Evaluation Report
I. Identifying Information
NAME:
AGE:
DIAGNOSIS:
PHYSICIAN:
REFERRAL SOURCE:
BILLING CODES:
Dr. Judith
70
Parkinson’s disease
Dr. *** (Primary Care Physician)
Dr. *** (Neurologist)
CPT: 92524 (Behavioral and qualitative analysis of voice and
resonance)
ICD-10: R49.0 (Dysphonia) and R47.1 (Dysarthria)
II. History
Dr. Judith, a 70-year-old female, was seen for a voice and speech evaluation. Dr. Judith
reported that she was diagnosed 8 years ago with idiopathic Parkinson’s disease (PD).
She reported 15 years prior to diagnosis that her husband first noticed motor symptoms
including abnormal left foot strike when running. Five years later he noticed a left foot
drag on the carpet at home, hesitant gait on descending stairs and decreased smiling.
Dr. Judith noticed symptoms approximately 5-7 years before her diagnosis including left
foot drag, difficulty threading a needle and micrographia at work. She also started
noticing voice and speech symptoms such as vocal fatigue at the end of her workday
and increased difficulty being heard in restaurants, which she attributed to restaurants
becoming louder and her husband and friends’ hearing getting worse.
Dr. Judith lives with her husband. She is a family physician and Medical Director of a
large primary care clinic. She uses her voice daily for work, hobbies and with family.
She has become aware that both her clinical staff and patients are straining to hear her.
There are many requests daily to repeat her comments. The difficulty with being heard
has carried over to social situations including both groups and one-on-one encounters.
She feels her voice fluctuates from audible and clear to inaudible and unclear. She is
frequently required to make presentations for work to variable sized groups, which is
becoming more difficult for her. She is feeling increased frustration from those who are
trying to listen to her and within herself when trying to speak.
Dr. Judith is co-leader of a weekly small discussion-based group at her church which
she describes as very dynamic. She reports that she is aware of difficulties with her
vocal delivery during group functions. She also reports difficulty communicating with her
spouse and friends, both of whom have commented about the difficulty they have
hearing her and have expressed concern. She reports vocal fatigue and notes that at
the end of the day she just “wants to be quiet and not have to talk to anyone.”
A laryngeal examination using videostroboscopy revealed mild bowing of the vocal
folds as well as lateral squeezing and an anterior-posterior supraglottic
hyperfunctional pattern during vocalization. Mild gastroesophageal (GERD) and mild
laryngopharyngeal reflux (LPR) noted. No masses, lesions, or paralysis/paresis were
observed.
Medical history is significant for Idiopathic Parkinson’s disease diagnosed 2 years ago,
osteoporosis, narcolepsy, intermittent exercise-induced asthma, and hypomagnesemia
with hypercalciuria.
Medications for PD include Rasagiline, Pramipexole, Rytary (carbidopa/levodopa).
Medications for non-PD include over-the-counter Multivitamin, Vitamin D, and Senna
and prescriptions for Benicar-Hydrochlorothiazide, Alendronate and Methylphenidate.
III. Evaluation Results
Hearing: Results of a hearing screening revealed Dr. Judith’s hearing to be within
normal limits bilaterally.
Acoustic Measures: Sound pressure level (SPL, acoustic correlate of vocal loudness)
frequency (Hertz) and duration (seconds) were measured using the LSVT Companion®
system. The microphone was placed 50 cm from the patient’s mouth during voice and
speech tasks. Acoustic findings are listed below:
TASK
Average dB
SPL
Range dB
SPL
Vowel
Duration
Exercise
Pitch Range
High Exercise
Pitch Range
Low Exercise
Text Reading
Exercise
Monitored
Conversation
Exercise
73.5
64.8-76.9
72.9
Average
Duration in
seconds
19.1
Range
Duration in
seconds
8-27
Average
frequency in
Hz
480 (with
strain)
170 (with
glottal fry)
72.5
67.1
64-72
66.4
65-73
These results represented reading and conversational vocal SPL levels that may
significantly reduce Dr. Judith’s audibility, speech intelligibility and communicative
effectiveness.
Perceptual Measures: The clinician engaged in conversation with the patient from 1.5
feet in a quiet environment. Dr. Judith’s functional speech intelligibility was judged to be
reduced from 100% to 75% in both known and unknown contexts. During conversation,
speech intelligibility was further reduced when any background noise was present and
when there was greater distance between the patient and the listener.
The Voice Handicap Index-10 (VHI-10) is a questionnaire designed to evaluate how a
person describes their voice and the effects of their voice on their life. Dr. Judith’s
results indicated a moderate impact on her daily life. She reported people have a
difficult time understanding her in a noisy room as well as within groups. Dr. Judith
indicated that she perceives her voice to be worse in the evenings and her voice is
upsetting to her. Dr. Judith indicated that she is asked to repeated herself often when
speaking face-to-face with someone.
Dr. Judith reported she feels she is “not loud enough” in conversation 70% of the time
and experiences a hoarse voice 90% of the time. She reported frequent vocal fatigue at
the end of the day stating this happens “almost every day.” She commented that people
frequently ask her to repeat including on the phone. She is very concerned about
communicating accurately with her patients and co-workers especially about medication
and dosages she is prescribing. During social gatherings, she noted decreased
confidence, and thus she speaks a reported 60% less than she previously did.
Oral Motor Examination: An oral motor speech exam revealed the structures and
functions of Dr. Judith’s speech mechanism to be within functional limits.
Stimulability Testing: Stimulability testing was completed to determine Dr. Judith’s
stimulability for the Lee Silverman Voice Treatment (LSVT LOUDâ). With stimulation to
“increase loudness” Dr. Judith increased her vocal loudness during sustained vowel
phonation to 79 dB and during reading of single words and short phrases to 70 dB.
Increased loudness levels resulted in an improvement in vocal quality, articulatory
accuracy, stress pattern, intonation, and intelligibility perceived by both the clinician and
the patient.
IV. Impressions
Dr. Judith presented with a mild to moderate voice disorder. Voice deficits included
reduced loudness, monotone pitch, and a hoarse voice quality, which contributed to an
overall decrease in speech intelligibility. During conversation, speech intelligibility is
reduced 70% of the time in known and unknown contexts, and this reduces further
when in noisier environments. Her voice disorder limits her ability to perform work
responsibilities/occupational demands and is causing her to withdraw from community
activities and family conversations. This is causing feelings of frustration and sadness.
Dr. Judith is an excellent candidate for therapy given her motivation to improve
communication, response to stimulability testing, her desire to communicate at work and
in her community, and her strong support system including her husband with whom she
communicates daily. Potential barriers to therapy include the sensory mismatch
between her self-perception of appropriate loudness when she is in fact inaudible. This
perceptual mismatch is characteristic of patients with PD and will be addressed
throughout her treatment course to target carryover of treatment gains into her everyday
communication. Further the difficulty Dr. Judith has in achieving normal volume levels,
unless cued or provided with a model, will also be addressed in treatment.
V. Recommendations
Given the patient’s decreased communication/engagement within her community, the
negative impact of her voice difficulties on her QOL, and her need to clearly
communicate at work with her patients and colleagues, intensive speech intervention
with a focus on voice therapy is deemed medically necessary. It is recommended Dr.
Judith receive LSVT LOUD treatment. LSVT LOUD is comprised of 16 one-hour
individual sessions delivered 4 days a week for 4 weeks. Daily carryover and homework
exercises are included in this intensive, high effort program.
LSVT LOUD is the only evidence-based treatment designed and proven to work for
individuals with Parkinson disease with over 30 years of research support including
three randomized controlled trials.*
VI. References
* Ramig, L. O., Halpern, A., Spielman, J., Fox, C., & Freeman, K. (2018). Speech treatment in Parkinson's
Disease: Randomized Controlled Trial (RCT). Movement Disorders, 1-15.
https://doi.org/10.1002/mds.27460
Ramig, L., Countryman, S., Thompson, L., & Horii, Y. (1995). A comparison of two forms
of intensive speech treatment for Parkinson disease. J. Speech and Hearing Research, 38, 1232-1251.
Fox, C. M., & Ramig, L. O. (1997). Vocal sound pressure level and self-perception of speech and voice in
men and women with idiopathic Parkinson disease. American Journal of Speech-Language Pathology,
6(2), 85-94.
Ramig, L., Sapir, S., Countryman S., Pawlas, A., O’Brien, C., Hoehn, M., & Thompson, L. (2001).
Intensive voice treatment (LSVT ) for individuals with Parkinson disease: A two-year follow-up. J.
Neurology, Neurosurgery, and Psychiatry. 71, 493-498.
Ramig, L., Sapir, S., Fox, C., & Countryman, S. (2001). Changes in vocal intensity following
intensive voice treatment (LSVT ) in individuals with Parkinson disease: A comparison with untreated
patients and normal age-matched controls. Movement Disorders, 16, 79-83.
VII. Treatment Plan
Dr. Judith reports having difficulty keeping her voice loud enough to be heard at work by
patients and co-workers.
Stimulability testing:
Patient’s conversational speech increases from baseline average 66.4 dB SPL
to 70 dB SPL with moderate clinician cueing and modeling.
Impressions Statement:
“Patient presents with decreased vocal loudness limiting her audibility during
work, which poses a safety risk if her patients or co-workers do not
understand her directions for care or prescriptions.”
STG: Patient will increase vocal loudness with minimal to no clinician cueing across
daily exercises, speech hierarchy exercises, and spontaneous speech using
healthy vocal loudness and quality.
Exercise
AH
HIGH
LOW
Reading
Conversation
Baseline (dB SPL)
73.5
72.9
72.5
67.1
66.4
LTG: Patient will increase loudness in conversational speech allowing her to be
heard and understood by her patients and co-workers 100% of the time.
Dr. Judith reports talking less at her discussion group and with her husband due to
difficulty keeping her voice loud enough, which frustrates her.
Stimulability testing:
Patient’s conversational speech increases from baseline 66.4 dB SPL to 70 dB
SPL with moderate clinician cueing and modeling
Impressions Statement:
“Patient presents with decreased vocal loudness, which limits her confidence
and engagement in socializing in the community causing feelings of frustration
and decreased quality of life.”
STG: Patient will increase vocal loudness with minimal to no clinician cueing across
daily exercises, speech hierarchy exercises, and spontaneous speech using
healthy vocal loudness and quality.
Exercise
AH
HIGH
LOW
Reading
Conversation
Baseline (dB SPL)
73.5
72.9
72.5
67.1
66.4
LTG: Patient will increase loudness in conversational speech allowing her to converse
in the community and with family, increase voice use, slow progression of vocal
deterioration, reduce vocal fatigue and improve her QOL.