REHABILITATION AFTER LARYNGECTOMY

Vocal rehabilitation after laryngectomy, using esophageal speech, may be achieved by any patient who can swallow and who has good hearing, provided he is psychologically prepared before operation and begins trying to learn soon after operation.A patient passes through the early postoperative period much more easily if he knows that within a few short weeks a useful method of communication can be learned.Instruction by a person who has had laryngectomy has psychic as well as didactic advantages.     

Collaboration of a dentist and speech-language pathologist in the rehabilitation of a stroke patient with dysarthria: a case study

Objective: To elucidate the effectiveness of the collaboration of a dentist and speech‐language pathologist (SLP) in the rehabilitation of a stroke patient with dysarthria. Design: A clinical case report treated in the rehabilitation hospital and dental surgery. Subject: A 71‐year‐old Japanese man who was admitted to the rehabilitation hospital for speech rehabilitation 2 years and 5 months after a stroke. Methods: Provision of prosthesis (palatal lift prosthesis + palatal augmentation prosthesis) for improving velopharyngeal incompetence (VPI) and articulation by dentist, and speech behavioural management by SLP including self‐monitoring and bio‐feedback training using the See‐Scape. Results: Speech behavioural management proved useful for promoting improvement in speech intelligibility to a functionally sufficient level after improving VPI by prosthesis. Conclusion: The collaborative efforts of the dentist and SLP in the rehabilitation of post‐stroke patients with velopharyngeal incompetence should be encouraged.     

Common Speech Problems Encountered in General Practice

The authors consider speech and communication in the light of whole patient care and point out that defects may be signs and symptoms of underlying organic disease. They describe the four classifications of speech disorders—articulation, rhythm, voice and language, with an indication of the speech therapy required and duration of treatment. Special emphasis has been given to those speech problems which are seen by the family physician; these are usually of the articulation group. A short discussion of stuttering and aphasia is given. Emphasis is put on the direction of treatment by the physician and the use of well-qualified personnel as members of the rehabilitation team.     

Automatic detection of voice impairments from text-dependent running speech

Acoustic analysis is a useful tool to diagnose voice diseases. Furthermore it presents several advantages: it is non-invasive, provides an objective diagnostic and, also, it can be used for the evaluation of surgical and pharmacological treatments and rehabilitation processes. Most of the approaches found in the literature address the automatic detection of voice impairments from speech by using the sustained phonation of vowels. In this paper it is proposed a new scheme for the detection of voice impairments from text-dependent running speech. The proposed methodology is based on the segmentation of speech into voiced and non-voiced frames, parameterising each voiced frame with mel-frequency cepstral parameters. The classification is carried out using a discriminative approach based on a multilayer perceptron neural network. The data used to train the system were taken from the voice disorders database distributed by Kay Elemetrics. The material used for training and testing contains the running speech corresponding to the well known “rainbow passage” of 140 patients (23 normal and 117 pathological). The results obtained are compared with those using sustained vowels. The text-dependent running speech showed a light improvement in the accuracy of the detection.     

3D Simulation of an Audible Ultrasonic Electrolarynx Using Difference Waves

A total laryngectomy removes the vocal folds which are fundamental in forming voiced sounds that make speech possible. Although implanted prosthetics are commonly used in developed countries, simple handheld vibrating electrolarynxes are still common worldwide. These devices are easy to use but suffer from many drawbacks including dedication of a hand, mechanical sounding voice, and sound leakage. To address some of these drawbacks, we introduce a novel electrolarynx that uses vibro-acoustic interference of dual ultrasonic waves to generate an audible fundamental frequency. A 3D simulation of the principles of the device is presented in this paper.     

Importance of correct therapeutic procedure selection in voice recovery

Psychological and physical patient state as well as the influence of other social factor is of great influence voice rehabilitation. A team of experts in the field of voice and its function are involved in voice therapy. Our research was focused on the successfulness of voice recovery depending on the patient vocal disorder approach. We made a comparison of two methods: RVT and Accent method. We attempted to evaluate clinically relevant voice disorders in relation to certain vocal methods, we propose that a lot can be learned about voice trough therapeutic procedures, which can also be used to enhance the practical application of vocal methods and raise the level of success in dealing with people that suffer from voice pathology.     

Carcinoma of the Larynx: Results of Therapy

Prognosis of laryngeal carcinoma varies considerably, depending on its site and stage of development. In the past, laryngectomy was considered the treatment of choice for all but very early lesions. Results of therapy and five-year survival rates were relatively good, but the patient deprived of his larynx frequently presented difficulties in rehabilitation.Recent advances in radiotherapy techniques have permitted treatment of a greater proportion of patients with laryngeal carcinoma by this means, with encouraging results. Results of a survey in the Toronto area suggest that radiotherapy should be used as primary treatment in early and intermediate stages of the disease; radical excision combined with radiotherapy is indicated for treatment failures among early cases and for those with far-advanced disease or carcinoma outside the larynx proper. With this program five-year survival rates are comparable to those achieved when laryngectomy is the primary treatment used, and two-thirds of those who survive maintain laryngeal function.     

Basics of voice dysfunction--etiology and prevention of voice damage

Voice is one of the most important means of communication and as such should be taken care of. The etiology of voice disorders is diverse. Due to the development of the society we live in, way of life, environmental factors, and exposure to pharmacological agents as well as demands we make towards our voice, there is a substantial growth in the number of people with voice disorders. We tasked ourselves to find out if it is possible to enlighten people on the importance of voice, to motivate them to take care of it, to notice the changes in its quality and eventually ask for help. We assessed in which measure do we understand the importance of a healthy voice, and do we know which is the most important factor that adds to its decline. For a long number of years voice therapists and other experts in the voice disorder field have been discussing the optimal voice impostation as well as vocal exercises and methods behind voice recovery. They have all come to the same conclusion that phonation is dependant on the sort of the voice disorder and the patient motivation. We wanted to go one step further and investigate, dependence of voice quality and the damage etiology (organic - functional), which are the predominant causes, what are the factors that account for the damage and how the disorder motivates the patient and therefore influences the rehabilitation success rate.     

Progress in larynx-sparing surgery for glottic cancer through tracheal transplantation.

The current surgical treatment for unilateral, advanced glottic cancer is a total laryngectomy. Usually, the noninvolved hemilarynx needs resection because the resulting laryngeal defect cannot be reconstructed after adequate tumor resection. Experimental findings suggest that segments of autologous trachea may restore extended laryngeal defects. The authors used tracheal transplantation to save laryngeal function after the removal of advanced glottic cancer. In this case series review, 10 patients were treated during a 1.5-year period, with an average follow-up of 8 months. Evaluated factors included survival of the tracheal transplant and functional outcome with regard to the onset and quality of the airway, speech, and deglutition. The authors showed that segments of cervical trachea may restore extended laryngeal defects after initial revascularization by a radial forearm fascial flap. The fascial flap served as a vascular carrier for the transplanted trachea. Follow-up showed the stability of the reconstruction. Compared with a total laryngectomy, a striking improvement in patient comfort and function was noticed. Transplantation of the trachea is a technique that may save laryngeal function after the treatment of advanced-stage glottic cancer. These findings may improve laryngeal preservation strategies in treating laryngeal cancer.     

Feasibility of intensity-modulated and image-guided radiotherapy for functional organ preservation in locally advanced laryngeal cancer

Purpose

The study aims to assess the feasibility of intensity-modulated and image-guided radiotherapy (IMRT, and IGRT, respectively) for functional preservation in locally advanced laryngeal cancer. A retrospective review of 27 patients undergoing concurrent chemoradiation for locally advanced laryngeal cancers (8 IMRT, 19 IGRT) was undertaken. In addition to regular clinical examinations, all patients had PET imaging at 4 months and 10 months after radiotherapy, then yearly. Loco-regional control, speech quality and feeding-tube dependency were assessed during follow-up visits.

Results

At a median follow-up of 20 months (range 6–57 months), four out of 27 patients (14.8%) developed local recurrence and underwent salvage total laryngectomy. One patient developed distant metastases following salvage surgery. Among the 23 patients who conserved their larynx with no sign of recurrence at last follow-up, 22 (95%) reported normal or near normal voice quality, allowing them to communicate adequately. Four patients (14.8%) had long-term tube feeding-dependency because of severe dysphagia (2 patients) and chronic aspiration (2 patients, with ensuing death from aspiration pneumonia in one patient).

Conclusions and Clinical Relevance

Functional laryngeal preservation is feasible with IMRT and IGRT for locally advanced laryngeal cancer. However, dysphagia and aspiration remain serious complications, due most likely to high radiation dose delivery to the pharyngeal musculatures.     

An oral hygiene protocol improves oral health for patients in inpatient stroke rehabilitation

The objective

To determine whether a simple oral hygiene protocol improves the oral health of inpatients in stroke rehabilitation.

The background data discussing the present status of the field

Poor oral health can lead to serious complications, such as pneumonia. The comorbidities associated with stroke, such as dysphagia, hemiparesis and cognitive impairment, can further impede independent oral care. International stroke guidelines recommend routine oral care but stop short of detailing specific regimes.

Materials and methods

The oral health assessment tool (OHAT) was conducted by speech‐language pathologists with 100 patients with and without dysphagia in three metropolitan inpatient stroke rehabilitation facilities. A simple nurse‐led oral hygiene regime was then implemented with all participants, which included twice daily tooth brushing and mouth rinsing after lunch, and oral health was measured again one week later.

Results

Initially, dysphagia was negatively associated with OHAT scores, and independence for oral hygiene was positively associated with oral health. After one week of a simple oral hygiene regime, the OHAT scores available for 89 participants indicated an improvement on average for all participants. In particular, 59% of participants with dysphagia had an improvement of 1 or more points. None of the participants developed pneumonia.

Conclusion

A simple, inexpensive oral hygiene regime resulted in positive outcomes for patients with and without dysphagia in inpatient stroke rehabilitation settings. Oral health assessments and oral hygiene regimes that are simple to implement by the interdisciplinary team can be incorporated into standard stroke care with positive effect.     

Effects of Biofeedback in Phonatory Disorders and Phonatory Performance: A Systematic Literature Review

The purpose of this article was to systematically review the literature on the effects of biofeedback therapy in the domain of phonatory disorders and phonatory performance, using studies in peer-reviewed journals. An extensive definition of biofeedback is given and its place in voice treatment is defined. Eighteen group or case studies or reports considering the effects of electromyographic, laryngoscopic and acoustic biofeedback in dysphonic patients (hyperfunctional voice disorders, hypofunctional voice disorders, psychogenic voice disorder, laryngeal trauma, total laryngectomy, vocal cord dysfunction) and participants with normal voices are included and an analysis of procedure as well as research design and results is presented. The usefulness of biofeedback in phonatory disorders and performance was to be interpreted based on tendencies, since there is a lack of randomized controlled efficacy studies. In only 3 of 18 studies (16.7%) did biofeedback therapy fail to improve voice quality or not result in better results than other forms of therapy. Recommendations for improved methodologies are made, which include the use of acoustic voice quality parameters.     

Performance evaluation of a motor-imagery-based EEG-Brain computer interface using a combined cue with heterogeneous training data in BCI-Naive subjects

Background and objective

There has been a growing interest in objective assessment of speech in dysphonic patients for the classification of the type and severity of voice pathologies using automatic speech recognition (ASR). The aim of this work was to study the accuracy of the conventional ASR system (with Mel frequency cepstral coefficients (MFCCs) based front end and hidden Markov model (HMM) based back end) in recognizing the speech characteristics of people with pathological voice.

Materials and methods

The speech samples of 62 dysphonic patients with six different types of voice disorders and 50 normal subjects were analyzed. The Arabic spoken digits were taken as an input. The distribution of the first four formants of the vowel /a/ was extracted to examine deviation of the formants from normal.

Results

There was 100% recognition accuracy obtained for Arabic digits spoken by normal speakers. However, there was a significant loss of accuracy in the classifications while spoken by voice disordered subjects. Moreover, no significant improvement in ASR performance was achieved after assessing a subset of the individuals with disordered voices who underwent treatment.

Conclusion

The results of this study revealed that the current ASR technique is not a reliable tool in recognizing the speech of dysphonic patients.     

Unfulfilled rehabilitation needs and dissatisfaction with care 12 months after a stroke: an explorative observational study

ABSTRACT: BACKGROUND: People who have suffered a stroke commonly report unfulfilled need for rehabilitation. Using a model of patient satisfaction, we examined characteristics in individuals that at 3 months after stroke predicted, or at 12 months were associated with unmet need for rehabilitation or dissatisfaction with health care services at 12 months after stroke. METHODS: The participants (n = 175) received care at the stroke units at the Karolinska University Hospital, Sweden. The dependent variables "unfulfilled needs for rehabilitation" and "dissatisfaction with care" were collected using a questionnaire. Stroke severity, domains of the Stroke Impact Scale (SIS), the Sense of Coherence scale (SOC) and socio demographic factors were used as independent variables in four logistic regression analyses. RESULTS: Unfulfilled needs for rehabilitation at 12 months were predicted by strength (SIS) (odds ratio (OR) 7.05) at three months, and associated with hand function (SIS) (OR 4.38) and poor self-rated recovery (SIS) (OR 2.46) at 12 months. Dissatisfaction with care was predicted by SOC (OR 4.18) and participation (SIS) (OR 3.78), and associated with SOC (OR 3.63) and strength (SIS) (OR 3.08). CONCLUSIONS: Thirty-three percent of the participants reported unmet needs for rehabilitation and fourteen percent were dissatisfied with the care received. In order to attend to rehabilitation needs when they arise, rehabilitation services may need to be more flexible in terms of when rehabilitation is provided. Long term services with scheduled re-assessments and with more emphasis on understanding the experiences of both the patients and their social networks might better be able to provide services that attend to patients' needs and aid peoples' reorientation; this would apply particularly to those with poor coping capacity.     

Bimanual training in stroke: How do coupling and symmetry-breaking matter?

Background  

The dramatic consequences of stroke on patient autonomy in daily living activities urged the need for new reliable therapeutic strategies. Recently, bimanual training has emerged as a promising tool to improve the functional recovery of upper-limbs in stroke patients. However, who could benefit from bimanual therapy and how it could be used as a part of a more complete rehabilitation protocol remain largely unknown. A possible reason explaining this situation is that coupling and symmetry-breaking mechanisms, two fundamental principles governing bimanual behaviour, have been largely under-explored in both research and rehabilitation in stroke.     

Communication and the primate brain: insights from neuroimaging studies in humans, chimpanzees and macaques

Considerable knowledge is available on the neural substrates for speech and language from brain-imaging studies in humans, but until recently there was a lack of data for comparison from other animal species on the evolutionarily conserved brain regions that process species-specific communication signals. To obtain new insights into the relationship of the substrates for communication in primates, we compared the results from several neuroimaging studies in humans with those that have recently been obtained from macaque monkeys and chimpanzees. The recent work in humans challenges the longstanding notion of highly localized speech areas. As a result, the brain regions that have been identified in humans for speech and nonlinguistic voice processing show a striking general correspondence to how the brains of other primates analyze species-specific vocalizations or information in the voice, such as voice identity. The comparative neuroimaging work has begun to clarify evolutionary relationships in brain function, supporting the notion that the brain regions that process communication signals in the human brain arose from a precursor network of regions that is present in nonhuman primates and is used for processing species-specific vocalizations. We conclude by considering how the stage now seems to be set for comparative neurobiology to characterize the ancestral state of the network that evolved in humans to support language.     

Qualitative analysis of stroke patients' motivation for rehabilitation

ObjectiveTo explore the attitudes and beliefs of stroke patients identified by professionals as having either “high” or “low” motivation for rehabilitation.DesignQualitative study with semistructured interviews.SettingThe stroke unit of an inner city teaching hospital.Participants22 patients with stroke who were undergoing rehabilitation; 14 with high motivation for rehabilitation and eight with low motivation.ResultsAll patients thought rehabilitation was important for recovery. High motivation patients were more likely to view rehabilitation as the most important means of recovery and to accord themselves an active role in rehabilitation. These patients were also more likely to understand rehabilitation and in particular to understand the specialist role of the nursing staff. Many patients reported independence at home as a personal goal, though few low motivation patients related this goal to success in rehabilitation. Information from professionals about rehabilitation, favourable comparisons with other stroke patients, and the desire to leave hospital had a positive effect on motivation. Conversely, overprotection from family members and professionals, lack of information or the receipt of “mixed messages” from professionals, and unfavourable comparisons with other patients had a negative effect.ConclusionsThere are some differences in beliefs between stroke patients identified as having low or high motivation for rehabilitation. These beliefs seem to be influenced by the environment in which the patient is rehabilitated. Professionals and carers should be made aware of the ways in which their behaviour can positively and negatively affect motivation.     

Chromosome 22q11.2 microdeletion in a patient with hemophilia A

We report a 6-year-old patient with hemophilia A, who also exhibited clinical features typical of 22q11.2 deletion syndrome (22qDS). The specific traits were mild mental retardation, speech delay, hypernasal speech, deficits in voice quality and articulation, narrow palpebral fissures, broad and depressed nasal root, high-arched palate, microstomia, and overfolded ears. The patient had no associated congenital cardiac or palatal malformations. It can be particularly difficult to identify this syndrome in newborns and infants without congenital heart defects. This case underlines that microdeletion of chromosome 22q11.2 should be considered in any patient who exhibits typical clinical features of 22qDS, regardless of whether they have another single-gene disorder.     

The Influence of Voice Volume, Pitch, and Speech Rate on Progressive Relaxation Training: Application of Methods from Speech Pathology and Audiology

Vocal characteristics of therapists, including voice volume, pitch and timbre of speech, and rate of speech have been hypothesized to facilitate the therapeutic process, particularly during procedures like progressive relaxation training (PRT). Very little empirical work, however, has examined the relation between vocal characteristics and treatment process or outcome. The purpose of this study was to examine the role of vocal characteristics during a single session of PRT applying technological innovations devised for speech pathology and audiology settings for evaluating therapist's vocal characteristics. Forty-eight high anxious young adult women were randomly assigned to one of four conditions for training: PRT with the recommended therapist voice (RV) that decreased in tone, volume, and rate across the session, PRT with conversational therapist voice during the session (CV), a credible treatment control called systematic self-relaxation (SR), or no treatment control (NT). All subjects participated in a single PRT session during which heart rate, EMG, self-report measures of tension (SRT) and anxiety, and treatment credibility ratings were obtained. Results revealed significant reductions in SRT, self-reported anxiety, and heart rate for participants in all groups. Only the RV group displayed significant reductions in EMG when compared with the other three groups. Participants in the RV group also rated the therapist's voice as “more facilitating” of relaxation when compared to the CV group. These results suggest that methods employed for evaluating the quality of vocal characteristics in speech and audiology clinics may be useful for evaluating the quality of therapist's voice when conducting PRT.     

Augmented visual feedback of movement performance to enhance walking recovery after stroke: study protocol for a pilot randomised controlled trial

ABSTRACT: BACKGROUND: Increasing evidence suggests that use of augmented visual feedback could be a useful approach to stroke rehabilitation. In current clinical practice, visual feedback of movement performance is often limited to the use of mirrors or video. However, neither approach is optimal since cognitive and self-image issues can distract or distress patients and their movement can be obscured by clothing or limited viewpoints. Three-dimensional motion capture has the potential to provide accurate kinematic data required for objective assessment and feedback in the clinical environment. However, such data are currently presented in numerical or graphical format, which is often impractical in a clinical setting. Our hypothesis is that presenting this kinematic data using bespoke visualisation software, which is tailored for gait rehabilitation after stroke, will provide a means whereby feedback of movement performance can be communicated in a more meaningful way to patients. This will result in increased patient understanding of their rehabilitation and will enable progress to be tracked in a more accessible way. METHODS: The hypothesis will be assessed using an exploratory (phase II) randomised controlled trial. Stroke survivors eligible for this trial will be in the subacute stage of stroke and have impaired walking ability (Functional Ambulation Classification of 1 or more). Participants (n = 45) will be randomised into three groups to compare the use of the visualisation software during overground physical therapy gait training against an intensity-matched and attention-matched placebo group and a usual care control group. The primary outcome measure will be walking speed. Secondary measures will be Functional Ambulation Category, Timed Up and Go, Rivermead Visual Gait Assessment, Stroke Impact Scale-16 and spatiotemporal parameters associated with walking. Additional qualitative measures will be used to assess the participant's experience of the visual feedback provided in the study. DISCUSSION: Results from the trial will explore whether the early provision of visual feedback of biomechanical movement performance during gait rehabilitation demonstrates improved mobility outcomes after stroke and increased patient understanding of their rehabilitation.Trial registrationCurrent Controlled Trials ISRCTN79005974.