Exercise-Induced Functional Changes in People with Parkinson's Disease following External Cueing and Task-Based Intervention.

Introduction: The purpose of this study was to evaluate change in motor function, gait speed, dynamic balance, balance confidence, and quality of life (QoL) in nine participants with Parkinson's disease (PwPD) completing Lee Silverman Voice Treatment BIG (LSVT-BIG), an external cueing and task-based intervention. Although supported as an efficacious treatment in PwPD, there is limited research examining clinically meaningful change in outcome measures related to external cueing and task-based interventions. Materials and Methods: This was a case series of nine PwPD (age range 64-76 years, 55% male) who completed the LSVT-BIG protocol. Disease duration ranged from 1 to 17 years and was classified as moderate in all participants (Hoehn and Yahr = 2 or 3). Outcome measures included motor function (MDS-UPDRS Part III Motor), gait speed, dynamic balance (MiniBEST), Activities-specific Balance Confidence (ABC), and Summary Index for PD Quality of Life 39 (PDQ-SI). Assessments were completed at baseline (BASE), end of treatment (EOT), and 4 weeks after EOT (EOT+4). Results: Minimal detectable change (MDC) or minimal clinical important difference (MCID) was observed in one or more outcome measures in 8 of 9 participants at EOT and EOT+4 across domains of motor function (67%, 78%), gait speed (78%, 67%), balance confidence (44%, 33%), quality of life (44%, 78%), and dynamic balance (22%, 22%). Discussion. In this case series, 8 of 9 participants showed MDC or MCID changes across multiple functional domains. Improvements were observed immediately post (EOT) and 4-week post-treatment (EOT+4) suggesting a temporal component of the LSVT-BIG impact on functional change. Future research should include clinical trials to examine additional external cueing and task-based intervention efficacy with consideration of intensity, frequency, and mode of delivery across disease severity.

The Facilitators and Barriers to Digital Health for Managing Nutrition in People With Parkinson's Disease and Their Caregivers: A Formative, Qualitative Study.

OBJECTIVE: Identify techniques to assist in designing digital health platforms for nutrition services for people with Parkinson's disease and caregivers to improve their quality of life. DESIGN: Semistructured, dyadic interviews with 20 dyads (20 people with Parkinson's disease and 20 caregivers). SETTING: Home visits were conducted in the northeast US. PARTICIPANTS: People with Parkinson's disease and their caregivers were recruited via email, flyers, news articles and announcements at support groups. PHENOMENON OF INTEREST: Identification of facilitators and barriers to using digital health platforms to inform future digital nutrition services. ANALYSIS: Interviews were recorded, transcribed and double-coded using a framework analysis method. RESULTS: Reported digital health platforms utilization facilitators were: knowledge acquisition, convenience, intention to use, socializing, enjoyment, and forced adoption. Barriers included: negative feelings toward technology, lack of access or knowledge, disinterest, product design, frustration and functional reliability, and applying health information. CONCLUSIONS AND IMPLICATIONS: Although dyads often lack knowledge on both how to use technology and nutrition, they are willing to use digital health platforms to increase their nutrition knowledge if platforms are convenient. Based on the identified facilitators and barriers, the added benefits of access and training nutrition digital health platforms must be clearly communicated to end-users to improve their quality of life.

Diet Quality and Nutrition Concerns of People with Parkinson's Disease and Their Informal Caregivers: A Mixed Methods Study.

Limited research exists regarding the diet quality and nutritional concerns of people with Parkinson's disease (PwPD) and their informal caregivers. The study's purpose was to assess diet quality via the Healthy Eating Index-2015 (HEI-2015) and self-reported nutrition concerns via semi-structured, dyadic interviews of 20 PwPD (69.7 ± 9.2 yrs) and their caregivers (66.7 ± 13.0 yrs). HEI-2015 scores were 58.3 ± 12.4 and 58.1 ± 10.6 for PwPD and caregivers, respectively. Reported dietary concerns related to PD included: change in appetite or amount eaten, gastrointestinal issues, food-medication management, chewing/swallowing issues, and change in taste/smell. The poor diet quality and nutrition concerns identified suggest nutrition professionals and caregivers are critical on the healthcare team to promote optimal health among PwPD. Future research should address overall and specific aspects of diet quality, and nutritional concerns identified by dyads in this study, such as gastrointestinal issues and food-medication management.

Acceptance and perception of digital health for managing nutrition in people with Parkinson's disease and their caregivers and their digital competence in the United States: A mixed-methods study.

BACKGROUND AND AIMS: This mixed-methods study examined participants' acceptance and perception of using digital health for managing nutrition and participants' digital competence. The results will be formative for making digital nutrition education more effective and acceptable for people with Parkinson's disease (PwPD) and their informal caregivers. METHODS: Qualitative data were collected through in-person semi-structured, dyadic interviews, and questionnaires from 20 dyads (20 PwPD and their caregivers) in the Northeastern United States and analyzed throughout the 2018 to 2019 academic year. Interview transcripts were deductively coded using the framework analysis method. Phrases related to acceptance of digital health were sub-coded into accept, neutral, or reject and those related to perceptions of digital health were sub-coded into perceived usefulness, perceived ease of use, and awareness of digital health. Quantitative data were analyzed using independent samples t tests and Fisher's exact tests. Qualitative codes were transformed into variables and compared to digital competence scores to integrate the data. An average acceptance rate for digital health was calculated through examining the mean percent of phrases coded as accept from interview transcripts. RESULTS: Twenty-five of 40 (62.5%) participants used the internet for at least 5 health-related purposes and the average acceptance rate was 54.4%. Dyads rejected digital health devices if they did not see the added benefit. The majority of participants reported digital health to be useful, but hard to use, and about half felt they needed education about existing digital health platforms. There was no difference in digital competence scores between PwPD and their caregivers (28.6 ± 12.6). CONCLUSION: Findings suggest that dyads accept and use technology but not to its full potential as technology can be perceived as hard to use. This finding, combined with digital competence scores, revealed that education is warranted prior to providing a digital nutrition intervention.

Acoustic Features of Transfeminine Voices and Perceptions of Voice Femininity.

The purpose of this study was to evaluate the relationships between acoustic measures of transfeminine voices and both self- and listener ratings of voice femininity. Connected speech samples were collected from 12 transfeminine individuals (M = 36.3 years, SD = 10.6 years) and a control group of five cisgender (cis) women and five cis men (M = 35.3 years, SD = 13.3 years). The acoustic measures of fundamental frequency (fo), fo variation, formant frequencies, and vocal intensity were calculated from these samples. Transfeminine speakers rated their own voices on a five-point scale of voice femininity. Twenty inexperienced listeners heard an excerpt of each speech sample and rated the voices on the same five-point scale of voice femininity. Spearman's rank-order correlation coefficients were calculated to measure the relationships between the acoustic variables and ratings of voice femininity. Significant positive correlations were found between fo and both self-ratings (r = 0.712, P = 0.009) and listener ratings of voice femininity (r = 0.513, P < 0.001). Significant positive correlations were found between intensity and both self-ratings (r = 0.584, P = 0.046) and listener ratings of voice femininity (r = 0.584, P = 0.046). No significant correlations were found between fo variation or formant frequencies and perceptual ratings of voice femininity. A Pearson's chi-square test of independence showed that the distribution of self- and listener ratings differed significantly (χ2 = 9.668, P = 0.046). Self- and listener ratings were also shown to be strongly correlated (r = 0.912, P < 0.001). This study provides further evidence to support the selection of training targets in voice feminization programs for transfeminine individuals and promotes the use of self-ratings of voice as an important outcome measure.

Auditory-Perceptual Speech Features in Children With Down Syndrome.

Speech disorders occur commonly in individuals with Down syndrome (DS), although data regarding the auditory-perceptual speech features are limited. This descriptive study assessed 47 perceptual speech features during connected speech samples in 26 children with DS. The most severely affected speech features were: naturalness, imprecise consonants, hyponasality, speech rate, inappropriate silences, irregular vowels, prolonged intervals, overall loudness level, pitch level, aberrant oropharyngeal resonance, hoarse voice, reduced stress, and prolonged phonemes. These findings suggest that speech disorders in DS are due to distributed impairments involving voice, speech sound production, fluency, resonance, and prosody. These data contribute to the development of a profile of impairments in speakers with DS to guide future research and inform clinical assessment and treatment.

Cognitive status and cardio-metabolic risk of patients with acquired brain injury and Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) and acquired brain injury (ABI) share common symptoms. People with PD and ABI risk nutritional decline at diagnosis, but little is known about their long-term health a year or more after diagnosis. OBJECTIVE: This cross-sectional study describes cognitive and dietary characteristics of people living with PD or ABI 12 months or more post diagnosis to identify cardio-metabolic risk factors. METHODS: Twelve community-dwelling participants (8 PD, 4 ABI) received interdisciplinary evaluations. Cognitive-linguistic status was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Nutritional and cardio-metabolic statuses were measured using the dietary screening tool (DST), anthropometrics, biochemical, and clinical measures. Descriptive statistics, independent t-tests and correlations were used to analyze the data. RESULTS: Mean BMI (n = 12) was 26.8 ± 3.0 kg/m(2) and the majority of participants were overweight. Participants with PD had significantly higher total RBANS scores than participants with ABI (87.1 ± 14.6 vs. 66.0 ± 12.6, p = 0.034, d = 2.455). DST scores indicated 58% (N = 7) at possible nutrition risk and 25% (N = 3) were at nutrition risk. A positive correlation was found between general activity level and DST scores (r = 0.697, p = 0.012). Multiple risk factors for development of cardiovascular disease (CVD) were present in all participants. CONCLUSION: These findings confirmed the presence of cognitive and dietary deficits in our participant group and support the need for an interdisciplinary team approach to improve health and prevent the development of symptoms for these populations a year or more after diagnosis.

Evidence-based treatment of voice and speech disorders in Parkinson disease.

PURPOSE OF REVIEW: Voice and speech impairments are present in nearly 90% of people with Parkinson disease and negatively impact communication and quality of life. This review addresses the efficacy of Lee Silverman Voice Treatment (LSVT) LOUD to improve vocal loudness (as measured by vocal sound pressure level vocSPL) and functional communication in people with Parkinson disease. The underlying physiologic mechanisms of Parkinson disease associated with voice and speech changes and the strength of the current treatment evidence are discussed with recommendations for best clinical practice. RECENT FINDINGS: Two randomized control trials demonstrated that participants who received LSVT LOUD were significantly better on the primary outcome variable of improved vocSPL posttreatment than alternative and no treatment groups. Treatment effects were maintained for up to 2 years. In addition, improvements have been demonstrated in associated outcome variables, including speech rate, monotone, voice quality, speech intelligibility, vocal fold adduction, swallowing, facial expression and neural activation. Advances in technology-supported treatment delivery are enhancing treatment accessibility. SUMMARY: Data support the efficacy of LSVT LOUD to increase vocal loudness and functional communication in people with Parkinson disease. Timely intervention is essential for maximizing quality of life for people with Parkinson disease.

Impact of a program of Tai Chi plus behaviorally based dietary weight loss on physical functioning and coronary heart disease risk factors: a community-based study in obese older women.

This study employed a quasi-experimental design in a community-based study translating the results of our recent findings on the combined effects of Tai Chi and weight loss on physical function and coronary heart disease (CHD) risk factors. A 16-week intervention was conducted to assess the impact of Tai Chi plus a behavioral weight loss program (TCWL, n = 29) on obese (body mass index [BMI] = 35.4 ± 0.8 kg/m²) older (68.2 ± 1.5 yr.) women compared to a control group (CON, n = 9, BMI = 38.0 ± 1.5 kg/m², 65.6 ± 2.7 yr.), which was asked to maintain their normal lifestyle. The TCWL group lost weight (1.6 ± 2.9 kg, P = 0.006) while the CON group did not (1.2 ± 1.9 kg, P = 0.106). Physical functioning as measured by the short physical performance battery improved in TCWL when compared to the CON group (ß = 1.94, 95% Confidence Interval [CI]: 1.12, 2.76, P < 0.001). TCWL also improved in sit-and-reach flexibility (ß = -2.27, 95% CI: -4.09, -0.46, P = 0.016), body fat mass (BMI, ß = -0.65, 95% CI: -1.03, -0.26, P = 0.002), waist circumference (ß = -1.78, 95% CI: -2.83, -0.72, P = 0.002), systolic blood pressure (ß = -16.41, 95% CI: -21.35, -11.48, P < 0.001), and diastolic blood pressure (ß = -9.52, 95% CI: -12.65, -6.39, P < 0.001). Thus, TCWL intervention may represent an effective strategy to improve physical function and ameliorate CHD risk in the older adult population.

Effects of respiratory muscle training (RMT) in children with infantile-onset Pompe disease and respiratory muscle weakness.

PURPOSE: Respiratory muscle weakness is a primary therapeutic challenge for patients with infantile Pompe disease. We previously described the clinical implementation of a respiratory muscle training (RMT) regimen in two adults with late-onset Pompe disease; both demonstrated marked increases in inspiratory and expiratory muscle strength in response to RMT. However, the use of RMT in pediatric survivors of infantile Pompe disease has not been previously reported. METHOD: We report the effects of an intensive RMT program on maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) using A-B-A (baseline-treatment-posttest) single subject experimental design in two pediatric survivors of infantile Pompe disease. Both subjects had persistent respiratory muscle weakness despite long-term treatment with alglucosidase alfa. RESULTS: Subject 1 demonstrated negligible to modest increases in MIP/MEP (6% increase in MIP, d=0.25; 19% increase in MEP, d=0.87), while Subject 2 demonstrated very large increases in MIP/MEP (45% increase in MIP, d=2.38; 81% increase in MEP, d=4.31). Following three-month RMT withdrawal, both subjects maintained these strength increases and demonstrated maximal MIP and MEP values at follow-up. CONCLUSION: Intensive RMT may be a beneficial treatment for respiratory muscle weakness in pediatric survivors of infantile Pompe disease.

Intensive treatment of dysarthria secondary to stroke.

This study investigated the impact of a well-defined behavioral dysarthria treatment on acoustic and perceptual measures of speech in four adults with dysarthria secondary to stroke. A single-subject A-B-A experimental design was used to measure the effects of the Lee Silverman Voice Treatment (LSVT(®) LOUD) on the speech of individual participants. Dependent measures included vocal sound pressure level, phonatory stability, vowel space area, and listener ratings of speech, voice and intelligibility. Statistically significant improvements (p < 0.05) in vocal dB SPL and phonatory stability as well as larger vowel space area were present for all participants. Listener ratings suggested improved voice quality and more natural speech post-treatment. Speech intelligibility scores improved for one of four participants. These data suggest that people with dysarthria secondary to stroke can respond positively to intensive speech treatments such as LSVT. Further studies are needed to investigate speech treatments specific to stroke.

Intensive treatment of dysarthria in two adults with Down syndrome.

OBJECTIVE: This study investigated the impact of an established behavioural dysarthria treatment on acoustic and perceptual measures of speech in two adults with Down syndrome (DS) and dysarthria to obtain preliminary measures of treatment effect, effect size and treatment feasibility. METHODS: A single-subject A-B-A experimental design was used to measure the effects of the Lee Silverman Voice treatment (LSVT®) on speech in two adults with DS and dysarthria. Dependent measures included vocal sound pressure level (dB SPL), phonatory stability and listener intelligibility scores. RESULTS: Statistically significant improvements (p < 0.05) in vocal dB SPL and phonatory stability were present following treatment in both participants. Speech intelligibility scores improved in one of the two participants. CONCLUSIONS: These data suggest that people with DS and dysarthria can respond positively to intensive speech treatment such as LSVT. Further investigations are needed to develop speech treatments specific to DS.

Intensive voice treatment (LSVT®LOUD) for Parkinson's disease following deep brain stimulation of the subthalamic nucleus.

PURPOSE: Intensive voice therapy (LSVT(®)LOUD) can effectively manage voice and speech symptoms associated with idiopathic Parkinson disease (PD). This small-group study evaluated voice and speech in individuals with and without deep brain stimulation of the subthalamic nucleus (STN-DBS) before and after LSVT LOUD, to determine whether outcomes for surgical subjects were comparable to non-surgical cohorts. METHODS: Eight subjects with PD (four with STN-DBS and four without) received LSVT LOUD four times a week for four weeks. Four additional subjects with PD remained untreated. Voice intensity (SPL), Vowel Articulation Index (VAI), the Voice Handicap Index (VHI), and a structured interview were evaluated before and after treatment and again six months later. RESULTS: Both treated groups showed significant increases in SPL from pre to post and six-month follow up. VAI was significantly higher for the treated groups compared to the untreated subjects at follow up. Several treated individuals had significant clinical improvement in VHI scores, particularly within the LSVT-DBS group. Treated individuals reported improvements in voice and speech in structured interviews; however, answers suggest more variable long-term maintenance within the LSVT-DBS group. The untreated group exhibited no significant changes in any measure throughout the study. CONCLUSIONS: Results support LSVT LOUD for treating voice and speech in individuals with PD following STN-DBS surgery. However, modifications may be required to maintain functional improvements. LEARNING OUTCOMES: As a result of this activity, the participant will be able to (1) describe how deep brain stimulation of the subthalamic nucleus may affect voice and speech in Parkinson disease; (2) describe the effects of intensive voice therapy (LSVT(®)LOUD) on people with PD both with and without STN-DBS; (3) describe how individuals with STN-DBS maintained treatment effects over time.

Effects of an extended version of the lee silverman voice treatment on voice and speech in Parkinson's disease.

PURPOSE: The present study examined vocal SPL, voice handicap, and speech characteristics in Parkinson's disease (PD) following an extended version of the Lee Silverman Voice Treatment (LSVT), to help determine whether current treatment dosages can be altered without compromising clinical outcomes. METHOD: Twelve participants with idiopathic PD received the extended treatment version (LSVT-X), similar to LSVT except that it was administered twice a week in 1-hr sessions over 8 weeks and required substantially more home practice. Recordings were made in a sound-treated booth immediately before and after treatment, and again 6 months later. Vocal SPL was measured for 4 different tasks and compared with data from a previous study, in which participants with PD received traditional LSVT 4 times a week for 4 weeks. Listener ratings were conducted with audio samples from both studies, using sentence pairs from a standard passage. LSVT-X participants completed the Voice Handicap Index (VHI) before each set of recordings. RESULTS: Participants receiving LSVT-X significantly increased vocal SPL by 8 dB after treatment and maintained increased vocal SPL by 7.2 dB at 6 months. VHI scores improved for 25% of the LSVT-X participants following treatment, and listener ratings indicated audible improvement in speech. CONCLUSIONS: LSVT-X successfully increased vocal SPL (which was consistent with improvements following traditional LSVT), decreased perceived voice handicap, and improved functional speech in individuals with PD. Further large-scale research is required to truly establish LSVT-X efficacy.