Efeitos dos exercícios vocais no tratamento da disfagia: revisão integrativa

RESUMO Objetivo verificar as evidências disponíveis sobre o efeito dos exercícios vocais no tratamento da disfagia. Estratégia de pesquisa foi realizado levantamento bibliográfico nas bases de dados PubMed, LILACS, SciELO e MEDLINE, sem restrições quanto ao período de publicação. Critérios de seleção artigos originais, estudos de caso e/ou revisões de literatura publicados nos idiomas português e/ou inglês, disponíveis eletronicamente na íntegra e que abordassem o tratamento clínico com exercícios vocais em adultos e idosos com disfagia. Foram excluídas publicações repetidas nas bases de dados, com população de crianças, com indivíduos que não apresentassem o diagnóstico de disfagia, com exercícios vocais sem especificação, com exercícios exclusivos de deglutição, artigos e/ou resumos sem possibilidade de acesso pelas plataformas institucionais e estudos com modelo animal. Resultados foram encontrados 2.356 artigos, dos quais, após aplicados os critérios de elegibilidade, foram selecionados 8 para a amostra final. Para avaliar os efeitos dos exercícios vocais, os estudos utilizaram avaliação clínica, videofluoroscopia, videoendoscopia e eletromiografia. Quanto aos efeitos dos exercícios vocais na deglutição, observou-se que as técnicas de som plosivo, empuxo, trato vocal semiocluído, som basal, modulação vocal, sobrearticulação, o método Lee Silverman Voice Treatment® e o uso de exercícios de treino de força muscular expiratória apresentaram efeitos positivos na reabilitação da disfagia. Conclusão os estudos com treino de força muscular expiratória, o método Lee Silverman e os exercícios vocais tradicionais demonstraram efeitos positivos no tratamento da disfagia. No entanto, ainda não foi possível comprovar o nível de evidências de todos os estudos.

Lee Silverman Voice Treatment to Improve Speech in Parkinson’s Disease: A Systemic Review and Meta-Analysis

Background. Speech changes occur in the early stages of Parkinson’s disease (PD) and cause communication difficulties, leading to social isolation. Lee Silverman voice treatment (LSVT) is a speech therapy approach designed to improve patients’ language and voice capabilities. Objective. The effectiveness of the LSVT was compared with that of other speech interventions or no treatment to evaluate PD patients with dysarthria. Design. Systematic review with meta-analysis of randomized trials. Data Sources: PubMed, Embase, Cochrane Library, CNKI, and SinoMed library were searched from inception to December 2021 related to PD and LSVT. Method. Abstracts were screened and reviewed against the eligibility criteria (intervention group participants were PD assessed based on LSVT (LSVT Loud) and randomized control). Result. Ten randomized controlled trials were identified on speech symptoms in patients with PD. Compared with the respiratory therapy (RET) exercise, or no training group, a significant improvement was detected in the sound press level (SPL) after immediate treatment during the reading of vowel and rainbow passages and an increase in semitone standard deviation (STSD). Furthermore, the LSVT training significantly increased the participants’ scores on unified Parkinson’s disease rating scale (UPDRS-III) and speech intelligibility. Conclusion. This meta-analysis demonstrated the efficacy of LSVT in increasing vocal loudness and functional communication among individuals with PD. However, most studies included participants with mild-moderate PD. Thus, additional randomized controlled trials (RCTs) with large sample sizes are needed to validate the efficacy of LSVT in patients with different progressions of PD, including severe PD.

Effectiveness of Interventions for Dysphagia in Parkinson Disease: A Systematic Review

Purpose: Dysphagia is a common sequela of Parkinson disease (PD) and is associated with malnutrition, aspiration pneumonia, and mortality. This review article synthesized evidence regarding the effectiveness of interventions for dysphagia in PD. Method: Electronic searches were conducted in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and speechBITE. Of the 2,015 articles identified, 26 met eligibility criteria: interventional or observational studies with at least five or more participants evaluating dysphagia interventions in adults with PD-related dysphagia, with outcomes measured using videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), or electromyography (EMG). Risk of bias (RoB) was evaluated using the Evidence Project tool and predetermined criteria regarding the rigor of swallowing outcome measures. Results: Interventions were classified as follows: pharmacological ( n = 11), neurostimulation ( n = 8), and behavioral ( n = 7). Primary outcome measures varied across studies, including swallowing timing, safety, and efficiency, and were measured using VFSS ( n = 17), FEES ( n = 6), and EMG ( n = 4). Critical appraisal of study findings for RoB, methodological rigor, and transparency showed the majority of studies failed to adequately describe contrast media used, signal acquisition settings, and rater blinding to time point. Low certainty evidence generally suggested improved swallow timing with exercises with biofeedback and deep brain stimulation (DBS), improved safety with DBS and expiratory muscle strength training, and improved efficiency with the Lee Silverman Voice Treatment and levodopa. Conclusions: Studies with lower RoB and greater experimental rigor showed potential benefit in improving swallowing efficiency but not safety. Further research investigating discrete changes in swallowing pathophysiology post-intervention is warranted to guide dysphagia management in PD. Supplemental Material https://doi.org/10.23641/asha.17132162

Occupational Performance and Hand Function in People With Parkinson’s Disease After Participation in Lee Silverman Voice Treatment (LSVT) BIG®

Importance: People with Parkinson’s disease (PD) experience motor and functional impairment that can negatively affect daily living and participation. Objective: To examine the occupational performance and hand function outcomes of people with PD who participated in a Lee Silverman Voice Treatment (LSVT) BIG® program. Design: Retrospective record review. Setting: Outcomes were extracted from patient charts at a hospital outpatient clinic. Participants: Sixty-six clinic outpatients with PD who completed the LSVT BIG program. Intervention: An occupational therapist and a physical therapist who were certified in LSVT BIG administration delivered the 16-session LSVT BIG program. Outcomes and Measures: The Canadian Occupational Performance Measure (COPM), grip strength, and Minnesota Manual Dexterity Test (MMDT) were administered before and after participation in LSVT BIG training. Results: For participant-identified COPM goals, pre–post changes were significant, ranging from 3 to 6 points for performance and satisfaction (p < .001). Grip strength in both hands showed significant gains; median scores for the right hand increased from 55.0 lb (interquartile range [IQR] 41.0, 70.0) to 64.0 lb (IQR 46.0, 80.0; p < .001) and for the left hand from 52.0 lb (IQR 39.0, 64.0) to 63.0 lb (IQR 44.5, 79.5; p < .001). MMDT median scores for right to left also significantly improved, from 124.0 s (IQR 113.0, 181.0) to 119.5 s (IQR 105.5, 163.5; p = .014). Conclusions and Relevance: Participation in the LSVT BIG program can improve perceived occupational performance and satisfaction and produce gains in hand strength and dexterity for people with PD. What This Article Adds: This study is the first retrospective review of data on occupational performance and hand function outcomes after participation in the LSVT BIG program. The findings of beneficial outcomes support the use of LSVT BIG in occupational therapy services to increase functional abilities among people with PD.

Improved morpho-syntax in discourse following intensive voice treatment in Parkinson's disease: Secondary outcome variables from a Randomized Controlled Trial (RCT)

It is well established that voice is disordered in nearly 90% of individuals with Parkinsons disease (PD). Given the role of voice in language expression, we pose that optimizing vocal function may lead to improved language production. Verb production is an area of language deficit in PD, particularly for verbs associated with an individuals location of impairment (upper vs. lower limbs). It is thought that damage to the motor system, given its connection to action verbs, underlies this lexical effect. If this is the case, then treatment improving vocal motor function may also improve access to verbs. Nineteen participants with PD underwent Lee Silverman Voice Treatment (LSVT LOUD), a 4-week intensive voice treatment (TXPD), in an IRB-approved randomized controlled voice treatment trial. Language production was contrasted with 20 untreated PD (UNTXPD) and 20 age-matched neurotypical control participants. Each provided 1-minute picture description narratives at baseline and after 4-weeks. Pre-post treatment within- and between-group comparisons identified effects of assessment time point and isolated treatment effects in the TXPD relative to UNTXPD and Controls. Given the intervention, the TXPD group demonstrated a significant increase in loudness during the picture description, as well as increased utterance length, diversity of word types used, verbs per utterance, and lexical density.

Voice Therapy According to the Rehabilitation Treatment Specification System: Expert Consensus Ingredients and Targets

Purpose Clinical trials have demonstrated that standardized voice treatment programs are effective for some patients, but identifying the unique individual treatment ingredients specifically responsible for observed improvements remains elusive. To address this problem, the authors used a taxonomy of voice therapy, the Rehabilitation Treatment Specification System (RTSS), and a Delphi process to develop the RTSS-Voice (expert consensus categories of measurable and unique voice treatment ingredients and targets). Method Initial targets and ingredients were derived from a taxonomy of voice therapy. Through six Delphi Rounds, 10 vocal rehabilitation experts rated the measurability and uniqueness of individual treatment targets and ingredients. After each round, revisions (guided by the experts' feedback) were finalized among a primary reader (a voice therapy expert) and two external readers (rehabilitation experts outside the field of voice). Consensus was established when the label and definition of an ingredient or target reached a supramajority threshold (≥ 8 of 10 expert agreement). Results Thirty-five target and 19 ingredient categories were agreed to be measurable, unique, and accurate reflections of the rules and terminology of the RTSS. Operational definitions for each category included differences in the way ingredients are delivered and the way individual targets are modified by those ingredients. Conclusions The consensus labels and operationalized ingredients and targets making up the RTSS-Voice have potential to improve voice therapy research, practice, and education/training. The methods used to develop these lists may be useful for other speech, language, and hearing treatment specifications. Supplemental Material https://doi.org/10.23641/asha.15243357

Spectral/cepstral analyses of connected speech in parkinson’s disease as compared with sustained phonation before and after voice treatment

Purpose: The primary purpose of this study was to assess the effect of Lee Silverman Voice Treatment (LSVT®LOUD) on selected spectral/cepstral measures of voice in connected speech. Spectral/cepstral analyses also were used to descriptively compare changes in connected speech to those previously reported in sustained vowels. An additional goal was to examine individual differences in responses to LSVT across the spectral/cepstral measures.Methods: Nine adult participants with PD were examined in a pre/post treatment design. Speech recordings were obtained on three different days within one week before and one week after LSVT. Speech recordings were analyzed for cepstral peak prominence (CPP), CPP Standard Deviation (CPP-SD), Low/High Spectral Ratio (L/H SR), and Cepstral/Spectral Index of Dysphonia (CSID) using the Analysis of Dysphonia in Speech and Voice (ADSV) program.Results: CPP and CSID were the only measures that detect treatment-related changes in connected speech. Investigating individual differences demonstrated more participants exhibiting an improvement in sustained phonation than in connected speech.Conclusions: Cepstral/spectral measures have been shown to be valid measures for estimating dysphonia severity in both continuous speech and sustained vowels. In addition, it extends the use of the cepstral/spectral measures for characterizing speech and voice aspects prior to treatment and for quantifying treatment outcomes. Moreover, it supports the use of LSVT as a treatment approach for improving voice quality in addition to intensity in PD.