Singing Exercises for Speech and Vocal Abilities
in Individuals with Hypokinetic Dysarthria:
A Feasibility Study
MEGUMI AZEKAWA, MM, MT-BC
A. BLYTHE LAGASSE, PhD, MT-BC
ABSTRACT:  Many individuals with Parkinson’s disease (PD) develop
characteristics of hypokinetic dysarthria during the course of the dis-
ease. As communication skills are predominant factors in everyday
life, dysarthric speech symptoms immediately influence decreased
competence in communication, thereby increased frustration, and
loss of confidence regardless of the degree of symptoms. The purpose
of this study was to investigate the feasibility of a group music ther-
apy protocol using Neurologic Music Therapy techniques for treat-
ing voice and speech deficits due to hypokinetic dysarthria seen in
individuals with PD. Five participants with PD exhibiting characteris-
tics of hypokinetic dysarthria participated in six weekly group music
therapy sessions. Three speech assessments were administered as pre-
test and posttest to assess participants’ improvement in variables that
measured vocal function, voice quality, articulatory control, and con-
nected speech intelligibility through acoustic and perceptual analy-
ses. Feasibility and outcome measures provided initial evidence to
warrant further study of the protocol.
Keywords: music therapy; Parkinson’s disease; speech communica-
tion; vocal training
Introduction
Parkinson’s disease (PD) is the second most common neurode-
generative disease after Alzheimer’s disease (de Lau & Breteler,
2006). In the United States, over one million people are affected
with the disease and approximately 60,000 new cases are diag-
nosed every year (Parkinson’s Disease Foundation, 2016). The
disease affects the dopamine depletion in the substantia nigra
of basal ganglia, resulting in resting tremor, rigidity, gait and
postural instability, bradykinesia, and hypokinesia (Duffy, 2005;
McNeil, 2008; National Parkinson Foundation, 2016). In add-
ition, over 80–90% of individuals with PD exhibit voice and
speech impairments at any stage of the disease (Mahler, Ramig,
& Fox, 2015; Walsh & Smith, 2012).
Common characteristics of voice and speech impairments
in PD include reduced volume of speech, monotone pitch,
reduced stress in speech pattern, breathy and hoarse voice
quality, imprecise articulation, and varied rate of speech,
which contribute to less speech intelligibility (Duffy, 2005;
Skodda, Grӧnheit, Mancinelli, & Schlegel, 2013). These symp-
toms, collectively called hypokinetic dysarthria, worsen over
time as PD progresses and negatively influence the individual’s
Address correspondence concerning this article to A. Blythe LaGasse, PhD, MT-BC,
1778 Campus Delivery, Fort Collins, CO 80523, USA. E-mail: blagasse@colostate.
edu.
© American Music Therapy Association 2017. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com
doi:10.1093/mtp/miw042
Advance Access publication February 9, 2017
Music Therapy Perspectives, 36(1), 2018, 40–49
40
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Colorado State University, Fort Collins, CO
Colorado State University, Fort Collins, CO
communication ability (Skodda et  al., 2013). Researchers
have suggested that vocal disturbances result in frustration,
decreased self-esteem, and withdrawal from conversations
(Miller, Andrew, Noble, & Walshe, 2011; Miller, Noble, Jones, &
Burn, 2006), indicating that viable treatment options could
improve communication and quality of life.
There has been no treatment yet established to either cure the
disease or stop the progression of Parkinson’s disease or hypoki-
netic dysarthria. Although the neural cause of voice and speech
symptoms of hypokinetic dysarthria is not yet fully understood, it
has been suspected that speech motor control is affected due to
impairments of the motor and sensory systems (Mahler et al., 2015).
Since speech is affected in individuals with PD, there is a need
for evidence-based treatments to maintain and improve speech
communication (Fox et al., 2008; Murdock & Whelan, 2009). Lee
Silverman Voice Training (LSVT) is one of the most widely admin-
istered treatments for improving the symptoms of hypokinetic dys-
arthria. LSVT consists of intensive and repetitive voice exercises
with the focus of increasing voice intensity, which is believed
to result in integrating respiratory, laryngeal, and articulatory
systems to exert overall improved speech output (Ramig, Fox, &
Sapir, 2004). However, Adams and Dykstra (2009) emphasized
that reduced speech intelligibility in hypokinetic dysarthria is
also largely influenced by nonlaryngeal processes, including
oral articulation, velopharyngeal control, respiratory function,
and postural control, which require additional approaches to
be utilized. In addition, a recent systematic review on speech
treatments for PD concluded that although there is some initial
evidence that LSVT can improve loudness and functional com-
munication (Mahler et al., 2015), there is not enough evidence
to support or refute any speech therapy treatment method (Herd
et al., 2012). Therefore, there is a need for research on treatments
that can target all of the symptoms associated with hypokinetic
dysarthria. Researchers have investigated the use of singing as a
possible treatment option (Barnish, Atkinson, Barran, & Barnish,
2016).
The act of singing shares physiological mechanisms with
speech (Wan, Rüber, Hohmann, & Schlaug, 2010) and directly
stimulates the musculature related to respiration, phonation,
articulation, and resonance (Thaut, 2014). This shared network
has led to the use of singing as a speech rehabilitation treatment
for individuals with dysarthria, aphasia, apraxia, fluency dis-
order, and delayed development of speech and language skills
(Baker & Tamplin, 2006; Wan et al., 2010). Success in using
singing for speech rehabilitation has been attributed to the
wide distribution of music processing and production through-
out the brain systems (Johnson, 2014). Several brain imaging
 Singing Exercises for Speech
studies have revealed the shared and extended neural net-
works between singing and speech, indicating that singing can
enhance neuroplasticity in regaining speech motor function
(Brown, Martinez, & Parsons, 2006; Kleber, Veit, Birbaumer,
Gruzlier, & Lotze, 2010; Özdemier, Norton, & Schlaug, 2006;
Patel, 2008). Another important factor is the effect of external
auditory rhythmic stimuli, which has been found as a driving
force for motor system arousal, including the speech motor sys-
tem (LaGasse, 2013a; Thaut, Miller, & Schauer, 1998).
Singing is proposed to enhance communication skills, which
are composed of a complex network involving the respiratory,
laryngeal, and articulatory systems (Johnson, 2014). Rhythmic
singing is suggested to drive anticipation for initiating speech
with an appropriate prosodic pattern (Johnson, 2014; Patel,
2008). Palmer and Kelly (1992) explained that in songs, metric
and stressed syllable alignments tend to occur by mimicking
the natural speech rhythm and stress patterns, which provides
a potential effect of singing exercises to encourage increased
speech prosody. Articulation imprecision also occurs in indi-
viduals with PD, affecting their speech intelligibility due to
an “articulatory undershoot” caused by abnormal control of
vocal fold abduction and adduction, as well as reduced range
of articulator movements, including reduced amplitude and
velocity of lip movements (Duffy, 2005). Temporal and rhyth-
mic structure of songs induces intrinsic anticipation to enun-
ciate target speech sounds with emphasis and clarity through
singing exercises, potentially improving speech intelligibility.
In addition, Tamplin and Grocke (2008) explained that dur-
ing controlled breathing (e.g., during singing), the cortex dir-
ectly controls the pacing and strength of respiratory muscles
contractions. Singing exercises with the songs that provide a
rhythmic structure to organize breathing and phonation timing
could assist in achieving improved muscle control, expanded
lung capacity, as well as increased vocal intensity.
Vocal warmup exercises could serve not only as a “warmup”
to prepare laryngeal musculature for speaking or singing, but
also as an application to strengthen the laryngeal musculature
and to maximize airflow for breathing and efficiency in glot-
tal function, which could yield to improved voice control in
speaking (Sabol, Lee, & Stemple, 1995). Humming requires
vocal cords to maintain a slight separation with minimal force
impact on the vocal folds. Incorporating a humming exercise
(i.e., humming an /m/ sound with lips closed in a relaxed man-
ner) as a part of vocal warmup exercises appears to result in
facilitating clearer voice quality (Yiu & Ho, 2002).
Additional elements of group singing should also be taken
into account to enhance the therapeutic effect of singing as
speech rehabilitation. First, group singing style may provide
the Lombard effect—the tendency to increase one’s own vol-
ume of speech/singing due to the masking effect to the sur-
rounded voices, which leads to providing less auditory feed-
back. Thus, group singing may encourage participants to sing
in a louder volume, which requires more breath support and
respiratory control (Quedas, Duprat Ade, & Gasparini, 2007;
Tonkinson, 1994). In addition, the use of preferred or familiar
songs will allow individuals with PD to practice respiratory,
prosodic, and articulatory control without overly demanding
cognition, since these songs are already committed to mem-
ory. This can encourage participation and engagement in treat-
ment targeting vocal skills (Clair & Memmot, 2009).
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41
Music therapy interventions using singing and vocal exer-
cises may function as a viable speech rehabilitation regimen
for a number of compensatory speech and vocal characteris-
tics due to hypokinetic dysarthria. A few music therapy stud-
ies have focused on the therapeutic use of singing and vocal
exercises to specifically target the symptoms of hypokinetic
dysarthria (Di Benedetto et  al., 2009; Elefant, Baker, Lotan,
Lagesen, & Skeie, 2012; Haneishi, 2001; Yinger & Lapointe,
2012). The extant studies include a wide variety of protocols
and measurements, lacking a clear indication of what factors
are successful in singing interventions and what measure-
ments are consistently improved.
Haneishi (2001) investigated individual sessions for 4 indi-
viduals with PD using a Music Therapy Voice Protocol (MTVP),
which consisted of vocal and singing exercises. The primary
outcome measure was speech intelligibility, which was deter-
mined via self-report of the participants and a rating form
completed by their caregivers. Haneishi also measured vocal
intensity, vocal range, fundamental frequency, and maximum
duration of vowel phonation. The group that received the MTVP
significantly improved in speech intelligibility as rated by car-
egivers and vocal intensity. Therefore, individualized treatment
may lead to some improvements in vocal characteristics.
Di Benedetto and colleagues (2009) investigated a mix
of individual speech therapy with group choral singing ses-
sions in a group of adults with PD. Speech therapy sessions
occurred twice weekly for one hour and focused on muscu-
lar relaxation and exercises for prosody, respiration, laryn-
geal function, and oral facial movements. The singing ses-
sions were held for two hours once weekly and consisted of
singing beginning “rhythmic popular” and “liturgical chants”
accompanied by piano. Measurements of vocal characteristics
included an acoustic analysis, auditory quality of voice ana-
lysis, and respiratory function evaluation. Significant improve-
ments were found for functional residual capacity, maximum
inspiratory and expiratory pressure, maximum duration of
sustained vowel phonation, and improved prosody in read-
ing. Although improvements were indicated, the mixture of
weekly speech therapy sessions with the choral singing makes
it difficult to determine whether the singing intervention con-
tributed to the improvements.
Other studies have investigated small-group singing inter-
ventions. Elefant and colleagues (2012) investigated the
impact of 20 group singing sessions on 10 individuals with PD.
Vocal characteristics were captured during passage reading,
sustained phonation, and singing, and were analyzed for flu-
ency, mean formant, singing pitch accuracy, voiced/voiceless
sound, and intensity. The intervention included opening/clos-
ing conversations, breathing exercises, vocal exercises (pro-
ducing a glissando from high to low pitch), and singing par-
ticipant-chosen songs to guitar accompaniment. The authors
found significant improvements for singing quality outcomes,
the voice handicap index, and voice range. They reported
no significant change for speaking-quality measures. Yinger
and Lapointe (2012) also investigated the impact of group
singing on vocal characteristics. Yinger and Lapointe used
a group adaptation of Haneishi’s MTVP, and measures were
taken before, during, and after a six-week treatment period.
The study involved a one-group pretest-posttest design with
10 participants. The authors analyzed the participants’ voices
 42
in conversational speech and in reading passages. Measures
were taken for vocal intensity, fundamental frequency, and
fundamental frequency variability. Significant results were
found only for intensity of reading passages.
The extant literature includes initial evidence that group
music therapy vocal interventions may help with aspects of
vocal quality. The cited studies all found that some vocal char-
acteristics were improved or maintained; however, there is
no research on the use of Neurologic Music Therapy (NMT)
techniques for speech and vocal quality in persons with PD.
Tamplin (2008) conducted a pilot study to examine the effect-
iveness of music therapy protocol using NMT techniques in
improving speech intelligibility and speech naturalness of indi-
viduals with acquired dysarthria due to traumatic brain injury
or stroke. The researcher used Oral Motor and Respiratory
Exercises, Vocal Intonation Therapy, and Therapeutic Singing
in their study. Statistically significant improvements in speech
intelligibility and speech naturalness were observed. This sug-
gests that music therapy protocol using vocal and singing
exercises based on the principles of NMT may be effective.
However, Tamplin only included individuals who acquired
dysarthria due to traumatic brain injury or a cerebral vascular
accident. Thus, further study should target the improvement of
dysarthric speech due to Parkinson’s disease by developing a
music therapy protocol using NMT techniques.
Neurologic Music Therapy is the “application of music to
cognitive, affective, sensory, language, and motor dysfunc-
tions due to disease or injury to the human nervous system”
(Thaut, McIntosh, & Hoemberg, 2014, p.  2). There are sev-
eral NMT techniques that address speech and vocal deficits,
and two that specifically use singing to rehabilitate speech.
Vocal Intonation Therapy (VIT) is the use of vocal exercises
to rehabilitate aspects of voice control, including inflection,
pitch, breath control, timbre, loudness, phonation, resonance,
and intonation (Thaut, 2014). Therapeutic Singing (TS) is the
use of singing exercises to facilitate better initiation, develop-
ment, and articulation in speech as well as improve respira-
tory apparatus functions. VIT and TS use shared neurological
networks between singing and speaking in order to strengthen
speech and vocal control (Johnson, 2014; Thaut, 2014).
Furthermore, aspects of music, including structure, anticipa-
tion, and familiarity, provide a clear template for producing
speech and vocal sounds. Since singing directly involves the
muscles used in speaking (Thaut, 2014), engaging in singing
may influence or improve speaking abilities.
The current study was designed to investigate the feasibil-
ity and benefit of NMT techniques to improve and prevent
Table 1
Participants’ Demographic Data
Years
Participant Age Gender post diagnosis
1 66 F 15
2 69 M 11
3 81 M 8
4 57 M 6
5 81 F 1
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Music Therapy Perspectives (2018), Vol. 36
voice and speech deficits seen in individuals with hypokinetic
dysarthria. The purpose of completing this feasibility study
was to ensure that testing procedures and measures would be
appropriate for a larger-scale study of the protocol. Therefore,
feasibility questions included: 1)  Will individuals consent
to study procedures? and 2)  Will individuals complete the
eight-week study protocol? The following questions regarding
treatment benefits were explored: 1)  Will vocal function of
the participants be maintained or improved as compared to
their baseline levels? 2) Will vocal quality of the participants
be maintained or improved compared to their baseline lev-
els? 3)  Will articulatory control of the participants be main-
tained or improved as compared to the baseline levels? and
4) Will speech intelligibility of the participants be maintained
or improved as compared to the baseline levels?
Method
Participants
The study used pilot study design with one group pretest-
posttest. Seven (three females and four males) individuals who
met the following inclusions were initially recruited from a
local support group: 1) a current diagnosis of Parkinson’s dis-
ease, 2) the severity of the disease determined by the Hoehn
& Yahr scale (Hoehn & Yahr, 1967) from 1 to 3, 3)  their age
over 50, 4)  the onset of PD after age 50, 5)  no co-morbid-
ity with other neurological impairments or cognitive deficits,
and 6)  use English as their native language. All participants
exhibited one or more characteristics of hypokinetic dysarth-
ria, including reduced volume of speech, monotone pitch,
reduced stress in speech pattern, breathy and hoarse voice
quality, imprecise articulation, and a varied rate of speech. Five
participants completed the study, with two excluded due to
absences. These five participants were between the ages of 57
and 81 (M = 70.8, SD = 10.30). Participant demographics are
shown in Table 1. A pre-study questionnaire form was distrib-
uted to each participant to obtain information regarding their
preferred songs and genres of music and the history and cur-
rent status of their musical experiences. Participants reported
that their preferred genres of music were country/western, folk,
popular music from the 1940s to the 1970s, and religious on
the pre-study questionnaires. Examples of the songs are shared
in Table 2. For their prior group singing experience, all five par-
ticipants had sung in church choirs and two of them had also
sung in school choirs. Informed consent was obtained prior to
the participation in the pretest. The study was approved by the
Institutional Review Board (IRB) at Colorado State University.
Hoehn & Yahr Scale Speech therapy participation
3 N
2.5 N
2.5 N
2.5 N
2.5 N
 Singing Exercises for Speech 43

Table 2
Description of a Session

Exercise Description Outcome

Opening exercise (5 minutes) The first author improvised music to guide Decrease muscle tension in the face and upper body
stretching and warmup gross motor movements. to prepare for the session.
Including playing ascending and descending
arpeggios to cue shoulder rolls, an ascending
melodic phrase to cue turning head to look over
shoulder with a descending melodic phrase to
return to midline, and descending rolled chords to
facilitate a jaw drop.
Vocal intonation therapy The first author provided a chord structure and Improve voice control, including respiratory control,
(15 minutes) increasing volume to cue participants to sustain phonatory controls, and increase vocal pitch range
and increase volume of an open “ah” sound. (for vocal prosody).
Providing a rhythmic and chord structure on the
piano to support descending pitch glides.
Complete each pitch guide while ascending the
scale in half steps.
Humming a slow and melodious song with the
sound /m/. Examples: “Edelweiss,” “Amazing
Grace,” “Scarborough Fair.”
Therapeutic singing The first author provided a chord structure and Exercise articulatory control on certain sounds of
(10 minutes) emphasis (using accents) to facilitate articulations speech (i.e., consonants/vowels/syllables) within a
in a preferred song. Two songs were used in each context of singing. Target sounds included, but not
session. Example: “Take Me Out to the Ball limited to, glottal (/k/, /g/), fricatives (/s/, /z/, /∫/, /ʒ/)
Game” and “Singing in the Rain.” and affricates (/t∫/, /dʒ/) (Logemann & Fisher, 1981)
Five-minute water break
Therapeutic singing The first author provided chord structure and Exercise respiratory support and control within a
(10 minutes) phrase cues (i.e., using ascending arpeggiated context of singing.
chords for the duration of phase) to facilitate
breath support and control in a preferred song with
connected phrasing patterns used. Two songs were
used in each session. Examples: “Springtime in the
Rockies” and “Your Cheatin’ Heart.”
Session closing The first author improvised music to guide Increase muscle relaxation and deep breathing.
stretching and relaxation motor movements.
Improvisation was also used to guide deep
breathing.

Procedure
Recruitment flyers were distributed along with a brief
announcement to the participants of the PD exercise group
held at a local university’s music therapy lab. After obtaining the
informed consent prior to the pretest, a pre-study questionnaire
form was distributed to each participant to obtain information
regarding their preferred songs and genres of music and the
history and current status of their musical experiences. A brief
interview was also given to obtain the participants’ demo-
graphic information such as age and the time of PD onset. Each
participant was administered with three speech tasks for a pre-
test measurement. Following a six-week intervention period,
each participant took the posttests. All interviews, pretests and
posttests, and interventions were given by the first author at the
music therapy lab. The rapport between the participants and
the first author had been established as the participants have
known of the researcher for two semesters prior to the study, as
this researcher had previously volunteered as a music therapy
student for the PD exercise class.
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Intervention
The treatment protocol was an adaptation of the Music
Therapy Voice Protocol developed by Haneishi (2001)
and later used in the group setting by Yinger and Lapointe
(2012). Similar to Yinger and Lapointe, we included physical
warmup, breathing exercises, vocal warmups, singing exer-
cises, and analysis of vocal data, and provided six weeks
of treatment. In contrast to Yinger and Lapointe (2012), we
omitted the opening and closing conversation and specif-
ically used NMT techniques, including Vocal Intonation
Therapy (VIT) and Therapeutic Singing (TS). As opposed to
presenting exercises such as “speaking phrases in unison at
varying rates” and “speaking phrases at various amplitudes”
(Yinger & Lapointe, 2012, p.  29), all speech goals were
addressed using singing through specific singing exercises
or through preferred songs that were selected to facilitate
the speech goal. Furthermore, we conducted this study with
a group who had not previously received music therapy for
vocal needs.
 44
A 50-minute weekly group music therapy intervention VIT
and TS was provided to the participants for six consecutive
weeks (six sessions). Each session started with a series of
voice control exercises facilitated by vocal intonation ther-
apy interventions for physical (upper body and oral facial
muscles) warmup as well as increased respiratory control,
phonatory controls, and vocal pitch range (for vocal pros-
ody). Next, therapeutic singing was used for articulation clar-
ity and breath support and control. The session ended with a
relaxation exercise to facilitate muscle relaxation with neck
stretches, shoulder/arm extensions, and deep breathing. The
details of the interventions with examples are described in
Table 2.
Vocal exercises and song lyrics were displayed on a screen
using PowerPoint slides and a projector to encourage the par-
ticipants to maintain upright sitting postures without looking
down on a lyric sheet and to prevent them from holding a
sheet with resting tremor. Each exercise was facilitated on a
weighted-key electric keyboard with sustained pedal, verbal
cues, and visual cues on the PowerPoint slides. A  speech-
language pathology clinical fellow was also present at each
session to model each vocal or singing exercise movement as
visual cues.
Interventions were provided by an equivalency graduate
student who had been trained as an intern at a local hospi-
tal’s inpatient neurorehabilitation unit during her final semes-
ter. The student had completed the NMT training workshop
prior to developing the protocol. All protocol development,
application, and data analysis was completed under the direct
supervision of board-certified music therapists who also car-
ried the affiliation of NMT Fellow.
Vocal Intonation Therapy was used to lead a series of vocal
warmup exercises aimed at expanding respiratory control,
improving phonatory controls, as well as improving vocal
prosody by expanding pitch range. For instance, a gliding
exercise was used to stretch the vocal folds by gliding from a
higher pitch to a lower pitch, ascending a half step each time.
Therapeutic Singing is a technique that includes exercises
for articulation and breath support to increase intelligibility.
Songs used in therapeutic singing were therefore selected
based on their appropriateness for these goals. Therapeutic
Singing song selections were made based on the partici-
pants’ responses in the pre-study questionnaire that asked
their preferred songs and genres of music to reinforce their
motivations. In addition, the following considerations were
included for the song selection process: 1) temporal flexibil-
ity to slow down and speed up the tempo of the songs to
effectively facilitate the interventions that address particular
vocal or speech goals while maintaining the musical char-
acteristics of the songs, and 2)  rhythmic anticipation and
rhythmic complexity to maximize the facilitation of speech
motor or respiratory movements through the songs (Johnson,
2014). For the articulation exercise songs, the songs were
selected based on the presence and number of target speech
consonants, and their locations (front, medial, and end part
of words). Different songs were selected for each session in
order to provide the participants with opportunities to prac-
tice different articulatory patterns. For breath support exer-
cise songs, the songs were selected based on the presence of
extended endings for each phrase, flexible phrasing patterns
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Music Therapy Perspectives (2018), Vol. 36
to create different levels of breath support through the phrase
lengths, and larger melodic patterns to naturally facilitate the
increment of the volume. Table  2 provides a more detailed
explanation of the music used within a session.
Outcome Measures
Three speech tasks, sustained vowel phonation task, dia-
dochokinesis test, and Rainbow Passage reading, were given
at pretest and posttest to examine four voice and speech
parameters, including vocal function, voice quality, articu-
latory control ability, and connected speech intelligibility,
at the baseline and post-intervention period. All participants
individually completed the testing measures, which were
collected by the primary author. A quiet room was used for
all testing. The pretest and posttest occurred within 10 days
before and after the singing groups began and ended,
respectively.
The sustained vowel phonation data were used to ana-
lyze vocal function and voice quality. This outcome measure
was previously used by Di Benedetto and colleagues (2009)
and Haneishi (2001). The duration measurement of sustained
vowel phonation was examined to explain the ability of glot-
tal function that requires for efficient voiced phonation. The
sustained vowel phonation for the longest duration also indi-
cated vocal tract function steadiness, which can be acoustic-
ally expressed in the variances of the first formant (f1) and sec-
ond (ƒ2) formant. Change of the formant frequencies directly
relates to the change of the shape of the vocal tract through
moving articulators such as the mandible, tongue, lips, larynx,
and the side walls of the pharynx (Sataloff, 2005). In particular,
the f1 is influenced by the opening of the mandible (i.e., jaw)
and the f2 is influenced by tongue shape (Nair, 1999; Sataloff,
2005). Researchers in prior studies on singing for PD did not
measure the variances of f1 and f2.
The diadochokinesis test was used to assess speech articula-
tory control ability. For this test, the researcher asked the par-
ticipants to repeat three monosyllables, /pa/, /ta/, and /ka/, as
a sequence for five seconds, requiring them to select or alter-
nate place for syllabic productions with similar voiced stops.
Since the test only involved the repetitions of monosyllables,
it enabled assessment of speech motor control ability without
the influence of language production (Padovani, Gielow, &
Behlau, 2009). Therefore, the rate of the diadochokinesis test
would be a valuable indicator for the participants’ speech
motor control ability. Researchers in prior studies on singing
for PD did not measure the diadochokinetic rate.
The Rainbow Passage reading task was administered to
assess connected speech intelligibility. At pretest and posttest,
the participants read a different paragraph of similar length
(the pretest paragraph was 35 words, and posttest paragraph
was 34 words). The recorded reading audio samples were
used to measure connected speech intelligibility by counting
the discernible words. Speech pauses, precisely, the number
of inter-word pauses (i.e., pauses between words), the dur-
ation of each inter-word pauses, and the pause ratio, were
measured. An inter-word pause was determined as greater
than 200 milliseconds (Kent, Kent, & Rosenbek, 1987; Van
Nuffelen, Bodt, Vanderwegen, de Heyning, & Wuyts, 2010).
Researchers in prior studies on singing for PD did not measure
inter-word pauses in a reading task.
 Singing Exercises for Speech
Two trained researchers (the first and second authors) indi-
vidually conducted acoustic analyses on spectrogram and
waveform displayed in the PRAAT vocal analysis software
program (PRAAT is the title of the program and Dutch for
“speak”). The second author was trained in vocal analysis in
her doctoral program and then trained the first author. PRAAT
allowed the researchers to visually detect the duration of the
sustained vowel phonation and the mean of the first formant
(ƒ1) and second (ƒ2) formant of the voiced sound from the
sustained vowel phonation audio samples, and the presence
and duration of each inter-word pause from the Rainbow
Passage reading audio samples. Reliability of the data analy-
ses between two raters was calculated by using a correlation
coefficient test.
The PRAAT was also used to compute jitter and shimmer as
well as Harmonics-to-Noise Ratio (HNR), the acoustic descrip-
tions of the abnormality of voice quality. Jitter and shimmer
have been considered variable indicators as the perturbation
level in the voice sound for acoustic analyses (Adams &
Dykstra, 2009). Jitter and Shimmer have previously been used
in music therapy and PD research (Di Benedetto et al., 2009).
Jitter displays cycle-to-cycle variation in frequency (i.e., time),
and shimmer describes cycle-to-cycle variation in amplitude
(Adams & Dykstra, 2009; Kent & Ball, 2000). The abnormal
increment of jitter and shimmer contribute to the percep-
tual effect, which is called “harshness” (Laver, Hiller, & Beck,
1992). Harmonics-to-Noise Ratio (HNR) is another acoustic
index of voice quality that refers to the proportion of noise to
the vocal sound measured. The greater the noise in the voice,
the lower the HNR (Forrest & Weismer, 2009). Thresholds for
jitter, shimmer, and HNR are shown in Table 3.
Recording Procedure
Speech audio samples at pretest and posttest were digitally
recorded in a quiet room with the Snowball USB condenser
microphone. Similar to procedures in Yinger and Lapointe
(2012), the phonatory analysis software PRAAT (Boersma &
Weenink, 2010) was used. The microphone was placed eight
inches in distance from the participant’s mouth to assure
accurate and reliable audio sample recording quality at both
pretest and posttest.
Analysis
For feasibility measures, the rate of consent was estab-
lished by dividing the number of individuals who consented
to the study by the number of individuals who expressed
interest and met the eligibility criteria. The rate of comple-
tion was calculated by determining the number of individu-
als who completed the study divided by the number who
began the study.
Table 3
Jitter, Shimmer, and the Harmonics-to-Noise Ratio—Threshold of
Pathology
Threshold of pathology
Jitter (%) > 1.040 %
Shimmer (%) >3.810 %
Harmonics-to-Noise Ratio (dB) < 20 dB
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45
Trends in data were visually examined for initial indication
of possible treatment outcomes. For non-normally distributed
data, a Wilcoxon test was completed. The mean of each datum
that was analyzed by two raters was used for the statistical
testing. Reliability of the data analyses between two raters was
calculated by using a correlation coefficient test. The calcula-
tion resulted in a mean agreement of r = .93, indicating a high
degree of agreement. For normally distributed data, a paired
samples t-test was used to determine whether there was a sig-
nificant difference between pretest and posttest data among
all participants in the voice and speech parameters.
Results
Feasibility Measures
Participants were recruited from an area Parkinson’s support
group. Seven individuals expressed an interest in the study
and consented to study procedures, for a 100% consent rate.
All individuals met the inclusion criteria. Seven individuals
began the study procedures; however, only five individuals
completed all study procedures, for a completion rate of 71%.
Participants who stopped coming reported illness as the pri-
mary reason.
Potential Benefits
Pretest and posttest data indicated that participants main-
tained or improved in maximum phonation time, vocal quality
(Harmonics-to-Noise Ratio and jitter), and articulatory control
(measured by the diadochokinesis test), with slight increases
in measurements. One measure for vocal quality (shimmer)
indicated a decrease in quality. Mean and standard deviation
data are shown in Table 4. Furthermore, participants showed a
reduction in inter-word pause times (Table 4).
In order to evaluate trends in the data, the paired samples
t-test was used to determine whether there was a significant
difference between pretest and posttest data among all par-
ticipants in the voice and speech parameters. Table 4 displays
the mean and standard deviations, t, p-values, and effect sizes
of each parameter. Results of connected speech intelligibility
assessment through the Rainbow Passage reading task exhib-
ited a significant difference for the total inter-word pause time
(t(4) = 3.313, p = .030). There were no other significant dif-
ferences exhibited (Table  4). The data for Jitter violated the
assumption of normality, and therefore the Wilcoxon test was
completed and indicated no significant difference (p = .893).
In addition to statistically significant differences for the total
inter-word pause time, this difference also had a large effect
size (d = 1.143; Cohen, 1988). Robust effect sizes were also
observed for mean inter-word pauses (d  =  .992), number of
inter-word pauses (d = 1.221), and pause ratio (d = .898). The
measure of maximum phonation time also yielded a large
effect size (d = 1.58). There was a medium effect size for shim-
mer (d = .517). All other effect sizes were small. Effect sizes
are shown in Table 4.
Discussion
The results of this feasibility study support continued study
of VIT and TS for speech and vocal skills in persons with PD.
Feasibility measures indicated that individuals consented to
the procedures with 100% consent rate. The completion rate
 46 Music Therapy Perspectives (2018), Vol. 36

Table 4
Means, Standard Deviations, Effect Sizes, t and p-values for each Parameter

Pretest Posttest
p
Mean SD Mean SD t (4) (2-tailed) Effect Size (d)
Maximum phonation time (s) 13.193 2.612 18.498 4.064 –1.869 .136 1.58
Mean f1 (Hz) 660.320 146.500 700.375 63.823 –.826 .455 .381
Mean f2 (Hz) 1198.844 104.906 1243.005 178.522 –1.169 .307 .312
Jitter (%)** .877 1.335 .742 .637 .208 .846 .137
Shimmer (%) 6.711 3.326 8.463 3.447 –.835 .451 .517
Harmonics-to-Noise Ratio (dB) 14.958 3.640 14.844 3.799 .082 .939 .031
Diadochokinesis rate (count) 4.00 1.541 4.35 1.764 –.555 .608 .21
Discernible words (%) 97.700 5.143 98.200 1.956 –.198 .853 .141
Number of inter-word pauses 2.800 1.483 1.300 .9747 2.739 .052 1.221
(count)
Mean inter-word pause time (ms) .474 .049 .342 .236 1.114 .328 .922
Total inter-word pause time (ms) 1.268 .539 .618 .601 3.313 .030* 1.143
Pause ratio (%) 9.703 3.519 5.700 5.393 2.033 .112 .898
*Significant at p < .05.
** Result for Jitter confirmed using a Wilcoxon Signed Rank Test.

of 71% demonstrates that most participants were able to com-
plete the treatment protocol by attending six weekly sessions.
Individuals who were not able to maintain attendance had
medical concerns that prevented travel to and from the facil-
ity where sessions were held. This rate of retention is higher
than the rate observed in Clair, Lyons, and Hamburg (2012),
where 50% of participants with PD withdrew from a move-
ment study. Consistent with the current study, medical issues
were cited as one reason for attrition (Clair et al., 2012). Clair
and colleagues also commented that transportation can be an
issue for adults with motor disability. Although no participants
in the current study specifically stated that transportation was
an issue, the authors recruited from a support group located in
the same geographical area as the intervention site. According
to the pre-study questionnaire results, all five participants had
prior group singing experiences in either school or church
choir. The participants’ past experiences may have contributed
to their high level of retention as well as engagement through-
out the intervention period.
Participants who completed the sessions made positive
comments about the treatment intervention. Although no
data were collected on participant perceptions of treatment,
the group did ask to continue with the interventions after the
study concluded. In response to the participants’ requests,
this group was made a permanent free offering to community
members with PD and grew from the original five individuals
included in the study to between 12 and 18 regular mem-
bers within one year. The group members further requested
that the sessions be held year-round (as summers are usually
off for these community groups) because they noticed decline
in their vocal skills when the group did not meet consistently.
Although these anecdotes must be considered with caution,
the researchers feel that not only was the protocol feasible
within the study, but it has been sustained over time with con-
sistent community interest.
Overall, the feasibility data support the feasibility of the
protocol. Additional factors that can be considered include
aspects relating to the resources and management of the study
(LaGasse, 2013b). As for resources, this protocol and study
required minimal resources. The primary analysis tool, PRAAT,
was freely available online, making it accessible to music ther-
apy researchers and clinicians. A  local university classroom
was used for the study and provided ample space for the group
session and data collection. The researchers were required to
move desks and other items for the purpose of the group; how-
ever, this process took no more than 15 minutes. Having a
dedicated clinical room would be more ideal for this type of
group treatment session. Due to the affiliation with a univer-
sity, all supplies were already owned, including the projector
and keyboard. The researchers found the speech-language
pathology clinical fellow to be open and willing to partici-
pate in the project and experienced no difficulties with their
involvement in the study. However, such collaboration may
be difficult for music therapists who do not have connections
with local speech-language pathologists.
With regard to acoustic data analyses instrument, the use
of PRAAT was introduced to examine the voice and speech
quality in this study. PRAAT has been used in voice and
speech acoustic analysis studies, which are accessible and
comprehensive for researchers, including music therapy clin-
ician researchers. The results of acoustic analyses of voice
and speech characteristics by using PRAAT that are defined
by clinical speech pathology terms may lead music therapy
research, in collaboration with allied therapy disciplines, to
optimize treatment outcomes.
In terms of management of the project, the researchers
experienced no difficulty with data collection or entry. All
participants successfully completed all measures used in the
study, and there were no difficulties with tracking of data in
Excel. The researchers were able to complete all components
of the project, including acquiring all necessary approvals,
collection of data, and providing the intervention. The process
of gaining IRB approval took longer than expected, requiring
over two months for approval to be gained. No adverse events
or protocol changes occurred during the study, and therefore
no notice to the IRB was required. Overall, the resource and

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 Singing Exercises for Speech
management aspects of the study supported feasibility for the
implementation of the research and treatment protocol.
Participants tolerated all assessments, and initial data indi-
cated maintenance or improvement of vocal qualities over
the eight-week period. In particular, Maximum Phonation
Time (MTP) nearly doubled for two participants at post-
test (Figure 1). The posttest result of Participant 2 (male) was
22.326 seconds, and that of Participant 5 (female) was 22.709
seconds. The normative data of the maximum vowel phon-
ation for males are within 25–35 seconds, and for females are
within 15–25 seconds (Mathieson, 2001). According to these
standards, Participant 2 was approaching the normal phon-
ation time, and Participant 5 achieved the normal phonation
time, which may indicate improved (i.e., more efficient) vocal
fold vibrations for a vowel phonation (Figure  1). The func-
tional relationship of this measure is the participant’s ability
to speak a sentence without running out of air. This measure
also yielded a large effect size, indicating clinical significance.
The researchers suggest continued use of this measure, as it is
simple to administer and sensitive enough to show changes
over time.
The data for jitter, shimmer, and the Harmonics-to-Noise
Ratio (HNR) demonstrated mixed results. A medium effect was
indicated for shimmer; however, the data for both shimmer
and HNR suggested worsened vocal quality. It should also be
noted that the changes in jitter and HNR are small (Table 4).
However, discrepancies may be due to the data-collection
method. Brockmann, Drinnan, Storck, and Carding (2011)
suggested ways to increase the sensitivity in measuring jitter
and shimmer, by standardizing the voice sound pressure level
(SPL) level at 80dB at 10 cm distance, using the vowel /a/ and
taking the mean of at least three phonations. Therefore, future
researchers may consider adaptations to plan a specific room
setting for audio sample recording of the assessment data and
provide the additional trials in the collection of the sustained
vowel for analysis purposes.
The data indicated maintenance of the participants’ dia-
dochokinesis rate; however, it is unknown whether individu-
als receiving no treatment would decline in a period of six
weeks. Although there was only a small effect size for these
data, the expectation was to maintain function. Overall, the
diadochokinesis rate measure indicated that the participants’
oral motor control was maintained, which is essential for
articulating speech. Finally, improvements were observed in
Figure 1.  changes in Maximum Phonation Yime (MPT) by Participiant
by sec.
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47
variables measuring speech pauses among all participants,
indicating decreased varied rate of speech, and yielded
robust effect sizes. In addition, all participants exhibited
high achievement in connected speech intelligibility, meas-
ured by the percentage of discernible words at pretest, and
retained over 90% at posttest (Table 5). This might be due
to the ceiling effect, as the participants achieved a high
level of connected speech intelligibility, including at pre-
test. Although past research has suggested the speech rate to
be one of the variables to indicate the speech intelligibility,
rate of speech and intelligibility should be considered separ-
ately (Duffy, 2005; Tamplin, 2008; Van Nuffelen et al., 2010).
Collectively, these data suggest that these measures were
appropriate to measure the participants’ level of intelligibil-
ity over the testing period; however, it is unknown whether
individuals not engaged in these groups would exhibit a
decline in this period of time.
Several limitations were present in this study. First, this pro-
ject was non-randomized and had a small sample size (n = 5),
which does not provide sufficient statistical power. Data
reporting is for feasibility purposes and should be interpreted
with caution. Another recommendation for future studies is
to separate the dual roles of the researcher/interventionist by
employing a researcher with adequate training for data col-
lection and music therapist as an interventionist to minimize
potential bias. Maturation should also be taken into consider-
ation, as Parkinson’s disease is a progressive, neurodegenera-
tive disease. Although maturation might influence the results
of the study, preserving their posttest results close to baseline
levels despite no significant improvement might be an indica-
tion of no progression of the target vocal and speech impair-
ments due to the singing and voice exercises. Therefore, the
addition of a control group in order to determine differences
in vocal quality in individuals not engaged in the singing
protocol is required.
The post PD diagnosis time of each recruited participant
widely ranged from one year to 15  years. It is reported that
speech deficits due to Parkinson’s disease can appear at
any stage of the disease, and worsens the symptoms as the
disease progresses (Pinto et  al., 2004; Stewart et  al., 1995).
Anecdotally, there are obvious similarities between motor and
speech impairments in individuals with PD due to hypokinesia.
According to the study by Cantiniaux et al. (2009), individuals
with PD have demonstrated similar spatiotemporal tendencies
between their gait and speech patterns. The variance in the
severity of PD among the participants might also be related to
their patterns of voice and speech deficits, thereby influencing
mixed results of the study. Future correlation research relating
to the severity of motor impairment and speech impairment
in individuals with PD would be beneficial. It is also recom-
mended to add an assessment tool on a quality-of-life measure
such as the Parkinson’s Disease Questionnaire (PDQ-39) (Peto,
Jenkinson, Fitzpatrick, & Greenhall, 1995) in future studies
to examine the impact of communication on quality of life
among the study participants (Takahashi, Kamide, Suzuki, &
Fukuda, 2016).
In future applications of this protocol, the authors would
suggest modifications for the facilitating music instrumen-
tation. The researcher (the first author) used a digital key-
board with weighted keys and a sustained pedal to facilitate
 48
Results of Variables Measuring Connected Speech Intelligibility by Participant
Number of
Discernible inter-word pauses
words (%) (frequency)
Part. Pre Post Pre Post
1 100 100 3 2
2 100 95.5 3 0
3 88.5 98.5 5 2.5
4 100 100 1 1
5 100 100 2 1
all exercises, including the upper-body warmup exercises.
Keyboard facilitated providing rhythmic and dynamics cues
as well as indicating the size and range (longer phrasing vs.
shorter phrasing patterns) and the contours of the phrasing
patterns. Another instrument, such as the autoharp, could also
be an effective musical instrument to facilitate the exercises if
used appropriately. Both keyboard instruments and autoharp
possess the features to provide these essential musical cues for
effective facilitation for the vocal and singing exercises. While
the piano/digital keyboard may limit the mobility of the instru-
ment during the facilitation due to its nature (size, weight, and
difficult to carry and play it simultaneously), the autoharp can
provide music therapists flexibility to physically situate them-
selves for the facilitation when adaptation is necessary. Using
piano/digital keyboard and autoharp for different types of
exercises may be an effective session facilitation strategy. This
study was designed for six weekly sessions and with no daily
exercises at home. Providing a handout to the participants to
encourage exercising at home with what they learned from
participating a group session would promote greater effect of
the protocol (Sabol et al., 1995).
Conclusions
Outcomes from this study indicate that the application of
VIT and TS in group music therapy is feasible and acceptable
to adults with PD. In addition, results from outcome measures
indicate possible benefit of VIT and TS for voice and speech
deficits of hypokinetic dysarthria due to PD. While there
has been a study on the effect of a music therapy protocol
for acquired dysarthria (Tamplin, 2008), this study provides
insights for music therapy clinicians regarding how to select
appropriate songs and vocal exercises that can specifically tar-
get vocal and speech symptoms due to hypokinetic dysarth-
ria. The results of this study support the further study of vocal
and singing exercises in a group setting. A larger size sample
with control group should be used to determine the effect of
the protocol. Furthermore, researchers should use additional
methods of data collection for jitter and also include measures
for speech rate in order to better quantify intelligibility.
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Music Therapy Perspectives (2018), Vol. 36
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