Reduced speech intensity (hypophonia) is one of the cardinal motor speech features associated with Parkinson’s disease (PD). Hypophonia in PD is an important contributor to decreased intelligibility and has been attributed to vocal fold stiffness or weakness, reduced respiratory support and increased chest wall rigidity. Vocal loudness and speech rate are also impacted by cognitive mechanisms (attention or self-perception) in individuals with PD.
Speech therapy behavioral interventions such as LSVT LOUD have been shown to be effective approaches for addressing motor speech symptoms but may be challenging to undertake for some patients as they typically are intensive interventions that require a higher cognitive load, a high level of motivation, daily practice during and after therapy and necessitate training both the motor and sensorimotor aspects of speech, with a goal that by the conclusion of therapy, patients will have internalized a cue to speak at a more normal level of loudness(1).
But, generalization of new vocal behaviors into everyday speech is difficult even for non-PD voice patients and may be especially difficult for individuals with PD due to consumption of self-regulatory resources, i.e. the constant demand for self-monitoring speech production. Hence, the patient who is louder during speech therapy when being cued by the therapist for loudness, may not be able to sustain the loudness during conversational speech when the demand to focus on vocal intensity, rate of speech, and language formulation deplete cognitive resources.
For many patients maintaining changes attained in speech therapy regardless the approach may be near impossible due to advancing disease, fatigue, fluctuations in motor symptoms, and cognitive decline. Carepartners often report frustration with communication at home when therapy gains are not maintained.
How Can Device Interventions Help?
Back in 2010, I was working with a Parkinson’s patient who was a retired college administrator. He loved to talk, and walked in and out of my office each visit talking, and yet, I could barely understand what he was saying. He was enrolled in speech therapy using the LSVT LOUD approach, and although, like many patients, he responded to the cue to “speak loud,” he was unable to maintain this when engaged in conversation.
I had an unusual epiphany one day, and wondered: “would he speak better if he couldn’t hear himself? I had a small radio in my gym bag in the office, and set it between stations on static, placed it on his ears and asked him to speak. Much to my amazement he spoke louder and clearer. From that day forward I began to explore Lombard effect. The reflex response that causes us to speak louder over background noise. Low and behold, I found that varying types of auditory masking had been employed from as far back as the 1930’s, and in the 1960’s were incorporated into a device called the Edinburgh Masker, an electronic device designed to reduce stuttering.
In 2012, my friend, Kate Kelsall, a PD blogger sent me a link regarding a device intervention SpeechVive, being developed at Purdue by speech-language pathology researcher, Jessica Huber. I reached out to Dr. Huber and in 2013 invited her to come to Florida and introduce her device and research at a Journal Club and Community-based Parkinson’s program I was involved with. I continued to follow Dr.Huber’s research and publications, and in 2015 obtained a device for use in my private practice. I began to incorporate the SpeechVive into all of my evaluations of patients with motor speech symptoms related to PD and maintain data which demonstrated improvements in vocal intensity for most patients.
Dr. Huber continues to publish research focusing on various aspects of the Lombard effect on speech including a study comparing the SpeechVive intervention to the LSVT LOUD approach for hypophonia secondary to Parkinson’s disease (PD) using self-reported measures of physical demand, mental demand, and vocal performance. When asked to target a specific loudness, both groups used more abdominal effort than at comfortable loudness, but speaking in background noise resulted in the largest increase in SPL with the most efficient respiratory patterns, suggesting natural or implicit cues may be best when treating hypophonia in individuals with PD (2).
(1)Effects of Loudness Cues on Respiration in Individuals with Parkinson’s disease. Neeraja Sadagopan and Jessica E. Huber Mov Disord. 2007 April 15; 22(5): 651–659. doi:10.1002/mds.21375.
(2) Perception of Physical Demand, Mental Demand, and Performance: A Comparison of Two Voice Interventions for Parkinson’s Disease Kelly Richardson, Jessica E. Huber, Brianna Kiefer and Sandy Snyder https://doi.org/10.1044/2022_AJSLP-22-00026.
Who is a Candidate for SpeechVive?
Disclosure: For the last year I have been providing some consulting services to SpeechVive which includes responding to general inquiries about candidacy for the device and also conducting some remote programming. I have summarized some of that information below.
The Speech Vive device is programmable, and based on the patient’s baseline speech. By accessing Lombard effect, it provides a 3-4dB increase in loudness. For some patients, the response is quite robust, and it requires no specific attention from the patient, thereby reducing cognitive load. Patients who obtain the most benefit are those who use their voice throughout the day, with 30 minutes as a goal. The device collects data and over any time frame of days or weeks can calculate daily voice use.
I emphasize to patients that the device is not “magic,” rather, it is helping them to speak at a more normal level of loudness, and the more they speak the more they will improve use of that musculature.
The best candidates are those patients with hypophonia as their primary speech/voice symptom and who have demonstrated stimulability for loudness. These are often patients who have completed LSVT or other speech therapy interventions in the past but can not retain the effect or self-cue for loudness, and this can include patients with mild cognitive impairment. The research thus far has been conducted on patients with motor speech symptoms associated with Idiopathic Parkinson’s disease and not with a diagnosis of atypical Parkinson’s such as MSA-PD and PSP. Just as these patients respond to behavioral interventions differently, the same may be expected from a device intervention.
Patients with rate disturbance or festinating speech patterns due to their disease or following DBS may not attain the same effect though an increase in vocal intensity may help to normalize breathing speech patterns.
Is SpeechVive compatible with other therapies and after therapy programs such as Speak OUT!? YES! The use of the Speech Vive device does not mean that the patient cannot receive or participate in other therapies. In fact, when not focusing on vocal intensity, a therapist may be able to spend more time addressing cognitive-linguistic problems, swallowing, or other concerns of the patient. If a patient is participating in an after-therapy program, use of the SpeechVive will provide them additional opportunities to be speaking and benefitting from device use.
To learn more about SpeechVive and/or to check your insurance eligibility for re-imbursement please visit their website: https://www.speechvive.com/
Hi-VOLT®4PD and Songbirds Streaming on Apple music, Spotify, youtube and more
Hi-VOLT®4PD CD is guided voice practice that was created to accompany the Hi-VOLT® voice activated, calibrated, feedback tool. Songbirds is speech practice set in music and perfectly fun for patients with motor speech problems or recovering from stroke. Visit my website to learn more: https://voiceaerobicsdvd.com/
My Mission: To enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Certified End of Life Specialist (CEOLS) * Voice Aerobics® A Whole Body Approach to Voice Practice