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Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3).
Voz e fala de Parkinsonianos durante situações de amplificação,
atraso e mascaramento****
Voice and speech of individuals with Parkinson´s Disease during amplification, delay and masking situations Sylvia Boechat Coutinho*Giovana Diaféria**Gisele Oliveira***Mara Behlau**** Abstract
Fonoaudiologia pela PontifíciaUniversidade Católica de São Paulo.
Background: individuals with Parkinson's disease present voice and speech alterations, especially regarding loudness and speech rate. Aim: to determine the immediate effect of modified auditory feedback: amplification, delay and masking in the voice and speech of individuals with Parkinson's disease, according to gender. Method: twenty-six subjects with Parkinson's disease (15 men and 11 women) with ages ranging between 40 and 86 years (mean age of 69 years) participated in the study. The speech material consisted of the counting from twenty to zero, four times, in four different listening conditions: habitual, amplified, delayed and masked. The following parameters were selected for the auditory-perceptual analysis: vocal quality, loudness, pitch, overall strain level, speech rate and articulation. The assessment was carried out by five Speech-Language Pathologists specialists in voice. The following parameters were selected for the acoustic analysis: fundamental frequency, intensity and maximum phonation time.
Fonoaudiologia na Associação BrasilParkinson (SP).
Results: regarding the auditory-perceptual analysis, an improvement in vocal quality, increase in loudnessand overall strain level was observed in the masking situation. On the other hand, a decrease in vocal quality, a decrease in loudness and overall strain level, a decrease in speech rate and in articulation precision was observed in the amplification and delay situations. In the acoustic analysis, an increase in pela Universidade Federal de SãoPaulo. Professora do Curso de the fundamental frequency and vocal intensity was observed in the masking situation and an increase of the maximum phonation time was observed in the delay situation. Conclusion: the masking situationpresents better immediate effect in the voice and speech of individuals with Parkinson's disease while the amplification and delay situations do not produce satisfactory immediate modifications.
Key Words: Parkinson´s Disease; Voice; Speak; Hearing.
pela Unifesp. Professora do Curso deEspecialização do CEV.
Tema: indivíduos com doença de Parkinson apresentam alterações de voz e fala, principalmente emrelação à loudness e velocidade de fala. Objetivo: verificar o efeito imediato do monitoramento auditivomodificado: amplificação, atraso e mascaramento na voz e fala de indivíduos com doença de Parkinson, de acordo com os sexos. Método: 26 indivíduos com doença de Parkinson, 15 homens e 11 mulheres, comfaixa etária entre 40 e 86 anos e idade média de 69 anos. O material de fala consistiu na contagem de vinte a zero, quatro vezes, em quatro diferentes situações de escuta: habitual, amplificada, atrasada e mascarada.
Para análise perceptivo-auditiva foram selecionados os seguintes parâmetros: qualidade vocal, loudness, pitch, nível geral de tensão, velocidade de fala e articulação. A avaliação foi realizada por cincofonoaudiólogas especialistas em voz. Para a análise acústica foram selecionados os seguintes parâmetros:freqüência fundamental, intensidade e tempo máximo de fonação. Resultados: Por meio da análiseperceptivo-auditiva, verificou-se melhora da qualidade vocal, aumento da loudness, maior tensão emelhor articulação na situação de mascaramento; piora da qualidade vocal, redução da loudness, menor tensão, lentificação na velocidade de fala e piora na articulação nas situações de atraso e amplificação. Na análise acústica, observou-se aumento da freqüência fundamental e intensidade vocal sob mascaramento e aumento do tempo máximo de fonação sob atraso. Conclusão: A situação de mascaramento produz Aceito para Publicação em 25.08.2009.
melhores efeitos imediatos na voz e na fala dos indivíduos com doença de Parkinson e as situações de
amplificação e atraso não produzem modificações imediatas satisfatórias.
Palavras-Chave: Doença de Parkinson; Voz; Fala; Audição.
Coutinho SB, Diaféria G, Oliveira G, Behlau M. Voice and speech of individuals with Parkinson´s Disease during amplification, delay and masking situations(original title: Voz e fala de Parkinsonianos durante situações de amplificação, atraso e mascaramento). Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3):219-24.
Voz e fala de Parkinsonianos durante situações de amplificação, atraso e mascaramento.
Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3).
on the speech with auditory stimulation reproducedto the ears of the individuals with a delay of fractions Parkinson's disease (PD) is a neurodegenerative of seconds. Such effect propitiates the reduction condition characterized by tremor at rest, akinesia, of the speech rate 6-7. The masking allows the muscular rigidity and postural instability. Although production of a reflex response - known as Lombard loss of neurons can occur in other structures of the effect. This effect is the tendency to increase vocal brainstem, the main abnormality is a degeneration intensity in noise, once the noise prevents one from of neurons in the substantia nigra that project to the striatum. The speech alteration is the most speech alterations, the purpose of the present study Individuals with PD may present voice, speech is to examine the immediate effects of the modified and even language alterations, besides difficulties auditory feedback on selected aspects of the in swallowing. Such communication problems may emission through auditory amplification, delay and favor social isolation. The vocal intensity is usually decreased and the voice can be hoarse 2, with anadditional swallowing impairment caused by weakness of laryngeal valve3. Some individualswith PD may present increased speech rate in This study was carried out from August, 2005 utterance segments alternated with segments of to July, 2006, at the Brazil Parkinson Association decreased speech rates, which can negatively (Associação Brasil Parkinson- BPA), in the state of interfere on the intelligibility of the message 3. For São Paulo. The research project was approved by some patients, especially in more advanced levels the Research Ethics Committee of the Voice Study of the disease, a cognitive impairment may be Centre (Centro de Estudos da Voz - CEV) under protocol number 3012/04. All subjects agreed to participate in the study and signed a Free and treatment for speech alterations of individuals with Parkinson involves three distinct approaches: Twenty-six individuals (15 men and 11 women) muscle therapy, coordination of speech structures, with ages ranging between 40 and 86 years (mean and breathing. Treatment is usually carried out once age of 69 years) participated in the study. The or twice a week, emphasizing articulation, speed inclusion criteria were: to present Parkinson's disease level 2 - according to the Modified Hoehn The literature shows evidence of level I for Lee and Yahr Scale 12 - as diagnosed by a neurologist; Silverman Voice Treatment (LSVT ®) rehabilitation and to present hearing assessment results within method, deloped by Ramig et al 5. This method normal limits or mild or moderate hearing loss - as focuses on the laryngeal level for treatment of voice proposed by Davis and Silvermann 13; assessment and speech impairments of individuals with PD.
that excluded alterations other than those related Although this method is considered the best one to PD (such as reflux, and Reinke's edema); and to rehabilitate individuals with PD - and there are clear indications for its administration - other revealed mild or moderate voice alteration, rehabilitation strategies, such as manipulation of auditory feedback, exist 6. The later strategy is corresponds to the overall level of voice alteration, based on the immediate impact that a change in the R to roughness, B to breathiness, A to asteny, S to listening condition of one's own voice causes on strain, and I to instability . Regarding the severity the vocal production. Such modification can be a level, 0 corresponds to absent or normal, 1 to mild, great resource for voice treatment once it can 2 to moderate, and 3 to severe. Individuals with promote changes in intensity, articulation, speed, voice alteration - such as palilalia and festinating phonation, prosody, rhythm, frequency and speech - and absence of language impairments that resonance. This monitoring can be modified in would compromise communication and execution several manners, among them: amplification, delay of required tasks were included in the study. Such and auditory masking. The amplification produces an immediate reduction of vocal intensity, an easier language observed during the formal initial and stable emission, less strained voice quality, and interview with patients. It was asked to the subject longer Maximum Phonation Time (MPT) 6. The to remember and answer to the following questions: delay produces the Lee effect. This effect consists about personal data (name, age, date of birth, Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3).
address and telephone number); history of PD through testing conditions with progressive (complaint, duration, signs and symptoms, data on increments of amplification, masking and delay and drug use); and general health condition.
were considered sufficient for the selected strategies. The habitual voice was recorded through according to the intensity of their symptoms the method of amplification without auditory through the use of: selegiline, anticholinergics, amantadine, levodopa and dopamine agonist.
The speech material was subjected to auditory- During the study period, all subjects were at the perceptual and acoustic analysis. In the auditory- ON period of medication, according to statement perceptual analysis, the selected parameters were: provided by their neurologists. The subjects were voice quality, loudness, pitch, overall strain level, receiving Speech-Language Pathology treatment speech rate and articulation. The speech material with the same routine of intervention, monitoring was presented randomly and without identification and frequency. Subjects with parkinsonism-plus of the listening condition to five Speech-Language were excluded from the study. Parkisonism -plus Pathologists (SLP) specialized in voice. The SLPs refers to a group of degenerative diseases that are expressed by akinetic-rigid syndrome associated corresponded to the best and worst voice quality; with other neurological manifestations usually not increased and reduced loudness; increased and reduced pitch; higher and lower strain; higher and For recording of the speech material, an HP lower speech rate; better and worse articulation.
Pavilion laptop, model 4940 and PCZE sound card To evaluate the intra-subject reliability, 20% of with output of 120dB, a LeSon Condenser MP-68 samples were repeated. The inter-evaluators Microphone Cardioid and a Leadership Group reliability was measured by the Cronbach Alpha headset were utilized. The software Fono Tools (version 1.5h, CTS Informática) was used for In the acoustic analysis, the selected parameters listening conditions with the pre-amplifier of the were: fundamental frequency (F0), vocal intensity system and with the following functions activated: amplification, delay and auditory masking.
performed with the same speech material of the auditory-perceptual analysis, through the software collected consisted of the counting of numbers from Vox Metro (version 2.2h, CTS). F0 was measured in twenty to zero, four times, in four different listening Hz; vocal intensity, in dB; and MPT in seconds.
conditions: habitual, amplified, delayed and masked.
The statistical test used for auditory-perceptual The recording sequence of the tasks was the same analysis was the chi-square adjusted by Fisher for all participants. Recordings were carried out with Statistics. For the acoustic analysis, the Wilcoxon the individual sitting in silent environment (noise test of signalized posts and Mann-Whitney test intensity lower than 50dB - as measured by the were used. The software Statistical Package for Realistic sound pressure meter from Radio Shack) Social Sciences (SPSS) version 13.0 was used. The with headphones and the microphone positioned significance level adopted was of 5% (0.050).
at an angle of 90 degrees and a distance of 10centimeters from the mouth. The exposure to theprocedures was not randomized.
A pilot study revealed the following values as Resultados
appropriate for this study: headphone output of100dB - such for amplification as for masking - and The results of the study are presented in Tables a 150ms speech delay 16. Such values were obtained Voz e fala de Parkinsonianos durante situações de amplificação, atraso e mascaramento.
Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3).
TABLE 1. Auditory-Perceptual analysis of habitual voice and conditions of amplification, delay and masking, according to gender.
The immediate effects observed in conditions of auditory parameter, which justifies the fact that the amplification, delay and masking were interesting and values mentioned above are higher than the total evident in individuals with PD once modifications in number of participants of the study (26). The loudness characteristic symptoms of the disease were observed.
increase can be explained by a reflex response to masking - named Lombard effect 6-11. By increasing masking condition (Table 1) it can be verified that the the strain, an improvement in glottic closure occurred, voice quality - such in men as in women - improved.
and, consequently, a more projected, less breathy, and This improvement probably occurred due to the possibly, richer in harmonics voice - thus more stable increase in loudness (men = 59 and women = 37), and socially acceptable - was produced.
strain (men = 58 and women = 34) and due to a more It can also be observed, in the present study, that precise articulation (men = 55 and women = 33). It the increase in vocal intensity has direct association should be noted that the evaluators could have with a more precise articulation, as reported by Ramig selected more than one utterance segment for each et al. 5 and Carrara et al.17. Similarly to such studies, Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3).
TABLE 2. Acoustic analysis of habitual voice and conditions of amplification, Similarly to the delay condition, the amplification delay and masking, according to gender.
condition (Table 1) offered unsatisfactory modifications. Loudness was reduced (men = 25 andwomen = 27). Such reduction can be justified by the tendency to decrease voice intensity when one hears his own voice amplified 6-7. This approach generally presents benefits for individuals with hyperkinetic dysphonia through the use of high intensity voice.
Therefore, delay and amplification showed similar results - as opposite to the ones of masking.
In conditions of masking, delay and amplification, men and women with PD presented similar responses when subjected to effects of auditory feedback. In conditions of delay and amplification, the subjects produced similar immediate modifications, different from those observed in the condition of masking.
Therefore, men and women presented similar settings It is important to highlight that the acoustic Mann-Whytney Test - Wilcoxon test of signalized posts: habitual F0 xamplification 0.360; habitual intensity x amplification 0.936; habitual MPT x analysis corroborated the findings of the auditory- amplification 0.036; habitual x amplification 0.069; habitual x amplification perceptual analysis. It was observed that the 0.322; habitual x amplification 0.001; habitual x amplification <0.001; habitual fundamental frequency (Table 2), showed statistically x amplification <0.00; habitual x amplification 0.446.
significant changes for both men and women with PDin all listening conditions (p = 0.001 for amplified andmasked and p <0.001 for delayed).
It was verified that, in the condition of masking the intensity increase fired an improvement in all (Table 2), there was an increase in the fundamental speech subsystems, including articulation, without frequency (men = 164.3 Hz, SD = 26.96 and women = the need for a direct treatment of the last.
207.3 Hz; SD = 24.07) - similar response to normal In contrast to the masking condition, the delay subjects. In a study carried out with healthy men, an condition (Table 1) proved to be the worst listening increase in the fundamental frequency was observed when participants were subjected to pure tone masking phonoarticulatory pattern. In this study, decrease in vocal quality (men = 36 and women = 31), loudness In general, fundamental frequency and voice (men = 30 and women = 31), strain (men = 24 and intensity (Table 2) showed significant differences in women = 32) and speech rate (men and women = 22 = the condition of masking, with increase in fundamental 41), and worsening in articulation (men = 36 and women frequency (men = 164.3 Hz, SD = 26.96 and women = = 31) could be observed. Reduction in speech rate 207.3 Hz, SD = 24.07) and intensity (men = 54.3 dB, SD occurred in the delay condition - which can be = 5.66 and women = 55.7 dB, SD = 7.74). In the condition of delay, an increase in the MPT (men = 20.8 s, SD = The modifications observed in delay condition 5.71 and women = 19.7 s, SD = 6.64) was observed.
are similar to modifications expected in normal It is concluded that individuals with PD presented individuals. Studies have indicated that the condition adjustments similar to those of normal individuals of listening produces a positive impact, particularly in when subjected to modified auditory feedback.
individuals who present palilalia and festinating Therefore, it can be affirmed that the voice of speech 6, by promoting a reduction in speech rate.
individuals with PD is flexible: it allows the auditory It was verified, in the present study, that positive feedback immediate impact - which can be used in effects can also be observed for patients with speech therapy and serve as a model and incentive hypokinetic dysarthria without such speech alterations. However, when the voice intensity wastoo reduced, this strategy did not promote observableimprovements.
Voz e fala de Parkinsonianos durante situações de amplificação, atraso e mascaramento.
Pró-Fono Revista de Atualização Científica. 2009 jul-set;21(3).
Moreover, the use of this technique can provide Conclusion
short and long term improvement in voice and speechof individuals with PD. Individuals with PD with weak The analysis of the effects of modifications on voice may present increased loudness when subjected the auditory feedback of the voice of individuals to auditory masking, and, if they present palilalia and with PD indicates that the condition of masking festinating speech, they can benefit from the delay can offer immediate benefits. The masking condition, which promotes the reduction of speech condition can be used in Speech Therapy once it provides voice with higher intensity and moreprecise articulation. In contrast, the amplificationand delay conditions presented modifications thatdo not contribute to minimizing the deviationsobserved in these patients. No between genderdifference was observed in any of the auditoryfeedback conditions.
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