Tuesday, October 21, 2014

Voice and Choral Singing Treatment: A New Approach for Speech and Voice DIsorders in Parkinson’s Disease 

Source: http://myaccess.library.utoronto.ca/login?url=http://search.proquest.com.myaccess.library.utoronto.ca/docview/67423449?accountid=14771

The purpose of this study was to develop a new rehabilitation program based on voice and choral singing treatment (VCST) for those suffering from Parkinson’s Disease (PD).  Whereas the Lee Silverman Voice Treatment (LSVT) achieves speech rehabilitation by improving vocal fold vibration in order to increase vocal loudness, this method uses speech therapy and choral singing combined.

20 PD patients (13 males and 7 females) received 20 hours of speech therapy (one hour, twice a week) and 26 hours of choral singing (two hours, once a week). Speech therapy was administered first, not to improve speech and voice abilities, rather, to prepare and teach patients choral singing techniques. This consisted of “oro-facial-neck-shoulders-muscular relaxation, respiratory exercises to improve pneumo-phono-articolatory coordination to facilitate diaphragmatic respiration, laryngeal exercises to improve pathological hypo/hyperkinesia, oral and facial exercises to improve vocal tract movement, prosodic exercises by stimulation particular situations like speaking emotions of sadness or happiness.” Participants were then taught to sing popular and liturgical chants with piano accompaniment, thereby enhancing rhythmic stimulation. 

All patients underwent pre- and post- assessments which consisted of neurological, otolaryngological and respiratory function evaluation. The neurological assessment was done through an interview where neurologist experts gathered patient information on drug therapy, disease history, their response to levodopa and demographic variables. Experts also used the Unified Parkinson’s Disease Rating Scale (UPDRS) two weeks before, and two weeks after treatment period to obtain information about the patients’ mental state, daily living and motor function. 

The otolaryngological assessment included laryngeal videostroboscopy before and after treatment to evaluate the amplitude and regularity of vocal folds movement, glottic closure, and the symmetry of their vocal folds vibrations. Maximum phonation time was also evaluated by having the participant sustain the “A” vowel for as long as possible on one breath. This was done three times, with the best of all attempts recorded. Vocal samples were recorded for voice analysis. Otolaryngological assessment was done before and after speech and voice treatment. 

Lastly, researchers gathered information on the patients’ respiratory function such as lung volume and airway resistance, spirometry with flow-volume loops, and maximal inspiratory and expiratory mouth pressures. As with maximum phonation, the best of three attempts was recorded. 

The results showed significant improvements in prosodia, functional residual capacity, phonation, maximum inspiratory pressure, and maximum expiratory pressure. The authors have concluded that VCST has delivered positive results – it can be used for long periods of time with good compliance. It is also cost effective as it costs less money than LSVT. VCST also contributes positively to the patients’ quality of life, based on feedback from caregivers, although there has been no quantitative data to illustrate this. Although this study was a preliminary study, the authors state that VCST has shown to be an amusing and agreeable approach for PD patients with speech and voice abnormalities, however, a randomized control trial is needed to further examine the benefits of VCST.

Before coming across this study, I did not know that PD patients could suffer from voice issues. I have learned in the past that singing can help those with strokes and I now know that it helps individuals with PD as well. I researched more on this and found that singing has proved to be a great resource especially considering that at least 75% of PD patients have speech abnormalities, yet only 3-20% have gone to a speech and language therapist. Singing not only helps speech abnormalities, but also can create social support if singing in a group, improve mood, anxiety, stress, and one’s quality of life. It is accessible to everyone, is cost effective and as this study has shown, is enjoyable to many. 
This study showed significant results, but I wonder how long the results lasted? I also wonder why the researchers taught liturgical chants to the participants. Is it because the participants were of a certain demographic? Were the particular chants easy to learn? Or was it chosen randomly? I liked how they incorporated the piano to provide a rhythmic basis, as I’m sure this would help a great deal. I also wonder why the participants were evaluated on maximum phonation time based on singing the “A” vowel. Is this because it is the easiest and most natural vowel to sing? It would be great to have a vocalist’s opinion on why this may be. 

Music never ceases to amaze me. Though it has been known that music has many benefits, it is incredible to see how powerful it really is – that it can help those with neurological disorders. This study was one example of the many disorders and symptoms that music can help alleviate and I am excited to learn what else music can do. I am sure there is a place for music in all things. Although I am primarily a pianist, I can understand the value of singing. It is great to know that although not everyone may be a musician, every individual has the ability to take part in music through singing. 

Source: Di Benedetto, P., Cavazzon M., Mondolo, F., Rugiu, G., Peratoner, A., & Biasutti, E. (2009). Voice and choral singing treatment: a new approach for speech and voice disorders in Parkinson’s disease. European Journal of Physical and Rehabilitation Medicine, 45 (1), 13-19. http://myaccess.library.utoronto.ca/login?url=http://search.proquest.com.myaccess.library.utoronto.ca/docview/67423449?accountid=14771

1 comment:

Carina Freitas said...

Thank you for posting this article. I read it with interest and I was surprised to find out that only 3 to 20% of the patients with Parkinson disease (PD) who have voice (monopitch, monoloudness) and speech abnormalities (i.e., dysarthria) search for specialized therapies. Even though this research was a pilot-study, preliminary results appear to be encouraging to proceed to Randomized Clinical Trials’ (RCT) stage.
The advantage of voice and choral singing treatments is its low price and amusement. I believe that if patients have fun together, as a group activity, they are more likely to show a higher adherence to their treatment, and therefore, better outcomes.
Singing in a choir is a synchronized group activity that coordinates the neurophysiological activity for timing, motor production of words and melody, respiration and HRV heart rate variability [1]. It has been reported that singing in a choir improves human health and well-being [2], and presumably can reduce mood disorders in PD patients. It is also believed that synchronized activities foster feelings of social connection, by releasing oxytocin [3]. In addition, a recent study on psychological and physiological effects of singing in a choir, revealed that singing in a choir have a significant impact on reducing negative affect and state anxiety levels of the singers [4]. Other three studies found that group singing boosts the immune system, by increasing IgA (immunoglobuline a) concentrations [5, 6, 7].

1- B. Vickhoff, H. Malmgren, R. Åström, G. Nyberg, S.R. Ekström, M. Engwall, J. Snygg, M. Nilsson, R. Jörnsten, “Music structure determines heart rate variability of singers”, Frontiers in Psychology, 4 (2013) 1-16.
2- L.O. Bygren, B.B. Konlaan, S.E. Johansson, “Attendance at cultural events, readings books or periodicals, and making music or singing in a choir as determinant of survival” Swedish interview survey of living conditions” British Medical Journal, 313 (1996) 1577-1580.
3- M.L. Chanda, D. Levitin, “The neurochemistry of music” Trends in Cognitive Sciences, 17 (2013) 179-193.
4- A.M. Sanal, S. Gorsev, “Psychological and physiological effects of singing in a choir”, Psychology of Music, 42 (2014) 420-429.
5- G. Kreutz , S. Bongard , S. Rohrmann , V. Hodapp , D. Grebe, “Effects of choir singing or listening on secretory immunoglobulin A, cortisol, and emotional state”, Journal of Behavioral Medicine, 27 (2004) 623-635
6- R.J. Beck, T.C. Cesario, A. Yousefi, H. Enamoto, “Choral singing, performance perception, and immune system changes in salivary immunoglobulin A and cortisol” Music Perception, 18 (2000) 87-106.
7- D. Kuhn, “The effects of active and passive participation in musical activity on the immune system as measured by salivary immunoglobulin A (siga)”, Journal of Music Therapy, 39 (2002) 30-39