10.14639/0392-100X-N1962
Objective. To investigate the effectiveness of Lee Silvermann Voice Treatment (LSVT®) in improving prosody in patients with Parkinson’s disease over medium-term follow-up. Methods. 15 patients with Parkinson’s disease were assessed before LSVT®, within one week, and 3 and 6 months after treatment. Subjective and objective evaluation included: Voice Handicap Index - 10 (VHI-10), perceptual assessment by GRBAS scale and item 18 of the Unified Parkinson’s Disease Rating Scale III (UPDRS III), maximum phonation time (MPT /s/) and acoustic analysis by means the Voice Range Profile (VRP) and the “Intonation Stimulability Protocol” of the Motor Speech Profile (MSP). Results. A significant increase of the mean values of Imax and rF0 was observed until 6 months post-therapy (p &lt; 0.001), whereas Running Speech Standard Deviation (rSTD) (p = 0.004), Amplitude Variability (rVAm) (p = 0.02) and Frequency Variability (rvF0) (p = 0-01) improved significantly after 3 months, but returned to pre-therapy levels after 6 months. The score of item 18 of the UPDRS III increased significantly early post-therapy (p = 0.03), but did not maintain the improvement at 3 and 6 months. Median values of Grade (G), Asthenia (A) and mean values VHI-10 score significantly decreased at each post-therapy control (p &lt; 0.05). Conclusions. In addition to the subjective and perceptual beneficial effect of LSVT®, we found a long-lasting increase of loudness and fundamental frequency. There was also improvement of acoustic parameters related to prosody, although it was temporary.
text/xml
1827-675X
1962
en
Lucia D'Alatri
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
dysarthria
Multidimensional voice assessment after Lee Silverman Voice Therapy (LSVT®) in Parkinson’s disease
Text.Serial.Journal
https://www.actaitalica.it/
42
Laryngology
2022-09-30
2021-12-11
2022-10-12
2022-10-12
348-354
1
Lucia D'Alatri
2022/09/30
10.14639/0392-100X-N1962
348
Head & Neck Department, Università Cattolica del Sacro Cuore, Rome, Italy
1827-675X
dysarthria
en
354
Multidimensional voice assessment after Lee Silverman Voice Therapy (LSVT®) in Parkinson’s disease
https://www.actaitalica.it/article/download/1962/848
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:348-354; doi: 10.14639/0392-100X-N1962




Laryngology


Multidimensional voice assessment after Lee Silverman
Voice Therapy (LSVT®) in Parkinson’s disease
Valutazione multidimensionale della voce dopo riabilitazione vocale sec.
Lee Silverman nei pazienti affetti da malattia di Parkinson
Maria Raffaella Marchese1, Ilaria Proietti1, Ylenia Longobardi1, Giorgia Mari1, Carolina Ausili Cefaro1, Lucia D’Alatri1,2
1
 Otorhinolaryngology Head & Neck Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” - IRCCS - Rome, Italy; 2 Head &
Neck Department, Università Cattolica del Sacro Cuore, Rome, Italy


SUMMARY
Objective. To investigate the effectiveness of Lee Silvermann Voice Treatment (LSVT®)
in improving prosody in patients with Parkinson’s disease over medium-term follow-up.
Methods. 15 patients with Parkinson’s disease were assessed before LSVT®, within one
week, and 3 and 6 months after treatment. Subjective and objective evaluation included:
Voice Handicap Index - 10 (VHI-10), perceptual assessment by GRBAS scale and item 18
of the Unified Parkinson’s Disease Rating Scale III (UPDRS III), maximum phonation time
(MPT /s/) and acoustic analysis by means the Voice Range Profile (VRP) and the “Intona-
tion Stimulability Protocol” of the Motor Speech Profile (MSP).
Results. A significant increase of the mean values of Imax and rF0 was observed until 6 months
post-therapy (p < 0.001), whereas Running Speech Standard Deviation (rSTD) (p = 0.004),
Amplitude Variability (rVAm) (p = 0.02) and Frequency Variability (rvF0) (p = 0-01) improved
significantly after 3 months, but returned to pre-therapy levels after 6 months. The score of item
18 of the UPDRS III increased significantly early post-therapy (p = 0.03), but did not maintain
the improvement at 3 and 6 months. Median values of Grade (G), Asthenia (A) and mean values
VHI-10 score significantly decreased at each post-therapy control (p < 0.05).                         Received: December 11, 2021
Conclusions. In addition to the subjective and perceptual beneficial effect of LSVT®,                 Accepted: April 21, 2022
we found a long-lasting increase of loudness and fundamental frequency. There was also
improvement of acoustic parameters related to prosody, although it was temporary.                     Correspondence
                                                                                                      Giorgia Mari
KEY WORDS: Parkinson’s disease, Lee Silverman speech treatment, acoustic analysis,
                                                                                                      Unità Operativa Complessa di Otorinolaringoia-
prosody, voice, dysarthria                                                                            tria, Dipartimento di Scienze dell’Invecchiamento,
                                                                                                      Neurologiche, Ortopediche e della Testa-Collo,
RIASSUNTO                                                                                             Fondazione Policlinico Universitario “A. Gemelli”
Obiettivo. Valutare l’efficacia del LSVT® nel migliorare gli aspetti prosodici dei pazienti           IRCCS, largo “A. Gemelli” 8, 00168 Rome, Italy
con malattia di Parkinson.                                                                            Tel. +39 06 30155193. Fax +39 06 3051194
Metodi. Sono stati valutati 15 pazienti subito dopo il LSVT® e nei follow-up a una settima-           E-mail: giorgia.mari@policlinicogemelli.it
na, a 3 e a 6 mesi dal termine del trattamento attraverso la somministrazione dei seguenti
strumenti: Voice Handicap Index -10 (VHI-10), scala GRBAS, item 18 dell’Unified Parkin-                 How to cite this article: Marchese MR, Proietti
son’s Disease Rating Scale III (UPDRS III), Tempo Massimo Fonatorio (TMF/s/), Voice                     I, Longobardi Y, et al. Multidimensional voice
Range Profile (VRP) e l’Intonation Stimulability Protocol del Motor Speech Profile (MSP).               assessment after Lee Silverman Voice Therapy
Risultati. Dopo la terapia i parametri acustici Imax e rF0 hanno mostrato un incremento si-             (LSVT®) in Parkinson’s disease. Acta Otorhi-
gnificativo che si è mantenuto nel follow-up a 6 mesi (p < 0,001), mentre per le variabili rSTD         nolaryngol Ital 2022;42:348-354. https://doi.
(p = 0,004), rVAm (p = 0,02) e rvF0 (p = 0-01) si è evidenziato un miglioramento significativo nel      org/10.14639/0392-100X-N1962
follow-up a 3 mesi che tuttavia non si è mantenuto nel successivo controllo a 6 mesi. Il punteggio
                                                                                                      © Società Italiana di Otorinolaringoiatria
dell’item 18 dell’UPDRS III ha mostrato un incremento significativo soltanto a una settimana dal      e Chirurgia Cervico-Facciale
termine del trattamento (p = 0,03). Infine si è evidenziato un miglioramento statisticamente signi-
ficativo dei parametri G (Grado) e A (Astenia) della scala GRBAS così come del valore medio del
                                                                                                                     OPEN ACCESS
VHI-10 sia subito dopo il LSVT® che nei successivi follow-up a 3 e a 6 mesi (p < 0,05).
Conclusioni. I risultati hanno evidenziato, oltre ad un miglioramento soggettivo e percettivo del-    This is an open access article distributed in accordance with
                                                                                                      the CC-BY-NC-ND (Creative Commons Attribution-Non-
la sintomatologia, un incremento dell’intensità e della frequenza fondamentale. Il miglioramento      Commercial-NoDerivatives 4.0 International) license. The
dei parametri acustici relativi alla prosodia è stato temporaneo e non si è mantenuto nel tempo.      article can be used by giving appropriate credit and mentio-
                                                                                                      ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: malattia di Parkinson, Lee Silverman voice treatment, analisi acustica,                only in the original version. For further information: https://
voce, prosodia, disartria                                                                             creativecommons.org/licenses/by-nc-nd/4.0/deed.en




348
                                                                                             LSVT in patients with Parkinson’s disease




Introduction                                                      Materials and methods
One of the most common voice symptoms and one of the              Patients and setting
primary targets of intervention in Parkinson’s disease (PD)       From April 2019 to November 2019, at the Phoniatric Unit
is reduced voice intensity. Parkinsonian hypokinetic dys-         of the Fondazione Policlinico Universitario “A. Gemelli”
arthria is mainly characterised by breathy and harsh voice,       IRCCS in Rome, we enrolled patients affected by PD. The
reduced loudness and monotonous speech. Loss in voice             inclusion criteria were: PD diagnosed by an expert neu-
production, which occurs along with other speech prob-            rologist according to the UK Parkinson’s disease Brain
lems, concerns the majority of patients with PD (90%) 1           Bank criteria 14; age between 40 and 80 years, H-Y stage
and results in a decrease in familiar, social and professional    no > III, able and willing to provide written informed
interactions, as well as in isolation and consequent deterio-     consent. The exclusion criteria were the following: par-
ration of quality of life 2. Although the neural mechanisms       kinsonism other than idiopathic PD, previous or current
underlying vocal symptoms are not clear, the combination          psychiatric problems or cognitive decline, history of voice
of bradykinesia/hypokinesia with psychological and senso-         or laryngeal disease requiring therapy or of pulmonary
ry components is pointed out as being responsible for voice       disease, previous neck surgery, past or present swallowing
impairment 3.                                                     or voice rehabilitation therapy, bilateral high-frequency
As medication and surgical treatments have only modest            stimulation of subthalamic nucleus (STN). The subjects
effects on parkinsonian speech 4-7, behavioural treatments        were studied by a team that included a neurologist trained
are preferred 8. Intensive voice therapy, specifically Lee Sil-   in movement disorders, a speech-language pathologist
verman Voice Treatment (LSVT®), has been shown to be              with over 10 years of experience working with patients af-
highly effective 9. LSVT® trains dysarthric patients with PD      fected by PD, two otolaryngologists and two speech-lan-
to speak louder while self-monitoring the effort required to      guage therapists.
produce that voice.
This method capitalises on the known effects of increased         Design
vocal effort and loudness on the respiratory, phonatory           Patients were evaluated before treatment (pre-therapy), with-
and articulatory subsystems of speech. LSVT® stimulates           in one week after therapy (early post-therapy), and at three
glottal closure with the aim of increasing vocal intensity        and six months after therapy. For each patient the functional
and, even if purely focused on voice, of improving ar-            assessment was always carried out at the same time of day,
ticulation by recalibrating the sensorimotor perception           one hour after intake of a standardised dosage of levodopa.
of the volume of voice 10. LSVT® increases respirato-             The author (MRM) involved with data collection was blind
ry drive and improves oral resonance/vocal loudness               to the patients’ status and treatment condition.
through increased jaw movements 11. The result is better
communication through reduction of vocal symptoms of              Voice therapy
the disease and adjustment of voice quality to personal           LSVT® was conducted by four of the authors (C.AC, Y.L,
and social needs. LSVT® has proven to be effective in             G.M., I.P.), certified by LSVT Global Inc., according to its
Level I Scientific Evidence, and for years has been the           main treatment protocol, published by Ramig et al. 15-17.
treatment of choice for patients with PD as shown by the          The treatment consists of 16 individual therapy sessions
predominance of studies using it 12. A recent review by           (four 1-hour sessions per week for 4 consecutive weeks)
Yuan et al. (2020) noted that most trials have considered         and involves multiple repetitions (15 times and more),
increased vocal loudness as the main outcome measure of           maximum effort of the individuals, and daily tasks. The
treatment 13, not focusing on prosody as another equally          complexity of the training increases during the 4 weeks,
important outcome measure. In fact, it is well known that         with greater cognitive/motor load of the exercises, longer
monotonic speech is one of the most characteristic aspects        duration and higher difficulty of the “speech” tasks assign-
of parkinsonian dysarthria interfering with the naturalness       ments. The exercises can be done at home. The treatment
of speech in these patients.                                      program was performed individually in a quiet room. Clin-
The aim of our study was to investigate the effectiveness of      ical assignments used in LSVT® were first translated into
LSVT® in improving prosody in patients with PD, by us-            Italian by a speech and language pathologist who was flu-
ing it a specific program for the first time – the “Intonation    ent in both English and Italian.
Stimulability Protocol” – included in the “Motor Speech
Profile” (MSP) software (MSP-model 5141, Kay Elemet-              Objective and subjective assessment
rics, Lincoln Park, NJ).                                          Strobovideolaryngoscopy was performed by an expert, in-



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M.R. Marchese et al.




dependent and blinded ENT physician (LD), using a flex-          eled with an upward and downward intonation to evaluate
ible laryngoscope (model Xion Gmbh Video-Nasopharyn-             the ability to vary pitch and intensity during speech. In the
goscope EV-NE) to exclude morphological abnormalities            recording, a sampling rate of 11025 Hz was used. The vari-
and motility impairment of the larynx.                           ables analysed with the “Intonation Stimulability Protocol”
Maximum phonation time (MPT /s/). This was obtained by           were: Running Speech Average Fundamental Frequency
having the patient sustain the vowel /a/ for as long as pos-     (rF0 – Hz), Running Speech Highest Fundamental Fre-
sible on a single breath. The longest of three attempts was      quency (rFhi – Hz), Running Speech Lowest Fundamental
calculated as MPT.                                               Frequency (rFlow – Hz), Running Speech Standard Devia-
Perceptual voice analysis. Blind perceptual evaluation           tion of F0 (rSTD – Hz), Frequency Variability (rvF0 – %)
was performed on recorded voice samples (reading task of         and Amplitude Variability (rvAm - %). The parameters
184 words, 362 syllables and 26 sentences) by unfamiliar         rSTD and rvF0 track the degree of pitch variations, low
listeners with expertise in voice disorders. It comprised        values suggesting a monotonic vocalisation. The param-
The Grade – Roughness – Breathiness – Asthenia – Strain          eter rvAm tracks the degree of amplitude variability, a
(GRBAS) scale18 and item 18 of the Unified Parkinson’s           mono-level vocalisation corresponding to lower values of
Disease Rating Scale III (UPDRS III), which requires rat-        rvAm.
ing speech on a 5-point Likert scale (from 0: Normal - no
speech problems - to 4: Severe: most speech is difficult to      Statistical analysis
understand or unintelligible).                                   For statistical analysis we used the MedCalc package (ver-
Patient self-assessment. Assessment of dysphonia-related         sion 12, Marienkerke, Belgium). Kolmogorov–Smirnov
quality of life was carried out by using the Italian version     test was employed to assess the distribution of the con-
of the Voice Handicap Index-10 (VHI-10) 19.                      tinuous variables examined in the study. Parametric (re-
Acoustic voice analysis. For acoustic voice analysis we          peated-measures ANOVA with Bonferroni correction and
used the Computerized Speech Lab model 4300B from                Student’s t-test for paired data) and non-parametric tests
Kay Elemetrics (Lincoln Park, NJ), recording with a Shure        (Wilcoxon) were applied depending on data distribution.
model SM48 microphone (Evanston IL) positioned at a 45°          The level of significance was set at p < 0.05.
angle and at a distance of 20 cm from patient’s mouth. The
microphone saturation input was fixed at 6/9 of Channel 1
                                                                 Results
and the environmental noise was < 30 dB sound pressure
level (SPL). The Voice Range Profile program (VRP-model          From a series of 23 patients, 8 (34.78%) did not meet in-
4326) was used to analyse speaking voice as described by         clusion criteria and 15 (65.2%) were thus considered. Of
D’Alatri and Marchese 20. Patients were asked to read twice      these, 14/15 (93.3%) cases were male and 1/15 (6.6%) was
20 sentences aloud at their most comfortable pitch and           female, with a mean age of 71 ± 7 years (min. 58, max. 78
loudness as in daily conversation. Subjects were allowed         years). The mean time since diagnosis was 2.6 years (min.
to practice reading the sentences aloud before actual re-        1 and max 5 years).
cording. The sentences were chosen to be characterised by
different prosodic features (i.e.: interrogative, affirmative,   Strobovideolaryngoscopy
exclamatory) and to express different feelings (i.e.: happi-     None of the 15 cases had morphological abnormalities and
ness, sadness, disbelief, disappointment). After recording,      motility impairment of the larynx.
the following parameters were analysed: lowest frequency
(Fmin, Hz), he highest frequency (Fmax, Hz), number of semi-     Maximum phonation time (MPT)
tones (st), minimum intensity (Imin, dB SPL), maximum in-        Repeated-measures ANOVA showed no significant differ-
tensity (Imax, dB SPL) and difference between Imax and Imin      ence among the times of observation (p > 0.05). However,
(range dB, dB SPL)                                               Student’s t-test for paired data revealed that MPT significant-
Motor Speech Profile (MSP– model 5141) analysis was              ly improved soon after the end of treatment (mean pre-thera-
performed by using the protocol ‘‘Intonation stimulabili-        py = 14.81 ± 9.10 s; mean early post-therapy = 17.81 ± 7.83
ty’’ that assesses the patient’s ability to listen to a target   s, p < 0.02), whereas this MPT increase was no longer sig-
speech token and then verbally match the target intonation       nificant at 3 months (mean = 16.18 ± 6.82 s, p > 0.05) and 6
pattern. Patients were asked to listen and to repeat the sen-    months post-therapy (mean = 15.27 ± 5.71 s, p > 0.05).
tence “Esci oggi o domani?” ([‘ɛ∫i ‘ɔʤ:i // oˬ do’mani
//]) in which all the phonemes except one – the fricative       Acoustic voice analysis
palato-alveolar [ʃ]) – are voiced. The sentence was mod-         VRP analysis by repeated-measures ANOVA showed a sig-



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nificant increase of Imax (F (3, 34) = 11.03; p < 0.001), and                            (p = 0.01) and for rSTD values Student’s t-test for paired
two-by-two comparisons demonstrated that the significant                                 data resulted in a significant increase between pre-therapy
improvement was obtained immediately after treatment                                     and 3 months post-therapy (p = 0.004). With regards to the
and maintained throughout follow-up. Repeated-measures                                   rvAm variable, repeated-measures ANOVA showed signif-
ANOVA did not reveal a significant increase of Fmax over                                 icant improvement over time (F (3, 35) = 39.60; p = 0.02),
time (p > 0.05). By Student’s t-test for paired data, signifi-                           with significant differences between both pre-therapy and
cant improvement was found between pre-therapy and ear-                                  early post-therapy, and between early post-therapy and 3
ly post-therapy (p = 0.01), and Fmax tended to decrease at 3                             months post-therapy.
and 6 months post-therapy. At repeated-measures ANOVA,                                   Regarding rFhi and rFlow variables, no significant increase
the increase in intensity range (dB) was nearly significant                              was found over time at repeated-measures ANOVA nor at
(p = 0.07). As for the above-mentioned variables, Student’s                              two-by two comparisons by Student’s t-test. Details con-
t-test for paired data showed significant improvement be-                                cerning the variables rF0, rvF0, rSTD, rvAm, rFHi and rFLo
tween pre-therapy and early post-therapy, after which a                                  are reported in Table II.
decreasing trend was observed. The comparison between
pre-therapy, early post-therapy, 3 and 6 months post-thera-                              Perceptual voice analysis
py did not detect significant differences in the mean num-                               A Wilcoxon Test was applied in order to analyse GRBAS
ber of semitones or mean values of Imin and Fmin (p > 0.05).                             and item 18 of UPDRS III scores. The Grade (G) variable
All data on acoustic voice analysis are detailed in Table I.                             decreased significantly between pre-therapy and early
At repeated-measures ANOVA, no significant improve-                                      post-therapy (p = 0.003) and between pre-therapy and the
ment of the rF0 variable was observed over time. Never-                                  two follow-up assessments after 3 (p = 0.007) and 6 months
theless, Student’s t-test for paired data showed significant                             (p = 0.03). At the early and 3 months post-therapy time
improvement between pre-therapy and early post-thera-                                    points, median values for Asthenia (A) were significant-
py (p < 0.001). These results remained stable at 3 and 6                                 ly decreased compared with pre-therapy ones (p = 0.03;
months after therapy. Similarly, the rvF0 and rSTD vari-                                 p = 0.01 respectively) (Fig. 1).
ables did not increase over time. However, for the rvF0 vari-                            With regards to the UPDRS III results, the score of item
able Student’s t-test for paired data showed significant im-                             18 significantly improved at the early post-therapy control
provement between pre-therapy and 3 months post-therapy                                  (median pre-therapy = 1, median early post-therapy = 0,


Table I. The results of speech range profile before and after LSVT®.
                                                       Pre                                Early                         3 months                    6 months
                                                     LSVT®                             Post-LSVT®                      post-LSVT®                  post-LSVT®
 Imin (dB SPL)                                        70.91 ± 2.70                    72.09 ± 3.08                    71.83 ± 2.71                72.13 ± 3.68
 Imax (dB SPL)                                        89.82 ± 4.07                   97.45 ± 2.66 *                    96 ± 3.85 *                 95.13 ± 3 *
 Fmin (/Hz/)                                         122.24 ± 27.29                  125.63 ± 30.82                  125.40 ± 24.23              130.45 ± 27.32
 Fmax (/Hz/)                                            224 ± 39                       268 ± 70 *                      253 ± 61.39               246.31 ± 37.27
 N. of semitones                                      10.73 ± 2.24                      12 ± 4.98                     12.50 ± 3.67                11.88 ± 1.81
 range dB                                             18.90 ± 2.91                    25.36 ± 2.54*                   17.63 ± 11.70               16.72 ± 10.90
* vs pre-therapy (p < 0.05). Imin: minimal Intensity; Imax: maximum Intensity; Fmin: minimal Frequency; Fmax: maximum Frequency.


Table II. Values obtained before and after therapy by the Intonation Stimulability Protocol.
                                                       Pre                           Early                     3 months                             6 months
                                                     LSVT®                       Post-LSVT®                          post-LSVT®                    post-LSVT®
 rF0 (/Hz/)                                          173.18 ± 27.64                 199.63 ± 39.59*                 201.36 ± 34.57 *             200.63 ± 34.14 *
 rFhi (/Hz/)                                          265 ± 52.54                   282.73 ± 58.25                   283.72 ± 59.38               279.18 ± 55.80
 rFlow (/Hz/)                                        112.29 ± 19.65                 122.98 ± 44.72                    133.22 ± 45 *               124.21 ± 34.23
 rSTD (/Hz/)                                          23.77 ± 8.81                   30.38 ± 14.63                   36.24 ± 17.31 *               24.07 ± 16.79
 rvF0 (/%/)                                           13.11 ± 4.08                    15.35 ± 5.84                    18.54 ± 8.46*                 14.46 ± 5.07
 rvAm (/%/)                                           36.34 ± 4.14                   43.20 ± 7.35*                    44.69 ± 8.15 *                40.21 ± 3.57
* = p < 0.05 vs pre-LSVT®. rF0: Running Speech Average Fundamental Frequency; rFhi: Running Speech Highest Fundamental Frequency; rFlow: Running Speech Lowest Fundamental
Frequency; rSTD: Running Speech Standard Deviation of F0; rvF0: Frequency Variability; rvAm: Amplitude Variability.




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M.R. Marchese et al.




 * = p < 0.05 vs pre-LSVT®                                                * = p < 0.05 vs pre-LSVT®

Figure 1. Results of perceptive assessment basing on the GIRBAS scale.   Figure 2. Self-assessment results (VHI-10) before and after therapy.


p = 0.03), but it did not at the 3 and 6 months post-therapy             LSVT® and did not change until the last follow-up. The
follow-up (p > 0.05).                                                    simultaneous increase in intensity and frequency was pre-
                                                                         dictable, since, as is known, the fundamental frequency in-
Patient self-assessment                                                  creases with intensity 21.
The VHI-10 mean scores before and after voice therapy are                In contrast with Ramig et al. 15,16, the increase in the average
shown in Figure 2. The mean values analysed by repeat-                   fundamental frequency of running speech we observed in
ed-measures ANOVA did not detect any significant dec-                    our patients after therapy did not relate to improvement in
rement over time. Nevertheless, Student’s t-test for paired              prosody. Indeed, in our study the prosody-related acoustic
data revealed a significant improvement (p = 0.04) between               parameters - rSTD, rvF0 and rvAm - showed a significant
pre-therapy (mean = 1 6.67 ± 8.63) and early post-thera-                 increase in the medium term, but did not preserve the effect
py (mean = 11.23 ± 5.80), and between pre-therapy and                    at the last control.
the two follow-up assessments at 3 (mean 10.57 ± 10.70)                  Subjectively, patients showed a significant decrease in
(p = 0.01) and 6 months (mean = 10.14 ± 6.64) (p = 0.01),                voice-related quality of life immediately after therapy and
as shown in Figure 2.                                                    at each time of follow-up. The overall perception of the se-
                                                                         verity of dysphonia improved until the 6-month control, in
Discussion and conclusions                                               particular due to the decrease in Grade and Asthenia, as
                                                                         also confirmed by the results of VHI-10.
The aim of this study was to investigate the effectiveness               Works assessing vocal function after LSVT® described
of LSVT® in improving prosody in patients with PD. For                   long-term improvement (up to 2 years) basing both on
this purpose, we analysed the acoustic parameters related                acoustic (SPL and semitone standard deviation) 15 and
to prosody using software specifically designed for motor                perceptual data 15-17. Our results show that, thanks to the
speech disorders.                                                        increase in vocal fold tension and subglottal pressure asso-
Clinical research 21-23 on PD has demonstrated that, even if             ciated with the increase in volume, LSVT® allows patients
dysarthria may impact all speech subsystems, vocal loud-                 to improve vocal fold adduction and the activation and syn-
ness and prosody are the most affected, impairing natural-               ergy of the laryngeal muscle, thus making the phonatory
ness and speech intelligibility.                                         system more efficient over time.
Ramig et al. 15,16 demonstrated that LSVT® improves both                 On the contrary, the recovery of prosody proved to be slow-
parameters related to vocal loudness (e.g. SPL during vow-               er and temporary. It cannot be excluded that rehabilitation
els and reading) and those related to prosody (e.g. funda-               of muscle activity aimed at intonation is more difficult and
mental frequency variability in monologue, inflection in                 may require repeated therapy cycles to obtain more stable
voice fundamental frequency), even in the long term.                     acoustic results. In this regard, the central sensory process-
In our group of patients, the mean values of Imax as well                ing and cueing deficits found in subjects with PD may also
as those of rF0 increased significantly immediately after                play a role. In particular, in patients with PD a selective



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                                                                                                      LSVT in patients with Parkinson’s disease




difficulty in recognising emotions from prosody and a gen-         References
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itored in their self-training and need continuous family           5
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involvement. Finally, long-term improvements can be                     bilateral stimulation of subthalamic nuclei in Parkinson’s disease: dif-
compromised by a worsening of general clinical condi-                   ferential effects on motor, speech and language function. J Parkinsons
tions, as is often the case with PD.                                    Dis 2012;2:29-40. https://doi.org/10.3233/JPD-2012-11049
Further studies are needed to confirm these results by an-         6
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                                                                        proficiency in patients with Parkinson’s disease following deep
alysing speech outcomes using tools more specific for PD                brain stimulation of the subthalamic nucleus and caudal zona in-
patients as the Italian protocol for dysarthria (QoL-Dys) 24            certa. J Speech Lang Hear Res 2014;57:1178-1190. https://doi.
and the Italian version of the Frenchay dysarthria Assess-              org/10.1044/2014_JSLHR-S-13-0010
ment (FDA) 25.                                                     7
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Conflict of interest statement                                          10.2217/nmt.15.16
The authors declare no conflict of interest.                       8
                                                                        Ho AK, Bradshaw JL, Iansek R, et al. Speech volume regulation in
                                                                        Parkinson’s disease: effects of implicit cues and explicit instructions.
                                                                        Neuropsychologia 1999;37:1453-1460. https://doi.org/10.1016/
Funding                                                                 s0028-3932(99)00067-6
This research did not receive any specific grant from fund-        9
                                                                        Tingting P, Min H, Xiangyu K, et al. Lee Silverman voice treatment
ing agencies in the public, commercial, or not-for-profit               to improve speech in Parkinson’s disease: a systemic review and
sectors.                                                                meta-analysis. Parkinsons Dis 2021;27;2021:3366870. https://doi.
                                                                        org/10.1155/2021/3366870
                                                                   10
                                                                        Wight S, Miller N. Lee Silverman voice treatment for people with
Author contributions                                                    Parkinson’s: audit of outcomes in a routine clinic. Int J Lang Commun
MRM: design of the study, interpretation of the data                    Disord 2015;50:215-225. https://doi.org/10.1111/1460-6984.12132
and manuscript writing, revision and final approval. IP:           11
                                                                        Sapir S, Spielman JL, Ramig LO, et al. Effects of intensive voice
acquisition, analysis and interpretation of data, revision              treatment (the Lee Silverman Voice Treatment [LSVT]) on vow-
                                                                        el articulation in dysarthric individuals with idiopathic Parkinson
and final approval of manuscript. YL: acquisition, analysis             disease: acoustic and perceptual findings. J Speech Lang Hear Res
and interpretation of the data and manuscript revision. GM:             2007;50:899-912. https://doi.org/10.1044/1092-4388(2007/064)
statistical analysis and interpretation of the data, manuscript    12
                                                                        Coutinho SB, Diaféria G, Oliveira G, et al. Voice and speech of in-
writing, revision and final approval. CAC: acquisition,                 dividuals with Parkinson’s Disease during amplification, delay and
                                                                        masking situations. Pró-Fono R Atual Cient 2009;21:219-224. https://
analysis and interpretation of data, revision and final approval        doi.org/10.1590/s0104-56872009000300007
of manuscript. LD’A: design of the study, interpretation of        13
                                                                        Yuan F, Guo X, Wei X, et al. Lee Silverman Voice Treatment for
data, revision and final approval of the manuscript.                    dysarthria in patients with Parkinson’s disease: a systematic review
                                                                        and meta-analysis. Eur J Neurol 2020;27:1957-1970. https://doi.
                                                                        org/10.1111/ene.14399
Ethical consideration                                              14
                                                                        National Institute for Health and Care Excellence. Parkinson’s disease
This research work was conducted in accordance with the                 in adults: diagnosis and management, July 2017. www.nice.org.uk/
principles contained in the Helsinki declaration and was                guidance/ng71. Accessed on October 13, 2021.
approved by the institutional review board (Fondazione             15
                                                                        Ramig LO, Sapir S, Countryman S, et al. Intensive voice treatment
Policlinico Gemelli, Protocol number: 0038806/21). A                    (LSVT) for patients with Pakinson’s disease: a 2 year follow-up.
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written consent was obtained from all the patients includ-              org/10.1136/jnnp.71.4.493
ed in the study after being informed verbally about the            16
                                                                        Ramig LO, Countryman S, Thompson LL, et al. Comparison of
aim of the study.                                                       two forms of intensive speech treatment for Parkinson’s disease. J




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