Efficacy of Intensive Phonatory-RTreatment (LSVT) for PresbyphoCase Reports

Fang-Ling Lu, Shannon Presley, and Becky Lammers, Dento

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Address correspondence and reprint requests to Fang-Ling Lu, Department of Speechminimize any handicap.39,40 Direct therapyinvolve strengthening exercises or physiolotechniques aiming to optimize vocal erespiratory-phonatory coordination. A few com

and Hearing Sciences, University of North Texas, 1155 Union Circle # 305010, Denton,TX 76203-5017. E-mail: flu@unt.eduJournal of Voice, Vol.-, No.-, pp. 1-130892-1997/$36.00 2013 The Voice Foundationhttp://dx.doi.org/10.1016/j.jvoice.2013.06.006Conventional voice therapy prescribed for presbyphonia mayinclude indirect approaches and direct therapy techniques. In-direct approaches normally focus on patient education, vocal

Accepted for publication June 11, 2013.Portions of this article were presented at the American Speech-Language-Hearing Asso-

ciation in Philadelphia, PA (2010) and the 6th Biennial Conference on Motor Speech inSanta Rosa, CA (2012).From the Department of Speech and Hearing Sciences, University of North Texas, Den-

ton, Texas.nia). The impact of presbyphonia may be benign ifs of laryngeal structures vocal function are gradualild, but the condition almost certainly has a cripplingover time on the individuals health and social in-on.2,3 Reportedly, 13% of individuals afflicted withphonia complained of a moderate to severe impact onuality of life.4,5 With the fast growing rate of the oldertion in the United States, it presents voice cliniciansn inevitable reality and an urgent need to seek viableent options for aging voice disorders.viduals with presbyphonia typically exhibit awide array ofdisturbances because of anatomical and physiologicals in the aging laryngeal mechanism. Age-related changese evident from gradual deterioration in the central

aperiodic and of reduced amplitude. Perceptpresbyphonia is described as a voice of thin, weak, and hquality, increased breathiness, low pitch, diminishedrange, increased strain and unsteadiness, and at timesvocal tremor.2227 Acoustically, elderly voice is characteby higher perturbations of frequency (ie, jitter), amplitudshimmer), and spectral noise, as well as fluctuatiofundamental frequency.14,16,2731

Efficacious treatment for presbyphonia requires a multiplinary approach. Current rehabilitation protocol typicallvoice therapy as the first line of treatment.6,3234 Whindividual with presbyphonia fails to achieve satisfaprogress through voice therapy, medical intervention ispursued to improve glottal closure. Thus far, suprocedures are not always desired by physicians or pabecause of their invasive nature and possible complicationsing, resulting in glottal incompetence and dysphonia (ie, pres-bypho

The mucosal wave of the aging vocal folds is reportedly13,21 ually,tal gaps. The purpose of this study was to examine theSilverman voice treatment [LSVT]) for glottal incompeteStudy Design. Nonrandomized prospective study.Methods. Two subjects with age-related vocal fold bowamination, phonatory function measurement, acoustical abaseline and 2 weeks posttreatment. Additional acousticmaximum phonation time, and pitch range, were also obResults. Both subjects exhibited significant improvemeand perceptual ratings of voice after treatment. Significaatively early and remained steady throughout the courseConclusions. These findings provide solid evidence thamay improve glottal competence and related vocal functhyperfunction after the LSVT.Key Words: PresbyphoniaGlottal incompetenceTreat

INTRODUCTIONThe current number of Americans aged 65 and older is approx-imately 41 million, more than one in every eight of the generalpopulation.1 The number of the elderly is expected to increaseby 3236% every decade during the next 20 years as a result ofthe growing population of the elderly from the baby boomergeneration. The literature reports that roughly 2030% of theelderly are affected by age-related vocal fold atrophy and bow-espiratorynia: Two

n, Texas

neither traditional voice therapy nor surgery was effica-severe cases with pronounced fold atrophy or larger glot-cacy of intensive respiratory-phonatory treatment (Leeassociated with presbyphonia.

received 4 weeks of the LSVT. Strobolaryngoscopic ex-ses, and perceptual judgments of voice were obtained atasures of phonatory function, including vocal intensity,d during 16 treatment sessions.in glottal closure, phonatory function, acoustic features,anges of phonatory function measures were noticed rel-eatment.akers with age-related vocal fold bowing and dysphoniaith neither laryngeal trauma nor maladaptive laryngeal

t efficacyLSVT.

and peripheral nervous system control of the laryngealmuscles, degenerative changes of muscle fibers and mucosal tis-sues, and declines in respiratory-phonatory coordination.611

Laryngoscopic characteristics of presbylaryngis include vocalfold atrophy and bowing, prominence of vocal processes,edema, or glottal gap.1218 The size of glottal gap may rangefrom no observable gap to a large spindle-shaped gap, relativelyunmatched to the severity of vocal fold atrophy and bowing.19,20

Journal of Voice, Vol.-, No.-, 20132techniques include resonance and tone exercises, stretch andflow, semioccluded vocal tract exercises, strengthening, vocalfunction exercises, and resonant voice therapy, to name a few.Through these approaches, the individual with presbyphonia isexpected to regain ability of producing the strongest clearestvoice without increasing muscle tension or vocal fold impactstress.6,32,34,4045 Conventional voice therapy for presbyphoniarequires multiple treatment sessions, typically 1 or 2 weeklysessions spanning 1 to 2 months.Numerous voice treatment studies have been published on ef-

ficacy for presbyphonia or vocal fold bowing,3,20,32,39,4648

which are briefly summarized in Table 1. Five of seven studiesunder review used traditional methods of voice therapy in oneor two treatment sessions per week. The total number of treat-ment sessions conducted in these studies varied widely, rangingfrom 1 session to as many as 12 sessions. Although these studiesreported posttreatment improvements on subjective assessment(eg, quality of life survey) and a few objective measures (eg,maximum phonation time [MPT], airflow measures), most ob-jective measures such as acoustic analysis or laryngeal exami-nation did not show significant changes after therapy. Incontrast, two other studies using rigorous exercise-based behav-ioral treatment yielded very promising results of glottal closureand phonatory function in subjects with presbyphonia.3,47

Ramig et al3 reported significant posttreatment improve-ments of vocal intensity and vocal fold adduction in three el-derly subjects aged 6870 years with presbyphonia when anintensive respiratory-phonatory treatment program (ie, Lee Sil-verman voice treatment [LSVT]) was applied. The LSVT wasoriginally designed to improve respiratory drive and vocalfold adduction in patients of Parkinson disease (PD) by usingloud and effortful phonatory tasks. The LSVT program is rou-tinely implemented in sixteen 60-minute treatment sessionsspanning a period of 4 weeks. Each treatment session typicallyconsists of intensive vocal fold exercise drills with copious rep-etitions, high physical exertion, incorporation of complex tasks,continuing calibration, and usage of shout-loud voice.49,50

Vocal exercises in the LSVT focus on vocal loudness,duration and pitch range of phonation, and assimilation offunctional speech in daily practices. In addition to in-housetreatment sessions, the LSVT protocol also requires individualsto complete daily homework assignments during therapy and tocontinue daily carryover exercises after treatment.LaGorio et al47 studied treatment efficacy for several subjects

of advanced age, between 58 and 82 years, and vocal fold bow-ing who underwent a combination therapy of transcutaneousneuromuscular electrical stimulation (NMES; VitalStim Ther-apy),51 and vocal exercises. The treatment protocol by LaGorioet al47 involves a 14-step series of progressive vocal exercisespaired with concurrent NMES. During treatment sessions, theNMES electrodes are placed toward the cricothyroid membraneand the superior laryngeal nerves intended to stimulate the cri-cothyroid muscles during vocal exercises. The 14-step progres-sive vocal exercises focus on duration, volume, and pitch rangeof phonation, with the 1st to 11th steps of exercise targeting thesustained phonation stimuli and the 12th to 14th steps on vari-

ous speech. The program is administered in fifteen 60-minuteBoth subjects underwent a routine voice assessment includinga videostrobolaryngoscopic examination, acoustical analysis,and perceptual judgment of voice quality. A screening of motorspeech function was also conducted to exclude potential con-comitant speech disorders. Strobolaryngoscopic examinationwas conducted during sustained vowel /i/ phonation at a habituallevel of pitch and loudness and during a pitch glide. The exam-ination was performed by way of a 70-degree rigid scope(model 9106; Kay Elemetrics, Lincoln Park, NJ), which wascoupled with a CCD Panasonics camera (model GP-KS152)and a stroboscopic light source (RLS 9100; Kay Elemetrics).Laryngoscopic images were captured and recorded on a com-puter using a digital video recording system (model 9200C;KayPENTAX, Lincoln Park, NJ) at the rate of 30 consecutiveframes per second. For acoustical analysis and perceptual audi-therapy sessions, including 2 training sessions and 13 full treat-ment sessions, over a period of 3 weeks. Results shown in thestudy by LaGorio et al indicate positive effects of the combinedtherapy on increasing glottal closure and improving associatedphonatory function in the elderly subjects of vocal fold bowing.The purpose of the present study was to provide an extensive

evaluation of LSVTefficacy for glottal incompetence and hypo-functional voice related to presbylaryngis. In this study, quanti-tative measurements of glottal gap size (GGS) and phonatoryfunction were conducted before, during, and after treatment.Subjective evaluation of the laryngeal configuration and per-ceptual voice rating was also conducted. Furthermore, thisstudy investigated if an increase of maladaptive laryngeal hy-perfunction occurred as a result of the LSVT.

METHOD

ParticipantsTwo patients were diagnosed with presbylaryngis by local oto-laryngologists and referred to the university clinic for compre-hensive voice evaluation and consideration of voice treatment.These two patients were denoted as subject 1 and subject 2, re-spectively, in this article.

Subject 1. Sixty-one-year-old female, a retired office worker,complained of a weak and breathy voice when engaging in longconversation and a moderate difficulty of being heard over thephone. The subject reported a history of asthma in the recent6 years for which she was prescribed steroid-based inhalersfor treatment. She also had a lengthy history of airborne aller-gies and year-round sinus problems since young adulthood.The only medication taken at the time of the voice evaluationwas an antireflux drug for suspected gastroesophageal refluxdisease (GERD).

Subject 2. Eighty-eight-year-old male, a retired professor invocal studies, complained of a weak and breathy voice anda great difficulty to be understood by others during conversa-tion. The subject had an unremarkable medical history exceptfor suspected GERD. His vocal difficulty started approximately5 years ago and had declined slowly over time.

Voice diagnostic assessmenttory assessment, the voice samples were obtained when each

TABLE 1.Voice Treatment Outcomes of Presbyphonia Studies

References Nature of Study

Subject WithPresbyphonia or Vocal

Fold Bowing Voice Therapy Outcome Measures Results

Berg et al32 Retrospective, chartreview

19 patients (6283 y) Vocal education,resonance and toneexercises, and vocalfunction exercises;approximately fourtherapy sessionsacross 5 mo

Patient-basedassessment per VRQOLsurvey

Improvement on theVRQOL score frommoderate to milddysphonia

Gartner-Schmidt andRosen39

Retrospective, chartreview

275 patients (5597 y) Individually designedtherapy using indirectapproaches (eg, vocalhygiene, patienteducation, relaxation,etc.) and direct therapytechniques (eg,resonant voice therapy,Lessac-Madsenresonant voiceprogram, flowphonation,semioccluded vocaltract exercises, etc.); nomention of treatmentschedule

Patient-basedassessment using theVHI-10

Unsatisfactory treatmentoutcomes, regardlessof voice therapy alone,surgery alone, or thecombined treatment

Gorman et al46 Prospective,experimental

19male patients (6078 y) Vocal function exercisefor 12 wk per weeklysessions and dailyhomeworkassignments (ie, 12treatment sessionsplus home exercises)

Glottal aerodynamicmeasures (glottalairflow and subglotticpressure) and MPTmeasures

Significantly longer MPTand improvement onsome airflowmeasures, suggestingimproved glotticclosure

LaGorio et al47 Prospective,experimental

Seven patients (5881 y) Fourteen-stepprogressive vocalexercises paired withNMES (VitalStim) perdaily 60-min sessionsfor 3 wk (ie, 15treatment sessions)

Acoustic analysis,judgment of glotticclosure perstroboendoscopicexamination,pulmonary functiontest, and patient-basedassessment using theVHI

Significant longer MPTand improved VHIscores, as well asincreased glottalclosure with lesssupraglotticcompression;insignificant changesin pulmonary function

(Continued )

Fang-LingLu,etal

Efficacy

ofLSVTforPresbyphonia

3

TABLE 1.(Continued )

References Nature of Study

Subject WithPresbyphonia or Vocal

Fold Bowing Voice Therapy Outcome Measures Results

Mau et al20 Retrospective, chartreview

67 patients (5691 y) Vocal exercises adoptedfrom the LSVT focusingon high pitch or loudvoice production, vocalfunction exercises,airflow/resonanceexercises, resonantvoice, and stretch/flowexercises; average 2.6sessions (median, 2;range, 17)

Clinician-basedassessment per FCMsfor voice (ASHANational OutcomesMeasurement System)and judgment of glottalclosure perstroboendoscopicexamination

Eighty-five percentshowed improved FCMscores; lessimprovement in casesof larger glottic gaps orpronounced vocal foldatrophy

Ramig et al3 Prospective,experimental

Three patients (6870 y) LSVT per daily 60-minsessions, four sessionsa week for 4 wk, plusdaily homeworkassignments (ie, 16treatment sessionsplus home exercises)

Vocal intensity measures(SPL), laryngeal EMG,subglottal pressure,and judgment of glottalclosure perstroboendoscopicexamination

Significant increases inSPL, subglottal airpressure, and the rateof thyroarytenoidmuscle modulation;improved vocal foldadduction

Sauder et al48 Prospective,experimental

Nine patients (6790 y) Practices of fourcomponents in thevocal functionexercises (MPT andpitch glides usingspecific pitch andphonetic contexts)twice daily for 6 wk;also weekly 60-mintherapy for 6 wk toreview the progressand practice extremeforward focus andbreath support (ie, dailyhome exercises plus sixtreatment sessions)

Acoustic analysis,patient-basedassessment per VHIand patients self-determined phonatoryeffort, judgment ofglottal closure perstroboendoscopiclaryngoscopicexamination, andperceptual rating

Significantly lower VHIscores, phonatoryeffort level and voicedisorder severity; voiceperceived as lessbreathy and strained;insignificant changesin othermeasurements,including MPT,acoustic analysis, andlaryngeal configuration

Abbreviations: VRQOL, voice-related quality of life; VHI, Voice Handicap Index; FCMs, functional communication measures; ASHA, American Speech-Language-Hearing Association; EMG,

electromyography.

JournalofVoice

,Vol.-,No.-,2013

4

subject performed five speech tasks: 5 seconds of sustainedvowel /a/ phonation, MPT, pitch glide, counting, and oral read-ings of the Rainbow Passage; each task was repeated for at leasttwo trials. These voice samples were saved as wav files (at48 000 Hz of sampling frequency and 16 bits of amplitude res-olution) on an Olympus LS-10 Linear PCM digital audio re-corder. The pretreatment baseline was conducted within1 week before the LSVT, and the posttreatment assessmentwas performed approximately 2 weeks after treatment.

Voice treatmentEach subject received a total of sixteen 60-minute sessions ofthe LSVT spanning a period of 4 weeks in the care of anLSVT-certified speech-language pathologist.41 The first 30min-utes of each treatment session contained drill exercises thatwere designed to maximize phonation time and pitch rangeand to practice a set of short personally salient sentences (ie,functional speech) using a shout loud vocal intensity. Thenext 30 minutes in each session centered on using high respira-tory and phonatory efforts (ie, increased vocal intensity) on var-

bowing, glottal closure, and vibratory pattern of the vocal folds.Status of the glottal closure was determined during the closingphase of vocal fold adduction; it was assessed based on the sizeof glottal gapcomplete closure (ie, no gap), small slit, moder-ate gap, and large gap.20 Special attention was also paid to doc-ument any vocal fold pathology or changes in supraglottic ortransglottic activity that might be indicative of therapy-induced lesion or maladaptive laryngeal hyperfunction.

Glottal gap measurement. Because actual measurementof the GGS is unattainable from the laryngoscopic images be-cause of limitations of current endoscopic technology, thepresent study attempted a relative estimation of glottal gaparea by adopting a measurement method described by Omoriet al.16 One-second video clip was obtained from each strobo-laryngoscopic examination when the vocal folds were seen toreach the adductory phase and when both anterior commissureand the tip of opposing vocal processes were also visible. Avideo editing program (Ulead Video Studio 11.0; Corel, Ot-tawa, CA) was used to process the 1-second video clip into30 consecutive freeze-frame photographic files. On each still

ben

ess d

Fang-Ling Lu, et al Efficacy of LSVT for Presbyphonia 5ious speech tasks, such as oral readings, off-the-cuff questions,word generation, and conversation. Data collection on phona-tory function was conducted during each treatment session. Inaddition to onsite treatment sessions, each subject was also re-quired to complete daily home exercise assignments to inte-grate and reinforce the acquired skills. When the LSVT wasconcluded, the subject was expected to continue daily practicesof maintenance exercises at home for retention purposes.

Treatment outcome measurement

Strobolaryngoscopic evaluation of laryngeal configu-ration. The first author, a speech-language pathologist with20 years of experience in voice disorders, assessed laryngealconfiguration from the laryngoscopic images for four parame-tersgeneral vocal health, severity of vocal fold atrophy and

FIGURE 1. Normalized measurement of glottal gap area. Left is theprocess; LVP, tip of the left vocal process; black line, intervocal proc(in area pixels).photographic image, the lines were measured in pixels andthe size of the area was measured in square pixels per linemeasurement and area measurement functions featuredin Adobe Creative Suite 6 software (version 13.0.1; AdobeSystems, Inc., San Jose, CA). In this study, because the dis-tance between the tips of opposing vocal processes on vocalfold adduction appeared relatively stable and constantthroughout each laryngoscopic examination, it was considereda feasible reference for calibration (Figure 1). Among 30 lar-yngoscopic images in each examination, the image containingthe smallest glottal gap was selected as the benchmark im-age, and on this image, the intervocal process distance wasused as a calibrating yardstick, and the corresponding GGS(measured in area pixels) was counted as one basic unit. Theglottal gap areas shown on the remaining 29 images (ie, target

chmark image, and right is a target image. RVP, tip of the right vocal

istance (in pixels); GG, glottal gap; dashed line area, glottal gap size

formula:

ences in the performance effort between therapy sessions andpretreatment/posttreatment assessments, one-way analysis ofvariance (ANOVA) was performed for between-session com-parisons and paired samples t tests were conducted forpretreatment-posttreatment comparisons.

RESULTS

Laryngeal configurationAll parameters pertaining to vocal fold status demonstrated dis-cernible improvements after therapy. Both subjects exhibited re-duced concavity of the vocal fold edges after treatment. Inresponse to the treatment, both subjects showed a marked de-crease of GGS, reducing from a small-to-moderate linear or fusi-form gap to a minute anterior slit, which at times alternated withcomplete or near-complete glottal closure. Positive changes of

Journal of Voice, Vol.-, No.-, 20136Normalized GGS (in unit) [(IVPD of the target image)/(IVPD of the benchmark image)]3[(GGS of the targetimage)/(GGS of the benchmark image, counted as 1 unit)]

In addition, the occurrence rate of glottal closure was alsoroughly estimated by tallying the number of video imagesshowing complete glottal contact during a vibratory cycle (mea-sured in percent).

Phonatory function measurement. Three phonatoryfunction measures, that is, vocal intensity, MPT, and pitchrange, were obtained at pretreatment and posttreatment, aswell as during each of the 16 therapy sessions. The level of vo-cal intensity was measured with a RadioShack sound pressurelevel (SPL) meter at 12 inches of mouth-meter distance whenthe subject performed four groups of speech tasksmaximumphonation of vowel /a/, functional speech, oral readings of sen-tences or paragraphs, and running speech (eg, off-the-cuff ques-tions, word generation, or conversation). MPT and pitch rangewere measured by using the Real-Time Pitch program (model5121; KayPENTAX).

Acoustical analyses. The 5-second voice samples of sus-tained vowel /a/ obtained before and after treatment were ana-lyzed acoustically using the Multi-Dimensional Voice Program(model 5105; KayPENTAX). Numerous acoustic parameterswere selected in analysis for their specific properties measuringthe status of vocal fold adduction and ability of sustaining a pe-riodic and uninterrupted voicing.52 These acoustic features in-cluded fundamental frequency (F0 and F0 standard deviation),perturbation (jitter and shimmer), noise evaluation (harmonic-to-noise ratio and soft phonation index [SPI]), voice break (de-gree of voice break and the number of voice breaks), and voiceirregularity (degree of voiceless segments and the number ofvoiceless segments).

Auditory-perceptual judgment. Voice quality of re-corded voice samples was assessed per a commonly usedperceptual rating system, that is, the Grade, Roughness,Breathiness, Asthenia, Strain (GRBAS) scale.53 Pretreatmentand posttreatment voice samples were rated on five parame-ters in the GRBAS scale: Grade (G) indicated the severityof overall voice abnormality; Roughness (R) representedvoice quality of inharmonic vocal fold vibrations and fluctu-ating fundamental frequency; Breathiness (B) was voice qual-ity with reference to air leakage through the glottis; Asthenia(A) was referred to voice quality of weak vocal loudness; andStrain (S) represented voice quality of tenseness or excess ef-fort indicative of hyperfunctional voice. Each parameter wasscored on a four-point scale with 0 for normal status, 1 formild deviance, 2 for moderate deviance, and 3 for severedeviance.

Data analysisPaired samples t tests were performed for pretreatment andimages) in each examination were then measured against thebenchmark image and normalized according to the followingposttreatment comparisons of GGS. Because of potential differ-

FIGURE 2. Means and standard errors of normalized glottal gapvocal fold coloration andmucosal vibrationwere also noted in re-lation to therapy. Although both subjects vocal folds were ofmild-to-moderate discoloration and dryness with dilated bloodvessels before treatment, they turned paler in color with reducedvasodilation after therapy. Vibratory pattern of the mucosal waveshowed positive outcomes after therapy as well, improving frommoderate deviance to normal or near-normal vibratory character-istics after treatment. It is noteworthy that neither subject ex-hibited vocal trauma or increased laryngeal hyperfunction aftertreatment. Although subject 2 illustrated a mild degree of medialand anterior-posterior compression of supraglottic structures atbaseline, the degree of supraglottic hyperactive behaviors re-mained relatively unchanged after treatment.

Glottal gap measurementBar charts in Figure 2 show normalizedGGSs of both subjects inrelation to therapy. Treatment-related differences in GGS wereanalyzed with paired samples t tests as well. Normalized GGS(in units) in subject 1 was significantly reduced from pretreat-ment (mean, 30.23; range, 9.1470.83; standard error [SE],2.49) to posttreatment (mean, 5.00; range, 1.0017.06;SE 1.06) at t(29) 10.50, P < 0.01. In subject 2, a significantreduction of theGGSwas also observed (t[29] 7.01,P< 0.01),from pretreatment (mean, 42.60; range, 10.7673.08; SE, 2.85)to posttreatment (mean, 20.18; range, 1.0059.03; SE, 3.20). Insize of two subjects before and after treatment.

subject 1 whose acoustic measures in nearly all categorieswere brought to within or close to normal ranges aftertreatment despite markedly deviant features at baseline. Onthe other hand, subject 2 exhibited only mild deviance onsome acoustic features that showed little changes aftertreatment with the exception of noise measures. Values ofnoise measures (ie, harmonic-to-noise ratio and SPI) in bothsubjects were lowered after treatment, which is of particular in-terest to this study because reduced SPI value may be an indi-

FIGURE 3. Mean of SPL (dB) of two subjects at pretreatment, dur-ing 16 therapy sessions, and at 2-week posttreatment. SPL data were

obtained for four speech tasks. Sixteen therapy sessions were denoted

as Pre (pretreatment), 1W1 (first session in the first week), 1W2 (sec-

ond session in the first week), 2-wk Post (2 weeks posttreatment), and

so on. Pretreatment and posttreatment data points were not connected

to the trend line of the treatment session data because of different per-

formance efforts. SPL measures on pretreatment and posttreatment as-

sessments were obtained when subjects performed at a habitual level of

pitch and loudness, whereas the SPL measures during treatment ses-

sions were collected when subjects practiced loudness drill exercises

using the think loud, shout loud strategy. Age-matched normative

values of habitual speaking intensity for males54 are 72.4 4.4 dB

and for females55 are 67.42 2.93 dB.

Fang-Ling Lu, et al Efficacy of LSVT for Presbyphonia 7addition, both subjects showed higher frequencies of completeglottal closure after treatment. Although both subjects had 0%of glottal closure at baseline, subject 1 reached complete glottalclosures at a rate of 20% in a vibratory cycle (ie, 4 of 20 frames)and subject 2 attained complete closures approximately 30% ina vibratory cycle (ie, 8 of 26 frames) after therapy.

Phonatory function measurementData of three phonatory function measures (ie, SPL, MPT, pitchrange) were analyzed using two statistical analysis systems,one-way ANOVA for between-session comparisons and pairedsamples t tests for pretreatment-posttreatment comparisons.

Vocal intensity. One-way ANOVA results indicated signifi-cant SPL changes across treatment sessions on all vocal activ-ities in both subjects (P < 0.05). Rises of SPL were particularlyevident starting the third session of therapy (ie, 1W3) in bothsubjects; the gains remained relatively level throughout the re-maining course of treatment (Figure 3). Results of paired sam-ples t tests revealed significantly higher SPL on all speech tasksafter treatment in both subjects (P < 0.05) (Table 2). The sub-jects SPL measurements rose from an abnormally low levelat baseline to a posttreatment level that has reached the normalranges appropriate for subjects respective ages and genders.

Maximum phonation time. Although both subjectsshowed significant differences in MPT across treatment ses-sions (P < 0.05), only subject 1 exhibited a slow and steady in-crease over time (Figure 4). Table 2 illustrates that subject 1 hada significant gain in MPT (P < 0.05) that reached normal limitsafter treatment. In contrast, subject 2 showed remarkably longMPTat baselinewhich, unsurprisingly, remained unchanged af-ter treatment (P 0.80).Pitch range. Figure 5 shows changes of three pitch range-related elementsthe highest and lowest attainable pitchlevels and the pitch range (in hertz)of both subjects overtime. Results of ANOVA and t tests (Table 2) indicate signif-icant increases in the course of treatment in both subjects innearly all aspects of pitch range (P < 0.05) except for the low-est attainable pitch level in subject 2 (P 0.78). Significantrises of the highest attainable pitch level and correspondingincreases of the pitch range were observed starting the fifthsession of therapy in subject 1 and the first session of therapyin subject 2. When the pitch range was converted to semitones(ST), the pitch range value of subject 1 improved from 20.5ST to 27.5 ST after treatment, whereas the pretreatment STof subject 2 was 16.1 and posttreatment STwas 40.3; the pitchrange of both subjects reached or rose above normal rangesafter treatment.

Acoustical analysesTable 3 displays the results of acoustical analysis on sustainedvowel phonation along with normative data for compari-sons.28,52 Statistical analysis of acoustic data was unattainablebecause of limited data points. However, posttreatmentchanges were noticed in most acoustic measures, suggestingincreased glottal competence and phonatory control after

treatment. Positive changes were particularly evident in cation of stronger vocal fold adduction.

etrea

/a/ phonation 65.17 (7.36) 5170

1117

Journal of Voice, Vol.-, No.-, 20138Functional speech 65.61 (3.79) 5370Reading 64.92 (3.49) 5270Running speech 60.29 (3.95) 5468

MPT (s) 8.19 (2.38) 5.5010.04Pitch range (Hz)Highest pitch 342.45 (28.10) 322.58396.83Lowest pitch 103.20 (28.73) 81.83135.86Range 257.38 (65.13) 186.72315.00

Subject 2Vocal intensity (dB)/a/ phonation 75.15 (3.32) 6780Functional speech 64.16 (2.70) 6069Reading 65.10 (3.10) 6071Running speech 58.96 (4.07) 5068TABLE 2.Means and SDs of Phonatory Function Measurement at PrPaired Samples t Tests

Measures

Pretreatment

M (SD) Range

Subject 1Vocal intensity (dB)Auditory-perceptual judgmentsThe pretreatment voice quality of subject 1 was perceived ashoarse, breathy, weak and of shortened phrasing, which wasrated on the four-point GRBAS scale as Grade (2), Roughness(1), Breathiness (2), Asthenia (2), and Strain (0), with 0 beingnormal to 3 being extremely deviant. Her voice quality aftertreatment was perceived to be relatively normal with just a traceof breathiness and was rated as G1R0B1A0S0. The voice qualityof subject 2 before therapy was characterized as hoarse,breathy, weak, and slightly shaky, which was rated asG2R2B2A2S0. His posttreatment voice quality was perceivedas mildly hoarse and shaky and was rated as G1R1B1A0S0.

DISCUSSIONThe present study supported efficacy of the LSVT for rehabili-tating hypofunctional voice associated with age-related vocalfold atrophy and bowing. In this study, two subjects demon-strated evident post-LSVT improvement in every aspect of vo-cal function, including glottal closure (ie, GGS and glottalclosure rate), coloration and mucosal vibration of the vocalfolds, phonatory function, acoustic features, and perceptualvoice quality. In subject 1, nearly all measures reached norma-tive ranges after treatment despite much pervasive glottal gap

MPT (s) 27.50 (10.79) 1237Pitch range (Hz)Highest pitch 389.81 (10.63) 378.79400.00 9Lowest pitch 83.86 (12.88) 72.8998.04Range 305.95 (18.54) 292.59327.11 8

Abbreviation: SDs, standard deviations.* Analysis of variance test: p < 0.05.tment and Posttreatment Assessments and Results of

PosttreatmentStatistical Results

(Two Tailed)

M (SD) Range t Values P Values

87.02 (4.43) 7097 5.82

Fang-Ling Lu, et al Efficacy of LSVT for Presbyphonia 9FIGURE 4. Means of MPT of two subjects at pretreatment, during16 therapy sessions, and at 2-week posttreatment. Sixteen therapy ses-

sions were denoted as Pre (pretreatment), 1W1 (first session in the first

week), 1W2 (second session in the first week), 2-wk Post (2 weeks

posttreatment), and so on. Pretreatment and posttreatment data points

were not connected to the trend line of the treatment session data be-

cause of different performance efforts. MPT measures on pretreatment

and posttreatment assessments were obtained when subjects performed

at a habitual level of pitch and loudness, whereas the MPT measures

during treatment sessions were collected when subjects practiced

MPT drill exercises potentially under the influence of loud speaking

behavior. Age-matched normative values of MPT (in seconds) for

males25 are 18.0 6.0 and for females55 are 20.57 8.51.and thus increase glottal closure. The LSVT programspecifically focuses on vocal activities including vocalintensity and pitch, which are two vocal parameters thatpredictably demand greater lung pressure and glottalresistance.57,58 Consequently, the individuals would acquiregreater respiratory drive and stronger contraction of laryngealmuscles, such as thyroarytenoids and cricothyroids, whenthey undergo the LSVT training program.3,30,5962 Bothsubjects in the present study demonstrated decreased vocalfold bowing and reduced glottal gap after treatment. In fact,normalized GGS decreased 83% (from 30 to 5 units) insubject 1 and 84% (from 43 to 7 units) in subject 2 when thetherapy was concluded, and the glottal closure rate pervibratory cycle rose from zero to 20% in subject 1 and from0% to 30% in subject 2 after treatment; normally, each glottalcycle has an opening/closing phase at 67% and a closedphase at 33%.6368 However, both glottal closure measuresobtained in the study should be viewed with great caution andnot to be compared with normative data that were collectedwith more sophisticated technology. This is because of thefact that one of several limitations of videostroboscopypertains to its low sampling rate, about 3035 frames persecond, which is too low to capture individual cycles of vocalfold vibration for precise measurement of glottal closure.69,70

Nonetheless, with the stringent measurement protocol appliedin this study, the glottal closure measures obtained in bothsubjects provide valid within-subject comparisons to determinethe treatment effect. Our strobolaryngoscopic findings also in-dicated positive changes pertaining to mucosal appearanceand vibration of the vocal folds after the LSVT. After treatment,discoloration, dryness, and hyperemia observed at baseline no-tably diminished, and the mucosal vibration approached a near-normal pattern in terms of amplitude and periodicity. Althoughsubjects in the present study did not develop any vocal fold le-sion or an increase of hyperfunctional laryngeal behavior afterthe LSVT, LaGorio et al47 in fact reported reduced supraglotticcompression in their subjects with vocal fold bowing aftera combined NMES and 14-step vocal exercises treatment. It

FIGURE 5. Means of the highest and lowest pitch levels of two sub-jects at pretreatment, during 16 therapy sessions, and at 2-week post-

treatment. Sixteen therapy sessions were denoted as Pre

(pretreatment), 1W1 (first session in the first week), 1W2 (second ses-

sion in the first week), 2-wk Post (2 weeks posttreatment), and so on.

Note that subject 2 had missing data for 7 of 18 recording sessions

(1W3, 1W4, 2W4, 3W2, 3W3, 3W4, 4W4) because of lost records.

The lightly shaded marker on each vertical line represents the highest

attainable pitch, and the black marker represents the lowest attainable

pitch. Pretreatment and posttreatment data points were not connected

to the trend line of the treatment session data because of different per-

formance efforts. Pitch glide measures on pretreatment and posttreat-

ment assessments were obtained when subjects performed at

a habitual loudness level, whereas the pitch glide measures during

treatment sessions were collected when subjects practiced pitch glide

drill exercises potentially under the influence of loud speaking

behavior.

rem

P

Journal of Voice, Vol.-, No.-, 201310is thought that a reduced amount of supraglottic hyperactivitymay be associated with improvement of glottal closure, indica-

TABLE 3.Means of Pretreatment and Posttreatment Acoustic Measu

Acoustic Measurements

Subject 1

Pre-LSVT Post-LSVT

Fundamental frequencyF0 (Hz) 229.10 248.43

F0 standard deviation (Hz) 14.49 3.81

PerturbationJitter (%) 3.12 0.51

Shimmer (dB) 0.81 0.51

Noise evaluationHarmonic-to-noise ratio 5.00 8.85

SPI 23.75 3.03

Voice breakDegree of voice break (%) 9.90 0No. of voice breaks 6 0

Voice irregularityDegree of voiceless (%) 25.53 1.13No. of unvoiced segments 33 5tive of positive effects from voice intervention on laryngealfunction.71

The evidence of improved glottal closure in both subjectsseems to be congruent with the changes in numerous acousticparameters, such as SPI or voice break, that are supposedly in-dicative of firmer vocal fold adduction and improved ability tosustain a steady and uninterrupted voice. Unfortunately, thedata points collected in the present study were insufficient foran in-depth acoustical analysis and could only render us a tenta-tive conclusion regarding the effect of the LSVT on acousticvoice features associated with presbyphonia. However, our re-sults indicated LSVT effectiveness on vocal fold adductionand vocal efficiency, as evidenced by improved phonatory func-tion and perceptual voice quality. In addition to obviousimprovements in vocal intensity, MPT, and pitch range, theGRBAS rating also demonstrated improvement in both subjectsafter treatment. Extensive research evidence reported in theliterature supports the efficacy of the LSVT for treating vocal in-competence in speakers of neurogenic communication disor-ders,61,72,73 and the regimen manifests the same effects in bothindividuals with presbyphonia in this study. Cumulativeevidence thus far affirms that intensive behavioral voicetherapy alone, namely the LSVT program, could be a cost-effective approach for rehabilitating dysphonia related topresbylaryngis. In spite of unequivocal therapeutic benefits ofelectrical muscular stimulation for strengthening limb mus-cles,7476 the benefit of using NMES alone for treating glottalincompetence remains debatable. A closer examination ofseveral treatment outcome studies indicates that NMES mayenhance vocal function improvement if applied in conjunction

ents

Subject 2 Age-Matched Norms*

re-LSVT Post-LSVT Norms of All Ages

165.11 170.06 Female* 183.4 31.928

Male* 144.9 34.628

4.75 4.84 Female* 5.2 3.228

Male* 10.3 8.128

0.94 0.73 Female* 1.15 0.8228

Male* 1.4 1.1128

0.12 0.12 Female* 0.3 0.1528

Male* 0.56 0.3928

6.06 7.09 Female* 9.57 5.3128

Male* 3.61 5.3428

9.79 4.54 Female 7.53 4.1352

Male 6.77 3.7852

0.05 0 Female/male 0.2 0.152

1 0 Female/male 0.2 0.152

1.37 2.54 Female/male 0.2 0.152

15 14 Female/male 0.2 0.152with behavioral therapy such as effortful swallowingtechnique,77 14-step vocal exercises,47 or unspecified vocal ex-ercise78 per daily treatment schedule, but there is no conclusiveevidence confirming the significance of NMES alone in voicetherapy.Despite the promising treatment outcomes of the LSVT for

speech and voice dysfunction of various etiologies, the mainchallenge of implementing the program in clinical settingslies in the accessibility issue. The demand of delivering thetreatment in daily in-person treatment sessions over a 4-week period is unfeasible for clients who have mobility andgeographic barriers and for clinicians who have heavy work-loads. Fortunately, the continuing efforts for developingmore and varied ways of service delivery offer potential solu-tions to meeting the needs of both patients and clinicians andto reaching a greater number of clients who can benefit fromthe treatment. The LSVT administered with an alternativetreatment schedule, that is, 16 treatment sessions deliveredover 2 months instead of 1 month, appeared equally effectiveas the original protocol.79 The use of online delivery of theLSVT via videoconferencing was also proven to be clinicallyvalid and reliable for treating the PD patients.7483

Furthermore, a recently developed assistive treatment system(ie, LSVT Companion), which allows the client to receivehalf of the LSVT sessions at home, also achieved similartreatment gains as the standard LSVT in a study by Halpernet al.84 The recent exploration of innovative technologyindeed offers alternative means for delivering the LSVT in

However, it is a reasonable assumption that the LSVT has equi-

20. Mau T, Jacobson BH, Garrett CG. Factors associated with voice therapy

outcomes in the treatment of presbyphonia. Laryngoscope. 2010;120:

Fang-Ling Lu, et al Efficacy of LSVT for Presbyphonia 11valent long-term effect on vocal function related to presbyphoniaas it does onPD.61,79,85Despite the aforementioned shortcomingsof the study, the results clearly show the potential of the LSVTregimen in treating glottal incompetence and hypofunctionalphonation.

CONCLUSIONThe results of our investigation show significant post-LSVT im-provement on glottal closure, phonatory function, acousticvoice features, and perceptual voice quality in two subjectswith presbyphonia. This study provides objective and subjec-tive outcome measures in support of intensive exercise-basedbehavioral therapy as an effective therapeutic approach for re-habilitating aging vocal folds. In the present study, methodicaldata collection and analysis were conducted for pretreatmentand posttreatment comparisons as well as the progress of pho-natory function in the course of therapy.Future investigation of the LSVT using a larger number of

elderly treatment-seeking and normal control subjects is war-ranted. Advanced instrumental measurements should also beused to investigate underlying changes of respiratory andphonatory functions in response to the LSVT. Additionally,future studies should include short-term and long-term fol-low-ups to determine sustainability of treatment-related im-provements associated with presbyphonia, even with speakerswith recurrent laryngeal nerve paralysis who also exhibithypofunctional voice. Finally, concurrent application ofNMES during the LSVT has merits for future investigation todetermine if adjunctive electrical muscular stimulation mayexpedite treatment progress or bolster long-term sustainabilitya cost-effective and feasible manner, which can also be seen asa motivational factor for the individuals who can benefit fromvoice therapy to seek treatment.It is recognized that the present study has several limitations.

With only two subjects, caution must be taken when generaliz-ing the results of this study to a broader treatment-seeking pop-ulation of presbyphonia. We recommend that future studiesinclude larger group comparisons (control group or NMESgroup) with inferential statistics and include an addition ofquality of life measures, such as voice-related quality of lifeor Voice Handicap Index. We also recommend that future stud-ies include visual and auditory evaluations of voice performedby an examiner blind to treatment conditions (before and after)or subject group. Given technological limitations of videostro-boscopy that do not allow detailed evaluation of the vocal foldsdynamic behavior, future studies should consider using moresophisticated technology or additional analyses, for example,videokymography, electromyography, electroglottography, ortransglottal airflow measure, to offer precise measurement ofvocal fold adduction or glottal closure during vocal fold vibra-tion. Furthermore, the present study did not conduct follow-upassessments beyond 2 weeks after treatment, thus it remains un-answered if positive gains from the LSVT could be sustained inspeakers with presbyphonia months or years after treatment.of improvements.11811187.

21. Biever D, Bless D. Vibratory characteristics of the vocal folds in young and

geriatric women. J Voice. 1989;3:120131.

22. Baken RJ. The aged voice: a new hypothesis. J Voice. 2005;19:317325.

23. HartmanD, Danhauer J. Perceptual features of speech for males in four per-

ceived age decades. J Acoust Soc Am. 1976;59:713715.

24. Lundy D, Silva C, Casiano R, Lu F, Xue J. Cause of hoarseness in elderlyAcknowledgmentsEquipment funding for this project was provided by the Re-search Infrastructure Grant from the University of North Texas.The authors thank Martha Norwood and Tiffanie Klement fortheir assistance in data collection.

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Fang-Ling Lu, et al Efficacy of LSVT for Presbyphonia 13

Efficacy of Intensive Phonatory-Respiratory Treatment (LSVT) for Presbyphonia: Two Case ReportsIntroductionMethodParticipantsSubject 1Subject 2

Voice diagnostic assessmentVoice treatmentTreatment outcome measurementStrobolaryngoscopic evaluation of laryngeal configurationGlottal gap measurementPhonatory function measurementAcoustical analysesAuditory-perceptual judgment

Data analysis

ResultsLaryngeal configurationGlottal gap measurementPhonatory function measurementVocal intensityMaximum phonation timePitch range

Acoustical analysesAuditory-perceptual judgments

DiscussionConclusionAcknowledgmentsReferences