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Clinical Assessment and Treatment of Individuals with Vocal Tremor (VT)

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Clinical Assessment and Treatment of Individuals with Vocal Tremor (VT) Clinical Assessment and Treatment of Individuals with Vocal Tremor (VT) Julie Barkmeier-Kraemer, PhD, CCC-SLP Professor, ASHA-F University of Utah [email protected] Julie Barkmeier-Kraemer, PhD, CCC-SLP, ASHA-F Professor, Otolaryngology – Head and Neck Surgery Clinic Director, Voice Disorders Center Adjunct Faculty, Dept of CSD DISCLOSURES: • Financial: • Affiliate instructor with royalties from MedBridge Inc for my online courses on vocal tremor • NIDCD funds my research on essential tremor and vocal tremor (R01 DC016838) • Non-Financial: • ASHA: Member of SIGs 3, 12, 18 • Member of the NSDA Scientific Advisory Council Presentation Objectives: 1. Identify and describe the updated classification tremor criteria applied to vocal tremor and speech structures, 2. Describe clinical assessment approaches that enable improved differentiation between vocal tremor and laryngeal dystonia, and 3. Summarize treatment options for those with vocal tremor. Differential diagnosis of voice disorders “Spasmodic Dysphonia” Focal Laryngeal Dystonia (Albanese et al, 2013) Hyperkinetic movement disorder affecting 1 body part “Sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both.” Associated with onset or worsening specific to volitional speech activity (i.e. task specific) Affects 1 per 100,000 dystonia cases (Nutt, Muenter, Aronson, Kurland, Melton, 1988; Konkiewitz et al, 2002) Less than 8% of those with SD have family members with dystonia (Xiao, Zhao, Bastian, et al, 2010; Hintze et al, 2017) Terminology: Classification is everything 2019: Laryngeal 1971- Dystonia present: (NIDCD Spasmodic workshop) 1959-1997: Dysphonia Spastic Dysphonia Simonyan K, Barkmeier-Kraemer J, Blitzer A, Hallett M, Houde JF, Jacobson Kimberley T, Ozelius LJ, Pitman MJ, Mark Richardson R, Sharma N, Tanner K; NIH/NIDCD Workshop on Research Priorities in Spasmodic Dysphonia/Laryngeal Dystonia. Laryngeal Dystonia: Multidisciplinary perspectives on terminology, pathophysiology, and research priorities. Neurology. 2021 Apr 15:10.1212/WNL.0000000000011922. doi: 10.1212/WNL.0000000000011922. Epub ahead of print. PMID: 33858994. LARYNGEAL DYSTONIA (LD) CHARACTERISTICS Idiopathic onset (Schweinfurth, Billante, Courey, 2002; Adler, Edwards, Bansberg, 1997) Onset typically occurs during mid-life ages of 30- 50 years of age (Schweinfurth, et al, 2002) Women are more often affected than men (4:1 ratio) (Adler, Edwards, Bansberg, 1997; Schweinfurth, et al, 2002; Blitzer, 2010; Simonyan et al, 2021) Progression is steepest during first year and is chronic thereafter (Izdebski, Dedo, Boles, 1984; Brin, Blitzer, Stewart, 1998; Tanner et al, 2011) Normal vegetative voice function (Ludlow, 1995) Laughing, Crying, Cough, Yawn, Whisper, Respiration SUBTYPES OF LD (using historical terms) TREMOR • “An involuntary, rhythmic, oscillatory movement of a body part.” • One of the most common neurologic movement disorders. • Classified by clinical features/phenotypes and etiology. (Crawford & Zimmerman, 2011; Louis, 2016; Elble, 2016; Bhatia et al, 2018) Tremor Features/Phenotypes • ACTION- INDUCED – Kinetic – Postural http://www.examiner.com/article/it- s-not-an-earthquake-its-just- • RESTING parkinson-s-disease – Supported from gravity http://gifsoup.com/view/1855096/pill Hallett, 2014; Weiss, 2016; Bhatia et al, 2018) -rolling-tremor.html Updated Criteria for Classification of Tremor Tremor Syndrome Clinical Features • Age of onset • Family history Medical History • Temporal evolution • Exposure to drugs and toxins • Anatomical distribution of tremor (focal vs Tremor segmental vs generalized) • Activation condition (e.g. postural, kinetic, task characteristics specific, resting) • Frequency (i.e. rate; <4, 4-8, 8-12, >12 Hz) Associated • Signs of systemic illness • Neurologic signs Signs • Soft signs • Electrophysiological tests Additional • Structural imaging • Receptor imaging laboratory tests • Serum and tissue biomarkers Etiology (Axis 2) Framework Genetically Acquired Idiopathic defined KEY POINTS: • A syndrome from Axis 1 map to Familial several etiologies. • Likewise, multiple syndromes can be associated with one etiology. • Clinical features offer the optimal Sporadic method for characterizing classes of tremor. Tremor Classification Criteria Essential Essential Parkinsonian Dystonic Tremor (ET) Tremor Plus Bradykinesia and Bilateral tremor of rigidity Tremor in a body part the upper limbs Same clinical affected by dystonia with or without features of ET Unilateral or head tremor or asymmetric Symptoms reduced by tremor of other resting tremor geste antagoniste locations (hands may (sensory tricks) Additional “soft” exhibit pill rolling Task specificity neurological signs tremor) Duration of at (e.g. mild memory Idiopathic, familial, or least 3 years impairment, Rest tremor sporadic impaired tandem diminishes with gait, subtle body Dystonia + tremor in Absence of initiation of different body parts = dystonia, ataxia, posturing similar to muscle dystonia) tremor associated with or parkinsonism contraction dystonia Vocal Tremor (VT) • Neurological voice disorder • Involuntary rhythmic modulation of Raw audio – PITCH (fo) – LOUDNESS (SPL) SPL • Can be a primary fo symptom, or associated with: – Essential Tremor – Dystonia (Brown & Simonson, 1963; Perez, Ramig, & Smith, 1996; Woodson, 2008; – Parkinson Disease Woolraich, Marchis-Crisan, Redding, Khella, Mirza, 2010) Vocal Tremor (VT) ● General characteristics ● Best perceived during sustained phonation task (Brown & Simonson, 1963; Lederle, Barkmeier-Kraemer, & Finnegan, 2012) ● Modulation of pitch and loudness can be further characterized(Gamboa et al, 1998; Dromey, Warrick, & Irish, 2002) ● RATE (3-12 Hz) ● MAGNITUDE (20-30%) ● Significantly slower speaking rate than normal speakers (3 vs 5 syllables/s) (Lundy, Roy, Xue, Casiano, & Jassir, 2004) ● May improve (lessen) when drinking alcohol, depending on etiology (Sulica and Louis, 2010) ● Voice stoppages/breathy breaks are rhythmic and associated with structural oscillations (Ludlow et al, 2018) CONCEPTUAL MODEL OF VOCAL TREMOR The acoustic consequence of tremor affecting structures within the speech apparatus resulting in an involuntary rhythmic modulation of the voice Figure taken from: Tortora, G.J. & Grabowski, S.R. (2003). The Respiratory System. In: Principles of Anatomy and Physiology Volume 4, The Maintenance and Continuity of the Human Body , 10th Edition (page 709). HOW DO WE CONCEPTUALIZE VOCAL TREMOR PHYSIOLOGY? 1. Respiratory System Oscillation – Subglottal pressure modulation – Ho: SPL modulation (Simulations provided by Brad Story, University of Arizona) HOW DO WE CONCEPTUALIZE VOCAL TREMOR PHYSIOLOGY? 1. Larynx Oscillation – fo modulation (vocal fold length changes) – Ho: fo modulation – Glottal width modulation – Ho: SPL modulation (fo modeled as constant) (Simulations provided by Brad Story, University of Arizona) HOW DO WE CONCEPTUALIZE VOCAL TREMOR PHYSIOLOGY? 4. Vocal Tract – Pharyngeal diameter and length modulation – Ho: Formant modulation • F1 and F2 modulation associated with SPL modulations (Simulations provided by Brad Story, University of Arizona) VT Classification Criteria VT Classification Criteria Essential Dystonic Parkinsonian Voice Tremor Tremor Tremor Idiopathic action Tremor predominantly tremor affecting the evident in the larynx Tremor mostly voice as part of ET that is task specific associated with vertical (included isolated (i.e. occurs during laryngeal movement in vocal tremor) speech) those with idiopathic Parkinson’s disease (PD) Affects muscles of the larynx, pharynx, Tremor in the larynx palate, other associated with articulators, and laryngeal dystonia (LD) respiratory musculature Geste antagoniste (Sensory Tricks) lessen Tremor is not task the tremor (e.g. specific (occurs during placement of phonation and nasoendoscope) respiration) What do we need to classify VT? • Medical History: – Age of onset of tremor (limbs, head, VT) – Onset associated with specific drugs or exposure to toxins – Condition(s) that improve VT (ETOH, sensory tricks) – Progression of tremor symptoms over time – Family history for VT or other forms of tremor – Signs of systemic illness – Diagnosed, or undiagnosed neurological signs – Signs of mild memory impairment, impaired tandem gait, or subtle body posturing (dystonia) Inter- or Multi-Disciplinary Team Evaluation • Speech-language pathologist (SLP) – voice/speech patterns and function • Otolaryngologist (preferably a laryngologist) – Upper airway pathology • Neurologist (movement disorders specialist) – Assessment and classification of movement disorder • All team members contribute toward patient education/counseling and the need for additional consultation Evaluation of Neurogenic Voice Disorders • Case history • Speech Motor Assessment – Cranial Nerve/Oral Mechanism Assessment – Speech Assessment • Diadochokinetic rate and integrity • Functional speech • Intelligibility and communication efficiency at word/sentence level • Auditory perceptual features with systematic speech assessment • Nasoendoscopic examination • Acoustic Analysis – primarily useful for vocal tremor detection and measurement See: https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942600&section=Assessment Clinical Features of VT • Body Distribution – All structures with tremor – Symmetry (Right vs Left) • Activation condition – Quiet breathing (posturing) – Task specificity (only speech) – All tasks (respiration and speech tasks) • Frequency – Estimated rate
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