logopedics Phoniatrics Vocology, DOI: 10.1080/14015439.2020.1792979
SDQ Portuguese data
mean age (yrs old)
75 PWP 65.7
65 Healthy subjects 64.4
3.24.5
9.9
Healthy subjects PD without swallowing
complaints
PD with swallowing
complaints
p<0.01
SCAS-PD (Swallowing Clinical Assessment Score in Parkinson’s Disease)
Score
0- no alterations
≤ 2 – normal swallowing
≥ 2 ; ≤ 15 - Functional swallowing
≥ 15 ; ≤ 35 - Mildly altered
≥ 35 ; ≤ 60 - Moderately altered
> 60 – Severely altered
Water Yogurt Cookie Maximum
20 ml 10ml
Oral phase
Altered lip closure 1.0 1.0 1.0 3.0
Labial discharge 1.0 1.0 1.0 3.0
Prolonged oral transit time 2.0 2.0 2.0 6.0
Residue 2.0 2.0 2.0 6.0
Pharyngeal phase
Multiple deglutition 2.0 2.0 2.0 6.0
Reduced larynx elevation 10.0 10.0 10.0 30.0
Altered cervical auscultation 10.0 10.0 10.0 30.0
Signs of penetration/aspiration
Throat clearing 10.0 10.0 10.0 30.0
Cough 15.0 15.0 15.0 45.0
Change voice quality 15.0 15.0 15.0 45.0
Choking 20.0 20,0 20.0 60.0
Alteration in breathing 30.0 30.0 30.0 90.0
354.0
4,76
0,17
4,05
10,3
2,6 2,8
Water Yogurt Cookie Total
PD Healthy
17 PD Patients – mean age=71yrs
20 Healthy subjects – mean age=75,5 yrs
SCAS-PD – Portuguese preliminar data
Score
0- no alterations
≤ 2 – normal swallowing
≥ 2 ; ≤ 15 - Functional swallowing
≥ 15 ; ≤ 35 - Mildly altered
≥ 35 ; ≤ 60 - Moderately altered
> 60 – Severely altered
1Nascimento(2017)
SCS-PD (Sialorrhea Clinical Scale for PD)
Original: Spain
Type: Patient Reported Outcome Measure (PROM)
Items: 7 statements
Scale: 4-point scale
Total possible score: 0-21 (severe disability)
0 1 2 3
No disability Slight Moderate Severe disability
SCS-PD Portuguese data
Logopedics Phoniatrics Vocology, DOI: 10.1080/14015439.2020.1792979
mean age (yrs old)
75 PWP 65.7
65 Healthy subjects 64.4
0,7
5,4
7,4
Healthy subjects PD without sialorrhea
complaints
PD with sialorrhea
complaints
p<0.01
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