Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatme... more Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatment for improving expiratory pressure. EMST proved to be effective in different patient groups to improve cough function. To date, EMST has not been tested in the total laryngectomy population (TL). Methods: This prospective, randomized case-series study examined feasibility, safety, and compliance of EMST in a group of TL participants and its effects on pulmonary function, physical exertion, fatigue, and vocal functioning. Ten TL participants were included in the study to perform a 4 till 8 weeks of EMST. Objective and subjective outcome measures included manometry, spirometry, cardio pulmonary exercise testing (CPET), voice recordings, and patient reported outcome measures. Group means were reported and estimates of the effect are shown with a 95% confidence interval, using single sample t-tests. Results: Nine participants completed the full study protocol. Compliance to the training pr...
The role of cough is of interest to speech-language pathologists (SLPs) for two seemingly contrad... more The role of cough is of interest to speech-language pathologists (SLPs) for two seemingly contradictory reasons: chronic, excessive cough and insufficient cough. Evidence supports the role of the SLP in behavioral strategies for both the reduction and/or elimination of chronic cough, as well as the use of pulmonary exercise to realize improved airway clearance in individuals with a weak, insufficient cough. At both ends of this continuum, anchored at one end by too much coughing and the other end anchored by inadequate cough for airway clearance/pulmonary health, the SLP has an important role.
This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and orophary... more This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and oropharyngeal pH levels in singers. We hypothesized that reported symptoms would correlate with objective measures of pH levels from the oropharynx, including the number and total duration of reflux episodes. Twenty professional/semiprofessional singers completed the Reflux Symptom Index (RSI) and underwent oropharyngeal pH monitoring. Mild, moderate, or severe pH exposure was recorded during oropharyngeal pH monitoring. Correlations were performed to examine potential relationships between reflux symptoms and duration of LPR episodes. Symptom severity did not correlate with pH levels; however, we found a number of covariances of interest. Large sample sizes are necessary to determine if true correlations exist. Our results suggest that singers may exhibit enhanced sensitivity to LPR and may therefore manifest symptoms, even in response to subtle changes in pH. This study emphasizes the importan...
Multiple sclerosis journal - experimental, translational and clinical
Weakening and dyscoordination of expiratory muscles in multiple sclerosis (MS) can impair respira... more Weakening and dyscoordination of expiratory muscles in multiple sclerosis (MS) can impair respiratory and swallow function. The objective of this paper is to test a novel expiratory muscle strength training (EMST) device on expiratory pressure, swallow function, and swallow-related quality-of-life (SWAL-QOL) in individuals with MS. Participants with MS were randomized to a five-week breathing practice of either positive pressure load (EMST) or near-zero pressure (sham). We compared baseline to post-treatment data according to maximum expiratory pressure (MEP), abnormal airway penetration and aspiration (PAS), and SWAL-QOL. Both groups improved in MEP (p < 0.001). Forty percent of the EMST group improved on PAS, and 15% worsened; conversely, 21.4% of the sham group worsened and 14.3% improved. There was no group difference in overall SWAL-QOL; but the EMST group had significantly greater gain versus sham on the Burden (p = 0.014) and Pharyngeal Swallow (p = 0.022) domains. Both gr...
Archives of Physical Medicine and Rehabilitation, 2015
To examine relationships between Peak expiratory (cough) airflow rate and swallowing symptom seve... more To examine relationships between Peak expiratory (cough) airflow rate and swallowing symptom severity in participants with Parkinson Disease DESIGN: Participants were cued to cough into an analog peak flow meter then swallowed three, 20 mL thin liquid barium boluses. Analyses were directed at detecting potential relationships among disease severity, swallowing symptom severity and PEFR. Sixty eight male and females with PD. Not applicable MAIN OUTCOME MEASURES: PEFR and swallow symptom severity RESULTS: PEFR varied significantly across swallowing severity classifications. Participants with more severe disease displayed a significant, linear decrease in PEFR compared to those participants with earlier stage, less severe disease. Swallowing symptom severity varied significantly across groups when comparing participants with less severe PD to those with more severe PD. Participants with early-stage PD demonstrated little to no swallowing symptoms and had the highest measures of PEFR. In contrast, participants with the most severe swallowing symptoms also displayed the lowest measures of PEFR. Relationships existed among PD severity, swallowing symptom severity and PEFR in participants with PD. PEFR may eventually stand as a non-invasive predictor of aspiration risk in those with PD, particularly later-stage disease. Inclusion of PEFRs into existing clinical swallowing assessments may increase the sensitivity and predictive validity of these assessments.
This study investigates if adults with adductor spasmodic dysphonia (ADSD) report to experience a... more This study investigates if adults with adductor spasmodic dysphonia (ADSD) report to experience anxiety and voice problems in particular situations, indicate the presence of negative speech-associated attitude, and/or the use of coping behaviors, by means of the Behavior Assessment Battery (BAB) modified for voice. Thirty-two participants with ADSD and 32 adults without a voice disorder participated in this study. Each person completed four different BAB-Voice subtests. These standardized self-report tests are adaptations of the original BAB for people who stutter and explore an individual&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s speech-related belief, negative emotional reaction to and speech problems in particular speech situations, and the use of concomitant behaviors. Individuals with spasmodic dysphonia (SD) scored statistically significantly higher compared to typical speakers on all BAB subtests, indicating that individuals with SD report being significantly more anxious and experiencing significantly more voice problems in particular speech circumstances. They also reported a significant amount of negative speech-associated attitude and the use of a significant number of coping behaviors. Internal reliability was good for three of the four BAB subtests. The BAB is capable of reflecting the dimensions that surround the disorder of SD. The self-report measures have the potential to augment the observations made by the clinician and may lead to a more diverse and all-encompassing therapy for the person suffering from SD. Future research with a revised version of the BAB-Voice will continue to explore the validity, reliability, and replicability of the initial data.
Finding measures that track disease progression and determine treatment efficacy is vital for app... more Finding measures that track disease progression and determine treatment efficacy is vital for appropriate management in Friedreich ataxia (FA). The purpose of this study was to determine which cepstral- and spectral-based measures extracted from prolonged vowels using Analysis of Dysphonia in Speech and Voice (ADSV) program discriminate between those who have FA and normal voice (NV) peers. This is a descriptive, prospective study. Initial 2 seconds of prolonged /a/, /i/, and /o/ were analyzed through ADSV from 20 individuals diagnosed with FA and 20 NV individuals. ADSV measures used were cepstral peak prominence (CPP), cepstral peak prominence standard deviation (CPP SD), low/high spectral ratio (L/H ratio), low/high spectral ratio standard deviation (L/H ratio SD), and the Cepstral/Spectral Index of Dysphonia (CSID). L/H ratio SD was the only measure where significant differences were found across all vowels between groups. Comparing measures per vowel, the vowel /o/ was significantly different between groups on four of five measures. Discrimination analysis revealed 100% of those in the FA group were classified correctly (sensitivity), whereas 95% of NV members were correctly identified (specificity) when all ADSV measures, with the exception of L/H ratio, were entered. Unstable periods of phonation, such as initiations of voice production in vowels, may yield robust acoustic cues in the FA population. ADSV provides measures that, when considered together, have excellent sensitivity and very good specificity. Vowels yielded differing results on ADSV measures; analysis of different vowel types is recommended.
Eagle's syndrome (ES) is rare condition, most frequently described within the context of case... more Eagle's syndrome (ES) is rare condition, most frequently described within the context of case study presentation. ES results from elongation of the styloid process, contributing to symptoms such as globus sensation in the throat, as well as pain localized to the ear, neck, face, or tongue. Additional symptoms can include hypersalivation, change in vocal quality, submandibular swelling, and dysphagia. This report discusses evaluation, diagnosis, and surgical intervention with respect to Eagle's Syndrome in a patient presenting with moderate-severe dysphagia.
International journal of pediatric otorhinolaryngology, 2004
Paradoxical vocal fold dysfunction (PVFD) with high effort exercise can result in disruptions to ... more Paradoxical vocal fold dysfunction (PVFD) with high effort exercise can result in disruptions to ventilation, dyspnea, inspiratory stridor, elevated heart rate, and syncope. This single subject study experimentally tested an inspiratory muscle strength training (IMST) program with behavioral therapy on a 15-year-old male crew member. Outcome variables were maximum inspiratory pressure (MIP), and dyspnea ratings. Following 5 weeks of IMST, MIP increased by 93% from baseline function while dyspnea ratings substantially decreased. Outcome included successful competition with his high-school crew team, a task he was previously unable to complete. Discussion focuses on IMST combined with traditional approaches of voice therapy for treating PVFD.
Studies in health technology and informatics, 2004
Technological advances in Augmented Reality (AR) and extraction of 3D patient specific medical da... more Technological advances in Augmented Reality (AR) and extraction of 3D patient specific medical data led to the creation of medical visualization using AR environments, in which the 3D data is registered and synchronized with the position of the patient. One of the challenges in such visualization environments is maintaining an accurate shape of the 3D data for self-deformable models such as lungs. An accurate deformation of lung model with 3D visualization may significantly increase the teaching and diagnosing ability of physicians. Modeling the deformation of lungs primarily involves the accurate representation of Pressure-volume relationship and the hysteresis in the relationship during inhalation and exhalation. This paper explains a real-time physiologically accurate deformation algorithm and its hardware rendering. We then introduce a novel approach for the representation of accurate pressure volume relationship based on an analogy with classical mechanics. Our simulation resul...
This study examined changes in voluntary cough airflow measures immediately following in-office i... more This study examined changes in voluntary cough airflow measures immediately following in-office injection of Radiesse in patients diagnosed with glottic insufficiency. Due to significant comorbidities, these patients were poor candidates for medialization under general anesthesia. Each patient presented with dysphonia and dysphagia and ineffective voluntary cough, resulting in a poor clearing of secretions and a presence of ingested fluids on examination. Prospective cohort and case series study. Three patients with a diagnosis of glottic insufficiency were included for study based on flexible endoscopy and laryngostroboscopic examination. Voluntary cough airflow measures were obtained approximately 30 minutes before and after the Radiesse injections. The airflow measures were: compression phase duration (CPD), expiratory rise time (EPRT), expiratory phase peak airflow (EPPF), and cough volume acceleration (CVA). Injection of Radiesse was found to improve voluntary cough airflow measures. The immediate increase in the objective airflow measures obtained from voluntary cough production after Radiesse injections can be used to document airway protection improvements. Cough airflow is a straightforward measure to obtain and is considered an objective measure of cough function. 4.
Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatme... more Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatment for improving expiratory pressure. EMST proved to be effective in different patient groups to improve cough function. To date, EMST has not been tested in the total laryngectomy population (TL). Methods: This prospective, randomized case-series study examined feasibility, safety, and compliance of EMST in a group of TL participants and its effects on pulmonary function, physical exertion, fatigue, and vocal functioning. Ten TL participants were included in the study to perform a 4 till 8 weeks of EMST. Objective and subjective outcome measures included manometry, spirometry, cardio pulmonary exercise testing (CPET), voice recordings, and patient reported outcome measures. Group means were reported and estimates of the effect are shown with a 95% confidence interval, using single sample t-tests. Results: Nine participants completed the full study protocol. Compliance to the training pr...
The role of cough is of interest to speech-language pathologists (SLPs) for two seemingly contrad... more The role of cough is of interest to speech-language pathologists (SLPs) for two seemingly contradictory reasons: chronic, excessive cough and insufficient cough. Evidence supports the role of the SLP in behavioral strategies for both the reduction and/or elimination of chronic cough, as well as the use of pulmonary exercise to realize improved airway clearance in individuals with a weak, insufficient cough. At both ends of this continuum, anchored at one end by too much coughing and the other end anchored by inadequate cough for airway clearance/pulmonary health, the SLP has an important role.
This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and orophary... more This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and oropharyngeal pH levels in singers. We hypothesized that reported symptoms would correlate with objective measures of pH levels from the oropharynx, including the number and total duration of reflux episodes. Twenty professional/semiprofessional singers completed the Reflux Symptom Index (RSI) and underwent oropharyngeal pH monitoring. Mild, moderate, or severe pH exposure was recorded during oropharyngeal pH monitoring. Correlations were performed to examine potential relationships between reflux symptoms and duration of LPR episodes. Symptom severity did not correlate with pH levels; however, we found a number of covariances of interest. Large sample sizes are necessary to determine if true correlations exist. Our results suggest that singers may exhibit enhanced sensitivity to LPR and may therefore manifest symptoms, even in response to subtle changes in pH. This study emphasizes the importan...
Multiple sclerosis journal - experimental, translational and clinical
Weakening and dyscoordination of expiratory muscles in multiple sclerosis (MS) can impair respira... more Weakening and dyscoordination of expiratory muscles in multiple sclerosis (MS) can impair respiratory and swallow function. The objective of this paper is to test a novel expiratory muscle strength training (EMST) device on expiratory pressure, swallow function, and swallow-related quality-of-life (SWAL-QOL) in individuals with MS. Participants with MS were randomized to a five-week breathing practice of either positive pressure load (EMST) or near-zero pressure (sham). We compared baseline to post-treatment data according to maximum expiratory pressure (MEP), abnormal airway penetration and aspiration (PAS), and SWAL-QOL. Both groups improved in MEP (p < 0.001). Forty percent of the EMST group improved on PAS, and 15% worsened; conversely, 21.4% of the sham group worsened and 14.3% improved. There was no group difference in overall SWAL-QOL; but the EMST group had significantly greater gain versus sham on the Burden (p = 0.014) and Pharyngeal Swallow (p = 0.022) domains. Both gr...
Archives of Physical Medicine and Rehabilitation, 2015
To examine relationships between Peak expiratory (cough) airflow rate and swallowing symptom seve... more To examine relationships between Peak expiratory (cough) airflow rate and swallowing symptom severity in participants with Parkinson Disease DESIGN: Participants were cued to cough into an analog peak flow meter then swallowed three, 20 mL thin liquid barium boluses. Analyses were directed at detecting potential relationships among disease severity, swallowing symptom severity and PEFR. Sixty eight male and females with PD. Not applicable MAIN OUTCOME MEASURES: PEFR and swallow symptom severity RESULTS: PEFR varied significantly across swallowing severity classifications. Participants with more severe disease displayed a significant, linear decrease in PEFR compared to those participants with earlier stage, less severe disease. Swallowing symptom severity varied significantly across groups when comparing participants with less severe PD to those with more severe PD. Participants with early-stage PD demonstrated little to no swallowing symptoms and had the highest measures of PEFR. In contrast, participants with the most severe swallowing symptoms also displayed the lowest measures of PEFR. Relationships existed among PD severity, swallowing symptom severity and PEFR in participants with PD. PEFR may eventually stand as a non-invasive predictor of aspiration risk in those with PD, particularly later-stage disease. Inclusion of PEFRs into existing clinical swallowing assessments may increase the sensitivity and predictive validity of these assessments.
This study investigates if adults with adductor spasmodic dysphonia (ADSD) report to experience a... more This study investigates if adults with adductor spasmodic dysphonia (ADSD) report to experience anxiety and voice problems in particular situations, indicate the presence of negative speech-associated attitude, and/or the use of coping behaviors, by means of the Behavior Assessment Battery (BAB) modified for voice. Thirty-two participants with ADSD and 32 adults without a voice disorder participated in this study. Each person completed four different BAB-Voice subtests. These standardized self-report tests are adaptations of the original BAB for people who stutter and explore an individual&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s speech-related belief, negative emotional reaction to and speech problems in particular speech situations, and the use of concomitant behaviors. Individuals with spasmodic dysphonia (SD) scored statistically significantly higher compared to typical speakers on all BAB subtests, indicating that individuals with SD report being significantly more anxious and experiencing significantly more voice problems in particular speech circumstances. They also reported a significant amount of negative speech-associated attitude and the use of a significant number of coping behaviors. Internal reliability was good for three of the four BAB subtests. The BAB is capable of reflecting the dimensions that surround the disorder of SD. The self-report measures have the potential to augment the observations made by the clinician and may lead to a more diverse and all-encompassing therapy for the person suffering from SD. Future research with a revised version of the BAB-Voice will continue to explore the validity, reliability, and replicability of the initial data.
Finding measures that track disease progression and determine treatment efficacy is vital for app... more Finding measures that track disease progression and determine treatment efficacy is vital for appropriate management in Friedreich ataxia (FA). The purpose of this study was to determine which cepstral- and spectral-based measures extracted from prolonged vowels using Analysis of Dysphonia in Speech and Voice (ADSV) program discriminate between those who have FA and normal voice (NV) peers. This is a descriptive, prospective study. Initial 2 seconds of prolonged /a/, /i/, and /o/ were analyzed through ADSV from 20 individuals diagnosed with FA and 20 NV individuals. ADSV measures used were cepstral peak prominence (CPP), cepstral peak prominence standard deviation (CPP SD), low/high spectral ratio (L/H ratio), low/high spectral ratio standard deviation (L/H ratio SD), and the Cepstral/Spectral Index of Dysphonia (CSID). L/H ratio SD was the only measure where significant differences were found across all vowels between groups. Comparing measures per vowel, the vowel /o/ was significantly different between groups on four of five measures. Discrimination analysis revealed 100% of those in the FA group were classified correctly (sensitivity), whereas 95% of NV members were correctly identified (specificity) when all ADSV measures, with the exception of L/H ratio, were entered. Unstable periods of phonation, such as initiations of voice production in vowels, may yield robust acoustic cues in the FA population. ADSV provides measures that, when considered together, have excellent sensitivity and very good specificity. Vowels yielded differing results on ADSV measures; analysis of different vowel types is recommended.
Eagle's syndrome (ES) is rare condition, most frequently described within the context of case... more Eagle's syndrome (ES) is rare condition, most frequently described within the context of case study presentation. ES results from elongation of the styloid process, contributing to symptoms such as globus sensation in the throat, as well as pain localized to the ear, neck, face, or tongue. Additional symptoms can include hypersalivation, change in vocal quality, submandibular swelling, and dysphagia. This report discusses evaluation, diagnosis, and surgical intervention with respect to Eagle's Syndrome in a patient presenting with moderate-severe dysphagia.
International journal of pediatric otorhinolaryngology, 2004
Paradoxical vocal fold dysfunction (PVFD) with high effort exercise can result in disruptions to ... more Paradoxical vocal fold dysfunction (PVFD) with high effort exercise can result in disruptions to ventilation, dyspnea, inspiratory stridor, elevated heart rate, and syncope. This single subject study experimentally tested an inspiratory muscle strength training (IMST) program with behavioral therapy on a 15-year-old male crew member. Outcome variables were maximum inspiratory pressure (MIP), and dyspnea ratings. Following 5 weeks of IMST, MIP increased by 93% from baseline function while dyspnea ratings substantially decreased. Outcome included successful competition with his high-school crew team, a task he was previously unable to complete. Discussion focuses on IMST combined with traditional approaches of voice therapy for treating PVFD.
Studies in health technology and informatics, 2004
Technological advances in Augmented Reality (AR) and extraction of 3D patient specific medical da... more Technological advances in Augmented Reality (AR) and extraction of 3D patient specific medical data led to the creation of medical visualization using AR environments, in which the 3D data is registered and synchronized with the position of the patient. One of the challenges in such visualization environments is maintaining an accurate shape of the 3D data for self-deformable models such as lungs. An accurate deformation of lung model with 3D visualization may significantly increase the teaching and diagnosing ability of physicians. Modeling the deformation of lungs primarily involves the accurate representation of Pressure-volume relationship and the hysteresis in the relationship during inhalation and exhalation. This paper explains a real-time physiologically accurate deformation algorithm and its hardware rendering. We then introduce a novel approach for the representation of accurate pressure volume relationship based on an analogy with classical mechanics. Our simulation resul...
This study examined changes in voluntary cough airflow measures immediately following in-office i... more This study examined changes in voluntary cough airflow measures immediately following in-office injection of Radiesse in patients diagnosed with glottic insufficiency. Due to significant comorbidities, these patients were poor candidates for medialization under general anesthesia. Each patient presented with dysphonia and dysphagia and ineffective voluntary cough, resulting in a poor clearing of secretions and a presence of ingested fluids on examination. Prospective cohort and case series study. Three patients with a diagnosis of glottic insufficiency were included for study based on flexible endoscopy and laryngostroboscopic examination. Voluntary cough airflow measures were obtained approximately 30 minutes before and after the Radiesse injections. The airflow measures were: compression phase duration (CPD), expiratory rise time (EPRT), expiratory phase peak airflow (EPPF), and cough volume acceleration (CVA). Injection of Radiesse was found to improve voluntary cough airflow measures. The immediate increase in the objective airflow measures obtained from voluntary cough production after Radiesse injections can be used to document airway protection improvements. Cough airflow is a straightforward measure to obtain and is considered an objective measure of cough function. 4.
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