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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