Assessment Strategies
Huntington’s Disease: Voice Assessment
Overview
Huntington’s Disease is a devastating and debilitating disease
that affects all aspects of a person’s life. In this section, we will explore
the assessment procedures and strategies associated with voice in Huntington’s Disease. Assessment of the voice for Huntington’s Disease requires the SLP to determine the severity of typical voice symptoms associated with Huntington’s. These may include: strained or strangled voice quality, monopitch, excessive loudness variations, equal stress on ordinary unstressed words, with sudden forced changes in breath control (Yorkston et al., 2004). The most prominent symptoms are the jerky, irregular bursts of loud voice and obvious interruptions of prosody. Knowing the symptoms will ideally guide the clinician as to which assessment will be best suited for a particular client. Depending on
how far the disease has progressed and determining the patient’s current
communication abilities are also key factors in figuring which assessment is
best for that particular client. Since the disease is progressive, assessment
and treatment is usually possible in the first few years after the onset of the disease. A study by Ho et. al. was conducted to investigate the impact of voice changes in patients at different stages of Huntington's disease severity. The questionnaire was designed to assess the participant's perception of their own quality of voice in speech and how they feel this influences their quality of life. The data showed that people living with Huntington's disease reported that they felt the impact of changes in speech and voice very early on, as early as in Stage 1. The results also support the better recognized impact of Huntington's in voice and speech in the later stages of disease. Most importantly, the sooner the client arrives for an assessment, the sooner the SLP can implement a plan that will prolong independence and maintain the highest level of function for the longest period of time for a client.
Function of the SLP and Elements in Voice Assessment
With Huntington’s Disease, the SLP needs to be looking at the vocal characteristics as they relate to the already diagnosed neurogenic
condition of Huntington’s Disease and how they affect respiration, phonation, resonance and prosody of the patient. A team approach will most likely be implemented in which a laryngologist, Speech Pathologist, Neurologist, and other medical professionals collaborate and decide on a medical treatment plan that best suites each paticular client and their medical needs. The impact upon voice will depend upon the stage of the disease.
Elements of a Voice Evaluation for HD:
· Case History
· Instrumental and Perceptual Evaluation of:
o Pitch
o Loudness
o Quality
o Air Wastage
· Analysis of ENT report
· Oral-Motor Examination
· Analyze videoendoscopic data
· Observe patient behavior
· Analyze electroglottographic data
Each element of the assessment provides essential information and data that is pertinent in the intervention stage of Huntington’s disease. The case history is crucial to establish rapport with the client as well as dechiper the client's wants and needs as they pertain to assessment and intervention. The SLP may ask questions and interview the client in order to get a vivid description, onset and duration, and variability of the problem. Observation of daily environmental tasks, behavior, and quality of life factors should also be discussed at this point. Perceptual and Instrumental evaluations are also vital to the assessment. Instrumentation evaluations will document and quantify the data and will supplement the perceptual evaluation. The instrumental evaluation can also aid in the measurement of progress and change as well as provide biofeedback. Some examples of the Instrumental evaluation for acoustic analysis include: the Speech Analyzer (range and average of frequency and pitch,etc),Visi-pitch (habitual pitch and loudness), and Phonatory Function Analyzer (evaluates phonation time,fundamental frequency, vocal intensity, airflow rate, and total volume of air during each phonation task). However, the perceptual evaluation, using a voice rating scale, provides the SLP with a qualitative scale to measure breathiness, thinness, tremor, hoarseness, tightness, and/or strain-strangled qualities and measurements of the client’s voice.
Factors and Tools
As we look at assessment, there are some factors and tools to consider. Factors that may affect how we assess are: the nature of the disorder, etiology, changes that may have occurred or are occurring as the disease
progresses, level of performance (current and future), factors that influence their performance, stimulability, client/family expectations, and existing evidence that pertains to HD and voice.
Tools that may be used for our assessments range from standardized (norm referenced) tests to non-standardized/formal (criterion referenced) assessments. The instruments an SLP can use are behavioral observation (structured vs. naturalistic) or an interview.
Strobovideolaryngoscopy and videoendoscopy are both commonly used to aid in the assessment and treatment planning of Huntington’s. Endoscopy provides a visual picture of the vocal tract anatomy and physiology as well as the mucosal wave.
Strobovideolaryngoscopy provides a permenant record and shows the laryngeal function during typical and clinically manipulated vocal production.
This will then aid in:
· Client counseling
· Compliance with therapy tasks
· Share pictures with referral source
· Compare pre/post therapy
· Frame-by-frame analysis of abnormal physiology mucosal wave
Overview
Huntington’s Disease is a devastating and debilitating disease
that affects all aspects of a person’s life. In this section, we will explore
the assessment procedures and strategies associated with voice in Huntington’s Disease. Assessment of the voice for Huntington’s Disease requires the SLP to determine the severity of typical voice symptoms associated with Huntington’s. These may include: strained or strangled voice quality, monopitch, excessive loudness variations, equal stress on ordinary unstressed words, with sudden forced changes in breath control (Yorkston et al., 2004). The most prominent symptoms are the jerky, irregular bursts of loud voice and obvious interruptions of prosody. Knowing the symptoms will ideally guide the clinician as to which assessment will be best suited for a particular client. Depending on
how far the disease has progressed and determining the patient’s current
communication abilities are also key factors in figuring which assessment is
best for that particular client. Since the disease is progressive, assessment
and treatment is usually possible in the first few years after the onset of the disease. A study by Ho et. al. was conducted to investigate the impact of voice changes in patients at different stages of Huntington's disease severity. The questionnaire was designed to assess the participant's perception of their own quality of voice in speech and how they feel this influences their quality of life. The data showed that people living with Huntington's disease reported that they felt the impact of changes in speech and voice very early on, as early as in Stage 1. The results also support the better recognized impact of Huntington's in voice and speech in the later stages of disease. Most importantly, the sooner the client arrives for an assessment, the sooner the SLP can implement a plan that will prolong independence and maintain the highest level of function for the longest period of time for a client.
Function of the SLP and Elements in Voice Assessment
With Huntington’s Disease, the SLP needs to be looking at the vocal characteristics as they relate to the already diagnosed neurogenic
condition of Huntington’s Disease and how they affect respiration, phonation, resonance and prosody of the patient. A team approach will most likely be implemented in which a laryngologist, Speech Pathologist, Neurologist, and other medical professionals collaborate and decide on a medical treatment plan that best suites each paticular client and their medical needs. The impact upon voice will depend upon the stage of the disease.
Elements of a Voice Evaluation for HD:
· Case History
· Instrumental and Perceptual Evaluation of:
o Pitch
o Loudness
o Quality
o Air Wastage
· Analysis of ENT report
· Oral-Motor Examination
· Analyze videoendoscopic data
· Observe patient behavior
· Analyze electroglottographic data
Each element of the assessment provides essential information and data that is pertinent in the intervention stage of Huntington’s disease. The case history is crucial to establish rapport with the client as well as dechiper the client's wants and needs as they pertain to assessment and intervention. The SLP may ask questions and interview the client in order to get a vivid description, onset and duration, and variability of the problem. Observation of daily environmental tasks, behavior, and quality of life factors should also be discussed at this point. Perceptual and Instrumental evaluations are also vital to the assessment. Instrumentation evaluations will document and quantify the data and will supplement the perceptual evaluation. The instrumental evaluation can also aid in the measurement of progress and change as well as provide biofeedback. Some examples of the Instrumental evaluation for acoustic analysis include: the Speech Analyzer (range and average of frequency and pitch,etc),Visi-pitch (habitual pitch and loudness), and Phonatory Function Analyzer (evaluates phonation time,fundamental frequency, vocal intensity, airflow rate, and total volume of air during each phonation task). However, the perceptual evaluation, using a voice rating scale, provides the SLP with a qualitative scale to measure breathiness, thinness, tremor, hoarseness, tightness, and/or strain-strangled qualities and measurements of the client’s voice.
Factors and Tools
As we look at assessment, there are some factors and tools to consider. Factors that may affect how we assess are: the nature of the disorder, etiology, changes that may have occurred or are occurring as the disease
progresses, level of performance (current and future), factors that influence their performance, stimulability, client/family expectations, and existing evidence that pertains to HD and voice.
Tools that may be used for our assessments range from standardized (norm referenced) tests to non-standardized/formal (criterion referenced) assessments. The instruments an SLP can use are behavioral observation (structured vs. naturalistic) or an interview.
Strobovideolaryngoscopy and videoendoscopy are both commonly used to aid in the assessment and treatment planning of Huntington’s. Endoscopy provides a visual picture of the vocal tract anatomy and physiology as well as the mucosal wave.
Strobovideolaryngoscopy provides a permenant record and shows the laryngeal function during typical and clinically manipulated vocal production.
This will then aid in:
· Client counseling
· Compliance with therapy tasks
· Share pictures with referral source
· Compare pre/post therapy
· Frame-by-frame analysis of abnormal physiology mucosal wave
Compiled by Karen Hord~November 2012