No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Respiratory Function and Variability in Individuals with Parkinson Disease: Pre- and Post-Lee Silverman Voice Treatment
Abstract
The high occurrence of speech symptoms, most notably reduced loudness, in individuals with Parkinson disease (PD) implicates the respiratory speech subsystem as a factor in speech disorders associated with PD. In the current study, respiratory kinematics were used to assess the function and variability of the respiratory subsystem during speech in six individuals with PD as compared to three normal age-matched controls. Individuals with PD were found to have a greater reliance on the abdomen for changing lung volume than control subjects. Further, individuals with PD had more variable respiratory movements than control subjects, and this variability increased when the individuals with PD were externally cued (by the researchers) to speak louder. Although individual data reflected various patterns of change in respiratory function accompanying increases in sound pressure level (SPL) following the Lee Silverman Voice Treatment (LSVT), these patterns were not consistent or significant for group data. All individuals with PD increased SPL when they were externally cued to be louder and post-LSVT. However, the amount of SPL increase and the strategies used for increasing SPL varied both within and across subjects. For four of the six individuals with PD, mechanisms for increasing SPL were different in the external cueing condition as compared to post-LSVT.
... The most commonly examined treatment outcome was vocal intensity. Twenty-eight studies reported changes in vocal intensity immediately following LSVT LOUD (Cannito et al., 2012;Constantinescu et al., 2011;de Azevedo et al., 2015;El Sharkawi et al., 2002;Griffin et al., 2018;Halpern et al., 2012;Huber et al., 2003;Körner Gustafsson et al., 2019;Moya-Gale et al., 2018;Nakayama et al., 2020;Narayana et al., 2010;Ramig et al., , 2018Ramig & Dromey, 1996;Ramig, Sapir, Fox, & Countryman, 2001;Sale et al., 2015;Sapir et al., 2007;Sauvageau et al., 2015;Searl et al., 2011;Spielman et al., 2007Spielman et al., , 2011Theodoros et al., 2006Theodoros et al., , 2016Traverse, 2016;Tripoliti et al., 2011;Wight & Miller, 2015;Wohlert, 2004); one of these was descriptive in nature (Wohlert, 2004). The combined results of these studies suggest posttreatment improvements in vocal intensity between 2.3 and 31.0 dB, depending on the elicitation task (see Supplemental Material S2.2). ...
... Three studies from the same research group reported no treatment effect on measures of forced vital capacity Ramig & Dromey, 1996). Another study examined the respiratory kinematic patterns (lung volume at speech initiation and termination) and percent vital capacity expended per syllable, finding no consistent effect of LSVT LOUD on respiratory kinematics or variability of the respiratory subsystem (Huber et al., 2003). Qualitative results indicated that different respiratory/laryngeal strategies for increasing volume following LSVT LOUD were used among participants (Huber et al., 2003). ...
... Another study examined the respiratory kinematic patterns (lung volume at speech initiation and termination) and percent vital capacity expended per syllable, finding no consistent effect of LSVT LOUD on respiratory kinematics or variability of the respiratory subsystem (Huber et al., 2003). Qualitative results indicated that different respiratory/laryngeal strategies for increasing volume following LSVT LOUD were used among participants (Huber et al., 2003). ...
Purpose
This systematic review represents an update to previous reviews of the literature addressing behavioral management of respiratory/phonatory dysfunction in individuals with dysarthria due to neurodegenerative disease.
Method
Multiple electronic database searches and hand searches of prominent speech-language pathology journals were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.
Results
The search yielded 1,525 articles, from which 88 met inclusion criteria and were reviewed by two blinded co-investigators. A large range of therapeutic approaches have been added to the evidence base since the last review, including expiratory muscle strength training, singing, and computer- and device-driven programs, as well as a variety of treatment modalities, including teletherapy. Evidence for treatment in several different population groups—including cerebellar ataxia, myotonic dystrophy, autosomal recessive spastic ataxia of Charlevoix–Saguenay, Huntington's disease, multiple system atrophy, and Lewy body dementia—were added to the current review. Synthesis of evidence quality provided strong evidence in support of only one behavioral intervention: Lee Silverman Voice Treatment Program (LSVT LOUD) in people with Parkinson's disease. No other treatment approach or population included in this review demonstrated more than limited evidence, reflecting that these approaches/populations require urgent further examination.
Conclusion
Suggestions about where future research efforts could be significantly strengthened and how clinicians can apply research findings to their practice are provided.
Supplemental Material
https://doi.org/10.23641/asha.24964473
... Several factors contribute to hypophonia including reduced rib cage (RC) compliance (Solomon & Hixon, 1993;Tzelepis et al., 1988;Weiner et al., 2002), decreased respiratory muscle strength and coordination (De Bruin et al., 1993;Hovestadt et al., 1989), decreased vocal fold approximation (Hanson et al., 1984;Perez et al., 1996), thoraco-abdominal asynchrony (Florêncio et al., 2019), and misaligned temporal coupling of the respiratorylaryngeal mechanisms (Solomon & Hixon, 1993). These physiological changes may adversely affect the efficiency of rest breathing (Tzelepis et al., 1988) and speech breathing (Bunton, 2005;Huber et al., 2003) in persons with PD. In general, two patterns of speech breathing have been previously identified in this clinical population. ...
... In the Stathopoulos et al. study,19 of 33 participants increased LVI and LVT the first time they used the SpeechVive prosthesis. In contrast, Huber et al. (2003) found that, in a small sample of people with PD, there were no consistent changes in respiratory patterns after treatment with LSVT LOUD. Three of the participants increased LVIs and LVTs, and three participants did not change LVIs and LVTs. ...
... However, Bunton (2005) postulated that the use of positive abdominal pressure at lower-than-normal lung volumes may offer respiratory efficiency in the form of mechanical tuning of the RC. The significant decrease in LVT observed at mid-and posttreatment for the LSVT LOUD speakers contrasts the results of Huber et al. (2003), who found no significant difference in respiratory kinematic patterns pre-to post-LSVT LOUD. These incongruent findings may be attributed to the smaller sample size (n = 6), differences in disease severity, and the high degree of variability observed within and across the Huber et al. study participants. ...
Purpose
The purpose of this study was to examine the respiratory strategies used by persons with Parkinson's disease (PD) to support louder speech in response to two voice interventions. Contrasting interventions were selected to investigate the role of internal and external cue strategies on treatment outcomes. LSVT LOUD, which uses an internal cueing framework, and the SpeechVive prosthesis, which employs an external noise cue to elicit louder speech, were studied.
Method
Thirty-four persons with hypophonia secondary to idiopathic PD were assigned to one of three groups: LSVT LOUD (n = 12), SpeechVive (n = 12), or a nontreatment clinical control (n = 10). The LSVT LOUD and SpeechVive participants received 8 weeks of voice intervention. Acoustic and respiratory kinematic data were simultaneously collected at pre-, mid- and posttreatment during a monologue speech sample. Intervention outcomes included sound pressure level (SPL), utterance length, lung volume initiation, lung volume termination, and lung volume excursion.
Results
As compared to controls, the LSVT LOUD and SpeechVive participants significantly increased SPL at mid- and posttreatment, thus confirming a positive intervention effect. Treatment-related changes in speech breathing were further identified, including significantly longer utterance lengths (syllables per breath group) at mid- and posttreatment, as compared to pretreatment. The respiratory strategies used to support louder speech varied by group. The LSVT LOUD participants terminated lung volume at significantly lower levels at mid- and posttreatment, as compared to pretreatment. This finding suggests the use of greater expiratory muscle effort by the LSVT LOUD participants to support louder speech. Participants in the SpeechVive group did not significantly alter their respiratory strategies across the intervention period. Single-subject effect sizes highlight the variability in respiratory strategies used across speakers to support louder speech.
Conclusions
This study provides emerging evidence to suggest that the LSVT LOUD and SpeechVive therapies elicit different respiratory adjustments in persons with PD. The study highlights the need to consider respiratory function when addressing voice targets in persons with PD.
... Hypokinetic dysarthria can manifest in respiratory, phonatory, articulatory and resonatory subsystems of voice production, with the interplay of these subsystem impairments resulting in further disturbances in prosody and overall speech intelligibility [8]. At the respiratory level, some of the side effects that have been measured are: reduced vital capacity, lower rib cage volume, irregular breath patterns, reduced endurance of respiratory muscles, asynchrony of speech and respiration with chest wall movements during speech [6] [7]. Impairments at the articulatory level include reductions in: range, accuracy of articulatory movements, and tremor in the orofacial muscles [7] [8]. ...
... At the respiratory level, some of the side effects that have been measured are: reduced vital capacity, lower rib cage volume, irregular breath patterns, reduced endurance of respiratory muscles, asynchrony of speech and respiration with chest wall movements during speech [6] [7]. Impairments at the articulatory level include reductions in: range, accuracy of articulatory movements, and tremor in the orofacial muscles [7] [8]. Features of phonatory hypofunction are: reduced vocal fold adduction; bowing; glottal chink; laryngeal phase asymmetry; and tremor [7]. ...
... Impairments at the articulatory level include reductions in: range, accuracy of articulatory movements, and tremor in the orofacial muscles [7] [8]. Features of phonatory hypofunction are: reduced vocal fold adduction; bowing; glottal chink; laryngeal phase asymmetry; and tremor [7]. PD is chronic as well as progressive i.e. it persists over a long period of time and its symptoms grow worse over time [13]. ...
Voice is the essential medium of man's communication in social as well as professional interactions. The human voice also reflects the state of health in many medical conditions which leads voice alterations in patients. This paper presents a voice analysis approach for discriminating the People With Parkinson (PWP) on the basis of extracted voice parameters. Voice analysis basically deals with decomposition of voice signal into voice parameters for processing the resulted features in desirable application. The features that are extracted in this paper are: frequency, pitch, voice intensity, formant, speech rate and pulse functions like Jitter (local), Jitter (local, absolute), Jitter (rap), Jitter (ppq5), Jitter (ddp), Shimmer (local), Shimmer (local, dB), Shimmer (apq3), Shimmer (apq5), Shimmer (apq11), Shimmer (dda) and Harmonic coefficients.
... In support of this hypothesis, studies of pulmonary function in individuals with PD have demonstrated disease-related reductions in forced vital capacity and forced expiratory volume in one second, even under the effects of anti-Parkinsonian medications (8,9). Abnormal movements of the rib cage and abdomen during the production of speech in individuals with PD, including increased abdominal and decreased rib cage volume initiations, abdominal paradoxing, a smaller contribution of the rib cage to overall lung volume change, and increased variability of respiratory movements compared to healthy older adults, have been reported (7,(10)(11)(12)(13). ...
... Given the previously reported differences, it is likely that people with PD use different respiratory strategies than healthy controls when speaking loudly. Huber, Stathopoulos, Ramig, and Lancaster (11) found that individuals with PD relied more on abdominal movement to make changes to lung volume while increasing loudness. Further, they documented individual differences in the strategies used to increase sound pressure level (SPL) in these patients. ...
... The COMF+10 cue may have been particularly difficult for both OC participants and individuals with PD because it required the speakers to divide their attention between reading the paragraph and maintaining the target SPL. However, it is important to remember that mechanisms used by individuals in response to a cue may differ from those used once they have learned to cue themselves through training or treatment (11). These data may suggest that a device that provides low levels of noise during speech (along the lines of delayed auditory feedback) may be an option for individuals who are unable to learn to cue themselves. ...
Individuals with Parkinson's disease (PD) demonstrate low vocal intensity (hypophonia) which results in reduced speech intelligibility. We examined the effects of three cues to increase loudness on respiratory support in individuals with PD. Kinematic data from the rib cage and abdomen were collected using respiratory plethysmography while participants read a short passage. Individuals with PD and normal age- and sex-matched controls (OC) increased sound pressure level (SPL) to a similar extent. As compared to OC, individuals with PD used larger rib cage volume excursions in all conditions. Further, they did not slow their rate of speech in noise as OC speakers did. Respiratory strategies used to support increased loudness varied with the cue, but the two groups did not differ in the strategies used. When asked to target a specific loudness, both groups used more abdominal effort than at comfortable loudness. Speaking in background noise resulted in the largest increase in SPL with the most efficient respiratory patterns, suggesting that natural or implicit cues may be best when treating hypophonia in individuals with PD. Data demonstrate the possibility that both vocal loudness and speech rate are impacted by cognitive mechanisms (attention or self-perception) in individuals with PD.
... The resultant increase in relaxation pressure during supine vowel production means that less muscular effort is required to produce an utterance during expiration (Hixon et al., 2018). Individuals with PD may exhibit rigidity and weakness of the rib cage musculature (Hovestadt et al., 1989;Sabate et al., 1996;Solomon & Hixon, 1993), increased reliance on abdominal muscles for expiration (Huber et al., 2003;Solomon & Hixon, 1993), as well as patterns of lung volume initiations and terminations which differ from those seen in older healthy adults Darling 2011, Bunton, 2005). Additional abdominal effort may be needed to overcome restrictions due to rigidity and weakness of the rib cage in PD. ...
... Despite the known respiratory deficits in PD (Hovestadt et al., 1989;Huber & Darling-White, 2017;Huber et al., 2003;Sabate et al., 1996;Solomon & Hixon, 1993), the absence of a significant PD * Upright interaction in our first mixed effects model shows that body position did not have a differential impact on SPL production between OHC and PD groups in the present study. However, it should be cautioned that the PD participants in this study were largely in the early-mid stages of the disease and may have experienced less rigidity and weakness within the respiratory apparatus. ...
Purpose
Functional magnetic resonance imaging (fMRI) has promise for understanding neural mechanisms of neurogenic speech and voice disorders. However, performing vocal tasks within the fMRI environment may not always be analogous to performance outside of the scanner. Using a mock MRI scanner, this study examines the effects of a simulated scanning environment on vowel intensity in individuals with Parkinson's disease (PD) and hypophonia and older healthy control (OHC) participants.
Method
Thirty participants (15 PD, 15 OHC) performed a sustained /ɑ/ vowel production task in three conditions: 1) Upright, 2) Mock Scanner + No Noise, and 3) Mock Scanner + MRI noise. We used a linear mixed-effects (multi-level) model to evaluate the contributions of group and recording environment to vowel intensity. A second linear mixed-effects model was also used to evaluate the contributions of PD medication state (On vs. Off) to voice intensity.
Results
Vowel intensity was significantly lower for PD compared to the OHC group. The intensity of vowels produced in the Upright condition was significantly lower compared to the Mock Scanner + No Noise condition, while vowel intensity in the Mock Scanner + MRI Noise condition was significantly higher compared to the Mock Scanner + No Noise condition. A group by condition interaction also indicated that the addition of scanner noise had a greater impact on the PD group. A second analysis conducted within the PD group showed no effects of medication state on vowel intensity.
Conclusion
Our findings demonstrate that performance on voice production tasks is altered for PD and OHC groups when translated into the fMRI environment, even in the absence of acoustic scanner noise. For fMRI studies of voice in PD hypophonia, careful thought should be given to how the presence of acoustic noise may differentially affect PD and OHC, for both group and task comparisons.
... These authors suggest that a breakdown in the synergistic force of the muscles of the rib cage and abdomen could contribute to inefficient breathing patterns during the speech production of individuals with PD. For example, individuals with PD have shown evidence of oppositional movement of rib cage and abdomen during expiration (Solomon & Hixon, 1993), and more variable lung volumes than healthy speakers (Huber, Stathopoulos, Ramig, & Lancaster, 2003). In addition, speakers with PD often have more difficulty controlling their vocal intensity (Sadagopan & Huber, 2007), and also planning in advance to support longer utterances (Bunton, 2005), particularly during extemporaneous speech (Huber & Darling, 2011). ...
... They also hypothesized that weakness of the AB musculature may explain the greater than normal outward displacement of the AB during the inspiratory and expiratory cycles of speech breathing. Huber et al. (2003) extended the speech breathing results to individuals with PD when instructed to increase their vocal intensity. In the present study, individual speakers used varied respiratory strategies to increase their vocal intensity. ...
... Within the non-speech domain, studies of pulmonary function in individuals with PD have demonstrated disease-related reductions in forced vital capacity and forced expiratory volume in one second (De Pandis et al., 2002;Weiner et al., 2002). Within the speech domain, studies have reported a large number of changes to respiratory support associated with PD, including lower lung volume initiations and terminations, larger abdominal initiations, smaller rib cage volume initiations, larger rib cage excursions, and more variability of respiratory movements than typical older adults (Bunton, 2005;Huber, Stathopoulos, Ramig, & Lancaster, 2003;Lethlean, Chenery, & Murdoch, 1990;Murdoch, Chenery, Bowler, & Ingram, 1989;Sadagopan & Huber, 2007;Solomon & Hixon, 1993). However, respiratory kinematic findings related to PD have not been consistent across studies, and a large amount of variability across subjects has been reported (Bunton, 2005;Huber et al., 2003). ...
... Within the speech domain, studies have reported a large number of changes to respiratory support associated with PD, including lower lung volume initiations and terminations, larger abdominal initiations, smaller rib cage volume initiations, larger rib cage excursions, and more variability of respiratory movements than typical older adults (Bunton, 2005;Huber, Stathopoulos, Ramig, & Lancaster, 2003;Lethlean, Chenery, & Murdoch, 1990;Murdoch, Chenery, Bowler, & Ingram, 1989;Sadagopan & Huber, 2007;Solomon & Hixon, 1993). However, respiratory kinematic findings related to PD have not been consistent across studies, and a large amount of variability across subjects has been reported (Bunton, 2005;Huber et al., 2003). For example, while one study of individuals with PD reported that they produced shorter utterances than age-matched control subjects in both reading and extemporaneous speech (Solomon & Hixon, 1993), Bunton (2005) reported a large amount of variability in utterance length across speakers with PD. ...
Purpose
To examine the effects of cognitive–linguistic deficits and respiratory physiologic changes on respiratory support for speech in individuals with Parkinson’s disease (PD) using two speech tasks: reading and extemporaneous speech.
Method
Five women with PD, 9 men with PD, and 14 age- and sex-matched control participants read a passage and spoke extemporaneously on a topic of their choice at comfortable loudness. Sound pressure level, syllables per breath group, speech rate, and lung volume parameters were measured. Number of formulation errors, disfluencies, and filled pauses were counted.
Results
Individuals with PD produced shorter utterances compared with control participants. The relationships between utterance length and lung volume initiation and inspiratory duration were weaker for individuals with PD than for control participants, particularly for the extemporaneous speech task. These results suggest less consistent planning for utterance length by individuals with PD in extemporaneous speech. Individuals with PD produced more formulation errors in both tasks and significantly fewer filled pauses in extemporaneous speech.
Conclusion
Both respiratory physiologic and cognitive–linguistic issues affected speech production by individuals with PD. Overall, individuals with PD had difficulty planning or coordinating language formulation and respiratory support, particularly during extemporaneous speech.
... The solution is also easily applicable to the monitoring of diseases that affect chest kinematics during breathing, such as those observed in post-operative or chronic patients [25,26,27,28]. The system's ability to monitor changes in predictions or features over time presents the prospect of interpreting disease progression, thus allowing for more precise and individualized assessments of specific cases. ...
This research introduces an innovative method for the early screening of cardiorespiratory diseases based on an acquisition protocol, which leverages commodity smartphone's Inertial Measurement Units (IMUs) and deep learning techniques. We collected, in a clinical setting, a dataset featuring recordings of breathing kinematics obtained by accelerometer and gyroscope readings from five distinct body regions. We propose an end-to-end deep learning pipeline for early cardiorespiratory disease screening, incorporating a preprocessing step segmenting the data into individual breathing cycles, and a recurrent bidirectional module capturing features from diverse body regions. We employed Leave-one-out-cross-validation with Bayesian optimization for hyperparameter tuning and model selection. The experimental results consistently demonstrated the superior performance of a bidirectional Long-Short Term Memory (Bi-LSTM) as a feature encoder architecture, yielding an average sensitivity of , specificity of , F1 score of , and accuracy of across diverse seed variations. We also assessed generalization capabilities on a skewed distribution, comprising exclusively healthy patients not used in training, revealing a true negative rate of . The sustained accuracy of predictions over time during breathing cycles within a single patient underscores the efficacy of the preprocessing strategy, highlighting the model's ability to discern significant patterns throughout distinct phases of the respiratory cycle. This investigation underscores the potential usefulness of widely available smartphones as devices for timely cardiorespiratory disease screening in the general population, in at-home settings, offering crucial assistance to public health efforts (especially during a pandemic outbreaks, such as the recent COVID-19).
... In fact, a recent study suggested three speech subtypes in PD, prosodic, phonatory-prosodic, and articulatory-prosodic, based on the speech characteristics of 111 participants with de novo PD (Rusz et al., 2021). Speech changes resulting from DBS may be further intricate due to large interspeaker variability regarding responses to medication or behavioral treatment (Huber et al., 2003;Knowles et al., 2018;Rusz et al., 2021). It is beyond the scope and capability of the current study to identify factors of the variability of speech characteristics and its effects on the speech outcomes of DBS. ...
Purpose
This study examined speech changes induced by deep-brain stimulation (DBS) in speakers with Parkinson's disease (PD) using a set of auditory-perceptual and acoustic measures.
Method
Speech recordings from nine speakers with PD and DBS were compared between DBS-On and DBS-Off conditions using auditory-perceptual and acoustic analyses. Auditory-perceptual ratings included voice quality, articulation precision, prosody, speech intelligibility, and listening effort obtained from 44 listeners. Acoustic measures were made for voicing proportion, second formant frequency slope, vowel dispersion, articulation rate, and range of fundamental frequency and intensity.
Results
No significant changes were found between DBS-On and DBS-Off for the five perceptual ratings. Four of six acoustic measures revealed significant differences between the two conditions. While articulation rate and acoustic vowel dispersion increased, voicing proportion and intensity range decreased from the DBS-Off to DBS-On condition. However, a visual examination of the data indicated that the statistical significance was mostly driven by a small number of participants, while the majority did not show a consistent pattern of such changes.
Conclusions
Our data, in general, indicate no-to-minimal changes in speech production ensued from DBS stimulation. The findings are discussed with a focus on large interspeaker variability in PD in terms of their speech characteristics and the potential effects of DBS on speech.
... Among the most prevalent changes to the parkinsonian voice is the development of hypophonia -a condition characterized by reduced loudness or "soft speech" (Duffy, 2019). The physiology of hypophonia includes deficits in both laryngeal function and respiratory support for speech breathing (Solomon and Hixon, 1993;Huber et al., 2003;Hammer et al., 2013;Huber and Darling-White, 2017). However, at the cortical level, it is not clear how reduced vocal intensity relates to changes in the activity of the motor cortices (i.e., primary motor cortex, premotor cortex, and SMA). ...
Introduction
Hypophonia is a common feature of Parkinson’s disease (PD); however, the contribution of motor cortical activity to reduced phonatory scaling in PD is still not clear.
Methods
In this study, we employed a sustained vowel production task during functional magnetic resonance imaging to compare brain activity between individuals with PD and hypophonia and an older healthy control (OHC) group.
Results
When comparing vowel production versus rest, the PD group showed fewer regions with significant BOLD activity compared to OHCs. Within the motor cortices, both OHC and PD groups showed bilateral activation of the laryngeal/phonatory area (LPA) of the primary motor cortex as well as activation of the supplementary motor area. The OHC group also recruited additional activity in the bilateral trunk motor area and right dorsal premotor cortex (PMd). A voxel-wise comparison of PD and HC groups showed that activity in right PMd was significantly lower in the PD group compared to OHC (p < 0.001, uncorrected). Right PMd activity was positively correlated with maximum phonation time in the PD group and negatively correlated with perceptual severity ratings of loudness and pitch.
Discussion
Our findings suggest that hypoactivation of PMd may be associated with abnormal phonatory control in PD.
... The most commonly used speech intervention for individuals with PD is the Lee Silverman Voice Treatment (LSVT) program. The only study of speech breathing patterns pre-post LSVT did not demonstrate improvements to speech breathing after intervention, although this study was small (Huber et al., 2003). The intervention with the most data to support its use for improving respiratory function in individuals with PD is expiratory muscle strength training, which has been shown to normalize speech breathing patterns and to result in improved cough strength (Sapienza et al., 2011;Troche et al., 2010). ...
Purpose
A critical component to the development of any type of intervention to improve speech production in individuals with Parkinson's disease (PD) is a complete understanding of the speech impairments present at each stage of the disease and how these impairments change with disease progression. The purpose of this longitudinal study was to examine the impact of disease on speech production and speech breathing during an extemporaneous speech task in individuals with PD over the course of approximately 3.5 years.
Method
Eight individuals with PD and eight age- and sex-matched control participants produced an extemporaneous connected speech task on two occasions (Time 1 and Time 2) an average of 3 years 7 months apart. Dependent variables included sound pressure level; utterance length; speech rate; lung volume initiation, termination, and excursion; and percent vital capacity per syllable.
Results
From Time 1 to Time 2, individuals with PD demonstrated decreased utterance length and lung volume initiation, termination, and excursion and increased speech rate. Control participants demonstrated decreased utterance length and lung volume termination and increased lung volume excursion and percent vital capacity per syllable from Time 1 to Time 2.
Conclusions
Changes in speech production and speech breathing variables experienced by individuals with PD over the course of several years are related to their disease process and not typical aging. Changes to speech breathing highlight the need to provide intervention focused on increasing efficient respiratory patterning for speech production.
... Abnormalities in the respiratory system reflected as reduced maximum phonation time, reduced airflow volume during vowel prolongation, fewer syllables per breath, shorter utterance length, increased breathing at the time of reading. Some of these characteristics are also related to laryngeal function abnormalities [61,121]. Other distinctive im- [58]. ...
Speech disorder is an early and prominent manifestation of neurological disorders. Therefore, the breakdown of speech disorders and detecting underlying pathophysiology have invaluable importance to clinical practice. Speech disorder is commonly attributed to aging onset, however, the pattern is mostly distinct for neurogenic voice. Parkinsonism is one of the neurological disorder that refers to idiopathic Parkinson’s Disease (PD) and Atypical Parkinsonian Syndromes (APS), such as Progressive Supranuclear Palsy (PSP) and Multiple System Atrophy (MSA). Differential diagnosis of latter disease groups is remains an challenging task due to similar symptoms at the early stages, while early diagnostic certainty is essential for the patient because of the diverging prognosis. Indeed, despite recent efforts, no validated objective speech marker is currently available to guide the clinician for the differential diagnosis. This thesis thus aims to design and define the speech markers that would provide deep insight into speech disorders caused by neurological diseases, and followed by differential diagnosis.Analysis of speech disorder demands at least a speech database by which pattern of speech abnormalities can be assessed. Speech database consisting PD and MSA-P neurological diseases is not available in French language. Thus development of a speech database (Voice4PD-MSA) from PD and MSA-P groups was one of the target of this thesis. While developing Voice4PD-MSA database, we explored CzechData database comprises of speech samples in Czech language for differential diagnosis.The automatic algorithm always in demand to quantify perceptual and visual observation to capture particular speech disorders. Clinically interpretable speech components are considered to capture speech abnormalities in respiration, vowel production, articulator movements, and prosody by objective methods from sustained vowel, word-initial consonants, diadochokinetic (DDK) tasks, and continuous speech. Imprecise vowel comprises deficits in vocal folds opening and closing, involuntary movements of articulator, hypernasality, tremor, and changes in vowel space area are observed to be important for differential diagnosis of MSA-P and PD patients. In imprecise obstruents, devoicing in voiced obstruents and burst in fricatives (anti-spirantization) are identified as distinctive speech markers for MSA-P. In addition, speech indexes related to the subsystem of speech production and dysarthria yield encouraging differentiation and disease specificity in disease groups. Given small amount of data, two-dimensional speech features are designed such that one of the disease group predominates in one speech dimension and consequently discriminate disease groups with good classification score.Early differential diagnosis was another critical objective of the current investigation. The present study observed some encouraging indications about early differential diagnosis exploring the trend of speech markers w.r.t. clinical signs. Thus we aspire that the presented methodology in this thesis would serve as a potential diagnosis tool in clinical practice and further inspire to develop automatic methods to investigate speech disorders in parkinsonism.
... Much of the research on loud speech interventions has been focused on testing the efficacy of the Lee Silverman Voice Treatment (LSVT R ) program (36,37), which was initially developed to improve speech in individuals with Parkinson disease (PD). Loud speech, in comparison to normal speech, elicits global gains across the speech system such as larger articulator displacements and faster movement speeds (9,17,(38)(39)(40)(41), greater respiratory drive (42,43), greater subglottal air pressure (44), and improved vocal fold function (45). These physiologic changes can have the overall effect of enhancing speech accuracy, speech clarity, and speech intelligibility (12,44,(46)(47)(48). ...
Despite signs of facial nerve recovery within a few months following face transplantation, speech deficits persist for years. Behavioral speech modifications (e.g., slower-than-normal speaking rate and increased loudness) have shown promising potential to enhance speech intelligibility in populations with dysarthric speech. However, such evidence-based practice approach is lacking in clinical management of speech in individuals with facial transplantation. Because facial transplantation involves complex craniofacial reconstruction and facial nerve coaptation, it is unknown to what extent individuals with face transplant are capable of adapting their motor system to task-specific articulatory demands. The purpose of this study was to identify the underlying articulatory mechanisms employed by individuals with face transplantation in response to speech modification cues at early and late stages of neuromotor recovery. In addition, we aimed to identify speech modifications that conferred improved speech clarity. Participants were seven individuals who underwent full or partial facial vascularized composite allografts that included lips and muscles of facial animation and were in early (~2 months) or late (~42 months) stages of recovery. Participants produced repetitions of the sentence “Buy Bobby a puppy” in normal, fast, loud, and slow speech modifications. Articulatory movement traces were recorded using a 3D optical motion capture system. Kinematic measures of average speed (mm/s) and range of movement (mm³) were extracted from the lower lip (± jaw) marker. Two speech language pathologists rated speech clarity for each speaker using a visual analog scale (VAS) approach. Results demonstrated that facial motor capacity increased from early to late stages of recovery. While individuals in the early group exhibited restricted capabilities to adjust their motor system based on the articulatory demands of each speech modification, individuals in the late group demonstrated faster speed and larger-than-normal range of movement for loud speech, and slower speed and larger-than-normal range of movement for slow speech. In addition, subjects in both groups showed overreliance on jaw rather than lip articulatory function across all speech modifications, perhaps as a compensatory strategy to optimize articulatory stability and maximize speech function. Finally, improved speech clarity was associated with loud speech in both stages of recovery.
... Later, immediate speech and voice therapy was recommended and started. Patient received Intensive speech and voice Therapy for 45 minutes for 6 consecutive days in a week [11][12][13]. Patient was trained with speech and voice techniques as follows ( After 6 consecutive days of speech and voice therapy the patient underwent with voice analyses to analyse the voice parameters and to correlate the voice parameters before and after the speech and voice therapy. ...
Stroke is the second leading cause of death worldwide and the brain damage caused by it can affect communication in several aspects. Voice analysis in dysarthria is challenging because of the complexity of the disorder and its effects on the speech production system. In this study we are presenting a 56-years-old male who was visited to Medanta Hospital with history of hypertension and chief complaint of Right upper limb weakness and slurred speech to the Emergency and later Clinically and Radio logically Diagnosed as LT MCA Infarct. Later, on the day 3 the patient has undergone Speech and Language Evaluation and Diagnosed with Spastic Dysarthria based on Frenched Dysarthria Assessment scale and later a detail Voice Analysis was done with using PRAAT software and analysed voice features. Voice analysis basically deals with decomposition of voice signal into voice parameters for processing the resulted features in desirable application. The features that are extracted in this paper are: frequency, pitch, voice intensity, formant, speech rate and pulse functions like Jitter (local), Jitter (local, absolute), Jitter (rap), Jitter (ppq5), Jitter (ddp), Shimmer (local), Shimmer (local, dB), Shimmer (apq3), Shimmer (apq5), Shimmer (apq11), Shimmer (dda) and Harmonic coefficients. Over all, we conclude with the voice parameters in spastic dysarthria which reveals interesting data on the voice quality with features which helps the clinician for better management. However, large sample study is required.
... In addition, deficits in speech breathing lead directly to many of the hallmark characteristics of speech impairment in individuals with PD, including reduced vocal intensity and short utterances. The evidence that current intervention techniques, focused on improving specific speech deficits (i.e., vocal intensity), improve speech breathing is mixed (Huber, Stathopoulos, Ramig, & Lancaster, 2003;Stathopoulos et al., 2014). In fact, focusing on specific speech deficits without directly addressing speech breathing may lead to maladaptive respiratory behavior (Sadagopan & Huber, 2007). ...
Purpose
The purpose of this study was to examine the impact of expiratory muscle strength training on speech breathing and functional speech outcomes in individuals with Parkinson's disease (PD).
Method
Twelve individuals with PD were seen once a week for 8 weeks: 4 pretraining (baseline) sessions followed by a 4-week training period. Posttraining data were collected at the end of the 4th week of training. Maximum expiratory pressure, an indicator of expiratory muscle strength, and lung volume at speech initiation were the primary outcome measures. Secondary outcomes included lung volume at speech termination, lung volume excursion, utterance length, and vocal intensity. Data were collected during a spontaneous speech sample. Individual effect sizes > 1 were considered significant.
Results
Maximum expiratory pressure increased in a majority of participants after training. Training resulted in 2 main respiratory patterns: increasing or decreasing lung volume initiation. Lung volume termination and excursion, utterance length, and vocal loudness were not consistently altered by training.
Conclusions
Preliminary evidence suggests that the direct physiologic intervention of the respiratory system via expiratory muscle strength training improves speech breathing in individuals with PD, with participants using more typical lung volumes for speech following treatment.
... 12 Analyses of respiratory function in patients with PD revealed irregular and reduced movement of the chest. It is assumed that breathing dysfunction might affect the loudness of voice and cause arrhythmic speech in patients with PD. 13,14 Parkinsonian patients were also diagnosed with an incomplete closure of the vocal folds, which in turn resulted in hoarse voice, improper phonation, and slow speech. [15][16][17] Lack of awareness of defective speech among the patients is an important aspect of communication deficit in PD. ...
Objectives:
This study aims to establish the frequency at which patients with Parkinson disease subjectively assess the intensity of their speech disorders, factors that the patients believe determine the severity of their vocal impairment, and how their subjective self-assessment of vocal impairment by means of the Voice Handicap Index compares with the objective evaluation of the performance of the articulatory organs by means of Frenchay Dysarthria Assessment.
Materials and methods:
The methods used Voice Handicap Index, Frenchay Dysarthria Assessment, and the Hoehn and Yahr scale.
Results:
Positive correlation was found between the subjective assessment of the performance of the speech organs and the impaired differentiation of lip movements and tongue sideways movements, impaired saliva control, dysfunction of the soft palate, and the pitch. Negative correlation was found between the subjective assessment of the severity of speech disorder, breathing at rest, and sentence comprehension.
Conclusions:
Although we observed correlation between the subjective perception of certain speech disorders of patients with Parkinson disease and the objective assessment carried out by means of the Frenchay Dysarthria Assessment scale, the subjects did not believe the disorders had a significant impact on the quality of speech. Negative results of an examination do not necessarily reflect the subjective perception of the decline in the functioning of the articulatory organs. It should be assumed that lack of correlation between the subjective perception measured using Voice Handicap Index and the objective Frenchay Dysarthria-based assessment of the performance of the articulatory organs may result from a good adaptation to the progressive changes.
... Studies have found a large number of changes to speech breathing, including shorter utterances, both higher and lower lung volume initiations (LVIs) and terminations (LVTs), and higher variability of respiratory movements. [6][7][8][9][10] In general, these findings suggest that, for individuals with PD, speech breathing patterns reflect a stiffer or more rigid chest wall, weaker respiratory muscles, and/or reduced coordination between speech production and breathing. Unfortunately, due to the variability of findings related to speech breathing, it is difficult to develop an understanding of the importance of direct treatment of the respiratory system to improve speech production and to identify potential respiratory treatment targets. ...
This longitudinal study examines changes to speech production and speech breathing in older adults with Parkinson's disease (PD) and older adults without PD. Eight participants with PD and eight age- and sex-matched older adults participated in two data collection sessions, separated by 3.7 years on average. Speech severity and speech rate increased for people with PD. Vital capacity decreased for both groups. Older adult control participants displayed significant increases in lung volume initiation and excursion and percent vital capacity expended per syllable. These changes allow older adults to utilize higher recoil pressures to generate subglottal pressure for speech production, potentially reducing work of breathing. Participants with PD displayed significant decreases in lung volume initiation and termination. Thus, unlike older adults, people with PD exert more expiratory muscle pressure during speech production, leading to increased effort. Speech-language pathologists need to consider direct treatment of respiratory patterns for speech to reduce effort and fatigue.
... Speakers with PD further tend to over-rely on the abdomen to produce lung volume change for speech, possibly owing to ribcage rigidity. [15] Facial -In humans, the neural circuitry underlying facial expressions differs, depending on whether facial expressions are spontaneously (i.e., limbic, subcortical) or voluntarily initiated (i.e., frontal cortex). It has been suggested that intentional facial expressions may be slowed (bradykinetic) and involve less movement, in much the same way that other intentional movements are affected by Parkinson's disease. ...
... In addition, various physiologic changes such as increased movement amplitude of the rib cage (larger excursions) during speech breathing [46], increased subglottal air pressure [26], and improved closure and larger/more symmetrical movements of the vocal folds [47] have been documented in individuals with PD immediately after LSVT LOUD. These findings are supported by perceptual data demonstrating listeners rated improved loudness and voice quality in individuals with PD immediately posttreatment [33]. ...
Over the past 20 years, amplitude oriented therapies, also known as LSVT (Lee Silverman Voice Treatment), have been developed and researched for people with Parkinson's disease. Beginning with a focus on the speech motor system (LSVT-LOUD), the concept has recently been expanded to address limb motor systems (LSVT-BIG). The unique aspects of LSVT programs include: (a) an exclusive focus on increasing amplitude (loudness in the speech motor system; bigness in the limb motor system), (b) a mode of delivery that is consistent with the principles that drive activity dependent neuroplasticity and motor learning, (c) a focus on sensory recalibration to help patients with PD recognize that movements that feel «too loud» or «too big» are actually within normal limits, and (d) training vigilance (attention-to-action) to ensure long-term maintenance of the treatment outcome. The purpose of this review article is to provide an integrative discussion of LSVT programs, including the rationale for the fundamentals of LSVT, its practical application and the published data on its efficacy.
... In addition, various physiologic changes such as increased movement amplitude of the rib cage (larger excursions) during speech breathing [46], increased subglottal air pressure [26], and improved closure and larger/more symmetrical movements of the vocal folds [47] have been documented in individuals with PD immediately after LSVT LOUD. These findings are supported by perceptual data demonstrating listeners rated improved loudness and voice quality in individuals with PD immediately posttreatment [33]. ...
Besides drug treatment and neurosurgical intervention, activating exercises including physiotherapy and occupational therapy as well as speech therapy are important complementary aspects of the management of Parkinson's disease. Long-term course of Parkinson's disease is often complicated by disturbances of speech, gait, and postural stability, which often respond poorly to drug treatment. Thus activating exercises are gaining increasing importance. Based on the positive experiences with the Lee Silverman Voice Treatment (LSVT® LOUD) a new physiotherapeutic approach named LSVT® BIG was recently introduced.
... To date, a number of studies of individuals with PD have provided evidence of reduced respiratory support Huber, Stathopoulos, Ramig, & Lancaster, 2003;Sadagopan & Huber, 2007;Solomon & Hixon, 1993), maladaptive changes to laryngeal structure and function (Canter, 1963;Duffy, 2005;Gallena, Smith, Zeffiro, & Ludlow, 2001;Goberman, Coelho, & Robb, 2005;Hanson, Gerratt, & Ward, 1984;Perez, Ramig, Smith, & Dromey, 1996), changes in vocal quality (Doyle, Raade, St. Pierre, & Desai, 1995;Goberman et al., 2002;Hertrich & Ackermann, 1995), and articulation deficits (Ackermann & Ziegler, 1991;Canter, 1965;Darley, Aronson, & Brown, 1969; R.D. Kent, J.F. Kent, Duffy, & Weismer, 1998;Logemann & Fisher, 1981). More specifically, the speech and voice impairments reported to date include reduced speaking volume (hypophonia), breathiness, hoarseness, consonant imprecision, and variable speech rates (Darley, Aronson, & Brown, 1969. ...
Purpose
The purpose of the current study was to investigate the effect of increased vocal intensity on interarticulator timing in individuals with Parkinson's disease (PD).
Methods
Ten individuals with mild to moderate hypophonia, secondary to PD, were selected for study. Over an 8-week treatment period, multi-talker babble noise was presented monaurally to the individuals with PD during everyday communication contexts to elicit increased vocal intensity (Lombard effect). Outcome measures included sound pressure level (SPL), voice onset time (VOT), VOT ratio, percent voicing, and speech intelligibility.
Results
Group and individual participant responses to the treatment are reported and discussed. Speakers with PD were shown to significantly increase SPL in response to treatment. Six of the ten speakers showed improved temporal coordination between the laryngeal and supralaryngeal mechanisms (interarticulator timing) in response to treatment. Four of the ten speakers, however, showed reduced laryngeal-supralaryngeal timing at the end of treatment. Group speech intelligibility scores were significantly higher post-treatment as compared to pre-treatment.
Conclusions
Voice treatment during everyday communication resulted in improved temporal coordination across the laryngeal and supralaryngeal mechanisms for the majority of speakers with PD and made them easier to understand. Further investigations are planned to explore individual differences in response to treatment. The identification of speaker-specific voicing and devoicing strategies is consistent with the heterogeneous nature of PD.
Learning Outcomes: Readers will be able to:
1. Describe the speech and voice characteristics of individuals with Parkinson's disease
2. Define the Lombard effect
3. Describe acoustic measures of voice onset time and percent voicing
Describe the effect of voice treatment on voice onset time and percent voicing in individuals with Parkinson's disease
... So fanden verschiedene Arbeitsgruppen eine Beeinträchtigung der Atemfunktionen mit konsekutiven Auswirkungen auf unterschiedliche Sprechparameter, z. B. resultierend in einer verringerten Anzahl der produzierten Silben pro Atemzug oder einer Reduktion der maximalen Vokalhaltedauer, was allerdings nicht in allen Untersuchungen reproduziert werden konnte [9][10][11][12]. Als ursächlich für die beobachteten Einschränkungen der Sprechatmung wurde zumeist ein erhöhter Widerstand des respiratorischen Systems bedingt durch einen Rigor der Atemmuskulatur angesehen, wobei zusätzlich Indizien für pathologische zentrale Atemmuster beim IPS gefunden wurden [13]. ...
... The simplest view of variability is that it is an index of a less mature (Smith & Zelaznik, 2004) or an impaired (Huber, Stathopoulos, Ramig & Lancaster, 2003) system. Thelen and colleagues (e.g. ...
ABSTRACT The aim of this study was to determine, using speech error and articulatory analyses, whether the binary distinction between iambs and trochees should be extended to include additional prosodic subcategories. Adults, children who are normally developing, and children with specific language impairment (SLI) participated. Children with SLI were included because they exhibit prosodic and motor deficits. Children, especially those with SLI, showed the expected increase in omission errors in weak initial syllables. Movement patterning analyses revealed that speakers produced differentiated articulatory templates beyond the broad categories of iamb and trochee. Finally, weak-weak prosodic sequences that crossed word boundaries showed increased articulatory variability when compared with strong-weak alternations. The binary distinction between iamb and trochee may be insufficient, with additional systematic prosodic subcategories evident, even in young children with SLI. Findings support increased interactivity in language processing.
... In addition, various physiologic changes such as increased movement amplitude of the rib cage (larger excursions) during speech breathing [46], increased subglottal air pressure [26], and improved closure and larger/more symmetrical movements of the vocal folds [47] have been documented in individuals with PD immediately after LSVT LOUD. These findings are supported by perceptual data demonstrating listeners rated improved loudness and voice quality in individuals with PD immediately posttreatment [33]. ...
Recent advances in neuroscience have suggested that exercise-based behavioral treatments may improve function and possibly slow progression of motor symptoms in individuals with Parkinson disease (PD). The LSVT (Lee Silverman Voice Treatment) Programs for individuals with PD have been developed and researched over the past 20 years beginning with a focus on the speech motor system (LSVT LOUD) and more recently have been extended to address limb motor systems (LSVT BIG). The unique aspects of the LSVT Programs include the combination of (a) an exclusive target on increasing amplitude (loudness in the speech motor system; bigger movements in the limb motor system), (b) a focus on sensory recalibration to help patients recognize that movements with increased amplitude are within normal limits, even if they feel "too loud" or "too big," and (c) training self-cueing and attention to action to facilitate long-term maintenance of treatment outcomes. In addition, the intensive mode of delivery is consistent with principles that drive activity-dependent neuroplasticity and motor learning. The purpose of this paper is to provide an integrative discussion of the LSVT Programs including the rationale for their fundamentals, a summary of efficacy data, and a discussion of limitations and future directions for research.
Purpose:
This systematic review evaluated the efficacy of therapeutic interventions on improving swallow, respiratory, and cough functions in Parkinson's disease (PD).
Method:
A PRISMA systematic search was implemented across six databases. We selected studies reporting pre- and post-assessment data on the efficacy of behavioural therapies with a swallow or respiratory/cough outcome, and excluded studies on medical/surgical treatments or single-session design. Cross-system outcomes across swallow, respiratory, and cough functions were explored. Cochrane's risk of bias tools were utilised to evaluate study quality.
Result:
Thirty-six articles were identified and further clustered into four treatment types: swallow related (n = 5), electromagnetic stimulation (n = 4), respiratory loading (n = 20), and voice loading (n = 7) therapies. The effects of some behavioural therapies were supported with high-quality evidence in improving specific swallow efficiency, respiratory pressure/volume, and cough measures. Only eleven studies were rated with a low risk of bias and the remaining studies failed to adequately describe blinding of assessors, missing data, treatment adherence, and imbalance assignment to groups.
Conclusion:
Behavioural therapies were diverse in nature and many treatments demonstrated broad cross-system outcome benefits across swallow, respiratory, and cough functions. Given the progressive nature of the condition, the focus of future trials should be evaluating follow-up therapy effects and larger patient populations, including those with more severe disease.
Purpose
To determine if people with Parkinson’s disease (PD) experience dyspnea (breathing discomfort) during speaking.
Method
The participants were 11 adults with PD and 22 healthy adults (11 young, 11 old). Participants were asked to recall experiences of breathing discomfort across different speaking contexts and provide ratings of those experiences (Retrospective ratings); then they rated the breathing discomfort experienced while performing speaking tasks that were designed to differ in respiratory demands (immediate Post-Speaking ratings).
Results
Participants with PD reported experiencing breathing discomfort during speaking significantly more frequently (approximately 60 % of the time) than did healthy participants (less than 20 % of the time). Retrospective ratings did not differ significantly from Post-Speaking ratings. Breathing discomfort was experienced by the fewest number of participants with PD for Conversation (two) and Extemporaneous Speaking (three) and by the greatest number for Extended Reading (ten) and Long Counting (nine), although the magnitude of the ratings generally reflected only “Slight” discomfort. Breathing discomfort was most frequently described as air hunger and breathing work, less frequently as mental effort, and very rarely as lung tightness. A few participants with PD reported experiencing emotions associated with their breathing discomfort and most reported using strategies to avoid breathing discomfort in their daily lives.
Conclusions
Individuals with PD are more apt to experience speaking dyspnea than healthy individuals, especially when speaking for extended periods or when using long breath groups. Such dyspnea may contribute to a tendency to avoid speaking situations and thereby impair quality of life.
Background
Evaluation of speech disorders in PD taking into account sociodemographic conditions is not frequent. This paper aims to establish correlations between articulation disorders in PD patients and factors such as the patients’ sex, age, education and residence. Methods
The study included 92 patients with idiopathic PD diagnosed by means of multiple neurological examinations, biochemical tests, MRI and CT scanning carried out in accordance with the United Kingdom Parkinson’s Disease Society Brain Bank (UKPDSBB) criteria. A speech and language test involved the assessment of the mobility of the speech organs as well as the reflexes inside the oral cavity. Frenchay Dysarthria Assessment was applied for an objective evaluation of dysarthria. ResultsThe study revealed the existence of significant relationship between the functionality of articulators in PD patients and their education and residence. Big city dwellers demonstrated lower incidence of disorders within speech organs, particularly those affecting mobility of the soft palate while eating. Disorders of moderate intensity were more frequently found in subjects living in villages. Subjects with a university education displayed better position of the lips at rest and better performance of both lips and the mandible while speaking. Conclusions
Abnormal functioning of the articulatory organs was observed more frequently in PD patients residing in rural areas than in those inhabiting urban areas. As for education, our cohort university graduates displayed a better position of the lips at rest and better performance of the lips and jaw during speaking than those with secondary and vocational education.
Hypokinetic dysarthria of Parkinson's disease is a multidimensional impairment associated with considerable communication deficits with great impact on quality of life in the majority of patients. The typical pattern of Parkinsonian dysarthria includes a reduction in loudness and intonation variability (monopitch and monoloudness) often combined with impaired speech respiration, phonation, articulation and temporal aspects of speech such as speech rate and rhythm. Pattern and degree of dysarthria can differ to some extent from individual to individual and show progressive deterioration over the course of disease progression. The underlying pathophysiology is still not fully understood; however, it cannot be explained by dopaminergic deficits alone. Speech/language therapy is the treatment of choice for Parkinsonian dysarthria. The diagnostic approach is based on perceptual analysis of speech in the clinical setting, but can be complemented by acoustic analyses, physiologic measures and functional neuro-imaging.
This article outlines the essential features and underlying principles of Lee Silverman Voice Treatment (LSVT®LOUD) and explores the delivery of this treatment via telepractice. A detailed summary of the core features of LSVT®LOUD and the principles underpinning this treatment are presented. Current evidence to support the feasibility and validity of synchronous and asynchronous delivery of LSVT®LOUD to people with Parkinson disease (PD) is reviewed. Technology specifications, cost-benefit analyses, and patient satisfaction are discussed. The challenges involved in delivery of LSVT®LOUD via telepractice, such as inconsistent audio and video quality during videoconferencing, accurate measurement of vocal parameters, technical skill level of the clinician, and patient candidacy, are highlighted. LSVT®LOUD can be effectively and reliably delivered via telepractice. Improvements in telecommunications are required to overcome some of the technology challenges encountered in this mode of delivery. Positive benefits of online treatment in relation to savings in time and money and reduced carer burden are emerging. Patient satisfaction with telepractice in the management of the speech disorder associated with PD is high. The uptake of LSVT®LOUD into telepractice is likely to steadily increase with advances in mobile technologies and web-based applications designed to deliver this treatment.
Speech and voice disorders are key elements in the diagnosis and management of individuals with Parkinson disease (PD). This chapter reviews the classic symptoms of speech and voice disorders in PD and their assessment. The complex origin of these disorders is described in relation to motor problems (hypokinesia/bradykinesia reflecting reduced muscle activation and abnormal scaling or maintenance of the gain of movement amplitude), sensory processing problems (abnormal gating of the somatosensory cortex, abnormal gating of the auditory cortex via feed-forward mechanisms, and abnormal perception of one's own voice), cueing problems (reflecting deficits in internal/implicit cueing), and neuropsychological problems (impaired attention to action, vocal vigilance, and self-regulation of vocal output). The impact of medical treatment (neuropharmacological, neurosurgical) on speech and voice is reviewed. Speech treatment is described with special emphasis on LSVT® LOUD, a scientifically tested, efficacious treatment consistent with principles that drive activity-dependent neural plasticity. The recommendation is made for early referral to a speech clinician for optimum management of speech and voice disorders in PD.
Dysarthria and dysphagia occur frequently in Parkinson's disease (PD). Reduced speech intelligibility is a significant functional limitation of dysarthria, and in the case of PD is likely related articulatory and phonatory impairment. Prosodically-based treatments show the most promise for addressing these deficits as well as for maximizing speech intelligibility. Communication-oriented strategies also may help to enhance mutual understanding between a speaker and listener. Dysphagia in PD can result in serious health issues, including aspiration pneumonia, malnutrition, and dehydration. Early identification of swallowing abnormalities is critical so as to minimize the impact of dysphagia on health status and quality of life. Feeding modifications, compensatory strategies, and therapeutic swallowing techniques all have a role in the management of dysphagia in PD.
Unlabelled:
This study examined patterns of lung volume use in speakers with Parkinson disease (PD) during an extemporaneous speaking task. The performance of a control group was also examined. Behaviors described are based on acoustic, kinematic and linguistic measures. Group differences were found in breath group duration, lung volume initiation, and lung volume termination measures. Speakers in the control group alternated between a longer and shorter breath groups. With starting lung volumes being higher for the longer breath groups and lower for shorter breath groups. Speech production was terminated before reaching tidal end expiratory level. This pattern was also seen in 4 of 7 speakers with PD. The remaining 3 PD speakers initiated speech at low starting lung volumes and continued speaking below EEL. This subgroup of PD speakers ended breath groups at agrammatical boundaries, whereas control speakers ended at appropriate grammatical boundaries.
Learning outcomes:
As a result of participating in this exercise, the reader will (1) be able to describe the patterns of lung volume use in speakers with Parkinson disease and compare them with those employed by control speakers; and (2) obtain information about the influence of speaking task on speech breathing.
Our 15 years of research have generated the first short- and long-term efficacy data for speech treatment (Lee Silverman Voice Treatment; LSVT/LOUD) in Parkinson's disease. We have learned that training the single motor control parameter amplitude (vocal loudness) and recalibration of self-perception of vocal loudness are fundamental elements underlying treatment success. This training requires intensive, high-effort exercise combined with a single, functionally relevant target (loudness) taught across simple to complex speech tasks. We have documented that training vocal loudness results in distributed effects of improved articulation, facial expression, and swallowing. Furthermore, positive effects of LSVT/LOUD have been documented in disorders other than Parkinson's disease (stroke, cerebral palsy). The purpose of this article is to elucidate the potential of a single target in treatment to encourage cross-system improvements across seemingly diverse motor systems and to discuss key elements in mode of delivery of treatment that are consistent with principles of neural plasticity.
Although diversity of symptoms and urgency of needs pose many challenges, management of the degenerative dysarthrias is a crucial aspect of clinical practice. The purpose of this article is to review current research literature on selected degenerative dysarthrias including those associated with Parkinson's disease, multiple sclerosis, and amyotrophic lateral sclerosis. These dysarthrias are prevalent yet represent distinct patterns of underlying neuropathology, symptoms, age of onset, and rate of progression. Literature searches including the period 1997-2006 yielded 148 different studies reporting data on communication issues related to dysarthria. By far the largest category of studies was that which provided a basic description of speech production including the neurophysiologic, acoustic, or perceptual properties of dysarthria. Other categories included management (assessment and treatment) and the psychosocial consequences of dysarthria. While the topic of management of degenerative dysarthria is a focused one, it provides a window into many issues critical to the field of communication disorders including fundamental properties of speech production, development of evidence-based treatment techniques, the staging of these techniques into an effective management sequence, and the psychosocial consequences of communication disorders along with techniques to maintain communicative participation in the face of degenerative conditions.
Purpose
To determine if respiratory and laryngeal function during spontaneous speaking were different for teachers with voice disorders compared with teachers without voice problems.
Method
Eighteen teachers, 9 with and 9 without voice disorders, were included in this study. Respiratory function was measured with magnetometry, and laryngeal function was measured with electroglottography during 3 spontaneous speaking tasks: a simulated teaching task at a typical loudness level, a simulated teaching task at an increased loudness level, and a conversational speaking task. Electroglottography measures were also obtained for 3 structured speaking tasks: a paragraph reading task, a sustained vowel, and a maximum phonation time vowel.
Results
Teachers with voice disorders started and ended their breath groups at significantly smaller lung volumes than teachers without voice problems during teaching-related speaking tasks; however, there were no between-group differences in laryngeal measures. Task-related differences were found on several respiratory measures and on one laryngeal measure.
Conclusions
These findings suggest that teachers with voice disorders used different speech breathing strategies than teachers without voice problems. Implications for clinical management of teachers with voice disorders are discussed.
Increasing phonatory effort, an integral component of the Lee Silverman Voice Treatment, LSVT, has been identified as an effective management strategy for adults with hypokinetic dysarthria associated with Parkinsonism. The present study compares the effects of increased loudness on lower lip movements to those of changes in speaking rate, another approach to the treatmentm of hypokinetic dysarthria. Movements of the lower lip/jaw during speech were recorded from 8 adults with IPD, 8 healthy aged adults, and 8 young adults. The spatiotemporal index (STI), a measure of spatial and temporal variability, revealed that for all speaker groups slow rate was associated with the most variability. Compared to the other conditions, STI values from the loud condition were closest to those from habitual speech. Also, the normalized movement pattern for the loud condition resembled that of habitual speech. It is hypothesized that speaking loudly is associated with a spatial and temporal organization that closely resembles that used in habitual speech, which may contribute to the success of the LSVT.
One purpose of the present study was to examine displacement variability of lower lip and jaw movements to determine whether sounds that are generally learned earlier and should, therefore, have been practiced more (e. g., stops and nasals) would be less variable than sounds that tend to develop later (e. g., fricatives). It was also of interest to determine whether individual articulators such as the lower lip and the jaw show any differences in displacement variability, given that lower lip gestures may need to be more precise than jaw movements. Repetitions of several labial-initial, CVC stimuli embedded in short phrases produced by three groups of children (5-, 8-, and 11-year-olds) and a group of adults were examined to determine the variability of articulatory gestures. No evidence was found to suggest that fricatives were more variable than stops or nasals for any of the groups. For the children but not the adults, lower lip gestures tended to be more variable than jaw movements.
Eighteen adults and 12 children, ranging from 7 to 11 years of age, participated in a study that investigated their abilities to control the temporal variability of their speech. For both the adults and the children, few substantive differences in performance were observed when considering control data versus findings from an experimental task in which they were specifically instructed to be as consistent as possible in producing various stimuli. Although some subjects did show reduced variability in the experimental condition, there was little evidence that such decreases typically represented more than random effects. In general, the results suggest that when producing multiple repetitions of words and short phrases, adults and 7-11-year-old children are essentially as consistent as they can be, whether specifically attempting to minimize variability or not. The basis for this could be that even in control conditions, subjects may perform at or near optimal levels of consistency across productions.
As part of ongoing research to investigate and document the efficacy of intensive voice therapy to improve functional communication in patients with idiopathic Parkinson disease, 45 patients were enrolled in a controlled, randomized, prospective study. Pre- to posttreatment comparisons are presented here on 22 of those patients who underwent laryngeal imaging examination. Of the 22 patients, 13 patients received intensive therapy aimed at increasing vocal and respiratory effort (VR), whereas nine received intensive therapy aimed at increasing respiratory effort (R) only. All patients had a pretreatment evaluation that included two (but sometimes only one) voice recordings and an otolaryngologic examination with laryngostroboscopy. At the completion of 4 weeks of therapy (16 sessions), two voice recordings were made, and laryngostroboscopy was again performed. The pre- and posttherapy videolaryngostroboscopy tapes were then randomized and rated by four judges. Raters' findings were then compared with vocal intensity measured before and after therapy. The VR therapy group showed improvements on laryngostroboscopic variables: less glottal incompetence and no significant change in supraglottal hyperfunction after therapy. No differences were observed in the R-only group. The mean intensity increase in the VR therapy group was 12.5 dB, compared with a decrease of 1.9 dB in the R-only group. These findings suggest that in patients with Parkinson disease, intensive therapy focusing on phonatory effort improves adduction of the vocal folds as assessed by laryngostroboscopy. Differences in laryngeal function in these patients observed with fiberoptic laryngoscopy and rigid telescopic laryngoscopy are discussed.
The execution of multiple-component movements has been shown to be impaired in Parkinson's disease patients. To determine whether this deficit is attributed to faulty motor programming, a two-segment movement was examined by studying the kinematics of the first segment when the second segment contained variable accuracy requirements. The performance of 15 Parkinson's disease patients was compared with an age-matched control group. Movement precision not only affected the kinematics of the final segment but also the kinematics of the first segment. This 'context effect' was observed in both groups. Since Parkinson's disease patients revealed similar movement patterns to those of controls, their motor programming appears to be intact. Furthermore, correlation analysis for the segment movement-times revealed subjects with high as well as low correlation indices in both groups. The correlation indices were related to the context effect only in the Parkinson's disease patients. Independent of these phenomenon. Parkinson's disease patients showed marked hesitations between the movement segments compared with controls, suggesting that they have difficulty in implementing and/or in switching between motor program steps. Impaired force control and a reduced capacity to terminate movements in Parkinson's disease are discussed as possible explanations of the deficit in motor program implementation.
Respiratory measurements were made using linearized magnetometers placed antero-posteriorly over the rib cages and abdomens of five healthy young women. Background noise was introduced over headphones simultaneously as "babble" presented binaurally at 55 dB ("moderate noise") and 70 dB ("high noise"). Speech during oral reading and spontaneous monologue was transduced with a microphone positioned near the lips, from which a speaking intensity signal (dBA) was derived. Subjects were instructed to speak during the noise conditions, but no instruction was given to alter speaking intensity. Compared with a "no noise" condition, the speaking intensities of all the subjects increased significantly for both speech tasks in the moderate and high noise conditions, thereby replicating the well-documented Lombard effect. No consistent trend of lung volume change was observed, in contrast to the linear increases in speech intensity as the noise level increased. For the higher speech intensities during the moderate and high noise conditions both initiation and termination lung volumes either increased or decreased. These preliminary findings suggest that when speech intensity is increased following the introduction of noise via headphones rather than by specific instructions to speak more loudly, speakers employ variable lung volume strategies for intensity control.
Since pneumotachograph masks are commonly used in studies of speech breathing, the purpose of this study was to measure the differences in respiratory volumetric and frequency measures during speech under two conditions: with and without a circumferentially vented pneumotachograph mask coupled to the face. Thus we sought to identify whether changes in breathing patterns occur with the use of a specific face mask, because these patterns are accepted as representative of normal speech breathing. Subjects were 10 normal-speaking women, each of whom produced a syllable train and a connected speech task, both at comfortable intensity levels. Respiratory measures were made using linearized magnetometers during speech production. The measurements included lung volume, rib cage volume, and abdominal volume at utterance initiation and termination, volume excursions during the utterance, and the number of breath groups during the speech task. There were no significant differences between the mask-on and mask-off conditions in volumetric and frequency measures. A significant task difference for abdominal initiation was found. It was concluded that the use of a circumferentially vented pneumotachograph mask does not alter the reliability of respiratory volume and frequency measures for studies of voice.
Researchers have hypothesized that the respiratory and laryngeal speech subsystems would respond to an air pressure bleed, but these responses have not been empirically studied. The present study examined the nature of the responses of the respiratory and laryngeal subsystems to an air pressure bleed in order to provide information relevant to the nature of motor control for speech. Participants produced a syllable train consisting of 7 syllables of [pα] 10 times with and without an air pressure bleed in place. Acoustic, aerodynamic, and respiratory kinematic data were collected. In the bleed condition, peak intraoral air pressure and average oral airflow during the [α] were lower, lung and rib cage volume excursions were longer, and rib cage volume terminations were more negative. This study provides empirical data demonstrating a clear interaction among the speech subsystems. Both active and passive mechanisms are suggested by the subsystems' responses.
The present study sought to investigate both perceptually and instrumentally the prosodic and respiratory abilities of two persons with Parkinson's disease, to determine firstly, whether the results of acoustic and perceptual analyses of prosody concur, and secondly, whether perceptual ratings of disordered respiration reflect a physiological impairment in the breathing apparatus. The results indicate that perceptual judgments alone fail to provide sufficiently sensitive information to enable clinicians to identify the underlying pathophysiological nature of the respiratory impairment in an individual with Parkinson's disease. Further, perceptual and acoustic measures of prosodic impairment in the subjects with Parkinson's disease frequently failed to agree. The need for careful instrumental measures in the optimum management of persons with Parkinson's disease is emphasized.
This article reviews speech and voice disorders accompanying idiopathic Parkinson's disease. Data are summarized that document laryngeal, respiratory, articulatory, velopharyngeal, and sensory kinesthesia disorders in this population. Medical and behavioral treatments are identified. The rationale, fundamental concepts, treatment techniques. and outcome data are presented for the Lee Silverman Voice Treatment (LSVT) an effective program for treating speech and voice disorders m individuals with idiopathic Parkinson's disease.
The basal ganglia are thought to play an important role in regulating motor programs involved in gait and in the fluidity and sequencing of movement. We postulated that the ability to maintain a steady gait, with low stride-to-stride variability of gait cycle timing and its subphases, would be diminished with both Parkinson's disease (PD) and Huntington's disease (HD). To test this hypothesis, we obtained quantitative measures of stride-to-stride variability of gait cycle timing in subjects with PD (n = 15), HD (n = 20), and disease-free controls (n = 16). All measures of gait variability were significantly increased in PD and HD. In subjects with PD and HD, gait variability measures were two and three times that observed in control subjects, respectively. The degree of gait variability correlated with disease severity. In contrast, gait speed was significantly lower in PD, but not in HD, and average gait cycle duration and the time spent in many subphases of the gait cycle were similar in control subjects, HD subjects, and PD subjects. These findings are consistent with a differential control of gait variability, speed, and average gait cycle timing that may have implications for understanding the role of the basal ganglia in locomotor control and for quantitatively assessing gait in clinical settings.
This study examined the regulation of speech volume in hypophonic subjects with Parkinson’s disease (PD) and age- and gender-matched controls. The first two experiments investigated the ability of subjects with PD to automatically regulate speech volume in response to two types of implicit cue: (i) background noise (BGN) and (ii) instantaneous auditory feedback (IAF). Control subjects demonstrated the Lombard effect by automatically speaking louder when competing against increasing levels of background noise. They also showed the reverse effect, decreasing speech volume when increasing levels of facilitative instantaneous auditory feedback were provided. Subjects with PD demonstrated decreased overall speech volume; they were less able than controls to appropriately increase volume as background noise increased, and to decrease volume as IAF increased. Thus, subjects with PD demonstrated over-constancy of speech volume and failed to respond to the implicit cues integral to volumetric scaling. A further experiment (3) was carried out to contrast the regulation of volume in response to implicit cue with an explicit attention-driven cue (i.e. instructions regarding volume level). As in Experiments 1 and 2, subjects with PD exhibited reduced speech volume. Under explicit volume instructions, the ability of subjects with PD to regulate volume was normalised. These findings suggest that subjects with PD have the capacity to speak with normal volume provided they consciously attend to speaking loudly. In subjects with PD, overall speech volume was always lower than for control subjects, suggesting a reduction of cortical motor set in the articulatory system similar to that demonstrated by the reduced amplitude of limb movements (hypokinesia) in the motor system.
The speech of 17 Parkinsonian patients was evaluated before and after the administration of L-DOPA therapy. A significant difference was demonstrated after treatment for voice quality, articulation, and pitch variation, but not for rate of speech. Amount of speech improvement correlated significantly with amount of physical improvement. Although age and duration of disease may exert some influence on speech change, the results suggest that these factors do not reliably predict the response. After 4 years of L-DOPA therapy, three out of four patients demonstrated additional improvement or the same degree of speech improvement.
The speech of three groups of Parkinson patients--nonsurgical, postunilateral and postbilateral thalamotomy--was evaluated. Dysarthria, bulbar motility and pyramidal tract indexes were determined for each patient. There was a statistically significant greater impairment in dysarthria and pyramidal tract indexes of patients with thalamotomy. L-Dopa and carbidopa therapy failed to significantly improve speech in any group.
When making discrete aiming movements, patients with Parkinson's disease show greater inherent variability in the endpoints of their movements than do normal subjects. Endpoint variability can be reduced, by moving more slowly, by utilizing visual guidance, and by making small amplitude movements. The greater variability of patients is not a universal finding, but depends on the conditions of movement. For small movements the performance of patients equates to that of controls. For larger movements the results indicate that if sufficient time is available, patients can use visual guidance (if available) to reduce the variability of their movements to the level of normals. Patients can generate fast and/or large amplitude arm movements if required, but they are erratic if made in the dark or over a short duration. Their difficulty lies not so much in the magnitude of muscle force available to them, but rather in an inability to produce it consistently for any given movement attempted. Bradykinesia may in part result from this inherent variability in that parkinsonian patients, in order to maintain accuracy within acceptable limits, are forced to increase the duration of their movements to a level where they can make use of visual guidance. In any event, theoretical explanations for the movement disorder in Parkinson's disease advanced in the literature need to take some account of this increased variability of movement.
Unlike the single joint arm movements so commonly the focus of Parkinson's disease (PD) studies, orofacial movements for speech are well-learned, complex motor sequences generated without visual guidance. The present study of upper lip, lower lip, and jaw movements during speech in PD was thus aimed at determining whether (1) PD speech kinematic deficits are comparable to those often observed in simpler limb movements; (2) coordination for multimovement actions such as speech is aberrant in PD, as recently claimed; and (3) the component muscle groups involved in this behaviour manifest uniform deficits. Results indicated that despite reduced amplitudes of jaw and upper lip displacement in PD subjects, all three of these oral movements were of normal duration. Secondly, PD lower lip movements manifested no deficits and bradykinesia (reduced velocity) was only found in movements of the jaw. Finally, there was an indication of movement coordination aberrations in these parkinsonian subjects. Overall, these results not only suggest a difference between orofacial and limb movement impairments in PD, but also document the need to broaden our perspectives on this movement disorder by examining a wider range of functional motor tasks.
Twenty-five consecutive patients with Parkinson's disease, who had been on levodopa for 10 or more years, were studied. Over the 12.9 years of treatment, the average Northwestern Disability Score had increased from 9.6 to 18.9. By this measure, 24 of 25 patients were worse, and one was unchanged. The progression of disability did not involve all pretreatment parkinsonian features equally in any of the patients studied. Instead a distinctive pattern of deterioration was seen: postural reflexes worsened in 24/25, speech in 24/25, and gait in 22/25. In contrast, rigidity was improved or unchanged in 17/25, tremor was improved or unchanged in 17/17, while handwriting was improved or unchanged in 21/22. Finger dexterity which was improved in 5/25, unchanged in 15/25, and worse in 5/25 which seemed to be between these two extremes. These observations demonstrate that some signs of parkinsonism can remain quite responsive to levodopa for more than 10 years while at the same time other manifestations of the disease are no longer as responsive to this form of treatment.
Programming and execution of arm movements in Parkinson's disease were investigated in choice and simple reaction time (RT) situations in which subjects made aimed movements at a target. A no-aiming condition was also studied. Reaction time was fractionated using surface EMG recording into premotor (central) and motor (peripheral) components. Premotor RT was found to be greater for parkinsonian patients than normal age-matched controls in the simple RT condition, but not in the choice condition. This effect did not depend on the parameters of the impending movement. Thus, paradoxically, parkinsonian patients were not inherently slower at initiating aiming movements from the starting position, but seemed unable to use advance information concerning motor task demands to speed up movement initiation. For both groups, low velocity movements took longer to initiate than high velocity ones. In the no-aiming condition parkinsonian RTs were markedly shorter than when aiming, but were still significantly longer than control RTs. Motor RT was constant across all conditions and was not different for patient and control subjects. In all conditions, parkinsonian movements were around 37% slower than control movements, and their movement times were more variable, the differences showing up early on in the movement, that is, during the initial ballistic phase. The within-subject variability of movement endpoints was also greater in patients. The motor dysfunction displayed in Parkinson's disease involves a number of components: (1) a basic central problem with simply initiating movements, even when minimal programming is required (no-aiming condition); (2) difficulty in maintaining computed forces for motor programs over time (simple RT condition); (3) a basic slowness of movement (bradykinesia) in all conditions; and (4) increased variability of movement in both time and space, presumably caused by inherent variability in force production.
Two groups of women, one aged 20-35 years and the other aged 75 years and older, read the 'Rainbow Passage' and produced the vowel/a/at minimum, conversational, and maximum intensity levels. The results indicate that the two groups did not exhibit significant differences in speech intensity for the reading passage or the conversational level vowel productions. On the other hand, the older women exhibited significantly higher minimum and significantly lower maximum intensity vowels than the younger women.
This paper examines how breathing differs in the upright and supine body positions. Passive and active forces and associated chest wall motions are described for resting tidal breathing and speech breathing performed in the two positions. Clinical implications are offered regarding evaluation and treatment of breathing behavior in clients with speech and voice disorders.
Variability and bilateral symmetry of EMG gait-cycle profiles were studied in parkinsonian and healthy elderly subjects in the gastrocnemius, tibialis anterior, and vastus lateralis muscles. Components reflecting shape and timing were defined by the magnitude and phase of the cross-correlation function between individual stride profiles and the latency corrected ensemble average (LCEA) (variability), and between bilateral LCEAs (symmetry). Statistical significance was set at a confidence level of 0.01 reflecting a Bonferroni adjustment due to multiple measures. Parkinsonian gait was significantly different from the healthy elderly in several measures: increased shape variability and asymmetry in the gastrocnemius and tibialis anterior muscles, and reduced timing variability in the gastrocnemius. A portion of the parkinsonian group participated in a 3 week therapy program where they walked to rhythmic auditory stimulation. Gait parameters shifted toward healthy elderly values in each measure where population differences were found. Significant changes were observed in decreased tibialis anterior shape variability and asymmetry, and gastrocnemius shape variability. Strong trends were also observed in increased gastrocnemius timing variability and reduced bilateral asymmetry. In addition to the expected decreased in variability and asymmetry of healthy elderly, increased timing variability in the gastrocnemius was associated with a more normal gait, possibly reflecting feedback adaptability of muscle activity which may be useful in generating stable locomotion.
Patients with Parkinson's disease have a high incidence of speech, voice, and laryngeal abnormalities. To characterize laryngeal abnormalities, visual-perceptual ratings of endoscopic and stroboscopic examinations of 22 patients diagnosed with idiopathic Parkinson's disease and 7 patients with Parkinson's-plus syndromes were carried out by for trained viewers. Incidence of tremor, tremor location, phase closure, phase symmetry, amplitude, and mucosal waveform were scored. Tremor was observed in one or more of these conditions-rest, normal pitch and loudness, or loud phonation-for most of the 29 patients. Fifty-five percent of the idiopathic Parkinson's disease patients had tremor, with the primary location being vertical laryngeal tremor. Sixty-four percent of the Parkinson's-plus patients had tremor, with the arytenoid cartilages being the primary location. Laryngeal tremor was observed early in the disease in these Parkinson's disease patients. The most striking stroboscopic findings for the idiopathic Parkinson's disease patients were abnormal phase closure and phase asymmetry. Amplitude and mucosal wave-form were essentially within normal limits in the majority of the idiopathic Parkinson patients.