Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial.

OBJECTIVE: Dysphagia is the main cause of aspiration pneumonia and death in Parkinson disease (PD) with no established restorative behavioral treatment to date. Reduced swallow safety may be related to decreased elevation and excursion of the hyolaryngeal complex. Increased submental muscle force generation has been associated with expiratory muscle strength training (EMST) and subsequent increases in hyolaryngeal complex movement provide a strong rationale for its use as a dysphagia treatment. The current study's objective was to test the treatment outcome of a 4-week device-driven EMST program on swallow safety and define the physiologic mechanisms through measures of swallow timing and hyoid displacement. METHODS: This was a randomized, blinded, sham-controlled EMST trial performed at an academic center. Sixty participants with PD completed EMST, 4 weeks, 5 days per week, for 20 minutes per day, using a calibrated or sham, handheld device. Measures of swallow function including judgments of swallow safety (penetration-aspiration [PA] scale scores), swallow timing, and hyoid movement were made from videofluoroscopic images. RESULTS: No pretreatment group differences existed. The active treatment (EMST) group demonstrated improved swallow safety compared to the sham group as evidenced by improved PA scores. The EMST group demonstrated improvement of hyolaryngeal function during swallowing, findings not evident for the sham group. CONCLUSIONS: EMST may be a restorative treatment for dysphagia in those with PD. The mechanism may be explained by improved hyolaryngeal complex movement. CLASSIFICATION OF EVIDENCE: This intervention study provides Class I evidence that swallow safety as defined by PA score improved post EMST.

Perceptual characteristics of Parkinsonian speech: a comparison of the pharmacological effects of levodopa across speech and non-speech motor systems.

The purpose of this study was to: (1) define perceptual speech characteristics of idiopathic Parkinson disease (IPD) across 35 speech dimensions adapted from Darley et al. [19] and grouped under six speech-sign clusters (respiration, phonation, resonance, articulation, prosody and rate); (2) examine the effects of levodopa on the 35 perceptual speech dimensions and speech-sign clusters; and (3) to compare the relative effectiveness of levodopa on global motor functioning vs. speech production. Sixteen patients with IPD read the 'Grandfather Passage' both 'on' and 'off' levodopa. Three blinded speech-language pathologists performed perceptual speech analyses using a seven-point scale. The diagnosis of IPD was made by a movement disorders fellowship trained neurologist who applied UK Brain bank criteria and administered the Unified Parkinson Disease Rating Scale. Concordant with previous studies, the results of this experiment indicated that IPD disrupted multiple speech production subsystems, with prosody being the most severely affected domain. The perceptual dimensions that were most severely affected included: (1) sound imprecision; (2) mono-loudness; (3) mono-pitch; (4) reduced stress and (5) harsh voice. No significant differences were obtained between medicated states ('on'/'off') for any of the 35 individual speech dimensions and speech-sign clusters. Global motor function significantly improved following dopaminergic medications.

Acoustic measures of symptoms in abductor spasmodic dysphonia.

Speech of patients with abductor spasmodic dysphonia (ABSD) was analyzed using acoustic analyses to determine: (1) which acoustic measures differed from controls and were independent factors representing patients' voice control difficulties, and (2) whether acoustic measures related to blinded perceptual counts of the symptom frequency in the same patients. Patients' voice onset time for voiceless consonants in speech were significantly longer than the controls (p = 0.015). A principle components analysis identified three factors that accounted for 95% of the variance: the first factor included sentence and word duration, frequency shifts, and aperiodic instances; the second was phonatory breaks; and the third was voice onset time. Significant relationships with perceptual counts of symptoms were found for the measures of acoustic disruptions in sentences and sentence duration. Finally, a multiple regression demonstrated that the acoustic measures related well with the perceptual counts (r2 = 0.84) with word duration most highly related and none of the other measures contributing once the effect of word duration was partialed out. The results indicate that some of the voice motor control deficits, namely aperiodicity, phonatory breaks, and frequency shifts, which occur in patients with ABSD, are similar to those previously found in adductor spasmodic dysphonia. Results also indicate that acoustic measures of intermittent disruptions in speech, voice onset time, and speech duration are closely related to the perception of symptom frequency in the disorder.

Consistency of voice produced by patients with adductor spasmodic dysphonia: a preliminary investigation.

Adductor spasmodic dysphonia (ADSD) is an idiopathic focal laryngeal movement disorder causing involuntary and uncontrollable spasms in the vocal fold musculature, primarily during voice onset. Although phonatory instability has been reported through clinical observation and empirical study, no examination of phonatory performance consistency in ADSD has been done. Phonatory instability refers to phonatory unsteadiness and has been previously defined by the presence of acoustic aberrations during speech. Performance consistency pertains to variations in these phonatory aberrations across repeated trials or over time. This study focused on the phonatory performance consistency of those with ADSD by using three acoustic measures of phonatory instability. Twenty patients with ADSD were recorded during three trials of reading a standard passage. Eight of the 20 patients were recorded twice during two separate recording sessions held approximately 6 months apart. The number of phonatory breaks, frequency shifts, and aperiodic segments were the dependent measures. Data were subjected to inferential statistical analysis to test for significant differences among the measures in two conditions: across three trials produced within one recording session and across multiple trials produced during two distinct recording sessions. No significant differences were found for any of the measures either as a function of trials recorded on the same day or across the two recording sessions. The data suggest a need for describing phonatory instability and performance consistency as separate entities with regard to neurological voice disorders.

Acoustic analyses of trained singers perceptually identified from speaking samples.

This study investigated selected acoustic cues in the speaking voices of five professional singers; cues that may have enabled naïve listeners to differentiate them from nonsingers and other trained singers who were not consistently identified from their speaking voices. Subjects were divided into three groups based on listeners' perceptual judgments. Group I, the identified singers, consisted of five professional singers, three males and two females, with an average identification score, from their speaking utterances, of 79%. Group II, the unidentified singers, consisted of 15 trained singers, seven males and eight females, who, as a group, were identified correctly from their speaking utterances only 52% of the time. Group III consisted of 20 nonsingers who were incorrectly identified from their speaking utterances as singers only 36% of the time, that is, they were correctly identified as nonsingers from their speech 64% of the time. Acoustic parameters chosen for measurement from vowel productions were: (1) percent jitter, (2) percent shimmer, and (3) noise-to-harmonic ratio. The second sentence of the "Rainbow Passage" was selected to compare several frequency and duration measures between the three groups. These were: (1) mean speaking fundamental frequency, (2) standard deviation of the fundamental frequency, (3) sentence duration, (4) word duration, and (5) consonant/vowel ratio. The data indicated that the acoustic parameters that most consistently distinguished the identified singers from the unidentified singers and the nonsingers were fundamental frequency variation and durational differences. The identified singers varied their speaking fundamental frequency significantly more than did both the unidentified singers and the nonsingers. The identified singers also had longer vocalic segments than did the others.

Adductor spasmodic dysphonia and muscular tension dysphonia: acoustic analysis of sustained phonation and reading.

Acoustic phonatory events were identified in 10 women diagnosed with adductor spasmodic dysphonia (ADSD) and compared to 5 women and 5 men diagnosed with muscle tension dysphonia (MTD). The three acoustic parameters examined during sustained vowel production and reading included phonatory breaks, aperiodicity, and frequency shifts. Intra- and intermeasurer correlations showed high reliability for the measures. Findings indicated that those with ADSD produced a greater number of aberrant acoustic events than those with MTD. The results suggested that: (1) only those with ADSD show evidence of phonatory breaks during vocalization, albeit a sustained vowel or voicing during reading; (2) those with ADSD demonstrate greater variation in the type of aberrant acoustic events produced as a function of speech task. The latter point suggests that control of the larynx varies as a function of task demand, a finding not evident in the functionally based disorder of MTD. MTD is a disorder that often presents itself in a similar clinical manner to ADSD because of its perceptual commonalties and resembling laryngoscopic characteristics. The acoustic analysis presented in this study could be used as a method to assist in distinguishing between the two disorder types.

Perceptual and acoustic study of professionally trained versus untrained voices.

Acoustic and perceptual analyses were completed to determine the effect of vocal training on professional singers when speaking and singing. Twenty professional singers and 20 nonsingers, acting as the control, were recorded while sustaining a vowel, reading a modified Rainbow Passage, and singing "America the Beautiful." Acoustic measures included fundamental frequency, duration, percent jitter, percent shimmer, noise-to-harmonic ratio, and determination of the presence or absence of both vibrato and the singer's formant. Results indicated that, whereas certain acoustic parameters differentiated singers from nonsingers within sex, no consistently significant trends were found across males and females for either speaking or singing. The most consistent differences were the presence or absence of the singer's vibrato and formant in the singers versus the nonsingers, respectively. Perceptual analysis indicated that singers could be correctly identified with greater frequency than by chance alone from their singing, but not their speaking utterances.

Voice and speech characteristics of persons with Parkinson's disease pre- and post-pallidotomy surgery: preliminary findings.

Pallidotomy surgery, lesioning the globus pallidus internal, has been performed to alleviate Parkinsonian symptoms and drug-induced dyskinesias. Improvements in limb motor function have been reported in recent years following pallidotomy surgery. The purpose of this preliminary study was to determine the effect of pallidotomy surgery on select voice and speech characteristics of 6 patients with Parkinson's disease. Acoustic measures were analyzed pre-pallidotomy surgery and again at 3 months following surgery. Preliminary findings indicated that all participants demonstrated positive changes in at least one acoustic measure; 2 of the participants consistently demonstrated positive changes in phonatory and articulatory measures, whereas 3 participants did not consistently demonstrate positive changes postsurgery. The results are discussed relative to the differential effects observed across participants.

Inspiratory pressure threshold training for glottal airway limitation in laryngeal papilloma.

A single-subject design was used to determine if inspiratory pressure threshold training increases inspiratory muscle strength and reduces the sensation of dyspnea during exercise and speech. The subject was a 23-year-old female with congenital juvenile papilloma which has been in remission for 10 years. A 4-week inspiratory muscle training program was implemented using an inspiratory pressure threshold trainer. The pressure threshold of the trainer was set by the experimenter. The pressure threshold setting of the trainer was based on a percentage of the subject's maximum inspiratory pressure measured prior to training. The average range of the pressure threshold was 40 to 70 cmH2O. In order for inspiratory air to flow, the subject generated inspiratory pressure, independent of airflow rate. Maximum inspiratory pressure (MIP) was the dependent variable used as the index of inspiratory muscle strength. Exercise dyspnea was a dependent variable rated by the subject during a progressive treadmill test. Dyspnea associated with speech was rated following production of a comfortable and loud speech task. MIP increased by 57% following the training program with a 2-scale point reduction in the perception of dyspnea during exercise. Dyspnea during loud speech decreased from moderate to mild. The changes in dyspnea, both during exercise and speech, are directly related to inspiratory muscle strengthening. The results suggest that inspiratory muscle training may improve respiratory related function in patients with restrictive upper airway disorders.

Effects of sound-field frequency modulation amplification on reducing teachers' sound pressure level in the classroom.

Voice problems are a frequent difficulty that teachers experience. Common complaints by teachers include vocal fatigue and hoarseness. One possible explanation for these symptoms is prolonged elevations in vocal loudness within the classroom. This investigation examined the effectiveness of sound-field frequency modulation (FM) amplification on reducing the sound pressure level (SPL) of the teacher's voice during classroom instruction. Specifically, SPL was examined during speech produced in a classroom lecture by 10 teachers with and without the use of sound-field amplification. Results indicated a significant 2.42-dB decrease in SPL with the use of sound-field FM amplification. These data support the use of sound-field amplification in the vocal hygiene regimen recommended to teachers by speech-language pathologists.

Acoustic variations in adductor spasmodic dysphonia as a function of speech task.

Acoustic phonatory events were identified in 14 women diagnosed with ADSD and compared to those of 14 women age-matched (+/-2 years) with no evidence of vocal pathology/dysfunction. The three acoustic parameters examined during sustained vowel production and reading included phonatory breaks, aperiodicity, and frequency shifts. Intra- and intermeasurer correlations showed high reliability for the measures. Findings indicated that those with ADSD produced a greater frequency of aberrant acoustic events than the controls during both tasks. For the group with ADSD, the amount and type of each event also varied with utterance type. The sustained vowel sample produced by those with ADSD consisted of a greater percentage of aperiodic segments followed by phonatory breaks and frequency shifts. During reading, frequency shifts were the predominant acoustic event, followed by phonatory breaks and aperiodicity. The advantage of segmenting the acoustic waveform into these measures and the relevancy of examining intertask performances by those with ADSD is discussed.

Variations in adductor spasmodic dysphonia: acoustic evidence.

Acoustic analysis was used to gain information about the normal, as well as the abnormal acoustic events associated with adductor spasmodic dysphonia (ADSD). This analysis was completed to determine whether specific acoustic events could be used to differentiate the voice of individuals with ADSD from those with normal voice. A group comparison between 14 women diagnosed with ADSD and 14 women (age-matched) with no evidence of vocal pathology or vocal dysfunction was completed. Phonatory breaks, aperiodicity, and frequency shifts, acoustic parameters previously identified in ADSD, were found throughout sustained vowel productions. The duration of the phonatory breaks and aperiodic segments was calculated and the amount of frequency shift was determined. The location of each acoustic event was marked relative to the onset of the vowel production. The subjects with ADSD presented with normal phonation and various amounts of each of the three acoustic parameters. Aperiodic segments primarily characterized the phonation of ADSD, followed by frequency shifts and phonatory breaks. The location of each of these acoustic events was within the midportion of the vowel production. The advantages of segmenting the acoustic waveform into these measures and separating the spasmodic events from normal phonation when examining laryngeal motor control of spasmodic dysphonics is discussed.

Approximations of open quotient and speed quotient from glottal airflow and EGG waveforms: effects of measurement criteria and sound pressure level.

Noninvasive measures of vocal fold activity are useful for describing normal and disordered voice production. Measures of open and speed quotient from glottal airflow and electroglottographic (EGG) waveforms have been used to describe timing events associated with vocal fold vibration. To date, there has been little consistency in the measurement criteria used to calculate quotient values. In this study, criteria of 20% and 50% were applied to the AC amplitude of glottal airflow and inverted EGG waveforms for measurement of open quotient. Criteria of 20%, 50%, and 80%, and a midslope criterion that segmented the waveform between 20% and 80% of the waveform amplitude, were used for the calculation of speed quotient. Subjects produced waveforms at sound pressure levels (SPL) of 70, 75, 80 and 85 dB. Results indicated that approximations of open quotient obtained from the glottal airflow waveform significantly decreased using both the 20% and 50% criteria as SPL increased from 80 to 85 dB. No significant changes were found in open quotient from the EGG waveform as a function of SPL. Results of speed quotient measures from the glottal airflow and EGG waveforms showed a generally increasing trend as SPL increased, although the differences were not statistically significant. The data suggest that the signal type, measurement criterion and SPL must be considered in interpreting quotient measures.

Developmental changes in laryngeal and respiratory function with variations in sound pressure level.

The development of the speech production system was investigated using a cross-sectional design that included children aged 4-14 years and adults. Given that the size and internal structure of the laryngeal and respiratory systems differ between children and adults, it was predicted that children would show functional distinctions from adults during speech. Aerodynamic, acoustic, and respiratory kinematic techniques were used to assess laryngeal and respiratory function while participants varied their sound pressure level. In general, the aerodynamic and acoustic results show that men and 14-year-old boys function differently than women and all other groups of children. For the respiratory function data, children's values are similar to adults' by the time they are 12-14 years of age. These changes correspond closely to developmental laryngeal and respiratory anatomic data. All participants used a combination of laryngeal and respiratory mechanisms to increase sound pressure level, but the combination of mechanisms differed across age groups. These data emphasize that the laryngeal and respiratory behavior of children is not easily predicted from an adult model.

Speech breathing during reading in women with vocal nodules.

This study examined speech breathing patterns during reading by women with bilateral vocal fold nodules judged as mildly dysphonic and by women without vocal nodules. Although it might be predictable that the speech breathing patterns of individuals with laryngeal dysfunction will differ from those without laryngeal dysfunction, there is a lack of empirical data to support such assumptions. The results of the current study indicated that glottal airflow was greater during reading for the women with vocal nodules and that a larger volume of air was expended both per syllable and per breath group during reading. The rate of speech did not significantly differ between the two groups of women. There was no significant difference for the average duration of the breath groups and no significant difference for the number of syllables spoken per breath group. Additionally, both groups of women demonstrated a similar pattern of inspiratory pause location during the reading. The results suggest that speech breathing patterns associated with dysphonia be examined independently to distinguish specifically the nature of the interaction between the laryngeal dysfunction and the speech breathing pattern. Certainly, more information on how the severity of a voice disorder influences speech breathing is necessary.

Aerodynamic and acoustic characteristics of the adult African American voice.

Laryngeal aerodynamic and acoustic characteristics of African American voice production were examined from vowel samples produced by ten adult female and ten adult male speakers. The data were compared with that for a control group consisting of ten adult female and ten adult male White speakers, matched for age, height, and weight. All measures were analyzed using Cspeech 4.0. Aerodynamic measurements, extracted from a glottal airflow waveform, included maximum flow declination rate, alternating glottal airflow, minimum glottal airflow, and airflow open quotient. Acoustic measures included fundamental frequency and sound pressure level. No significant mean differences between the African American and White speakers were found, except for maximum-flow declination rate. The White speakers produced significantly higher declination rates than the African American speakers. The factor of sex for the African American speakers was statistically significant for the measures of maximum-flow declination rate, alternating glottal airflow, open quotient, and fundamental frequency, consistent with the functioning of the White speakers. The results suggest that during vowel production, where the vocal tract is in a fairly static position, acoustic and aerodynamic characteristics for African American and White Speakers are comparable.

Glottal airflow characteristics of women's voice production along an aging continuum.

Anatomical and physiological changes of the speech production mechanism that occur with aging may result in phonatory distinctions between older and younger speakers. This investigation examined amplitude-based glottal airflow characteristics from sustained vowel production in healthy adult women. Sixty women participated in this study, 10 each in six age groups of 20-, 30-, 40-, 50-, 60-, and 70-year-olds. Measures included peak, alternating, and minimum glottal airflow. Additionally, a ratio of minimum to peak glottal airflow was calculated. Results from an analysis of variance indicated no significant group mean difference for any of the dependent measures. A greater variability in peak glottal airflow for the 70-year-old age group as compared to the 20-year-old age group was found. None of the dependent variables were significantly related to age and therefore were not good predictors of age. The results imply that laryngeal senescence in healthy women may not be significant enough to affect the magnitude of phonatory function parameters. Either the assumed anatomical changes produce less significant phonatory change in the healthy individual or the healthy individual is more capable of using strategies to counteract degenerative laryngeal changes.

Laryngeal aerodynamic aspects of women with adductor spasmodic dysphonia.

OBJECTIVE: To determine if laryngeal aerodynamic parameters distinguish the voice of patients diagnosed as having adductor spasmodic dysphonia (SD) from individuals with normal voice production. DESIGN: A group comparison between 10 women diagnosed as having adductor SD and 10 women with no evidence of vocal abnormalities or vocal dysfunction. SETTING: University and university-affiliated health center. PATIENTS: Ten women (age range, 38 through 82 years) diagnosed as having adductor SD and 10 age-matched women (+/- 2 years) with no evidence of pathologic vocal features or vocal dysfunction. RESULTS: Multivariate statistical analysis revealed significantly higher values for amplitude-based glottal airflow measures of maximum flow declination rate, peak glottal airflow, and minimum glottal airflow. CONCLUSIONS: Spasmodic dysphonia affects the ability of the laryngeal mechanism to function effectively. To date, few empirical studies have examined glottal airflow characteristics associated with adductor SD. Results from our study demonstrate that certain amplitude-based glottal airflow parameters distinguish adductor SD from normal voice. Therefore, aerodynamic measures may offer additional objectivity for the study.

Respiratory and laryngeal function associated with experimental coupling of the oral and nasal cavities.

Three experimental openings (10 mm2, 20 mm2, 30 mm2) were placed one at a time in a man's palatal obturator at a location approximating the junction of the prepalate and the palatal shelves. The man's laryngeal and respiratory function were examined during his production of a series of CV syllables [pa] repeated at a comfortable and loud vocal intensity for each of the three experimental conditions. Two more conditions, in which the subject's obturator was not altered (no hole) and in which no obturator was worn, were also included for study. Laryngeal and respiratory function adjustments were most apparent during the 30 mm2 hole size and no obturator conditions. Laryngeal adjustment, as measured by fundamental frequency, was the most identifiable. A respiratory adjustment, which involved the expenditure of more lung volume as nasal airflow leakage increased, was also observed. These observations imply an active physiologic adjustment rather than a passive response to aberrant oronasal coupling.

Speech task effects on acoustic and aerodynamic measures of women with vocal nodules.

Vowel prolongation is often used to evaluate disordered voice production. In light of previous findings showing that co-articulation has significant influence on laryngeal function measures, the practice of using prolonged vowels to represent a speech sample is questioned. To test whether disordered and normal voice during vowel production is generalizable to connected speech, three speaking tasks were investigated: sustained vowel prolongation, syllable repetition and reading. Statistical differences were found between these tasks for certain amplitude and time based laryngeal function measures for adult women with disordered and normal voice. However, for the specific measures which were statistically different, the actual numerical and perceptual differences may be quite small. From a clinical assessment standpoint, the choice of the speech task may not make an apparent difference in the objective evaluation of disordered voice.