Comparison of Two Forms of Intensive Speech Treatment for Parkinson Disease

Lorraine Olson Ramig; Stefanie Countryman; Laetitia L. Thompson; Yoshiyuki Horii

doi:10.1044/jshr.3806.1232

Open Access

Research Article | December 01, 1995

Comparison of Two Forms of Intensive Speech Treatment for Parkinson Disease

Lorraine Olson Ramig, Stefanie Countryman, Laetitia L. Thompson, and Yoshiyuki Horii

Author Affiliations & Notes

Article Information

Journal of Speech, Language, and Hearing Research, December 1995, Vol. 38, 1232-1251. doi:10.1044/jshr.3806.1232

History: Received November 18, 1994; Accepted April 28, 1995

This study investigated the effect of two forms of intensive speech treatment, (a) respiration (R) and (b) voice and respiration (Lee Silverman Voice Treatment [LSVT]), on the speech and voice deficits associated with Idiopathic Parkinson disease. Forty-five subjects with Idiopathic Parkinson disease completed extensive pretreatment neurological, otolaryngologicai, neuropsychological, and speech assessments. All subjects completed 16 sessions of intensive speech treatment, 4 times a week for 1 month. Pre- and post-treatment measures included intensity and maximum duration during sustained vowel phonation. Intensity, habitual fundamental frequency, fundamental frequency variability, and utterance and pause duration were measured during reading of the “Rainbow Passage” and conversational monologue as well. Family and subject self-ratings were completed pre- and post-treatment for the perceptual variables loudness, monotonicity, hoarseness, overall intelligibility, and initiation of conversation. Significant pre- to post-treatment improvements were observed for more variables and were of greater magnitude for the subjects who received the voice and respiration treatment (LSVT). Only subjects who received the LSVT rated a significant decrease post-treatment on the impact of Parkinson disease on their communication. Correlations between descriptive prognostic variables (i.e., stage of disease, speech/voice severity rating, depression, and time since diagnosis) and magnitude of treatment-related change indicated these factors did not significantly predict treatment effectiveness. These findings suggest that intensive voice and respiration (LSVT) treatment, focusing on increased vocal fold adduction and respiration, is more effective than respiration (R) treatment alone for improving vocal intensity and decreasing the impact of Parkinson disease on communication.

Parkinson disease is a progressive, degenerative neurological disease resulting from nigrostriatal dopamine deficiency (Homykiewicz, 1966; Homykiewicz & Kish, 1986). At least 75% of the 1.5 million patients with Parkinson disease have a speech disorder that may limit their ability to function fully in society (Canter, 1965; Hoberman, 1958; Logemann, Fisher, Boshes, & Blonsky, 1978; Oxtoby, 1982; Streifler & Hofman, 1984). The perceptual characteristics of disordered speech and voice in Parkinson disease include reduced loudness, monopitch, monoloudness, imprecise articulation, and disordered rate (Darley, Aronson, & Brown, 1969a, 1969b; Logemann et al., 1978). Traditionally, speech treatment for Parkinson disease has met with limited success (Allan, 1970; Aronson, 1985; Greene, 1980; Sarno, 1968; Weiner & Singer, 1989). Consequently, many Parkinson disease patients do not receive speech treatment (Mutch, Strudwick, Roy, & Downie, 1986; Oxtoby, 1982) and their speech deteriorates as their disease progresses (Logemann et al., 1978; Morley, 1955).

Recently, Ramig and colleagues (Countryman & Ramig, 1993; Countryman, Ramig, & Pawlas, 1994; Ramig, 1995; Ramig, Bonitati, Lemke, & Horii, 1994; Ramig, Horii, & Bonitati, 1991; Ramig et al., 1988) have reported positive findings following a voice treatment program for Parkinson disease (The Lee Silverman Voice Treatment [LSVT]) that focuses on increasing vocal loudness by increasing phonatory effort. Subjects have been trained to increase vocal fold adduction in maximum phonatory effort tasks and generalize the increased vocal effort to louder speech. Significant increases in maximum duration sustained vowel phonation, maximum fundamental frequency range, habitual fundamental frequency, and fundamental frequency variability in speech have also been documented following this intensive voice treatment (Ramig et al., 1994). Perceptual reports supported corresponding post-treatment increases in vocal loudness and improvements in speech intelligibility and functional communication (Ramig, 1992). The rationale for the Lee Silverman Voice Treatment is summarized in Table 1.

TABLE 1.Logic for development and rationale for treatment goals and tasks for the Lee Silverman Voice Treatment.

Perceptual characteristics of speech	Hypothesized laryngeal and/or respiratory physical pathology	Treatment goals and tasks
Reduced loudness	Reduced vocal fold adduction e.g., bowed vocal folds	• Increase vocal fold adduction via isometric effort (pushing, lifting) during phonation
Breathy, weak voice	Reduced respiratory support	• Increase maximum duration vowel phonation at greater vocal intensity
		• “Think loud/shout”
Hoarseness	Rigidity, hypokinesia, in laryngeal and/or respiratory muscles	• Improve vocal quality during sustained phonation and speaking
Monotone	Rigid cricothyroid muscle	• Increase maximum fundamental frequency range
		• High/low pitch glides
		• Sustained phonation at highest and lowest pitches

View Large

TABLE 1.Logic for development and rationale for treatment goals and tasks for the Lee Silverman Voice Treatment.

Perceptual characteristics of speech	Hypothesized laryngeal and/or respiratory physical pathology	Treatment goals and tasks
Reduced loudness	Reduced vocal fold adduction e.g., bowed vocal folds	• Increase vocal fold adduction via isometric effort (pushing, lifting) during phonation
Breathy, weak voice	Reduced respiratory support	• Increase maximum duration vowel phonation at greater vocal intensity
		• “Think loud/shout”
Hoarseness	Rigidity, hypokinesia, in laryngeal and/or respiratory muscles	• Improve vocal quality during sustained phonation and speaking
Monotone	Rigid cricothyroid muscle	• Increase maximum fundamental frequency range
		• High/low pitch glides
		• Sustained phonation at highest and lowest pitches

Reduced vocal loudness observed in Parkinson disease has been associated with limited respiratory support (Canter, 1965; Critchley, 1981) as well as reduced vocal fold adduction (Hanson et al., 1984; Smith, Ramig, Dromey, Perez, & Samandari, in press; Perez, Ramig, Smith, & Dromey, in press). Treatment directed toward increasing vocal loudness is dependent upon improving the function of one or both of these systems (Dromey, Ramig, & Johnson, 1995; Ramig, Dromey, Johnson, & Scherer, 1994; Ramig, Fazoli, Scherer, & Bonitati, 1990; Titze & Sundberg, 1992). Although initial studies (Countryman & Ramig, 1993; Ramig, 1992,1995; Ramig et al., 1988; Ramig et al., 1991; Ramig et al., 1994) have identified phonatory effort and increased loudness (intensity) as key elements in efficacious treatment for Parkinson disease patients, studies have not compared the contributions of the respiratory and laryngeal systems to treatment-related change in intensity.

The interaction of the respiratory and laryngeal systems for control of intensity has been well described in non-disordered speakers (Stathopoulos & Sapienza, 1993a, 1993b). Increases in intensity have been associated with increased subglottal air pressure (Holmberg, Hillman, & Perkell, 1988; Isshiki, 1964) and vocal fold adduction (Colton, 1984; Titze & Sundberg, 1992). Given the significant role of the respiratory system in controlling subglottal air pressure (Hixon, Goldman, & Mead, 1973; Hixon, Mead, & Goldman, 1976; Stathopoulos & Sapienza, 1993a), speech treatment that is designed to improve inspiratory and expiratory respiratory muscle activity should contribute to increased subglottal air pressure and vocal intensity in patients with Parkinson disease. However, given the glottal incompetence frequently observed in patients with Parkinson disease, it is likely that treatment designed to increase vocal fold adduction also would be necessary to generate optimum gains in intensity. For example, Berke et al. (1990) concluded that increasing intensity (in an in vivo canine model) by medial adductory compression was more efficient than by increasing air flow. They reported that increasing air flow alone produced a significantly greater open quotient and vocal fold vibratory excursion. Clarification of the interactive roles of the respiratory and laryngeal systems in treatment-related change will contribute to enhancing the effectiveness of treatment for patients with Parkinson disease.

Identification of patient suitability or prognostic factors for treatment success is another issue of importance in studies of speech treatment efficacy. Previous research has not considered characteristics of Parkinson disease patients such as age, sex, stage of disease, time since diagnosis, and severity of speech disorder in relation to the efficacy of intensive speech treatment. In addition, depression and dementia (cognitive ability or functioning), which are frequently observed in Parkinson disease (Duvoisin, 1984; Gauthier, Dalziel, & Gauthier, 1987; Mayeux, Williams, Stern, & Cote, 1986) and associated with performance limitations (Beatty et al. 1989; Cummings, 1986), should be considered for their potential impact on treatment-related change. Although preliminary work (Mead, Ramig, & Beck, 1989) suggested that moderate dementia is not a limiting factor for speech treatment success, neither cognitive status nor depression has been considered systematically for its impact on the efficacy of speech treatment in Parkinson disease. Clarification of the prognostic role of certain patient characteristics will contribute to maximizing treatment effectiveness.

This study was designed to evaluate the speech and voice characteristics of patients with Parkinson disease following one of two forms of intensive treatment: (a) treatment designed to increase respiratory support for speech (R); and (b) treatment designed to increase vocal fold adduction and respiratory support (LSVT). Pre- to post-treatment changes in intensity and duration characteristics were measured during sustained vowel phonation. Intensity, habitual fundamental frequency and fundamental frequency variability, and utterance and pause duration were measured during reading and conversational speech as well. Utterance and pause duration measurements were included as a secondary measurement of respiration and rate. It was assumed that treatment-related changes in inspiration and expiration would influence these measures because of the relationship previously reported between these respiratory gestures and speech rate (Bellaire, Yorkston, & Beukelman, 1986; Crystal, 1969).

This study was also designed to document treatment-related changes in relation to subject characteristics including: age, sex, stage of disease, time since diagnosis, severity of speech/voice deficits, glottal incompetence, depression, and cognitive functioning.

Method

Subjects

Forty-five patients with idiopathic Parkinson disease volunteered to participate in this study. All subjects were residents of the Denver, Colorado, area. All subjects participated in baseline pretreatment neurological, neuropsychological, otolaryngological, and speech assessments. Subjects were stratified on the variables age, sex, and stage of Parkinson disease (Hoehn & Yahr, 1967), score on the motor examination section (section III) of the Unified Parkinson’s Disease Rating Scale (UPDRS) (Fahn, Elton, & members of the UPDRS Development Committee, 1987), time since diagnosis, magnitude of glottal incompetence, and severity of speech disorder. These stratified subjects were randomly assigned to one of two treatment groups: respiration (R) or voice and respiration (LSVT).

An analysis of variance revealed no significant differences between the two groups of subjects at baseline for the variables age, F(1,43) = .4368, p = .51, stage of disease, F(1,43) = 2.6113, p = .11, score on the motor examination section of the UPDRS, F(1,40) = .0309, p = .86, time since diagnosis, F(1,43) = .6609, p = .42, glottal incompetence, F(1,19) = 1.8274, p = .19, and severity of speech disorder, F(1,43) = .6704, p = .41. Lack of subject compliance with pre- and post-treatment assessments and experimental and treatment protocols resulted in unequal group sizes and gender distribution. Difficulty recruiting female patients resulted in a limited female sample (n = 12). Descriptive characteristics of the 45 subjects obtained during baseline assessments are summarized in Table 2 and details of the baseline assessments are described below. Subjects initiated no other forms of treatment (e.g., physical therapy, occupational therapy, psychological counseling) while they participated in this study.

TABLE 2.Descriptive characteristics of subjects who received the Lee Silverman Voice Treatment (voice and respiration) and subjects who received treatment focusing only on respiration.

Subject	Sex	Age	Years since diagnosis	Hoehn & Yahr stage (1967)	UPDRS Motor exam	Medication* †	Speech/Voice deficits (severity rating)	Glottal incompetence
Subjects who received the Lee Silverman Voice Treatment
1	F	73	10	4.0	48.0	a, c, f	reduced loudness imprecise articulation	2.25
							(5)
2	F	52	13	3.0	17.0	a, f, o	reduced loudness rapid rate	1.50
							(3)
3	F	49	9	2.0	4.0	a, d, g	hoarseness	1.5
						(1)
4	F	32	1	2.0	UA∼	a, j	hoarseness
							(1)
5	F	74	1	1.5	12.0	b, c	hoarseness tremor
							(2)
Mean (F)		56.0	6.8	2.5	20.25		2.4	1.75
(SD)		(17.7)	(5.5)	(1.0)	(19.3)		(1.67)	(0.4)
6	M	49	1	2.0	13.0	a, b, c	monotone reduced loudness	1.33
							(1)
7	M	76	1	2.0	20.0	a	hoarseness monotone
							(2)
8	M	76	5	3.0	28.0	b, c, I	imprecise articulation reduced loudness	1.75
							(3)
9	M	62	3	2.0	26.0	a, c	hoarseness reduced loudness	2.0
							(3)
10	M	71	11	3.5	43.5	i, h	hoarseness reduced loudness	1.75
							(4)
11	M	50	18	2.0	19.5	a, c, d	reduced loudness monotone
							(2)
12	M	68	6	3.0	40.5	a, k	reduced loudness hoarseness	2.0
							(3)
13	M	75	20	3.5	47.0	b, n	reduced loudness imprecise articulation	1.25
							(4)
14	M	69	1	3.0	32.0	none	imprecise articulation reduced loudness
							(2)
15	M	61	1	2.0	16.0	a, c	reduced loudness imprecise articulation	1.0
							(2)
16	M	72	5	3.0	30.0	a, c, h	reduced loudness monotone	1.0
							(2)
17	M	67	8	3.0	16.0	a	reduced loudness imprecise articulation	1.75
							(3)
18	M	64	7	2.0	26.0	a,	monotone reduced loudness	1.0
							(2)
19	M	73	10	3.0	27.5	a, h	monotone reduced loudness
							(3)
20	M	79	1	3.0	33.0	a, c	monotone imprecise articulation
							(3)
21	M	62	4	3.5	35.0	k, n	aphonia hoarseness
							(4)
Subjects who received the Lee Silverman Voice Treatment
22	M	52	18	3.0	34.0	a, c, d, e	rapid rate reduced loudness
							(3)
23	M	75	7	2.0	32.0	a, c	reduced loudness hoarseness
						(3)
24	M	61	4	3.0	22.5	a, c, d	imprecise articulation reduced loudness
						(4)
25	M	54	15	3.5	45.5	b, i, k	reduced loudness monotone	2.25
						(4)
26	M	56	7	2.0	2.0	a, c, h	rapid rate reduced loudness	1.0
						(3)
Mean (M)		65.3	8.7	2.7	28.0		2.86	1.5
(SD)		(9.3)	(10.1)	(0.6)	(11.3)		(0.85)(0.5)
Group Mean		63.5	8.3	2.7	26.8		2.77	1.6
(SD)		(11.5)	(9.3)	(0.7)	(12.7)	(1.03)	(0.45)
Subjects who received treatment focusing only on respiration
27	F	64	2	3.0	29.0	a, c, p	hoarseness reduced loudness	1.55
							(1)
28	F	71	3	1.0	UA∼	a	hoarseness tremor
							(2)
29	F	68	1	2.0	1.0	a, b, c	reduced loudness
							(1)
30	F	68	4	2.0	12.0	a, c	reduced loudness monotone	1.75
							(3)
31	F	63	3	3.0	42.0	a, c	imprecise articulation slow rate	2.5
							(4)
32	F	51	4	1.0	16.0	none	reduced loudness	1.75
							(1)
33	F	83	7	3.0	33.0	a	strained/strangled rapid rate	1.75
							(4)
Mean (F)		66.9	3.4	2.1	23.6		2.29	1.8
(SD)		(9.6)	(1.9)	(0.9)	(14.3)		(1.38)	(0.2)
34	M	70	4	3.0	32.0	a, c	reduced loudness monotone	1.0
							(3)
35	M	71	4	3.0	43.0	a, n	reduced loudness monotone	1.25
							(4)
36	M	69	1	2.0	27.0	i	monotone reduced loudness
							(3)
37	M	65	8	3.0	19.0	none	imprecise articulation rapid rate	1.0
							(2)
38	M	52	14	2.0	31.0	a, d, e, p	pallilalia rapid rate	1.0
							(3)
39	M	67	18	3.5	UA	b, c, j	imprecise articulation reduced loudness
							(4)
40	M	51	6	1.5	3.0	a, c	rapid rate pallilalia
							(4)
41	M	66	12	3.0	41.0	a, c, i	strained/strangled reduced loudness
							(3)
Subjects who received treatment focusing only on respiration
42	M	81	2	2.0	24.5	a, c, n	reduced loudness	1.0
							(2)
43	M	69	6	2.0	36.0	a, k	reduced loudness monotone
							(3)
44	M	64	10	3.0	43.0	a	imprecise articulation monotone	1.5
							(4)
45	M	54	3	1.0	3.0	b, c, h	reduced loudness monotone
							(1)
Mean (M)		64.9	7.3	2.4	27.1		3.0	1.1
(SD)		(8.7)	(5.2)	(0.8)	(15.0)		(0.95)	(0.2)
Group Mean		65.6	5.9	2.3	25.6		2.74	1.38
(SD)		(8.9)	(4.7)	(0.8)	(14.4)		(1.15)	(0.4)

* Parkinson medications a = sinemet, b = sinemet-cr, c = eldyprel, d = parlodel, e = Symmetrel, f = pergolide, g = cogentin, h = artane i = amantadine, j = permax, k = deprenyl, I = parsidol † Anti-depressants n = amitriptyline, o = tofranil, p = elavil ∼ unavailable Note. Glottal incompetence ratings are on a scale of 1–5. 1 = slight, 3 = moderate, 5 severe. Higher scores on the UPDRS indicate greater disability. Scores range from 0–108.

View Large

TABLE 2.Descriptive characteristics of subjects who received the Lee Silverman Voice Treatment (voice and respiration) and subjects who received treatment focusing only on respiration.

Subject	Sex	Age	Years since diagnosis	Hoehn & Yahr stage (1967)	UPDRS Motor exam	Medication* †	Speech/Voice deficits (severity rating)	Glottal incompetence
Subjects who received the Lee Silverman Voice Treatment
1	F	73	10	4.0	48.0	a, c, f	reduced loudness imprecise articulation	2.25
							(5)
2	F	52	13	3.0	17.0	a, f, o	reduced loudness rapid rate	1.50
							(3)
3	F	49	9	2.0	4.0	a, d, g	hoarseness	1.5
						(1)
4	F	32	1	2.0	UA∼	a, j	hoarseness
							(1)
5	F	74	1	1.5	12.0	b, c	hoarseness tremor
							(2)
Mean (F)		56.0	6.8	2.5	20.25		2.4	1.75
(SD)		(17.7)	(5.5)	(1.0)	(19.3)		(1.67)	(0.4)
6	M	49	1	2.0	13.0	a, b, c	monotone reduced loudness	1.33
							(1)
7	M	76	1	2.0	20.0	a	hoarseness monotone
							(2)
8	M	76	5	3.0	28.0	b, c, I	imprecise articulation reduced loudness	1.75
							(3)
9	M	62	3	2.0	26.0	a, c	hoarseness reduced loudness	2.0
							(3)
10	M	71	11	3.5	43.5	i, h	hoarseness reduced loudness	1.75
							(4)
11	M	50	18	2.0	19.5	a, c, d	reduced loudness monotone
							(2)
12	M	68	6	3.0	40.5	a, k	reduced loudness hoarseness	2.0
							(3)
13	M	75	20	3.5	47.0	b, n	reduced loudness imprecise articulation	1.25
							(4)
14	M	69	1	3.0	32.0	none	imprecise articulation reduced loudness
							(2)
15	M	61	1	2.0	16.0	a, c	reduced loudness imprecise articulation	1.0
							(2)
16	M	72	5	3.0	30.0	a, c, h	reduced loudness monotone	1.0
							(2)
17	M	67	8	3.0	16.0	a	reduced loudness imprecise articulation	1.75
							(3)
18	M	64	7	2.0	26.0	a,	monotone reduced loudness	1.0
							(2)
19	M	73	10	3.0	27.5	a, h	monotone reduced loudness
							(3)
20	M	79	1	3.0	33.0	a, c	monotone imprecise articulation
							(3)
21	M	62	4	3.5	35.0	k, n	aphonia hoarseness
							(4)
Subjects who received the Lee Silverman Voice Treatment
22	M	52	18	3.0	34.0	a, c, d, e	rapid rate reduced loudness
							(3)
23	M	75	7	2.0	32.0	a, c	reduced loudness hoarseness
						(3)
24	M	61	4	3.0	22.5	a, c, d	imprecise articulation reduced loudness
						(4)
25	M	54	15	3.5	45.5	b, i, k	reduced loudness monotone	2.25
						(4)
26	M	56	7	2.0	2.0	a, c, h	rapid rate reduced loudness	1.0
						(3)
Mean (M)		65.3	8.7	2.7	28.0		2.86	1.5
(SD)		(9.3)	(10.1)	(0.6)	(11.3)		(0.85)(0.5)
Group Mean		63.5	8.3	2.7	26.8		2.77	1.6
(SD)		(11.5)	(9.3)	(0.7)	(12.7)	(1.03)	(0.45)
Subjects who received treatment focusing only on respiration
27	F	64	2	3.0	29.0	a, c, p	hoarseness reduced loudness	1.55
							(1)
28	F	71	3	1.0	UA∼	a	hoarseness tremor
							(2)
29	F	68	1	2.0	1.0	a, b, c	reduced loudness
							(1)
30	F	68	4	2.0	12.0	a, c	reduced loudness monotone	1.75
							(3)
31	F	63	3	3.0	42.0	a, c	imprecise articulation slow rate	2.5
							(4)
32	F	51	4	1.0	16.0	none	reduced loudness	1.75
							(1)
33	F	83	7	3.0	33.0	a	strained/strangled rapid rate	1.75
							(4)
Mean (F)		66.9	3.4	2.1	23.6		2.29	1.8
(SD)		(9.6)	(1.9)	(0.9)	(14.3)		(1.38)	(0.2)
34	M	70	4	3.0	32.0	a, c	reduced loudness monotone	1.0
							(3)
35	M	71	4	3.0	43.0	a, n	reduced loudness monotone	1.25
							(4)
36	M	69	1	2.0	27.0	i	monotone reduced loudness
							(3)
37	M	65	8	3.0	19.0	none	imprecise articulation rapid rate	1.0
							(2)
38	M	52	14	2.0	31.0	a, d, e, p	pallilalia rapid rate	1.0
							(3)
39	M	67	18	3.5	UA	b, c, j	imprecise articulation reduced loudness
							(4)
40	M	51	6	1.5	3.0	a, c	rapid rate pallilalia
							(4)
41	M	66	12	3.0	41.0	a, c, i	strained/strangled reduced loudness
							(3)
Subjects who received treatment focusing only on respiration
42	M	81	2	2.0	24.5	a, c, n	reduced loudness	1.0
							(2)
43	M	69	6	2.0	36.0	a, k	reduced loudness monotone
							(3)
44	M	64	10	3.0	43.0	a	imprecise articulation monotone	1.5
							(4)
45	M	54	3	1.0	3.0	b, c, h	reduced loudness monotone
							(1)
Mean (M)		64.9	7.3	2.4	27.1		3.0	1.1
(SD)		(8.7)	(5.2)	(0.8)	(15.0)		(0.95)	(0.2)
Group Mean		65.6	5.9	2.3	25.6		2.74	1.38
(SD)		(8.9)	(4.7)	(0.8)	(14.4)		(1.15)	(0.4)

Patients were excluded from participation in this study if they had a form of Parkinson disease other than idiopathic or a laryngeal pathology that would contraindicate phonatory effort treatment (e.g., vocal nodules, gastric reflux). Voice treatment efficacy data from patients with non-idio-pathic Parkinsonism such as Shy-Drager syndrome, multiple system atrophy, progressive supranuclear palsy and bilateral thalamotomy are summarized elsewhere (Countryman & Ramig, 1993; Countryman et al., 1994).

Baseline Neurology, Neuropsychology, Otolaryngology, and Speech Assessments

Neurological assessment

Routine neurological assessment was carried out on all subjects within 1 month of the initiation of treatment. Stage of Parkinson disease, score on the motor examination section (section III) of the UPDRS, time since diagnosis, and anti-Parkinson medications are summarized in Table 2. Subjects were considered neuro-pharmacologically stable before and during treatment and did not change medications or dosage during the treatment period.

Neuropsychological assessment

A battery of neuropsychological tests was administered within 1 month of the initiation of treatment to determine status of cognitive functioning in these Parkinson disease subjects. These measures focused on attention and concentration, learning and memory, vocabulary and auditory verbal comprehension, and visual spatial skills. Four subtests from the Wechsler Adult Intelligence Scale-Revised were administered (Vocabulary, Block Design, Object Assembly, Digit Symbol; Wechsler, 1981). In addition, parts A and B of the Trail Making Test (Reitan & Wolfson, 1985), the Digit Vigilance Test (Lewis & Kupke, 1977), Story and Figure Memory Test (Heaton, Chelune, & Lehman, 1978), and the Complex Ideational Material auditory comprehension subtest from the Boston Diagnostic Aphasia Exam (Goodglass & Kaplan, 1972) were included. These measures produced 13 scores, all of which were converted to T scores (mean of 50, standard deviation of 10) that correct for demographic variables of age, education, and sex (Heaton, Grant, & Matthews, 1991). After completion of the cognitive evaluation, subjects were interviewed by the clinical neuropsychologist, who then rated depression using the Montgomery Asberg Depression Rating Scale (MADRS; Montgomery & Asberg, 1979). At this time subjects also completed a self-report depression scale, the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) as well as the Sickness Impact Profile (SIP; Bergner, Bobbit, Carter, & Gilson, 1981). The SIP instrument assesses the extent to which patients perceive their illness to affect 12 different areas of their lives. For the purposes of this paper, the individual scores for the impact of illness on communication and social interaction were included. Both the BDI and the SIP were completed pretreatment and post-treatment after completion of the last speech treatment session. Pretreatment neuropsychological data for each individual subject as well as group means are summarized in Table 3. Results of analysis of variance revealed no significant differences between treatment groups in cognitive functioning, level of depression, or sickness impact on communication or social interaction at baseline. However, a main effect for gender was revealed for the self-rating of depression, F(1,41) = 7.368, p = .010, as well as clinical rating of depression, F(1,41) = 9.971, p = .003, with the females (n = 12) being more depressed than the males (n = 33).

TABLE 3.Neuropsychological characteristics of the Lee Silverman Voice Treatment (voice and respiration) subjects and the respiration-only subjects.

Subject	Cognition (T score)	Beck Depression (self-rating)	Depression (clinician’s rating)	SIP communication	SIP social interaction
Subjects who received the Lee Silverman Voice Treatment
1	40.38	10	12	65.24	12.55
2	40.08	11	7	56.41	13.03
3	40.54	20	14	0.00	33.93
4	45.31	20	9	9.66	13.17
5	42.62	14	11	9.66	11.03
Mean (F)	41.79	15.0	10.6	28.19	16.74
(SD)	(2.21)	(7.28)	(2.70)	(30.21)	(9.65)
6	46.54	6	3	0.00	0.00
7	47.00	5	0	9.66	0.00
8	42.69	0	3	21.10	3.59
9	44.54	2	7	9.66	9.03
10	42.69	6	6	56.00	7.38
11	39.54	3	8	31.31	6.00
12	41.15	4	7	39.17	3.52
13	42.62	13	15	22.48	9.10
14	44.08	4	5	67.86	0.00
15	45.69	1	4	0.00	0.00
16	39.77	12	3	41.79	18.62
17	48.69	12	8	65.24	11.79
18	50.31	3	1	30.24	0.00
19	43.54	16	5	40.41	0.00
20	41.23	4	6	51.86	17.03
21	37.38	12	5	63.03	24.89
22	42.08	12	8	63.86	3.52
23	53.69	15	13	11.45	11.45
24	44.38	8	13	52.41	6.83
25	50.38	10	5	28.97	6.83
26	48.31	11	3	30.76	15.72
Mean (M)	44.59	7.57	6.10	35.11	7.40
(SD)	(4.08)	(4.87)	(3.86)	(21.75)	(7.11)
Group Mean	44.05	9.0	6.96	33.78	9.19
(SD)	(3.92)	(5.62)	(4.05)	(23.07)	(8.33)
Subjects who received treatment focusing only on respiration
27	53.31	10	9	0.00	0.00
28	39.31	7	7	39.17	6.07
29	48.85	12	0	0.00	0.00
30	50	3	7	18.48	6.48
31	40.54	25	19	73.10	55.17
32	52.77	13	12	0.00	26.76
33	40.54	12	11	55.03	9.10
Mean (F)	46.47	11.71	9.29	26.54	14.80
(SD)	(6.14)	(6.82)	(5.79)	(29.77)	(19.95)
34	49.38	11	1	0.00	3.52
35	34.46	10	3	32.55	17.59
36	50.69	11	1	9.66	3.52
37	43.85	0	3	40.41	3.52
38	43.54	22	6	52.41	31.38
39	40.31	10	3	66.21	20.41
40	46.08	3	6	9.66	11.45
41	50.08	13	11	63.86	18.69
42	49.23	5	5	9.66	20.48
43	37.54	12	2	31.31	9.59
44	33.91	8	13	52.41	7.10
45	51.92	1	5	0.00	0.00
Mean (M)	44.25	8.83	4.92	30.68	12.27
(SD)	(6.42)	(6.04)	(3.75)	(24.52)	(9.45)
Group Mean	45.07	9.90	6.53	29.15	13.20
(SD)	(6.24)	(6.31)	(4.95)	(25.83)	(13.74)

Note. T scores below 40 are considered impaired. Scores above 9 on self-rating of depression suggest some depression. Scores of 6 or greater on clinician ratings of depression are suggestive of depression. Scores that are larger on the SIP indicate more impact of the sickness in that area. Scores of 0.00 on the SIP indicate no difficulty in that area.

View Large

TABLE 3.Neuropsychological characteristics of the Lee Silverman Voice Treatment (voice and respiration) subjects and the respiration-only subjects.

Subject	Cognition (T score)	Beck Depression (self-rating)	Depression (clinician’s rating)	SIP communication	SIP social interaction
Subjects who received the Lee Silverman Voice Treatment
1	40.38	10	12	65.24	12.55
2	40.08	11	7	56.41	13.03
3	40.54	20	14	0.00	33.93
4	45.31	20	9	9.66	13.17
5	42.62	14	11	9.66	11.03
Mean (F)	41.79	15.0	10.6	28.19	16.74
(SD)	(2.21)	(7.28)	(2.70)	(30.21)	(9.65)
6	46.54	6	3	0.00	0.00
7	47.00	5	0	9.66	0.00
8	42.69	0	3	21.10	3.59
9	44.54	2	7	9.66	9.03
10	42.69	6	6	56.00	7.38
11	39.54	3	8	31.31	6.00
12	41.15	4	7	39.17	3.52
13	42.62	13	15	22.48	9.10
14	44.08	4	5	67.86	0.00
15	45.69	1	4	0.00	0.00
16	39.77	12	3	41.79	18.62
17	48.69	12	8	65.24	11.79
18	50.31	3	1	30.24	0.00
19	43.54	16	5	40.41	0.00
20	41.23	4	6	51.86	17.03
21	37.38	12	5	63.03	24.89
22	42.08	12	8	63.86	3.52
23	53.69	15	13	11.45	11.45
24	44.38	8	13	52.41	6.83
25	50.38	10	5	28.97	6.83
26	48.31	11	3	30.76	15.72
Mean (M)	44.59	7.57	6.10	35.11	7.40
(SD)	(4.08)	(4.87)	(3.86)	(21.75)	(7.11)
Group Mean	44.05	9.0	6.96	33.78	9.19
(SD)	(3.92)	(5.62)	(4.05)	(23.07)	(8.33)
Subjects who received treatment focusing only on respiration
27	53.31	10	9	0.00	0.00
28	39.31	7	7	39.17	6.07
29	48.85	12	0	0.00	0.00
30	50	3	7	18.48	6.48
31	40.54	25	19	73.10	55.17
32	52.77	13	12	0.00	26.76
33	40.54	12	11	55.03	9.10
Mean (F)	46.47	11.71	9.29	26.54	14.80
(SD)	(6.14)	(6.82)	(5.79)	(29.77)	(19.95)
34	49.38	11	1	0.00	3.52
35	34.46	10	3	32.55	17.59
36	50.69	11	1	9.66	3.52
37	43.85	0	3	40.41	3.52
38	43.54	22	6	52.41	31.38
39	40.31	10	3	66.21	20.41
40	46.08	3	6	9.66	11.45
41	50.08	13	11	63.86	18.69
42	49.23	5	5	9.66	20.48
43	37.54	12	2	31.31	9.59
44	33.91	8	13	52.41	7.10
45	51.92	1	5	0.00	0.00
Mean (M)	44.25	8.83	4.92	30.68	12.27
(SD)	(6.42)	(6.04)	(3.75)	(24.52)	(9.45)
Group Mean	45.07	9.90	6.53	29.15	13.20
(SD)	(6.24)	(6.31)	(4.95)	(25.83)	(13.74)

Otolaryngologicsl assessment

An otolaryngological history and videolaryngostroboscopy examination were obtained on all subjects prior to beginning treatment. Laryngeal imaging and videolaryngostroboscopy examination were conducted utilizing well-described techniques (Bless, Hirano, & Feder, 1987). The nasal passage was topically anesthetized with 4% lidocaine spray. Endoscopic examination was conducted with both an Olympus ENF-P3 fiberscope and Nagashima SFT-1 70-degree rigid telescope. Light sources included both an Olympus halogen constant light source and a Nagashima LS-3A laryngoscope. The subjects were instructed to say /i/ at a comfortable pitch and loudness. Images were recorded with a CCD camera, using a 35-mm lens for the fiberscope and 60-mm lens for the rigid telescope, and a VHS or SVHS tape recorder. The data for pretreatment glottal incompetence ratings were prepared by creating a “master” study videotape that included segments from the laryngostroboscopic videotapes of each subject. The order of the subject videotapes was determined by a computer random number generator. Six subjects’ recordings were repeated to assess intrajudge reliability. The audio signal from each subject tape was removed to eliminate auditory perceptual cues. Instead, a “prompter” was over-dubbed onto the audio track information that identified the tasks performed during examination of each patient to allow raters to identify them. Glottal incompetence was rated during comfortable pitch, comfortable loudness /i/. Three speech-language pathologists and one otolaryngologist with experience in voice research assessed the recordings. They independently and as a group viewed a practice tape, and met several times to develop standard rating criteria. Ninety-five percent intrarater agreement was achieved on the practice tape. Following the practice procedures, they independently viewed and rated the master tape. Twenty-four percent of the glottal incompetence ratings were reanalyzed to determine reliability. Interexaminer reliability ranged between .78 and .94 whereas intraexaminer reliability ranged between .87 and 1.0. The magnitude of glottal incompetence pretreatment is summarized in Table 2 for 25 of the 45 subjects. Videostroboscopy ratings could not be obtained on 20 subjects due to their inability to tolerate the procedure, excessive involuntary movement, or technical problems. Results of analysis of variance revealed no significant difference between the two treatment groups in glottal incompetence at baseline. Additional details of pretreatment (Perez, Ramig, Smith, & Dromey, in press) and pre- to post-treatment laryngological characteristics (Smith et al., in press) have been previously reported.

Speech assessment

Standard speech and voice assessments were completed at the time of the first pretreatment data collection session. None of the subjects exhibited oral motor and/or speech and voice characteristics uncommon to Parkinson disease. The primary speech and/or voice characteristics and severity of speech disorder rating for each subject determined by clinical observations are presented in Table 2.

In order to provide additional descriptive information on the subjects and to evaluate the relationship between magnitude of speech and voice disorder and severity of Parkinson disease, correlation coefficients were completed on these baseline data for all 45 subjects. Severity of speech and voice disorder rated on a 1–5 point scale at the time of clinical intake (pre-treatment) were correlated (Pearson product moment) with the variables time since diagnosis (r = .43, p = .003), rating on the motor examination section of the UPDRS (r = .63, p = .001), Parkinson disease stage (r = .62, p = .001), and depression rating (r = .45, p = .004). These findings suggest that subjects who had Parkinson disease longer and were more motorically impaired also had more severe speech and voice deficits.

EXPERIMENT

Instrumentation

In order to measure intensity, frequency, and duration data, sound pressure level (B & K 2230 sound level meter) and microphone (AKG C410) signals were transduced and recorded onto a Sony PC-108M 8-channel digital audiotape recorder (DAT). Forced vital capacity was measured with a Collins wet spirometer (Model RS 2785).

Tasks

Experimental tasks were designed to sample a broad continuum of speech production to address both underlying mechanisms of treatment-related change as well as functional aspects of speech production. Data were collected while subjects performed the following tasks: forced vital capacity, maximum duration sustained vowel phonation, reading of the phonetically balanced “Rainbow Passage” (Fairbanks, 1960) and 25–30 sec of conversational monologue. Because the sound level meter and microphone offer noninvasive signal transduction, measures of intensity, frequency, and duration could be collected from all subjects.

In order to evaluate the subjects’ impressions of treatment effectiveness and the impact of treatment on functional communication, perceptual rating scales were completed by all 45 subjects at the time of data collection. Family members from 20 of the 45 subjects completed the perceptual rating scales as well.

Procedures

Pretreatment experimental data were collected within the week before treatment was initiated. Post-treatment data were collected within the week following treatment. For assessment of intrasubject variability and reliability, 58% of the subjects repeated their pretreatment data collection and 36% of the subjects repeated their post-treatment data collection. For experimental data collection, subjects were seated in a medical examining chair located in an IAC sound-treated booth and transducers were positioned and calibrated using standard procedures. The sound level meter was positioned 50 cm from the lips and the microphone was positioned on a head mount 8 cm from the lips. A calibration tone of known intensity was generated at the subjects’ lips at the beginning and end of each recording session.

After 2 minutes of tidal breathing, forced vital capacity was measured. Subjects were asked to take their deepest breath and blow out “as hard and fast and long as you can.” This task was repeated two or three times at the beginning and end of the recording session and the best performance was taken as maximum forced vital capacity. Because of motor and balance problems of some subjects, all subjects performed the task in a seated position. One subject could not perform the task pre- or post-treatment.

To obtain maximum duration sustained vowel phonation, subjects were instructed to “take a deep breath and sustain ‘ah’ for as long as you can.” A timer with a second hand was within view of the subjects and they were encouraged to monitor their performance and sustain phonation for a longer duration each time. No instructions were given for loudness level. This task was repeated four times at the beginning of the recording session and two times at the end of each recording. For a few subjects, only three of the initial four consecutive maximum duration sustained phonations were possible, due to fatigue. Because of potential instabilities in measures of maximum performance associated with subjects’ inconsistent generation of maximum effort (Kent, Kent, & Rosenbek, 1987) as well as the variability in the performance of Parkinson disease patients (Canter, 1965; King, Ramig, Lemke, & Horii, 1994), the experimenter was careful to elicit consistent maximum effort performance from each subject at each recording trial as determined by her clinical decision. The same experimenter collected all the data.

Samples of reading and conversational speech were obtained by asking subjects to read aloud the “Rainbow Passage” at a comfortable rate and loudness and generate a 25–30 sec monologue on a topic of their choice.

A visual analog scale (Kempster, 1984; Schiffman, Reynolds, & Young, 1981) was used to obtain subject self-ratings as well as family member ratings of loudness, monotonicity, hoarseness, overall intelligibility, and the extent to which the subject initiated conversation.

Treatment

Both forms of treatment were designed to be intensive (16 sessions in one month) and high effort (subject was pushed to maximum performance levels throughout the entire duration of each session). Each type of treatment stimulated high effort tasks in repeated drills for half of each 50-minute treatment session and then stimulated carryover of the drilled behavior to speech tasks during the final half of each session. The implementation of high effort, intensive treatment is based on neurology and physical therapy practices (England & Schwab, 1959; Hallet & Khosbin, 1980; McDowell, Lee, & Sweet, 1986) that suggest when pushed to higher effort levels, patients with Parkinson disease can compensate for bradykinesia and improve task performance. The daily training of high effort to increase magnitude of speech motor output is based upon the potentially similar problems in scaling the magnitude of output (e.g., stride length in walking, letter stroke in writing) observed in patients with Parkinson disease (Brooks, 1986; Grill, Demirchi, Mc Shane, & Hallett, personal communication; Muller & Stelmach, 1991; Stemach, 1991). We speculate that intensive high effort speech treatment teaches patients to rescale the magnitude of speech motor output (Ramig, 1995; Ramig, Bonitati, Lemke, & Horii, 1994) and that daily treatment with intensive practice (Schmidt, 1975, 1988) and feedback (knowledge of results) (Adams, 1971, 1986) facilitates this training.

The respiratory treatment (R) was designed to train increased respiratory muscle activity for inspiration and expiration and sustained expiration to enable subjects to generate increased volumes and subglottal air pressure for speech (Leinonen & Laakso, 1990; McKenzie & Gandevia, 1986; Netsell & Daniel, 1979; Panzarella, 1995; Yorkston, Beukelman, & Bell, 1988). The R treatment trained subjects to increase respiratory effort through tasks such as maximum inhalation and exhalation (Hardy, 1983; Netsell & Rosenbek, 1986), maximum duration of the voiceless continuants /s/ and /f/, and sustained intraoral air pressure (with and without leak tube) (Iowa Oral Performance Instrument [IOPI]; Leith & Bradley, 1976; Robin, Goel, Somodi, & Luschei, 1992). Subjects were stimulated to take deep, frequent breaths during reading and speaking and were given visual feedback (NIMS Respigraph System PN SY03) of the excursion of their rib cage and abdomen during both sustaining of /s/ and /f/ and while reading and speaking. In the respiratory treatment group, no attention was directed toward increasing vocal fold adduction or increasing vocal loudness.

The voice and respiratory treatment (LSVT) focused on increased vocal loudness through increasing vocal fold adduction. Tasks such as pushing the hands together or pushing down or lifting up on the arms of a chair or table while phonating (Aronson, 1990; Froeschels, Kastein, & Weiss, 1955) were used to stimulate increased vocal fold adduction. Drills were carried out on tasks such as maximum duration “ah” phonation and maximum fundamental frequency range. Subjects were encouraged to “think loud” during these tasks and use the same loud, good quality voice generated during sustained phonation during reading and speaking. Attention was directed toward the respiratory system only in the form of encouraging these subjects to take deep breaths frequently and speak “on top of the breath.” However, because maximum effort phonatory tasks such as maximum duration of sustained vowel phonation also stimulate respiratory function, the treatment was considered to address both voice and respiration. Feedback for adequate loudness was given using a voice light (lights up at target intensity level) and tape recorder (for self-monitoring of intensity). Training materials for the LSVT approach are summarized elsewhere (Countryman, Ramig, & Pawlas, 1994; Ramig, 1995; Ramig, Bonitati, & Winholtz, 1994; Ramig, Pawlas, & Countryman, 1995).

It is important to point out that the treatment goal of increasing vocal fold adduction in Parkinson disease is designed to maximize the efficiency of the phonatory source. Because of the glottal incompetence frequently observed in patients with Parkinson disease, increased vocal fold adduction may allow patients the ability to generate adequate intensity. It is never the goal of treatment to increase vocal fold adduction so the voice becomes pressed or hyperad-ducted. The goal is a voice with sufficient loudness, generated with maximum phonatory efficiency (Ramig, 1995).

The treatment intensiveness, daily homework, daily quantification of treatment variables and carryover were all stimulated equally in both treatment groups. Subjects in both treatment groups made progress during treatment as reflected in their daily treatment variables (e.g., maximum durations and ranges). No attention was directed toward improvement of intonation, articulation, or rate in either treatment group. Two clinicians delivered the treatment to all the subjects; both clinicians administered both forms of treatment and were randomly assigned to individual patients. The clinicians worked closely together to ensure consistency and equivalent high effort and motivation across both forms of treatment. A typical treatment session consisted of 25 min of repeated and intensive maximum effort drills and 25 min of high effort speech production tasks moving through a hierarchy of single words, phrases, sentences, reading, and conversation during the 4-week period. Performance feedback (knowledge of results; Adams, 1971, 1986) was provided to subjects using a variety of instruments: tape recorder, stop watch, voice light, respigraph, IOPI, visipitch, and vocal demodulator (Winholtz & Ramig, 1992) depending upon the treatment group.

Data analysis

Sound pressure level (SPL) measures for sustained phonation, reading and the monologue were analyzed using a custom-built software program. The sound level meter signal (Bruel and Kjaer 2230) was preamplified and then digitized at 5000 samples per second into a VAX 4000/200 system computer through a 16-bit resolution DSC-200 A/D converter. The software program displayed the sound level meter signal in decibels (dB). To avoid the inclusion of nonvoiced or pausal segments in the analysis, data points below the noise floor were eliminated from the signal. This was achieved by cursor-marking the first and last negativegoing peaks of the signal and then identifying the percentage below which nonvoiced or pausal data points occurred. The percentage was input into the analysis program and the signal was displayed with the percentage cutoff line. This enabled the analyzer to determine if the correct percentage was chosen. After the correct percentage was determined, the program displayed the mean SPL of the signal.

The SPL was measured from five to six maximum duration sustained “ah” vowel phonations and one reading of the “Rainbow Passage” per recording session for all 45 subjects. Due to limited and variable utterance duration, the SPL for conversational monologue was obtained from 29 of the 45 subjects pre- to post-treatment. The average duration of these monologues ranged from 25–30 sec.

Duration of sustained vowel phonation was also calculated by the SPL program using the markings between the first and last negative going peaks. Duration and SPL data were obtained from the same five to six sustained vowel phonations for each subject. After obtaining the mean SPL for each individual /a/, data were averaged across all maximum duration sustained vowel phonations to obtain an overall average mean SPL for sustained phonation.

To obtain measures of mean fundamental frequency and fundamental frequency variability during reading and monologue, the microphone signal was digitized at 5000 samples per second into the same VAX system described above. The files were downloaded onto a 486 computer and then analyzed using CSpeech software (Milenkovic, 1987). The program calculated mean fundamental frequency (F₀) and standard deviation in Hertz. Using standard procedures, the Hertz standard deviation was then converted to express frequency variability in semitones (STSD) (Horii, 1994). Two subjects in the R group had unanalyzable habitual fundamental frequency and fundamental frequency variability data during reading due to severe dysphonia.

Utterance and pause duration data were obtained from both the “Rainbow Passage” and the 25–30 sec monologue. The data of 4 subjects during reading of the “Rainbow Passage” were unanalyzable; thus, 41 passages and 29 monologues were analyzed. The recorded voices were played back, fullwave rectified and smoothed by an RC lowpass filter (Dobkin, 1969). The rectifying and smoothing extracted the intensity envelope in real time. This intensity envelope was digitized by a 12-bit analog-to-digital converter at a rate of 1000 times per second and stored on a 386 microcomputer disk using CSRE (Canadian Speech Research Environment) software.

The digital intensity envelope was subsequently analyzed for utterance and pause durations by software developed by Horii (1983) . Given a specification of the maximum amplitude threshold for pause, the minimum duration of pause, and the minimum duration of utterance, the program identified utterances and pauses. The program then printed out means and standard deviations of utterance and pause durations reported here. Standard procedures for analysis of visual analog scales (Boeckstyns & Backer, 1989) were used to obtain perceptual data from the subjects and families.

Results

Reliability

For an assessment of intra-subject reliability, 58% of the subjects completed a second pretreatment voice recording and 36% of the subjects completed a second post-treatment voice recording. One hundred percent of the subjects completed a second set of perceptual self-rating scales pre-and post-treatment. Correlation coefficients reflecting intrasubject reliability for all acoustic and perceptual variables are summarized in Table 4. T-tests for related measures were carried out on the acoustic and perceptual variables obtained in the two pre- and the two post-recordings. There were no significant differences among any of these repeated measures. Reliability of perceptual ratings completed by the families are also included in Table 4. Sixty percent of the 20 families completed a second pretreatment visual analog scale and 20% completed a second post-treatment visual analog scale.

TABLE 4.Intrasubject (test-retest) reliability for acoustic and perceptual variables expressed in Pearson product-moment correlation coefficients.

Variables	Pre-1 to Pre-2 correlations	Post-1 to Post-2 correlations
SPL
Sustained phonation	0.78	0.96
Rainbow Passage	0.78	0.97
Monologue	0.82	0.82
Maximum duration	0.83	0.93
STSD
Rainbow Passage	0.95	0.91
Monologue	0.39	0.43
F₀
Rainbow Passage	0.98	0.99
Monologue	0.96	0.96
FVC	0.98	0.99
Perceptual-Subject (n = 45)
Loudness	0.65	0.68
Monotonicity	0.55	0.72
Hoarseness	0.69	0.45
Intelligibility	0.67	0.76
Initiate conversation	0.81	0.83
Perceptual-Family (n = 20)
Loudness	0.61	0.86
Monotonicity	0.87	0.99
Hoarseness	0.75	0.92
Intelligibility	0.63	0.98
Initiate conversation	0.93	0.71

Note. Correlation coefficients are based upon the following sample sizes: 58% of the 45 subjects repeated the pre-treatment and 36% of the 45 subjects repeated the post-treatment acoustic measures; 100% of the 45 subjects repeated the pre- and post-treatment perceptual self-ratings; 60% of the 20 families repeated the pretreatment and 20% of the 20 families repeated the post-treatment perceptual ratings.

View Large

TABLE 4.Intrasubject (test-retest) reliability for acoustic and perceptual variables expressed in Pearson product-moment correlation coefficients.

Variables	Pre-1 to Pre-2 correlations	Post-1 to Post-2 correlations
SPL
Sustained phonation	0.78	0.96
Rainbow Passage	0.78	0.97
Monologue	0.82	0.82
Maximum duration	0.83	0.93
STSD
Rainbow Passage	0.95	0.91
Monologue	0.39	0.43
F₀
Rainbow Passage	0.98	0.99
Monologue	0.96	0.96
FVC	0.98	0.99
Perceptual-Subject (n = 45)
Loudness	0.65	0.68
Monotonicity	0.55	0.72
Hoarseness	0.69	0.45
Intelligibility	0.67	0.76
Initiate conversation	0.81	0.83
Perceptual-Family (n = 20)
Loudness	0.61	0.86
Monotonicity	0.87	0.99
Hoarseness	0.75	0.92
Intelligibility	0.63	0.98
Initiate conversation	0.93	0.71

Twenty percent of the data were reanalyzed to determine measurement reliability. Correlation coefficients were 0.99 for all measures of SPL, STSD, and F₀ of the “Rainbow Passage,” F₀ during conversation, and maximum duration of sustained vowel phonations, and 0.92 for STSD in conversational monologue. Twenty percent of the perceptual data from the subjects’ self-ratings as well as the families’ perceptual ratings were remeasured to determine measurement reliability. Correlation coefficients were 0.99 for all categories of the visual analog scale.

Acoustic Variables

An analysis of variance carried out to determine pretreatment comparability between the two groups on acoustic and perceptual variables revealed no significant differences. In addition, there were no statistically significant differences on these acoustic and perceptual variables between the two groups of males or the two groups of females at baseline.

A three factor (treatment group × gender × time) repeated measures analysis of variance (ANOVA) was used to evaluate the statistical significance of pre- to post-treatment changes (Campbell & Stanley, 1966). F and p values for the acoustic variables are reported in Table 5. All means and standard deviations of each acoustic variable for each group and gender pre- to post-treatment are summarized in Table 6.

TABLE 5.F and p values for the acoustic variables.

	Between-subject effect									Within-subject effect
Dependent variables	Group		Gender		Group × Gender		Time			Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	df	F	p	F	p	F	p	F	p
SPL
Sustained phonation	15.55	.000	0.49	.486	0.66	.421	1,41	43.63	.000	53.72	.000	0.11	.738	7.37	.01
Rainbow Passage	4.88	.033	5.30	.027	4.62	.037	1,41	29.41	.000	4.70	.036	1.62	.210	4.85	.033
Monologue	0.39	.537	3.65	.067	1.14	.296	1,25	14.02	.001	3.27	.083	3.67	.067	1.90	.180
Maximum duration	1.68	.202	1.49	.230	.85	.361	1,41	9.29	.004	.63	.431	.51	.480	.48	.493
F₀							1,39
Rainbow Passage	6.48	.015	83.64	.000	1.34	.252		35.58	.000	1.14	.292	1.52	.225	1.61	.212
STSD							1,39
Rainbow Passage	2.20	.146	1.45	.235	.90	.348		43.29	.000	1.98	.168	.00	.968	2.40	.129
F₀							1,25
Monologue	.88	.358	85.92	.000	1.39	.250		3.62	.069	2.97	.097	.61	.443	.03	.856
STSD							1,25
Monologue	.22	.645	.50	.484	.32	.578		1.02	.321	8.48	.007	.43	.516	.94	.340
Utterance duration
Rainbow Passage	.07	.786	.60	.442	.90	.350	1,37	19.30	.000	.16	.696	.03	.864	.03	.875
Monologue	1.36	.254	8.90	.006	4.47	.044	1,27	2.23	.147	1.84	.186	.45	.506	.07	.793
Pause duration
Rainbow Passage	2.97	.093	1.67	.204	4.83	.034	1,37	30.15	.000	6.61	.014	.85	.364	2.79	.103
Monologue	2.02	.167	.29	.593	1.06	.313	1,27	1.87	.183	3.02	.093	.65	.427	3.06	.091
FVC	.70	.408	17.87	.000	.30	.586	1,40	.04	.852	.28	.599	.03	.870	2.15	.151

View Large

TABLE 5.F and p values for the acoustic variables.

	Between-subject effect									Within-subject effect
Dependent variables	Group		Gender		Group × Gender		Time			Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	df	F	p	F	p	F	p	F	p
SPL
Sustained phonation	15.55	.000	0.49	.486	0.66	.421	1,41	43.63	.000	53.72	.000	0.11	.738	7.37	.01
Rainbow Passage	4.88	.033	5.30	.027	4.62	.037	1,41	29.41	.000	4.70	.036	1.62	.210	4.85	.033
Monologue	0.39	.537	3.65	.067	1.14	.296	1,25	14.02	.001	3.27	.083	3.67	.067	1.90	.180
Maximum duration	1.68	.202	1.49	.230	.85	.361	1,41	9.29	.004	.63	.431	.51	.480	.48	.493
F₀							1,39
Rainbow Passage	6.48	.015	83.64	.000	1.34	.252		35.58	.000	1.14	.292	1.52	.225	1.61	.212
STSD							1,39
Rainbow Passage	2.20	.146	1.45	.235	.90	.348		43.29	.000	1.98	.168	.00	.968	2.40	.129
F₀							1,25
Monologue	.88	.358	85.92	.000	1.39	.250		3.62	.069	2.97	.097	.61	.443	.03	.856
STSD							1,25
Monologue	.22	.645	.50	.484	.32	.578		1.02	.321	8.48	.007	.43	.516	.94	.340
Utterance duration
Rainbow Passage	.07	.786	.60	.442	.90	.350	1,37	19.30	.000	.16	.696	.03	.864	.03	.875
Monologue	1.36	.254	8.90	.006	4.47	.044	1,27	2.23	.147	1.84	.186	.45	.506	.07	.793
Pause duration
Rainbow Passage	2.97	.093	1.67	.204	4.83	.034	1,37	30.15	.000	6.61	.014	.85	.364	2.79	.103
Monologue	2.02	.167	.29	.593	1.06	.313	1,27	1.87	.183	3.02	.093	.65	.427	3.06	.091
FVC	.70	.408	17.87	.000	.30	.586	1,40	.04	.852	.28	.599	.03	.870	2.15	.151

TABLE 6.Means and standard deviations (in parentheses) for the acoustic variables collected pre- to post-treatment. Means are listed for each group as well as males and females. The n is listed for each group, LSVT followed by R.

	LSVT		R only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Intensity (dB) (at 50cm)
Sustained phonation
Group (n = 26;19)	68.20 (4.70)	81.20 (4.65)	69.32 (5.05)	68.01 (4.31)
Males (n = 21;12)	68.03 (4.60)	81.99 (3.93)	70.23 (3.75)	66.99 (4.49)
Females (n = 5;7)	68.02 (5.70)	77.91 (6.40)	67.76 (6.80)	69.75 (3.64)
Rainbow Passage
Group (n = 26;19)	66.30 (4.02)	74.33 (4.83)	65.68 (2.68)	68.16 (3.33)
Males (n = 21;12)	66.56 (4.37)	75.69 (4.06)	66.02 (2.53)	67.94 (3.62)
Females (n = 5;7)	65.19 (1.96)	68.58 (3.51)	65.11 (3.05)	68.56 (3.00)
Monologue
Group (n = 16;13)	64.67 (3.37)	69.17(4.10)	64.66 (2.58)	66.24 (2.11)
Males (n = 11 ;8)	64.94 (3.66)	70.35 (3.61)	65.19 (2.40)	66.70 (2.01)
Females (n = 5;5)	63.96 (1.66)	65.34 (3.46)	64.66 (2.58)	65.52 (2.77)
Max duration (sec)
Sustained phonation
Group (n = 26;19)	21.12 (7.63)	24.84(10.35)	18.39 (9.65)	21.20 (8.78)
Males (n = 21; 12)	21.62 (8.17)	24.67 (11.44)	20.67(11.09)	23.47 (7.93)
Females (n = 5;7)	19.00(4.77)	25.57 (3.79)	14.47 (5.10)	17.32 (9.37)
F₀ (Hz)
Rainbow Passage
Males (n = 21;12)	124.73 (22.10)	140.78 (23.66)	120.13 (18.72)	125.57 (21.45)
Females (n = 5;5)	198.35 (12.13)	214.23 (13.56)	171.47 (11.47)	188.26 (17.58)
F₀ variability (STSD)
Rainbow Passage
Group (n = 26; 17)	1.82 (0.53)	2.38 (0.67)	1.80 (0.41)	2 09 (0.34)
Males (n = 21;12)	1.73 (0.42)	2.33 (0.63)	1.82 (0.41)	2.05 (0.30)
Females (n = 5;5)	2.22 (0.80)	2.62 (0.87)	1.77 (0.49)	2.19 (0.44)
F₀ (Hz)
Monologue
Males (n = 12; 10)	114.33 (13.19)	120.64 (16.81)	119.80 (21.85)	118.81 (18.62)
Females (n = 4;3)	190.52 (20.71)	201.40 (15.34)	179.15 (15.43)	180.99 (25.26)
F₀ variability (STSD)
Monologue
Group (n = 16;13)	1.68 (0.39)	1.97 (0.58)	2.13 (0.72)	1.95 (0.67)
Males (n = 12;10)	1.66 (0.39)	1.90 (0.39)	2.11 (0.73)	1.95 (0.72)
Females (n = 4;3)	1.80 (0.61)	2.38 (0.88)	2.18 (0.84)	1.95 (0.59)
Utterance duration (msec)
Rainbow Passage
Group (n = 24; 17)	2665.88 (666.03)	2186.24 (511.62)	2524.08 (530.33)	2132.55 (396.94)
Males (n = 19;11)	2671.59 (741.40)	2192.50 (512.17)	2409.05 (421.21)	2040.95 (361.57)
Females (n = 5;6)	2644.19 (276.33)	2162.44 (568.97)	2734.97 (680.22)	2300.48 (436.48)
Monologue
Group (n = 18;13)	1943.19 (389.51)	1948.66 (672.05)	2165.12 (851.82)	1872.51 (569.48)
Males (n = 13;9)	1883.38 (346.72)	1915.60 (661.21)	1829.16 (582.93)	1604.47 (299.41)
Females (n = 5;4)	2098.69 (492.24)	2034.62 (771.47)	2921.04 (946.43)	2475.60 (598.07)
Pause duration (msec)
Rainbow Passage
Group (n = 24;17)	568.93 (175.95)	720.49 (198.89)	514 67 (138 151	844.11 (342.80)
Males (n = 19;11)	605.95 (178.80)	771.64 (190.17)	536.54 (146.02)	783 43 (268.57)
Females (n = 5;6)	428.24 (53.83)	526.13 (71.22)	474.58 (124.09)	955.36 (456.97)
Monologue
Group (n = 18; 13)	620.11 (282.66)	753.40 (338.93)	714.79(297.50)	941.33 (406.46)
Males (n = 13;9)	675.24 (292.09)	855.67 (320.08)	721.49 (242.41)	900.16(332.84)
Females (n = 5;4)	440.94 (169.95)	421.03 (101.09)	699.72 (443.71)	1033.89 (590.71)
FVC (ml)
Males (n = 20;12)	3500.00 (720.38)	3535.00 (672.99)	3458.33 (1015.75)	3425.00 (1010.96)
Females (n = 5;7)	2580.00 (601.66)	2520.00 (554.08)	2142.86 (506.15)	2228.57 (590.80)

View Large

	LSVT		R only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Intensity (dB) (at 50cm)
Sustained phonation
Group (n = 26;19)	68.20 (4.70)	81.20 (4.65)	69.32 (5.05)	68.01 (4.31)
Males (n = 21;12)	68.03 (4.60)	81.99 (3.93)	70.23 (3.75)	66.99 (4.49)
Females (n = 5;7)	68.02 (5.70)	77.91 (6.40)	67.76 (6.80)	69.75 (3.64)
Rainbow Passage
Group (n = 26;19)	66.30 (4.02)	74.33 (4.83)	65.68 (2.68)	68.16 (3.33)
Males (n = 21;12)	66.56 (4.37)	75.69 (4.06)	66.02 (2.53)	67.94 (3.62)
Females (n = 5;7)	65.19 (1.96)	68.58 (3.51)	65.11 (3.05)	68.56 (3.00)
Monologue
Group (n = 16;13)	64.67 (3.37)	69.17(4.10)	64.66 (2.58)	66.24 (2.11)
Males (n = 11 ;8)	64.94 (3.66)	70.35 (3.61)	65.19 (2.40)	66.70 (2.01)
Females (n = 5;5)	63.96 (1.66)	65.34 (3.46)	64.66 (2.58)	65.52 (2.77)
Max duration (sec)
Sustained phonation
Group (n = 26;19)	21.12 (7.63)	24.84(10.35)	18.39 (9.65)	21.20 (8.78)
Males (n = 21; 12)	21.62 (8.17)	24.67 (11.44)	20.67(11.09)	23.47 (7.93)
Females (n = 5;7)	19.00(4.77)	25.57 (3.79)	14.47 (5.10)	17.32 (9.37)
F₀ (Hz)
Rainbow Passage
Males (n = 21;12)	124.73 (22.10)	140.78 (23.66)	120.13 (18.72)	125.57 (21.45)
Females (n = 5;5)	198.35 (12.13)	214.23 (13.56)	171.47 (11.47)	188.26 (17.58)
F₀ variability (STSD)
Rainbow Passage
Group (n = 26; 17)	1.82 (0.53)	2.38 (0.67)	1.80 (0.41)	2 09 (0.34)
Males (n = 21;12)	1.73 (0.42)	2.33 (0.63)	1.82 (0.41)	2.05 (0.30)
Females (n = 5;5)	2.22 (0.80)	2.62 (0.87)	1.77 (0.49)	2.19 (0.44)
F₀ (Hz)
Monologue
Males (n = 12; 10)	114.33 (13.19)	120.64 (16.81)	119.80 (21.85)	118.81 (18.62)
Females (n = 4;3)	190.52 (20.71)	201.40 (15.34)	179.15 (15.43)	180.99 (25.26)
F₀ variability (STSD)
Monologue
Group (n = 16;13)	1.68 (0.39)	1.97 (0.58)	2.13 (0.72)	1.95 (0.67)
Males (n = 12;10)	1.66 (0.39)	1.90 (0.39)	2.11 (0.73)	1.95 (0.72)
Females (n = 4;3)	1.80 (0.61)	2.38 (0.88)	2.18 (0.84)	1.95 (0.59)
Utterance duration (msec)
Rainbow Passage
Group (n = 24; 17)	2665.88 (666.03)	2186.24 (511.62)	2524.08 (530.33)	2132.55 (396.94)
Males (n = 19;11)	2671.59 (741.40)	2192.50 (512.17)	2409.05 (421.21)	2040.95 (361.57)
Females (n = 5;6)	2644.19 (276.33)	2162.44 (568.97)	2734.97 (680.22)	2300.48 (436.48)
Monologue
Group (n = 18;13)	1943.19 (389.51)	1948.66 (672.05)	2165.12 (851.82)	1872.51 (569.48)
Males (n = 13;9)	1883.38 (346.72)	1915.60 (661.21)	1829.16 (582.93)	1604.47 (299.41)
Females (n = 5;4)	2098.69 (492.24)	2034.62 (771.47)	2921.04 (946.43)	2475.60 (598.07)
Pause duration (msec)
Rainbow Passage
Group (n = 24;17)	568.93 (175.95)	720.49 (198.89)	514 67 (138 151	844.11 (342.80)
Males (n = 19;11)	605.95 (178.80)	771.64 (190.17)	536.54 (146.02)	783 43 (268.57)
Females (n = 5;6)	428.24 (53.83)	526.13 (71.22)	474.58 (124.09)	955.36 (456.97)
Monologue
Group (n = 18; 13)	620.11 (282.66)	753.40 (338.93)	714.79(297.50)	941.33 (406.46)
Males (n = 13;9)	675.24 (292.09)	855.67 (320.08)	721.49 (242.41)	900.16(332.84)
Females (n = 5;4)	440.94 (169.95)	421.03 (101.09)	699.72 (443.71)	1033.89 (590.71)
FVC (ml)
Males (n = 20;12)	3500.00 (720.38)	3535.00 (672.99)	3458.33 (1015.75)	3425.00 (1010.96)
Females (n = 5;7)	2580.00 (601.66)	2520.00 (554.08)	2142.86 (506.15)	2228.57 (590.80)

SPL—Vowels

Statistical analysis of SPL during sustained vowel phonation revealed a significant time (pre- to post-treatment) by treatment group (R or LSVT) by gender interaction [F(1,41) = 7.37, p = .01] (Table 5). Both the males and females who received the LSVT increased SPL post-treatment (mean increases of 13.96dB [SD 5.01] and 9.89dB [SD 5.66], respectively) (Table 6 and Figure 1a). Whereas the females who received the R treatment increased on average 1.99 dB (SD 6.09), the males who received the R treatment decreased on average 3.23 dB (3.83) pre- to post-treatment.

FIGURE 1.

Means and standard deviations for sound pressure level (SPL) before and after treatment for the LSVT and R treatment groups, showing male, female, and overall group values. Tasks included: (a) sustained phonation, (b) reading of the Rainbow Passage, and (c) conversational monologue. All measures of SPL were made at a distance of 50cm.

Full Size | Slide (.ppt)

SPL—Reading and Conversation

Statistical analysis for SPL during reading revealed a significant time by treatment group by gender interaction, F(1,41) = 4.85, p = .033. Both the males and females who received the LSVT increased in SPL pre- to post-treatment (mean increases of 9.13dB [6.05] and 3.39dB [1.91], respectively) (Table 6; Figure 1b). The females who received the R treatment also increased SPL (mean 3.45dB [4.77]); the males who received the R increased on average 1.92dB (2.30).

Statistical analysis for SPL during conversational monologue revealed a significant main effect for time, F(1,25) = 14.02, p = .001. There were no significant interactions between treatment group or gender (Table 5; Figure 1c). Subjects in both treatment groups significantly improved SPL in conversation from pre- to post-treatment.

Maximum Duration of Sustained Vowel Phonation

Statistical analysis of maximum duration of sustained vowel phonation revealed a statistically significant main effect for time, F(1,41) = 9.29, p = .004. There were no significant interactions between treatment group or gender (Table 5). Males and females from both treatment groups significantly increased maximum duration of sustained vowel phonation from pre- to post-treatment (Table 6).

Fundamental Frequency (Mean F₀) and Variability (STSD)—Reading and Conversation

Statistical analysis of mean habitual fundamental frequency while reading revealed a significant main effect for time, F(1,39) = 35.58, p = .001. There were no significant treatment group or gender interactions (Table 5). Males and females from both treatment groups significantly increased their fundamental frequency from pre- to post-treatment (Table 6). Statistical analysis of corresponding fundamental frequency variability (STSD) while reading the “Rainbow Passage” revealed a significant main effect for time, F(1,39) = 43.29, p = .001. Again, there were no significant interactions (Table 5). Male and female subjects from both treatment groups significantly increased STSD from pre- to post-treatment.

Statistical analysis of fundamental frequency during the conversational monologue revealed no significant changes pre- to post-treatment for either gender or treatment group. Statistical analysis of corresponding fundamental frequency variability (STSD) during the monologue revealed a significant time by treatment group interaction, F(1,25) = 8.48, p = .007, (Table 5). Subjects who received the LSVT significantly increased their STSD during monologue from pre- to post-treatment whereas the subjects who received the R treatment decreased their STSD during monologue from pre- to post-treatment. Despite the statistically significant finding, individual variability was apparent in the magnitude of change across treatment groups and in the intrasubject reliability.

Rate

Statistical analysis for utterance duration during reading revealed a significant main effect for time, F(1,37) = 19.30, p = .001. Both males and females in both treatment groups statistically significantly reduced their utterance duration during reading from pre- to post-treatment (Table 6). Statistical analysis for utterance duration during monologue revealed no significant main effect or interactions pre- to post-treatment (Table 5). Statistical analysis for pause duration during reading of the “Rainbow Passage” revealed a significant time by treatment group interaction, F(1,37) = 6.61, p = .014. Both groups increased on this measure; however, only subjects who received the R treatment demonstrated a statistically significant pre- to post-treatment increase (Table 5). Statistical analysis for pause duration during the monologue revealed no significant main effect or interactions pre- to post-treatment (Table 5).

Forced Vital Capacity (FVC)

FVC data are summarized in Table 6. Statistical analysis revealed no significant main effect for time or interactions (Table 5).

Perceptual Variables

F and p values for the analysis of variance carried out on the perceptual variables are presented in Table 7. Means and standard deviations for the perceptual variables for subject self-ratings are presented in Table 8.

TABLE 7.F and p values for the perceptual variables

	Between-subject effect								Within-subject effect
	Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
Subject self-rating
(n = 45) (df = 1,41)
Loudness	.03	.872	.06	.805	1.51	.226	19.26	.000	.10	.751	.42	.520	4.17	.048
Monotonicity	.01	.922	2.16	.149	2.94	.094	11.82	.001	.17	.686	1.87	.179	1.59	.215
Hoarseness	.22	.645	.51	.481	3.37	.073	11.64	.001	.39	.535	.00	.955	.04	.843
Intelligibility	.00	.978	.15	.697	.67	.416	11.92	.001	.02	.901	.21	.653	.67	.417
Initiate conversation	.07	.791	4.62	.037	.72	.401	10.39	.002	.13	.718	.45	.506	3.98	.053
Family ratings
(n = 20) (df = 1,16)
Loudness	.50	.490	.28	.602	.53	.476	5.73	.029	.09	.773	.03	.867	.20	.660
Monotonicity	.56	.464	2.14	.163	.12	.735	1.50	.239	.15	.707	1.23	.283	.74	.403
Hoarseness	.01	.925	2.27	.151	1.81	.197	.44	.517	.28	.602	.60	.450	1.15	.299
Intelligibility	.40	.538	.87	.366	.62	.442	15.81	.001	6.74	.019	.10	.752	1.56	.230
Initiate conversation	2.80	.114	8.66	.010	.22	.645	1.24	.282	2.62	.125	.07	.791	2.42	.139

View Large

TABLE 7.F and p values for the perceptual variables

	Between-subject effect								Within-subject effect
	Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
Subject self-rating
(n = 45) (df = 1,41)
Loudness	.03	.872	.06	.805	1.51	.226	19.26	.000	.10	.751	.42	.520	4.17	.048
Monotonicity	.01	.922	2.16	.149	2.94	.094	11.82	.001	.17	.686	1.87	.179	1.59	.215
Hoarseness	.22	.645	.51	.481	3.37	.073	11.64	.001	.39	.535	.00	.955	.04	.843
Intelligibility	.00	.978	.15	.697	.67	.416	11.92	.001	.02	.901	.21	.653	.67	.417
Initiate conversation	.07	.791	4.62	.037	.72	.401	10.39	.002	.13	.718	.45	.506	3.98	.053
Family ratings
(n = 20) (df = 1,16)
Loudness	.50	.490	.28	.602	.53	.476	5.73	.029	.09	.773	.03	.867	.20	.660
Monotonicity	.56	.464	2.14	.163	.12	.735	1.50	.239	.15	.707	1.23	.283	.74	.403
Hoarseness	.01	.925	2.27	.151	1.81	.197	.44	.517	.28	.602	.60	.450	1.15	.299
Intelligibility	.40	.538	.87	.366	.62	.442	15.81	.001	6.74	.019	.10	.752	1.56	.230
Initiate conversation	2.80	.114	8.66	.010	.22	.645	1.24	.282	2.62	.125	.07	.791	2.42	.139

TABLE 8.Perceptual variables for the subjects’ (n = 45) self-ratings by group and gender as well as the families’ ratings for both groups. Standard deviations are presented in parentheses.

	LSVT		R Only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Loudness
Group	46.85 (20.23)	64.15 (20.89)	51.37 (29.01)	65.42(19 88)
Males	43.95 (18.21)	63.14 (18.59)	57.33 (27.83)	64.42 (23.33)
Females	59.00 (25.93)	68.40 (31.17)	41.14 (30 20)	67.14 (11 471
Family (n = 20)	45.50 (22.63)	60.50 (18.47)	49.73 (28.64)	63.12 (21.84)
Monotonicity
Group	47.00 (22.54)	66.73(16 28)	57.00 (26.13)	68.05 (22 87)
Males	41.38 (18.45)	64.76 (14.74)	57.42 (29.23)	68.75 (22.48)
Females	70.60 (24.69)	75.00 (21 561)	56.29 (21.91)	66.86 (19.44)
Family (n = 20)	52.67 (27.49)	66.75 (19.34)	57.91 (27.03)	68.88 (21.92)
Hoarseness
Group	55.65 (21.89)	70.11 (16.42)	64.58 (24 14)	75.11 (21.61)
Males	54.52 (23.13)	68.62 (17 66)	70.08 (23.03)	81.00 (23.30)
Females	60.40 (16 92)	76.40 (8.02)	55.14 (24.73)	65.00 (14.75)
Family (n = 20)	61.58 (27.10)	66.58 (19.67)	70.45 (18.06)	70.38 (18.75)
Intelligibility
Group	57.12 (20.30)	71.12 (16.77)	61.63 (20.20)	72.00 (19.99)
Males	54.95 (20.11)	70.52 (15.63)	63.00 (21.17)	72.50 (21 65)
Females	66.20 (20.62)	73.60 (22.96)	59.29 (19 81)	71.14 (18.38)
Family (n = 20)	49.50 (17.93)	67.33 (19.59)	57.55 (22.81)	64.63 (17.94)
Initiate conversation
Group	50.96 (22 37)	66.85 (16.30)	61.85 (22.06)	68.89 (20.83)
Males	45.90 (18.97)	64.90 (15.07)	59.83 (18.17)	68.89 (20.83)
Females	72.20 (25.10)	75.00 (21.00)	63.71 (29 03)	76.43 (15.91)
Family (n = 20)	54.67 (20.70)	70.33 (16.70)	67.09 (28.55)	71.50(18.41)

Note. Perceptual characteristics of loudness, hoarseness, intelligibility, and initiation of conversation are on a scale of 0–100% with 0% the most severe and 100% the least severe.

View Large

TABLE 8.Perceptual variables for the subjects’ (n = 45) self-ratings by group and gender as well as the families’ ratings for both groups. Standard deviations are presented in parentheses.

	LSVT		R Only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Loudness
Group	46.85 (20.23)	64.15 (20.89)	51.37 (29.01)	65.42(19 88)
Males	43.95 (18.21)	63.14 (18.59)	57.33 (27.83)	64.42 (23.33)
Females	59.00 (25.93)	68.40 (31.17)	41.14 (30 20)	67.14 (11 471
Family (n = 20)	45.50 (22.63)	60.50 (18.47)	49.73 (28.64)	63.12 (21.84)
Monotonicity
Group	47.00 (22.54)	66.73(16 28)	57.00 (26.13)	68.05 (22 87)
Males	41.38 (18.45)	64.76 (14.74)	57.42 (29.23)	68.75 (22.48)
Females	70.60 (24.69)	75.00 (21 561)	56.29 (21.91)	66.86 (19.44)
Family (n = 20)	52.67 (27.49)	66.75 (19.34)	57.91 (27.03)	68.88 (21.92)
Hoarseness
Group	55.65 (21.89)	70.11 (16.42)	64.58 (24 14)	75.11 (21.61)
Males	54.52 (23.13)	68.62 (17 66)	70.08 (23.03)	81.00 (23.30)
Females	60.40 (16 92)	76.40 (8.02)	55.14 (24.73)	65.00 (14.75)
Family (n = 20)	61.58 (27.10)	66.58 (19.67)	70.45 (18.06)	70.38 (18.75)
Intelligibility
Group	57.12 (20.30)	71.12 (16.77)	61.63 (20.20)	72.00 (19.99)
Males	54.95 (20.11)	70.52 (15.63)	63.00 (21.17)	72.50 (21 65)
Females	66.20 (20.62)	73.60 (22.96)	59.29 (19 81)	71.14 (18.38)
Family (n = 20)	49.50 (17.93)	67.33 (19.59)	57.55 (22.81)	64.63 (17.94)
Initiate conversation
Group	50.96 (22 37)	66.85 (16.30)	61.85 (22.06)	68.89 (20.83)
Males	45.90 (18.97)	64.90 (15.07)	59.83 (18.17)	68.89 (20.83)
Females	72.20 (25.10)	75.00 (21.00)	63.71 (29 03)	76.43 (15.91)
Family (n = 20)	54.67 (20.70)	70.33 (16.70)	67.09 (28.55)	71.50(18.41)

Note. Perceptual characteristics of loudness, hoarseness, intelligibility, and initiation of conversation are on a scale of 0–100% with 0% the most severe and 100% the least severe.

Statistical analysis for self-ratings of loudness revealed a significant time by treatment group by gender interaction, F(1,41) = 4.17, p = .048. Males who received the LSVT and females who received the R rated the greatest improvements (mean increases 19.19; SD 17.41 and 26.00; SD 25.24), respectively. Significant main effects for time were measured for the perceptual variables monotonicity, F(1,41) = 11.82, p = .001, hoarseness, F(1,41) = 11.64, p = .001, intelligibility, F(1,41) = 11.92, p = .001, and initiating conversation, F(1,41) = 10.39, p = .002. Both male and female subjects from both treatment groups rated statistically significant improvements on these measures from pre- to post-treatment (Table 8).

Family ratings (n = 20) of pre- to post-treatment perceptual variables are presented in Table 8. Family ratings of loudness revealed a significant main effect for time, F(1,16) = 5.73, p = .029 (Table 7). As seen in Table 8, families of subjects from both treatment groups rated statistically significant pre- to post-treatment improvement in loudness. Family ratings of overall intelligibility revealed a significant time by treatment group interaction, F(1,16) = 6.74, p = .019. Although families of subjects from both treatment groups rated improvement on overall intelligibility pre- to post-treatment, only the families of the subjects who received the LSVT rated statistically significant improvement. Family ratings of monotone, hoarseness, and initiating conversation were not statistically significantly different pre- to post-treatment. Families rated that female subjects initiated conversation significantly more often than male subjects, F(1,16) = 8.66, p = .010.

Neuropsychological Variables of Self-Rated Depression and Sickness Impact

The Beck Depression Inventory (BDI: subject self-rating of depression) and the Sickness Impact Profile on communication and social interaction were completed pre- and post-treatment. The F and p values for the analysis of variance are presented in Table 9. Pre- and post-treatment means and SDs are presented in Table 10. Statistical analysis revealed no significant main effect or interactions for the BDI (n = 35) pre- to post-treatment. Statistical analysis of the SIP on communication (n = 35) revealed a significant time by treatment group interaction, F(1,31) = 6.86, p = .014. Only subjects who received the LSVT rated a statistically significant reduction in the impact of their sickness on their communication from pre- to post-treatment. Statistical analysis of the SIP on social interaction (n = 35) revealed no significant main effect or interactions pre- to post-treatment.

TABLE 9.F and p values for the neuropsychological variables.

	Between-subject effect								Within-subject effect
Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
(n = 35) df (1,31)
BDI (self-rating of depression)	.81	.374	9.17	.005	6.64	.015	.45	.508	1.04	.316	.30	.589	.65	.427
SIP Communication	.02	.886	2.19	.149	1.65	.209	10.95	.002	6.86	.014	.04	.839	.11	.741
SIP Social interaction	.14	.711	.08	.776	4.72	.038	2.36	.135	.23	.635	1.20	.282	.40	.533

View Large

TABLE 9.F and p values for the neuropsychological variables.

	Between-subject effect								Within-subject effect
Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
(n = 35) df (1,31)
BDI (self-rating of depression)	.81	.374	9.17	.005	6.64	.015	.45	.508	1.04	.316	.30	.589	.65	.427
SIP Communication	.02	.886	2.19	.149	1.65	.209	10.95	.002	6.86	.014	.04	.839	.11	.741
SIP Social interaction	.14	.711	.08	.776	4.72	.038	2.36	.135	.23	.635	1.20	.282	.40	.533

TABLE 10.Means and SD’s (in parentheses) for the neuropsychological variables completed by subjects both pre- and post-treatment.

	LSVT		R Only
Scale (n = 35)	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment
BDI (self-rating of depression)
Group	8.3 (6.0)	7.4 (4.6)	8.7 (5.5)	8.9 (5.3)
Male	6.1 (4.4)	5.8 (3.3)	8.5 (6.3)	8.6 (6.2)
Female	16.3(4.5)	13.3(3.9)	9.0 (4.1)	9.6 (2.7)
SIP communication
Group	28.9 (21.8)	11.9(11.7)	25.6 (25.1)	23.1 (23.6)
Male	29.2 (19.6)	12.4 (11.5)	32.7 (26.1)	29.1 (26.2)
Female	28.2 (30.2)	10.6 (13.8)	11.5 (17.4)	11.1 (12.0)
SIP Social interaction
Group	9.6 (8.1)	7.9 (4.4)	11.0 (10.4)	9.7 (11.7)
Male	7.2 (6.3)	6.8 (4.4)	12.6 (10.4)	11.8 (13.2)
Female	16.7 (9.6)	11.5 (2.4)	7.9 (11.0)	5.7 (7.5)

View Large

TABLE 10.Means and SD’s (in parentheses) for the neuropsychological variables completed by subjects both pre- and post-treatment.

	LSVT		R Only
Scale (n = 35)	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment
BDI (self-rating of depression)
Group	8.3 (6.0)	7.4 (4.6)	8.7 (5.5)	8.9 (5.3)
Male	6.1 (4.4)	5.8 (3.3)	8.5 (6.3)	8.6 (6.2)
Female	16.3(4.5)	13.3(3.9)	9.0 (4.1)	9.6 (2.7)
SIP communication
Group	28.9 (21.8)	11.9(11.7)	25.6 (25.1)	23.1 (23.6)
Male	29.2 (19.6)	12.4 (11.5)	32.7 (26.1)	29.1 (26.2)
Female	28.2 (30.2)	10.6 (13.8)	11.5 (17.4)	11.1 (12.0)
SIP Social interaction
Group	9.6 (8.1)	7.9 (4.4)	11.0 (10.4)	9.7 (11.7)
Male	7.2 (6.3)	6.8 (4.4)	12.6 (10.4)	11.8 (13.2)
Female	16.7 (9.6)	11.5 (2.4)	7.9 (11.0)	5.7 (7.5)

Correlations to Treatment-Related Change

The relationships between magnitude of treatment-related change and patient suitability or prognostic factors for treatment success were examined. Subject pre- and post-treatment change in SPL during reading the “Rainbow Passage” and conversational monologue were correlated (Pearson product moment) with pretreatment age, stage of disease, rating on the motor examination section of the UPDRS, time since diagnosis, severity of speech disorder, glottal incompetence, dementia (cognitive ability), and depression.

All Subjects

There were no significant correlations for the group as a whole between pre- to post-treatment change in SPL and age, stage of disease, rating on the motor examination section of the UPDRS, time since diagnosis, severity of speech disorder, glottal incompetence, cognitive ability, and depression variables or subject ratings of the impact of their disease on communication and social interaction.

All males

No significant correlations were observed for male subjects between prognostic variables and magnitude of treatment-related change in SPL.

All females

No significant correlations were observed for female subjects between prognostic variables and magnitude of treatment-related change in SPL.

LSVT subjects

There was a significant correlation (r = .56, p = .023) between the magnitude of pre- to post-treatment change in SPL in monologue (n = 16) and mean T score pretreatment. Subjects who had greater cognitive ability pretreatment had greater post-treatment increases in SPL in monologue than subjects with lower cognitive abilities. For the males only in the LSVT group there were no significant correlations between magnitude of treatment-related change in SPL and prognostic variables. For the females only (n = 5) there was a significant negative correlation (r = −.88, p = .05) between magnitude of pre- to post-treatment change in SPL on the “Rainbow Passage” and chronological age. Younger female subjects had greater increases in SPL than did older female subjects.

R subjects

No significant correlations were observed for this group as a whole or male or female subjects in this group between prognostic variables and magnitude of treatment-related change in SPL.

Summary

The following pre- to post-treatment changes were statistically significant for all subjects regardless of treatment group: SPL during conversation, mean habitual fundamental frequency and fundamental frequency variability during reading, maximum duration sustained vowel phonation and utterance duration during reading, and perceptual self-ratings of monotonicity, intelligibility, and initiation of conversation, and family ratings of loudness. Only for subjects who received the LSVT were the following pre- to post-treatment changes statistically significant: SPL during vowels, SPL during reading, fundamental frequency variability in monologue, perceptual self-ratings of loudness (males), family ratings of overall intelligibility, and the Sickness Impact Profile for the impact of Parkinson disease on their communication. Only for subjects who received the R treatment were the following pre- to post-treatment changes statistically significant: SPL during reading (females), pause duration during reading and perceptual self-ratings of loudness (females).

Discussion

This study was designed to compare the effects of two forms of intensive speech treatment (respiration [R] and voice and respiration [Lee Silverman Voice Treatment; LSVT]) on the speech and voice deficits of subjects with Idiopathic Parkinson disease. The study also examined the magnitude of treatment-related change relative to subject characteristics including: age, stage of disease, time since diagnosis, severity of speech/voice disorder, glottal incompetence, depression, and cognitive ability.

The data of this study document that intensive speech treatment, particularly the LSVT, made significant short-term improvements in speech and voice characteristics of the subjects studied. Although the R treatment improved some aspects of speech and voice, the subjects who received the LSVT made greater and more consistent post-treatment changes in intensity and fundamental frequency variation. Furthermore, only subjects who received the LSVT reported significant reductions in the impact of Parkinson disease on oral communication following treatment. Given the low vocal loudness reported in patients with Parkinson disease (Aronson, 1985; Blonder, Gur, & Gur, 1989; Boshes, 1966; Critchley, 1981; Darley, Aronson, & Brown, 1969a, 1969b) and its association with reduced speech intelligibility (Ramig, 1992), these findings distinguish these two forms of speech treatment on an important variable.

These findings are logical outcomes when the focus of treatment for each group is considered. The changes in maximum duration sustained phonation and utterance and pause duration are consistent with the goals of the R treatment. It is likely that R treatment contributed to significant post-treatment increases in duration, magnitude, and frequency of inspiration and expiration and the respiratory system control of volume, pressure, and flow (Dromey et al., 1995). However, only following the LSVT were consistent and significant post-treatment increases in intensity observed. It is likely that the improved respiratory support together with the increased vocal fold adduction observed following the LSVT (Brosovic, 1994; Smith et al., in press) resulted in these significant post-treatment increases in intensity. These findings suggest that treatment that trained both increased vocal fold adduction and respiratory support (LSVT) was necessary to generate significant increases in intensity post-treatment in these subjects with idiopathic Parkinson disease. Increasing respiratory support alone was not sufficient to generate significant and consistent increases in intensity in these glottally incompetent subjects.

The intensity changes pre- to post-treatment for the LSVT group were of a perceptually significant magnitude (Pichney, Durlach, & Braida, 1986; Pickett, 1956) for sustained phonation and reading. The pre- to post-treatment increase in intensity for conversational monologue was statistically significant; however, the magnitude was somewhat less than observed in sustained phonation and reading. Given the cognitive disorders and difficulty with complex tasks observed in patients with Parkinson disease (Berardelli, Dick, Rothwell, Day, & Marsden, 1986; Brooks, 1986), this was not surprising. The finding of a statistically significant correlation between cognitive levels and magnitude of pre- to post-treatment changes in intensity in monologue suggests that it is difficult for the more cognitively impaired subjects with IPD to generalize treatment effects. In addition, increased intensity may be more easily achieved and maintained in a task that requires constant vocal fold adduction (e.g., sustained phonation). The reading and monologue tasks require more dynamic abductory and adductory gestures, as well as more attention and concentration, and might therefore have been more difficult for subjects to maintain at a high phonatory effort level.

The changes observed in habitual fundamental frequency and fundamental frequency variability in these subjects are notable given the fact that these variables were not directly trained in treatment. While both treatment groups improved post-treatment, the magnitude and consistency of improvements of the LSVT subjects were greater. Training of adduction and maximum frequency ranges may be the basis for these post-treatment increases in fundamental frequency and fundamental frequency variability. Another explanation may relate to the perception of the LSVT subjects that their communication skills were much less affected by their disease post-treatment. Only the LSVT subjects rated a significant reduction in the impact of their sickness on their communication skills post-treatment. It may be speculated that as the LSVT subjects improved their ability to communicate, their confidence, attitude, and affect improved. This attitude could be reflected in increased pitch and intonation during speech. Higher pitch and increased pitch variability have been associated with descriptive characteristics of happiness, joyfulness, and confidence (Fairbanks & Pronovost, 1939; Scherer, London, & Wolf, 1973). Improvements in confidence, attitude, and affect are also consistent with our subjective observations of the subjects who received the LSVT immediately post-treatment. This finding suggests that improved communication can play an important role in the psychosocial well-being of individuals with Parkinson disease.

Although activities of respiration were the focus of the R treatment and activities of vocal fold adduction and respiration were the focus of the LSVT, it was apparent by clinical observation that post-treatment changes were observed in magnitude and precision of articulatory gestures as well (Ramig, Dromey, Johnson, & Scherer, 1994). These observations were most apparent in subjects who received the LSVT and are consistent with reports of Schulman (1989) who studied articulatory changes following loud speech in nondisordered speakers. These post-treatment changes in untreated articulation have been quantified in a patient with IPD following a course of the LSVT (Dromey et al., 1995). Such findings are in agreement with those of Scott and Caird (1983) who reported that phonation in particular was a prerequisite for intelligible, effective speech in Parkinson disease and as voice production improved other aspects of speech also improved. In addition, they are consistent with those of Rubow and Swift (1985) who reported a positive relationship between improved loudness and articulatory skills in one patient with Parkinson disease. These observations suggest that multiple levels of speech production in patients with Parkinson disease can benefit from a single treatment focus of increased phonatory effort (Ramig et al., 1994). This is useful information since a treatment that is simple is optimal for IPD patients given their known cognitive disorders and difficulty with complex tasks (Beneckel, Rothwell, Dick, Day, & Marsden, 1986; Yanagisawa, Fujimato, &Tamaru, 1989).

The perceptual data presented here were considered as an initial probe of the impact of treatment-related changes on functional communication. Although the ratings of subjects and family members may be biased and less reliable, they represent one important level of assessment of the perceived impact of treatment on functional communication. These findings suggest that both forms of treatment influenced subject and family perceptions of overall communication skills and are consistent with general positive treatment effects across both groups. However, they also suggest that, consistent with acoustic data, subjects who received the LSVT perceived the greatest impact of the treatment on these perceptual variables.

These findings of significant treatment-related change are in contrast to previous reports from Allan (1970), Aronson (1985), Greene (1980), Sarno (1968), and Weiner and Singer (1989) who concluded that speech treatment was not effective for patients with Parkinson disease. The most reasonable explanation for the positive findings reported here is the focus and style of treatment. Previous approaches to treatment for Parkinson disease have focused on articulation and rate and were administered in the classic speech treatment style of once or twice a week. Both treatments studied here were administered 4 days a week for 16 high effort sessions and focused on respiration (R) or voice and respiration (LSVT). Based upon our findings here, we suggest that intensive treatment with the focus on voice and respiration (LSVT) is effective in increasing vocal intensity in patients with Parkinson disease. These findings are consistent with Scott & Caird (1983) and Robertson & Thompson (1984) who also concluded that intensive voice treatment could increase loudness in patients with Parkinson disease.

We suggest that increasing vocal loudness through high phonatory effort (LSVT), teaches patients to rescale the magnitude of their speech motor output. Such interpretation is consistent with amplitude rescaling changes discussed in other motor systems of patients with Parkinson disease (Teulings & Stelmach, 1991). High effort respiratory (R) treatment generated fewer significant changes in the speech of these patients. Therefore, it appears that high effort with the focus on phonation is a critical combination in the successful treatment of patients with Parkinson disease.

Of the 45 subjects in this investigation, prognostic variables of stage of disease, time since diagnosis, severity of speech disorder, glottal incompetence, and depression did not significantly influence post-treatment effects. Age and cognitive status may influence magnitude of treatment-related change (with younger and more cognitively intact subjects improving more on certain measures). This observation must be studied more closely before conclusive statements are made. It should be noted, however, that most of the subjects studied here were in the mild-to-moderate range of their disease. Further research should be carried out in order to examine more severely involved as well as very recently diagnosed subjects to assess the generalizability of treatment across all stages of IPD. Given the heterogeneous nature of Parkinson disease, it is reasonable to assume that all subjects would not respond to treatment in the same way. This variability is clearly reflected in individual subject responses to treatment. It is important to keep in mind that subject heterogeneity may reduce statistically significant group effects despite positive findings for individual subjects. This is an important consideration in evaluating the efficacy of treatment.

The gender differences observed in certain of the pre- to post-treatment data deserve further consideration. The smaller number of females in both treatment groups, the heterogeneity of the females in the LSVT group and the overall higher depression scores for females limit conclusive statements at this time. However, the findings indicate that further study of the effects of intensive speech treatment for female subjects with idiopathic Parkinson disease is essential.

Databased efficacious treatment programs for patients with progressive neurological disorders are virtually nonexistent (Yorkston, Beukelman, & Bell, 1988). Given the degenerative nature of Parkinson disease, the accompanying cognitive impairment, generalized involvement at multiple levels of the speech mechanism, depression, and comprehensive physical impairment, documentation of statistically significant pre- to post-treatment changes for group data of the magnitude reported here is an important step in enhancing the efficiency of treatment for this population. The maintenance of these changes is being addressed in ongoing work (Ramig, Countryman, O’Brien, & Smith, 1995). Although the degenerative course of some neurological disorders cannot be altered at this time, improved oral communication may be an important component in developing the highest levels of functioning and independence for each individual.

Acknowledgments

The research presented here was supported by NIH grant No. RO1DC01150. Our deepest gratitude is extended to the subjects who participated in this research study. The authors would like to thank Annette Arnone Pawlas and Drs. Marshall Smith, Margaret Hoehn, Christopher O’Brien, and Christopher Dromey for their assistance during various parts of this research.

References

Adams, J. A. (1971). A closed-loop theory of motor learning. Journal of Motor Behavior, 3, 111–150. [Article]

Adams, J. A. (1986). Use of the model’s knowledge of the results to increase observer’s performance. Journal of Human Movement Studies, 12, 89–98.

Allan, C. M. (1970). Treatment of non-fluent speech resulting from neurological disease: Treatment of dysarthria. British Journal of Disorders of Communication, 5, 3–5. [Article]

Aronson, A. E. (1990). Clinical voice disorders. New York: Thieme-Stratton.

Beatty, W. W., Staton, R. D., Weir, W. S., Monson, N., & Whitaker, H. A. (1989). Cognitive disturbances in Parkinson disease. Journal of Geriatric Psychiatry and Neurology, 2, 22–33.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. [Article]

Bellaire, K., Yorkston, K., and Beukelman, D. (1986). Modification of breath patterning to increase naturalness of a mildly dysarthric speaker. Journal of Communication Disorders, 19, 271–280. [Article]

Beneckel, R., Rothwell, J. C., Dick, J. P., Day, B. L., & Marsden, C. D. (1986). Performance of simultaneous movements in patients with Parkinson’s disease. Brain, 109, 739–757. [Article]

Berardelli, A., Dick, J. P., Rothwell, J. C., Day, B. L., & Marsden, C. D. (1986). Scaling of the size of the first agonist EMG burst during rapid wrist movements in patients with Parkinson’s disease. Journal of Neurology, Neurosugery, and Psychiatry, 49, 1273–1279. [Article]

Bergner, M., Bobbit, R. A., Carter, W. B., & Gilson, B. S. (1981). The sickness impact profile: Development and final revision of a health status measure. Medical Care, 19, 787–805. [Article]

Berke, G. S., Hanson, D. G., Gerratt, B. R., Trapp, J. K., Macagba, C., & Natividad, M. (1990). The effect of airflow and medial compression on vocal efficiency and glottal vibration. Otolaryngology, Head and Neck Surgery, 102, 212–280. [Article]

Bless, D. M., Hirano, J., & Feder, R. J. (1987). Videostroboscopic evaluation of the larynx. Ear, Nose, and Throat Journal, 66(7), 289–296.

Brin, M. Fahn, S., Blitzer, A., Ramig, L., and Stewart, C. (1992) Movement disorders of the larynx. In Blitzer A., Sasaki C., Fahn S., Brin M., & Harris K. (Eds.), Neurological disorders of the larynx (pp. 248–278). New York: Thieme-Medical Publications.

Blonder, L. X., Gur, R. E., & Gur, R. C. (1989). The effects of right and left hemiparkinsonism on prosody. Brain and Language, 36, 193–207. [Article]

Boeckstyns, M. E., & Backer, M. (1989). Reliability and validity of the evaluation of pain in patients with total knee replacement. Pain, 38(1), 29–33. [Article]

Boshes, B. (1966). Voice changes in parkinsonism. Journal of Neurosurgery, 24, 286–288.

Brooks, V. B. (1986). The neurological basis of motor control. New York: Oxford University Press.

Brosovic, G. (1994). Electroglottographic measures of vocal adduction pre- and post-treatment in Parkinson disease. Unpublished master’s thesis, University of Colorado-Boulder.

Brown, R. G., & Marsden, C. D. (1987). Neuropsychology and cognitive function in Parkinson’s disease: An overview. In Marsden C.D. & Fahn S. (Eds.), Movement disorders (2nd ed., pp. 99–123). London: Butterworth Scientific.

Campbell, D., & Stanley, J. (1966). Experimental and quasi-experimental designs for research. Chicago: R. McNally.

Canter, G. J. (1965). Speech characteristics of patients with Parkinson’s disease: II. Physiological support for speech. Journal of Speech and Hearing Disorders, 30, 44–49. [Article]

Colton, R. (1984). Glottal waveform variations associated with different vocal intensities. Transcripts of the 13th Symposium: Care of the Professional Voice. Part I: Scientific Papers (pp. 39–47). New York: The Voice Foundation.

Countryman, S., & Ramig, L. O. (1993). Effects of intensive voice therapy on voice deficits associated with bilateral thalamotomy in Parkinson disease: A case study. Journal of Medical Speech-Language Pathology, 1, 233–249.

Countryman, S., Ramig, L. O., & Pawlas, A. (1994). Speech and voice deficits in Parkinsonian plus syndromes: Can they be treated? Journal of Medical Speech-Language Pathology, 2, 211–225.

Critchley, E. M. R. (1981). Speech disorders of Parkinsonism: A review. Journal of Neurology, Neurosurgery, and Psychiatry, 44, 751–758. [Article]

Crystal, D. (1969). Prosodic systems and intonation in English. London: Cambridge University Press.

Cummings, J. L. (1986). Subcortical dementia: Neuropsychology, neuropsychiatry, and pathophysiology. British Journal of Psychiatry, 149, 682–687. [Article]

Cummings, J. L. (1988). Intellectual impairment in Parkinson’s disease: Clinical, pathologic, and biochemical correlates. Journal of Geriatric Psychiatry and Neurology, 1, 24–36.

Darley, F. L., Aronson, A. E. & Brown, J. R. (1969a). Differential diagnostic patterns of dysarthria. Journal of Speech and Hearing Research, 12, 246–269. [Article]

Darley, F. L., Aronson, A. E., & Brown, J. R. (1969b). Clusters of deviant speech dimensions in the dysarthrias. Journal of Speech and Hearing Research, 12, 462–469. [Article]

Dobkin, R. C. (1969). Precision AC/DC converters. National Semiconductor Corporation, LB8, 1–2.

Dromey, C., Ramig, L. O., & Johnson, A. (1995). Phonatory and articulatory changes associated with increased vocal intensity in Parkinson disease: A case study. Journal of Speech and Hearing Research, 38, 751–764. [Article]

Duvoisin, R. C. (1984). Parkinson’s disease: A guide for patient and family (2nd ed.). New York: Raven Press.

England, A. C., & Schwab, R. S. (1959). The management of Parkinson’s disease. AMA Archives of Internal Medicine, 104, 439–460. [Article]

Fahn, S., Elton, R. L. , & members of the UPDRS Development Committee (1987). Unified Parkinson’s Disease Rating Scale. In Fahn S., Marsden C.D., Goldstein M., & Caine D.B. (Eds.), Recent developments in Parkinson’s disease (Vol. 2, pp. 153–163). New York: Macmillan Press.

Fairbanks, G. (1960). Voice and articulation drill book. New York: Harper and Brothers.

Fairbanks, G., & Pronovost, W. (1939). An experimental study of the pitch characteristics of the voice during expression of emotion. Speech Monographs, 6, 87–104. [Article]

Froeschels, E., Kastein, S., Weiss, D. (1955) A method of therapy for paralytic conditions of the mechanisms of phonation, respiration and glutination. Journal of Speech and Hearing Disorders, 20, 3645–370. [Article]

Gauthier, L., Dalziel, S., & Gauthier, S. (1987). The benefits of group occupational therapy for patients with Parkinson’s disease. American Journal of Occupational Therapy, 41, 360–365. [Article]

Goodglass, H., & Kaplan, E. (1972). The assessment of aphasia and related disorders. Philadelphia: Lee and Leafebiger.

Greene, H. C. L. (1980). The voice and its disorders. London: Pitman Medical.

Hallet, M., & Khosbin, S. (1980). A psychological mechanism of bradykinesia. Brain, 103, 301–314. [Article]

Hanson, D. G., Gerratt, B. R., & Ward, P. H. (1984). Cinegraphic observations of laryngeal function in Parkinson’s disease. Laryngoscope, 94, 348–353. [Article]

Hardy, J. (1983). Cerebral palsy. Englewood Cliffs, NJ: Prentice-Hall.

Heaton, R. K., Chelune, G., & Lehman, R. A. W. (1978). Using neuropsychology and personality tests to assess the likelihood of patient employment. Journal of Nervous and Mental Disease, 166, 408–416. [Article]

Heaton, R. K., Grant, I., & Mathews, C. G. (1991). Comprehensive norms for an expanded Halsted-Reitan battery. Odessa, FL: Psychological Assessment Resources.

Hixon, T. J., Goldman, M. H., & Mead, J. (1976). Dynamics of the chest wall during speech production: Volume displacements of the rib cage, abdomen, and lung. Journal of Speech and Hearing Research, 16, 78–115. [Article]

Hixon, T. J., Mead, J., & Goldman, M. D. (1976). Dynamics of the chest wall during speech production: Function of the thorax, rib cage, diaphragm, and abdomen. Journal of Speech and Hearing Research, 19, 297–356. [Article]

Hoberman, S. G. (1958). Speech techniques in aphasia and Parkinsonism. Journal of the Michigan State Medical Society, 57, 1720–1723.

Hoehn, M., & Yahr, M. (1967). Parkinsonism: Onset, progression and mortality. Neurology, 17, 427. [Article]

Holmberg, E. B., Hillman, R. B., & Perkell, J. (1988) Glottal airflow and transglottal air pressure measurements for male and female speakers in soft, normal and loud voice. Journal of the Acoustical Society of America, 84, 511–529. [Article]

Horii, Y. (1983). An automatic analysis method of utterance and pause lengths and frequencies. Behavior Research Methods and Instrumentation, 15, 449–452. [Article]

Hornykiewicz, O. (1966). Metabolism of brain dopamine in human Parkinsonism: Neurochemical and clinical aspects. In Costa E., Cote L., & Yahr M. (Eds.), Biochemistry and pharmacology of the basal ganglia (pp. 171–185). New York: Raven Press.

Hornykiewicz, O., & Kish, S. J. (1986). Biochemical pathophysiology of Parkinson’s disease. In Yahr M.D. & Bergman K.J. (Eds.), Advances in neurology (pp. 19–34). New York: Raven Press.

Isshiki, N. (1964). Regulatory mechanisms of voice intensity variation. Journal of Speech and Hearing Research, 7, 17–29. [Article]

Kempster, G. B. (1984). A multidimensional analysis of vocal quality in two dysphonic groups. Unpublished doctoral dissertation, Northwestern University, Evanston, IL.

Kent, R. D., Kent, J. F., & Rosenbek, J. C. (1987). Maximum performance tests of speech production. Journal of Speech and Hearing Disorders, 52, 367–387. [Article]

King, J. B., Ramig, L. O., Lemke, J., & Horii, Y. (1994). Parkinson’s disease: Longitudinal variability in acoustic parameters of phonation. Journal of Medical Speech-Language Pathology, 2, 29–42.

Leinonen, L., & Laakso, M. (1990) Control of static pressure by expiratory muscles during expiratory effort and phonation. Journal of Voice, 4(3), 256–263. [Article]

Leith, D., & Bradley, M. (1976) Ventilatory muscle strength and endurance training. Journal of Applied Physiology, 41(4), 508–516. [Article]

Levin, B. E., Llabre, M. M., & Weiner, W. J. (1989). Cognitive impairments associated with early Parkinson’s disease. Neurology, 39, 557–561. [Article]

Lewis, R., & Kupke, T. (1977). The Lafayette clinic repeatable neuropsychological test battery: Its development and research applications. Paper presented at the annual meeting of the Southeastern Psychological Association, Hollywood, FL.

Logemann, J. A., Fisher, H. B., Boshes, B., & Blonsky, E. R. (1978). Frequency and concurrence of vocal tract dysfunctions in the speech of a large sample of Parkinson patients. Journal of Speech and Hearing Disorders, 42, 47–57. [Article]

Mayeux, R., Williams, J. B. W., Stern, Y., & Cote, L. (1986). Depression and Parkinson’s disease. In Yahr M.D. & Bergmann K.J. (Eds.), Advances in neurology (pp. 241–250). New York: Raven Press.

McDowell, F. H., Lee, J. E., & Sweet, R. D. (1986). Extrapyramidal disease. In Baker A.B. & Joynt R.J. (Eds.), Clinical neurology (pp. 24–26). Philadelphia: Harper and Row.

McKenzie, D., & Gandevia, S. (1986). Strength and endurance of inspiratory, expiratory, and limb muscles in asthma. American Review of Respiratory Disease, 134, 999–1004. [Article]

Mead, C., Ramig, L. O., & Beck, J. (1989). Parkinson’s disease with dementia: Effectiveness of intensive voice therapy. Asha, 31(10), 118.

Milenkovic, P. (1987). Least mean square measures of voice perturbation. Journal of Speech and Hearing Research, 30, 529–538. [Article]

Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382–389. [Article]

Morley, D. E. (1955). The rehabilitation of adults with dysarthric speech. Journal of Speech and Hearing Disorders, 20, 58–64. [Article]

Muller, F., & Stelmach, G. E. (1991). Scaling problems in Parkinson’s disease. In Requin J. & Stelmach G.E. (Eds.), Tutorials in motor neuroscience (pp. 161–174). Netherlands: Kluwer Academic Publishers. [Article]

Mutch, W. J., Strudwick, A., Roy, S. L., & Downie, A. W. (1986) Parkinson disease: Disability, review and management. British Medical Journal, 293, 675–677. [Article]

Netsell, R., & Daniel, B. (1979). Dysarthria in adults: Physiologic approach to rehabilitation. Archives of Physical Medicine and Rehabilitation, 60, 502–508.

Netsell, R., & Rosenbek, J. (1986). Treating the dysarthrias. In Netsell R. (Ed.), A neurobiologic view of speech production and the dysarthrias (pp. 123–152) San Diego: College-Hill Press.

Oxtoby, M. (1982). Parkinson’s disease patients and their social needs. London: Parkinson’s Disease Society.

Panzarella, K. J. (1995). Expiratory muscle conditioning in speech-impaired children. Unpublished thesis, State University of New York at Buffalo.

Perez, K., Ramig, L. O., Smith, M., & Dromey, C. (in press). The Parkinson larynx: Tremor and videostroboscopic findings. Journal of Voice.

Pichney, M. A., Durlach, N. I., & Braida, L. D. (1986). Speaking clearly for the hard of hearing: II. Acoustic characteristics of clear and conversational speech. Journal of Speech and Hearing Research, 29, 434–446. [Article]

Pickett, J. M. (1956). Effects of vocal force on the intelligibility of speech sounds. Journal of the Acoustical Society of America, 28, 902–905. [Article]

Ramig, L. O. (1992). The role of phonation in speech intelligibility: A review and preliminary data from patients with Parkinson’s disease. In Kent R.D. (Ed.), Intelligibility in speech disorders: Theory, measurement and management (pp. 119–156). Amsterdam: John Benjamin. [Article]

Ramig, L. O. (1995). Speech therapy for patients with Parkinson’s disease. In Koller W.C. and Paulson G. (Eds.), Therapy of Parkinson’s disease (pp. 539–548). New York: Marcel Dekker.

Ramig, L. O., Bonitati, C., Lemke, J., & Horii, Y. (1994). Voice treatment for patients with Parkinson disease: Development of an approach and preliminary efficacy data. Journal of Medical Speech-Language Pathology, 2, 191–209.

Ramig, L. O., Bonitati, C., & Winholtz, W. (1994). Lee Silverman Voice Treatment. A treatment video tape. Blue Springs, MO: Wintronix, Inc.

Ramig, L. O., Countryman, S., O’Brien, C., & Smith, M. (1995, May). Efficacy of voice treatment for Parkinson disease. Paper presented to the annual meeting of the American Academy of Neurology, Seattle, WA.

Ramig, L. O., Fazoli, K., Scherer, R., & Bonitati, C. (1990, January). Changes in phonation following voice therapy in patients with Parkinson’s disease. Paper presented to the Clinical Dysarthria Conference, San Antonio, TX.

Ramig, L., Y., Horii, & Bonitati, C. (1991). The effectiveness of speech therapy for patients with Parkinson’s disease. National Center for Voice and Speech Research Report, 1, 61–86.

Ramig, L. O., Mead, C., Scherer, R., Horii, Y., Larson, K., & Kohler, D. (1988, February). Voice therapy and Parkinson’s disease: A longitudinal study of efficacy. Paper presented at the Clinical Dysarthria Conference, San Diego, CA.

Ramig, L. O., Pawlas, A., & Countryman, S. (1995). The Lee Silverman Voice Treatment (LSVT): A practical guide to treating the voice and speech disorders in Parkinson disease. Iowa City, IA: University of Iowa, National Center for Voice and Speech.

Reitan, R. M., & Wolfson, D. (1985). The Halsted-Reitan Neuropsychological Test Battery. Tucson, AZ: Neuropsychology Press.

Robin, D. A., Goel, A., Somodi, L. B., & Luschei, E. S. (1992). Tongue strength and endurance: Relation to highly skilled movements. Journal of Speech and Hearing Research, 35, 1239–1245. [Article]

Rubow, R., & Swift, E. (1985). A microcomputer-based wearable biofeedback device to improve transfer of treatment in Parkinsonian dysarthria. Journal of Speech and Hearing Disorders, 50, 178–185. [Article]

Sarno, M. T. (1968). Speech impairment in Parkinson’s disease. Archives of Physical Medicine and Rehabilitation, 49, 269–275.

Scherer, K. R., London, H., & Wolf, J. (1973). The voice of confidence: Paralinguistic cues and audience evaluation. Journal of Research Personality, 7, 31–44. [Article]

Schiffman, S., Reynolds, M. L., & Young, F. W. (1981). Introduction to multidimensional scaling: Theory, methods and applications. New York: Academic Press.

Schmidt, R. A. (1975). A schema theory of discrete motor skill learning. Psychological Review, 82, 225–260. [Article]

Schmidt, R. A. (1988) Motor control and learning. Champaign, IL: Human Kinetic Publishers.

Schulman, R. (1989). Articulatory dynamics of loud and normal speech. Journal of the Acoustical Society of America, 85, 295–312. [Article]

Scott, S., & Caird, F. L. (1983). Speech therapy for Parkinson’s disease. Journal of Neurology, Neurosurgery and Psychiatry, 46, 140–144. [Article]

Smith, M., Ramig, L. O., Dromey, C., Perez, K., & Samandari, R. (in press). Intensive voice treatment in Parkinson’s disease: Laryngostroboscopic findings. Journal of Voice.

Stathopoulos, E., & Sapienza, C. (1993a). Respiratory and laryn geal function of women and men during vocal intensity variation. Journal of Speech and Hearing Research, 36, 64–75. [Article]

Stathopoulos, E., & Sapienza, C. (1993b). Respiratory and laryngeal measures of children during vocal intensity variation. Journal of the Acoustical Society of America, 94, 2531–2543. [Article]

Stelmach, G. E. (1991). Basal ganglia impairment and force control. In Requin J. & Stelmach G.E. (Eds.), Tutorials in motor neuroscience (pp. 137–148). Netherlands: Kluwer Academic Publishers. [Article]

Streifler, M., & Hofman, S. (1984). Disorders of verbal expression in Parkinsonism. In Hassler R.G. & Christ J.F. (Eds.), Advances in neurology (pp. 385–393). New York: Raven Press.

Teulings, H.-L., & Stelmach, G.E. (1991). Control of stroke size, peak acceleration, and stroke duration in parkinson handwriting. Human Movement Science, 10, 315–334. [Article]

Titze, I. R., & Sundberg, J. (1992). Vocal intensity in speakers and singers. Journal of the Acoustical Society of America, 91, 2936–2946. [Article]

Wechsler, D. (1981). WAIS—R manual. New York: The Psychological Corporation.

Weiner, W. J., & Singer, C. (1989). Parkinson’s disease and nonpharmacologic treatment programs. Journal of the American Geriatrics Society, 37, 359–363. [Article]

Winholtz, W. S., & Ramig, L. (1992). Vocal tremor analysis with the vocal demodulator. Journal of Speech and Hearing Research, 35, 562–573. [Article]

Yanagisawa, N., Fujimato, S., & Tamara, F. (1989). Bradykinesia in Parkinson’s disease: Disorders of onset and execution of fast movement. European Neurology, 29 (Suppl.), 19–28. [Article]

Yorkston, K., Buekelman, D., and Bell, K. (1988). Clinical management of dysarthria speech. Boston: College Hill.

FIGURE 1.

Full Size | Slide (.ppt)

TABLE 1.Logic for development and rationale for treatment goals and tasks for the Lee Silverman Voice Treatment.

Perceptual characteristics of speech	Hypothesized laryngeal and/or respiratory physical pathology	Treatment goals and tasks
Reduced loudness	Reduced vocal fold adduction e.g., bowed vocal folds	• Increase vocal fold adduction via isometric effort (pushing, lifting) during phonation
Breathy, weak voice	Reduced respiratory support	• Increase maximum duration vowel phonation at greater vocal intensity
		• “Think loud/shout”
Hoarseness	Rigidity, hypokinesia, in laryngeal and/or respiratory muscles	• Improve vocal quality during sustained phonation and speaking
Monotone	Rigid cricothyroid muscle	• Increase maximum fundamental frequency range
		• High/low pitch glides
		• Sustained phonation at highest and lowest pitches

View Large

TABLE 1.Logic for development and rationale for treatment goals and tasks for the Lee Silverman Voice Treatment.

Perceptual characteristics of speech	Hypothesized laryngeal and/or respiratory physical pathology	Treatment goals and tasks
Reduced loudness	Reduced vocal fold adduction e.g., bowed vocal folds	• Increase vocal fold adduction via isometric effort (pushing, lifting) during phonation
Breathy, weak voice	Reduced respiratory support	• Increase maximum duration vowel phonation at greater vocal intensity
		• “Think loud/shout”
Hoarseness	Rigidity, hypokinesia, in laryngeal and/or respiratory muscles	• Improve vocal quality during sustained phonation and speaking
Monotone	Rigid cricothyroid muscle	• Increase maximum fundamental frequency range
		• High/low pitch glides
		• Sustained phonation at highest and lowest pitches

TABLE 2.Descriptive characteristics of subjects who received the Lee Silverman Voice Treatment (voice and respiration) and subjects who received treatment focusing only on respiration.

Subject	Sex	Age	Years since diagnosis	Hoehn & Yahr stage (1967)	UPDRS Motor exam	Medication* †	Speech/Voice deficits (severity rating)	Glottal incompetence
Subjects who received the Lee Silverman Voice Treatment
1	F	73	10	4.0	48.0	a, c, f	reduced loudness imprecise articulation	2.25
							(5)
2	F	52	13	3.0	17.0	a, f, o	reduced loudness rapid rate	1.50
							(3)
3	F	49	9	2.0	4.0	a, d, g	hoarseness	1.5
						(1)
4	F	32	1	2.0	UA∼	a, j	hoarseness
							(1)
5	F	74	1	1.5	12.0	b, c	hoarseness tremor
							(2)
Mean (F)		56.0	6.8	2.5	20.25		2.4	1.75
(SD)		(17.7)	(5.5)	(1.0)	(19.3)		(1.67)	(0.4)
6	M	49	1	2.0	13.0	a, b, c	monotone reduced loudness	1.33
							(1)
7	M	76	1	2.0	20.0	a	hoarseness monotone
							(2)
8	M	76	5	3.0	28.0	b, c, I	imprecise articulation reduced loudness	1.75
							(3)
9	M	62	3	2.0	26.0	a, c	hoarseness reduced loudness	2.0
							(3)
10	M	71	11	3.5	43.5	i, h	hoarseness reduced loudness	1.75
							(4)
11	M	50	18	2.0	19.5	a, c, d	reduced loudness monotone
							(2)
12	M	68	6	3.0	40.5	a, k	reduced loudness hoarseness	2.0
							(3)
13	M	75	20	3.5	47.0	b, n	reduced loudness imprecise articulation	1.25
							(4)
14	M	69	1	3.0	32.0	none	imprecise articulation reduced loudness
							(2)
15	M	61	1	2.0	16.0	a, c	reduced loudness imprecise articulation	1.0
							(2)
16	M	72	5	3.0	30.0	a, c, h	reduced loudness monotone	1.0
							(2)
17	M	67	8	3.0	16.0	a	reduced loudness imprecise articulation	1.75
							(3)
18	M	64	7	2.0	26.0	a,	monotone reduced loudness	1.0
							(2)
19	M	73	10	3.0	27.5	a, h	monotone reduced loudness
							(3)
20	M	79	1	3.0	33.0	a, c	monotone imprecise articulation
							(3)
21	M	62	4	3.5	35.0	k, n	aphonia hoarseness
							(4)
Subjects who received the Lee Silverman Voice Treatment
22	M	52	18	3.0	34.0	a, c, d, e	rapid rate reduced loudness
							(3)
23	M	75	7	2.0	32.0	a, c	reduced loudness hoarseness
						(3)
24	M	61	4	3.0	22.5	a, c, d	imprecise articulation reduced loudness
						(4)
25	M	54	15	3.5	45.5	b, i, k	reduced loudness monotone	2.25
						(4)
26	M	56	7	2.0	2.0	a, c, h	rapid rate reduced loudness	1.0
						(3)
Mean (M)		65.3	8.7	2.7	28.0		2.86	1.5
(SD)		(9.3)	(10.1)	(0.6)	(11.3)		(0.85)(0.5)
Group Mean		63.5	8.3	2.7	26.8		2.77	1.6
(SD)		(11.5)	(9.3)	(0.7)	(12.7)	(1.03)	(0.45)
Subjects who received treatment focusing only on respiration
27	F	64	2	3.0	29.0	a, c, p	hoarseness reduced loudness	1.55
							(1)
28	F	71	3	1.0	UA∼	a	hoarseness tremor
							(2)
29	F	68	1	2.0	1.0	a, b, c	reduced loudness
							(1)
30	F	68	4	2.0	12.0	a, c	reduced loudness monotone	1.75
							(3)
31	F	63	3	3.0	42.0	a, c	imprecise articulation slow rate	2.5
							(4)
32	F	51	4	1.0	16.0	none	reduced loudness	1.75
							(1)
33	F	83	7	3.0	33.0	a	strained/strangled rapid rate	1.75
							(4)
Mean (F)		66.9	3.4	2.1	23.6		2.29	1.8
(SD)		(9.6)	(1.9)	(0.9)	(14.3)		(1.38)	(0.2)
34	M	70	4	3.0	32.0	a, c	reduced loudness monotone	1.0
							(3)
35	M	71	4	3.0	43.0	a, n	reduced loudness monotone	1.25
							(4)
36	M	69	1	2.0	27.0	i	monotone reduced loudness
							(3)
37	M	65	8	3.0	19.0	none	imprecise articulation rapid rate	1.0
							(2)
38	M	52	14	2.0	31.0	a, d, e, p	pallilalia rapid rate	1.0
							(3)
39	M	67	18	3.5	UA	b, c, j	imprecise articulation reduced loudness
							(4)
40	M	51	6	1.5	3.0	a, c	rapid rate pallilalia
							(4)
41	M	66	12	3.0	41.0	a, c, i	strained/strangled reduced loudness
							(3)
Subjects who received treatment focusing only on respiration
42	M	81	2	2.0	24.5	a, c, n	reduced loudness	1.0
							(2)
43	M	69	6	2.0	36.0	a, k	reduced loudness monotone
							(3)
44	M	64	10	3.0	43.0	a	imprecise articulation monotone	1.5
							(4)
45	M	54	3	1.0	3.0	b, c, h	reduced loudness monotone
							(1)
Mean (M)		64.9	7.3	2.4	27.1		3.0	1.1
(SD)		(8.7)	(5.2)	(0.8)	(15.0)		(0.95)	(0.2)
Group Mean		65.6	5.9	2.3	25.6		2.74	1.38
(SD)		(8.9)	(4.7)	(0.8)	(14.4)		(1.15)	(0.4)

View Large

TABLE 2.Descriptive characteristics of subjects who received the Lee Silverman Voice Treatment (voice and respiration) and subjects who received treatment focusing only on respiration.

Subject	Sex	Age	Years since diagnosis	Hoehn & Yahr stage (1967)	UPDRS Motor exam	Medication* †	Speech/Voice deficits (severity rating)	Glottal incompetence
Subjects who received the Lee Silverman Voice Treatment
1	F	73	10	4.0	48.0	a, c, f	reduced loudness imprecise articulation	2.25
							(5)
2	F	52	13	3.0	17.0	a, f, o	reduced loudness rapid rate	1.50
							(3)
3	F	49	9	2.0	4.0	a, d, g	hoarseness	1.5
						(1)
4	F	32	1	2.0	UA∼	a, j	hoarseness
							(1)
5	F	74	1	1.5	12.0	b, c	hoarseness tremor
							(2)
Mean (F)		56.0	6.8	2.5	20.25		2.4	1.75
(SD)		(17.7)	(5.5)	(1.0)	(19.3)		(1.67)	(0.4)
6	M	49	1	2.0	13.0	a, b, c	monotone reduced loudness	1.33
							(1)
7	M	76	1	2.0	20.0	a	hoarseness monotone
							(2)
8	M	76	5	3.0	28.0	b, c, I	imprecise articulation reduced loudness	1.75
							(3)
9	M	62	3	2.0	26.0	a, c	hoarseness reduced loudness	2.0
							(3)
10	M	71	11	3.5	43.5	i, h	hoarseness reduced loudness	1.75
							(4)
11	M	50	18	2.0	19.5	a, c, d	reduced loudness monotone
							(2)
12	M	68	6	3.0	40.5	a, k	reduced loudness hoarseness	2.0
							(3)
13	M	75	20	3.5	47.0	b, n	reduced loudness imprecise articulation	1.25
							(4)
14	M	69	1	3.0	32.0	none	imprecise articulation reduced loudness
							(2)
15	M	61	1	2.0	16.0	a, c	reduced loudness imprecise articulation	1.0
							(2)
16	M	72	5	3.0	30.0	a, c, h	reduced loudness monotone	1.0
							(2)
17	M	67	8	3.0	16.0	a	reduced loudness imprecise articulation	1.75
							(3)
18	M	64	7	2.0	26.0	a,	monotone reduced loudness	1.0
							(2)
19	M	73	10	3.0	27.5	a, h	monotone reduced loudness
							(3)
20	M	79	1	3.0	33.0	a, c	monotone imprecise articulation
							(3)
21	M	62	4	3.5	35.0	k, n	aphonia hoarseness
							(4)
Subjects who received the Lee Silverman Voice Treatment
22	M	52	18	3.0	34.0	a, c, d, e	rapid rate reduced loudness
							(3)
23	M	75	7	2.0	32.0	a, c	reduced loudness hoarseness
						(3)
24	M	61	4	3.0	22.5	a, c, d	imprecise articulation reduced loudness
						(4)
25	M	54	15	3.5	45.5	b, i, k	reduced loudness monotone	2.25
						(4)
26	M	56	7	2.0	2.0	a, c, h	rapid rate reduced loudness	1.0
						(3)
Mean (M)		65.3	8.7	2.7	28.0		2.86	1.5
(SD)		(9.3)	(10.1)	(0.6)	(11.3)		(0.85)(0.5)
Group Mean		63.5	8.3	2.7	26.8		2.77	1.6
(SD)		(11.5)	(9.3)	(0.7)	(12.7)	(1.03)	(0.45)
Subjects who received treatment focusing only on respiration
27	F	64	2	3.0	29.0	a, c, p	hoarseness reduced loudness	1.55
							(1)
28	F	71	3	1.0	UA∼	a	hoarseness tremor
							(2)
29	F	68	1	2.0	1.0	a, b, c	reduced loudness
							(1)
30	F	68	4	2.0	12.0	a, c	reduced loudness monotone	1.75
							(3)
31	F	63	3	3.0	42.0	a, c	imprecise articulation slow rate	2.5
							(4)
32	F	51	4	1.0	16.0	none	reduced loudness	1.75
							(1)
33	F	83	7	3.0	33.0	a	strained/strangled rapid rate	1.75
							(4)
Mean (F)		66.9	3.4	2.1	23.6		2.29	1.8
(SD)		(9.6)	(1.9)	(0.9)	(14.3)		(1.38)	(0.2)
34	M	70	4	3.0	32.0	a, c	reduced loudness monotone	1.0
							(3)
35	M	71	4	3.0	43.0	a, n	reduced loudness monotone	1.25
							(4)
36	M	69	1	2.0	27.0	i	monotone reduced loudness
							(3)
37	M	65	8	3.0	19.0	none	imprecise articulation rapid rate	1.0
							(2)
38	M	52	14	2.0	31.0	a, d, e, p	pallilalia rapid rate	1.0
							(3)
39	M	67	18	3.5	UA	b, c, j	imprecise articulation reduced loudness
							(4)
40	M	51	6	1.5	3.0	a, c	rapid rate pallilalia
							(4)
41	M	66	12	3.0	41.0	a, c, i	strained/strangled reduced loudness
							(3)
Subjects who received treatment focusing only on respiration
42	M	81	2	2.0	24.5	a, c, n	reduced loudness	1.0
							(2)
43	M	69	6	2.0	36.0	a, k	reduced loudness monotone
							(3)
44	M	64	10	3.0	43.0	a	imprecise articulation monotone	1.5
							(4)
45	M	54	3	1.0	3.0	b, c, h	reduced loudness monotone
							(1)
Mean (M)		64.9	7.3	2.4	27.1		3.0	1.1
(SD)		(8.7)	(5.2)	(0.8)	(15.0)		(0.95)	(0.2)
Group Mean		65.6	5.9	2.3	25.6		2.74	1.38
(SD)		(8.9)	(4.7)	(0.8)	(14.4)		(1.15)	(0.4)

TABLE 3.Neuropsychological characteristics of the Lee Silverman Voice Treatment (voice and respiration) subjects and the respiration-only subjects.

Subject	Cognition (T score)	Beck Depression (self-rating)	Depression (clinician’s rating)	SIP communication	SIP social interaction
Subjects who received the Lee Silverman Voice Treatment
1	40.38	10	12	65.24	12.55
2	40.08	11	7	56.41	13.03
3	40.54	20	14	0.00	33.93
4	45.31	20	9	9.66	13.17
5	42.62	14	11	9.66	11.03
Mean (F)	41.79	15.0	10.6	28.19	16.74
(SD)	(2.21)	(7.28)	(2.70)	(30.21)	(9.65)
6	46.54	6	3	0.00	0.00
7	47.00	5	0	9.66	0.00
8	42.69	0	3	21.10	3.59
9	44.54	2	7	9.66	9.03
10	42.69	6	6	56.00	7.38
11	39.54	3	8	31.31	6.00
12	41.15	4	7	39.17	3.52
13	42.62	13	15	22.48	9.10
14	44.08	4	5	67.86	0.00
15	45.69	1	4	0.00	0.00
16	39.77	12	3	41.79	18.62
17	48.69	12	8	65.24	11.79
18	50.31	3	1	30.24	0.00
19	43.54	16	5	40.41	0.00
20	41.23	4	6	51.86	17.03
21	37.38	12	5	63.03	24.89
22	42.08	12	8	63.86	3.52
23	53.69	15	13	11.45	11.45
24	44.38	8	13	52.41	6.83
25	50.38	10	5	28.97	6.83
26	48.31	11	3	30.76	15.72
Mean (M)	44.59	7.57	6.10	35.11	7.40
(SD)	(4.08)	(4.87)	(3.86)	(21.75)	(7.11)
Group Mean	44.05	9.0	6.96	33.78	9.19
(SD)	(3.92)	(5.62)	(4.05)	(23.07)	(8.33)
Subjects who received treatment focusing only on respiration
27	53.31	10	9	0.00	0.00
28	39.31	7	7	39.17	6.07
29	48.85	12	0	0.00	0.00
30	50	3	7	18.48	6.48
31	40.54	25	19	73.10	55.17
32	52.77	13	12	0.00	26.76
33	40.54	12	11	55.03	9.10
Mean (F)	46.47	11.71	9.29	26.54	14.80
(SD)	(6.14)	(6.82)	(5.79)	(29.77)	(19.95)
34	49.38	11	1	0.00	3.52
35	34.46	10	3	32.55	17.59
36	50.69	11	1	9.66	3.52
37	43.85	0	3	40.41	3.52
38	43.54	22	6	52.41	31.38
39	40.31	10	3	66.21	20.41
40	46.08	3	6	9.66	11.45
41	50.08	13	11	63.86	18.69
42	49.23	5	5	9.66	20.48
43	37.54	12	2	31.31	9.59
44	33.91	8	13	52.41	7.10
45	51.92	1	5	0.00	0.00
Mean (M)	44.25	8.83	4.92	30.68	12.27
(SD)	(6.42)	(6.04)	(3.75)	(24.52)	(9.45)
Group Mean	45.07	9.90	6.53	29.15	13.20
(SD)	(6.24)	(6.31)	(4.95)	(25.83)	(13.74)

View Large

TABLE 3.Neuropsychological characteristics of the Lee Silverman Voice Treatment (voice and respiration) subjects and the respiration-only subjects.

Subject	Cognition (T score)	Beck Depression (self-rating)	Depression (clinician’s rating)	SIP communication	SIP social interaction
Subjects who received the Lee Silverman Voice Treatment
1	40.38	10	12	65.24	12.55
2	40.08	11	7	56.41	13.03
3	40.54	20	14	0.00	33.93
4	45.31	20	9	9.66	13.17
5	42.62	14	11	9.66	11.03
Mean (F)	41.79	15.0	10.6	28.19	16.74
(SD)	(2.21)	(7.28)	(2.70)	(30.21)	(9.65)
6	46.54	6	3	0.00	0.00
7	47.00	5	0	9.66	0.00
8	42.69	0	3	21.10	3.59
9	44.54	2	7	9.66	9.03
10	42.69	6	6	56.00	7.38
11	39.54	3	8	31.31	6.00
12	41.15	4	7	39.17	3.52
13	42.62	13	15	22.48	9.10
14	44.08	4	5	67.86	0.00
15	45.69	1	4	0.00	0.00
16	39.77	12	3	41.79	18.62
17	48.69	12	8	65.24	11.79
18	50.31	3	1	30.24	0.00
19	43.54	16	5	40.41	0.00
20	41.23	4	6	51.86	17.03
21	37.38	12	5	63.03	24.89
22	42.08	12	8	63.86	3.52
23	53.69	15	13	11.45	11.45
24	44.38	8	13	52.41	6.83
25	50.38	10	5	28.97	6.83
26	48.31	11	3	30.76	15.72
Mean (M)	44.59	7.57	6.10	35.11	7.40
(SD)	(4.08)	(4.87)	(3.86)	(21.75)	(7.11)
Group Mean	44.05	9.0	6.96	33.78	9.19
(SD)	(3.92)	(5.62)	(4.05)	(23.07)	(8.33)
Subjects who received treatment focusing only on respiration
27	53.31	10	9	0.00	0.00
28	39.31	7	7	39.17	6.07
29	48.85	12	0	0.00	0.00
30	50	3	7	18.48	6.48
31	40.54	25	19	73.10	55.17
32	52.77	13	12	0.00	26.76
33	40.54	12	11	55.03	9.10
Mean (F)	46.47	11.71	9.29	26.54	14.80
(SD)	(6.14)	(6.82)	(5.79)	(29.77)	(19.95)
34	49.38	11	1	0.00	3.52
35	34.46	10	3	32.55	17.59
36	50.69	11	1	9.66	3.52
37	43.85	0	3	40.41	3.52
38	43.54	22	6	52.41	31.38
39	40.31	10	3	66.21	20.41
40	46.08	3	6	9.66	11.45
41	50.08	13	11	63.86	18.69
42	49.23	5	5	9.66	20.48
43	37.54	12	2	31.31	9.59
44	33.91	8	13	52.41	7.10
45	51.92	1	5	0.00	0.00
Mean (M)	44.25	8.83	4.92	30.68	12.27
(SD)	(6.42)	(6.04)	(3.75)	(24.52)	(9.45)
Group Mean	45.07	9.90	6.53	29.15	13.20
(SD)	(6.24)	(6.31)	(4.95)	(25.83)	(13.74)

TABLE 4.Intrasubject (test-retest) reliability for acoustic and perceptual variables expressed in Pearson product-moment correlation coefficients.

Variables	Pre-1 to Pre-2 correlations	Post-1 to Post-2 correlations
SPL
Sustained phonation	0.78	0.96
Rainbow Passage	0.78	0.97
Monologue	0.82	0.82
Maximum duration	0.83	0.93
STSD
Rainbow Passage	0.95	0.91
Monologue	0.39	0.43
F₀
Rainbow Passage	0.98	0.99
Monologue	0.96	0.96
FVC	0.98	0.99
Perceptual-Subject (n = 45)
Loudness	0.65	0.68
Monotonicity	0.55	0.72
Hoarseness	0.69	0.45
Intelligibility	0.67	0.76
Initiate conversation	0.81	0.83
Perceptual-Family (n = 20)
Loudness	0.61	0.86
Monotonicity	0.87	0.99
Hoarseness	0.75	0.92
Intelligibility	0.63	0.98
Initiate conversation	0.93	0.71

View Large

TABLE 4.Intrasubject (test-retest) reliability for acoustic and perceptual variables expressed in Pearson product-moment correlation coefficients.

Variables	Pre-1 to Pre-2 correlations	Post-1 to Post-2 correlations
SPL
Sustained phonation	0.78	0.96
Rainbow Passage	0.78	0.97
Monologue	0.82	0.82
Maximum duration	0.83	0.93
STSD
Rainbow Passage	0.95	0.91
Monologue	0.39	0.43
F₀
Rainbow Passage	0.98	0.99
Monologue	0.96	0.96
FVC	0.98	0.99
Perceptual-Subject (n = 45)
Loudness	0.65	0.68
Monotonicity	0.55	0.72
Hoarseness	0.69	0.45
Intelligibility	0.67	0.76
Initiate conversation	0.81	0.83
Perceptual-Family (n = 20)
Loudness	0.61	0.86
Monotonicity	0.87	0.99
Hoarseness	0.75	0.92
Intelligibility	0.63	0.98
Initiate conversation	0.93	0.71

TABLE 5.F and p values for the acoustic variables.

	Between-subject effect									Within-subject effect
Dependent variables	Group		Gender		Group × Gender		Time			Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	df	F	p	F	p	F	p	F	p
SPL
Sustained phonation	15.55	.000	0.49	.486	0.66	.421	1,41	43.63	.000	53.72	.000	0.11	.738	7.37	.01
Rainbow Passage	4.88	.033	5.30	.027	4.62	.037	1,41	29.41	.000	4.70	.036	1.62	.210	4.85	.033
Monologue	0.39	.537	3.65	.067	1.14	.296	1,25	14.02	.001	3.27	.083	3.67	.067	1.90	.180
Maximum duration	1.68	.202	1.49	.230	.85	.361	1,41	9.29	.004	.63	.431	.51	.480	.48	.493
F₀							1,39
Rainbow Passage	6.48	.015	83.64	.000	1.34	.252		35.58	.000	1.14	.292	1.52	.225	1.61	.212
STSD							1,39
Rainbow Passage	2.20	.146	1.45	.235	.90	.348		43.29	.000	1.98	.168	.00	.968	2.40	.129
F₀							1,25
Monologue	.88	.358	85.92	.000	1.39	.250		3.62	.069	2.97	.097	.61	.443	.03	.856
STSD							1,25
Monologue	.22	.645	.50	.484	.32	.578		1.02	.321	8.48	.007	.43	.516	.94	.340
Utterance duration
Rainbow Passage	.07	.786	.60	.442	.90	.350	1,37	19.30	.000	.16	.696	.03	.864	.03	.875
Monologue	1.36	.254	8.90	.006	4.47	.044	1,27	2.23	.147	1.84	.186	.45	.506	.07	.793
Pause duration
Rainbow Passage	2.97	.093	1.67	.204	4.83	.034	1,37	30.15	.000	6.61	.014	.85	.364	2.79	.103
Monologue	2.02	.167	.29	.593	1.06	.313	1,27	1.87	.183	3.02	.093	.65	.427	3.06	.091
FVC	.70	.408	17.87	.000	.30	.586	1,40	.04	.852	.28	.599	.03	.870	2.15	.151

View Large

TABLE 5.F and p values for the acoustic variables.

	Between-subject effect									Within-subject effect
Dependent variables	Group		Gender		Group × Gender		Time			Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	df	F	p	F	p	F	p	F	p
SPL
Sustained phonation	15.55	.000	0.49	.486	0.66	.421	1,41	43.63	.000	53.72	.000	0.11	.738	7.37	.01
Rainbow Passage	4.88	.033	5.30	.027	4.62	.037	1,41	29.41	.000	4.70	.036	1.62	.210	4.85	.033
Monologue	0.39	.537	3.65	.067	1.14	.296	1,25	14.02	.001	3.27	.083	3.67	.067	1.90	.180
Maximum duration	1.68	.202	1.49	.230	.85	.361	1,41	9.29	.004	.63	.431	.51	.480	.48	.493
F₀							1,39
Rainbow Passage	6.48	.015	83.64	.000	1.34	.252		35.58	.000	1.14	.292	1.52	.225	1.61	.212
STSD							1,39
Rainbow Passage	2.20	.146	1.45	.235	.90	.348		43.29	.000	1.98	.168	.00	.968	2.40	.129
F₀							1,25
Monologue	.88	.358	85.92	.000	1.39	.250		3.62	.069	2.97	.097	.61	.443	.03	.856
STSD							1,25
Monologue	.22	.645	.50	.484	.32	.578		1.02	.321	8.48	.007	.43	.516	.94	.340
Utterance duration
Rainbow Passage	.07	.786	.60	.442	.90	.350	1,37	19.30	.000	.16	.696	.03	.864	.03	.875
Monologue	1.36	.254	8.90	.006	4.47	.044	1,27	2.23	.147	1.84	.186	.45	.506	.07	.793
Pause duration
Rainbow Passage	2.97	.093	1.67	.204	4.83	.034	1,37	30.15	.000	6.61	.014	.85	.364	2.79	.103
Monologue	2.02	.167	.29	.593	1.06	.313	1,27	1.87	.183	3.02	.093	.65	.427	3.06	.091
FVC	.70	.408	17.87	.000	.30	.586	1,40	.04	.852	.28	.599	.03	.870	2.15	.151

	LSVT		R only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Intensity (dB) (at 50cm)
Sustained phonation
Group (n = 26;19)	68.20 (4.70)	81.20 (4.65)	69.32 (5.05)	68.01 (4.31)
Males (n = 21;12)	68.03 (4.60)	81.99 (3.93)	70.23 (3.75)	66.99 (4.49)
Females (n = 5;7)	68.02 (5.70)	77.91 (6.40)	67.76 (6.80)	69.75 (3.64)
Rainbow Passage
Group (n = 26;19)	66.30 (4.02)	74.33 (4.83)	65.68 (2.68)	68.16 (3.33)
Males (n = 21;12)	66.56 (4.37)	75.69 (4.06)	66.02 (2.53)	67.94 (3.62)
Females (n = 5;7)	65.19 (1.96)	68.58 (3.51)	65.11 (3.05)	68.56 (3.00)
Monologue
Group (n = 16;13)	64.67 (3.37)	69.17(4.10)	64.66 (2.58)	66.24 (2.11)
Males (n = 11 ;8)	64.94 (3.66)	70.35 (3.61)	65.19 (2.40)	66.70 (2.01)
Females (n = 5;5)	63.96 (1.66)	65.34 (3.46)	64.66 (2.58)	65.52 (2.77)
Max duration (sec)
Sustained phonation
Group (n = 26;19)	21.12 (7.63)	24.84(10.35)	18.39 (9.65)	21.20 (8.78)
Males (n = 21; 12)	21.62 (8.17)	24.67 (11.44)	20.67(11.09)	23.47 (7.93)
Females (n = 5;7)	19.00(4.77)	25.57 (3.79)	14.47 (5.10)	17.32 (9.37)
F₀ (Hz)
Rainbow Passage
Males (n = 21;12)	124.73 (22.10)	140.78 (23.66)	120.13 (18.72)	125.57 (21.45)
Females (n = 5;5)	198.35 (12.13)	214.23 (13.56)	171.47 (11.47)	188.26 (17.58)
F₀ variability (STSD)
Rainbow Passage
Group (n = 26; 17)	1.82 (0.53)	2.38 (0.67)	1.80 (0.41)	2 09 (0.34)
Males (n = 21;12)	1.73 (0.42)	2.33 (0.63)	1.82 (0.41)	2.05 (0.30)
Females (n = 5;5)	2.22 (0.80)	2.62 (0.87)	1.77 (0.49)	2.19 (0.44)
F₀ (Hz)
Monologue
Males (n = 12; 10)	114.33 (13.19)	120.64 (16.81)	119.80 (21.85)	118.81 (18.62)
Females (n = 4;3)	190.52 (20.71)	201.40 (15.34)	179.15 (15.43)	180.99 (25.26)
F₀ variability (STSD)
Monologue
Group (n = 16;13)	1.68 (0.39)	1.97 (0.58)	2.13 (0.72)	1.95 (0.67)
Males (n = 12;10)	1.66 (0.39)	1.90 (0.39)	2.11 (0.73)	1.95 (0.72)
Females (n = 4;3)	1.80 (0.61)	2.38 (0.88)	2.18 (0.84)	1.95 (0.59)
Utterance duration (msec)
Rainbow Passage
Group (n = 24; 17)	2665.88 (666.03)	2186.24 (511.62)	2524.08 (530.33)	2132.55 (396.94)
Males (n = 19;11)	2671.59 (741.40)	2192.50 (512.17)	2409.05 (421.21)	2040.95 (361.57)
Females (n = 5;6)	2644.19 (276.33)	2162.44 (568.97)	2734.97 (680.22)	2300.48 (436.48)
Monologue
Group (n = 18;13)	1943.19 (389.51)	1948.66 (672.05)	2165.12 (851.82)	1872.51 (569.48)
Males (n = 13;9)	1883.38 (346.72)	1915.60 (661.21)	1829.16 (582.93)	1604.47 (299.41)
Females (n = 5;4)	2098.69 (492.24)	2034.62 (771.47)	2921.04 (946.43)	2475.60 (598.07)
Pause duration (msec)
Rainbow Passage
Group (n = 24;17)	568.93 (175.95)	720.49 (198.89)	514 67 (138 151	844.11 (342.80)
Males (n = 19;11)	605.95 (178.80)	771.64 (190.17)	536.54 (146.02)	783 43 (268.57)
Females (n = 5;6)	428.24 (53.83)	526.13 (71.22)	474.58 (124.09)	955.36 (456.97)
Monologue
Group (n = 18; 13)	620.11 (282.66)	753.40 (338.93)	714.79(297.50)	941.33 (406.46)
Males (n = 13;9)	675.24 (292.09)	855.67 (320.08)	721.49 (242.41)	900.16(332.84)
Females (n = 5;4)	440.94 (169.95)	421.03 (101.09)	699.72 (443.71)	1033.89 (590.71)
FVC (ml)
Males (n = 20;12)	3500.00 (720.38)	3535.00 (672.99)	3458.33 (1015.75)	3425.00 (1010.96)
Females (n = 5;7)	2580.00 (601.66)	2520.00 (554.08)	2142.86 (506.15)	2228.57 (590.80)

View Large

	LSVT		R only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Intensity (dB) (at 50cm)
Sustained phonation
Group (n = 26;19)	68.20 (4.70)	81.20 (4.65)	69.32 (5.05)	68.01 (4.31)
Males (n = 21;12)	68.03 (4.60)	81.99 (3.93)	70.23 (3.75)	66.99 (4.49)
Females (n = 5;7)	68.02 (5.70)	77.91 (6.40)	67.76 (6.80)	69.75 (3.64)
Rainbow Passage
Group (n = 26;19)	66.30 (4.02)	74.33 (4.83)	65.68 (2.68)	68.16 (3.33)
Males (n = 21;12)	66.56 (4.37)	75.69 (4.06)	66.02 (2.53)	67.94 (3.62)
Females (n = 5;7)	65.19 (1.96)	68.58 (3.51)	65.11 (3.05)	68.56 (3.00)
Monologue
Group (n = 16;13)	64.67 (3.37)	69.17(4.10)	64.66 (2.58)	66.24 (2.11)
Males (n = 11 ;8)	64.94 (3.66)	70.35 (3.61)	65.19 (2.40)	66.70 (2.01)
Females (n = 5;5)	63.96 (1.66)	65.34 (3.46)	64.66 (2.58)	65.52 (2.77)
Max duration (sec)
Sustained phonation
Group (n = 26;19)	21.12 (7.63)	24.84(10.35)	18.39 (9.65)	21.20 (8.78)
Males (n = 21; 12)	21.62 (8.17)	24.67 (11.44)	20.67(11.09)	23.47 (7.93)
Females (n = 5;7)	19.00(4.77)	25.57 (3.79)	14.47 (5.10)	17.32 (9.37)
F₀ (Hz)
Rainbow Passage
Males (n = 21;12)	124.73 (22.10)	140.78 (23.66)	120.13 (18.72)	125.57 (21.45)
Females (n = 5;5)	198.35 (12.13)	214.23 (13.56)	171.47 (11.47)	188.26 (17.58)
F₀ variability (STSD)
Rainbow Passage
Group (n = 26; 17)	1.82 (0.53)	2.38 (0.67)	1.80 (0.41)	2 09 (0.34)
Males (n = 21;12)	1.73 (0.42)	2.33 (0.63)	1.82 (0.41)	2.05 (0.30)
Females (n = 5;5)	2.22 (0.80)	2.62 (0.87)	1.77 (0.49)	2.19 (0.44)
F₀ (Hz)
Monologue
Males (n = 12; 10)	114.33 (13.19)	120.64 (16.81)	119.80 (21.85)	118.81 (18.62)
Females (n = 4;3)	190.52 (20.71)	201.40 (15.34)	179.15 (15.43)	180.99 (25.26)
F₀ variability (STSD)
Monologue
Group (n = 16;13)	1.68 (0.39)	1.97 (0.58)	2.13 (0.72)	1.95 (0.67)
Males (n = 12;10)	1.66 (0.39)	1.90 (0.39)	2.11 (0.73)	1.95 (0.72)
Females (n = 4;3)	1.80 (0.61)	2.38 (0.88)	2.18 (0.84)	1.95 (0.59)
Utterance duration (msec)
Rainbow Passage
Group (n = 24; 17)	2665.88 (666.03)	2186.24 (511.62)	2524.08 (530.33)	2132.55 (396.94)
Males (n = 19;11)	2671.59 (741.40)	2192.50 (512.17)	2409.05 (421.21)	2040.95 (361.57)
Females (n = 5;6)	2644.19 (276.33)	2162.44 (568.97)	2734.97 (680.22)	2300.48 (436.48)
Monologue
Group (n = 18;13)	1943.19 (389.51)	1948.66 (672.05)	2165.12 (851.82)	1872.51 (569.48)
Males (n = 13;9)	1883.38 (346.72)	1915.60 (661.21)	1829.16 (582.93)	1604.47 (299.41)
Females (n = 5;4)	2098.69 (492.24)	2034.62 (771.47)	2921.04 (946.43)	2475.60 (598.07)
Pause duration (msec)
Rainbow Passage
Group (n = 24;17)	568.93 (175.95)	720.49 (198.89)	514 67 (138 151	844.11 (342.80)
Males (n = 19;11)	605.95 (178.80)	771.64 (190.17)	536.54 (146.02)	783 43 (268.57)
Females (n = 5;6)	428.24 (53.83)	526.13 (71.22)	474.58 (124.09)	955.36 (456.97)
Monologue
Group (n = 18; 13)	620.11 (282.66)	753.40 (338.93)	714.79(297.50)	941.33 (406.46)
Males (n = 13;9)	675.24 (292.09)	855.67 (320.08)	721.49 (242.41)	900.16(332.84)
Females (n = 5;4)	440.94 (169.95)	421.03 (101.09)	699.72 (443.71)	1033.89 (590.71)
FVC (ml)
Males (n = 20;12)	3500.00 (720.38)	3535.00 (672.99)	3458.33 (1015.75)	3425.00 (1010.96)
Females (n = 5;7)	2580.00 (601.66)	2520.00 (554.08)	2142.86 (506.15)	2228.57 (590.80)

TABLE 7.F and p values for the perceptual variables

	Between-subject effect								Within-subject effect
	Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
Subject self-rating
(n = 45) (df = 1,41)
Loudness	.03	.872	.06	.805	1.51	.226	19.26	.000	.10	.751	.42	.520	4.17	.048
Monotonicity	.01	.922	2.16	.149	2.94	.094	11.82	.001	.17	.686	1.87	.179	1.59	.215
Hoarseness	.22	.645	.51	.481	3.37	.073	11.64	.001	.39	.535	.00	.955	.04	.843
Intelligibility	.00	.978	.15	.697	.67	.416	11.92	.001	.02	.901	.21	.653	.67	.417
Initiate conversation	.07	.791	4.62	.037	.72	.401	10.39	.002	.13	.718	.45	.506	3.98	.053
Family ratings
(n = 20) (df = 1,16)
Loudness	.50	.490	.28	.602	.53	.476	5.73	.029	.09	.773	.03	.867	.20	.660
Monotonicity	.56	.464	2.14	.163	.12	.735	1.50	.239	.15	.707	1.23	.283	.74	.403
Hoarseness	.01	.925	2.27	.151	1.81	.197	.44	.517	.28	.602	.60	.450	1.15	.299
Intelligibility	.40	.538	.87	.366	.62	.442	15.81	.001	6.74	.019	.10	.752	1.56	.230
Initiate conversation	2.80	.114	8.66	.010	.22	.645	1.24	.282	2.62	.125	.07	.791	2.42	.139

View Large

TABLE 7.F and p values for the perceptual variables

	Between-subject effect								Within-subject effect
	Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
Subject self-rating
(n = 45) (df = 1,41)
Loudness	.03	.872	.06	.805	1.51	.226	19.26	.000	.10	.751	.42	.520	4.17	.048
Monotonicity	.01	.922	2.16	.149	2.94	.094	11.82	.001	.17	.686	1.87	.179	1.59	.215
Hoarseness	.22	.645	.51	.481	3.37	.073	11.64	.001	.39	.535	.00	.955	.04	.843
Intelligibility	.00	.978	.15	.697	.67	.416	11.92	.001	.02	.901	.21	.653	.67	.417
Initiate conversation	.07	.791	4.62	.037	.72	.401	10.39	.002	.13	.718	.45	.506	3.98	.053
Family ratings
(n = 20) (df = 1,16)
Loudness	.50	.490	.28	.602	.53	.476	5.73	.029	.09	.773	.03	.867	.20	.660
Monotonicity	.56	.464	2.14	.163	.12	.735	1.50	.239	.15	.707	1.23	.283	.74	.403
Hoarseness	.01	.925	2.27	.151	1.81	.197	.44	.517	.28	.602	.60	.450	1.15	.299
Intelligibility	.40	.538	.87	.366	.62	.442	15.81	.001	6.74	.019	.10	.752	1.56	.230
Initiate conversation	2.80	.114	8.66	.010	.22	.645	1.24	.282	2.62	.125	.07	.791	2.42	.139

TABLE 8.Perceptual variables for the subjects’ (n = 45) self-ratings by group and gender as well as the families’ ratings for both groups. Standard deviations are presented in parentheses.

	LSVT		R Only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Loudness
Group	46.85 (20.23)	64.15 (20.89)	51.37 (29.01)	65.42(19 88)
Males	43.95 (18.21)	63.14 (18.59)	57.33 (27.83)	64.42 (23.33)
Females	59.00 (25.93)	68.40 (31.17)	41.14 (30 20)	67.14 (11 471
Family (n = 20)	45.50 (22.63)	60.50 (18.47)	49.73 (28.64)	63.12 (21.84)
Monotonicity
Group	47.00 (22.54)	66.73(16 28)	57.00 (26.13)	68.05 (22 87)
Males	41.38 (18.45)	64.76 (14.74)	57.42 (29.23)	68.75 (22.48)
Females	70.60 (24.69)	75.00 (21 561)	56.29 (21.91)	66.86 (19.44)
Family (n = 20)	52.67 (27.49)	66.75 (19.34)	57.91 (27.03)	68.88 (21.92)
Hoarseness
Group	55.65 (21.89)	70.11 (16.42)	64.58 (24 14)	75.11 (21.61)
Males	54.52 (23.13)	68.62 (17 66)	70.08 (23.03)	81.00 (23.30)
Females	60.40 (16 92)	76.40 (8.02)	55.14 (24.73)	65.00 (14.75)
Family (n = 20)	61.58 (27.10)	66.58 (19.67)	70.45 (18.06)	70.38 (18.75)
Intelligibility
Group	57.12 (20.30)	71.12 (16.77)	61.63 (20.20)	72.00 (19.99)
Males	54.95 (20.11)	70.52 (15.63)	63.00 (21.17)	72.50 (21 65)
Females	66.20 (20.62)	73.60 (22.96)	59.29 (19 81)	71.14 (18.38)
Family (n = 20)	49.50 (17.93)	67.33 (19.59)	57.55 (22.81)	64.63 (17.94)
Initiate conversation
Group	50.96 (22 37)	66.85 (16.30)	61.85 (22.06)	68.89 (20.83)
Males	45.90 (18.97)	64.90 (15.07)	59.83 (18.17)	68.89 (20.83)
Females	72.20 (25.10)	75.00 (21.00)	63.71 (29 03)	76.43 (15.91)
Family (n = 20)	54.67 (20.70)	70.33 (16.70)	67.09 (28.55)	71.50(18.41)

Note. Perceptual characteristics of loudness, hoarseness, intelligibility, and initiation of conversation are on a scale of 0–100% with 0% the most severe and 100% the least severe.

View Large

TABLE 8.Perceptual variables for the subjects’ (n = 45) self-ratings by group and gender as well as the families’ ratings for both groups. Standard deviations are presented in parentheses.

	LSVT		R Only
Variables	Pretreatment	Post-treatment	Pretreatment	Post-treatment
Loudness
Group	46.85 (20.23)	64.15 (20.89)	51.37 (29.01)	65.42(19 88)
Males	43.95 (18.21)	63.14 (18.59)	57.33 (27.83)	64.42 (23.33)
Females	59.00 (25.93)	68.40 (31.17)	41.14 (30 20)	67.14 (11 471
Family (n = 20)	45.50 (22.63)	60.50 (18.47)	49.73 (28.64)	63.12 (21.84)
Monotonicity
Group	47.00 (22.54)	66.73(16 28)	57.00 (26.13)	68.05 (22 87)
Males	41.38 (18.45)	64.76 (14.74)	57.42 (29.23)	68.75 (22.48)
Females	70.60 (24.69)	75.00 (21 561)	56.29 (21.91)	66.86 (19.44)
Family (n = 20)	52.67 (27.49)	66.75 (19.34)	57.91 (27.03)	68.88 (21.92)
Hoarseness
Group	55.65 (21.89)	70.11 (16.42)	64.58 (24 14)	75.11 (21.61)
Males	54.52 (23.13)	68.62 (17 66)	70.08 (23.03)	81.00 (23.30)
Females	60.40 (16 92)	76.40 (8.02)	55.14 (24.73)	65.00 (14.75)
Family (n = 20)	61.58 (27.10)	66.58 (19.67)	70.45 (18.06)	70.38 (18.75)
Intelligibility
Group	57.12 (20.30)	71.12 (16.77)	61.63 (20.20)	72.00 (19.99)
Males	54.95 (20.11)	70.52 (15.63)	63.00 (21.17)	72.50 (21 65)
Females	66.20 (20.62)	73.60 (22.96)	59.29 (19 81)	71.14 (18.38)
Family (n = 20)	49.50 (17.93)	67.33 (19.59)	57.55 (22.81)	64.63 (17.94)
Initiate conversation
Group	50.96 (22 37)	66.85 (16.30)	61.85 (22.06)	68.89 (20.83)
Males	45.90 (18.97)	64.90 (15.07)	59.83 (18.17)	68.89 (20.83)
Females	72.20 (25.10)	75.00 (21.00)	63.71 (29 03)	76.43 (15.91)
Family (n = 20)	54.67 (20.70)	70.33 (16.70)	67.09 (28.55)	71.50(18.41)

Note. Perceptual characteristics of loudness, hoarseness, intelligibility, and initiation of conversation are on a scale of 0–100% with 0% the most severe and 100% the least severe.

TABLE 9.F and p values for the neuropsychological variables.

	Between-subject effect								Within-subject effect
Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
(n = 35) df (1,31)
BDI (self-rating of depression)	.81	.374	9.17	.005	6.64	.015	.45	.508	1.04	.316	.30	.589	.65	.427
SIP Communication	.02	.886	2.19	.149	1.65	.209	10.95	.002	6.86	.014	.04	.839	.11	.741
SIP Social interaction	.14	.711	.08	.776	4.72	.038	2.36	.135	.23	.635	1.20	.282	.40	.533

View Large

TABLE 9.F and p values for the neuropsychological variables.

	Between-subject effect								Within-subject effect
Group		Gender		Group × Gender		Time		Time × Group		Time × Gender		Time × Group × Gender
Dependent variables	F	p	F	p	F	p	F	p	F	p	F	p	F	p
(n = 35) df (1,31)
BDI (self-rating of depression)	.81	.374	9.17	.005	6.64	.015	.45	.508	1.04	.316	.30	.589	.65	.427
SIP Communication	.02	.886	2.19	.149	1.65	.209	10.95	.002	6.86	.014	.04	.839	.11	.741
SIP Social interaction	.14	.711	.08	.776	4.72	.038	2.36	.135	.23	.635	1.20	.282	.40	.533

TABLE 10.Means and SD’s (in parentheses) for the neuropsychological variables completed by subjects both pre- and post-treatment.

	LSVT		R Only
Scale (n = 35)	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment
BDI (self-rating of depression)
Group	8.3 (6.0)	7.4 (4.6)	8.7 (5.5)	8.9 (5.3)
Male	6.1 (4.4)	5.8 (3.3)	8.5 (6.3)	8.6 (6.2)
Female	16.3(4.5)	13.3(3.9)	9.0 (4.1)	9.6 (2.7)
SIP communication
Group	28.9 (21.8)	11.9(11.7)	25.6 (25.1)	23.1 (23.6)
Male	29.2 (19.6)	12.4 (11.5)	32.7 (26.1)	29.1 (26.2)
Female	28.2 (30.2)	10.6 (13.8)	11.5 (17.4)	11.1 (12.0)
SIP Social interaction
Group	9.6 (8.1)	7.9 (4.4)	11.0 (10.4)	9.7 (11.7)
Male	7.2 (6.3)	6.8 (4.4)	12.6 (10.4)	11.8 (13.2)
Female	16.7 (9.6)	11.5 (2.4)	7.9 (11.0)	5.7 (7.5)

View Large

TABLE 10.Means and SD’s (in parentheses) for the neuropsychological variables completed by subjects both pre- and post-treatment.

	LSVT		R Only
Scale (n = 35)	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment
BDI (self-rating of depression)
Group	8.3 (6.0)	7.4 (4.6)	8.7 (5.5)	8.9 (5.3)
Male	6.1 (4.4)	5.8 (3.3)	8.5 (6.3)	8.6 (6.2)
Female	16.3(4.5)	13.3(3.9)	9.0 (4.1)	9.6 (2.7)
SIP communication
Group	28.9 (21.8)	11.9(11.7)	25.6 (25.1)	23.1 (23.6)
Male	29.2 (19.6)	12.4 (11.5)	32.7 (26.1)	29.1 (26.2)
Female	28.2 (30.2)	10.6 (13.8)	11.5 (17.4)	11.1 (12.0)
SIP Social interaction
Group	9.6 (8.1)	7.9 (4.4)	11.0 (10.4)	9.7 (11.7)
Male	7.2 (6.3)	6.8 (4.4)	12.6 (10.4)	11.8 (13.2)
Female	16.7 (9.6)	11.5 (2.4)	7.9 (11.0)	5.7 (7.5)