Effects of Tactile Biofeedback by a Portable Voice Accumulator on Voice Sound Level in Speakers with Parkinson's Disease

Using Portable Voice Accumulators to Study Transfer of Speech Outcomes Following Intervention - A Feasibility Study

OBJECTIVES

To evaluate the process and scientific feasibility of using a portable voice accumulator (PVA) to study carry-over of treatment effects on speech and voice in people with mild-moderate Parkinson's disease.

METHODS

The study was guided by the checklist in Consolidated Standards of Reporting Trials (CONSORT) 2010 statement: extension to randomized pilot and feasibility trials. Participants with Parkinson's disease were recruited within the context of a randomized controlled trial with random allocation to intervention with either HiCommunication, a program targeting speech and communication, or HiBalance, a program targeting balance and strength. Before and after intervention data was collected from standardized studio recordings of speech and registrations of voice use in daily life with the PVA VoxLog.

RESULTS

Fifteen participants were included in the study and sufficient data was yielded from six of them. Reasons for insufficient data included technical issues and difficulties handling the PVA. Changes in voice sound level from pre to post intervention differed at an individual level when assessed in daily life compared to studio recordings. Registrations in daily life provided information on phonation ratio and ability to adapt voice sound level to environmental noise.

CONCLUSION

This study highlights the challenges of studying intervention effects on voice use in daily life using a PVA. Improvements of test protocols in future studies are suggested. We exemplify how PVA data may generate a more detailed and ecologically valid picture of voice use complementing studio recordings of speech. Finally, we encourage technical development of more user-friendly PVAs.

Daily Phonatory Activity of Individuals With Parkinson's Disease

PURPOSE

This study evaluated the amount of phonatory activity of Persons with Parkinson disease (PwPD) compared to adults without Parkinson's disease measured over 3 days. The relationship between the amount of phonatory activity and Voice Handicap Index (VHI) total score was assessed as were differences in voicing activity across 3 days of data collection.

METHODS

Fifteen PwPD receiving dopaminergic medication and fifteen age and sex matched adults without Parkinson's disease completed the VHI and then wore a VocaLog vocal monitor (VM) for 3 consecutive days. From the VM data, the number of 1-second windows with dB sound pressure level > 0 were summed as a measure of phonatory activity (PA) and reported relative to the time the VM was worn (%PA).

RESULTS

The percentage of time the VM was worn did not differ between groups or across days. The PwPD had statistically significantly fewer minutes of PA per day than controls (F = 21.782, P < 0.001) by 54 minutes on average. The %PA also differed significantly (F = 31.825, P < 0.001) with a mean of 11.1% for PwPD and 18.6% for controls. Neither PA nor %PA differed across the 3 days of vocal monitoring. VHI total score was significantly correlated with PA (r = -0.436, P = 0.016) and %PA (r = -0.534, P = 0.002) for all participants.

CONCLUSIONS

The results indicate that PwPD engaged in less verbal communication in their daily environment compared to adults without Parkinson's disease. The findings support reports in the literature indicating that PwPD often have reduced communication participation. Measures such as %PA could serve as a quantifiable metric in future studies assessing communication changes in PwPD as a function of disease progression or therapeutic interventions.

Treatment of Hypophonia in Parkinson's Disease Through Biofeedback in Daily Life Administered with A Portable Voice Accumulator

OBJECTIVES

The purpose of this study was to assess the outcome following continuous tactile biofeedback of voice sound level administered, with a portable voice accumulator to individuals with Parkinson's disease (PD).

METHOD

Nine out of 16 participants with PD completed a 4-week intervention program where biofeedback of voice sound level was administered with the portable voice accumulator VoxLog during speech in daily life. The feedback, a tactile vibration signal from the device, was activated when the wearer used a voice sound level below an individually predetermined threshold level, reminding the wearer to increase voice sound level during speech. Voice use was registered in daily life with the VoxLog during the intervention period as well as during one baseline week, one follow-up week post intervention and 1 week 3 months post intervention. Self-to-other ratio (SOR), which is the difference between voice sound level and environmental noise, was studied in multiple noise ranges.

RESULTS

A significant increase in SOR across all noise ranges of 2.28 dB (SD: 0.55) was seen for participants with scores above the cut-off for normal function (>26 points) on the cognitive screening test Montreal Cognitive Assessment (MoCA) (n = 5). No significant increase was seen for the group of participants with MoCA scores below 26 (n = 4). Forty-four percent ended their participation early, all which scored below 26 on MoCA (n = 7).

CONCLUSIONS

Biofeedback administered in daily life regarding voice level may help individuals with PD to increase their voice sound level in relation to environmental noise in daily life, but only for a limited subset. Only participants with normal cognitive function as screened by MoCA improved their voice sound level in relation to environmental noise.

Behavioral Management of Respiratory/Phonatory Dysfunction for Dysarthria Associated With Neurodegenerative Disease: A Systematic Review

PURPOSE

This systematic review represents an update to previous reviews of the literature addressing behavioral management of respiratory/phonatory dysfunction in individuals with dysarthria due to neurodegenerative disease.

METHOD

Multiple electronic database searches and hand searches of prominent speech-language pathology journals were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.

RESULTS

The search yielded 1,525 articles, from which 88 met inclusion criteria and were reviewed by two blinded co-investigators. A large range of therapeutic approaches have been added to the evidence base since the last review, including expiratory muscle strength training, singing, and computer- and device-driven programs, as well as a variety of treatment modalities, including teletherapy. Evidence for treatment in several different population groups-including cerebellar ataxia, myotonic dystrophy, autosomal recessive spastic ataxia of Charlevoix-Saguenay, Huntington's disease, multiple system atrophy, and Lewy body dementia-were added to the current review. Synthesis of evidence quality provided strong evidence in support of only one behavioral intervention: Lee Silverman Voice Treatment Program (LSVT LOUD) in people with Parkinson's disease. No other treatment approach or population included in this review demonstrated more than limited evidence, reflecting that these approaches/populations require urgent further examination.

CONCLUSION

Suggestions about where future research efforts could be significantly strengthened and how clinicians can apply research findings to their practice are provided.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24964473.

Incorporating Mobile App Technology in Voice Modification Protocol for Transgender Women

PURPOSE

Motivated by practice and feedback principles of motor learning, a hybrid clinic-home protocol for voice feminization was developed to minimize the role of SLPs to 1 of supervision and professional guidance and to maximize learning during independent practice apart from intervention sessions. The purpose was to explore the effectiveness and acceptability of the innovative service delivery.

METHOD

This single-subject changing criterion design included four transgender women who completed a 10-week hybrid clinic-home voice intervention program delivered via 30 -minute weekly in-clinic sessions and a technology-supported home program. The program was client-centered and capitalized on principles of motor learning in that it incorporated frequent practice with intermittent, knowledge-of-result feedback. Participants' desired outcomes were measured using acoustics, self and listener ratings of audio samples, and a program evaluation questionnaire.

RESULTS

Average speaking fundamental frequency of phrases and picture descriptions gradually increased into the 170-220 Hz range for all except one participant. All four transgender women were perceived to sound more feminine following treatment compared to baseline. Participants found the in-clinic sessions useful, the app easy to use, and noted limited fatigue or discomfort.

CONCLUSION

Four transwomen met their goals using this hybrid clinic-home service delivery format. Further investigations may elucidate key factors of the success achieved in the current study by designing comparison delivery models and including people from other populations.

Volitional and Non-volitional Devices Used in Voice Therapy and Training: A Scoping Review-Part A

OBJECTIVE

To map the volitional and non-volitional devices used by speech and language pathologists (SLPs) in voice training and therapy and characterize their use in research on voice interventions.

METHODS

This scoping review is the first part of a larger study. The electronic search was carried out by mapping the references in PubMed/Medline, LILACS/BVS, Scopus, Web of Science, EMBASE, and the Cochrane Library, and the manual search was carried out in the grey literature. Two blind independent reviewers selected and extracted data; divergences were solved by consensus. The data extracted in this part of the study were the authorship and year of publication, country, study design, sample characteristics, intervention modality, ingredient, target, mechanism of action, dosage, and outcome measures. They were addressed with descriptive analysis.

RESULTS

Publications that use devices as ingredients are mostly from the last two decades, mainly carried out in the United States of America and Brazil, in adults of both sexes with behavioral dysphonia. Forty-two types of devices were used, many of them with similar approaches but different nomenclatures. Most devices were used voluntarily, focusing on vocal function, and aiming to increase source and filter interaction. Most studies used silicone tubes. The most reported technical specification to apply the ingredient was surface electrodes on the neck. Device dosage was time-controlled, and the most used outcomes were self-assessment and acoustic analysis.

CONCLUSION

Devices are currently used as ingredients in vocal interventions, with a greater focus on increasing the source and filter interaction, associated with silicone tubes (the most used devices in these studies), which have been dosed with performance time. Outcomes were measured with self-assessment instruments.

Conversational Vocal Intensity in Parkinson's Disease: Treatment and Environmental Comparisons

BACKGROUND

Vibrotactile Feedback (VF) using wearable devices is an emerging treatment option for hypophonia in Individuals with Parkinson's disease (IwPD). Studies evaluating the effectiveness of VF in improving conversational vocal intensity in real-life environment in IwPD are limited.

OBJECTIVE

To determine the effect of VF on conversational vocal intensity and compare vocal intensity between a) clinic and real-life environment b) VF and Lee Silverman Voice Treatment (LSVT LOUD®)vs. VF alone in IwPD using a portable voice monitor (VocaLog2).

METHODS

Eight individuals with hypophonia secondary to PD were randomly assigned to two treatment groups- VF and LSVT LOUD® (Group 1) and VF (Group 2). VF was provided using VocaLog2 device. Duration of treatment was 4 weeks for both groups. Vocal intensity was measured in the real-life environment at baseline, during treatment, and at one-month follow-up. Vocal intensity in clinic was obtained at baseline and one-month follow-up. Voice Handicap Index (VHI) questionnaire was administered at baseline and one-month follow-up.

RESULTS

There was no significant difference in conversational vocal intensity between a) clinic and real-life environment at any point of time b) baseline and follow up for both treatment groups c) the two treatment groups at baseline, during each of the 4 weeks of treatment and at follow up d) VHI baseline and one month follow up scores.

CONCLUSION

VF, including when combined with LSVT LOUD®, is limited in improving conversational vocal intensity in real-life in IwPD. The effects of frequency and duration of VF on conversational vocal intensity must be systematically investigated using large scale studies in IwPD.

Do-It-Yourself Voice Dosimeter Device: A Tutorial and Performance Results

PURPOSE

Voice dosimeters gather voice production data in the daily lives of individuals with voice disorders. Additionally, voice dosimeters aid in understanding the pathophysiology of voice disorders. Previously, several voice dosimeters were commercially available. However, these devices have been discontinued and are not available to clinicians and researchers alike. In this tutorial, instructions for a low-cost, easy-to-assemble voice dosimeter are provided. This do-it-yourself (DIY) voice dosimeter is further validated based on performance results.

METHOD

Ten vocally healthy participants wore the DIY voice dosimeter. They produced a sustained /a/ vowel and read a text with three different vocal efforts. These tasks were recorded by the DIY voice dosimeter and a reference microphone simultaneously. The expanded uncertainty of the mean error in the estimation of four voice acoustic parameters as measured by the DIY dosimeter was performed by comparing the signals acquired through the reference microphone and the dosimeter.

RESULTS

For measures of sound pressure level, the DIY voice dosimeter had a mean error of -0.68 dB with an uncertainty of 0.56 dB. For fundamental frequency, the mean error was 1.56 Hz for female participants and 1.11 Hz for male participants, with an uncertainty of 0.62 Hz and 0.34 Hz for female and male participants, respectively. Cepstral peak prominence smoothed and L₁ minus L₂ had mean errors (uncertainty) of -0.06 dB (0.27 dB) and 2.20 dB (0.72 dB).

CONCLUSION

The mean error and uncertainties for the DIY voice dosimeter are comparable to those for the most accurate voice dosimeters that were previously on the market.

Voice Biofeedback via Bone Conduction Headphones: Effects on Acoustic Voice Parameters and Self-Reported Vocal Effort in Individuals With Voice Disorders

PURPOSE

This study explores sidetone amplification (amplified playback of one's own voice) provided via bone conduction in participants with voice disorders. The effects of bone conduction feedback on acoustic voice parameters and vocal effort ratings are examined.

METHODS

Speech samples of 47 participants with voice disorders were recorded in three auditory feedback conditions: two with sidetone amplification delivered via bone conduction and one condition with no alteration of the feedback. After each task, the participants rated their vocal effort on a visual analog scale. The voice recordings were evaluated by a speech-language pathologist through the GRBAS scale and processed to calculate the within-participant centered sound pressure level (SPL) values, the mean pitch strength (PS), the time dose (Dt%), and cepstral peak prominence smoothed (CPPS). The effects of the feedback conditions on these acoustic parameters and vocal effort ratings were analyzed.

RESULTS

The high sidetone amplification condition resulted in a statistically significant decrease in the within-participant centered SPL values and mean pitch strength across all participants. The feedback conditions had no statistically significant effects on the vocal effort ratings, time dose (Dt%), or CPPS.

CONCLUSIONS

This study provides an evidence that bone conduction sidetone amplification contributes to a consistent adaptation in the within-participant centered SPL values (ΔSPL) in patients with vocal hyperfunction, glottal insufficiency, and organic/neurological laryngeal pathologies compared to conditions with no feedback.

Daily Phonotrauma Index: An Objective Indicator of Large Differences in Self-Reported Vocal Status in the Daily Life of Females With Phonotraumatic Vocal Hyperfunction

PURPOSE

The purpose of this study is to evaluate if the Daily Phonotrauma Index (DPI) can quantitatively discriminate large differences in overall vocal status in the daily life of patients with phonotraumatic vocal hyperfunction (PVH).

METHOD

For 1-4 weeks, 23 females with PVH wore an ambulatory voice monitor and answered three vocal status questions (i.e., difficulty producing soft, high-pitched phonation; discomfort; and fatigue) at the beginning, at 5-hr intervals, and the end of each day. DPI values were obtained for each patient's time periods of worst and best self-rated vocal status, and data for the group were analyzed for significant changes using a linear mixed-effects regression model.

RESULTS

The DPI was significantly lower during periods self-rated as "best vocal status" compared to during periods self-rated as "worst vocal status" (mean difference in DPI = 0.53) with a medium-to-large effect size (Cohen's d = -0.68).

CONCLUSIONS

In a group of patients with phonotraumatic lesions, the DPI indicated lower potential for phonotrauma during time periods of better vocal status compared to time periods of worse vocal status. Assuming that a large portion of variance in vocal status for patients with PVH is associated with the extent to which voicing is phonotraumatic, these results support the validity of obtaining estimates of DPI for much shorter time periods (i.e., an estimate every 2 min of voicing) than previous studies (i.e., a single estimate for the entire day or week). Future work can investigate the DPI's use for in-clinic assessment/treatment and ambulatory biofeedback and can gain further insights into phonatory mechanisms that underlie DPI via comparisons with other physiologically relevant measures and computational vocal fold modeling.

Voice Use in Daily Life Studied With a Portable Voice Accumulator in Individuals With Parkinson's Disease and Matched Healthy Controls

Purpose The purpose of this work was to study how voice use in daily life is impacted by Parkinson's disease (PD), specifically if there is a difference in voice sound level and phonation ratio during everyday activities for individuals with PD and matched healthy controls. A further aim was to study how variations in environmental noise impact voice use. Method Long-term registration of voice use during 1 week in daily life was performed for 21 participants with PD (11 male, 10 female) and 21 matched healthy controls using the portable voice accumulator VoxLog. Voice use was assessed through registrations of spontaneous speech in different ranges of environmental noise in daily life and in a controlled studio recording setting. Results Individuals with PD use their voice 50%-60% less than their matched healthy controls in daily life. The difference increases in high levels of environmental noise. Individuals with PD used an average voice sound level in daily life that was 8.11 dB (female) and 6.7 dB (male) lower than their matched healthy controls. Difference in mean voice sound level for individuals with PD and controls during spontaneous speech during a controlled studio registration was 3.0 dB for the female group and 4.1 dB for the male group. Conclusions The observed difference in voice use in daily life between individuals with PD and matched healthy controls is a 1st step to objectively quantify the impact of PD on communicative participation. The variations in voice use in different levels of environmental noise and when comparing controlled and variable environments support the idea that the study of voice use should include methods to assess function in less controlled situations outside the clinical setting.

Accuracy of the quantities measured by four vocal dosimeters and its uncertainty

Although vocal dosimeters are often used for long-term voice monitoring, the uncertainty of the quantities measured by these devices is not always stated. In this study, two common vocal dosimetry quantities, mean vocal sound pressure level and mean vocal fundamental frequency, were measured by four vocal dosimeters (VocaLog2, VoxLog, Voice Care, and APM3200). The expanded uncertainty of the mean error in the estimation of these two quantities as measured by the four dosimeters was performed by simultaneously comparing signals acquired through a reference microphone and the devices themselves. Dosimeters, assigned in random order, were worn by the participants (22 vocally healthy adults), along with a head-mounted microphone, which acted as a reference. For each device, participants produced a sustained /a/ vowel four times and then read a text with three different vocal efforts (relaxed, normal, and raised). The measurement uncertainty was obtained by comparing data from the microphone and the dosimeters. The mean vocal sound pressure level was captured the most accurately by the Voice Care and the VoxLog while the APM3200 was the least accurate. The most accurate mean vocal fundamental frequency was estimated by the Voice Care and the APM3200, while the VoxLog was the least accurate.

Self-Ratings of Vocal Status in Daily Life: Reliability and Validity for Patients With Vocal Hyperfunction and a Normative Group

PURPOSE

The aim of this study was to establish reliability and validity for self-ratings of vocal status obtained during the daily activities of patients with vocal hyperfunction (VH) and matched controls.

METHOD

Eight-four patients with VH and 74 participants with normal voices answered 3 vocal status questions-difficulty producing soft, high-pitched phonation (D-SHP); discomfort; and fatigue-on an ambulatory voice monitor at the beginning, 5-hr intervals, and the end of each day (7 total days). Two subsets of the patient group answered the questions during a 2nd week after voice therapy (29 patients) or laryngeal surgery (16 patients).

RESULTS

High reliability resulted for patients (Cronbach's α = .88) and controls (α = .95). Patients reported higher D-SHP, discomfort, and fatigue (Cohen's d = 1.62-1.92) compared with controls. Patients posttherapy and postsurgery reported significantly improved self-ratings of vocal status relative to their pretreatment ratings (d = 0.70-1.13). Within-subject changes in self-ratings greater than 20 points were considered clinically meaningful.

CONCLUSIONS

Ratings of D-SHP, discomfort, and fatigue have adequate reliability and validity for tracking vocal status throughout daily life in patients with VH and vocally healthy individuals. These questions could help investigate the relationship between vocal symptom variability and putative contributing factors (e.g., voice use/rest, emotions).

Measuring vocal motor skill with a virtual voice-controlled slingshot

Successful voice training (e.g., singing lessons) and vocal rehabilitation (e.g., therapy for a voice disorder) involve learning complex, vocal behaviors. However, there are no metrics describing how humans learn new vocal skills or predicting how long the improved behavior will persist post-therapy. To develop measures capable of describing and predicting vocal motor learning, a theory-based paradigm from limb motor control inspired the development of a virtual task where subjects throw projectiles at a target via modifications in vocal pitch and loudness. Ten subjects with healthy voices practiced this complex vocal task for five days. The many-to-one mapping between the execution variables pitch and loudness and resulting target error was evaluated using an analysis that quantified distributional properties of variability: Tolerance, noise, covariation costs (TNC costs). Lag-1 autocorrelation (AC1) and detrended-fluctuation-analysis scaling index (SCI) analyzed temporal aspects of variability. Vocal data replicated limb-based findings: TNC costs were positively correlated with error; AC1 and SCI were modulated in relation to the task's solution manifold. The data suggests that vocal and limb motor learning are similar in how the learner navigates the solution space. Future work calls for investigating the game's potential to improve voice disorder diagnosis and treatment.

Ambulatory Voice Biofeedback: Relative Frequency and Summary Feedback Effects on Performance and Retention of Reduced Vocal Intensity in the Daily Lives of Participants With Normal Voices

Purpose

Ambulatory voice biofeedback has the potential to significantly improve voice therapy effectiveness by targeting carryover of desired behaviors outside the therapy session (i.e., retention). This study applies motor learning concepts (reduced frequency and delayed, summary feedback) that demonstrate increased retention to ambulatory voice monitoring for training nurses to talk softer during work hours.

Method

Forty-eight nurses with normal voices wore the Voice Health Monitor (Mehta, Zañartu, Feng, Cheyne, & Hillman, 2012) for 6 days: 3 baseline days, 1 biofeedback day, 1 short-term retention day, and 1 long-term retention day. Participants were block-randomized into 3 different biofeedback groups: 100%, 25%, and Summary. Performance was measured in terms of compliance time below a participant-specific vocal intensity threshold.

Results

All participants exhibited a significant increase in compliance time (Cohen's d = 4.5) during biofeedback days compared with baseline days. The Summary feedback group exhibited statistically smaller performance reduction during both short-term (d = 1.14) and long-term (d = 1.04) retention days compared with the 100% feedback group.

Conclusions

These findings suggest that modifications in feedback frequency and timing affect retention of a modified vocal behavior in daily life. Future work calls for studying the potential beneficial impact of ambulatory voice biofeedback in participants with behaviorally based voice disorders.

Integration of Motor Learning Principles Into Real-Time Ambulatory Voice Biofeedback and Example Implementation Via a Clinical Case Study With Vocal Fold Nodules

PURPOSE

Ambulatory voice biofeedback (AVB) has the potential to significantly improve voice therapy effectiveness by targeting one of the most challenging aspects of rehabilitation: carryover of desired behaviors outside of the therapy session. Although initial evidence indicates that AVB can alter vocal behavior in daily life, retention of the new behavior after biofeedback has not been demonstrated. Motor learning studies repeatedly have shown retention-related benefits when reducing feedback frequency or providing summary statistics. Therefore, novel AVB settings that are based on these concepts are developed and implemented.

METHOD

The underlying theoretical framework and resultant implementation of innovative AVB settings on a smartphone-based voice monitor are described. A clinical case study demonstrates the functionality of the new relative frequency feedback capabilities.

RESULTS

With new technical capabilities, 2 aspects of feedback are directly modifiable for AVB: relative frequency and summary feedback. Although reduced-frequency AVB was associated with improved carryover of a therapeutic vocal behavior (i.e., reduced vocal intensity) in a patient post-excision of vocal fold nodules, causation cannot be assumed.

CONCLUSIONS

Timing and frequency of AVB schedules can be manipulated to empirically assess generalization of motor learning principles to vocal behavior modification and test the clinical effectiveness of AVB with various feedback schedules.

Recent Innovations in Voice Assessment Expected to Impact the Clinical Management of Voice Disorders

This article provides a summary of some recent innovations in voice assessment expected to have an impact in the next 5–10 years on how patients with voice disorders are clinically managed by speech-language pathologists. Specific innovations discussed are in the areas of laryngeal imaging, ambulatory voice monitoring, and “big data” analysis using machine learning to produce new metrics for vocal health. Also discussed is the potential for using voice analysis to detect and monitor other health conditions.

Dysphonia risk screening protocol

OBJECTIVE

To propose and test the applicability of a dysphonia risk screening protocol with score calculation in individuals with and without dysphonia.

METHOD

This descriptive cross-sectional study included 365 individuals (41 children, 142 adult women, 91 adult men and 91 seniors) divided into a dysphonic group and a non-dysphonic group. The protocol consisted of 18 questions and a score was calculated using a 10-cm visual analog scale. The measured value on the visual analog scale was added to the overall score, along with other partial scores. Speech samples allowed for analysis/assessment of the overall degree of vocal deviation and initial definition of the respective groups and after six months, the separation of the groups was confirmed using an acoustic analysis.

RESULTS

The mean total scores were different between the groups in all samples. Values ranged between 37.0 and 57.85 in the dysphonic group and between 12.95 and 19.28 in the non-dysphonic group, with overall means of 46.09 and 15.55, respectively. High sensitivity and specificity were demonstrated when discriminating between the groups with the following cut-off points: 22.50 (children), 29.25 (adult women), 22.75 (adult men), and 27.10 (seniors).

CONCLUSION

The protocol demonstrated high sensitivity and specificity in differentiating groups of individuals with and without dysphonia in different sample groups and is thus an effective instrument for use in voice clinics.

Videos Influence Behavior Change Measures for Voice and Speech in Individuals with Parkinson's Disease

The majority of individuals with Parkinson's disease (PD) experience voice and speech difficulties at some point over the course of the disease. Voice therapy has been found to help improve voice and speech in individuals with PD, but the majority of these individuals do not enroll in voice therapy. The purpose of this study was to determine whether watching short videos about voice symptoms and treatment in Parkinson's disease influences readiness to change, stages of change, and self-efficacy in individuals with PD. Eight individuals with PD participated in the study. Fifteen videos were chosen, three representing each of the five stages of change. We chose videos from YouTube that represented variety in speakers, content, and genre. We found that readiness to change significantly increased after watching videos, suggesting that watching videos helped these individuals move closer to actively improving their voice and speech. In addition, five of the eight participants showed forward movement in stages of change. Finally, self-efficacy demonstrated a positive trend following video watching. Overall, our results demonstrate that watching videos available on the internet can influence individuals with Parkinson's disease in changing vocal behavior. Implications for future wireless health applications are described.

Dysarthria and Quality of Life in neurologically healthy elderly and patients with Parkinson's disease

PURPOSE: To compare the speech and voice of Parkinson's disease (PD) patients and neurologically healthy elderly adults (control group, CG), to find out whether these features are related to the disease or the normal aging process, and investigate the impact that dysarthria has on the Quality of Life (QoL) of these individuals. METHODS: This is a cross-sectional study involving 25 individuals, 13 patients with PD and 12 CG. All the participants underwent vocal assessment, perceptual and acoustic analysis, based on "Dysarthria Assessment Protocol" and analysis of QoL using a questionnaire, "Living with Dysarthria". The data underwent statistical analysis to compare the groups in each parameter. RESULTS: In the assessment of dysarthria, patients with PD showed differences in prosody parameter (p=0.012), at the habitual frequency for females (p=0.025) and males (p=0.028), and the extent of intensity (p=0.039) when compared to CG. In QoL questionnaire, it was observed that patients with PD showed more negative impact on the QoL compared to CG, as indicated by the total score (p=0.005) with various aspects influencing this result. CONCLUSION: The degree of modification of speech and voice of patients with PD resembles those seen in normal aging process, with the exception of prosody and the habitual frequency, which are related to the greatest negative impact on the QoL of patients with PD.

Behavioral treatments for speech in Parkinson's disease: meta-analyses and review of the literature

SUMMARY 

Parkinson's disease (PD) results from neurodegenerative processes leading to alteration of motor functions. Most motor symptoms respond well to pharmacological and neurosurgical treatments, except some axial symptoms such as speech impairment, so-called dysarthria. However, speech therapy is rarely proposed to PD patients. This review aims at evaluating previous research on the effects of speech behavioral therapies in patients with PD. We also performed two meta-analyses focusing on speech loudness and voice pitch. We showed that intensive therapies in PD are the most effective for hypophonia and can lead to some improvement of voice pitch. Although speech therapy is effective in handling PD dysarthria, behavioral speech rehabilitation in PD still needs further validation.

The Effect of Voice Ambulatory Biofeedback on the Daily Performance and Retention of a Modified Vocal Motor Behavior in Participants With Normal Voices

PURPOSE

Ambulatory biofeedback has potential to improve carryover of newly established vocal motor behaviors into daily life outside of the clinic and warrants systematic research that is lacking in the literature. This proof-of-concept study was designed to establish an empirical basis for future work in this area by formally assessing whether ambulatory biofeedback reduces daily vocal intensity (performance) and the extent to which this change remains after biofeedback removal (retention).

METHOD

Six participants with normal voices wore the KayPENTAX Ambulatory Phonation Monitor for 3 baseline days followed by 4 days with biofeedback provided on odd days.

RESULTS

Compared to baseline days, participants exhibited a statistically significant decrease in mean vocal intensity (4.4 dB) and an increase in compliance (16.8 percentage points) when biofeedback was provided above a participant-specific intensity threshold. After biofeedback removal, mean vocal intensity and compliance reverted back to baseline levels.

CONCLUSIONS

These findings suggest that although current ambulatory biofeedback approaches have potential to modify a vocal motor behavior, the modified behavior may not be retained after biofeedback removal. Future work calls for the testing of more innovative ambulatory biofeedback approaches on the basis of motor control and learning theories to improve retention of a desired vocal motor behavior.

Tolerance of the VocaLog™ Vocal Monitor by Healthy Persons and Individuals With Parkinson Disease

OBJECTIVE

To assess subject tolerance of extended use of the VocaLog™ vocal monitor (VM), a device marketed to log calibrated decibel sound pressure level.

STUDY DESIGN

Prospective between-subjects design including two age- and sex-matched groups: individuals with Parkinson disease (IWPD) and healthy persons.

METHODS

After an initial session to calibrate the device and demonstrate its use, participants wore the VM during waking hours for five consecutive days. At a second visit to return the VM, participants completed a survey and a short interview regarding their experience with and perceptions of the device.

RESULTS

Those with PD and control subjects reported relatively few issues with use of the VM. There were no group differences regarding convenience, others' reactions, technical issues, or future participation in similar studies. Participants with PD indicated similar frequency of discomfort issues but higher severity ratings for discomfort during VM use compared with healthy participants.

CONCLUSIONS

The VocaLog™ offers a method to monitor vocal loudness during everyday activities for several consecutive days. The device was well tolerated by participants from both groups. IWPD reported greater discomfort than controls, possibly reflecting altered sensory perceptions associated with PD. The current data offer some reassurance that this VM can be tolerated by both healthy persons and those with PD for clinical and research purposes.

The clinical utility of vocal dosimetry for assessing voice rest

OBJECTIVES/HYPOTHESIS

Voice rest is frequently recommended following surgical disruption of vocal fold epithelium, but patients report variable adherence to voice rest recommendations. The objective of this study was to assess the clinical utility of an ambulatory vocal dosimeter for measuring adherence to voice rest recommendations.

STUDY DESIGN

Outcomes research.

METHODS

Part 1: To determine the utility of the dosimeter in nonclinical use, the relationship between self-reported voice use and dosimeter measurements was examined in normal subjects (n = 11) who prospectively logged voice use while wearing the dosimeter. Part 2: To determine clinical utility of the dosimeter, patients undergoing vocal fold surgery for which postoperative voice rest was recommended (n = 11) wore a dosimeter for 2 days prior to and 2 days after surgery. Phonation percent and sound level were compared at baseline and during voice rest.

RESULTS

The dosimeter performed as hypothesized with both normal subjects and patients. A moderate correlation (r = 0.62) was noted between self-reported voice use and dosimeter measurements in normal subjects. In patients on voice rest, a statistically and clinically significant decrease was observed in measured voice use, both in phonation time (P = .002) and intensity of phonation (P = .004).

CONCLUSIONS

Ambulatory vocal dosimetry may have clinical utility for assessing adherence to voice rest recommendations. This information will be useful for the design of future studies on voice rest.

Direct Comparison of Three Commercially Available Devices for Voice Ambulatory Monitoring and Biofeedback

Purpose: To provide a direct comparison of three commercially available devices for voice ambulatory monitoring and biofeedback to assist voice clinicians and researchers in choosing the device that best meets their needs.

Methods: The Ambulatory Phonation Monitor (APM), VocaLog, and VoxLog were descriptively compared regarding cost, availability, physical characteristics, and operational features; and quantitatively compared regarding measures of loudness (dB sound pressure level [SPL]), pitch (fundamental frequency – F0), and phonation time. The quantitative comparison used simultaneous registrations acquired during a 90-minute lecture which also included a Smartphone-based system designed to capture the raw voice signal as a reference.

Results: Differences regarding cost, physical characteristics, and operational features could influence device choice. All three devices register SPL and phonation time, and also biofeedback based on SPL. Furthermore, the APM and VoxLog provide monitoring and biofeedback for F0 with the associated capability of providing additional measures related to vocal dose. All devices produced comparable results for common measures, except for the overestimation of phonation time by the VocaLog.

Conclusions: The cost, operational features, and performance characteristics of the three commercially available devices for voice ambulatory monitoring and biofeedback differ in ways that can significantly impact decisions about which one is best suited for a particular application.