Treatment of Velopharyngeal Inadequacy - PowerPoint Presentation

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Treatment of Velopharyngeal Inadequacy in Dysarthric Speakers

Motor Speech Conference

Antwerp University Hospital

October 24, 2019

Joe Duffy, Ph.D., BC-NCD

Mayo Clinic

Rochester, MN

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OverviewVP function & speechClinical features of VPIManagement issues & principlesTreatments

Medical

Prosthetic

Behavioral

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Velopharyngeal Closure & SpeechClosure is necessary for:All pressure consonants (stops, fricatives, affricates)Acceptable resonance balance on vowels and vocalic consonants (e.g., r, l, w.)

Closure is

inappropriate

for

Nasals (in English, /m/, /n/, /ng/)

VP closure occurs normally as a steady or constant coarticulation in speech, with periodic release from closure for production of nasal consonants

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Velopharyngeal Muscle Functions

Tensor veli palatini

Levator veli palatini

Palatoglossus

Palatopharyngeus

constrictor pharyngeus superior

(from Fritzell 1969)

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Velopharyngeal Movements During Speech4 Patterns

Retraction, elevation & stretch of velum

Mesial movement of lateral pharyngeal walls

Anterior movement of Passevant’s ridge

Circular/sphincteric

superior

lateral

frontal

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Normal

Inadequate

Velopharyngeal Mechanism Function

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Primary Speech Consequences of VPI Hypernasality (a vowel phenomenon)“Weak” pressure consonants (reduced perceptual distinctiveness) secondary to audible or inaudible nasal emissionCan place added demands on respiratory & laryngeal functions

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Secondary/Compensatory Speech Consequences of VPI Short breath groups/phrases (air wastage)Reduced loudness (damping effects)Increased subglottal pressure &/or laryngeal hyperadductionFacial grimacing & nares pinching

Glottal stops; pharyngeal fricatives; breathy-hoarse quality; pharyngeal stops; velar fricatives; mid-dorsum palatal stops

Primary & secondary features can reduce intelligibility & efficiency

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Management

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Resonance & VP Speech FunctionCrude assessment of effect of VPI on intelligibility & perhaps other problems – nares occluded vs. unoccludedupright vs. supine

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Focus on Velopharyngeal Function?The pertinent question:If this person was not hypernasal & did not have weak pressure consonant production because of abnormal nasal airflow & VPI, would speech be

More

intelligible

?

More efficient?

Less disabling or handicapping?The answer may be NO for patients with significantly impaired respiratory, phonatory & articulatory abilitiesWhen VP problems outweigh problems in other speech subsystems, focus on VP functions may be appropriate

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Dysarthria Types & VPIType

VP Impairment

Flaccid

May be prominent (Vagus nerve)

Spastic

May be prominent

Ataxic

Normal or intermittent

Hypokinetic

May be prominent, but not common

Hyperkinetic

If evident, intermittent or mild

Unilateral UMN

Uncommon, mild if evident

Mixed

May be prominent, esp. flaccid-spastic

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Other Factors Influencing VP Management DecisionsMedical diagnosis & prognosis Staging SeverityAssociated problemsNonspeech sensorimotor deficitsCognitive-language deficitsEnvironment & communication partners

Motivation, preferences

& needs – Crucial!

The

Health Care System!!!

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Yorkston KM et al.: Evidence-based practice guidelines for dysarthria: Management of velopharyngeal dysfunction. J Med Speech-Lang Pathol, 9:257, 2001.Provides information useful to clinical decision making for surgical, prosthetic & behavioral interventions for VP problems associated with

dysarthria

See Academy of Neurologic Communication Disorders & Sciences website

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Approaches to TreatmentMedicalPharmacologicSurgicalProstheticBehavioral

None are mutually exclusive!

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Approaches to TreatmentMedicalPharmacologicSurgicalProsthetic

Behavioral

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Pharmacologic? No meds that target VPI in any dysarthria type but … Flaccid dysarthria (myasthenia gravis)Mestinon (pyridostigmine bromide) – myasthenia gravisHypokinetic dysarthria (PD)

L-Dopa (levodopa)

Sinemet (carbidopa-levodopa)

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Surgical Pharyngeal flap or sphincter pharyngoplastyGenerally less favorable than prosthetic management; no recent +/- reports Insufficient evidence to permit recommending surgical interventions for VPI in dysarthria

(Yorkston et al., 2001)

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Injection Pharyngoplasty(hyaluronic acid & dextranomer copolymer, calcium hydroxylapatitie, autologous fat) Mostly reported for cleft palate, CA, wind musicians with VPI

Peck et al. (2017)

25 consecutively treated adults with VPI, 52

%

with neuro

etiology (e.g., vagus n; MS, MG, brainstem CVA, myopathy - i.e., flaccid dysarthria) Median follow-up 7.4 months76% required only 1 injection to achieve final resultSig improved resonance, nasalance, & VP gap size Most effective for nonmalignant etiologies & those with good lateral wall motion May hold promise for well-selected dysarthric speakers

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Approaches to TreatmentMedicalPharmacologicSurgicalProsthetic

Behavioral

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Palatal Lift Prostheses

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Palatal Lift Prostheses – evidence compositeEsposito et al. (2000)retrospective study - 25 Ss with ALS 84% had reduced hypernasality76% benefitted for at least 6 months

Yorkston

KM et al

. (2001)

33

articles reviewed Concluded that palatal lift is effective treatment for well-selected individuals with dysarthria

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Palatal Lift Prostheses (cont.) In general, “effective” means increased intelligibilitydecreased hypernasality improved clarity of articulationMost often reported for patients with flaccid >, spastic,

&

mixed

F-S dysarthrias

Some with stable VPI may develop

improved palatal function without lift, perhaps through lift stimulation of neuromuscular responses

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Palatal lift prostheses (cont.)Best candidatesstable or not declining/improving rapidlyless significant/minimal deficits @ other levels

adequate dentition

no significant spasticity (e.g., gag)

motivated, patient, & good self-care ability

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“Minor” Prostheses (nares occlusion)When? Interim while awaiting more substantial interventionRapid changes - decline or improvementPatient uninterested or not candidate for other intervention What?Nasal obturator, nose clip,

one-way

nasal speaking

valves

(Hakel et al., 2004; Suwaki et al., 2008) Manually occluding nares Maybe not for constant use, but helpful for breakdown repairs

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Nares Occlusion

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Approaches to TreatmentMedicalPharmacologicSurgicalProsthetic

Behavioral (modify pattern of speech)

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Principles of Motor Learning “Specificity of training” - Improving speech requires speaking!Training should be as specific as possible to movement patterns, ROM, velocity, force, etc. of ultimate goals of TX“Drill”

–

systematic practice of selected, ordered exercises

Frequent (e.g., twice or more per day)

Frequent brief periods probably better than infrequent lengthy practice

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Behavioral Treatment - VPI Four general behavioral approaches (Yorkston et al., 2001) Techniques focused on nonspeech activities Resistance training during speech Online “instrumental” feedback

Modifying

the pattern of speaking

Limited

evidence. Mixed opinions. Generally felt that dysarthria-based severe & chronic VPI do not benefit from behavioral intervention

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Behavioral Treatment- NonspeechFacilitation techniques - pressure, brushing, icing, stroking, vibratory.Inhibition techniques - prolonged icing, pressure stim., vibration

Motor control tasks

to modify

breath stream (e.g., blowing bubbles, cotton balls, whistles)

Nonspeech strengthening

exercise (blowing, sucking)“The general consensus…these exercises are disappointing and generally ineffective” (Johns, ‘85, p. 158)Nonspeech VP strengthening exercise for dysarthria not justified (Yorkston et al., 2001)

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Resistance Training During Speech Continuous Positive Airway Pressure (CPAP)Positive airflow into nasal cavities through hose & nasal mask assembly Challenges VP muscles to overcome positive pressure (resistance load) to

achieve

VP

closure during

speech

Meets specificity of training motor learning principle Positive effects reported for small # of dysarthric speakers (Cahill et al., 2004; Kuehn et al., 1994; Liss et al., 1994) Success likely reflects careful subject selection & specificity of training speech

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Behavioral Management - Instrumental FeedbackFeedbackMirror at nares; See Scapenasal-flow transducer/nasometernasoendoscope other simple or sophisticated devices that provide feedback about nasal airflow

Mostly testimonial evidence for dysarthrias

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Behavioral Treatment- Instrumental FeedbackVideo game rehab of VP dysfunction (Cler et al., 2017)Feasibility study - at-home case series of

children with

VP

dysfunction

using interactive

video game providing real-time biofeedback from nasal accelerometry to facilitate appropriate nasalizationResults suggest video game–based systems may provide useful platform for real-time feedback of speech nasalizationN = 5 (probably not neuro based)

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Behavioral Treatment- Modifying pattern of speaking (cont.) Active (require learning/practice)Exaggerate jaw movementOverarticulate (“clear speech”)Increase effort/loudness (hypokinetic?)Reduce rate Reduce duration of pressure consonants

Passive

Postural adjustments

(e.g., supine, adjustable bed/wheelchair)

(Yorkston et al., 2001)

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ReferencesDuffy, J.R. (2013) Motor speech disorders: substrates, differential diagnosis, and management (3rd edition), St. Louis: Mosby Elsevier. Guyton

KB et al. Acquired velopharyngeal dysfunction: survey, literature review, and clinical

recommendations

.

Am J Speech-Lang Pathol

; 27: 1572-1597, 2018.Kuehn DP. The development of a new technique for treating hypernasality: CPAP. Am J Speech Lang Pathol. 6:5, 1997.McNeil, M. R. (Ed.) (2009). Clinical Management of Sensorimotor Speech Disorders. (2nd ed.) New York: Thieme Medical Publishers.Peck BW, Baas BS, Cofer SA Injection pharyngoplasty with a hyaluronic acid and dextranomer copolymer to treat velopharyngeal insufficiency in adults. Mayo Clin Proc Inn Qual Out 2017;1(2):176-184.

Yorkston KM et al.: Evidence-based practice guidelines for dysarthria: Management of velopharyngeal dysfunction. J Med Speech-Lang Pathol 9:257, 2001.