Journal of the Neurological Sciences 383 (2017) 180–187

Contents lists available at ScienceDirect

Journal of the Neurological Sciences

journal homepage: www.elsevier.com/locate/jns

Effect of Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and T

cough in Parkinson's disease: A pilot study
⁎
Anna Milesa, , Marie Jardinea, Felicity Johnstona, Martin de Lislea, Philippa Friarya,
Jacqui Allena,b
a
The University of Auckland, New Zealand
b
Waitemata District Health Board, Auckland, New Zealand

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Lee Silverman Voice Treatment (LSVT LOUD®) is an effective therapy for phonation in Parkinson's
LSVT LOUD® Disease (PD) but little is known about any additional spread of effects to swallowing and cough function. This
Dysphagia pilot study examined the effect of LSVT LOUD on pharyngeal swallowing parameters and reflexive cough
Swallowing strength.
Voice
Methods: Twenty participants (14 men, 6 women; mean 68 years, SD3.5) with PD referred for LSVT LOUD with
Parkinson's disease
complaints of voice deterioration were recruited. Mean duration of PD was 6 yrs., SD 3. Self-reported Eating
Cough
Assessment Tool-10 scores ranging from 0 to 25 (normal < 3). Prior to LSVT LOUD, 1-week post- and 6-months
post-treatment, participants undertook a videofluoroscopic study of swallowing and aerodynamic measures of
involuntary cough.
Results: All participants completed the LSVT LOUD programme; 3 participants were lost to follow-up at 6-
months. All participants made significant gains in average sound pressure level (dB SPL). Aspiration was not
observed. Pharyngeal residue (p < 0.05) and pharyngeal area at rest reduced (p < 0.01) while maximal
opening of pharyngoesophageal segment (PES) (p < 0.05) and PES opening duration (p < 0.05) significantly
increased. There was a significant improvement in involuntary cough peak expiratory flow rate and peak ex-
piratory flow rise time. All changes were maintained at 6-months.
Conclusion: LSVT LOUD demonstrates additional spread effects on pharyngoesophageal deglutitive function and
involuntary cough effectiveness in people with mild PD referred with voice complaints. Consequently, LSVT
LOUD has potential to provide additional benefits for swallowing safety and efficiency in this patient group.

1. Introduction presence of dementia [3]. In instrumental studies, using videofluoro-

The leading cause of death in people with Parkinson's disease (PD) is
aspiration pneumonia associated with the presence of dysphagia and/or
dystussia [1]. Unfortunately, although the traditional therapies for PD
such as medications and implantable deep brain stimulation have been
hugely beneficial for the limb motor aspects of PD, they are largely
ineffective in assisting speech, swallowing and cough [2]. The recorded
frequency of swallowing abnormalities in people with PD varies greatly
depending on the assessment approach. In self-reported survey-based
studies, the prevalence of symptoms is around 12%, with increased
symptoms associated with older age, time since PD diagnosis and
scopy or fiberoptic endoscopic evaluation of swallowing, presence of
swallowing abnormalities reaches as high as 80% [4]. PD frequently
results in rigidity and bradykinesia of tongue movement during the oral
phase of swallowing [5,6] as well as deficits of pharyngeal transit,
upper esophageal sphincter (UES) opening and esophageal dysmotility
[7].
Dysphagia is associated with malnutrition [8], dehydration [9],
pneumonia [10], increased length of hospital stay [11], increased in-
cidence of medication errors [12] depression and anxiety [13] and
death [10]. Swallowing impairment leads to food and drink being as-
pirated into the lungs. Dystussia makes clearing food, drink and

Abbreviations: VFSS, videofluoroscopic study of swallowing; TPT, Bolus transit time [total pharyngeal transit time; AEdur, airway closure duration maximum; Hdur, hyoid displacement
duration; AEcl-BP1, airway closure time (AEcl) in relation to bolus reaching PES (BP1); PESdur, pharyngoesophageal sphincter (PES) opening duration; PAhold, pharyngeal area at rest;
Hmax, maximum hyoid displacement; HL, hyoid-larynx displacement; PESmax, maximal opening of the pharynoesophageal sphincter; PCR, pharyngeal constriction ratio; CPD, com-
pression phase time; PEFR, peak expiratory flow rate; PEFRT, peak expiratory flow rise time; CVA, cough volume acceleration; EMST, expiratory muscle strength training
⁎
Corresponding author at: School of Psychology, Tamaki Campus, The University of Auckland, Private Bag 92019, Auckland, New Zealand.
E-mail address: a.miles@auckland.ac.nz (A. Miles).

https://doi.org/10.1016/j.jns.2017.11.015
Received 30 May 2017; Received in revised form 23 October 2017; Accepted 14 November 2017
Available online 15 November 2017
0022-510X/ © 2017 Elsevier B.V. All rights reserved.
A. Miles et al.
secretions from the lungs difficult. Diminished cough strength is
common in neurological disease [14,15]. People with PD present with
impaired somatosensory function, which is demonstrated in clinical
assessment by uncoordinated airway closure during swallowing, altered
laryngeal sensitivity, reduced cough reflex thresholds and weaker re-
flexive cough [16,17]. A recent study used quantitative swallowing
measures during Videofluoroscopic Study of Swallowing (VFSS) to
identify swallowing abnormalities in PD. The most prevalent were de-
layed airway protection and reduced pharyngeal constriction [18,19].
Lee Silverman Voice Treatment (LSVT LOUD®) is a popular voice
therapy proven to improve loudness in people with PD up to two years
after treatment [20–22]. The success of LSVT LOUD has been attributed
to its intensive and high-effort speech exercises. Although it primarily
targets loudness, system-wide effects to the sensorimotor speech system
occur including improvements in speech intelligibility, facial expres-
sion, breath support, and voice quality [23]. LSVT LOUD involves 16
treatment sessions (four sessions per week for four weeks) as well as
daily home practice. Exercises include prolonged vowel phonation with
increasing volumes and changing pitch, functional words and phrases
with increasing volumes. Throughout the 16 sessions, participants
progress through a systematic hierarchy of speech exercises beyond
words and phrases and into conversation and ‘outside of the therapy
room’ carryover tasks. Ongoing instrumental feedback regarding pitch
and loudness is provided throughout therapy. There is a focus on sen-
sory recalibration as participants are supported to build a new effort
and intensity level for normal loudness [23,24]. LSVT LOUD clinicians
encourage their patients to continue practice daily beyond the therapy
block.
There is good scientific logic to suggest that people who undergo
LSVT LOUD will also make gains in swallowing and cough function.
Evidence for a shared neurological network comes from a recent PET
study of patients after LSVT LOUD where right anterior insular cortex
changes were significant [25]. Early PET studies of voluntary swal-
lowing in healthy adults show the primary sensorimotor cortex, right
anterior insular cortex and brain stem all strongly activated during
voluntary swallowing [26]. More recently, Narayana and colleagues
extended this work and using Hs15O-positron emission tomography
found a shift in cortical activity to the right hemisphere following LSVT
LOUD [27]. The developers of LSVT LOUD propose that vocal loudness
and sensory recalibration is a trigger for recalibrating the whole sen-
sorimotor process and targets inadequate muscle activation of the same
motor system involved in swallowing [23]. One previous pilot study
with eight participants demonstrated a positive effect of LSVT LOUD on
oropharyngeal transit time and oral residue with a 51% reduction in the
number of swallowing deficits found on videofluoroscopy [28]. The
authors suggest that LSVT LOUD may have an overall effect on the
aerodigestive tract and may benefit those with swallowing as well as
voice and speech difficulties [23,24].
Given the poor response to pharmacological and surgical treatment
of swallowing deficits in PD, alternative interventions are needed. A
non-invasive solution already readily available has potential to benefit
the greatest number of people with PD. LSVT LOUD works on overall
pharyngolaryngeal effort including respiratory drive, vocal cord ad-
duction and lingual function [23] – all required in swallowing as well as
speech acts (Fig. 1).
The aim of this pilot study was to investigate the additional spread
effects of LSVT LOUD on deglutition by measuring quantitative swal-
lowing and cough parameters in a group of patients referred for voice
treatment. The study's primary hypothesis was pharyngeal timing and
displacement measures will improve after LSVT LOUD even in patients
with no self-reported swallowing difficulties. Secondary hypotheses
were i) participants will perceive improvements in swallowing and
Parkinson's disease symptoms after LSVT LOUD, ii) expiratory cough
measures will improve after LSVT LOUD, and iii) swallowing and cough
improvements will be maintained at six-months post-LSVT LOUD even
in patients with no self-reported swallowing difficulties.
181
Journal of the Neurological Sciences 383 (2017) 180–187
2. Methods
2.1. Participants
Twenty people with PD participated in this prospective non-ran-
domized single-blinded cohort intervention study. The study received
appropriate ethical approval (HDEC 14/STH/123) and all participants
provided written, informed consent. A power calculation was com-
pleted and 13 participants were required to detect a change of more
than one standard deviation (SD) in swallowing ability. This was de-
termined using the measurement of maximum displacement of the
pharyngoesophageal segment (PESmax) (see measures in [29]) to es-
tablish population size needed to achieve 80% power and an alpha level
of α = 0.05. Allowing for an attrition rate of 15%, recruitment of 20
participants was estimated. All individuals with PD presenting to a
speech-language pathologist in the Auckland Region between July 2015
and January 2016 with vocal deterioration, who met the inclusion
criteria for LSVT LOUD, were invited to participate in the study. No
further inclusion criteria were set so that participants represented
people commonly completing LSVT LOUD including adequate motiva-
tion, cognition and hearing, logistic ability to attend the full pro-
gramme, and a laryngologist assessment reporting no contraindications
to treatment. Exclusion criteria included no comorbidity affecting
swallowing.
2.2. Study design
Demographic and medical information were collected: age, gender,
time since PD onset, other medical history, medications, other con-
current activities and Unified Parkinson's disease rating scale (UPDRS)
(0 = no disability, 199 = worst disability) scores [30]. Participants
completed assessments at three time points i) prior to commencing
LSVT LOUD, ii) one week after LSVT LOUD and iii) six months after
LSVT LOUD. These assessment sessions were conducted by authors not
involved in the participants' LSVT LOUD treatment. LSVT LOUD treat-
ment sessions and the three quantitative assessments were conducted at
approximately the same time of day in order to avoid on/ off medica-
tions effects. Participants were all in an ‘on’ state for treatment and
assessments. At each time point, participants received a VFSS, under-
took quantitative peak airflow measures of reflexive cough, undertook
speech measures as per LSVT LOUD protocol, rated the Parkinson's
disease Questionnaire (PDQ-8) [31] and the Eating Assessment Tool-10
(EAT-10) [32], and reported any changes in medications, physical ac-
tivities/therapies or medical status.
2.3. LSVT LOUD protocol
LSVT LOUD programmes were administered as per protocol in six-
teen sessions across four weeks by five certified LSVT LOUD clinicians
(two of the authors and three community-based speech-language pa-
thologists). Sixteen of the treatments were carried out by two authors
who had two and five years of experience in LSVT LOUD; while com-
munity clinicians with three - six years experience in LSVT LOUD
completed the other four treatments. Each participant completed their
full LSVT LOUD programme with the same treating clinician. At the end
of treatment, LSVT LOUD clinicians were asked to subjectively rate
each client on a scale of 1–5 on motivation and commitment during the
programme (1 = not at all motivated; 5 = extremely motivated).
2.4. Self-rated questionnaires
EAT-10 and PDQ-8 surveys were completed independently by par-
ticipants. The PDQ-8 scores range from 0 to 40 but are standardized out
of 100 with 100 representing greatest severity. The EAT-10 scores range
from 0 to 40 with any score over 3 considered abnormal.
A. Miles et al.
2.5. Acoustic speech protocol
Speech measures were taken as per the LSVT LOUD standardized
protocol: sustained vowel (/a/), maximum phonation time (MPT)
(maximum phonation value recorded of three attempts), average
reading dB SPL (“Rainbow Passage”) and average conversation dB SPL
(2 min) [21,23,33]. A sound level meter (CEL-244 Class 2, Casella) was
calibrated with a CEL-110/2 Acoustic calibrator, and was placed on a
tripod 30 cm away from the participant's lips. LSVT LOUD sessions were
conducted in a quiet room in participants' own homes, without back-
ground noise. Voice signals (dB SPL) were recorded throughout each
session and averages were later calculated. Assessors were blinded to
the participants' previous scores.
2.6. Videofluoroscopic study of swallowing
VFSS studies were performed in a radiology suite using a
Videofluoroscope (DF-323H, Toshiba, Japan) and were recorded at 30
frames per second onto USB drive. Timing information was super-
imposed on the fluoroscopic recording in 100ths of a second using a
Horita VS-50 Video Stopwatch (Horita, California USA). A 20 mm
diameter radio-opaque ring was taped to the patient's chin (in the lat-
eral plane) and shoulder (in the anterior-posterior plane) to allow ca-
libration for displacement measures. A Medical Radiation Technician
(MRT) and an experienced speech-language pathologist participated at
all procedures. In the lateral plane, the patient was presented with
20 ml of thin liquid barium (E-Z Paque 96% w/v diluted to 19%) fol-
lowed by 100 ml of thin liquid barium through a straw with the in-
struction “drink the whole cup in your own time but without stopping”.
The participant was then given 5 ml of barium paste (E-Z-paste 60%w/
w). The same sequence was administered during VFSS per participant.
Bolus textures and volumes were trialled once and used so that mea-
sured data could be compared to previously published normative data
[29,34]. These also represent commonly swallowed texture con-
sistencies as produced by mastication of foodstuffs. Screening captured
the oral cavity, pharynx, upper esophagus and upper airway. Studies
were truncated if significant aspiration or coughing occurred. No
prompting was provided to swallow or cough during the protocol. In
the anterior-posterior plane, the participant was positioned standing
and asked to “swallow all in one go” (to avoid deglutitive inhibition) a
20 ml bolus. The bolus was followed from the oral cavity through to the
lower esophageal sphincter. Screening was continued for up to 15 s. If
there was still residue in the esophagus, screening was ceased for 15 s,
then recommenced for another 15 s. If residue was still present, the
182
Journal of the Neurological Sciences 383 (2017) 180–187
Fig. 1. Physiological changes after LSVT LOUD.
participant was asked to perform a dry swallow to see if clearance oc-
curred. At 60 s, screening was terminated irrespective of presence of
residue to limit radiation exposure in keeping with the local policy.
2.7. Aerodynamic protocol
Strength of reflexive cough was calculated using ADInstruments™
Spirometry (Bella Vista, Australia) coupled to a nose covering face-
mask with a side delivery port linked via a one-way valve to a
PulmoMate Nebuliser model 4650I (DeVilbiss Healthcare LLC,
Pennsylvania, US). LabChart™ software from ADInstruments™ recorded
cough flow parameters. Reflexive cough was elicited once using 0.8 M
citric acid [a supramaximal concentration expected to trigger a re-
flexive response in the majority of adults [35]], vaporized through the
mask with the instruction “cough if you need to”. The nebulizer was
stopped after three successive coughs or after 30-s if no cough occurred.
2.8. Quantitative measures
All measures were completed by one of two authors who were not
involved in the participants' LSVT LOUD programme. Both authors
were experienced in aerodynamic and videofluoroscopic quantitative
measures. They were given all de-identified data at the end of data
collection and were blinded to participant and time point.
Each videofluoroscopic study of swallowing was analysed using
‘Swallowtail’ [Version 1 (2016), BellDev Medical, IL]. Each swallow
was rated using the eight-point penetration-aspiration scale where
1 = no penetration/aspiration and 8 = aspiration below the vocal
cords with no attempt to clear [36]. Residue was measured as flat
surface area of residue (using 1st frame after epiglottis returns to rest
position) using the area measuring tool in Swallowtail. Swallow studies
were measured quantitatively using validated parameters (Table 1)
derived from the protocol published by Leonard and Kendall [29].
These parameters have proven sensitive to subtle changes in swal-
lowing physiology in both healthy and dysphagic subjects [37,38].
Twenty-percent of VFSS videos were randomly selected using a random
number generator for measurement by a second rater. Inter-rater re-
liability across all measures was strong [ICC (3,1) > 0.85] [39].
Cough recordings were measured on the first cough in the reflexive
cough sequence (Table 2) [40]. Twenty-percent of cough recordings
were randomly selected using a random number generator for mea-
surement by a second rater. Inter-rater reliability across all measures
was strong [ICC (3,1) > 0.95] [39].
A. Miles et al. Journal of the Neurological Sciences 383 (2017) 180–187

Table 1 LOUD and six months post-LSVT LOUD for each dependent variable
Oropharyngeal measures of timing, displacement, and area [29]. using an adjusted p value (adjusted alpha level = 0.05/5 repeated
tests = 0.025) given the repeat testing. Where assumptions were vio-
Measure Description
lated, Friedman test was used with post hoc analysis using Wilcoxon
Bolus transit time (seconds) signed-rank test.
B1 Onset of bolus transit Associations between motivation scores and acoustic speech mea-
BP2 Tail of bolus clears UES
sures were calculated using Spearman's Correlation (2-tailed) test re-
Total pharyngeal transit time BP2 – B1
(TPT) Total time of bolus passage through ported with means and standard deviations.
the pharynx Two-way mixed, single measures intra-class correlation coefficients
Swallow gesture times (seconds) for absolute agreement (ICC3,1) were used to calculate the intra- and
AEs Airway begins to close inter-rater reliability of the experienced raters. The Cicchetti inter-
AEc Airway is closed
pretation of ICC estimates was used to determine the strength of
H1 First movement of hyoid towards
displacement agreement: poor (0.00–0.39), fair (0.40–0.59), good (0.60–0.74), and
H2 Hyoid is maximally displaced excellent (0.75–1.00) [39].
H3 Hyoid begins to return to resting
position
3. Results
Pop UES first opens
PESmax UES is at its maximum opening
Pcl UES closes Twenty participants with PD received LSVT LOUD treatment (14
Em Epiglottis returns to upright position male; mean 69 yrs., SD9.0, range 50–83; 6 female; mean 64.5, SD8.7,
Airway closure duration (AEdur) Em – AEc range 49–76). Mean UPDRS was 25, range 9–48, SD11 with a mean
Total time airway is closed during
duration of PD of 6 yrs., range 1–15, SD 3. All participants took med-
the swallow
Pharyngoesophageal sphincter (PES) Pcl – Pop ications for their PD and none had received deep brain stimulation. All
opening duration (PESdur) Total time UES is open during the participants were assessed pre- and one week post-LSVT LOUD; three
swallow participants were lost to follow-up at six-months due to logistics with
Maximum hyoid displacement duration H3 – H2
travel to the radiology suite. All participants reported eating a normal
(Hdur) Total time hyoid is maximally
displaced during the swallow
diet with no modifications to fluids or food; however eight participants
Displacement measures (cm) (40%) scored outside the normal range (> 3 points) on their pre-
Maximum hyoid displacement (Hmax) Distance between hyoid at rest and treatment EAT-10 suggesting some early swallowing disturbances
maximally displaced within the group (Table 3). No changes in medical status, physical ac-
Hyoid-larynx displacement (HLmax) Distance between hyoid and larynx
tivities or medications were reported during the study. No additional
at rest and maximally approximated
Maximal opening of the PES (PESmax) The maximum opening of the UES speech therapy was provided between the LSVT LOUD treatment and
Anatomical measures (cm2) the six-month follow-up. However, all participants had been re-
Pharyngeal area at rest (PAhold) Area of Pharynx at rest commended to continue practising daily as per LSVT LOUD protocol.
PAmax Maximal constriction of pharynx
PAmax/PAhold Pharyngeal Constriction Ratio (PCR)
3.1. Motivation, PDQ-8, EAT-10 and acoustic speech outcomes

Table 2 All participants completed the full treatment programme. Ten par-
Aerodynamic measures [40]. ticipants were given a score of 5 out 5 for their motivation and com-
mitment to their LSVT LOUD programme and homework completion
Measure Description with eight participants receiving a 4 and only two participants receiving
Compression phase duration peak inspiratory flow during the inspiratory
a score of 2. Motivation rating was not significantly associated with
(CPD) phase of the cough speech outcomes: maximum phonation time (MPT) (R = 0.42,
Peak expiratory flow rate (PEFR) peak airflow during the expiratory phase of p = 0.067), average reading dB SPL (R = 0.30, p = 0.20) or average
the cough conversation dB SPL (R = 0.28, p = 0.23).
Peak expiratory flow rise time time from the beginning of the expiratory
There were significant increases in MPT, average reading dB SPL
(PEFRT) phase to the peak expiratory flow
Cough volume acceleration expiratory peak flow/expiratory phase rise and average conversation dB SPL one week post-LSVT LOUD
(CVA) time (p < 0.001). This was maintained six months post-LSVT LOUD for
MPT and average reading dB SPL (p < 0.01) but not average con-
versation dB SPL (p = 0.32). PDQ-8 (p < 0.01) and EAT-10
2.9. Data analyses (p < 0.001) significantly reduced across time with a significant dif-
ference between pre- LSVT LOUD and one week and six months post-
Descriptive statistics were compiled. Data were compared to pre- LSVT LOUD; with no significant change between one week post-LSVT
viously published normative data for videofluoroscopic swallowing LOUD and six months post-LSVT LOUD (Table 4). Of the eight parti-
parameters [29] and voluntary cough parameters [40,42]. Statistical cipants who scored outside of the normal range for EAT-10 pre-treat-
analyses were completed using SPSS Version 23 (SPSS, Chicago, IL). An ment, six participants improved their scores (range of score reduction
Intention-to-treat analysis approach was taken using data from all 3–18), one remained the same, and one scored themselves three points
participants including the three participants lost to follow-up at six- higher than pre-treatment.
months. Missing data points were managed using single mean im-
putation. Each dependent variable, measured at the three time points, 3.2. Videofluoroscopic study of swallowing measures
was analysed using repeated measures ANOVA (with a Greenhouse-
Geisser correction where sphericity assumptions were violated). A No instances of aspiration occurred (all boluses scored 1 on the
p < 0.05 was considered statistically significant for all ANOVA ana- penetration/aspiration scale) consistent with the participants' mild PD
lyses. presentation. Pre-LSVT LOUD, only three swallowing measures were
When the ANOVA was significant (< 0.05), Bonferroni post hoc more than 1SD outside of previous normative data: AEdur, PCR and
tests were completed to determine significant changes between pre- PESmax [29].
LSVT LOUD and one week post-LSVT LOUD and between pre-LSVT While nine participants (45%) had PESmax opening more than 1SD

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A. Miles et al. Journal of the Neurological Sciences 383 (2017) 180–187

Table 3
Participants' demographic information and self-reported Parkinson's disease severity scores.

Age (years) Gender Duration of UPDRS (0 = no PDQ-8 (0 = no impact of EAT-10 (0–3 = normal Working Other activities
PD (years) disability, 199 = worst symptoms, 100 = maximum range, 40 = worse
disability) impact) difficulties)

Participant 1 66 M 5 NA 40 21 Yes Nil

Participant 2 69 M 4 NA 20 2 Retired Gym
Participant 3 69 F 6 48 58 16 Retired Nil
Participant 4 59 M 4 12 7.5 1 Yes Yoga, walking
Participant 5 75 M 6 26 17.5 1 Retired Physio group
Participant 6 67 M 10 39 60 1 Retired Nil
Participant 7 83 M 3 44 57.5 25 Retired Bowls
Participant 8 67 F 4 27 20 3 Retired Choir
Participant 9 69 M 5 11 12.5 7 Retired Gym, boxing
Participant 10 68 F 4 28 20 3 Retired Nil
Participant 11 79 M 3 18 30 0 Retired Nil
Participant 12 50 M 1 17 17.5 12 Retired Physio group
Participant 13 76 F 2 30 40 2 Retired Physio group
Participant 14 58 F 11 14 15 1 Retired Gym
Participant 15 64 M 15 29 37.5 4 Retired Gardening
Participant 16 77 M 6 28 40 19 Retired Physio group
Participant 17 75 M 9 28 27.5 0 Retired Physio group
Participant 18 49 F 3 20 7.5 2 Yes Swimming, gym
Participant 19 59 M 10 9 62.5 0 Retired Nil
Participant 20 79 M 6 35 37.5 18 Retired Nil

Table 4
Self-rating scales and speech outcomes pre-, post- and 6-months post-LSVT LOUD.

Mean, SD p value

Pre- LSVT LOUD Post- LSVT LOUD 6 months post- LSVT LOUD Statistic

PDQ-8 (raw score out of 40) 12.55, 7.11 10.50, 4.82⁎ 10.55, 4.96⁎ F 6.29, p < 0.01
EAT-10 (raw score out of 40) 10.55, 4.95 4.10, 5.31⁎ 4.2, 5.91⁎ X2 18.03 p < 0.001
Maximum phonation time (secs) 13.93, 6.47 17.40, 5.72⁎ 20.74, 14.28⁎ X2 7.15 p < 0.05
Average dB SPL reading 66.16, 4.77 73.71, 5.72⁎ 71.89, 3.68⁎ X2 25.05 p < 0.001
Average dB SPL conversation 65.99, 4.04 71.11, 4.43⁎ 64.6, 17.55 X2 16.69 p < 0.001

⁎
Statistically different from baseline pre-LSVT LOUD.

below the normative data pre-therapy, this had reduced to only three
participants post-LSVT LOUD. There was a significant increase in PES
opening duration and PES maximum opening during ingestion of the
20 ml fluid bolus between pre-LSVT LOUD and one week post-LSVT
LOUD. Improvements were maintained at six months.
There was a significant reduction in residue with the paste bolus
between pre-LSVT LOUD and one week post-LSVT LOUD that was
maintained at six months post-LSVT LOUD (p < 0.05). Only one par-
ticipant had a PCR outside of 1SD from the norm and this did not reach
normal range post-LSVT LOUD. There was a significant decrease in
pharyngeal area (cm2) at rest across time with a significant decrease
between one week post-LSVT LOUD and six months post-LSVT LOUD as
well as between pre-LSVT LOUD and one week post-LSVT LOUD
(p < 0.05) (Table 5).
Although airway closure time (AEdur) between time frames did not
reach statistical significance (p = 0.08), the number of participants
who fell more than 1SD outside of the norm, reduced from seven to one
participant after LSVT LOUD.
4. Discussion
This study assessed the additional swallowing-related effects of
LSVT LOUD in those already attending treatment. Patients were se-
lected based on meeting voice treatment criteria for LSVT LOUD irre-
spective of their swallowing difficulties. Self-reported overall PD
symptoms and self-reported swallowing symptoms improved after
treatment. Data demonstrated significant reduction in pharyngeal area
at rest suggestive of improved overall pharyngeal tone, significantly
improved pharyngoesophageal inlet opening duration and improved
PES opening diameter. These parameters are associated with improved
pharyngeal bolus transit, reduced pharyngeal residue and therefore
reduced post-deglutitive aspiration risk [29]. There was also a sig-
nificant improvement in involuntary cough peak expiratory flow rate
and peak expiratory flow rise time. Most importantly, the improve-
ments documented here were sustained at six months following LSVT
LOUD treatment.
4.1. Swallowing parameters

3.3. Aerodynamic cough measures
All participants produced an immediate multiple cough sequence in
response to the citric acid. A number of participants exhibited abnormal
cough measures pre-treatment with 70% of participants measured to be
more than 1SD outside of the norm for PEFR [42] (Fig. 2).
There was a significant improvement in PEFR and PEFRT but not
CPD or CVA between pre-LSVT LOUD and post-LSVT LOUD (Table 6).
PEFR and PEFRT improvements were maintained at six-months.
LSVT LOUD is a validated therapy for hypophonia. As has been
shown previously, participants in this study achieved greater loudness
and maintained gains after the treatment period [20]. LSVT LOUD is
non-invasive and intensive. Primary treatment aims include improving
respiratory drive to the larynx and recruiting muscles that support
phonation. These activities are also crucial in deglutitive function. One
previous study found improvement in oropharyngeal transit time and
residue following standard LSVT LOUD treatment [28] but evaluated a
small sample size with measures of bolus timing and residue only.

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A. Miles et al. Journal of the Neurological Sciences 383 (2017) 180–187

Table 5
Videofluoroscopic measures pre-, post- and 6-months post-LSVT LOUD.

Measure Mean, SD Statistic p value

Pre-LSVT LOUD 1 week post-LSVT LOUD 6 months post-LSVT LOUD

Single sip (20 ml)

Timing (seconds) TPT 0.76, 0.09 0.82, 0.13 0.79, 0.11 F 1.07 p = 0.37
AEdur 0.72, 0.07 0.61, 0.35 0.72, 0.08 F 1.19 p = 0.08
PESdur 0.44, 0.14 0.48, 0.06⁎ 0.58, 0.07⁎ F 4.11 p < 0.05
Hdur 0.33, 0.13 0.37, 0.12 0.36, 0.12 F 0.17 p = 0.84
AEcl 0.14, 0.08 0.10, 0.05 0.15, 0.05 F 1.89 p = 0.20
20 ml fluid esophageal transit time 14.20, 20.34 6.57, 2.79 8.26, 2.28 F 0.656 p = 0.46
Displacement PESmax (cm) 0.54, 0.20 0.68, 0.15⁎ 0.73, 0.17⁎ F 3.87 p < 0.05
Hmax(cm) 1.70, 0.55 1.57, 0.61 1.83, 0.37 F 0.34 p = 0.72
HL (cm) 0.92, 0.39 0.77, 0.50 0.62, 0.48 F 0.52 p = 0.61
PCR (cm2) 0.04, 0.04 0.06, 0.07 0.06, 0.05 F 1.05 p = 0.38
Anatomical measure PAhold (cm2) 12.30, 2.75 10.94, 2.06⁎ 8.57, 2.27⁎ F 5.01 p < 0.05

Paste (5 ml)
⁎
Residue (cm2) 0.16, 0.26 0.09, 0.18 0.09, 0.22⁎ F 4.9 p < 0.05

Continuous straw drinking (100 ml)

Duration (seconds) 12.42, 5.34 10.47, 3.48 10.80, 2.82 F 2.46 p = 0.14
No. of swallows 7.08, 2.93 7.31, 2.02 7.03, 2.82 F 0.12 p = 0.89
No. of breaths 5.08, 4.01 4.62, 3.73 4.40, 2.22 F 0.09 p = 0.92

Bold = statistically significant p < 0.05.

⁎
Statistically different from baseline pre-LSVT LOUD.

residue, pharyngeal area, timing, and displacement in this study sup-

plement these earlier findings and strengthen the view of a more global
effect of LSVT LOUD.
LSVT LOUD appears to reinforce neural pathways increasing
strength and recruitment of laryngopharyngeal muscles [23]. The area
of the pharynx at rest is an important component of pharyngeal con-
striction and the reduced resting area likely correlates with improved
tone. Further investigation of pharyngeal tone following LSVT LOUD is
warranted. Increased opening diameter and opening duration of the
PES were also significantly increased, even in this group where many
participants demonstrated initial swallowing measures within the
standard deviation range for normal elderly. This corresponds with a
recent finding of normal PES opening for people with PD and dysphagia
[19]. Opening of the PES is influenced by hyolaryngeal movement and
Fig. 2. Involuntary cough measures outside normative data (1SD) pre-, post- and 6-
by pharyngeal pressure generation which together open the PES and
months post-LSVT LOUD, excluding the three participants lost to follow-up at six-months
[42].
provide impetus to the bolus which dilates the PES. Airway closure is
important in protecting the pulmonary system and reducing choking or
coughing of misdirected bolus. Laryngeal closure precedes each
Table 6 swallow, or should, if one wishes to avoid airway violation. Suprahyoid
Aerodynamic measures pre-, post- and 6-months post-LSVT LOUD.
musculature that elevate and protect the laryngeal complex are likely
Measure Mean, SD Statistic p value activated by the high intensity, high repetition and increased com-
plexity volume, pitch and speech exercises of LSVT LOUD. Interestingly,
Pre- LSVT 1-week post- 6-months increased water intake is also encouraged during the LSVT LOUD pro-
LOUD LSVT LOUD post- LSVT
gramme perhaps resulting in increased overall daily swallowing. It is
LOUD
also possible that subtle improvements in airway protection improve
CPD1 (ms) 253, 150 276, 140 268, 130 F 1.16 p = 0.33 confidence in swallowing and facilitate increased effortful swallows.
PEFR2 (L/s) 3.01, 1.04 3.41, 1.06⁎ 3.69, 1.17⁎ F 8.17 p ≤ 0.001 Given that our participants all demonstrated mild PD ratings, the
PEFRT3 (sec) 0.04, 0.01 0.05, 0.01⁎ 0.05, 0.01⁎ F 6.31 p ≤ 0.001
results demonstrated may differ in individuals with a greater PD
CVA4 (L/s/s) 82.87, 30 80.42, 26 78.31, 23 F 0.25 p = 0.78
burden. Potentially, patients with greater pharyngeal manifestations of
Bold = statistically significant p < 0.05. PD may benefit to a greater extent from improvement in bolus transit
⁎
Statistically different from baseline pre-LSVT LOUD. efficiency. As poor pharyngeal constriction is highly predictive of as-
piration [18,43] and presence of pharyngeal residue [44,45] improve-
Change in total pharyngeal transit time was not observed in this cohort; ment in these measures would reduce aspiration risk and enhance de-
however paste residue did significantly reduce. In this pilot study of glutition.
individuals with PD having mild swallowing deficits, effect size is dif-
ficult to determine. Previously published data demonstrated 51% im- 4.2. Cough effectiveness
provement across measured swallowing parameters [28]. Given that
the current cohort of patients did not report severe swallowing deficits, Improvements in cough strength also support more global effect
we expected the effect size to be smaller. Actual improvements between from LSVT LOUD than merely phonatory loudness. Significantly im-
pre-LSVT LOUD and post-LSVT LOUD were 9% PESdur; 26% PESmax; proved expiratory cough measures indicate greater pulmonary force
11% PAhold; 44% pharyngeal residue. The quantitative changes in generation. This improves secretion clearance and expulsion of

185
A. Miles et al.
misdirected bolus (compensating for reduced swallowing safety).
Seventy percent of participants performed below normal range in their
reflexive cough PEFR. Although changes in CPD (a measure of glottal
closure) and CVA (a measure of cough effectiveness) did not reach
significance, PEFR and PEFRT significantly improved. The 12% im-
provement in PEFR across the cohort has been demonstrated to corre-
late with clinically relevant change in people with asthma [46]. The
high-effort respiratory tasks in LSVT LOUD perhaps heighten re-
spiratory drive for the forced expiratory task of reflexive cough. Similar
concurrent changes in expiratory cough measures and swallowing
safety have also been seen following expiratory muscle strengthening
training (EMST) where a patient expires forcefully into a calibrated
device [47–50].
4.3. Limitations and future directions
The frequent interaction of patient with therapist during LSVT
LOUD may have a bearing on perceptual responses. Motivation ratings
were high in the majority of participants. Frequent encouragement with
specific direct feedback can enhance motor learning and bolster moti-
vation [23]. This supportive effect may play a role in the perceived
benefit of therapy leading to improved perception of PD symptoms
(PDQ-8) and swallowing symptoms (EAT-10) despite the participants'
treating clinician not being involved in the assessment sessions. Im-
provement in quantitative measures are, however, beyond the partici-
pants' control. Participants were blind to the measures that were being
assessed and therapy focuses on speech only. This reduces the risk of
approval bias whereby the patient is seeking approval from the clin-
ician for achieving certain outcomes.
The study cohort was small, non-randomized and without a control,
with follow up limited to only six months. It should be noted that the
use of multiple LSVT LOUD clinicians increases risk of variability in
treatment delivery. Now that we have clear evidence of benefit, a larger
randomized controlled study will be performed, with a control group to
assess natural variability over time. An accurate power calculation can
now be made based on the significant changes in residue, timing, dis-
placement and/or pharyngeal area in this pilot work. Further in-
vestigation of the correlation between functional outcomes and quan-
titative swallowing and cough measures in a large, more impaired
sample will add clarity to physiological mechanisms of change. Future
considerations include a longer duration of follow up, to identify
whether drop-off in function occurs and if repeating LSVT LOUD would
demonstrate repeated effect or cumulative improvement. Participants
were recruited solely through the LSVT LOUD service secondary to
complaints of voice dysfunction. Future studies will expand on these
positive results and assess if similar outcomes can be achieved in those
with more severe swallowing difficulties. Further quantitative in-
vestigation of pharyngeal strength and tone following LSVT LOUD
would be valuable. Future studies should further address the changes in
swallowing and cough seen after LSVT, by using a range of instrumental
assessments that extend beyond two-dimensional imaging. These might
include investigating changes of PES function post LSVT, through in-
tramuscular EMG testing and High-resolution manometry [HRM] [51].
Combined videomanometry might also allow correlation between dy-
namic timing measures and strength profiles analysed via the Clouse
plots of HRM. Previous work has demonstrated correlation between
PCR and manometric measures [43,52,53]. LSVT LOUD focusses on
sensory calibration and awareness of effort and intensity. It is possible
that this has an impact on the sensory aspects of both swallowing and
cough and this deserves further research attention.
Sustained improvement in swallowing function, demonstrated by
this prospective pilot study, holds great promise, particularly because it
has been achieved using a non-invasive technique that also greatly
improves phonatory function and quality. Given that most current
treatment options in PD, whether it be pharmacotherapy or deep brain
stimulation, offer limited benefit for voice and swallowing parameters,
186
Journal of the Neurological Sciences 383 (2017) 180–187
there is a need to develop other treatment options and to minimize
patient risk and discomfort. The possible side effects of medication and
the risks of surgery are completely avoided using this rehabilitative
intervention. LSVT LOUD has been proven to reap greatest results in
people with mild-moderate PD and requires a reasonable level of cog-
nition, motivation and stamina [54]. This study offers promise in pro-
tecting these people against life-compromising swallowing and re-
spiratory difficulties suffered later in PD. It is possible that in patients
already suffering from more significant swallowing dysfunction and
airway compromise, who are still cognitively able to participate in the
rigorous programme, that the effects of LSVT LOUD may have an even
greater protective effect and a recalibration of the whole sensorimotor
process [23]. Further investigation is warranted.
5. Conclusions
LSVT LOUD demonstrates additional spread effects on quantitative
pharyngoesophageal deglutitive function and involuntary cough effec-
tiveness in people with mild PD referred with voice complaints. This
offers promise in protecting against the respiratory and deglutitive
symptoms suffered by people with mild PD in a non-invasive manner.
However, LSVT LOUD is not a replacement for direct swallowing
treatment for this population at this time. This pilot data justifies a
randomized controlled study to understand whether the identified
benefits can be found in those with more severe PD and dysphagia and
to assess overall duration of benefit.
Declarations
The authors have no conflicts of interest to declare. This project was
supported by a Neurological Foundation Project Grant and a Maurice
Phyllis & Paykel Trust Project Grant.
Acknowledgements
Thank you to the participants of this study for their enthusiasm,
support and participation. We would also like to acknowledge
Waitemata District Health Board for their support, LSVT LOUD-certified
speech-language pathologists Sharon Broadmore, Sharon Farao and
Louise Hume as well as the continuing support of Miriam Maslin,
Medical Radiation Technician, Radiology, Waitemata District Health
Board and Alex Hunting and The University of Auckland speech pa-
thology students for contributions to assessment and measurement.
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