Speech Therapy for Motor Speech Disorders: Is It Worth The Effort? - PowerPoint Presentation

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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

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Speech Therapy for Motor Speech Disorders: Is It Worth The Effort?

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Possible AnswersWe do not knowNo (never)Yes (always)Sometimes yes, sometimes no, sometimes we do not know…It depends…

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One CertaintyThere are no simple answers to complex problems and this problem – the treatment/management of MSDs –

IS complex

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Is It Worth the Effort?What is “IT” ?What is “WORTH” ?

What is “EFFORT” ?

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What is “It” (“speech therapy”) ???

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“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)

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A 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).

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Ingredients can be…MedicalPharmacologicSurgicalProsthetic

Behavioral

None are mutually exclusive!

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Medical Interventions Surgical or pharmacologic interventions that directly or indirectly affect speech…

Speaker-oriented

Often should precede or be concurrent with behavioral therapy

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Medical 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

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Prosthetic 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

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More 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

.

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Behavioral 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

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Demonstrating 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

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Primary 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

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Primary Directions of ManagementRestore lost function - reduce impairmentPromote use of residual function -

compensate

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Is asking “Is it worth the effort?” the same as asking “Is it effective & efficacious?”

???

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“Is it effective/efficacious?”What is the level of evidence?

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Evidence 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)

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“There is no special treatment for the dysarthric disturbance of speech.” (Mohr, 1991)

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Is 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

)

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At the top of the pyramid……

Yetley

et al., 2016

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Rosenbek 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

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Rosenbek 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

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Rosenbek 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

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Rosenbek 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)

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Rosenbek 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.”

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Less 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

)

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So…Is “it” effective?Teaser - “

Today

most reasonable treatments are supported, even if feebly.”

(Rosenbek, 2016)

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The Dysarthrias

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Published 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.

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Pharmacologic (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

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Medical/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

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Prosthetic 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

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Prosthetic/Behavioral Management

Speech modifiers (require learning)

Delayed auditory feedback (DAF)

Pacing board

Alphabet supplementation

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Prosthetic & 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

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Behavioral 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

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Lee 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)

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LSVTEffective 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)

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Of 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

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Behavioral 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

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Behavioral 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

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Behavioral 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”

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Ingredient 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)

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Communication-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

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Apraxia of speech (AOS)

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Published 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.

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Prosthetic/Behavioral ManagementRate reduction devicesMetronomePacing board

Biofeedback

EMG feedback

&

vibrotactile

stimulation

EMA & EPG

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Adjunctive TreatmentsTranscranial direct current stimulation (tDCS)Patients with chronic AOS

improved

articulatory accuracy beyond that achieved with speech therapy alone

(

Marangolo

et al., 2011, 2013).

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Behavioral Management - AOSOn average, ahead of dysarthria behavioral treatment re evidence

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Articulatory-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)

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Rate/Rhythm ApproachesMetrical Pacing Therapy (MPT) (Brendel & Ziegler)Melodic intonation therapy (Sparks et al.)

Metronome

& related pacing techniques

Pacing board, hand tapping

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What is “Worth” ???Efficacy/Effective?By what measure(s)?At what cost?

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Worth/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

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Worth/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)

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Factors 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

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What is “Effort” ???

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Effort?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

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Effort - 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

Slide61

Treatment 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)

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In rehabilitation, knowing what methods do not work is as important as knowing the ones that do

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Managing 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)

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Managing 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)

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So, 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

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The 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