Comprehensive Study Guide: Speak Out, Loud Crowd, and Forte Therapy Models

Article 1: Hybrid Speak Out Treatments

• Study Design: This was a quasi-experimental study design focusing on hybrid Speak Out treatments.

• Participant Demographics:

  • Total participants: 157.

  • Diagnosis: Individuals with Parkinson’s disease and secondary hypokinetic dysarthria.

• Treatment Targets: The primary focus was on "speaking with intent" approaches.

• Clinical Outcomes and Measures:

  • Observed increases in maximum phonation time ($MPT$).

  • Improvements in peak expiratory flow ($PEF$) and peak cough flow ($PCF$).

  • Improvements in Patient-Reported Outcome Measure ($PROM$) scores.

  • The results supported the treatment's effectiveness in improving function, activity levels, and overall participation.

Article 2: Telehealth and Functional Speech Measures

• Study Design: An experimental study focusing on the effects of Speak Out and Loud Crowd on functional speech measures in Parkinson’s disease.

• Participant Demographics: Six adult patients with hypokinetic dysarthria secondary to Parkinson’s disease.

• Methodology:

  • All six participants underwent Speak Out and Loud Crowd therapy.

  • Notably, the majority of sessions were conducted via telehealth rather than in-person.

• Findings:

  • The study supported the effectiveness of these treatment programs for improving communication participation and communication skills.

  • The positive effects noted in telehealth sessions suggest it is a viable alternative to in-person promotion, which is less commonly discussed in literature.

Article 3: In-Person Speak Out and Loud Crowd Parameters

• Study Design: An experimental study involving 40 participants with hypokinetic dysarthria resulting from Parkinson’s disease.

• Treatment Dosage and Setting:

  • All sessions were conducted in person.

  • Speak Out: 12 individual sessions, conducted three times per week over the course of four weeks ($12\,sessions \times 3\,weeks^{-1} \times 4\,weeks$).

  • Loud Crowd: Group sessions conducted one time per week ($1\,session\,week^{-1}$).

• Clinical Measures:

  • Increasing prosody.

  • Increasing Cepstral Peak Prominence ($CPP$) or steep shoulder prominence.

  • Increase in the Voice-Related Quality of Life ($V-RQOL$) measure, which is a patient-reported outcome ($PRO$).

• Outcome: The treatment was found effective across all measured areas following post-treatment assessment.

Theoretical Framework for Parkinson’s Speech Therapy

• Treatment Targets: Improving vocal loudness, vocal quality, speech intelligibility, speaking rate, and overall respiratory rate.

• Key Ingredients:

  • Pitch glides and sustained phonation ($e.g.,$ sustained vowels).

  • Breathing exercises.

  • Producing sentences (reading or conversational).

  • Reading oral passages (moving from sustained vowels to connected speech).

  • External cueing provided by clinicians to redirect the patient toward clear, purposeful speech.

• Mechanism of Action:

  • Focuses on the muscles of the larynx responsible for the coordination of phonation.

  • Overcoming impaired neural pathways in the basal ganglia and thalamus that manage habitual/automatic speech.

  • By using intentional speech, patients bypass automatic motor deficits.

• Volition Targets:

  • Speaking with intent and speaking loudly.

  • Breath control.

  • Directing cognitive effort volitionally toward speech production.

• General Dosage Parameters (Consolidated):

  • Speak Out: Typically three to four sessions per week ($3-4\,sessions\,week^{-1}$), lasting $45-50\,minutes$ each, for a duration of four to eight weeks.

  • Loud Crowd: Typically one group session per week ($1\,session\,week^{-1}$) for maintenance.

Therapeutic Interpretation and Considerations

• Pathology Context: In Parkinson’s disease, internal cues for speech intensity and loudness originate in the basal ganglia and thalamus. Because these are impaired, patients have an altered perception of their own loudness (autonomic function failure).

• Structural Variations: Treatment responses differ because every patient has unique anatomy, structural/functional limitations, and a range of severity/symptom progression.

• Cognitive and Salience Factors: Therapy materials (like those in the Speak Out book) must provide salience to the patient to ensure motivation and participation.

• Limitations of Treatment:

  • Improvement in aerodynamic measures (like $MPT$ or intensity) does not always guarantee improved functional communication.

  • Improvement in a patient's perception of their quality of life might occur even if objective measures (like $CPP$) do not show significant change.

  • Success is not guaranteed across all three domains (aerodynamics, communication, and perception) simultaneously.

Demonstration: Speak Out and Loud Crowd Components

• Component 1: Sustained Phonation: Producing a sustained "ah" ($\text{ah}$) with intent. The patient is cued to "speak as if talking to the wall behind the clinician."

• Component 2: Numerical Sequences: Counting (e.g., 1 to 12) with purposeful pauses every three to five numbers ($1, 2, 3 \dots 4, 5, 6 \dots$) to help with speaking rate and percent pause time.

• Component 3: Connected Speech: Reading passages or sentences ($e.g.,$ "I am a graduate student of speech pathology at East Tennessee State University").

• Component 4: Cognitive-Linguistic Exercises (Loud Crowd): Engaging in group conversation about daily life ($e.g.,$ weekend plans) while maintaining intent. This requires word-finding skills and creating novel responses while managing posture and loudness.

• Omitted Components in Demo: Nasal phoneme warm-ups and pitch glides.

Forte and Expiratory Muscle Strength Training (EMST)

• EMST Targets and Mechanism:

  • Target: Maximum Expiratory Pressure ($MEP$).

  • Mechanism: Increasing the strength of thoracic, intercostal, and abdominal muscles to generate forceful exhalation.

  • Outcome goal: Decrease the demand on vocal folds to prevent phonotrauma or overcompensation.

• Forte Protocol:

  • Targets: Acoustic qualities, vocal quality, loudness, and decreasing vocal effort.

  • Population: Often used for presbyphonia (age-related voice changes, such as breathiness or atrophy).

  • Ingredients: High-intensity and low-intensity functional phrases, pitch glides ($\text{ah} \uparrow, \text{ah} \downarrow$), and sustained phonation.

• Dosage: Patients are often tasked with home exercises five times per day, five sets each ($5\,sets \times 5\,times\,day^{-1}$), six times per week.

Case Studies in Presbyphonia

• Case 1 (Single Subject): Participants met for a four-week timeframe. Intervention included IMST/EMST set at $75\%$ intensity. Findings showed improvement in vocal intensity and respiratory strength based on the Voice Handicap Index ($VHI$).

• Case 2 (Forte vs. Forte + EMST):

  • Participants: Originally 26, 16 completed ($n=16$). All aged >55 (average age $73.5\,years$).

  • Groups: Forte only vs. Forte + EMST ($70\%$ resistance).

  • Results:

    • Vocal intensity increased in both: Forte only increased by $4\,dB$; Forte + EMST increased by $6-8\,dB$.

    • $MEP$ significantly increased in the combination group ($Forte + EMST$).

    • Normal $MEP$ for females is roughly $80\,cm\,H_2O$ and for males $100\,cm\,H_2O$. Participants started below these levels.

• Case 3 (VFE vs. VFE + Strength Training):

  • Groups: Vocal Function Exercises ($VFE$), $VFE + IMST$, and $VFE + EMST$.

  • Highest satisfaction and carryover was found in the $VFE + IMST$ group due to combined vocal quality and respiratory support focus.

Questions & Discussion

• Q: Which program is individualized and which is group-focused?

  • A: Speak Out is primarily individualized (one patient, one clinician). Loud Crowd is group-focused therapy (maintenance and practice).

• Q: What is hypokinetic dysarthria?

  • A: It is a speech disorder characterized by a slower rate of speaking (hypo- meaning less/low), tremors, and muscle weakness common in Parkinson’s, making speech difficult to understand and execute at a normal rate.

• Q: Is Loud Crowd done in public (like a coffee shop)?

  • A: While it involves groups, the research observed it in controlled clinic environments rather than noisy public spaces.

• Q: Why does sitting upright help if intensity is the only target?

  • A: Posture changes the anatomical features. Sitting upright decreases pressure on the chest and opens the airway, facilitating better airflow and laryngeal adjustment, which allows for louder phonation without straining.

• Q: Is Speak Out training available?

  • A: Training for Speak Out is currently free. Additionally, the term "Loud Crowd" is being phased out in favor of the name "Speak Out Group Therapy."

• Q: How do you identify presbyphonia specifically?

  • A: Diagnosis involves acoustic and perceptual analysis. Characteristics include a weakened voice, thinning of the vocal folds (atrophy), and maximum expiratory pressures falling below normal ranges.

• Q: What was the role of the mobile app mentioned in the research?

  • A: It was used to track vocal intensity at home. Participants had to hold the phone exactly $12\,cm$ from their face in a room with no background noise. Due to these strict requirements and lifestyle conflicts, only $20\%$ of participants used it reliably.