The Effects of Oral-Motor Exercise on
Tongue Strength,
Oral-Motor Agility, Speech Intelligibility,
and Dysarthria in Individuals with
Parkinson’s Disease
Kylie G. Hockenberry, M.S., CF‐SLP
Rita L. Bailey, Ed.D., CCC‐SLP, BRS‐S
Maureen E. Angell, Ph.D.
Jean Sawyer, Ph.D., CCC‐SLP
Department of Communication Sciences and Disorders
Illinois State University
Introduction
Parkinson’s disease (PD): idiopathic, degenerative, neurological PD results from degeneration of neurons in a region of the brain that controls movement (Carroll, 1992).
• Three most common symptoms: tremor, muscular rigidity, and bradykinesia (Carroll, 1992). • Exercise has been found to improve function and counteract the degenerative nature of PD (Carroll, 1992). • Potential benefits of exercise on swallowing and speech intelligibility in individuals with PD (Robbins et al., 2008; Sapir, Spielman, Ramig, Story, & Fox, 2007). •
•
– Lee Silverman (Sapir et al., 2007)
– Oral‐motor exercises have been found useful in improving tongue strength, mass, and swallowing ability and quality of life (Robbins et al., 2005; Robbins et al., 2008)
•
Minimal research objectively documents the effects of oral‐motor exercise on tongue strength, oral‐motor agility, speech intelligibility, and dysarthria. Purpose of the Investigation and Hypothesis
To determine the effects of a structured oral‐motor exercise program using the Ora‐Light System (Kapitex Healthcare, 2004) on tongue strength, oral‐motor agility, single word level speech intelligibility, and dysarthria in individuals with advanced PD.
Hypothesis: • Oral‐motor exercises based on principles of motor learning and neural plasticity will increase tongue strength and function. • These increases will improve word intelligibility, oral‐motor agility, and markers of dysarthria in individuals with PD. Experimental Design, Setting, and Participants
• Single‐subject multiple baseline design
– Intervention was implemented in a staggered time‐lagged fashion across 4 participants to demonstrate experimental control • Each participant served as his or her own control (Maxwell & Satake, 2006)
• All intervention and assessment sessions were conducted at a nursing home, an assisted living facility, and Illinois State University’s Speech and Hearing Clinic
• 3 females (Nora, Ellen, Ida) and 1 male (Mark)
– Ages 74 to 92, recruited from nursing home and university speech and hearing clinic. – All participants had been diagnosed with late stage or stage V PD as defined by Hoehn and Yahr (1967)
• “Confinement to bed or wheelchair unless aided”
Independent Variable
y The Ora‐Light System (Kapitex Healthcare, 2004) is a structured oral‐motor exercise system.
y Designed to strengthen the musculature of the tongue, lips, and cheeks to facilitate neuromuscular coordination and competency for speech and swallowing. y The exercise tools have activating shapes and textures on the handle and palatal portions to provide increased sensory feedback. y Standardized protocol was used as described in the manual that accompanied the tools.
Independent Variable
Description of the Intervention
• Ora‐Light oral‐motor exercise system (Kapitex Healthcare, 2004) implemented 4 days per week, 15 minutes per day for 14 weeks.
• Introduced in a time‐lagged manner across three tiers; thus each participant received a different number of total intervention sessions: – Tier 1 (Mark and Ida): Intervention began immediately after baseline condition – Tier 2 (Nora): Intervention began 3 weeks after onset of intervention in the first tier. – Tier 3 (Ellen) : Intervention began 6 weeks after onset of intervention in the first tier. Mark received the largest number of intervention sessions and Ellen
received the least. Dependent Variables Assessment Battery
• Pre‐ and Post‐Intervention assessments:
– Frenchay Dysarthria Assessment – Second Edition (FDA‐2) (Enderby & Palmer, 2008)
– Measurements of tongue strength using the Iowa Oral Performance Instrument (IOPI) (Luschei, 2008) • Bi‐weekly probe assessments:
– Word speech intelligibility using a subtest of the Assessment of Intelligibility of Dysarthric Speech (ASSIDS) (Yorkston & Beukelman, 1984)
– Oral‐motor agility assessment (an informal assessment developed by the researchers)
Results
Performance Data Trends Across Participants: IOPI (Luschei, 2008)
• 3 of 4 participants, Mark, Ida, and Nora, made marked gains in tongue strength (see Figure 1) as measured by the IOPI.
• Tongue strength in these 3 participants increased at mid‐ and post‐
intervention measurements, indicating that the intervention was not just initially effective but incrementally effective as well.
• Ellen participated in the fewest number of intervention sessions (28) and maintained, but did not improve, tongue strength.
Figure 1. Iowa Oral Performance Instrument (IOPI) pre‐, mid‐, and post‐intervention scores.
IO P I S c o re s
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Performance Data Trends Across Participants: Oral‐Motor Agility and Word Intelligiblity Assessments
• Results of oral‐motor agility assessment and word intelligibility assessment were variable across participants
• See participant graphs for individual participant results
Percentage Accuracy
Oral-Motor Agility Assessment
Single Word Intelligibility Assessment
Mark's Performance Data
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Figure 2. Individual participant performance data on bi‐
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Gains observed on oral‐motor agility and word intelligibility scores were minimal and highly variable. 100
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Ellen's Performance Data
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Performance Data Trends Across Participants: FDA‐2 (Enderby & Palmer, 2008)
• All participants made gains from pre‐ to post‐
intervention on the FDA‐2
• Results were variable across participants (see graphs for individual participant ratings).
Performance Data Trends: Summary of IOPI scores
• Increases in tongue strength in 3 participants (Mark, Ida, and Nora) indicated positive intervention effects
• Use of the Ora‐Light System (Kapitex Healthcare, 2004) oral‐motor exercise program appeared to have positive therapeutic benefits on several markers of dysarthria as measured by the FDA‐2 and on tongue strength as measured by the IOPI in these participants with PD Results, continued
• The amount of intervention received appeared to relate to the amount of measured tongue strength increase
• Due to variable and inconsistent results across participants on oral‐motor agility and word intelligibility assessments, a functional relationship between the intervention and these measures was NOT established Individual Participant Assessment Results: Mark • Pre‐Intervention Assessment Results:
– Tongue Strength: 9kPa
– Mean Oral‐motor agility: 17% – Mean Word intelligibility: 3%
• Post‐Intervention Outcomes: – Tongue Strength: 17kPa (Mid‐intervention) 25kPa (Increase)
– Mean Oral‐motor agility: 24% (Increase)
– Mean word intelligiblity: 9% (Increase)
Figure 3. Visual Depiction of Mark’s Pre- and Post-Intervention Frenchay Dysarthria
Assessment-2nd Edition (FDA-2) Results.
Figure 4. Bar graph presentation of Mark’s pre‐ and post‐intervention Frenchay Dysarthria Assessment‐2nd
Edition (FDA‐2) results.
Individual Participant Assessment Results: Ida • Pre‐Intervention Assessment Results:
– Tongue Strength: 19 kPa
– Mean Oral‐motor agility: 100% – Mean Word intelligibility: 83%
• Post‐Intervention Outcomes: – Tongue Strength: 24 kPa (Mid‐intervention) 29 kPa (Increase)
– Mean Oral‐motor agility: 100% (Maintain)
– Mean word intelligiblity: 94% (Increase)
Figure 5. Visual Depiction of Ida’s Pre- and Post-Intervention Frenchay Dysarthria
Assessment-2nd Edition (FDA-2) Results.
Figure 6. Bar graph presentation of Ida’s pre‐ and post‐intervention Frenchay Dysarthria Assessment‐2nd Edition (FDA‐2) results.
Individual Participant Assessment Results: Nora
• Pre‐Intervention Assessment Results:
– Tongue Strength: 9kPa
– Mean Oral‐motor agility: 83% – Mean Word intelligibility: 91%
• Post‐Intervention Outcomes: – Tongue Strength: 16kPa (Mid‐intervention) 24kPa (Increase)
– Mean Oral‐motor agility: 94%(Increase)
– Mean word intelligiblity: 89%(Decrease)
Figure 7. Visual Depiction of Nora’s Pre- and Post-Intervention Frenchay Dysarthria
Assessment-2nd Edition (FDA-2) Results.
Figure 8. Bar graph presentation of Nora’s pre‐ and post‐intervention Frenchay Dysarthria Assessment‐
2nd Edition (FDA‐2) results.
Individual Participant Assessment Results: Ellen • Pre‐Intervention Assessment Results:
– Tongue Strength: 13 kPa
– Mean Oral‐motor agility: 60% – Mean Word intelligibility: 70%
• Post‐Intervention Outcomes:
– Tongue Strength: 11 kPa (Mid‐intervention) 13 kPa (maintained)
– Mean Oral‐motor agility: 34% (Decrease) – Mean word intelligiblity: 52% (Decrease)
Figure 9. Visual Depiction of Ellen’s Pre- and Post-Intervention Frenchay Dysarthria
Assessment-2nd Edition (FDA-2) Results.
Figure 10. Bar graph presentation of Ellen’s pre‐
and post‐intervention Frenchay Dysarthria Assessment‐2nd Edition (FDA‐2) results.
Discussion
Tongue Strength in PD
• This study is based on the knowledge that the musculature of the tongue is adversely affected in individuals with PD
• Previous research had shown that individuals with PD have below normal tongue strength and endurance (Solomon, Robin, and Luschei, 2000; Solomon, Lorell, Robin, Rodnitzky, & Luschei, 1995) • The findings of this study support previous reports that individuals with PD have reduced tongue strength (Solomon et al., 1995). Increases in Tongue Strength
• Oral‐motor exercise and tongue strength have been investigated in other populations (Kays et al., 2004; Robbins et al., 2005; Sullivan et al., 2001)
• Oral‐motor exercise has been found effective in increasing tongue strength in each of these populations as measured by the IOPI (Luschei, 2008). • Results of the current study, which showed increases in tongue strength in 3 of 4 participants (Mark, Ida, and Nora) with advanced PD, support previous research on the positive effects of oral‐
motor exercise on tongue strength. Improvements in Swallowing
• Multiple studies investigating oral‐motor exercise programs (Kays et al., 2004; Logemann et al., 1997; Robbins et al., 2007; Sullivan et al., 2001) have found the exercises effective in increasing tongue strength and improving swallowing. • Effects related to swallowing associated with the measured increases in participants’ tongue strength were not objectively measured in this study. Application of Principles of Neural Plasticity and Motor Learning Theory
• Results of this investigation appear to be in agreement with recent theories of neural plasticity (Clark, 2003; Kleim & Jones, 2008; Robbins et al., 2008) that indicate that the human brain constantly changes its neural circuitry to adapt to new experiences and allow functional changes to occur. • Thus, individuals with neurological impairments such as PD may benefit from exercise because of the brain’s potential for neural plasticity. Acknowledgements • This project was funded by a $500.00 grant from Kapitex Healthcare, Inc.
– The grant was used to purchase Ora‐Light System kits for use with each participant and extra tongue bulbs for the IOPI.
• The IOPI (Luschei, 2008) was loaned for the duration of the project by Dr. Eric Luschei.
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