Breathy Voice as a Compensatory Strategy for Essential Vocal Tremor: A Single Case Experiment Across Participants.

OBJECTIVE: Essential vocal tremor (EVT) manifests as nearly rhythmic modulations of fundamental frequency (fo) and intensity and causes a shaky voice. Although research on behavioral therapy for EVT is limited, previous studies have shown that a breathy voice reduces the perception of simulated EVT and might be an effective compensatory strategy. The current study aimed to measure the acoustical and perceptual effects of a breathy voice strategy in speakers with EVT. STUDY DESIGN: A single-case experimental design (SCED) was used to investigate acoustical effects, and a pair comparison listening task was used to investigate perceptual effects. METHODS: Three participants with EVT matched five different levels of breathiness produced by a computational model. Acoustical analyses of the rate and extent of fo and intensity modulation were performed to estimate EVT severity for baseline and treatment trials. Statistical analyses were completed using Tau-U. Twenty novice listeners participated in the perceptual study to determine if treatment trials sounded less "shaky" than baseline trials. Statistical analyses were completed using one sample t tests. RESULTS: The acoustical effects were variable across different levels of breathiness for all three participants. All participants were able to adjust their levels of breathiness based on auditory models and verbal cues but did not achieve the target levels of breathiness. Listeners did not perceive the breathy trials to be less "shaky" than baseline trials for any level of breathiness. CONCLUSION: The breathy voice strategy had variable effects on the acoustical measures of EVT, supporting the use of a single-case experimental design to investigate the effectiveness of behavioral treatment for EVT. Listeners perceived breathy trials to be "shakier" than baseline trials, which was inconsistent with our hypothesis and previous studies of EVT. Future research should evaluate the use of a breathy voice in speakers with confirmed laryngeal tremor, optimize cueing for breathiness, and provide more opportunities to practice the breathy strategy.

Speaker-induced Suppression in EEG during a Naturalistic Reading and Listening Task.

Speaking elicits a suppressed neural response when compared with listening to others' speech, a phenomenon known as speaker-induced suppression (SIS). Previous research has focused on investigating SIS at constrained levels of linguistic representation, such as the individual phoneme and word level. Here, we present scalp EEG data from a dual speech perception and production task where participants read sentences aloud then listened to playback of themselves reading those sentences. Playback was separated into immediate repetition of the previous trial and randomized repetition of a former trial to investigate if forward modeling of responses during passive listening suppresses the neural response. Concurrent EMG was recorded to control for movement artifact during speech production. In line with previous research, ERP analyses at the sentence level demonstrated suppression of early auditory components of the EEG for production compared with perception. To evaluate whether linguistic abstractions (in the form of phonological feature tuning) are suppressed during speech production alongside lower-level acoustic information, we fit linear encoding models that predicted scalp EEG based on phonological features, EMG activity, and task condition. We found that phonological features were encoded similarly between production and perception. However, this similarity was only observed when controlling for movement by using the EMG response as an additional regressor. Our results suggest that SIS operates at a sensory representational level and is dissociated from higher order cognitive and linguistic processing that takes place during speech perception and production. We also detail some important considerations when analyzing EEG during continuous speech production.

The Effect of Pitch and Loudness Auditory Feedback Perturbations on Vocal Quality During Sustained Phonation.

OBJECTIVE: Dysphonia is a reduction in vocal quality that impacts communication and is often an early sign of a voice disorder. There is little information regarding the effects of auditory feedback control of loudness and pitch on voice quality. In this study, we used both loudness-shift and pitch-shift paradigms to study the relationship between auditory feedback control and vocal quality as measured by smoothed cepstral peak prominence (CPPS), which reflects the harmonicity of the voice signal. STUDY DESIGN: Experimental, mixed design. METHODS: We applied 200 ms loudness-shifts (± 0, 3, or 6 dB) and pitch-shifts (± 0, 50, and 100 cents) to auditory feedback during sustained vowel production in 25 healthy adults. We then measured CPPS before and after the loudness-shift or pitch-shift to investigate the effect of changes in auditory feedback on vocal harmonicity. RESULTS & CONCLUSIONS: Results showed that, on average, CPPS significantly decreased between the first half of the measured segment and the last half of the segment in the absence of auditory feedback shifts, suggesting that voice quality may be reduced across longer vowels over time. Upward and downward shifts in loudness auditory feedback caused a relative increase in CPPS, indicating an improvement in vocal harmonicity, even in cases when vocal intensity was reduced. Pitch alterations had inconsistent and minimal effects. We propose that there may be a control mechanism for voice quality that increases harmonicity of the voice signal to improve voice audibility (ie, ability to be heard) in the presence of unpredictable variability in voice intensity.

Behavioral Therapy for Tremor or Dystonia Affecting Voice in Speakers with Hyperkinetic Dysarthria: A Systematic Review.

INTRODUCTION: Hyperkinetic dysarthria is characterized by atypical involuntary movements within the speech mechanism that may affect the respiratory, laryngeal, pharyngeal-oral, or velopharyngeal-nasal subsystems and may alter speech production. Although articulatory impairments are commonly considered in hyperkinetic dysarthria, speakers with hyperkinetic dysarthria may also present with changes in voice quality, pitch, and loudness. In approximately 70% of speakers with hyperkinetic dysarthria, these voice alterations are associated with tremor or dystonia. The purpose of this systematic review was to investigate the association between behavioral therapy for tremor or dystonia affecting voice in speakers with hyperkinetic dysarthria and improvement in the functional, perceptual, acoustical, aerodynamic, or endoscopic characteristics of voice. METHOD: MEDLINE (PubMed), Embase, PsycINFO, and ClinicalTrials.gov online databases were searched in August 2017, December 2018, and April 2020 for relevant studies. The searches provided 4,921 unique records, and six additional unique records were added from other sources. Twelve studies met the criteria for inclusion in the systematic review. Participants who received concurrent medical treatment were included in this review to ensure that the search was inclusive of all relevant studies and informative for typical clinical scenarios. RESULTS: The most commonly administered treatment ingredient was relaxation training, which was investigated in three of the four studies on tremor and three of the eight studies on dystonia. Of these six studies, only one used an experimental design and administered relaxation training as the only behavioral approach. This single-case experiment reported a significant reduction in participant ratings of tremor severity and interference with activities of daily living, although the speaking subscale reportedly did not improve and oral medications were administered concurrently. In two group studies that tested potential behavioral therapy targets, production of a low pitch improved acoustical measures for participants with essential tremor and improved auditory-perceptual judgments for participants with laryngeal dystonia. Behavioral therapy improved functional, acoustical, and aerodynamic outcomes in participants with laryngeal dystonia who were also receiving botulinum toxin injections in a randomized cross-over study and a non-randomized controlled study. Because one study employed easy onset and breathing exercises, while the other employed loud voice exercises, the mechanism of action for improvement in voice associated with behavioral therapy requires further investigation. CONCLUSION: This systematic review describes the current evidence for treatment of tremor and dystonia affecting voice in speakers with hyperkinetic dysarthria and highlights the need for future research on behavioral therapy for these disorders.

Auditory-Motor Control of Fundamental Frequency in Vocal Vibrato.

PURPOSE: The purpose of this study was to investigate how classically trained singers use their auditory feedback to control fundamental frequency (fo) during production of vocal vibrato. Two main questions were addressed: (1) Do singers produce reflexive foresponses to sudden perturbation of the fo of their auditory feedback during production of vibrato indicative of feedback control? (2) Do singers produce adaptive foresponses to repeated perturbation of the fo of their auditory feedback during production of vibrato indicative of feedback and feedforward control? In addition, one methodological question was addressed to determine if adaptive fo responses were more precisely assessed with or without an auditory cue for fo during the repeated fo perturbation paradigm. METHOD: Ten classically trained singers produced sustained vowels with vibrato while the fo and harmonics of their auditory feedback were suddenly perturbed by 100 cents to assess reflexive control or repeatedly perturbed by 100 cents to assess adaptive control. Half of the participants completed the repeated perturbation experiment with an auditory cue for fo, and the other half completed the experiment without an auditory cue for fo. Acoustical analyses measured changes in mean fo in response to the auditory feedback perturbations. RESULTS: On average, participants produced compensatory responses to both sudden and repeated perturbation of the fo of their auditory feedback. The magnitude of the responses to repeated perturbations was larger than the responses to sudden perturbations. Responses were also larger in the cued, repeated fo perturbation experiment than in the uncued, repeated fo perturbation experiment. CONCLUSIONS: These findings indicate that classically-trained singers use both feedforward and feedback mechanisms to control their average fo during production of vibrato. When compared to prior studies of singers producing a steady voice, the reflexive fo responses were larger in the current study, which may indicate that the feedback control system is engaged more during production of vibrato.

Task-Dependent Modulation of Auditory Feedback Control of Vocal Intensity.

Auditory feedback control of fundamental frequency (fo) is modulated in a task-dependent manner. When voice pitch auditory feedback perturbations are applied in sentence versus sustained-vowel production, larger and faster vocal fo responses are measured in sentence production. This task-dependency reflects the scaling of auditory targets for pitch for the precision required in each speech task. When the range for the pitch auditory target is scaled down for precision (as in the sentence-production task), a greater degree of mismatch is detected from the feedback perturbation and a larger vocal response is measured. The purpose of this study was to determine whether auditory feedback control of vocal intensity is also modulated in a task-dependent manner similar to the control of vocal pitch. Twenty-five English speakers produced repetitions of a sentence and a sustained vowel while hearing their voice auditory feedback briefly perturbed in loudness (+/- 3 or 6 dB SPL, 200 ms duration). The resulting vocal intensity responses were measured, and response magnitudes were robustly larger in the sentence (mean: 1.96 dB) than vowel production (mean: 0.89 dB). Additionally, response magnitudes increased as a function of perturbation magnitude only in sentence production for downward perturbations but decreased in magnitude by perturbation magnitude for upward perturbations. Peak response latencies were robustly shorter in sentence (mean: 184.94 ms) than in vowel production (mean: 214.92 ms). Overall, these results support the hypothesis that auditory feedback control of pitch and loudness are modulated by task and that both pitch and loudness auditory targets are scaled for the precision required for the speaking task.

The Effects of Masked and Delayed Auditory Feedback on Fundamental Frequency Modulation in Vocal Vibrato.

PURPOSE: Although relatively precise control over the extent and rate of fundamental frequency (fo) modulation may be needed for optimal production of vibrato, the role of auditory feedback in controlling vibrato is not well understood. Previous studies altered the gain and timing of auditory feedback in singers producing vibrato and showed inconsistent effects on the extent and rate of fo modulation, which may have been related to small sample sizes or limited analyses. Therefore, the purpose of this study was to further investigate whether the gain or timing of auditory feedback impacts control of vibrato in a larger sample of speakers and with advanced statistical analyses. METHOD: Ten classically-trained singers produced sustained vowels with vibrato while their auditory feedback was masked with pink noise or multi-talker babble to reduce the gain of their auditory feedback and while their auditory feedback was delayed by about 200 or 300 milliseconds to alter the timing of their auditory feedback. Acoustical analyses measured changes in the extent and rate of fo modulation in the masked and delayed trials relative to control trials. Bayesian modeling was used to analyze the effects of noise-masked, babble-masked, and delayed auditory feedback on the extent and rate of fo modulation. RESULTS: There was compelling evidence that noise masking increased the extent of fo modulation, and babble masking increased the variability in the rate of fo modulation (ie, jitter of fo modulation). Masked auditory feedback did not affect the average rate of fo modulation. Delayed auditory feedback did not affect the extent, rate, or jitter of fo modulation. CONCLUSIONS: The current study demonstrated that reducing the gain of the auditory feedback with noise masking increased the extent of fo modulation but did not affect the average rate of fo modulation in classically-trained singers producing vibrato. Reducing the gain of the auditory feedback with babble masking and altering the timing of auditory feedback with imposed delays did not affect the average extent or rate of fo modulation. However, babble masking increased the jitter of fo modulation rate, which suggests that modulated auditory feedback may affect the periodicity of fo modulation from one modulation cycle to the next. These findings clarify the role of auditory feedback in controlling vibrato and may inform the current reflex-resonance models of vibrato.

Feedback and Feedforward Auditory-Motor Processes for Voice and Articulation in Parkinson's Disease.

PURPOSE: Unexpected and sustained manipulations of auditory feedback during speech production result in "reflexive" and "adaptive" responses, which can shed light on feedback and feedforward auditory-motor control processes, respectively. Persons with Parkinson's disease (PwPD) have shown aberrant reflexive and adaptive responses, but responses appear to differ for control of vocal and articulatory features. However, these responses have not been examined for both voice and articulation in the same speakers and with respect to auditory acuity and functional speech outcomes (speech intelligibility and naturalness). METHOD: Here, 28 PwPD on their typical dopaminergic medication schedule and 28 age-, sex-, and hearing-matched controls completed tasks yielding reflexive and adaptive responses as well as auditory acuity for both vocal and articulatory features. RESULTS: No group differences were found for any measures of auditory-motor control, conflicting with prior findings in PwPD while off medication. Auditory-motor measures were also compared with listener ratings of speech function: first formant frequency acuity was related to speech intelligibility, whereas adaptive responses to vocal fundamental frequency manipulations were related to speech naturalness. CONCLUSIONS: These results support that auditory-motor processes for both voice and articulatory features are intact for PwPD receiving medication. This work is also the first to suggest associations between measures of auditory-motor control and speech intelligibility and naturalness.

The Effects of Remote Signal Transmission and Recording on Acoustical Measures of Simulated Essential Vocal Tremor: Considerations for Remote Treatment Research and Telepractice.

PURPOSE: Studies on medical and behavioral interventions for essential vocal tremor (EVT) have shown inconsistent effects on acoustical and perceptual outcome measures across studies and across participants. Remote acoustical and perceptual assessments might facilitate studies with larger samples of participants and repeated measures that could clarify treatment effects and identify optimal treatment candidates. Furthermore, remote acoustical and perceptual assessment might allow clinicians to monitor clients' treatment responses and optimize treatment approaches during telepractice. Thus, the purpose of this study was to evaluate the accuracy of remote signal transmission and recording for acoustical and perceptual assessment of EVT. METHOD: Simulations of EVT were produced using a computational model and were recorded using local and remote procedures to represent client- and clinician-end recordings respectively. Acoustical analyses measured the extent and rate of fundamental frequency (fo) and intensity modulation to represent vocal tremor severity and the cepstral peak prominence (CPPS) to represent voice quality. The data were analyzed using repeated measures analysis of variance (ANOVA) with recording as the within-subjects factor and sex of the computational model as the between-subjects factor. RESULTS: There was a significant main effect of recording on the rate of fo modulation and significant interactions of recording and sex for the extent of intensity modulation, rate of intensity modulation, and CPPS. Posthoc pairwise comparisons and analysis of effect size indicated that recording procedures had the largest effect on the extent of intensity modulation for male simulations, the rate of intensity modulation for male and female simulations, and the CPPS for male and female simulations. Despite having disabled all known software and computer audio enhancing options and having stable ethernet connections, there was inconsistent attenuation of signal amplitude in remote recordings that was most problematic for samples with a breathy voice quality but also affected samples with typical and pressed voice qualities. CONCLUSIONS: Acoustical measures that correlate to perception of vocal tremor and voice quality were altered by remote signal transmission and recording. In particular, signal transmission and recording in Zoom altered time-based estimates of intensity modulation and CPPS with male and female simulations of EVT and magnitude-based estimates of intensity modulation with male simulations of EVT. In contrast, signal transmission and recording in Zoom minimally altered time- and magnitude-based estimates of fo modulation with male and female simulations of EVT. Therefore, acoustical and perceptual assessments of EVT should be performed using audio recordings that are collected locally on the participant- or client-end, particularly when measuring modulation of intensity and CPP or estimating vocal tremor severity and voice quality. Development of procedures for collecting local audio recordings in remote settings may expand data collection for treatment research and enhance telepractice.

Characterization of Source-Filter Interactions in Vocal Vibrato Using a Neck-Surface Vibration Sensor: A Pilot Study.

PURPOSE: Vocal vibrato is a singing technique that involves periodic modulation of fundamental frequency (fo) and intensity. The physiological sources of modulation within the speech mechanism and the interactions between the laryngeal source and vocal tract filter in vibrato are not fully understood. Therefore, the purpose of this study was to determine if differences in the rate and extent of fo and intensity modulation could be captured using simultaneously recorded signals from a neck-surface vibration sensor and a microphone, which represent features of the source before and after supraglottal vocal tract filtering. METHOD: Nine classically-trained singers produced sustained vowels with vibrato while simultaneous signals were recorded using a vibration sensor and a microphone. Acoustical analyses were performed to measure the rate and extent of fo and intensity modulation for each trial. Paired-samples sign tests were used to analyze differences between the rate and extent of fo and intensity modulation in the vibration sensor and microphone signals. RESULTS: The rate and extent of fo modulation and the extent of intensity modulation were equivalent in the vibration sensor and microphone signals, but the rate of intensity modulation was significantly higher in the microphone signal than in the vibration sensor signal. Larger differences in the rate of intensity modulation were seen with vowels that typically have smaller differences between the first and second formant frequencies. CONCLUSIONS: This study demonstrated that the rate of intensity modulation at the source prior to supraglottal vocal tract filtering, as measured in neck-surface vibration sensor signals, was lower than the rate of intensity modulation after supraglottal vocal tract filtering, as measured in microphone signals. The difference in rate varied based on the vowel. These findings provide further support of the resonance-harmonics interaction in vocal vibrato. Further investigation is warranted to determine if differences in the physiological source(s) of vibrato account for inconsistent relationships between the extent of intensity modulation in neck-surface vibration sensor and microphone signals.

The Relation of Articulatory and Vocal Auditory-Motor Control in Typical Speakers.

Purpose The purpose of this study was to explore the relationship between feedback and feedforward control of articulation and voice by measuring reflexive and adaptive responses to first formant (F 1) and fundamental frequency (f o) perturbations. In addition, perception of F 1 and f o perturbation was estimated using passive (listening) and active (speaking) just noticeable difference paradigms to assess the relation of auditory acuity to reflexive and adaptive responses. Method Twenty healthy women produced single words and sustained vowels while the F 1 or f o of their auditory feedback was suddenly and unpredictably perturbed to assess reflexive responses or gradually and predictably perturbed to assess adaptive responses. Results Typical speakers' reflexive responses to sudden perturbation of F 1 were related to their adaptive responses to gradual perturbation of F 1. Specifically, speakers with larger reflexive responses to sudden perturbation of F 1 had larger adaptive responses to gradual perturbation of F 1. Furthermore, their reflexive responses to sudden perturbation of F 1 were associated with their passive auditory acuity to F 1 such that speakers with better auditory acuity to F 1 produced larger reflexive responses to sudden perturbations of F 1. Typical speakers' adaptive responses to gradual perturbation of F 1 were not associated with their auditory acuity to F 1. Speakers' reflexive and adaptive responses to perturbation of f o were not related, nor were their responses related to either measure of auditory acuity to f o. Conclusion These findings indicate that there may be disparate feedback and feedforward control mechanisms for articulatory and vocal error correction based on auditory feedback.

The Effect of Pitch Auditory Feedback Perturbations on the Production of Anticipatory Phrasal Prominence and Boundary.

Purpose In this study, we investigated how the direction and timing of a perturbation in voice pitch auditory feedback during phrasal production modulated the magnitude and latency of the pitch-shift reflex as well as the scaling of acoustic production of anticipatory intonation targets for phrasal prominence and boundary. Method Brief pitch auditory feedback perturbations (±200 cents for 200-ms duration) were applied during the production of a target phrase on the first or the second word of the phrase. To replicate previous work, we first measured the magnitude and latency of the pitch-shift reflex as a function of the direction and timing of the perturbation within the phrase. As a novel approach, we also measured the adjustment in the production of the phrase-final prominent word as a function of perturbation direction and timing by extracting the acoustic correlates of pitch, loudness, and duration. Results The pitch-shift reflex was greater in magnitude after perturbations on the first word of the phrase, replicating the results from Mandarin speakers in an American English-speaking population. Additionally, the production of the phrase-final prominent word was acoustically enhanced (lengthened vowel duration and increased intensity and fundamental frequency) after perturbations earlier in the phrase, but more so after perturbations on the first word in the phrase. Conclusion The timing of the pitch perturbation within the phrase modulated both the magnitude of the pitch-shift reflex and the production of the prominent word, supporting our hypothesis that speakers use auditory feedback to correct for immediate production errors and to scale anticipatory intonation targets during phrasal production.

Sensorimotor adaptation of voice fundamental frequency in Parkinson's disease.

OBJECTIVE: This study examined adaptive responses to auditory perturbation of fundamental frequency (fo) in speakers with Parkinson's disease (PD) and control speakers. METHOD: Sixteen speakers with PD and nineteen control speakers produced sustained vowels while they received perturbed auditory feedback (i.e., fo shifted upward or downward). Speakers' pitch acuity was quantified using a just-noticeable-difference (JND) paradigm. Twelve listeners provided estimates of the speech intelligibility for speakers with PD. RESULTS: Fifteen responses from each speaker group for each shift direction were included in analyses. While control speakers generally showed consistent adaptive responses opposing the perturbation, speakers with PD showed no compensation on average, with individual PD speakers showing highly variable responses. In the PD group, the degree of compensation was not significantly correlated with age, disease progression, pitch acuity, or intelligibility. CONCLUSIONS: These findings indicate reduced adaptation to sustained fo perturbation and higher variability in PD compared to control participants. No significant differences were seen in pitch acuity between groups, suggesting that the fo adaptation deficit in PD is not the result of purely perceptual mechanisms. SIGNIFICANCE: These results suggest there is an impairment in vocal motor control in PD. Building on these results, contributions can be made to developing targeted voice treatments for PD.

Evidence for Auditory-Motor Impairment in Individuals With Hyperfunctional Voice Disorders.

Purpose: The vocal auditory-motor control of individuals with hyperfunctional voice disorders was examined using a sensorimotor adaptation paradigm. Method: Nine individuals with hyperfunctional voice disorders and 9 individuals with typical voices produced sustained vowels over 160 trials in 2 separate conditions: (a) while experiencing gradual upward perturbations in the fundamental frequency (fo) of their auditory feedback (shift-up) and (b) under no auditory perturbation (control). The shift-up condition consisted of 4 ordered (fixed) phases: baseline (no perturbation), ramp (gradual increases in heard fo), hold (a consistently higher heard fo), and after-effect (no perturbation). Adaptive responses were defined as the difference in produced fo during control and shift-up conditions. Results: Adaptive responses were significantly different between groups. Individuals with typical voices generally showed compensatory adaptive responses, with decreased fo during the ramp and hold phases. Conversely, many individuals with hyperfunctional voice disorders instead displayed the opposite effect by following the direction of the perturbation. When fo was experimentally increased, speakers further increased their fo. Conclusion: Results indicate that some individuals diagnosed with hyperfunctional voice disorders have disrupted auditory-motor control, suggesting atypical neurological function. These findings may eventually allow for the development of new interventions for hyperfunctional voice disorders.

The effects of physiological adjustments on the perceptual and acoustical characteristics of vibrato as a model of vocal tremor.

The purpose of this study was to investigate the effects of physiological adjustments on listeners' perception of the magnitude of modulation of voice and to determine the characteristics of the acoustical modulations that explained listeners' judgments. This research was carried out using singers producing vibrato as a model of vocal tremor. Twenty healthy adults participated in a perceptual study involving pair-comparisons of the magnitude of "shakiness" with singers' samples, which differed by fundamental frequency, vocal quality, and vowel. Results revealed that listeners perceived a higher magnitude of voice modulation when female samples had a pressed vocal quality. Acoustical analyses were performed with voice samples to determine the features that predicted listeners' judgments. Based on regression analyses, listeners' judgments were predicted to some extent by modulation information in frequency bands across the spectrum.