Voice Treatment for Parkinson's Disease

Surgical and pharmacological management of the motor-based symptoms of PD has made great
strides over the last few decades. The behavioral management of the speech and voice symptoms
however, has not grown by the same leaps and bounds. Despite the prevalence of speech and
voice symptoms associated with PD, few evidence-based treatment options are currently
available. In the face of good efficacy data, the Lee Silverman Voice Treatment (LSVT LOUD)
program continues to be the gold standard for voice treatment. LSVT LOUD trains patients to
monitor and adjust their vocal intensity when they perceive that their voice is soft.
Therefore, the success of LSVT LOUD is predicated, in part, on an individual's ability to
self-monitor and self-cue (internal cueing) during speech production. While LSVT LOUD has
fostered significant improvements in communication for many patients with PD, not all
patients respond to treatment. It has been postulated that underlying sensory and cognitive
factors may hinder treatment outcomes. A new behavioral treatment for speech and voice
impairment has recently been introduced. The SpeechVive, a small in-the-ear device, uses an
external noise cue to elicit louder speech. While LSVT LOUD and the SpeechVive have both been
shown to significantly increase sound pressure level (SPL) in patients with PD, the
physiologic adjustments supporting these changes in SPL remain unclear. This is an important
area of study for two reasons. First, both treatments are exercised-based programs, yet the
physiologic changes associated with these treatments are not well understood. Second, there
is evidence to suggest that the use of an external cue, such as the noise cue used in
SpeechVive training, elicits more efficient respiratory patterns in neurologically-healthy
and neurologically-involved patients, in comparison to self-initiated cueing strategies, such
as those used in LSVT LOUD. This study proposes to compare the influence of cueing strategy
on treatment outcomes by examining simultaneous respiratory-laryngeal adjustments before and
after participation in LSVT LOUD (internal cueing) and SpeechVive (external cueing) training.
It is important to study respiratory-laryngeal interactions because both of these subsystems
contribute to vocal intensity regulation. In addition, exercise physiology studies have
indicated that internal and external forms of cueing elicit different perceptions of physical
and mental effort during exercise. It is important to understand the patients' level of
perceived physical and mental effort, associated with each treatment program, as these
variables can effect adherence to the treatment regime. In summary, the proposed study is
intended to 1) fill a critical void in the investigator's understanding of
respiratory-laryngeal adjustments used to support increased SPL under two evidence-based
behavioral voice treatment programs, and 2) to better understand how patients' perceptions of
physical and mental effort are shaped by each treatment paradigm. The information generated
in this study could potentially lead to more efficient voice rehabilitation for persons with
PD.

Inclusion Criteria:

- Diagnosis of Parkinson's disease

- Problems with speech loudness due to Parkinson's disease

- No asthma or other respiratory problems

- No head, neck or chest surgery (Pacemaker surgery is okay)

- Non-smoking for the last 5 years

- Not currently participating in another treatment study

- Typical cognitive skills

- Free of symptoms of depression

- Unaided hearing in at least one ear

- No voice therapy or voice therapy maintenance within the last 12 months

Exclusion Criteria:

- Other neurological diseases, other than Parkinson's disease

- History of asthma or respiratory problems

- Head, neck or chest surgery

- Smoker within the last 5 years

- Currently involved in another treatment study

- Decreased cognition

- Symptoms of depression

- Wear a hearing aid in both ears

- Participated in voice therapy within the last 12 months.