Motor Speech Conference Antwerp University Hospital October 24 2019 Joe Duffy PhD BCNCD Mayo Clinic Rochester MN Speech Therapy for Motor Speech Disorders Is It Worth The Effort ID: 916820
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Slide1
Speech Therapy for Motor Speech Disorders: Is It Worth The Effort?
Motor Speech Conference
Antwerp University Hospital
October 24,
2019
Joe Duffy, Ph.D., BC-NCD
Mayo Clinic
Rochester, MN
Slide2Speech Therapy for Motor Speech Disorders: Is It Worth The Effort?
Slide3Possible AnswersWe do not knowNo (never)Yes (always)Sometimes yes, sometimes no, sometimes we do not know…It depends…
Slide4One CertaintyThere are no simple answers to complex problems and this problem – the treatment/management of MSDs –
IS complex
Slide5Is It Worth the Effort?What is “IT” ?What is “WORTH” ?
What is “EFFORT” ?
Slide6What is “It” (“speech therapy”) ???
Slide7“It” is…The provision ofIngredients (e.g., intense loudness practice)Targets (e.g., increased loudness)
Aims
(e.g., improved
intelligibility)
Mechanisms of action
(why ingredients should work
)
For people with multiple biopsychosocial traits, including MSDs
Due to a particular condition
(e.g., stroke, PD, ALS)
In a particular context
(e.g., acute hospital, rehab)
Slide8A step back –Diagnosis is often “therapeutic”
DX can provide relief/comfort
prior
uncertainty was
source
of
distress
Even
when
no
curative medical therapy or when available therapies are
suboptimal
Sometimes, diagnosis
is
the
treatment
Patients
with essential voice tremor
may
be satisfied with
explanation/label/reassurance; no
desire
for TX
Diagnosis & explanation may
have psychosocial
value
Pts
with
SD
receive more favorable personality ratings when
label available
to listeners
(
Eadie
at al., 2016).
Slide9Ingredients can be…MedicalPharmacologicSurgicalProsthetic
Behavioral
None are mutually exclusive!
Slide10Medical Interventions Surgical or pharmacologic interventions that directly or indirectly affect speech…
Speaker-oriented
Often should precede or be concurrent with behavioral therapy
Slide11Medical Interventions Often require collaboration, especially when speech improvement is their purposeSpeech clinician helps ID need
likelihood of benefit
specific benefits
what it will not accomplish
need for behavioral therapy
cost-benefit estimate
Slide12Prosthetic Management
Temporary or permanent mechanical & electronic devices designed to improve speech or assist
communication
May or may not require much learning/practice
Speaker-oriented or communication-oriented
Slide13More generally known about surgical, pharmacologic & prosthetic treatments than behavioral management May have quickly apparent & sometimes rapidly dramatic effects on speech
When ineffective
outcome known
more
quickly
reason
for
failure often apparent
subsequent
modifications or
alternative treatments
can be
pursued
.
Slide14Behavioral TreatmentPatient does something aimed at improving function & adheres to suggested performance requirementsRequires mental &/or physical effortTwo general types of ingredients:
Directly geared to
achieve
TX
effect
exercise
increased
loudness
Instructional
or motivational
help
maximize
chance patient
will perform
exercise and
as instructed (e.g., two times
daily)
Speaker or communication-oriented
Slide15Demonstrating efficacy of behavioral TX is more difficult than for most medical
& prosthetic interventions
Behavioral
tx
takes time (skill acquisition)
Tx
effects
interact with natural course & variability of underlying disease
Defining behavioral TX so it can be replicated not easy
Change - even when meaningful - may not be dramatic
Measuring outcomes can be challenging
Slide16Primary Aims of “It”Maximize effectiveness, efficiency
, &
naturalness
of communication (any one or all)
Examples
Mild – perhaps all three goals
Moderate – intelligibility or comprehensibility, & efficiency
Severe – Effective & efficient augmented or alternative means of communication
Slide17Primary Directions of ManagementRestore lost function - reduce impairmentPromote use of residual function -
compensate
Slide18Is asking “Is it worth the effort?” the same as asking “Is it effective & efficacious?”
???
Slide19“Is it effective/efficacious?”What is the level of evidence?
Slide20Evidence Based Practice‘‘… is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.’’
(
Sackett et al., 1996)
Slide21“There is no special treatment for the dysarthric disturbance of speech.” (Mohr, 1991)
Slide22Is this the recent best evidence?2017 Cochrane Database systematic review concluded there are no definitive, adequately powered RCTs of intervention for adult-acquired, non-progressive dysarthrias
(Mitchell et al., 2017
)
Slide23At the top of the pyramid……
Yetley
et al., 2016
Slide24Rosenbek JC. Tyranny of the randomised control trial. Int J Speech-Lang Pathol. 2016; 18:241-249.Required reading!Re-evaluate the RCT’s dominance
Addresses limitations of much published treatment research in neurologic communication disorders
Not just RCTs
Slide25Rosenbek JC. Tyranny of the randomised control trial. Int J Speech-Lang Pathol. 2016; 18:241-249.Three components of Evidence Based Practice (EBP)
Evidence
: research-based data (with RCTs as king)
Expertise
Patient
preference
Clinicians often told by those under tyranny’s heel that no evidence exists for certain techniques
Because of absence of RCTs
Slide26Rosenbek JC. Tyranny of the randomised control trial. Int J Speech-Lang Pathol. 2016; 18:241-249.Most clinicians outside university/research
environments cannot do what is done in most studies
Can’t
provide the dose or patients can’t handle
dose
(e.g., Page & Wallace, 2014, re aphasia)
Heterogeneity
is norm in many practices
In research, sample homogeneity is critical to
validity
Slide27Rosenbek JC. Tyranny of the randomised control trial. Int J Speech-Lang Pathol. 2016; 18:241-249.ConclusionsAbsence of RCTs is not absence of evidence
No
RCT goes
automatically to
top of
hierarchy
Replace RCT tyranny with tripartite governance
Best
available
evidence
Clinical experience & expertise
‘‘
Without clinical expertise, practice risks becoming
tyrannised
by evidence’’
(Sackett et al.
1996
)
Patient preference & reported outcomes (PROs)
Slide28Rosenbek JC. Tyranny of the randomised control trial. Int J Speech-Lang Pathol. 2016; 18:241-249.Caveat!
“Clinicians
need to remember that the weaker the evidence the
greater
the need for
vigilance.”
Slide29Less Tyranny?Recent Cochrane Database systematic review concluded there are no definitive, adequately powered RCTs
of intervention for adult-acquired, non-progressive
dysarthrias
“People
with dysarthria after stroke or brain injury should continue to receive rehabilitation according to clinical guidelines.”
(Mitchell et al., 2017
)
Slide30So…Is “it” effective?Teaser - “
Today
most reasonable treatments are supported, even if feebly.”
(Rosenbek, 2016)
Slide31The Dysarthrias
Slide32Published Systematic Reviews- Dysarthria
Baylor et al. A systematic review of outcome measurement in
unilateral vocal fold paralysis
.
J Med Speech-Lang
Pathol
14:xxvii, 2006.
Duffy
& Yorkston:
Medical interventions for
spasmodic dysphonia
and some related conditions: A systematic review.
J Med Speech-Lang
Pathol
11: ix, 2003.
Hanson, Yorkston,
&
Beukelman
:
Speech supplementation techniques
for dysarthria: a systematic review.
J Med Speech-Lang
Pathol
12:ix, 2004.
Spencer, Yorkston, & Duffy:
Behavioral management of
respiratory/phonatory dysfunction
for
dysarthria: A flowchart for guidance in clinical decision-making.
J Med Speech-Lang
Pathol
11:xxxix, 2003.
Yorkston et al. Evidence for effectiveness of
treatment of loudness, rate, or prosody
in dysarthria: a systematic review.
J Med Speech-Lang
Pathol
15:xi, 2007.
Yorkston et
al.: Evidence-based practice guidelines for dysarthria: Management of
velopharyngeal dysfunction
.
J Med Speech-Lang
Pathol
9:257, 2001.
Yorkston, Spencer,
& Duffy JR: Behavioral management of
respiratory/phonatory dysfunction
from dysarthria: a systematic review of the evidence.
J Med Speech-Lang
Pathol
11:xiii, 2003.
Slide33Pharmacologic (examples)
Artane
(
trihexyphenidyl
)
Dantrium
(
dantrolene
sodium)
Elavil (amitriptyline)
Inderal (propranolol)
Klonopin
(clonazepam)
L-Dopa (levodopa)
Xanax (alprazolam)
Lioresal
(baclofen)
Nuedexta
(dextromethorphan)
Mestinon
(
pyridostigmine
bromide)
Mysoline
(primidone)
Reserpine
Sinemet
(carbidopa-levodopa)
Tegretol
(carbamazepine)
Valium (diazepam)
Botox
Slide34Medical/Surgical (examples)Medialization laryngoplasty (vocal fold paralysis, hypofunction)
Injectible
substances
(e.g.)
autologous fat,
gelfoam
, hyaluronic acid - laryngeal or velopharyngeal incompetence
Botox - laryngeal dystonia (SD); tremor; mandibular dystonia
Deep brain stimulation (DBS)
- PD, E.T., dystonia
Pre DBS MSD might be targeted
Slide35Prosthetic ManagementTemporary or permanent mechanical & electronic devices designed to improve speech or assist communication
Vocal Tract Modifiers – structural/postural
Palatal lift prostheses
Nose
clip/nasal
obturator
Neck brace or cervical collar (posture
)
Adjustable beds/wheelchairs
Bite block
Acoustic signal modifications – electronic
Voice amplifiers
Vocal intensity feedback devices
Slide36Prosthetic/Behavioral Management
Speech modifiers (require learning)
Delayed auditory feedback (DAF)
Pacing board
Alphabet supplementation
Slide37Prosthetic & Behavioral Management
--
Alternative Communication
Low-tech to high tech
Dramatic development & refinement
Wide array of dedicated electronic & computerized devices
Apps for non-dedicated, very portable devices (e.g., smart phones, iPad)
Most dramatically effective for people with MSDs & relatively preserved/adequate cognitive/language abilities
No further discussion today
Slide38Behavioral Management - DysarthriasIn general, for many ingredients, level of evidence (data) is not highSome single S design studies Uncontrolled case reports (pre-post)Expert opinion & patient testimony
Slide39Lee Silverman Voice Treatment (LSVT) -- A model for establishing behavioral tx efficacy? Strong theoretical & clinical rationale
Well-specified, replicable treatment program for a specific disorder (hypokinetic dysarthria; PD)
Programmatic approach to efficacy research
(multiple data-based refereed publications since early 1990s)
Pre-post case studies
Group outcomes (pre vs post tx)
Group comparisons (e.g., LSVT vs respiration tx)
Documented short- & long-term benefits
Tx effects documented multiple ways
(e.g., perceptual, aerodynamic,
laryngostroboscopic
, acoustic, social validity, neuroimaging)
Slide40LSVTEffective outcomes obtained with same # sessions spread over 8-weeks or with fewer sessions during 4-weeks with
increased home
practice
Delivered
via
telerehabilitation
or
though iPad-based
Facetime resulted
in clinical
& QOL
outcomes
similar to that obtained face-to-face
(Griffin
et al.,
2018;
Theodoros
et al.,
2016)
Slide41Of note…LSVT versus “traditional dysarthria therapy” (combinations of many behavioral techniques) examined in 26 people with variety of chronic dysarthria types caused by stroke or
TBI
TX 1
hour per
day x 4
days a
week x 4 weeks
Improvements in intelligibility for both
treatments, with no differences between
TXs
(
Wenke
et al.,2010)
Suggests
intensity
is an important active ingredient
Slide42Behavioral Management Ingredients (N = 64) Respiratory/Speech Breathing (18)Controlled exhalation (slow uniform exhalation) Expiratory muscle strength training (EMST)
inspiratory
checking
Phonation (12)
Effort closure
techniques
Initiate
phonation @ start of
exhalation
Intense
, high-level phonatory effort (LSVT)
Resonance (7)
Exaggerate jaw movement
CPAP
Slide43Behavioral Management Ingredients (cont.) Articulation (15)Strengthening exercises
Biofeedback
(e.g., EMA, EPG)
Sensory tricks
exaggeration of consonants (“clear speech
”)
Prosody & Naturalness (6)
Contrastive
stress tasks (may also help rate control)
Referential tasks focused on stress
Slide44Behavioral Management IngredientsRate - “
Maybe
the most powerful behaviorally modifiable variable for improving intelligibility”
(6)
(
Yorkston et al ‘92
)
hand/finger
tapping
Syllable x syllable production
“Clear
speech”
Slide45Ingredient effects may or may not vary as function of dysarthria typeType-independentslow rate; “clear speech” Specific to typeLSVT (hypokinetic)
strengthening exercise (flaccid)
Botox & sensory tricks (hyperkinetic)
Contraindicated/no face validity for type
Botox (flaccid); strengthening exercise (ataxic, hyperkinetic)
Slide46Communication-oriented ingredients- appropriate for all MSDs (examples)
Speaker Strategies
Alerting signals
Set context
Modify content & length
Listener
Strategies
Maximize
listener hearing & visual acuity
Perceptual
training or listener
familiarization
(
Borrie
&
Schäfer
, 2017
)
Interaction Strategies
Maintain eye contact
Establish
methods of feedback
(e.g., locus of breakdown, cues for repairs, fail-proof strategies)
Establish
what works best when
Slide47Apraxia of speech (AOS)
Slide48Published Systematic Reviews- AOS
Ballard, K.J.,
Wambaugh
, J.L., Duffy, J.R.,
Layfield
, C., Maas, E.,
Mauszycki
, S., & McNeil, M.R. (2015). Treatment for acquired
apraxia of speech
: a systematic review of intervention research between 2004 and 2012.
American Journal of Speech-Language Pathology
, DOI:10.1044/2015_AJSLP-14-0118.
Wambaugh
et al.: Treatment guidelines for acquired
apraxia of speech
: a synthesis and evaluation of the evidence. J Med Speech-Lang
Pathol
, 14, 15-32, 2006.
Wambaugh
et al.: Treatment guidelines for acquired
apraxia of spe
ech
: treatment descriptions and recommendations. J Med Speech-Lang
Pathol
, 14, 25-67, 2006.
Slide49Prosthetic/Behavioral ManagementRate reduction devicesMetronomePacing board
Biofeedback
EMG feedback
&
vibrotactile
stimulation
EMA & EPG
Slide50Adjunctive TreatmentsTranscranial direct current stimulation (tDCS)Patients with chronic AOS
improved
articulatory accuracy beyond that achieved with speech therapy alone
(
Marangolo
et al., 2011, 2013).
Slide51Behavioral Management - AOSOn average, ahead of dysarthria behavioral treatment re evidence
Slide52Articulatory-Kinematic (A-K) approachesSound Production Treatment (SPT) (Wambaugh et al.)
Efficacy data more adequate than any other AOS
TX
Eight-step continuum
(
Rosenbek
)
Prompts for
Restruturing
Oral Muscular Phonetic Targets (PROMPT)
(
Chumpelik
et al.)
Motor Learning Guided (MLG) Treatment
Multiple other approaches & techniques
Biofeedback (EMA, EPG)
Slide53Rate/Rhythm ApproachesMetrical Pacing Therapy (MPT) (Brendel & Ziegler)Melodic intonation therapy (Sparks et al.)
Metronome
& related pacing techniques
Pacing board, hand tapping
Slide54What is “Worth” ???Efficacy/Effective?By what measure(s)?At what cost?
Slide55Worth/ValueWhat does treatment buy?Normalcy – intelligible, efficient, natural?Improved intelligibility? How much?Improved communication? How much?Patient & others’ satisfaction with care?Including counseling
Including recommendation for no treatment
Unnecessary or not desired
Inappropriate for time, place, circumstances
Slide56Worth/ValueConvey estimate prior to TX, based on Evidence (data)Experience & opinionIncluding options, when appropriateIf TX A, then outcome B (e.g., LSVT)If TX X, then outcome Y (e.g., comprehensibility strategies)
Slide57Factors influencing management decisions & what TX may buy (examples)Biopsychosocial traitsEtiology & prognosis (e.g., stroke, TBI, ALS, PD)
Severity
Social support
Motivation & needs (crucial!)
Context
Duration of hospitalization, rehab facility, NH
Outpatient tx options (e.g., ability to travel; telepractice)
Health care coverage
Slide58What is “Effort” ???
Slide59Effort?DurationMotor learning requires practice - Practice takes timeOne session, one month, extendedPhysical demands
High vs low intensity
Sustained effort
Cognitive demands
Many TXs are
cognitive-motor
Sustained effort
Slide60Effort - Compliance/Adherence “From the perspective of concerningly poor therapy compliance…we should be asking if what we offer to patients is what they need or what we
want
them to need.”
(
Spencer
, 2015
)
Decision to treat and what and how to treat should be mutually determined to increase probability of adherence to TX recommendations
Slide61Treatment for some will failDespite well-planned, skilled, evidence & experienced-based efforts True for health care in general Requires more than passive acceptance or denial
“There
is an ethical imperative to be more explicit in our communal recognition of the limits of
treatment…there
is a pressing need for greater research into and discussion of the limits of treatment and treatment failure.”
(
Wolpert
, 2016)
Slide62In rehabilitation, knowing what methods do not work is as important as knowing the ones that do
Slide63Managing MSDs - The Current Bottom Line
Dysarthria
“There is both scientific & clinical evidence that individuals with dysarthria benefit from the services of speech-language pathologists. This evidence is documented in experimental research, program evaluation data, & case studies.”
(
Yorkston, 1996)
Slide64Managing MSDs - The Current Bottom LineApraxia of speech AOS)
“…
an ever-increasing literature supports the efficacy of treatment…”
McNeil
, Robin & Schmidt,
2009
“
The most important global clinical conclusion from this review is that the weight of evidence supports a strong effect for both articulatory–kinematic and rate/rhythm approaches to AOS treatment.”
Ballard
et al (2015)
Slide65So, Is It Worth It?YES… ifSupported by evidence data – the stronger the better!; experience; expert opinionProvided to those whose preferences & biopsychosocial traits appropriately fit the TX At a point in time & in a setting in which the TX can be applied with fidelity
Slide66The Yes” is a work in progressWe do not know as much about effects of treatment for MSDs as we shouldNot unusual for health care interventions
in
general
Long-range goal
MSD TX to
be conducted with firm evidence of
efficacy
ineffective
treatments
recognized & discarded
new
treatments
embraced
because of factual rather than factitious information about
efficacy