امکان سنجی درمان صدای گروهی برای افراد با بیماری پارکینسون

Abstract Purpose The primary purpose was to demonstrate the feasibility of executing treatment tasks focused on increasing loudness in a group format for individuals with Parkinson's disease (PD). A second purpose was to report preliminary pre-to-post treatment outcomes for individuals with PD immediately after they complete the group program. Methods The group intervention is described. Fifteen adults with PD who participated in the group and three clinicians leading the group provided feedback about the execution of the intervention. The participants also provided voice samples and self-ratings of voice handicap once before completing the 8-week voice group and once immediately after completing the voice group. Outcome measures included voice intensity, fundamental frequency (F0) mean, standard deviation and range, maximum phonation time, and listener judgment of loudness. Results Feedback from the clinicians suggested that many, but not all, of the voice activities could be executed within a group setting. Participants with PD indicated they understood the focus of the group and that subjectively they felt the group was helpful for increasing loudness. Statistically significant increases occurred for voice intensity, F0 maximum, and F0 range. Voice handicap scores decreased significantly and 80% of the participants were judged louder post intervention. Conclusions Clinician and participant feedback indicated that it was feasible to execute most LSVT® tasks in a group format with some modifications. The preliminary outcome data indicate that the targeted behavior (voice dB and loudness) did change in the predicted direction as did several other measures. Future studies comparing outcomes of group intervention to the gold standard LSVT®, and exploring retention of treatment gains over time, are needed. Learning outcomes: After reading the manuscript, readers will be able to: (1) Describe previous attempts at group intervention to improve voice for individuals with Parkinson's disease. (2) List three ways that the group intervention tried in this study differed from LSVT®. (3) Identify three limitations to this study that must be addressed before advocating implementation of the group approach in clinical situations.

Voice and speech disorders are common in individuals with Parkinson's disease (PD) (Hartelius and Stevens, 1994 and Logemman et al., 1978) and reduced loudness is frequently reported (Ramig, Fox, & Sapir, 2004). Unfortunately, pharmacological and surgical treatments that are often effective in managing PD symptoms in the limbs do not consistently facilitate speech, and therefore, cannot be relied upon as a primary treatment approach for the hypokinetic dysarthria in this population (De Letter et al., 2006, Kompoliti et al., 2000, Quaglieri and Celesia, 1977, Skodda et al., 2010 and Tripoliti et al., 2011; see Trail et al., 2005 for review). Until the early 1990s, individual speech therapy for voice deficits associated with PD often yielded disappointing results with therapeutic gains sometimes limited in terms of the magnitude of change or the ability to retain improvements outside the therapeutic situation (e.g., Downie et al., 1981, Erb, 1973 and Sarno, 1968). However, over the past 15 years, the Lee Silverman Voice Treatment® (LSVT®) has been tested via randomized controlled trials which have provided evidence of both immediate voice and speech changes and long-term retention of gains up to 2 years post-completion of the therapy (Fox et al., 2006 and Ramig et al., 2001). LSVT® is intended to increase voice loudness in individuals with PD, although improvements to communication extending beyond loudness have been documented, including voice quality (Baumgartner, Sapir, & Ramig, 2001), prosody (Ramig et al., 2001), and articulation (Sapir, Spielman, Ramig, Story, & Fox, 2007). Several unique aspects of the LSVT® program are likely responsible for successful outcomes, including the intensity and frequency of the treatment (60 min, high effort sessions; 4 times/week for 4 weeks), and a focus on both sensory (i.e., recognizing appropriate effort and loudness level) and motor training (i.e., using increased effort and loudness). The intensity and frequency of the treatment are believed to be important, along with a simple and singular focus on being loud. The therapy is designed to facilitate the learning of a new motor task to the point where the higher effort and louder voice becomes an automatic behavior not requiring external cuing (Spielman, Ramig, Mahler, Halpern, & Gavin, 2007). To offer therapy using the name LSVT®, a speech-language pathologist (SLP) must complete a certification course and administer the program as prescribed. This is done, in part, to help assure the individual with PD that they are receiving the therapy upon which the outcome research has been completed. However, the developers of the LSVT® program, and others, have recognized that the treatment schedule may limit how many SLPs offer, and how many individuals with PD receive LSVT® (Spielman et al., 2007). Scheduling a patient for four therapy sessions a week for 4 weeks in a row may be difficult for many SLPs unless they have specific time set aside to deliver LSVT®. The intense schedule may be problematic for the individuals with PD if they are working, live far from a licensed and LSVT®-certified SLP, or rely on others for transportation. These therapy access concerns have prompted a search for ways to increase accessibility to the program or to alter its delivery. In this study we describe the feasibility of executing group intervention on a less frequent treatment schedule than LSVT®.