Monday, April 22, 2013

Other Neurogenic Voice Disorders

Overview & Cause:


Other Neurologic Diseases may cause voice disorders or voice problems may develop as a symptom of the following disorders:
  • Parkinson's Disease (PD): a degenerative disorder of the central nervous system, symptoms include motor impairments due to death of dopamine generating cells in the mid brain. Motor impairments include: shaking, rigidity, slowness of initiation to start moving or speaking. Can see tremor in the hands or entire body and gait when walking. The voice can become dysphonic or in severe cases aphonic. The voice may be hoarse and breathy, monopitch and monoloud.
  • Myasthenia Gravis (MG): chronic autoimmune disease causing weakness and fatigue. Can affect voluntary muscles of the body such as: the eyes, the mouth, the throat and the limbs. Voice may be breathy, monotone. monoloudness, voice fatigues with use- recover with rest.
  • Amyotrophic Lateral Sclerosis (ALS, a.k.a. Lou Gherig's disease): neurodegenerative disease that affects nerve cells in the brain and spinal cord, upper motor neuron (UMN) or lower motor neuron (LMN). Symptoms include: LMN symptoms: atrophy, fasciculations, weakness and UMN symptoms: tight, stiff muscles, spasticity/rigidity and exaggerated reflexes (Hypereflexia) dysphagia (swallowing difficulty),  and difficulty speaking. These patients can exhibit pseudobulbar affect or "emotional lability". Voice quality can present in a mixed fashion since this is characterized as a Mixed Dysarthria: the voice can be hypernasal, strain/strangled, slow effortful, monopitch, monoloudness, decreased range of motion.
  • Stroke (Cerebrovascular Accident CVA): limited or no brain function due to loss of blood supply to the brain. This can be due to Ischemia - lack of blood flow caused by, a blockage (Thrombosis or Arterial Embolism or hemorrhage. Symptoms of strokes vary as does severity but they include inability to move one side of the body, inability to understand or formulate speech and inability to see one side of the visual field. Voice qualities and problems can vary dependent on the stoke, lesion location and severity.
  • Traumatic Brain Injury (TBI): this is a closed or penetrating injury to the brain which can have varying symptoms and outcomes. It can be widespread  or focal damage. It is a major cause of disability and death. It is more common in males than females. Voice disorders concomitant with TBI vary depending on each patient. Often times a voice disorder that coexists with these disorders is termed as dysarthria.


Symptoms:

Parkinson's Disease:

The following symptoms may be present:
  • Breathy voice
  • Monopitch
  • Monoloudness
  • Short, fast rushes of speech
  • Trouble with initiating speech

Myasthenia Gravis:

The following symptoms may be present:
  • Monotone
  • Monoloudness
  • Fatigue with vocal use

Amyotrophic Lateral Sclerosis:

The following symptoms may be present:
  • Strained and strangled sounding voice
  • Hyponasal vocal quality
  • Slow and effortful speech
  • Monoloudness (reduced volume)
  • Monopitch
  • Breathy voice

Stroke/CVA:

The quality of voice and symptoms depend on the location and the severity of the stoke.

Traumatic Brain Injury:

The quality of voice and symptoms depend on the location and the severity of the injury.

Treatment:


In regards to these neurogenic disorders treatment varies depending on the person and how they are affected. The treatment given may help the primary disease or disorder and in addition a voice treatment will be given such as Botox injections or surgery.  See the Treatment sections on Spasmodic Dysphonia and Paralysis/Paresis for some applicable information.

Functional Voice Therapy will be helpful for all these types of Neurogenic Disorders- depending on the symptoms presented voice therapy would work on: pitch, rate, timing, prosody, volume, stress (word and sentence), word finding, vocabulary and several different communication modalities: sign language, communication boards, Alternative Augmentative Communication devices (AAC) would also be an option for a patient who loses their ability to speak or if it becomes effortful over time. You can find more information here.


Parkinson's Disease, patients with voice disorders with PD have benefitted from the Lee Silverman Voice Treatment (LSVT ). This treatment is specifically directed toward PD and focuses on intensive high effort speech exercises and increasing vocal loudness in a healthy way. For more information on LSVT, click here.

Here are two videos that may be helpful:

       Video 1: Think Big

       Video 2: Think Big, 2 Years Later

Myasthenia Gravis (MG) can be treated in different ways. As fatigue is an associated symptom that affect both gross motor movements and speech productions, oral medications that reduce fatigue are helpful. ALS, stroke & traumatic brain injury are all treated in various different ways, as the symptoms themselves are treated depending on their severity.

References:


Ramig, L., Verdolini, K. (1998). Treatment Efficacy Voice Disorders. Journal of Speech, Language and Hearing Research, (41), S101-S116.


Ramig, LO., Fox, C., Sapir, S. (2004). Parkinsons disease: speech and voice disorders and their treatment with the Lee Silverman Voice Treatment. Semin Speech Language. (2) 169-80.


Watts, C., Vanryckeghem, M. (2001).Laryngeal Dysfunction in ALS: a review and case report. BMC Ear, Nose and Throat Disorders. 1;1.




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