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A group intervention model for speech and communication skills in patients with Parkinson's disease: initial observations.

Various speech and voice disorders affect 70% to 85% of individuals with Parkinson's disease (PD). Speech treatment is generally conducted on an individual basis, with family member involvement. Clinical experience indicates that many patients do not practice treatments at home or apply the learned techniques in everyday situations. An eight-session, task-oriented group intervention with PD patients who also had learned speech techniques individually prior to this program is described. Preliminary observations using subjective and objective measures indicate improvement in voice characteristics, self-perception of speech intelligibility, communication skills, and application of these skills in everyday communication situations.

Speech and voice disorders affect 70% to 85% of individuals with Parkinson's disease (PD; Schulz & Grant, 2000). These disorders are considered to be the result of dysfunction with systems involved in respiration, phonation, articulation, resonance, and prosody (Logemann, Fisher, Boshes, & Blonsky, 1978; Swigert, 1997). Speech disorders associated with PD are known as Parkinsonian dysarthria or hypokinetic dysarthria (Schulz & Grant, 2000). They include hypophonia, reduced loudness, hoarseness, monotone, and mono-loudness (Aronson, 1990). Additional characteristics of Parkinsonian dysarthria include imprecise articulation, reduced stress, and instability in speech rate (Johnson & Pring, 1990). Moreover, there may be a reduction in the pragmatic communication skills, especially in the areas of conversational appropriateness, turn-taking, prosodics, and proxemics (McNamara & Durso, 2003). Furthermore, people with PD often exhibit reduced motivation for communication and low morale (Giladi et al., 2000).

These aspects of PD directly affect the social skills, lifestyle, and psychological well-being of people with PD (Coates & Bakheit, 1997; Ramig, Countryman, O'Brien, Hoehn, & Thompson, 1996). These patients often report experiencing feelings of embarrassment, isolation in social situations, and reluctance to engage in social interaction (Scott & Caird, 1983).

Speech therapy is considered valuable and effective for people with PD, particularly when treatment is administered intensively and patients are motivated and actively involved in the therapeutic process (Kerschan, Pankl, & Auff, 1998). Researchers have suggested various therapeutic approaches for patients with PD who exhibit speech disturbances. During the 1980s, speech therapy mainly addressed the prosodic aspects of speech (Le Dorze, Dionne, Ryalls, Julien, & Ouellet, 1992; Robertson & Thomson, 1984; Scott & Caird, 1983; Scott, Caird, & Williams, 1985). Later other facets of speech and communication were added to the evolving therapeutic scheme, including respiration, articulation, pitch variation, vocal loudness, strength and speed of articulators, speaking rate, intonation and stress patterns, and communication intelligibility (Hammen & Yorkston, 1996). These modifications in the treatment program were reported to have a favorable effect on various aspects of speech. Moreover, most patients reported that the improved speech pattern was maintained after the conclusion of the therapy program (Schulz & Grant, 2000).

At present, speech therapy programs for patients with PD who exhibit hypokinetic dysarthria mainly target vocal loudness, following the Lee Silverman Voice Treatment (LSVT) protocol (Ramig, Countryman, Thompson, & Horii, 1995; Ramig, Pawlas, & Countryman, 1995). In essence, the LSVT focuses on increasing respiratory effort and improving vocal fold adduction, thus increasing vocal loudness. The program is administered systematically and intensively, and patients attend four 50-60 min sessions per day throughout four consecutive weeks (Ramig, Countryman et al., 1995; Ramig & Dromey, 1996; Ramig, Pawlas, & Countryman, 1995; Ramig, Sapir, Countryman, & Fox, 2001). The effectiveness of the LSVT program has been demonstrated in comparison with other programs (Ramig, Countryman, et al., 1995) and in a 24-month posttreatment follow-up (Ramig et al., 2001). De Swart, Willemse, Maassen, and Horstink (2003) suggested an addition to the LSVT program. They recognized the importance of increasing loudness for people with PD but contended that pitch monitoring is also necessary to prevent a strained voice. To that end, they developed a Pitch Limiting Voice Treatment (PLVT) approach, which is based on the LSVT and focuses on increasing loudness while maintaining vocal pitch at an appropriate level.

Speech therapy for people with PD is traditionally conducted individually (Scott & Caird, 1983). Individual therapy enables therapists to maximize the direct practice time in the therapy session and facilitates specific exercises tailored to individual needs. It also enables the patient to receive the therapist's undivided attention. Furthermore, our clinical experience has shown that some patients with PD are more open to discussing personal problems related to communication and swallowing than they would be in a group setting. The possibilities of practicing communicative skills within an individual setting, however, are limited. Such tasks as turn-taking in conversation, engaging in an argument, communicating with more than one person, asking and answering different people's questions, and talking in front of a group of people can only be practiced in a group setting. Several authors have suggested that individual speech therapy is not always sufficiently productive for patients with PD and that long-term carryover could be limited (Adams, 1997; Yorkston, 1996).

The literature on group speech therapy for patients with PD is scarce. The existing literature, however, does suggest that group settings can have an advantageous effect on patients' communication and verbal skills. Furthermore, a group setting may improve patients' abilities in coping with the psychosocial ramifications of the disease (Posen et al., 2000). Sullivan, Brune, & Beukelman (1996), for example, described an 8-session behavioral intervention group that focused on speech performance for six patients with PD and their spouses. Sullivan et al. reported that the patients' speech performances improved and that improvements were preserved 10 months following the intervention. De Angelis et al. (1997) conducted a 13-session voice rehabilitation group therapy program for patients with PD. This 1-month program primarily targeted increasing laryngeal sphincteric activity. Routine clinical voice therapy measures, such as an increase in maximal phonation times, decrease in the values of the s/z ratio (examining the ratio between the maximum time that a patient can sustain /s/to the maximum time he can sustain/z/) and air flow, increase in vocal intensity, decrease in the complaints of weak and strained voice, and elimination of complaints of swallowing alterations, revealed improved glottic efficiency and enhanced functionality of oral communication posttreatment.

A group setting enables participants to observe, evaluate, and learn from each other and provides an opportunity to develop and apply coping skills for use in the outside world (Yalom, 1985). Patients with PD who participate in a group can increase their awareness of speech intelligibility through observation of other individuals' speech difficulties. A group also provides opportunities for practicing spontaneous speech and for social interaction in a supportive environment as preparation for daffy communication. An additional benefit of group work is that, in an era of managed health care, group work with patients with speech difficulties has been found to be time- and cost-effective (Ramig & Bennet, 1997).

The Movement Disorders Unit at the Tel Aviv Sourasky Medical Center provides therapy for patients with PD who exhibit speech and swallowing disorders. Similar to many other medical institutions, this center has faced growing financial constraints that have led to a reduction in the number of speech-language pathologists (SLPs) and restrictions on insurance coverage for individual intensive speech programs. As a result, speech therapy for people with PD switched from daffy sessions to weekly sessions. A preliminary clinical evaluation indicated a pronounced decrease in our patients' motivation to practice therapy techniques at home and to apply the learned techniques in daily situations, as well as a decrease in the clinical effectiveness of the program.

These clinical observations led us to search for an alternative therapy approach that would improve patient motivation and promote generalization. This article provides an initial description of the treatment program that our team developed and presents preliminary observations regarding the clinical process. We hope that our findings will facilitate further exchanges on clinical and theoretical models among professionals who work with people with PD.

This program is a task-oriented, holistic group treatment for communication difficulties. It was specifically adjusted to the unique needs of patients with PD. It targets the improvement of speech intelligibility and the pragmatic use of language while addressing concerns in communication difficulties experienced by patients with PD. The three major components of the program are (a) voice exercises based primarily on the LSVT program, (b) a supportive group setting to enhance communication skills, and (c) external visual cues to improve speech intelligibility. At present, this group is intended for patients with PD who have already participated in an individual speech therapy program.


Eight 75-minute consecutive group sessions are conducted weekly. All sessions are led by an SLP and a social worker, both with experience in speech therapy related to PD and group therapy for patients with PD. Each session has four parts: (a) spontaneous interaction, (b) practice, (c) guided discussion, and (d) task assignments. The opening 15 minutes of each session are allocated to encouraging informal communication among the patients. This section encourages social interaction among the group members and increases the naturalness of the communicative situation. The next 20 minutes are devoted to structured group exercises consisting of introducing and practicing new speech exercises as well as reviewing the previous week's assignments. Exercises are based on the LSVT treatment program; thus, exercises focus on increasing loudness and phonatory effort. External visual cues are employed during the speech tasks, based on previous reports of the contribution of these cues to patients with PD in general, (e.g., Georgiou et al., 1993; Rubinstein, Giladi, & Hausdorff, 2002; Ramig, Fox, & Sapir, 2004) and in improving repetitive articulate movements specifically (Ackermann, Koncsak, & Hertrich, 1997). The external cues consist of printed signs on which "wide open mouth", "slow rate," and "loud voice" are written. We noted that these cues assisted the patients in internalizing the instructions during continuous speech and group interaction without interrupting their flow of speech. This improved and shortened the generalization process.

The third part of each session is a 30-minute discussion focused on the difficulties encountered by the patients in specific speech situations. This segment is led by the social worker with the support of the SLP. Coping mechanisms are typically raised by the group leaders, but sometimes by members of the group as well. The topic of discussion can be selected in accordance with the relevant therapeutic goal and the exercises practiced. The external visual cues are also used during this segment. The final 10 minutes of the session are reserved for assigning homework. The exercises typically target increasing phonatory effort in various speech tasks, and the participants are instructed to practice speech in selected and predetermined communication situations.

Each session is viewed as both a separate entity and a part of a gradual buildup of increasingly complex speech and communication skills. During the course of therapy, the patients are encouraged to participate and initiate communication more extensively. The amount of voice and speech exercises assigned for home practice and in different communication situations is gradually increased as well.

In this therapy framework, three voice exercises adapted from the LSVT program were defined as core exercises. These exercises are practiced in each session and usually are followed by supplementary exercises. Furthermore, participants are instructed to perform these exercises at home for 10 minutes each day throughout the course of the program. The core exercises include the following:

1. Maximum Phonation Time: The patient sustains the vowel/a/three times for as long as possible;

2. Increased Vocal Loudness: The patient produces the vowel/al 10 times for 3 to 4 seconds as loudly as possible; and

3. Maximum Pitch Range: The patient produces the vowel/a/10 times in the highest and lowest pitches possible.

Because core exercises are performed simultaneously by all patients during group sessions, measuring voice intensity and pitch range is impractical. Thus, objective measurements of pitch intensity range are performed individually before and after initiating the program. Additional voice exercises included in the program target loudness control in gradually lengthened utterances (i.e., single words, short phrases, sentences, and conversation; see Table 1).

Prior to the program, all group members complete a questionnaire (Johnson, 1975; McGarr & Osberger, 1978; Ramig, Countryman et al., 1995; Ramig, Pawlas, & Countryman, 1995; Schiffman, Reynolds, & Young, 1981) that rates their difficulties in a variety of communication situations, such as communication with a stranger, answering and initiating conversations on the telephone, welcoming guests, and ordering in a restaurant. On the basis of the responses to this questionnaire, group discussions are aimed at targeting specific communication situations that were reported by the participants as most difficult. Guided and open discussions are used to elicit active participation of all patients. Furthermore, role-playing is used as a tool for group practice of specific communicative tasks. Task assignments for home practice are designed to follow the exercises and discussion plan for each session. The assignments include repetitive performance of the core exercises followed by such communicative tasks as conversing with a bank clerk, ordering in a restaurant, and speaking at a family function.

At the end of each session, the participants receive a list of tasks for home practice that gradually becomes longer and more complex. The participants complete a homework time table, which is presented to the SLP at the next session. Any difficulties in carrying out task assignments are discussed in the group. In the group setting, participants can relate their difficulties in performing such tasks as the core exercises or spontaneous speech tasks. Some participants may decide to meet outside of group sessions to reinforce one another's practice sessions. Within the group, participants may share practical tips on ways to overcome embarrassment. This method encourages individual commitment, which is reinforced by the supportive group setting and is an integral part of the program.

Most sessions follow a similar format; the sixth session, however, is conducted differently. Each participant is accompanied by a family member of his or her choice and the guests are required to participate actively in the voice exercises. The discussion focuses on the role and expectations of the family and patients in communication situations. Patients are instructed to perform the home assignments with the active participation of the accompanying guest, following the guidelines described and discussed during the session. The inclusion of family members in the therapy program serves as an additional bridge to the outside world by exposing group participants to active communication with people other than the group members. It also increases family involvement in the treatment process and the ability of family members to take an active role in practicing.

Because patients with PD exhibit decreased speech intelligibility and reduced speech initiation, the first five sessions of the program focus on strengthening patients' speech and initiation abilities before introducing them to the extended group with family members. A detailed description of the segments of each of the eight sessions is presented in Table 1.

Yael Manor

Tel-Aviv Sourasky Medical Center

lennie Posen

Tel-Aviv Sourasky Medical Center

Ofer Amir

Sackler Faculty of Medicine, Tel-Aviv University

Nechama Dori

Tel-Aviv Sourasky Medical Center

Nir Giladi

Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine,

Tel-Aviv University
Table 1. Activity Plan for Group Therapy

Session   Spontaneous
          speech        Voice exercises

1         [check]       * Core exercises

2         [check]       * Core exercises
                        * Single-word production
                          with increased loudness

3         [check]       * Core exercises
                        * Phrase production with
                          increased loudness

4         [check]       * Core exercises
                        * Sentence production with
                          increased loudness

5         [check]       * Core exercises
                        * Question production, focus
                          on modifying intonation
                          and loudness

6                       * Core exercises (mutual
                          practice by participants
                          and guests)

7                       * Core exercises
                        * Speech initiation, with
                          increased loudness

8                       * Core exercises
                        * Spontaneous speech, focus
                          on loud voice

Session   Spontaneous   Topic of group
          speech        discussion

1         [check]       * Meeting new people and
                          introducing myself

2         [check]       * Individual versus group
                        * Identifying personal difficulties

3         [check]       * Communication with strangers
                          in specific situations (e.g.,
                          bank, mall)

4         [check]       * Difficulties in social situations
                        * Role-playing practice

5         [check]       * Initiation in telephone
                        * Role-play of telephone

6                       * Expectations from and of
                          participants in communication

7                       * Free discussion among the

8                       * Self-evaluation of program
                          and specific techniques

Session   Spontaneous   Task assignment

1         [check]       * Core exercises,
                          10 minutes/day

2         [check]       * Core exercises, 10 minutes/day
                        * Loud production of common

3         [check]       * Core exercises 10 minutes/day
                        * Using specific phrases in public

4         [check]       * Core exercises 10 minutes/day
                        * Using key sentences in social

5         [check]       * Core exercises 10 minutes/day
                        * Asking and answering questions
                          on the telephone

6                       * Core exercises 10 minutes/day
                          (participants and guests)
                        * Engaging in structural
                          conversation between guest and
7                       * Core exercises 10 minutes/day
                        * Spontaneous speech in social

8                       * Maintaining loud voice and
                          "speech rules" in everyday

Table 2. Results for the Participants in the Therapy Group

                          Pretreatment (TI)

                                Acoustic analysis

                                F0       Amp
Participant   VAPRS    SAS      range    range

1                 63        4    67.57    15.57
2                 81        5    66.86    14.79
3                 51        4    54.29    10.79
4                 44        3    23.29    10.76
5                 63        5    86.50    14.54
6                 73        3    44.79     9.42
7                 56        2    37.02    15.82
8                 55        4    42.12    14.55
M              60.75     3.75    52.80    13.28
SD             11.96     1.04    20.18     2.52

                       Posttreatment (T2)

                                Acoustic analysis

                                F0       Amp
Participant   VAPRS    SAS      range    range

1                 74        5    52.74    10.54
2                 76        5   112.56    11.59
3                 58        5    79.38    16.96
4                 64        4    53.50    12.04
5                 80        6   121.02    17.14
6                 46        5    65.25    13.99
7                 63        3    77.73    14.18
8                 82        5    80.56    19.66
M              67.88     4.75    80.34    14.51
SD             12.33     0.89    25.10     3.17

Note. VAPRS = Visual Analogue Perceptual Rating Scale (Schiffman et
al., 1981); SAS = Speech Assessment Scale (Johnson, 1975; McGarr &
Osberger, 1978; Ramig, Countryman et al., 1995; Ramig, Pawlas, &
Countryman, 1995); FO range = fundamental frequency range; Amp
range = amplitude range.
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Article Details
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Author:Manor, Yael; Posen, Jennie; Amir, Ofer; Dori, Nechama; Giladi, Nir
Publication:Communication Disorders Quarterly
Geographic Code:1USA
Date:Dec 22, 2005
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