Immediate and long-term effects of speech treatment targets and intensive dosage on Parkinson's disease dysphonia and the speech motor network: Randomized controlled trial.

This study compared acoustic and neural changes accompanying two treatments matched for intensive dosage but having two different treatment targets (voice or articulation) to dissociate the effects of treatment target and intensive dosage in speech therapies. Nineteen participants with Parkinsonian dysphonia (11 F) were randomized to three groups: intensive treatment targeting voice (voice group, n = 6), targeting articulation (articulation group, n = 7), or an untreated group (no treatment, n = 6). The severity of dysphonia was assessed by the smoothed cepstral peak prominence (CPPS) and neuronal changes were evaluated by cerebral blood flow (CBF) recorded at baseline, posttreatment, and 7-month follow-up. Only the voice treatment resulted in significant posttreatment improvement in CPPS, which was maintained at 7 months. Following voice treatment, increased activity in left premotor and bilateral auditory cortices was observed at posttreatment, and in the left motor and auditory cortices at 7-month follow-up. Articulation treatment resulted in increased activity in bilateral premotor and left insular cortices that were sustained at a 7-month follow-up. Activation in the auditory cortices and a significant correlation between the CPPS and CBF in motor and auditory cortices was observed only in the voice group. The intensive dosage resulted in long-lasting behavioral and neural effects as the no-treatment group showed a progressive decrease in activity in areas of the speech motor network out to a 7-month follow-up. These results indicate that dysphonia and the speech motor network can be differentially modified by treatment targets, while intensive dosage contributes to long-lasting effects of speech treatments.

Speech treatment in Parkinson's disease: Randomized controlled trial (RCT).

BACKGROUND: As many as 89% of people with Parkinson's disease (PD) develop speech disorders. OBJECTIVES: This randomized controlled trial evaluated two speech treatments for PD matched in intensive dosage and high-effort mode of delivery, differing in subsystem target: voice (respiratory-laryngeal) versus articulation (orofacial-articulatory). METHODS: PD participants were randomized to 1-month LSVT LOUD (voice), LSVT ARTIC (articulation), or UNTXPD (untreated) groups. Speech clinicians specializing in PD delivered treatment. Primary outcome was sound pressure level (SPL) in reading and spontaneous speech, and secondary outcome was participant-reported Modified Communication Effectiveness Index (CETI-M), evaluated at baseline, 1, and 7 months. Healthy controls were matched by age and sex. RESULTS: At baseline, the combined PD group (n = 64) was significantly worse than healthy controls (n = 20) for SPL (P < 0.05) and CETI-M (P = 0.0001). At 1 and 7 months, SPL between-group comparisons showed greater improvements for LSVT LOUD (n = 22) than LSVT ARTIC (n = 20; P < 0.05) and UNTXPD (n = 22; P < 0.05). Sound pressure level differences between LSVT ARTIC and UNTXPD at 1 and 7 months were not significant (P > 0.05). For CETI-M, between-group comparisons showed greater improvements for LSVT LOUD and LSVT ARTIC than UNTXPD at 1 month (P = 0.02; P = 0.02). At 7 months, CETI-M between-group differences were not significant (P = 0.08). Within-group CETI-M improvements for LSVT LOUD were maintained through 7 months (P = 0.0011). CONCLUSIONS: LSVT LOUD showed greater improvements than both LSVT ARTIC and UNTXPD for SPL at 1 and 7 months. For CETI-M, both LSVT LOUD and LSVT ARTIC improved at 1 month relative to UNTXPD. Only LSVT LOUD maintained CETI-M improvements at 7 months. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Narrative analysis in individuals with Parkinson's disease following intensive voice treatment: secondary outcome variables from a randomized controlled trial.

Communication is often impaired in individuals with Parkinson's disease (PD), typically secondary to sensorimotor deficits impacting voice and speech. Language may also be diminished in PD, particularly for production and comprehension of verbs. Evidence exists that verb processing is influenced by motor system modulation suggesting that verb deficits in PD are underpinned by similarities in the neural representations of actions that span motor and semantic systems. Conversely, subtle differences in cognition in PD may explain difficulty in processing of complex syntactic forms, which increases cognitive demand and is linked to verb use. Here we investigated whether optimizing motor system support for vocal function (improving loudness) affects change in lexical semantic, syntactic, or informativeness aspects of spoken discourse. Picture description narratives were compared for 20 Control participants and 39 with PD, 19 of whom underwent Lee Silverman Voice Treatment (LSVT LOUD®). Treated PD narratives were also contrasted with those of untreated PD and Control participants at Baseline and after treatment. Controls differed significantly from the 39 PD participants for verbs per utterance, but this difference was largely driven by untreated PD participants who produced few utterances but with verbs, inflating their verbs per utterance. Given intervention, there was a significant increase in vocal loudness but no significant changes in language performance. These data do not support the hypothesis that targeting this speech motor system results in improved language production. Instead, the data provide evidence of considerable variability in measures of language production across groups, particularly in verbs per utterance.

Intensive Voice Treatment (Lee Silverman Voice Treatment [LSVT LOUD]) for Children With Down Syndrome: Phase I Outcomes.

PURPOSE: This study examined the effects of an intensive voice treatment Lee Silverman Voice Treatment (LSVT LOUD) on children with Down syndrome (DS) and motor speech disorders. METHOD: A Phase I, multiple baseline, single-subject design with replication across nine participants with DS was used. Single-word intelligibility, acoustic measures of vocal functioning, and parent perceptions of pre- and posttreatment communication function were used as treatment outcome measures. RESULTS: All participants completed the full dose of LSVT LOUD and showed gains on one or more of the outcome measures. Patterns of posttreatment improvements were not consistent across participants but were more frequently observed on trained maximum performance tasks compared to tasks reflecting generalization of the treatment skillset. Some participants exhibited a stronger response to treatment, whereas others showed a mixed or weaker response. Parents liked the treatment protocol, perceived benefits from intensive intervention, and indicated they would strongly recommend LSVT LOUD to other parents who have children with DS and motor speech disorders. CONCLUSIONS: These preliminary results show that children with DS tolerated intensive voice treatment without adverse effects and made select meaningful therapeutic gains. The treatment evidence from this study warrants Phase II treatment studies using LSVT LOUD with a larger group of children with DS.

Single Word Intelligibility of Individuals with Parkinson's Disease in Noise: Pre-Specified Secondary Outcome Variables from a Randomized Control Trial (RCT) Comparing Two Intensive Speech Treatments (LSVT LOUD vs. LSVT ARTIC).

The majority of people with Parkinson's disease (PD) experience both prosodic changes (reduced vocal volume, reduced pitch range) and articulatory changes (imprecise articulation) that often limit speech intelligibility and may contribute to significant declines in quality of life. We conducted a randomized control trial comparing two intensive treatments, voice (LSVT LOUD) or articulation (LSVT ARTIC) to assess single word intelligibility in the presence of background noise (babble and mall). Participants (64 PD and 20 Healthy) read words from the diagnostic rhyme test (DRT), an ANSI Standard for measuring intelligibility of speech, before and after one month (treatment or no treatment). Teams of trained listeners blindly rated the data. Speech intelligibility of words in the presence of both noise conditions improved in PD participants who had LSVT LOUD compared to the groups that had LSVT ARTIC or no treatment. Intensive speech treatment targeting prominent prosodic variables in LSVT LOUD had a positive effect on speech intelligibility at the single word level in PD.

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.

Impact of four nonclinical speaking environments on a child's fundamental frequency and voice level: a preliminary case study.

PURPOSE: The aim of this study was to investigate how a child's fundamental frequency (F(0)) and estimated voice level (dB SPL) change in distinct speaking environments. METHOD: A child age 5;7 (years;months) wore a National Center for Voice and Speech voice dosimeter for 4 days. The 2 parameters measured were F(0) and dB SPL. During analysis, the F(0) and dB SPL data were segmented to represent 4 typical speaking environments of school-age children: (a) free-play (2.5 hr), (b) preschool (3 hr), (c) home (10.7 hr), and (d) adult (5.6 hr). Unique to this study, the child's voice data were presented as voice use profiles. RESULTS: The child's F(0) and dB SPL patterns within an adult environment were similar to that found in the literature but showed much greater variation in the free-play environment. The preschool environment elicited speech of a lower modal F(0) than did the home, but a higher median and mean F(0), as well as a somewhat elevated mean dB SPL. CONCLUSION: The child produced significantly different F(0) and dB SPL patterns across 4 different speaking environments. If future studies substantiate this pattern, clinicians and researchers must be aware of this difference when working with children.

Innovative technology for the assisted delivery of intensive voice treatment (LSVT®LOUD) for Parkinson disease.

PURPOSE: To assess the feasibility and effectiveness of a newly developed assistive technology system, Lee Silverman Voice Treatment Companion (LSVT(®) Companion™, hereafter referred to as "Companion"), to support the delivery of LSVT(®)LOUD, an efficacious speech intervention for individuals with Parkinson disease (PD). METHOD: Sixteen individuals with PD were randomized to an immediate (n = 8) or a delayed (n = 8) treatment group. They participated in 9 LSVT LOUD sessions and 7 Companion sessions, independently administered at home. Acoustic, listener perception, and voice and speech rating data were obtained immediately before (pre), immediately after (post), and at 6 months post treatment (follow-up). System usability ratings were collected immediately post treatment. Changes in vocal sound pressure level were compared to data from a historical treatment group of individuals with PD treated with standard, in-person LSVT LOUD. RESULTS: All 16 participants were able to independently use the Companion. These individuals had therapeutic gains in sound pressure level, pre to post and pre to follow-up, similar to those of the historical treatment group. CONCLUSIONS: This study supports the use of the Companion as an aid in treatment of hypokinetic dysarthria in individuals with PD. Advantages and disadvantages of the Companion, as well as limitations of the present study and directions for future studies, are discussed.

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.

The inability to produce soft voice (IPSV): a tool to detect vocal change in school-teachers.

PURPOSE: This study investigated whether clinicians could detect voice changes reported by teachers, from self-ratings teachers conducted of their inability to produce soft voice (IPSV). METHODS: Ten teachers wore a vocal dosimeter and completed daily IPSV ratings approximately every 2 hours for 14 days. Following the 2 weeks of dosimetry, two speech clinicians specialized in voice rated the teachers' IPSV from dosimeter recordings. Teacher and clinician ratings were compared for each participant. RESULTS: Although agreement between teacher and clinician ratings was not significant, descriptive analyses demonstrated an average difference score of 1.7 (SD 1.4) between teacher and clinician ratings. CONCLUSIONS: This study supports the potential usefulness of the IPSV as a simple tool to detect voice changes in oneself or others.