976267

review-article2020
CRE0010.1177/0269215520976267Clinical RehabilitationMuñoz-Vigueras et al.

CLINICAL
Systematic Review REHABILITATION

Clinical Rehabilitation

Speech and language therapy 1­–17

© The Author(s) 2020
Article reuse guidelines:
treatment on hypokinetic sagepub.com/journals-permissions
DOI: 10.1177/0269215520976267
https://doi.org/10.1177/0269215520976267

dysarthria in Parkinson journals.sagepub.com/home/cre

disease: Systematic review

and meta-analysis

Natalia Muñoz-Vigueras , Esther Prados-Román ,

Marie Carmen Valenza , Maria Granados-Santiago,
Irene Cabrera-Martos , Janet Rodríguez-Torres
and Irene Torres-Sánchez

Abstract
Objective: To assess the effect of speech and language therapy (SLT) on Hypokinetic dysarthria (HD)
in Parkinson’s disease.
Design: Systematic review and meta-analysis of randomized controlled trials.
Methods: We performed a literature search of randomized controlled trials using PubMed, Web of
Science, Science Direct and Cochrane database (last search October 2020). Quality assessment and risk
of bias were assessed using the Downs and Black scale and the Cochrane tool. The data were pooled and
a meta-analysis was completed for sound pressure levels, perceptual intelligibility and inflection of voice
fundamental frequency.
Results: We selected 15 high to moderate quality studies, which included 619 patients with Parkinson’s
disease. After pooling the data, 7 studies, which compared different speech language therapies to no
treatment, control groups and 3 of their variables, (sound pressure level, semitone standard deviation and
perceptual intelligibility) were included in the analysis.
Results showed significant differences in favor of SLT for sound pressure level sustained phonation
tasks (standard mean difference = 1.79; 95% confidence interval = 0.86, 2.72; p ⩽ 0.0001). Significant
results were also observed for sound pressure level and semitone standard deviation in reading tasks
(standard mean difference = 1.32; 95% confidence interval = 1.03, 1.61; p ⩽ 0.0001). Additionally, sound
pressure levels in monologue tasks showed similar results when SLT was compared to other treatments
(standard mean difference = 0.87; 95% confidence interval = 0.46, 1.28; p ⩽ 0.0001).

Department of Physiotherapy, Faculty of Health Sciences, Corresponding author:

University of Granada, Granada, Spain Marie Carmen Valenza, Department of Physiotherapy,
Faculty of Health Sciences, University of Granada, Av. De la
Ilustración, 60, Granada, 18016, Spain.
Email: cvalenza@ugr.es
2 Clinical Rehabilitation 00(0)
Conclusion: This meta-analysis suggests a beneficial effect of SLT for reducing Hypokinetic Dysarthria
in Parkinson’s disease, improving perceptual intelligibility, sound pressure level and semitone standard
deviation.
Keywords
Parkinson’s disease, language disorders, Hypokinetic Dysarthria, speech language therapy, Lee Silverman
Voice Treatment
Received: 14 January 2020; accepted: 4 November 2020
Introduction
More than 89% of individuals with Parkinson’s dis-
ease suffer from speaking and swallowing issues
during the course of their illness.1 Among those
impairments, a distinctive perceptual motor speech
disorder associated with basal ganglia control cir-
cuit pathology, called Hypokinetic Dysarthria, is
the most frequent one.2 This may appear in all of the
respiratory, phonatory, resonatory, articulatory and
prosody levels of speech, but its characteristics are
most evident in voice, articulation and prosody.3
This specific speech disorder4 is characterized
by reduced loudness,5 imprecise consonants, vowel
centralization, and rate changes6 accompanied by
involuntary facial movements.7
The Hypokinetic Dysarthria deleterious effects
on patient’s communication and social participa-
tion may lead to social isolation, reducing the qual-
ity of life.8
Speech and language therapy in Hypokinetic
Dysarthria aims to improve the intelligibility of
speech with behavioral treatment techniques and
instrumental aids.9 Behavioral techniques and
instrumental aids pursue the modification of behav-
ior, influencing one or several speech motor func-
tions, as well as linguistic or communicative
behavior, with the possible inclusion of specific
devices and/or feedback instruments.10
Speech and language therapy has already been
seen to be an integral component of treatment in
Parkinson’s disease. However, the most recent
review in 201511 concluded that there was insuffi-
cient evidence to conclusively support or refute the
efficacy of any form of speech and language ther-
apy to treat Hypokinetic Dysarthria. The lack of
evidence was mainly due to the small number of
examined patients, methodological flaws, and the
possibility of publication bias. Therefore, the study
fails to analyze specifically designed programs for
Hypokinetic Dysarthria. The effect should be rele-
vant for everyday life and lead to long-term
improvement,12 but the reported effectiveness,
components and duration of the published speech
and language therapy studies are scarce. Thus, the
main objective in this study is to systematically
review the results of specific speech and language
therapy programs for Hypokinetic Dysarthria.
Additionally, a metanalysis will be performed in
order to analyze the results found among the differ-
ent programs.
Methods
This review has been written in accordance with the
Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) Statement.13 The
review has been registered at the International
Prospective Register of Systematic Review (PROS
PERO) with registration number: CRD4201911
9605.
An electronic search was conducted using three
electronic databases: PudMed, Web of Science,
Science Direct and Cochrane database of rand-
omized controlled trials. The terms used can be
seen in the online appendix. Relevant publications
were included from inception until 9 October 2020.
To define the research question, the PICOS14
(Participants, Interventions, Comparisons, Outcome
and Study design) model was applied. The inclusion
Muñoz-Vigueras et al. 3
criteria were: (1) patients with Parkinson’s disease;
(2) speech and language therapy interventions
focused on dysarthria; (3) the speech and language
therapy intervention had to be compared to a con-
trol intervention or no-treatment; (4) Motor speech
control was included in the outcomes; (5) only ran-
domized clinical trials were included. Full texts in
English were included.
After the records were obtained from the differ-
ent databases, duplicates were removed. Then, two
reviewers (N.M. and I.T.) performed independent
evaluations of the titles and abstracts of all obtained
papers and further reviewed the studies to ensure
eligibility. All disagreement or differences in crite-
ria where resolved by a third reviewer (E.P).
When the articles were selected, we extracted
the data and performed a quality assessment. The
methodological quality of the included studies was
assessed using the Downs and Black quality assess-
ment method.15 It consists of 27 elements with five
subscales (study quality, external validity, study
bias, confounding and selection bias, and study
power). A study is considered excellent when it
reaches a score between 26 and 28 points, good
between 20 and 25, fair between 15 and 19, and
poor when it is less or equal to 14. This scale has
been ranked as one of the six highest quality assess-
ment scales suitable for use in systematic reviews,
due to its high validity and reliability.16,17
The risk of bias was assessed using the Cochrane
Risk of Bias Tool for Randomized Controlled
Trials method.18 It consists of seven elements with
six subscales (selection bias, performance bias,
detection bias, attrition bias, reporting bias and
other bias). It is considered that a study is of high
quality when there is low risk for each domain. Fair
quality19 when one criterion does not meet (i.e.
high risk of bias for one domain) or two criteria are
unclear, and there is no known important limitation
that could invalidate the results. Poor quality, when
one criterion does not meet or two criteria are
unclear, and there are important limitations that
could invalidate the results; and when two or more
criteria are listed as high or unclear risk of bias.
When possible, study results were pooled and a
meta-analysis was undertaken using Review
Manager Software (RevMan version 5.1, updated
March 2011). Because of the clinical heterogene-
ity of the included studies, meta-analysis was lim-
ited. The I2 statistic was utilized to determine the
degree of heterogeneity, where the percentages
quantified the magnitude of heterogeneity:
25% = low, 50% = medium, and 75% = high hetero-
geneity. Using this scale, if I2 was 50%, a random
effects model was used. All the included outcomes
were of continuous data, Sound Pressure Level,
Semitones Standard Deviation and perceptual
intelligibility and the mean difference with 95%
confidence interval (CI) was used in the analysis.
Forest plots were generated to illustrate the overall
effect of interventions.
Results
The search results and the final included studies are
shown in Figure 1.
A total of 619 participants with Parkinson’s dis-
ease and clinical diagnosis of Hypokinetic
Dysarthria were recruited. Study design, clinical
characteristics of patients and main outcomes, for-
mal measures and quality scores are detailed in
Supplementary Table 1.
The severity of the disease in the majority of the
cases was mild to moderate as measured by the
Hoehn-Yahr scale20 and the range of time since
diagnosis was from 4.77 ± 3.021 to 12.5 ± 7.422
years.
The most frequent outcomes were loudness
measured by sound pressure level22–29 and pitch,
measured by semitone standard deviation.25,27
The quality assessment using the Downs and
Black scale shows high quality for 722,27,29–33 of the
included studies and fair for 821,24–29,34,35 of the
studies. However, when Cochrane Risk of bias
Assessment was applied, the risk of bias shown is
generally low.
Table 1 shows intervention characteristics and
main conclusions obtained for each included study.
Among the included studies, five studies23,24,28,33,34
compared speech and language therapy to no treat-
ment; and five studies21,25–27,31 compared speech and
language therapy to control treatment (Respiratory
effort treatment). Additionally, four studies29,30,32,35
included three groups, (Two different groups of
4 Clinical Rehabilitation 00(0)

Identification Records identified through database searching:

Pub Med = 94; Web of Science = 538;
ScienceDirect= 118; Cochrane data base=16

Studies
identified
from
other
sources Total of articles
=1
(n = 766)
Screening

Duplicated articles
(n = 168)

Total of elegible articles

(n = 598)

Excluded articles (n = 434),

reason for exclusion:
Elegibility

Title and abstract not related to

the topic
Full text articles analyzed
(n = 164)

Excluded articles (n=150), reason for

exclusion:

Review: n=59; Quasiexperimental:

n=71; Case report: n=10; Others non
Included articles
RCT: n= 10
(n = 14)
Included

Excluded articles from meta-analysis

Studies included in
(n=8), reason for exclusion:
qualitative analysis:
Lack of agreement in variables used to
(n= 15)
evaluate outcomes

Studies included in
quantitative analysis: (n=7)

Figure 1. Flowchart.
Muñoz-Vigueras et al. 5

Table 1.  Characteristics of interventions.

Authors Interventions (n) Duration of intervention Main conclusions

(year)
Program duration (weeks);
Session duration (minutes);
Frequency (days per week)
Robertson Standard-SLT (Breathing; 2; 210–240; 5 Standard SLT group improved significantly
and phonation; resonance; all measured variables after intervention and
Thomson34 articulation; prosody; remains at follow up.
facial muscles): (n = 12) Between groups analysis post-intervention
No treatment: (n = 6) – showed significant differences in favor of
Standard SLT group that remains at
follow up.
Johnson and Standard-SLT (breathing; 4; 60; 2–3 Standard SLT group improved all measured
Pring24 phonation, resonance; variables significantly after intervention and
articulation; prosody): remains at follow up.
(n = 6) Between groups analysis post-intervention
No treatment: (n = 6) – showed significant differences in favor of
Standard SLT group that remains at
follow up.
Ramig et al.25 LSVT: (n = 26) 4; 50; 4 Both groups improved in all measured
Respiratory treatment: 4; 50; 4 variables during intervention.
(n = 18) LSVT group improved significantly in SPL
subscales, F0, impact profile and family and
self-perceived ratings. RET group improved
significantly in SPL subscales and self-ratings.
After intervention, LSVT group showed
higher results in all measured outcomes
being significantly better in F0 rainbow and
SIP, when compared to RET group.
Ramig and LSVT: (n = 26) 4; 60; 4 LSVT group improved significantly all
Dromey26 Respiratory treatment: 4; 60; 4 measures during treatment.
(n = 19) RET group showed no significant differences
after treatment.
Between group comparisons showed
significant differences in all variables
measured in favor of LSVT group.
Ramig et al.27 LSVT: (n = 21) 4; 60; 4 LSVT group improved significantly all
Respiratory 4; 60; 4 variables after intervention and are
treatment:(n = 12) maintained at follow up.
RET group improved significantly SPL
and STSD rainbow subscores that are
not maintained at follow up. Differences
between groups were found in favor of
LSVT group and maintained at follow up.
Ramig et al.28 LSVT: (n = 14) 4; 60; 4 LSVT group improved significantly in SPL
No treatment:(n = 15) – subscales. There were no significantly
differences between post-intervention and
at follow up in LSVT group.
Between groups analysis showed significant
differences in favor of LSVT group after
intervention and at follow up.
(Continued)
6 Clinical Rehabilitation 00(0)

Table 1. (Continued)

Authors Interventions (n) Duration of intervention Main conclusions

(year)
Program duration (weeks);
Session duration (minutes);
Frequency (days per week)
Baumgartner LSVT: (n = 13) 4; 60; 4 LSVT improved significantly all variables
et al.31 Respiratory treatment 4; 60; 4 after intervention.
(n = 7) RET group showed no differences after
intervention.
LSVT group showed significant differences
in all variables measured compared to RET
group after intervention and follow up.
Sapir et al.21 LSVT: (n = 22) 4; 60; 4 LSVT improved significantly all variables
Respiratory treatment 4; 50; 4 after intervention.
(n = 13) RET group showed no differences after
intervention.
LSVT group showed statistically significant
differences in all variables measured
compared to RET group after intervention
and follow up.
Sapir et al.23 LSVT: (n = 14) 4; 50–60; 4 LSVT group showed significant changes in
No treatment: (n = 15) – SPL, F2u, F2i/F2u and perception of quality
of vowel after intervention.
Between groups analysis post-intervention
showed significant differences in favor of
LSVT group.
Dumer LSVT: (n = 16) 4; 60; 4 LSVT and LSVT artic group improved all
et al.35 ARTIC: (n = 12) 4; 60; 4 variables significantly after intervention.
No treatment: (n = 17) – Comparisons between groups after
intervention showed significant differences
in favor of LSVT groups compared to
untreated group.
LSVT group showed significantly higher
values in the majority of variables after
intervention when compared to LSVT artic
group, with similar results in happiness sub
score.
Sackley LSVT: (n = 30) 4; 50–60; 4 Both intervention groups showed significant
et al.32 Standard-SLT: 6–8; 45; 1 improvements in all variables.
(Breathing; phonation; LSVT group and Standard-SLT group
resonance; articulation; showed significant differences in all variables
prosody): (n = 30) measured after intervention in favor of
No treatment: (n = 29) – LSVT group.
At follow up those differences remains.
Ramig et al.29 LSVT: (n = 22) 4; 60; 4 LSVT group showed improvements in all
LSVT ARTIC: (n = 20) 4; 60; 4 variables after intervention.
No treatment: (n = 22) – LSVT artic group showed no differences
after intervention. Between groups
comparisons showed significant differences
between groups in favor of LSVT group, that
last at follow up.
(Continued)
Muñoz-Vigueras et al. 7

Table 1. (Continued)

Authors Interventions (n) Duration of intervention Main conclusions

(year)
Program duration (weeks);
Session duration (minutes);
Frequency (days per week)
Saffarian LSVT: (n = 13) 4; 60; 4 LVST group showed significantly differences
et al.33 No treatment: (n = 10) – in the perception of loudness and quality of
voice after intervention and follow up.
Significant differences were found between
groups after intervention and at follow up in
all measured variables in favor of LSVT.
Tamplin Parkinsong (vocal 52; 180; NR Both intervention groups showed significant
et al.22 warm-ups, exercises improvements in all variables.
to develop respiratory Parkinsong weekly group were significantly
strength and control, louder than the other 3 groups.
vocal loudness, Significant differences were found after
articulation, pitch Parkinsong weekly intervention.
control, communication At 12 months follow up those differences
confidence activities) decreased but remained significantly higher
Weekly sessions: (n = 20) than baseline.
Control (dancing, 52; 180; NR
painting, tai chi or peer
support groups) Weekly
sessions: (n = 27)
Parkinsong (vocal 52; 180; 1
warm-ups, exercises
to develop respiratory
strength and control,
vocal loudness,
articulation, pitch
control, communication
confidence activities)
Monthly sessions:
(n = 15)
Control (dancing, 52; 180; 1
painting, tai chi or peer
support groups) Weekly
Monthly sessions:
(n = 13)
Levy et al.30 Voice treatment (focus 4; 60; 4 Voice and articulation treatment group
on loudness; respiratory- increased significantly TA after intervention.
laryngeal systems): Between groups, the increases in the voice
(n = 19) group were significantly greater than those
Articulation treatment 4; 60; 4 for both the articulation group and the no
(focus on enunciation; treatment group.
orofacial–articulatory Differences in TA changes between the
system): (n = 19) articulation group and the no treatment
No treatment: (n = 19) – group were not significant.

SLT: Speech and language therapy; CG: Control group; PD: Parkinson’s disease; EI: Experimental Intervention; CI: Control
Intervention; LSVT: Lee Silverman Voice Treatment; ARTIC: Articulation; RET: Respiratory effort treatment; F2u: Second formant
vowel u; F2i: Second formant vowel i; NR: No reported.
8 Clinical Rehabilitation 00(0)
speech and language therapies and a non-treatment
group).
The study of Tamplin et al.22 compared four
groups, two of them with the same SLT interven-
tion with different frequencies. One group received
treatment once a week and the other one received
treatment once per month. There were also two
respective control groups.
Feedback during speech and language therapy
interventions was used in eight21,24–27,30,31 of the
studies.
The most commonly applied method was Lee
Silverman’s Voice Treatment in different modali-
ties (Loudness and Articulation). All the studies
carried out the intervention using an individual
approach, except the one by Robertson and
Thomson that used a group dynamic.32
All the results obtained were in favor of experi-
mental interventions. When speech and language
therapy was compared to non-treatment, signifi-
cant improvements were found. These improve-
ments were maintained at the follow-up in all
measured outcomes.24,34
In the case of the studies comparing speech and
language therapy with a control group, speech and
language therapy groups showed better results in
all outcomes that were maintained at follow up.
This positive effect lead to a general improvement
in communication and dysarthria.
Especially for loudness and pitch variables,
when speech and language therapy treatment was
compared with the control group, the results were
in favor of speech and language therapy after treat-
ment and at follow up.
Detailed data about included aspects of dysar-
thria in the SLT interventions of each included
study (slurred speech, impaired muscle tone, lack of
coordination and hypophonia) were included as
supplementary material (see supplementary data
Table 1).
Results obtained in meta-analysis
Results obtained in loudness and pitch characteris-
tics have been analyzed across different subtasks
(sustained phonation, reading and monologue).
The measurements of the sound pressure level
and the standard deviation of semitones were
analyzed to obtain concrete results on the charac-
teristics of the treatment. To acquire the sound
pressure level, we used three subtasks: the sus-
tained phonation, the reading and the monologue
as shown in Figures 2–5. The results on the stand-
ard deviation of semitones were obtained by
using the reading and monologue subtasks and
can be seen in Figures 6 and 7.
For the sustained phonation subtask, the pooled
mean difference (MD) showed significant overall
effect of speech and language therapy: standard
speech and language therapy, Lee Silverman Voice
Treatment Loudness, Lee Silverman Voice Treatment
Articulation, ParkinSong Weekly and ParkinSong
Monthly; when compared to no intervention
(MD = 1.11; 95% CI = -0.30, 2.52; p = 0.0003), or to a
comparison group: Respiratory Treatment, Control
treatment Weekly and Control treatment Monthly
(MD = 2,24; 95% CI = 0.97; 3.51; p ⩽ 0.0001).
Heterogeneity was high (I2 = 91.28%; I2 = 90.01%)
respectively. Compared to no intervention with the
comparison group: (MD = 1.79; 95% CI = 0.86; 2.72;
p ⩽ 0.0001). Heterogeneity was high (I2 = 90.54%).
When the reading subtask was analyzed, the
effect of speech and language therapy was further
examined by pooling the data. The mean difference
(MD) shows significant overall effect of speech and
language therapy: standard speech and language
therapy, Lee Silverman Voice Treatment Loudness
and Lee Silverman Voice Treatment Articulation;
when compared to no intervention (MD = 0.99;
95% CI = 0.42, 1.56; p < 0.0001) and comparison
group: Respiratory Treatment (MD  = 
1.62; 95%
CI = 1.15, 2.09; p <  0.0001) Heterogeneity was
(I2 = 52.72%; I2 = 0%) respectively. Compared to
no intervention with comparison group: (MD = 1.32;
95% CI = 1.03; 1.61; p ⩽ 0.0001). Heterogeneity
was low (I2 = 0%).
When the Monologue subtask was analyzed, the
effect of speech and language therapy was further
examined by pooling the data.
For the monologue subtask the mean difference
(MD) shows significant overall effect of speech and
language therapy: standard speech and language
therapy, Lee Silverman Voice Treatment Loudness,
Lee Silverman Voice Treatment Articulation and
ParkinSong Weekly and ParkinSong Monthly;
when compared to no intervention (MD = 1.07; 95%
 Muñoz-Vigueras et al.

Study or Treatment group Comparison group Weight Mean difference dB Mean difference dB
subgroup Mean SD Total Mean SD Total % IV, Random, 95% CI IV, Random, 95% CI
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs No treatment
Ramig 2001 82.4 3.9 14 70.5 4.4 15 25.66 2.78 [1.76, 3.80]
Ramig 2018 84.3 10.6 22 76.1 8.3 22 38.94 0.85 [0.23, 1.46]
Speech language therapy (Lee Silverman Voice Treatment Articulation) vs No treatment
Ramig 2018 75.2 7.9 20 76.1 8.3 20 35,40 -0.11[-0.71, 0.50]
Subtotal (95%CI) 56 57 100 1.11[-0.30, 2.52]
Heterogeneity:Tau2=1.3990,Chi2= 11.47, df= 2 (P= <0.0001 ), I2= 91.28%
Test for overall effect: Z= 3.5837 (P= 0.0003)
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs Comparison group
Ramig 1995 81.2 4.6 26 68.0 4.3 19 26.47 2.87 [2.03, 3.71]
Ramig 1996 81.7 3.1 10 65.2 4.2 7 10 4.37 [2.61, 6.13]
Ramig 2001 82.36 3.9 21 68.7 4.8 12 19.41 3.14 [2.10, 4.18]
Speech language therapy (Parkinsong) vs Comparison group
Tamplin 2020 W 90,08 10,1 20 80,8 9,4 15 20.58 0.92 [0.22, 1.62]
Tamplin 2020 M 80,56 11,6 27 74,5 10,1 13 23.59 0.53 [-0.14, 1.21]
Subtotal (95%CI) 104 66 100 2.24 [0.97, 3.51]
Heterogeneity:Tau2=1.8124,Chi2= 10.01, df= 4 (P= <0.0001 ), I2= 90.01%
Test for overall effect: Z= 8.5421 (P= <0.0001)
Heterogeneity:Tau2=1.5610,Chi2= 10.57, df= 7 (P= <0.0001 ), I2= 90.54%
Test for overall effect: Z= 8.6518 (P= <0.0001)

Figure 2.  Meta-analysis; sustained phonation; sound pressure level.

9
 10

Study or Treatment group Comparison group Weight Mean difference dB Mean difference dB
subgroup Mean SD Total Mean SD Total % IV, Random, 95% CI IV, Random, 95% CI
Standard speech language therapy vs No treatment
Johnson 1990 76.5 6.3 6 70.1 2.4 6 9.68 1.24 [0.00, 2.47]
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs No treatment
Ramig 2001 77.9 4.2 14 70.5 4.4 14 22.58 1.67 [0.82, 2.52]
Ramig 2018 76.8 6.2 22 71.3 4.8 22 35.48 0.97 [0.35, 1.60]
Speech language therapy (Lee Silverman Voice Treatment Articulation) vs No treatment
Ramig 2018 73.2 5.1 20 71.3 4.8 20 32.26 0.38 [-0.23, 0.99]
Subtotal (95%CI) 62 62 100 0.99 [042, 1.56]
Heterogeneity:Tau2=0.1713,Chi2= 2.11, df= 3 (P= 0.0960), I2= 52.72%
Test for overall effect: Z= 4.8273 (P= <.0001)
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs Comparison group
Ramig 1995 74.33 4.83 26 68.16 3.33 19 47.37 1.42 [0.76, 2.08]
Ramig 1996 74.2 3.5 10 66.9 3.9 7 17.89 1.89 [0.73, 3.05]
Ramig 2001 75.31 4.22 21 68.03 3.36 12 34.74 1.80 [0.97, 2.64]
Subtotal (95%CI) 57 38 100 1.62 [1.15, 2.09]
Heterogeneity:Tau2=0, Chi2= 1, df= 2 (P=0.6880), I2= 0.00%
Test for overall effect: Z=6.7347 (P= <.0001)
Heterogeneity:Tau2=0, Chi2= 0.89, df= 6 (P=0.4994), I2= 0.00%
Test for overall effect: Z=8.8469 (P= <.0001)

Figure 3.  Meta-analysis; reading; sound pressure level.

Clinical Rehabilitation 00(0)
 Muñoz-Vigueras et al.

Study or subgroup Treatment group Comparison group Weight Mean difference dB Mean difference dB
Mean SD Total Mean SD Total % IV, Random, 95% CI IV, Random, 95% CI
Standard Speech language therapy vs No treatment
Johnson 1990 77.5 8.8 6 69.5 3.8 6 9.45 1.09 [-0.12, 2.30]
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs No treatment
Ramig 2001 74.5 4 14 64.9 3.9 15 22.83 2.36 [1.41, 3.31]
Ramig 2018 74.9 6.2 22 70.2 4.7 22 34.64 0.84 [0.22, 1.46]
Lee Silverman Voice Treatment Articulation vs No treatment
Ramig 2018 71,4 5.6 20 70.2 4.7 22 33.07 0.23 [-0.38, 0.84]
Subtotal (95%CI) 62 65 100 1.07 [0.22, 1.93]
Heterogeneity: Tau2=0.5812, Chi2= 4.64, df= 3 (P= 0.0030), I2= 78.46%
Test for overall effect: Z= 4.5452 (P= <.0001)
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs Comparison group
Ramig 1995 69.17 4.1 29 66.2 2.1 13 21.76 0.85 [0.08, 1.61]
Ramig 1996 70 3.5 17 67.1 2.9 7 12.43 0.84 [-0.17, 1.85]
Ramig 2001 69.4 3.4 18 65.8 2.7 6 12.43 1.07 [0.03, 2.11]
Speech language therapy (Parkinsong) vs Comparison group
Tamplin 2020 W 68,9 5,5 35 62.9 5.7 15 25.90 1.04 [0.32, 1.75]
Tamplin 2020 M 62,2 8,3 40 61.4 9.0 13 27.46 0.10 [0.03, 2.11]
Subtotal (95%CI) 139 54 100 0.90 [-0.56, 0.76]
Heterogeneity: Tau2=0.0303, Chi2=1.18, df= 4 (P= 0.3182), I2= 15.10%
Test for overall effect: Z= 3.8716 (P= 0.0001)
Heterogeneity: Tau2=0.2204, Chi2=2.38, df= 8 (P= 0.0147), I2= 57.96%
Test for overall effect: Z= 5.9379 (P= 0.0147)

Figure 4.  Meta-analysis; monologue; sound pressure level.

11
 12

Study or subgroup Treatment group Comparison group Weight Mean difference dB Mean difference dB
Mean SD Total Mean SD Total % IV, Random, 95% CI IV, Random, 95% CI
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs No treatment
Ramig 2001 74.4 4.3 14 70.7 4.1 15 25.22 0.86 [0.10, 1.62]
Ramig 2018 74.8 5.9 22 69.8 4.9 22 38.26 0.91 [0.28, 1.53]
Speech language therapy (Lee Silverman Voice Treatment Articulation) vs No treatment
Ramig 2018 71.8 6.3 20 69.8 4.9 22 36.52 0.35 [-0.26, 0.96]
Subtotal (95%CI) 56 59 100 0.68 [0.30, 1.06]
Heterogeneity: Tau2=0, Chi2= 1.00, df= 2 (P= 0.3988 ), I2= 0.00%
Test for overall effect: Z= 3.5316 (P= 0.0004)

Figure 5.  Meta-analysis; picture description; sound pressure level.

Study or subgroup Treatment group Comparison group Weight Mean difference dB Mean difference dB
Mean SD Total Mean SD Total % IV, Random, 95% CI IV, Random, 95% CI
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs Comparison group
Ramig 1995 2.38 0.67 26 2.09 0.34 17 57.33 0.50 [-0.12, 1.12]
Ramig 2001 2.48 0.71 20 2.17 0.36 12 42.66 0.50 [-0.23, 1.22]
Subtotal (95%CI) 46 29 100 0.50 [0.03, 0.97]
Heterogeneity: Tau2=0, Chi2=1.00, df= 2 (P= 0.9915), I2= 0.00%
Test for overall effect: Z= 2.0855 (P= 0.0370)

Figure 6.  Meta-analysis; reading; semitone standard deviation.

Clinical Rehabilitation 00(0)
Muñoz-Vigueras et al. 13

CI = 0.22, 1.93; p < 0.001) and comparison group:

Respiratory Treatment, Control treatment Weekly
and Control treatment Monthly (MD = 0.90; 95%
CI = –0.56, 0.76; p = 0.0008). Analysis showed a het-
erogeneity (I2 = 78.46%; I2 = 15.10%), respectively.
Compared to no intervention with comparison
group: (MD = 0.87; 95% CI = 0.46, 1.28; p = 0.0147).
Heterogeneity was (I2 = 57.96%).
IV, Random, 95% CI
Mean difference dB

When the picture description task was analyzed,

the mean difference (MD) showed significant over-
all effect of speech and language therapy: standard,
Lee Silverman Voice Treatment Loudness and Lee
Silverman Voice Treatment Articulation) when
compared to no intervention (MD = 0.68; 95%
CI = 0.30, 1.06; p = 0.0004). Analysis showed no
heterogeneity (I2 = 0%).
Results obtained in pitch characteristics have
IV, Random, 95% CI
Mean difference dB

been analyzed across different subtasks (reading

-0.07 [-0.96, 0.81]
0.03 [-0.70, 0.76]

0.07 [-0.40, 0.54]

and monologue). For the reading subtask, semitone

standard deviation scores were analyzed and pre-
sented in speech and language therapy: Lee
Silverman Voice Treatment when compared to
comparison group: Respiratory Treatment, signifi-
Weight

59.18
40.82
100
%
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs Comparison group

cant effects were found in favor of speech and lan-

guage therapy. The mean difference (MD) shows
Total

overall effects when compared to control interven-

13

22
9
Comparison group

tions in semitone standard deviation (MD = 0.50;

Figure 7.  Meta-analysis; monologue; semitone standard deviation.
0.34
0.36

95% CI = 0.03, 0.97; p = 0.0370). Heterogeneity

SD

was (I2 = 0%).
Heterogeneity: Tau2=0, Chi2=1.00, df= 1 (P= 0.8561), I2= 0.00%
Mean

2.09
2.17

For the monologue subtask, semitone standard

deviation scores were analyzed and presented in
Total

Figure 7.
16
11
27
Treatment group

Compared to comparison group: Respiratory

Test for overall effect: Z= -0.0417 (P= 0.9667)
0.58
0.56

Treatment. No significant effects were found in

SD

semitone standard deviation (MD  = 0.07; 95%

Mean

1.97
2.09

CI = –0.40, 0.54; p = 0.9667). Both analyses showed

no heterogeneity (I2 = 0%).
When the Intelligibility (%) perceptual task was
analyzed (presented in Figure 8), the mean differ-
Study or subgroup

Subtotal (95%CI)

ence (MD) showed significant overall effect of

Ramig 1995
Ramig 2001

speech and language therapy: Lee Silverman Voice

Treatment Loudness and ParkinSong Weekly and
ParkinSong Monthly) when compared to compari-
son group: Respiratory Treatment and Control
treatment Weekly and Control treatment Monthly
(MD = 0.22; 95% CI = –0.29, 0.74; p = 0.1454).
Analysis showed heterogeneity (I2 = 48.14%).
14 Clinical Rehabilitation 00(0)

Discussion
Our results support the idea that speech and lan-
guage therapy treatment is effective in the treat-
ment of Hypokinetic Dysarthria in Parkinson’s
disease patients. Nonetheless, our systematic anal-
ysis of the literature, related to components and
design, has to be interpreted with caution due to the
differences in the intensity of therapy, differences
IV, Random, 95% CI

in the application of speech and language therapy,

Mean difference dB

and differences in effect sizes of the included

studies.
Among speech and language therapy interven-
tions, the Lee Silverman Voice Treatment program
was the most used and the most frequent control
treatment was respiratory training. When com-
pared, speech and language therapy showed sig-
nificantly better results in all measured variables
IV, Random, 95% CI
Mean difference dB

-0.05 [-0.64, 0.54]

-0.01 [0.68, 0.66]

0.22 [-0.29, 0.74]

and were better maintained at the different timeline

0.78 [0.10, 1.47]

follow up. Despite this, more research is needed to

determine the concrete effects of SLT in different
phenotypes of the Parkinson’s disease.
Our findings are in line with previous system-
atic reviews performed in the Parkinson’s disease
Weight

59.16

29.16
33.33
Speech language therapy (Lee Silverman Voice Treatment Loudness) vs Comparison group

100
%

population.11,21,36–41 These suggest that the speech

problems are due to hypokinetic dysarthria and
Total

19
Comparison group

15
13

Lee Silverman’s Voice Treatment publications

Heterogeneity: Tau2=0.1012, Chi2= 1.93, df= 2 (P= 0.1454 ), I2= 48.14%

also suggest the same. This paper is relevant and

19.9

12.5
21.3
SD

needed because it is updated and provides high

quality level of evidence. The results of our sys-
Mean

92.9
72.9
72
Speech language therapy (Parkinsong) vs Comparison group

tematic review suggest that speech and language

therapy can have a beneficial effect on aspects of
Total

Figure 8.  Meta-analysis; perceptual intelligibility (%).

26

20
27
Treatment group

Hypokinetic Dysarthria like: slurred speech, lack

Test for overall effect: Z= 1.1018 (P= 0.2706)

of coordination and hypophonia. However, we

16.7

17.4
SD

8.6

found no effect on impaired muscle tone. This

Mean

71.1

92.7
87.9

could be due to the insufficient data to analyze the

pooled effect.
When analyzing the results obtained comparing
Study or subgroup

speech and language therapy to no treatment, other

Subtotal (95%CI)
Tamplin 2020 W

reviews found similar results with less available

Tamplin 2020 M

evidence.11 However, when the analysis was per-

Ramig 1995

formed taking into account the main symptoms of

Hypokinetic Dysarthria in Parkinsonians, the evi-
dence showed that speech and language therapy pro-
grams fail to include the work of facial muscles in
the designs. Previous studies42,43 have analyzed the
importance of the assessment of orofacial muscle
Muñoz-Vigueras et al. 15
tone due to their interest in differential diagnosis of
the dysarthrias. The relevance of evaluating facial
muscle tone in patients with Hypokinetic Dysarthria
in Parkinson’s,42,43 highlights the clinical relevance
of standardized procedures and normative data. Our
analysis of the SLT interventions showed that this
aspect is usually not included as a measure or a com-
ponent in the proposed programs. Those limitations
yield inconclusive results regarding facial muscles
tone and activity after speech and language therapy
treatment.
In addition to the positive effects of speech and
language therapy in Hypokinetic Dysarthria after
intervention, our review found that the reported
changes continue at follow up in the majority of
reviewed articles.21,24,28,29,32,34 The follow up time
period ranged between 1 month,24 3, 6, 12 months,32
1–7 months29 and 2 years.27
What has been found regarding Hypokinetic
Dysarthria in Parkinson’s disease affirms the need
for monitoring for signs and symptoms of dysar-
thria in order to propose interventions that use
breathing, phonation, resonance, articulation, pros-
ody and facial muscles to improve dysarthria
symptoms in Parkinson’s disease.
When speech and language therapy interven-
tions were compared with other treatments, the
results were in favor of the speech and language
therapy. However, in some cases such as the mono-
logue subtask, it was difficult to draw a significant
conclusion. This could be due to the high cognitive
demand of the monologue subtask which may have
affected the results but had not been measured.
The studies included in our review combine dif-
ferent speech and language therapy programs with-
out a conceptual framework of the speech and
language therapy discipline, highlighting the impor-
tance of developing a definition of speech and
language therapy interventions. Some studies23,32,34
included in the review use the “Standard speech and
language therapy intervention”, which is not recog-
nized as a concrete and structured intervention. The
Lee Silverman Voice Treatment defines a structured
and replicable intervention that permits a scientific
recognition of the evidence associated with speech
and language therapy intervention in Parkinson’s
disease.
The Dumer et al.35 study compares two inter-
ventions, Lee Silverman Voice Treatment Loudness
vs Lee Silverman Voice Treatment Articulation.
However, they do not measure tone and volume of
voice, making it difficult to compare with other
articles.11
This study has some limitations; firstly, the major-
ity of interventional groups used the Lee Silverman
Method as a treatment, being scarce in the descrip-
tion of the dosage, intensity and individualization of
the treatment. Different modalities of application
were carried out, with the number of sessions rang-
ing from 8 to 16, with a training frequency ranging
from 1 to 5 sessions per week and a treatment time
ranging from 45 to 240 minutes per session.
Secondly, some heterogeneity in the outcome
measures within the included studies was observed.
One of the included studies applied tests such as
estimated subglottal pressure, maximum flow dec-
lination rate, open quotient and electroglotto-
graphic signal pulse with adduction to measure
variables of the upper airway.25 These instruments
were not used in any of the other articles reviewed.
More studies that assess these variables may be
needed to measure the effect of different types of
speech and language therapy on more specific
aspects that are affected by the Hypokinetic
Dysarthria of Parkinson’s disease.
Thirdly, there are significant differences in the
results obtained in our meta-analysis that affect, in
a relevant manner, our conclusions. The heteroge-
neity of outcomes has impacted the number of
included studies in the analysis performed for each
independent variable.
This meta-analysis has also some clinical impli-
cations for rehabilitation practice. There is a num-
ber of functions attributed to speech and language
therapy in rehabilitation of Hypokinetic Dysarthria
in Parkinson’s disease. As well as improving
patient’s outcomes on standardized measures,
speech and language therapy is also thought to be
an essential part of multidisciplinary therapeutic
approach for enhancing global patient functional-
ity. Speech and language therapy has demon-
strated specific results in speech parameters
(sound pressure level, semitone standard devia-
tion and perceptual intelligibility). The therapy is
16 Clinical Rehabilitation 00(0)
usually administered in a weekly format, in an
individualized approach and can have mid-term
lasting effects (3–6  months after intervention).
Therefore, future research should focus on specific
groups of patients to determine when and how
speech and language therapy is most effective in
the treatment of Hypokinetic Dysarthria. However,
to improve the strength of the evidence on the
effects of speech and language therapy, future stud-
ies need to be large randomized controlled trials
reporting clear protocols for speech and language
therapy, including bigger samples.
Clinical messages
•• Speech and language therapy improves
dysarthria signs in people with Parkinson’s
disease when compared with other treat-
ments or no treatment.
•• Therapy programs have a significant effect
on improving sound pressure level, semi-
tone standard deviation and perceptual
intelligibility characteristics in dysarthria
Parkinson’s disease patients.
•• Benefits may be maintained at follow up.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iDs
Natalia Muñoz-Vigueras https://orcid.org/0000-
0002-6019-7023
Esther Prados-Román https://orcid.org/0000-0002-
8453-4864
Marie Carmen Valenza https://orcid.org/0000-0003-
2368-1307
Irene Cabrera-Martos https://orcid.org/0000-0003-
4711-0701
Irene Torres-Sánchez https://orcid.org/0000-0002-
5459-230X
Supplemental material
Supplemental material for this article is available online.
References
1. Ramig LO, Fox C and Sapir S. Speech treatment for
Parkinson’s disease. Exp Rev Neurother 2008; 8(2): 297–
309.
2. Sunwoo MK, Hong JY, Lee JE, et al. Depression and
voice handicap in Parkinson disease. J Neurol Sci 2014;
346(1–2): 112–115.
3. Boshes B. Voice changes in parkinsonism. J Neurosurg
1966; 24: 286.
4. Darley FL, Aronson AE and Brown JR. Differential diag-
nostic patterns of dysarthria. J Speech Hear Res 1969; 12:
246–269.
5. Logemann JA and Fisher HB. Vocal tract control in
Parkinson’s disease: phonetic feature analysis of misar-
ticulations. J Speech Hear Disord 1981; 46: 348–352.
6. Skodda S and Schlegel U. Speech rate and rhythm in
Parkinson’s disease. Mov Disord 2008; 23: 985–992.
7. Fox CM and Ramig LO. Vocal sound pressure level and
self- perception of speech and voice in men and women
with idiopathic Parkinson disease. Am J Speech Lang
Pathol 1997; 6: 85–94.
8. Miller N, Noble E, Jones D, et al. Life with communi-
cation changes in Parkinson’s disease. Age Ageing 2006;
35(3): 235–239.
9. Duffy JR. Motor speech disorders: substrates, differential
diagnosis, and management. St. Louis: Mosby, 2019.
1 0. Schröter-Morasch H and Ziegler W. Rehabilitation
of impaired speech function (dysarthria, dysglossia).
GMS Curr Top Otorhinolaryngol Head Neck Surg
2005; 4: Doc15.
11. Atkinson-Clement C, Sadat J and Pinto S. Behavioral
treatments for speech in Parkinson’s disease: meta-analy-
ses and review of the literature. Neurodegen Dis Manage
2015; 5(3): 233–248.
12. Delgado J and Izquierdo LM. Eficacia de la rehabili-
tación de la voz en etapas tempranas de la Enfermedad de
Parkinson. Rev Dis Cli Neuro 2016; 3(1): 42–47.
13. Moher D, Shamseer L, Clarke M, et al. Preferred reporting
items for systematic review and meta analysis protocols
(PRISMA-P) 2015 statement. Syst Rev 2015; 4: 1.
14. Centre for Reviews & Dissemination. Systematic reviews:
CRD’s guidance for undertaking systematic reviews in
healthcare. New York: York Publishing Services Ltd,
2009.
15. Downs SH and Black N. The feasibility of creating a
checklist for the assessment of the methodological quality
both of randomised and non-randomised studies of health
care interventions. J Epidemiol Community Health 1998;
52: 377–384.
16. Deeks JJ, Dinnes J, D’Amico R, et al. International Stroke
Trial Collaborative Group, European Carotid Surgery
Trial Collaborative Group. Evaluating non-randomised
Muñoz-Vigueras et al. 17
intervention studies. Health Technol Assess 2003; 7(27):
iii–x, 1–173.
17. Saunders LD, Soomro GM, Buckingham J, et al. Assessing
the methodological quality of nonrandomized intervention
studies. West J Nurs Res 2003; 25(2): 223–237.
18. Higgins JP and Green S (eds.). Cochrane handbook for
systematic reviews of interventions, vol. 4. West Sussex:
John Wiley & Sons, 2011.
19. Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane
Collaboration’s tool for assessing risk of bias in ran-
domised trials. Brit Med J 2011; 343: d5928.
20. Hoehn MM and Yahr MD. Parkinsonism: onset, progres-
sion and mortality. Neurology 1967; 17: 427–442.
21. Sapir S, Raming LO, Hoyt P, et al. Speech loudness
and quality 12 months after intensive voice treatment
(LSVT®) for Parkinson’s disease: a comparison with an
alternative speech treatment. Folia Phoniatr Logop 2002;
54: 296–303.
22. Tamplin J, Morris ME, Marigliani C, et al. ParkinSong:
outcomes of a 12-month controlled trial of therapeutic
singing groups in Parkinson’s disease. J Parkinsons Dis
2020; 10(3): 1217–1230.
23. Sapir S, Spielman JL, Ramig LO, et al. Effects of inten-
sive voice treatment (the Lee Silverman Voice Treatment
[LSVT]) on vowel articulation in dysarthric individuals
with idiopathic Parkinson disease: acoustic and percep-
tual findings. J Speech Lang Hear Res 2007; 50(4): 899–
912. Erratum in: J Speech Lang Hear Res 2007; 50(6):
1652.
24. Johnson JA and Pring TR. Speech therapy and Parkinson’s
disease: a review and further data. Brit J Disord Commun
1990; 25: 183–194.
25. Ramig L, Pawlas A and Countryman S. Lee Silverman
voice treatment: a practical guide to treating the voice
and speech disorders in Parkinson disease. Iowa City, IA:
National Center for Voice and Speech, 1995.
26. Ramig LO and Dromey C. Aerodynamic mechanisms
underlying treatment-related changes in vocal intensity in
patients with Parkinson disease. J Speech Hear Res 1996;
39(4): 798–807.
27. Ramig LO, Sapir S, Countryman S, et al. Intensive voice
treatment (LSVT®) for patients with L O Parkinson’s dis-
ease: a 2 year follow up. J Neurol Neurosurg Psychiatry
2001; 71: 493–498.
28. Ramig LO, Sapir S, Fox C, et al. Changes in vocal loud-
ness following intensive voice treatment (LSVT) in
individuals with Parkinson’s disease: a comparison with
untreated patients and normal age-matched controls. Mov
Disord 2001; 16: 79–83.
29. Ramig L, Halpern A, Spielman J, et al. Speech treat-
ment in Parkinson’s disease: randomized controlled trial
(RCT). Mov Disord 2018; 33(11): 1777–1791.
30. Levy ES, Moya-Gale G, Chang YHM, et al. The effects of
intensive speech treatment on intelligibility in Parkinson
disease: arandomized controlled trial. EClin Med 2020;
24: 100429.
31. Baumgartner CA, Sapir S and Ramig LO. Voice quality
changes following phonatory–respiratory effort treatment
(LSVT®) versus respiratory effort treatment for individu-
als with Parkinson disease. J Voice 2001; 15: 105–114.
32. Sackley CM, Smith CH, Rick CE, et al. Lee Silverman
Voice treatment versus standard speech and language
therapy versus control in Parkinson's disease: a pilot ran-
domised controlled trial. Pilot Feasibility Stud 2018; 4:
30.
33. Saffarian A, Amiri Shavaki Y, Shahidi GA, et al. Lee
Silverman voice treatment (LSVT) mitigates voice diffi-
culties in mild Parkinson’s disease. Med J Islam Repub
Iran 2019; 33: 5.
34. Robertson SJ and Thomson F. Speech therapy in
Parkinson’s disease: a study of the efficacy and long term
effects of intensive treatment. Br J Disord Commun 1984;
19(3): 213–224.
35. Dumer AI, Oster H, McCabe D, et al. Effects of the
Lee Silverman Voice Treatment (LSVT® LOUD) on
hypomimia in Parkinson’s disease. J Int Neuropsychol
Soc 2014; 20: 302–312.
36. Herd CP, Tomlinson CL, Deane KH, et al. Comparison of
speech and language therapy techniques for speech prob-
lems in Parkinson’s disease. Cochrane Database Syst Rev
2012; 2012(8): CD002814.
37. Serrano R, Torro N and Figueiredo A. Effectiveness and
limitations of vocal therapy in Parkinson’s disease: a lit-
erature review. Rev CEFAC 2016; 18(3): 758–765.
38. Theodoros D, Aldridge D, Hill AJ, et al. Technology-
enabled management of communication and swallowing
disorders in Parkinson’s disease: a systematic scoping
review. Int J Lang Commun Disord 2019; 54(2): 170–188.
39. Fox CM, Ramig LO, Ciucci MR, et al. The science and
practice of LSVT/LOUD: neural plasticity-principled
approach to treating individuals with Parkinson disease
and other neurological disorders. Semin Speech Lang
2006; 27(4): 283–299.
40. Sapir S, Raming L and Fox C. Speech and swallowing dis-
orders in Parkinson disease. Curr Opin Otolaryngol Head
Neck Surg 2008; 16: 205–210.
41. Mahler LA, Ramig LO and Fox C. Evidence-based treat-
ment of voice and speech disorders in Parkinson disease.
Curr Opin Otolaryngol Head Neck Surg 2015; 23(3):
209–215.
42. Dietsch AM, Solomon NP, Sharkey LA, et al. Perceptual
and instrumental assessments of orofacial muscle tone in
dysarthric and normal speakers. J Rehabil Res Dev 2014;
51(7): 1127–1142.
43. Mackenzie C, Muir M and Allen C. Non-speech oro-
motor exercise use in acquired dysarthria management:
regimes and rationales. Int J Lang Commun Disord 2010;
45(6): 617–629.