Nihms429670 Speech Breathing Treatment PDF

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J Med Speech Lang Pathol. Author manuscript; available in PMC 2013 August 12.
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J Med Speech Lang Pathol. 2004 December ; 12(4): 213219.
Speech-Breathing Treatment and LSVT for a Patient With

Hypokinetic-Spastic Dysarthria After TBI
Nancy Pearl Solomon, Ph.D.,
Walter Reed Army Medical Center, Washington, DC
Matthew J. Makashay, Ph.D.,
Leslie S. Kessler, M.A., and
The Language Experience, Rockville, Maryland
Katherine W. Sullivan, M.A.
Abstract
Previously, we reported improved speech breathing and intelligibility after behavioral treatment
for a man with hypokinetic-spastic dysarthria following traumatic brain injury (TBI) (Solomon,
McKee, & Garcia-Barry, 2001). Treatment included the Lee Silverman Voice Treatment (LSVT)
program followed by 6 weeks of speech-breathing training, physical therapy, and LSVT-type
tasks. In this article, we report a new patient with similar speech characteristics post-TBI.
Breathing-for-Speech Treatment (BST), custom designed to improve nonspeech- and speech-
breathing coordination, was followed by LSVT. After BST, speech breathing approached normal
levels; after LSVT, speech breathing improved further and intelligibility improved markedly.
Gains generally were maintained up to 4 months, but were limited by the spastic characteristics of
his dysarthria and sporadic medical complications.
The Lee Silverman Voice Treatment (LSVT) program was developed to improve speech in
persons with hypokinetic dysarthria associated with Parkinson disease (PD) (Ramig, 1995).
It has been tested in a relatively large number of people with PD, and available evidence
supports its effectiveness for up to 2 years (Ramig et al., 2001). Less often, LSVT has been
used with patients who have other etiologies, including Parkinson-plus syndromes
(Countryman, Ramig, & Pawlas, 1994) and multiple sclerosis (Sapir et al., 2001). Results
from these cases are guarded by the apparent need to supplement or extend the standard 4-
week program and evidence of decreased effectiveness over subsequent months.
Previously, we published a case study of a young man who presented with mixed
hypokinetic-spastic dysarthria 20 months post-TBI (Solomon et al., 2001). He participated
in LSVT followed by 6 weeks of Combination Treatment that included speech-breathing
training, physical therapy, and LSVT-type tasks. The additional treatment was deemed
necessary because of minimal improvement in speech breathing and speech intelligibility
following LSVT alone. Marked improvements resulted after the full 10-week program, and
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

Address correspondence to Nancy Pearl Solomon, Ph.D., CCC-SLP, Army Audiology & Speech Center, Walter Reed Army Medical
Center, 6900 Georgia Ave. NW, Washington, DC 20307 USA. Nancy.P.Solomon@us.army.inil.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting
the views of the Department of the Army or the Department of Defense.
Solomon et al. Page 2
these gains were maintained for several months. To further examine the viability of LSVT as
a treatment strategy for patients with mixed hypokinetic-spastic dysarthria, we replicated the
study in a similar patient. In contrast to the previous study, we simplified the Combination
Treatment to focus only on nonspeech and speech breathing, conducted treatments in reverse
order, and included multiple baseline assessments. Data also were collected after 6 weeks of
Breathing-for-Speech Treatment (BST), after the 4-week LSVT program, and 1- and 4-
months posttreatment.
CASE DESCRIPTION
CM (fictitious initials), a 58-year-old highly educated man, sustained a traumatic closed-
head injury following a suspected assault and fall. CT imaging revealed subarachnoid
hemorrhage (left > right), including contusions of the left frontal and both temporal lobes.
His 1.5-month hospital course was significant for a 15-day coma, intubation, and a
percutaneous gastrostomy tube. After discharge, CM participated in a 2-month rehabilitation
day program. At 8-months postinjury, he was re-admitted briefly for suicidal ideations,
disinhibition, and general functional decline. At that time, speech-language assessments
revealed global cognitive-linguistic deficits and mild-moderate dysarthria, with 71%
sentence intelligibility (Sentence Intelligibility Test [SIT]) (Yorkston, Beukelman, & Tice,
1996) to an unfamiliar listener. At 10 months postinjury, CM was seen in our outpatient
speech clinic. His primary complaint was poor speech intelligibility that prevented
functional independence and socialization.
Motor-Speech Evaluation
Clinical evaluation 10 months post-TBI revealed moderate hypokinetic dysarthria with
milder spastic features. Speech was characterized by low loudness, short breath groups,
rushes of speech, imprecise consonants, monopitch, harsh voice, and hypernasality.
Intelligibility (SIT) was 79.5% to an unfamiliar listener. Speech alternating motion rates
(AMRs) were rapid and blurred. Nonverbal oral apraxia and volitional-breathing
dyscoordination were notable. The lower face (L > R) and tongue evidenced spastic paresis.
Rigid videostroboscopy revealed normal laryngeal structure and function bilaterally. Vital
capacity was 4.32 L (97% predicted).
To assess CMs candidacy for LSVT, we conducted two sessions of trial therapy 3 weeks
apart. Volitional control of breathing was markedly uncoordinated, but performance
improved in the supine position and with tactile feedback. CMs initial attempts at loud
phonation resulted in a strained, harsh voice. He was inconsistently stimulable for loud,
clear phonation during vowels. Positive prognostic indicators included high motivation,
good comprehension of tasks, and dysarthria type. Negative indicators were impaired
cognition, history of depression, and limited stimulability. We explained LSVT to CM and

prescribed daily breathing-coordination exercises.
Treatments
An experienced LSVT-certified speech-language pathologist (SLP) conducted all treatment
sessions. The first treatment phase, BST, took 11 hour-long sessions over 6 weeks (from 04
sessions/week, constrained by vacations and illnesses). The goals of BST were to achieve
relaxed, coordinated breathing for nonspeech and speech activities. Nonspeech breathing
targeted slow-to-moderately paced abdominal and rib cage expansion during inspiration, and
relaxed expiration. Breathing was produced without motor overflow or excessive muscle
tension, especially in the tongue or neck. Body position progressed from supine to seated to
standing. Movements then progressed from walking in place, treadmill walking, and free
walking. At each level, tactile cues were used and quickly faded, and 90% accuracy was
required. Speech-breathing tasks required the same essential target behaviors with the
additional goal of rapid inspiration followed by controlled expiration with vocalization.
Tasks progressed from sustained phonation to words to short phrases to simple sentences to
complex speech tasks including complex sentences, poetry, paragraph reading, question-
answer responses, and conversation.
The second treatment phase was LSVT, which, in brief, consisted of four hourly sessions per
week for 4 weeks. Goals were to maximize (1) loudness and duration of sustained vowels;
(2) pitch range; and (3) loudness during short phrases, paragraph reading, and conversation.
Full calibration (habituation of effort level) at each level was required.
DATA COLLECTION
Data were collected twice before initiating intervention (BL1 & BL2, 2 months apart), twice
1 month later, immediately following trial therapy (BL3 & BL4, 1 week apart), once the day
after completing BST, once the day after completing LSVT, and 1 month and 4 months
following discharge from treatment. CM continued LSVT exercises daily after discharge.
Unfortunately, between the 1-month and 4-month follow-up sessions, CM experienced
seizure activity and transient functional decline. Details regarding laboratory data-collection
procedures were published previously (Solomon et al., 2001) and are summarized briefly
here.
Self-Rating of Speech Disability

The Voice Handicap Index (VHI) (Jacobson et al., 1997), was self-administered. To
improve its relevance, we instructed CM to substitute speech for voice.
Intelligibility
CM was instructed to read sentences clearly that were randomly selected from the SIT
inventory, according to standard instructions in the manual (Yorkston et al., 1996). The
sentences were played later over headphones to three normal listeners, who followed
standard scoring procedures. Median scores (percent of words identified correctly) were
used.
Breathing Assessment
Chest-wall kinematic signals, using respiratory inductive plethysmography (RIP,
Ambulatory Monitoring), provided data for breathing-task assessments. CM was seated in a
sound-treated booth for all tasks. Rib cage and abdomen signals were calibrated for lung
volume by multiple isovolume maneuvers at resting expiratory level (REL), and specific-
volume maneuvers (~1 L above and ~0.5 L below REL, MedGraphics CPFS/D). Kinematic
and acoustic data (AKG C420 head-mounted microphone) were digitized simultaneously at
6 kHz (DATAQ DI-720) onto a laboratory computer. Breathing data were taken from
resting tidal breathing (RTB, 1015 cycles), two oral readings of the Rainbow Passage
(sentences 26; total = 2432 breath groups), and two extemporaneous monologues (15
breath groups from each, excluding the first). Perceptual studies and orthographic
transcriptions of the reading and monologue (and SIT) tasks relied on acoustic signals also
recorded on a digital workstation (Boss BR-1180) at 44.1 kHz.
Measurement variables were lung-volume initiation, termination, and excursion (LVI, LVT,
LVE), number of syllables, and duration of each breath group (expiratory phase). Expiratory
speech rate (ESRate) was calculated as syllables per speech-expiration duration. Summary
data from the baseline sessions were averaged and used for comparison to the posttreatment
sessions according to the criteria established by Schulz, Peterson, Sapienza, Greer, and
Friedman (1999) and as used by Solomon et al. (2001).
Other Perceptual Measures

Sentences 26 (~30 second) of one reading trial and a 2832-second excerpt from a
monologue from each session were rated by five SLPs (833 years experience) for
articulatory precision, breathiness, and overall severity along separate 7-point scales (1 =
normal; 7 = severe). A 30-minute training session included listening to seven nontest speech
samples by CM, rating three additional speech samples, and consensus discussions. The
SLPs then independently listened over headphones to the test samples from each session,
which were randomized within task and across listeners. Median ratings were used.
RESULTS
Voice Handicap Index
CMs score on the VHI indicated a substantial handicap during the initial assessment (10-
months post-TBI). After LSVT, his ratings indicated minimal disability (Table 1), but the
score returned to the severe range 4 months after discharge from treatment.
Sentence Intelligibility
SIT scores varied from 62 to 91% across three sessions in the 5 weeks before treatments
(Table 1). Scores appeared to be related to loudness level; during Session BL3, which
immediately followed trial therapy, CM spontaneously read quite loudly (because we had
told him about LSVT, and he was trying to impress us) and attained a SIT score of 91%.
When asked to read typically, intelligibility dropped to 62%. Because of this discrepancy,
we repeated the SIT 1 week later (Session BL4), first instructing him to read typically and
then to read loud and clear. Both productions resulted in similarly low scores, revealing
that improved intelligibility was not under consistent volitional control. Moreover, scores
from BL3 provided clear evidence that CM was able to improve intelligibility, and hence,
was a good candidate for treatment.
After BST, sentence intelligibility was essentially unchanged. After LSVT, SIT improved to
96%, a level that was maintained 1 month after discharge whether he was instructed to speak
loudly or typically. Four months after treatment, SIT scores decreased slightly (8791%).
Speech Breathing
Speech breathing was markedly abnormal before treatment (Figure 1). Most notably, speech
typically was initiated at approximately the same lung-volume level as RTB rather than at
the expected level of twice RTB. Speech breath groups were short in terms of number of
syllables and duration (Table 1). After BST, lung-volume levels tended to improve towards
normal values, and reading rate tended to decrease. After LSVT, LVI and LVE increased
reliably from baseline, and more syllables tended to be produced per breath group for both
tasks. Phrasing and breath-group length were abnormally low at each assessment session.
Syllables per breath group increased after trial therapy (BL3), but CM accomplished this by
increasing ESRate. After LSVT, syllables per breath group during monologue tended to
increase without a concomitant increase in ESRate. Four months after treatment, lung-
volume levels generally were maintained, and reading rate continued to decrease.
Perceptual Ratings of Speech

Experienced SLPs rated CMs speech as mildly to moderately impaired for breathiness,
articulation, and overall dysarthria for all sessions. Mild improvements in articulatory
precision and breathiness were perceived after treatments. However, there was no systematic
difference in overall severty of dysarthria. Articulatory precision and overall severity were
affected by apparent spasticity of the tongue and lips, as well as persistent hypernasality.
DISCUSSION
One year after a severe TBI, CMs primary residual complaint was dysarthria. He
successfully completed two phases of treatment, BST and LSVT, by meeting all treatment
goals. CM expressed extreme satisfaction with his treatments, as indicated by a drastic
reduction in his VHI scores. However, several months later, his VHI score returned to the
severe range, indicating his continuing awareness of deficits, frustration from new seizure
activeity, and perhaps reflecting his cognitive difficulties responding to a graded rating
scale. Despite this score, CM claimed that he was more confident, better able, and more
willing to engage in communication. His wifes appraisal of his handicap, a structured
interview, confidence ratings, or some other psychosocial measure might have better
captured CMs functional and social abilities.
Speech breathing before treatment was characterized by lower than normal lung volume
initiations and short phrases. BST alone improved speech breathing, but there was no
corresponding increase in intelligibility. Despite variable SIT scores before treatment, we
were able to demonstrate a consistent improvement in sentence intelligibility after the full
course of treatment (BST followed by LSVT). Four months later, speech-breathing gains
remained, and sentence intelligibility only declined slightly. Perceptual characteristics of
speech improved subtly after treatment, and these changes were not maintained after 4
months. Our clinical impression is that persisting features of spastic dysarthria had an
overriding effect on listeners perceptions. Contributing instead to increased intelligibility
may have been the improvements in phrasing and rate. These measures may have been more
sensitive to functional improvements in speech than the perceptual judgments. Including
multiple measures was beneficial because each appeared to address different aspects of
dysarthria. Caution must be exercised, however, when comparing the SIT scores to the
speech ratings from the reading and monologue samples because of task differences.
The two cases of hypokinetic-spastic dysarthria secondary to TBI that we have reported thus
far demonstrated improved speech breathing and consistently improved speech intelligibility
after treatment, and to some extent for at least several months after discharge. Other
functional gains included sustained employment by the previously published patient
(Solomon et al., 2001) and decreased self-perceived disability by this patient. Both the BST
and LSVT treatment phases appeared necessary to effect positive outcomesdespite
providing the treatments in opposite order, neither patient demonstrated improvements in
intelligibility after the first phase. Furthermore, progress for both patients was limited by the
spastic features of their dysarthria. Careful manipulation of treatments in additional patients
and continued follow-up are needed to more completely address treatment effectiveness for
hypokineticspastic dysarthria after TBI.
Acknowledgments
This research was supported in part by NIDCD Grant R03-DC06096. A portion of the clinical services was donated
by The Language Experience, a speech-language pathology private practice in Rockville, MD. We appreciate the
assistance of Laura Battiata, Joyce Gurevich, JoAnn Lamm, Sandra Martin, and Lisa Newman.
REFERENCES
Countryman S, Ramig LO, Pawlas AA. Speech and voice deficits in parkinsonian plus syndromes:
Can they be treated? Journal of Medical Speech-Language Pathology. 1994; 2:211225.
Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, Newman CW. The
Voice Handicap Index (VHI): Development and validation. American Journal of Speech-Language
Pathology. 1997; 6:6670.
Ramig, LO. Speech therapy for patients with Parkinsons disease. In: Roller, WC.; Paulson, G.,
editors. Therapy of Parkinsons disease. New York: Marcel Dekker; 1995. p. 539-548.
Ramig LO, Sapir S, Countryman S, Pawlas AA, OBrien C, Hoehn M, Thompson LL. Intensive voice
treatment (LSVT) for patients with Parkinsons disease: A 2 year follow up. Journal of Neurology,
Neurosurgery, & Psychiatry. 2001; 71:493498.
Sapir S, Pawlas A, Ramig L, Seeley E, Fox C, Corboy J. Effects of intensive phonatory-respiratory
treatment (LSVT) on voice in two individuals with multiple sclerosis. Journal of Medical Speech-
Language Pathology. 2001; 9:3545.
Schulz GM, Peterson T, Sapienza CM, Greer M, Friedman W. Voice and speech characteristics of
persons with Parkinsons disease pre- and post-pallidotomy surgery: Preliminary findings. Journal
of Speech, Language, and Hearing Research. 1999; 42:11761194.
Solomon NP, McKee AS, Garcia-Barry S. Intensive voice treatment and respiration treatment for
hypokinetic-spastic dysarthria after traumatic brain injury. American Journal of Speech-Language
Pathology. 2001; 10:5164.
Yorkston, K.; Beukelman, D.; Tice, R. Sentence Intelligibility Test. Lincoln, NE: Institute for
Rehabilitation Science and Engineering, Madonna Rehabilitation Hospital; 1996.
Figure 1.
Lung-volume data for resting tidal breathing (RTB), oral reading, and monologue
production before treatments (BLl3), after BST, after LSVT, and 4-months after discharge
from treatments. The dashed horizontal line at LV = 0 L represents resting expiratory level
(REL). Each bar represents mean lung-volume initiation (LVI) at the top, and mean lung-
volume termination (LVT) at the bottom. Consequently, the length of the bar represents
mean lung-volume excursion (LVE). Error bars at the top and bottom of each bar are
standard deviations of LVI and LVT, respectively. Typically, normal speech is initiated at
about twice LVI for RTB (~0.8 L) and terminated near REL (~0 L).
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
TABLE 1
Results for auditory-perceptual ratings, speech phrasing, SIT, and VHI across sessions.
1Month 4-Months
Measure BL1 BL2 BL3 BL4 Post-BST Post-LSVT Posttreatment osttreatment
Solomon et al.
Reading
Overall * 3 4 3 3 4
Imprecise * 4 4 3 3 4
Breathy * 2 3 2 2 2
Syl/breath 7.01 6.17 9.16 8.70 7.89 7.89

Duration 1.37 1.29 1.68 1.96 1.97 2.13
ESRate 5.11 4.53 5.53 4.41 4.11 3.60
Monologue
Overall * 2 4 5 3 4
Imprecise * 3 4 5 3 4
Breathy * 2 3 3 2 2
Syl/breath 5.77 5.73 6.13 6.53 7.80 6.27

Duration 1.16 1.20 1.16 1.24 1.51 1.29
ESRate 5.20 4.92 5.32 5.27 5.06 4.99
SIT (loud; typical) * 87.7 90.5; 61.8 62.7; 67.3 70.0 95.5 95.9; 97.3 86.8; 91.4
VHI 103 13 94
*
Missing data due to acoustic distortion

Did not test
VHI: Voice Handicap Index (scores range from 0120 where 030 is minimal; 3160 is moderate, and 61120 is substantial);
SIT: Sentence Intelligibility Test (in percentage of words understood; median of 3 unfamiliar listeners); typical or loud and typical productions;
Overall, Imprecise, and Breathy: rated from 1 (normal) to 7 (severe); median scores of 5 experienced SLPs;
Syl/breath: Number of syllables produced per speech expiration (normal = ~18);
Duration: Duration (in s) of expiratory phase of speech breath groups (normal = ~3.5 s);
ESRate: Expiratory Speech Rate = syllables produced per duration (in s) of speech expiration (normal = ~4.8).
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J Med Speech Lang Pathol. 2004 December ; 12(4): 213219.

Speech-Breathing Treatment and LSVT for a Patient With

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

functional independence and socialization.

cognition, history of depression, and limited stimulability. We explained LSVT to CM and

Self-Rating of Speech Disability

Other Perceptual Measures

Perceptual Ratings of Speech

Syl/breath 7.01 6.17 9.16 8.70 7.89 7.89

Syl/breath 5.77 5.73 6.13 6.53 7.80 6.27

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